Which of the following are civility practices for professional nurses? select all that apply.

Iran J Nurs Midwifery Res. 2017 Mar-Apr; 22(2): 157–163.

Abstract

Background:

Many articles have studied workplace incivility and its influence on outcomes, but very few have been conducted to assess how to prevent this issue. In this study, we aimed to determine how to prevent workplace incivility from the nurses' perspective.

Materials and Methods:

This was a qualitative study which was based on a conventional content analysis approach. Thirty four nurses (25 to 52 years old) from seven training hospitals in Tabriz, Iran were selected through purposive sampling. Thirty six semi-structured interviews and eight field notes were analyzed.

Results:

The data analysis revealed 417 codes, ten categories, three subthemes and one theme, that is, A Need for a Comprehensive Attempt. Attempt of organization, nurses, and public as subthemes are needed to prevent workplace incivility.

Conclusions:

The findings of the study indicated that a comprehensive and systematic attempt was needed to prevent incivility. Nurses should try to improve their skills; officials should try to show the real image and position of nurses and hospitals to the community.

Keywords: Iran, nurses, qualitative research, violence, workplace

Introduction

Workplace incivility (WPI) is a significant problem in healthcare centres, disturbing not only the clinicians enduring the negative behaviors but also the care that is delivered under the shadow of incivility.[1] Hutton and Gates stated that “incivility is characteristically rude and disrespectful, revealing a lack of respect for others.[2]

Individuals who experience incivility, either as targets or witnesses, may suffer numerous negative behavioral, psychological, and somatic effects.[3,4,5,6,7,8,9,10,11,12,13,14,15] In addition, threatening and disruptive actions can also lead to medical errors, reduce patient satisfaction, and increase the cost of care; meanwhile, with the recent modifications in the health care system, such concerns have become even more crucial to address.[16]

The incidence rate of incivility, in terms of experiencing incivility or witnessing WPI was reported to be 11 to 99%.[17,18,19,20] High prevalence of incivility and even violence is reported in Iran,[21,22,23] and some studies even see it as inevitable.[24] Therefore, in this case, further investigation and clarification of the perspectives regarding prevention methods is warranted. However, a limited number of surveys, to our knowledge, have focused on the attitudes which nurses, as the major staff in the health care system, have regarding incivility prevention. Many studies have been published about WPI but most have focused on the frequency, types, and significance of uncivil behavior in healthcare organizations. Meanwhile, describing the experience of incivility prevention from nurses' perspective is valuable to a better understanding of its risk factors, outcomes, and ways of prevention. Exploring these perspectives is important because they could affect the way nurses are challenged to prevent and manage incivility.[25,26]

This qualitative study is aimed at determining how to prevent WPI from nurses' perspective. The findings of the study may provide a valuable understanding into the perspective of nurses toward the prevention and management of WPI.

Materials and Methods

Design

Because the objective of the current study was to describe the nurses' experiences pertaining to their perspective about how to prevent WPI, the descriptive qualitative study design was used.

Settings and participants

Participants were selected purposively from nurses employed in the educational hospitals of Tabriz University of Medical Sciences based on saturation principles. Saturation of data occurred when additional sampling provided no new information but only redundancy of previously collected data. Nurses were chosen using two inclusion criteria: (1) At least one year of nursing experience and (2) at least a bachelor's degree in nursing. In the initial stage of sampling, nurses with a history of incivility were invited to participate. Sampling was ongoing with simultaneous analysis of interviews and field notes. Next, the participants were selected according to findings and to observe the maximum variation of nurses' characteristics (age, gender, nursing experiences, and history of incivility). Demographic characteristics of participants are presented in Table 1.

Table 1

Demographic characteristics of participants

Data collection

The data were collected from March 2015 to July 2015. Unstructured interviews were conducted for gathering the data. In-depth individual interviews, which lasted 35 to 65 min, were performed. Two of participants were interviewed for the second time because the researcher was faced with some questions and ambiguity during coding process. All interviews were conducted at the participants' desired time and place. Thirty interviews were conducted in the hospital and 6 interviews at the researcher's workplace. Each interview started with general questions such as “What experiences do you have about incivility prevention?, What are your experiences of probable incivility with you?, Give an example of what you do to prevent uncivil behavior?” The questions became more detailed and structured with the progress of the interviews. The interviews were audiotape-recorded. In addition, behaviors of participants were observed in the work place during nursing care or other actions. The researcher did not have any direct participation in the delivery of care and wrote the field notes (n = 8) in detail as soon as possible after the observations and before talking to anyone else about the observations.

