We present research examining the role of organizational justice in the perceptions of
patients visiting the urgent care department of a hospital. Patients’ perceptions of uncertainty were found to mediate the relationship between waiting time and satisfaction and
between waiting time and anger. Further, waiting time was significantly negatively related to procedural justice perceptions. Procedural justice perceptions were significantly
positively related to distributive justice perceptions, which in turn, were significantly positively associated with satisfaction. We discuss the implications concerning managing
the attitudes of waiting customers.
Waiting is generally considered a pervasive and arduous element of
most customer service situations (Taylor, 1994). For many customers,
waiting for service is viewed as a negative experience (Scotland,
1991). Thus, improving the speed at which services are delivered is
increasingly becoming critical to service organizations (Katz, Larson,
and Larson, 1991).
Hospitals have traditionally focused on delivering quality medial care
according to some set of internally established standards. However,
today it is recognized that patients’ quality perceptions are equally
important. At the same time, urgent care department overcrowding has
become a national concern. As a result, increasing numbers of
patients are experiencing prolonged waiting times, lower satisfaction,
and delays in treating painful afflictions (Lowe, Bindman, Ulrich, Norman, Scaletta, Keane, Washington, and Grumbach, 1994). Given
there are no indications that overcrowding will decrease, researchers
have begun to recognize that it is important to better understand perceptions of patients waiting for treatment (e.g., Dansky and Miles,
1997). The procedure used to determine which patients see a doctor
first, which have to wait, and how long they wait is called "triage"
(George, Read, Westlake, Williams, Pritty, and Fraser-Moodie, 1993;
Lowe et al., 1994; Llewellyn, 1992; Mallett and Woolwich, 1990; Teres,
1993; Yurt, 1992). The current study examines patients’ perceptions of
the triage process in an urgent care department of a hospital in rural
Research in one area of the service sector, the airline industry, offers
some basis from which to make predictions. In a study of airline passengers waiting for delayed flights, Taylor (1994) found that delays
were positively related to feelings of uncertainty and anger. She also
found that uncertainty led to anger, and perceptions of anger led to
lower overall service satisfaction levels. One purpose of the current
study is to extend Taylor’s (1994) research to patients waiting for medical treatment. Specifically, we examine the effect of actual waiting time
on the uncertainty and anger perceptions of patients waiting for medical treatment in the urgent care department of a hospital. Another purpose of the current study is to add to the literature on waiting phenomena by presenting and testing a model of the organizational justice
perceptions of patients waiting for treatment. Little research or theory
has addressed the underlying psychological processes operating while
individuals wait for service. In particular, we examine the influences of
waiting, uncertainty, and anger on patients’ procedural and distributive
justice perceptions. Finally, we explore the influence of justice, uncertainty and anger on patients’ overall satisfaction perceptions. In sum,
this study identifies, in a single model, the underlying psychological
perceptions that occur while patients wait for treatment in an urgent
Considerable research in the services marketing area has shown that
the longer customers wait for service, the lower their satisfaction with
service performance (e.g., Lovelock, 1988; Katz, Larson, and Larson,
1991; Clemmer and Schneider, 1993). Similar findings have been
reported in a health care setting. For example, Mowen, Licata, and
McPhail (1993) found that patients in the urgent care department who
waited longer than their expected waiting times had significantly lower
satisfaction levels than patients whose waiting-time expectations were
met or positively exceeded. We define institutional satisfaction as
patients’ perceptions about the extent to which they are satisfied with
their overall experience with the institution.
Hypothesis 1a: The longer the wait, the lower the patient’s institutional satisfaction perceptions.
To examine patients’ fairness perceptions of their experience in the
urgent care department, two types of organizational justice will be
examined: procedural and distributive justice. Procedural justice
(Thibaut and Walker, 1975; Leventhal, 1976; Tyler and Caine, 1981)
refers to the perceived fairness of the rules and processes used to
deliver outcomes or resources. In the current study, procedural justice
involves patients’ perceived fairness of the triage procedures. Distributive justice (Homans, 1961), on the other hand, is concerned with the
perceived fairness of outcomes themselves (e.g., Freedman and Montanari, 1980; Greenberg, 1982). In the current study, distributive justice
refers to patients’ perceived fairness of the outcomes of the triage procedure (e.g., how long the patient had to wait to see a doctor).
