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JONA
Volume 41, Number 1, pp 41-47
Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION The Impact of Workplace Incivility
on the Work Environment, Manager
Skill, and Productivity
Patricia Smokler Lewis, PhD, RN, NEA-BC, CNML
Ann Malecha, PhD, RN
Objective: The objective of the study was to investigate the impact of workplace incivility (WPI) on
staff nurses related to cost and productivity.
Background: Healthful practice environments are
one of the goals of the American Organization of
Nurse Executives 2010 to 2012 Strategic Plan.
Healthy work environments are linked to patient
safety and quality.
Methods: A postal survey was sent to 2,160 staff
nurses (n = 659 completed) and included the Nursing
Incivility Scale and Work Limitation Questionnaire.
Results: Although almost 85% (n = 553) reported
experiencing WPI in the past 12 months, nurses
working in healthy work environments(defined as
MagnetA, Pathway to Excellence, and/or Beacon Unit
recognition) reported lower WPI scores compared
with nurses working in the standard work environment (P G .001). Workplace incivility scores varied
between types of unit. Nurses’ perception of their
manager’s ability to handle WPI was negatively associated with WPI scores (P G .001). Lost productivity
Authors’ Affiliations: Nursing Director (Dr Lewis), Methodist Sugar Land Hospital, Sugar Land, Texas; Professor and Research Director (Dr Malecha), Texas Woman’s University, Houston,
Texas.
Corresponding author: Dr Lewis, Methodist Sugar Land Hospital, 16655 SW Freeway, Sugar Land, TX 77479 (pslewis@tmhs.org).
Partial financial grant funding was received from the following organizations: Houston Organization of Nurse Executives;
Sigma Theta Tau Beta Beta Chapter Houston, Texas; Tillie and
Tom Small research grant from Texas Woman’s University; and
the Houston-Gulf Coast Chapter of the American Association of
Critical-Care Nurses.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s Web site
(www.jonajournal.com).
DOI: 10.1097/NNA.0b013e3182002a4c as a result of WPI was calculated at $11,581 per
nurse per year.
Conclusions: Not only does WPI exist at high rates,
but also it is costly. Nursing leaders play a vital role
ensuring a healthy work environment.
Workplace violence can be viewed as a continuum
from low-level nonphysical workplace violence to
physical violence.1 Physical violence in the workplace
makes the headlines; however, the more insidious
forms of workplace violence, such as workplace incivility (WPI), can have long-lasting effects on an
organization. Workplace incivility is defined as Blowintensity deviant behavior with ambiguous intent to
harm the target, in violation of workplace norms for
mutual respect. Uncivil behaviors are characteristically rude and discourteous, displaying a lack of
regard for others.[2 Until this decade, the topic of
WPI had rarely been mentioned; however, an interest
has developed because of the evolving understanding of the importance of creating and sustaining a
healthy work environment. Workplace incivility,
usually occurring under the radar, is thought to be
benign and frequently is not apparent to the leaders
of the organization.
In nursing, a healthy environment is defined as a
hospital with MagnetA designation or Pathway to
Excellence designation3 from the American Nurse
Credentialing Center as well as the Beacon Award for
Critical Care/Progressive Care Unit Excellence from
the American Association of Critical-Care Nurses
(AACN).4 The forces of Magnetism are aligned with
the concepts of a healthy work environment, especially the force of interdisciplinary relationships and
autonomy. The Pathway to Excellence program also JONA Vol. 41, No. 1 January 2011 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 41 supports a healthy work environment in that it ensures professional satisfaction of nurses and the best
places to work.3 The Beacon Award for Critical Care
Unit Excellence from the AACN promotes a healthy,
professional work environment that ensures quality
patient outcomes based on the evidence.4
Effective work relationships are necessary for a
healthy work environment. Kramer and Schmalenberg5
state that staff nurses want a collaborative interdisciplinary and nurse-physician relationship, which is one
of the attributes of a satisfying and productive work
environment. This collaborative relationship is described as Bone based on mutual trust, power, and
respect between parties.[5(p58) The relationship between the nurse and the nurse’s manager and peer
relationships are critical to healthy work environments. The role of the manager sets the tone of the
environment and impacts retention.6 Positive relationships with colleagues are as important as the relationship with the unit/department manager.6,7 Workplace Incivility
Most of the WPI research has focused on the business or
nonhealthcare setting.8-13 Recent research has focused
on the target, witnesses, and outcomes of WPI and
found that WPI has major ramifications on the workforce leading to absenteeism, reduced productivity, and
turnover.8,9,11 The literature on WPI is relatively new in
the field of nursing science with one published WPI
state-of-the-science article14 and a limited number of
nursing research studies on WPI.6,7,15
Hutton and Gates15 explored the frequency of
incivility experienced by nurses and nonlicensed assistive personnel and its impact on productivity and
costs to the organization. Two instruments, the Incivility in Healthcare Survey and the Work Limitations Questionnaire (WLQ),16 were used. These
researchers modified the Nursing Incivility Scale
(NIS) developed by Guidroz et al17 into a frequency
instrument measuring source-specific WPI in the
healthcare setting. The authors found that the lowest
reported incivility was from the direct supervisor and
the greatest incivility was from the general environment. The direct care staff rated WPI at a mean of
2.12, which is just above Brarely occurs.[ There was a
correlation between WPI from direct supervisors and
productivity (r = 0.284, P = .001) and WPI from
patients and productivity (r = 0.204, P = .006).
