The relationship between leadership style and nurse-to-nurse incivility: turning the lens inward

Transcription

1 Journal of Nursing Management, 2017, 25, The relationship between style and nurse-to-nurse incivility: turning the lens inward JENNIFER A. KAISER PhD, MSN, RN CNE Senior Nurse Researcher, Spectrum Health, Grand Rapids, MI, USA Correspondence Jennifer A. Kaiser Spectrum Health 251 Michigan Street NE Grand Rapids MI USA KAISER J.A. (2017) Journal of Nursing Management 25, The relationship between style and nurse-to-nurse incivility: turning the lens inward Aim The aim of this study was to examine the impact of styles on the reported rates of lateral hostility in nurses. Background Previous explanations of horizontal incivility point to oppressed group behaviour and socialisation of nurses. Leadership and organisational culture are known to have a profound impact on workplace behaviour, yet few studies have examined the relationship between style and nurse-tonurse incivility. Methods A survey was used to assess the perceived levels of incivility and the styles experienced by 237 participants defined as staff nurses. Results Transformational style had the strongest correlation with low levels of incivility. Staff input and leader/staff teamwork also influence staff incivility. Conclusions Leadership style is not a definitive factor of incivility, but leader behaviours impact the level of incivility between staff nurses. The relationship between leaders and staff and the empowerment of staff have the strongest impact on nurse incivility. Implications for nursing management The factors found to correlate with incivility in this study are under the influence of nurse leaders. Relationships and interpersonal dynamics must be attended to. Leaders can also instil the structures known to foster nurse empowerment, which are discussed. Keywords: bullying, incivility, styles, nursing Accepted for publication: 20 September 2016 Introduction Few nurse leaders are unfamiliar with the problem of workplace violence that has been documented for the past 25 years in the professional nursing literature. Incivility is a clear problem in the nursing profession that poses a threat to both the well-being of nursing professionals and the safety of those patients in their care. The negative consequences of incivility are widespread and deleterious, yet a broad understanding of the causes of incivility, particularly in relationship to, remains sparse in the literature. Previous 110 explanations of incivility examine individual trait characteristics that influence susceptibility to or engagement in workplace bullying. This research study explores the problem of incivility by turning the lens toward nurse leaders. Background Nursing has been considered the primary occupation at risk of horizontal violence and workplace incivility (Skarbek et al. 2015). Studies find incivility at a 10 15% higher rate in nursing than in non-nursing DOI: /jonm.12447

2 Leadership and incivility occupations (Hunt & Marini 2012). The terms bullying, workplace violence, lateral or horizontal violence and harassment are all used to describe varying levels of poor interpersonal behaviours in the workplace. Bullying tends to denote a power differential between perpetrator and victim, whereas lateral or horizontal violence indicates an equal power relationship (Embree & White 2010, Weaver Moore et al. 2013). For this study, incivility is used to signify impolite, discourteous, or rude conduct that shows disregard or disrespect for others (Clark & Carnosso 2008). Common forms of incivility involve rudeness, condescending language, impatience, reluctance or refusal to answer questions, disrespect, and undermining (Roberts 2015). The word civility is derived from the Latin civilitas, meaning community or city (Clark & Carnosso 2008). Incivility can be translated as acts to exclude its recipient from the group or the community. Incivility has an elusive definition as it is extremely subjective as to what amounts to uncivil behaviour, and the range of behaviours is broad and often very subtle. Cynthia Clark provided the first concept analysis of civility in nursing in 2008; prior to this, sources used the term but did not clearly define it (Clark & Carnosso 2008). Recognising uncivil behaviour is critical to addressing and understanding the problem; hence, a clear definition of incivility is imperative. While an unambiguous definition of incivility is not established, its history and impact in nursing are distinct. Predominant theories as to why the nursing profession is susceptible to incivility are chiefly based on the premise that nursing is an oppressed professional group; hence, nurses exhibit behaviours characteristic of similarly oppressed groups (Roberts 2015). Members of oppressed groups direct frustrations regarding their inferiority toward each other, as they cannot act out direct to those who create the oppression (Freire 2000). Besides a culture of oppression, the socialisation of nurses into the profession propagates a culture of incivility (Bartholomew 2006). From this perspective, incivility in nursing is the reaction to the socialisation and subordination experienced by nurses as a collective oppressed entity. Organisational culture and incivility Oppressed group theory