Waiting time has also been shown to influence customers’ organizational justice perceptions. Research by Dansky and Miles (1997) found
that delays in service had a negative influence on patients’ organizational justice perceptions in emergency departments in the United
States. Consequently we expect similar results to hold for patients in
an urgent care department in England.
Hypothese 1b: The longer the wait, the lower the patient’s procedural justice perceptions.
Hypothese 1c: The longer the wait, the lower the patient’s distributive justice perceptions.
Service customers often do not know how long their waits will be. As a
result, they can experience anger and uncertainty while waiting (Maister, 1985). Uncertainty has been defined as « a lack of information
about future events, so that alternatives and their outcomes are unpredictable » (Hinings, Hickson, Pennings, and Schneck, 1974: 27). Taylor
(1994) examined the length of flight delays on passengers’ perceived
levels of anger and uncertainty. Taylor found that there was a significant, negative relationship between delay time and perceived levels of
anger and uncertainty.
Hypothesis 2a: The longer the wait, the more uncertainty the
patient will feel.
Hypothesis 2b: The longer the wait, the more angry the patient will
Reasons for customers getting angry while waiting for services are
numerous (Taylor, 1994). Maister (1985) and Osuna (1985) attribute
much of the anger associated with waiting to uncertainty. For example,
when a customer experiences uncertainty, he or she is less able to cope
with the waiting by planning more effectively or better managing their
waiting time. As the uncertainty increases, so does the inability of customers to plan and so increases a perceived loss of power in the situation (Taylor, 1994). Based on this logic, the following was hypothesized.
Hypothesis 3: The more uncertainty the patient feels, the more
angry he/she will feel.
Taylor (1994) also found that the level of anger and uncertainty experienced by airline passengers while waiting for a flight influenced their
subsequent overall satisfaction levels. The same result is expected
here, and the following were hypothesized.
Hypothesis 4a: As uncertainty increases, satisfaction perceptions
Hypothesis 4b: As anger increases, satisfaction perceptions will
Ideally, to improve patient satisfaction, hospitals should strive to
reduce the actual amount of time that patients have to wait for treatment. In practice, though, reducing waiting times is unlikely with ever
declining health care resources. We argue that a more plausible way
to improve patient satisfaction is by treating patients fairly during the
waiting process. Treating people fairly during a variety of service
encounters has been shown to increase satisfaction with that experience (e.g., Tyler, 1987; Clemmer, 1993). We expect such findings to
extend to a hospital setting.
Hypothese 5a: The higher a patient’s procedural justice perceptions, the higher his or her overall satisfaction perceptions.
Hypothese 5b: The higher a patient’s distributive justice perceptions, the higher his or her overall satisfaction perceptions.
Dansky and Miles (1997) found that waiting times influenced patients’
organizational justice perceptions in U. S. emergency departments.
Additionally, Taylor (1994) found that uncertainty and anger influences
the relationship between delays and customer satisfaction perceptions. Combining these findings, it is hypothesized here that the levels
of anger and uncertainty experienced by patients while waiting may
mediate the relationship between waiting times and perceptions of
Hypothese 6a: Patients’ perceived level of uncertainty will mediate
the relationship between the actual waiting time and their procedural
Hypothese 6b: Patients’ perceived level of uncertainty will mediate
the relationship between the actual waiting time and their distributive
The relationships presented in the six hypotheses were integrated into
a model (please see Figure 1).
Means, standard deviations, reliability estimates, and zero-order correlations appear in Table 1.
The hypotheses were tested using path analysis in Lisrel 8 (Joreskog
and Sorbom, 1993). The chi-square (?2 = 6.87; p = 0.44) and goodness
of fit index (GFI = .99) suggested by Gerbing and Anderson (1993)
indicated that the overall model fit the data well. The significant paths
indicated by the data appear in Figure 2. The non-significant paths
were removed and thus, we relied on the data of the trimmed model to
establish model fit. An examination of the significant and non-significant hypotheses follows.
