Balancing service inclusion for primary and secondary customers experiencing vulnerabilities

1. Introduction

It’s so lovely to come here. You get care for yourself, too. Originally, I thought I’m only a next-of-kin, that there’s no need for them to comfort me. But when you call here and the nurse says, ‘Don’t you worry ‘bout a thing, you come when you can, everything’s fine here.’ And it’s like […] mercy. (Family member of a nursing home resident)

As this quote indicates, the influence potential of some services considerably extends beyond the primary customer, most often to family members. The primary customers of elderly care services are the elderly, who can be regarded as customers experiencing vulnerabilities. When the primary customer faces vulnerabilities, family members usually take on caregiver roles, and they can experience secondary vulnerability (Pavia and Mason, 2014), which is different from the vulnerability experienced by the primary customer but directly related to it. Often, family members are also closely involved and in supportive roles with regard to the service. Consequently, and based on their potential experience of secondary vulnerability, they can be regarded as secondary customers of these services (Leino, 2017).

Family members often make decisions on behalf of or together with the primary customer – typically due to the primary customer’s bounded abilities – and they consider themselves and the person being cared for as a unit (Sarvimäki et al., 2017). Johns and Davey (2019) introduce the concept of the transformative service mediator (TSM) to explain how multiple actors (from service providers to consumer advocates, such as family members) can mediate services and value outcomes for consumers experiencing vulnerabilities. Besides mediating services for the primary customer, secondary customers are also influenced by the service provided to their close other (Leino, 2017). Furthermore, individuals that experience secondary vulnerability may seek relief from systems and services originally designed for the primary customers facing vulnerabilities (Pavia and Mason, 2014). Thus, secondary customers also have special needs relating to these services, presumably other- and self-related. This may cause challenges if the services are not prepared to acknowledge both primary and secondary customers’ needs and hence, service inclusion (Fisk et al., 2018) is not adequately fostered.

Transformative service research (TSR) advocates for value creation and well-being generation for the entire family (Anderson et al., 2013; Rosenbaum et al., 2011) or customer entity (Anderson et al., 2018). Family-centred care and family systems thinking are recommended, yet not systematic (Byrne, 2016; Fogarty and Mauksch, 2017). In health services such as hospice care, support for family caregivers is considered central, but studies and assessment tools typically concentrate on patients’ rather than family caregivers’ needs (Hudson et al., 2010). Family members’ needs are understudied, especially in long-term care service environments (Garity, 2006), and more family-friendly practices should be developed, inclusive of the needs of the family (Bauer, 2007). This suggests that while family members may have access to services as companions of primary customers, their needs often remain undiscovered and/or unmet by the service provider.

Moreover, the COVID-19 pandemic has concretely highlighted how access to services and access to the customers within services is not self-evident. In particular, some individuals experiencing vulnerabilities have suffered from the pandemic and from service exclusion (Finsterwalder et al., 2020). The inclusion or exclusion of family members of customers who are experiencing vulnerabilities is not explicitly addressed in the emergent service inclusion theory from the TSR paradigm, which Fisk et al. (2018, p. 835) conceptualise as “an egalitarian system that provides customers […] with fair access to a service, fair treatment during a service and fair opportunity to exit a service”. Using service inclusion theory, Bianchi (2021) does study family members’ role in assisting and thus enhancing elderly individuals’ service inclusion, but the family members’ experiences of vulnerability or their service exclusion are not addressed. Furthermore, Finsterwalder and Kuppelwieser (2020) call for clarity in the academic debate concerning the effects of transformative services beyond the focal actors involved.

Therefore, we use service inclusion as a lens through which to understand primary and secondary customers’ experiences of vulnerability. The purpose herein is to study secondary customers’ needs and their relationship to primary customers’ needs in a nursing home service context. This is an essential context because the ageing population is a global phenomenon, and the number of elderly people who require caretaking is rapidly rising (Fisk et al., 2018; United Nations, 2017). Consequently, there is a high number of family members involved. We answer the following research questions: What kinds of needs do secondary customers have in a nursing home service environment? How do these needs relate to primary customers’ needs? How do they reflect vulnerabilities?

