Background: The shift towards family-centered care, while beneficial, has heightened the risk of interpersonal conflict in hospitals. Incivility from patients’ families is characterized by low- intensity disrespectful behaviors, which is a growing systemic concern, particularly in high-stress environments like intensive care units (ICUs). Such behavior is hypothesized to impair clinician cognition, increase stress, and disrupt care processes, posing a direct threat to patient safety and healthcare outcomes. However, empirical evidence quantifying this specific association, especially in resource-constrained settings, remains limited.
Objective: This study aimed to assess and analyze the association between family member incivility and ongoing patient care outcomes within a critical care hospital swat.
Methodology: A cross-sectional study was conducted among 74 registered nurses working in the ICU, coronary care unit (CCU), emergency room (ER), and high dependency unit (HDU). Data were collected using a structured questionnaire incorporating an adapted Nursing Incivility Scale and a tool measuring care disruption. Analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 27 with descriptive statistics and Chi-square testing.
Results: Approximately 25.7% of nurses reported frequent exposure to family incivility, while 40.5% reported frequent disruptions in patient care. A significant association was observed between incivility and care disruptions (χ²=3.69, p=0.055).
Conclusion: Family incivility is a significant risk factor affecting patient care processes, necessitating targeted institutional interventions.

Incivility, Family members, Patient care outcomes, Critical care, Nursing, Patient safety, Workplace climate.

The contemporary healthcare provision is seen as a complicated social process that is formed by the interactions between patients, the family, and medical workers.[1] Family-centered care in this setting means a collaborative practice that directly engages the relatives in the development and administration of patient care.[2] Incivility is described as a low-intensity deviant behavior with an unclear aim of injuring others, such as insults, rude gestures, or doubt of their professional competency.[3] Patient care outcomes in the critical care setting are an indication of the quality, safety, and promptness of the nursing and medical care provided to the patient. To have safe and effective healthcare systems, it is critical to understand the role of interpersonal behaviors in affecting these outcomes.[4]

Incidents of incivility in the healthcare environment have been on the rise all over the world, especially in high-stress units like ICUs.[5] Research findings indicate that around 3540% of the critical care staff encounter some form of rude behavior by the relatives of patients at least once a week.[6] The pressure of the post-pandemic period, the increasing anxiety of the population, and the burdened healthcare systems have only added to the negative relations in hospitals.[7] In underdeveloped countries where there are limited resources in healthcare and the number of patients is high, disruptive behaviors caused by families are even more frequently reported to be higher.[8] These statistics point to the increasing scale of the problem.

The ICU has been a care setting that is also distinctively stressful, in which families are confronted with uncertainty, fear, and emotional distress surrounding the critical illness of a loved one.[9] Although family support might increase emotional supportive procedure of patients, escalated anxiety might be revealed through aggression, impatience, or verbal aggression towards staff.[10] These practices are a source of tension in the care teams and will break the workflow in high-acuity environments where accuracy and focus are essential.

Healthcare providers have cognitive implications for exposure to incivility. The studies indicate that uncivil or aggressive encounters decrease the scope of working memory of the clinicians and weaken the capacity to make clinical judgments.[11] Experimental research has indicated that there are more diagnostic and medication errors among the teams subjected to rude behaviors than those who were treated respectfully.[12] These results indicate that patient safety can be threatened by even low-intensity incivility.

In addition to cognitive performance, psychological distress and professional burnout of the nurses are related to constant exposure to incivility.[13] Burnout, which is manifested by emotional exhaustion and personality, diminishes empathy and interest in patient care. Nurses who have chronic hostility can disengage with their families or restrict communication, thus preventing the continuity of care and monitoring.

Family incivility has organizational impacts that are also important. Greater turnover intentions and less job commitment are linked to increased stress and dissatisfaction among the nursing staff.[14] The turnover leads to staffing shortages in the organization, which means that the remaining staff must work harder, leading to more workload, stress, and susceptibility to further conflict.

Overcrowding, nurse-to-patient ratio, and poor communication infrastructure in Pakistan and other resource-limited environments could further increase the strains between families and health workers in such settings.[8] As families might see assertive or aggressive behavior as the only way to ensure that their loved ones get attention, they will unconsciously aggravate the situation of care delivery. Thus, the statistical relationship between family member incivility and patient care outcomes should be studied to inform hospital policies, support systems, and plans to protect the well-being of providers and patient safety.

