Linkages Between Organization Climate and Work Outcomes

LINKAGES BETWEEN ORGANIZATION CLIMATE
AND WORK OUTCOMES: PERCEPTUAL

DIFFERENCES AMONG HEALTH SERVICE
PROFESSIONALS AS A FUNCTION OF
CUSTOMER CONTACT INTENSITY
DENNIS J. SCOTTI
JOEL HARMON
Fairleigh Dickinson University
Acknowledgement
Work on this project was partly supported by a grant from the
US National Science Foundation (NSF), Innovation & Change
Division. We acknowledge the Veterans Health Administration
(VHA) for providing data used in this study. The views
expressed in this article do not necessarily represent those of the
VHA or NSF. The co-authors contributed equally to this paper.
ABSTRACT
The delivery of high-quality service, rendered by health

service professionals who interact with customers (patients), increases
the likelihood that customers will form positive evaluations of the
quality of their service encounters as well as high levels of customer
satisfaction. Using linkage theory to develop our conceptual
framework, we identify four clusters of variables which contribute to a
chain of sequential events that connect organization climate to personal
and operational work outcomes. We then examine the perceptual
differences of service professionals, grouped by intensity of customer
contact, with respect to these variables.
National data for this project were obtained from multiple
sources made available by the Veterans Healthcare Administration
(VHA). Cross-group differences were tested using a series of variance
analyses. The results indicate that level of customer-contact intensity
plays a significant role in explaining variation in perceptions of support
staff, clinical practitioners, and nurses at the multivariate and univariate
levels of analysis. Contact intensity appears to be a core determinant of
418 JHHSA SPRING 2014
the nature of work performed by health service professionals as well as

their psychological responses to organizational and customer-related
dynamics.
Health service professionals are important resources because
of their specialized knowledge, labor expense, and scarcity. Based on
findings from our research, managers are advised to survey employees
perceptions of their organizational environment and design practices
that respond to the unique viewpoints of each of the professional
groups identified in this study. Such tailoring should help executives
maximize the value of investments in human resources by underwriting
patient satisfaction and financial sustainability.
INTRODUCTION
In response to recent statutory pressures to improve

service quality, healthcare organization managers have
developed a keen interest in gaining clearer insights
regarding factors that determine customer perceptions of
their experiences as patients, which are substantially shaped
by their contact with employees. Under the Value Based
Purchasing (VBP) program, recently implemented as part
of reforms contained in the Affordable Care Act of 2010,
patient experiences of care will significantly impact
Medicare payments to healthcare providers. Employees that
come in direct contact with patients play a critical role in
shaping their perceptions of such experiences (Scotti,
Harmon, and Behson, 2009). Moreover, empirical findings
indicate that the delivery of high-quality service rendered
by frontline employees, with high-intensity customer
interactions, increase the likelihood that customers will
form positive evaluations of the quality of their service
encounters as well as high levels of customer satisfaction
(Deitz, Pugh, and Wiley, 2004; Mayer, Ehrhart, and
Schneider, 2009). High levels of customer satisfaction, in
turn, translate into customer loyalty and financial
performance of the firm (Heskett, Sasser, and Schlesinger,
1997).
JHHSA SPRING 2014 419
Evidence supports the importance of creating a

work environment or climate that enables, motivates, and
rewards the provision of high-quality service by employees
within an organizational milieu that emphasizes concern for
its customers (Pugh et al., 2002). Also of importance is the
role played by employee perceptions of their job conditions
(e.g., work stressors and empowerment) in mediating the
interface between organizational climate and work
outcomes such as employee evaluations of their service
capability, satisfaction, and turnover intentions (Ruyter,
Wetzels, and Feinberg, 2001) as well as their judgments of
job performance (Arnold, et al., 2009, Leggat et al., 2010).
Strategic marketers and human resource managers
have struggled to discover the ideal combination of
actions to foster an organizational climate for service; but
there is no reason to expect that all employees will respond
homogeneously to a uniform set of managerial practices.
What if we better understood how different occupational
groups, particularly among health service professionals,
may respond asymmetrically to stimuli in their work
environment depending on their intensity of customer
(patient) contact? This very question inspired us to search
for an answer that will help managers understand which
specific aspects of change-producing forces in the
workplace matter most to different groups of healthcare
professionals (e.g., support professionals, direct clinical
providers, nurses) so as to maximize the value of
investments in human resources.
In the following sections we offer a concise review
of the extant literature undergirding the arguments made
above and draw on linkage theories spanning several
streams of research relating to service climate, job
conditions, and performance outcomes. We first review the
literature to illuminate our research questions regarding
meaningful psychological response differentials across the
previously mentioned groups of health service
professionals stratified by the intensity of their patient

encounters, and then examine these questions using data
from 113 Veterans Health Administration facilities
comprising 59,454 service professionals categorized by
occupational groupings. Our findings are presented and
discussed with attention to implications for practicing
healthcare managers.
BACKGROUND AND CONCEPTUAL

FOUNDATION
The present study borrows from a substantial and

growing body of literature, commonly known as linkage
research, that seeks to explain the temporal chain of events
that connect employee perceptions of managerial practices
with operational and strategic outcomes consequential to
organizational performance (Dean, 2004 traces the
evolution of linkage research). We do this in order examine
the locus and magnitude of influence exerted by contact
intensity in this chain across occupational groupings of
health service professionals. As further detailed below,
early studies conducted on retail service firms focused on
linkages at the business-unit level and established robust
evidence to support the positive impact of organizational
climate on desirable organizational service outcomes
such as employee and customer perceptions of service
quality, employee and customer satisfaction, and
profitability. Subsequent empirical inquiries studied the
influence of personal factors that mediate this causal chain
of events. A summary of the core linkage variables that we
examine for group differences, and the position they
occupy in the temporal chain, is presented in Table 1.
Work Climate
The climate of an organization is determined by
employees shared perceptions of the managerial practices
and kinds of behaviors that are expected, supported, and

rewarded in a contextual setting (Schneider, 1990). The
quality of service provided by employees is influenced by
two conceptually distinguishable but interrelated
environmental dimensions of workplace climate: strategic
human resource management (SHRM) practices and
customer orientation. Collectively, HRM practices and
customer orientation reflect managements concern for two
key stakeholder groups, employees and customers,
respectively (Borucki and Burke, 1999).
Table 1
Summary of Core Drivers in Linkage Model and Study
Measures.
Linkage Clusters and Core Drivers Study Measures
Work Climate Work Climate

Strategic Human Resource Practices High-Performance Work Systems
Customer Orientation Customer Orientation
Job Conditions Job Conditions

Role Ambiguity Task Clarity
Role Conflict Role Alignment
Role Overload Workload Balance
Work-Family Conflict Work-life Balance
Job Control Job Control
Personal Work Outcomes Personal Work Outcomes

Work Stress Work Stress
Service Capability Service Capability
Job Satisfaction Employee Satisfaction
Organization Commitment Not available
Turnover Intentions Intent to Stay
Service Outcomes Service Outcomes

Service Quality Employee-Perceived Service Quality
Customer Satisfaction Employee-Perceived Customer
Satisfaction
Customer Loyalty Not available
Organizational Performance Outcomes Organizational Performance Outcomes

