Abstract
Introduction
Workplace violence (WPV) is a global phenomenon and a problem within healthcare (Vento et al., 2020). Nurses are at higher risk for WPV compared to other roles within healthcare due to spending more time providing direct patient care (Vento et al., 2020). Although Li et al. (2020) found 20% of nurses experience physical violence within the context of their job annually, verbal WPV events are more prevalent. Schablon et al. (2018) found 94% of nurses experience verbal violence each year. Verbal violence is defined as behavior that humiliates, degrades, indicates a lack of respect, or compromises the dignity and worth of an individual (Fisekovic Kremic et al., 2017; Vento et al., 2020). Alsharari et al. (2021) identified verbally abusive behaviors toward nurses and it includes being yelled at, humiliated or belittled, and being the recipient of nasty, rude, hostile, or inappropriate language. This may also include threats of legal actions, job terminations, or physical harm.
Verbally violent behaviors may also occur in written form. The United States Department of Labor, as well as The Joint Commission, considers verbally violent messages a form of WPV (The Joint Commission, n.d.; U.S. Department of Labor, n.d.). Within healthcare, WPV has received much attention to address the complex problem yet, there is a dearth of understanding about written WPV while providing patient care.
Review of Literature
Digital communications within healthcare are a unique form of patient and family contact within the nursing profession. For nurses, nonverbal communication assessments are an integral part of patient interactions (Wanko-Keutchafo et al., 2020). However, digital forms of communication eliminate nonverbal forms of communication such as body language, interpreting tone or emotions, and assessments of psychological states (Marra et al., 2020). And, digital communications are asynchronous, without verbal cues or direct personal contact, and create an opportunity for the sender to be disinhibited and disassociated from how the typed message may be perceived (Richard et al., 2020).
Cyber forms of WPV, defined as cyber incivility by Lim and Teo (2009), are aggression that occurs over emails within the workplace. However, aggressive email behaviors may present with various levels of severity. Cyber-incivility is defined as low-intensity, deviant behavior with ambiguous intent to harm the target (Porath & Erez, 2007). Cyber-uncivil behaviors may manifest more severely and are noted to be rude and discourteous messages displaying a lack of regard for others (McCarthy et al., 2019). Cyber-aggression is the most severe and is described as messages which instill intentional harm via electronic means to a person or group who perceives the message as offensive, derogatory, harmful, or unwanted (Nocera et al., 2022). These digital behaviors violate workplace norms of mutual respect within an organization and undermine an individual's sense of dignity (Andersson & Pearson, 1999).
Nurses are easily accessible to the perpetrators of cyber incivil, uncivil, or aggressive (IUA) messages while providing patient care. The messages arrive within the context of their job and therefore nurses have little control as to when and how they address the IUA message (Oksanen et al., 2020). Nurses are expected to handle the IUA messages in a professional manner and in a manner that represents the organization in a favorable light (Niven et al., 2021). This may add to nurse stress due to this adherence to professionalism regardless of the sender deviating from professional norms (Niven et al., 2021).
Consequences after receiving IUA messages can be significant. Digital IUA messages may trigger psychological distress such as sadness, fear, or anger and may lead to work exhaustion (Niven et al., 2021; Oksanen et al., 2020). This may be from the direct assault on one's identity as a valued, respected, and capable professional, perhaps to the degree that the message is a violation of human decency (Niven et al., 2021). Additionally, aggressive messages may trigger negative rumination lasting weeks’ post-IUA message (Richard et al., 2020). Overall, these disruptive behaviors and IUA messages may affect the nurse recipient's sense of well-being, the work environment, and work productivity (Oksanen et al., 2020).
The COVID-19 pandemic compounded nurse exposure to IUA messages due to the increased volume of digital and cyber communications. As patient care shifted online, clinical and nonclinical work was performed via virtual platforms (El Ghaziri et al., 2022). Between 2019 and March of 2020, healthcare experienced a 683% increase in tele-healthcare compared to previous years when only 8% of healthcare visits were conducted remotely (Kludacz-Alessandri et al., 2021). This resulted in an explosion of electronic/digital forms of communication unprecedented within healthcare, and nurses were exposed to more cyber IUA behaviors than ever before (El Ghaziri et al., 2022).
