Article Text
PDF
Abstract
Background Incivility or rudeness is a form of interpersonal aggression. Studies suggest that up to 90% of healthcare staff encounter incivility at work with it being considered ‘part of the job’.
Methods Qualitative, in-depth, semistructured interviews (n=14) undertaken between June and December 2019. Purposive sampling was used to identify front-line paramedics working for one NHS Ambulance Trust. Interviews lasted between 16 and 45 min, were audiorecorded, verbatim transcribed and analysed using thematic analysis.
Results Four themes were identified: paramedics reported a lack of respect displayed both verbally and non-verbally from other professional groups. The general public and interdisciplinary colleagues alike have unrealistic expectations of the role of a paramedic. In order to deal with incivility paramedics often reported taking the path of least resistance which impacts on ways of working and shapes subsequent clinical decision-making, potentially threatening best practice. Finally paramedics report using coping strategies to support well-being at work. They report that a single episode of incivility is easier to deal with but subsequent episodes compound the first.
Conclusions This study highlights the effect incivility can have on operational paramedics. Incivility from the general public and other health professionals alike can have a cumulative effect impacting on well-being and clinical decision-making.
- paramedics
- effectiveness
- prehospital
- prehospital care
- communications
- qualitative research
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Data are anonymised audio transcription quotes of which are used in this paper.
Statistics from Altmetric.com
Key messages
What is already known on this subject
Up to 90% of healthcare workers experience incivility at work.
It has adverse consequences on clinical decision-making and performance and can lead to frustration and reduced job satisfaction.
What this study adds
Incivility from the general public and other health professionals alike can have a cumulative effect impacting on paramedics’ mental well-being and clinical decision-making.
Expectations and lack of understanding about the scope of practice of a paramedic can lead to confusion, frustration and often confrontation from patients and other healthcare professionals.
Background
Incivility or rudeness is a form of interpersonal aggression. Customers, clients and patients serve as the primary perpetrators of incivility1 2 particularly in high-intensity, service-oriented organisations such as the prehospital environment.3–5 Studies suggest that up to 90% of healthcare staff encounter incivility at work.6 7 Although the rude behaviours regularly experienced by healthcare practitioners can seem benign, they have the potential to result in patient safety errors with potentially devastating outcomes.6
Research suggests that incivility or rudeness has adverse consequences on clinical decision-making, diagnostic and procedural performance. Rudeness from relatives was shown to result in statistically significant poorer medical team performance from teams under stress8 with diagnostic and procedural interventions are worse with incivility. Porath and Pearson suggest that 38% of recipients reduce the quality of their work when faced with incivility.9 Laschinger and Nosko found that incivility and quality of nursing care was directly related, reporting that nurses felt that incivility caused then to make more clinical errors.10
A study by Cash et al 11 of 2815 emergency medical service workers found nearly half of respondents experienced incivility at least once a week or more. Exposure to this behaviour led to increased job dissatisfaction, intention to leave, increased levels of moderate to severe stress and workplace absence. Workplace incivility has been shown to be a contributor to staff turnover,12 long-term absence,13 loss of work motivation14 and incidence of post-traumatic stress disorder.10
There is considerable anecdotal evidence about both verbal and physical aggression being displayed to paramedics while on duty. However, there is limited research exploring the incidence of this negative behaviour and, in turn, the effect this has on the paramedics delivering clinical care at the scene.
Previous research has largely focused on the impact of incivility on patient outcomes. This study specifically aimed to explore experiences of incivility among front-line paramedics, who were encouraged to consider their experiences and identify what impact these experiences had.
Methods
Design and setting
An interpretivist perspective was taken to allow an in-depth exploration of incivility as experienced and understood by front-line paramedics. Interpretivism aims to gain knowledge of the world by understanding the meanings that humans attach to their actions and reactions.15 The interpretivist paradigm considers reality as complex and multifaceted. A single behaviour can have multiple interpretations. In studying practitioner experiences, qualitative research techniques are used that will help us understand how people interpret and interact within their social environment.