Data analysis

To analyse the data, the MAXQDA software version 10 was used. The researcher transcribed 8 field notes and 36 interviews verbatim. Transcripts were checked for errors and were read several times to obtain better understanding of the facts. The overt and covert messages in the transcribed file were analyzed by conventional qualitative content analyses approach.

The meaningful units of data were considered to be words, sentences, and paragraphs, accordingly. The meaningful units were condensed, abstracted, and labelled with codes. Codes were organized into subcategories based on present similarities and differences. To end with, the data were cited in the main subthemes and then the main theme was abstracted.

Rigor

Principles of credibility, dependability, transferability, and conformability were established as the rigor of this study. Credibility of data was strengthened through the ongoing presence of the authors in the clinical setting, and the findings were discussed in the presence of the research team, as well as independent colleagues (2 nurses). Transferability was enhanced by purposive sampling to include participants who varied on basic characteristics, history of incivility, and ability to prevent probable uncivil actions. Dependability was strengthened by engaging more than one researcher in data analysis (the first and corresponding author). Conformability was enhanced by keeping an easy-to-follow audit trial of data, methodological decisions, and analysis notes.

Ethical consideration

The Research Council and Ethics Committee affiliated to the Tabriz University of Medical Sciences approved the proposal (with No 94/3/22-5/4/1926). The aims of the study were explained in detail to the participants. In addition, the ensuing information including the voluntary nature of the participation, their right to privacy, anonymity, and confidentiality, as well as the right to withdraw from the study at any time without any penalty was given. The nurses signed an informed consent form.

Results

Thirty four participants were interviewed; the demographic characteristics of the participants are shown in Table 1. Finally, 36 interviews and 8 filed notes were analyzed. At the beginning of analyses, 417 codes were derived from the collected data. Then, through overlapping and integrating the codes, 10 subcategories were left. Finally through categorizing these subcategories, 3 subthemes and 1 core theme was left. Table 2 shows the stages of theme formation.

Table 2

The stages of theme formation

Nurse

One of the main groups involved in preventing WPI was nurses. They must do and not do many things to prevent incivility. Completing tasks, improving knowledge and skill, communicating effectively are the subcategories, described below.

Completing tasks

Nurses are in hospitals to do specific activities and are expected to present a perfect job. Nurses claim that completing task accurately and correctly is one of the most important factors in preventing incivility because in most cases incivility is experienced due to failing to do their responsibility. An operating room nurse who had 18 years of nursing experience said that:

“After all those bad experiences, I know what I should do to prevent it. I go to the operating room in time, I predict everything in advance. Definitely no problem comes out when the surgeon sees me standing there and doing my task perfectly.“

Improving knowledge and skill

Nursing responsibilities are important and delicate and require good skills, knowledge, and capabilities. According to the finding, improving nursing skills is another factor in preventing incivility. Participants claim that evidence-based caring prevents incivility toward them. One nurse, who was employed in the internal ward, said that:

“The resident asked me by phone furiously: Why should I come ‘now’? Is radiography report ready? And I replied: “Report is not ready, but it is clear that this is pulmonary oedema.” She got surprised that I can interpret it. So she came in and the patient's family was relaxed, and discontinued agitation and the resident never spoke to me like that.”

Communicating effectively

Nurses considered lack of appropriate communication with others, especially with patients and their attendants (mainly one of the family members), as one of the important factors in creating incivility. They talked about some experiences of having good communication and consequently preventing incivility. A pediatric nurse narrated her experience in this manner:

“When I want to insert IV, I convince the mom that it is necessary for the infants' treatment, then it may decrease incivility.”

Organization

The second subtheme is organization. Approximately half of the subcategories and codes are related to this subtheme. Nurses see the root of some incivilities in mismanagement and disorganization of hospitals, and hence they think officials of organization could play important role to prevent WPI. The related subcategories are described as follow.