The study design was a quantitative cross-sectional study where the researchers aimed to establish the connection between the incivility of family members and the current patient care outcomes in the critical care units. The choice of this design is due to the possibility to evaluate the relationships between variables at one point in time, and the design allows assessing the trends and relationships without conducting longitudinal follow-up. It was done in a tertiary care hospital in Swat, Khyber Pakhtunkhwa. Registered nurses working in critical care departments (ICU, CCU, HDU, and ER) comprised the target population. The sample population had a total of 90 nurses. The sample size that was calculated was 74 participants using the Raosoft sample size calculator, a 95% level of confidence, and a margin of error of 5%. The eligible nurses were recruited through a convenience sampling method and could volunteer to take part as discussed in the inclusion criteria.

Data collection procedure: The process of collecting data was initiated upon receiving the official permission of the Academic Studies and Research Board (AS&RB) as well as the Ethical Review Board (ERB). This was approved by hospital administration and the Chief Nursing Superintendent. Eligible nurses were contacted during their work shifts and informed about the objective of the study, procedures, and the voluntary nature of the research. Informed consent was taken in the form of a written consent before taking part. The structured and self-administered questionnaire based on the Nursing Incivility Scale and a disruption scale developed by the researcher was used to gather data. The questionnaire was administered face-to-face, and the questionnaires were filled out anonymously in a special section within the hospital to ensure confidentiality and allow the respondents to be honest.

Data analysis procedure: Data input and output were done through IBM SPSS version 27.0 statistics. Continuous variables, mean, and standard deviation as descriptive statistics of age and years of experience were calculated. Categorical variables were summarized using frequencies and percentages. Pearson correlation coefficient was calculated in order to establish the strength and direction of correlation between family incivility and disruption in patient care. The p-value was used as a statistically significant value less than 0.05.

Demographic characteristics of participants: The demographic information on the 74 registered nurses can be taken as a valuable source of contextualization of the research results on family member incivility and patient care outcomes in the critical care environment. There was a significant gender imbalance in the sample, where males constitute 68 % (n=50) and females 32 %t (n=24). The majority of respondents had a degree in Nursing, Bachelor of Scientists (77% n=57 participants), 20% (n=15) had a diploma qualification, and only 3% (n=2) had a master’s degree, indicating that most participants were frontline clinicians with undergraduate training. The pattern of professional experience was found to be bimodal, 31 % (n=23) of the respondents had work experience exceeding ten years, and 26 % (n=19) reported having 1 to 2 years of experience, which indicates different levels of exposure and ability to cope with demanding family behaviors. Bedside nurses were the largest in the category of professional roles (45% n=33) and then head nurses (31% n=23), charge nurses (16% n=12), and nurse supervisors (8% n=6), which are the representatives of all hierarchical levels. The sample was selected from various high-acuity units (Emergency Room 39%, CCU 26%, ICU 12%, and other special units 26%), as well as night (38%), morning (36%), and evening (26%) shifts. The presentation of a variety of representations enhances the extensiveness and applicability of the results.

Table 1: Demographic characteristics of nurses

The descriptive statistics of the nine items of family incivility (fiQ1-fiQ9) demonstrate the medium scale of perceived incivility based on the 74 nurses who participated in the study. The average scores were 1.365 to 2.149 based on the five-point Likert scale, indicating that the uncivil behaviors of the patient’s family members were encountered a few times and sometimes. fiQ3 (Mean = 2.149, standard deviation (SD) = 0.975) had the highest mean, whereas fiQ1 (Mean = 2.135, SD = 1.102) had the second highest, meaning that people were exposed to these particular uncivil behaviors comparatively more frequently. On the contrary, fiQ7 (Mean = 1.365, SD = 1.041) and fiQ9 (Mean = 1.446, SD = 0.862) enshrined perceived frequency. The standard deviations between 0.862 and 1.177 are indicators of moderate variability of responses, indicating that there are differences in the individual experiences of the respondents. It is important to note that the fiQ6 had the highest variability (SD = 1.177, Variance = 1.385), which means that more perceptions varied on that item. On the whole, the results indicate that although family incivility is not said to occur most of the time, it is deployed periodically, with different types of behaviors being variable.