Currently, little is known about cyber or digital WPV within healthcare. As healthcare continues to evolve technologically, an understanding of how IUA messages manifest related to patient care is essential before interventions can be effectively established. The purpose of this study was to identify which patients may be more prone to send IUA messages, perform a thematic analysis to describe what constitutes an IUA message, and measure the impact on nurse recipients of IUA messages.
Methods
Design
This was a descriptive, secondary data, cross-sectional study analyzing IUA cyber or digital patient portal messages sent to nurses. Portal system messages received between October 2021 through April 2022 were included. Analysis of the messages occurred May of 2022.
Research Question
The research questions for this study: (1) what are the characteristics of patient or patient-advocate sent portal messages within healthcare and (2) how do the messages compare to what is known about cyber WPV?
Sample and Setting
This study was conducted at a spine and pain ambulatory care clinic within a large western academic healthcare system. The clinic is part of a large ambulatory care building that incorporates numerous specialty care areas on the academic campus. The clinic had approximately 20,000 patient care visits during the previous year and provides care to patients 18–85+ year of age with a myriad of diagnoses related to chronic pain, including spine pathology and spinal pre/postsurgical care. The clinic was selected due to the ongoing patient communications through the patient portal about acute and chronic pain management and other patient care needs. Messages enter the portal system generated by the patient or patient advocate. The messages are first read by clinic nurses who triage the messages, answer questions or solve patient care problems, or route the message to the appropriate location to address the patient or advocate's concerns. An autogenerated message is sent through the patient portal indicating a response should be received within the next 48 business hours. This process was standard across the organization.
Ethical Considerations
This study was reviewed by the organization's institutional review board (IRB), Colorado Multiple Institutional Review Board. The study received a determination of “exempt as a study related to secondary data analysis.” Whereas most secondary data analysis projects analyze objective clinical data or outcomes, this study analyzed retrospective patient portal communications.
Procedures
Nursing staff were asked to identify, based upon their perception, IUA messages received during digital patient care. The nurse forwarded the messages to the clinic leadership, who was also a study coinvestigator. The nurse rated their level of distress after receiving the message on a five-point Likert scale, from one being mild, up to five as extreme distress. The coinvestigator leader tracked sender demographic data identifying gender, age, ethnicity, insurance, marital status, and if opioids were part of the patient's treatment plan. Next, the message was copied into a password-protected document, and text was de-identified. All data were stored on a password-protected encrypted server accessible by only the research team.
Analysis Plan
Each de-identified message was sent to the investigating team. Each author/investigator completed the analysis independently. Once the analyses were completed, the authors came together to compare results. Any dissention about the message content and analysis was discussed until consensus was reached.
Sender demographics were quantified using descriptive statistics. Message characteristics were quantified with discrete counts of expletives as determined by the seven common curse root words in English with compound word variations, flames (e.g., “incompetent” and “you suck”), and orthographic features (e.g., uppercase words, repeated punctuation, and texting symbols used in place of letters). Grade level and spelling/punctuation analyses were conducted using the editor function within the word processing system where the messages were copied. This was to gauge the impulsivity of the sender and the lack of proofreading prior to the message being sent. The editing function was limited to messages of 100 characters or longer due to the limitations of the editing program. If the message contained repeat exchanges, all written communications were merged to create one response for editing capabilities.
The framework used to identify and evaluate the message's prosodic tone (e.g., disgust and anger) and dimensions was developed by McCarthy et al. (2019) as noted in “From Cyber to Email Incivility: A Psychometric Assessment and Measure Validation Study.” The eight dimensions, with definitions, included:
negative tone; harsh or brisk message impolite; no pleasantries included, condescending insensitive; message sent without thinking how the information will be perceived by the receiver careless; replies to a message without carefully reading the original message accusatory; imputation of wrongdoing, guilt, or blame function and structure; requests something and copies to many people including superiors passive-aggressive; implying manipulation or noncooperation, and demanding; no pleasantries, rude, forcefully insisting on action.
