“We’ll Get to You When We Get to You”: Exploring Potential Contributions of Health Care Staff Behaviors to Patient Perceptions of Discrimination and Satisfaction

Abstract

Objectives. We qualitatively assessed patients’ perceptions of discrimination and patient satisfaction in the health care setting specific to interactions with nonphysician health care staff.

Methods. We conducted 12 focus-group interviews with African American and European American participants, stratified by race and gender, from June to November 2008. We used a topic guide to facilitate discussion and identify factors contributing to perceived discrimination and analyzed transcripts for relevant themes using a codebook.

Results. We enrolled 92 participants: 55 African Americans and 37 European Americans, all of whom reported perceived discrimination and lower patient satisfaction as a result of interactions with nonphysician health care staff. Perceived discrimination was associated with 2 main characteristics: insurance or socioeconomic status and race. Both verbal and nonverbal communication style on the part of nonphysician health care staff were related to individuals’ perceptions of how they were treated.

Conclusions. The behaviors of nonphysician health care staff in the clinical setting can potentially contribute to patients’ perceptions of discrimination and lowered patient satisfaction. Future interventions to reduce health care discrimination should include a focus on staff cultural competence and customer service skills.

Despite the increased attention given to the subject of health disparities in the United States over the past few decades,¹ minorities and low-income patients continue to experience worse health outcomes than nonminority Whites and patients with higher income.² Review articles of health services research have consistently observed that differential treatment of patients on the basis of racial/ethnic and socioeconomic status in the health care setting is one of the factors shown to contribute to these disparities,³ finding associations between unequal treatment and numerous negative health outcomes, including infant mortality, coronary heart disease, stroke, obesity, diabetes, and hypertension.^3–5 In the 2001 publication Crossing the Quality Chasm, the Institute of Medicine identified equitable care as 1 of 6 key areas of health care quality.⁶ Although efforts to eliminate racial/ethnic and socioeconomic disparities in health care delivery have increased since the publication of Crossing the Quality Chasm, they continue to persist in the United States and are attributed to factors at both the systems level and the interpersonal level.⁵ At the interpersonal level, much of the attention has focused on patient–provider communication, with little to no attention given to patient interactions with nonphysician health care staff (e.g., receptionists, medical assistants, licensed practical nurses) or how those interactions influence patient perceptions.

The current literature has suggested that perceived as well as overt discrimination are associated with negative mental and physical health outcomes.^7–10 For instance, Pascoe and Smart Richman⁷ found that perceived discrimination was directly associated with an increase in depression, anxiety, and other mental health issues. In a clinical sample of patients with diabetes, Piette et al.¹⁰ found that perceived discrimination was associated with greater symptom burden and worse physical functioning. More specifically, perceived discrimination in the health care setting has been linked to worse perceived quality of care and reduced patient satisfaction.^11,12 This finding is notable because higher patient satisfaction is associated with improvement in symptoms, improved treatment plan adherence, and better overall health outcomes.^13–15 As such, reducing perceived discrimination and improving overall patient satisfaction are important goals that should be part of any broader effort aimed at achieving equitable care and better health outcomes.

Because perceived discrimination in health care settings may contribute significantly to health care disparities, it is important to understand the ways in which patients perceive certain behaviors as being discriminatory. As mentioned, studies to date have mostly focused on physician-related factors without considering the impact other members of the health care team may have on perceived discrimination or quality of care. As a result, interventions have mainly focused on health care professionals’ cultural competence,^16,17 which does not address the role that nonphysician health care staff may play in the development of patients’ opinions about the quality of their health care. To our knowledge, no studies have investigated the potential contribution of nonphysician health care staff to perceived discrimination and patient satisfaction. To address this gap, we conducted focus-group interviews to qualitatively assess patients’ perceptions of discrimination and patient satisfaction in the health care setting specific to nonphysician health care staff behaviors.

