Perceptions of Disrespect in the Hospital Workforce During the COVID-19 Pandemic: Analysis and Implications for the Future

doi:10.21203/rs.3.rs-4046166/v1

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Research Article

Perceptions of Disrespect in the Hospital Workforce During the COVID-19 Pandemic: Analysis and Implications for the Future

https://doi.org/10.21203/rs.3.rs-4046166/v1

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Background

The COVID-19 pandemic brought disruption and uncertainties to hospital settings. The objective of the study is to expand our understanding of how the intensity and stressors of the pandemic impacted perceptions of disrespect among the United States (US) hospital workforce. This investigation focuses on three core dimensions. First, the study seeks to shed light on how perceptions of disrespect during the pandemic varied by job category, including physicians, nurses, clinical specialists, supervisors, and non-clinical support staff. Second, this analysis looks at the effect of having direct patient interaction on the likelihood that hospital workers perceived disrespect. And, lastly, this research compares worker perceptions of disrespect during the early versus later pandemic timeframes.

Methods

This study uses logistic regression and bivariate comparative analysis of publicly available data from the US Agency for Healthcare Research and Quality’s (AHRQ) 2021 and 2022 Hospital Surveys on Patient Safety Culture 2.0, spanning survey years of 2020–2022.

Results

Perceptions of workplace disrespect during the COVID-19 pandemic varied across job categories. Nurses and support staff are found to perceive the most disrespect, and physicians are much less likely than nurses to perceive disrespect (-.53 OR, p < 0.01). For both nursing and support workers, direct patient interaction did not play a role in the likelihood of perceiving disrespect. By contrast, for physicians, clinical specialists, and supervisors, directly interacting with patients is found to significantly impact the likelihood of perceiving disrespect. Physicians are also the job category with the greatest percentage shift (20–25%) in increased perceptions of disrespect from early to later stages of the COVID-19 pandemic.

Conclusions

Removing blind spots to experiences of disrespect within the workforce is essential to reducing it. Equipping workers with multiple pathways to safely report perceived disrespect without fear of retribution is the first step that can enable healthcare institutions to address it. Heightened accountability at all levels of an organization, conflict management and communication training, and team and individual interventions such as one-on-one coaching and peer support programs may all be useful strategies for improving cultures of respect.

Disrespect

COVID-19

Workforce

Respect

Patient Safety Culture

Disrespect within healthcare settings is present in many forms. It may involve disruptive, demeaning, or offensive behaviors between workers. It can appear in the interactions between healthcare workers, patients, and their families. And it emerges through failures and hostile conditions baked into system design or institutional expectations. Disrespectful behavior undermines patient safety, quality care, and the well-being of the workforce (Leape et al, 2012; Lateef, 2020; Rangachari and Woods, 2020).

Leape et al. (2012) provide a detailed exploration that could help healthcare leaders understand the many dimensions where disrespect may be felt. Disrespect has been described as humiliating, demeaning, or shaming behaviors (Leape et al, 2012). These acts can be intentional, such as an individual annoying or dissing another, deliberately avoiding communication, or it can be due to systemic factors that lead to frustration or feelings of victimization, such as being expected to work without enough time to do a good job, when exhausted, or when expected to prioritize certain tasks even if one’s sense of professionalism and morality would dictate otherwise. Personal insecurities or inherent proclivity toward aggressive communication and learned behaviors can each play a role in why individuals are disrespectful (Leape et al, 2012). The experience of disrespect may appear because of challenging interactions between patients, families, and healthcare workers, or may arise within teams. These experiences of disrespect can directly impact the quality and safety of patient care and they contribute to worsened mental-being, as workers struggle with the stresses of perceived disrespect (Leape et al, 2012).

Within the professionalism standards set by the Accreditation Council on Graduate Medical Education and by the American Board of Medical Specialties (ABMS), respect is a core element (Leape et al., 2012). The Joint Commission, a key accreditation body in United States (US) health care, and the US Centers for Medicare and Medicaid Services define standards of respect across many policies (Sokol-Hessner, et al., 2015). And respect for patients, colleagues, and other health professionals is a central principle of the American Medical Association Code of Medical Ethics (AMA Principles of Medical Ethics, 2021). Despite many guiding medical codes and standards where respect stands prominently, identifying and addressing disrespect within healthcare organizations remains a challenge, which was exacerbated within sectors of the workforce during the pandemic. By studying the extent to which disrespectful behavior impacted the US healthcare workforce during the COVID-19 pandemic, we aim to offer guidance to leaders looking to cultivate a culture of respect as we move into a post-pandemic world and look to reshape our healthcare organizations to be more resilient to disruptions and more capable of supporting the well-being of workers, patients, and communities.

