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The Effect of Educational Intervention about Incivility on Psychological Wellbeing and Burnout among Nurses

Sabah Hassan El-Amrosy*, Soha Mamdouh Elkholy, Shimaa Ebrahim Elshall

Psychiatric and Mental Health Nursing, Faculty of Nursing, Menoufia University, Egypt2Nursing Management Department, Faculty of Nursing, Menoufia University, Egypt

Abstract: Workplace incivility pervades nursing practice and adversely effects nurses, patients, and organizations. Failure to address uncivil behaviors can negatively affect the physical and mental health of nurses. As a result, nurses may experience decreased job satisfaction, increased turnover, absenteeism and work-related injuries. The study aimed to evaluate the effect of educational intervention about incivility on psychological wellbeing and burnout among nurses. Quasi-experimental design with pre-posttest was used to achieve the aim of this study. The study was conducted in Menoufia Main university hospital. A simple random sample of 50 staff nurses were selected to constitute the present study. Data were collected using workplace incivility scale, the ryff scales of psychological well-being and maslach burnout inventory (MBI). The results was found that, the studied nurses were in age group (23-49) years and the mean age is 34.14years, the majority of the sample 72% had Bachelor of nursing, 96% were female, The highest frequency (94%) was married. There was a highly statistically significant difference found regarding psychological well- being, burnout and incivility among the studied nurses pre and post intervention .In conclusion, one can say that the implementation of educational intervention about incivility has a positive effect on improving psychological well-being and decrease burnout among nurses. Based upon the results of the study, a recommendation to implement educational intervention about incivility throughout the organization to improve psychological well-being and decrease burnout.

Keywords: incivility, psychological well-being, burnout

Received September 10, 2019; Revised October 16, 2019; Accepted October 29, 2019

Citation: Sabah Hassan El-Amrosy, Soha Mamdouh Elkholy, Shimaa Ebrahim Elshall, The Effect of Educational Intervention about Incivility on Psychological Wellbeing and Burnout among Nurses. American Journal of Nursing Research, 7 (6). 1069-1077. January 2019. doi:10.12691/ajnr-7-6-21

1. Introduction

Workplace incivility (WPI) is a significant problem in healthcare centers, disturbing not only the clinicians enduring the negative behaviors but also the care that is delivered under the shadow of incivility [1]. Workplace incivility refers to uncivil behaviors characterized by low intensity, ambiguous intent to harm, and violating workplace norms of mutual respect, example behaviors include rude comments, using a condescending tone, and addressing someone unprofessionally. These uncivil behaviors are very common in the workplace. Workplace incivility related to decreased job satisfaction, less intention to stay, reduced satisfaction with supervisors and coworkers, decreased mental and physical health, as well as increased work-family conflict and depression [2].

Individuals who experience incivility, either as targets or witnesses, may suffer numerous negative behavioral, psychological, and somatic effects. included stress related responses, such as negative mood or irritability, headaches or fatigue, fear or helplessness, anxiety or worry, impaired social skills, depression, fatigue, loss of concentration and cognitive distraction, psychosomatic complaints, posttraumatic stress disorder, and burnout [3]. In addition, threatening and disruptive actions can also lead to medical errors, reduce patient satisfaction, and increase the cost of care. [4].

Psychological wellbeing is the worker state of mind; one of the dimensions of the psychological well-being is the relationship with others and will behave in a positive way in the work environment [5]. The impact of workplace incivility on employee psychological wellbeing created through stressful situations and adverse emotional responses which hit their psychological state badly [6]. Workload and hostile behavior on work also connected with negative effect on psychological wellbeing of employees [7].

Job burn-out is an individual reaction to emotional and interpersonal stress and is related to work pressure and occupational stress. Burnout is characterized by emotional exhaustion, cynicism, and professional inefﬁcacy. Emotional exhaustion is considered to be the core element of burnout, resulting in cynicism toward one's work and colleagues and low efﬁcacy levels [8]. The reasons for job burn-out mainly include excess workload, lack of support and resources, impeded information and reduced sense of control, organizational injustice, interpersonal roles conflict, and interpersonal emotional stress at work. [9].

