After abstracting counts of each of these three linguistic features, we used descriptive statistics to explore their distributions by race and gender. Because quotes and judgment words were less common and because we hypothesized that the presence of one such linguistic feature in a note was significant, we created binary variables to indicate whether that feature appeared at all in the note. Because evidentials were substantially more frequent, and because we hypothesized that it was the number of evidentials rather than the presence of one that might convey more doubt of the patient, we modeled evidentials as a continuous variable, representing the number of times that the evidential was used in each note.
Testimonial injustice is one of a broader category of epistemic injustices, first described by philosopher Miranda Fricker, who defines testimonial injustice as that which occurs when a speaker receives an unfair deficit of credibility due to prejudice on the part of the hearer.28 Many of the examples used by Fricker draw on interactions of Black Americans with law enforcement, where credibility bias contributes to substantial harms in the Black community, including mass incarceration, disproportionate use of the death penalty, and the murder of innocent people by police officers.28 In healthcare settings, there are also very real harms that can occur when people are not believed, such as delayed diagnosis, inappropriate treatments, unnecessary pain and suffering, and even death.2, 5, 7, 8
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The fact that the use of the linguistic features we examined may, in some instances, be non-prejudicial (or a different sort of prejudicial) may raise concern as to whether our results reflect true testimonial injustice. However, the fact that we found racial and gender differences in the use of this language suggests that there is a pernicious influence behind their use. To the extent that there were instances of non-prejudicial use of these linguistic features, it would introduce misclassification bias into our study. However, the misclassification would be non-differential; there are no compelling reasons for systematically greater use of evidentials, judgment words, and quotes for Black and female patients, other than race or gender bias. Non-differential misclassification of outcomes generally biases results towards the null,31 which in our study would make it more difficult to detect race and gender differences. The fact that we found race and gender differences, despite this potential for misclassification, suggests that our findings represent a conservative estimate of testimonial injustice in medical records.
As a profession, physicians must recognize and neutralize the impact of racial prejudice in credibility assessments by seriously and constantly considering that we might make implicitly biased judgments that are unwarranted. When we have attempted to account for this bias and still have doubts about patient credibility, we must consider respectful ways to document that doubt. Using scare quotes or judgmental language may unfairly put the patient at risk for lower-quality care and disrespect from future providers. Further research is needed to explore the phenomenon of testimonial injustice and other forms of stigmatizing language in patient medical records,32 and interventions should be developed to reduce their impact.
The aims of the present study are formulated to test theoretical assumptions of the incivility spiral presented by Andersson and Pearson (1999). The first aim is to investigate possible longitudinal outcomes of witnessed workplace incivility, in the form of instigated incivility and well-being. An additional aim is to explore whether witnessed workplace incivility is indirectly related to instigated incivility or well-being over time, via lower levels of perceived organizational justice. Lastly, we aim to explore if control, social support (from coworkers and supervisors), and job embeddedness moderate the relationship between witnessed and instigated incivility over time. An online questionnaire was distributed to a panel of Swedish engineers at three time points over one year with about six months between waves. Longitudinal data were provided by 341 respondents. Results from longitudinal structural equation panel models showed that witnessed workplace incivility, over time, predicted subsequent higher levels of instigated incivility but not lower levels of well-being. In addition, witnessed incivility predicted lower levels of perceived organizational justice over time but perceived organizational justice did not mediate the relationship between witnessed and instigated incivility or well-being. Finally, the results showed that control, social support from supervisors (but not coworkers), and job embeddedness partly moderated the relationship between witnessed and instigated incivility over time. The relationship between witnessed and instigated incivility between time 1 and time 2 was stronger when levels of control, support and job embeddedness were high. However, job embeddedness was the only robust moderator of the relationship.
As both vicarious incivility and perceived injustice have been linked to reduced levels of well-being (Ford and Huang 2014; Lim et al. 2008), we also investigate whether witnessed incivility is directly or indirectly related to lower levels of well-being over time via low levels of perceived organizational justice. The focus in the present study is on psychological well-being, which comprises components such as positive mood, interest and energy (Bech et al. 2003), as vicarious experiences of incivility previously have been directly linked to lower levels of psychological well-being (Lim et al. 2008). By exploring the possible long-term effect of witnessed incivility on well-being, we contribute theoretically by testing the theorized assumption that incivility is detrimental to well-being over longer periods of time because of chronic exposure to a low-intensity stressor (Cortina et al. 2001). Exploring long term consequences of witnessed incivility is an important step in understanding the extent of harm that vicarious incivility may, or may not, cause over time. In other words, this could provide information about if employees recover from such strain, or if it has a more lasting impact.
A few studies have explored the relationship between incivility and the different facets of justice defined by Colquitt and Greenberg (2003). For instance, Griffin (2010) found that experienced organizational-level incivility negatively predicted interactional justice climate, which refers to perceptions of fair interpersonal treatment. Blau and Andersson (2005) found that distributive (perceived unfair distribution of resources), but not procedural (perceived unfairness of organizational processes) and interactional injustice, was related to increased instigated incivility over time. However, Sayers et al. (2011), found both procedural and interactional justice to be negatively correlated with instigated incivility. Although these studies report on facets of justice, they may indicate a link between workplace incivility and overall justice perceptions. For instance, Mohammad et al. (2019) found that perceptions of justice are mediated via overall justice, which suggests it to be an overarching mechanism. Similarly, Ambrose and Schminke (2009) have stated that individuals make holistic judgments of justice. In light of this, the relationship between overall perceived organizational justice and instigated incivility may be more informative to explore, rather than the inconclusive facet-level correlations found in previous studies. From a bystander perspective, Porath et al. (2010) found that customers who witnessed a manager engage in incivility towards a subordinate reported higher levels of anger, and desire for revenge towards the manager, which was mediated by their perceptions of deontic injustice.
The survey was administered at three occasions. The union randomly sampled a pool of about 5000 of their members. The survey was then administered via e-mail to everyone in the pool at each respective occasion. Time gaps between measurement occasions were roughly 6 months. Responses were matched over time via a unique identification code for each participant. The survey had a full-panel design, meaning that all study variables were measured at all three occasions.
A consent form was presented at all three measurement occasions. The consent form informed participants that participation was voluntary, that their responses would be treated confidentially, and that raw data would not be shared with the union. The study protocol was approved by the Swedish Ethical Review Board (dnr 2016/926).
For the moderation hypotheses, we estimated models with interaction terms. To reduce analytical complexity, observed rather than latent constructs were used to test the interaction hypotheses. These models are specified in the same way as the structural equation models, but with scales rather than latent variables, including all three time points of the predictor, the moderator and the dependent variables, with autocorrelations between waves, and intercorrelations within time points. The only difference is the addition of interaction terms between the predictor and moderator within the model (one at time 1 and one at time 2). One model was assessed for each moderator, to test their influence independently. When testing moderation over three time-waves, the influence of the moderator is tested for each consecutive measurement occasion, i.e. between time 1 and 2, as well as 2 and 3. We included interaction terms between witnessed incivility and each moderator at each time point (t1witnessed incivility x t1moderator, and t2witnessed incivility x t2moderator, mean-centered) with paths predicting t2 and t3 instigated incivility respectively (Little 2013). The interaction terms are entered as saturated correlates of all other variables at all time points in the model, apart from the dependent variable it is predicting, where a direct path is specified. In such models, a significant path between the interaction term and the subsequent measure of the dependent variable indicates evidence for the presence of a longitudinal moderation effect (Little 2013). 2ff7e9595c
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