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Workplace Incivility: Perceptions Of Urologic Nurses.

Incivility, a term used to describe lateral violence or workplace bullying, has been documented in the nursing literature since the mid-1980s (Roberts, 1983). As a research construct, workplace incivility was initially described by Andersson and Pearson in 1999 as "low-intensity deviant behavior with ambiguous intent to harm" (p. 456). These behaviors differ from overlap aggressive, violent, deviant, and antisocial behaviors. According to Andersson and Pearson (1999), incivility is differentiated from these behaviors. As depicted in the model, if incivility is not addressed, it may spiral, resulting in more frequent occurrences that have greater intensity. Ultimately, there is a tipping point, where employees are at risk to be physically and/or psychologically harmed, and the organization becomes an uncivil entity (Kamp & Brooks, 1991).

The issue of workplace incivility in health care and its effects have reached such epidemic proportions that The Joint Commission (TJC) (2008), the American Nurses Association (ANA) (2015a), and the World Health Organization (WHO) (2015) published position statements and outlined responsibilities and recommendations. Outcomes from workplace incivility within the profession of nursing have been categorized as personal, patient-related, and organizational. Personal consequences include job dissatisfaction (Rodwell, Brunetto, Demir, Shacklock, & Farr-Wharton, 2014), decreased personal health (Spector, Zhou, & Che, 2014), increased absenteeism (Samnini & Singh, 2012), and leaving the profession (Vessey, Demarco, & DiFazio, 2010). Organizational outcomes include decreased productivity (Edward, Ousey, Warelow, & Liu, 2014), retention (Laschinger, 2014), and expenses associated with investigating, managing, and providing legal assistance (Lipscomb & London, 2015). Negative patient outcomes include medication errors and patient falls (Roche, Diers, Duffeld, & Catling-Paull, 2010), as well as physical assaults by patients or members of their family (ANA, 2014). Incidences of incivility have been reported by 43% of registered nurses (ANA, 2015b).

Incivility within the profession of nursing may occur in relationships that are irregular (patient/family/visitor), vertical (manager to nurse or nurse to manager), unrelated (nurse to other healthcare professional or other healthcare professional to nurse), or horizontal (nurse to nurse) (Longo & Sherman, 2007). The terms horizontal and lateral have been used interchangeably to describe uncivil behaviors between peers at the same level (Longo & Sherman, 2007). While each form of incivility has specific definitions, descriptions, and outcomes, this study focused on lateral incivility, or incivility among nurses working in clinical settings that provide urologic care.

The goal of this research project was to determine the presence of workplace incivility from a peer among members of the Society of Urologic Nurses and Associates (SUNA). This focus was selected to obtain data useful in developing and implementing interventions specific to the nursing population--how nurses can change the work environment for their peers. While there is a plethora of research data describing workplace incivility, in both clinical and academic settings, there is a paucity of data specific to urology nurses and urologic healthcare settings.

Incivility and the Urologic Nurse

The urgency of treatment for a patient with a urologic condition results in care being provided in clinical settings known to have high incidences of incivility. Robinson, Jagim, and Ray (2004) posit that stress and the acuity of patients, along with staffing issues and burnout in clinical areas that provide critical care, result in higher incidences of incivility. While incivility can occur in any clinical setting, emergency departments and operative settings are at greater risk (McNamara, 2012), a result of the urgency of care provided in these settings.

Initially described by Spence Laschinger, Leiter, Day, and Gilin in 2009, workplace incivility was a strong predictor for job retention. This finding has been supported through subsequent research (Leiter, Price, & Spence Laschinger, 2010), with Generation X nurses (those between the ages of 32 and 50 years) reporting greater negative work environments, defined as burnout, turnover intent, physical symptoms, supervisor incivility, and coworker and team incivility. Each variable has been linked to retention issues. While organizational structure and zero-tolerance policies are necessary to prevent and discipline individuals who engage in incivility, personal knowledge is also necessary. Lachman (2014) describes nurses, without specifying educational preparation, as lacking skills necessary to identify and deal with workplace incivility. These include conflict resolution and assertiveness training (Lachman, 2014). Knowing and providing interventions specific to peer-to-peer work environments for urologic nurses will strengthen our profession and provide a mechanism to ensure the care we provide remains stellar.


