Nursing Incivility on Professional Quality of Life Among Nurses in A Government Hospital

Nursing Incivility on Professional Quality of Life Among Nurses in A Government Hospital

Ashiyah H. Polog, MAN, RN and Joan P. Bacarisas, DM, MAN, RN

Graduate School of Allied Health Sciences, University of the Visayas

DOI: https://doi.org/10.51244/IJRSI.2025.120700112

Received: 03 July 2025; Accepted: 08 July 2025; Published: 06 August 2025

ABSTRACT

Keeping and maintaining a civil climate in the clinical area is important in every organization. An organization where there is incivility may cause dissatisfaction and can be a source of stress or burnout and can greatly influence the quality of professional life among employees. Findings of the study reveal that overall, there, was a high patient incivility and a moderate general incivility, nurse incivility, and physician incivility. Lastly, there was a low supervisor incivility. There was a moderate level of compassion satisfaction, burnout, and secondary trauma stress. Abusive supervision of supervisor incivility and abusive supervision of physician incivility, and lack of respect of physician incivility predicted burnout. Hostile climate by the nurse incivility predicted secondary trauma stress. With the professional quality of life of the nurses being on a moderate level, the professional quality of life enhancement plan was proposed. Healthcare professionals and hospital administrators should work hand in hand to prevent or keep work incivility at a minimum to maintain good working relationship among healthcare professionals and to effect positive patient outcomes.

Keywords: Nursing incivility; Professional quality of life; Nurses; Government hospital; Descriptive correlational (predictive) design.

INTRODUCTION

A lot of people may have experienced work incivility in their respective work areas but they just did not know that what they experienced are work incivility already. As simple as incidents of walking into work with a nurse supervisor, and holding the door open for her or him. She breezes through without even saying thank you. When getting into the nurses’ lounge to have a glass of water, and unfortunately find that the water dispenser is empty—the last person did not refill the dispenser. All of these behaviors are examples of incivility, a low intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect and courtesy (Andersson & Pearson, 1999 as cited in Sliter, 2013). The key component of this definition that separates incivility from other forms of interpersonal mistreatment is the concept of “ambiguous intent.” (Sliter, 2013).

As a nurse working in the hospital, several instances where the research experienced the concept of incivility in the workplace. The magic words such as “thank you” and “please” seemed to have disappeared when they are supposed to be given. While everybody in the healthcare is really busy with the advent of the COVID-19 pandemic, this should not be a reason everyone in the healthcare to become uncivil. Working in the ward goes beyond collaboration, there are times when nurses extend rendering care to patients not assigned to them. The researcher had experienced this when she was caring for other patients not under her load, like giving of the medications as the assigned nurse was busy attending to her other patients. While the researcher is not expecting something in return for such good deed, a simple thank you will suffice already but at the end of the shift there was even no words of gratitude offered. These experiences of incivility do not only extend to the co-workers of the nurses from his or her managers, the other healthcare team members but also patients and significant others. The findings in the study of Shi et al. (2018) showed that workplace incivility was positively correlated with anxiety and job burnout of new nurses. The positive relation between anxiety and job burn-out was also significant. Moreover, anxiety partially mediated and resilience moderated the association between workplace incivility and job burn-out. Experience of workplace incivility by new nurses would likely generate anxiety in the victims. Further, the increased anxiety state could elevate their level of job burn-out. New nurses with high levels of resilience could buffer the negative influence of workplace incivility by using a positive coping style.

Keeping and maintaining a civil climate in the clinical area is important in every organization. It is in this premise this study was conceptualized on the grounds that not much studies have been conducted in the healthcare setting; all the more being conducted in the hospital where the researcher works. In an effort of the researcher to provide a baseline information about the civil climate in the nursing service department, it is also the intention of the researcher to assess if a civil workplace will have influence on the professional quality of life of the nurses if this allows them to achieve compassion satisfaction or compassion fatigue. The researcher assumes that an organization where there is incivility may cause dissatisfaction and can be a source of stress or burnout and can greatly influence the quality of professional life among employees.

The possible influence of incivility on the professional quality of life is one of the gaps that will be addressed in the study. According to the Professional Quality of Life Organization (ProQOL.org)  (2019), compassion satisfaction and compassion fatigue are two aspects of professional quality of life. They encompass the positive (compassion satisfaction) and the negative (compassion fatigue) parts of helping others who have experienced suffering (especially during this time of CVOID-19 pandemic). Simply put, Compassion satisfaction involves “the ability to receive gratification from caregiving” (Simon et al., 2006). Compassion fatigue breaks into two parts. The first part concerns things such as such as exhaustion, frustration, anger and depression typical of burnout. Secondary Traumatic Stress is a negative feeling driven by fear and work-related trauma. It is important to remember that some trauma at work can be direct (primary) trauma. In other cases, work-related trauma be a combination of both primary and secondary trauma. If working with others’ suffering changes you so deeply in negative ways that your understanding of yourself changes, this is vicarious traumatization. Learning from and understanding vicarious traumatization can lead one to vicarious transformation (PRoQOL.org, 2019).

In the study of O-Callaghan et al. (2020), it was found out that average to high levels of compassion satisfaction and low to average levels of compassion fatigue were found in emergency nurses. Issues contributing to stress were work and role related. An understanding of these stressors may help nurses and nurse managers to ameliorate emergency nurses’ levels of stress and help limit staff burnout.