Job burn-out showed a high incidence in the nursing group. Worse still, job burn-out can result in a series of adverse outcomes for nursing staff and hospital organizations, such as disappearance of sense of organization belonging, decline of nursing group cohesion, poor nursing work efficiency and lower job performance. It may even lead to the loss of nursing talents. [10] Incivility is expected to be positively associated with job burnout which is a predictor of turnover intention across a number of industries [11].

1.1. Significance of the Study

[12] Porath and Pearson (2013) reported that 98% of more than 14,000 people they had surveyed in the past 14 years had experienced workplace incivility at work, with half of them reporting being treated rudely at least once a week. High prevalence of incivility and even violence is reported in Iran [13] .Due to this high prevalence; a great deal of research has been done to explore its negative effects on both individuals and organizations.

Workplace incivility (WPI) affected many occupations, especially the nursing profession [14]. Incivility was defined as “rude or disruptive behaviors that often result in psychological or physiological distress for the people involved and, if left unaddressed, may progress into a threatening situation”. Workplace incivility pervades nursing practice and adversely effects nurses, patients, and organizations.. Failure to address uncivil behaviors can negatively affect the physical and mental health of nurses. As a result, nurses may experience decreased job satisfaction, increased turnover, absenteeism and work-related injuries [15]

One of the main groups involved in preventing WPI was nurses. Nurses claim that completing tasks accurately and correctly, improving knowledge and skill, communicating effectively is one of the most important factors in preventing incivility [16]. Nurses must be educated on how to recognize incivility, how this behavior impacts themselves, their patients, and their organizations, and how to confront and eliminate incivility in the workplace for this resolution to be successfully enacted. Recently issued a call to advance civility in nursing. This proclamation calls upon “all nurses to recognize nursing civility and take steps to systematically eliminate all acts of incivility in their professional practice, workplace environments and in our communities” [17]. Education on incivility and the utilization of cognitive rehearsal programs have mixed effects on nurses’ ability to confront incivility, so the study aimed to evaluate the effect of educational intervention about incivility on psychological wellbeing and burnout among nurses.

1.1.2. Aim of the Study

The aim of the study is to evaluate the effect of educational intervention about incivility on psychological wellbeing and burnout among nurses.

1.1.3. Research Hypotheses

Application of educational intervention about incivility will improve psychological wellbeing and decrease burnout among nurses.

2. Methods

2.1. Research Design

Quasi-experimental design ((one group pre test post test design) was used to achieve the aim of the study.

2.2. Setting

The study was conducted in Menoufia Main university hospital. The Main university hospital consists of seven floors, which contain 142 beds. It provides services to the community through the medical, urology, kidney dialysis, orthopedic, ophthalmology, ENT and toxicology departments. In addition to three operating theaters. Staff nurses in this hospital are 200.

2.3. Sample Size

Sample size was calculated according to the study design and the objectives of the study. Based on review of past literature Spiri et al. 2016 “Incivility in the workplace: A study of nursing staff in the Military health system’. Approximately 88% of respondents reported some sort of incivility in the work Based on this results sample size was calculated at power 80% and confidence level 80% by the following equation

• n = Sample Size

• DEFF = Design effect (for cluster surveys-DEFF): (1.0)

• d= Confidence limits as % of 100(absolute +/- %) (5%)

• N= Population size

• P = margin of error (0.05).

• Z21-α/2 is standard normal variate (at 5% type I error (p <0.05) it is 1.96

The calculated sample was 50 participants.

2.4. Subjects

A simple random sample of 50 staff nurses were selected to constitute the present study subjects from Menoufia Main university hospital under study. Five nurses were chosen from each unit.