provides one consideration, but it is not the only factor that impacts incivility in nursing (Weinand 2010, Hutchinson & Hurley 2013). The theoretical framework for this study is best described by Hutchinson et al. (2010) who found that singular, conflict-based interpretations of workplace violence ignore the overlay of organisational power and its role in the dynamic. Based on Clegg s Circuits of Power Framework, power is the result of alignments of particular relationships along various circuits. In the dispositional circuit, power is achieved through relationships and group membership (Hutchinson et al. 2010). Organisational culture, work environment and workplace demands can either attenuate or create pressures and opportunity for incivility by influencing how members perceive both organisational and interpersonal transactions and how they manage and respond to such interactions (Hutchinson et al. 2010). Organisations that fail to recognise the cultural antecedents to workplace incivility, such as power imbalances and low costs to offenders, create a bully-supportive environment (Dzurec & Bromley 2012). Organisations that are rule- and outcome- oriented are more likely to attribute blame for workplace problems to individuals, seeing bullying as a personality conflict rather than a reflection of organisational practices (Hutchinson & Hurley 2013, p. 557). The assumption that incivility is simply a result of the unique socialisation of nurses as a subordinate group fails to consider the organisational contexts in which nurses work, as well as the organisational factors that impact uncivil behaviours. The purpose of this study is to examine the association between style and nurse-to-nurse incivility, and to explore leader behaviours that impact staff relationships. The corollary role of Most of the literature regarding and bullying examines the role of the leader as a perpetrator of workplace violence. Further, the direct impact of leader behaviours on lateral or horizontal violence among nurses remains relatively unexamined in the current body of nursing literature. There is an emerging understanding that leaders have some impact on workplace incivility. Consequently, there is a pressing need to better understand which styles and specific behaviours offer the best opportunity for diminishing incivility among nurses. The power of leaders to influence the organisational culture and climate is well documented. Leaders are compelling role models, and their actions communicate messages as to what is considered acceptable behaviour. Ultimately, people are more likely to follow the performance cues of those with power or social status within an organisation (Clark et al. Journal of Nursing Management, 2017, 25,

3 J. A. Kaiser 2013). Leaders set the tone of the organisational culture; thus, an examination of the effect of leaders on nurse-to-nurse relationships and behaviour is warranted. Table 1 provides a summary of the styles used in this study. An understanding of the behaviours seen in each style is important when considering their impact on nursing incivility. Cultures that facilitate incivility are typically characterised as competitive, adversarial and politicised, with little tolerance for nonconformity (Keashly & Neuman 2010). Bullying is associated with power differentials and negative relationships in which those targeted find it difficult to defend themselves, as seen in organisations with autocratic (Roberts 2015). Studies would suggest that a laissez-faire style of facilitates bullying in the workplace. Those who have reported counterproductive work behaviours concurrently experienced a disinterested or ineffective management team (Spence Laschinger et al. 2014). It is suggested that a perceived lack of response to incivility normalises such behaviours (Clark et al. 2013). In other words, failing to address incivility is Table 1 Summary of behaviourist styles Transformational Autocratic Democratic Laissez-faire Transactional Involves identifying a need for change, creating and instilling a vision in the group, and assisting followers to exceed their abilities in order to attain the vision Leaders have a vested, personal interest in helping followers reach their fullest potential Focus on interpersonal relationships between leader and follower Team members are engaged, highly motivated and fully empowered Traditional style of emphasising heirachy and power differentials Little job control or decision-making by subordinates Emphasises task completion over interpersonal relationships, viewing people merely as instruments to perform task-defined work Minimal communication and interaction occurs between the leader and subordinates Leader seeks input from group members and considers their feedback in making decisions Encourages the expression of ideas from members, solicits discussion and weighs all information to make the best possible decision Empowers members and supports teamwork Members and leaders are treated as equals; power differentials are unimportant Passive/avoidant style Leader is hands off and uninvolved with organisational members Leader provides little direction to employees Emphasis on management aspects of Centred on control, organisation and short-term planning Little attention is paid to interpersonal relationships