Operational Efficiency Not available
Return on Investment
Market Performance
Deployment of systematic assemblages of best

practices in SHRM, frequently dubbed high-performance
work systems (HPWS; e.g., Nadler and Gerstein 1992;
Lawler, Mohrman, and Ledford 1995), is widely believed
to yield performance results that are superior to
implementing such practices on a piecemeal basis
(Huselid,1995; Combs et al., 2006, Delery, 1998). Also
referred to in the literature as progressive HRM practices or
high-involvement work systems, HPWS comprise an
integrated and aligned set of SHRM practices that enable
workers knowledge and skills through training, align their
activities with clear and important goals, increase their
involvement through participation in decision making,
empower them to innovatively adapt to customer needs by
granting them discretion, amplify their individual
effectiveness through cooperation and teamwork, and
motivate them to perform by offering proper recognition
and incentives (see Becker and Huselid, 1998 for a superb
review and synthesis of the conceptual and empirical
underpinnings of the HPWS construct). Customer
orientation refers to the importance that management
places on customers needs and expectations relating to the
firms service offerings (Kelley, 1992). Prior research in
the banking industry identified a connection between
strategic HR practices and customer-service orientation and
found that both played a role in shaping employee and
customer perceptions of service quality (Schneider and
Bowen, 1985, Schneider, White, and Paul, 1998). In their
study of automobile service centers, Rogg et al. (2001)
found that a customer-oriented climate formed a mediating
link between HPWS and customer satisfaction. More
recently, empirical confirmation of these linkages was
extended to the healthcare sector (Scotti, Harmon, and
Behson, 2007; Scotti, Harmon and Behson, 2009).
Job Conditions
The relationship between an organizations
workplace climate and employee/customer perceptions of
service outcomes is not direct and is also influenced by
worker perceptions of job conditions and their personal
(attitudinal) reactions to those conditions. The occupational
milieu in which employees perform their work roles is
influenced by several sources of strain that engender
psychological distress, which ultimately affects their
service quality. Accodring to Katz and Kahn (1978)
sources of work strain typically include role ambiguity
(unclear work role expectations), role conflict (expectations
to fulfill two or more incompatible roles), and role overload
(excessive job demands with insufficient time for
completion). More recently, work-family conflict
incompatible demands from work and family life has
attracted the attention of occupational psychologists as a
contributor to strain in the workplace (Frone, 2003; Kossek
& Ozeki, 1998). In addition to classical work stressors,
contemporary literature has underscored the importance of
job control an employees perception of the amount of
discretion at his/her disposal to meet the demands of a task
as a critical element of job conditions that influences
personal work outcomes (Liu, Spector and Jex, 2005).
Personal Work Outcomes

Perceptions of work stressors have been linked to
lower levels of frontline employee satisfaction (Hartline
and Ferrell, 1996; Chebat and Kollias, 2000), lower
perceptions of performance capability (Gilboa et al, 2008),
and increased turnover intentions (Chang, 2008). Similar
effects of work stressors have been observed among
hospital nurses (Huber, 1995). Spector (1986) concluded
from his meta-analysis of over 100 studies that job control
was positively linked to employee satisfaction,
performance, and turnover intentions. Perceived job control
and related feelings of empowerment have also been

associated with heightened confidence about ones self-
efficacy and service capabilities (Gist and Mitchell, 1992;
Robinson, Neeley, and Williamson, 2009) and job
satisfaction (Schlesinger and Zornitsky, 1991). Moreover, a
sense of job control has been linked to better quality of care
delivered by hospital employees (Gibson, 2001). In the
healthcare domain, the co-occurrence of high job stressors
and low job control has been directly and negatively
correlated with satisfaction and professional commitment
among physicians (MacNeil, 1998).
Service Outcomes
Ultimately, the collective effects of these dynamic
linkages translate into employee perceptions of service
quality (Ma et al., 2009; Slatten, 2008) and their
perceptions of customer satisfaction (Johnson, 1996). It is
well worth noting that direct-contact employee perceptions
of key service outcomes such as service quality and
customer satisfaction have been shown to be strongly
correlated with and predictive of actual customer appraisals
of these outcomes in retail enterprises (Schneider and
Bowen, 1985; Schneider and White, 2004) and in
healthcare settings (Scotti, Harmon, and Behson, 2007).
Contrary to conventional beliefs, recent evidence suggests
that health service employees are actually more stringent
and critical in their evaluations of service quality than are
their customers (Fottler et al., 2006) and that assessments
of service quality by professionally-trained providers are
more accurate than other employees (Young et al., 2009).
Organizational Performance Outcomes

Prior research has established the empirical link
between market orientation, service quality and business
profitability (Chang and Chen, 1998) and has provided
strong evidence that employee psychological outcomes,
customer service outcomes and organizational outcomes

(i.e., profit and revenue growth) are connected through a
service-profit chain (Heskett, Sasser, and Schlesinger,
1997). Other investigators have added to our understanding
of the service-profit chain by focusing attention on the
importance of customer satisfaction (Bernhardt, Donthu,
and Kennett, 2000) and customer retention (Anderson and
Mittal, 2000) as mediating factors along the path to
superior financial performance. In the healthcare sector,
connections between patients judgments of service quality
and improved financial performance at 51 U.S. hospitals
have been empirically verified by Nelson et al. (1992) and,
more recently, Goldstein (2003) found significant
relationships among employee outcomes, customers
satisfaction and revenue growth in a sample of 220 U.S.
hospitals.
At least one author (Silvestro, 2002) has called into
question the positive link between employee outcomes (i.e.,
satisfaction and loyalty) and organizational performance
(i.e. productivity and profitability) based on findings from
his study of a small sample of U.K. grocery stores. This
author states, however, that:
in services where there are high levels of

contact between customers and staff, few
opportunities for technological substitution,
staff/customer contact is a critical aspect of
service value to the customer, and labour costs
represent a significant proportion total costs, then
there may well be a direct link between employee
satisfaction, loyalty, unit productivity and profit.
(Silvestro, 2002, p.44)
The contextual qualities identified by Silvestro are

precisely those that characterize the provision of healthcare
services. Accordingly, we feel assured that the favorable
connection generally assumed to exist between employee

outcomes and organization performance outcomes holds
true for hospitals and other health services organizations.
To be certain, the exact composition, sequencing
and interaction of the complex system of relationships thus
far described remain an issue among researchers. While
there is some consensus regarding the core set of drivers
constituting a comprehensive linkage model, and their
causal clustering in the chain of events, a fully integrated
conceptual framework has not yet been validated
empirically in the extant literature. As stated in the
introduction, our purpose in the present study is not to
propose and test such a model. Rather, we believe that the
current state of linkage research has reached a point that
invites inquiry into an important question: Irrespective of
the precise causal relationships among the core set of
drivers, do all service providers (particularly health service
professionals) perceive and evaluate the levels of these
drivers homogenously? Moreover, if notable differences
are observed, to what degree does contact intensity explain
such differential perceptions?
Contact Intensity as a Moderating Force

Prior to the turn of the century, linkage research
studies subsumed frontline employees under the universal
rubric of service workers. Rogelberg, Barnes-Farrel, and
Creamer (1999) were perhaps the first authors to
distinguish among types of service positions and to propose
a taxonomy for classifying service providers based on
interaction medium (remote vs. direct), type of service
outcome (standardized vs. customized), and frequency of
contact. Subsequent empirical investigations found that the
frequency of customer contact moderated the relationship
between employees perspectives of work climate and
customer evaluations of service outcomes at retail service
firms (Dietz, Pugh, and Wiley, 2004; Mayer, Ehrhart, and
Schneider, 2009), and between high-contact healthcare

services vs. low-contact claim-processing services (Scotti,
Harmon, and Behson, 2009).
Compared with direct care providers (clinical
practitioners and nurses), the work performed by healthcare
support staff (administrative, financial, and technical staff)
involves limited face-to-face contact with patients, is
largely transactional in nature, and of short duration. In
contradistinction to acute-care (inpatient) nurses, patient
encounters with ambulatory care (outpatient) nurses can
occur repeatedly over an extended period of time, but tend
to be brief and discontinuous (Swan, 2007) and may entail
considerable indirect interactions (Cusack, Jones-Wells,
and Chisholm, 2004); a job profile descriptive of lower
contact intensity than the duties of inpatient nurses. To
date, we are aware of no studies that have examined or
described subgroups of clinical practitioners employed in
hospitals with respect to contact intensity; however, it is
reasonable to argue that the nature of work performed by
physicians and therapists generally demands less frequency
and intimacy of contact with patients than is required by
nurses.
Guided by direct findings and inferences from
previous research, the following research questions are
proposed and tested:
Research Question 1: Do perceptions of linkage