2.5. Tools of Data Collection

Based on the review of the related literature four tools were utilized by the researcher to achieve the aim of the study: as the following:

Tool (1): Semi-structured interviewing questionnaire:

Which include socio-demographic characteristics, including: age, sex, education.

Tool (2): Workplace Incivility Scale

Workplace incivility scale developed by [18]. It contain 12 items which were selected to represent workplace incivility on a 5-point Likert scale, ranging from 1 to 5 (1=never, 2=one time, 3=two and three times, 4=more than four times, 5=frequently). Higher scores represented a higher occurrence rate of workplace incivility. The researcher made modification for the scoring system ranges on a 3-point Likert scale from 1 to 3. (1=never, 2= two and three times, 3=frequently)

Tool (3): The Ryﬀ Scales of Psychological Well-Being

The Ryff Scales of Psychological Well-Being was developed by [19], which adapted from [20] to assess Psychological wellbeing. It consists of 42 items covering six dimensions (Autonomy, Environmental mastery, Self-acceptance, Personal growth, Purpose in life, Positive relations with others). The responses were rated on a 7-point scale (1 = strongly agree; 7 = strongly disagree). 1 = strongly agree; 2 = somewhat agree; 3 = a little agree; 4 = neither agree nor disagree; 5 = a little disagree; 6 = somewhat disagree; 7 = strongly disagree. The researcher made modification for the scoring system ranges, as the responses were rated on a 3-point Likert scale labelled from (1 = strongly disagree; 2 = agree; 3 = strongly agree). High score indicate greater well-being.

Tool (4): Maslach Burnout Inventory (MBI)

The Maslach Burnout Inventory (MBI) was developed by [21] consisting of 22 items pertaining to occupational burnout to assess an individual's experience of burnout. The MBI measures three dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. The scoring dimension ranges on a 7-point Likert scale from 0 to 6. (0 = never; 1 = A few times a year; 2 = Once a month or less ; 3 = A few times a month; 4 = Once a week ; 5 = A few times a week; 6 = Very day . The researcher made modification for the scoring system ranges, as the responses were rated on a 3-point Likert scale from 1 to 3. (1 = never; 2 = sometimes; 3 = Very day). Higher scores indicate greater burnout.

2.5.1. Content Validity of Tools

Workplace incivility scale, the ryff scales of psychological well-being and maslach burnout inventory (MBI) were translated by the researcher to Arabic language and tested for its content validity by group of five experts in the psychiatric medicine and nursing. The required modification was carried out accordingly.

2.5.2. Reliability of Tools

Reliability was applied by the researcher for testing the internal consistency of the tool, by administration of the same tools to the same subjects under similar conditions on one or more occasions. Answers from repeated testing were compared (Test-re-test reliability). The tools revealed reliable at 0.82 for tool (1), 0.81 for tool (2) and at 0.83 for tool (3).

2.6. Pilot Study

A pilot study conducted on 10 % of the total sample to test feasibility, clarity and applicability of the tools then necessary modifications were done. Data obtained from the pilot study were not included in the current study.

2.7. Preparatory Phase

-This phase include reviewing of relevant literature and different studies related to the topic of research, using textbooks, article magazines, periodicals, and internet research to get a clear picture of all aspects related to the research topic.

-Administrative and ethical considerations: An official approval was obtained from the Dean of Faculty of Nursing forwarded to the director of Menofia University Hospital. The patients were asked to give an informed verbal consent to participate. It was emphasized that all collected data was strictly confidential and the data would be used for scientific purposes only.