The study addresses extended experiences of vulnerability within a family, responding to the call to study different layers of vulnerability (Luna, 2019; Pavia and Mason, 2014). This brings a novel perspective to the service inclusion discussion since the expanded understanding of relational customer needs and experienced vulnerabilities provides insights into how service inclusion, as a concept, relates to secondary customers. The study advocates for service inclusion for all members of a customer entity, but also introduces possible complexities arising from such inclusion. This responds to Kuppelwieser and Klaus’ (2020) call to build more awareness of the inclusion challenge for the service marketing discipline. Thus, the study contributes to three specific, partially intertwined areas in the service theory and literature:

1. consumers who experience vulnerability;

2. secondary customers within services; and

3. service inclusion.

2. Customers’ multi-layered experiences of vulnerability in transformative services

TSR advocates for research that studies how services can enhance the well-being of individuals and their families or community collectives (Anderson et al., 2013; Rosenbaum et al., 2011). To generate well-being, the service provider must recognise and meet customers’ needs, including their latent needs (Hurmerinta and Sandberg, 2015). Research has been called for, especially on the omitted area of how service design and processes influence consumers experiencing vulnerabilities (Anderson et al., 2018; Rosenbaum et al., 2017). A focussed design for service inclusion is needed because service systems have a crucial role in promoting human well-being and because consumers who experience vulnerability often suffer from service exclusion (Fisk et al., 2018, 2020).

Fisk et al. (2018) suggest four pillars of service inclusion: enabling opportunities (providing access to services and the ability to receive and co-create valued services), offering choice (between different service offerings and opting out of services), relieving suffering (fair access to essential services that fulfil basic human needs) and fostering happiness (hedonic well-being from services) (p. 844). To understand how the pillars of service inclusion relate to the different layers of customers’ vulnerability experiences, it is essential to first discuss vulnerability in general and in the customer context.

Vulnerability has been defined by the factors causing it, by its durability and by the sphere of influence. Universal human vulnerability (Rogers et al., 2012) or ordinary vulnerability (Sellman, 2005) refers to the paradigm that considers all human life as characterised by vulnerability, based on human embodiment, sociality and dependency on others. Contextual vulnerability refers to a relative and context-specific condition that may be faced by anyone in any situation (Baker et al., 2005; Luna, 2019; Shultz and Holbrook, 2009). These definitions imply that all of us can experience vulnerability, thus suggesting that issues such as service exclusion or service failing to meet our essential needs can generate feelings of vulnerability.

However, there are also specific factors that can exacerbate the experiences of vulnerability of some individuals or trigger experiences of extraordinary vulnerability (Rogers et al., 2012; Sellman, 2005). Often, this kind of vulnerability experience results from the presence of an underlying condition, such as health-related or capability-related challenge resulting from deficits in cognitive, biological and physiological abilities (Griffiths and Harmon, 2011; Hare et al., 2013), and from depending on others for care (Sellman, 2005). Thus, it typically concerns primary customers of healthcare or nursing services.

Dependency also generates experiences of vulnerability through another mechanism; due to the dependencies involved in human relationships, vulnerability is extended to close others (Mackenzie et al., 2014). This supports the concept of secondary vulnerability (Pavia and Mason, 2014) which is a relevant concept when considering the experiences of vulnerability and the service outcomes for the entire customer entity.

Experiences of secondary vulnerability or dependencies within a customer entity have been labelled with various parallel concepts in recent service research. Fletcher-Brown et al. (2020) introduce principal vulnerable consumers who are directly affected by the chronic disease and associate vulnerable consumers who have some proximity to the disease, for instance, by family or friendship connection. Associate vulnerable consumers act in consumer–producer roles, which highlights their active and co-creative roles even outside the service settings. Kelleher et al. (2020) label family caregivers as nonreferent beneficiaries who coordinate value co-creation in service systems on behalf of dependent family members (labelled as referent beneficiaries), thus describing their active role in service systems. Similarly, Johns and Davey’s (2019) TSM concept implies an active role, as it explains how other actors mediate the services and their value outcomes for consumers experiencing vulnerabilities. These actors can range from service providers to consumer advocates, service gatekeepers and risk analysts, encompassing unofficial and official actors related to the consumer; thus, all TSMs are not in close relations with the consumer. Leino (2017) focuses on those actors who can be regarded as close others of the vulnerable customers and calls them secondary customers. She underscores their role as service recipients alongside the primary customers: ‘secondary customers should be seen as an integral part of the service process […] created to serve both the primary and secondary customers, yet recognising and addressing their differing needs in the service design.’ (Leino, 2017, p. 766)

