Witnessed Incivility and Perceptions of Patients and Visitors in Hospitals

Abstract

Research has examined instances of incivility witnessed by physicians, nurses, or employees in hospitals. Although patients and visitors are members in hospitals, witnessed incivility from their perspective has rarely been empirically investigated. The aims of the current study are 2-fold: (1) to investigate the forms of incivility patients/visitors witness in hospitals and (2) to examine whether these patients/visitors believe these incivilities impact the target’s sense of perceived control. An integration of interpretative phenomenological analysis and thematic analysis was used to code qualitative data (N = 77). Eight themes of witnessed incivility and 3 themes for impact on perceived control were identified. The results illuminate patterns of incivility targeted at marginalized groups, historically underrepresented in hospital-focused incivility research (eg, homeless individuals, incarcerated individuals, the elderly individuals). The majority of witnesses believed the incident of incivility would negatively impact the target’s perception of control, possibly affecting their experience and health. The current study demonstrates that empirically investigating witnessed incivility from the patient/visitor perspective provides critical information about the unique patterns of mistreatment occurring within hospital contexts.

Keywords

incivility respect patients well-being

Introduction

There is a growing body of scholarship examining interpersonal mistreatment within hospitals and academic medical centers (1 –4). Studies suggest incivility is one of the most frequently occurring forms of mistreatment in part because it’s a “mild” form of mistreatment (5). Incivility includes disrespectful verbal and nonverbal behaviors (6). One review highlighted that most incivility research focuses on instances of experienced incivility (7 –10). Accumulating evidence suggests it is necessary to empirically examine witnessed incivility (5,11). Incivility often occurs in the presence of others, and studies demonstrate that incivility can be witnessed by observers located within the same context (12). Specific to hospitals, majority of the literature examines witnessed incivility from the perspective of physicians, nurses, or hospital workers (10,13,14). For instance, one recent study found maternal health providers witnessed disrespectful care toward women during childbirth (15).

Although scholars have noted patients/visitors witness incivility (16), their direct observations have rarely been centralized and empirically investigated. Rather, patients/visitors are commonly discussed in an indirect way. Many studies have discussed how incivility among health care providers may have downstream consequences on patient safety and health outcomes (17,18). Other studies have documented incivility and other forms of mistreatment toward patients, but through the lens of health care providers (19 –21). Patients/visitors are active members within hospitals, and understanding their perspective is critical because their roles and experiences are fundamentally distinct than those employed. For example, one study found 40% of people who used drugs stated they avoided health care because they anticipated mistreatment (22). In the current study, this gap is addressed to better understand the complicated phenomena of witnessing incivility in hospitals (23).

Evidence suggests that individuals who witness incivility may make sense of the incident (9). Theory of mind states that individuals routinely consider the thoughts, emotions, and behaviors from the perspective of others (24). What remains unknown is whether witnesses of incivility believe uncivil behaviors affect the psychological well-being of the person being targeted. Therefore, the current study also aims to examine whether patients/visitors believe incivility affects the target’s sense of perceived control. Perceived control—the belief that one has control over outcomes in their life—is a critical health-related factor (25,26). Perceived control is believed to be shaped in part by the nature of one’s interpersonal environment (27 –29). It is likely that witnesses of incivility will believe uncivil interactions shape the target’s sense of perceived control.

The Current Study

Therefore, the aims of the current study are 2-fold: (1) to investigate the forms of incivility patients/visitors witness in hospitals and (2) to examine whether the patients/visitors believe these incivilities impact the target’s sense of perceived control.

Methods

The study was determined exempt from ongoing Institutional Review Board (IRB) oversight by the University of Michigan IRB (HUM00141390). The data from the current study are part of a larger qualitative survey examining various perceptions and experiences of patients/visitors in hospitals (1).

Study Participants

Participants (N = 400) were recruited on TurkPrime, a website which accesses a crowdsourcing platform for data acquisition. This method of recruitment is commonly used in behavioral sciences (30 –32). Following Larkin and colleagues (33), we purposefully recruited participants from across the United States (U.S.), so the data represented the “triangulation” of viewpoints. The inclusion criteria included participants who indicated their location as the United States and who had a 95% human intelligence task (HIT) approval rating (34). Informed consent was obtained, and participants were compensated US$1.00 upon survey completion.

