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Let’s be civil

Elaborating the link between civility climate and hospital performance

Oppel, Eva-Maria; Mohr, David C.; Benzer, Justin K.

doi: 10.1097/HMR.0000000000000178
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Background: The importance of interpersonal behavior at the workplace is increasingly recognized in the health care industry and related literature. An unresolved issue in the existing health care research is how a climate of courteous interpersonal behavior may form the foundation for strong hospital care performance.

Purpose: The aim of this study was to test the link between a climate of courteous interpersonal behavior, termed “civility climate,” and hospital care performance. We conceptualize a multidimensional model of care performance by contrasting two dimensions: performance as perceived by employees and performance as perceived by patients. Furthermore, for both performance perspectives, we test an intermediate variable (error orientation climate) that may explain the relationship between civility climate and hospital care performance.

Methodology: The 2011 study sample comprised responses from 6,094 nurses and 38,627 patients at 123 Veterans Health Administration acute care inpatient hospitals in the United States. We developed and empirically tested a theoretical model using regression modeling, and we used a bootstrap method to test for mediation.

Results: The results indicate a direct effect of civility climate on employee perceptions of care performance and an indirect effect mediated by error orientation climate. With regard to patient perceptions of care performance, the analyses reveal a direct effect of civility climate. The indirect effect mediated by error orientation climate was not supported.

Practice Implications: Our findings point to the importance of strengthening interpersonal interactions for ensuring and improving both employees’ and patients’ perceptions of care, which constitute key success factors in the increasingly competitive hospital market. The insights may further stimulate discussion regarding interventions to foster a strong civility climate in hospitals.

Eva-Maria Oppel, PhD, Research Fellow at Department of Health Care Management, Universität Hamburg, and Research Fellow at Hamburg Center for Health Economics, Germany. E-mail: eva.oppel@uni-hamburg.de.

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

Justin K. Benzer, PhD, Implementation Science Core Chief, VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA Healthcare System, Waco, and Associate Professor at Department of Psychiatry, Dell Medical School, University of Texas at Austin.

This material is based on 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, CDA 11-246).

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.

The work environment in which employees deliver and patients receive hospital care is increasingly recognized as a key success factor in the health care industry (e.g., McCaughey, McGhan, Walsh, Rathert, & Belue, 2014; Rathert & May, 2007). In this context, the construct of organizational climate has garnered a great deal of attention in the health care literature (e.g., McFadden, Stock, & Gowen, 2015; Richter, McAlearney, & Pennell, 2016; Singer et al., 2009). Organizational climate refers to shared perceptions related to the policies, procedures, and practices that govern behaviors in a specific area of interest. Organizational climate has been characterized as foundational or specific (Schneider, Ehrhart, & Macey, 2013). Foundational climates are shared perceptions that reference the broad workplace environment and can provide a supportive foundation for specific climates to develop (Schneider et al., 2013). Specific climates focus on specific types of behaviors, such as customer service and safety. Despite acknowledging that interpersonal interactions may be important determinants of care performance (e.g., Gittell, Godfrey, & Thistlethwaite, 2013; Wright & Khatri, 2015), health care scholars have devoted scant attention to foundational climates of courteous interpersonal behavior. Addressing this research gap, in this article, we develop a conceptual framework for how civility climate, a foundational climate that represents courteous interpersonal behavior (Leiter, Spence Laschinger, Day, & Oore, 2011; Osatuke, Moore, Ward, Dyrenforth, & Belton, 2009), impacts hospital care performance as measured by employee and patient perceptions. Building on prior research, we define civility climate as a shared perception of the extent to which an organization rewards, supports, and expects (a) respect and acceptance, (b) cooperation, (c) supportive relationships between coworkers, and (d) fair conflict resolution (Osatuke et al., 2009).

The purpose of the current study is to test a conceptual framework that advances health care research in three ways. First, adding to the growing, but limited, civility research in health care, we investigate the link between civility climate, a foundational climate, and care performance. Prior civility research in the health care context has focused on the evaluation of employee-based civility interventions and the impact of civility on health care provider outcomes (Laschinger & Read, 2016; Leiter et al., 2011; Osatuke et al., 2009). McGonagle, Walsh, Kath, and Morrow (2014) provided initial evidence on the association between civility norms and workplace safety, such as unsafe worker behaviors and injuries. While acknowledging this research for highlighting the importance of civility in the health care context, there remains limited knowledge on whether and how shared perceptions of civil interactions at work affects perceptions of care performance.

