International Journal of Health and Pharmaceutical The Analysis of The Influence of Ethical Communication and Patient Trust on The Decision to Reuse Dialysis Services Marsha Vania1.
Purwanti Aminingsih2.
Enrico Adhitya Rinaldi3* MasterAos Program in Hospital Administration.
Universitas Respati Indonesia.
Indonesia University of Muhammadiyah.
Prof.
DR.
HAMKA Faculty of Medicine.
Indonesia *Corresponding Author:
Email: marshaav19@gmail.
Abstract.
Chronic kidney disease (CKD) is a global health problem with increasing prevalence, making haemodialysis a critical service in hospitals.
Patients' decisions to reuse dialysis services are influenced not only by medical factors, but also by ethical communication between healthcare professionals and patient trust.
This study aims to analyse the influence of ethical communication and patient trust on the decision to reuse dialysis services at Dr.
Dradjat Prawiranegara Regional General Hospital.
Serang.
Indonesia.
The study used a quantitative approach with a survey of 133 active haemodialysis patients.
Instrument validity was tested using Confirmatory Factor Analysis (CFA) with a loading factor >0.
5 and Cronbach's Alpha reliability >0.
Data analysis was performed using Structural Equation Modelling (SEM) using AMOS.
The results of the study proved that ethical communication had a positive and significant effect on patient trust (CR = 7.
p = 0.
, patient trust had a significant effect on the decision to reuse dialysis services (CR = 6.
p = 0.
, and patient trust was proven to be a mediating variable that strengthened the influence of ethical communication on patient decisions .
ndirect effect = 0.
This study emphasized the importance of integrating ethical communication and strengthening patient trust as a managerial strategy to improve service quality and support the sustainability of dialysis services.
Keywords: Ethical communication.
hospital service quality.
patient trust and reuse decisions.
INTRODUCTION
Chronic kidney disease (CKD) is a major global health problem, showing an increasing trend year after year.
According to the Global Burden of Disease .
, the prevalence of CKD has increased by more than 30% in the last two decades, making it the 10th leading cause of death worldwide .
In Indonesia, based on data from the Indonesian Renal Registry (IRR) in 2023, the number of active hemodialysis patients reached more than 170,000 people with an increasing trend of new patients every year .
A patient's decision to reuse dialysis services is influenced not only by medical factors, but also by psychosocial and ethical factors in the interaction between the patient and healthcare provider.
According to Golsorkhi et al.
, effective communication between doctors and patients in the management of advanced kidney disease plays a significant role in establishing a therapeutic relationship, improving patient understanding, and supporting shared decision-making .
The importance of ethical communication is also emphasized in national regulations.
Minister of Health Regulation No.
42 of 2018 concerning the Code of Ethics and Hospital Law stipulates that healthcare workers are required to uphold ethical principles in providing services, including honesty, openness, respect for patient rights, and maintaining professional dignity.
Dr.
Dradjat Prawiranegara Regional General Hospital in Serang is a regional referral hospital with over 200 active haemodialysis patients each month.
Despite a repeat patient visit rate of 85Ae90%, the hospital still faces challenges in maintaining patient trust, with complaints related to a lack of clear medical explanations, delays in information, and a lack of empathy in clinical interactions.
Based on this background, this study aims to: .
analyze the influence of ethical communication on patient trust.
analyze the influence of patient trust on the decision to reuse dialysis and .
analyze the role of patient trust as a mediating variable in the relationship between ethical communication and the decision to reuse dialysis services at Dr.
Dradjat Prawiranegara Regional Hospital.
Serang.
Indonesia.
II.
METHODS
This study used a quantitative approach with a cross-sectional survey design.
The study population was all active patients undergoing routine haemodialysis therapy in the haemodialysis unit of Dr.
Dradjat https://ijhp.
International Journal of Health and Pharmaceutical Prawiranegara Regional Hospital.
Serang Indonesia.
The study sample consisted of 133 respondents selected using a purposive sampling technique, considering predetermined inclusion and exclusion criteria.
The research instrument consisted of three validated questionnaires: .
Doctor Patient Communication Questionnaire (D-PCQ) to measure ethical communication.
Evaluation of the Trust in Physician Scale (TIPS) to measure patient trust .
revisit intention questionnaire to measure the decision to reuse dialysis services .
Instrument validity was tested using Confirmatory Factor Analysis (CFA), with all indicators having a loading factor >0.
Reliability was assessed using Cronbach's Alpha with a value >0.
Data analysis was performed using Structural Equation Modeling (SEM) with AMOS software.
Model feasibility was assessed based on the Goodness of Fit index, including RMSEA <0.
GFI and AGFI >0.
and CFI and TLI >0.
Hypothesis testing was conducted to analyze the direct and indirect influences between the research variables .
RESULT AND DISCUSSION
Respondent Characteristics This study involved 133 respondents who were active hemodialysis patients at Dr.