Participants were asked to respond to 2 open-ended questions: (1) “Have you ever witnessed someone else experiencing incivility in a hospital setting (eg, being talked down to)? If you have witnessed this, please describe the event.” Participants were instructed to respond to a follow-up question: (2) “Do you think this experience impacts that person’s sense of control in the hospital context? If so, please describe.” Exclusion criteria included those who indicated they had never been to a hospital, did not answer the questions, included nonsensical answers, or indicated they had not witnessed incivility (analytic N = 77).

Analytic Approach

We used interpretative phenomenological analysis to analyze the open-ended responses following previous research (35). This method centralizes participants as the experts of their own experiences (35,36). The general principles of thematic coding were also used, given the larger sample size to develop a succinct list of themes (37). First, one participant’s responses were closely read and annotated to develop preliminary themes. Then the remaining participants’ responses were integrated, one at a time, and the same procedure was followed. Throughout, the interpretation of responses was consistently reevaluated. After, an initial list of themes was produced and ultimately condensed into the final set of superordinate themes. Saturation was clear after it was evident that no additional novel data emerged from the participant responses (38). The final themes were reviewed multiple times for uniformity and consensus among the team, all diverging points were discussed. Although some responses overlapped with several themes, responses were categorized into 1 primary theme and these cases were discussed among the research team. This process was conducted independently for each question.

Results

Demographics

The majority of the sample was female (N = 47, 61.0%) and aged 36.32 years (standard deviation [SD] = 10.88). Most participants were white (78%). Participants indicated on 1 (poor) to 5 (upper class) their socioeconomic status as working/middle class (mean = 2.70; SD = .76).

Witnessed Incivility Themes

A total of 8 themes were identified. More detailed explanations and examples of each theme are detailed below.

Yes (unspecified)

Some participants indicated they witnessed incivility and answered “yes,” but provided limited, if any, detail about the incident. For example, one mentioned seeing it “happen to a drunk driver who was injured.” Participant’s responses demonstrated that experiences of incivility were directed toward a range of targets, including siblings and a working nurse.

Insensitivity/rudeness

Insensitivity/rudeness was the largest subtheme, which included witnessing incivility that was primarily perpetrated by medical professionals and directed toward patients and patient’s families. This theme captured behaviors that were considered by the witness to be insensitive in nature, lacking concern, or respect for others feelings. While many witnessed patients being “talked down to,” others, like participant 119, described additional ways in which these behaviors occurred and the insensitivity was evidenced:

I have overheard nurse station staff sometimes talking to family members of patients like they were children or that they were “bothering” the staff…” [#119, 42 y/o, man, white]

Although many participants indicated the incivility was perpetrated by medical professionals, participant’s responses suggested that the range of perpetrators may be expansive. For instance:

I have seen [a] hospital receptionist being rude to a patient’s family member, telling them what to do, as oppose[d] to be[ing] [a] professional and knowing how to deal with a potential customer. She displayed a nasty behavior…[#268, 40 y/o, man, Native American]

Instances of insensitivity may be especially harmful in a hospital environment, where the efficacy of the employees and well-being of the patients are rooted in trust between these individuals. Rudeness between these groups of individuals may undermine this necessary trust.

Social identity

Social identity incivility included instances of insensitivity that were observed to be linked to the target’s marginalized social identity, social position, or condition. For example, several participants described instances in which patients with possible psychological health conditions were treated poorly. Often the displayed uncivil behaviors did not consider the dignity of the target. In addition, participants also cited language barriers as the basis for the target’s mistreatment:

Yes, I saw somebody that didn’t know English be treated very rudely by a white nurse because they were asking too many questions in a language other than English. [#210, 31 y/o, man, Latino/ Hispanic]

Further, one participant mentioned witnessing a woman facing incivility because she arrived at the hospital from prison, while another mentioned witnessing a homeless individual facing incivility:

I saw a woman who was from prison having a baby, and it was hard to watch the staff being rude to her. [#284, 34 y/o, woman, White]

I’ve seen someone who was homeless and clearly had been there before talked down to. [#39, 35 y/o, woman, White]

Although the unique details of each interaction are not known, emerging patterns suggest marginalized individuals may be more vulnerable to being targeted with incivility. Although hospitals are generally considered to be stressful contexts, these circumstances of stress may be exacerbated among marginalized individuals.