Table 2: Mean, std. deviation and variance of patient family members’ incivility questions

The frequency distribution of family incivility responses also helps to show that most of the behaviors were experienced at the lower frequency levels. Using the original five-point scale, 11% (n=76) responded Not at all, 27% (n=183) responded Few times, and 37% (n=245) responded Sometimes. These categories were put together as the Rarely group, which took up 75 % (n=504) of the entire responses when combined analytically. Contrarily, 20% (n=130) of answers were given as most times, 5 % (n=32) as all the time. These two higher frequency classes were combined as Frequently, and this represented 25 % (n=162) of all responses. On the whole, although most nurses said that family incivility was not a frequent occurrence, a noteworthy segment of the responses indicated that family members of patients are driving uncivil behaviors that were still prevalent and common in the critical care setting.

Table 3: Distribution of family incivility frequency reported by participants (N=666)

Frequency distribution of care outcome (co) responses shows that there is a larger proportion of care disruptions response as compared to the care incivility response. Out of the initial five-point scale, 11% (n=76) of the answers were not at all, 21% (n=139) a few times, and 28% (n=188) to be sometimes. These categories were combined with each other to constitute the Rarely category when grouped to be analyzed, where 60% (n=403) of the total responses gave them. Conversely, 28% (n=186) of answers were to the effect that it was most times, and 12% (n=77) of answers said that it was always the case. These more frequent categories were grouped together into the Frequently category, which is 40 percent (n=263) of the responses. This distribution indicates that most of the disruptions in care occurred rarely, but a significant percentage of two out of every five responses reported frequent interruptions in the care processes of patients. The results indicate that the perceived interference in the continued care delivery in critical care environments is significant.

Table 4: Distribution of patient care outcome frequency reported by participants (N=666)

This Chi-square test was done as a way of determining the relationship between family member incivility and patient care outcome disruption. The Chi-Square test was 3.69, and the degree of freedom was 1, which gave a p-value of 0.055. Likewise, the Likelihood Ratio test gave a figure of 3.72 (df = 1, p = 0.054), and the Linear-by-Linear Association gave 3.66 (df = 1, p = 0.056). Even though all three statistical tests show the positive tendency toward the association of the variables, the p-values are somewhat higher than the traditional level of statistical significance (p < 0.05). Thus, the findings suggest that the interdependence between family incivility and care disruptions is close to statistical significance and falls short of the rigid significance parameter. This implies that there could be a relationship between the two that could be explored further with a bigger sample size to establish the strength and meaning of the relationship.

Table 5: Results of the chi-square test of association between family incivility and care outcome (n=148)

The results of the current study show that there is a significant trace of incivility of family members in the critical care environment, with 25% of the responses falling under the frequent exposure category. Though most of the nurses stated that they rarely saw incivility, the percentage of frequent exposure is clinically significant. These results are similar to the reports of many research works conducted in other countries that state that 30-40 % of the nurses working in critical care regularly experience rude or hostile treatment by family members.[15] The same trends have been noticed in the high-acuity settings where emotional stress and uncertainty increase family tensions.[2] Nevertheless, the frequency of exposure in this study is slightly less than the frequencies reported in some Western healthcare systems. Family aggression rates have been reported to be over 45 per cent in some tertiary ICUs.[16]

The research also established that 40 % of care disruption responses were labeled as frequent, implying that interruptions in the administration of medications, monitoring, and communication are very regular. This result confirms earlier studies that family conflicts are the cause of workflow interruptions and decreased clinical effectiveness.[17] Experimental research has demonstrated that rudeness affects the performance of clinical tasks negatively and predisposes the occurrence of medical errors.[18] Although our results were not a direct measure of clinical errors, our disruption percentage was high, which is aligned with the literature on incivility being related to worsening patient safety outcomes.[19]

According to the association analysis, there was an almost statistically significant interaction between family incivility and care disruption (p = 0.055), which implies a positive tendency. Even though the association was not found to be statistically significant (p < 0.05), the findings suggest the possibility of a relationship between them, and this should be further investigated. Other researchers have found statistically significant relationships between workplace incivility and patient safety incidents.[7] The moderate increase in the p-value in the current study can be explained by the fact that the sample size is limited or by the specifics of the local healthcare setting.[20]

