An executive summary for managers and
The impact of structure
and process attributes
on satisfaction and
behavioral intentions
Dawn Bendall-Lyon and
Thomas L. Powers
The authors
Dawn Bendall-Lyon is Assistant Professor of Marketing at the
University of Montevallo, Montevallo, Alabama, USA.
Thomas L. Powers is Professor of Marketing at the University of
Alabama at Birmingham, Birmingham, Alabama, USA.
Keywords
Consumer psychology, Behaviour, Health services
Abstract
This paper develops a framework that links satisfaction with
structure and process attributes to global satisfaction and
behavioral intentions. The authors develop and present a
structural equation model that encompasses these relationships
based on a survey of 635 consumers of healthcare services. The
results indicate that satisfaction with both structure and process
attributes have a significant impact on global satisfaction. Global
satisfaction was found to directly influence both intention to
recommend and intention to return to the healthcare service
provider.
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Journal of Services Marketing
Volume 18 · Number 2 · 2004 · pp. 114-121
q Emerald Group Publishing Limited · ISSN 0887-6045
DOI 10.1108/08876040410528719
114
executive readers can be found at the end of
this article
Introduction
Existing research has examined structure and
process attributes in terms of their impact on
service quality (Zifko-Baliga and Krampf, 1997).
However, these elements have seldom been
examined in terms of their impact on satisfaction
despite the fact that satisfaction measures provide
useful information about the structure, process,
and outcomes (Bell et al., 1997). Satisfaction is an
important outcome of a service delivery process.
Given that research has proven that satisfaction
assessments and service quality perceptions are
closely connected, it can be useful to examine
satisfaction in terms of structure and process
(Fowler et al., 1999; Oswald et al., 1998).
Satisfaction, like quality, is a multi-dimensional
construct. Quality cannot readily be evaluated by
consumers of healthcare, making their assessment
of satisfaction all the more important to
understand in attempt to achieve high customer
retention rates in a highly competitive industry
(Oswald et al., 1998). In this research, we delineate
satisfaction with individual attributes from global
satisfaction (Oliva et al., 1992). In addition, we
delineate the individual attributes into structure
and process components (Hennig-Thurau, 2001).
We then examine the influence of these factors on
global satisfaction, intention to return and
intention to recommend. This research
contributes to the literature by providing an
empirically supported model of the structure and
process attributes and the mechanism by which
they contribute to global satisfaction and
behavioral intentions. In addition, this research
indicates that, unlike findings from previous
research that found process attributes to be the
most important aspect of services in the healthcare
industry (Cohen, 1996; Ross et al., 1993), process
and structure attribute are equally important and
influential to global satisfaction.
Literature review
There is a complex relationship between
satisfaction with service delivery attributes, global
satisfaction, and behavioral intentions and how
these factors are interrelated. Global satisfaction
with a service organization is based on satisfaction
with multiple aspects of the organization (Crosby
and Stephens, 1987; Oliver and Swan, 1989;
 Structure and process attributes
Dawn Bendall-Lyon and Thomas L. Powers
Suprenant and Solomon, 1987). Global
satisfaction is a construct with multiple indicators
at the attribute level (Oliva et al., 1992).
Consumers’ satisfaction and dissatisfaction
become a driving force that ultimately shapes
their subsequent attitudes and behavior (Strasser
et al., 1993; Bolton, 1998). Behavioral intentions
are considered to be an outcome of overall
satisfaction that includes intention to return and
intention to recommend.
Satisfaction is based on the customer’s reaction
to the perceived difference between performance
appraisal and expectations. Disconfirmed
expectations cause the customer to approach a
state of dissatisfaction, while the confirmation of
expectations leads to satisfaction (Hennig-
Thurau, 2001). To be judged positively, a service
must perform well on most dimensions, whereas to
be judged negatively, poor performance on one or
just a few dimensions is sufficient (Ofir and
Simonson, 2001).
