Nurses represent a significant proportion of all health care workers in Canada (Canadian Institute of Health Information, 2014). It is widely acknowledged that countries around the world are currently facing nursing shortages, which are expected to worsen as the nursing workforce and the population age (Buchan & Calman, 2006; Buchan, O’May, & Dussault, 2013; Pisanti et al., 2015). Training and retaining highly qualified professional nurses are crucial for addressing this supply-and-demand imbalance to ensure that high-quality health care can be provided to meet the health care needs of the public.
Research in the past decade has revealed several negative consequences of the increasing nursing workforce shortage (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Increased workloads and constrained resources have led to tensions in nursing work environments, resulting in higher levels of workplace incivility and bullying, leading to increased burnout (Aiken et al., 2002; Leiter, Laschinger, Day, & Oore, 2011). Given the links between incivility and burnout, and negative health and organizational outcomes, it is important to understand what factors may prevent these negative experiences.
This study draws on Bandura’s (1986) social cognitive theory with the aim of investigating the protective role of relational occupational coping self-efficacy (ROC-SE) against nurses’ experiences of workplace incivility and burnout (in terms of emotional exhaustion and cynicism), health, and turnover intentions one year later. We chose to investigate this specific form of self-efficacy for two reasons. First, several studies have shown that self-efficacy influences how individuals experience events in the workplace and their stress response (Consiglio, Borgogni, Alessandri, & Schaufeli, 2013). Specifically, employees with higher perceived capability in managing daily challenges at work are more able to cope with job stressors, experience less burnout and stress, are more satisfied and committed with their job, and have fewer health-related problems. Second, we decided to investigate self-efficacy in relation to a specific domain, that is, the perceived capability in managing work relationships with colleagues, supervisors, and physicians, because we acknowledge that self-efficacy is a task- and situation-specific construct. Indeed, “people differ in the areas in which they cultivate their efficacy” (Bandura, 2006, p. 307), and so the system of self-beliefs may vary in relation to the specific task and work situation. Moreover, as underlined by Bandura (2006), self-efficacy should not be considered as a global trait, and specific self-efficacy measures should be used in relation to the object of interest. Finally, although burnout has been developed as a three-dimensional construct, we chose to investigate only emotional exhaustion and cynicism and not the sense of ineffectiveness in line with the literature suggesting that this last dimension is a function of the other two dimensions (Maslach, Schaufeli, & Leiter, 2001). Overall, little attention has been paid to the potentially protective role of ROC-SE in the context of a stressful nursing work environment.
Relational Occupational Coping Self-Efficacy
Self-efficacy is a construct introduced by Bandura and represents one of the core mechanisms of personal agency (Bandura, 1991). Self-efficacy is the beliefs individuals have about their capabilities “to organize and execute courses of action required to manage prospective situations” (Bandura, 1997, p. 2). It is the expression of an individual’s self-regulatory skills and affects the way they regulate their behavior, thoughts, and affects and the choices individuals make as well as the effort and persistence they put in (Bandura, 1986, 1997, 2006). According to Bandura, individuals can successfully achieve their goals under challenging situations if they believe to have the capabilities to perform the required set of actions (Bandura, 1997). Overall, self-efficacy has been shown to be protective against negative psychological factors such as stress (Bandura, 1997), burnout (Laschinger, Borgogni, Consiglio, & Read, 2015; Pisanti, Lombardo, Lucidi, Lazzari, & Bertini, 2008), and poor mental health (Laschinger, et al., 2015). Generally, higher levels of self-efficacy have been shown to have a beneficial effect on various workplace outcomes through their influence on how individuals interpret their surroundings. A few studies have shown links between individual characteristics, such as self-efficacy, and turnover intentions in nursing (Han, Sohn, & Kim, 2009). Theoretically, self-efficacy is related not only to control over actions but also to self-regulation of psychological and emotional states, such as work attitudes (Bandura, 1986). Self-efficacy has been related to more effective coping in challenging work situations, resulting in greater job satisfaction and lower intentions to quit (Gruman, Saks, & Zweig, 2006). According to Bandura (1997), highly self-efficacious individuals are more able to handle workplace stressors and are therefore less likely to choose to escape frustrating situations by quitting their jobs.