METHODS

We partnered with the University of Alabama at Birmingham Facility for Access to Clinical Enrollment Services to recruit participants of varied socioeconomic backgrounds from community organizations, churches, and social service organizations. Postcards describing the study were mailed to potential participants; individuals who did not opt out received a follow-up phone call explaining the study in more detail and an invitation to participate in the study. Individuals were eligible if they were English-speaking African or European American adults (aged > 19 years) who had visited a health care provider in the previous 12 months. Participants provided informed consent and received refreshments and a $20 gift card for their participation.

Focus Groups

We developed a topic guide based on a review of the existing literature to encourage discussion about how patients perceive discrimination during their primary care encounter (see the box on this page). In December 2007, we pilot tested the topic guide with a convenience sample of 8 African American patients recruited from a local clinic. After the group’s conclusion, participants were told about the study objectives and then discussed the topic guide in light of these objectives. Initially, the guide did not explicitly use the word discrimination, but participants recommended using the word directly to more explicitly explore the topic.

Topic Guide Questions for Focus-Group Discussions: Birmingham, AL, June–November 2008

1. What kinds of things make it easy for you to interact with the office staff?

2. What kinds of things make it hard for you to interact with office staff?

3. What are some specific things doctors, nurses, or other health care staff do to make you feel like you are not being treated well or as well as other patients?

4. How do you know when you are being discriminated against?

5. Tell me about specific behaviors that make you think you are being discriminated against when seeking care from your primary care provider.

6. What aspects of the physical environment can affect if you feel discriminated against?

We then held 12 focus groups from June to November 2008. The groups were stratified by race (African American and European American) to facilitate transparency in discussions. Informed consent was obtained before the start of each focus group. In addition, participants completed a demographic questionnaire. A moderator trained in qualitative methods and matched to the participants’ race led each group using the topic guide; a designated note taker was also present to capture comments on a flip chart and to keep track of nonverbal behavior and level of engagement in various topics. Audio from all focus groups was recorded and transcribed. Debriefing sessions attended by the project investigators, moderator, and note taker were held immediately after each focus group to compare notes on the overall process and impressions unique to each group.

Analysis

The focus-group transcriptions were analyzed in 4 stages. First, 2 investigators (L. A. and C. P.) independently read the focus-group transcripts to identify emerging themes. Second, we discussed the identified themes, came to an agreement on categories, and created a coding guide based on these categories (Table 1).

TABLE 1—

Coding Guide for Focus-Group Interview Transcripts

Code for Staff	Description
Communication
Nonverbal	Comments about body language, posture, facial expressions, mannerisms (eye contact, touches patient, smile, attentiveness), all of which show that staff are fully engaged
Paraverbal	Comments about how the doctor communicates with the patients in terms of voice tone, pitch, pacing, rate, cadence, all of which show that staff are fully engaged; how it is said is paraverbal
Verbal	Comments about verbal cues to show staff are fully engaged (addressing the patient by name, using open-ended questions, allowing sufficient time for response before speaking); strictly linguistic, understandability; what is said is verbal
Forthright	Honest, direct, not mincing words (manner)
Humane	Comments marked by compassion or consideration for the patient, such as caring, sensitive, kind, etc., or lack thereof
Personable	Comments about the staff interest in the patient as more than just a patient; also involves comments that deal with staff–patient interactions (personable, rapport); small talk, nonmedical conversation (personal life); being friendly
Respectful	Comments characterized by or showing politeness or deference, that is, respect for patient input or the lack thereof, such as staff treats patient as though stupid; staff talking in front of patient; authoritative, paternalistic (denoting status, position, hierarchy); uncooperative, antagonistic, nasty disposition or manner in regard to a person or thing; nasty disposition or manner
Takes time	Comments about hurrying through the visit, time spent with patient
Technical skills
Management	Mostly, front desk: capability for organization and administration of day-to-day operations, that is, providing test results, sending patients in correctly, updating patients about waiting times; time management and wait times
Professionalism	Judgment, advice, and behaviors based on set of values, that is, Hippocratic oath, integrity, and honesty; knowledge and use of ethical and legal aspects of medicine; staff being self-regulated by their moral values; accountability; altruism

Third, we read the transcripts again and organized the previously identified themes into categories. Fourth, once we agreed on the final grouping, we independently coded each transcript with an interrater reliability of 80%. Results were analyzed separately for European American and African American groups and then compared for similarities and differences.

