The empowering role of hospitable telemedicine experience in reducing isolation and anxiety: evidence from the COVID-19 pandemic

Yusi Cheng (Rosen College of Hospitality Management, University of Central Florida, Orlando, Florida, USA)
Wei Wei (Rosen College of Hospitality Management, University of Central Florida, Orlando, Florida, USA)
Yunying Zhong (Rosen College of Hospitality Management, University of Central Florida, Orlando, Florida, USA)
Lu Zhang (The School of Hospitality Business, Michigan State University, East Lansing, Michigan, USA)

International Journal of Contemporary Hospitality Management

ISSN: 0959-6119

Article publication date: 18 January 2021

Issue publication date: 15 March 2021

1324

Abstract

Purpose

This paper aims to explore how hospitable telemedicine services empowered patients during the COVID-19. Expanding from the technology aspect, this research integrated the philosophy of hospitality organizational culture by including factors related to human-human interaction as significant predictors for patients’ sense of empowerment (perceived competence and control) in coping with their emotional stress (anxiety and isolation).

Design/methodology/approach

Survey data were obtained from 409 general consumers who have used video-based virtual consultation since February 2020. Stepwise multiple regression and simple linear regression analyses were used for hypotheses testing.

Findings

The results reveal that the doctors’ reliability, responsiveness and empathy significantly predict patients’ perceived competence and control. Perceived usefulness and convenience of telemedicine technology enhance patients’ perceived competence and control. Patients’ sense of empowerment significantly reduces their anxiety and sense of isolation.

Research limitations/implications

To fully understand the role of hospitality in people’s telemedicine experiences, future studies are encouraged to not only examine the patients-clinicians interactions but also explore the patients-support staff interactions.

Practical implications

Health care providers’ “bed-side” manners empower patients in managing their emotional stress. Health care providers should be trained for their empathetic ability and communication skills. Strategies such as collaborating with hospitality schools and business schools can be implemented to help build medical student’s patient-centric attitudes and skills.

Originality/value

This paper provided empirical evidence for the value of hospitality in health care and offered useful suggestions for health care providers, especially by empowering vulnerable people during catastrophic events such as COVID-19.

Keywords

Citation

Cheng, Y., Wei, W., Zhong, Y. and Zhang, L. (2021), "The empowering role of hospitable telemedicine experience in reducing isolation and anxiety: evidence from the COVID-19 pandemic", International Journal of Contemporary Hospitality Management, Vol. 33 No. 3, pp. 851-872. https://doi.org/10.1108/IJCHM-07-2020-0786

Publisher

:

Emerald Publishing Limited

Copyright © 2020, Emerald Publishing Limited


1. Introduction

The role of hospitality in improving health care experiences has drawn growing attention in recent years (Kelly et al., 2016; Pizam, 2020). Hospitality, derived from the Latin word “hospitalitat,” not only indicates offering physical comfort to travelers but also implies providing heartfelt acts to sick and vulnerable people (King, 1995). Pizam (2020) further pinpointed that adopting and practicing hospitality in a health care setting will contribute to patients’ positive emotions and feelings and ultimately improve their physical well-being. Such insights offered a foundation for current work, which aimed to explore the role of hospitality in a unique health care service – telemedicine.

Telemedicine improves people’s access to health care. While telemedicine technology has already been practiced in consultation and treatment for patients with chronic diseases and/or who are unable to physically present at the hospital, its use becomes especially significant and essential during the COVID-19 pandemic. In response to the enforcement of social distancing practices and people’s fear of uncertainty, telemedicine offers vulnerable people an alternative of seeking medical assistance (Hollander and Carr, 2020; Leite et al., 2020). As people all over the world are shrouded in the shadow of COVID-19, the “kind and sympathetic” gene in hospitality is in dire demand. Powerless people are now more eager than at any other time to seek humane help and support provided by health care organizations (Li et al., 2020). As such, COVID-19 accentuates the importance of the hospitality components in health care. Understanding people’s experiences of using telemedicine during COVID-19 and exploring how hospitality components in telemedicine may empower people becomes a timely and valuable topic for scholars and practitioners in both hospitality and health care.

As industry practitioners recognized the benefits of telemedicine, researchers from various areas also acknowledged telemedicine as a significant topic of discussion. Articles about telemedicine are found to be published in journals beyond medicine and health, and extended to the fields of information management, business, and tourism and hospitality (George and Henthorne, 2009; Hu et al., 1999), suggesting telemedicine as a multidisciplinary research topic. These articles predominantly approached telemedicine as an emerging diagnostic, consultation and treatment tool of enhancing patients’ satisfaction and use intentions (Rho et al., 2014). Despite the growing research body on telemedicine, the present research pinpointed two research gaps. First, a large amount of telemedicine research has investigated the technological aspects of telemedicine (i.e. technology adoption and use intention), however, limited research focused on the role of the intangible telemedicine services (e.g. how hospitable the doctor is). Hospitality, as a significant component in service organizations, has begun to be recognized in a hospital setting (Kelly et al., 2016; Quinan and Costa Filho, 2020), yet its role and implications for telemedicine experience are less understood. Second, previous research assesses telemedicine based on either its clinical outcomes or customer satisfaction (Gustke et al., 2000; Rho et al., 2014) while overlooking the Emotional outcomes of the patients. The emotional aspect warrants investigations because people in diseased conditions often experience distress and their emotional pressure is undoubtedly heightened by the current pandemic. In addition, previous research rarely investigated the underlying mechanism for patients to reach certain outcomes.

To fill the void in prior research and to provide clearer insights for “hospitality in health care,” this research expands beyond the technological aspect of telemedicine and investigates the role of hospitable services in a health care setting; and focuses on people’s affective outcomes instead of clinical outcomes as a reflection of the hospitality culture. Given that the global pandemic makes people feel less empowered than they would under normal circumstances, the theory of empowerment (Zimmerman, 2000) was adopted as the theoretical foundation to conceptualize the empowering impact of telemedicine experiences. Empowerment theory demonstrates a framework of empowering processes and outcomes, suggesting that empowering actions or activities can lead to a sense of being empowered (Zimmerman, 2000). Because telemedicine is one of the most feasible and appropriate avenues to support vulnerable patients during this pandemic (Smith et al., 2020), the experience of using it is expected to empower people to better manage their health conditions and defend against potential health risks. Thus, the theory of empowerment was chosen to examine how telemedicine experiences empower people to deal with such difficulties. The objectives of this study were twofold:

  1. to investigate the impact of patients’ experience with telemedicine (through interacting with technology and clinicians) on their sense of empowerment (perceived competency and perceived control); and

  2. to examine the influence of empowerment on patients’ affective outcomes (i.e., anxiety and isolation reduction).