One to one, semistructured interviews were used to elicit discussion about experiences and their meanings. This approach gave participants the opportunity to focus on issues most important to them in a confidential environment, avoiding the influence of a peer perspective. A qualitative approach aimed to give participants a ‘voice’15 and minimise the imposition of external categories that may represent underlying assumptions on the part of the researcher.
The study took place in one NHS Ambulance Trust in England, UK, between June and December 2019. The use of one ‘site’ ensures that the ways of working at the Trust were understood by the research team; reflexive notes identify that this not only supported access but that an understanding of the trust/ site processes and student education requirements provided invaluable context information.
Sampling
A call for participants was circulated across the Ambulance Service Trust via internal newsletter and social media.
The xxxx, supported by xxxx, is undertaking some research to explore the incidence and impact of incivility in pre-hospital care. The research involves 30–45 min interviews with registered paramedics exploring your thoughts and ideas. It is anticipated that the research will provide an insight into how incivility can impact on decision making and ultimately affect patient care.
The only inclusion criteria was that the participant must be a front-line paramedic. All those who offered participation were recruited16 and were given the opportunity to take part in the research; all participants who agreed to take part were recruited and data were collected until data saturation was reached.
The project is small scale (n=14); however, this allowed for the collection of rich, deep17 data, with sample sizes for qualitative research between 10 and 20 seen as acceptable.16
The focus of the study was to gain insight into incivility experienced by front-line operational paramedics and how that impacted on them both personally and professionally. Recruitment, interviewing of participants and analysis of data occurred iteratively and these processes overlapped to allow for themes and codes to be saturated. Despite the low numbers of participants, data saturation was achieved18 and guided recruitment and participant numbers.
Recruitment
A call for participants was circulated by the principal investigator using the NHS Ambulance Trust newsletter and twitter feeds. Paramedics that expressed interest in the study were given 7 days to consider the information sheet and decide whether to take part. Participants recruited into the study were interviewed at their convenience. Consent was taken immediately prior to interview; participants were allocated numeric codes to ensure anonymisation.
Data collection
In-depth, semistructured interviews, of 20 min, on average, followed an interview schedule and were audiorecorded (see box 1). All interviews were professionally transcribed and checked for accuracy. Interviews were undertaken by a non-paramedic researcher to reduce bias.
Interview schedule
What do you understand by the term ‘incivility’?
How often do you encounter incivility during your normal working day?
Which group do you feel are the least civil (colleagues, patients, family members, the general public)?
Tell me about an incident where you have encountered incivility in the prehospital environment.
How does incivility make you feel?
Do you feel that incivility affects your well-being at work?
Do you think experiencing incivility affects your decision-making?
For how long does an incident of incivility affect you for?
What do you think could be done to reduce the amount of incivility you encounter?
What would help you cope better with incivility at work?
Analysis
Transcripts were analysed using thematic analysis.19 Data were organised into codes; links between the codes were then considered which informed the development of themes. Analysis was carried out by both researchers (NJC and CW) independently; the final analysis was agreed through discussion, guided by reflexive field notes made during data collection. To maximise confirmability20 and interpretive rigour,18member checking was undertaken both through discussion and reading of transcripts with participants who confirmed resonance with their experiences.
Results
The study recruited 14 participants. The sample was made up of males (n=10; 71%) and females (n=4; 29%); all participants were between 25 and 45 years of age, the majority had been in service for 5 years. No participants dropped out of the study. All participants stated that they experienced incivility on at least a weekly basis. This incivility came from the public, patients and their family and friends as well as other professional groups and colleagues. Four key themes that emerged from the transcripts were as follows:
Interdisciplinary respect.
Patient and interdisciplinary expectations.
Path of least resistance.
Well-being at work.
Theme: interdisciplinary respect
A lack of respect from other professional groups was an issue discussed by all participants. Participants reported different ways this ‘disrespect’ was expressed, both verbally and non-verbally.
