Workplace incivility and the professional quality of life in nurses

Abstract

Background

Workplace Incivility is a common issue in the nursing profession. Nurses who are affected by such behaviors may experience distress.

Objectives

This study aimed to assess the relationship between workplace incivility and nurses’ professional quality of life.

Research design

This cross-sectional correlational study was conducted in 2021 in “Tehran”. Data were collected using a demographic questionnaire, the Nursing Incivility Scale (NIS), and the Professional Quality Of Life scale (ProQOL). Data analysis was performed through the Pearson correlation and multiple linear regression, using the SPSS v.16.

Participants and research context

Participants were 200 nurses randomly recruited from selected hospitals of “TUMS”.

Ethical considerations

The study obtained research ethics approval and all participants were informed of the voluntary and anonymous nature of their participation.

Findings

The mean age of participants was 32.30 ± 7.22, and 76.5% were female. There was a significant correlation between the professional quality of life and workplace incivility (r = −0.23, p = .001). Multiple regression analysis between the subscales of workplace incivility and professional quality of life demonstrated that the incivility from the supervisor (β = −0.29, p = .001) and incivility from patients (β = −0.27, p < .001) can predict the compassion satisfaction dimension. The incivility from the supervisor (β = 0.24, p = .001) and incivility from patients (β = 0.26, p < .001) can explain burnout. The incivility of the patients can explain secondary traumatic stress (β = 0.14, p = .02).

Conclusion

This study showed that workplace incivility is significantly related to professional quality of life. Therefore, the reduction of behaviors of incivility can lead to the improvement of the professional quality of life.

Keywords

Nurses quality of life incivility workplace violence interprofessional relations

Introduction

Incivility behaviors are likely in all occupations and work environments, but hospitals are a prevalent workplace for these behaviors.¹ Incivility behaviors have become a widespread problem among health professionals.² Nurses are more exposed to incivility behaviors in hospitals. The studies have described that 27% to 85% of nurses experience incivility in the workplace.^3,4

The American Nurses Association defines incivility as “one or more rude, discourteous, or disrespectful actions that may or may not have a negative intent behind them.”⁵ Incivility behaviors are quite different from physical aggression and violence.⁶ In uncivil behaviors, the person may not intend to harm someone directly, and these behaviors are not necessarily overt.⁷ Incivility behaviors towards nurses can be from other nurses, supervisors, physicians, and patients.⁸ Nurses affected by such behaviors in their work environment may experience psychological and physiological distress.⁵ Incivility is rising and becoming a pervasive issue and a serious concern in the healthcare system.^9,10 These behaviors include sarcastic remarks, grinning, contemptuous tone of voice, hostile looks, interrupting others, shouting, spreading rumors, taking advantage of others’ attempts and achievements, and ignoring authority and identity in front of colleagues.^11,12

Professional quality of life is the perceived feeling of each person toward his or her work,¹³ which includes two dimensions compassion satisfaction and compassion fatigue.¹⁴ Compassion satisfaction and fatigue are individuals’ attitudes toward their job and are related to their feelings or willingness to do their job.¹⁵ Nurses with a high quality of professional life have a more cohesive organizational identity, higher job satisfaction, and performance¹⁶ and will provide better care.¹⁷ Professional quality of life can probably be affected by communication in the hospital.

Nurses are the core of the care team and one of the most human resources in healthcare organizations.¹⁸ Workplace communication problems can also lead to reduced quality of patient care, and poor health outcomes in patients.¹⁹ Incivility behaviors disrupt workplace communication because it creates alienation, degrades trust, and erodes productive conversation. Interprofessional relations are fundamental to healthcare well-being.²⁰ The results of past studies have been contradictory. More studies are needed for better clarification. In addition, socio-cultural factors can affect the results.²¹ It can be the beginning of interventions to reduce incivility by recognizing the predictors and predictands variables in hospitals. There are limited studies on the relationship between workplace incivility and nurses’ professional quality of life. Our hypothesis is that workplace incivility is related to the professional quality of life in nurses, and we assessed this hypothesis.