Second, the vast majority of empirical studies in the health care context have related climate directly to organizational outcomes, neglecting the “black box” of the processes intervening between organizational climate and performance (Hofmann & Mark, 2006; Singer et al., 2009). Reviewing prior health care climate research, two streams emerge. Foundational climate research, focusing on aspects related to the psychosocial work environment or workplace bullying, tend to focus on employee-related outcomes, such as employee well-being (e.g., Rodwell, Demir, Parris, Steane, & Noblet, 2012). Research focusing on specific climate dimensions, such as safety climate, tends to focus on the impact on patient outcomes (e.g., McFadden et al., 2015; Singer et al., 2009). This fragmentation in existing research limits our understanding of (a) the link between foundational and specific climates and (b) mediating process through which climate affects different dimensions of performance in health care. In an attempt to address this research gap, we combine foundational and specific climate research. Specifically, we test hypotheses regarding how error orientation climate (i.e., a shared perception of attitudinal and behavioral tendencies relevant to handling and processing errors) might explain the link between civility climate and performance. Error orientation is a key factor in safety climate, a specific climate, and concerns desirable workplace attitudes and behaviors that are pivotal for delivering high-quality health care (Hofmann & Mark, 2006; Naveh & Katz-Navon, 2014). Considering that medical errors are frequently related to interactions within the hospital care team (Buljac-Samardžic, Van Woerkom, & Paauwe, 2012), a shared perception of error orientation is assumed to be particularly sensitive to interpersonal aspects of the work environment (Naveh & Katz-Navon, 2014), such as civility. Taking up on this evidence, we conceive error orientation climate as an important mediator in the civilityperformance link. We posit that a strong foundational civility climate is needed to promote error orientation climate, which may explain how civility climate affects care perceptions.

Third, addressing the need for multidimensionality in performance measurement, we test a multidimensional model of care performance by contrasting two performance dimensions: performance as perceived by employees and performance as perceived by patients. Acknowledging that employees and patients might perceive different dimensions of the performance construct (DiMatteo & DiNicola, 1981), patient perspectives are being increasingly incorporated into previously clinician-centric and organization-centric performance theories (Rathert, Wyrwich, & Boren, 2013; Singer et al., 2011). Considering both performance perspectives, we aim to add to civility research by investigating whether a strong civility climate is not only beneficial for employees but also for patients.

The conceptual model tested in this study is summarized in Figure 1.

Figure 1

Figure 1

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Conceptual Model and Research Hypotheses

Civility Climate and Perceptions of Care Performance

Care performance is multidimensional in part because employees and patients may perceive and value different types of care performance behaviors. Prior research has revealed that supportive interactions among employees are associated with employee perceptions of performance (Leggat, Bartram, Casimir, & Stanton, 2010). In contrast, patient-perceived quality of care may be influenced both by the individualized interactions between employees and patients as well as the environment in which patients are treated (Aiken, Clarke, & Sloane, 2002; Greenslade & Jimmieson, 2011). These differences in care performance suggest two distinct frameworks for how and why civility climate matters. At the employee level, Bandura’s (1986) self-efficacy theory posits that social influences provide information from which individuals judge their capabilities, strength, and vulnerability to dysfunction. That is, social aspects of the work environment can strengthen individuals’ beliefs that they can perform effectively. Extending this relationship to the collective level, we expect that civility policies, procedures, and practices that support respect and acceptance, cooperation, supportive relationships, and fair conflict resolution among coworkers will collectively strengthen individuals’ beliefs that they can perform effectively. Elaborating on this theory, we argue that in the health care context, where employees are often engaged in complex interdependent work, a civil social environment helps employees call on one another’s expertise, energy, and competences. Civility climate induces courteous and considerate behavior toward other people and thereby enhances the quality of working relationships and, in turn, perceived performance (e.g., Ortega, Sánchez-Manzanares, Gil, & Rico, 2013). Indeed, evidence from the health care context demonstrates that the absence of civility is associated with lower work efforts, less engagement in tasks and activities beyond job descriptions, decreased voluntary efforts, and assistance to colleagues (Pearson, Andersson, & Porath, 2000). Thus, this leads to our first hypothesis.