Hypotheses 1a through 1c examined the influence of waiting time on
patients’ satisfaction and organizational justice perceptions. Hypothesis 1a, which examined the influence of waiting time on patients’ satisfaction perceptions, was not supported. As shown in Figure 2, the
path from waiting time to satisfaction was not significant. Hypothesis
1b was supported: procedural justice perceptions were significantly,
negatively related to waiting time (? = –.16, p < .05). The path from distributive justice to waiting time, however, was not significant. Thus,
Hypothesis 1c was not supported.
Table 1 - Means, Standard Deviations, Reliabilities, and Intercorrelationsa
1. Waiting time‡
4. Procedural justice
5. Distributive justice
a N = 195. Higher scores reflect higher values for variables.
†: standard deviation; ‡: Waiting time was measured in minutes.
** p < .01; * p < .05
Hypothesis 2a, which examined the relationship between waiting time
and uncertainty, was supported (? = .28, p < .05). However, the path
from waiting time to anger was not significant; Hypothesis 2b was not
Hypothesis 3 was supported. A significant, positive relationship was
found between patients’ anger and uncertainty levels (? = .69, p < .05).
Hypothesis 4a was also supported. A significant, negative relationship
was found between patients’ uncertainty and satisfaction perceptions
(? = –.10, p < .05). The more uncertainty patients felt, the lower their
satisfaction levels. Hypothesis 4b was supported as well: a significant,
negative relationship was found between patients’ anger levels and
satisfaction levels (? = –.29, p < .05). The more angry patients felt, the
lower their satisfaction levels.
Hypotheses 5a and 5b examined the influence of organizational justice
perceptions on patients’ overall satisfaction perceptions. Hypothesis
5a was not supported: procedural justice did not exhibit a significant
direct relationship with satisfaction. However, Hypothesis 5b was supported: the higher the distributive justice perceptions, the higher the
satisfaction perceptions (? = .55, p < .05).
Hypotheses 6a and 6b examined the mediating role of patients’ uncertainty levels on the relationship between waiting time and organizational justice perceptions. As shown in Figure 2, uncertainty did not
mediate the relationship between waiting time and organizational justice perceptions. Interestingly, uncertainty instead mediated the relationship between waiting time and satisfaction perceptions and
between waiting time and anger.
Figure 2 - Results
The main purpose of the current study was to build on the growing body
of research examining how people react while waiting for services. As
noted earlier, little research or theory has addressed the underlying psychological processes operating while individuals wait for service. Another purpose was to examine the influences of those reactions on organizational justice and institutional satisfaction perceptions. As shown in
Figure 2, several complex relationships emerged. More specifically,
uncertainty was found to mediate the relationship between waiting time
and satisfaction and between waiting time and anger. Further, waiting
time was significantly negatively related to procedural justice perceptions. Procedural justice perceptions were significantly positively related to distributive justice perceptions, which in turn, were significantly
positively associated with satisfaction.
This study provides additional support from customers that waiting
times are related to service evaluations (e.g., Clemmer and Schneider,
1989; Katz, Larson, and Larson, 1991, Taylor, 1994). The present
study suggests that healthcare managers can influence the satisfaction perceptions of their customers. The research indicates that lowering waiting times for services can diminish uncertainty which, in turn,
enhances customer satisfaction. Unfortunately, with ever-declining
resources, reducing waiting times may not always be possible. Indeed,
waiting times may even increase as ever-shrinking medical staffs have
to treat increasing numbers of patients. We identify a more plausible,
indirect way to improve patient satisfaction: attention to patients’ fairness perceptions during the waiting process. Treating patients fairly
while they wait may reduce the influence of waiting time on institutional satisfaction. Managers who follow procedures and distribute outcomes in a manner that their patients perceive as fair may be able to
increase the satisfaction levels of their patients, even if those patients
have to wait longer than they expect for medical treatment.