Occupational coping self-efficacy refers to individuals’ ability to deal with workplace-specific stressful events. Nursing is a demanding profession, and the ability to cope with the high level of stress that nurses face in the workplace is important to nurses’ workplace health and well-being. Pisanti and colleagues (2008) developed a scale measuring occupational coping self-efficacy for nurses, including a specific self-efficacy dimension concerning employees’ belief in their ability to cope with interpersonal conflict in the workplace (ROC-SE). Nurses scoring higher in this dimensions showed better coping strategies and less burnout (Pisanti et al., 2008). Overall, this literature supports the hypothesis that nurses’ level of ROC-SE could have significant implications for how they interpret and cope with workplace stressors stemming from their relationships with others and, consequently, their outcomes.
Workplace incivility is a subtle form of workplace violence defined as “low-intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect” (Andersson & Pearson, 1999, p. 457). Uncivil behaviors include rude and discourteous comments and actions and generally displaying a lack of concern for others. Incivility can have multiple sources within a work setting, including coworkers, superiors, or even clients or patients (Cortina, Magley, Williams, & Langhout, 2001). Several studies by Laschinger and colleagues have shown that uncivil behaviors in the workplace contribute to experiences of burnout among nurses (Laschinger, Finegan, & Wilk, 2008), as well as to job turnover (Read & Laschinger, 2013) and intent to leave the nursing profession (Laschinger, 2012).
Burnout is a psychological response to chronic exposure to emotionally demanding job demands (Maslach et al., 2001). Although originally characterized by emotional exhaustion, depersonalization, and reduced personal efficacy at work, the burnout theory has developed over the years to include the concept of cynicism rather than depersonalization. Emotional exhaustion has consistently been identified as the core component of burnout, along with cynicism in recent work supported by evidence that personal efficacy fits better with the concept of work engagement than burnout (Schaufeli & Salanova, 2007). Nurse burnout has been identified as significant source of career dissatisfaction and, in turn, job and career turnover (Aiken et al., 2002; Leiter & Maslach, 2009). The prevalence of burnout in nursing has been found to be particularly high relative to other professions (Greenglass, Burke, & Fiksenbaum, 2001). Thus, burnout is an important factor to address in order to prevent voluntary turnover caused by preventable chronic workplace stress. Across numerous studies, burnout has been shown to be important for outcomes in the nursing profession. Burnout has been found to have a direct effect on important outcomes related to nurse retention, including job satisfaction, organizational commitment, and turnover intentions (Laschinger & Fida, 2014a; Laschinger, Leiter, Day, & Gilin, 2009).
Mental Health at Work and Job Turnover Intentions
Nurses’ ability to deal with workplace stressors (e. g., inflexibility, nonsupportive relationships) is directly linked to mental health (Laschinger & Fida, 2014b). Mental health issues have important implications for both individual nurses and organizations. Left untreated, short-term mental health issues, such as depression and anxiety, lead to long-term psychological traumatic effects (e. g., Post-Traumatic Stress Disorder; Matthiesen & Einarsen, 2004). In addition, burnout has been linked to poor mental health among nurses (Laschinger & Fida, 2014b), as well as workplace incivility (Laschinger et al., 2009), which, in turn, has been related to poor mental health among nurses.
Job turnover carries significant costs for organizations: both direct financial costs (Hayes et al., 2012) and indirect costs such as lost productivity, lower morale, and an increased workload for remaining staff (Johnson & Buelow, 2003). These conditions are commonly associated with employee burnout (Consiglio et al., 2013). Leiter and Maslach (2009) found that both emotional exhaustion and cynicism, resulting from poor fit between expectations and actual working conditions, were associated with nurses’ intentions to leave their jobs. Laschinger and Fida (2014a) found similar effects for new graduate nurses experiencing burnout in response to bullying. The link between nurse burnout and turnover intent has been repeatedly shown in the nursing literature (Van Bogaert, Clarke, Roelant, Meulemans, & Van de Heyning, 2010).
Aim and Hypotheses
On the basis of this review of the literature, the aim of this study was to examine the role of ROC-SE as a protective factor against workplace incivility and its later consequences (burnout, mental health, and job turnover intentions one year later). On the basis of the literature suggesting that ROC-SE may influence employee’s experience of workplace stress, we propose the following hypotheses depicted in Figure 1:
Hypothesis 1A: ROC-SE will be related to perceptions of workplace incivility, such that nurses with higher ROC-SE will perceive less frequent workplace incivility from coworkers, supervisors, and physicians.
Hypothesis 1B: ROC-SE will directly influence nurses’ burnout. Specifically, nurses with higher self-efficacy will report lower levels of burnout one year later.