Structure and process dimensions of
satisfaction
Service quality has been found to be a multi-
dimensional construct that is composed of two sets
of attributes: structure and process (Grönroos,
1995). “Structure” refers to the physical
environment and physical facilities in which the
service occurs. “Process” refers to the interaction
with service personnel within that environment
during the service performance. Structure involves
where the customer actually receives the service
whereas process involves the way the service is
delivered to the consumer (Richard and Allaway,
1993). Consumers hold normative standards
regarding many different aspects of the healthcare
encounter and often assess their satisfaction in
terms of structure and process (Kravitz, 1996;
Zifko-Baliga and Krampf, 1997). The literature
indicates that structure and process both influence
satisfaction, which, in turn, influences behavioral
intentions (Hennig-Thurau, 2001).
Structure satisfaction is the healthcare
consumer’s assessment of the structure
characteristics or various tangible elements
associated with a particular healthcare service
which includes both the physical environment and
physical facilities in which the service occurs, as
well as billing procedures and other amenities such
as food and parking. During a health care
encounter, the healthcare consumer is exposed to a
variety of stimuli (i.e. service attributes) that are
cognitively processed and help to shape the
consumer’s satisfaction (Scotti and Dolinsky,
1997; Anderson and Mittal, 2000; Hanson, 1992;
Mittal et al., 1998). These attributes comprise the
structure of the service and include comfort of
115
Journal of Services Marketing
Volume 18 · Number 2 · 2004 · 114-121
resting areas, layout and comfort of rooms, overall
cleanliness, décor, cheerfulness of the facilities,
convenient locations, and modern equipment
(Fottler et al., 2000). Previous research has
documented the importance of the tangible
elements of a healthcare service (Reidenbach and
Sandifer-Smallwood, 1990).
Process satisfaction is the healthcare consumer’s
assessment of the intangible elements associated
with the interaction between the consumer and
service personnel during healthcare service. These
include aspects such as responsiveness,
friendliness, courtesy, competence, access,
communication, and availability of the physician
and other hospital staff. Other process
characteristics include the interpersonal
relationship between patient and caregivers, and
caregiver expressions of empathy (Reidenbach and
Sandifer-Smallwood, 1990). Consumers of
healthcare services frequently rank
communication and interpersonal aspects of the
healthcare experience highest in importance
(Cohen, 1996; Hall and Dornan, 1988; Williams
and Calnan, 1991; Ross et al., 1993).
Behavioral intentions
Behavioral intentions are an outcome of the
satisfaction process (Anderson et al., 1994;
Anderson and Mittal, 2000). Behavioral intentions
can be grouped into two categories; economic
behaviors and social behaviors (Smith et al., 1999).
Economic behavioral intentions are customer
behaviors that impact the financial aspects of the
firm such as repeat purchase behavior (Anderson
and Mittal, 2000), willingness to pay more, and
switching behavior (Zeithaml et al., 1996). A
positive relationship has been reported between
customer satisfaction and repeat purchasing
(Szymanski and Henard, 2001). Repurchase
intentions of satisfied customers are significantly
higher than the intentions of dissatisfied customers
(Halstead and Page, 1992). Increasing overall
satisfaction leads to greater repurchase intentions
(Anderson et al., 1994; Anderson and Mittal,
2000; Ralston, 1996; Zeithaml et al., 1996), as well
as actual repurchase behavior (Anderson and
Mittal, 2000; Bolton, 1998). For the purpose of
the present research, we refer to economic
behavioral intentions in the context of intention to
return.
Social behavioral intentions are customer
behaviors that impact the responses of other
existing and potential customers of the firm such
as complaint behaviors (Johnston, 1998; Nyer,
1999; Tax et al., 1998) and word-of-mouth
communication (Szymanski and Henard, 2001;
Wright et al., 1996). Social behavioral intentions,
both positive and negative, impact the individual
 Structure and process attributes
Dawn Bendall-Lyon and Thomas L. Powers
customer as well as to influence the opinions of
other customers as well. Information disseminated
through word of mouth of existing customers is
then used as an input for expectations of future
customers (Anderson et al., 1994). Consumers
take performance outcomes of a product/service
and then use the information to shape their own
subsequent expectations as well as expectations of
others through word-of-mouth (Oliver, 1997). For
the purpose of the present research, we refer to
social behavioral intentions in the context of
intention to recommend.