Incivility from physicians, coworkers, and the general
environment was not statistically significant. Logistic
regression found no significance between employment
characteristics and demographics and WPI. The
analysis did find a significant relationship between
incivility and decreased productivity (F = 4.04, P = 42 .0017, R2 = 0.1046). Each factor was run against
incivility, and only 2 factors were significant, direct
supervisors (F = 15.65, P = .0001, R2 = 0.0808) and
patients (F = 7.69, P = .0061, R2 = 0.0361). The
authors also found that the annual cost of the decreased
productivity for the sample was $264,847.34, with
the mean nursing assistant lost productivity costs at
$1,235.14 and $1,484.03 for a nurse. A t test found
that there was a significant difference between nurses
and nursing assistants in the level of reduced productivity for the cumulative WLQ. Incivility had a greater
impact on productivity than on the frequency of WPI.
The limitation of this study was the small sample size,
with a response rate of 22%.15
Laschinger et al6,7 recently published two studies
exploring WPI. The first study used the Workplace
Incivility Scale of Cortina et al.8 This study examined
the influence of workplace empowerment, manager
and coworker incivility, and burnout on retention, job
satisfaction, organizational commitment, and turnover
intent. Incivility from supervisors was experienced by
67.5% of the nurses, whereas 77.6% reported coworker incivility. A small percentage of nurses
reported ongoing incivility (bullying) of 4.4% from
supervisors and 2.7% from coworkers. Supervisor
incivility, empowerment, and cynicism most strongly
predicted job dissatisfaction and low organizational
commitment (P G .001), whereas the major predictors
of turnover intent were emotional exhaustion, cynicism, and supervisor incivility (P G .001).6 The second
study was designed to examine supportive professional
practice environments, civility, and empowerment on
graduate nurses experience with burnout. Incivility
was measured using 4 items from the ICU NursePhysician Questionnaire of Shortell et al.18 Graduate
nurses reported relatively positive scores for civility in
the workplace. Laschinger et al7 found that the combination of a supportive practice environment (" =
j0.221, P = .004), civility (" = j0.18, P = .003), and
empowerment (" = j0.245, P = .001) contributed to
less emotional exhaustion leading to burnout in graduate nurses. The lower scores of emotional exhaustion
explained 28% of the variance of burnout.7 Study Objectives
This impetus for this study was to add to the nursing
science literature on organizational factors that influence WPI and the impact of WPI on cost due to
lost productivity.
The aims of this study were to (1) determine if
there were differences in reported WPI between
healthy work environments and the standard work
environment, (2) determine if there is a difference in
WPI scores between hospital settings (academic JONA Vol. 41, No. 1 January 2011 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. medical center, community, and rural), (3) evaluate the
impact of WPI on cost and productivity of staff nurses
in the hospital setting, (4) determine if there is a relationship between WPI subscales and productivity
subscales, (5) examine the relationships between the
manager’s skill (manager’s awareness and ability to
handle WPI) and WPI, (6) determine if there are differences between the type of unit/department and WPI
scores, and (7) determine if there were organizational
factors that predict WPI in the hospital setting. Methods
This study is a nonexperimental, correlational, comparative, and predictive model design using a survey
methodology with institutional review board approval. The setting for this study was in the state of
Texas. Initially, the investigators obtained a mailing
list of active RNs employed in the state of Texas from
the Board of Nursing (BON) of Texas. The investigators selected only active RNs who were in a staff
nurse role. The population of active staff nurses as
of January 2, 2009, was 95,195 licensed staff nurses
in Texas (personal communication, Texas BON,
January 2009).