The modular mean scores on incivility (between 1.36 and 2.15) indicate that the nurses reflect their behaviors infrequently and not constantly. This is contrary to the reported post-pandemic research in Europe and North America, where an increase in average levels of exposure was recorded.[9] Disagreements can be affected by cultural practices in Pakistan, where respect for medical practitioners is quite high despite the pressure posed by the system.[21] However, even a level of incivility at times has been found to be detrimental to the cognitive performance and emotional well-being of health care professionals.[5]

The socioeconomic profile of the sample group, especially male nurses occupying most of the sample, and the diversity of their professional experience can also affect incivility perceptions. Research has demonstrated that inexperienced nurses indicate that they experience greater psychological distress when subjected to aggressive communication in comparison to senior nurses.[22] The bimodality of the experience of this research is an indication that the coping strategies and resilience might not be equal among all participants, which might moderate the magnitude of the observed relationship.

The observation that occurrences of care disruption were greater than those of frequent incivility indicates that the low-to-moderate levels of hostility can disproportionately impact workflow. This observation is backed by previous studies that have shown that even minor rude remarks can constrict the mental bandwidth of clinicians and decrease situational awareness.[12] Small cognitive distractions can lead to quantifiable negative care quality in high-stakes settings like ICUs.[13] Consequently, the pattern of this research is aligned with the trend in the world, highlighting the potent albeit indirect impacts of incivility.

In general, the research provides context-specific data of a tertiary hospital in Khyber Pakhtunkhwa with little previous research quantifying such a relationship. Although the substantial links between incivility and adverse care outcomes are always reported in the international literature, the current results point to the emerging yet significant trend in the local context.[22] The statistical outcome, which is close to significant, reminds the necessity of larger multicenter research to prove the power of this association and to implement policy-based interventions that could help enhance the well-being of staff and patient safety in critical care units.

Recommendations: This study highlights the urgent need for a multi-component intervention plan to be implemented in critical care units to address disruptions in patient care. Hospital administration should enforce structured family communication and de-escalation policies, including the RESOLVE framework, and integrate evidence-based, family-centered care checklists into routine workflows to proactively manage relationships and minimize conflict.

At the same time, unit-specific training programs should be developed and mandated, focusing on emotional regulation, conflict management, and resilience-building, particularly for novice nurses, who are most vulnerable. In addition, incident reporting systems should be strengthened to formally track family-related care disruptions as a patient safety concern. This shift would elevate the issue from an interpersonal challenge to a system-wide priority within the organization’s quality and safety agenda.

This paper has proven the mediocre, correlational relationship between family member rudeness and interruptions to continued patient care, resulting in a tertiary hospital critical care unit. The results are consistent with the modern theoretical frameworks that focus on cognitive and emotional requirements of working in healthcare, and can be added to the emerging body of research that family-staff relationships are a quantifiable determinant of quality care and patient safety. Although additional studies are required to prove causality and develop the most effective mitigation efforts, the findings as illustrated herein emphasize the significance of considering family incivility as one of the core patient safety programs in the intensive care unit.

The authors would like to express their sincere gratitude to Dr. Shah Hussain, Principal/Associate Professor, Janbar, College of Nursing, Swat, for his invaluable supervision, guidance, and support throughout the course of this study.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Corresponding Author:
Fida Ur Rahman
Department of Nursing
Hassan College of Nursing, Swat
Email: [email protected]

Co-Authors:
Wajid Ali, Azmat Ali, Abdul Salam, Hina Ahmad, Imad Khan, Atiq Ahmad
Department of Nursing
Hassan College of Nursing, Swat

Shah Hussain
Department of Nursing
Janbar College of Nursing, Swat

Fida Ur Rahman, Wajid Ali, Azmat Ali, and Abdul Salam contributed to data collection and data analysis. Hina Ahmad and Atiq Khan were involved in data collection and literature review. Imad contributed to data collection and data organization, while Shah Hussain was responsible for interpretation.

Ethical Approval was obtained from the Saidu Teaching Hospital, Swat, Ref No SGTH/IRB/2026/22.

The authors declare that there is no conflict of interest regarding the publication of this paper.

Fida Ur Rahman is the guarantor of this study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.

https://doi.org/10.63096/medtigo3092321

Rahman  FU, Ali W, Ali A, et al. The Association Between Patient Family Members’ Incivility and Ongoing Patient Care Outcomes in Critical Care Settings at Tertiary Care Hospital, Swat. medtigo J Emerg Med. 2026;3(2):e3092321. doi:10.63096/medtigo3092321 Crossref