You’ll get a sort of derogatory look, you can see their eyes roll when you walk in with a patient, a bit of a tut and a bit of huffing and puffing. (Participant 10)
She [nurse] asked what’s he in for (the patient)…then she just blanked me and started talking to the doctor. (Participant 13)
[members of staff] challenge why you haven’t done something…it’s the aggressive nature…it’s sometimes the way you speak to people not what you say….Sometimes all you want when you take a patient in [to ED] is for people to just listen to me for a minute…for everyone in that team to absorb the information. (Participant 8).
This led to some feeling undermined, Participant 8 discussed this, concluding ‘they don’t believe our clinical judgement and decision making’. The participants acknowledged that the pressure faced daily by the NHS can impact on professional behaviours and that often staff need support.
The nurse who can be frustrated because her workloads massive and she’s under intense pressure. I don’t think she intentionally becomes uncivil. (Participant 5)
They’ve essentially got a department that’s bursting at the seams…you can see why people get stressed, why tempers get frayed…it’s almost like a perfect boiling point for incivility. (Participant 4)
I took it as a sign that he’s out of his comfort zone and he’s struggling a bit, so we probably actually need to help him. (Participant 6)
In addition, participants report that incivility from colleagues and other professionals is harder to manage than from a patient.
There is also a bigger problem within the workforce in terms of personal and professional standards of behaviour…incivility among colleagues and peers which is fairly low level but consistent, on a day to day basis, is actually worse than incivility that you might encounter from a patient or relative. (Participant 3).
Theme: patient and interdisciplinary expectations
It became evident from the interviews that there was a lack of understanding about the role of a paramedic with both patients and relatives and other health professionals. Paramedics expressed that there was a ‘lack of knowledge of what our service is and what we are here for’ (Participant 2). This was evident in relation to clients and their families, where there is an expectation they will be given access to hospital care, with one participant stating, ‘If they dial 999, they expect to be taken to hospital’ (Participant 5).
Paramedics also noted that clients misunderstand the role of the paramedic, seeing it as the consumption of a service, rather than the provision of professional guidance and care.
[When referring to a clinical situation] He had the opinion that he was the patient and that he could say what he wanted. (Participant 12)
He (the patient) said I pay your wages, you’re a civil servant, you have to do what I tell you. (Participant 14)
This role confusion was also apparent in terms of interprofessional working; a number of participants talked about ‘people not knowing other people’s roles about our scope of practice’ with inevitable consequences for care quality.
Sometimes there is no justification for what they are saying…they don’t understand how you work; some will ask have you done this and it’s something we can’t do. (Participant 6)
Theme: path of least resistance
Participants discussed how experiences of incivility impacted their clinical decision-making. The resulting strategies differed if the perpetrator was a patient or a colleague and ranged from avoidance to calling out bad behaviour. When the incivility was received from a patient or relative, adhering to best practice and the impact on clinical decision-making featured heavily in the discussion. Feeling vulnerable in particular was discussed, as well as the way this shapes ‘negotiations’ with the patient. Vulnerability undermines the practitioner’s confidence in their own practice potentially impacting on the quality of the care provided.
In a situation where perhaps there is a higher level of incivility displayed I would say that lowers your threshold, you’re more likely to take a defensive position or more risk averse decision than you would have…it will impact on your clinical decision making. (Participant 3)
Because they’re being rude and quite aggressive towards you it can be difficult to follow best practice…when you go into someone’s house and they’re immediately aggressive it can be off-putting, do I really want to be in that environment, do I really want to be helping this person…in their environment you’re very vulnerable. (Participant 12)
Sometimes I feel we’re giving people what they want as opposed to what they need and therefore we’re not teaching people and educating people, you end up just appeasing people and giving in. (Participant 2)
You feel a bit defensive…it makes me feel sad that they would want to be rude to you when you’re trying to help them…I question have I done the right thing. (Participant 13)
It can destroy your attitude for the rest of the shift…I’ve left that job feeling angry or upset and I’m sure it’s carried forward into my next job. (Participant 7)
Generally, however, participants felt that incivility from patients was less problematic as they are in a vulnerable situation, often scared and in pain but that incivility from other colleagues or professional groups was most challenging. Incivility from colleagues impacts on ways of working and shapes subsequent clinical decision-making, potentially threatening best practice. Past experiences of inter-professional incivility can lead to confusion about the best way to get the patient the timely care needed.