The investigators randomly selected 2,160 RNs
for the sample and mailed a packet consisting of a
cover letter, a hard copy of the survey, and a return
postage-paid envelope. Each participant had the
option of completing and returning a hard copy of
the survey or completing the survey online using
PsychData. By May 2009, the investigators had a
response rate of 8% (n = 164). A revised approach was
used to increase the sample size. The snowball
sampling function was activated in the PsychData
survey to allow a staff nurse to forward the survey to
other colleagues. Additionally, the investigators contacted key resources at 15 professional organizations in
Texas and requested that the organization leaders
electronically mail their members the PsychData URL
link. The final sample size was 659 completed surveys. Instruments
Three instruments were used in this study: the NIS,17
the WLQ,16 and a demographic component designed
by the investigators. The NIS is an agreement scale
survey that measures source-specific (coworkers
[nurses], supervisor, physicians, patients/visitors, and
the general environment) incivility. This 43-item instrument has demonstrated reliability, with internal
consistency !’s ranging from .88 to .94 for each of the
subscales. The subscales represent 2 general incivility
factors (inappropriate jokes, hostility/rudeness), 3
nursing factors (free-riding, gossip/rumors, inconsid- erate), and 1 factor for patients/visitors, supervisor
and physician scales. A 5-point Likert scale is used in
the NIS.17
The WLQ, designed by The Health Institute at
Tufts Medical Center, is a 25-item instrument designed
to measure productivity by the degree of interference
an individual has in performing one’s job role. The
components of the WLQ include time management,
physical demands, mental-interpersonal demands, and
output demands. Responses range from Bdifficult at all
times[ to Bnot difficult at all.[ The WLQ index is calculated to indicate overall productivity. The WLQ possesses excellent scaling properties as well as content,
construct, and criterion validity.16 For this study, the
Cronbach ! range for the subscales was .88 to .94.
The WLQ Productivity Loss Score indicates the
percentage reduction in work output due to a workrelated limitation (incivility). The WLQ Productivity
Loss score determines the estimated percent difference
in output compared with those who do not have the
work-related limitations (experience with WPI).16 To
calculate the cost of WLQ Productivity Loss, the
investigators followed the process outlined by Hutton
and Gates.15 The percent productivity loss is multiplied by the mean annual salary of the direct care staff
nurse. The investigators used salary data from Keefe
and O’Brien,19 who conducted a national survey of
4,553 nurses from August through September 2008.
The average salary range for a staff nurse in Texas
was $60,000 to $64,999. The inpatient direct care
staff nurse base pay in Texas was $30.54 per hour. Findings
The sample included 659 direct care nurses, with a
mean age of 46.38 years and 92% (n = 597) being
female. The ethnic/race distribution of the sample
was diverse. Almost half of the sample (48%) had a
baccalaureate degree in nursing (BS/BSN), and the
majority of the sample (85.7%) had more than 6
years’ experience as a nurse. The work environment
was described by the work setting, type of unit, and
special designations associated with healthy work
environments. An academic medical center was the
work setting for 38.6% of the nurses, whereas 37%
were employed in a community hospital. Only 8.1%
of the nurses identified themselves as working in a
rural setting. Eleven percent of the nurses described
themselves as working in an urban setting. Magnet
designation, Pathway to Excellence, and Beacon status for critical care and progressive care units are
recognition awards associated with healthy work environments with excellence in nursing. Thirty-eight
percent of the nurses (n = 251) worked in Magnet
hospitals, and 31% (n = 200) worked in Pathway to JONA Vol. 41, No. 1 January 2011 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 43 Excellence hospitals. Only 6.4% of the sample (n = 42)
identified themselves as employed in a Beacon Unit.
The type of unit varied, with the highest percentage
being the operating room (OR) (30%), followed
by medical-surgical (MedSurg) units (16.4%) and
ICUs at 14.6%. The emergency department (ED) and
women’s services were similar at 6.6% and 6.5%,
respectively.
A large majority of the nurses in the sample
experienced WPI in the last year (84.8%, n = 553).