H1a: Civility climate will be positively associated with employee perceptions of care performance.

At the patient level, service climate researchers theorize that employees treat customers in a manner similar to their own treatment within an organization (Schneider, Wheeler, & Cox, 1992). Robust evidence indicates that certain aspects of the interpersonal work climate, such as perceptions of fairness, are positively associated with employee attitudes and behaviors toward customers, which may in turn enhance customer satisfaction (Schneider et al., 1992). Elaborating on this evidence and adapting service climate research to the health care setting, we argue that a strong civility climate induces favorable employee attitudes and behaviors, which affect employees’ interactions with patients. This effect is particularly likely in the hospital setting because care services are characterized by intense personal and unique relationships between health care workers and patients. Indeed, patient outcomes and perceived quality of care have been associated with the environment in which patients are treated as well as with employee–patient interactions (Aiken et al., 2002; Greenslade & Jimmieson, 2011). More specifically, prior research from the hospital context indicated that high-quality provider relationships helped care providers to develop effective relationships with their patients (Gittell, 2002). Furthermore, nurses’ perceptions of social interaction and trust among nurses have been associated with the extent of customer-oriented prosocial behavior and ultimately with patient satisfaction (Hsu, Chang, Huang, & Chiang, 2011). Thus, both theory and a small but growing body of empirical studies suggest that a strong civility climate may induce employee behaviors that can strengthen patients’ perceptions of care performance.

H1b: Civility climate will be positively associated with patient perceptions of care performance.

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Error Orientation Climate as a Mediator Between Civility Climate and Performance

As a key dimension of safety climate, error orientation climate (Hofmann & Mark, 2006; Leape et al., 1998) can be defined as the shared attitudinal and behavioral tendencies relevant to handling and processing errors (e.g., Rybowiak, Garst, Frese, & Batinic, 1999). A positive error orientation climate is indicative of an environment that is supportive of open dialogue and facilitates safer practices, whereas a negative error orientation climate is characterized by distrust and fear and results in unwillingness to assume responsibility for mistakes (van Dyck, Frese, Baer, & Sonnentag, 2005). We conceive error orientation climate as a potential mediator of the relationship between civility climate and care performance for the following reasons: First, consistent with the theory regarding foundational and specific climates, civility climate may form the necessary foundation for developing a strongly shared error orientation. Strong interpersonal relationships may be needed to facilitate a constructive discussion of errors. Broadly, interpersonal aspects of the work environment are thought to affect employees’ attitudes and behaviors with regard to errors (Naveh & Katz-Navon, 2014). For instance, Edmondson (2003) found that the likelihood of hiding errors is associated with employee perceptions of others’ disapproval and/or the negative personal consequences that employees might experience. Research evidence from the nursing context also indicates how negative interpersonal behaviors, such as bullying behaviors, affect the psychological/behavioral responses of nurses, such as their handling of medical errors (Wright & Khatri, 2015).

Second, error orientation climate can affect hospital care performance (Buljac-Samardžic et al., 2012; Leape et al., 1998; Mark et al., 2008). Error orientation climate can promote self-efficacy and thereby increasing beliefs that the organization cares about improving patient care (Rybowiak et al., 1999). A strong error orientation climate is critical to reducing the consequences of negative errors (e.g., reduced patient safety outcomes and hiding errors) and promoting the benefits of positive errors (e.g., learning from errors and knowledge building) in terms of the quality and safety of patient care (Naveh & Katz-Navon, 2014; van Dyck et al., 2005). Open-error communication and reporting are likely to facilitate rapid error detection and handling, encourage learning from errors, and enable specific safety improvement interventions (Hofmann & Mark, 2006). By contrast, research has identified weak error orientation as a contributing factor when the number of medical errors is unacceptably high and care performance is low (Mark et al., 2008).