Appropriate steps should be taken by the nursing service department to maintain a civil climate that will promote compassion satisfaction and prevent compassion fatigue, keeping in mind that promoting civility can both reduce negative employee outcomes and increase organizational effectiveness which will eventually benefit the patients.  Maintaining a civil work environment is not easy, particularly due to the fast-paced, often interpersonally disconnected work environment, where communication is quick and online platforms of communications can be resorted to quickly without a thought. Plus, he fact that measures are currently instituted to halt the spread of COVID-19, The researcher is hopeful that through this research an output will be proposed to improve workplace civility that will promote professional quality of life among nurses. This can only be achieved through the determination and the competence of the researcher in conducting research.

RESEARCH OBJECTIVES

This research was primarily for the purpose of assessing whether the facets of nursing incivility predicted professional quality of life among nurses in Amai Pakpak Medical Center for the last quarter of 2020.

Specifically, it answered the following questions:

What is the perceived nursing incivility by the nurses in terms of general, such as hostile climate, inappropriate jokes, and inconsiderate behavior; nurse, such as hostile climate, gossip and rumors, and free-riding; supervisor, such as abusive supervision and lack of respect; physician, such as abusive supervision and lack of respect; and patient, such as lack of respect and displaced frustration?

What is the professional quality of life among nurses in terms of compassion satisfaction; and compassion fatigue such as burnout and secondary traumatic stress?

Which facets of nurse incivility predict compassion satisfaction; compassion fatigue; burnout; and secondary trauma stress?

What professional quality of life enhancement plan can be proposed based on the findings of the study?

Statement of Null Hypotheses

Ho1: The facets of nursing incivility do not predict compassion satisfaction.

Ho2: The facets of nursing incivility do not predict burnout.

Ho3: The facets of nursing incivility do not predict secondary traumatic stress

REVIEW OF RELATED LITERATURE AND STUDIES

Nursing Incivility. Workplace incivility is a significant problem in healthcare centers, disturbing not only clinicians enduring negative behaviors but also care delivered under the shadow of incivility (Kodjebacheva, 2014; Hutton & Gates, 2018). Results were mostly inconsistent regarding individual characteristics of targets of incivilities, but less experienced healthcare professionals were more exposed (Keller et al., 2020). Participants reported experiencing incivilities mainly within their own professional discipline rather than across disciplines, with surgery cited as an uncivil specialty. Situational and cultural predictors included high workload, communication or coordination issues, patient safety concerns, lack of support, and poor leadership (Keller et al., 2020).

Data analysis revealed that a comprehensive and systematic attempt was needed to prevent incivility, with organization, nurses, and public as subthemes (Abdollahzadeh et al., 2017). Workplace incivility was negatively associated with compassion competence of nurses, with psychological capital having conditional moderating effects (Woo & Kim, 2020). Workplace incivility is a well-documented issue in nursing with potential to cause emotional and physical distress and affect quality of care. Evidence suggests using educational training, effective response training, and active learning activities to improve ability to manage incivility (Armstrong, 2018).

Workplace incivility and bullying were significantly related to authentic leadership, structural empowerment, worklife fit, and psychological capital, with bullying having stronger negative effects (Read & Laschinger, 2013). The highest mean score was for patient or visitor incivility, and the lowest was for supervisor incivility (Alquwez, 2020). General and nurse incivilities had multivariate effects on six dimensions of patient safety competence, with experiences of uncivil acts from nurses and general incivility negatively impacting competence (Alquwez, 2020). Nurses experienced incivility from General Hostile Climate, Nurse Gossip and Rumors, Physician Abusive Supervision, and Patient and Visitor Displaced (Gillian, 2015).

Sources of Workplace Incivility.  In developing an incivility measure for nurses, it is important that the scale address the number of sources from whom nurses commonly experience incivility. Previous research has found that uncivil behavior is likely to differ according to the instigator (Jackson, Clare, & Mannix, 2002 as cited in Guidroz et al., 2010; Nabb, 2000 as cited in Guidroz et al., 2010). Verbal abuse by a physician, for example, may affect nurses differently than verbal abuse by a patient. We were particularly interested in measuring nurses’ experiences of incivility with physicians, nurse supervisors, other nurses, and patients as distinct experiences. In the following section, we review research conducted both within and outside of hospital settings by the source of incivility (Guidroz et al., 2010).

Incivility from Physicians. Poor working relationships between nurses and physicians are a long observed and widely researched topic in nursing and medicine (Faigin, 1992 as cited in Guidroz et al., 2010; Porter, 1991 as cited in Guidroz et al., 2010; Sirota, 2007 as cited in Guidroz et al., 2010; Stein, 1967 as cited in Guidroz et al., 2010; Stein et al., 1990 as cited in Guidroz et al., 2010). Poor nurse–physician relationships are often attributed to inappropriate, disruptive, or abusive behavior by physicians  (Rosenstein & O’Daniel, 2005 as cited in Guidroz et al., 2010); physicians holding dismissive attitudes toward nurses (Faigin, 1992 as cited in Guidroz et al., 2010; Rosenstein, 2002 as cited in Guidroz et al., 2010); power and gender issues in the workplace (Porter, 1991 as cited in Guidroz et al., 2010; Zelek & Phillips, 2003 as cited in Guidroz et al., 2010); and communication and collaboration issues (Leonard et al., 2004 as cited in Guidroz et al., 2010; Sirota, 2007 as cited in Guidroz et al., 2010). Although the reasons are numerous, the negative outcomes for nurses when nurses and physicians have poor working relationships are significant. Rosenstein and O’Daniel (2002, 2005) as cited in Guidroz et al. (2010) have shown that mistreatment by a physician was negatively related to job satisfaction and positively related to work distress and turnover intentions. Hillhouse and Adler (1997) as cited in Guidroz et al. (2010) found in their research that physician and co-worker conflict was equally common, however, physician conflict was associated with more severe psychological distress.

