Relationship of Workplace Incivility, Stress, and Burnout on Nurses Turnover Intentions and Psychological Empowerment

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1 JONA Volume 43, Number 10, pp Copyright B 2013 Wolters Kluwer Health Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Relationship of Workplace Incivility, Stress, and Burnout on Nurses Turnover Intentions and Psychological Empowerment Olubunmi Oyeleye, DNP, RN Patricia Hanson, PhD, RN This study explored the relationships among perceived workplace incivility, stress, burnout, perceived turnover intentions, and perceived level of psychological empowerment among acute care nurses (medicalsurgical and critical care) in community and tertiary hospitals through the lens of complexity science. An exploratory study was conducted, and findings demonstrate significant relationships among workplace incivility, stress, burnout, turnover intentions, total years of nursing experience, and RN education levels. Creating targeted retention strategies and policies that will be sensitive to the needs and interests of nurses at high risk for leaving their organizations is imperative for nurse executives. Nurses turnover and empowerment have become priorities in healthcare. Studies report the cost of nursing turnover ranging from about $22,000 to more than $64,000 per nurse. 1 Nurses turnover intention refers to nurses considering leaving the organization and is considered to be part of a cognitive withdrawal process. 2 In 2010, the American Nurses Association reported that 53% of nurses were considering leaving their current position. 3 Empowered employees report Author Affiliations: Director, Patient Care Services (Dr Oyeleye); Professor (Drs Hanson, O Connor, and Dunn), School of Nursing, Madonna University, Livonia, Michigan. The authors declare no conflicts of interest. Correspondence: Dr Oyeleye, Detroit Medical Center, Detroit, MI (ooyeleye@dmc.org). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal s Web site ( DOI: /NNA.0b013e3182a3e8c9 Nancy O Connor, PhD, RN Deborah Dunn, EdD, RN less intention to turn over their jobs 4 and less job stress. 5 Psychological empowerment is defined as a cognitive state characterized by a sense of perceived control, competence, and goal internalization that employees must experience for interventions to be successful. 6 Several studies have linked empowerment to factors identified as important to retaining nurses. 7,8 There has not been any study on acute care nurses as it relates to the impact of workplace incivility (WI), stress, and burnout on their intention to leave their jobs and levels of perceived psychological empowerment; however, studies on individual or a combination of the variables have been addressed. 2,9-16 Nursing is 1 of the most stressful and challenging professions because of the need for specialization, complexity, and requirement to handle emergency situations. 17 Negative influences creating increased stress for nurses and caregivers are staff conflict and turnover. 17 People have different innate abilities to adapt to stress. 18 Previous studies have identified sources of job stress for nurses, 9,10 including their demographics, 11 and stress responses. 12 Sources of stress in nursing include conflicts with other employees. 13 Prolonged job stress has been shown to result in burnout. 14 Burnout is a syndrome of emotional exhaustion, depersonalization, and personal accomplishment (lack of) that occurs frequently among individuals who do people work. 19 As burned out individuals emotional resources are depleted, workers feel they are no longer able to give of themselves at a psychologically healthy level. 14 Depersonalization results from the development of negative, cynical attitudes and feelings. The lack of personal accomplishment results from the tendency to evaluate oneself negatively, particularly with 536 JONA Vol. 43, No. 10 October 2013

2 regard to one s work with clients. 19 Workers may feel unhappy about themselves and dissatisfied with their personal job accomplishments, thereby transferring the frustration to their coworkers. 14 Exposure to emotionally distressing dilemmas on a frequent basis followed by insurmountable fatigue and exhaustion increases the risk of nurses leaving the profession. 14 Working in an unfriendly workplace, a result of a perception of conflict in the workplace, has been identified as a precursor to nurses leaving organizations. 20 Workplace incivility is defined as low intensity deviant behavior with ambiguous intent to harm the target, and violates workplace norms for mutual respect. 21(p457) Organizational culture may contribute to the presence of WI by either rejecting or embracing incivility. An organization s cultural norms for coworker treatment must be supported by a strong positive culture that evolves among nurses. 15 If cultural norms include sanctioning an atmosphere of general workplace disrespect or arrogance, it can be referred to as the dance of incivility. 