Research objective and method
The objective of this research is to evaluate the
impact of healthcare consumers’ evaluations of
structure (attributes encountered during the service)
and process (interpersonal interactions between
healthcare consumer and medical personnel during
the service) elements of the healthcare encounter
and their global satisfaction and behavioral
intentions. In order to examine the impact of
attribute satisfaction with structure and process
elements on overall satisfaction and behavioral
intentions, the study involved a mail survey of
healthcare consumers who received inpatient
medical services at a teaching hospital affiliated with
a Carnegie I extensive research university. The
survey was sent to 2,000 consumers immediately
post-discharge. The consumers were randomly
selected from records of patients discharged over a
three-month period. There were 635 surveys
returned for a response rate of 32 percent.
Consumers completed a questionnaire
containing satisfaction measures for the various
aspects of the service encounter for each of the
structure and process attributes. Structure
attributes included admitting, food, room, and
discharge process, while process attributes
included doctor in charge, intern/resident, nurse,
and surgery. Each of these measures contained
subscales ranging from four to eight items. Global
satisfaction, intention to return, and intention to
recommend were assessed using a one-item scale
that captures the consumers’ overall feelings
toward the organization (Cronin and Taylor,
1992). The Appendix contains the measures used
in the study. Reliability of the attribute measures
was tested using Cronbach alpha. The Cronbach
alpha values are as follows:
.
six-item admitting subscale, 0.8693;
. eight-item doctor in charge subscale, 0.9316;
.
five-item intern subscale, 0.9536;
.
five-item surgery subscale, 0.8491;
.
eight-item nurse subscale, 0.9593;
.
five-item room subscale, 0.8251;
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Volume 18 · Number 2 · 2004 · 114-121
.
four-item food subscale, 0.8897; and
.
four-item discharge process subscale, 0.3105.
The attribute subscales, with the exception of the
discharge process subscale, were deemed
appropriate since they exceeded the minimum of
0.70 required (Nunnally, 1978).
Validity of the measures was verified using factor
analysis. The variables used in the study were
surgery, doctor in charge, intern, nurse, food, room,
and admitting. It was posited that surgery, doctor in
charge, intern, and nurse were process elements,
while food, room, admitting, and discharge process
were considered to be structure elements. The
factor analysis using a varimax rotation revealed that
surgery, doctor in charge, and intern were process
elements, whereas nurse, food, room, and admitting
were structure elements. Discharge process did not
load on either factor. Consequently, discharge
process was eliminated and nurse was considered a
structure element in the analysis that followed. The
possible reasons for nurse and discharge process not
loading as predicted are discussed later in the paper.
Results and findings
The data were analyzed using the AMOS
structural equation modeling program to
determine the relationships between satisfaction
with structure and process attributes of health
care, global satisfaction, and behavioral intentions.
The model tested global satisfaction, intention to
return, and intention to recommend as equal
outcomes of structure and process elements.
Latent variables were created for structure and
process satisfaction. The initial model is seen in
Figure 1. Multiple gauges of goodness of fit were
used to determine model quality (Bollen, 1990).
The chi-square statistic, the comparative fit index
(CFI), and the goodness of fit index (GFI) were
used to gauge the adequacy of the model. The
initial chi-square statistic for the model before
revisions were made was significant
(x2 ¼ 730:304, df ¼ 32, p , 0:001). The
goodness of fit index (GFI) was equal to 0.804 and
the CFI was 0.702, both short of the 0.90 standard
thresholds for GFI and CFI (Byrne, 2001).
