Scholarly article on topic 'Evaluating the Incivility between Staff Nurses and Matrons Employed in Iran / Procena nepristojnog ponašanja u međusobnom odnosu medicinskih sestara i glavnih medicinskih sestara zaposlenih u Iranu'

Evaluating the Incivility between Staff Nurses and Matrons Employed in Iran / Procena nepristojnog ponašanja u međusobnom odnosu medicinskih sestara i glavnih medicinskih sestara zaposlenih u Iranu Academic research paper on "Educational sciences"

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Acta Facultatis Medicae Naissensis
OECD Field of science

Academic research paper on topic "Evaluating the Incivility between Staff Nurses and Matrons Employed in Iran / Procena nepristojnog ponašanja u međusobnom odnosu medicinskih sestara i glavnih medicinskih sestara zaposlenih u Iranu"

DOI: 10.1515/afmnai-2015-0014


UDC: 616-083:316.772.4(55)

Original article

Evaluating the Incivility between Staff Nurses and

Matrons Employed in Iran

Abbas Heydari1 , Mojtaba Rad2, Mostafa Rad3

1Associate Professor, School of Nursing and Midwifery,Mashhad University of Medical Sciences, Mashhad, Iran 2Faculty Member of Nursing and Midwifery College, Sabzevar University of Medical Sciences, Sabzevar, Iran

3PhD candidates in Nursing, Department of Nursing, Faculty of Nursing and Midwifery, Mashhad University of

Medical Sciences Mashhad, Iran


Incivility among nurses and matrons can lead to various issues such as employment turnover and dysfunctional patient care. Therefore, the need to examine and assess the uncivil behaviors among nurses and matrons is evident. The main purpose of this article is to study and determine the frequency of incivility between nurses and matrons from nurses' point of view.

In this cross-sectional study, 200 nurses were selected from three educational hospitals of Mashhad using stratified-cluster random sampling method. The main research instrument was the edited Ottinofs questionnaire of "perceived workplace civility climate scale (PWCC)" as well as general demographic information questionnaire. Data were analyzed using descriptive and inferential statistics in SPSS version 11.5.

According to research findings, 22.6% of isolating behaviors, 27% of gossiping behaviors, 28% of hostile behaviors, and 26.5% of privacy violation behaviors were reported among matrons for at least one instance. In total, 28.8% (45 persons) admitted that they had observed at least one instance of uncivil behaviors in workplace once or twice.

Incivility exists among a quarter of nurses and matrons. Since in nursing society and culture of Islamic Iran these behaviors cannot be tolerated, it is highly recommended that managers, strategists, and nursing teachers pay a special attention to such behaviors among students, employers, and co-workers.

Key words: incivility, nurses, matrons, interactions, behavior, Iran

Corresponding author: Mostafa Rad



Incivility is a behavior which is not as intense as violence and is vague in its purpose and generally intends to harm the other side of communication (victim). This behavior usually violates workplace's norms (1), and characterized by its rudeness and discourtesy, it generally displays a lack of regard for others. Other forms of incivility include sarcasm, humiliation (in voice tone or contemptuous phrases), hostile stares and ignoring others' questions or communications, neglecting others, shouting, interrupting others' conversations, gossiping, and abusing others' privileges. (2, 3).

Incivility and bullying in nurses is a complex issue which attracts a lot of interest of scholars and researchers. Evidences have shown that incivility in workplace can lead to many harmful issues for nurses, patents, and health care organizations (3, 4). Changes in working conditions, increasing workloads, complexity of health care systems, and defective and incomplete communications in workplaces equipped with modern technologies such as voice mails, emails, and teleconferences are some of the reasons believed to be behind these behaviors (5).

Improving workplace environment as well as boosting the supportive connection between nurses are some important factors that can increase organization's productivity and prevent nurses from leaving their jobs. Correct interaction between nurses in workplace not only improves self-efficacy, hope, optimism, and flexibility, but also can reduce occupational burnout, physical and mental health risks, and employment turnover in stressful conditions. Nursing managers should help to prepare a supportive tension-free workplace in order to keep their current staff as well as attracting new employees (6). Uncivil behaviors in workplace are threatening forces causing undesirable reactions such as shame, embarrassment, and incompetence among nurses which can lead to health issues as well as disrupting the atmosphere of organization's environment which in turn would cause countless negative effects if not properly controlled (1).