Decreasing workload

The majority of nurses, pointing to high workload, stated that nurses should have less work-related stress and pressure to prevent WPI. They say that nurses' comfort was accompanied by better behavior and higher tolerance threshold; it results in prevention of incivility. One nurse of surgical ward presented her idea as: “When my work load is high, I get nervous, then the patient and his/her family get agitated too, what will happen?. But when the workload is low, and there are enough staff, I do my job on time, I can calm the patient, and incivility doesn't occur.”

Supporting nurse

Being supported is considered by nurses as an effective factor in preventing incivility. Nurses claimed that if a nurse is strongly supported, no one dares to behave impolitely. Nurses spoke about their bitter experiences when they looked for a support after having a conflict but found no appropriate support, which gave others enough courage to show incivility towards the nurses. One nurse, while her voice was trembling out of sadness, told us about a case of incivility despite her resourcefulness: “The supervisor came and said: “What has happened?” I told her about the patient rude behaviors, I expected her to defend me but she ordered me to apologize to the patient in front of all patients and their attendants. I was shocked. Thereafter, whenever the patient saw me, turned her face insultingly. Well, if they know I'm supported, it never happens.”

Decreasing doctor-related problems

Some of the doctor-related problems such as late visits, difficult accessibility, and rare availability could agitate patients and their family, and they may insult the nurse as a front line and “always in access” to get their results. A hemodialysis nurse said: “The patient got lethargic. Her son came in and just screaming at me, more I call and search for resident, more he insulted me. After a while when resident came in, he closed his lips… I told the resident “from this time forward, if you wouldn't stay in ward, I will report.” I did not face any incivility thereafter.”

Facilitating hospitalization process

Nurses consider principled organization of activities and convenient hospitalization process as effective factors in decreasing incivility rate towards themselves. Because unclear procedure of insurance, crowded admission line, and similar issues expose nurses to agitated attendants. A supervisor explains his experience as: “When I came to this hospital, incivility was too prevalent. I gave some good suggestion to the officials to improve discharge procedures, like preparing insurance cart in advance and … now incivility is decreased to some extent.”

Managing attendants' presence

In Asian countries, family and emotional ties are really strong, and it makes family members not to leave their patient alone in the hospital. In Iran as well, attendants (mostly a family member) have a right to be near their patients most of the time and in most of the wards. All of the nurses, except operation room nurses, complained about the attendants' presence in the wards and found it as the major source of incivility. An experienced CCU nurse who usually acted as a chief, said that: “With a lot of flattery and giving assurance to the patient and attendants, I make the attendants not to stay in the ward. You can't believe how peaceful the ward would be, because there's no one to disturb you, picking on you, showing ingratitude and then leave!”

Public

According to the experiences of the nurses, not only their own and hospitals staff's but also the patients, clients and all public are responsible to prevent incivility. Two subcategories, namely, improving views toward nurses and increasing medical knowledge are presented in this regard.

Improving views toward nurses

A disrupted public view against nurses is one of the oldest problems. Similarly, in this study, some nurses pointed out that public view toward nurses is not appropriate; because they find nurses inefficient and of low-level class, they dare to insult them. Therefore, to make people aware of actual character and position of nursing is advantageous in preventing incivility. For instance, one nurse when talking about her personal experiences told us that: “Attendant told me that I'm penniless to stay out in the hospital at night, at the morning when he saw that doctors and head nurse thank me for my valuable CPR, he dropped his teeth.”

Increasing medical knowledge

Some nurses, pointing to the inappropriate expectations by patients and attendants, that has root in unknowing, stated that the level of public medical knowledge is low, resulting in incivility based on unawareness. For instance, an ICU nurse said that: ”The patient's son told us repeatedly and aggressively: Get it (endotracheal tube) out, she can't breathe. You are killing her out of hunger. He wasn't convinced at all… He got on our nerves. When he knew that the tube saved her life, or the food was as poison to her, he never did so.”

Discussion

Assuming all the negative impact of incivility, it is absolutely essential to know how to prevent incivility in a healthcare setting. In this study, when nurses' experiences were explored, attitudes were rather diverse. Nurses did not consider preventing incivility as an individual or monodimensional task. They believed that to prevent this “ominous” issue, multidimensional steps must be taken, and the nurses as well as the organization or even the society and media must be unified.