2.8. Data Collection Phase

The study was carried out in the period from March 2019 to May 2019. The researcher divided the staff nurses into four groups; each group consisted from 12 nurses and only two groups contain 13 nurses. The researcher meets each two group one day per week from 9 AM to 11 AM, One hour for each one. The period of implementation of the study was three months which passed into three phases (assessment phase, implementation phase, and post assessment phase)

2.8.1. Assessment Phase

In the first week, a comfortable, private place was chosen for the interview. Orientation was done about the purpose of the study and content of the study. Each nurse was individually interviewed where pre assessment was done using structured interviewing questionnaire, workplace incivility scale, the ryff scales of psychological well-being and maslach burnout inventory (MBI(

2.8.2. Implementation Phase

This study hypothesized that application of educational intervention about incivility will improve the nurses' psychological wellbeing and decrease burnout. This was achieved through 10 specific sessions each session lasted for one hour. The educational intervention was utilized several teaching methods such as brain storming, group discussion; role playing, data show, picture, laptop and posters were used as media. At the end of each session summary, feedback, further clarification was done for vague items and homework activity for the following session

2.8.3. Content of Session

Session 1: Concerned with open discussion for identification, integration of the group, clarification of purpose and time table allowed for program.

Session 2: included didactic session about definitions and examples of incivility and the different ways it can manifest to increase their perception and awareness about incivility.

Session 3: In this session the information was presented on the potential effects of incivility on nurses, patient safety, and organizations

Session 4: included different ways to reduce incivility in work environment

Session 5: Concentrated on how to use the appropriate cognitive rehearsal techniques to respond to incivility.

Session 6: practicing for cognitive rehearsal techniques through role play as a reaction for different situation "give examples in the session"

Session 7: focused on therapeutic communication skills and how to practice it.

Session 8: practicing therapeutic communication skills by role play

Session 9: concerned with various techniques of assertiveness" to increase nurse empowerment when incivility is anticipated.

Session 10: practicing different techniques of assertiveness.

2.8.4. Post Assessment Phase

Evaluation was done using interviewing questionnaire, nurse incivility scale, the ryff scales of psychological well-being and maslach burnout inventory to evaluate the effect of educational intervention about incivility on psychological well-being and burnout among nurses.

A short description of the techniques employed in the study are discussed below.

1-Cognitive rehearsal technique: Cognitive rehearsal in three acts

Griffin, 2014 [22] described cognitive rehearsal as a three-part process. First is participation in didactic instruction. This can include learning to recognize unprofessional behavior, understanding the consequences for employees and patients, discussing the theoretical underpinnings of incivility and bullying, and learning about the work and environmental factors that contribute to the behaviors.

The second part is learning and rehearsing specific phrases to use during uncivil encounters. By using examples of experienced incivility from nurses, the researcher encouraged nurses to form a response utilizing the prompting cards provided. Prompting cards included 10 types of incivility experiences with suggested responses for pre-rehearsal. Incivility situations included nonverbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect, and broken confidences. For example, in response to a nonverbal innuendo, such as a colleague raising her eyebrows, you might say, “I sense (I see from your facial expression) that there may be something you want to say to me. It’s okay to speak directly to me.” In a situation of sabotage or negativity, the response could be, “There is more to this situation than meets the eye. Can you and I meet in private and explore what happened?” If you find that someone is withholding information, you might say, “It’s my understanding that there’s more information available regarding this situation and I believe if I had known that, it would have affected the outcome.”

The final part of the process is rehearsing the responses in preparation for encountering the behaviors in practice. Take about 20 minutes in a relaxed, nonthreatening environment to practice your responses before you meet with the other person.

2- Assertiveness techniques

Various techniques were used to effectively help the participants in the process of becoming an assertive person. Such techniques include responding as a broken record to repeat in a calm voice the simple statement of refusal. Also, agreeing assertively on negative aspects about one when accepting constructive criticism. Another technique is negative inquiring which consists of requesting further, more specific criticism about the negative aspects. Moreover, defusing/delaying assertively by putting off further discussion with another angry individual until one is calmer. Clouding/fogging technique when one can respond to destructive criticism without becoming defensive and without agreeing to change by agreeing with a small part of what an antagonist is saying. Finally, using of "I" statement instead of "You" to express one's feelings and wishes from a personal position [23].

3-Effective Communication Skills

• Listening. Being a good listener is one of the best ways to be a good communicator.

