Journal of Nursing Management, 2013
Incivility from patients and their families: can organisational justice protect nurses from burnout? KRISTIE L. CAMPANA
PhD
1
and SAMMIRA HAMMOUD
MA
2
Assistant Professor, Minnesota State University, Mankato, MN, and 2Graduate Student, Minnesota State University, Mankato, MN, USA 1
Correspondence Kristie Campana 23 Armstrong Hall Mankato MN 56001 USA E-mail: [email protected]
(2013) Journal of Nursing Management Incivility from patients and their families: can organisational justice protect nurses from burnout?
CAMPANA K.L. & HAMMOUD S.
Aim To determine whether interpersonal and informational justice influence the association between daily experiences of incivility and burnout among nurses. Background Research has suggested that incivility is a concern for managers. Nurses regularly experience incivility, particularly from their patients and patients’ families. Incivility, in turn, can increase symptoms of burnout. Method Seventy-five nurses provided data on interpersonal and informational justice within their organisation. During five working days, nurses completed a twice-daily survey assessing incivility and burnout. Hierarchical linear modelling analyses examined the main effects and interaction effects of the three variables on burnout. Result Incivility was positively associated with burnout. In addition, interpersonal justice strengthened the incivility–burnout relationship. Informational justice did not significantly affect the incivility–burnout relationship. Conclusion Incivility is associated with more burnout. The work environment also influences burnout; when organisations provide informational justice, nurses experience less burnout. In organisations where interpersonal justice is high, nurses are more likely to experience burnout. Implications for nursing management Nursing managers can help employees by ensuring that management’s decisions are transparent. In addition, managers should be aware that in organisations with higher interpersonal justice, nurses might be more likely to experience symptoms of burnout as a result of incivility from patients and their families. Keywords: burnout, experience sampling method, incivility, justice Accepted for publication: 30 October 2013
Introduction Health care workers, as a whole, have a relatively high probability of experiencing violence or threats of violence at work; nurses who work directly with patients and their families are particularly at risk of physical and verbal aggression (National Institute of Occupational Safety & Health 2002). Aggression DOI: 10.1111/jonm.12201 ª 2013 John Wiley & Sons Ltd
towards nurses is a topic that has been well established in the nursing literature, particularly with respect to physical assaults (Whittington et al. 1996, Ferns 2006). Recently, research attention has turned towards more psychological forms of aggression, such as bullying (Johnson 2009), verbal abuse (Inoue et al. 2006) and incivility (Felblinger 2011). These types of aggression tend to be quite common, but are also 1
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subtler in nature. Nevertheless, psychological aggression can have important effects on outcomes such as shame (Pearson et al. 2001, Felblinger 2008), psychological wellbeing (Cortina et al. 2001), task performance (Porath & Erez 2007) and withdrawal from the workplace (Caza & Cortina 2007). One of the more prevalent types of psychological aggression nurses face is incivility. Winstanley and Whittington (2002) found that in a sample of 375 hospital staff, 26% of respondents reported frequently encountering incivility in the workplace. Research has also suggested that the general public believes that incivility in general is on the rise (Farkas et al. 2002). Incivility, which is a relatively new construct, developed concomitantly with a number of other similar constructs (e.g. emotional abuse, bullying, harassment). As a result, incivility shares a number of characteristics with other psychologically aggressive behaviours. Pearson et al. (2005) have defined incivility as ‘low-intensity deviant (rude, discourteous) behaviour with ambiguous intent to harm the target in violation of workplace norms for mutual respect’. Behaviours that are considered uncivil can range from failing to return a colleague’s telephone call to demeaning someone publicly. Incivility is a broad construct and can subsume other psychologically aggressive behaviours such as bullying, emotional abuse and horizontal aggression. Incivility has three key distinguishing features: it is ambiguous in its intent, it can come from any source and it can be an isolated incident. For example, if a patient’s mother rolls her eyes when a nurse is providing treatment instructions, this would be considered uncivil. It is unclear whether the mother intends to harm the nurse and this behaviour may be a one-time incident. Another example might be if a patient criticises a nurse while she is drawing blood. Even though the aggressor has a different relationship to the nurse than the previous example, it would still be considered uncivil. If the patient criticises the nurse each time he sees her, the behaviour would be uncivil and may also fit the definition for bullying (Hershcovis 2011). This example also illustrates that a behaviour could fit the definition for several different types of psychological aggression, and that incivility typically is a broader construct compared with other forms of psychological aggression. Incivility is also a compelling variable because it is so pervasive. For example, Early (2004) found that 38% of nurses had experienced psychological aggression from patients and 30% experienced psychological aggression from visitors. Similarly, McKenna et al (2003) 2
found that one-third of nurses reported experiencing psychological aggression from patients. This poses a difficult problem for nursing management. Patients can be restrained if demonstrating overt, physically aggressive behaviours but it is more difficult to identify and prevent incivility because it is subtle. Yet, the research shows that incivility can have serious and negative consequences, including psychological distress (Martin & Hine 2005), decreased satisfaction with life (Lim & Cortina 2005), decreased task performance (Porath & Erez 2007), and decreased job satisfaction (Cortina et al. 2001). Empirical findings suggest that incivility from these sources can be particularly detrimental to nurses, leading to withdrawal from the workplace, emotional exhaustion and depersonalization (Winstanley & Whittington 2002, Guidroz et al. 2010). This finding is of great concern, particularly because nursing is a stressful profession in general; research has indicated that nurses are already at risk of many negative psychological and physical health problems (Gibbons et al. 2011). Hence, examining and addressing incivility directed towards nurses could help ameliorate the effects of stress on nurses. One particular psychological outcome that has garnered attention in the nursing literature is burnout (Kent & Lavery 2007). Burnout is a ‘psychological syndrome of exhaustion, cynicism, and inefficacy which is experienced in response to chronic job stressors’ (Maslach 2003). Burnout is typically characterised by individuals feeling emotionally exhausted, low in efficacy and disconnected from other individuals. Employees who experience burnout also tend to experience a negative impact of this on mental and physical health (Ahola et al. 2008). Employees who experience burnout are also more likely to withdraw from or leave the workplace (Laschinger et al. 2012). This last consequence is particularly problematic for the nursing profession, as there is a current shortage of nurses that is expected to become more serious over time (Lin et al. 2008, Juraschek et al. 2012). Because nurses experience burnout from some sources that managers cannot control, such as patients, it seems reasonable to examine what characteristics of the work context may aggravate or buffer the effects of incivility on nurse burnout. Greenberg (2004) suggested that one organisational characteristic that may influence the effects of stressors in the workplace is interactional justice – that is, whether an individual feels that she/he has been treated with dignity, and has been given information about how rewards and consequences are distributed. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
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According to Greenberg’s (2004) Theory of Justice Salience Hierarchy, when an individual experiences an unfair event in the workplace, the individual considers whether she/he has received a fair outcome (distributive justice), and whether she/he was treated with respect in response to this event (interactional justice). Greenberg argues that because managers and supervisors can influence how employees are treated, they may play an important role in how workers judge the fairness of the work environment. Indeed, Greenberg (2006) found support for this argument: nurses who were experiencing pay cuts tended to be less affected by insomnia when their supervisors were trained to demonstrate higher levels of interactional justice throughout the duration of the pay cut. Greenberg argued that interactional justice in an organisation serves as a buffer in the stressor–strain relationship; that is, even when employees are upset by unfair events in the workplace, if they feel they receive respectful treatment from their organisation, they are less likely to experience strains in response to the unfair event. As an illustrative example, a nurse may feel that a patient has treated her disrespectfully; if she feels that her workplace is an environment where she is often treated in an undignified way, that instance of incivility might contribute to feelings of burnout. However, if she is treated rudely, but generally feels that her organisation treats her well, this may protect her against feelings of stress. This in turn may help her avoid experiencing burnout. Helping nurses to avoid burnout can also lead to improved patient care (Van Bogaert 2009). In the present study, we opted not to examine distributive justice because managers generally do not have influence over this – distribution of outcomes is not always equal, and research suggests that most people accept that reality (Greenberg 1993). Thus, we focused on interactional justice. To examine the influence of interactional justice in some detail we therefore chose to further divide interactional justice into its two subcomponents: interpersonal and informational justice. If an individual believes she/he has received timely and adequate information about how a decision is made, that individual will experience informational justice. If an individual feels she/he is treated with dignity and respect when a decision is made, that individual will experience interpersonal justice. Although interpersonal and informational justice are frequently correlated, they are considered separate dimensions of justice and each predicts unique variance in organisational constructs such as job satisfaction (Loi et al. 2009). This approach also allows us ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
to gain a more nuanced understanding of how justice relates to burnout. Given these theoretical arguments, we propose the following hypotheses: H1: On days nurses experience more incivility from patients and their families, they will also experience higher levels of burnout. H2: Nurses who feel they experience higher levels of interpersonal justice in their workplace will experience lower levels of burnout when incivility is not present. H3: Nurses who feel they experience higher levels of informational justice in their workplace will experience lower levels of burnout when incivility is not present. H4: The relationship between incivility and burnout will be affected by perceptions of interpersonal justice, such that nurses who report higher perceptions of justice will experience a weaker association between incivility and burnout. H5: The relationship between incivility and burnout will be affected by perceptions of informational justice, such that nurses who report higher perceptions of informational justice will experience a weaker association between incivility and burnout.
