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Researchers consider that the service quality theory is based on the literature of client satisfaction and product quality (Brady & Cronin, 2001). Liljander and Strandvik (1995) observed that client satisfaction is determined by the overall perception of the service quality. This overall picture about service quality of the organization is reached easily if a client regularly uses service of the organization (Liljander & Strandvik, 1995). Lagace, Dahlstrom, and Gassenheimer (1991) found that by including “ethics” as component of the quality of the relationship between pharmaceutical buyers and sellers, ethical behavior led to higher levels of relationship quality and ethical behavior has been positively associated with client satisfaction (Lagace, et.al., 1991). Also, the research conducted in bank sector by Emari, Iranzadeh and Bakhshayesh (2011) found a significant relationship between perceived quality and client satisfaction, and testing Gronroos three dimensions model – which consists from technical, functional and image, the research revealed that general perceptions of the service quality is influenced by the technical quality, – in other words it is influenced by outcomes what one receives (Straiter, 2005).
According to above mentioned, service quality evaluated by the client can be considered as related to their satisfaction level. Similarly, when considering the service quality gap between employees and clients, we assume that, service quality gap decreases the level of client satisfaction with the organization. We want to reveal the service quality gap relationship with client satisfaction with intellectual disability care centers:
H2a: Higher is the gap in service quality evaluation lower is the relatives’ satisfaction with the organization (fig I).
The relationship between service quality and client satisfaction has been reported to be different in terms of strength between industries as well as between contexts (Ame, 2005, 2009; Sureshchandar et.al. 2002). Accordingly, researchers consider that some factors must be responsible in influencing this relationship. These include, but not limited to, the type of industry studied, nature of service, income levels of client, management culture, client’ social culture, gender, etc, (Ame, 2005). The various empirical findings on studies about service quality and client satisfaction have suggested that relationships on these variables may be moderated by some factors.
Client perceived justice is one of the popular factors among researches in the field of service. Liao (2007) confirmed client perceived justice mediation effects on client satisfaction and service recovery performance. Also the study conducted to determine the influence of emotions on justice for client satisfaction conducted by Ellyawati, Purwanto and Dharmmesta (2012) found that clients’ perceived justice impacts on clients’ satisfaction. According to the one of the Justice theories – Equity Theory, the inequality can be observed when person perceives that he/she is putting more and is getting less value, and satisfaction much depends on how one perceives the justice, – injustice can lead to dissatisfaction and anger (Adams, 1965). Clients’ perceptions of the input and output, and their perception about the fair distribution of resources, information etc. is expected to have a moderator role for their satisfaction. Accordingly we expect that organizational justice perceived by the relatives of PIDs can moderate the relationship of service quality gap and relatives’ satisfaction with the center:
H2b: Relatives perception of organizational justice moderates relationship between service quality gap and relatives satisfaction with the organization (fig I).
We discussed the problems of ethic in service quality from the side of the employees and from the side of the client (relatives). However, the situation is getting more complex and critical especially when considering the primary goal of the organization oriented on mental health care: to increase the quality of life of people with intellectual disabilities (PIDs). We review this aspect in the next section.
The World Health Organization (WHO) defines Quality of Life (QoL) as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns” (The World Health Organization Quality of Life Assessment – WHOQOL, 1997, p. 1). We can say that QoL exists when one perceives that lives with dignity, feels that dreams and ideas are respected, and is an active handler and responsible of own life (Tamarit, 2002). QoL as usually includes subjective evaluations of positive and negative aspects of life (World Health Organization Quality of Life Assessment 1998). Generally it includes health perceptions at physical and mental level and their relations—including conditions, social support, etc. (Kindig, Booske & Remington, 2010).
Organizations that provide services to people with intellectual disabilities (PIDs) also contribute to developing their QoL (FEAPS, 2010), and are designed to care the QoL of individuals with intellectual disabilities (Martinez-Tur, Peiró, Moliner, & Potocnik, 2010). These organizations are the basic sources of QoL for people with intellectual disabilities (Moliner, Gracia, Lorente, & Martinez-Tur, 2013).
Since QoL of PIDs is directly derived from service quality that is provided for them, we suppose that it can be affected by the ethical challenges in services; service provided from professionals includes dilemma: to whom it must be ethical – to PIDs or to relatives? As we mentioned above service quality perceived by relatives and service provided by employees is related to challenges since they have different standards about how service should be provided. Usually for the mental healthcare service organizations a relevant source of information is the relative of the PIDs; QoL of Persons with Intellectual Disabilities can be evaluated from professionals/employees or from relatives. Since information which comes from external subject is more objective it is more relevant to use family member as the main evaluators to assess QoL of PIDs (Moliner, et. al., 2013). When there is a gap in service quality and QoL is evaluated by the relatives we argue that it can have influence on the level of QoL of PID. Therefore in order to improve quality for future development in mental care related services the assessment of QoL is an important tool (Moliner, et. al., 2013). Our next hypothesis aims to find out this relationship among gap and QoL:
H3a: Higher is the gap in service quality evaluation lower is the quality of life of PIDs’ perceived by their relatives (fig I).
Any attempt to judge the service quality provided by mental healthcare services would be less complete not considering the experiences of people who use the product and receiving the service. By finding out what service users think, important information can be obtained which can have impact on other factors (National Institute for Health & Clinical Excellence, 2012).
National Institute for health and care excellence (NICE) claims that past years are characterized with more initiatives highlighting the importance of considering the service user’s experience about the service quality. E.g. Lord Darzi’s report on High Quality Care for All (2008) focuses on the importance of the entire service user experience to ensure that they are in a safe and well-managed environment (Darzi, 2008). To understand how center is operating to deliver high service quality to direct users (PIDs) it is important to understand what users think about their care and treatment. Our last hypothesis stresses on the effect of PIDs perceived service quality that can moderate the service quality gap effect on their QoL:
H3b: PIDs’ service quality evaluation moderates the relationship between service quality gap and PIDs’ quality of life perceived by their relatives (fig I).
With the almost universal increase the involvement and support for mental healthcare services more concerns are about the responsibility of the agencies and professionals who provide such assistance (Roth, Fonagy, & Parry, 1996), the QoL of people with intellectual disabilities becomes a very important question nowadays. Specifically, social, educational and health services are focusing on providing services to people with intellectual disabilities, and establishing this subject as a specific goal of the organizational in order to find new ways of developing a QoL in the future (Schalock & Verdugo, 2007). These questions and hypothesis give opportunities to orient organizations’ activities in order to improve the service quality, mental health, satisfaction and QoL at the centers for intellectual disabilities.
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