RESULTS

We conducted 12 focus groups stratified by race and gender. Focus-group attendance varied but ranged from 4 to 12 participants per session. A total of 92 participants were enrolled; 55 participants were African American with the majority being female (52.7%), and 37 participants were European American with the majority being male (51.4%). Participants’ mean age was 49.7 years (SD = 10.9) for African Americans and 46.7 years (SD = 16.1) for European Americans. Of European Americans, 32% had no insurance, compared with 5.6% of African Americans. However, 22.2% of African Americans had Medicare or Medicaid coverage compared with 5.4% of European Americans. Nearly our entire sample of African American and European American participants had obtained at least a high school diploma (Table 2).

TABLE 2—

Characteristics of Focus-Group Participants: Birmingham, AL, June–November 2008

Characteristic	African American (n = 55)	European American (n = 37)
Gender, no. (%)
Male	26 (47.3)	19 (51.4)
Female	29 (52.7)	18 (48.6)
Education, no. (%)
< HS education	4 (7.4)	1 (2.7)
HS graduate	14 (25.9)	16 (43.2)
Technical college	5 (9.3)	3 (8.1)
College	24 (44.4)	14 (37.8)
Graduate school	7 (13.0)	3 (8.1)
Insurance status, no. (%)
HMO	24 (44.4)	18 (48.7)
Medicare/Medicaid	12 (22.2)	2 (5.4)
Private	6 (11.1)	4 (10.8)
VA	3 (5.6)	1 (2.7)
No insurance	3 (5.6)	12 (32.4)
Other	6 (11.1)	0 (0.0)
Age, y
Mean ±SD	49.7 ±10.9	46.7 ±16.1
Range	23–66	21–78

Note. HMO = health maintenance organization; HS = high school; VA = Department of Veterans Affairs.

Several themes regarding nonphysician health care staff contributions to perceived discrimination and patient satisfaction became evident during our analysis of the results of the 12 focus-group sessions. After reviewing focus-group responses, we observed that feelings of discrimination among participants seem to be associated with 2 main characteristics, insurance or socioeconomic status and race, with both African Americans and European Americans reporting incidents of discrimination based on these factors. European American participants reported discrimination based on age, but African American participants did not. Communication style, including both verbal and nonverbal factors, was related to the way individuals perceived they were treated. These themes were common to both African American and European American participants. Participants also mentioned some of the ways in which staff could help to ensure patients had a better experience.

Insurance and Socioeconomic Status

Participants reported feeling that they were treated differently depending on their socioeconomic status, specifically as related to health insurance status. For example, participants noticed a difference in how people with and without insurance were treated by staff.

One African American participant noted,

When you got medical insurance, it’s a total difference. Like I have medical insurance. I go to the doctor. If I have a 9:15 appointment, I’m waited on between 9:15 and 9:30, or else them girls going to come out and say, “Ms. [Y], Dr. [X] is running a little late. We’ll be right with you as soon as we can.” It’s just a total difference.

A European American participant explained,

I had Medicaid . . . they just treated me like I was something they set outside for the trash to pick up. . . . I have to go to the clinic, because I have nothing, because things were cut off, and I wasn’t able to work.