Last time I took a patient in (to ED) with this they absolutely wiped the floor with me, let’s see if I can persuade the patient to not go…I don’t want to take the patient to that hospital because they’ll just fob me off. (Participant 4)
It might take me longer to go through that thought process and maybe make it more complicated…next time do I make the phone call (pre-alert into ED), do I ring them and then just take the brunt of it when I get there when they say what have you rung us for…it makes you second guess yourself…question your ability. (Participant 8).
Theme: well-being at work
Participants discussed a range of coping strategies. It was evident that while team working played a large supportive role, staff felt that the impact of incivility had a significant negative effect on their mental well-being. Incivility appears to have a cumulative effect; a single episode is easier to deal with but subsequent episodes compound the first. Not only is this cumulative, it also impacts as it continues over time. This has long-term, career level, implications.
There’s feeling of absolute frustration, you’re getting backing into a corner because you are having to control your own behaviour because all you really want to do it retaliate in that situation, There’s that constant sense of disappointment. It takes emotional energy to deal with it and you can feel quite fatigued by constantly wanting to do the right thing in terms of upholding your own set of personal professional standards and trying to lead by example. (Participant 3)
When discussing an example of rudeness from a colleague you feel belittled and embarrassed…you feel worthless, you feel completely worthless. There’s definitely a cumulative effect…it slowly eats away and then the little things become a big thing and then you call into question your capability and it does make you feel inadequate. (Participant 8)
The pressures are incessant, the workloads incessant and you’re then juggling lots of balls at the same time and its bound to lead to frustration and stress. (Participant 10)
it has a toll on you in the long run with a lot of people leaving the ambulance service and it probably plays a big part of it. (Participant 14)
It doesn’t make you perform to the best of your ability and I don’t think anyone goes to work to not perform…you need some breathing space, headspace, increase your bandwidth again. (Participant 7).
Coping strategies discussed by participants ranged from putting the issue to one side to adapting to the situation. Wider factors also were reported as important; good team working was discussed by participants as an effective source of support, for example one participant commented: ‘we bounce off each other’ (Participant 9).
However, this is not the case for everyone, all the time with all colleagues, even for people who work in effective teams. Lack of proactive support from senior staff (intraprofessional), can increase stress for paramedics. Some participants report strategies that show they are adapting to manage the pressures of the system within which they work, by evaluating the scope of their daily practice to minimise their stress. However, this is an energy-consuming process in an already demanding job.
I don’t hang on to things in my mind, I put them in a filing cabinet…it makes you feel a bit worthless…it de-energises you. (Participant 5)
I think you have to kind of ignore it…work out what you can do differently. (Participant 14)
Sometimes you are made to feel like you have to put up with it and you shouldn’t have to at all. (Participant 2)
I look after the people around me as best as I can, I feel it’s a broken system, I’ve done the best that I can personally do, I’ve tried to make my mark for that shift. (Participant 4)
There’s feeling of absolute frustration, you’re getting backing into a corner because you are having to control your own behaviour because all you really want to do it retaliate in that situation, There’s that constant sense of disappointment. It takes emotional energy to deal with it and you can feel quite fatigued by constantly wanting to do the right thing in terms of upholding your own set of personal professional standards and trying to lead by example. (Participant 3).
Discussion
In summary, this study suggests that incivility can cause a practitioner to question their actions and ability which can negatively impact on clinical decision-making. Participants suggested that they may ‘take the path of least resistance’. This may shape care options available to patients, as it makes decision-making more complex. Practitioners must balance the patients’ perspective against increasing risk as well as best practice, as they negotiate a pragmatic way forward. The negative impact of incivility among professionals has also been clearly identified by the study participants. The impact of incivility on the quality of care has been well documented (eg, nursing,21 medics22 and emergency medical services professionals11) in relation to both interprofessional and intraprofessional team working and learning.