15 Developing a more civil workplace environment and better interpersonal skills includes refusals to take part in an act of incivility, intolerance of rudeness, and perpetrators apologizing to peers for disrespectful behaviors. Refusals and apologies set the standard for others to emulate and promote a civil relationship, which is referred to as the dance of civility. 15 Organizations and leaders must be vigilant to prevent the conditions leading to disempowerment and turnover intentions as nurses are constantly challenged to adapt to complex and chaotic healthcare environments. Complexity science can guide a greater understanding of the healthcare systems. 22 Healthcare is constantly changing, with a high degree of complexity. Complexity science, as related to healthcare, is the science of moving in a nonlinear and interactive manner where unpredictable outcomes are often realized; organizations are described as ever-changing collections of individuals and conditions in the organization; and patterns of interaction among individuals and connections are made in day-today practices among and between individuals. 22 Complexity principles explain the unpredictable and often chaotic nature of organizations. 23 Healthcare organizations are complex adaptive systems (CASs) or a group of individuals interacting with their environment in ways that are interconnected and unpredictable. 24 Complex Adaptive Systems Complexity science encompasses systems thinking, which investigates patterns and structures. This underscores the ability to fully see, integrate, and appreciate the emerging view of unity and wholeness, reciprocity, interdependence, and cocreation in the web of life. 25 One s actions will continue to influence the actions of the other, no matter how far they are separated by time or distance. 26 In the nursing profession, a nurse s negative attitude can have a lasting negative impression on other nurses, even if removed from the negative environment. Nurses integrate the complementary functions of both science and art into a larger whole. They have learned to harness and distribute energy while working with new forms of technology and systems. The spiritual side of humanity (adaptive mechanisms) has been slower to develop. 27 Self-awareness, a spiritual component for humanity, can lead to psychological empowerment fostering civility in the workplace. Selfawareness encompasses knowing one s self and the self of others. An adaptive strategy to promote civility is developing a method to find deeper meaning in one s life and more comprehensive solutions to dilemmas. 27 Bolstered with the interconnectedness of their personal lives and professional practice, nurses are able to propagate the culture of civility in the face of heightened level of stress and burnout. The application of the understanding of healthcare as a CAS involves cultivating an environment of collegial work relationships by allowing even small nonthreatening interactions that attract and retain nurses. 26 The purpose of this study was to explore the relationships and differences among WI, stress, burnout, turnover intentions, and level of psychological empowerment on acute care nurses in the hospital settings using CAS as the theoretical framework. Study Framework In this study, encounters with missed or avoided opportunities for psychological empowerment are seen as maladaptive modes that increase WI occurrences, stress, and burnout, leading to turnover intentions. On the other hand, encounters with seized opportunities for psychological empowerment are seen as adaptive modes that propagate civil behavior with decreased stress and burnout levels among nurses, leading to a decrease in turnover intention and high psychological empowerment (Figure 1). This framework guided the study examining the dynamic environment in community and tertiary hospitals among acute care in relation to (a) perceived WI, (b) levels of stress and burnout, (c) nurses turnover intention, (d) turnover, and (e) level of perceived psychological empowerment. The implication of this framework is that the heightened level of stress can lead to burnout and WI; likewise, burnout can lead to heightened levels of stress, which can foster WI (Figure 2). 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3 Figure 1. Conceptual framework modified, depicting relationship of study variables. 4,26,28 Research Questions 1. Are there differences between acute care nurses perceived WI, stress levels, burnout, intent to leave, and levels of psychological empowerment? 