Previous studies have shown that incivility and dictatorship is fairly common among nurses. With a frequency reported to be between 80-90%, verbal abuse is one the most common uncivil behaviors among healthcare-related workers. Bullying is believed to range from 1 to 4% (1). Among medical teams, the most verbal abuses belong to doctors and

nurses, respectively (7). Bullying is a hidden issue among American nurses which is affecting patient care quality as well as employees' potency (8). In an article, 89% of Americans called incivility "a serious issue" while 78% believed that things got even worse in the last 10 years. Workplace incivility is not limited to this field and can be found in nearly all organizations and therefore its psychological damages is a universal and worrisome issue (1). In Cortina's article it was reported that 71% of nurses have had uncivil behaviors in the last 5 years in which over one third of them were from people in power positions. While its effect is evident in both groups, females are victimized more than males (5). In a study by Rad et al. it has been shown that incivility exists among Iranian students and educators, and disrespectful behavior will change them into uncivil personnel in the long run (9). Incivility can ultimately lead to violence. In a study regarding violence in workplace, 38.9% of verbal abuse incidents in the last 12 months were reported. Moreover, 3.1% of physical abuse and 7% of rape incidents were also reported (10). Shoghi et al. (2008) reported 87.6 cases of verbal abuses during a 6-month period and 27.6 cases of physical violence during that same period (11). Vessey (2009) reported that 70% of nurses have experienced bullying behaviors from their superior staff (8). While incivility is distinct from violence and physical aggression, since the perpetrator does not want to directly harm anyone, yet such uncivil behaviors can lead to bullying and violence and ultimately have severe consequences on job satisfaction and effectiveness of health care workers especially nurses (12).

Studies have confirmed an alarming rate of incivility in western societies. Regarding workplace violence, a few researches have been conducted and confirmed its relatively high occurrence (11). Only one study has been conducted on workplace behavior and its results showed that the most uncivil behaviors have been between nurses and doctors, while their frequency has been higher in high stress positions such as emergency department staff (14).

A quality health care service needs a good communication between nurses and other related staff. Unfortunately, the communication between nurses has been on a downward spiral in recent years and incivility and bullying are alarmingly increasing day by day. Power abuse, insulting, unnerving, offending, and repetitive unjust actions will prompt victims to feel humiliated and vulnerable causing

dangerous physical and mental stress which could eventually destroy their self-esteem (14). Discontentment towards working environment is one of their culprits behind employment turnover (15). Since there are not enough nurses in Iran and the employed nurses have a great responsibility in their working environments, managers and leaders should take appropriate actions to protect them from any form of incivility including verbal abuse, hostility and grudge, gossiping, and sabotage (16). To fully eradicate incivility, nurses and matrons should have a complete understanding regarding these behaviors (1). Therefore, considering the issues caused by incivility among nurses and matrons, recognizing and understanding these behaviors is imperative. This knowledge would help managers to improve their methods to prevent these behaviors from happening in their work environment. This research was conducted to evaluate the frequency of incivility among nurses and matrons.


This research is a cross-sectional study conducted on 200 nurses employed in the educational hospitals of Mashhad University of Medical Sciences. Research units were selected from 3 educational hospitals of Mashhad using multi-step stratified-cluster random sampling method. After calculating the sample size, 3 hospitals were randomly selected from 12 educational hospitals of Mashhad. Then, considering the population of nurses in each selected hospitals, a specific number of qualified persons were selected from each hospital and each department.

Sampling process and data collecting was done during a 2-month period (June - July of 2014). Entry criteria of nurses for this research were their bachelor or master's degree, their employment in educational hospitals, and at least one year of clinical work on their service record. In order to gather data, incivility and demographic info questionnaires were used. An edited version of "perceived workplace civility climate scale (PWCC)" questionnaire from Ottinot's research was used. This questionnaire was extracted from his thesis on evaluating employees' understanding of incivility and verbal violence in workplace. The original research had been done with the help of 189 new workers and 99 veterans (17).