The concept of a secondary customer is adopted in this paper because the purpose is to specifically acknowledge the customer status of the family members, hence underscoring their needs as service recipients. The construct “customers’ experiences of vulnerability” is used to refer to the customers’ own experiences of vulnerability, but also to vulnerability experiences as observed by others, because some individuals “do not have the full range of capacities necessary to articulate the subjective experience of vulnerability”, for instance infants or those with Alzheimer's disease (Sellman, 2005, p. 7).

3. Nursing homes as a service and research context

Besides the ageing population, the nursing home context is important due to the research gaps concerning family members. There is a shortage of research, especially on family-caregiver adjustment and family-caregiving roles in nursing home environments (Davies and Nolan, 2006; Garity, 2006). Moreover, this service context is sensitive and prone to triggering experiences of vulnerability, as it often evokes strong, even ambivalent emotions, such as guilt and relief in family members (Alonso et al., 2017; Paun et al., 2015).

Pavia and Mason (2014) propose that experiences of secondary vulnerability are emphasised in contexts where experiences of primary vulnerability result from complex, dynamic and unresolvable situations, meaning that the situation leading to experienced vulnerability cannot be remediated and the challenges leading to it are changing and ongoing. This applies to many transformative service contexts, nursing homes being among those, because the elderly need to move to the nursing home due to the unresolvable challenge of not coping independently and typically of the changing and ongoing decline in cognitive and/or physiological conditions. Furthermore, Sellman (2005) notes that to be in need of nursing, automatically means experiencing extraordinary vulnerability, due to feelings of dependency on others. In addition, nursing homes share certain features, such as the care being permanent and terminal, which may trigger experiences of vulnerabilities in both primary and secondary customers.

The family members’ involvement in care has also been considered influential regarding primary customers’ well-being (Backhaus et al., 2020; Reid and Chappell, 2017; Verbeek, 2017), but challenges in establishing partnerships between staff and family members are common (Verbeek, 2017). Bianchi (2021) argues that family members have a vital role in value co-creation and well-being for elderly consumers when they assist them in service inclusion by acting as TSMs (Johns and Davey, 2019). This implies that family members’ (secondary customers’) successful service inclusion may be an element that needs to be added to the service inclusion theory concerning primary customers who are experiencing vulnerability. Thus, family members’ needs should be profoundly understood. The staff–family member relationship has been studied (Bauer, 2007) and individualised practices in family involvement have been recommended (Reid and Chappell, 2017), but the family members’ personal customer needs and their relation to the residents’ (primary customers’) needs lack specific research. We address this gap in research.

4. Methods

We conducted an explorative, qualitative study in two private nursing homes. Pearl (pseudonymised) was established in the 2010s and Diamond (pseudonymised) was established in the 1990s. Pearl had 12 residents and Diamond had 48 residents. Each resident had a single room with bathroom facilities. The nursing homes offered a home-like environment – shared spaces with kitchen, dining space and a TV corner with sofas.

To engage customer needs in this context, we adopted multiple perspectives and qualitative methods for data collection (triangulation). This study used views on customers’ needs from three perspectives: family members, residents and nurses (Figure 1).

All three perspectives were required to gain an accurate picture of the research phenomenon. Nurses served as validators and offered external clarifying views when residents were not able to properly express themselves, also sharing their experiences concerning family members’ and residents’ needs; these views were especially valuable for perceiving and interpreting latent needs. Due to the subject sensitivity and individuals’ potential experiences of vulnerability, an ethical statement from our university’s Research Ethics Committee was included.

All parties were informed about the study and assured of confidentiality. Participation was voluntary, and withdrawal was allowed without consequences. A signed informed consent to interview was acquired from residents and their family members; the latter on the part of residents who had impaired decision-making capacities. Residents’ willingness for interviews was always ensured (Israel and Hay, 2006).