Compiling the theoretical and empirical evidence presented, we suggest that a strong civility climate should facilitate a strong error orientation climate and, in turn, care performance in hospitals. Specifically, employees in an organization with a strong civility climate that signals a personally nonthreatening and supportive interpersonal environment should be more likely to freely speak up if they observe something that may negatively affect patient care or to question the decisions or actions of those with more authority in situations involving patient care. Thus, we hypothesize that the link between civility climate and employee perceptions of care performance will be explained by the intermediate mechanism of error orientation climate. Nonetheless, we acknowledge that civility climate may affect care performance through additional mechanisms not explored here.

H2a: The relationship between civility climate and employee perceptions of care performance will be mediated by error orientation climate.

Error orientation climate may affect patients’ experiences of care performance through two possible mechanisms. First, employees’ attitudes toward the acceptance of errors will improve quality of care because it prevents negative consequences of hiding errors and enhances positive consequences of learning from errors. Although patients might not be able to observe directly these quality-enhancing learning processes resulting from a strong error orientation climate, they still might experience increased quality of care. However, the patient experience literature demonstrates mixed results regarding patients’ ability to recognize the handling of errors (Weissman et al., 2008). A recent review noted that this ability of patients remains an open question (Doyle, Lennox, & Bell, 2013). If patients are able to recognize and distinguish between a strong or weak error orientation climate displayed in their inpatient units, then we would expect that a strong error orientation climate to increase their beliefs that they will be informed in a transparent way if an error occurs, which in turn will enhance their perceptions of care performance. Second, Hofmann and Mark (2006) theorized that error orientation may also promote nurse responsiveness to patient concerns. Nurse responsiveness is a factor that may be experienced directly by both employees and patients, but likely in different ways. Nurses may experience responsiveness as high-quality care and may increase opportunities to identify or prevent medical errors. In contrast, patients may experience responsiveness as interpersonally satisfying because they view it as evidence that nurses care about them and their well-being.

Thus, we anticipate that the link between civility climate and patient perceptions of care performance will be explained by the intermediate mechanism of error orientation climate.

H2b: The relationship between civility climate and patients’ perceptions of care performance will be mediated by error orientation climate.

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Methods

Data and Research Setting

As a research setting, we focused on the Veterans Health Administration (VHA) within the U.S. Department of Veterans Affairs. Providing subsidized medical care to almost 22 million veterans, the VHA is organized into regional networks divided into 144 hospitals and more than 1,000 freestanding outpatient clinics at the time of the study. To ensure the comparability of the respondents included in our sample, we used patient and employee responses from acute inpatient services. We included nursing employees, including registered nurses and licensed practical nurses. Hospital nurses provide and coordinate patient care and work closely with a team of other skilled health care professionals. Thus, nurses play an integral role in achieving high-quality health care performance (Wright & Khatri, 2015). The study was reviewed and approved by a VHA Institutional Review Board.

Survey data were drawn from three sources collected in 2011. First, data on civility climate were obtained from the VHA All Employee Survey restricting to our sample respondents of interest (68% national response rate; Nsample = 6,094). Second, data on error orientation climate and employees’ perceptions of care performance were collected from a VHA National Center for Patient Safety survey (21% response rate; Nsample = 1,755). Third, data on patient perceptions of care performance were obtained from the VHA Survey of Healthcare Experiences of Patients (44% response rate; Nsample = 38,627). Responses to each survey were aggregated at the facility level. The final data set contained 123 unique VHA hospitals.

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Variable Measurement

Civility climate

Civility climate was assessed with an eight-item scale used in prior research (Leiter et al., 2011; Osatuke et al., 2009) using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) with good reliability (α = .94). Employees assessed personal interest and respect from coworkers, cooperation or teamwork in the facility, fairness of conflict resolution, and the value of individual differences by coworkers and supervisor within a work group and across an organization. For each respondent, civility climate was computed as the average of the eight items for respondents who answered at least half of the items in the scale.

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Error orientation climate

Seven items adapted from the comprehensive Rybowiak et al.’s (1999) Error Orientation Questionnaire were used to measure error orientation climate on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) with good reliability (α = .79). For example, employees assessed the extent to which “Staff will freely speak up if they see something that may negatively affect patient care” or “My co-workers will not lose respect for me if they know I’ve made a mistake.” The seven items were aggregated to form a single index of error orientation climate using a similar computation method as civility.