Method Design This study utilised experience sampling methodology (ESM), also known as a diary study, to evaluate daily experiences of incivility and burnout. This methodology allows participants to reflect on events throughout the day, rather than asking them to retrospectively consider events in the distant past. We chose this approach because it has been found to produce more valid and reliable reports (Richardson 1994). In order to maintain the validity of pre-established measures, some prompts were revised to reflect the daily (rather than long-term) nature of the scales; this is common practice in ESM studies where daily measures of variables are not available, and can help illustrate how daily experiences are associated with chronic conditions such as burnout (Bolger et al. 2003, Cranford et al. 2006).
Participants The Minnesota State University Institutional Review Board granted approval for the research in November 2009. Data collection took place from December 2009 until March 2011. A sample of 75 nurses participated in this study in return for monetary compensation. 3
K. L. Campana and S. Hammoud
These nurses were recruited from two different resources. One group of participants was recruited from a hospital on the campus of a large, Midwestern university. With permission from the university, flyers were posted at the university hospital, with instructions on how interested nurses could contact the researchers. We are unable to provide a response rate for this sample, as we do not know how many nurses viewed our flyers. Nurse e-mail addresses were also obtained from the Nursing Licensing Board of Minnesota. The response rate for this recruitment method was 6%. Because participants were recruited from this source, they held a wide variety of positions, including registered nurse, licensed practical nurse, nurse practitioner and advanced practice registered nurse. Participants were required to have patient contact during their shifts, so nursing managers were not included in this sample. We sent emails to nurses in the metro area with at least a bachelor’s degree, inviting them to participate in the study. The final sample was 93% female, with an average age of 39 years (SD 12.32). Participants had an average tenure of 8.82 years (SD 7.71).
Measures Incivility We assessed incivility using an adapted version of Cortina et al.’s (2001) six-item measure. The original measure asked respondents about uncivil behaviours over the past year. Because we were interested only in events for each day, we altered the measure to read ‘Today, how often did your patients or members of your patients’ families….’. We also altered the ratings scale to specify how much each behaviour occurred for that day. The rating scale ranged from 1 (This did not happen to me today) to 5 (This happened to me almost constantly today). An example item is, ‘Put you down or behave condescendingly towards you’ Higher scores indicated that the nurse experienced more incivility from patients and their families that day. We calculated scores by averaging across items; hence, scores on this measure could range from 1 to 5. The original measure created by Cortina et al. (2001) had a Cronbach’s alpha coefficient of 0.89. The altered version of the scale demonstrated adequate reliability in the final sample (Cronbach’s a = 0.79). Burnout In order to assess feelings of burnout among participants, we asked them to fill out a shortened inventory (Wharton 1993) based on the Maslach Burnout Inventory (Maslach et al. 1997). This shortened version of the survey contained six items; these items were rated 4
from 1 (strongly disagree) to 5 (strongly agree). We also altered the language slightly to emphasise that the respondents should focus only on his or her feelings that day. An example item is ‘Today, I feel emotionally drained’. Higher scores indicate more symptoms of burnout. Because burnout is a chronic condition, an individual who reported a high number of daily burnout symptoms across the 2-week testing period is more likely to meet the definition of chronic burnout (Bolger et al. 2003). The total score for this scale was created by averaging across items, so the range of possible scores was from 1 to 5. The original version of the measure created by Wharton (1993) demonstrated a Cronbach’s alpha of 0.87. This altered measure demonstrated good reliability in the final sample (Cronbach’s a = 0.91), suggesting that this measure maintained its validity as a daily measure. Justice Interpersonal and informational justice were measured using subscales adapted from Colquitt (2001). Items were adapted to clarify who the decision-makers were in the organisational context (i.e. administration/managers). Both measures used a 1 (strongly disagree) to 5 (strongly agree) scale. Interpersonal justice was measured using two items. A sample item is ‘People at my workplace treat me with dignity’. The original version of this measure had good reliability (Cronbach’s a = 0.92); our adapted version continued to demonstrate good reliability in the final sample (Cronbach’s a = 0.83), suggesting that the alterations did not disrupt reliability. Informational justice was measured using three items. A sample item is ‘Decision-makers (e.g. administration/ managers) communicate the details of a decision in a timely manner’. The original version of this scale demonstrated good reliability (Cronbach’s a = 0.90); our adapted version continued to show adequate reliability in the final sample (Cronbach’s a = 0.79). Scores for both justice scales were calculated by averaging across items, so possible scores could range from 1 to 5.
Procedure Participants were asked to complete a background survey that consisted of demographic questions and the organisational justice measure. After completing the background survey, participants were asked to complete additional surveys over the course of a working week. These surveys, which were administered online, contained the incivility and burnout measures. Participants were asked to complete these surveys twice during each workday, for five workdays (for a total of 10 ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Incivility, burnout and justice
daily surveys). Participants were instructed to take the first survey during a break at some point in their working day and the second survey after their working day was completed. These daily surveys took approximately 3 minutes to complete and required participants to complete every item before submitting. This was because the scales were brief and allowing participants to omit items or measures would limit the usefulness of the information gathered from them. We sent daily reminders to participants, and checked to see if they wanted to leave the study if they missed a day. No participants in the final sample opted to leave the study. Nurses completed, on average, 7.83 of the 10 daily surveys.
experienced a greater amount of incivility also reported higher levels of burnout, and lower levels of informational justice (Table 1). These between-subject analyses also suggested that individuals who, on average, experienced burnout also reported experiencing less informational justice (although there does not appear to be a significant relationship with interpersonal justice). Next, to test specific hypotheses, we conducted an HLM analysis in two steps, examining the main effects of incivility, interpersonal justice and informational justice first. We then conducted an additional analysis examining the interactional effects. Results of these HLM analyses are presented in Table 2.
Data analysis
Effect of justice on burnout
In order to test the hypotheses, we conducted hierarchical linear modelling (HLM) analyses (Raudenbush & Bryk 1992) using HLM version 7.01 (Bryk et al. 2008). This type of modelling has several benefits in this particular analysis. First, HLM can account for missing data, and gives participants who complete only a few daily surveys less weight in equations, while participants who completed all surveys are more heavily weighted in equations. Hence, provided that participants completed the background survey and at least two daily surveys, they were included in the analyses. In addition, HLM can be useful with research designs where respondents fill out surveys repeatedly; this is because surveys completed by the same individual will correlate more highly with one another than with surveys completed by a different individual. This analysis allows for simultaneous modelling of two-level models, with within-person variables (i.e. daily incivility and daily evaluations of burnout) at the first level, and betweenperson variables (i.e. interpersonal and informational justice) at the second level. This type of modelling allows us to examine within-individual dependencies, while also allowing us to examine cross-level interactions (specifically, the fourth and fifth hypotheses in this study). Hence, the equations for our models are: Level 1: Burnoutij = b0j + b1j*(Incivilityij) + eij Level 2: b0j = c00 + c01*(Interpersonal Justicej) + c02* (Informational Justicej) + u0j, b1j = c10 + c11* (Interpersonal Justicej) + c12*(Informational Justicej)
A pseudo-R2 of the main effects model indicated that our model explained approximately 12% of the variance. The HLM analysis indicated the coefficient for this effect (c00) was 2.39, suggesting that on days where a participant experienced more incidents of incivility, they were also likely to report a significantly higher level of burnout. Hence, we found support for the first hypothesis. According to the results presented in Table 2, there was only a small and negative effect of interpersonal justice on burnout (c01 = –0.09). In other words, the experience of burnout among nurses in workplaces with high interpersonal justice was not notably different from those in workplaces with low interpersonal justice. Hence, hypothesis 2 was not supported. Our third hypothesis indicated that nurses who report higher levels of informational justice in the workplace would experience lower levels of burnout. As noted in Table 2, the results of the HLM model indicate that nurses who perceive high levels of informational justice in their organisation report notably lower levels of burnout (c02 = –0.23). This finding supports the third hypothesis.