except for the purpose of task-related work translated as condoning the behaviour (Hoel et al. 2010). In this case, the lack of involvement on behalf of management creates low perceived costs of poor behaviour by the perpetrator. This failure to act causes as much, if not more damage, than the uncivil behaviours themselves (Clark et al. 2013). Similarly, transactional leaders tend to be overly focused on details and day-to-day actions and to convey a lack of interest in staff as individuals, resulting in a culture that tolerates mistreatment and concerns unrelated to work output (Hutchinson & Hurley 2013). The keynote feature of transformational is the empowerment of team members. Empowerment of nurses has been associated with increased job satisfaction, job retention, inter-professional collaboration, autonomy in professional practice and other factors (Beteh & Heyliger 2014, Kennedy et al. 2015). Empowerment tends to play a key role in nurse-tonurse incivility (Spence Laschinger et al. 2014, Wing et al. 2015). Empowerment has been defined as a process of providing the tools and resources to develop the effectiveness of workers to reach individual and collective goals (Grossman 2013). Spence Laschinger et al. (2014) reasoned that dis-empowering work environments create conditions for incivility as nurses respond negatively to a lack of necessary support and resources to accomplish their work in meaningful ways (p. 6). Understood as a helping process whereby groups or individuals who are unable to change a situation are given the skills, resources, opportunities, and authority to do so (Bartholomew 2006, p. 115), empowerment can also act against the forces that create a sense of oppression. A leader is one of the primary vehicles to provide access to the structures of empowerment (Spence Laschinger et al. 2014). The transformational style, which focuses on empowerment, hence creates a more positive interpersonal work environment. Methods A survey was designed to measure nurse leader behaviours and styles and levels of incivility among the nurses under their charge. The portion of the instrument was developed based on the Vannsimpco Leadership Survey which has been substantiated for validity and reliability (Vann et al. 2014). Slight modifications were made to this survey, and the three developers reviewed these changes for validity. Fifteen questions assessed the involvement of staff in decisionmaking, the relationship between leader and subordinates, the focus of the leader on procedural vs. 112 Journal of Nursing Management, 2017, 25,

4 Leadership and incivility big-picture issues, and the level of involvement of the leader with the nurse s daily work. Ten of the questions in the section were factored into more than one dominant style. Participants were asked to consider only their immediate nurse manager or supervisor and the limit to interactions within the past 3 months. Answers to these items were categorised to determine the predominant style(s) perceived by the respondent as autocratic, democratic, laissez-faire, transactional and/or transformational. Items related to incivility were developed using previous conceptions of incivility and the occupation-specific Nursing Incivility Scale developed by Guidroz et al. (2010), which has also been substantiated. For the incivility section of the survey, the respondents were asked to consider only fellow nurse co-workers behaviour on the unit, excluding the behaviour of their supervisor or non-nursing individuals. The perceived frequency of behaviour, ranging from almost never, occasionally, half the time, most of the time and almost always, was used to determine the overall level of incivility. The incivility portion of the survey was reviewed by five nurses with over 20 years of experience for content validity. The full survey was piloted by 42 nurses in two separate clinical units. To test reliability, the same group of nurses repeated the survey 11 days after the initial administration. One question proved a consistent outlier and was removed from the questionnaire. Reliability analysis between the mean scores of the first and second administration reflected a coefficient alpha of r(40) = , P < 0.05 for each variable. The internal consistency coefficient for levels of styles was in the range r(3) = , P < 0.05 and was r(8) = 0.958, P < Both positive and negative responses are presented in the survey to balance questions and to increase precision. Demographic data included the gender of the participant, the number of years as a nurse, the number of years working on the unit, the level of education and the type of nursing unit. The type of nursing unit was delineated as medical-surgical, paediatric, obstetric, mental health, long-term care, intensive care, emergency department or other. Disclosure of this information was voluntary and not required for survey completion or inclusion. The IRB approval was attained by the researcher s university, as well as institutional IRB approval for the pilot study. The sample consisted of 237 nurses who identified themselves as staff nurses in non- positions from acute care and continuing care settings using the online services of Survey Monkey, Inc. ( Sample power based on the target population and margin of error was calculated to be >0.90. Nurse