Overall, this research not only adds insights to current telemedicine literature but serves as an effort in bridging the hospitality and health care fields. The article is structured as follows: first, the theoretical underpinnings and hypotheses development are elucidated. Then, the methodology is outlined and the results are presented. The article concludes with implications for both theory development and industry practices.

2. Theoretical underpinnings and hypotheses development

2.1 Hospitality in telemedicine

Telemedicine was broadly recognized as any type of medical activity performed at a distance (Craig and Patterson, 2010, p. 6). This article focused on the video-audio based telemedicine in accordance with the current stage of technology development.

The COVID-19 outbreak has heightened the timely significance of telemedicine. Owing to the enforced restrictions on people’s mobility for health safety concerns, people are in dire need of help and support in both physical and mental sense (Jiang and Wen, 2020). Physically, the enforced quarantine measures nationwide result in both inconvenience and fear of seeing doctors face-to-face (Xiao, 2020). People with health problems alternatively seek professional advice through telemedicine. Mentally, this unprecedented time of crisis generated stress and caused potential threats to mental health (Cao et al., 2020). Recognized as a reliable health care delivery mode in face of disasters and public health emergencies (Lurie and Carr, 2018), telemedicine was recommended for its potential of reducing symptoms of post-traumatic stress disorder caused by social isolation (Leite et al., 2020). Taken together, exploring people’s experience with telemedicine during COVID-19 is both theoretically meaningful and practically timely.

As a type of health care service, telemedicine was predominantly evaluated by industry for its “utilitarian aspect” rather than the “hedonic (service) side.” Hospitality, as an important component of service, is not only beneficial to patients’ well-being but also helpful in enhancing hospital businesses (Kelly et al., 2016; Pizam, 2020; Severt et al., 2008). The call for extending hospitality to hospital patients’ experience can date back to approximately 40 years ago, when Cassee and Reuland (1983) suggested that there may be a place for hospitality in the hospital setting. A subsequent study conducted by Hepple et al. (1990) raised a concern about how hospitalization depersonalized patients and identified some critical attributes of “hospitable” hospital stay – security, physiological comfort and psychological comfort. With the increasing commercial competition in traditional non-profit-making organizations (e.g. health care), a greater emphasis on service quality has been advocated (Randall and Senior, 1994). Nonhospitality organizations are in dire need of improving customer satisfaction by applying a hospitality model in their operation processes (King, 1995). The increasing number of hospitality studies addressing this phenomenon (Kelly et al., 2016; Severt et al., 2008; Suess and Mody, 2017) is a testament to the importance of hospitality in a hospital setting.

To provide a more nuanced understanding of hospitality in telemedicine during COVID-19, the present research adopted the proposition that hospitality is a type of organizational culture, as introduced by Pizam (2020), to examine the effect of practicing a hospitality organizational culture in a health care setting. Hospitality organizational culture illustrates a strong belief that all service organizations, no matter whether they are hedonic (e.g. theme parks and hotels) or utilitarian (e.g. health care and retail), should ultimately provide exceptional service and memorable satisfactory experiences to all stakeholders. The conceptual framework of hospitality organizational culture demonstrates the relationships between its five dimensions and patients’ emotions, in which patients can gain more confidence when doctors practice the “hospitality principle,” and thereby alleviate negative feelings. The present research took the customer side where the two dimensions – patient-clinicians interactions and patient-support staff interactions – are more relevant in the context of telemedicine. We focused on the patient-clinicians interactions only because the patient-support staff interactions are not always available in people’s telemedicine experience; telemedicine patients may be directly guided to the doctor after they completed administrative processes. To provide a more holistic understanding of user experience with telemedicine, the current research included both human-technology interactions and human-human interactions in its investigation. Their respective influence on patients is discussed in the next section.

2.2 The impacts of telemedicine experiences on empowerment

2.2.1 Empowerment theory.

The rapid evolution of COVID-19 may increase people’s feeling of powerlessness, especially those who needed medical support but did not have access to a hospital or feared to go in person. Previous research found that people who experienced crisis or disasters were likely to develop an overall sense of stress and helplessness because people who have lived through a catastrophic event often felt as if they had lost control over their lives (DiRaddo and Brock, 2012). Such unusual mental pressures result in high levels of health anxiety, leading individuals to misinterpret harmless bodily sensations as signs of illness or evidence that they are infected, making people’s psychological processes different from normal times when they consult through telemedicine, and this will, in turn, unfavorably cause their irrational behaviors (Asmundson and Taylor, 2020). The empowerment model provides us with unique insights into how to stop this vicious cycle. In particular, the critical components contained in the theory (e.g. perceived control and perceived competency) can help to defer people’s felt powerlessness caused by the pandemic. Therefore, by positioning telemedicine as a “warm” remote intervention, this study adopted the empowerment theory (Zimmerman, 2000) to examine how telemedicine experience may render strength and resources to people who are more devoid of power than normal times, for them to better cope with the difficult situations they confront in the pandemic.

The theory of empowerment conceptualizes both the empowering process (e.g. where people develop skills to obtain more resources and become more independent) and outcomes (e.g. the consequences/advantages of individuals’ efforts to gain greater control) (Zimmerman, 2000). In the current research, the authors conceptualized that the experience of using telemedicine service is akin to an empowering process, where people could gain higher competence and control as a result of their interactions with both telemedicine technology (human-technology interaction) and telemedicine personnel (human-human interactions). The perceived competence denotes self-efficacy with respect to the demands of the role and the perceived control refers to beliefs about autonomy and decision-making, both of which have been widely accepted as two important dimensions of empowerment (Menon, 2001, 2002).