Incivility from Supervisors. Interpersonal mistreatment received from a figure higher in the organizational hierarchy is common within workplaces. In a survey of nearly 1,200 public sector employees, Cortina and colleagues (2001) as cited in Guidroz et al. (2010) found that one-third of the most powerful individuals within the organization were the instigators of workplace incivility. Researchers (e.g., Frone, 2000 as cited in Guidroz et al., 2010; Tepper, 2000 as cited in Guidroz et al., 2010) have found that when people experience incivility from their supervisor this can result in lower commitment to the organization, low job satisfaction, high psychological distress, and stronger intentions to find another job. For example, Tepper (2000) as cited in Guidroz et al. (2010) found in a sample of employees from a wide variety of occupations and industries that those who reported more uncivil behavior from their supervisor also reported lower commitment to the organization, more dissatisfaction with their job, more psychological distress, and higher intentions to quit. Frone (2000) as cited in Guidroz et al. (2010) also found similar results; when participants experienced high levels of conflict with their supervisor, they reported lower job satisfaction and organizational commitment, and higher intentions to quit (Guidroz et al., 2010).

Incivility from Other Nurses. Several researchers have found that mistreatment from co-workers can lead to psychological distress. Frone (2000) as cited in Guidroz et al. (2010) found that co-worker incivility led to feelings of depression, somatic symptoms, and low self-esteem. Within health care organizations this type of common low-level aggression has been well-documented in nursing samples and has been linked to both personal and organizational outcomes. Duffy (1995) as cited in Guidroz et al. (2010) coined the term horizontal aggression as the aggression experienced from one’s own coworkers and found this to be highly prevalent within hospitals. Horizontal aggression is particularly distressful for nurses (Farrell, 1997 as cited in Guidroz et al., 2010) and has been cited as the one form of workplace mistreatment that is most concerning to nurses (Farrell, 1998 as cited in Guidroz et al., 2010). McKenna et al. (2003) as cited in Guidroz et al. (2010) measured the frequency of horizontal aggression experienced by nurses during the first year of practice. Their research indicated that not only does horizontal aggression affect a high number of the respondents, it is also associated with increased absenteeism and thoughts about quitting the field of nursing all together (McKenna et al., 2003 as cited in Guidroz et al., 2010).

Incivility from Patients.  Uncivil treatment from the patients one cares for is an additional source of workplace conflict that can result in negative effects on nurses. Outside of a health care setting, researchers have found that customer-related social stressors, such as verbal aggression or unusual customer demands, were significant predictors of burnout (Dormann & Zapf, 2004 as cited in Guidroz et al., 2010), decreased employees’ ability to regulate their emotions when dealing with subsequent hostile customers (Grandey et al., 2004 as cited in Guidroz et al., 2010), and occurred more frequently than aggression with co-workers or supervisors (Grandey et al., 2007 as cited in Guidroz et al., 2010). Within health care organizations, the findings are similar. A recent hospital study found that the majority of nurses identified their patients as the main perpetrators of verbal or physical abuse (Farrell et al., 2006 as cited in Guidroz et al., 2010). This abuse influenced the severity of distress that nurses experienced, their overall productivity, and increased sentiments for withdrawing from the career of nursing. Additionally, researchers have found that nurses who receive high levels of verbal aggression from patients are more prone to experience emotional exhaustion and depersonalization, two of the components of burnout (Winstanley & Whittington, 2002 as cited in Guidroz et al., 2010).

Compassion Satisfaction. Compassion satisfaction is about the pleasure a person derived from being able to do his or her work. For example, a person may feel like it is a pleasure to help others through what he or she does at work. He or she may feel positively about their colleagues or his or her ability to contribute to the work setting or even the greater good of society through his or her work with people who need care. On the other side of compassion satisfaction can be compassion fatigue, which is the negative aspect of helping those who experience traumatic stress and suffering (ProQOL.org, 2019).

Female gender was associated with higher levels of compassion fatigue, and therapists with specialized training in trauma work reported higher levels of compassion satisfaction than non-specialists. Provider discipline proved to be an important factor, with psychiatrists reporting higher levels of compassion fatigue than their non-medical counterparts. The most rural providers reported increased levels of burnout but could not be distinguished from their colleagues on the compassion fatigue and compassion satisfaction subscales (Sprang et al., 2007). In the study of Sacco et al. (2015), nurses reported significant differences in compassion satisfaction and compassion fatigue on the basis of sex, age, educational level, unit, acuity, change in nursing management, and major systems change. Understanding the elements of professional quality of life can have a positive effect on work environment. The relationship between professional quality of life and the standards for a healthy work environment requires further investigation. Once this relationship is fully understood, interventions to improve this balance can be developed and tested.

Compassion Fatigue. According to Coetzee and Klopper (2010), compassion fatigue is the progressive and cumulative outcome of prolonged, continuous, and intense contact with patients, self-utilization, and exposure to multidimensional stress leading to compassion discomfort that exceeds nurses’ endurance levels. By profession, nurses are caring and compassionate individuals who provide support, healing, and encouragement, but constant exposure to stress and traumatic experiences contributes to reduced job satisfaction, compassion fatigue, and burnout leading to high turnover rates (Harris & Griffin, 2015; Halfer & Graf, 2006). Compassion fatigue and burnout negatively impact nurses’ wellbeing (Rudman & Gustavsson, 2011), job satisfaction (Kalliath & Morris, 2002; Piko, 2006; Ross et al., 2009; Stewart, 2009), willingness to remain in the profession (Ohue et al., 2011), patient outcomes (Cimiotti et al., 2012), and patient satisfaction (Leiter et al., 1998 as cited in Zhang et al., 2015).