2. Are there relationships among perceived WI, stress levels, burnout, turnover intention, and levels of psychological empowerment in acute care nurses in the community and tertiary hospitals? Methods This quantitative study used exploratory, correlational methods. All statistical procedures were performed using SPSS version Statistically significant associations and correlations were considered at a P value of.05. Setting and Sample After institutional review board approval was obtained from Wayne State University and Madonna University, a convenience sample of acute care nurses from 2 community hospitals and 1 tertiary hospital in a healthcare system located in the Midwest region of the United States was obtained. Four hundred surveys were distributed; 200 surveys were sent to the tertiary hospital and 100 surveys were sent to each of the 2 community hospitals. Reminders were sent to nonresponders at weeks 3 and 5. The final survey response rate was 15% (n = 61). Three quarters (72%; n = 44) of the respondents were from the tertiary hospital, whereas the remaining quarter (28%; n = 17) were from the community hospitals. Respondents were mostly women (87%, n = 53), with a minority of male respondents (13%, n = 8). Ages ranged from 23 to 61 years, with a mean of 40 years. Most respondents were white (82%, n = 50), with 11 respondents identifying as nonwhite (Asian, 12%, n = 7; African Americans, 5%, n = 3; other, 2%, n = 1). The sample represents experienced nurses, ranging from 1 to 40 years of experience; more than half of the sample had 8 years or more of nursing experience (mean [SD], 11 [9.3] years). Of the respondents, 59% (n = 36) worked in medicalsurgical settings, whereas 41% (n = 25) worked in critical care. Most (90%) respondents worked fulltime. Highest level of nursing educational preparation was queried; most respondents were associate degree prepared (62%; n = 38), whereas more than one-third of the respondents were bachelor prepared (38%;n=23). 538 JONA Vol. 43, No. 10 October 2013

4 Figure 2. Research and measurement model. Data Collection Instruments Data collection instruments included 5 tools to measure stress, burnout, WI, turnover intentions, and psychological empowerment. Stress was measured using the Perceived Stress Scale (PSS10), a 10-item, 5-point Likert scale (0 = never to 4 = very often), with total scores ranging from 0 to The PSS10 exhibited construct validity (P G.0001) with other stress measures, health, health service utilization, health behaviors, life satisfaction, and help-seeking behaviors. 27 Burnout was measured using the Maslach Burnout Inventory (MBI; 3rd edition), a 22-item 7-point Likert scale (0 = very strongly disagree to 6 = very strongly agree), with total scores ranging from 0 to The MBI exhibited internal consistency and convergent and discriminant validity with behavioral ratings, job characteristics, and other psychological constructs at P G Workplace incivility was measured using a combination and modification of 2 instruments, the Uncivil Workplace Behaviors questionnaire 16 and the Workplace Incivility Scale (WIS). 29 The reliability and validity of the modified scale are unknown; however, the WIS has reported reliability (! =.89). 29 Turnover intention was measured using a 4-item tool with a 5-point Likert scale (0 = strongly disagree and5=stronglyagree),withtotalscoresranging from0to Psychological empowerment was measured using the Spreitzer Psychological Empowerment Scale (PES), a 16-item Likert scale tool (0 = strongly disagree to 6 = very strongly agree), with scores ranging from 0 to Convergent and discriminant validity with self-esteem, locus of control, social desirability, information, effectiveness, and innovation was established for the PES with a reported! of Results The 1st study question examined whether there were differences between acute care nurses on the study variables (incivility, stress, burnout, turnover intentions, JONA Vol. 43, No. 10 October

5 and psychological empowerment levels). Descriptive statistics were initially examined. Results demonstrated that perceived stress scores ranged from 15 to 31 (n = 61; mean [SD], 21.5 [3.78]), burnout scores ranged from 42 to 91 (n = 54; mean [SD], 64 [12.0]), and scoresforwirangedfrom19to74(n=61;mean [SD], 40.5 [12.2]). Turnover intention scores ranged from0to16(n=61;mean[sd],4.9[2.9]),and psychological empowerment scores ranged from 15 to 96 (n = 61; mean [SD], 75.2 [13.5]). To explore if there were differences between acute care nurses on the 5 study variables, unpaired t tests were conducted. Results demonstrated no statistically significant differences in mean scores (Table 1). The 2nd study question explored relationships among the 5 study variables. Correlations revealed statistically significant relationships between stress and incivility (P =.001), stress and burnout (P =.000), burnout and incivility (P =.005), and burnout and turnover intention (P =.005). In addition, turnover intention and incivility were significantly related (P =.000), whereas psychological empowerment scores did not correlate with any study variables. Additional tests were done with demographic characteristics as related to their potential relationship with the 5 study variables. Total years of nursing experience was significantly correlated with burnout (P=.045), incivility (P =.007), and turnover intention (P =.047), whereas education levels correlated with burnout (P=.038) (see