2.2.2 The impact of human-technology interactions on perceived competence and control.

Previous research of empowerment in health care suggested that the perceived competence relied on patients’ ability to acquire useful knowledge, manage minor ailments, seek specialized medical assistance and keep a healthy lifestyle (Menon, 2002). The following four factors, mostly derived from the technology acceptance model (TAM), were chosen as predictors of perceived competence in the context of telemedicine because they helped enhance patients’ health management capabilities from the technology side. Although previous literature has acknowledged that TAM can predict people’s technology-related attitudes and use intentions (Wu and Chen, 2017), this study examines such relationships in telemedicine within a global pandemic context. That is to say, this research is beyond confirming the existing knowledge from TAM but tackles a situation where people are involuntarily into using a technology as a result of the enforced quarantine and social distancing practices.

First, perceived usefulness (PU), originally defined as “the degree to which a person believes that using a particular system would enhance his or her job performance” (Davis, 1989, p. 320), was known as the extent to which a person believed that the telemedicine is useful in the present context (Hu et al., 1999; Rho et al., 2014). According to Hu et al. (1999), PU can be understood as the degree to which patients felt telemedicine technology is useful to improve their efficiency of health management. The more useful the patients perceive the telemedicine technology, the more competence they may obtain to manage their health conditions.

Perceived ease of use (PEOU) was recognized as another predictor of perceived competence. Perceived ease of use is often referred as “the degree to which a person believes that using a particular system would be free of effort” (Davis, 1989, p. 320). Same as PU, PEOU is considered as a critical factor in telemedicine service acceptance model (Huang, 2011; Rho et al., 2014). In Huang’s (2011) study on the acceptance of telemedicine by senior citizens, PEOU was found as a significant determinant when predicting the technology adoption. In the context of this study, PEOU is thus defined as the degree of ease that patients associate with their use of telemedicine service. This research posited that the more comfortable and easier people feel when using telemedicine technology, the more likely they have higher capabilities of managing their health condition.

Convenience and technical adequacy were adopted as another two factors in the domain of human-technology interactions. The construct of convenience (i.e. in terms of time and place when using technology) has been widely studied in the extended TAM model (Chang et al., 2012; Yoon and Kim, 2007). Telemedicine increases the opportunities for patients to obtain medical support without being co-present in the same physical environment, particularly when social isolation is needed. The more convenient it is for patients to see a doctor virtually via telemedicine, the more likely patients perceive they have the capabilities to better maintain health during the pandemic. Thus, convenience of telemedicine was proposed as an important predictor of patients’ perceived competence. Technical adequacy refers to the audio clarity and image resolution and has been recognized as the most important factor in a successful telemedicine encounter (LeRouge et al., 2015). This research proposed that when patients found the telemedicine system was easy to access, the audio clarity and the image resolution was good, they could feel greater competence in managing their health situation because the telemedicine made it easier for them to receive health-related advice.

Based on the discussion above, H1a-H1d were formulated as follows:

H1.

(a) Perceived usefulness (PU), (b) perceived ease of use (PEOU), (c) convenience, and (d) technical adequacy in telemedicine technology will have a positive impact on patients’ perceived competence.

Perceived control refers to the belief that one has the autonomy to make one’s own determinations (Wallston et al., 1987). The literature of empowerment in health care has also delineated that the perceived control depends on the level of access and quality of encounter when individuals need medical assistance (Menon, 2002). Based on the definitions, perceived ease of use (PEOU; Davis, 1989; Rho et al., 2014) and convenience (Chang et al., 2012; Yoon and Kim, 2007) can lower the threshold of accessing telemedicine; making this technology handier. Perceived usefulness and technical adequacy could influence the quality of a telemedicine service encounter because they describe the extent to which patients can productively and clearly receive the service content. Therefore, this research put forward H2a-H2d:

H2.

(a) Perceived usefulness (PU), (b) perceived ease of use (PEOU), (c) convenience and (d) technical adequacy in telemedicine technology will have a positive impact on patients’ perceived control.

2.2.3 The impact of human-human interactions on perceived competence and control.

Health care is not only an industry that cures people’s discomfort but also a place that provides caring and warmth to their customers (Pizam, 2020; Severt et al., 2008). Telemedicine, as a unique service model of health care, is no exception. To acknowledge the relevance and significance of the behaviors a physician displays when interacting with a patient, the current study adopted the SERVQUAL model to measure the interactions between patients and health providers. SERVQUAL was widely used to evaluate customers’ assessments of service quality (Parasuraman et al., 1988) and has been applied to evaluate hospitals or health care organizations (Büyüközkan et al., 2011; Wu and Hsieh, 2012), especially in telemedicine research (Yin et al., 2016). Considering the context of this research, the authors selected four human-human dimensions introduced in the SERVQUAL model (reliability, responsiveness, assurance and empathy) to examine their impacts on empowerment.

Prior literature about empowerment in health care has suggested patient-physician interactions as a source of patient empowerment (Ouschan et al., 2006). When interacting with health providers, patients feel more competent if they believe they can better manage their health condition (Menon, 2002). Reliability in a health care context denotes the trustworthiness and accurateness patients perceive during their interaction with health providers (Wu and Hsieh, 2012; Yin et al., 2016). When the doctor can provide reliable health-related information, offer trustworthy suggestions and address patients’ concerns during a video telemedicine consultation, patients are more likely to feel competent because the experience enhances their knowledge to understand their health situation. Responsiveness in a health care context often describes the efficiency of doctors’ reactions to patients’ requests (Büyüközkan et al., 2011; Wu and Hsieh, 2012). Doctors’ prompt response to patients’ health-related questions during a video telemedicine appointment can increase perceived competence because the experience enhances the patient’s confidence in handling his/her health concerns in a timely manner with the assistance of professionals.