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Employee perceptions of care performance

Seven items focusing on quality and safety (e.g., Spence Laschinger, Shamian, & Thomson, 2001) were used to measure employee perceptions of care performance on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) with good reliability (α = .90). For example, nurses assessed the extent to which “the facility has a reputation for high quality performance” or “the patient safety processes and procedures in this facility are better than the processes and procedures found in other facilities.”

For each respondent, a single index of care performance was computed as the average of the seven items when at least half of the items were answered.

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Patient perceptions of care performance

A single item was used to measure overall patient perceptions of care performance. Patients were ask to indicate on a 0–10 scale, where 0 is the worst hospital possible and 10 is the best hospital possible, what number they would use to rate this hospital during their stay. Because patient characteristics have been associated with their ratings on care experiences (Xiao & Barber, 2008), we computed the residualized value for patient experience accounting for characteristics of health status, age, gender, marital status, and race/ethnicity. Then, scores were aggregated to the facility level.

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Control variables

Three variables were used to account for potential influences of facility-level factors on patient and employee perceptions of care performance (Singer et al., 2009; van Dyck et al., 2005). First, facility size was measured by total full-time equivalent employee values for nurses. Second, we included staffing ratios, defined as the number of nursing hours per patient day. Both measures were obtained from internal VHA administrative sources. Third, we accounted for whether a hospital was located in an urban or rural metropolitan statistical area (using values of 1 = urban/0 = rural).

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Aggregation Statistic

Intraclass correlation coefficients, ICC(1) and ICC(2), and within-group agreement (rwg) provided sufficient empirical support for aggregating the scores for our variables at the facility level (James, Demaree, & Wolf, 1984). Across all variables in our study, the average ICC(1) value was .10, ranging from .08 to .13. The average ICC(2) was .68, ranging from .61 to .79. The rwg values ranged from .79 to .90. Taken together, our statistics provided sufficient empirical support for aggregating the scores for our variables at the facility level.

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Analytical Strategy

Our approach to analysis was first to assess the associations of civility climate and error orientation climate with employees’ perceptions of care performance (Models 1 and 2) and with patients’ perceptions of care performance (Models 4 and 5). We then tested models with both civility climate and error orientation climate included in the same model (Models 3 and 6). To test the direct effects of civility climate (Hypotheses 1a and 1b), we performed ordinary least squares regressions using SAS version 9.2. Mediation was tested using the PROCESS macro developed by Hayes (2013) for SPSS Statistics, Version 21. The PROCESS macro provides 95% bootstrap confidence intervals around the indirect effect of civility climate as mediated through error orientation climate (H2a and H2b). The bootstrapping procedure is superior to traditional mediation methods because it allows a direct estimation of standard errors for indirect effects, whereas other methods require the use of formulas that have been criticized in recent years (Hayes, 2013).

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Results

Descriptive statistics and correlations of the study variables are presented in Table 1.

Table 1

Table 1

Table 2 shows the direct effects of civility climate and error orientation climate on employees’ perception of care performance (Models 1–3) and patients’ perceptions of care performance (Models 4–6). Civility climate was significantly related to employee care performance perceptions (Model 1: β = 0.332, p < .01), supporting Hypothesis 1a, and to patient perceptions of care performance (Model 4: β = 0.286, p < .01), supporting Hypothesis 1b.

Table 2

Table 2

To test H2a and H2b, we analyzed the mediating effects of error orientation climate on the relationship between civility climate and perceptions of care performance. The results indicated that civility climate had a positive direct effect on error orientation climate (β = 0.377, p < .01), and error orientation climate was positively related to both employee perceptions of care performance (Model 2: β = 0.644, p < .01) and patient perceptions of care performance (Model 5: β = 0.219, p = .04). Mediation hypotheses are supported if a significant indirect effect is observed between civility and care performance through the intermediate influence of error orientation climate. We tested indirect effects using the bootstrap method (Hayes, 2013). Applying the PROCESS macro developed by Hayes (2013) for SPSS, we obtained 95% bootstrap confidence intervals around the indirect effect to correct for biased standard errors. For the employee model, the bias-corrected confidence interval for error orientation climate (0.20, 0.83) does not contain zero; hence, the indirect effect is significantly different from zero. These results support Hypothesis 2a, which posits that the positive association between civility climate and employee perceptions of care performance is mediated by error orientation climate. In contrast, for the patient model, the bias-corrected confidence interval for error orientation climate (−0.04, 0.15) does contain zero. Thus, H2b is rejected because we cannot state that the indirect effect is significantly different from zero.