Burnout is associated with feelings of hopelessness and difficulties in dealing with work effectively, reflecting high workload or non-supportive work environments (ProQOL.org, 2019). Secondary traumatic stress (STS) is related to vicarious trauma and involves secondary exposure to extremely stressful events at work, leading to symptoms such as fear, sleep difficulty, and intrusive images (ProQOL, 2019). Compassion fatigue occurs across disciplines and negatively impacts the nurse, patient, organization, and healthcare system (Peters, 2018). Undergraduate students also experience average levels of compassion fatigue and burnout, indicating the need for knowledge and coping strategies in nursing training (Mathias & Wentzel, 2017).

Studies show burnout is common among healthcare professionals, with highest levels reported among nurses, associated with work environments, emotional distress, and low social support (Chemali et al., 2019; Dubale et al., 2019). Oncology nurses with more years of experience, passive coping styles, and personality traits such as neuroticism showed higher compassion fatigue and burnout (Yu et al., 2016). High levels of depersonalization and emotional exhaustion were linked to alcohol and tobacco use among healthcare workers (Petrelli et al., 2018). Nurses working long hours and with patients with disorders of consciousness reported moderate to low burnout, but nurses in intensive care, mental health, paediatrics, and oncology remain particularly vulnerable to work-related stress (Leonardi et al., 2013; Sabo, 2011). Empathic nurses often become victims of compassion fatigue, affecting job satisfaction, health, productivity, and turnover (Lombardo & Eyre, 2011).

Incivility and Professional Quality of Life. In the study of Alshehry et al. (2019), nurses perceived a moderate level of workplace incivility from different sources of uncivil acts measured. Among the five sources explored, nurses reported the majority of workplace incivility experienced from patients/visitors, while the lowest was from supervisors. The mean scores in the compassion satisfaction, burnout, and secondary traumatic stress subscales were 36.50, 26.43, and 26.47, respectively. General incivility, supervisor incivility, physician incivility, and patient/visitor incivility showed a significant multivariate effect on the three Professional Quality of Life (ProQOL) subscales. Findings in the study of Oyeleye et al. (2013) demonstrated 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 are sensitive to the needs and interests of nurses at high risk for leaving their organizations is imperative for nurse executives.

In the study of Shi et al. (2018), findings showed that workplace incivility was positively correlated with anxiety and job burnout of new nurses. The positive relation between anxiety and job burnout was significant, with anxiety partially mediating and resilience moderating the association between workplace incivility and job burnout. Experience of workplace incivility by new nurses would likely generate anxiety, elevating their level of job burnout, but new nurses with high levels of resilience could buffer the negative influence of workplace incivility by using a positive coping style.

RESEARCH METHODOLOGY

Design. This quantitative research made use of the descriptive, correlational (predictive) design). The study made use of the correlational research design which can either be relational (leading to correlation analysis) or predictive (leading to regression analysis). In the study, the correlational predictive design was used. Correlational predictive design is used in those cases when there is an interest to identify predictive relationship between the predictor and the outcome/criterion variable (University of Phoenix, 2020). In application to the study, the predictive design was used to assess whether the dimensions of nursing incivility predicted professional quality of life among nurses in for the last quarter of 2020.

Environment. This study was conducted at the Amai Pakpak Medical Center. Amai Pakpak Medical Center is currently approved as a 350-bed capacity tertiary hospital located in Barangay Datu Saber, Marawi City, Province of Lanao del Sur. It is the mission and vision of the hospital to being committed to hasten its development into a tertiary health facility of 350-bed capacity and its transformation into a training center that will provide access to quality health service. By the year 2010 and beyond, APMC shall be the premier medical center in the Muslim Mindanao Region, through effective delivery of quality health care service, equipped with excellent facilities and competent personnel. The hospital is manned by over a thousand hospital personnels.

Respondents. The research involved 312 nurses in the nursing service department.

Sampling Design. A complete enumeration was utilized in the study.

Inclusion and Exclusion Criteria. To qualify as a study respondent, the nurse should be of legal age regardless of sex, marital status, educational attainment, and religion, and currently employed in the hospital for at least 3 months regardless of employment status (contractual, probationary, or regular) and position (nursing staff, head nurse, nurse managers, nurse supervisors, and chief nurse). He or she must be willing to participate and provide voluntary consent by signing the informed consent form. Excluded in the study were nurses who have submitted their resignation letters or letters of intent on retirement, those who were on leave during the time of data gathering, and those identified to be vulnerable subjects.

Instrument. Part one of the instrument is the Nursing Incivility Scale (NIS), composed of 43 items divided into five sources of incivility: General, Nurse, Supervisor, Physician, and Patient. The General Incivility scale has three subscales with three items each: Hostile Climate, Inappropriate Jokes, and Inconsiderate Behavior. Nurse Incivility contains 10 items across Hostile Climate, Gossip and Rumors, and Free-riding. Supervisor and Physician factors each have seven items divided into Abusive Supervision and Lack of Respect. Patient Incivility has 10 items under Lack of Respect and Displaced Frustration. Responses use a 5-point Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree). Scores are interpreted as very low (1.00–1.80), low (1.81–2.60), moderate (2.61–3.40), high (3.41–4.20), and very high (4.21–5.00).

Part two is the updated Professional Quality of Life (ProQOL) 5 Self-Score (2012), a 30-item tool with subscales for compassion satisfaction, burnout, and secondary traumatic stress (STS). It is rated from 1 (never) to 5 (very often). Compassion satisfaction scores below 33 suggest issues with job satisfaction, 23–41 is moderate, and 42 or more is high. For burnout, below 18 reflects positive feelings, 23–41 is moderate, and 42 or more is high. The average burnout score is 22, and a persistent high score may be a cause for concern.