The data was gathered through interviews in everyday social settings at the nursing homes during two sequential periods: in 2014 at Pearl and in 2018 at Diamond. In addition, observing, interacting and living the phenomena within the nursing homes generated data (Figure 1), as the study included ethnographical features (Berg and Lune, 2004). After analysing the data collected at Pearl from different viewpoints, it seemed important to complement the data and validate the results by also collecting data in another nursing home, Diamond. Prolonged time in the field and gaining tacit knowledge on the cultural codes of the nursing home context, without a strictly structured scheme for observation, increased the rigour of the study by enabling us to extract the essential issues (such as relationships, interactions and latent needs) and centralise them in our analysis (von Koskull, 2020).

The interviews of residents and family members were based on predetermined themes stemming from the theoretical background – nursing home conceptions, and service expectations and experiences. The length of the resident interviews was 40 min on average, taking into account the residents’ condition. Interviews of family members (like spouses and children) lasted from one to two hours. Fifteen residents and 29 family members were interviewed (Table 1). The low number of residents was due to memory disorders, which often made interviews impossible.

The nurses’ interviews were also based on predetermined themes (expectations and needs of residents and families, roles and relationships, co-operation with customers). Altogether, 24 nurses were interviewed during their working hours. This led to a significant variation in interview length (15 min to 2 h).

Altogether, the researchers spent 12 days systematically collecting observation data (Table 1) that focussed on daily life and behaviour, interactions and discussions that took place between residents, family members and nurses. The prolonged time for data collection enabled the observation of issues that would otherwise have gone unnoticed; the time spent on site also fostered informants’ trust towards researchers. Informal, daily discussions with residents and their family members fundamentally advanced our understanding of primary and secondary customers’ needs. Experiences of vulnerabilities are challenging to study explicitly and unequivocally, but they were inductively interpreted during interviews and observations (Baker et al., 2005). The interpretation of needs also revealed experiences of vulnerabilities. In addition to what the interviewees said, it was revealing how they said it and what their emotional state was.

The data analysis initially began in the data-collection phase. The transcribed data was analysed in three phases. Researchers first read the transcripts to gain an overview of needs emerging from the data. Based on this review, a loose analysis frame was determined, which included self-related/other-related concepts and the source of the information (resident, family member, nurse). The data was then imported into NVivo and coded according to these concepts. Inductive coding allowed novel interpretations and classifications to arise from the data. The aim was to find upper-level categories for single subcategories that could be integrated into abstract patterns that illustrated their dynamic relationships. This required several iteration cycles, wherein terms and codes based on the quotes were combined, discussed and conceptualised by the researchers (Corley and Gioia, 2004; Gioia et al., 2013). Finally, a framework for the relationships between primary and secondary customers’ self-related and other-related needs was created (Figure 2).

The tables in the Findings section highlight the information attained, with quotes to illustrate the logic of the analysis. The short narratives of pseudonymised customers and quotes integrated into the text aim to bring ‘readers closer to the phenomenon’ (Bansal and Corley, 2011, p. 235), to lead them to feel like they are in the nursing homes, sharing our interpretations.

5. Findings

Four dimensions of family members and residents’ needs, and their relationship, arose from the data (Figure 2). Needs can be separate from each other (family members’ and residents’ needs are different) or congruent (a family member has a need of their own that is similar to the resident’s need). They can also be intertwined: satisfying residents’ needs also satisfies family members’ needs (and vice versa) and/or generates well-being. Finally, needs can be discrepant: the family members’ self- or other-related need contradicts the residents’ self-related need.

These dimensions are presented in this section by introducing the themes behind them, exemplified by narratives and quotes. Each second-order theme is divided into subsections according to the ‘owner’ and type of need (other-related vs. self-related).

6. Discussion

This section analyses the relationship between experienced vulnerability, customer needs and service inclusion. Building on the extant theory on vulnerability and on the findings from our study, it seems that universal human vulnerability has an overarching influence, as customers are emotionally affected and experience vulnerability regarding themselves and others, especially when depending on others for care. This can manifest, for instance, as fear and sorrow, thus further influencing their service needs. In a nursing home environment, dependency often occurs within the primary customer–secondary customer(s)–staff triad. This can generate context-related experiences of vulnerability, together with the care facilities and their boundaries, for both primary and secondary customers (e.g. due to a lack of self-efficacy or agency). For primary customers, the condition-based experience of vulnerability (e.g. illness or an inability to cope independently due to Alzheimer’s disease) is typically the reason for becoming a care service customer, and this generates multiple service needs (e.g. regarding emotional and physical support). Since secondary customers’ experiences of secondary vulnerability stem from the primary customer’s experiences of vulnerability, they mostly manifest as other-related needs, such as concern over the primary customer’s well-being, but also as self-related needs concerning, for instance, emotional support and the adequacy of information.