The 2021–2022 Hospital Survey on Patient Safety Culture (HSOPS 2.0) is a survey tool released by the US Agency for Healthcare Research and Quality (AHRQ) in 2004 to assess hospital worker perceptions of patient safety culture on dimensions such as teamwork, leadership support, and communication. US hospitals voluntarily chose to submit their survey data to the AHRQ publicly available database. This study uses data from the 2021 and 2022 Survey on Patient Safety (SOPS) database waves, which accounts for 572 hospitals, and a total sample size of 227,790 individual respondents, who completed the SOPS survey between November 2018 and July 2022. This study utilized a subset of the 2021 and 2021 database waves, focusing on data from all surveys submitted by US hospital workers between April 2020 and July 2022. Even though hospital participation in the public database was voluntary, the datasets are considered fairly consistent with the distribution of hospitals registered by the American Hospital Association (AHA) (Hare et al., 2022; Famolaro et al., 2021).

For this study, “perception of disrespect” is the main outcome variable of interest. The original survey question poses: “How much do you agree or disagree that there is a problem with disrespectful behavior by those working in your unit?” The original survey responses were based on a 5-item scale “Strong Disagree, Disagree, Neither Agree or Disagree, Agree, Strongly Agree,” which this research collapses into a binomial variable: one category for those who strongly agreed, agreed, or were neutral; and a second category for those who disagreed or strongly disagreed. This empirical study includes survey responses by all hospital workers that responded to the survey question of interest, except for those respondents who reported “don’t know” and “does not apply” responses.

The HSOPS survey organizes hospital workers into six categories: (1) supervisor, manager, clinical leader or senior leader; (2) nurses, which includes Licensed Practical Nurses (LPNs) and Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), advanced nurse practitioners, and nursing aides (3) physicians, including attendings, residents, fellows, and interns, and physician assistants (PAs) (4) clinical specialists, such as dietitians, pharmacists, social workers, respiratory, occupational, and speech therapists, (5) non-clinical support staff, such as Information Technology (IT), housekeeping and facilities staff, transporters, food service workers and (6) an undefined “other” category. This research considers the following covariates: workers' year in profession, weekly hours worked, census region, bed size category; workers’ feeling that mistakes are held against them; and workers’ feeling of support by coworkers. “Direct patient contact” is a binary variable based on a yes/no response to the question: “In your staff position, do you typically have direct interaction or contact with patients?”

To explore variations in perceived disrespect within the hospital workforce, this research uses regression and comparative descriptive analyses. The first part of the investigation employs multivariable logistic regressions to examine the degree to which US hospital workers in varied job categories perceive disrespect. The second part of the analysis uses multivariable logistic regression to examine whether worker perceptions of disrespect are influenced by whether they have direct patient contact. Descriptive bivariate comparative analysis is used within the third and final stage of the study to investigate the percentage changes in perception of disrespect during early versus late phases of the COVID-19 pandemic with the US. Point estimates and P- values are reported. All statistical analyses were performed in Stata 16.1 software.

Table 1 shows variations in perceptions of disrespect reported by US hospital workers between April 2020 to July 2022. When controlling for workers’ years in the profession, hours worked each week, census region, and bed size category, results show that physicians and PAs are significantly less likely to perceive disrespect compared to nurses (Odds Ratio (OR): 0.53 ; P < 0.001). By contrast, workers who self-identify as support staff, such as transporters, housekeepers, and food service employees, have 12% greater odds of perceiving disrespect compared to nurses (OR: 1.12 ; P < 0.001). Additionally, compared to nurses, leaders, including those who identify as supervisors, clinical, and senior leaders, are 6% less likely to perceive (OR: 0.94; P < 0.001) disrespectful behavior within their work units. And, clinical specialists, such as dieticians, pharmacists, respiratory, occupational, and speech therapists report 14% lower odds of perceiving disrespect compared to nurses.