model variables specifically, workplace climate,
job conditions, personal work outcomes and
organizational service outcomes vary
significantly across occupational groups of health
service professionals?
Research Question 2: Are perceptions of linkage

model variables specifically, workplace climate,
job conditions, personal work outcomes and
organizational service outcomes meaningfully

ordered across occupational groups of health
service professionals as a function of increasing
customer-contact intensity as follows: support
staff, clinical practitioners, outpatient nurses, and
inpatient nurses?
METHODS
The data for this project were obtained from
multiple sources made available by the Veterans Healthcare
Administration (VHA), including a national survey of
employees, existing internal patient volume and case-
intensity measures, and other archival data. There were
74,662 responses to a confidential and self-administered
survey questionnaire (72% response rate) representing
employees in 147 VHA medical centers across the United
States. The survey asked for employee observations and
opinions on a wide variety of topics surrounding their work
experiences. However, we confined our analyses only to
those facilities for which employee survey data could be
reliably paired with other facility data. Initially, this yielded
usable data from 113 VHA facilities; specifically,
responses of 59,464 employees. Due to concerns over
anonymity and confidentiality by the VHA, the data
collected by them and made available to us did not include
demographic variables or information that would permit us
to trace employees to their specific work units within their
respective facilities.
Variables and Measures
Dependent variables. To capture the several streams of

research forming the theoretical foundation for this study,
we classified the dependent variables into four related
subsets of measured employee perceptions: 1) workplace
climate, 2) job conditions, 3) personal work outcomes, and
4) service outcomes. Measures of organizational outcomes

(e.g. financial or market performance) were unavailable
and, in any case, would not be different across occupational
groups. Given that the study data are drawn from a
convenience sample, our selection of measures to
operationalize the concepts of interest in this study was
reliant on and limited to survey questionnaire items
designed by the VHA and administered to its employees.
Respondents replied to VHA employee survey items using
a fivepoint Likert-type scale (anchored at 1 = strongly
disagree, 5 = strongly agree except where otherwise noted)
for all measures except role alignment, workload balance
and job control, which utilized a 4-point semantically
anchored scale. Where feasible, we created reliable multi-
item constructs by averaging employee responses to
constituent questions into a single scale. The internal
consistency (reliability) of multi-item measures was
estimated by Cronbachs coefficient alpha (), using
.70 as our level of sufficiency for basic research (Nunnally,
1978). The studys dependent measures are discussed
below and summarized in Table 2 along with their
reliability coefficients (where appropriate).
Work Climate. We used two measures to assess
employee perceptions of the overall work climate: high
performance work systems (HPWS) and customer
orientation. HPWS was measured using a composite scale
comprising ten factor-analytically derived indicators (goal-
alignment, communication, involvement, empowerment,
teamwork, training, trust, creativity, performance enablers
and performance-based rewards) extracted from the VA
employee survey that has been previously tested and
validated (see Harmon, et al., 2003, for a fuller explication
of how this scale was derived and validated through a series
of confirmatory factor analyses).
We measured customer orientation by averaging into a
single scale responses to three items that assessed the
degree to which employees believed that their organization

was geared towards accommodating its customers: (1)
Products, services and work processes are designed to
meet customer needs and expectations, (2) Customers are
informed about the process for seeking assistance,
commenting, and or complaining about products and
services, and (3) Customers have access to information
about products and services.
Table 2
Dependent Measures used in Analyses
Dependent Variables Survey Questions
Work Climate
High-Performance Work A composite of ten factor-analytically derived indicators
Systems (goal-alignment, communication, involvement,
(Cronbachs alpha = .91) empowerment, teamwork, training, trust, creativity,
1 = Strongly Disagree, performance enablers, and performance-based rewards)
5 = Strongly Agree extracted from the VA employee survey that has been
previously tested and validated (see Harmon, et al.,
2003, for a fuller explication of items and how this scale
was derived and validated through a series of
confirmatory factor analyses).
Customer Orientation A three-item scale previous tested and validated by
(Cronbachs alpha =.83) Scotti, et al, 2007:
1. Products, services and work processes are designed
1 = Strongly Disagree to meet customer needs and expectations.
5 = Strongly Agree 2. Customers are informed about the process for
seeking assistance, commenting, and or complaining
about products and services.
3. Customers have access to information about
products and services.
Job Conditions
Task Clarity Employees are kept informed on issues affecting their
1 = Strongly Disagree, jobs.
5 = Strongly Agree
Role Alignment I am free from conflicting demands that other people
make on me.
Workload Balance 1. I have too much work to do everything well.
(Cronbachs alpha = .76) (reverse coded)
1 = Strongly Disagree, 2. I have enough time to get the job done.
4 = Strongly Agree
Work-life Balance Supervisors/team leaders understand and support
1 = Strongly Disagree, employees family/personal life responsibilities.
5 = Strongly Agree
Job Control 1. It is basically my own responsibility to decide how
(Cronbachs alpha = .84) my job gets done.
1 = Strongly Disagree, 2. I am given a lot of freedom to decide how to do my
4 = Strongly Agree own work.
Table 2
Dependent Measures used in Analysis (contd)
Personal Work Outcomes
Perceived Service 1. Conditions in my job allow me to be as productive
Capability as I can be.
1 = Strongly Disagree, 5 =
Strongly Agree
Employee Satisfaction 1. Considering everything, how satisfied are you
(Cronbachs alpha = .87) with your job?
1 = Very Dissatisfied, 2. Considering everything, how would you rate your
5 = Very Satisfied satisfaction with the organization at present time?
Dependent Variables Survey Questions
Intentions to Stay How likely are you to leave your current work unit for
1 = Very Likely another federal job within the next two years?
5 = Very Unlikely
Perceived Service
Outcomes
Employee-Perceived 1. Overall, how would you rate the quality of service
Service Quality provided to veterans by your facility or office?
(Cronbachs alpha = .87) 2. Overall, how would you rate the quality of care
1 = Very Poor, provided at this health care facility?
5 = Very Good 3. Compared to a year ago, how would you rate the
quality of care patients receive at your health care
facility?
Perceived Customer How satisfied do you think your organizations
Service Quality customers are with the products and services it
1 = Very Dissatisfied provides?
5 = Very Satisfied
Job Conditions. It should be noted that our

conceptualization and operationalization of job conditions
in the present study preserves the original framing of the
VHA survey questionnaire and is consistent with the
emerging field of positive organizational behavior
(Luthans, 2002; Cooperrider & Whitney, 2005). At the core
of this perspective is application of affirmative
interventions to unleash human capacities that can be
developed and managed for performance improvement.
Accordingly, we have exchanged negative constructs (i.e.,
role ambiguity, role conflict, role overload, and work-
family conflict) for positive constructs such as task clarity,
role alignment, workload balance and work-life balance.
We measured Task clarity by responses to the item:
Employees are kept informed on issues affecting their
jobs. Role alignment was measured by responses on a 4-

point scale to the question I am free from conflicting
demands that other people make on me. We measured
Workload balance by averaging employee responses to two
survey questions on a 4-point scale: (1) I have too much
work to do everything well (reverse coded), and (2) I
have enough time to get the job done. Work-life balance
was measured by the responses to the question:
Supervisors/team leaders understand and support
employees family/personal life responsibilities. We
measured job control by averaging employee responses to
two survey questions on a 4-point scale: (1) It is basically
my own responsibility to decide how my job gets done,
and (2) I am given a lot of freedom to decide how to do
my own work.
Personal Work Outcomes. We measured employee
perceptions of their Service Capability by responses to a
global survey question: Conditions in my job allow me to
be as productive as I can be. Work stress was measured by
averaging the employee responses to two survey questions:
(1) I often feel tense and stressed on my job, and (2)
Work is a source of a great deal of stress. We measured
employee satisfaction by employee responses to two survey
questions: (1) Considering everything, how satisfied are
you with your job? and (2) Considering everything, how
would you rate your satisfaction with the organization at
the present time? (1=very unsatisfied to 5=very satisfied).
We measured turnover intentions by employee responses to
the question: How likely are you to leave their current
work unit for another federal job within the next two years
(1=very likely to 5=very unlikely). The original coding of
the questions results in a positive operational measure of
intent to stay.
Service Outcomes. We measured employee
perceptions of service quality with a three-item scale
derived from the employee satisfaction survey reflecting
their ability to deliver high-quality customer service at their