The purpose of this survey design study was to allow members of SUNA to describe their experience with respect to workplace incivility from a peer, referred to as lateral incivility.



Study data included demographic data and two instruments that assess workplace incivility from nurses employed in clinical settings. These instruments were the Positive and Negative Affect Schedule Short-Form (PANASSF) tool (Thompson, 2007) and the Uncivil Behavior in Clinical Nursing Education (UBCNE) survey (Anthony, Yastik, MacDonald, & Marshall, 2014). In addition to demographic data, each participant was provided the opportunity to numerically (0 [not at all] to 10 [extremely satisfied]) describe job satisfaction and peer collaboration from his or her perspective.

Demographic data. Specific demographic data were collected to describe the study population. Urologic nursing-specific data, such as the clinical site, educational background, and urology certification, were also obtained. Two items--assessing job satisfaction and satisfaction with peer collaboration--were added to the demographic data section. These items were added to assess 'hallmark' characteristics of nursing work environments as identified by the American Association of Colleges of Nursing (AACN) (2002).

PANAS-SF. This 10-item mood scale allows the participant to describe the frequency (never to always) for 5 positive and 5 negative adjectives (Thompson, 2007). Study instructions directed the participant to select the response that best described his or her feelings in general. Reliability data for the PANAS-SF are similar to that reported for the 60-item PANAS (Watson & Clark, 1994). Research, using the PANAS-SF (Mackinnon et al., 1999), attained a reliability measured by Cronbach alpha as 0.87. Confirmatory factor analysis attained a two-factor model in which all items loaded to the appropriate construct and were statistically significant. The decision to use the PANAS-SF was made to provide brevity in data collection without loss of reliability. Each participant describes (from never to always) how often he or she feels the adjective used in the survey. Previous research demonstrated a relationship between the PANAS to depression and anxiety (Crawford & Henry, 2004). Depression, anxiety, and stress have been correlated to staff nurse job satisfaction, satisfaction with the quality of care provided, and job attrition (El-aal & Hassan, 2014).

Scoring responses on the PANAS-SF were performed as outlined by Thompson (2007). Positive affect was assessed by responses on 5 adjectives (active, determined, attentive, inspired, alter). Total PANAS scores for positive attributes were computed by summation of the alert, inspired, determined, attentive, and active metrics; mean was computed as total positive PANAS scores divided by 5, with higher scores correlating to higher positivity affectivity. Negative affect was assessed by responses on five adjectives (afraid, nervous, upset, hostile, and ashamed). Total PANAS scores for negative attributes were computed by summation of the upset, hostile, ashamed, nervous, and afraid metrics; mean was computed as total negative PANAS scores divided by 5, with higher scores correlating to higher negativity affectivity.

UBCNE. The original UBCNE was a 30-item, Likert-response survey purported to measure incidences of incivility, specifically between nurses, within a clinical setting. After initial testing (Anthony et al., 2014), the survey was revised by eliminating 8 items. These items were dropped as a result of loading highly on more than one component or not loading on the expected component. For the purpose of this study, items within the UBCNE survey were edited to reflect clinical scenarios rather than clinical rotations. Thus, the UBCNE contains no reference to student nurses and consists of 12 items that assess uncivil behavior using a 5-point Likert-type scale. Possible responses range from 0 (never) to 4 (very often). A total incivility score can be calculated by summing total scores; hostile/rude and exclusionary behavior subscale scores may also be calculated. Thus, the UBCNE is capable of describing incivility in a clinical setting and determining if the source of the incivility is due to hostile/rude behavior or exclusionary behavior. Inter-item reliability of the UBCNE, when administered to 106 clinical nurses, was 0.93. Reliability of the two subscales was as follows: hostile/rude was 0.86, and exclusionary was 0.86. Thus, the UBCNE has demonstrated reliability in assessing incivility as the result of hostile/rude or exclusionary behavior between nurses in clinical settings.