Results Intercorrelations among variables An initial, between-subjects analysis indicated several findings. First, individuals who, on average, ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Table 1 Descriptive statistics and Pearson correlations among study variables (n = 77) Variable
Mean
SD
1
2
3
Incivility Burnout Interpersonal justice Informational justice
1.12 2.40 4.03 3.03
0.26 0.81 0.41 0.83
– 0.41*** 0.07 –0.24*
– –0.03 –0.34**
0.27*
Incivility and burnout were daily measures; hence, the descriptive statistics and correlations for those variables were calculated by averaging each individual’s score across all daily measures. * P < 0.05, **P < 0.01, ***P < 0.001.
5
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Table 2 Predicting factors of burnout using hierarchical linear modelling (n = 77) Variables
Coefficient
Main effects Incivility (c00) Interpersonal justice (c01) Informational justice (c02) Interactions Incivility (c10) Interpersonal justice (c11) Informational justice (c12)
SE
t-ratio
2.39 –0.09 –0.23
0.07 0.16 0.08
35.48*** –0.055 –2.94**
0.60 0.80 –0.28
0.14 0.33 0.22
4.40*** 2.44* –1.30
Incivility, interpersonal justice, and interactional justice have been centred around the grand mean. *P < 0.05, **P < 0.01, ***P < 0.001.
Effect of justice on the incivility–burnout relationship Adding interactional effects to our model significantly improved its fit (v2(2) = 11.80, P < 0.01) and the pseudo-R2 suggests that this model explains an additional 2% of variance. With respect to the fourth hypothesis, we found a significant trend in the opposite direction of what we hypothesised: individuals who perceived their workplace as interpersonally just appeared to experience a significantly stronger association between incivility and burnout (c11). This trend is presented in Figure 1. This suggests that interpersonal justice may actually exacerbate the effects of incivility 2.56
on an individual. With respect to the fifth hypothesis, Figure 2 demonstrates the data trends in the expected direction. However, this buffering effect was too small to be statistically significant in this sample. Thus, we did not find support for the last hypothesis.
Enduring effects of incivility Finally, to explore whether incivility from early in the day affects burnout later in the day, we conducted lagged HLM analyses. In other words, we used ratings of incivility completed in the first survey completed that day to predict burnout ratings from the second survey completed that same day. Because not all participants filled out both surveys each day, the sample size was reduced to 71 participants (who completed both surveys for an average of 3.26 days each). As demonstrated in Table 3, our findings were similar to the previous analyses: incivility and informational justice appear to have main effects on burnout in the expected direction, and interpersonal justice strengthens the incivility–burnout relationship. These findings suggest that the effects of incivility are not transient and that they persist throughout the working day.
Discussion This study investigated how daily instances of incivility affected burnout, as well as whether perceptions of 2.90
Low Interpersonal High Interpersonal
High Informational
2.70
BURNOUT
BURNOUT
2.48
2.40
2.32
2.24 –0.12
2.50
2.29
–0.03
0.05
0.13
0.22
INCIVILITY
Figure 1 Moderating effect of interpersonal justice on the relationship between incivility and burnout. For illustrative purposes, we dichotomised the interpersonal justice variable into a low interpersonal justice group (those with a score one standard deviation below the mean or lower) and a high interpersonal justice group (those with a score one standard deviation above the mean or higher).
6
Low Informational
2.09 –0.12
–0.03
0.05
0.13
0.22
INCIVILITY
Figure 2 Moderating effect of informational justice. For illustrative purposes, we dichotomised the informational justice variable into a low informational justice group (those with a score one standard deviation below the mean or lower) and a high informational justice group (those with a score one standard deviation above the mean or higher). ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
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Table 3 Lagged analysis of predicting factors of burnout using hierarchical linear modelling (n = 71) Variables Main effects Incivility (c00) Interpersonal justice (c01) Informational justice (c02) Interactions Incivility (c10) Interpersonal justice (c11) Informational justice (c12)
Coefficient
SE
t-ratio
2.40 0.18 –0.34
0.08 0.18 0.09
29.92*** 0.95 –3.64***
0.26 1.17 –0.30
0.25 0.53 0.23
0.29 2.21* –1.35
Incivility, interpersonal justice, and interactional justice have been centred around the grand mean. *P < 0.05, ***P < 0.001.
justice affected this relationship. The first hypothesis, that on days the nurse encountered more incivility she/he would also report higher levels of burnout, was supported. For each 1-point increase on the incivility scale, scores increased 0.60 of a point on the burnout measure. This finding corroborates other incivility research, which indicates that rude behaviour often leads to psychological distress among recipients (Caza & Cortina 2007, Leiter et al. 2012). However, this is one of the first investigations in a nursing population of how daily instances of incivility can also affect daily experiences of burnout symptoms. Hence, the data here provide evidence that nurses do, on average, experience at least some incivility on a daily basis, and that these experiences can have important effects on how that nurse feels during that same day. Our second hypothesis, that interpersonal justice would have a main effect on the experience of burnout, was not supported. Although the data suggested that nurses who perceived their organisation as interpersonally just tended to report lower levels of burnout on average, this relationship was not strong enough to be statistically significant. It is possible that other aspects of the nurse’s environment, such as his/ her coworkers, patients, or immediate supervisor, may provide positive interpersonal experiences that would compensate for a lack of interpersonal justice that comes from administrators or decision-makers within a health care organisation. Recent research has indicated that supervisor support acts as a buffer in other work contexts (Sakurai & Jex 2012); future research might explore what other sources of social support are used by nurses to counteract daily frustrations. Our third hypothesis, that there would be a main effect of informational justice on burnout, was supported. Specifically, individuals who perceived their workplace as providing information about how decisions are made tended to experience less burnout on ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
average. In conjunction with the second hypothesis, this finding suggests that whereas nurses may not depend upon administration to help them feel that they are treated with dignity, they do depend upon administration to help them understand why decisions are made and why policies are in place. When administrations fail to do this, the findings here suggest it can contribute to burnout among nurses. This finding builds on some initial findings from Moliner et al. (2005), who did not find any link between interactional justice and burnout; this may indicate that separating interactional into interpersonal and informational is a helpful step in identifying statistically significant relationships. We also had several interactions in this study. Our fourth hypothesis suggested that interpersonal justice would buffer the incivility–burnout relationship, such that more interpersonal justice would be associated with a weaker relationship between incivility and burnout. However, we found a significant trend in the opposite direction. This suggests that when nurses encounter incivility in the workplace, it is those who work for interpersonally just organisations that are the most negatively affected by incivility. There are a number of reasons why this may be the case. For example, if an organisation’s culture emphasises the importance of respectful interactions among members, it may be much more upsetting (and therefore stressful) when a member encounters rude behaviour. In this scenario, a culture of interpersonal justice instead serves as an enhancer of the incivility–burnout relationship. Alternatively, as noted in the definition presented at the beginning of this article, a primary feature of incivility is that it goes against the norms of respect for the organisation. Thus, it may be that nurses who have become accustomed to disrespectful behaviour at work become desensitised to acts of incivility; they may have more intense feelings of burnout overall, but additional acts of incivility do little to change their level of burnout. Future research should further elucidate this finding. In addition, we hypothesised that perceived informational justice in the organisation would be associated with a weaker incivility–burnout association. Although the results demonstrated a trend in the expected direction, it was not strong enough to be statistically significant. Therefore, although informational justice may have an important direct effect on burnout, it does not appear to protect nurses from patients and their families. Finally, lagged analyses suggested that incivility experienced during the beginning of a participant’s 7
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workday had important implications for how that participant felt later that day; instances of incivility significantly predicted burnout at a later time during that day. This suggests that effects of incivility can occur quickly, and can persist throughout the day. Future research should investigate what types of variables or events might prevent uncivil events from spilling over into attitudes or emotions later in the day. For example, organisations can provide restorative experiences that can help repair damaged moods and ensure that nurses leave work feeling fulfilled rather than frustrated, even when negative events occur throughout the working day.
