THE INFLUENCE OF EFFECTIVE COMMUNICATION, PATIENT EXPERIENCE ON PATIENT LOYALTY MEDIATED BY TRUST

The attitude of loyalty of customers (patients) to a service product in hospitals can be grown by service providers (hospitals) by improving the quality of their services to these patients. Satisfaction with the patient, so that by creating a sense of patient satisfaction, the attitude of patient loyalty to hospital services will be formed. The patient's assessment of quality is determined by two things, namely the patient's expectations of quality (expected quality) and the patient's perception of quality (perceived quality). Patient perceptions of service quality are influenced by expectations of the desired service (Zeithaml et al., 1985) . The aim of this research is to analyze the effect of effective communication, patient experience on patient loyalty mediated by trust. The research method is to use associative quantitative by testing the hypothesis with the path analysis approach. The results showed that there was an effect of effective communication, patient experience on patient loyalty mediated by trust.


Introduction
Communication between doctors and patients is the most important component in health services.The professional attitude of doctors is shown when dealing with their duties which means they are able to complete their duties according to their roles and functions; able to manage oneself such as being punctual, dividing professional tasks with other personal tasks and being able to deal with various types of patients and being able to work together with other health professionals.The professional attitude of a doctor will be seen from the patient handling process which will be a measure of his success and professionalism Loyalty can be interpreted as the loyalty of someone who subscribes to a particular product or service.Patient loyalty as a user of hospital services is patient loyalty in using the services available at the hospital when the patient needs it.Efforts to retain customers by increasing customer loyalty can reduce marketing costs for service providers because loyal customers can be a source of marketing services to the community, so that customer loyalty can provide benefits for service providers (Melinda & Faried, 2019 ) Patient loyalty in general can be defined as patient loyalty to a product or service offered by a health service provider, so that he will continue to buy products or use these services continuously (Ara et al., 2015) .(Kotler & Keller, 2003) mentions that the costs incurred to retain old customers (patients) are far less than the costs to bring in new customers (patients).The hospital will benefit from the loyalty of the patient because the patient is committed to surviving and will voluntarily recommend it to his relatives (Griffin, 2005) .In the study by (Juhana et al., 2015) it was explained that patient satisfaction is influenced by three things which are customer The Influence of Effective Communication, Patient Experience on Patient Loyalty Mediated By Trust Zainah Fitriah , Endang Ruswanti , M. Reza Hilmy 2675| P a g e experience quality, but this has not been widely studied, namely outcome quality, interaction quality and peer-to-peer quality .
The attitude of loyalty of customers (patients) to a service product in a hospital can be grown by service providers (hospitals) by improving the quality of their service to these patients.The patient's assessment of quality is determined by two things, namely the patient's expectations of quality (expected quality) and the patient's perception of quality (perceived quality).Patient perceptions of service quality are influenced by expectations of the desired service (Zeithaml et al., 1985) .These expectations are shaped by what consumers hear from other consumers through word of mouth, patient needs, past experiences and external communication influences.Services received from existing expectations affect consumers on service quality (Puspita & Alfatih, 2020) .
Sumbawa Regional Hospital is a Regional Hospital that plays an important role in providing services in the Sumbawa area.Based on 2021 data, the patient visit rate at the hospital is 58% and repeat visits are 42%.Where there is a decrease in the level of visits to the hospital.An important factor that can increase patient loyalty is patient trust.Consumer/patient trust in service providers will increase the value of the relationship that exists with service providers.High trust will affect the possibility of switching to another service provider.Hospitals that are able to respect their patients will be able to increase the trust of the patients they serve.
Based on the background of the problem above, there are several variables that can be taken which can be examined simultaneously, namely consulting effectiveness, service quality, patient experience and loyalty, so the title of this study is "The Effect of Effective Communication, Patient Experience on Patient Loyalty Mediated by Trust."

Research Methods
This research method uses associative quantitative with hypothesis testing to see the effect between variables.The research method uses the path analysis research model.There are several Path Analysis models (Sunyoto & Prihatin, 2017) using multiple regression models.