Methods

Design

This cross-sectional correlational study was conducted from May to November 2021 in “Tehran”. The research setting was 20 wards (including internal, surgical, and orthopedic) of “Imam Khomeini Hospital Complex” and “Shariati Hospital” under the “Tehran University of Medical Sciences”.

Participants

Participants included 200 nurses working in “Imam Khomeini Hospital Complex” and “Shariati Hospital” of “Tehran University of Medical Sciences”. The total number of nurses was about two thousand. We prepared a list of the names of all the nurses in the research setting in all shifts and then selected the participants based on a random number table. We distributed the questionnaires to the nurses and received the completed questionnaires (100% of response rate). The sample size was calculated based on the formula. $n = {(Z 1 - \frac{α}{2} + Z 1 - β)}^{2} / {(\frac{1}{2} \ln 1 + r / 1 - r)}^{2} + 3 \to n = {(1.96 + 0.842)}^{2} / {(\frac{1}{2} \ln 1 + 0.2 / 1 - 0.2)}^{2} + 3 = 194$ . (α = 0.05 and 1-β = 0.8) and assuming a correlation coefficient of at least (0.2).²² Inclusion criteria included having at least 2 years of work experience and not being a supervisor or a matron, and the exclusion criterion was incomplete completion of questionnaires and associate degrees. We tried to include at least 10 nurses from each ward in the study.

Data collection

Data were collected by self-report demographic questionnaire, incivility in workplace questionnaire, and professional quality of life scale in the hospital nursing office in the presence of the researcher. The tools were used after confirming the face validity by eight experts.

1. The Nursing Incivility Scale (NIS) includes 43 items and five subscales: general incivility (9 items), the incivility of the colleagues (10 items), head nurses/supervisors (7 items), doctors (7 items), and patients/patient companions (10 items). Items scored on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), resulting in a total score of 43 to 215, with higher scores indicating more incivility in the workplace.⁸ The validity and reliability of the Persian version of NIS have been evaluated. Cronbach’s alpha for subscales has been between 0.82 and 0.92.¹² We calculated content validity index (CVI) and content validity ratio (CVR) based on the Lawshe table. The CVI was between 0.8 and 1 and the CVR was between 0.7 and 1 for each item. Cronbach’s alpha was 0.94 in this study (general incivility: 0.82, the incivility of the colleagues: 0.92, head nurses/supervisors: 0.93, doctors: 0.90, and patients/patient companions: 0.93.

2. The Professional Quality Of Life scale (ProQOL). This questionnaire has 30 questions in three subscales: compassion satisfaction (10 items), burnout (10 items), and secondary traumatic stress (10 items). Items scored on a 5-point Likert scale from 1 (never) to 5 (often). Scores 22 and less indicate low; scores 23 to 41 indicate moderate, and scores 42 or higher indicate high compassion satisfaction, burnout, and secondary traumatic stress.¹⁴ It evaluated the validity and reliability of the Persian version of ProQOL. Its CVI was between 0.75 and 0.94 and CVR was between 0.78 and 0.90. Cronbach’s alpha was for the three subscales of satisfaction with compassion, burnout, and secondary traumatic stress, respectively, 0.85, 0.71, and 0.80.¹⁶ Cronbach’s alpha was 0.95 (compassion satisfaction: 0.82, burnout 0.94, and secondary traumatic stress: 0.93).

Data analysis

Data were analyzed using SPSS v.16. Descriptive statistics show mean and standard deviation. We used an independent t-test to compare the data between the two groups and Pearson correlation coefficient and multiple regression analysis by the “Enter” method to examine the relationship between incivility in the workplace and the quality of the professional life of nurses.

Ethical considerations

We confirm that all methods were carried out following relevant guidelines and regulations in our manuscript or Declaration of Helsinki. This study has been approved by the ethical committee of the “****” (Ref: ****). Written informed consent was obtained from all subjects. All participants were reassured that their information would be kept confidential.