Limitations This study has several limitations. First, because all data was provided in self-reports, the results may demonstrate inflated correlations owing to common source variance. Second, the sample was exclusively from the Midwestern region of the USA, and hence our participants worked in organisations with a strong union presence at the time the data were collected; the presence of unions in the workplace may have had important implications for respondents’ perceptions of justice, and may have also helped to insulate them from burnout (Burke & Greenglass 2001). Finally, this study asked participants to complete two daily surveys over five working days. The requirements of this study could have led to a less diverse sample. Nurses who were less busy and less stressed were more likely to respond to our recruitment emails and flyers, and were more likely to complete all surveys. Thus, these data may not accurately represent the experiences of nurses in particularly stressful jobs. Also, the nurses who did complete the survey may not have completed surveys during particularly stressful days. Several participants e-mailed after their work shift notifying us that they were extremely busy and were unable to complete one of their surveys during their work shift. Although one strength of using HLM analyses is that missed measurement values can be estimated using other data points, it is possible that these missed surveys could have provided valuable and unique information about how busy and frustrating days in particular affect nurse burnout.
Conclusion This study has demonstrated that daily experiences of incivility are associated with daily symptoms of burnout. This relationship appears to be stronger among 8
nurses who experience high levels of interpersonal justice in the workplace. Nurses who feel that management keeps them informed about the reasons behind decisions, tend to experience less burnout. These findings suggest that management can help ameliorate the effects of incivility by being transparent in decisionmaking and by helping to prepare nurses in interpersonally just environments to anticipate rudeness from patients and their families.
Implications for nursing management and future research directions The findings of this study have several implications for the practice of nursing management, as well as future investigations into the topic. First, our findings emphasise the importance of incivility on nurses’ experience of burnout – on days where nurses are treated rudely by patients or patients’ families, they are more likely to experience burnout. These feelings can persist throughout the day, so continual exposure to rude patients may lead to chronic feelings of burnout. Second, this research indicates that managers can influence this process. Specifically, when nurses feel that they are informed about why decisions are made they tend to experience lower levels of burnout. Third, this research also indicates that in environments where nurses feel they are treated with dignity, they will be more disturbed by rude patient behaviour. Thus, it might be particularly important in these environments for managers to help nurses anticipate mistreatment from patients and cope with it more effectively. Our findings also suggest some avenues for future research. For example, understanding the predictors and consequences of burnout among nurses is a major concern in the field, particularly when considering the link between burnout and low rates of retention (Laschinger et al. 2009). Considering the current shortage of nurses that is likely to grow more serious in the future, recruiting new nurses and retaining incumbent nurses will become vital for health care organisations (Juraschek et al. 2012). Given that organisational justice appears to influence burnout among nurses, other organisational characteristics should be examined, particularly those that nursing managers can influence. It may also be important to investigate how new graduates are affected by incivility and by organisational policies. Research has suggested that many new nurses are unprepared for the realities of nursing work, and at times may find their environment unwelcoming (Duchscher 2001, Laschinger et al. 2009). Nursing management can play an important role in ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
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socialising and creating a supportive environment for these nurses. Being transparent about policies is one way to do this, as demonstrated in this research. However, other types of justice may also temper other negative outcomes for nurses such as turnover or low motivation. This research only explored the effect of patient and family incivility. Previous research has indicated that many nurses expect this sort of treatment, because they know patients are under a great deal of stress (Guidroz et al. 2010). More research is needed to examine how the source of incivility might affect nurse burnout. For example, nurses may find incivility from physicians or other nurses to be more upsetting than from patients; however, at this time, research has not carefully explored the effect of the source of incivility on burnout or other consequences.
Acknowledgement This research was funded by a Faculty Research Grant from Minnesota State University, Mankato.
Source of funding This research was funded by a Faculty Research Grant from Minnesota State University, Mankato.
Ethical approval Ethical approval was obtained from the IRB at Minnesota State University, Mankato, in November of 2009.
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Cortina L.M., Magley V.J., Williams J.H. & Langhout R.D. (2001) Incivility in the workplace: incidence and impact. Journal of Occupational Health Psychology 6 (1), 64–80. Cranford J.A., Shrout P.E., Iida M., Rafaeli E., Yip T. & Bolger N. (2006) A procedure for evaluating sensitivity to withinperson change: can mood measures in diary studies detect change reliably? Personality and Social Psychology Bulletin 32 (7), 917–929. Duchscher J.B. (2001) Out in the real world: newly graduated nurses in acute care speak out. Journal of Nursing Administration 31, 426–439. Early M.R. (2004) Recognizing and managing violence in the NICU. Neonatal Network 23, 31–34. Farkas S., Johnson J., Duffett A. & Collins K. (2002) Aggravating Circumstances: A Status Report on Rudeness in America. Public Agenda, New York, NY. Felblinger D.M. (2008) Incivility and bullying in the workplace and nurses’ shame responses. Journal of Obstetric, Gynecologic, and Neonatal Nursing 37 (2), 234–242. Felblinger D.M. (2011) Incivility and bullying in the nursing workplace. In Handbook of Stress in the Occupations (D.M. Felblinger ed), pp. 5–15. Edward Elgar Publishing, Northampton, MA. Ferns T. (2006) Violence, aggression, and physical assault in healthcare settings. Nursing Standard 21, 42–46. Gibbons C., Dempster M. & Moutray M. (2011) Stress, coping and satisfaction in nursing students. Journal of Advanced Nursing 67 (3), 621–632. Greenberg J. (1993) Stealing in the name of justice: informational and interpersonal moderators of theft reactions to underpayment inequity. Organizational Behavior and Human Decision Processes 54 (1), 81–103. Greenberg J. (2004) Stress fairness to fare no stress: managing workplace stress by promoting organizational justice. Organizational Dynamics 33 (4), 352–365. Greenberg J. (2006) Losing sleep over organizational injustice: attenuating insomniac reaction to underpayment inequity with supervisory training in interactional justice. Journal of Applied Psychology 91 (1), 58–69. Guidroz A.M., Burnfield-Geimer J.L., Clark O., Schwetschenau H.M. & Jex S.M. (2010) The nursing incivility scale: development and validation of an occupation-specific measure. Journal of Nursing Measurement 18 (3), 176–200. Hershcovis M. (2011) ‘Incivility, social undermining, bullying… Oh my!’: a call to reconcile constructs within workplace aggression research. Journal of Organizational Behavior 32 (3), 499–519. Inoue M., Tsukano K., Muraoka M., Kaneko F. & Okamura H. (2006) Psychological impact of verbal abuse and violence by patients on nurses working in psychiatric departments. Psychiatry and Clinical Neurosciences 60 (1), 29–36. Johnson S.L. (2009) International perspectives on workplace bullying among nurses: a review. International Nursing Review 56, 34–40. Juraschek S.P., Zhang X., Ranganathan V. & Lin V.W. (2012) United States registered nurse workforce report card and shortage forecast. American Journal of Medical Quality 27, 241–249. Kent P. & Lavery J.F. (2007) Burnout in nursing. Australian Journal of Advanced Nursing 24, 43–48.