Due to a lack of healthcare-specific frameworks or tools regarding cyber-incivility, this tool was chosen as it outlined dimensions of message incivility. Of note, the dimensions were defined from employee questionnaires within interdepartmental emails at an internet sales company.
Qualitative analysis of the messages followed Braun and Clarke's (2006) Thematic Analysis, also known as Reflexive Thematic Analysis (University of Auckland, n.d.). This process relied on researchers’ experiences to identify themes within the data. This included semantic and latent analysis; semantic themes captured the surface, obvious, or explicit meanings in the messages, and latent themes captured implicit meanings in the messages. The analysis followed a six-step process: familiarization, coding, generating themes, reviewing the themes, defining the themes, and dissemination (University of Auckland, n.d.).
Results
Nursing staff identified and forwarded 32 IUA messages to clinic leadership. Two messages were from the same patient in a continuous communication thread but accessed by two different nurses, both of whom identified the message as IUA. This resulted in a singular message. Thus, 31 messages were analyzed.
Sender demographics are listed in Figure 1. Senders were evenly split between the genders, most were married, two-thirds of the senders had Medicare or Medicaid insurance versus private or commercial insurance. Most patients (58%) did not have opioids as part of their treatment plan. Nearly 50% of the senders were 60 or older and 15% were 40 or younger. This distribution is comparable to the client distribution for the clinic.
Sender demographics (
Message Analysis
Discrete counts of the message characteristics can be found in Table 1. Expletives and flames were in few messages. Orthographic effects were in 68% (
Message Characteristics.
Messages with the highest nurse distress of four or five totaled 23% (
Nurse Level of Distress.
The dimensions with the strongest IUA tones were negative, impolite, accusatory, passive-aggressive, and demanding, using the psychometric business categories (McCarthy et al., 2019). However, it was difficult to distinguish between negative and impolite tones within this context as all messages qualified as both with this definition. None of the messages appeared to be careless, insensitive, or addressed function structure as defined by McCarthy et al. (2019).
Themes
Semantic thematic analysis identified all messages as negative or impolite, yet further investigation revealed alternative representations of negative or impolite messages within this setting. The negative messages contained language which was personally or professionally antagonistic, demeaning, demanding, accusatory/blaming, passive-aggressive, condescending, overtly threatening, impatient, and/or impulsive. Most of the messages contained more than one of these categories within the same message thread, that is, “you people (condescending) …screwed me up (accusing/blaming) and I expect… (demanding).” See Table 3 for examples from messages.
IUA Message Examples.
Latent thematic analysis identified antecedents as a subset of the messages. These preceding factors, noted in the current negative messages, were found to be related to unmet expectations, difficulty navigating the healthcare system, lack of personal accountability or control, and lack of understanding of the portal system. The most frequently noted antecedent was unmet expectations (
An example of an antecedent message thread contained approximately 4500 characters in the patient responses. The thread started with questions regarding menstrual cramp management and the nurse directed the patient to contact primary care to address the problem (demonstrating a patient lack of understanding about navigating the healthcare system). However, the sender began to personally and professionally attack the nurse: “nurses attempting to inappropriately troubleshoot issues themselves” and “nurses had been completely incorrect.” Later, the sender denied asking about menstrual cramp support (lack of personal accountability) and followed with accusing/blaming dialogue with personal and professional attacks: “portal communications with nurses have proven counterproductive, inefficient, and often inaccurate.” Therefore, a negative patient portal message may contain multiple categories of negative responses while illustrating multiple antecedents. See Figure 2 which highlights antecedents and the negative message themes.
Cyber-incivility themes framework (
Discussion
This study demonstrated nurses experience WPV when exposed to IUA patient portal messages while providing patient care. Understanding of IUA messages relied on a literal interpretation, assessment of word choice, orthographic characters, and semantic tone to convey meaning. Negative IUA portal interactions caused distress for nurse recipients. The most distressing messages manifested as personal or professional ad hominems, demanding, accusatory or blaming, passive-aggressive, impulsive, impatient, and contained threats with the intent to cause harm. Thus, cyber-incivility/cyber-aggression in healthcare converges with the definition of WPV.