The modification indices from the initial analysis
were examined for areas of improvement. The
model was re-specified to accommodate both the
data and theory (Joreskog, 1993). No covariances
were allowed between error terms, and no new
paths were allowed between variables that did not
agree with information gathered through the
literature review. The second model was improved
by revising the structure based on both the
modification indices and the literature to place
 Structure and process attributes
Dawn Bendall-Lyon and Thomas L. Powers
Figure 1 Initial model
satisfaction as an intermediate variable following
structure and process satisfaction and then linked to
intention to recommend and intention to return.
The chi-square statistic for the second model was
also significant (x2 ¼ 681:351, df ¼ 34, p , 0:001)
and the fit indices did not show strong support for
the model (GFI ¼ 0:845, CFI ¼ 0:724).
The modification indices from the second
model indicated that the model would be
substantially improved if intention to return were
directly linked to intention to recommend. This
change produced the final revised model with a
substantially improved, although still significant,
chi-square statistic (x2 ¼ 335:628, df ¼ 33,
p , 0:001). This result was expected, however,
since large sample sizes tend to generate large chi-
square estimates (Joreskog and Sorbom, 1993).
The goodness of fit index (GFI) for the revised
model was equal to 0.912 and the CFI was 0.871.
Table I summarizes the improvement in fit made
by revising the hypothesized model. The revised
model is seen in Figure 2.
Test of hypotheses
Structural equation modeling is used for
confirmation and the additional exploratory
improvement of a hypothesized model (Joreskog,
1993). The following hypotheses were developed:
H1. Structure satisfaction is positively correlated
to global satisfaction.
H2. Process satisfaction is positively correlated
to global satisfaction.
H3. Global satisfaction is positively correlated to
intention to recommend.
H4. Global satisfaction is positively correlated
to intention to return.
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Volume 18 · Number 2 · 2004 · 114-121
Table I Goodness of fit results for initial and revised models
Model x2 df p GFI CFI
Initial model 730.304 32 0.000 0.804 0.702
Second model 681.351 34 0.000 0.845 0.724
Final revised model 335.628 33 0.000 0.912 0.871
Figure 2 Final revised model
H5. Intention to return is positively correlated
to intention to recommend.
Support was found for all five hypotheses. Path
coefficients are seen in Figure 2 and in Table I that
indicate the relationship between the variables
tested in the hypotheses. H1 was supported,
indicating that satisfaction with structure
attributes is associated with global satisfaction. H2
was also supported, indicating that that
satisfaction with process attributes are directly
associated with global satisfaction. H3 was
supported, indicating that global satisfaction is
directly associated with intention to recommend.
H4 was supported, indicating that global
satisfaction is directly associated with intention to
return. Finally, H5 was supported, indicating that
intention to return is associated with intention to
recommend. Table II shows the extent to which
support was found for the individual hypotheses.
Discussion
The results of this study indicate that satisfaction
with both structure and process attributes of a
healthcare service contribute equally to global
satisfaction. Global satisfaction, in turn, directly
influences intention to return and intention to
recommend a healthcare service provider. Limited
 Structure and process attributes
Dawn Bendall-Lyon and Thomas L. Powers
Table II Support for hypotheses, final revised modela
Hypothesis Path coefficient
H1. Structure attribute elements are is
positively correlated to satisfaction 0.118***
H2. Process attribute elements are positively
correlated to satisfaction 0.065***
H3. Satisfaction is positively correlated to
intention to recommend 0.275***
H4. Satisfaction is positively correlated to
intention to return 0.413***
H5. Intention to return is positively
correlated to intention to recommend 0.565***
a
Notes: n = 635; *p, 0.05; **p , 0.01; ***p , 0.001
research has examined the impact of structure and
process attributes on satisfaction, while these
attributes have been widely researched in the area of
service quality. It has not been clear how satisfaction
with structure and process attributes of care relate to
global satisfaction and behavioral intentions.
Understanding satisfaction in terms of structure and
process attributes is important, particularly in the
healthcare industry where providers are evaluated
based on satisfaction rather than service quality, and
gives a clear picture of how these attributes influence
future behavioral intentions.