Findings

The mean age of participants was 32.30 ± 7.22 (Other demographic variables in Table 1). Age was positively and significantly correlated only with compassion satisfaction (r = 0.15, p = .03) and incivility from other nurses (r = 0.16, p = .01) subscales. There was no significant difference between the scores of the subscales of incivility and quality of professional life in male and female nurses (p = not significant). The work experience of the participants was 8.15 ± 6.55 years and had no significant correlation with incivility (p = not significant).

Table 1.

Demographic characteristics of the participants.

		n	%
Sex	Male	47	23.5
Sex	Female	153	76.5
Marital status	Married	104	52
Marital status	Single	96	48
Education	Bachelor	163	81.5
Education	Master	37	18.5
Shift	Morning	40	20
	Evening	5	2.5
	Night	25	12.5
	Rotating	130	65

Table 2 illustrates that the burnout subscale was significantly different between the two genders. The professional quality of life and incivility of the supervisor was more experienced by nurses with higher education. The incivility from other nurses and incivility from supervisor subscales were less reported by married nurses. The Kolmogorov–Smirnov test showed that the data has a normal distribution p _NIS = 0.20 and p _ProQOL = 0.09.

Table 2.

Mean difference and standard deviation of subscales of incivility behavior and professional quality of life.

		Sex		p ^*	Education		p ^*	Marriage		p ^*
		Male	Female		Bachelor	Master		Single	Married
		Mean ± SD	Mean ± SD		Mean ± SD	Mean ± SD		Mean ± SD	Mean ± SD
Professional quality of life	Compassion satisfaction	37.44 ± 8.30	36.64 ± 8.17	.55	37.46 ± 7.92	34.03 ± 8.84	.02	35.73 ± 8.24	37.83 ± 8.05	.07
	Burnout	25.17 ± 7.59	27.69 ± 6.88	.03	26.34 ± 6.97	30.43 ± 6.85	.001	28.10 ± 7.10	26.17 ± 7.03	.06
	Secondary traumatic stress	27.87 ± 6.52	28.98 ± 6.72	.32	27.92 ± 6.45	32.27 ± 6.55	<.001	28.77 ± 6.85	28.68 ± 6.53	.92
	Total scores	90.48 ± 9.44	93.25 ± 10.47	.36	91.66 ± 10.15	96.72 ± 9.99	.62	92.61 ± 10.42	92.59 ± 10.21	.90
Incivility in workplace	General incivility	28.97 ± 7.48	28.14 ± 5.91	.42	28.04 ± 6.57	29.64 ± 4.83	.16	29.23 ± 6.04	27.50 ± 6.46	.06
	Incivility from other nurse	30.42 ± 9.81	28.81 ± 8.64	.27	28.82 ± 9.28	30.81 ± 7.07	.22	30.64 ± 9.14	27.84 ± 8.55	.02
	Incivility from supervisor	19.91 ± 7.85	18.64 ± 6.86	.28	18.07 ± 6.89	22.75 ± 6.87	<.001	20.08 ± 7.88	17.90 ± 6.17	.03
	Incivility from physicians	20.36 ± 6.83	21.37 ± 6.35	.34	20.87 ± 6.42	22.32 ± 6.62	.22	20.53 ± 6.45	21.70 ± 6.46	.20
	Incivility from patients	29.42 ± 8.97	30.23 ± 9.26	.59	30.10 ± 9.05	29.78 ± 9.82	.85	29.96 ± 9.48	30.11 ± 8.93	.91
	Total scores	129.11 ± 33.40	127.25 ± 26.59	.61	125.94 ± 28.81	135.32 ± 24.69	.54	130.54 ± 29.76	125.07 ± 26.70	.60

*DF = 198, SD: Standard Deviation.

Table 3 shows that there is a correlation between subscales of incivility and quality of professional life in nurses. There was a significant negative correlation between the professional quality of life and workplace incivility (r = −0.23, p = .001).

Table 3.

Correlation between subscales of incivility behavior and professional quality of life in nurses.