Antecedents
Message antecedents outlined the latent impetus for the message negativity. “Unmet expectations” was the most common antecedent for IUA messages. This is similar to other forms of WPV in healthcare. Najafi et al. (2017) found unmet expectations to be an antecedent to face-to-face WPV, regardless of the expectation being correct, appropriate, or realistic. Another antecedent identified was “difficulty navigating the healthcare system.” This is similar to antecedents identified by Spencer et al. (2022) when nurses experience verbal violence over the telephone within ambulatory care.
Negative Message Descriptions and Characteristics
Patients were the senders of IUA messages much of the time (
The characteristics of the IUA messages were heterogeneous. Messages were of varying lengths; messages contained innumerable errors or were articulate; and messages rarely addressed medications or requested opioids. Of the few messages that contained overt expletives, nurses rated these messages as lower levels of distress.
Grade level of the messages also varied. The message with the lowest grade level started with an unclear question. When the nurse responded by asking for clarity, the patient sent “Why doesn’t the nurse do her homework before sending a stupid response!!! (sic).” The nurse rated the thread as highly distressing. Conversely, other highly distressing messages were of a higher grade level and contained fewer errors which may be an indication of proofreading. Although it is unclear from this study if senders proofread their messages, Larigauderie et al. (2020) found proofreading improved clarity, reduced phonetical, grammatical, and orthographic errors, and engaged executive function for written content. Therefore, the sender of distressing IUA patient portal messages was deliberate regarding message content and appears intentional to cause harm to the recipient.
Sender intent is significant when addressing verbal violence. Perpetrators of verbal violence are often aware of what they are saying at the time of the event. Unlike physical events when the patient may be detoxing or in an altered metabolic state, perpetrators of verbal violence are often lucid and in a normal state of consciousness (d’Ettorres et al., 2018). In the current study, the intent of the sender was not investigated and thus the level of intent is not clear, but the number of errors and grade level may be an indication of care given to composing the IUA message prior to being sent.
Furthermore, senders of IUA messages are not physically present with the recipient and may not be as concerned about communicating civilly. Heischman et al. (2019) found the lack of physical presence provides senders with a sense of disinhibition, as the sender is able to disassociate from the recipient. The content may be more hostile than it would be during a face-to-face encounter when the recipient is physically present. Additionally, Kruger et al. (2005) found that senders of IUA messages overestimated their ability to clearly convey meaning in emails and overestimated the recipient's ability to accurately interpret the messages. Unfortunately, the physical distance prevents the recipient from other verbal cues or body language to aid in interpreting the sender's intent.
Thematic Analysis of IUA Messages
Thematic analysis allowed for a greater understanding of IUA message content and also helped to illustrate why these messages were distressing to nurses. The most distressing messages sent to nurses were personally/professionally antagonistic, demanding, accusatory, or threatening. Thus, they transcended into verbal violence. Senders intentionally used ad hominems within the message, that is, personal flames such as “stupid,” or were overtly demeaning asserting the nurse was “lazy” or “incompetent.” One message identified a staff person by name and repeatedly signed out of portal messages with “(name deleted) IS NOT TO BE INVOLVED IN MY CASE!!!!!!!!!! (sic),” even when the message purpose was for routine reasons such as organizing transportation.
These personal attacks may be displaced anger. Meier and Semmer (2013) found anger plays a critical role in uncivil behaviors and the portal system provides an emotional and physical distance from the recipient to act out negative emotions without reciprocity. Particularly, the use of “you” within the messages depicted intentional and personally directed ad hominems setting a demanding and accusatory tone. Some portal messages contained phrases such as “you guys,” “you people,” “you twisted,” “you don't,” or “you won't.” Kubany et al. (1992) found that the use of “you” is known to communicate blame or insults, used to verbally attack, and may evoke hostile reactions. As an established form of aggressive communication, “you” is intentionally used to antagonize and impede resolution. This contrast “I” messages which elicit cooperation (Kubany et al., 1992).