Table, Supplemental Digital Content 1, The results of the data analyses are depicted in Figure 2. The theoretical framework guided the study examining the dynamic environment in community and tertiary hospitals among acute care nurses in relation to (a) perceived WI, (b) levels of stress and burnout, (c) nurses turnover intention, and (d) level of perceived psychological empowerment. Findings support that a heightened level of stress and burnout can lead to WI. Discussion The conceptual model guiding this research study posited that stress, burnout, and incivility are factors that may contribute to nurses turnover intention and level of psychological empowerment. In this sample of 61 acute care nurses, moderate levels of stress, burnout, and incivility were found, whereas turnover intention was low. Examining the relationships among the variables in this sample supported relationships between stress and burnout. Both stress and burnout were related to WI. Factors relating to turnover intention included incivility and burnout, whereas psychological empowerment was not found to be related to any study variable. Findings are consistent with the literature 9-14,17,18,20,21,28,30,32 documenting relationships among burnout, stress, and incivility and linking them to nurse turnover. These data thus support previous evidence of the importance of work environments that enable nurses to practice in collegial work settings in which nurses respect each other and refrain from uncivil behaviors in daily practice and use appropriate tools to decrease job stress and burnout. Research has demonstrated that nursing leadership is crucial to ensuring elements of supportive professional practice environments. 4-8,11,12,21,28 Nurse administrators can monitor for the dance of incivility and the associated cognitive dissonance that prompt Table 1. t-test Differences Between MS and CC Nurses on Study Variables Group/Variable n Mean SD t Test df P (2 tailed) Stress MS CC j Burnout MS CC j Incivility MS CC j Turnover intention MS CC j Empowerment MS CC j Abbreviations: CC, critical care; MS, medical-surgical. 540 JONA Vol. 43, No. 10 October 2013

6 nurses to leave their jobs. Conversely, nurse administrators can work toward fostering the dance of civility until it becomes the norm for organizational culture. The consequences of unmanaged stress and burnout are costly; therefore, it is important to proactively identify factors that contribute to the development of stress and burnout in the workplace. From a theoretical perspective, actualizing empowerment is linked to nurses perceptions of psychological empowerment. Nurses in this study reported moderate levels of perceived psychological empowerment; however, psychological empowerment was not found to be associated with stress, burnout, or WI. Limitations of the study include the low response rate and the nonrepresentativeness of the sample to the population of employees. Approximately 82% of the respondents were white/non-hispanic, demonstrating limited diversity in the sample. Further research is needed. Conclusions and Recommendations Nurse administrators can intervene to lead organizational cultural change toward the dance of civility. A zero-tolerance policy for incivility must be mandatory, and employees should be aware of the existence of the policy and related processes. Nurse leaders must be provided with tools for conflict management. Research shows that when managers are illequipped for addressing WI conflicts, the tendency to ignore those conflicts is high. 21 Because WI is used as a litmus test for workplace violence, managers must be fluent in identifying factors that predispose their environment to dance of incivility. Connecting WI to nurses stress and burnout reinforces the nurse s accountability for attitude and behavior through selfawareness. A code of professionalism and mutual respect must be enforced by nursing administrators and can result in organizational cultural change to a dance of civility. To cultivate a dance of civility in the work environment, managers must create an open communicative environment where nurses feel free to express their concerns without feelings of powerlessness, intimidation, and oppression. Nurse leaders are encouraged to provide stress-reducing interventions that can help in alleviating job stress and subsequently decrease or prevent the incidence of work place incivility. On the basis of this research, further investigation should explore interventions that nurse leaders can use to positively influence WI, stress, and burnout and play a meaningful role in reducing/preventing turnover intentions. As previously mentioned, self-awareness, a key concept to psychological empowerment, is important for nurses psychological well-being. The ability for nurses to develop greater self-awareness increases their ability to manage and use emotions to respond more appropriately to one s needs and those of others. 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