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Discussion

This study demonstrated that civility climate is associated with both employee and patient perceptions of care performance. Error orientation climate was found to mediate the association between civility climate and employee perceptions of care performance. This result suggests that error orientation climate, a specific climate and key aspect of the safety climate, helps to explain how civility climate, a foundational climate, is translated into increased employee perceptions of care performance. By contrast, for patients’ perceptions of care performance, both civility climate and error orientation climate had main effects, but only civility climate was associated with patient care performance when both variables were included in the model; the mediating influence of error orientation climate was not supported.

This study contributes to the health care literature in several ways. First, by focusing on civility climate, this study contributes to the nascent body of research on positive interpersonal aspects of the work environment (Laschinger & Read, 2016; Leiter et al., 2011; Osatuke et al., 2009). Despite evidence from the health care literature on the negative relationship between incivility and both individual and organizational performance outcomes—such as increased turnover, reduced individual well-being, lower job satisfaction and performance, and lower self-reported team effectiveness (e.g., Wright & Khatri, 2015)—research has fallen short in investigating whether and how hospital care performance might improve by creating and strengthening a positive interpersonal work climate. Our study highlights civility climate as an important success factor in the hospital service context.

Second, our study contributes to the literature by exploring intermediate processes through which perceptions of civility climate are linked to hospital care performance. Despite a growing body of research highlighting the important role of organizational climate for ensuring high quality and safety in patient care (e.g., Singer et al., 2009), limited research has sought to identify mediators of the climate–performance link in the hospital context. By linking civility climate, a foundational climate, to error orientation climate, a specific climate, we provide new theoretical insights on the interrelation between foundational and specific climate dimensions. Specifically, we highlight how the work environment (civility climate) affects employees’ shared perceptions of attitudinal and behavioral reactions to handling errors (error orientation climate). This insight is especially informative given the persistent problems associated with hospital employees underreporting adverse events as well as the resulting negative patient consequences despite increasing investment in error reporting systems (e.g., Naveh & Katz-Navon, 2014). Considering that reporting systems work only if employees are willing to use these systems, our study suggests that much benefit can be gained by fostering a civility climate that facilitates error reporting. More precisely, our results suggest that a strong civility climate has the potential to indirectly affect hospital care performance by creating an atmosphere in which individuals are willing to reveal, discuss, and learn from their own mistakes.

Third, by accounting for the multidimensionality in hospital care performance, our findings indicate that a strong civility climate not only benefits employees but also improves patient perceptions of care performance. The results suggest that patients notice how employees interact with one another. Hospitals that support these civil interactions—particularly in terms of respect and acceptance, cooperation, supportive relationships, and fair conflict resolution—may have a significant influence on patient perceptions of care performance. In contrast to our expectations, we did not find that error orientation climate mediated the association between civility climate and patient perceptions of care performance. Error orientation climate had a smaller association with patient perceptions of care performance than with employee perceptions of care performance. This finding may suggest that patients have a limited ability to detect behaviors related to error orientation climate. Nurses’ behaviors relevant to handling errors might be less observable for patients due to information asymmetry and the lack of detailed medical knowledge. Furthermore, patients may be more likely to experience the outcome of error orientation climate, such as actual errors, than whether dimensions of error orientation, such as whether staff will freely speak up if they see something, as these discussions may happen outside of patient observations. Any strong interpersonal behaviors that patients observe may thus be attributable only to civility climate, not to error orientation climate.