When nurses receive verbally violent/ad hominem messages, perceived to be written with an intent to harm and written clearly and articulately, the messages are particularly distressing. When messages include personal attacks, criticisms, or blaming, the nurse may find the verbal event more difficult to cope with compared to a physical event perpetrated by a confused patient (Jakobsson et al., 2020). These articulate IUA messages are personally directed toward the nurse recipient causing higher levels of distress.
Reactive Expressive Versus Passive Aggressive Messages
For nurses receiving these negative messages, simplification of the categories may ease understanding of negative messages. Following Ramirez and Andreu's (2003) early work related to aggression typology, cyber IUA messages are an indirect form of aggression that causes harm but in a more circuitous manner since there is no direct contact. The typology identifies reactive/expressive aggression as impulsive, threatening, and a response to anger and frustration intended to evoke fear, anger, or rage. Passive aggressive aggression also intends to harm while disguised as “justifiable criticism” (p. 7). Figure 2 outlines the cyber IUA negative message themes within this typology.
Healthcare Versus Interdepartmental Messages
This study demonstrated that IUA messages occur in healthcare and are dissimilar to incivil interdepartmental sales messages. With interdepartmental messages, careless was defined as replying without reading the information completely, and insensitive was defined as submitting the message without thinking about how the message may be received or perceived (McCarthy et al., 2019). For messages within the patient portal, patients or advocates initiated the messages instead of replying without reading carefully. Moreover, the patient portal messages surpassed insensitive as noted by the prosodic negative tones and intentionality by the sender.
Consequences
This study identified approximately a quarter of the IUA messages as highly distressing. When nurses encounter IUA messages, they have low control and are required to manage the messages professionally. The impact is underestimated because digital messages are considered low intensity and short-lived (Niven et al., 2021). However, negative messages, especially those directed toward the nurse, demonstrated a lack of regard and respect for other's welfare. This may trigger a sense of injustice that violates norms and fair treatment in the workplace (Niven et al., 2021). Additionally, negative emotions from IUA messages may be severe and shape nurses’ attitudes and behaviors, even several months later (Niven et al., 2021; Park et al., 2018). Thus, IUA messages may increase work distress, psychological distress, job dissatisfaction, and turnover.
Strengths and Limitations
As a seminal project investigating cyber-incivility and cyber-aggression in healthcare, this study used existing tools identified from other industries to support the categorization of IUA messages. However, the differences between interdepartmental collegial emails within an internet sales company and healthcare patient communications were markedly noted. The study limitations included methodology challenges which relied on nurse perception to identify IUA messages they encountered during patient care; this may not encompass all IUA messages that were sent to the clinic during the data collection window. Also, the unit for the study setting has a specific patient population and may not represent other IUA messages from different clinics.
Implications for Nursing Practice
Nurses experience distress when exposed to IUA messages. Nurses are required to respond in a professional manner despite being personally or professionally attacked in the portal message. With a greater understanding of how IUA messages manifest, tools may be developed to help nurses process and resist and the emotional effects of negative messages. This healthcare-specific cyber-incivility and cyber-aggression framework sets a foundation for actionable interventions to be created, tailored to different clinical areas, and support nurse well-being.
Conclusion
Written communications within healthcare may manifest as varying degrees of negativity and are unlike business messages. This study demonstrated that messages may be incivil but may also be uncivil or aggressive. Negative portal messages appeared as personally or professionally ad hominens, demanding, accusing, passive-aggressive, impatient, or threatening, sometimes with several categories within a single message. Antecedents appeared to be related to unmet expectations, difficulty navigating healthcare, or lacking personal accountability. Although considered low impact compared to a physical assault, negative portal messages are personally directed and may cause distress in nurses lasting longer than a physical injury. With a greater understanding about IUA messages, interventions to mitigate nurses’ effects may be developed.
Footnotes
Authors’ Note
Declaration of Conflicting Interests
Funding
ORCID iD