administrators, managers, directors and advanced practitioners were excluded from the sample. The survey was completed electronically with no identification of participants. Completion of the survey implied consent. Results Leadership styles Ordinal data were collected and coded numerically. Recent analysis supports the use of parametric tests for Likert scale instruments (Norman 2010). Overall the levels of incivility were moderate for this sample (M = 2.15). The mean level of each style reported is shown below in Figure 1. In this sample, transactional was found to be the most common style of (M = 3.32), and transformational the least common (M = 2.85). Autocratic, democratic and laissez-faire styles clustered around a mean level of 3.0. ANOVA testing produced a significant F ratio (F 5,231 = 46.53, P < ), indicating a difference in the mean levels of incivility between the styles surveyed. Correlation and regression analysis for each style is displayed in Table 2. Mean levels of were also analysed, with mean levels of >4.0 considered as high and <2.0 as low and compared with the mean levels of incivility. Regression analysis showed that the transformational most strongly reduced incivility levels (F 1,234 = 61.7, P < 0.05). The variance of this relationship is r 2 = Not only did this relationship have the highest correlation coefficient (r(235) = 0.46, P < 0.05), but high levels of transformational style were comparatively associated with the lowest mean levels of incivility (M = 1.83). Democratic and Mean level of style Figure 1 Leadership style. Leadership style Journal of Nursing Management, 2017, 25,

5 J. A. Kaiser autocratic styles had similarly moderate correlation coefficients (r(235) = 0.45 and 0.44, P < 0.5), respectively, with inverse effects on levels of incivility. Cohen s effect size for these three styles indicated there is moderate influence. Laissez-faire was the second most frequent style reported in the sample, but had a statistically small effect on incivility (r(235) = 0.17, P < 0.05). However, high levels of laissez-faire yielded the second highest mean level of incivility (M = 2.29). It is difficult to draw conclusive data based on this sample for laissez-faire as it was only seen at moderate levels; almost no participants reported very high or low levels of this style of. Transactional was the most frequently reported style, but it had no significant impact on levels of incivility (F 1,231 = 0.02, P > 0.05). One might conclude from these results that it is not the style of the leader that causes uncivil behaviour, but that leader behaviours do have the ability to impact this issue. Leader behaviours and incivility Separating individual leader behaviours to analyse the effect on incivility yields a trend of leader involvement leading to decreased levels of incivility. The behaviours that had the strongest impact on decreasing the levels of incivility were creating a sense of teamwork between leader and staff and working together to complete tasks or make decisions (r (235) = 0.441, P < 0.05). Behaviours that showed regard for individuals and solicited staff input also had a positive effect on incivility. Behaviours that positively impact interpersonal relationships, in order of position, included: Creating a strong sense of teamwork between staff and supervisor; working together to complete tasks or make decisions Being highly involved in day-to-day issues and work processes on the unit Empowering staff by asking for input and making decisions based on staff feedback Showing a genuine interest in staff development; helping staff to develop their abilities Having a close relationship with staff members Recognising and rewarding good work Having a vision for the organisation and involving staff in this vision Asking for input or ideas from the staff Seeking input from staff when formulating policies and procedures before implementing them Enforcing policies and procedures in daily workflow Table 2 Correlations between style and levels of incivility Leadership style Behaviours that had a negative impact on incivility were those that made staff feel uninvolved in the decisions and processes of the organisation, relegating staff nurses to direct patient care and related tasks. The leader removed from interpersonal relationships with staff saw higher levels of nursing incivility. Leader behaviours that negatively impacted nurse relationships, in positional order, include: Maintaining total authority and control over issues on the unit; dictating decisions to staff without much staff input. Failing to be a strong presence on the unit; leaving all the work and decisions up to the nurses Delineating big picture issues for the organisation to administration; delineating the nurses role in the unit to care for patients and to take care of unit issues Focusing on deadlines and work to be done in the unit vs. interpersonal relationships Unfortunately, when the reported frequency of leader behaviours was compared with those that decrease incivility, many of the more frequent behaviours are those that lead to incivility, while those behaviours that decrease incivility are less prevalent. Table 3 illustrates this relationship. Demographic variables Pearson s product-moment correlation coefficient r F ratio Variance (r 2 ) Autocratic (P < 0.05) Democratic (P < 0.05) Laissez-faire (P < 0.05) Transactional (P < 0.05) (controlled for outliers) Transformational (controlled for outliers) (P < 0.05) Essentially, none of the demographic variables had any reportable effect on the levels of incivility. The type of unit in which the participants were employed had a small correlation with the level of incivility (F 8,233 = 7.16, P < 0.05), with the highest levels of incivility in obstetrics (M = 2.65), long-term care (M = 2.47) and surgery (M = 2.4). Neither gender, years employed as a nurse, years at the current unit, age, nor education of the participants had any significant impact on the perceived levels of incivility. 114 Journal of Nursing Management, 2017, 25,