This scale was edited and corrected by scholars

and its validity was confirmed using confirmatory factor analysis. A preliminary study was done on 50 nurses, and reliability of the scale was confirmed with Cronbach's alpha coefficient of 90%. Final edited questionnaire included 43 items for uncivil behavior in workplace, which in turn were categorized into four sections of gossiping, isolating, hostility, and privacy violation behaviors. Scaling of the items was set from 1 to 5; 1 meant that the person had never encountered incivility in workplace, 2 meant that the person had encountered incivility 1 or 2 times in workplace, 3 meant that the person had encountered incivility 1 or 2 times per month in workplace, 4 meant that the person had encountered incivility 1 or 2 times per week in workplace, and 5 meant that the person encounterd incivility on a daily basis. This questionnaire also includes 11 items to scale job satisfaction, 4 items to scale interpersonal conflicts in work environment. Job satisfaction was measured using a five score Likert scale (1 to 5). One meant the least satisfaction regarding workplace, and 5 meant the highest satisfaction regarding working environment. Finally, demographic info questionnaire consisted of 9 items designed to gather appropriate data. After sharing the questionnaire with 10 nursing university masters and 5 staff nurses of Mashhad hospitals, in order to improve its face and content validity, several items were omitted due to their cultural incompatibility or repetitiveness, and the final incivility questions were reduced to 43 questions.

After receiving permissions and introduction letters from Mashhad University of Medical Sciences, research team was granted the permission to all desired departments. Team members discussed the purpose of the research to all nurses working in desired departments and were granted their cooperation. Then, questionnaires were delivered to selected departments and after consulting with participants, delivery time was determined. The distributed questionnaires were filled out by nurses. Researchers collected the questionnaires on the specified date. Researchers collected the forms on the specified date. The questionnaire was designed to ask the participants to express their opinion regarding incivility based on a 5-point scale system. From the initial 200 distributed forms, 157 forms were filled completely and therefore included in the final analysis and 43 forms were incomplete and thus omitted from the research. Incivility was assessed in four categories of isolating, gossiping, hostility, and

privacy violation behaviors. Collected data were entered into SPSS version 11.5 to be analyzed. Using descriptive statistics such as average, standard deviation, and absolute and relative frequency, and statistical inference such as average, median, Mann-Whitney's nonparametric test, Spearman correlation coefficient, Kruskal-Wallis nonparametric test, the relationship between demographic info and incivility in workplace were evaluated. The significance level was set at 0.05.


According to the collected data, 68.8% of the participants were females (108 persons) and 31.2% of the participants were males (49 persons). Average service record of the participants was 7.2 years with a 5.4 standard deviation, and the least service record was one year, and maximum age was 27 years.

Seventy-nine point six percent of nurses were females and 20.4% were males. Eighty-six percent of the participants (135 persons) had a bachelor's degree.

Regarding the incivility of matrons towards nurses, the results showed that 22.6% of participants had seen splitting behaviors at least one or two times from their superior matrons. Twenty-seven percent of participants (45 persons) reported gossiping behaviors from their matrons for more than two

times. Regarding hostile behaviors, 28% of nurses reported one or two instances from their superior matrons. Privacy violation was reported by 26.5% of nurses for one or two times. In total, 28.8% of nurses (45 persons) reported one form of incivility in their workplace for one or two times where the average total incivility behavior was 1.96±0.6 from five.

According to conducted analysis, there was no significant relationship between various departments of the hospital and frequency of incivility. Kruskal-Wallis test did not show any significant difference (p=0.554 and x=3.02). Moreover, Mann-Whitney's test did not show a significant difference between incivility forms in emergency and other departments (u=1.67 and p=0.231). Comparison of other departments did not show a significant difference regarding incivility between nurses and matrons.