We illustrate these perceptions of customers’ experienced vulnerabilities and their influence on the needs in Figure 3. In the middle of the figure, the primary and secondary customers’ needs are depicted in relation to one another, as based on our findings: they can be separate, congruent, intertwined or discrepant. The figure does not, however, imply that needs are dictated by vulnerability experiences. It is also essential to note that experiences of vulnerability vary individually and over time. Hence, the same context can trigger experiences of vulnerability for some customers but not for others.

Next, primary and secondary customers’ experienced vulnerabilities and relational needs will be discussed in light of the four pillars of service inclusion: enabling opportunities, offering choice, relieving suffering and fostering happiness (Fisk et al., 2018).

The primary customers’ experiences of vulnerability stemming from deterioration in self-efficacy and a lack of self-determination were emphasised, especially during the first few weeks of adjustment. Homesickness and rebellion were typical manifestations of these experiences. Thus, in this context, access to the service caused experience of vulnerability for primary customers due to lack of choice (it was not possible to exit the service), even though service inclusion was pursued through fair treatment, as their suffering was relieved and even their happiness was fostered through good care and meaningful activities. In other words, meeting all of the primary customer’s self-related needs was not possible, and complete service inclusion was challenging if the customer was reluctant to accept the service. If the adjustment was successful the well-being outcomes were positive for both primary and secondary customers and this seemed to alleviate the experiences of vulnerability.

The secondary customers’ experiences of secondary vulnerability appeared to result from issues such as them feeling guilty about moving their elderly relative into a nursing home or because they no longer had control over the care arrangements. Also, the life-changing transition phase, the resident’s adjustment and changes in the relationship were confusing for family members. A latent need to receive guidance and support appeared, but often family members were not able to express the need explicitly. Also, concerns over the resident’s well-being and uncertainty related to his/her future changes and end-of-life care seemed to trigger experiences of vulnerability and preoccupy family members. They manifested especially as needs concerning emotional support, trust in the care quality and adequate information concerning the resident’s well-being. These aspects highlight the importance of secondary customers’ service inclusion: enabling opportunities for them to be involved in the service, to receive support, and to gain access to information, and relieving their suffering (alleviating concerns) through creating trust in good care. Suffering is a strong word and refers to unmet basic needs in Fisk et al. (2018), but it is considered relevant in this context because constant other-related concerns cause mental suffering for family members.

Thus, services can increase or decrease the experienced vulnerability by meeting or not meeting customer needs. Vulnerabilities triggered in or by the service can also generate additional needs for both primary and secondary customers, such as support needs or even a need to exit the service. For instance, some residents had moved to Diamond because they did not adjust to their previous nursing home, which is an example of offering choice (to exit) for the primary customer, and consequently, for the secondary customer.

Due to the intertwined needs and well-being of primary and secondary customers, fostering happiness had a multiplier effect: providing meaningfulness and happy moments for primary customers also generated well-being and happiness for secondary customers. Moreover, the primary customers’ happiness was often dependent on the secondary customers’ visits, which indicates that the service inclusion of secondary customers was necessary to generate well-being for primary customers. Yet, in some cases, the impact was the opposite; if the primary and secondary customers’ needs were discrepant, granting service inclusion for the secondary customer was potentially negative for the primary customer’s well-being if it resulted in aggressive visits or excessive power of choice within the service setting.

Overall, this discussion generates insights for service inclusion theory (Fisk et al., 2018):

• it is challenging to ensure complete service inclusion for a reluctant customer;

• each of the service inclusion pillars is also pertinent for secondary customers’ well-being, especially when they experience strong secondary vulnerability; and

• secondary customers’ service inclusion is essential for the happiness and well-being of primary customers; without it, some pillars of service inclusion for primary customers may remain incomplete.

Yet, sometimes, although very rarely (in the case of false motives and malevolent behaviour), the inclusion of secondary customers may harm primary customers’ well-being.

7. Conclusions