Table 1

Variations in Perception of Disrespect in the US Hospital Health Workforce During the Pandemic
Perceptions of Disrespect
Hospital Workers	Odds Ratio	P-value
Nursing (N = 101,329)	Reference	n.a
Physicians and Physician Assistants(N = 10,340)	0.53	0.000
Clinical Specialists (N = 46,843)	0.87	0.000
Supervisor, Clinical or Senior Leaders	0.94	0.004
Support (N = 32,179)	1.12	0.000
Other (N = 18,332)	0.99	0.722
Sample Size	227,790
Source: 2021–2022 Hospital Survey on Patient Safety (2.0) Notes: Our total sample size is227,790. N.a: not applicable. We define the COVID-19 start period on April 1st, 2020, and the time-period for our study goes up till July 1st, 2022. We excluded March 2020 for our analysis since the survey date started March 1st, 2020, which was not applicable for the pandemic. In Table 1, outcome variable is perceptions of disrespect. We included the following covariates worker’s year in the profession, hours worked each week, census region, and bed size category. Hospital workers feel mistakes held against them being written up; or in the opposite light, hospital workers feel their environment fosters helping one another. Nursing is the reference group. All estimates are odds ratios. A. Support includes facilities, food services, housekeeping, and environmental services; information technology, health information services and clinical informatics; security, transporter; unit clerk, secretary, receptionist, and office staff. B. Nursing includes advanced practice nurse, licensed vocational nurse (LVNs), and licensed practical nurse (LPNs); c. Physicians include patient care aide, hospital aide and nursing assistant; Registered Nurse (RNs). D. Other Clinical Position include dietitian, pharmacist, and pharmacy technician; physical. Occupational or speech therapist; psychologist; respiratory therapist; social worker; technologist and technician.

In Table 2, we observe that between April 2020 and July 2022, perceptions of disrespect are shaped, with statistically significant margins, for supervisors and clinical leaders, physicians and PAs, and clinical specialists who work directly with patients (as opposed to workers in these same job categories who do not interact with patients). For example, physicians and PAs with direct patient contact are 64% less likely (OR: 0.64; P < 0.001) to perceive disrespect compared to physicians and PAs who do not interact directly with patients. By contrast, direct patient contact does not appear as a significant factor associated with perceptions of disrespect for nurses and support workers.

Table 2

Differences in Perceptions in Disrespect by Direct Patient Contact Status of Health Workers during the Pandemic
Health Workers	Direct Patient Contact Status
Health Workers	Odds Ratio With direct patient contact	P- value
Nursing (N = 101,329)	1.03	0.444
Physicians and Physician Assistants (N = 10,340)	0.64	0.000
Clinical Specialists (N = 46,843)	0.82	0.000
Supervisor, Clinical or Senior Leader (N = 32,179)	1.17	0.000
Support (N = 32,179)	1.01	0.744
Other (N = 18,332)	1.02	0.650
Sample	227,790
Source: 2021–2022 Hospital Survey on Patient Safety (2.0) Notes: Our total sample size is 227,790. We define the COVID-19 start period on April 1st, 2020, and the time-period for our study goes up till July 1st, 2022. We excluded March 2020 for our analysis since the survey date started March 1st, 2020, which was not applicable for the pandemic. In Table 2, outcome variable is perception in disrespect. We included the following covariates worker’s year in the profession, hours worked each week All estimates are odds ratios. a. Support includes facilities, food services, housekeeping, and environmental services; information technology, health information services and clinical informatics; security, transporter; unit clerk, secretary, receptionist, and office staff. b. Nursing includes advanced practice nurse, licensed vocational nurse (LVNs), and licensed practical nurse (LPNs); c. Physicians include patient care aide, hospital aide and nursing assistant; Registered Nurse (RNs). d. Other Clinical Position include dietitian, pharmacist, and pharmacy technician; physical. occupational or speech therapist; psychologist; respiratory therapist; social worker; technologist and technician.

Table 3 provides analysis of how perceptions of disrespect changed between the early phase (April 2020 to April 2021) and later phases (May 2021 to July 2022) of the COVID-19 pandemic. The bivariate descriptive analysis shows only smalls shifts in perceptions of disrespect for support workers, nurses, clinical specialists, and supervisors between the early to later phases of the pandemic. By contrast, there is a 5% increase in perceptions of disrespect among physicians and PAs across these two timeframes (20% vs. 25%, chi2 = 0.00). This jump in perceived disrespect for physicians and PAs is surprising since the analysis (Table 1) shows that across the overall pandemic time frame (April 2020-July 2022) physicians are significantly less likely than nurses to perceive disrespect on their units.