Characteristics of Respondents
The research was conducted by distributing questionnaires to respondents directly for 2 weeks, at the Sumbawa Hospital to 130 patients.Based on the questionnaire distributed by the researcher, there are characteristics of the respondents namely, Age, Gender and Education, which are presented in the following Primary data sources that have been processed for 2023 data Based on the table above, it was found that the characteristics of the respondents with the highest number of years of service were 31-50 years of service with a percentage of 46.15%, the characteristics of the respondents with the most categories of gender were women with a percentage of 53.84%, the characteristics of respondents in the last education category were S1 and S1 Profession as much as 30.76%

Path Analysis
The following are the results of regression processing on variables X and Z on Y: a) Loyalty Patient Model X2 and Z experience a one-unit increase in the variable, it will result in the Y variable also increasing by the value of the regression coefficient.

b) Trust Models
The following is the result of the regression processing on variables X to Z: The above equation can be explained as follows: a.Based on the results of the regression equation above, a constant value of 1.475 is obtained.This means, if the condition variables (X1) and (X2) are considered constant, then the variable (Z) is 1.475 b.The regression coefficient values at X1 and X2 are positive so that it can be said that these variables have a positive relationship to variable (Z).This means that if X1 and X2 experience a one-unit increase in the variable, it will result in variable Z also increasing by the value of the regression coefficient.
Based on the results above, the Path Analysis Diagram is found as follows :

F Test
The F test in this study is a test conducted to determine the relationship between the independent variables and the dependent variable, whether the variables (X1), (X2), (Z) really have an effect simultaneously (together) on the dependent variable ( Y).The results of the F test in this study can be seen in table 4 below: The first regression model Y: Primary data sources that have been processed for 2023 data Based on table 4.17.from the results of the F test in this study, the calculated F value was 21.634 with a significance figure (P value) of 0.001.With a significance level of 95% (α = 0.05).Significance figure (P value) of 0.001 <alpha 0.05.On the basis of this comparison, it means that the variables X1, X2, and Z have a significant influence simultaneously on variable Y. First regression model Z: Table 5 F test results Primary data sources that have been processed for 2023 data Based on table 5 from the results of the F test in this study, the calculated F value was 33.712 with a significance figure (P value) of 0.001.With a significance level of 95% (α = 0.05).Significance figure (P value) of 0.001 <alpha 0.05.On the basis of this comparison, it means that the variables X1 and X2 have a significant influence simultaneously on variable Z.

Partial Test (Statistical Test t)
The t test in this study aims to test the significance or not of the relationship between the independent variables X1, X2 and Z with the dependent variable job Attitude (Y).The results of the t test in this study can be seen in • H0: β = 0, variable (X) does not have a partially significant effect on variable (Y).
Significance figure (P Value) of 0.001 <0.05.On the basis of this comparison, H0 is rejected or it means that the Patient Experience variable (X2) has a significant influence on the Patient Loyalty variable (Y).c. Trust Variable (Z) • H0: β = 0, variable (Z) does not have a partially significant effect on variable (Y).
• On the variable Trust (Z) with a significance level of 95% (α = 0.05).Significance figure (P Value) of 0.188 <0.05.On the basis of this comparison, H0 is accepted or it means that the Trust (Z) variable has no significant effect on the Patient Loyalty variable (Y).

Second Regression Model Z:
Journal Multidisciplinary Indonesia 2680| P a g e • H 0 : β = 0, variable (X) does not have a partially significant effect on variable (Z).• H 0 : β ≠ 0, (X) has a partially significant effect on variable (Z).
• In Organizational Culture variable (X2) with a significance level of 95% (α = 0.05).Significance figure (P Value) of 0.001 <0.05.On the basis of this comparison, H0 is rejected or it means that the Patient Experience variable (X2) has a significant influence on the Trust variable (Z).