In preventing incivility toward the nurses, nurses in this study believed that they are the most important person to act strenuously. Nurses believed that, to prevent incivility, they should act appropriately because completed duty serves as an obstacle to WPI. Uncompleted tasks may result in creating critical condition and consequently others, especially patients and doctors, see it as their right to behave disgracefully toward nurses. Evidences about good nurse also indicate that a professional and skilled nurse is seen as a good and respectful nurse.[27]

In addition, communication has been strongly identified as a preventive technique in WPI. In a similar study, care staff was introduced as a “bad attitude” from other personals as a characteristic that could increase the risk of WPI.[28] Poor communication was seen to increase the risk of aggravating incivility.[28] In a study by Babayi et al., patients' companions declare that one of the causes of their abusive behaviors is inappropriate relationship of personnel with them.[29] In another study, care staff and patients claimed that, if staff listened more and patients talked more, incivility and violence would be avoided.[30] In another research, mental health inpatients, acknowledged improvements if workers behaved respectfully.[31] For patients, communication-related concerns are generally described in terms of “respect.”[32] Communication-related preventive strategies include talking with others or calming them down,[28] spending time with other people,[32] interpersonal skills,[33] maintaining “kind and nice attitude” toward them,[34] and having a calm relaxed attitude toward them.[28]

According to the findings, nurses, pointing at a high workload and staff shortage, considered the facilitated situations as preventive method. Heavy workload is one situational issue that has repeatedly been noted as a possible initiator to incivility.[11,32] According to Johnson and Indvik, unfamiliar behaviors at work were the results of stress and overburden.[11] Accordingly, in a study by Gordon et al., decreasing workload was stated as a good way to prevent incivility.[35] Some evidence suggests that high workload intensifies feelings of frustration, time pressure, and stress, which may result in increased perceptions of uncivil actions.[11] Nurses under stress may experience weakened ability to judge others' behaviors accurately[11] and display diminished tolerance for usual actions.[32] The research by Fonseca et al. indicated that less political responses were shown by person under cognitive load in response of an even norm action.[36] In addition, those with high workload may think that uncivil behaviors are needed to complete duties well.[37] In other words, they may think there is not enough time to “be nice.”[38] Therefore, decreasing workload seems essential to prevent WPI.

In this study, nurses knew the supportive resource as a prevention measure. In a recent study, nurses with better perceived supervisor support experienced additional positive job consequences and less negative results.[39] Workplace support is also related with job stress,[40] as well as satisfaction and burnout,[41] which seems to affect WPI. There is evidence that nursing managers are not sufficiently supportive to them and even nurses are not usually supportive of each other.[42]

In several studies, rules were identified as an important factor for violence prevention.[43,44,45] Similary, in this study, the clear and constant application of rules and policy about doctors and hospitalization processes were identified by nurses to be of help in the prevention of incivility. Similar to the study by Bensley et al., patients identified a lack of strong rules causative to incivility,[46] whereas clear expectations was regarded as a preventive technique.[32] According to Gordon et al., advances in the policies surrounding incivility and violence were suggested as necessary changes to improve safety.[35] Patients and staff in Sweden indicated that the rules in the ward are good for incivility and violence prevention.[47]

According to the findings, nurses see limiting family present as a prevention of WPI. There are some supportive articles for family presence during invasive procedures or CPR,[48] but a few assessed the long presence of attendants during hospitalization. That may be the result of limiting rules in other countries. In some studies in Iran, patients' companions are identified as main source of workplace violence against nurses.[29,49,50] Therefore, their short presence is considered as incivility prevention. This phenomena (long presence of attendants) can be seen from two perspectives: Supportive role of family for patients and disruptive factor for nurses. Because of the lack of the evidences, it needs more in-depth investigation to conclude.