Assurance is defined as the feeling of safety and courtesy patients perceive based on their interactions with health service providers (Büyüközkan et al., 2011; Yin et al., 2016). In this research, the safer patients feel in their interactions with the doctor, and the more friendly, courteous and warm the doctor appears, the more likely patients feel competent in their ability to learn the truth of their health condition. Empathy refers to doctors’ sympathy for patients’ feelings and opinions (Wu and Hsieh, 2012; Yin et al., 2016). During a video telemedicine consultation, when the doctor was perceived to have the patient’s best interest at heart and give personal attention to one’s feelings and opinions, the more likely the patient would believe that he/she could better deal with the current discomfort. Taken together, all of the four factors were posited to empower patients to believe that they have the knowledge and capabilities to better handle their health condition. Therefore, H3a-H3d were proposed as follows:

H3.

(a) Reliability, (b) responsiveness, (c) assurance, and (d) empathy demonstrated by the doctor during a telemedicine consultation will have a positive impact on patients’ perceived competence.

People tend to feel a higher sense of control when they have more choices (Hui and Bateson, 1991). In this study, when doctors provided more trustworthy information and responded to patients’ questions and concerns more quickly, the patients are likely to perceive they have more options to handle their discomfort promptly. Therefore, the reliability and responsiveness (Büyüközkan et al., 2011; Yin et al., 2016) demonstrated by a doctor during a video consultation can increase the patients’ perceived control over their health condition.

A high-quality service experience that patients have with health care providers could also contribute to a sense of control (Menon, 2002). Suess and Mody (2018) found that a hotel-like hospital environment can foster patients’ sense of control because the “patient-friendly” design gives them more rights to make decisions. In a telemedicine setting, service quality is largely determined by patients’ interactions with doctors. When the doctors are friendly and courteous (i.e. assurance) as well as paying personal attention to patients’ feelings and concerns (i.e. empathy), patients may think they can use more resources to cope with the difficulties, and ultimately, feel more control over their health condition. Therefore, the authors put forwarded H4a-H4d:

H4.

(a) Reliability, (b) responsiveness, (c) assurance, and (d) empathy demonstrated by the doctor during a telemedicine consultation will have a positive impact on patients’ perceived control.

2.3 The impacts of empowerment on emotional outcomes

The empowered outcomes are defined as the consequences gained through the empowering process (Zimmerman, 2000). Under the COVID-19 backdrop, the present research focused on people’s emotional responses considering the enormous impact the pandemic has exerted on people’s mental stress (Li et al., 2020; Roy et al., 2020; Zhou et al., 2020). Feeling of isolation is one of the most widely spread emotions at this unprecedented time because of the requested quarantine and social distancing practices in the USA. As a result, people may receive less access to support from family and friends and less regular medical support especially for those who were infected or at risks (Chen, 2020; Zhou et al., 2020).

Previous researchers have suggested the relationship between perceived competence and isolation among less empowered people; they found that individuals who do not have enough competence or think they do not have adequate capabilities to handle stressful situations feel a greater level of isolation (Clinton and Anderson, 1999; Shapiro et al., 2003). On the contrary, as patients gained greater competence from their experience with telemedicine, their feeling of isolation could be reduced. Social psychologists have also found that people with a low sense of control usually feel alienated and isolated (Seeman, 1983). Powerless people often feel isolated when they are excluded from decision-making (Kuypers and Bengtson, 1973), but the sense of control can help them deter such feeling in frustrating situations (Collins, 2001). In the context of this research, the more capabilities patients gained through telemedicine to manage their health condition and the more choices they have in face of their discomfort, the less isolated they may feel. H5a and H5b were thus formulated as follows:

H5.

(a) Perceived competence and (b) perceived control patients have gained during a telemedicine consultation will have a positive impact on their isolation reduction.

In addition, previous research in psychology provided evidence that the perception of competence can predict people’s emotional states such as anxiety, loneliness and depression (Rubin and Mills, 1988). People who have less competence tend to have a higher level of anxiety, especially when they fail to obtain appropriate skills to cope with difficulties (Affrunti and Ginsburg, 2012). The self-determined theory indicated that perceived control could also influence people’s anxiety levels (Black and Deci, 2000); when people think they have the autonomy to choose or make decisions, a reduction of tension and anxiety is likely to occur (Deci and Ryan, 2000). By the same token, patients would feel less tense and anxious as they develop more confidence in and control of handling their discomfort by using telemedicine. H6a and H6b were formulated accordingly:

H6.

(a) Perceived competence and (b) perceived control patients have gained during a telemedicine consultation will have a positive impact on their anxiety reduction.

The conceptual framework is presented in Figure 1.

3. Methodology

3.1 Procedure and sample

Prior studies provided well-established scales to evaluate individuals’ telemedicine experience and empowerment outcomes. Thus, this research adopted a quantitative methodology for hypotheses testing by using an online questionnaire. Participants were recruited from Amazon Mechanical Turk, which is a crowd-sourcing platform that recruits workers with diverse backgrounds to complete surveys. Buhrmester et al. (2011) and Paolacci et al. (2010) examined the data quality obtained through MTurk and found that the data from MTurk were as reliable as that of online panels. Our survey was posted on MTurk from May 30th to June 2nd in 2020.

A cover page was presented to introduce the purpose of this research. Following the cover page, a brief explanation of telemedicine was presented. This research targeted individuals who had the video-based virtual consultation (e.g. a doctor’s appointment via secured video portals) since February 2020 (it is the time when the community transmission of COVID-19 became apparent in the USA). As such, people who did not meet the criteria were screened out. Two attention-check questions were included in the survey too. Participants who failed to choose the right item(s) in either question were removed from the analyses.

3.2 Questionnaire and measurement scales

The questionnaire consists of four sections. All measurement scales were adapted from previous research in telemedicine, service and information technology, which were further modified to highlight the telemedicine context during COVID-19. Prior to the main questionnaire, all participants were instructed to recall their most recent use of telemedicine during COVID-19 and the length of that experience.