workplace. The three items were: (1) Overall, how would
you rate the quality of service provided to veterans by your
facility or office? (2) Overall, how would you rate the
quality of care provided at this health care facility? and (3)
Compared to a year ago, how would you rate the quality
of care patients receive at your health care facility?
Respondents were asked to rate each of the three items
using a 5-point scale (1=very poor to 5=very good). We
measured employee perceptions of customer satisfaction at
their facility by the question How satisfied do you think
your organizations customers are with the products and
services it provides? using a 5 point scale (1=very
dissatisfied to 5=very satisfied).
Independent and control variables.

Contact intensity is designated as the independent
variable in this study. Individuals were assigned to one of
the four categories of professional health service workers
using their responses to a combination of demographic
survey questions indicating their job category, clinical
specialty, and service line. The resulting four occupational
groups, each posited as having successively more intense
(direct, frequent, intimate) service encounters with patients,
are as follows: 1) support staff (trained professionals who
are not directly involved in delivery of care e.g., IT, HR,
procurement, engineering, finance, accounting, program
management, medical records administration, laboratory);
2) clinical practitioners (licensed professionals directly
involved in diagnosis and delivery of clinical treatments
e.g., physicians, dentists, therapists); 3) outpatient nurses
(usually working in ambulatory care settings), and 4)
inpatient nurses (usually working in acute care settings).
Wage grade workers were excluded from our analyses. The
number of professional workers that could be reliably
assigned was 38,821, of which 14,025 (36%) were support
staff, 14,044 (36%) were clinical practitioners, 4,929 (13%)

were out-patient nurses, and 5,823 (15%) were in-patient
nurses.
Patient volume and case-mix intensity (CMI) were
included as potential control variables that might exert
influence on the perceptions of healthcare professionals
included in this study. A recent study of caregivers in
operating rooms within VHA hospitals found that the
volume and relative difficulty of cases treated are important
determinants of facility complexity and influenced worker
perceptions of organization climate (Carney et al., 2010).
Patient volume counts the total number of patients served
by each medical facility and reflects the size of the
organizational unit. Larger organizational entities are likely
to be more formally structured, governed by standardized
practices, and be able to afford greater flexibility in work
scheduling due to slack resources, which together may
well influence, for example, perceptions of task clarity,
workload balance, and stress. Case mix intensity accounts
for differences in the acuity and complexity of care
delivered to patients. The VHA categorizes patients into
one of 94 patient classes that reflect treatment resource
intensity regardless of setting (i.e., inpatient or outpatient)
and assigns a relative value to each class derived from
national VA data of all patients in all classes. Multiplying
the total number of patients by the treatment intensity value
for each patient (effectively a weighted patient or risk-
adjusted patient) produces the weighted units of work for
each facility. We calculated a case-mix intensity ratio (CMI
ratio) by dividing the facility total weighted units of work
(numerator) by the total number of actual patients. Thus,
we have a single ratio that can be compared across the
system. For the 113 facilities in the study, a higher ratio
indicates a facility with a more intense patient case mix. A
more resource-intensive and riskier patient load is likely to
associated with a more highly-trained, specialized and well
equipped workforce faced with challenging cases, which

together may well influence, for example, perceptions of
service capability and satisfaction.
Data analyses were conducted using the SPSS
Version 19.0 software package, and propositions of cross-
group differences were tested using Multivariate Analysis
of Covariance (MANCOVA) and univariate Analysis of
Variance (ANOVA). Initially, we conducted a full set of
analyses at both the individual and facility levels. For
individual-level analyses, we simply used the scores on
each measure for every individual in each professional
category. For facility-level analyses, we aggregated survey
data by averaging the responses of individuals in each
occupational group within each of the 113 VHA facilities
to produce separate facility-level group scores on each
measure. In both sets of analyses, survey-based measures of
employee perceptions were matched with each facilitys
patient count and case-mix intensity (CMI) ratio.
The patterns of cross-group differences revealed by
the individual and facility-level analyses were virtually
identical. We chose to report the results only at the facility
level for two key reasons. First, the findings will be more
conservative due to reduced sample size (113 facilities
versus more than 38,000 individuals), which is in keeping
with the largely exploratory nature of our inquiry. Second,
using facility-level scores allows us to partially offset a
myriad of unmeasured, but potentially important,
contextual differences that influence groups across very
diverse VHA locations; such as variations in re-
organization history, organization culture and leadership,
geographic culture, and economic conditions. Thus we
would be better able to answer this studys key question: In
what ways do different professional occupational groups
within the same local facility context have differing
perceptions and evaluations of that context?
RESULTS
Table 3 reports the means and correlations of the

measures used in this study. Preliminary analyses showed
significant effects of patient count and CMI on most study
measures. As can be seen in Table 3, both measures were
significantly correlated with greater workload balance and
role alignment, and reduced work stress. Healthcare
professionals in facilities with more intense case mixes also
perceived greater job control and task clarity, and reported
stronger service capability and satisfaction. A departure
from this pattern is that greater patient volumes were
associated with weaker employee intentions to stay in their
work unit. However, for the most part, healthcare
professionals appear to have had more positive perceptions
of their work environment in larger and/or more
challenging facilities.
We also found significant effects of both patient
volume and CMI as covariates in each of the multivariate
models testing group differences discussed below. More
specifically, volume was a significant predictor of group
differences for three categories of employee perceptions
job conditions, personal work outcomes, and service
outcomes (all Pillais Trace Fs > 4.1, p < .002, eta2 > .03;
eta2 is equivalent to an R2 measure of explained variance).
Case mix also was a significant predictor of group
differences for three categories of employee perceptions
overall workplace climate, job conditions, and personal
work outcomes (all Pillais Trace F > 2.4, p < .002, eta2 >
.04). However, although the above analyses confirmed the
importance of controlling for volume and case mix, the
introduction of these control variables did not alter our
findings with respect to any of the specific effects of job
contact intensity on study measures; the focus of our
investigation. Thus, for simplification, these two control
variables are omitted from further reporting.
To avoid spurious findings attributable to our

relatively large number of variables, we first used
multivariate analysis of covariance (MANCOVA) to test
for group differences across the variables within each set of
dependent measures workplace climate, job conditions,
personal work outcomes, and perceived service outcomes
(relying on Pillais Trace criterion due to a statistically
significant Boxs M test indicating unequal variance of
covariance matrices across groups). Where a significant
multivariate effect for the contact-intensity job types was
confirmed, we then performed univariate ANOVAs to
identify the specific variables that contributed to the
multivariate effect. Where significant univariate effects
were found, we conducted post-hoc tests on the
independent (grouping) variable to determine which
professional job types differed significantly in their
perceptions of that dependent variable (using Dunnetts C
as a conservative test of pairwise comparisons across job
classifications because Levenes test indicated unequal
error variances for almost all our dependent variables).
Testing of Research Questions