		Professional quality of life
		Mean ± SD	Compassion satisfaction	Burnout	Secondary traumatic stress
		Mean ± SD	37.03 ± 8.89	27.10 ± 7.11	28.72 ± 6.67
Incivility in workplace	General incivility	53.72 ± 17.52	−0.16*	0.25**	0.21**
	Incivility from other nurse	47.97 ± 22.33	−0.24**	0.26**	0.24**
	Incivility from supervisor	42.65 ± 25.38	−0.33**	0.35**	0.19**
	Incivility from physicians	50.50 ± 23.10	−0.21**	0.28**	0.29**
	Incivility from patients	50.11 ± 22.95	−0.36**	0.42**	0.31**

**p < .05, ***p < .01.

Table 4 shows that the dimensions of incivility from the supervisor (β = −0.29, p = .001) and incivility from patients (β = −0.27, p < .001) can explain the compassion satisfaction dimension. The dimensions of incivility from the supervisor (β = 0.24, p = .001) and incivility from patients (β = 0.26, p < .001) can explain burnout. The incivility from the patient’s dimension can explain secondary traumatic stress (β = 0.14, p = .02).

Table 4.

Multiple regression analysis between subscales of incivility behavior and professional quality of life in nurses.

		Professional quality of life
		Compassion satisfaction				Burnout				Secondary traumatic stress
		B	β	p	VIF	B	β	p	VIF	B	β	p	VIF
Incivility in workplace	General incivility	0.13	0.10	0.26	1.93	0.06	0.05	0.55	1.93	0.03	0.03	0.75	1.94
	Incivility from other nurse	−0.08	−0.09	0.34	2.15	−0.03	−0.03	0.73	1.98	0.04	0.06	0.57	1.97
	Incivility from supervisor	−0.29	−0.25	0.001	1.34	0.24	0.24	0.001	1.34	0.05	0.05	0.52	1.35
	Incivility from physicians	0.05	0.04	0.64	1.64	0.03	0.02	0.76	1.64	0.13	0.12	0.15	1.65
	Incivility from patients	−0.27	−0.30	<0.001	1.46	0.26	0.34	<0.001	1.46	0.14	0.20	0.02	1.47
Constant			48.20				13.32				18.68
F			9.24				11.92				5.56
R²			0.19				0.24				0.13
Adjusted R square			0.17				0.22				0.10
Residual			10,738.55				7703.28				7746.689

B: The Unstandardized Beta, β: The Standardized Beta, P: Probability Value, F: F-Test, R²: The Coefficient of Determination, VIF: Variance Inflation Factor.

Discussion

This study aimed to investigate the relationship between workplace incivility and professional quality of life in nurses. This study showed that workplace incivility is significantly related to the professional quality of life. Incivility behaviors from supervisors and patients were associated with compassion satisfaction and burnout. Incivility behaviors from patients were associated with secondary traumatic stress.

The findings showed that nurses experience moderate incivility in their work environment. A systematic review also reported the prevalence of incivility toward nurses to be about 55%.²³ The highest mean scores were related to general incivility, and the lowest were to other nurses and supervisors. In two different studies, results revealed that the highest incivility behavior score was from physicians, and the lowest scores were from other nurses and supervisors.^24,25 The dissimilarity in the highest perceived subscale score can be attributed to different work environments, intra-organizational relationships, and less cooperative spirit among “****” physicians and nurses. The married nurses experienced incivility from other nurses and supervisors. The flexibility and cooperation with married people are higher based on socio-cultural factors in Iranian hospitals, and it is also possible that single nurses are more sensitive than married people. Incivility from supervisors and patients could explain the professional quality of life. It can be due to the direct contact that nurses have with the supervisor and patients in their work environment, and these two factors can have a negative impact on the quality of their professional life.

The incivility from the supervisors and patients could explain the professional quality of life. This study showed that nurses experience incivility in their workplace. Previous studies also showed similar results that incivility had a positive and significant effect on nurses’ anxiety and burnout.^1,6,9 A systematic review study also found that there is a high level of uncivilized behavior between patients and nurses.²³ Factors that can lead to incivility behaviors include poor communication, negative organizational culture, and inflexible or rigid rules.²⁶ Incivility behaviors could lead to anxiety, depression, fatigue, illness, and reduced health and mental well-being of nurses,^27–29 and this could explain the effect of workplace incivility on quality of life.