Scoring responses on the UBCNE were performed as outlined by Anthony and associates (2014). Hostile/rude behavior was assessed by responses on 6 scenarios; exclusionary behavior was assessed by responses on 6 scenarios. Total incivility scores were computed by summation of all 12 UBCNE metrics; the mean incivility was total incivility score divided by 12. The hostile behavior sum score was computed by summation of the following metrics: being embarrassed in front of others, rolled eyes at you, used inappropriate tone, raised their voice, told you that you were incompetent, and refused to help you. The exclusionary behavior sum score was computed by summation of the following metrics: incomplete report, avoid taking report, avoid giving report, made snide remarks, and did not involve you in patient care. As described by Anthony and colleagues (2014), higher scores on the UBCNE correlate to increased incidences of incivility.


This survey design study obtained data from volunteer participants who are nurses and members of SUNA. Participants in this study are engaged in the profession of nursing, leaders in their organizations, and dedicated to enhancing the workplace experience for all.

Institutional Review Board (IRB) permission to conduct the study was secured by the Social Science IRB at the employer of the primary investigator (PWS). In accordance with the Federal Policy for the Protection of Human Subjects 45 CFR Part 46.101b, the study met criteria for exempt status; thus, consent was implied upon submission of survey responses. Data were collected using Research Electronic Data Capture (REDCap) (Harris et al., 2009), a secure web-based research electronic data capture software program. This software program complies with HIPAA regulations and provides greater security than other web-based data collection formats.

A study invitational email was sent from the SUNA National Office to each current member of the organization. A study description, aim, time requirement, and a link to access the study surveys were contained within this email. If participation was desired, the individual was instructed to click on the survey link. Once clicked, the initial item confirmed consent for participation. From there, each survey, with instructions detailing how to complete it, was provided.


The study invitational email was sent to an estimated 2,050 individuals, which represents all SUNA members. Study inclusion criteria were limited to presently employed registered nurses; thus, the potential study population is unknown. In response to the email, the study site link was opened by 664 individuals, with 207 opening the survey. This calculates to a 31.2% study contact rate (207/664). Surveys were completed by 173 of these individuals, indicating an 83.6% completion, or response, rate (173/207). Thus, the study population consisted of 173 consented, uncompensated, volunteer nurse participants who were members of SUNA.

Frequency statistics were calculated and determined these data met the assumptions of normalcy; thus, parametric statistics were appropriate. Data were compared using Student's t test for continuous variables and Chi square for categorical variables. Analyses were conducted with SPSS Software version 24 (IBM, 2015). All tests performed were two-tailed, and p values less than 0.05 were considered statistically significant. Complete case analyses were performed.

Demographic characteristics. Demographically, 76.3% of these participants (n=132) described themselves as over the age of 46 years. The most frequent age range was 56 to 60 years (n=40; 23.1%), following closely by 51 to 55 years (n=36; 20%), with 61 to 65 years (n=27; 15.6%) the third most frequent category. According to AACN (2016), the average age of a nurse is 47 years; 55% of the RN workforce is age 50 years or older. Thus, this study population mirrors the composition of nurses. The age distribution is displayed in Table 1.

Academically, 29.5% of these participants (n=51) identified their highest degree earned as a bachelor of science degree in nursing (BSN). Forty-three participants stated they have a master degree in nursing (MSN). Combining these data with the 15 participants who report having a doctorate in nursing (DNP) or a doctorate in philosophy in nursing (PhD) allows a comparison of the study population to data maintained by AACN (2011).