With respect to Research Question 1, we found
significant and, in some cases strong, multivariate effects
affirming that contact-intensity job types (support staff,
clinical practitioners, outpatient nurses, inpatient nurses)
are differentially distributed in regard to their perceptions
on the sets of measures comprising workplace climate
(Pillais Trace = 6.2, p < .001, eta2 > .04), job conditions
(Pillais Trace = 20.1, p < .001, eta2 > .19), personal work
outcomes (Pillais Trace = 15.3, p < .001, eta2 > .12), and
service outcomes (Pillais Trace = 7.4, p < .001, eta2 > .05).
As shown in Table 4, significant univariate ANOVA
effects (F values > 3.8, p < .01) were found for every
dependent measure except workload balance, with effect
sizes (R2) ranging from 3% to 35% variance explained.
Post hoc statistical analyses were performed to
establish discrete differences between the higher-intensity
inpatient and outpatient nursing groups versus the lower-
intensity groups of technical support staff and clinical
practitioners as indicated by the subscripts in Table 4.
Several noteworthy differences were evidenced across the
spectrum of healthcare service professionals:
Technical support staff clearly were most favorable
in their perceptions of work-life balance, job
control, and service quality, yet were also much less
likely to stay in their work units.
Clinical practitioners rated job role alignment
significantly more favorably than other groups of
professionals. They also report being the least
stressed and most likely to stay in their work unit.
In general, nurses registered the least favorable
perceptions across the array of dependent variables
we studied. In particular, nurses had significantly
less positive readings of role alignment and job
control. Viewed as a group, nursing professionals,
especially inpatient nurses, were significantly more

stressed than clinical practitioners.
Work-life balance warrants special attention. This
was the only dependent variable on which all
groups were significantly different from one
another. As a group, nurses reported the lowest
appraisals of work-life balance and inpatient nurses
perceived significantly less work-life balance than
outpatient nurses.
Regarding perceptions of service outcomes, support
professionals viewed service quality most favorably
and clinical practitioners believed customers were
the most satisfied; however, no remarkably distinct
differences were observed.
The results in Table 4 also reveal a pattern that in

most instances indicates a monotonic ordering of the
cohorts when inpatient and outpatient nurses are
combined: perceptual favorability decreases as contact
intensity increases. This observation lends substantial
support to the proposition set forth in H2 that our
classification of service professionals according to
customer contact intensity is not merely categorical, but
behaves as a meaningfully ordered measure ranked
from low to high in following succession: 1= support
staff, 2=clinical practitioners, 3= nurses.
Table 4
Analysis of Variance Results for Professionals Grouped by
Customer Contact Intensity.
Support Clinical Outpatient Inpatient R2
Staff Practitioners Nurses Nurses /
N=113 N=113 N=113 N=113 Sig
facilities
Vars Mean s.d. Mean s.d. Mean s.d. Mean s.d.
Work
Climate
HPWS 3.04 a .20 3.00 a,b .22 2.93 b,c .29 2.86 b,c .30 .07
***
Customer 3.66 a .18 3.62 a,b .16 3.58 b .25 3.59 b .21 03
Orient. **
Job
Condit.
Task 3.18 a .21 3.16 a .26 3.11 a,b .34 3.03 b .35 .04
Clarity ***
Role 2.26 a .13 2.37 b .12 2.25 a .22 2.21 a .18 .11
Align: ***
4 pts
Wkload 2.39 .14 2.41 .14 2.36 .21 2.37 .17 .02
Bal.: 4pts ns
Work- 3.54 a .18 3.45 b .22 3.27 c .35 3.12 d .33
Life Bal. .25
Balance
Job 2.94 a .10 2.80 b .11 2.69c .19 2.68 c .17 ***
.35
Control: ***
4 pts
Personal
Work
Outcomes
Work 3.30 a,b .15 3.26 a .17 3.34 b,c, .28 3.41 c .26 .06
Stress ***
Service
scale 3.25 a .18 3.10 b .20 3.12 b .31 3.05 b .26 .09
Capab ***
Emp. Sat 3.51 a .17 3.50 a .18 3.48 a .27 3.38 b .29 .05
***
Intent to 3.32 a .24 3.64 b .21 3.61 b .33 3.60 b .26 .19
Stay ***
Service
Outcomes
Service 3.73 a, .25 3.66 a,b .23 3.62 b .29 3.58 b .26 .04
Quality ***
Customer 3.84 a,b .21 3.89 b .18 3.79 a .27 3.79 a .26 03
Sat **
Note: * denotes ANOVA p < .05, ** denotes p < .01, *** denotes p <.001.
Means in the same row that do not share the same subscripts differ at p < .05 on the
Dunnett-C measure of between-group differences.
DISCUSSION AND MANGERIAL IMPLICATIONS
Changing reimbursement methods and competitive

pressures have made customer service an issue of elevated
concern to health policy analysts and healthcare managers.
Obtaining a better understanding of the characteristics of
professional subgroups that may lead them to respond
differentially to workplace dynamics believed to drive
organizational performance is of importance to healthcare
decision-makers who wish to successfully address the
customer service imperative. Results from the present study
revealed differences in perceptions of workplace climate
and service outcomes between support staff and front-line
service professionals as a function of customer contact
intensity. This finding is consistent with, and further
reinforces, prior research. Our study is, however, the first
attempt that we are aware of to document such potentially
important differences among various subgroups of direct
service professionals and to do so in a health care setting.
The fundamental conclusion drawn from our research is
straightforward. Both place of work (climate) and
circumstances of work (job conditions) are critical
determinants of the personal attitudes and ultimate service
outcomes of professional employees. Moreover, these
dynamics are further influenced by the type of work
(customer contact intensity) performed by different
subgroups of service professionals.
The mere acknowledgement that subgroups of
health service professionals vary in their assessments and
response to pre-established rudiments linking climate to
outcomes should spur healthcare administrators to
undertake a systematic examination of the nature and
magnitude of such differences both within and across
classes of professional support staff, clinical practitioners,
and nurses. Qualitative insights can be gained through the
use of structured interviews and focus groups to elicit
unique perspectives from the various classes of

professionals. Further knowledge can be gained by better
understanding the ways in which contact with customers
variably impacts the work processes and emotional labor
performed by alternative classes of health service
professionals. A particularly fruitful approach for such
efforts may be drawn from the field of participatory action
research (PAR) as applied to healthcare settings (Glasson et
al, 2008; Kowalski et al, 2003; Pugh et al, 2009). PAR uses
a collaborative, cyclical, reflective inquiry design that
focuses on problem solving, improving work practices, and
understanding the effect of the research or intervention as
part of the process. It calls for involvement of a team of key
individuals with a fundamental knowledge of the context
and felt need for improvement in repeated cycles of
incremental change and sense-making, analogous to 'plan-
do-study-act.'
There are multiple interpretations that may account
for the cross-group differences observed in this study. One
possibility is that management creates a uniform set of
working conditions yet different groups of professionals
perceive their work environments non-uniformly
(asymmetrically). Another possibility is that management
invests in creating different work climates customized for
various groups of professionals, and employees
perceptions accurately reflect these different management
practices. It is also possible that upper management invests
in creating different work climates for various groups of
professionals but middle management fails to properly
expose professionals to these interventions (through
ineffective implementation) resulting in perceptions that
differ from upper managements strategic intent (i.e., there
is a gap between policy and practice). We raise the latter as
a concern in light of recent evidence that senior-level
commitment to strategic work practices has gained limited
support among mid-level managers and line supervisors
(Young et al., 2010). Of course it is conceivable that more