There is an effect of effective communication, patient experience on patient loyalty mediated by trust
Based on the results of the study, it was found simultaneously that the variable of effective communication, Patient Experience mediated by Trust, has a significant effect on patient loyalty, where the results above show that P = 0.001, which means it is smaller than P = 0.005.Based on the results of the three boxes it is known that the average value for the Effective Communication variable (X1) is 83.04 and is included in the "Medium" category.The highest index is found in the statement "I get good attention from doctors and nurses" with an index value of 84.80 most respondents answered well/agree and the lowest index is included in the medium category found in the statement "In addition to getting medical service needs, my non-medical services are also considered with good communication" with an index value of 81.80.Furthermore, it is known The Influence of Effective Communication, Patient Experience on Patient Loyalty Mediated By Trust Zainah Fitriah , Endang Ruswanti , M. Reza Hilmy 2681| P a g e that the average value for the Patient Experience variable (X2) is 77.70 and is included in the "Medium" category.The highest index is included in the moderate category and is found in the statement "Very good coordination" with an index value of 82.60, while the lowest index is included in the medium category, found in the statement "I received good information" with an index value of 71.40. it is known that the average value for the variable Trust (Y1) is 83.33 and is included in the "Medium" category.The highest index is in the moderate category found in the statement "Doctor's honesty in communicating makes me believe about the disease I have" with an index value of 84.60, while the lowest index is in the medium category found in the statement "I have the intention to continue taking treatment at the hospital" with an index value of 81.80.And it is also known that the average value for the Patient Loyalty variable is 90.66 and is included in the "Medium" category.The highest index is in the moderate category found in the statement "I will continue to use the services at the hospital even though many people have doubts about doing it" with an index value of 91.40 while the lowest index is in the medium category, found in the statement "I appreciate all the doctor's answers to my questions" with an index value of 90.20 According to Stewart L. Tubbs and Sylavia Moss, effective communication is characterized by understanding, can generate pleasure, influence attitudes, improve good social relations, and ultimately lead to action.According to (Meinen et al., 2016) The most commonly used definition of patient experience is the definition from the Beryl Institute which argues that patient experience is the entire interaction shaped by organizational culture that influences patient perceptions across the continuum of care.This definition is the result of discussions by health care leaders who identify key elements in the patient experience.According to (Hoy & Tschannen-Moran, 1999) say trust is the willingness of a person or group to be vulnerable to another party based on the belief of his last action in showing benevolent (good intentions), reliable (trustworthy), competent ( competence), honest (honesty), and open (openness).According to (Oliver, 2014) "customer loyalty is a strong commitment to repurchase or subscribe to a preferred product consistently in the future, giving rise to a series of repeated purchases of the same product, even though situational influences and marketing efforts have the potential to cause brand switching".Thus loyalty will be greatly influenced by good communication, existing experience and trust.The theory above describes the meaning of each, but in this study patient loyalty to the hospital is inseparable from experience and trust that also comes from service and well-built communication with patients.So this study proves that a patient who is loyal will be greatly influenced by communication, and experience and deep trust.This research is in line with research conducted by (Dewi, 2016) which stated that the results of data analysis found that: service quality has a positive and significant effect on patient satisfaction, service quality has a positive and significant effect on patient loyalty, patient satisfaction has a positive and significant effect on patient loyalty.This study has not yet mentioned the effectiveness of doctor consultation with patients on loyalty.In addition, it is also in line with research conducted by Ozgun Unal which states that patient-doctor communication has a significant effect on doctor and hospital loyalty.In addition, patient loyalty has a mediating role in the effects of patient-physician communication

There is no effect of Effective Communication on Loyalty
Based on the results of the research above, individual communication has no effect on loyalty, where the value of P = 0.212, which means it is greater than P = 0.005.Good communication will lead to satisfaction and make patients come back.According to (Oliver, 2014) "customer loyalty is a strong commitment to repurchase or subscribe to a preferred product consistently in the future, giving rise to a series of repeated purchases of the same product, even though situational influences and marketing efforts have the potential to cause brand switching".Thus loyalty will be greatly influenced by good communication, existing experience and trust.Meanwhile, according to Stewart L. Tubbs and Sylavia Moss, effective communication is characterized by understanding, can generate pleasure, influence attitudes, improve good social relations, and ultimately lead to an action.This means that in this study there is no link between effective communication and loyalty.
Based on the results of the three boxes it is known that the average value for the Effective Communication variable (X1) is 83.04 and is included in the "Medium" category.The highest index is in the statement "I get good attention from doctors and nurses" with an index value of 84.80 the most answered are good/agree by respondents and the lowest index is included in the medium category found in the statement "In addition to getting medical service needs, nonmedical services my medical attention is also good with good communication" with an index value of 81.80.And it is also known that the average value for the Patient Loyalty variable is 90.66 and is included in the "Medium" category.The highest index is in the medium category found in the statement "I will continue to use the services at the hospital even though many people have doubts about doing it" with an index value of 91.40 while the lowest index is in the medium category , found in the statement "I appreciate all the doctor's answers to my questions" with an index value of 90.20This research is in line with research conducted by (Stark et al., 2021) which states that the results in this sample show no correlation patient-centered communication and patient satisfaction.There was also no significant difference between the intervention and control groups.