The first section collected information concerning participants’ telemedicine using experience. Perceived usefulness was measured via four items adapted from Davis (1989) and Hu et al. (1999) (Cronbach’s α = 0.845). Perceived ease of use was captured using four items also adapted from Davis (1989) and Hu et al. (1999) (Cronbach’s α = 0.714). To measure convenience, three items were adapted from Ozturk et al. (2016) and Yoon and Kim (2007) (Cronbach’s α = 0.811). Technical adequacy was measured via three items adapted from Aladwani and Palvia (2002) and LeRouge (2015) (Cronbach’s α = 0.755). As for human-human interaction, the researchers focused on patience’s interaction with the doctor. Reliability was measured via three items adapted from Babakus and Mangold (1992) and Yin et al. (2016) (Cronbach’s α = 0.776). Responsiveness of the doctor was measured by three items adapted from Babakus and Mangold (1992) and Lam (1997) (Cronbach’s α = 0.734). A scale from Babakus and Mangold (1992) was used to measure assurance with three items (Cronbach’s α = 0.842). The last variable, empathy, was captured via three items adapted from Babakus and Mangold (1992) and Yin et al. (2016) (Cronbach’s α = 0.808).

The second section included questions specific to the two dimensions of empowerment: perceived competence and perceived control. To measure perceived competence, three items adapted from Menon (2001) were used (Cronbach’s α = 0.824). Perceived control was measured by using four items adapted from Menon (2001) and Moser et al. (2009) (Cronbach’s α = 0.804).

In the third section, isolation reduction and anxiety reduction were measured as the emotional outcomes of empowerment. Isolation reduction was measured via three items adapted from Hawthorne (2006) (Cronbach’s α = 0.770). Anxiety reduction was measured via three items adapted from Moorey et al. (1991) (Cronbach’s α = 0.830) (Appendix). Respondents’ demographic information was collected at the end.

In addition, perceived severity of the patient’s health condition and urgency of the appointment were measured via two single-item scales to serve as control variables, given that patients’ sense of empowerment and emotional responses may vary with the severity and urgency of their health-related problems. Participants’ prior experience with telemedicine and the length of the recalled appointment were controlled too. All items were measured on a seven-point Likert-type scale (1 = strongly disagree; 7 = strongly agree).

3.3 Data analysis

Participants who failed the attention check, who had identical answers for a large number of items or who missed any single question were removed from the analyses. A total of 499 completed surveys were collected. After eliminating the unqualified ones, 409 usable responses were kept for further analysis. Stepwise multiple regression and simple linear regression were used for data analysis.

4. Results

4.1 Participants profile

The demographic information of the participants is summarized in Table 1. Approximately 43.8% of respondents were female and 51.9% are 26–40 years of age. About half were married (57.2%) and held a four-year bachelor’s degree (51.8%). The majority of the participants were Caucasians (62.6%). Participants demonstrated a diverse range of occupations as well.

4.2 Hypotheses testing

To test the impact of human-technology interaction and human-human interaction on empowerment, four stepwise multiple regression analyses were performed. Stepwise regression is a hybrid procedure that combines forward selection and backward elimination, which is a good model building method (Wang et al., 2005). This method was selected given the exploratory nature of the present research in differentiating the contribution of each individual variable (Tsang et al., 2004).

The first predicted model (i.e. the impact of human-technology interaction on perceived competence) contained three of the four predictors (i.e. PU, convenience and technical adequacy) and was reached in four steps. PEOU was excluded. Thus, H1b was not supported. The model was statistically significant (F(4,404) = 81.11, p < 0.001) and accounted for approximately 45% of the variance of perceived competence (R2 = 0.445, Adjusted R2 = 0.440). Perceived competence was primarily predicted by PU, followed by convenience and technical adequacy. Next, the same set of variables were used in a stepwise multiple regression to predict perceived control. Three predictors were retained (i.e. PU, PEOU and convenience) and were reached in four steps. Technical adequacy was excluded from the model. Thus, H2d was not supported. The model was statistically significant (F(4,404) = 121.86, p <* 0.001) and accounted for approximately 55% of the variance of perceived control (R2 = 0.547, Adjusted R2 = 0.542). PU received the strongest weight in the model again, followed by convenience and PEOU.

Similarly, two stepwise multiple regression analyses were employed to test the impact of human-human interaction on empowerment. The first predicted model contained three predictors (i.e. reliability, empathy and responsiveness) and was reached in five steps. Assurance was excluded. Thus, H3c was not supported. This model was statistically significant (F(5,403) = 59.995, p < 0.001) and accounted for approximately 43% of the variance of presence (R2 = 0.427, Adjusted R2 = 0.420). Reliability was the strongest predictor, followed by Empathy and Responsiveness. Moreover, all four predictors entered the last predicted model (i.e. the impact of human-human interaction on Perceived Control). Thus, H4a, H4b, H4c and H4d were supported. The model was statistically significant (F(4,404) = 121.86, p <* 0.001) and accounted for approximately 53% of the variance of presence (R2 = 0.532, Adjusted R2 = 0.527). Among those four variables, responsiveness received the strongest weight, whereas empathy received the lowest weight (Table 2).

Last, two simple linear regressions were performed to predict the impact of empowerment on isolation reduction and anxiety reduction. Results indicated that perceived competence and perceived control were significant predictors of isolation reduction (perceived competence: β = 0.142, t = 2.416, p < 0.05; perceived control: β = 0.447, t = 7.489, p <* 0.001; R2 = 0.335) and anxiety reduction (perceived competence: β = 0.417, t = 7.434, p < 0.001; perceived control: β = 0.241, t = 4.239, p <* 0.001; R2 = 0.395). Thus, H5a, H5b, H6a and H6b were supported. Table 3 was prepared to summarize the results of hypotheses testing.

4.3 Sensitivity test

Further, we conducted a sensitivity test by including demographic variables (i.e. age, gender, etc.) into the model. Results indicated that the effect of human-human factors on perceived competence remained consistent. However, age turned out to be a significant factor for the rest of the models. Specifically, for the effect of human-technology factors on perceived competence, the predicted model contained three factors: PU (b = 0.493, t = 8.625, p < 0.001), convenience (b = 0.223, t = 3.859, p < 0.001) and age (b = 0.103, t = 2.126, p < 0.05). PEOU and technique adequacy were excluded. The second predicted model examined the effect of the same factors on perceived control and contained four significant factors: PU (b = 0.303, t = 6.283, p < 0.001), convenience (b = 0.245, t = 4.939, p < 0.001), PEOU (b = 0.198, t = 4.695, p < 0.001) and age (b = 0.112, t = 2.889, p < 0.01). Technique adequacy was excluded. Further, the effect of human-human interactions on perceived control was examined. The predicted model contained five variables: responsiveness (b = 0.342, t = 6.663, p < 0.001), reliability (b = 0.178, t = 3.197, p < 0.01), assurance (b = 0.115, t = 2.128, p < 0.05), age (b = 0.098, t = 2.486, p < 0.05) and empathy (b = 0.114, t = 2.199, p < 0.05).