There was a significant relationship between gender and isolating behavior. Mann-Whitney's test showed that average score of this behavior was 1.85 for males, while it was 1.53 for females (P=0.014 and U=2.467). There was not any significant relationship between other forms of incivility, total incivility, and gender (P=0.218 and U=1274). According to Spearman test, there was not any significant relationship between education and perception of incivility (P=0.236 and r=-0.088) (Table 1).

Table 1. Comparing average perception of incivility of matrons toward nurses totally and categorically by

demographic characteristics

Variable Isolating behavior Gossiping Hostility Privacy violation behaviors Total incivility

Sex Male 1.85±0.131 3.84±0.13 1.95±0.165 1.85±0.141 2.1±0.141

Female 1.56±0.057 3.69±0.056 1.73±0.069 1.7±0.063 1.87±0.61

P Value 0.014 0.105 0.161 0.155 0.218

Education Associate degree 1.68±0.18 4.14±0.24 2.04±0.249 1.95±0.21 2.17±0.22

bachlor 1.55±0.056 3.66±0.047 1.74±0.064 1.71±0.06 1.89±0.06

P Value 0.385 0.123 0.252 0.196 0.236

1-5 years 1.55±0.07 3.69±0.08 1.85±0.1 1.74±0.08 1.96±0.08

Work 6-10 years 1.63±0.11 3.81±0.08 1.85±0.09 1.82±±0.11 1.95±0.094

experience 11-20 years 1.5±0.1 3.5±0.195 1.62±0.145 1.56±0.118 1.77±0.128

0ver 21 years 1.3±0.185 3.5±0.193 1.38±0.2 1.48±0.29 1.77±0.128

P Value 0.638 0.117 0.396 0.303 0.342

ICU 1.46±0.186 3.86±0.24 1.67±0.22 1.6±0.184 1.83±0.2

Emergency 1.57±0.11 3.54±0.075 1.92±0.147 1.78±0.117 1.99±0.11

Medical 1.62±0.132 3.82±0.12 1.89±0.165 1.83±0.152 2.2±0.15

Surgical 1.57±0.074 3.73±0.9 1.7±0.09 1.73±0.086 1.88±0.08

Department Gynecology 1.38±0.2 3.5±0.144 1.59±0.33 1.53±0.2 1.72±0.262

Pediatric 1.61±0.25 3.7±0.2 1.63±0.09 1.63±0.12 1.82±0.09

Medical 1.62±0.132 3.82±0.12 1.89±0.165 1.83±0.152 2.2±0.15

Surgical 1.57±0.074 3.73±0.9 1.7±0.09 1.73±0.086 1.88±0.08

Gynecology 1.38±0.2 3.5±0.144 1.59±0.33 1.53±0.2 1.72±0.262

Pediatric 1.61±0.25 3.7±0.2 1.63±0.09 1.63±0.12 1.82±0.09

Moreover, Spearman test did not show a significant relationship between participants' age and perception of incivility (P=0.08 and r=-1.146). Average score of matrons' incivility toward nurses from nurses' point of view were 1.59±0.63 for

isolating behaviors, 1.77±0.76 for gossiping, 1.77±0.76 for hostility, 1.76±0.69 for privacy violation, and total incivility was 1.91±0.6. Average confliction between nurses and matrons was reported as 2.18±0.5 (Table 2).

Table 2. Average score of matrons' incivility from nurses' point of view

Incivility dimension

Mean score

Standard deviation


Isolating behaviors Gossiping behaviors Hostility behavior Privacy violation behaviors

1.59 from 5 1.77 from 5 1.77 from 5 1.76 from 5

0.63 0.76 0.76 0.69

28 26.5

Results showed that 24.6% of nurses had been victims of incivility by their matrons for one or two instances. Moreover, 7.8% of nurses reported one or two instances of incivility per month. Two pont one percent of nurses have experienced incivility one or two times per week. Finally, 66.5% of nurses had not seen and incivility from their matrons.

Since incivility has a great impact on job satisfaction, participants' satisfaction regarding their workplace and superiors was evaluated. Fifty-two point eight percent of nurses did not have job satisfaction. Total amounts of nurses' job satisfaction in their workplace by gender and position of matrons are summarized in Table 3.