When combined, 58 participants, or 33.5% of the study population, reported having an advanced degree in nursing. Ten participants reported earning an advanced degree not in nursing (see Table 2). Reports from AACN (2017) include only individuals with advanced degrees in nursing; thus, individuals with advanced degrees not in nursing were excluded from academic preparation calculations.

Multiple options allowed each participant to describe their practice setting a variety of ways; thus, there are 194 responses to this item. Collapsing these categories into general settings (inpatient, outpatient/clinic, private/ specialty practice) provides an overview of the settings in which these participants provide urologic care. According to AACN (2016), 62.2% of all employed nurses work in a hospital setting. Assuming the outpatient/clinic settings are adjacent to an inpatient setting and adding these individuals to the inpatient category result in 109 (56.1%) of the study population who work in a hospital setting (AACN, 2016). This is still below the national average; thus, the workplace of this study population does not reflect the nursing workforce in general. A significant number of the study population (43.8%) work in private practice or academic/industry settings, which are considered non-traditional by AACN (2016). Table 3 displays practice setting descriptions.

Certification as a urologic nurse (through the Certification Board for Urologic Nurses and Associates [CBUNA]) was reported by 67 (38.7%) of participants; 34 (50.1%) of these individuals were also educationally prepared at an MSN level or higher.

Within demographics, such as age category, academic preparation, specialty, practice type, clinic type, years practicing total, and years practicing urologic-specific, there were no significant differences (see Table 4). Nurses not certified in urology were significantly (p=0.019) more likely to report plans to leave their current job in the next 12 months.

Nurses who did not plan to remain in their current job for 12 months had higher total incivility scores (19.96[+ or -]10.62 versus 14.20[+ or -]9.538, p=0.005) and higher average scores (1.66[+ or -]0.88 versus 1.18[+ or -]0.79, p=0.005). Nurses who did not plan to remain in their job for 12 months were more likely to have experienced exclusionary and hostile behavior (10.11[+ or -]5.82 versus 7.21[+ or -]5.24, p=0.01; 9.85[+ or -] 5.63 versus 6.99[+ or -]4.83, p=0.007), respectively. Nurses planning to not remain in their current position for 12 months scored lower on the PANAS positive attribute scales both in total and on average (19.66[+ or -]3.55 versus 21.24[+ or -]2.71, p=0.009; 3.93[+ or -]0.71 versus 4.24[+ or -] 0.54, p=0.009, respectively), and higher on negative PANAS attribute scales in total and on average (12.14[+ or -]4.67 versus 9.64[+ or -]3.36, p=0.001; 2.42[+ or -]0.93 versus 1.92[+ or -] 0.67, p=0.001, respectively).

Summary and Conclusion

Demographically, the study population varies from national statistics. The highest degree earned for 31.4% of participants of this study was reported as a BSN, while nationally, 36.8% of registered nurses have a BSN (AACN, 2017). The Institute of Medicine (IOM) (2010) recommends that 80% of RNs attain a BSN by 2020 and that essential course content include identifying and addressing workplace incivility. Thus, the decreased number of BSN-prepared nurses may contribute to the incivility experience. Earning an advanced degree (MSN, DNP, PhD) was reported by 33.6% of the study population. This is almost three times the national average of 13.2% of nurses who report earning an advanced degree (AACN, 2011). Comparing the study population to national norms reflects a slightly lower number of BSN-prepared nurses yet a higher-than-average number of MSN-prepared nurses. Participants in this study were not generalist nurses, but nurses with a specific specialty. Greggs-McQuilkin (2005) determined that individuals who are members of a professional organization differ from non-members. Members of professional organizations seek educational, networking, and career assistance. In summarizing the experiences of lateral violence among nurses with all educational preparation, the new graduate or novice nurse is most vulnerable (Ciocco, 2017).

In an effort to describe the impact of lateral violence, subgroups were developed based on the participant's response to remaining on the job for the next 12 months. Comparing experiences of these two groups provided a method of determining the effect lateral violence has on retention.