In this study nurses pointed at improving public image of nursing to prevent incivility. Evidences showed that public image of nurses is not appropriate but diverse.[51] This can to some extent be a result of nurses' self-created image because they are not visible enough nor have enough discourse in public.[52] This self-concept and professional identity is driven from nurses' public image, work place, work values, education, and social and cultural values. Hard work is required to make nurses communicate their profession to the public.[53] Social media such as television could propagate what the nurses really do. Moreover, nurses should increase their visibility to obtain stronger position and promote their public image. Moreover, by using strategic positions, such as case manager, clinical nurse specialist, etc., nurses can reflect to the public what they are really involved in.

In the 21st century, the century of technology, people are expected to have basic knowledge about the fields in which they are involved, or may be involved. Lack of awareness about medical procedures can cause the patients and/or their relatives to have unrealistic expectations of nurses, and, consequently, unmet expectations lead to violence.[22] Low awareness was introduced as incivility initiator and basic medical knowledge was considered as preventive factor in this study. Consulting with a nurse specialist in film production and informing public via social media seems to be effective in this case.

Conclusion

The findings of this study indicated that a comprehensive and systematic attempt was needed to prevent incivility. Therefore, nurses, officials, and people as clients, need to be involved in this process. Nurses should try to improve their own nursing and communication skills. Teaching communication skills in in-service training courses, improving quality of nursing education, and introducing new methods of caring seems useful in this case. Showing the real image and position of nurses and hospitals to the public and improving public knowledge about hospitalization processes could also prevent WPI. It is necessary to consider WPI at the local and national level. We checked only nurses' perspective, and because most of the incivilities were from patients, their visitors, and residents, it is suggested that their opinions are also assessed.

Financial support and sponsorship

The study was funded by the research department at Tabriz University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

Our appreciation goes to all the study participants for their contributions and the research department of Tabriz University of Medical Sciences for their financial support.

References

1. Kodjebacheva DG. Workplace incivility affecting CRNAs: A study of prevalence, severity, and consequences with proposed interventions. AANA J. 2014;82:437–45. [PubMed] [Google Scholar]

2. Hutton S, Gates D. Workplace incivility and productivity losses among direct care staff. AAOHN J. 2008;56:168–75. [PubMed] [Google Scholar]

3. Bennett K, Sawatzky JAV. Building emotional intelligence: A strategy for emerging nurse leaders to reduce workplace bullying. Nurs Adm Q. 2013;37:144–51. [PubMed] [Google Scholar]

4. Wilson BL, Diedrich A, Phelps CL, Choi M. Bullies at work: The impact of horizontal hostility in the hospital setting and intent to leave. J Nurs Adm. 2011;41:453–8. [PubMed] [Google Scholar]

5. Cleary M, Hunt GE, Horsfall J. Identifying and addressing bullying in nursing. Issues Ment Health Nurs. 2010;31:331–5. [PubMed] [Google Scholar]

6. Murray JS. Workplace bullying in nursing: A problem that can't be ignored. Medsurg Nurs. 2009;18:273–6. [PubMed] [Google Scholar]

7. Cortina LM, Magley VJ. Patterns and profiles of response to incivility in the workplace. J Occup Health Psychol. 2009;14:272–88. [PubMed] [Google Scholar]

8. Embree JL, White AH. Concept analysis: Nurse-to-Nurse lateral violence. Nurs Forum. 2010;45:166–739. [PubMed] [Google Scholar]

9. Holloway EL, Kusy ME. Disruptive and toxic behaviors in healthcare: Zero tolerance, the bottom line, and what to do about it. J Med Pract Manage. 2010;25:335–40. [PubMed] [Google Scholar]

10. Pearson CM, Andersson LM, Wegner JW. When workers flout convention: A study of workplace incivility. Human Relat. 2001;54:1387–419. [Google Scholar]

11. Johnson PR, Indvik J. Rudeness at work: Impulse over restraint. Public Pers Manage. 2001;30:457–65. [Google Scholar]

12. Estes B, Wang J. Workplace incivility: Impacts on individual and organizational performance. Hum Resour Dev Rev. 2008;7:218–40. [Google Scholar]

13. Lim VK, Teo TS. Mind your E-manners: Impact of cyber incivility on employees' work attitude and behavior. Info Manag. 2009;46:419–25. [Google Scholar]

14. Giumetti GW, McKibben ES, Hatfield AL, Schroeder AN, Kowalski RM. Cyber incivility @ work: The new age of interpersonal deviance. Cyberpsychol Behav Soc Netw. 2012;15:148–54. [PubMed] [Google Scholar]