Race

Both African American and European American participants noted differential treatment based on race. Some African American participants even expected it; one participant explained, “We’re all Black, and we know that there is discrimination and prejudice out there, so we expect that. So you come in there armed, you should come in there armed and ready to deal with that.” Another African American participant reported, “They’re kind to somebody right before you [who is not Black], and they’re not to you. They’re short-spoken to you, and here again there’s the body language and what have you.” European Americans also reported being discriminated against on the basis of race when interacting with African American staff. One European American participant reported,

Well, then somebody else will come . . . another Black person, whatever, and like, boom, [the staff’s] attitude changes, and they’re like all friendly and stuff. They don’t know them, either, you know. They don’t, you know, give you the same respect. . . . I guess they just don’t like White people.

Long wait times and being passed over because of race were also reported by both African Americans and European Americans. One African American participant noted,

Well, I actually felt that I was being discriminated against . . . the first place you go, once you’ve signed in, is to triage, and I know that’s not by appointment, you know . . . and there was some Caucasians that came in there after me, and they were called. I got up and asked, why were they being seen before me? And the answer was, “I apologize, I didn’t see your name.” How on God’s green earth did you not see my name right there, you know?

Another African American participant reported,

You can feel when you’re being discriminated against, and I know, for example, when you go to a [clinic], and you know you was there before somebody else was, and then you sit there an hour, 2 hours, and then other people coming and going about you, and you know you’re being discriminated against.

One European American participant stated that,

I had a bad eye infection . . . and I felt like, and it might have been my paranoia, but I felt like I waited. They said they, you know, misplaced my chart. But there were a lot of Black nurses there, and I, I just, I, I got, I got paranoid about it. I thought it’s because I’m White.

Age

Themes of discrimination on the basis of age were reported in our focus groups, but this theme was only observed among European American participants. One European American participant noted, “It seems like, maybe it’s just because we’re getting older, but the younger people, they, a lot of them don’t have patience with old people, or they just don’t relate to them.” Another participant stated,

And especially, you know, when you go to the doctor, and you’re sick, sometimes you need some help, especially when you get older . . . and [some staff will] be very considerate, but then there’s the others that are not considerate at all. In fact, you wonder what they’re doing even working in an office setting like that for a doctor, and that they need to be out there as a car hop or something.

Verbal and Nonverbal Communication

Both African American and European American participants reported feeling disrespected and discriminated against as a result of staff’s verbal communication and tone of voice. For example, one European American participant reported,

Yeah . . . you can tell when a person is talking down to you, you know, like you weren’t quite bright, and this sort of thing. . . . I think it happens with, a lot, really with, with the poor people, and with minority groups.

Another European American participant reported,

Maybe the tone of the voice or the shortness in how they answer you, compared to it not being so with another person. . . . I’ve felt like I’ve been discriminated against.

One African American participant noted poor treatment by both White and Black staff:

I’m not going to say it’s just White people that do [it]. I mean, you have Black people, you go, you go up there, and you trying to, trying to sign, [and the staff says] “Well, sign in over there.” I mean, like, all I did was ask where the sign-in book was. But just look, elderly White lady come up and, “Oh, Miss So,” [staff] know her by name. I’ve been going here, I’ve been going here as long as probably them, but you don’t know my name.

Nonverbal communication was also felt to be an important component of nonphysician health care staff behavior related to perceived racism. Participants noted that the lack of staff smiling and other facial expressions contributed to feelings of disrespect. One African American participant described surprise that staff would not smile:

And it seems like what you being a receptionist or someone at the front desk, it seem like you would be the first one to have a smile or greet you with a smile, you know, you’re coming into a medical facility.

Participants also found it difficult to deal with what they described as negative attitudes. The lack of attention was upsetting. One European American participant explained,

I’m not big on people multitasking while I’m talking to them . . . don’t be shuffling paperwork or, you know, writing over here on something else, you know? If, if we’re having a conversation, you know, at least take the time to stop and look up at me and talk to me, not talk down to the paper.

One African American participant also reported that doctors’ attitudes were actually better than staff attitudes. “Well, I think that if the staff had the attitude that the doctors have, it’d probably be a better facility.”