Interestingly, 36.7% (n = 239) of the nurses in the
sample indicated that they had instigated WPI to
another person in the last year. The sample demographics can be seen in Supplemental Digital Content 1, http://links.lww.com/JONA/A38. Work Environments and Nursing Incivility
Research question 1 asked: Is there a difference in reported WPI between healthy work environments and
the standard work environment? A difference was
found between healthy work environments and the
standard work environment in respect to WPI. Staff
nurses working in healthy work environments were
found to have lower WPI scores than nurses working in
the standard work environment (P G .001) in all subscales except the patient/visitor (Table 1). The investigators followed with research question 2: Is there a
difference in WPI scores and hospital setting? An
analysis-of-variance (ANOVA) statistic indicated the
means to be very close, with no significant difference in
the WPI scores of direct care nurses working in academic medical center, community, or rural hospitals. Productivity, the Cost of Lost
Productivity, and WPI
Research question 3 asked: Does WPI among staff
nurses impact productivity and costs? The WLQ productivity loss score estimates the percentage
difference in output compared with those not experiencing the limitation (WPI). Lost productivity was
calculated to be a mean of 0.19 or 20% (SD, 3.21).
The WLQ index is multiplied by $30.54 (average
hourly base salary for staff nurses in Texas, which
calculates to an annual salary of $63,523.00). Subtracting nonproductive time of a 3-week vacation and
8 days of holidays computes to $11,581 per nurse per
year of lost productivity as a result of WPI. The
investigators went on to ask if there was a difference
in lost productivity related to WPI between healthy
work environments and the standard work environment. An ANOVA was performed to determine
whether the means between groups were different.
The means were close; therefore, there was no difference in lost productivity scores between healthy work
environments and the standard work environment.
This finding indicates that the presence of any WPI
impacts productivity, and the costs are the same. The
investigators followed with question 4: Is there a
relationship between the WPI and the productivity?
Table 2 depicts a correlation between general environment, nurse, supervisor, and patient/visitor and
the time management, mental/interpersonal skill,
and output subscales. There was a negative relationship indicating that the higher the incivility, the
lower the productivity. The physical subscale of the
work limitation questionnaire has no correlation
with WPI. Organizational Factors and WPI
Research question 5 asked: Is there a relationship
between manager’s skill and WPI scores? There was
no correlation between the direct care nurses’ perception of their manager’s awareness of WPI on their
unit/department. Conversely, direct care nurses’ perception of their manager’s ability to handle WPI was Table 1. Is There a Difference Between Healthy Work Environments and the Standard Work
Environment and NIS Scores? 44 Nursing Incivility Subscales Healthy Work Environment Mean (SD) F/df/P General environment No
Yes 293
348 3.36 (0.734)
3.07 (0.815) 6.102/639/G.001 Nurse No
Yes 292
344 3.36 (0.816)
3.03 (0.852) 1.129/634/G.001 Direct supervisor No
Yes 292
343 2.32 (1.07)
2.07 (0.99) 5.206/633/G.002 Physician No
Yes 290
340 3.14 (1.03)
2.75 (1.04) .182/628/G.001 Patient/visitor No
Yes 287
339 2.02 (0.826)
2.13 (0.875) .153/624/.112 JONA Vol. 41, No. 1 January 2011 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 2. Is There a Relationship Between WPI and Productivity?
Subscales General Environment Nurse Direct Supervisor Physician Patient/Visitor j0.212a
.000
603 j0.292a
.000
603 j0.263a
.000
603 j0.257a
.000
603 j0.309a
.000
603 0.084b
.039
602 0.088b
.031
602 j0.284a
.000
601 j0.319a
.000
601 j0.293a
.000
601 j0.268a
.000
601 j0.312a
.000
601 j0.195a
.000
600 j0.234a
.000
600 j0.253a
.000
600 j0.217a
.000
600 j0.265a
.000
600 j0.252a
.000
599 j0.307a
.000
599 j0.295a
.000
599 j0.278a
.000
599 j0.305a
.000
599 WLQ time management
R
P (2-tailed)
N
WLQ physical
R
P (2-tailed)
N
Mental interpersonal skill
R
P (2-tailed)
N
WLQ output
R
P (2-tailed)
N
WLQ productivity index
R
P (2-tailed)
N 0.064
.117
602 0.044
.276
602 0.134a
.001
602 a Correlation is significant at the .01 level (2-tailed).
Correlation is significant at the .05 level (2-tailed). b negatively associated with WPI scores in general
environment, nurse, supervisor, and physician subscales of the NIS (P G .001). The patient/visitor
subscale was not significant. Direct care nurses who
demonstrated lower WPI scores were associated
with a perception of their manager being able to
handle WPI in the unit/department (Table 3).