6 Leadership and incivility Table 3 Frequency of leader behaviors and relationship to incivility Leader behaviour Relationship to mean level of incivility r (235), P < 0.05 Rank according to frequency of behaviour Creates a strong sense of teamwork between staff and supervisor Works together to complete tasks or make decisions Is highly involved in day-to-day issues and work processes on the unit Empowers staff by asking for input and making decisions based on staff feedback Shows a genuine interest in staff development helps staff to develop their abilities Has a close relationship with staff members Recognises and rewards good work Has a vision for my organisation, involves staff in this vision Asks for input or ideas from the staff Seeks input from staff when formulating policies and procedures before implementing them Enforces policies and procedures in daily workflow Gives staff complete freedom to make decisions and do their job Focuses on deadlines and work to be done in the unit vs. interpersonal relationships Delineates big picture issues for the organisation to administration Delineates nurses role in the unit to care for patients and take care of unit issues Is not a strong presence in the unit Leaves all the work and decisions up to the nurses Maintains total authority and control over issues on my unit Dictates decisions to staff without much staff input Compared with the demographic variables included in the survey, only behaviours had a practical significance in the factors that affect incivility. Discussion Incivility in any workplace has deep and harmful effects that are readily recognised. A broad discovery of the many facets that influence incivility is imperative. Few studies have examined the impact of organisational culture and behaviours on interpersonal relationships between nurses. This exploratory study found only some styles have an association with the level of incivility among staff nurses, but leader behaviours can significantly impact nurse-to-nurse relationships. The effect of style on incivility, or the influence of on incivility, is moderate to inconsequential. The data found an association between particular leader behaviours and the levels of incivility among nurses. There is no clear indication that style directly relates to the levels of incivility among nurses. Rather, the data tell us that behaviour can be a vehicle to positively impact nurse-to-nurse relationships, but is not a facilitating or causative factor. Overall levels of incivility among nurses were lower than expected, although this has been a finding in other studies addressing the issue (Spence Laschinger et al. 2014). This may be a flaw in the methodology, or it may reflect a larger problem in truly recognising and identifying uncivil behaviours. The subtle nature of incivility makes it difficult to put into words. Often uncivil behaviour involves a stronger nonverbal message than what is actually said, and hence it is difficult objectively to define or convey (Dzurec & Bromley 2012). The difficulty in defining and expressing acts of incivility further compounds the difficulty in addressing the problem effectively. It is important to note that non-modifiable characteristics, such as gender, years as a nurse and age, did not have a significant correlation with incivility levels. This is an optimistic finding, as it is possible to cultivate behaviours but impossible to change these factors. Transactional style was the most frequently reported, which is historically characteristic of nursing, given its general overlap with management. Transactional leaders focus on work processes and outcomes, and are little concerned with interpersonal relationships or the emotional welfare of staff (Hutchinson & Hurley 2013). A lack of statistical correlation was found between transactional leader behaviours and incivility, and a similiarly small correlation with laissez-faire. This may indicate a lack of action on the part of the leader who is too task-focused and hands-off, failing to address or even recognise such behaviours. More importantly, these particular styles do not exhibit the leader behaviours found to influence uncivil behaviours. Journal of Nursing Management, 2017, 25,