For STS, the average score is 13. Scores above 17 suggest one may need to reflect on work-related stress or trauma, while a score of 22 or less is low, 23–41 is moderate, and 42 or more is high. The ProQOL measures the positive and negative effects of helping others experiencing suffering and trauma.

Data Gathering Procedures. Before data gathering, three potential research titles were submitted for title defense. Once a title was approved, the researcher requested permission from the College of Allied Health Sciences Dean and the Medical Center Chief of Amai Pakpak Medical Center. After seeking all approvals, a panel of reactors examined the research during a design hearing. Once suggestions and recommendations were complied with, the research was sent to the Institutional Review Board of the university (UV-IRB) for ethical approval and securing of the notice to proceed (NTP). If the notice was given, this signaled the researcher to start recruiting respondents.  Considering that the researcher works in the hospital where the study was conducted, an enumerator was hired to distribute and collect questionnaires from those who signed the consent, ensuring completion before retrieval. Questionnaires were distributed to nurses who qualified based on inclusion and exclusion criteria. Due to COVID-19 restrictions, recruitment used a modified face-to-face intercept, distributing questionnaires during different shifts while observing social distancing, wearing masks and face shields, and practicing frequent hand sanitation. Contact was limited to giving and retrieval of the questionnaire, placed in sanitized plastic envelopes, and pens were sanitized before and after use. Nurses were given an option to answer at home and email their responses, but retrieval on the same or following day was preferred. All answered questionnaires were placed in an electronic file for statistical treatment. Results were presented in tables with explanations, implications, and supporting literature and studies. Responded questionnaires were discarded or shredded at the end of the study, along with deleting all soft copies of tallied data.

Statistical Treatment of Data.  Mean Score this measure of central tendency was used to determine the scores of the respondents in terms of the nursing incivility and all its facets and sub-facets.  Summation was used to determine the respective scores of the respondents on their professional quality of life in terms of their compassion satisfaction and compassion fatigue (burnout and secondary trauma stress). Multiple Linear Regression was be used in order to assess whether workplace incivility predicts professional quality of life (compassion satisfaction and compassion fatigue [burnout and secondary trauma stress].

Ethical Consideration. Ethical considerations are an essential component of any research study. The study was submitted for ethical approval prior to data gathering.

Presentation, Interpretation and Analysis of Data

Table 1 Perceived Client Satisfaction on the Services of the Radiologic Department

Facets of Nurse Incivility	Mean score	SD	Interpretation
General Incivility
Hostile climate	3.63	1.00	High
Inappropriate jokes	2.36	1.24	Low
Inconsiderate behavior	3.04	1.01	Moderate
Factor mean score	3.01	0.91	Moderate
Nurse Incivility
Hostile climate	2.51	1.10	Low
Gossip and rumors	3.33	1.06	Moderate
Free-riding	2.63	1.10	Moderate
Factor mean score	2.82	0.88	Moderate
Supervisor Incivility
Abusive supervision	2.17	1.21	Low
Lack of respect.	2.06	1.08	Low
Factor mean score	2.12	1.09	Low
Physician Incivility
Abusive supervision	2.72	1.08	Moderate
Lack of respect.	2.63	1.05	Moderate
Factor mean score	2.67	1.02	Moderate
Patient Incivility
Lack of respect	3.54	1.07	High
Displaced frustration	3.31	1.02	Moderate
Factor mean score	3.43	1.00	High

Note: n=300.

Legend: Parametric scores and interpretation for the workplace incivility are as follows: a score of 1.00 – 1.80 is very low, 1.81 to 2.60 is low, 2.61 – 3.40 is moderate, 3.41 – 4.20 is high, and 4.21 – 5.00 is very high.

Incivility may arise because of certain events such as the pandemic, triggering colleagues to become uncivil due to pressures of the situation, personal or familial problems, or having a bad day. Developing an incivility measure for nurses should address the number of sources from whom nurses commonly experience incivility, as uncivil behavior differs by instigator (Guidroz et al., 2010). Overall, there was a moderate level of nurse incivility, with hostile climate rated low, gossip and rumors moderate, and free-riding moderate. Gossiping and spreading rumors may be linked to Filipino culture and crab mentality. Co-worker incivility can lead to psychological distress, depression, low self-esteem, increased absenteeism, and thoughts about quitting the nursing field (Frone, 2000; Duffy, 1995; Farrell, 1997, 1998; McKenna et al., 2003 as cited in Guidroz et al., 2010).

Supervisor incivility was low, with low levels of abusive supervision and lack of respect. This implies nurse supervisors are respectful and equipped with leadership skills, knowing that being verbally abusive will not help staff efficiency. However, interpersonal mistreatment from higher organizational figures is common and linked to lower commitment, low job satisfaction, psychological distress, and higher intentions to quit (Cortina et al., 2001; Tepper, 2000; Frone, 2000 as cited in Guidroz et al., 2010). Physician incivility was moderate, with moderate levels of abusive supervision and lack of respect, affecting job satisfaction and increasing distress (Rosenstein & O’Daniel, 2002, 2005; Hillhouse & Adler, 1997 as cited in Guidroz et al., 2010). Poor nurse–physician relationships are attributed to disruptive behavior, dismissive attitudes, power and gender issues, and communication problems.

Patient incivility was high, with high levels of lack of respect and moderate displaced frustration. Patients may become reactive due to illness discomfort or demands for service satisfaction. Uncivil treatment from patients results in negative effects such as burnout, emotional exhaustion, and depersonalization (Dormann & Zapf, 2004; Grandey et al., 2004, 2007; Farrell et al., 2006; Winstanley & Whittington, 2002 as cited in Guidroz et al., 2010). In the study of Alshehry et al. (2019), nurses perceived a moderate level of workplace incivility, highest from patients/visitors and lowest from supervisors. Regarding professional quality of life, majority of nurses had moderate compassion satisfaction, with almost a quarter reporting high level, as the COVID-19 pandemic tested nurses’ compassion and commitment to the profession.