It is important to note that another factor that would be expected to
influence patients’ procedural justice perceptions would be patient perceptions that they have been “bumped” (i.e., the perception that another patient who arrived later is being treated before him/her). The vast
majority of patients in our sample did not report the perception of being
“bumped”. However, this is an important variable to consider in future
research with different samples that might experience varying degrees
of this perception as it would likely have a significant impact on
patients’ procedural justice perceptions.
Our findings regarding organizational justice add to the growing body
of research in this area. Our findings are consistent with a recent metaanalytic review of 25 years of justice research that suggested that both
procedural and distributive justice contribute incremental variance to
individual’s fairness perceptions (Colquitt, Conlon, Wesson, Porter,
and Ng, 2001). This review argued that procedural justice is more likely to exhibit a direct relationship with system-referenced variables
(e.g., waiting time in the present study) than distributive justice. In
addition, consistent with our study, the review suggested that distributive justice is more likely to demonstrate a direct effect on satisfaction
than procedural justice (Colquitt et al., 2001).
This study also provides evidence that customers or patients may
experience anger and uncertainty while waiting. The results indicate
that steps managers take toward reducing uncertainty may reduce
customers’/patients’ levels of anger. Further research should examine
cost-effective methods through which organizations can reduce the
uncertainty levels experienced by customers or patients waiting for
services. For example, Dansky and Miles (1997) examined the methods of keeping patients occupied while they were waiting and also
telling patients how long their expected wait times might be. Future
research might explore the role of voice (i.e., the degree to which
patients are vocal toward getting their needs met during the waiting
process) in the waiting time–satisfaction relationship.
The current study both extends and builds on Taylor’s (1994) research
on U. S. airline passengers waiting for delayed flights. The present findings extend Taylor’s research to hospitals; in addition, other variables
not measured by Taylor (e.g., organizational justice) were added to the
model. Interestingly, it appears that the attitudes formed while waiting
may not be limited to only passengers in the United States, given the
similar results found with hospital patients in England. Further
research might examine whether the same waiting phenomena occur
in other countries dissimilar to the U. S. and England.
In summary, extended waiting times can cause patients to have higher uncertainty levels about what is going to happen to them and when.
The uncertainty levels then can lead to higher anger levels and lower
levels of justice and satisfaction perceptions. Clearly a key way to
improve patients’ satisfaction and fairness perceptions is by lowering
waiting times for treatment. When that is not possible, the current
study supports that managers should have their staffs focus on reducing uncertainty and anger levels in customers, which may result in
higher satisfaction and fairness perceptions of triage processes.
It is important to caution that the findings of the present study occurred
under a specific set of conditions beyond which generalization may not
be possible. The data were collected during a one-week period from a
single hospital urgent care department in a rural setting in England.
Recall that the patients who visited the treatment facility tended to be
higher in socio-economic status and educational level than many who
visit other facilities. As such, the findings reported here may not directly apply to other types of medical treatment facilities or other service
providers (such as non-medical ones), or to other types of patient
groups. In addition, future research should examine different times of
day (e.g., night) and different times of year to determine if there are differences in waiting perceptions. Despite these generalization concerns, given the findings of Taylor (1994), more confidence can be
placed on the present results.
Other potential limitations concern the use of survey data. Acquiescent
response bias, defined as the tendency to agree with the items independently of the content of the items (Wiggins, 1980), can result in
inflated scores, narrow standard deviations, and artificially high reliability values. This problem is minimized somewhat in our study by the
characteristics of the sample since highly acquiescent respondents
tend to be older, less educated, and in poor health (Ross et al., 1995).
In contrast, our sample involved was relatively young, highly educated,
and higher socioeconomic status. Further, the standard deviations
observed were not particularly narrow and are consistent with similar
Whenever survey data are employed, common method bias is also
often a concern. However, the fact that the key independent variable,
actual waiting time, was measured by objective data provided by triage
nurses reduces the likelihood that common method bias explains the
current results. In conclusion, despite some limitations, the present
study points to the potential value of treating people fairly while they
wait for services. It also provides additional evidence that the attitudes
and reactions of customers and patients waiting for services should be
managed in ways that result in higher evaluations of organizational justice and overall service satisfaction.