Although our study offers a number of important contributions, it does have limitations, each of which offers avenues for future research. The first set of limitations relate to the measurement and selection of the variables used in our study. In particular, we focused on employees’ and patients’ perceptions of care performance as an indicator of hospital care performance. Although patient care perceptions are a relevant performance outcome in the hospital setting (e.g., Spence Laschinger et al., 2001), future studies could extend our research by replicating our model using objective external hospital performance data, such as adverse event reporting and safety incident rates. In addition, we focus on the specific occupational group of nurses. Given that occupational groups in hospitals are likely to differ in their occupational values, work structure, responsibilities, professional education, and culture, future studies could examine whether civility climate produces the same degree of positive effects on occupational groups other than nurses. Further research is needed to identify how and under which conditions civility climate may influence interprofessional relations, such as relations between nurses and doctors. In addition, none of our data measured how patients perceive their interaction with employees. Through the direct measurement of patient perceptions of their interaction with bedside hospital staff, further research might empirically analyze additional mediating mechanisms, such as patient–provider interactions through which civility climate may improve care performance from the patient perspective.

The second limitation concerns the facility level of analysis used in this study. Our research design linked several anonymous surveys by a common facility identifier. This limited our ability to test more complex relationships across different levels of analysis. Considering that climate perceptions might be influenced by team structure, professional norms, prior working experience, or leadership, researchers should make allowance for the coexistence of multiple and heterogeneous civility climate perceptions within hospital facilities. Future research is needed to combine different levels of analysis (e.g., work group, team, and facility) and investigate multilevel research questions.

Third, our observational and cross-sectional research design limits the extent to which cause–effect relationships can be inferred from the findings. For instance, our design prevents us from drawing conclusions on whether civility climate, a foundational climate, affects error orientation climate, a specific climate, or vice versa. The literature on civility climate in hospitals would benefit from interventional or longitudinal studies that are better equipped to make causal statements and address the possibility of reverse causality. Finally, this study was conducted in the specific context of the VA Healthcare System, a federally administered system that differs from other health care systems in ways that may limit the generalizability of the findings. Although our findings should be applicable to settings with similar health care system designs, hospital management practices, and employment structures, further research should test whether the results can be replicated in private hospitals, other health systems (e.g., U.K. National Health Service), and different service sectors.

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Implications for Practice

Despite its limitations, this study provides valuable insights and useful information for hospital managers. Overall, our findings point to the importance of positive interpersonal work environments as a powerful tool for ensuring and improving both employees’ and patients’ perceptions of care, which constitute key success factors in the increasingly competitive hospital market. With employee perceptions of care performance serving as an important predictor of job satisfaction, well-being, motivation, and organizational commitment (Spence Laschinger, Grau, Finegan, & Wilk, 2012), a strong civility climate and the resulting improved care perceptions might counteract human resource-related challenges, such as high turnover rates and increasing workforce shortages among clinical staff. Interventions to establish a strong civility climate could include workshops, structured exercises, discussion points, and facilitation points to promote more civil interactions among employees (Osatuke et al., 2009). For more detailed information on interventions to enhance civility in the hospital work context, we refer to the work by Osatuke et al. (2009). The results indicate that investing in interventions that establish both a strong civility climate and strong error orientation climate may also improve patient perceptions of care performance. Patients’ perceptions of care performance are an indicator of care quality and are believed to be an important contributor to other health outcomes (e.g., continued use of health services; Greenslade & Jimmieson, 2011). Building on our results, hospital managers are well advised to foster a civility climate, which can also support people speaking up about errors, prevent incidents from occurring, and reduce the number of “near misses” in health care. Particularly in consideration of the high costs of errors and adverse events in health care, it is of utmost importance to detect factors that may prevent errors.

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Conclusions

Our study tested a model to determine how civility climate affects care performance as perceived by both employees and patients. The key innovation of this study was in the conceptual and theoretical links between civility climate, error orientation climate, and care performance as experienced by both employees and patients. Our analyses highlighted the importance of a strong civility climate for ensuring that both employees and patients perceive high-quality care in hospitals. The results of these analyses have important implications for civility climate interventions as means to improve care performance. The insights may further stimulate discussions regarding the importance of civility climate for both patient- and employee-related outcomes.

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Keywords:

civility; error orientation; hospital; organizational climate; performance

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