15. Martin RJ, Hine DW. Development and validation of the uncivil workplace behavior questionnaire. J Occup Health Psychol. 2005;10:477–90. [PubMed] [Google Scholar]

16. Lachman VD. Ethical issues in the disruptive behaviors of incivility, bullying, and horizontal/lateral violence. Medsurg Nurs. 2014;23:56–8. [PubMed] [Google Scholar]

17. Johnson SL, Rea RE. Workplace bullying: Concerns for nurse leaders. J Nurs Adm. 2009;39:84–90. [PubMed] [Google Scholar]

18. Simons S. Workplace Bullying Experienced by Massachusetts Registered Nurses and the Relationship to Intention to Leave the Organization. ANS Adv Nurs Sci. 2008;31:E48–59. [PubMed] [Google Scholar]

19. Cortina LM, Magley VJ, Williams JH, Langhout RD. Incivility in the workplace: Incidence and impact. J Occup Health Psychol. 2001;6:64–80. [PubMed] [Google Scholar]

20. Porath CL, Pearson CM. The cost of bad behavior. Organ Dyn. 2010;39:64–71. [Google Scholar]

21. Aghajanloo A, Nirumand-Zandi K, Safavi-Bayat Z, Alavi-Majd H. Clinical violence in nursing students. Iran J Nurs Midwifery Res. 2011;16:284–7. [PMC free article] [PubMed] [Google Scholar]

22. Fallahi-Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Afshani S. Physical violence against health care workers: A nationwide study from Iran. Iran J Nurs Midwifery Res. 2016;21:232–8. [PMC free article] [PubMed] [Google Scholar]

23. Eslamian J, Akbarpoor AA, Hoseini SA. Quality of work life and its association with workplace violence of the nurses in emergency departments. Iran J Nurs Midwifery Res. 2015;20:56–62. [PMC free article] [PubMed] [Google Scholar]

24. Esfahani AN, Shahbazi G. Workplace bullying in nursing: The case of Azerbaijan province, Iran. Iran J Nurs Midwifery Res. 2014;19:409–15. [PMC free article] [PubMed] [Google Scholar]

25. McCann TV, Baird J, Muir-Cochrane E. Attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient units. BMC Psychiatry. 2014;14:80. [PMC free article] [PubMed] [Google Scholar]

26. Trossman S. It can make nurses sick. Aiming to prevent incivility, bullying, violence. Am Nurs. 2015;47:1–6. [PubMed] [Google Scholar]

27. Brady M. Hospitalized children's views of the good nurse. Nurs Ethics. 2009;16:543–60. [PubMed] [Google Scholar]

28. Bond K, Brimblecombe N. Violent incidents and staff views. Mental Health Nursing. 2003;23:10–2. [Google Scholar]

29. Babayi N, Rahmani A, Mohajjel-aghdam A, Zamanzadeh V, Dadashzadeh A, Avazeh M. Perception of patients' companions about nature of workplace violence against nurses in tabriz medical educational centers. Iran J Forensic Med. 2014;20:111–7. [Google Scholar]

30. Ilkiw-Lavalle O, Grenyer BF. Differences between patient and staff perceptions of aggression in mental health units. Psychiatr Serv. 2003;54:389–93. [PubMed] [Google Scholar]

31. Middleby-Clements JL. The interpersonal dynamics of aggression and violence in mental health inpatient units: University of Wollongong Thesis Collection. 2009:807. [Google Scholar]

32. Hallett N, Huber JW, Dickens GL. Violence prevention in inpatient psychiatric settings: Systematic review of studies about the perceptions of care staff and patients. Aggression Violent Behavior. 2014;19:502–14. [Google Scholar]

33. Spokes K, Bond K, Lowe T, Jones J, Illingworth P, Brimblecombe N, et al. Hovis–the Hertfordshire/Oxfordshire violent incident study. J Psychiatr Ment Health Nurs. 2002;9:199–209. [PubMed] [Google Scholar]