Results from the PANAS-SF described statistically significate lower total scores (p=0.009), statistically significant positive attribute scores (alert, inspired, determined, attentive, and active) (p=0.009), and higher negative attribute scores (upset, hostile, ashamed, nervous, and afraid) (p=0.001). These results indicate negative feelings toward the present work environment. There are notable differences in workplace incivility; those planning to exit their present workplace described an uncivil workplace.

Results from each subscale (hostility and exclusionary) of the UBCNE were summed then compared. Participants not planning to remain in their present position reported higher incidences of general uncivil behaviors. While both exclusionary (p=0.01) and hostile behaviors (p=0.007) were described as a reason, hostile behaviors had a greater impact.

For SUNA members, incivility appears to have a statistically significant impact on the desire to remain in one's present position. While knowing 18.5% of SUNA members plan to change jobs in the next 12 months may be comforting, AACN (2017) predicts a 20% shortage of nurses by 2020. Thus, the need for urologic nurses will be as critical as the need for any nurse. Participants in this study who are certified as urologic nurses (n=67; 38.7%) indicated a higher-than-average desire to remain in their present position.

Results of this study provide research evidence that can be used when developing and implementing programs to address workplace incivility, specifically for the urologic nurse. Mentoring and career development programs should focus on the identification of negative feelings and ways to prevent/minimize their effect. Anxiety and stress have been identified as outcomes of workplace incivility; educational offerings can provide skills necessary to cope with these feelings. These results also describe hostile behaviors that result in workplace incivility. Educational sessions that identify these behaviors and provide appropriate responses are beneficial. Knowing how to properly address inappropriate behaviors and an awareness of the organizational policies that prevent workplace incivility would allow the nurse to prevent further episodes of inappropriate behavior.

Workplace incivility has significant negative implications for nurses, our patients, and healthcare organizations. Conversations and interventions aimed at identifying and addressing incivility must occur. Data from this study describe the scenario specific to SUNA members. While these results may be more positive than those experienced by general nurses or in other clinical specialty areas, we have challenges. Providing a safe, civil workplace environment requires efforts from all urology nurses. One effect of incivility, as reported by these participants, is the intent to leave the present position. While job changes occur for many reasons, these data reflect the effect incivility has. While organizational change, policy development and implementation, and behavioral consequences should be developed, identifying and addressing exclusionary and hostile behaviors that occur laterally are interventions all can provide.

Research Summary


Workplace incivility, or a negative work environment, has been linked to professional burnout, turnover intent, physical symptoms, and patient errors. Obtaining data directly from healthcare professionals who provide urologic care will allow workplace issues to be assessed directly, assuring interventions developed and presented are evidence-based.


The purpose of this survey design study was to allow members of the Society of Urologic Nurses and Associates (SUNA) to describe their experience with respect to workplace incivility from a peer (lateral incivility).


Data encompassed two previously validated survey instruments and self-disclosed demographic responses. Instruments included the Positive and Negative Affect Schedule Short-Form (PANAS-SF) and Uncivil Behavior in Clinical Nursing Education (UBCNE) instruments and minimal demographic data. Demographic data were used to describe the study population and correlate responses to each instrument based on intent to remain in the present job for the next 12 months.


Data were collected from 173 SUNA members. Workplace incivility was described by 25.3% of the study population as severe enough for them to be planning to leave their present position within the next 12 months. This number is higher among participants not certified in urology.

Level of Evidence--III-B

Johns Hopkins Hospital/Johns Hopkins University, 2016.

doi: 10.7257/1053-816X.2018.38.1.20

Peggy Ward-Smith, PhD, RN, is Interim Dean, School of Graduate Studies, and Associate Professor, School of Nursing & Health Studies, University of Missouri Kansas City, Kansas City, MO; and a member of the Urologic Nursing Editorial Board

Jane Hokanson Hawks, PhD, RN-BC, FAAN, is a Professor and Core Coordinator, MSN Nurse Executive Program, Nebraska Methodist College, Omaha, NE; and is the former Editor of Urologic Nursing.