Elderly targeted incivility

Another form of witnessed incivility included mistreatment toward the elderly individuals. These instances of incivility were primarily based on the intersection of age and ability. For example, participant 25 described an instance in which hearing loss from old age was seen as an inconvenience.

I’ve watched a receptionist treat an older gentleman very rudely. He was hard of hearing, and she told him that she didn’t have time for this. [#25, 29 y/o, man, White]

Elderly individuals were made fun of behind their backs or were openly treated poorly by medical professionals. Interestingly, this was the only theme in which some participants explicitly labeled such behaviors as “mocking”:

My great aunt has Alzheimer’s and is frequently ending up in the ER for various things. A lot of the time, these doctors are not wanting to deal with her because she is very difficult to handle. However, doctors on her service are constantly mocking her and repeating themselves in a tone that doesn’t need to be. [#79, 25 y/o, woman, White]

For these targets, often medical professionals expressed an unwillingness to be accommodating to the unique difficulties that elderly individuals face.

Ignored/needs not met

This theme was defined as participants witnessing others being ignored or not having their needs completely met. These interactions were perceived as a lack of medical care or assistance when needed:

My mother was very ill and needed to be cleaned up, and a nurse said that it was ‘not her responsibility,’ and that my mother would just have to wait for the nursing aides to clean her even though she had asked for over an hour to be cleaned. [#95, 53 y/o, woman, White]

While some experiences were not necessarily life-threatening, they were stressful and avoidable. Other situations became dangerous when individuals with time-sensitive issues faced a lack of care, as observed by participants:

My brother was in the [ED] for suspected MERSA. He is a diabetic. The doctor told him that he was a poor diabetic in that he didn’t take care of himself and that the concern was just poor food and insulin management. Really angry at my brother. 24 hours later, my brother was in intensive care for MERSA [#265, 63 y/o, woman, White]

Witnesses of incivility were watching other individual’s lives at risk because their experiences were not believed. Importantly, the high-stakes nature of such medical conditions was clear to those around the patients, further emphasizing the perception that medical professionals were indifferent to patient concerns.

Physical interactions/harm

This incivility was defined by instances of direct negative physical interactions and harm. Three participants indicated witnessing this form of incivility. Participants described instances in which individuals were treated physically roughly by medical professionals:

There was a nurse at a VA hospital in the 70s that shoved a wash rag in an old man’s mouth just to shut him up. [#215, 63 y/o, man, White]

From these interactions, participants felt as though the behaviors were excessive and harmful. Rather than showing care for individuals, hospital workers were perceived as being rude and uncaring, whether this is true or not.

Issues with medication/instructions

This theme was defined as instances of incivility occurring due to difficulties associated with medication adherence or medical instructions. For example, this participant mentioned how medical professionals’ behaviors changed based on the perception of whether the patient complied:

I witnessed another patient constantly being given conflicting guidance from nurses and doctors, only to be yelled and scolded by them repeatedly. The doctor would tell him to walk more, and then a nurse would later stop him and use a chair alarm to ensure he didn’t get up from his chair. Later, the doctor would scold the patient for not walking. [#197, 27 y/o, woman, Native American]

Some observers noted important contextual information about these interactions. For instance, some participants believed medical professionals weren’t fully considering the perspective of the patient or giving them the space to talk in that moment to help prevent these issues. Better communication may have alleviated these problems.

Incivility toward hospital workers

The last subtheme involved incivility directed toward hospital workers or medical professionals and generally included arguing, and this was often perpetrated by patients.

The patient in the room with me treated the nurse poorly, questioning everything she did and saying she was lying to him” [#246, 39 y/o, woman, White]

This subtheme demonstrates that the high-stress environment may yield uncivil interactions between all individuals. It also supports research positing that patients can be perpetrators of incivility as well, in addition to being the target.

Control

Three major themes for the perceived control data were identified for Aim 2.

Yes, impacted

For those who answered yes, they thought the uncivil event impacted the target’s perception of control. Most participants recognized how incivility could undermine perceptions of control. Further, many described the process by which the target’s perception of control would be reduced:

Yes, it could impact their feelings of how much the staff truly takes her best interests to heart. [#26, 30 y/o, woman, Latina/Hispanic]

Through various mechanisms, participants felt that incivility could contribute to a loss of control, and several suggested targets would have difficulty regaining it, if ever. Importantly, some participants suggested that in these high-stakes environments, a major reduction in control could be damaging for the target’s well-being.