7 J. A. Kaiser Transformational was the least frequently reported style, yet had the strongest impact on attenuating nurse-to-nurse incivility. This reinforces the finding that particular leader behaviours can have a positive impact on interpersonal relationships. The crucial feature of this style is empowerment. Empowerment is different from the granting of power and the delegation of authority. Empowerment is rather a sense of self-determination and self-efficacy, and any strategy to strengthen these feelings makes individuals feel empowered. Leaders can empower their staff by enhancing the meaningfulness of their work, foster participation when decision-making, express confidence in nurses, facilitate goal accomplishment and provide autonomy in practice (Cziraki & Laschinger 2015). Leader behaviours that are both empowering and relational have the strongest impact on mediating incivility. Unfortunately, in this study, these same behaviours were the least reported. Leaders who were generally more involved with the unit and had close relationships with staff saw lower levels of incivility. An emphasis on staff participation and input into decisions and processes was correlated with lower levels of incivility. Behaviours that escalated levels of incivility were seen in leaders who placed more emphasis on work than on people. Participants who felt uninvolved in the decisions and processes of the organisation, whose roles were delineated to patient care and work processes, reported more negative work environments. There are limitations to consider in this study. Both the constructs of and incivility are subjective and sometimes nebulous. Incivility can manifest in multiple forms, from subtle, non-verbal messages to open hostility. An unequivocal definition of incivility has yet to be established. The instrument had ten items that described uncivil behaviours, but there remain variations in this concept. Similarly, there exist multiple theories of. A behavioural perspective was selected for this study, but can occur in many different forms outside of this framework. Furthermore, the number of items used to assess style were abbreviated to maintain a reasonable length of questionnaire. The survey study method is based strictly on respondent perceptions, and may not accurately gauge the true levels of incivility and styles on the nursing unit. The sample included participants from several discrete units, so there was no overall measure of the perceptions from multiple respondents. A pilot of the survey was evaluated, but extensive testing for psychometric properties was not performed to develop the measurement tool. Implications for nursing management This study has important implications for the nursing profession by providing new insight into the factors that influence nurse incivility. Nurse administrators can use this information toward the creation of a healthy workplace. Understanding the leader behaviours that impact incivility provides invaluable information toward creating a culture of respect. The two primary areas that most impact incivility, shown both in this study and others, are the empowerment of staff and interpersonal attention. Interpersonal, relational styles are associated with both job satisfaction and employee engagement (Spence Laschinger et al. 2014). The first and most important step is for leaders to recognise and accept their direct role in not only addressing, but influencing, uncivil behaviours among their staff. Nurse leaders must not underestimate the impact they have on nurse relationships. Nurse managers can promote positive nurse relations by demonstrating an interest in staff, having a strong presence on the unit, confronting conflicts and creating an inclusive environment. A strong emphasis on how to foster healthy relationships is essential (Weaver et al. 2013). Often interpersonal relations are the most difficult aspect of management, but it is critical to intentionally attend to the culture of the unit (Cziraki & Laschinger 2015). Included in the message from must be a clear definition of incivility and that it will not be tolerated or supported in any way. Repeated evidence shows that it is critical, through transformational, that leaders empower their staff. Empowerment is explained as a personal sense of self-determination and self-efficacy, which can result from ensuring the presence of structural empowerment factors in the work environment (Conger & Kanungo 1988). Leaders have a direct influence on the latter. Structures of empowerment, best described by E. Kanter, include: (1) access to information, knowledge and expertise, (2) support in the form of guidance and feedback, (3) resources including materials, supplies and personnel and (4) opportunities for growth and development (Spence Laschinger et al. 2014). Intentional assurance that these structures are in place leads to the empowerment of nurses. Specific behaviours and strategies that leaders can use toward these ends include: 116 Journal of Nursing Management, 2017, 25,