There is an Influence of Patient Experience on Loyalty
Based on the results of the above study it was found that patient experience had a significant effect on loyalty where the value of P = 0.001 which means it is smaller than P = 0.005.According to (Meinen et al., 2016) The most commonly used definition of patient experience is the definition from the Beryl Institute which argues that patient experience is the entire interaction shaped by organizational culture that influences patient perceptions across the continuum of care.This definition is the result of discussions by health care leaders who identify key elements in the patient experience.In this case the experience is the interaction felt by the patient, whether the interaction is good or bad in getting service will greatly impact patient satisfaction which will ultimately make the patient feel the need to return to the hospital.Thus According to (Oliver, 2014) "customer loyalty is a strong commitment to repurchase or subscribe to a preferred product consistently in the future, giving rise to a series of repeated purchases of the same product, even situational influences and marketing efforts have the potential to cause brand switching."This means that experience will have an impact on patient loyalty.This explains that patient experience has a significant influence on patient loyalty.Where the patient will be loyal if he has a good experience provided by the hospital.
Based on the three box results it is known that the average value for the Patient Experience variable (X2) is 77.70 and is included in the "Medium" category.The highest index is included in the moderate category and is found in the statement "Very good coordination" with an index value of 82.60, while the lowest index is included in the medium category, found in the statement "I received good information" with an index value of 71.40.And it is also known that the average value for the Patient Loyalty variable is 90.66 and is included in the "Medium" category.The highest index is in the medium category found in the statement "I will continue to use the services The Influence of Effective Communication, Patient Experience on Patient Loyalty Mediated By Trust Zainah Fitriah , Endang Ruswanti , M. Reza Hilmy 2683| P a g e at the hospital even though many people have doubts about doing it" with an index value of 91.40 while the lowest index is in the medium category, found in the statement "I appreciate all the doctor's answers to my questions" with an index value of 90.20This research is in line with research conducted by (Indra et al., 2022) which states that the results of the study show that service quality has a significant effect on patient loyalty with patient satisfaction and relational marketing as intervening variables; Service quality has a significant effect on satisfaction and relational marketing, but has no effect on patient loyalty; Patient satisfaction and relational marketing have a significant effect on patient loyalty.Managerial implications based on research results are that it is recommended that hospitals create information containers, both printed and digital; evaluate the implementation of SPO (Standard Operational Procedure); Complete supporting inspection facilities; Improving employee capabilities and skills through seminars or training.The same research was also conducted by (Sumaedi et al., 2014) , where patient satisfaction is proven to affect patient loyalty, because patients who feel satisfied with the services they go through, they will reuse these services and at the same time become informal marketing agents for the company.

There is no Effect of Effective Communication on Trust
Based on research, effective communication cannot affect trust where the value of P = 0.153, which means it is greater than P = 0.05.Good communication will have an impact on someone's trust.According to Stewart L. Tubbs and Sylavia Moss, effective communication is characterized by understanding, can generate pleasure, influence attitudes, improve good social relations, and ultimately lead to action.This means that communication can provide attitudes that improve social relations, this also has an impact on trust.Where according to (Hoy & Tschannen-Moran, 1999) say trust is the willingness of a person or group to be vulnerable to other parties based on the belief of their last action in showing benevolent (good intentions), reliable (can be trusted) , competent (competence), honest (honesty).), and open(openness).Thus effective communication is able to create strong trust from patients to the hospital.Good communication does not always create trust, so that in this study respondents considered that communication could not affect their trust