than one of these scenarios may be operant within a
particular organization. Accordingly, we encourage
executives to be mindful of each when designing
qualitative inquiries mentioned earlier.
More specifically, based on our findings from one
of the worlds largest health systems, we encourage
managers to pay particular attention to the asymmetric
impact of workplace climate variables on professionals
perceptions of job conditions. Even after controlling for the
generally positive influence that larger and more complex
health facilities had on perceptions, differences across
cohorts persisted. This suggests that our findings pertaining
to group differences apply across facilities of various size
and complexity. Job control and work-life balance warrant
special attention. As a case in point, inpatient nurses sensed
that they have significantly less task clarity and control
over the way they perform their work than other
professional groups. Whereas clinical practitioners are
likely to derive their sense of job control and task clarity
from external sources (e.g., professional affiliations and
standards of practice) when shaping definition of their
roles, nurses may be more dependent on internal
management practices (e.g., organizational training and
development activities) as their primary source of role
definition. With respect to work-life balance, which is
particularly crucial to the retention of physicians and nurses
(Nowak, Holmes, and Morrow, 2010), managers are
advised to survey employees and design practices that
reflect the unique viewpoints of each of the professional
groups identified in this study. Our finding that support
staff are significantly more likely to leave their work units
than are direct care providers might be explained by their
possession of skill sets that are portable across work units
and industry boundaries; however, for the VHA this may be
the lesser of evils because turnover of direct care
professionals inflicts greater organization costs and erosion

of patient care quality. Notwithstanding, this observation
calls for further inquiry by management.
In contrast with conventional practice, a universal
approach to human resource management may not be the
most appropriate method to invest scarce organizational
resources. The present study suggests that it may be
prudent for healthcare executives to consider a more
tailored strategy for managing the interface between
workplace climate and employee work outcomes (personal
and organizational). Investment decisions should be
matched to the level required to stimulate positive
employee perceptions of key parameters that drive
desirable outcomes, and should reflect the cost of human
capital acquisition associated with each class of
professionals and their relative contribution to achieving
the firms mission and strategic objectives (Lepak et al.,
2007). Professionals are important resources because of
their specialized knowledge, labor expense, and scarcity
(Capelli, 1997). Efforts such as those described herein,
should go a long way toward maximizing human resource
investments by underwriting patient satisfaction and
financial sustainability.
Very recent discussions with VHA human resource
executives indicate that the importance of occupational-
group differences such as those reported here are being
increasingly recognized within the organization and that a
number of programs to address them have been undertaken
since around 2005. For example, data from entry, exit and
general employee surveys are being more carefully
analyzed to gain a deeper understanding of how key
recruitment, retention, satisfaction and performance factors
vary across occupational specialization (particularly in such
critical categories as physicians, nurses, pharmacists, and
diagnostic technicians). Systems-design initiatives at both
the national and regional network levels, involving multi-
disciplinary teams (e.g., physicians, nurse leaders, staff

nurses), have generated clearer service-line agreements on
how work gets done and who does what, creating greater
role clarity and job control for nurses. To help lessen the
work-life tension for bedside nurses between tending to
their personal responsibilities versus caring for patients,
policies have been introduced (some codified in union
contracts) to reduce rotating-shift scheduling and
mandatory overtime, and provide onsite childcare. A final
example is that training programs have been introduced at
all levels to help supervisors and managers (particularly
those with long tenure) become more aware of important
inter-group and inter-generational differences and how they
might be addressed.
Although not the focus of the present study, we
performed a series of follow-up regression analyses (see
appendix) which, consistent with prior linkage research,
show that important organizational outcomes are linked to
the variables examined in this study (with climate
predicting job conditions and personal outcomes, and these
factors predicting service quality, actual customer
satisfaction, and cost efficiency). Given our findings of
significant differences across occupational groups in the
variables that shape perceived customer service quality,
attention to such cross-group differences is likely to have
meaningful impact on organization outcomes.
Our research is not without limitations. First, we
were limited to convenience measures by the design of the
VHA survey, although the face, content, and construct
validities of our measures appear to be acceptable. Second,
the reported findings are based on cross-sectional data,
restricting our ability to certify the durability of employee
perceptions of the dependent variables and the extent to
which their assessments are subject to effects of tenure as
they progress through the various stages of the chain
model. Third, the broad classification schema utilized in the
VHA survey did not permit us to isolate more granular and

refined distinctions between clinical practitioners whose
subspecialties promote prolonged and more intense contact
with their clients versus those that deal episodically with
the immediate needs of patients (e.g., primary care
physicians versus surgeons, mental health social workers
versus discharge planners). It is likely that this limitation
constrained our ability to reveal the full effect of significant
variation in contact intensity among clinical professionals,
leading to a more conservative estimate of the impact of
this independent variable. Fourth, employee perceptions of
work environment and service outcome were drawn from
the same source, which raises concern about common
method bias; however, this limitation may not be as
problematic as is widely suspected (Judge, et al. 1998;
Meade et al, 2007). Finally, the data supporting this study
were garnered from a single, albeit very large and diverse,
public health system. The extent to which findings can be
generalized to private sector health organizations is
unclear; although a recent study of healthcare employee
perceptions of work climate and service quality found no
differences between public and private hospitals (Rod and
Ashill, 2010).
Of foundational importance to the line of inquiry we
advance here is future research that thoroughly documents
the work of various direct service professionals and
rigorously maps that work along a widely accepted
continuum of contact intensity. Additionally, the relative
importance of the dependent variables to various groups of
professionals needs to be identified. Subsequent studies
should also strive to measure and examine the influence on
employee perceptions of variables not available for
inclusion in the present study such as age, seniority, years
in practice, job security, and personality traits (e.g., locus-
of-control and self-esteem). For example, our finding that
nurses had the lowest appraisals of their work-life balance
may be partially accounted for by unmeasured factors such

as their age and the disruptive nature of the work shifts
relative to the other professional groups under study.
Finally, future research needs to incorporate the use of
actual rather that perceptions of service outcomes to elevate
the level of confidence in our findings.
In summary, we do not propose to offer a definitive
conceptualization of the complex web of organizational
dynamics that fully explains the flow of events which
translate work climate into high performance outcomes, nor
do we claim that the suggested framework accurately
captures the totality of forces that mediate and/or moderate
the linkages within and among the subsets of variables in
the linkages chain. We do, however, believe our conceptual
approach and findings that perceptions across groups of
service professionals vary by their level of customer
contact intensity provide a launch point for energizing
confirmatory investigation and for stimulating dialog
among and between strategic managers, operational
supervisors, and various groups of professional service
workers. Such investigation and dialogue are very likely to
be quite consequential. Our supplemental analyses (shown
in the appendix) comport with the system of relationships
that constitute the linkage research reviewed in our
foundation section, and that have been shown to
significantly impact organization effectiveness. Thus we
conclude that strategic human resource practices tailored to
the varied needs of different groups of direct service
providers along the contact-intensity continuum hold
considerable potential for optimizing the performance of
service organizations.
APPENDIX
Supporting the temporal relationships posited in the

linkage literature, regression analyses revealed that
aggregated employee assessments of service outcomes
(service quality and customer satisfaction) by all the
professionals in each of our 113 facilities were strong
predictors of actual quality ratings and expressions of
satisfaction and loyalty by the outpatient customers of these
facilities (using customer survey measures previously
reported in Scotti et al (2009); F > 55.7 and R2 > .49 for
both measures). Moreover, perceived service quality was a
significant predictor of lower average treatments costs
across facilities (using a measure of treatment cost
efficiency previously reported in Harmon et al (2003); F
6.0, R2.04). We also found that the overall workplace
climate measures (HPWS and customer orientation) jointly
predicted a significant amount of variation in: 1) all our
measures of job conditions (ranging from F > 8.4 and R2 >
.12 for workload balance to F > 208 and R2 > .79 for task
clarity), 2) all our measures of personal outcomes except
intent to stay (Fs > 21.5 and R2 > .27), and 3) both
measures of service outcomes (both Fs > 55.7 and R2 >
.49). Further, the five job condition measures collectively
predicted a significant amount of variation in: 1) each
personal outcome measure (ranging from F > 2.4 and R2 >
.06 for intent to stay to F > 47.2 and R2 > .67 for
satisfaction), and 2) both measures of service outcomes
(both Fs > 11.3 and R2 > .32). Finally, we found the
personal outcome measures to collectively be an even
stronger predictor of service outcomes than those for job
conditions (both Fs > 20.0 and R2 > .39).
REFERENCES
Anderson, E. W., & Mittal, V. (2000). Strengthening the

satisfaction-profit chain. Journal of Services
Research 3 (2): 107-120.
Arnold, T., Flaherty, K. E., Voss, K. E., & Mowen, J. C.