Table 3

Changes in Perceptions of Disrespect between Early vs. Late Phases during the COVID-19 Pandemic
	Positive Perception (%)	Negative Perception (%)	Positive Perception (%)	Negative Perception (%)	Chi2
Overall	69%	31%	69%	31%	0.000
Nursing (N = 90,181)	68%	32%	69%	31%	0.002
Physicians, Physician Assistants (N = 8,813)	80%	20%	75%	25%	0.000
Clinical Specialists (N = 41,694)	69%	31%	70%	30%	0.023
Supervisor, Clinical or Senior Leader (N = 16,897)	77%	23%	78%	22%	0.201
Support (N = 28,223)	63%	37%	64%	36%	0.084
Other (N = 15,766)	66%	34%	67%	33%	0.315
Sample Size	44,610	19.908	114,612	49.368	228,498
Source: 2021–2022 Hospital Survey on Patient Safety (2.0) Notes: Our total sample size is228,498. We define the COVID-19 start period on April 1st, 2020, and the time-period for our study goes up till July 1st, 2022. We excluded March 2020 for our analysis since the survey date started March 1st, 2020, which was not applicable for the pandemic. The early phase of COVID19 in our study period is between April 2020 to April 2021 and later phase of COVID19 is between May 2021 to July 2022. a. Support includes facilities, food services, housekeeping, and environmental services; information technology, health information services and clinical informatics; security, transporter; unit clerk, secretary, receptionist, and office staff. b. Nursing includes advanced practice nurse, licensed vocational nurse (LVNs), and licensed practical nurse (LPNs); c. Physicians include patient care aide, hospital aide and nursing assistant; Registered Nurse (RNs). d. Other Clinical Position include dietitian, pharmacist, and pharmacy technician; physical. occupational or speech therapist; psychologist; respiratory therapist; social worker; technologist and technician. We use Chi2 to examine whether there’s significant changes in disrespect perceptions across subgroups between early vs. later phase of COVID-19.

Table 1 shows significant variations based on a workers’ position types, with individuals who self-identify as supervisors and leaders perceiving less disrespectful behavior on care units compared to nurses. This finding is consistent with prior research showing how job status insulates those with higher status from perceiving disrespect (Nembhard and Edmondson, 2006; Kreindler et al, 2012; Singer et al., 2008). Examples from prior research shows that workers of lower status may perceive that their higher status counterparts are responsible for perpetuating disrespectful behaviors. Workers who are in non-leadership positions may also be more willing to express themselves in a way that is perceived as disrespectful without fear that a supervisor will intervene, as is the case with nurse bullying behaviors (Hafferty, 1998). And lower status workers may also be more exposed and vulnerable to feelings of disrespect caused by difficult patient interactions, which leaders may not experience with as much regularity within the scope of day-to-day work (Leape et al, 2012).

Table 2 shows whether working directly with patients shapes hospital worker perceptions of disrespectful behaviors. We anticipated that those with direct patient contact would be more likely to perceive disrespect, since this group is directly responsible for patient care, and more likely work in high stakes situations, under situations with uncertainty, COVID-19 infection risks, and time pressure (Singer et al., 2008; Firew, et al., 2020). The findings suggest otherwise. We find that while nurses and support staff are more likely to perceive disrespect than other worker groups overall, having direct patient contact does not play a role in nurse and support staff perceptions of disrespect. For the physicians and PAs job category and for the clinical specialists’ job category, by contrast, those that work directly with patients report a much lower likelihood of perceiving disrespect compared to their counterparts who do not work directly with patients (Physicians/ PAs: OR: .64, P < .0001; Other clinical: OR: .82, P < .0001). For supervisors, it is notable that the reverse effect appears. Supervisors who directly interact with patients report 17% increased odds of perceiving disrespect compared to supervisors who do not directly interact with patients (OR: 1.17, P < .0001). These results demonstrate that directly interacting with patients does not uniformly shape the likelihood of workers perceiving disrespect. While we can only speculate on the reasons for this variability, it may be the case that clinicians are able to feel higher personal satisfaction in making a positive impact on patients when they directly interact with them, which may impact their perceptions of disrespect. It may also be the case that supervisors that directly interact with patients are interfacing with patients around problems, where tensions may be higher, leading to a greater chance of perceiving disrespect. Future directions in qualitative research may be useful to further examine these dynamics.