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Laschinger H.K.S., Finegan J. & Wilk P. (2009) New graduate burnout: the impact of professional practice environment, workplace civility, and empowerment. Nursing Economics 27, 377–383. Laschinger H.K.S., Wong C.A. & Grau A. (2012) The influence of authentic leadership on newly graduated nurses’ experiences of workplace bullying, burnout, and retention outcomes: a cross-sectional study. International Journal of Nursing Studies 49 (10), 1266. Leiter M.P., Day A., Oore D.G. & Laschinger H.K.S. (2012) Getting better and staying better: assessing civility, incivility, distress, and job attitudes one year after a civility intervention. Journal of Occupational Health Psychology 17 (4), 425–434. Lim S. & Cortina L.M. (2005) Interpersonal mistreatment in the workplace: the interface and impact of general incivility and sexual harassment. Journal of Applied Psychology 90 (3), 483–496. Lin V.W.-H., Juraschek S.P., Jones L. & Turek J. (2008) California regional registered nurse workforce forecast. Nursing Economic$ 26, 85–105. Loi R., Yang J. & Diefendorff J.M. (2009) Four-factor justice and daily job satisfaction: a multilevel investigation. Journal of Applied Psychology 94 (3), 770–781. Martin R.J. & Hine D.W. (2005) Development and validation of the uncivil workplace behavior questionnaire. Journal of Occupational Health Psychology 10 (4), 477–490. Maslach C. (2003) Job burnout: new directions in research and intervention. Current Directions in Psychological Science 12, 189–192. Maslach C., Jackson S.E. & Leiter M.P. (1997) Maslach Burnout Inventory: Third Edition, pp. 191–218. Scarecrow Education, Lanham, MD. McKenna K., Poole S.J., Smith N.A. & Coverdale C.G. (2003) A survey of threats and violent behaviour by patients against registered nurses in their first year of practice. International Journal of Mental Health Nursing 12 (1), 56–63. Moliner C., Martinez-Tur V., Peir o J.M. & Ramos J. (2005) Linking organizational justice to burnout: are men and women different? Psychological Reports 96 (3), 805–816.
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National Institute of Occupational Safety and Health (2002) Violence Occupational Hazards in Hospitals. NIOSH Publication 2002-101. Available at: http://www.cdc.gov/niosh/docs/ 2002–101/, accessed 21 October 2013. Pearson C.M., Anderson L. & Wegner J.W. (2001) When workers flout convention: a study of workplace incivility. Organization Science 7, 615–631. Pearson C.M., Andersson L.M. & Porath C.L. (2005) Workplace incivility. In Counterproductive Workplace Behavior: Investigations of Actors and Targets (S. Fox & P.E. Spector eds), pp. 177–200. American Psychological Association, Washington, DC. Porath C.L. & Erez A. (2007) Does rudeness really matter? The effects of rudeness on task performance and helpfulness. Academy of Management Journal 50, 1181–1197. Raudenbush S.W. & Bryk A.S. (1992) Hierarchical Linear Models: Applications and Data Analysis Methods. Sage Publications Inc., Thousand Oaks, CA. Richardson A. (1994) The health diary: an examination of its use as a data collection method. Journal of Advanced Nursing 19, 782–791. Sakurai K. & Jex S.M. (2012) Coworker incivility and incivility targets’ work effort and counterproductive work behaviors: the moderating role of supervisor support. Journal of Occupational Health Psychology 17 (2), 150–161. Van Bogaert P. (2009) Hospital nurse practice environment, burnout, job outcomes and quality of care: test of a structural equation model. Journal of Advanced Nursing 65, 2175– 2185. Wharton A. (1993) The affective consequences of service work: managing emotions on the job. Work Occupations 20 (2), 205–232. Whittington R., Shuttleworth S. & Hill L. (1996) Violence to staff in a general hospital setting. Journal of Advanced Nursing 24, 326–333. Winstanley S. & Whittington R. (2002) Anxiety, burnout and coping styles in general hospital staff exposed to workplace aggression: a cyclical model of burnout and vulnerability to aggression. Work & Stress 16 (4), 302–315.
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Incivility from patients and their families: can organisational justice protect nurses from burnout? KRISTIE L. CAMPANA
PhD
1
and SAMMIRA HAMMOUD
MA
2
Assistant Professor, Minnesota State University, Mankato, MN, and 2Graduate Student, Minnesota State University, Mankato, MN, USA 1
Correspondence Kristie Campana 23 Armstrong Hall Mankato MN 56001 USA E-mail: [email protected]
(2013) Journal of Nursing Management Incivility from patients and their families: can organisational justice protect nurses from burnout?
CAMPANA K.L. & HAMMOUD S.
Aim To determine whether interpersonal and informational justice influence the association between daily experiences of incivility and burnout among nurses. Background Research has suggested that incivility is a concern for managers. Nurses regularly experience incivility, particularly from their patients and patients’ families. Incivility, in turn, can increase symptoms of burnout. Method Seventy-five nurses provided data on interpersonal and informational justice within their organisation. During five working days, nurses completed a twice-daily survey assessing incivility and burnout. Hierarchical linear modelling analyses examined the main effects and interaction effects of the three variables on burnout. Result Incivility was positively associated with burnout. In addition, interpersonal justice strengthened the incivility–burnout relationship. Informational justice did not significantly affect the incivility–burnout relationship. Conclusion Incivility is associated with more burnout. The work environment also influences burnout; when organisations provide informational justice, nurses experience less burnout. In organisations where interpersonal justice is high, nurses are more likely to experience burnout. Implications for nursing management Nursing managers can help employees by ensuring that management’s decisions are transparent. In addition, managers should be aware that in organisations with higher interpersonal justice, nurses might be more likely to experience symptoms of burnout as a result of incivility from patients and their families. Keywords: burnout, experience sampling method, incivility, justice Accepted for publication: 30 October 2013
Introduction Health care workers, as a whole, have a relatively high probability of experiencing violence or threats of violence at work; nurses who work directly with patients and their families are particularly at risk of physical and verbal aggression (National Institute of Occupational Safety & Health 2002). Aggression DOI: 10.1111/jonm.12201 ª 2013 John Wiley & Sons Ltd
towards nurses is a topic that has been well established in the nursing literature, particularly with respect to physical assaults (Whittington et al. 1996, Ferns 2006). Recently, research attention has turned towards more psychological forms of aggression, such as bullying (Johnson 2009), verbal abuse (Inoue et al. 2006) and incivility (Felblinger 2011). These types of aggression tend to be quite common, but are also 1
K. L. Campana and S. Hammoud
subtler in nature. Nevertheless, psychological aggression can have important effects on outcomes such as shame (Pearson et al. 2001, Felblinger 2008), psychological wellbeing (Cortina et al. 2001), task performance (Porath & Erez 2007) and withdrawal from the workplace (Caza & Cortina 2007). One of the more prevalent types of psychological aggression nurses face is incivility. Winstanley and Whittington (2002) found that in a sample of 375 hospital staff, 26% of respondents reported frequently encountering incivility in the workplace. Research has also suggested that the general public believes that incivility in general is on the rise (Farkas et al. 2002). Incivility, which is a relatively new construct, developed concomitantly with a number of other similar constructs (e.g. emotional abuse, bullying, harassment). As a result, incivility shares a number of characteristics with other psychologically aggressive behaviours. Pearson et al. (2005) have defined incivility as ‘low-intensity deviant (rude, discourteous) behaviour with ambiguous intent to harm the target in violation of workplace norms for mutual respect’. Behaviours that are considered uncivil can range from failing to return a colleague’s telephone call to demeaning someone publicly. Incivility is a broad construct and can subsume other psychologically aggressive behaviours such as bullying, emotional abuse and horizontal aggression. Incivility has three key distinguishing features: it is ambiguous in its intent, it can come from any source and it can be an isolated incident. For example, if a patient’s mother rolls her eyes when a nurse is providing treatment instructions, this would be considered uncivil. It is unclear whether the mother intends to harm the nurse and this behaviour may be a one-time incident. Another example might be if a patient criticises a nurse while she is drawing blood. Even though the aggressor has a different relationship to the nurse than the previous example, it would still be considered uncivil. If the patient criticises the nurse each time he sees her, the behaviour would be uncivil and may also fit the definition for bullying (Hershcovis 2011). This example also illustrates that a behaviour could fit the definition for several different types of psychological aggression, and that incivility typically is a broader construct compared with other forms of psychological aggression. Incivility is also a compelling variable because it is so pervasive. For example, Early (2004) found that 38% of nurses had experienced psychological aggression from patients and 30% experienced psychological aggression from visitors. Similarly, McKenna et al (2003) 2