Hypothesis 1C: ROC-SE will positively influence mental health, such that nurses with higher ROC-SE will report fewer mental health symptoms one year later.
Hypothesis 1D: ROC-SE will negatively influence job turnover intentions, such that nurses with higher ROC-SE will report lower intentions to leave their job one year later.
In addition, it is reasonable to expect that incivility would influence later nurses’ burnout, which in turn would influence mental health and job turnover intention.
Hypothesis 2: Perceptions of incivility will significantly influence later burnout, such that nurses who perceive more frequent incivility will experience higher levels of burnout one year later.
Hypothesis 3A: Burnout will be significantly associated to nurses’ mental health, such that nurses who report greater burnout will also report poorer mental health.
Hypothesis 3B: Burnout will be significantly related to job turnover intentions, such that nurses who experience greater burnout will report greater intentions to leave their job.
Finally, considering the protective role of self-efficacy we also hypothesize that:
Hypothesis 4: ROC-SE will play a protective role against later mental health problems and job turnover intentions not only directly but also indirectly through its effect on incivility and burnout.
Figure 1 gives the graphical representation of these hypotheses.
A two-wave design was used to examine a national sample of Canadian nurses (n = 596). Before commencing the study, researchers obtained university ethics board approval. A randomly selected sample of registered nurses working in direct care settings was obtained from the professional registry databases from 10 Canadian provinces. Each participant was mailed a survey package that included a letter of information and study questionnaire. As incentive to take part in the study, the package also included a $2 coffee voucher. The Dillman procedure (Dillman, Smyth, & Christian, 2008) was used to optimize response rates. Specifically, nonresponders received a reminder letter 4 weeks after the initial mailing, followed by a second survey package 4 weeks later. At Time 2 (one year later), a follow-up questionnaire was mailed to nurses who responded to the survey at Time 1. Of the 3,743 eligible nurses who received a survey at Time 1, 1,410 nurses returned a completed questionnaire (response rate = 37.6%). At Time 2, 603 of nurses resurveyed returned a completed questionnaire (response rate = 42.8%). After removing seven ineligible participants working in supervisor or teaching positions, 596 cases were included in the analysis.
Table 1 provides the demographic characteristics of the sample. There were no noteworthy differences between matched cases and those lost to follow-up at Time 2 in relation to sample characteristics and study variables.
ROC-SE was assessed by the relational subscale of the Occupational Coping Self-Efficacy Questionnaire for Nurses (Pisanti et al., 2008), comprising three items rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Reliability indices ranged from. 78 (Cronbach’s α) to .97 (factor score determinacy) in the current study (see Table 2).
Incivility was assessed using the Straightforward Incivility Scale (Leiter & Day, 2013) comprising three subscales that assess the frequency of incivility experienced from one’s supervisor, coworkers, and physicians over the past 6 months. Each subscale consists of five items rated on a 7-point scale ranging from 0 (never) to 6 (daily). High reliability was shown for all three subscales (see Table 2).
Burnout was assessed using the emotional exhaustion and cynicism subscales of the Maslach Burnout Inventory-General Survey (Maslach, Jackson, & Leiter, 1986). Both subscales consist of five items on a 7-point Likert-type scale ranging from 0 (never) to 6 (daily). High reliability was shown for both dimensions (see Table 2).
Mental health was assessed using the General Health Questionnaire (Goldberg & Williams, 1988). This scale has 12 items on a 4-point scale ranging from 1 (not at all) to 4 (much more than usual) and assesses the frequency of mental health symptoms experienced. Half of the items are negatively worded and were reverse-scored before being included with the six positively worded items. Reliability indices ranged from .82 (maximal reliability) to .94 (factor score determinacy) in the current study (see Table 2).
Job turnover intentions were assessed using three items modified from Kelloway, Gottlieb, and Barham (1999). Each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). One item was negatively worded and was reverse-coded prior to calculating mean scores. Reliability indices ranged from .87 (Cronbach’s α and composite reliability) to .94 (factor score determinacy) in the current study (see Table 2).
Descriptive statistics and correlations were performed using SPSS. Structural equation modeling (SEM) analysis in Mplus was used to test the hypotheses. ROC-SE, emotional exhaustion, cynicism, and turnover intentions were defined as latent variables measured by their items, whereas mental health was measured by four parcels (Coffman & MacCallum, 2005). Given the nonnormality of incivility dimensions, we used the Mplus robust maximum likelihood method for parameter estimation. Finally, in order to test the significance of the indirect effect of self-efficacy on mental health and job turnover intentions through incivility and burnout, we conducted the indirect effect test with the bootstrap procedure (MacKinnon, 2008) implemented in Mplus.