This research found that global satisfaction with
the service delivery process is impacted by structure
and process attributes. Based on the findings, service
providers should focus on both structure and process
attributes of service delivery. Increasing emphasis on
process and outcome in quality research in the past
few years has often eliminated structure as a
concern. Results of this study indicate that structure
is as important as process, and satisfaction with
service delivery is influenced equally by both of these
elements.
It is interesting to note that in the factor analysis
used to validate the attribute scales, the nurse
measure loaded as a structure attribute rather than a
process attribute. One possibility for this occurrence
is that a nurse may be seen as being tied to the
organization or is perhaps more associated with a
consumer’s room. Since the scale items for nurse
were similar to that for doctor in charge, it definitely
leads the researchers to believe there is a clear
difference in perception that is causing this result.
The discharge process was eliminated from the
analysis as it did not load on either the structure or
process factor. This may be due to the fact that this
occurs after the delivery of care and is not seen as an
integral part of the healthcare experience.
The model developed in this research supports
the literature that indicates that global satisfaction
is comprised of individual attribute satisfaction
elements that, in turn, influence the behavioral
outcomes of intention to return and intention to
recommend. The results differ, however, from
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Volume 18 · Number 2 · 2004 · 114-121
Standard error Standardized path coefficients
0.011 0.503***
0.009 0.283***
0.025 0.305***
0.034 0.434***
0.026 0.595***
previous research that indicates that process
attributes are the most important aspects of a
healthcare service. This research indicates process
and structure attributes are equally important and
influential to global satisfaction. This paper has
contributed to the literature by confirming this
relationship in the healthcare area and, at the same
time, it has identified the separate roles that
structure and process elements play in this process.
Summary and conclusion
Much work is necessary to fully understand the
relationships identified in this research and to
understand how this process is tied to organizational
performance. There has been a call to link
marketing activities to firm performance outcomes,
including such measures of sales, market share,
return on investment, and firm value (Moorman
and Rust, 1999; Phillips et al., 1983; Zeithaml,
2000). A logical extension of the linkage between
attribute and global satisfaction and behavioral
intentions would be to extend this to the linkage
between these elements and firm performance
(Anderson et al., 1994; Anderson and Mittal, 2000;
Zeithaml, 2000).
The present research examined the relationship
between satisfaction with structure and process
health care delivery attributes and behavioral
intentions. To gain a better understanding of the
relationship between satisfaction and behavioral
intentions, this study examined satisfaction in two
components, satisfaction with process and
structure attributes. Behavioral intentions were
measured in terms of intention to recommend and
intention to return. The results indicated that
satisfaction with both structure and process
attributes had a significant impact on global
satisfaction with a healthcare service. Global
satisfaction was found to directly influence both
intention to recommend and intention to return to
the healthcare service provider.
 Structure and process attributes
Dawn Bendall-Lyon and Thomas L. Powers
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Courtesy and respect for your privacy shown
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by the operating room staff.
Services, Vol. 17 No. 1, pp. 28-35. .
Attention and concern shown by the nurses
after you moved into the recovery room.

Further reading
Oliver, R.L. (1999), “Whence consumer loyalty?”, Journal of Nursing staff
Marketing, Vol. 63 No. 4, Special Issue, pp. 33-44. .
Skill and knowledge of the nursing staff.
.
Time they spent with you.
.
Courtesy and respect the nursing staff showed
you.
Appendix. Measures used .
How quickly they came when you called.
.
How well they answered your questions.
Admitting .
How well the nursing staff explained things to
.
How quick and easy it was to be admitted. you.
.
Courtesy of admitting staff. .
How well they listened to your other concerns.
.
Courtesy and respect shown by the emergency .
How well the nursing staff taught you to care
department staff. for yourself at home.
.
How well the staff kept you or a family
member informed about any delays.
.
How well the nurse or doctor explained your
condition. Room
.
Overall grade for the emergency department. .
Courtesy of the housekeeping staff.
.
Cleanliness of your room.
.
Condition of furniture and equipment.