There is an Influence of Patient Experience on Trust
Based on the results of the study, patient experience has a significant influence on trust where the value of P = 0.001 means that it is smaller than P = 0.005.The patient's experience will have an impact on the patient's trust in being able to receive services from the hospital.According to (Meinen et al., 2016) The most commonly used definition of patient experience is the definition from the Beryl Institute which argues that patient experience is the entire interaction shaped by organizational culture that influences patient perceptions across the continuum of care.This definition is the result of discussions by health care leaders who identify key elements in the patient experience.This means that the existing experience gives a separate perception by the patient so that there is trust from the patient to get more services.According to (Hoy & Tschannen-Moran, 1999) say trust is the willingness of a person or group to be vulnerable to another party based on the belief of their last action in showing benevolent (good intentions), reliable (trustworthy), competent ( competent), honest (honesty), and open (openness).Thus experience has a strong influence on patient confidence in obtaining services.Experience has a strong impact on trust.If the experience is good, then a person's trust will be very large in the services provided.
Furthermore, based on the results of the three boxes it is known that the average value for the Patient Experience variable (X2) is 77.70 and is included in the "Medium" category.The highest index is included in the moderate category and is found in the statement "Very good coordination" with an index value of 82.60, while the lowest index is included in the medium category, found in the statement "I received good information" with an index value of 71.40. it is known that the average value for the variable Trust (Y1) is 83.33 and is included in the "Medium" category.The highest index is in the moderate category found in the statement "Doctor's honesty in communicating makes me believe about the disease I have" with an index value of 84.60, while the lowest index is included in the medium category found in the statement "I have the intention to continue taking treatment at the hospital" with an index value of 81.80 This research is in line with research conducted by Salsabila Az Zahra at'all where as many as 11 of the 86 articles found were selected for literature review.Based on 11 articles that have been reviewed discussing customer value and trust in patient loyalty.Hospitals and Community Health Centers as health service providers have a relationship between the perceived value of patient medical services, patient-provider relationship commitment, and patient loyalty.Furthermore, when patients exhibit higher levels of trust in healthcare providers, the relationship of patients' perceived value, commitment, and loyalty is also enhanced.

There is no influence of trust on patient loyalty
Based on the research results, trust does not have a significant effect on loyalty where the value of P = 0.188 means that it is greater than P = 0.005.Loyalty will arise due to trust.Patient loyalty to the hospital is inseparable from experience and trust that also comes from service and well-built communication with patients.According to Stewart L. Tubbs and Sylavia Moss, effective communication is characterized by understanding, can generate pleasure, influence attitudes, improve good social relations, and ultimately lead to action.In this case trust does not have a strong impact on loyalty.For respondents, trust does not mean that patients will be loyal to the services provided.

Conclusion
Based on the results of the research and discussion, the researcher can draw a conclusion as follows: 1. Effective Communication and Patient experience have a positive and significant effect on patient loyalty with trust as mediation.Improving communication and patient experience can be done through increasing patient confidence in the services taken.2. Effective communication has no positive and significant effect on patient loyalty in the outpatient care of Sumbawa Hospital.Good communication that is not supported by other factors does not necessarily affect patient loyalty.3. Patient Experience has a positive and significant effect on patient loyalty in the outpatient care of Sum Bawah Hospital.The better the patient's experience, the more loyal the patient is to hospital services.4. Effective communication has no positive and significant effect on patient trust in outpatient care at Sumbawa Hospital.Good communication does not always create trust.5. Patient experience has a positive and significant effect on trust in the outpatient care of Sumbawa Hospital.When the patient has a good experience in the service, the patient's trust in the service will increase Trust has no positive and significant effect on patient loyalty in the outpatient care of Sumbawa Hospital.Patient trust does not have a strong impact on patient loyalty, so it must be supported by other factors.

Figure
Figure 1 Path Analysis Diagram

Table 4
table 6 below: Based on table 9, the hypothesis of the t test results is obtained as follows:a.Effective Communication Variable (X1) • H0: β = 0, variable (X) does not have a partially significant effect on variable (Y).•H0: β ≠ 0, (X) has a partially significant effect on variable (Y) • On the Effective Communication variable (X1) with a significance level of 95% (α = 0.05).Significance figure (P Value) of 0.212 <0.05.On the basis of this comparison, H0 is accepted or it means that the Effective Communication variable (X1) does not have a significant effect on the Patient Loyalty variable (Y).b.Patient Experience Variable (X2)

Table 7
Partial test results (t test) , (X) has a partially significant effect on variable (Z).• On the Effective Communication variable (X1) with a significance level of 95% (α = 0.05).Significance figure (P Value) of 0.153 <0.05.On the basis of this comparison, H0 is accepted or it means that the Effective Communication Style variable (X1) does not have a significant effect on the Trust variable (Z).b.Patient Experience Variable (X2)

Fitriah , Endang Ruswanti , M. Reza Hilmy
The Influence of Effective Communication, Patient Experience on Patient Loyalty Mediated By Trust Zainah