The descriptive statistics and correlations for all studied variables are presented in Table 2. Results showed that incivility dimensions were not normally distributed with both skewness and kurtosis higher than |1|. The correlation analysis showed that ROC-SE significantly correlated with incivility dimensions, with the exception of physician incivility, and with later burnout dimensions, mental health, and job turnover intention measured one year later. Similarly, incivility dimensions significantly correlated with later burnout, mental health, and turnover intentions. Finally, all outcome measures included in this study were significantly correlated with each other.
With regard to SEM, the model displayed in Figure 2 yielded an excellent fit: χ2(531) = 1,122.367, CFI = .95, RMSEA = .043 (.040–.047), p = 1.00, SRMR = .047. In line with Hypothesis 1A, ROC-SE was negatively related to the perception of incivility. Specifically, nurses with higher levels of ROC-SE perceived significantly lower levels of incivility from coworkers (β = −.23) and supervisors (β = −.11), whereas there was no significant effect on physician incivility. Furthermore, supporting Hypothesis 1B, ROC-SE was significantly and negatively related to both burnout dimensions measured one year later. That is, nurses with higher levels of ROC-SE experienced lower levels of emotional exhaustion (β = −.16) and cynicism (β = −.15). ROC-SE was also negatively related to mental health measured one year later (β = .15), consistent with Hypothesis 1C. Unexpectedly, ROC-SE was not significantly related to later job turnover intentions.
Results of our model partially supported Hypothesis 2. Specifically, physician and coworker incivility significantly influenced emotional exhaustion and cynicism measured one year later, whereas supervisor incivility did not have a significant effect on either burnout dimension. Furthermore, as hypothesized (Hypothesis 3A), emotional exhaustion and cynicism were significantly related to mental health (β = −.27 and −.41 respectively). Although cynicism was significantly related to job turnover intentions (β = .63), emotional exhaustion was not, contrary to our hypotheses (Hypothesis 3B). Overall, the model explained 46% of general health and 42% of job turnover intentions. Finally, the results revealed significant indirect effects of ROC-SE on later mental health and job turnover intentions. Specifically, it indirectly influenced mental health (total indirect effects: β = .134, 95% bootstrap CI [.078, .191]) and turnover intentions (total indirect effects: β = −.127, 95% bootstrap CI [−.187, −.067]).
The SEM analysis provided support for most of the hypothesized paths. Overall, ROC-SE played a protective role in the process from incivility to later burnout and, ultimately, to mental health and turnover intentions measured one year later. Specifically, results suggested that the more nurses believed in their capability to cope with relational stressors in the workplace, the less they perceived incivility from coworkers and supervisors. The stronger influence of ROC-SE on coworker incivility relative to supervisor or physician incivility is important because nurses work as part of teams that change from week to week. Confidence in their ability to handle incivility from team members is a crucial factor in maintaining a cohesive work group necessary for high-quality patient care. Nurses’ confidence in their ability to deal with incivility from supervisors is also important for effective teamwork to deliver effective patient care. If managers are dismissive of concerns or ideas from frontline coworkers (incivility), patient care is threatened. Therefore, strategies to strengthen nurses’ ROC-SE for dealing with incivility from different sources are critical in ensuring high-quality patient care.
The nonsignificant effect between ROC-SE and incivility from physicians could be due to gender and power distance issues between nurses and physicians (Zelek & Phillips, 2003). Numerous studies have shown that the hierarchical nature of health care working relationships often result in controlling and dismissive behaviors toward nurses on the part of physicians, which are stressful and hinder effective communication about patient care issues (Rosenstein, 2002). These conditions make it difficult for nurses to build effective relationships with physicians and feel confident in dealing with uncivil behavior.
The link between ROC-SE and various sources of incivility is a new finding. There is some evidence relating general self-efficacy to bullying (Mikkelsen & Einarsen, 2002) and studies linking psychological capital (which includes work-related self-efficacy) to bullying (Roberts, Scherer, & Bowyer, 2011), but we could find no studies linking incivility to ROC-SE.