This study indicated that the nurses have a moderate professional quality of life. The highest mean score was in the compassion satisfaction subscale. The lowest mean score was related to the burnout subscale. Other studies have also found that the professional quality of life of nurses is at a moderate level.^16,18 Yang and Kim’s study also confirmed that nurses experience a moderate professional quality of life.³⁰ Factors affecting the quality of professional life include long working hours, high workload, work sensitivity, inflexible regulations, and so on. Men experience less burnout than women. A study showed that women report job burnout more than men and demographic characteristics do not explain the cause.³¹ It has been stated that women are slightly more emotionally exhausted than men.³²

Workplace incivility had a significant negative correlation with compassion satisfaction, the strength of the relationship between them is weak according to correlation classifications (weak: < 0.4, moderate: 0.4 to 0.6, strong: > 0.6).³³ Workplace incivility had a positive and significant correlation with burnout and secondary traumatic stress. Alshehry et al. also found that workplace incivility was negatively correlated with compassion satisfaction and positively correlated with burnout and traumatic stress in nurses.¹ Shi et al. demonstrated that incivility was positively and significantly correlated with anxiety and burnout and negatively and significantly correlated with resilience.⁶

The findings of this study showed that workplace incivility could lead to a decline in the professional quality of life. Of course, the strength of the relationship indicates the influence of other factors that should be investigated in other studies (such as workload). Interprofessional relations lead to maintaining the proper functioning of the healthcare system.³⁴ The professional quality of life is a key component of the healthcare system that affect the promotion of care.³⁴ Improving the professional quality of life can reduce the physical and psychological distress of nurses and thus increase the quality of care, improve health outcomes in patients, and reduce medication errors, organizational conflicts, burnout, increased job stress, and declined organizational commitments.^19,35 Incivility from the supervisor and patients can explain compassion satisfaction and burnout. Incivility from the patients only can explain secondary traumatic stress. It seems that the behavior of supervisors and patients affects the professional quality of life more than others. According to these results, a study found that incivility from patients and supervisors had a negative association with the organizational culture.³⁶ Low organizational support leads to misbehavior against nurses in Iranian hospitals.

We tried to create maximum diversity by selecting participants from different wards. The strength of this study is that sampling was done from two large hospital centers that represent the main population. The low number of participants and limited sampling environments are some of the limitations that can decline the generalizability of the results.

Conclusion

Incivility behaviors may be experienced in all occupations and work environments however hospitals are considered a common source—of these behaviors. This study showed that nurses experience moderate incivility in their work environment. Nurses have a professional life of average quality. Workplace incivility significantly correlated with the professional quality of life. Only the incivility behaviors of the supervisor and patients could predict the professional quality of life. Therefore, it seems necessary to identify uncivil behaviors and to reduce them through various ways like continuous training courses, clarifying the roles of nurses, organizational support, and improving the professional image in society. It is recommended to evaluate the effect of each of these factors on uncivilization in future studies.

Applying Research to Occupational Health Practice

We investigated whether incivility behaviors are related to professional quality of life in nurses, and found that both variables were significantly correlated. Also, this study showed that the incivility of supervisors and patients has a significant relationship with all three dimensions of quality of professional life in nurses in the regression model. Nurses should make efforts to develop interventions to reduce incivility behavior and increase the professional quality of life by improving interactions with colleagues and patients in hospitals.

Footnotes

Acknowledgments

We thank all the nurses and administrators who assisted us in this study.

Author contributions

SN, NN, and FF were involved in the original conception and design of the study. Data acquisition and statistical analysis were conducted by SH and PFA drafted the initial manuscript which has been revised with input from all other listed authors. The final manuscript has been reviewed by all the authors and approved for submission/publication.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Pouya Farokhnezhad Afshar

Appendix

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