No, not impacted

A minority of participants felt as though the incivility they witnessed did not impact the perceptions of control for the target. One participant pointed out how patients have no control in hospitals, so these indignities wouldn’t make a difference. Other participants, like participant 257, signaled the opposite:

…They can always go to another provider if they were really unhappy [#257, 42 y/o, woman, Asian/Asian American/Pacific Islander]

From this perspective, a target’s control is not impacted because witnesses believe targets always have a choice to return or go somewhere else for treatment.

Maybe

Few participants were not sure if a target’s control would be impacted or not. Participant 251 exemplifies this perspective:

I have no idea. I don’t know either of the people.” [# 251, 36 years old, man, White]

These participants viewed control as an individual factor, and some felt they needed additional information about the target or the situation to make a judgment.

Discussion

The current study is among the first to examine witnessed incivility from the perspective of patients/visitors in hospitals. Evidence indicated that this group witnessed a variety of uncivil behaviors. Although most uncivil behaviors were targeted at patients, incivility was also targeted at hospital workers and medical professionals, and mostly everyone perpetrated incivility.

There are also important areas of overlap between the themes of witnessed incivility and themes of incivility identified in research documenting experienced incivility (1). The findings of the current study indicated similar patterns, such as “being ignored.” The distinct perspective of witnesses in the current study provided powerful insight, and unique patterns of incivility were able to be identified. Specifically, the data demonstrated how incivility is targeted at various marginalized groups. For instance, participants described instances of incivility targeted toward elderly individuals. A substantial body of extant research has documented instances of abuse of elderly individuals (39 –42), but less has focused on elderly individuals’ incivility. The results demonstrate that in addition to various forms of abuse, elderly individuals are likely to face this more “minor” form of mistreatment. Currently, the U.S. population is rapidly aging, and soon hospitals will be taking care of greater proportions of elderly individuals with multiple comorbidities (43). More research is needed on the elderly targeted incivility.

There was evidence of witnessed incivility directed toward homeless individuals. Although this group has been underrepresented in the incivility literature, they may be at an increased risk of facing mistreatment in hospitals. Research shows homeless individuals visit hospitals to seek medical help for multiple comorbid conditions and shelter (44). Research has suggested that a lack of stable housing is a barrier in treating and managing health conditions (45). Homeless individuals may face recurrent incivility in hospitals due to their marginalized status, frequent hospital visits, or stigmatized conditions. However, experiences of incivility are not often recorded from the perspective of these individuals (46), and future work should prioritize this sample. Additionally, one participant witnessed incivility being targeted at a woman entering the hospital from prison. This observation highlights another group of individuals (ie, incarcerated individuals) which remains understudied in the incivility research.

The control data demonstrated that the majority of witnesses believed the incident of incivility would impact the targets’ sense of control. This perception was true across all themes of witnessed incivility. Importantly, the quotes from participants revealed that the event would undermine the target’s sense of control. This study shows that in addition to witnessing the event, witnesses are also considering how targets of incivility may feel.

Limitations

First, our survey instructed participants to recall their perceptions. It is possible critical details about the incident were forgotten or misremembered. Researchers should instruct participants to write down their perspectives immediately after leaving a hospital. Although our methodology of using open-ended responses is reflective of a larger call for novel data collection methods (47), the responses were limited in depth and perhaps lacking in finer detail. Future research should conduct interviews to collect additional data to permit a deeper analysis. Although our participants were from across the United States, our sample was not entirely demographically representative of the U.S. population. We suggest that researchers implement a focused recruitment strategy to address this gap.

Conclusion

Patients/visitors provide critical information about the patterns of incivility within hospitals. Witnesses consider the impact from the target’s perspective and believe that targets may face decreases in their sense of control.

Footnotes

Authors’ Note

The research was conducted at the University of Michigan. All procedures in this study were conducted in accordance with the University of Michigan HUM00141390 approved protocols. Written informed consent was obtained from the participants for their anonymized information to be published in this article. Riley A. Marshall and Emily A. Vargas are now affiliated with UCLA Psychology Department, Building 1285, Los Angeles, CA, USA.

Acknowledgments

At the time of manuscript preparation, EAV was funded by the T32 Research Training Program in Cardiovascular Disease Epidemiology and Prevention at Northwestern University, Department of Preventive Medicine.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors, exclusively internal funding from the University of Michigan.

ORCID iD

Emily A. Vargas, PhD

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