Similarly, in line with previous research (Consiglio et al., 2013), highly efficacious nurses experienced fewer stress-related outcomes. Indeed, ROC-SE had a significant direct negative effect on both components of burnout measured one year later and a positive effect on later mental health. Consiglio et al. (2013) suggest that the protective nature of self-efficacy has an energizing effect on nurses, enabling them to cope with organizational constraints and challenges more effectively, preventing emotional exhaustion and cynicism related to their work. Given the well-documented negative health effects of burnout, ROC-SE is an important intrapersonal resource to develop for dealing with negative workplace experiences and incivility.
Consistent with Laschinger et al.’s (2008) findings, incivility affected both burnout components, suggesting that nurses who experience incivility in their workplace are more likely to have emotional exhaustion and cynicism and their negative effects. Surprisingly, although supervisor incivility was significantly correlated with both burnout components, these paths were not significant in the SEM analysis. This may be due to the to the fact that the three incivility types were significantly related to each other, and therefore, much of the variance from supervisor incivility was already accounted for in the burnout components by the other sources of incivility. The significant intercorrelations among incivility sources are consistent with previous research (Laschinger et al., 2009). This may represent the notion of incivility spirals suggested by Anderson and Pearson (1999), whereby incivility from one source may create a sense of acceptability for this type of behavior in the work environment and lead others to engage in uncivil behaviors, negatively affecting organizational attitudes and behaviors. Our results show that incivility is associated with burnout, poor mental health, and turnover intentions. Thus, every effort must be made to ensure that incivility is not tolerated and that nurses are supported in developing a sense of efficacy for dealing with these negative behaviors.
In line with Leiter and Maslach (2009) and Laschinger and Fida (2014a), cynicism was more strongly related to both organizational and health outcomes than emotional exhaustion. This suggests that nurses who withdraw psychologically from their work through cynicism may eventually withdraw socially by leaving their job. The significant relationship between emotional exhaustion and mental health is consistent with numerous studies (Laschinger & Fida, 2014b; Lavoie-Tremblay, O’Brien-Pallas, Gélinas, Desforges, & Marchionni, 2008). It is not surprising that nurses who are emotionally exhausted from prolonged exposure to stressful negative interactions at work, such as uncivil behaviors from colleagues, would be more likely to experience poor mental health. Reducing incivility and helping nurses develop ROC-SE to cope effectively with negative workplace relationships appear to be effective strategies to reduce these negative outcomes.
Our results suggest that administrators must attend to workplace conditions that generate feelings of cynicism, such as workplace incivility, and circumstances that lead to emotional exhaustion. Our findings suggest that ROC-SE plays a key role in protecting nurses from these negative conditions. According to Bandura (1986), ROC-SE can be developed by exposing individuals to various sources of efficacy information. The strongest source of efficacy information is active attainment or actual experience with behaviors to handle difficult situations. Providing nurses with opportunities to build their coping strategies for managing job demands and difficult interpersonal interactions would be helpful. Similarly, providing exposure to effective role models and providing meaningful verbal encouragement are other sources of efficacy information for building ROC-SE for handling job demands and challenging interpersonal interactions.
In addition to the positive impact that individual leaders can have on employees under their direct supervision, unit and organization-level strategies have also shown promising results. For example, Leiter et al. (2011) showed the effectiveness of a workplace civility intervention (CREW: Civility, Respect, and Engagement in the Workplace) in improving interpersonal working conditions in Canadian health care settings. Although ROC-SE was not included in their study, a similar intervention involving group training and support may be an effective way to enhance nurses’ capability to deal with relationship challenges in the workplace.
Several methodological issues in the current study necessitate caution when interpreting the results. First, the two-wave design used in this research precludes the ability to infer all the relationships longitudinally. Future longitudinal study with at least 4 time points testing the posited model would strengthen the results and provide additional support for our conclusions. Second, given the nature of self-report data, specifically the risk of response bias (Antonakis, Bendhan, Jacquart, & Lalive, 2010), results should be viewed with some caution. Finally, when the same participants complete all measures of a single study, common method variance can be a concern. However, all of the measures used in this study are well validated, thus decreasing the likelihood of common method variance (Spector, 2006).
The results of this study demonstrate promising support for the notion that relational occupational self-efficacy plays a protective role against workplace incivility, burnout, and their detrimental outcomes. These results are encouraging, because self-efficacy is a malleable intrapersonal resource that can be supported and promoted by proactive management. Every effort must be made by hospital management to create work conditions that prevent workplace incivility and subsequent burnout to ensure both employee and organizational health.
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