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“Paying it forward”

The link between providers’ civility climate, civility toward patients and patient experience outcomes

Oppel, Eva-Maria; Mohr, David C.

doi: 10.1097/HMR.0000000000000209
Features: PDF Only

Background: Interpersonal relationships are increasingly recognized as an important determinant for care performance and quality in the health care context. An unresolved issue in health care research is whether and to which extent providers’ perceptions of their work relationships are associated with their interactions with patients and, in turn, patient experience outcomes.

Purpose: The aim of this study was to investigate the extent to which nurses’ experiences of their work relationship climate (i.e., civility climate) affect their interactions with patients (i.e., civility towards patients), which in turn contribute to patient experience outcomes (i.e., overall hospital rating, willingness to return, intent to recommend). Furthermore, we analyze the mediating role of civility toward patients in the relation between civility climate and patient experience outcomes.

Methodology: The 2011 study sample comprised responses from 6,019 nurses and 38,619 patients at 123 Veterans Health Administration acute care inpatient hospitals located in the United States. We developed and empirically tested a theoretical model using multilevel regression modeling and assessing multilevel mediation.

Results: The results indicate a positive association between civility climate and civility toward patients. With regard to patient experience outcomes, the analyses reveal a direct effect of civility climate on overall hospital rating, intent to recommend, and willingness to return and an indirect effect mediated by civility toward patients.

Conclusion and Practice Implications: This is one of the first studies theorizing and testing the extent to which relationship climate among providers affect their interactions with patients. The findings provide support that providers who experience a positive civility climate are more likely to pay forward this relationship experience and engage in civility toward patients. The results point to the importance of a civility climate for ensuring and potentially improving patient experience of care.

Eva-Maria Oppel, PhD, is Assistant Professor, Department of Health Care Management, University of Hamburg, and Investigator, Hamburg Center for Health Economics, Germany. E-mail:

David C. Mohr, PhD, is Investigator, Center for Healthcare, Organization and Implementation Research, VA Boston Healthcare System, Boston, and Research Assistant Professor, Boston University School of Public Health, Massachusetts.

This material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Health Services Research and Development (IIR 08-067).

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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