Susanne A. Quallich, PhD, ANP-BC, NPC, CUNP, FAANP, is an Andrology Nurse Practitioner, Division of Andrology and Urologic Health, Department of Urology, University of Michigan Health System, Ann Arbor, MI; and Editor, Urologic Nursing.

Jeremy Provance, MS, is a Software Analyst--Kansas City School of Medicine, University of Missouri, Kansas City, MO.

Authors' Note: This study was supported by a grant made available by the Society of Urologic Nurses and Associates (SuNa) Foundation and The Allergan Foundation.

Findings of the study do not necessarily reflect the opinions of SUNA. The views expressed herein are those of the authors, and no official endorsement by SUNA is intended or should be inferred.


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Table 1.
Age Distribution of Study Population

Age Range (Years)    Number of        Percent of
                    Participants   Study Population

20 to 25                 2               1.2
26 to 30                 7               4.0
31 to 35                10               5.8
36 to 40                16               9.2
41 to 45                 6               3.5
46 to 50                22              12.7
51 to 55                36              20.8
56 to 60                40              23.1
61 to 65                27              15.6
Greater than 65          7               4.0

Table 2.
Academic Preparation

Educational Preparation                Number of        Percent of
                                      Participants   Study Population

Associate degree in nursing (ADN)         33              19.1
Diploma in nursing (Dipl)                 21              12.1
Bachelor degree in nursing (BSN)          51              29.5
Master degree in nursing (MSN)            43              24.9
Non-nursing master degree                  8               4.6
  (MA or MS)
Doctorate degree in nursing                7               4.0
  practice (DNP)
Doctorate degree in nursing (PhD)          8               4.6
Non-nursing doctorate degree (PhD)         2               1.2

Table 3.
Practice Setting Descriptions

Clinical Setting               n (%)

Inpatient                    29 (14.9%)
Outpatient/Clinic            80 (41.0%)
Private/Specialty practice   57 (29.5%)
Academic/Industry/Other      28 (14.5%)

Table 4.
Plans to Remain in Current Job Comparison, Incivility, and PANAS

Metric                  Plan to remain in job for the next 12 months?

                              No (n=27)             Yes (n=146)

Total Incivility        19.96 [+ or -] 10.62   14.20 [+ or -] 9.538
  Sum Score
Mean Incivility Score     1.66 [+ or -] 0.88     1.18 [+ or -] 0.79
Exclusionary Behavior    10.11 [+ or -] 5.82     7.21 [+ or -] 5.24
  Sum Score
Hostile Behavior          9.85 [+ or -] 5.63     6.99 [+ or -] 4.83
  Sum Score
Total PANAS Positive     19.66 [+ or -] 3.55    21.24 [+ or -] 2.71
Mean PANAS Positive       3.93 [+ or -] 0.71     4.24 [+ or -] 0.54
Total PANAS Negative     12.14 [+ or -] 4.67     9.64 [+ or -] 3.36
Mean PANAS Negative       2.42 [+ or -] 0.93     1.92 [+ or -] 0.67

Metric                  p-Value

Total Incivility         0.005
  Sum Score
Mean Incivility Score    0.005
Exclusionary Behavior    0.010
  Sum Score
Hostile Behavior         0.007
  Sum Score
Total PANAS Positive     0.009
Mean PANAS Positive      0.009
Total PANAS Negative     0.001
Mean PANAS Negative      0.001

Note: Continuous variables compared using Student's t test;
categorical variables compared using Chi-square.
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Title Annotation:Research
Author:Ward-Smith, Peggy; Hawks, Jane Hokanson; Quallich, Susanne A.; Provance, Jeremy
Publication:Urologic Nursing
Article Type:Report
Date:Jan 1, 2018
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