found that one-third of nurses reported experiencing psychological aggression from patients. This poses a difficult problem for nursing management. Patients can be restrained if demonstrating overt, physically aggressive behaviours but it is more difficult to identify and prevent incivility because it is subtle. Yet, the research shows that incivility can have serious and negative consequences, including psychological distress (Martin & Hine 2005), decreased satisfaction with life (Lim & Cortina 2005), decreased task performance (Porath & Erez 2007), and decreased job satisfaction (Cortina et al. 2001). Empirical findings suggest that incivility from these sources can be particularly detrimental to nurses, leading to withdrawal from the workplace, emotional exhaustion and depersonalization (Winstanley & Whittington 2002, Guidroz et al. 2010). This finding is of great concern, particularly because nursing is a stressful profession in general; research has indicated that nurses are already at risk of many negative psychological and physical health problems (Gibbons et al. 2011). Hence, examining and addressing incivility directed towards nurses could help ameliorate the effects of stress on nurses. One particular psychological outcome that has garnered attention in the nursing literature is burnout (Kent & Lavery 2007). Burnout is a ‘psychological syndrome of exhaustion, cynicism, and inefficacy which is experienced in response to chronic job stressors’ (Maslach 2003). Burnout is typically characterised by individuals feeling emotionally exhausted, low in efficacy and disconnected from other individuals. Employees who experience burnout also tend to experience a negative impact of this on mental and physical health (Ahola et al. 2008). Employees who experience burnout are also more likely to withdraw from or leave the workplace (Laschinger et al. 2012). This last consequence is particularly problematic for the nursing profession, as there is a current shortage of nurses that is expected to become more serious over time (Lin et al. 2008, Juraschek et al. 2012). Because nurses experience burnout from some sources that managers cannot control, such as patients, it seems reasonable to examine what characteristics of the work context may aggravate or buffer the effects of incivility on nurse burnout. Greenberg (2004) suggested that one organisational characteristic that may influence the effects of stressors in the workplace is interactional justice – that is, whether an individual feels that she/he has been treated with dignity, and has been given information about how rewards and consequences are distributed. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Incivility, burnout and justice
According to Greenberg’s (2004) Theory of Justice Salience Hierarchy, when an individual experiences an unfair event in the workplace, the individual considers whether she/he has received a fair outcome (distributive justice), and whether she/he was treated with respect in response to this event (interactional justice). Greenberg argues that because managers and supervisors can influence how employees are treated, they may play an important role in how workers judge the fairness of the work environment. Indeed, Greenberg (2006) found support for this argument: nurses who were experiencing pay cuts tended to be less affected by insomnia when their supervisors were trained to demonstrate higher levels of interactional justice throughout the duration of the pay cut. Greenberg argued that interactional justice in an organisation serves as a buffer in the stressor–strain relationship; that is, even when employees are upset by unfair events in the workplace, if they feel they receive respectful treatment from their organisation, they are less likely to experience strains in response to the unfair event. As an illustrative example, a nurse may feel that a patient has treated her disrespectfully; if she feels that her workplace is an environment where she is often treated in an undignified way, that instance of incivility might contribute to feelings of burnout. However, if she is treated rudely, but generally feels that her organisation treats her well, this may protect her against feelings of stress. This in turn may help her avoid experiencing burnout. Helping nurses to avoid burnout can also lead to improved patient care (Van Bogaert 2009). In the present study, we opted not to examine distributive justice because managers generally do not have influence over this – distribution of outcomes is not always equal, and research suggests that most people accept that reality (Greenberg 1993). Thus, we focused on interactional justice. To examine the influence of interactional justice in some detail we therefore chose to further divide interactional justice into its two subcomponents: interpersonal and informational justice. If an individual believes she/he has received timely and adequate information about how a decision is made, that individual will experience informational justice. If an individual feels she/he is treated with dignity and respect when a decision is made, that individual will experience interpersonal justice. Although interpersonal and informational justice are frequently correlated, they are considered separate dimensions of justice and each predicts unique variance in organisational constructs such as job satisfaction (Loi et al. 2009). This approach also allows us ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
to gain a more nuanced understanding of how justice relates to burnout. Given these theoretical arguments, we propose the following hypotheses: H1: On days nurses experience more incivility from patients and their families, they will also experience higher levels of burnout. H2: Nurses who feel they experience higher levels of interpersonal justice in their workplace will experience lower levels of burnout when incivility is not present. H3: Nurses who feel they experience higher levels of informational justice in their workplace will experience lower levels of burnout when incivility is not present. H4: The relationship between incivility and burnout will be affected by perceptions of interpersonal justice, such that nurses who report higher perceptions of justice will experience a weaker association between incivility and burnout. H5: The relationship between incivility and burnout will be affected by perceptions of informational justice, such that nurses who report higher perceptions of informational justice will experience a weaker association between incivility and burnout.
Method Design This study utilised experience sampling methodology (ESM), also known as a diary study, to evaluate daily experiences of incivility and burnout. This methodology allows participants to reflect on events throughout the day, rather than asking them to retrospectively consider events in the distant past. We chose this approach because it has been found to produce more valid and reliable reports (Richardson 1994). In order to maintain the validity of pre-established measures, some prompts were revised to reflect the daily (rather than long-term) nature of the scales; this is common practice in ESM studies where daily measures of variables are not available, and can help illustrate how daily experiences are associated with chronic conditions such as burnout (Bolger et al. 2003, Cranford et al. 2006).
Participants The Minnesota State University Institutional Review Board granted approval for the research in November 2009. Data collection took place from December 2009 until March 2011. A sample of 75 nurses participated in this study in return for monetary compensation. 3
K. L. Campana and S. Hammoud
These nurses were recruited from two different resources. One group of participants was recruited from a hospital on the campus of a large, Midwestern university. With permission from the university, flyers were posted at the university hospital, with instructions on how interested nurses could contact the researchers. We are unable to provide a response rate for this sample, as we do not know how many nurses viewed our flyers. Nurse e-mail addresses were also obtained from the Nursing Licensing Board of Minnesota. The response rate for this recruitment method was 6%. Because participants were recruited from this source, they held a wide variety of positions, including registered nurse, licensed practical nurse, nurse practitioner and advanced practice registered nurse. Participants were required to have patient contact during their shifts, so nursing managers were not included in this sample. We sent emails to nurses in the metro area with at least a bachelor’s degree, inviting them to participate in the study. The final sample was 93% female, with an average age of 39 years (SD 12.32). Participants had an average tenure of 8.82 years (SD 7.71).
Measures Incivility We assessed incivility using an adapted version of Cortina et al.’s (2001) six-item measure. The original measure asked respondents about uncivil behaviours over the past year. Because we were interested only in events for each day, we altered the measure to read ‘Today, how often did your patients or members of your patients’ families….’. We also altered the ratings scale to specify how much each behaviour occurred for that day. The rating scale ranged from 1 (This did not happen to me today) to 5 (This happened to me almost constantly today). An example item is, ‘Put you down or behave condescendingly towards you’ Higher scores indicated that the nurse experienced more incivility from patients and their families that day. We calculated scores by averaging across items; hence, scores on this measure could range from 1 to 5. The original measure created by Cortina et al. (2001) had a Cronbach’s alpha coefficient of 0.89. The altered version of the scale demonstrated adequate reliability in the final sample (Cronbach’s a = 0.79). Burnout In order to assess feelings of burnout among participants, we asked them to fill out a shortened inventory (Wharton 1993) based on the Maslach Burnout Inventory (Maslach et al. 1997). This shortened version of the survey contained six items; these items were rated 4
from 1 (strongly disagree) to 5 (strongly agree). We also altered the language slightly to emphasise that the respondents should focus only on his or her feelings that day. An example item is ‘Today, I feel emotionally drained’. Higher scores indicate more symptoms of burnout. Because burnout is a chronic condition, an individual who reported a high number of daily burnout symptoms across the 2-week testing period is more likely to meet the definition of chronic burnout (Bolger et al. 2003). The total score for this scale was created by averaging across items, so the range of possible scores was from 1 to 5. The original version of the measure created by Wharton (1993) demonstrated a Cronbach’s alpha of 0.87. This altered measure demonstrated good reliability in the final sample (Cronbach’s a = 0.91), suggesting that this measure maintained its validity as a daily measure. Justice Interpersonal and informational justice were measured using subscales adapted from Colquitt (2001). Items were adapted to clarify who the decision-makers were in the organisational context (i.e. administration/managers). Both measures used a 1 (strongly disagree) to 5 (strongly agree) scale. Interpersonal justice was measured using two items. A sample item is ‘People at my workplace treat me with dignity’. The original version of this measure had good reliability (Cronbach’s a = 0.92); our adapted version continued to demonstrate good reliability in the final sample (Cronbach’s a = 0.83), suggesting that the alterations did not disrupt reliability. Informational justice was measured using three items. A sample item is ‘Decision-makers (e.g. administration/ managers) communicate the details of a decision in a timely manner’. The original version of this scale demonstrated good reliability (Cronbach’s a = 0.90); our adapted version continued to show adequate reliability in the final sample (Cronbach’s a = 0.79). Scores for both justice scales were calculated by averaging across items, so possible scores could range from 1 to 5.