Research question 6 explored the impact of WPI
on the type of unit. The investigators asked: Is there a
difference in type of unit/department (ICU, MedSurg,
OR, ED) and WPI scores? An ANOVA was performed to determine whether there were differences
between means (F12,641 = 4.27, P G .001). Post hoc
Bonferroni tests were performed to determine where
the significant differences existed. For the general
environment subscale, the OR was different than the
ICU and MedSurg (P G .001). The ICU and MedSurg units had lower incivility scores. The ICU was also
different from the ED (P G .002). For the nurse subscale (lateral hostility), the ICU and MedSurg units
were significantly different than the OR (P G .001).
Again the WPI scores were lower in the ICU and
MedSurg area. For the direct supervisor subscale, the
OR was significantly different than the ICU and
MedSurg units (P G .001 and P G .003, respectively).
For the physician subscale, the OR was significantly
different from the ICU (P G .001), MedSurg (P G
.001), and ED (P G .002). ICU, MedSurg, and ED all
demonstrated lower incivility scores than the OR
staff. For the patient/visitor subscale, the OR was
significantly different than the ICU, MedSurg, and
ED (P G .001). Conversely, the OR demonstrated the
lowest incivility scores for the patient/visitor subscale
than the other 3 departments. Table 3. Is There a Relationship Between Manager Skills and WPI?
Subscales General Environment Manager’s awareness of WPI
R
P (2-tailed)
N
Manager’s ability to handle WPI
R
P (2-tailed)
N 0.063
.111
641
j0.353b
.000
638 Nurse
0.088a
.026
636
j0.417b
.000
633 Direct Supervisor Physician Patient/Visitor j0.076
.055
635 0.073
.067
630 j0.159a
.000
626 j0.462b
.000
632 j0.326b
.000
627 j0.054
.175
623 a Correlation is significant at the .05 level (2-tailed).
Correlation is significant at the .01 level (2-tailed). b JONA Vol. 41, No. 1 January 2011 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 45 Organizational Factors Predicting WPI
The investigators asked research question 7: Are
there organizational factors that predict WPI? The
manager’s awareness of WPI was a statistically
significant (z = 23.896, P G .001) predictor of the
manager’s ability to handle WPI. A participant
who agrees that their manager is aware of WPI is
7 times more likely to agree on the ability of the
manager to handle WPI. Furthermore, the type of
unit was significantly associated with the manager’s ability to handle WPI (R2 = 34.51, P G .001).
With the OR as a reference group, ORs differ from
ICUs (z = 23.049, P G .001) in predicting the manager’s ability to handle WPI. A participant from the
ICU is 4.5 times more likely to agree that their
manager is able to handle WPI than participants
from the OR. Similarly, participants from MedSurg
are 3.29 times more likely to agree that their manager can handle WPI than those from the OR. The
ED staff demonstrated no significant difference
from the OR. Discussion
This study supports the work of Hutton and Gates,15
demonstrating that incivility has an impact on productivity as well as the cost of lost productivity.
Furthermore, this research is congruent with the
work of Laschinger et al7 indicating that a supportive or healthy work environment is associated
with less incivility. To date, investigators measuring WPI in nursing have used a variety of surveys. 8,15,17,18 Finding the best instrument to
measure incivility will be beneficial to the science
related to WPI.
This investigation clearly indicates the importance that nursing leaders have in setting the tone
and expectations of the work environment. Creating an environment with heightened mindfulness
or awareness of the effects of incivility is essential,
given how it has become a normative behavior in
our society. The Joint Commission launched a sentinel event alert in July 2008 stating that disruptive
behaviors undermined a culture of safety20 and
that zero-tolerance policies need to be implemented
and enforced. Nurse leaders who actively manage
incivility in the work environment are noticed and
appreciated by staff nurses.
To support a healthy work environment, staff
and management can jointly develop a code of conduct to set expectations and hold staff accountable
for their actions and behaviors (Figure 1). Frequent
rounding by nurse executives and managers is 46 Figure 1. Sample code of conduct. designed to role model and observe staff interactions with coworkers, other department personnel,
physicians, and patients/visitors.21-24 Reviewing
WPI scenarios in staff meetings and discussing
strategies for handling each situation will help staff
develop the communications skills needed to respond to WPI and other disruptive behaviors.21
Interdisciplin...