Dradjat Prawiranegara Regional Hospital.
Serang Indonesia.
Complete respondent characteristics are presented in Table 1, below.
Table 1.
Respondent Characteristic .
= .
Characteristics Frequency (Peopl.
Percentage (%) Male Female < 30 Tahun 30 Ae 45 Tahun 46 Ae 60 Tahun > 60 Tahun Total Elementary Education Middle Education Higher education < 1 Year 1 Ae 3 Years > 3 Years Married Unmarried Gender Total Age Education Total Length of Dialysis Total Marital Status Total Sources: Process by Researcher, 2025 https://ijhp.
International Journal of Health and Pharmaceutical Based on Table 1, the majority of respondents were male .
9%).
Based on age group, the largest proportion was in the 30Ae45 age group .
3%), followed by the 46Ae60 age group .
8%).
The majority of respondents had a primary education .
8%), and most had been on dialysis for 1Ae3 years .
9%).
In terms of marital status, the majority of respondents were married .
2%).
Validity and Reliability Test The results of the validity test using Confirmatory Factor Analysis (CFA) showed that all indicators in the three research variables had loading factor values >0.
5, thus being declared valid.
The loading factor value for the Ethical Communication variable ranged from 0.
760 to 0.
926, with a Construct Reliability (CR) The loading factor value for the Decision to Reuse variable ranged from 0.
772 to 0.
864, with a CR The reliability test results showed Cronbach's Alpha values >0.
7 for all variables, indicating that the research instrument is reliable and consistent.
SEM Model Goodness of Fit Test The results of the SEM model goodness-of-fit test are presented in Table 2.
Although several indices (Chi-square.
Significant Probability.
GFI.
AGFI) did not meet the cut-off value, the RMSEA.
CMIN/DF.
TLI, and CFI results indicated adequate fit.
This is acceptable in studies with many indicators, as stated by Hair et al.
that models with complex samples cannot always meet all indices simultaneously.
Table 2.
Results of the SEM Model Goodness of Fit Test Goodness of Fit Index Cut-off Value Research Model Description Chi-square O 927,255 .
470,048 Not Fit
Significant Probability Ou 0,05 0,001 Not Fit
RMSEA
O 0,08
0,043
Fit
GFI
Ou 0,90 0,824 Not Fit
AGFI
Ou 0,90 0,783 Not Fit
CMIN/DF
O 2,0
1,247
Fit
TLI
Ou 0,90 0,973 Fit
CFI
Ou 0,90 0,977 Fit Sources: Output AMOS, 2025 Ethical Communication Variable Based on the results of the descriptive analysis, the ethical communication variable obtained an overall average score of 3.
20 and was categorized as good.
Physicians were assessed as being able to listen carefully to patients, encourage patients to express their concerns, and demonstrate a calming and respectful Conceptually, ethical communication is the process of conveying information between medical personnel and patients based on the principles of honesty, empathy, respect for patient dignity, and transparency.
These findings align with research by Street which states that doctors' ability to actively listen and demonstrate empathy is a key factor in improving the quality of the doctor-patient relationship in patients with chronic diseases.
The lowest average scores were found for the ease of understanding of doctors' explanations and the completeness of medical information.
This condition may be influenced using overly technical medical terms, limited consultation time, and differences in patients' health literacy levels .
Hypothesis Testing Results Table 3.
Hypothesis Testing Results Hypothesis Estimate Result
H1: Ethical Communication Ie Patient Trust
0,555
0,072
7,669
0,000
Significant H2: Ethical Communication Ie Decision to Reuse Services 0,163 0,081 2,005 0,045 Significant H3: Patient Trust Ie Decision to Reuse Services 0,847 0,133 6,388 0,000 Significant https://ijhp.
International Journal of Health and Pharmaceutical Hypothesis Direct Indirect Result H4: Ethical Communication Ie Patient Trust Ie Decision to Reuse Services (Re-Visit Hospita.
0,166 0,476 Significant Souces: Output AMOS, 2025 Patient Trust Variable The patient trust variable received an overall average score of 3.
14 and was categorized as good.
The aspects of doctor honesty and competence received the highest ratings, indicating that patients trust that doctors convey medical information honestly and possess adequate professional skills.
However, several indicators received lower scores, particularly those related to the accuracy of medical assessments.
According to Mechanic and Meyer .
, patient trust is dynamic and influenced by repeated clinical experiences, particularly in chronic illnesses.
Dialysis Service Reuse Variable The dialysis service reuse variable obtained an average score of 3.
37 and is categorized as good.
The item with the highest score relates to the patient's willingness to recommend the hospital to others.
According to Kotler and Keller, willingness to recommend services is a strong indicator of customer loyalty.
Patients' intention to reuse services in the future showed a relatively lower score, indicating that loyalty is still rational and influenced by situational considerations.
The Effect of Ethical Communication on Patient Trust The results of the hypothesis testing indicate that ethical communication has a positive and significant effect on patient trust (CR = 7.
p = 0.