Procedure Participants were asked to complete a background survey that consisted of demographic questions and the organisational justice measure. After completing the background survey, participants were asked to complete additional surveys over the course of a working week. These surveys, which were administered online, contained the incivility and burnout measures. Participants were asked to complete these surveys twice during each workday, for five workdays (for a total of 10 ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Incivility, burnout and justice
daily surveys). Participants were instructed to take the first survey during a break at some point in their working day and the second survey after their working day was completed. These daily surveys took approximately 3 minutes to complete and required participants to complete every item before submitting. This was because the scales were brief and allowing participants to omit items or measures would limit the usefulness of the information gathered from them. We sent daily reminders to participants, and checked to see if they wanted to leave the study if they missed a day. No participants in the final sample opted to leave the study. Nurses completed, on average, 7.83 of the 10 daily surveys.
experienced a greater amount of incivility also reported higher levels of burnout, and lower levels of informational justice (Table 1). These between-subject analyses also suggested that individuals who, on average, experienced burnout also reported experiencing less informational justice (although there does not appear to be a significant relationship with interpersonal justice). Next, to test specific hypotheses, we conducted an HLM analysis in two steps, examining the main effects of incivility, interpersonal justice and informational justice first. We then conducted an additional analysis examining the interactional effects. Results of these HLM analyses are presented in Table 2.
Data analysis
Effect of justice on burnout
In order to test the hypotheses, we conducted hierarchical linear modelling (HLM) analyses (Raudenbush & Bryk 1992) using HLM version 7.01 (Bryk et al. 2008). This type of modelling has several benefits in this particular analysis. First, HLM can account for missing data, and gives participants who complete only a few daily surveys less weight in equations, while participants who completed all surveys are more heavily weighted in equations. Hence, provided that participants completed the background survey and at least two daily surveys, they were included in the analyses. In addition, HLM can be useful with research designs where respondents fill out surveys repeatedly; this is because surveys completed by the same individual will correlate more highly with one another than with surveys completed by a different individual. This analysis allows for simultaneous modelling of two-level models, with within-person variables (i.e. daily incivility and daily evaluations of burnout) at the first level, and betweenperson variables (i.e. interpersonal and informational justice) at the second level. This type of modelling allows us to examine within-individual dependencies, while also allowing us to examine cross-level interactions (specifically, the fourth and fifth hypotheses in this study). Hence, the equations for our models are: Level 1: Burnoutij = b0j + b1j*(Incivilityij) + eij Level 2: b0j = c00 + c01*(Interpersonal Justicej) + c02* (Informational Justicej) + u0j, b1j = c10 + c11* (Interpersonal Justicej) + c12*(Informational Justicej)
A pseudo-R2 of the main effects model indicated that our model explained approximately 12% of the variance. The HLM analysis indicated the coefficient for this effect (c00) was 2.39, suggesting that on days where a participant experienced more incidents of incivility, they were also likely to report a significantly higher level of burnout. Hence, we found support for the first hypothesis. According to the results presented in Table 2, there was only a small and negative effect of interpersonal justice on burnout (c01 = –0.09). In other words, the experience of burnout among nurses in workplaces with high interpersonal justice was not notably different from those in workplaces with low interpersonal justice. Hence, hypothesis 2 was not supported. Our third hypothesis indicated that nurses who report higher levels of informational justice in the workplace would experience lower levels of burnout. As noted in Table 2, the results of the HLM model indicate that nurses who perceive high levels of informational justice in their organisation report notably lower levels of burnout (c02 = –0.23). This finding supports the third hypothesis.
Results Intercorrelations among variables An initial, between-subjects analysis indicated several findings. First, individuals who, on average, ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Table 1 Descriptive statistics and Pearson correlations among study variables (n = 77) Variable
Mean
SD
1
2
3
Incivility Burnout Interpersonal justice Informational justice
1.12 2.40 4.03 3.03
0.26 0.81 0.41 0.83
– 0.41*** 0.07 –0.24*
– –0.03 –0.34**
0.27*
Incivility and burnout were daily measures; hence, the descriptive statistics and correlations for those variables were calculated by averaging each individual’s score across all daily measures. * P < 0.05, **P < 0.01, ***P < 0.001.
5
K. L. Campana and S. Hammoud
Table 2 Predicting factors of burnout using hierarchical linear modelling (n = 77) Variables
Coefficient
Main effects Incivility (c00) Interpersonal justice (c01) Informational justice (c02) Interactions Incivility (c10) Interpersonal justice (c11) Informational justice (c12)
SE
t-ratio
2.39 –0.09 –0.23
0.07 0.16 0.08
35.48*** –0.055 –2.94**
0.60 0.80 –0.28
0.14 0.33 0.22
4.40*** 2.44* –1.30
Incivility, interpersonal justice, and interactional justice have been centred around the grand mean. *P < 0.05, **P < 0.01, ***P < 0.001.
Effect of justice on the incivility–burnout relationship Adding interactional effects to our model significantly improved its fit (v2(2) = 11.80, P < 0.01) and the pseudo-R2 suggests that this model explains an additional 2% of variance. With respect to the fourth hypothesis, we found a significant trend in the opposite direction of what we hypothesised: individuals who perceived their workplace as interpersonally just appeared to experience a significantly stronger association between incivility and burnout (c11). This trend is presented in Figure 1. This suggests that interpersonal justice may actually exacerbate the effects of incivility 2.56
on an individual. With respect to the fifth hypothesis, Figure 2 demonstrates the data trends in the expected direction. However, this buffering effect was too small to be statistically significant in this sample. Thus, we did not find support for the last hypothesis.
Enduring effects of incivility Finally, to explore whether incivility from early in the day affects burnout later in the day, we conducted lagged HLM analyses. In other words, we used ratings of incivility completed in the first survey completed that day to predict burnout ratings from the second survey completed that same day. Because not all participants filled out both surveys each day, the sample size was reduced to 71 participants (who completed both surveys for an average of 3.26 days each). As demonstrated in Table 3, our findings were similar to the previous analyses: incivility and informational justice appear to have main effects on burnout in the expected direction, and interpersonal justice strengthens the incivility–burnout relationship. These findings suggest that the effects of incivility are not transient and that they persist throughout the working day.
Discussion This study investigated how daily instances of incivility affected burnout, as well as whether perceptions of 2.90
Low Interpersonal High Interpersonal
High Informational
2.70
BURNOUT
BURNOUT
2.48
2.40
2.32
2.24 –0.12
2.50
2.29
–0.03
0.05
0.13
0.22
INCIVILITY
Figure 1 Moderating effect of interpersonal justice on the relationship between incivility and burnout. For illustrative purposes, we dichotomised the interpersonal justice variable into a low interpersonal justice group (those with a score one standard deviation below the mean or lower) and a high interpersonal justice group (those with a score one standard deviation above the mean or higher).