Overall physicians and PAs were much less likely to perceive disrespect compared to nurses (Table 1). At the same time, physicians and PAs were also the group with the most significant percentage shift in perceptions of disrespectful behavior from the early to late phases of the pandemic (20% vs. 25%, Chi2 = 0.00) (Table 3). This finding suggests that as the pandemic progressed, physicians came to feel less insulated from disrespect than they experienced previously. Coupling these findings with earlier work, which found steep rises in physician emotional exhaustion during the later periods of the pandemic, there is evidence of a pandemic-related shift in physician workplace experiences (Sexton et al., 2022; Nembhard and Edmondson, 2006; Leape et al. 2012, Zisook, et al., 2022). Some of the causes of this trend toward perceiving more disrespect may be due to the confluence of existing underlying system and cultural factors that have impacted physician experiences, such as shifts toward practice models with physician employees rather than solo practices, expectations within medical culture of perfectionism, independence, and sacrifice within a broader societal culture that has moved toward accepting fallibility, the need for collaboration, and work-life balance (Shanafelt, 2021). Simultaneously, the pandemic compounded stressors for all clinicians, which impacted physicians and PAs too– increased distrust in medicine within communities, communication challenges posed by infection control procedures, high work demands caused by large patient loads, and fears of getting sick. It could be that this anomaly will ‘correct’ itself as the pandemic shifts into the rearview mirror, and physicians will become less alarmed by disrespect. It also could be that the shift is a signal that the pandemic triggered a larger scale change amongst physician experiences of disrespect.

With the end of emergency COVID-19 pandemic procedures, healthcare organizations face the opportunity to create data-driven post-pandemic priorities to cultivate cultures of respect in the workplace. This study shows that nurses and support staff struggled the most with experiencing disrespect, whether they were in direct contact with patients, and that physicians faced the greatest shift during the pandemic in their experiences of disrespect.

The post-pandemic moment offers an opportunity to re-engage anew with addressing disrespect, with knowledge about the deep consequences of how disrespect has harmed patient safety and workforce well-being during the period of heightened COVID-related workplace stressors. These harms included burnout, turnover, harms to patient safety, and worse well-being (Singer et al, 2022; Fact Sheet, 2023; Shanafelt, 2021, Corbaz-Kurth et al., 2022).

The only viable pathway to address a problem is to identify it, understand it, and then create an action plan to address it. In the case of disrespect, greater attention is needed to support workers in safely reporting experiences of disrespect. To do this, workers need to be equipped with multiple pathways to safely report perceived disrespect without fear of retribution (Lipsky et al., 2003). Just as healthcare organizations have developed reporting mechanisms for physical harm events and use patient experience surveys to understand the patient experience with disrespect, defining disrespect for the workforce, and creating assessment tools that enable workers to share details about the severity and nature of perceived disrespect, can be a step toward addressing it through improvement processes. Steps to foster cultures of respect can be incorporated into strategic planning for improvement. Once known, workers at all levels of an organization– including those in high power positions—need to be held to the same accountability standards for adhering to standards of conduct. Action steps to foster improved interactions under moments of disagreement and stress can be developed via conflict management and communication training, and team and individual interventions. Interventions can include processes such as one-on-one coaching and peer support programs to support workers in improving their own skills for listening and engaging with others.

The impacts of disrespectful behavior on patient safety, quality, workplace morale, and worker mental well-being are felt broadly, even if the experience of disrespectful behavior may be more acute for some workers than others. As we seek out ways to repair and rebuild stronger workplace cultures in this post-pandemic period, the heightened experiences of disrespect caused by COVID-time strain indicate that it may be worthwhile to give special attention to identifying and understanding the way workplace conditions, organizational design, and institutional expectations can be transformed to support cultures of respect and patient safety.

AMA, ABMS, AHRQ, HCUP, HSOPS, IT, LVNs, LPNs, OR, PA, US

Ethics approval and consent to participate

IRB Exemption Letter issued on March 6, 2023, the University of Maryland College Park IRB Consent for publication, reference # 2000778-1.

Availability of data and materials

The data that support the findings of this study are available from the Agency for Healthcare Research and Quality, but restrictions apply to the availability of these data, and were used under permission granted for the current study. SOPS survey data from the SOPS Database must submit a completed De-Identified Research Abstract Form and signed Data Release Agreement in order to receive permission to use the data.

The SOPS® data used in this analysis were provided by the SOPS Database. The SOPS Database is funded by the U.S. Agency for Healthcare Research and Quality (AHRQ) and administered by Westat under Contract No. HHSP233201500026I / HHSP23337004T.

Competing interests

The authors declare that they have no competing interests.

Funding

There were no funders involved in enabling this research.

Authors' contributions

LE drafted the Abstract, Introduction, Discussion, and Implications sections, and reviewed and edited the full manuscript. CZ conducted full statistical analyses and contributed to the manuscript. Both authors reviewed, edited, and approved of manuscript for submission.

Acknowledgements

Authors acknowledge Neil Sehgal, PhD and Luisa Franzini, PhD for guidance on statistical analyses.

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Perceptions of Disrespect in the Hospital Workforce During the COVID-19 Pandemic: Analysis and Implications for the Future

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Abstract

Background

Methods

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Conclusions

Introduction

Methods

Results

Discussion

Conclusions

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