000 < 0.
, thus accepting the first hypothesis.
The most dominant indicator is the clarity and openness of medical information, with a loading factor of 0.
This finding aligns with research by Lee and Lin, which showed that physician ethical communication has a direct and significant influence on patient trust, particularly through the dimensions of information clarity and empathy.
From a medical ethics perspective, the principles of autonomy, beneficence, nonmaleficence, and justice Beauchamp & Childress, 2021 place ethical communication as the primary means of implementing clinical ethics.
Research by Birkhimer, confirms that honest and transparent communication is a key determinant of trust in modern healthcare .
Therefore, the better the quality of ethical communication demonstrated by healthcare professionals, the higher the patient trust.
The Influence of Patient Trust on Reuse Decisions The SEM analysis results demonstrated that patient trust had a positive and significant influence on the decision to reuse dialysis services (CR = 6.
p = 0.
000 < 0.
The Construct Reliability value of 968 indicates very high internal consistency.
This finding aligns with the commitment-trust theory, which states that trust is a primary prerequisite for forming commitment and repeat behavior in long-term relationships.
Al-Doghaither's research on dialysis patients concluded that patient trust in clinical competence was the most determining factor in the decision to reuse.
Around 20% of respondents did not show a strong intention to revisit, indicating the need to strengthen procedural transparency and institutional accountability so that trust is not merely pragmatic.
The Role of Patient Trust as a Mediating Variable The results of the indirect effect test indicate that patient trust acts as a significant mediating variable .
ndirect effect = 0.
direct effect = 0.
p < 0.
The larger indirect effect compared to the direct effect indicates that most of the ethical communication's influence on reuse decisions operates through the mechanism of trust formation.
From the perspective of Rosenstock's Health Belief Model, trust acts as a psychological mediator that strengthens the perception of service benefits.
From Deci & Ryan's SelfDetermination Theory, trust strengthens the sense of connectedness between patients and medical personnel, which encourages sustainable behaviour .
Birkhyuer's meta-analysis also confirmed that patient trust consistently acts as a mediator between the quality of healthcare provider interactions and various patient behavioural outcomes.
Overall, these findings emphasize that investing in healthcare providers' ethical communication competencies is a strategy that not only improves the quality of the therapeutic relationship but also ensures the sustainability of dialysis services.
https://ijhp.
International Journal of Health and Pharmaceutical IV.
CONCLUTION
Based on the results of research on 133 active haemodialysis patients at Dr.
Dradjat Prawiranegara Regional General Hospital.
Serang.
Indonesia the following conclusions can be drawn: .
Ethical communication of healthcare workers is in the good category, characterized by honesty, empathy, openness of information, and respect for patient dignity.
Patient trust is at a good level, especially regarding the professional competence and integrity of medical personnel.
The decision to reuse dialysis services is in the good category with rational loyalty influenced by situational factors.
Ethical communication has a positive and significant effect on patient trust (CR = 7.
p = 0.
Ethical communication has a significant effect on the decision to reuse services (CR = 2.
p = 0.
Patient trust has a positive and significant effect on the decision to reuse services (CR = 6.
p = 0.
Patient trust has been shown to act as a mediating variable in the relationship between ethical communication and the decision to reuse services .
ndirect effect = 0.
Hospitals are advised to: conduct systematic active listening training for all healthcare workers.
establish monthly internal discussion forums as a medium for professional carry out regular monitoring and internal audits of communication quality and patient trust.
increase transparency of medical procedures with easy-to-understand language.
maintain the confidentiality of medical data.
and align service policies with Minister of Health Regulation No.
42 of 2018 so that ethical and sustainable haemodialysis services can be realized.
ACKNOWLEDGMENTS
The management of Dr.
Dradjat Prawiranegara Serang Regional General Hospital recommends optimizing the service process in the hemodialysis unit through regular evaluations of the quality of ethical communication among healthcare workers, adjusting the number of medical staff during peak service hours, and implementing a structured, data-driven patient trust monitoring system.
Furthermore, ethical communication training for all healthcare workers in the Hemodialysis Unit needs to be improved and implemented regularly to ensure the delivery of medical information, explanations of dialysis procedures, and clinical interactions are consistent, empathetic, and patient safety-oriented.
Improving waiting room facilities, strengthening patient data confidentiality, and establishing an internal reflection forum for healthcare workers should also be prioritized to minimize barriers to service delivery.
For future researchers, it is recommended to include additional variables that could potentially influence patient trust and the decision to reuse dialysis services, such as medical staff workload, the quality of the hospital's physical facilities, patient family support, or more in-depth patient sociodemographic characteristics.
A longitudinal research design could also be used to examine changes in patient trust levels and the decision to reuse services over time following a quality improvement intervention, thereby providing a more comprehensive understanding of the effectiveness of hemodialysis service quality improvement strategies.
REFERENCES