6
Low Informational
2.09 –0.12
–0.03
0.05
0.13
0.22
INCIVILITY
Figure 2 Moderating effect of informational justice. For illustrative purposes, we dichotomised the informational justice variable into a low informational justice group (those with a score one standard deviation below the mean or lower) and a high informational justice group (those with a score one standard deviation above the mean or higher). ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Incivility, burnout and justice
Table 3 Lagged analysis of predicting factors of burnout using hierarchical linear modelling (n = 71) Variables Main effects Incivility (c00) Interpersonal justice (c01) Informational justice (c02) Interactions Incivility (c10) Interpersonal justice (c11) Informational justice (c12)
Coefficient
SE
t-ratio
2.40 0.18 –0.34
0.08 0.18 0.09
29.92*** 0.95 –3.64***
0.26 1.17 –0.30
0.25 0.53 0.23
0.29 2.21* –1.35
Incivility, interpersonal justice, and interactional justice have been centred around the grand mean. *P < 0.05, ***P < 0.001.
justice affected this relationship. The first hypothesis, that on days the nurse encountered more incivility she/he would also report higher levels of burnout, was supported. For each 1-point increase on the incivility scale, scores increased 0.60 of a point on the burnout measure. This finding corroborates other incivility research, which indicates that rude behaviour often leads to psychological distress among recipients (Caza & Cortina 2007, Leiter et al. 2012). However, this is one of the first investigations in a nursing population of how daily instances of incivility can also affect daily experiences of burnout symptoms. Hence, the data here provide evidence that nurses do, on average, experience at least some incivility on a daily basis, and that these experiences can have important effects on how that nurse feels during that same day. Our second hypothesis, that interpersonal justice would have a main effect on the experience of burnout, was not supported. Although the data suggested that nurses who perceived their organisation as interpersonally just tended to report lower levels of burnout on average, this relationship was not strong enough to be statistically significant. It is possible that other aspects of the nurse’s environment, such as his/ her coworkers, patients, or immediate supervisor, may provide positive interpersonal experiences that would compensate for a lack of interpersonal justice that comes from administrators or decision-makers within a health care organisation. Recent research has indicated that supervisor support acts as a buffer in other work contexts (Sakurai & Jex 2012); future research might explore what other sources of social support are used by nurses to counteract daily frustrations. Our third hypothesis, that there would be a main effect of informational justice on burnout, was supported. Specifically, individuals who perceived their workplace as providing information about how decisions are made tended to experience less burnout on ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
average. In conjunction with the second hypothesis, this finding suggests that whereas nurses may not depend upon administration to help them feel that they are treated with dignity, they do depend upon administration to help them understand why decisions are made and why policies are in place. When administrations fail to do this, the findings here suggest it can contribute to burnout among nurses. This finding builds on some initial findings from Moliner et al. (2005), who did not find any link between interactional justice and burnout; this may indicate that separating interactional into interpersonal and informational is a helpful step in identifying statistically significant relationships. We also had several interactions in this study. Our fourth hypothesis suggested that interpersonal justice would buffer the incivility–burnout relationship, such that more interpersonal justice would be associated with a weaker relationship between incivility and burnout. However, we found a significant trend in the opposite direction. This suggests that when nurses encounter incivility in the workplace, it is those who work for interpersonally just organisations that are the most negatively affected by incivility. There are a number of reasons why this may be the case. For example, if an organisation’s culture emphasises the importance of respectful interactions among members, it may be much more upsetting (and therefore stressful) when a member encounters rude behaviour. In this scenario, a culture of interpersonal justice instead serves as an enhancer of the incivility–burnout relationship. Alternatively, as noted in the definition presented at the beginning of this article, a primary feature of incivility is that it goes against the norms of respect for the organisation. Thus, it may be that nurses who have become accustomed to disrespectful behaviour at work become desensitised to acts of incivility; they may have more intense feelings of burnout overall, but additional acts of incivility do little to change their level of burnout. Future research should further elucidate this finding. In addition, we hypothesised that perceived informational justice in the organisation would be associated with a weaker incivility–burnout association. Although the results demonstrated a trend in the expected direction, it was not strong enough to be statistically significant. Therefore, although informational justice may have an important direct effect on burnout, it does not appear to protect nurses from patients and their families. Finally, lagged analyses suggested that incivility experienced during the beginning of a participant’s 7
K. L. Campana and S. Hammoud
workday had important implications for how that participant felt later that day; instances of incivility significantly predicted burnout at a later time during that day. This suggests that effects of incivility can occur quickly, and can persist throughout the day. Future research should investigate what types of variables or events might prevent uncivil events from spilling over into attitudes or emotions later in the day. For example, organisations can provide restorative experiences that can help repair damaged moods and ensure that nurses leave work feeling fulfilled rather than frustrated, even when negative events occur throughout the working day.
Limitations This study has several limitations. First, because all data was provided in self-reports, the results may demonstrate inflated correlations owing to common source variance. Second, the sample was exclusively from the Midwestern region of the USA, and hence our participants worked in organisations with a strong union presence at the time the data were collected; the presence of unions in the workplace may have had important implications for respondents’ perceptions of justice, and may have also helped to insulate them from burnout (Burke & Greenglass 2001). Finally, this study asked participants to complete two daily surveys over five working days. The requirements of this study could have led to a less diverse sample. Nurses who were less busy and less stressed were more likely to respond to our recruitment emails and flyers, and were more likely to complete all surveys. Thus, these data may not accurately represent the experiences of nurses in particularly stressful jobs. Also, the nurses who did complete the survey may not have completed surveys during particularly stressful days. Several participants e-mailed after their work shift notifying us that they were extremely busy and were unable to complete one of their surveys during their work shift. Although one strength of using HLM analyses is that missed measurement values can be estimated using other data points, it is possible that these missed surveys could have provided valuable and unique information about how busy and frustrating days in particular affect nurse burnout.
Conclusion This study has demonstrated that daily experiences of incivility are associated with daily symptoms of burnout. This relationship appears to be stronger among 8
nurses who experience high levels of interpersonal justice in the workplace. Nurses who feel that management keeps them informed about the reasons behind decisions, tend to experience less burnout. These findings suggest that management can help ameliorate the effects of incivility by being transparent in decisionmaking and by helping to prepare nurses in interpersonally just environments to anticipate rudeness from patients and their families.
Implications for nursing management and future research directions The findings of this study have several implications for the practice of nursing management, as well as future investigations into the topic. First, our findings emphasise the importance of incivility on nurses’ experience of burnout – on days where nurses are treated rudely by patients or patients’ families, they are more likely to experience burnout. These feelings can persist throughout the day, so continual exposure to rude patients may lead to chronic feelings of burnout. Second, this research indicates that managers can influence this process. Specifically, when nurses feel that they are informed about why decisions are made they tend to experience lower levels of burnout. Third, this research also indicates that in environments where nurses feel they are treated with dignity, they will be more disturbed by rude patient behaviour. Thus, it might be particularly important in these environments for managers to help nurses anticipate mistreatment from patients and cope with it more effectively. Our findings also suggest some avenues for future research. For example, understanding the predictors and consequences of burnout among nurses is a major concern in the field, particularly when considering the link between burnout and low rates of retention (Laschinger et al. 2009). Considering the current shortage of nurses that is likely to grow more serious in the future, recruiting new nurses and retaining incumbent nurses will become vital for health care organisations (Juraschek et al. 2012). Given that organisational justice appears to influence burnout among nurses, other organisational characteristics should be examined, particularly those that nursing managers can influence. It may also be important to investigate how new graduates are affected by incivility and by organisational policies. Research has suggested that many new nurses are unprepared for the realities of nursing work, and at times may find their environment unwelcoming (Duchscher 2001, Laschinger et al. 2009). Nursing management can play an important role in ª 2013 John Wiley & Sons Ltd Journal of Nursing Management
Incivility, burnout and justice
socialising and creating a supportive environment for these nurses. Being transparent about policies is one way to do this, as demonstrated in this research. However, other types of justice may also temper other negative outcomes for nurses such as turnover or low motivation. This research only explored the effect of patient and family incivility. Previous research has indicated that many nurses expect this sort of treatment, because they know patients are under a great deal of stress (Guidroz et al. 2010). More research is needed to examine how the source of incivility might affect nurse burnout. For example, nurses may find incivility from physicians or other nurses to be more upsetting than from patients; however, at this time, research has not carefully explored the effect of the source of incivility on burnout or other consequences.
Acknowledgement This research was funded by a Faculty Research Grant from Minnesota State University, Mankato.
Source of funding This research was funded by a Faculty Research Grant from Minnesota State University, Mankato.
Ethical approval Ethical approval was obtained from the IRB at Minnesota State University, Mankato, in November of 2009.
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