34. Chen WC, Wang JD, LewTing CY, Chiu HJ, Lin YP. Workplace violence on workers caring for long-term institutionalized schizophrenic patients in Taiwan. J Occup Health. 2007;49:311–6. [PubMed] [Google Scholar]

35. Gordon LT, Gordon JD, Gardner D. A study of assaultive/aggressive behaviour on staff by patients/clients in psychiatric facilities. J Occup Health Safety Aust New Zealand. 1996;12:169–77. [Google Scholar]

36. Fonseca A, Brauer M, Moisuc A, Nugier A. Cognitive load causes people to react ineffectively to others' norm transgressions. J Appl Soc Psychol. 2013;43:1518–27. [Google Scholar]

37. Andersson LM, Pearson CM. Tit for tat? The spiraling effect of incivility in the workplace. Acad Manage Rev. 1999;24:452–71. [Google Scholar]

38. Pearson CM, Porath CL. On the nature, consequences and remedies of workplace incivility: No time for “nice”?Think again. Acad Manag Exec. 2005;19:7–18. [Google Scholar]

39. Hall DS. The relationship between supervisor support and registered nurse outcomes in nursing care units. Nurs Adm Q. 2007;31:68–80. [PubMed] [Google Scholar]

40. Flateau-Lux LR, Gravel T. Put a stop to bullying new nurses. Home Healthc Nurse. 2014;32:225–9. [PubMed] [Google Scholar]

41. Hayes B, Douglas C, Bonner A. Work environment, job satisfaction, stress and burnout among haemodialysis nurses. J Nurs Manag. 2015;23:588–98. [PubMed] [Google Scholar]

42. Paliadelis P, Cruickshank M, Sheridan A. Caring for each other: How do nurse managers ‘manage’ their role? J Nurs Manag. 2007;15:830–7. [PubMed] [Google Scholar]

43. Vagharseyyedin SA. Nurses' perspectives on workplace mistreatment: A qualitative study. Nurs Health Sci. 2015;18:70–8. [PubMed] [Google Scholar]

44. Jones MD. Antecedents and outcomes of work-linked couple incivility: Purdue University. 2015 [Google Scholar]

45. Rad M, Ildarabadi Eh, Moharreri F, Moonaghi HK. Causes of incivility in Iranian nursing students: A qualitative study. Int J Community Based Nurs Midwifery. 2016;4:47–56. [PMC free article] [PubMed] [Google Scholar]

46. Bensley L, Nelson N, Kaufman J, Silverstein B, Shields JW. Patient and staff views of factors influencing assaults on psychiatric hospital employees. Issues Ment Health Nurs. 1995;16:433–46. [PubMed] [Google Scholar]

47. Bjorkdahl A, Hansebo G, Palmstierna T. The influence of staff training on the violence prevention and management climate in psychiatric inpatient units. J Psychiatr Ment Health Nurs. 2013;20:396–404. [PubMed] [Google Scholar]

48. Bell L. Family presence during invasive procedures. Am J Crit Care. 2015;24:539. [PubMed] [Google Scholar]

49. Imani B, Nazari L, Majidi L, Taajobi M. Investigation of the causes and solutions to violence in the workplace, emergency nurses in selected hospitals of Hamadan University of Medical Sciences. Pajouhan Scientific Journal. 2014;12:64–74. [Google Scholar]

50. Hemati Esmaeili M, Heshmati Nabavi F, Reihani HR. Evaluation of violence of patients and their families against emergency nurses. Iran J Crit Care Nurs. 2015;7:227–36. [Google Scholar]

51. Kagan I, Biran E, Telem L, Steinovitz N, Alboer D, Ovadia K, et al. Promotion or marketing of the nursing profession by nurses. Int Nurs Rev. 2015;62:368–76. [PubMed] [Google Scholar]

52. Girvin J. Editorial: The public understanding of nursing–time for a step change? J Clin Nurs. 2015;24:3341–2. [PubMed] [Google Scholar]

53. Hoeve Yt, Jansen G, Roodbol P. The nursing profession: Public image, self-concept and professional identity. A discussion paper. J Adv Nurs. 2014;70:295–309. [PubMed] [Google Scholar]

Articles from Iranian Journal of Nursing and Midwifery Research are provided here courtesy of Wolters Kluwer -- Medknow Publications