Incivility can have an insidious effect23 for individual practitioners, and ultimately, the wider profession. Our participants reported both verbal and non-verbal incivility. Whether overt or covert, the cumulative effect is much greater than the sum of its parts and negatively affects well-being at work. The subtler forms such as eye rolling or being ignored during a handover can be even more insidious than overt bullying and aggression.7 They seem minor at first and therefore ignored or overlooked. However, they build up and erode staff morale, reduce confidence and negatively impact well-being. This leads to a feeling of apathy and a desire to leave the profession altogether.
When considering the findings of this study within the context of the wider literature there appears to be evidence of increasing incivility within the workplace environment.8 Literature in many areas of medicine suggest that incivility is commonplace, reporting examples from the general public and healthcare professions. Incivility is unacceptable from any individual; however, it is acknowledged that patients and their relatives are often under a great deal of physical and psychological stress, which could explain their behaviour. Interestingly, despite the suggestion that incivility among professionals may also be the result of stress, this is generally less accepted.8 Strategies to manage incivility have been suggested, informed by an aim to ensure healthcare professionals have appropriate skills when working with patients21; however, this does not regularly extend to working with other professionals. Interprofessional incivility represents a use of power to enact a hierarchical position,21 many paramedics are not able to challenge this, especially where the instigator is supported by cultural structures. In addition, a focus on individual skills does not acknowledge the impact of the situational,24 organisational22 and policy context.25 High workload, heavy responsibilities, lack of resources, negative workplace culture and ineffective leadership may increase the likelihood of incivility.24 Strategies that address and acknowledge these wider factors are necessary to support effective professional relationships and reduce occurrences and impact of incivility arising from, what is perceived as, a lack of professional respect. Although for the individual practitioner, it is prudent to ‘choose your battles’, it is also necessary for best clinical practice, to promote good interprofessional and intraprofessional communication central to healthy and critical team working.26 A cultural shift towards strategies that actively support professional respect and understanding may be necessary.
Lack of awareness and conflicting expectations surrounding the paramedic role was seen by participants as an additional driver to incivility among both patients and their relatives as well as other professional groups. For patients and relatives, this was used to explain, in part, their incivility; among professional groups, this was seen as professionally inappropriate. This resonates with work by Armstrong who found that managing incivility from clients is seen by healthcare professionals as an expected part of providing care; among other professionals it was seen as a sign of professional disrespect and at worse, the imposition of hierarchy.27 Both aspects are viewed as unprofessional, with a detrimental impact on communication and team working.25 A clearer understanding of the role and skills of healthcare professional groups would help to reduce these confusions.28 This is particularly pertinent at a time when roles and responsibilities in clinical practice are fluid29 and expedient, in response to the COVID-19 pandemic and the shortfall in healthcare staff.
Further qualitative research is needed to explore in more detail, experiences of incivility in relation to working with patients and their families, but also interprofessional and intraprofessional working. This would support to a holistic approach to addressing incivility both in relation to individual strategies, but also at an organisational level.
Limitations
As a small piece of qualitative work there are a number of limitations to this study. First in relation to sampling, we acknowledge that the response to recruitment may have resulted in a participant group that does not report on the full range of experiences across the paramedic workforce. Most of the participants were male with the sample drawn from a single Trust, which potentially further limits the transferability of any findings; however, the aim here is to scope and explore and to identify areas for further research.
Conclusion
Although rudeness and incivility can seem like an accepted part of the job, this study highlights the effects this behaviour has on operational paramedics. Participants reported that incivility from the general public and other health professionals alike can have a cumulative effect impacting on their mental well-being and clinical decision-making. Expectations and lack of understanding about the scope of practice of a paramedic can lead to confusion, frustration and often confrontation from patients and other healthcare professionals. Further research is recommended to explore potential intervention strategies to support front-line emergency workers.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Data are anonymised audio transcription quotes of which are used in this paper.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was obtained from the University of Hull, Faculty of Health Sciences Ethics Committee (approval number FHS121).
Footnotes
Handling editor Ellen J Weber
Twitter @credland_nicki
Contributors Both authors contributed equally to the production of this paper.
Funding This research was funded by East Riding of Yorkshire Clinical Commissioning Group.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.