• Nonverbal Communication. Your body language, eye contact, hand gestures, and tone of voice all color the message you are trying to convey

• Clarity and Concision

• Friendliness

• Confidence

• Empathy

• Open-Mindedness

• Respect

2.9. Statistical Analysis

Data were collected, tabulated, statistically analyzed using an IBM personal computer with Statistical Package of Social Science (SPSS) version 20 where the following statistics were applied.

a. Descriptive statistics: in which quantitative data were presented in the form of mean (), standard deviation (SD), range, and qualitative data were presented in the form numbers and percentages.

b. Analytical statistics: used to find out the possible association between studied factors and the targeted disease. The used tests of significance included:

*Student t-test: is a test of significance used for comparison between two groups having quantitative variables.

*ANOVA (f) test: is a test of significance used for comparison between three or more groups having quantitative variables

*Pearson correlation (r): is a test used to measure the association between two quantitative variables.

P value of >0.05 non-significant

P value of <0.05 significant

P <0.001 was considered statistically highly significant.

3. Results

Regarding to basic data among the studied nurses, as shown in (Table 1), it was found that, the studied nurses were in age group (23-49) years and the mean age is 34.14years, the majority of the sample 72% had Bachelor of nursing, 96% were female, The highest frequency (94%) was married, according to income, 56% had enough income.

Concerning to incivility score (Figure 1) revealed that, there was a highly statistically significant difference pre and post intervention (P<0.05).

The result in (Figure 2) illustrated that, there was a highly statistically significant difference found in total psychological well- being and its dimensions score among the studied nurses pre and post intervention (P<0.05).

According to burnout and its dimensions score, as shown in (Figure 3), it was found that there was a highly statistically significant difference found in total mean burnout score and its dimensions among the studied nurses pre and post intervention (P<0.05).

The result in (Table 2) illustrated that, there was statically significant positive correlation between burnout and incivility pre and post intervention .i.e. when incivility increase burnout will increase (P<0.05). There was statically significant negative correlation between psychological well-being, burnout and incivility pre and post intervention. i.e. when incivility decrease psychological well-being will improve, also when psychological well-being improved burnout will decrease.

As shown in (Table 3), it was found that, there was negative correlation between age, psychological well-being, burnout and incivility post intervention .i.e. incivility and burnout increased with young age and psychological well-being was higher with young age (P<0.05)

Table 4, illustrated that, there was a statistically significant difference between all socio-demographic characteristic and total psychological well-being score pre and post intervention except with level of education post intervention.

Table 5, illustrated that, there was a statistically significant difference between between all socio-demographic characteristic and total burnout i score except with level of gender pre intervention.

Table 6, illustrated that, there was a statistically significant difference between all socio-demographic characteristic and total incivility score.

Table 1. Socio-Demographic Characteristics of The Studied Nurses (N=50)

Figure 1. Total Mean Incivility Score among The Studied Nurses Pre And Post Intervention (N=50)

Figure 2. Total Mean Psychological Well- Being and Its Dimensions Score Pre And Post Intervention (N=50).

Figure 3. Total Means Burnout And Its Dimensions Score Among The Studied Nurses Pre And Post Intervention (N=50)

Table 2. Pearson Correlation between Psychological Well- Being, Incivility And Burnout

Table 3. Pearson Correlation between Psychological Well- Being, Incivility, Burnout And Age

Table 4. Relation between Psychological Well-Being and Socio Demographic Characteristics of the Studied Group (N=50)

Table 5. Relation between Burnout and Socio Demographic Characteristics of The Studied Group (N=50)

Table 6. Relation Between Incivility And Socio Demographic Characteristics Of The Studied Group (N=50)

4. Discussion

Acts of incivility are devastating to nurses, affecting their performance, mental health, and intention to remain with an organization or even within the profession of nursing. Hospitals and healthcare organizations experience additional consequences from an uncivil work environment through increased costs related to nursing turnover, absenteeism, and decreased work performance [24]. Also nurses who experienced incivility reported decreased morale, job satisfaction and a loss of productivity [25]. In addition to stress related responses, such as negative mood or irritability, headaches or fatigue, fear or helplessness, anxiety or worry, impaired social skills, depression, fatigue, loss of concentration and cognitive distraction, psychosomatic complaints, posttraumatic stress disorder, and burnout [3].