5. Discussions

5.1 Conclusions

Telemedicine begets a new form of involvement from the patients. They assume active roles not only in communicating with their medical providers, as they do in face-to-face visits but also in using the technology. However, it is still unclear whether technological interfaces provide patients with a sense of empowerment to influence and manage their health condition. Mick and Fournier (1998) pointed out that consumers commonly experienced “paradoxes of technologies”: technology can facilitate a sense of control and feeling of competence. It can also lead to chaos and a sense of ineptitude when it presents technical complexity and problems for users. Due to the pandemic situation, telemedicine technology has the potential to empower people to manage their health and alleviate their anxiety and isolation. On the other side of the coin, it can breed the opposite condition of upheaval and emotional stress.

Our study results suggest that telemedicine technology significantly empowers patients during the current pandemic situation by influencing the sense of control and competence in managing their health conditions. Overall, respondents rated high in telemedicine technology’s perceived usefulness (M = 5.58), PEOU (M = 5.48), convenience (M = 5.78) and technological adequacy (M = 5.73). Among these four antecedents, perceived usefulness is the most salient factor in influencing patients’ perceived competence and perceived control. These findings indicate that patients are relatively “pragmatic,” and they focus on using the technology to fill their needs of seeking medical assistance. Since convenience can be perceived as telemedicine’s “useful” benefits that allow patients access to medical assistance at convenient time and location, it is reasonable that the convenience factor is also a significant predictor for patients’ perceived competence and control.

In addition, technical adequacy is found to significantly affect patients’ perceived competence in managing their health. Technical quality such as technological sophistication, audio clarity and high image resolution enables both doctors and patients to receive clearer and more accurate health-related content. However, this study disconfirms TAM partially: PEOU does not significantly contribute to patients’ sense of competence. The finding might reflect the unique characteristics of the user population in this study. The sample has a high level of education (72.4% respondents have a Bachelor or Master degree) and high perceived computer efficacy (M = 5.77). They can assimilate to the new technology quickly and become familiar with the technology easily. As a result, they might not consider PEOU a critical issue for them to consider in affecting their competence.

On the other hand, PEOU was found as a significant determinant of patients’ perceived control in addition to perceived usefulness and convenience. Seeking health care service during a pandemic can be enormously stressful and the PEOU in technology certainly prevents adding obstacles and complexity, thus contributing to patients’ perceived control in their situation. Different from previous studies, technical adequacy turned out to have no significant impact on patients’ perceived control, indicating that patients might view technical features as out of their control. Similar to LeRogue et al.’s (2015) finding, doctors and patients should be able to focus on their health care, rather than figuring out technology. Technological quality needs to be managed by equipment design and organization management, mostly prior to patients-clinicians encounters.

The study results also demonstrate that attributes with respect to human-human interactions play significant roles in affecting patients’ perceived competence and control. Doctors’ reliability, responsiveness and empathy significantly affect patients’ perceived competence and control. For a successful telemedicine interaction, not only patients’ medical goals need to be met, but also their expressive and emotional needs (LeRouge et al., 2012). Our study results are consistent with that conclusion. Patients’ perceived competence and control hinge on doctors’ understanding of their medical needs and communicating trustworthy diagnosis-related information (i.e. reliability), listening attentively to their personal feelings and concerns (i.e. empathy), and addressing their medical and expressive needs in a timely manner (i.e. responsiveness). While assurance, as defined as the feeling of safety and courtesy patients perceive during their communication with the doctors, significantly impacted their perceived control and did not affect their perceived competence. In other words, doctors’ pleasant demeanor is certainly appreciated by patients as it facilitates stressful medical interactions. However, patients’ sense of competence in managing their health condition relies more on their doctors’ actions of listening to their concerns and communicating trustworthy solutions rather than friendly manners and bonding. Additional sensitivity test results show that age is the only demographic variable that significantly impacts the weight of human-technology interactions and human-human interactions on patients’ sense of empowerment. Overall, our study findings suggest that the older patients are, the more likely they will feel empowered through a smooth technological experience and hospitable interactions with their doctors. This is a meaningful finding considering the effects of the current COVID-19 pandemic. In general, older people are susceptible for psychological distress due to increasing physical decline and social isolation as they age. The current COVID-19 pandemic has heightened their risk for depression and anxiety (Armitage and Nellums, 2020). Our study shows that telemedicine has larger marginal effects on their sense of empowerment as patients increase with age.

Last but not the least, our study results also point out that patients’ sense of empowerment (i.e. perceived competence and control) leads to meaningful emotional outcomes. It significantly reduces patients’ anxiety and sense of isolation in managing their health condition in a stressful pandemic situation. Patient empowerment has only been investigated in health care literature, and most of them are limited to conceptual discussions (Ben Ayed and El Aoud, 2017; Menon, 2002). This study empirically shows that empowerment is a potential psychological mechanism that can help patients manage their health condition and health-related emotions in the context of telemedicine.

5.2 Theoretical implications

This study contributes to the existing literature on hospitality and telemedicine in meaningful and insightful ways. For hospitality literature, this study represents one of the few studies that push the boundary of redefining and reconceptualizing hospitality into other “non-hedonic” and “dark” service sectors including health care, senior living and funeral homes (Filimonau and Brown, 2018; Kelly et al., 2016; Pizam, 2014, 2020; Severt et al., 2008; Suess and Mody, 2017). Historically, hospitality embodies settings where guests voluntarily seek pleasure, relaxation and entertainment while traveling for leisure or business (Severt et al., 2008). Hotels, restaurants and bars are the traditional research sectors. The recent scientific discourse in hospitality, however, has expanded beyond its industry boundary to explore the theoretical underpinning of hospitality service (Filimonau and Brown, 2018). Existing literature has reconceptualized hospitality service based on exceptional quality customer services (Filimonau and Brown, 2018), memorable experience (Sipe and Testa, 2018), experiencescape and aesthetic architectural appeal (Pizam and Tasci, 2019; Suess and Mody, 2017) and organizational culture (Pizam, 2020).