Table 3. Total amount of job satisfaction of nurses regarding their workplace and superiors evaluation

Variable Nurses workplace satsfaction

Matron's gender Male 3.92±0.92

Female 3.92+0.069

P Value 0.852

Matron s workplace ICU 3.88+0.073

Emergency 3.81+0.065

Medical 3.87+0.136

Surgical 4.02+0.125

Gynecology 3.97+0.129

Pediatric 4+0.1

P Value= 0.295

Interpersonal confliction between nurses and matrons in workplace was also one of the items included into the questionnaire in order to confirm incivility. Results showed that 65.2% of nurses (102 persons) had had a conflict with their superior matrons for one or two instances. Sixty-nine point seven percent of nurses (109 persons) reported verbal abuse and shouting behavior from their matrons for one or two times. Rudeness from matrons toward nurses for one or two times was reported by 70.3% of nurses (113 persons).


This research showed that incivility and its various forms including gossiping, isolating, hostility, and privacy violation behaviors exist between nurses and their matrons. Although the frequency is reported to be one or two times, nonetheless, such behaviors do exist between nurses and matrons.

In this research, 33.5% of nurses (53 persons) have experienced incivility from their matrons. In Wilson's study of vertical hostility between nurses, the amount of uncivil behaviors was reported to be 85%, which is higher than the findings of this research (18). In Wilson's study incivility was evaluated between co-workers, while in this research it was between nurses and matrons. Another reason for this difference could be research environment, society and cultural differences, since Wilson's study was done in the western society.

Fifty-two point eight percent of nurses were not satisfied with their working conditions due to uncivil behaviors. In a similar research, the number of unsatisfied nurses who are ready to leave their posts was reported to be 30% by Phillips (19). Other studies have not focused specifically on dissatisfaction resulting from incivility and have assessed other reasons of employees' dissatisfaction such as recognition and appreciation, and organizational problems such as injustice and lack of job security (20). As is evident from Pearson and Saberinia studies, justice, recognition and appreciation of active and useful employees would increase their job satisfaction which is in line with this research's findings (12, 20).

Regarding Isolating behavior, 32.6% of nurses reported one or two instances of incivility. These behaviors could manifest as taking away employee's authority and freedom in his job which was reported by about one third of the participants. In Shoghi's article (2008), verbal abuse was reported to be 87% during a 6-month period (11). Verbal abuse, as one of uncivil behaviors that is pretty common in work environments, has been lower than in the aforementioned research which could be a result of differences between research, environment and type as well as the fact that unlike Shoghi's research which assessed all job violence aimed toward nurses, this article just investigated the uncivil behaviors of matrons toward nurses.

The frequency of hostility form of incivility was reported to be 28%. Kamchuchat study showed that 70% of nurses experienced hostile and bullying

behaviors mostly from staff nurses of high service record (10). As is evident, findings of this research reported lower hostility behaviors which could be attributed to the focus of this research on matrons. Nevertheless, even a low level of incivility in medical teams should be investigated carefully, because as is reported by Hershcovis's meta-analysis, between incivility and any forms of violence such as bullying in workplace, there is no a significant difference. Moreover, he argued that any amount of incivility could have similar effects as bullying and violence. Therefore, any form of incivility should be investigated carefully regardless of their amount (21).

According to the results, there was not a meaningful difference between incivility occurrences in various departments, while Kalantari argued that there is a significant relationship between working department and incivility between nurses. In his research, the highest level of incivility was reported in emergency department and lowest was in women's department (14). In another research, bullying behavior from co-workers which is a high level incivility was reported to be 23% in internal surgery department, 18% in intensive care department, 9% in operating room and anesthesia, and 7% in gynecology and obstetrics (10). As is evident, the results of various articles are not unanimous on the effect of working department on incivility. Another reason behind the difference between this research's findings and previous studies could be the relatively a smaller number of samples.

In this study, no significant relationship was reported between gender and incivility which is in line with Kalantari et al. research (14). Regarding isolating behavior, there is a significant difference between this form of incivility and gender, which could mean that either males are experiencing more uncivil behaviors or males are reporting these incidents more easily.