(2009). Role stressors and retail performance: The
role of perceived competitive climate. Journal of
Retailing, 85 (2): 194-205.
Becker, B.E., & Huselid, M.A. (1998). High-performance

work systems and firm performance: A synthesis of
research and managerial implications. In Ferris,
G.R. (Ed.), Research in Personnel and Human
Resources Management, Vol. 16, 53-101. Stamford,
CT: JAI Press.
Bernhardt, K. L., Donthu, N., & Kennett, P. A. (2000). A

longitudinal analysis of satisfaction and
profitability. Journal of Business Research, 47 (2):
161-171.
Borucki, C. C, & Burke, M. J. (1999). An examination of

service-related antecedents to retail store
performance. Journal of Organizational Behavior,
20 (6): 943-962.
Capelli, P. (1997). Rethinking the nature of work: a look at

the research evidence. Compensation and Benefits
Review, 29 (4): 50-59.
Carney, B. T., West, P., Neily, J., Mills, P. D., & Bagian, J.
(2010). The effect of facility complexity on
perceptions of safety climate in the operating room:
Size matters. American Journal of Medical Quality,
25 96): 457-461.
Chang, T., & Chen, S. (1998). Market orientation, service

quality and business profitability: A conceptual
model and empirical evidence. Journal of Services
Marketing,12: 246-64.
Chang, S. (2008). Work role stressors and turnover

intentions: A study of it personnel in South Korea.
Zeitschrift fr Personalforschung,22 (3): 272-290.
Chebat, J. C., & Kollias, P. (2000). The impact of

empowerment on customer contact employees
roles in service organizations. Journal of Service
Research, 3 (1): 66-81.
Combs, J., Liu, Y., Hall, A., & Ketchen, D. (2006). How
much do high-performance work practices matter?
A meta-analysis of their effects on organizational
performance. Personnel Psychology, 59 (3): 501-
527.
Cooperrider, D., & Whitney, D. (2005). Appreciative

Inquiry: A Positive Revolution in Change. San
Francisco, CA: Berrett-Koehler Publishers, Inc.
Cusack, G., Jones-Wells, A., & Chisholm, L. (2004).

Patient intensity in an ambulatory oncology
research center: A step forward for the field of
ambulatory care. Nursing Economics, 22 (2): 58-63.
Dean, A. M. (2004). Links between organizational and

customer variables in service delivery: Evidence,
contradictions, and challenges. International
Journal of Service Industry Management, 15 (4):
332-350.
Deitz, J., Pugh S. D., & Wiley, J. W. (2004). Service

climate effects on customer attitudes: an
examination of boundary conditions. Academy of
Management Journal, 47: 81-92.
Delery, J. E. (1998). Issues of fit in strategic human

resource management: Implications for research.
Human Resource Management Review, 8: 289-309.
Fottler, M. D., Duncan D., Ford, R. C., Bradley, K., &

Johnson L. (2006). Comparing hospital staff and
patient perceptions of customer service: A pilot
study utilizing survey and focus group data. Health
Services Management Research, 19 (1): 52-66.
Frone, M. R. (2003). Workfamily balance. In Quick, J.C.

and Tetrick, L.C. (Eds.), Handbook of Occupational
Health Psychology. Washington, D.C.: APA , 143-
162.
Gibson, C.B. (2001). Me and us: Differential relationships

among goal-setting, training, efficacy and
effectiveness at the individual and team level.
Journal of Organizational Behavior, 22: 789-808.
Gilboa, S., Shirom, A., Fried, Y., & Cooper, C. (2008). A

meta-analysis of work demand stressors and job
performance: Examining main and moderating
effects. Personnel Psychology, 61 (2): 227-271.
Gist, M. E., & Mitchell, T. R. (1992). Self-efficacy: A

theoretical analysis of its determinants and
malleability. Academy of Management Review, 17
(April), 183-211.
Glasson, JB, Chang, EM, Bidewell, JW (2008). The value

of participatory action research in clinical nursing
practice. International Journal of Nursing Practice,
14 (1):34-39.
Goldstein, S. M. (2003). Employee development: an

examination of service strategy in a high-contact
service environment. Production and Operations
Management, 12 (2): 186-203.
Hartline, M.D., & Ferrell, O.C. (1996). The management of

customer-contact service employees: An empirical
investigations. Journal of Marketing, 60 (10): 52-
70.
Harmon, J., Scotti, D.J., Behson, S.J., Farias, G., Petzel, R.,
Neuman, J., & Keashly, L. (2003). Effects of high-
involvement work systems on employee satisfaction
and service costs in Veterans healthcare. Journal of
Healthcare Management, 48 (6): 393-405.
Heskett, J. L., Sasser, W. E., & Schlesinger, L. A. 1997.

The Service-Profit Chain. New York: Free Press.
Huselid, M. A. (1995). The impact of human resource

management practices on turnover, productivity,
and corporate financial performance. Academy of
Management Journal, 38: 635-672.
Huber, D. (1995). Understanding the sources of stress for

nurses. Australian Journal of Nursing, 12, 87-100.
Johnson, J. (1996). Linking employee perceptions of
service climate to customer satisfaction. Personnel
Psychology, 49 (4): 831-851.
Judge, T. A., Locke, E. , Durham, C. C., & Kluger, A. N.

(1998). Dispositional effects on job and life
satisfaction: the role of core evaluations. Journal of
Applied Psychology, 83 (1): 17-34.
Katz, D., & Kahn, R. L. (1978). The Social Psychology of

Organizations, Willey, New York, NY.
Kelley, S. W. (1992). Developing customer orientation

among service employees. Journal of the Academy
of Marketing Science, 20: 27-36.
Kossek, E. E., and Ozeki, C. (1998). Work-family conflict,

policies, and the job-life satisfaction relationship: A
review and directions for organizational behavior
human resources research. Journal of Applied
Psychology, 83: 139-149.
Kowalski, R., J. Harmon, L. Yorks & D. Kowalski. (2003).

reducing workplace stress and aggression: An
action research project at the U.S. Department of
Veterans Affairs. Human Resources Planning
Journal, vol. 26, no. 2, 39-53.
Lawler, E. E., S. A. Mohrman, & G. E. Ledford. (1995).

Creating High Performance Organizations. San
Francisco: Jossey-Bass.
Leggat, S. A., Bartram, T., Casimir, G., & Stanton, S.

(2010). Nurse perceptions of the quality of patient
care: Confirming the importance of empowerment
and job satisfaction. Health Care Management
Review, 35 (4); 355-364.
Lepak, D. P., Taylor, M. S., Tekleab, A., Marrone, J. A., &

Cohen, D. J. (2007). An examination of the use of
high-investment human resources systems for core
and support employees. Human Resource
Management, 46 (2): 223-246.
Liu, C., Spector, P. E., & Jex, S. M. (2005). The relation of

job control with job stains: A comparison of
multiple data sources. Journal of Occupational and
Organizational Psychology, 78 (9): 325-336.
Luthans, F. (2002). The need for and meaning of positive

organizational behavior. Journal of Organizational
Behavior, 23 (6): 695-706.
Ma, J.C., Lee, P.H, Yang, Y.C., & Chang, W.Y. (2009).
Predicting factors related to nurses intention to
leave, job satisfaction, and perception of quality of
care in acute care hospitals. Nursing Economics, 27
(3): 178-202.
Mac Neill, K. M. (1998). Controlling physician stress:

Moderating effect of perceived job control on
relationship between job stressors and job attitudes.
Thesis. California State University, Long Beach.
Mayer, D. M., Ehrhart, M. G., & Schneider, B. (2009).