The evolution of hospitality theory enables its innovative practices in other fields that are not traditionally considered in the realm of hospitality. Take health care for instance. A hospital experience often involves patients’ involuntary inhabitants, uncomfortable situations, unpleasant emotion and privacy disclosure which would not be seen in the hedonic hospitality settings. It is such unique characteristics in medicine, as Severt et al. (2008) argued, that magnify the importance of hospitality. Our study builds on this innovative approach to hospitality management and recontextualizes hospitality in telemedicine. Adapting from Pizam’s (2020) multidimensional conceptualization of hospitality in health care, the study includes the factors related to human-human interactions (patients-clinicians interaction specifically in this study), in addition to the technological aspects. The results provide strong evidence that hospitable service from doctors is critically important in developing patients’ sense of empowerment in managing their own health condition through telemedicine, connoting the great potential of how the “culture of hospitality” can feedback to other sectors of the service economy.

For the health care literature, this study applies the empowerment theory to describe the psychological process for telemedicine patients to successfully cope with their health conditions and emotions. While existing literature on telemedicine mostly shows positive outcomes such as high levels of satisfaction (Gustke et al., 2000; Rho et al., 2014), it does not explain the underlying psychological mechanism. This study demonstrates an innovative theoretical angle on how telemedicine empowers people in managing their health. In addition, unlike previous telemedicine literature that concentrates on telemedicine’s clinical outcomes, technological application and economic value, this study focuses on patients’ emotional outcomes from their telemedicine experience. It is important to investigate the emotional aspect because of the pressure commonly existing in health care interactions (Severt et al., 2008). The current COVID-19 pandemic exerts additional stress on people in addressing their health care needs (Cao et al., 2020). Telemedicine not only provides safe and needed access to medical care but also, as indicated by this study, plays a positive role in alleviating a people’s anxiety and sense of isolation. In addition, the pandemic has potentially forced people to use telemedicine technology involuntarily; the study further expands the TAM model by showing that human-technology interaction factors can be essential in influencing patients’ telemedicine outcomes in situations when they have no choice but to use the technology.

5.3 Practical implications

From a practical perspective, this study helps hospitality practitioners and academic programs to identify an innovative field to expand related training and educational programs. The COVID-19 pandemic has significantly curtailed consumer demand and dampened the employment prospect of hospitality graduates. Health care sector, however, rises as a promising field for hospitality businesses to explore revenue opportunities in providing training programs related to service culture. For hospitality education institutions, the health care sector also presents job replacement opportunities for hospitality graduates in customer service positions. More importantly, certificate and continuing education programs for doctors on “hospitality in health care” can expand hospitality programs into a brand-new field. In fact, some medical schools have already started collaborating with other disciplines (e.g. business schools and hospitality schools) to develop innovative curricular for building students’ patient-centric attitudes and skills (Greenspun et al., 2016). Initiatives like these received empirical support from the present research. Our study shows that “bed-side” manners from doctors do matter. More specifically, patients expect doctors to meet both their medical and emotional needs – providing reliable diagnostic information, listening to their concerns carefully and addressing their needs promptly. In this aspect, our study identifies some core competencies and skillsets for designing the “hospitality in health care” training programs.

For medical practitioners, this study can help them in developing and implementing successful telemedicine practices. Technology wise, perceived usefulness and convenience of telemedicine technology help build people’s perceived competence and control in managing their health conditions. It is widely endorsed that empowerment exerts significant influences on people’s behavioral and emotional self-management (Ben Ayed and El Aoud, 2017). Due to this connection, medical providers need to educate and clearly communicate with patients on telemedicine’s benefits in achieving their health-management goals. Telemedicine should not be passively positioned as the only alternative under the current unfortunate circumstances. Instead, the useful benefits of telemedicine should be directed and solidified to patients before and after their telemedicine experience.

5.4 Limitations and future research

Like any other research, our study also has limitations. First, this study adopted a critical incident technique (i.e. respondents to answer the questionnaire based on their most recent use of telemedicine during COVID-19). Although this technique is widely used in experience research, potential memory bias cannot be fully ruled out. Researchers are encouraged to consider other qualitative research methods in the future (e.g. focus groups and interviews) to better understand patients’ emotional responses.

Second, this study shows that telemedicine can empower people to manage their health conditions and cope with their emotions during the current pandemic. Our empowerment model on telemedicine is contended to be valid beyond the current backdrop. It is argued that the outbreak serves as a catalyst for people to adopt telemedicine, but the psychological process of empowerment people experience from telemedicine should be in effect regardless of the circumstantial restrictions. Future studies are encouraged to test our empowerment model in more contexts to identify potential contingencies.

Third, this study uses one major dimension (patients-clinicians interactions) from Pizam’s (2020) conceptualization of hospitality as an organizational culture. The study contends that telemedicine usually involves less time and interactions with support staff, and doctors are the ones who play a major role in shaping the patient’s telemedicine experience. Therefore, the study focuses on the patient-clinicians interaction for the purpose of model parsimony. Further studies are encouraged to explore the roles of support staff versus doctors and examine their relative importance in empowering patients through telemedicine.

Finally, to increase the generalizability of this model, future studies are suggested to examine the effects of patients’ characteristics on the validity of the models. For example, the severity of patients’ health problems and their previous offline relationships with doctors may influence the weight of human-technology interactions and human-human interactions on people’s sense of empowerment.

Figures

Proposed conceptual framework

Figure 1.