Table 2 Professional Quality of Life among Nurses

Professional Quality of Life	Average score	f	%
Compassion Satisfaction
Low	18.33	3	1.00
Moderate	34.96	229	76.33
High	45.47	68	22.67
Average Score	37.18	Moderate
Compassion Fatigue
Burnout
Low	18.50	4	1.33
Moderate	32.82	282	94.00
High	46.07	14	4.67
Average Score	33.25	Moderate
Secondary Trauma Stress
Low	18.65	94	31.33
Moderate	29.06	198	66.00
High	47.50	8	2.67
Average Score	26.29	Moderate

Note: n=300.

Legend: In scoring the instrument, the compassion satisfaction, a score of 22 or less is low while a score between 23 and 41 is moderate and a score of 42 or more is high. For the burnout, a score of 22 or less is low while a score between 23 and 41 is moderate and a score of 42 or more is high. For the secondary traumatic stress (STS), a score of 22 or less is low while a score between 23 and 41 is moderate and a score of 42 or more is high.

This pandemic has given nurses an opportunity to do an introspection on themselves in terms of why they are here in the nursing profession. Nurses had been identified as front liners during the pandemic, allowing them to see the real purpose of their profession and gain a certain level of compassion satisfaction for being in service to people. A moderate level of compassion satisfaction implies that nurses get moderate satisfaction from helping people, feeling invigorated after working, liking their work as a helper, being pleased with keeping up with techniques and protocols, having happy thoughts about those they help, believing they can make a difference, being proud of what they can do, thinking they are a “success” as a helper, and being happy they chose their work. Compassion satisfaction is about the pleasure a person derived from being able to do his or her work and feeling positively about colleagues or the ability to contribute to the greater good. On the other side of compassion satisfaction can be compassion fatigue, the negative aspect of helping those who experience traumatic stress and suffering (ProQOL.org, 2019).

Majority of nurses had a moderate level of burnout while a minimal had high or low levels. The COVID-19 pandemic greatly contributed to this. Findings imply they are moderately happy, feel connected to others, and are not as productive because they lose sleep over traumatic experiences of those they help. Moderate burnout is brought about by feeling trapped by their job, having beliefs that sustain them, feeling worn out, overwhelmed by endless workload, feeling “bogged down” by the system, and being very caring. Burnout describes workers’ negative behaviors and attitudes toward work in response to job strain (Davis et al., 2013) and impacts wellbeing, job satisfaction, willingness to remain in the profession, patient outcomes, and satisfaction from healthcare (Rudman & Gustavsson, 2011; Kalliath & Morris, 2002; Piko, 2006; Ross et al., 2009; Stewart, 2009; Ohue et al., 2011; Cimiotti et al., 2012; Leiter et al., 1998 as cited in Zhang et al., 2015).

Furthermore, majority had a moderate level of secondary trauma stress, over a quarter had low, and a few had high. Nurses witnessed patients struggling with COVID-19 and numerous deaths, adding to their trauma, fear, anxiety, and stress. Moderate secondary trauma stress is brought about by being preoccupied with more than one person they help, being startled by sounds, finding it difficult to separate personal life from work, thinking they might have been affected by traumatic stress of those they help, feeling “on edge,” depressed by traumatic experiences, feeling as if experiencing others’ trauma, avoiding activities that remind them of frightening experiences, having intrusive thoughts, and inability to recall parts of work with trauma victims. Secondary Traumatic Stress (STS) is an element of compassion fatigue related to vicarious trauma (ProQOL, 2019). Compassion fatigue occurred across disciplines, negatively impacting nurses, patients, organizations, and the healthcare system. Prevention is achieved through professional boundaries, self-care, self-awareness, and education at individual and organizational levels (Peters, 2018).

Table 3 Facets of Nurse Incivility Predicting Compassion Satisfaction

Compassion satisfaction (Dependent variable)	B value	Std. Err	Beta value	t value	p value	Decision	Interpretation
(Constant)	35.889	1.589		22.592	.000
Hostile Climate (General)	-.002	.566	.000	-.003	.998	Failed to reject the null hypothesis	Not significant
Inappropriate Jokes (General)	.380	.392	.074	.970	.333	Failed to reject the null hypothesis	Not significant
Inconsiderate Behavior (General)	-.588	.601	-.093	-.978	.329	Failed to reject the null hypothesis	Not significant
Hostile Climate (Nurse)	-.971	.495	-.168	-1.963	.051	Failed to reject the null hypothesis	Not significant
Gossip and Rumors (Nurse)	.746	.569	.125	1.310	.191	Failed to reject the null hypothesis	Not significant
Free Riding (Nurse)	.651	.454	.113	1.432	.153	Failed to reject the null hypothesis	Not significant
Abusive Supervision (Supervisor)	-.750	.613	-.143	-1.225	.222	Failed to reject the null hypothesis	Not significant
Lack of Respect (Supervisor)	.411	.635	.070	.647	.518	Failed to reject the null hypothesis	Not significant
Abusive Supervision (Physician)	.344	.666	.059	.516	.606	Failed to reject the null hypothesis	Not significant
Lack of Respect (Physician)	-.365	.693	-.060	-.527	.598	Failed to reject the null hypothesis	Not significant
Lack of Respect (Patient)	.717	.654	.121	1.096	.274	Failed to reject the null hypothesis	Not significant
Displaced Frustration (Patient)	-.397	.752	-.064	-.528	.598	Failed to reject the null hypothesis	Not significant

Legend: Significant if p value is < .05. Model Summary: R value is .240; R squared value is .058; Adjusted R squared is .018; and Standard Estimated Error is 6.281. ANOVA: F value: 1.463 and Sig. = .137

If R-squared value < 0.3 this value is generally considered a None or Very weak effect size, if R-squared value 0.3 < r < 0.5 this value is generally considered a weak or low effect size, if R-squared value 0.5 < r < 0.7 this value is generally considered a Moderate effect size, and if R-squared value r > 0.7 this value is generally considered strong effect size (Moore et al., 2013).