Participants also reported that lack of eye contact was a nonverbal source of discomfort, with some staff barely looking up from their desk. One European American participant stated,

They’re talking, you come up: “Well, have a seat, somebody will be with you in a minute.” They just kind of briefly give you they eye contact, then go back talking about their dates or what they’re going to do that night, or whatever.

Some staff would not even look up at all; for example, one European American participant noted “Well . . . she wouldn’t. She didn’t look at me.” Dismissive attitudes were also nonverbal cues to participants as to whether the staff member was showing them respect or disrespect. One African American participant explained that one could sense this type of attitude “by the way they treat you, because some of them can treat you so, I mean, look at you, like, up and down, like you ain’t nothing.” Participants noted impatience on the part of staff. For example, a European American participant stated,

They bounce out there, and they call your name, and because you don’t just hop right up, I mean, you’re having a hard time getting up and everything. They’ll turn around; almost shut the door in your face.

The perception that staff did not value the patient’s time was also an issue. An African American participant noted, “They made you wait. They don’t care. Call us whenever. It makes your time, it’s not valuable. We’ll get to you when we get to you.”

Participant Recommendations to Reduce Perceived Discrimination

Participants were also asked for their own ideas on how perceived discrimination could be addressed. Smiling was an easy way for staff to make patients feel comfortable and appreciated. An African American participant suggested,

When they’re friendly when you walk in the office, and they greet you with a smile, you know, laugh and talk to you, you know, like you’re just friends, you know, you make me more comfortable

Participants also suggested that patience and listening could go a long way. As one European American participant noted, “Listening to what you have to say, you know? Not cutting you off when you’re trying to talk to them.”

General pleasantries could be very helpful as well. One African American participant commented, “You come in there, be nice, pleasant, ‘Good morning. How you doing?’” In fact, participants reported that a little TLC and customer service could go a long way toward making them feel welcomed. “I’m disappointed, because I’m going there, actually expecting some TLC. Customer service is, oh, wow, you know, it goes a long way,” stated an African American participant. Finally, walking a mile in someone else’s shoes was also suggested by a European American participant:

I think that if they were on the other side of the table, and they were treated the way some of the descriptions here, if they just considered if they were sitting in that person’s place, just put themselves, try to put themselves in that person’s place, coming when they’re hurting, or not feeling well, or somebody’s not talking to them very kindly.

DISCUSSION

In this qualitative study among African American and European American patients, we found that patient interaction with health care staff is a potential source of perceived discrimination as well as diminished patient satisfaction. Patients reported race-, insurance-, age-, and socioeconomic status–based discrimination as a result of the communication style, both verbal and nonverbal, of nonphysician health care staff. To our knowledge this is the first study to identify health care staff as a potential source of perceived discrimination. Our findings suggest that interventions aimed at reducing perceived discrimination and improving patient experiences in the health care setting need to extend beyond patient–provider interactions to include the entire health care team, beginning with front desk staff.

Verbal communication that was curt and factors such as limited eye contact or not smiling, dismissive attitudes, and impatience were identified as sources that evoked feelings of perceived discrimination among patients. Although we have no studies on nonphysician staff populations with which to compare our results, these results are consistent with current literature on physician and patient interactions that has found lack of common courtesy and respect to be associated with perceived discrimination in the health care system.¹⁰ Although these behaviors may or may not be racially or socioeconomically driven, they are often perceived by the recipient as discriminatory.^10,18–20

According to several researchers, the interaction between patients and health care providers is complex and is influenced by both the provider and the patient.^3,10,21,22 Explicit bias and stereotyping can influence communication from the provider.^23–25 However, patients also have their own stereotypes and biases that can lead to perceptions of discrimination. For example, LaVeist et al.²⁰ found that although African Americans and Whites reported being treated badly at a similar rate (9% vs 7%), African Americans were approximately 8 times more likely to attribute these experiences to their race than were Whites. Although these findings suggest that African American patients may be more likely to view poor treatment as discrimination, they are not surprising given the history of racial discrimination in the United States and African American distrust of the health care system.^10,26 Thus, interventions aimed at improving patient satisfaction in minority communities should include efforts to reduce perceived discrimination.