Proposed conceptual framework

Participants profile (N = 409)

Characteristics (%)
Gender
Male
Female
Prefer not to disclose
55.5
43.8
0.7
Age
18–25 years old
26–40
41–60
Above 60
Prefer not to disclose
13.9
51.9
29.1
4.4
0.7
Marriage
Single
Married
Other
Prefer not to disclose
39.1
57.2
2.5
1.2
Ethnicity
Asian
Black/African
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Others
Prefer not to disclose
12.5
11.5
62.6
7.6
1.9
0.5
2.7
0.7
Education
High school or less
College or Associate degree
Bachelor’s degree
Master’s degree
Doctoral degree
Other
Prefer not to disclose
8.8
13.7
51.8
20.6
3.9
0.5
0.7
Occupation
Student
Employed for salary/wages
Self-employed
Out of work
Military
Retired
Other
Prefer not to disclose
3.7
71.1
14.5
6.1
0.2
2.0
0.7
1.7

Stepwise multiple regression results

Model b SE-b Beta t sig sr2
The effect of human-technology interaction on Perceived competence
Constant 0.836 0.273 3.062 <0.01
PU 0.461 0.058 0.446 7.921 <0.001 0.086
Convenience 0.165 0.066 0.158 2.491 <0.05 0.008
Technical 0.138 0.063 0.126 2.208 <0.05 0.007
The effect of human-technology interaction on Perceived control
Constant 1.535 0.207 7.399 <0.001
PU 0.295 0.048 0.319 6.102 <0.001 0.042
Convenience 0.254 0.050 0.272 5.127 <0.001 0.030
PEOU 0.194 0.017 0.017 4.604 <0.001 0.024
The effect of human-human interaction on Perceived competence
Constant 0.657 0.288 2.285 <0.05
Reliability 0.385 0.068 0.362 5.669 <0.001 0.046
Empathy 0.205 0.061 0.197 3.376 <0.01 0.016
Responsiveness 0.178 0.061 0.171 2.926 <0.01 0.012
The effect of human-human interaction on Perceived control
Constant 1.264 0.206 6.131 <0.001
Responsiveness 0.342 0.052 0.367 6.591 <0.001 0.050
Reliability 0.186 0.056 0.197 3.321 <0.01 0.013
Assurance 0.118 0.054 0.129 2.175 <0.05 0.005
Empathy 0.110 0.052 0.118 2.096 <0.05 0.005
Note:

sr2 is the squared semi-partial correlation

A summary of results of hypotheses testing

Path relationships Results
H1a: Perceived usefulness Perceived competence Supported
H1b: Perceived ease of use Perceived competence Not supported
H1c: Convenience Perceived competence Supported
H1d: Technical adequacy Perceived competence Supported
H2a: Perceived usefulness Perceived control Supported
H2b: Perceived ease of use Perceived control Supported
H2c: Convenience Perceived control Supported
H2d: Technical adequacy Perceived control Not supported
H3a: Reliability Perceived competence Supported
H3b: Responsiveness Perceived competence Supported
H3c: Assurance Perceived competence Not supported
H3d: Empathy Perceived competence Supported
H4a: Reliability Perceived control Supported
H4b: Responsiveness Perceived control Supported
H4c: Assurance Perceived control Supported
H4d: Empathy Perceived control Supported
H5a: Perceived competence Isolation reduction Supported
H5b: Perceived control Isolation reduction Supported
H6a: Perceived competence Anxiety reduction Supported
H6b: Perceived control Anxiety reduction Supported

Measures of variables

Variable Measurement scales
Human-technology interaction
Perceived usefulness
(Davis, 1989; Hu et al., 1999)
PU1: It can enable me to receive my health care service quickly
PU2: It can improve my productivity of health management
PU3: It can make my health management easier
PU4: It is useful/advantageous
Perceived ease of use
(Davis, 1989; Hu et al., 1999)
PEOU1: It is easy to learn
PEOU2: It is easy to use
PEOU3: Using this telemedicine technology was of little difficulty
PEOU4: It did not require me much effort to learn
Convenience
(Ozturk et al., 2016; Yoon and Kim, 2007)
CV1: I can see my doctor conveniently from home
CV2: I can have my doctor appointment at a convenient time
CV3: It is convenient for me to receive my health care service
Technical adequacy
(Aladwani and Palvia, 2002; LeRouge, 2015)
TA1: The telemedicine system (e.g. online portal and/or video meeting) was easy to access
TA2: The audio clarity was good
TA3: The image resolution was good
Human-human interaction
Reliability
(Babakus and Mangold, 1992; Yin et al., 2016)
RL1: The doctor showed/expressed concern about my needs (e.g. emotional needs and needs for health-related information)
RL2: The doctor addressed my health-related problems accurately
RL3: The doctor provided trustworthy and reliable suggestions for my discomfort
Responsiveness
(Babakus and Mangold, 1992; Lam, 1997)
RP1: The doctor provided health consultation in a timely manner
RP2: The doctor quickly addressed my health-related questions
RP3: The doctor never too busy to respond to my health-related requests
Assurance
(Babakus and Mangold, 1992)
AS1: I felt safe in the interactions with doctor
AS2: I felt warm and easy when interacting with the doctor
AS3: I felt the doctor was friendly and courteous
Empathy
(Babakus and Mangold, 1992; Yin et al., 2016)
EP1: The doctor gave me personal attention during the consultation
EP2: The doctor paid attention to my feelings and opinions
EP3: The doctor had my best interests at heart
Two empowerment dimensions
Perceived competence
(Menon, 2001)
CP1: I have more competence to manage my health condition during this special time
CP2: I have more knowledge and abilities to manage my health condition during this special time
CP3: I have more capabilities required to manage my health condition during this special time
Perceived control
(Menon, 2001; Moser et al., 2009)
CT1: Even though I can’t go out, I can still find help when my health condition is bad
CT2: I can do more things myself to cope with the current situation when my health condition is bad
CT3: I can influence the way my health condition is managed
CT4: I can influence decisions related to my health condition
Emotional responses
Isolation reduction
(Hawthorne, 2006)
IR1: I felt less isolated from the society because I can be treated
IR2: I felt less separated from other people because I can reach out to medical support
IR3: I felt it was easier to get in touch with doctors when I needed to because of the telemedicine technology
Anxiety reduction
(Moorey et al., 1991; Snaith, 2003)
AR1: I felt less tense of my health condition
AR2: I had fewer worrying thoughts going through my mind about my health condition
AR3: I felt something awful are about to happen about my health condition (delete)
AR4: I felt more relaxed

Appendix

Table AI

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Corresponding author

Yusi Cheng can be contacted at: yusicheng@knights.ucf.edu

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