Nurse incivility negatively affects nurses, organizations and patients. Nurses must be able to recognize and confront incivility in order to manage this behavior in their work environments. Educating nurses on incivility and teaching them cognitive behavioral techniques to deal with this behavior affected their ability to recognize and confront incivility and examined the effect on perceived instances of incivility and job satisfaction [26]. The current result agreed with this statement where our study showed that, there was a highly statistically significant difference pre and post intervention regarding incivility. This indicates the effectiveness of education and cognitive rehearsal techniques in increasing nurses’ awareness and ability to confront of uncivil behavior. In other hand, this is congruent with [27]. Who reported that the use of a combination of educational training about workplace incivility, training about effective responses to uncivil workplace behaviors, and active learning activities to practice newly learned communication skills, in assisting nurses in improving their ability to manage incivility in the workplace.

According to burnout and psychological well- being score, it was found that there was a highly statistically significant difference in total mean burnout and psychological well- being score among the studied nurses pre and post intervention .i.e. the educational intervention about incivility had positive effect on the psychological well-being among nurses where improved after intervention and also had positive effect on burnout among nurses where decreased after intervention. This is congruent with the results of the present study which revealed that there was statically significant negative correlation between psychological well-being and incivility pre and post intervention .i.e. when incivility decreased psychological well-being improved and significant positive correlation between burnout and incivility pre and post intervention .i.e. when incivility decreased burnout decreased.

The result illustrated that, there was statically significant negative correlation between psychological well-being and incivility pre and post intervention .i.e. when incivility decreased psychological well-being improved. This result supported by [28]. Who indicated that workplace incivility is significantly correlated with psychological wellbeing of the study where r is equal to .597 with p value of 0.01. Also the current study revealed that, There was statically significant negative correlation between psychological well-being and burnout pre and post intervention .i.e when psychological well-being improved burnout decreased. This result supported by [28]. Who mentioned that the contrary relationship between emotional exhaustion (burnout) and employee psychological wellbeing has strong associations.

The result showed that, there was statically significant positive correlation between burnout and incivility pre and post intervention. i.e. when incivility decreased burnout decreased. This result in the same line with [28] who found that workplace incivility has a strong association with emotional exhaustion (burnout). Also this result constant with the results of [29]. Indicated that workplace incivility, and burnout explained signiﬁcant variance. In addition this result supported by [10] which the findings showed that workplace incivility was positively correlated with job burn-out (r=0.238, p<0.01) of new nurses.

The current study revealed that, the studied nurses were in age group (23-49) years and the mean age is 34.14years and rang of years of experience is 23 years. This result disagreed with the finding of [30] . Who indicated that the majority of the participants were in the age range of 41-50 (26%) and 51-60 (21%). Fifty-six percent of the nurses surveyed indicated having between two to twenty years of experience. Also the present result founded that the majority of the sample 72% had Bachelor of nursing. On the contrary [30] . Illustrated that over half of the participants (54%) had an associate degree in nursing, 38% had a bachelor degree, and 8% had a master degree.

This study showed that 96% were female. This result supported by [31]. Who mentioned that the data indicate that a majority of the sample is women (90.4%) with an average age of 24.6 years. Also the present result founded that the highest frequency (94%) was married, this result contradicted by [31] who found that almost 85.3% are unmarried.

5. Conclusion

Implementation of educational intervention about incivility has a positive effect on improving psychological well-being and decreasing burnout among nurses.

6. Recommendation

Based upon the results of the study, a recommendation to implement educational intervention about incivility throughout the organization to improve psychological well-being and decrease burnout among nurses.

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