Table 3 presents the data on whether the different facets of nurse incivility predicted compassion satisfaction. The p values for all independent variables of general incivility (hostile climate, inappropriate jokes, and inconsiderate behavior); nurse incivility (hostile climate, gossip and rumors, and free riding); supervisor incivility (abusive supervision and lack of respect); physician incivility (abusive supervision and lack of respect); and patient incivility (lack of respect and displaced frustration) were greater than .05. These findings were considered not significant, leading to the decision of failing to reject the null hypothesis. This means none of the facets of nurse incivility predicted compassion satisfaction, and no regression equation was derived from the findings. This implies that compassion satisfaction is not dependent on levels of nursing incivility. During the pandemic, nurses’ commitment and compassion were tested, and being of service to people remains a major source of satisfaction. Even if incivility existed, it did not stop nurses from fulfilling their professional oaths. Contrary to these findings, Alshehry et al. (2019) showed significant multivariate effects of general, supervisor, physician, and patient incivility on ProQOL subscales, while Oyeleye et al. (2013) found significant relationships among workplace incivility, stress, burnout, turnover intentions, years of experience, and RN education levels, suggesting the need for targeted retention strategies and policies for nurses at risk of leaving.

Table 4 Facets of Nurse Incivility Predicting Burnout

Burnout (Dependent variable)	B value	Std. Err	Beta value	t value	p value	Decision	Interpretation
(Constant)	28.403	1.174		24.186	.000
Hostile Climate (General)	.065	.418	.013	.154	.877	Failed to reject the null hypothesis	Not significant
Inappropriate Jokes (General)	.527	.290	.136	1.818	.070	Failed to reject the null hypothesis	Not significant
Inconsiderate Behavior (General)	-.154	.444	-.032	-.347	.729	Failed to reject the null hypothesis	Not significant
Hostile Climate (Nurse)	.324	.366	.074	.887	.376	Failed to reject the null hypothesis	Not significant
Gossip and Rumors (Nurse)	.182	.421	.040	.433	.665	Failed to reject the null hypothesis	Not significant
Free Riding (Nurse)	.013	.336	.003	.037	.970	Failed to reject the null hypothesis	Not significant
Abusive Supervision (Supervisor)	-.900	.453	-.225	-1.987	.048	Reject the null hypothesis	Significant
Lack of Respect (Supervisor)	.439	.469	.099	.935	.351	Failed to reject the null hypothesis	Not significant
Abusive Supervision (Physician)	-1.023	.492	-.230	-2.077	.039	Reject the null hypothesis	Significant
Lack of Respect (Physician)	1.415	.512	.308	2.761	.006	Reject the null hypothesis	Significant
Lack of Respect (Patient)	.688	.483	.153	1.424	.155	Failed to reject the null hypothesis	Not significant
Displaced Frustration (Patient)	.016	.556	.003	.029	.977	Failed to reject the null hypothesis	Not significant

Legend: Significant if p value is < .05. Model Summary: R value is .326; R squared value is .106; Adjusted R squared is .069; and Standard Estimated Error is 4.643. ANOVA: F value: 2.849 and Sig. = .001.

If R-squared value < 0.3 this value is generally considered a None or Very weak effect size, if R-squared value 0.3 < r < 0.5 this value is generally considered a weak or low effect size, if R-squared value 0.5 < r < 0.7 this value is generally considered a Moderate effect size, and if R-squared value r > 0.7 this value is generally considered strong effect size (Moore et al., 2013).

As shown in the table, the p values for abusive supervision of supervisor incivility, abusive supervision of physician incivility, and lack of respect of physician incivility were less than .05, interpreted as significant, leading to rejection of the null hypothesis. This meant these variables predicted burnout of compassion fatigue. The t values for abusive supervision of supervisor incivility (-1.987) and physician incivility (-2.077) were negative, meaning for each unit decrease, burnout increases by 1.987 and 2.077 units, respectively. The positive t value for lack of respect of physician incivility (2.761) means that as lack of respect increases by one unit, burnout increases by 2.761 units. While abusive supervision adds to stress, findings showed that decreasing abusive supervision still increases burnout, likely due to the pandemic’s effect on workload. Lack of respect from physicians also increases burnout, as nurses value mutual respect in collaboration for patient care. The regression equation derived was: Burnout = 28.403 – (.900 x abusive supervision of supervisor incivility) – (1.023 x abusive supervision of physician incivility) + (1.415 x lack of respect of physician incivility). The r squared value was .106, meaning the prediction model was negligible or very weak despite significance. The p values for general incivility (hostile climate, inappropriate jokes, inconsiderate behavior), nurse incivility (hostile climate, gossip and rumors, free-riding), lack of respect of supervisor incivility, and patient incivility (lack of respect and displaced frustration) were greater than .05, interpreted as not significant, failing to reject the null hypothesis. These findings align with Alshehry et al. (2019), showing significant multivariate effects of incivility on ProQOL subscales, and with Oyeleye et al. (2013), who found significant relationships among workplace incivility, stress, burnout, and turnover intentions, highlighting the need for targeted retention strategies for nurses.