The main limitation of this research was a small number of samples. Another limitation was the method of self-reporting. Although the participants were assured of their privacy, fear of disclosure and identity revelation and subsequent worsening of their relationship with matrons have affected the answers. Length of the questionnaire and lack of accuracy was another limitation. There is a probability that nurses who answered the questions were the ones with vulnerability issues. Different perception of incivility by people could have affected the results; thus, in some cases, a simple communication issue can be viewed as an act of incivility.


Although incivility of matrons was lower than in similar foreign studies, in our culture and with our religious beliefs, even a low level of these behaviors would not be tolerated. Therefore, findings of this research could be an alarm for all related managers and strategists regarding the existence of such behaviors and the need for reduction and preventing them. Emphasis on civil behaviors from supervisors in all departments either by educational plans or cultural programs would ensure a healthy workplace for all employees. Finally, due to importance of this matter, it is highly recommended that other scholars examine this issue more thoroughly.


We hereby want to thank all nurses who took their time and participated in this research. We also thank educational deputy of Nursing and Midwifery School of Mashhad University of Medical Sciences who kindly provided the introduction letters to various departments needed for the research process. I owe a great debt to Dr Mohammad Reza Armat who helped me in the analyzing process.


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Procena nepristojnog ponasanja u medusobnom odnosu medicinskih sestara i glavnih medicinskih sestara zaposlenih u Iranu

Abbas Heydari1 , Mojtaba Rad2, Mostafa Rad3

1Vanredni profesor, Fakultet za sestrinstvo i akuserstvo, Univerzitet medicinskih nauka Mashhad, Mashhad, Iran 2Clan Fakulteta za sestrinstvo i akuserstvo, Univerzitet medicinskih nauka Sabzevar, Sabzevar, Iran

3Doktorant iz oblasti bolnicke nege, Departman za edukaciju medicinskih sestara, za sestrinstvo i akuserstvo, Univerzitet medicinskih nauka Mashhad, Mashhad, Iran


Nepristojno ponasanje u medusobnom odnosu medicinskih sestara i glavnih medicinskih sestara moze da dovede do mnogih posledica, poput promene radnog mesta i neadekvatne nege bolesnika. Iz tog razloga, potreba za ispitivanjem i procenom nepristojnog ponasanja u medusobnom odnosu medicinskih sestara i glavnih medicinskih sestara je ocigledna. Cilj ovog rada bio je da analizira i odredi ucestalost nepristojnog ponasanja u odnosu izmedu medicinskih sestara i glavnih medicinskih sestara sa stanovista medicinskih sestara.

Za ovu studiju preseka odabrano je dvesta medicinskih sestara iz triju bolnica u Mashhadu pomocu stratifikovane kluster metode slucajnog uzorka. Osnovni instrument istrazivanja bio je prilagodeni Ottinot-ov upitnik sa skalom za procenu pristojnosti na radnom mestu (PWCC skala), kao i upitnik o opstim demografskim podacima. Podaci su analizirani primenom deskriptivne i inferentne statistike, u SPSS programskom paketu, verzija 11.5.

Prema rezultatima istrazivanja, u ponasanju glavnih medicinskih sestara identifikovano je 22,6% izolovanog ponasanja, 27% ogovaranja, 28% neprijateljskog ponasanja i 26% narusavanja privatnosti. Ukupno, 28,8% (45 osoba) je priznalo da su na radnom mestu primetili barem jedan oblik nepristojnog ponasanja jednom ili dva puta.

Nepristojno ponasanje je zabelezeno kod jedne cetvrtine medicinskih sestara i glavnih medicinskih sestara. S obzirom da se u krugovima sestrinstva i islamske zajednice ovi oblici ponasanja ne mogu tolerisati, menadzerima, stratezima i nastavnicima se ozbiljno preporucuje da obrate paznju na ovakve oblike ponasanja medu studentima, zaposlenima i saradnicima.

Kljucne reci: nepristojno ponasanje, medicinske sestre, glavne medicinske sestre, interakcije, ponasanje, Iran