Some attitudes and behaviors of nonphysician health care staff, such as not meeting patients with a warm greeting, were a source of perceived discrimination. However, one explanation for participants’ negative interactions with nonphysician health care staff could relate to the types of health care facilities found in many underserved communities. It is well documented that such facilities are often underresourced and lower performing than other private health care facilities.^27–29 Thus, the attitudes and behaviors of staff could, in part, be a result of poor training and tired or inadequate staff.^30–32 However, another, more insidious potential contributor to the differences in perceived treatment is implicit bias. Implicit bias is a subconscious positive or negative belief that can often differ from explicit biases.³³ In other words, although people might not explicitly express negative feelings toward different races or groups, subconsciously, most if not all individuals have biases that occur as a result of living in a society in which stereotypes and biases exist.³³ Previous literature has demonstrated this concept.^34–36

For instance, although physicians in their sample reported no explicit preference for White patients versus Black patients, using an Implicit Association Test³⁵ to measure implicit bias, Green et al.³⁶ found an implicit favoring of White patients over Black patients. More importantly, implicit bias has been shown to influence behavior.³³ For example, Green et al. found that as physicians’ implicit bias for Whites increased, their likelihood of not appropriately treating Black patients with cardiac symptoms increased as well.^34,36 This literature suggests that future interventions aimed at enhancing the patient experience by targeting nonphysician health care staff not only should consider cultural competence and customer service but may also do well to raise awareness of implicit biases.

Limitations

Although our study presents first-of-its-kind evidence of patients’ experiencing perceived discrimination from nonphysician health care staff, our study does have limitations. Although we followed appropriate focus-group methodology, our results are based on self-reported qualitative data from a relatively small sample. In addition, these data were obtained from a convenience sample of patients from an urban environment in Birmingham, Alabama. The European American men, and to a lesser extent the women, were recruited from an organization that assists with securing housing and employment, hence the unusually low rate of education and health insurance. Thus, generalizing our findings to different populations, especially outside of the Southeastern United States, should be done with caution.

Conclusions

We have presented evidence that staff interactions with patients result in perceived discrimination. This is troubling given that perceived discrimination is associated with both negative health outcomes^7,10 and negative perceptions of quality of care.^11,12 Understanding the relationship between staff–patient interaction and perceived discrimination could be of interest to researchers, policymakers, and health care providers who are interested in improving disparities and quality of care. Future research should quantitatively assess the qualitative findings of this study, particularly the extent to which perceived discrimination on the basis of race, insurance, and age is associated with health behaviors (e.g., medication adherence, clinic attendance) in an outpatient primary care setting.

As suggested by participants in this study, improvements in customer service and courtesy, regardless of a patient’s race or ability to pay, could go a long way toward reducing feelings of perceived discrimination. Interventions to improve these areas of staff and patient interaction could possibly lead to improvements in overall patient satisfaction. In addition, future research should measure the extent of health care staff’s implicit bias and the potential impact that implicit bias can have on perceived discrimination. Although modifying implicit bias in the short term may not be feasible, interventions could be formulated to raise staff awareness of implicit bias and enhance patient-centered care. To that end, we are currently conducting an evaluation of an intervention designed to raise staff awareness of implicit bias and teach skills that promote reflection and intentional behaviors in 10 local primary care clinics. With a new national commitment to patient satisfaction and patient-centered care signaled by the passage of the Patient Protection and Affordable Care Act and the Patient Centered Outcomes Research Institute, as well as hospital reimbursement being tied to patient satisfaction, improvements in health care staff and patient interactions could be highly beneficial for health care organizations.