8 Leadership and incivility communicating a clear role and team expectations and guidelines allowing staff to make important decisions (e.g. self scheduling, evidence-based practice (EBP) protocol development, unit governance) providing opportunities for advancement and unit development (e.g. special projects, quality initiatives, preceptorship, charge nurse responsibilities) encouraging ideas and innovations in care processes discussing challenges and engaging in goal setting with staff encouraging the professional development of staff to achieve set goals role modelling an inclusive environment supporting and promoting teamwork through patient care assignments and other projects seeking and accepting feedback about oneself and the unit, even if it is not positive engaging in respectful dialogue about issues and challenges (Conger & Kanungo 1988, Cziraki & Laschinger 2015). Conclusion This study implores nurse leaders to recognise the importance of staff empowerment and relational factors to positively impact nurse relationships and to promote a healthy, civil culture. The results find that factors outside of demographic characteristics and styles create the culture of incivility widely reported in the nursing profession. Continued work to identify and address these agents is needed. It is clear, however, that leader behaviours can ameliorate staff incivility. Future studies are needed to verify and more clearly define which specific leader behaviours have a positive impact on incivility. It is also essential to identify best practices to prepare and support leaders to recognise and employ such behaviours. Given the prevalence of incivility in the profession, a multi-factorial approach that explores all aspects of the problem is needed to address this critical issue. Acknowledgements No other individuals contributed to this work, which was part of the dissertation for degree requirements of the author. Source of funding No funding was utilized for this project. Ethical approval This project was approved by the University of Cumberlands IRB. References Bartholomew K. (2006) Ending Nurse-to-Nurse Hostility: Why Nurses Eat their Young and Each Other. HCPro Inc, Marblehead, MA. Beteh J. & Heyliger W. (2014) Academic administrator styles and the impact on faculty job satisfaction. Journal of Leadership Education 13 (3), Clark C.M. & Carnosso J. (2008) Civility: a concept analysis. The Journal of Theory Construction & Testing 12 (1), Clark C.M., Olender L., Kenski D. & Cardoni C. (2013) Exploring and addressing faculty to-faculty incivility: a national perspective and literature review. Journal of Nursing Education 52 (4), Conger L.A. & Kanungo R.N. (1988) The empowerment process: integrating theory and practice. The Academy of Management Review 13 (3), Cziraki K. & Laschinger H. (2015) Leader empowering behaviors and work engagement: the mediating role of structural empowerment. Nursing Leadership 28 (3), Dzurec L.C. & Bromley G.E. (2012) Speaking of workplace bullying. Journal of Professional Nursing 28 (4), Embree J.L. & White A.H. (2010) Concept analysis: nurse-tonurse lateral violence. Nursing Forum 45 (3), Freire P. (2000) Pedagogy of the Oppressed, 30th, anniversary edn. Continuum Publishers, New York. Grossman S.C. (2013) Mentoring in Nursing: A Dynamic and Collaborative Process, 2nd edn. Springer, New York. Guidroz A.M., Brunfield-Giemer J.L., Clark O., Schwetschenau H.M. & Jex S.M. (2010) The Nursing Incivility Scale: development and validation of an occupation-specific measure. Journal of Nursing Measurement 18 (3), Hoel H., Glaso L., Hetland J., Cooper C.L. & Einarsen S. (2010) Leadership styles as predictors of self-reported and observed workplace bullying. British Journal of Management 2, Hunt C. & Marini Z.A. (2012) Incivility in the practice environment: a perspective from clinical nursing teachers. Nurse Education in Practice 12, Hutchinson M. & Hurley J. (2013) Exploring capability and emotional intelligence as moderators of workplace incivility. Journal of Nursing Management 21, Hutchinson M., Vickers M., Jackson D. & Wilkes L. (2010) Bullying as circuits of power: an Australian nursing perspective. Administrative Theory & Praxis 32 (1), Keashly L. & Neuman J.H. (2010) Faculty experiences with bullying in higher education: causes, consequences, and management. Administrative Theory & Praxis 32 (1), Kennedy S., Hardiker N. & Staniland K. (2015) Empowerment an essential ingredient in the clinical environment: a review of the literature. Nurse Education Today 35, Norman G. (2010) Likert scales, levels of measurement and the laws of statistics. Advances in Health Science Education 15 (5), doi: /s y. Journal of Nursing Management, 2017, 25,

9 J. A. Kaiser Roberts S.J. (2015) Lateral violence in nursing: a review of the past three decades. Nursing Science Quarterly 28 (1), Skarbek A.J., Johnson S. & Dawson C.M. (2015) A phenomenological study of nurse manager interventions related to workplace bullying. The Journal of Nursing Administration 45 (10), Spence Laschinger H.K., Cummings G.G., Wong C.A. & Grau A.L. (2014) Resonant and workplace empowerment: the value of positive organizational cultures in reducing workplace incivility. Nursing Economic$ 32 (1), 5 16, 44. Vann B.A., Coleman A.N. & Simpson J.A. (2014) Development of the Vannsimpco survey: a delineation of hybrid styles. Swiss Business School Journal of Applied Business Research 3, Weaver Moore L., Leahy C., Sublett C. & Lanig H. (2013) Understanding nurse-to-nurse relationships and their impact on work environments. MedSurg Nursing 22 (3), Weinand M.R. (2010) Horizontal violence in nursing: history, impact, and solution. The Journal of Chi Eta Phi Sorority 54 (1), Wing T., Regan S. & Spence Laschinger H.K. (2015) The influence of empowerment and incivility on the mental health of the new graduate nurse. Journal of Nursing Management 23, Journal of Nursing Management, 2017, 25,