Table 5 Facets of Nurse Incivility Predicting Secondary Trauma Stress

Secondary Trauma Stress (Dependent variable)	B value	Std. Err	Beta value	t value	p value	Decision	Interpretation
(Constant)	18.944	1.682		11.264	.000
Hostile Climate (General)	-1.053	.599	-.148	-1.757	.080	Failed to reject the null hypothesis	Not significant
Inappropriate Jokes (General)	.737	.415	.128	1.774	.077	Failed to reject the null hypothesis	Not significant
Inconsiderate Behavior (General)	.249	.636	.035	.391	.696	Failed to reject the null hypothesis	Not significant
Hostile Climate (Nurse)	1.175	.524	.182	2.244	.026	Reject the null hypothesis	Significant
Gossip and Rumors (Nurse)	.013	.603	.002	.022	.983	Failed to reject the null hypothesis	Not significant
Free Riding (Nurse)	.807	.481	.125	1.678	.094	Failed to reject the null hypothesis	Not significant
Abusive Supervision (Supervisor)	-.372	.648	-.063	-.574	.566	Failed to reject the null hypothesis	Not significant
Lack of Respect (Supervisor)	-.121	.672	-.018	-.180	.857	Failed to reject the null hypothesis	Not significant
Abusive Supervision (Physician)	-.901	.705	-.137	-1.277	.203	Failed to reject the null hypothesis	Not significant
Lack of Respect (Physician)	1.342	.734	.198	1.829	.069	Failed to reject the null hypothesis	Not significant
Lack of Respect (Patient)	-.355	.692	-.054	-.513	.608	Failed to reject the null hypothesis	Not significant
Displaced Frustration (Patient)	1.450	.796	.207	1.820	.070	Failed to reject the null hypothesis	Not significant

Legend: Significant if p value is < .05. Model Summary: R value is .400; R squared value is .160; Adjusted R squared is .125; and Standard Estimated Error is 6.649. ANOVA: F value: 4.566 and Sig. = .000.

If R-squared value < 0.3 this value is generally considered a None or Very weak effect size, if R-squared value 0.3 < r < 0.5 this value is generally considered a weak or low effect size, if R-squared value 0.5 < r < 0.7 this value is generally considered a Moderate effect size, and if R-squared value r > 0.7 this value is generally considered strong effect size (Moore et al., 2013).

As reflected in the table, the p value for hostile climate by nurse incivility was less than .05, interpreted as significant, leading to rejection of the null hypothesis. This meant that hostile climate of nurse incivility predicted secondary trauma stress of compassion fatigue. The t value was positive (2.244), meaning for every one unit increase in hostile climate by nurse incivility, secondary trauma stress increases by .182 unit. The regression equation derived was: Secondary Trauma Stress = 18.944 + (1.175 x hostile climate by nurse incivility). The r squared value was .160, meaning the prediction model was negligible or very weak despite significance. A hostile climate caused by nurses, such as arguing, violent outbursts, or screaming, can greatly influence nurses in feeling secondary stress. These stressful events can cause fear, sleep difficulty, intrusive images, and avoidance behaviors, affecting teamwork, collaboration, and ultimately patient care outcomes.

The table also shows that p values for general incivility (hostile climate, inappropriate jokes, inconsiderate behavior), nurse incivility (gossip and rumors, free-riding), supervisor incivility, physician incivility (abusive supervision, lack of respect), and patient incivility (lack of respect, displaced frustration) were greater than .05, interpreted as not significant, leading to failing to reject the null hypothesis. These variables did not predict secondary trauma stress, meaning levels of incivility did not influence it. The findings align with Alshehry et al. (2019), showing significant multivariate effects of incivility on ProQOL subscales, and with Oyeleye et al. (2013), demonstrating significant relationships among workplace incivility, stress, burnout, turnover intentions, years of nursing experience, and RN education levels, highlighting the need for targeted retention strategies for nurses.

CONCLUSION AND RECOMMENDATIONS

Conclusion. In conclusion, abusive supervision of supervisor incivility, abusive supervision of physician incivility, and lack of respect for physician influenced burnout. Burnout is increased by a decrease in the abusive supervision by supervisors and physicians and an increase in the lack of respect by the physicians. Further, hostile climate of the nurse incivility influenced secondary trauma stress. An increase in the hostile climate increases secondary trauma. True to the Workplace Incivility Theory that also maintain that all organizations have norms for respect that encourage cooperation among co-workers and that incivility violates these norms as proven in the study that there were low to high specific workplace incivility. On the other hand, nurses were able to feel a quality of life in relation to their work as a helper to individuals, community, national, and even international crises as reflected by a moderate level of compassion satisfaction, burnout and secondary trauma stress as findings of the study. With the professional quality of life of the nurses being on a moderate level, the professional quality of life enhancement plan was proposed. Healthcare professionals and hospital administrators should work hand in hand to prevent or keep work incivility at a minimum to maintain good working relationship among healthcare professionals and to effect positive patient outcomes.

Recommendations. The results of this study guide the following suggestions are offered:

1. The professional quality of life enhancement plan be recommended for use in healthcare facilities. A copy of which shall be provided to the healthcare facilities including the Department of Health. That the accredited professional organization both in the national and local level, should establish activities as part of the continuing professional education in which nurse incivility is a topic for seminars and workshops.
2. The concept of work incivility be incorporated in the concept under Nursing Management and the Code of Ethics for Filipino Nurses.
3. As an internal policy among healthcare organizations, it should form part of the internal policy that workplace incivility be assessed periodically as part of the strategic or operational plan.
4. Finally, the following topics are suggested for future research undertakings:

4.1 Validating abusive behavior predicting burnout among nurses;

4.2 Hostile climate as predictor of secondary trauma stress among nurses; and;

4.3 The unheard voices of nurses experiencing work incivility: A phenological inquiry.

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