Doctor in charge of your care .
Temperature of your room.
.
Skill and knowledge of your Doctor. .
How quiet your room was at night.
.
Time your Doctor spent with you.
.
Courtesy and respect your Doctor showed
you.
.
How well your Doctor answered your Food
questions. .
Courtesy of the food service delivery staff.
.
How well your Doctor listened to your . How often you received what you ordered
concerns. (consider special diet restrictions).
.
How well your Doctor explained your illness .
Temperature of the food.
or condition. .
Overall satisfaction with the food service.
120
 Structure and process attributes
Dawn Bendall-Lyon and Thomas L. Powers
Executive summary and implications for
managers and executives
This summary has been provided to allow managers
and executives a rapid appreciation of the content of
this article. Those with a particular interest in the topic
covered may then read the article in toto to take
advantage of the more comprehensive description of the
research undertaken and its results to get the full benefit
of the material present.
Global satisfaction with a service
organization
Customers’ satisfaction with a service organization
is based on their reaction to the difference they
perceive between the performance they expected
from the organization, and the service they actually
receive. Customers tend to be satisfied if their
expectations are confirmed and dissatisfied if they
are not. To be judged positively, a service must
perform well on most dimensions, whereas to be
judged negatively, poor performance on one or
only a few dimensions is sufficient. Global
satisfaction with a service organization is based on
satisfaction with multiple aspects of the
organization.
Structure and process
Service quality is composed of structure and
process. Structure refers to the physical
environment and physical facilities in which the
service occurs. Process refers to the interaction
with service personnel within that environment
during the service performance. Structure involves
where the customer actually receives the service
whereas process involves the way the service is
delivered to the customer.
Behavioral intentions
Behavioral intentions are an outcome of the
satisfaction process. Behavioral intentions can be
split into economic and social behaviors. The
former are customer behaviors that affect the
financial aspects of the firm, such as whether the
customer will repeat his or her purchase, whether
he or she will pay more for the service and whether
he or she will switch to another service provider.
Bendall-Lyon and Powers, for the purpose of their
research, refer to economic behavioral intentions
in the context of the customer’s intention to
return.
Social behavioural intentions are customer
behaviors that affect the responses of other existing
121
Journal of Services Marketing
Volume 18 · Number 2 · 2004 · 114-121
and potential customers of the firm, such as
complaint behaviors and word-of-mouth
communication. Bendall-Lyon and Powers, for the
purpose of their research, refer to social
behavioural intentions in the context of the
customer’s intention to recommend.
The variables used in the study
The authors examine the impact of healthcare
consumers’ evaluations of the structure and
process elements of the healthcare encounter and
their global satisfaction and behavioral intentions.
The variables used in the study were surgery,
doctor in charge, intern, nurse, food, room and
admitting procedures. It was posited that the first
four elements in this list were process elements,
while food, room, admitting and discharge
procedures were structure elements. However, it
became apparent during the research that surgery,
doctor in charge and intern were process elements,
whereas nurse, food, room and admitting
procedures were structure elements, and that
discharge procedures were considered relatively
unimportant. A possible reason for nurses being
considered a structure element rather than a
process element is that the nurse may be seen as
being tied to the organization or is perhaps more
associated with a customer’s room. A possible
reason for the relative unimportance of discharge
procedures is that these occur after the delivery of
care and are not seen as an integral part of the
healthcare experience.
The results of the study
The results of the authors’ research among 635
consumers indicate that satisfaction with both the
structure and process attributes of healthcare
service contribute equally to global satisfaction.
Global satisfaction, in turn, directly influences
intention to return and intention to recommend a
healthcare service provider.
While previous research has indicated that
process attributes are the most important aspects
of a healthcare service, this research shows that
process and structure are equally important to, and
influential upon, global satisfaction. Service
providers should therefore focus on both structure
and process attributes of service delivery.
(A précis of the article “The impact of structure and
process attributes on satisfaction and behavioral
intentions”. Supplied by Marketing Consultants for
Emerald.)