Service attribute boundary conditions of the service
climate-customer satisfaction link. Academy of
Management Journal, 52 (5): 1034-1050.
Meade, A. W., Watson, A. M., & Kroustalis, C. M. (2007).

Assessing common method bias in organizational
research. Paper presented at the 22nd Annual
Meeting of the Society for Industrial and
Organizational Psychology, April, 2007, New York,
1-8.
Nadler, D. A., & M. S. Gerstein. (1992). Designing high-

performance work systems: organizing people, work,
technology and information. In Organizational
Architecture, edited by D. A. Nadler, M. S.
Gerstein, R. B. Shaw and associates, 11032. San
Francisco: Jossey-Bass.
Nowak, P., Holmes, G. & Morrow, J. (2010). A model for

reducing health care employee turnover. Journal of
Hospital Marketing & Public Relations, 20: 14-25.
Nunnally, J. C. (1978). Psychometric theory (2nd ed.). New

York: McGraw-Hill.
Pugh, S.D., Diets, J., Wiley, J.W., & Brooks, S.M. (2002).
Driving Service Effectiveness Through Employee-
Customer Linkages. Academy of Management
Executive, 16 (4): 73-84.
Pugh, J. A., L. K. Leykum, H. J. Lanham, J. Harmon, & R.

R. McDaniel, Jr. (2009). Implementation research
design: Integrating participatory action research into
randomized controlled trials. Implementation
Science. 46 (69). doi:10.1186/1748-5908-4-69,
http://www.implementationscience.com/content/4/1
/69.
Robinson, L., Neeley, S. E., & Williamson, K. (2009).

Implementing service recovery through customer
relationship management: Identifying the
antecedents. Journal of Services Marketing, 25 (2):
90-100.
Rod, M., & Ashill, N.J. (2010). Management commitment

to service quality and service recovery performance:
A study of frontline employees in public and private
hospitals. International Journal of Pharmaceutical
and Healthcare Marketing, 4 (1): 84-103.
Rogelberg, S.G., Barnes-Farrell, J. L., & Creamer V.

(1999). Customer Service Behavior: The
Interaction of Service Predisposition and Job
Characteristics. Journal of Business and
Psychology, 13 (3): 421-435.
Rogg, K. L., Schmidt, D. B., Shull, C., & Schmitt, N.

(2001). Human resource practices, organizational
climate, and customer satisfaction. Journal of
Management, 27: 431-449.
Ruyter, K. Wetzels, M. & Feinberg, R. (2001). Role of

stress in call centers: Its effects on employee
performance and satisfaction. Journal of Interactive
Marketing, 15 (2): 23-35.
Schneider, B. (Ed.). (1990). Organizational Climate and

Culture. San Francisco: Jossey-Bass.
Schneider, B., & D. E. Bowen. (1985). Employee and

Customer Perceptions of Service in Banks:
Replication and Extension. Journal of Applied
Psychology, 70: 423-433.
Schneider, B., White, S.S., & Paul, M.C. (1998). Linking

Service Climate and Customer Perceptions of
Service Quality: Test of a Causal Model. Journal
of Applied Psychology, 83: 150-163.
Schneider, B. and White, S. S. (2004). Service Quality

Research Perspectives. Thousand Oaks, CA: Sage.
Scotti, D.J., Harmon, J., & Behson, S.J. (2007). Links

Among High-Performance Work Environment,
Service Quality, and Customer Satisfaction: An
Extension to the Healthcare Sector. Journal of
Healthcare Management, 52 (3): 109-125.
Scotti, D.J., Harmon, J., & Behson, S.J. (2009). Structural

relationships between work environment and
service quality perceptions as a function of
customer contact intensity: Implications for human
service strategy. Journal of Health and Human
Services Administration, 32 (2): 195-233.
Silvestro, R. (2002). Dispelling the modern myth:

employee satisfaction and loyalty drive service
profitability. International Journal of Operations &
Production Management, 22 (1):30-49.
Slatten, T. (2008). Antecedents and effects of emotional

satisfaction on employee-perceived service quality.
Managing Service Quality, 18 (4): 370-386.
Spector, P. E. (1986). Perceived control by employees: A

meta-analysis of studies concerning autonomy and
participation at work. Human Relations, 39 (11):
1005-1016.
Swan, B. A. (2007). Transitioning from acute care to

ambulatory care. Nursing Economics, 25 (2): 130-
134.
Young, G. J., Meterko, M. M., Mohr, D., Shwartz, M., &

Lin, H. (2009). Congruence in the assessments of
service quality between employees and customers: a
study of a public health care delivery system.
Journal of Business Research, 62: 1127-1135.
Young, S., Bartram, T., Stanton, P., & Leggat S. G. (20100.

High performance work systems and employee
well-being: a two stage study of a rural Australian
hospital. Journal of Health Organization and
Management, 24 (2): 182-199.
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Linkages Between Organization Climate and Work Outcomes

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LINKAGES BETWEEN ORGANIZATION CLIMATE

AND WORK OUTCOMES: PERCEPTUAL

The delivery of high-quality service, rendered by health

the nature of work performed by health service professionals as well as

In response to recent statutory pressures to improve

Evidence supports the importance of creating a

professionals stratified by the intensity of their patient

BACKGROUND AND CONCEPTUAL

The present study borrows from a substantial and

and kinds of behaviors that are expected, supported, and

Work Climate Work Climate

Job Conditions Job Conditions

Personal Work Outcomes Personal Work Outcomes

Service Outcomes Service Outcomes

Organizational Performance Outcomes Organizational Performance Outcomes

Deployment of systematic assemblages of best

Personal Work Outcomes

and related feelings of empowerment have also been

Organizational Performance Outcomes

customer service outcomes and organizational outcomes

in services where there are high levels of

The contextual qualities identified by Silvestro are

connection generally assumed to exist between employee

Contact Intensity as a Moderating Force

Schneider, 2009), and between high-contact healthcare

Research Question 1: Do perceptions of linkage

Research Question 2: Are perceptions of linkage

organizational service outcomes meaningfully

Variables and Measures

Dependent variables. To capture the several streams of

4) service outcomes. Measures of organizational outcomes

degree to which employees believed that their organization

Job Conditions. It should be noted that our

jobs. Role alignment was measured by responses on a 4-

their ability to deliver high-quality customer service at their

Independent and control variables.

staff, 14,044 (36%) were clinical practitioners, 4,929 (13%)

equipped workforce faced with challenging cases, which

Table 3 reports the means and correlations of the

To avoid spurious findings attributable to our

Testing of Research Questions

especially inpatient nurses, were significantly more

The results in Table 4 also reveal a pattern that in

DISCUSSION AND MANGERIAL IMPLICATIONS

Changing reimbursement methods and competitive

unique perspectives from the various classes of

(Young et al., 2010). Of course it is conceivable that more

professionals inflicts greater organization costs and erosion

disciplinary teams (e.g., physicians, nurse leaders, staff

VHA survey did not permit us to isolate more granular and

may be partially accounted for by unmeasured factors such

Supporting the temporal relationships posited in the

Anderson, E. W., & Mittal, V. (2000). Strengthening the

Arnold, T., Flaherty, K. E., Voss, K. E., & Mowen, J. C.

Becker, B.E., & Huselid, M.A. (1998). High-performance

Bernhardt, K. L., Donthu, N., & Kennett, P. A. (2000). A

Borucki, C. C, & Burke, M. J. (1999). An examination of

Capelli, P. (1997). Rethinking the nature of work: a look at

Chang, T., & Chen, S. (1998). Market orientation, service

Chang, S. (2008). Work role stressors and turnover

Chebat, J. C., & Kollias, P. (2000). The impact of

Cooperrider, D., & Whitney, D. (2005). Appreciative

Cusack, G., Jones-Wells, A., & Chisholm, L. (2004).

Dean, A. M. (2004). Links between organizational and