Abstract
The finding of incivility in occupational therapy workplaces underscores the importance of developing positive work cultures to ensure the health and safety of clients and practitioners.
Occupational therapy practitioners place a high value on their collaborative relationships with clients, peers, supervisors, managers, and the interprofessional team (Mason & Hennigan, 2019). In her inaugural address, American Occupational Therapy Association President Wendy C. Hildenbrand (2019) stressed the need for healthy, civil relationships based on mutual respect, kindness, and compassion; she also observed that incivility “undercuts relationships and partnerships.” Incivility can lead to decreased quality of patient care, decreased employee engagement and retention, and increased employer costs (Kreitzer & Klatt, 2017). Although incidences of incivility have been documented widely in health care settings (Cortina et al., 2017), information about the prevalence of incivility in occupational therapy settings is primarily anecdotal.
Definitions of Incivility and Bullying
Civility has been defined as tolerance, respect, and concern for others, with mutual sharing, polite disagreement, and cooperation (Von Bergen et al., 2012). Incivility occurs when one violates norms for respect by exhibiting rude or condescending behaviors toward another (Cortina et al., 2017). It can be perpetrated by peers, supervisors, interprofessional team members, clients, families, or students. Some scholars have defined incivility as thoughtlessness rather than malice, because the intent to harm the victim is often ambiguous (Porath & Pearson, 2013). Repeated acts of incivility or more egregious forms of incivility (e.g., threatening words or actions) constitute bullying (Einarsen et al., 2009). Incivility is distinguished from discrimination and harassment, which include unfavorable treatment and unwelcome conduct based on race, religion, and other categories protected under federal law.
Three forms of incivility have been described in the workplace (Einarsen et al., 2009). The first is work-related incivility, which corresponds to negative interactions surrounding workplace responsibilities. Examples include making negative comments (e.g., “How could you be so stupid?”), being dismissive of one’s ideas, and imposing unfair or unrealistic workloads. Person-related incivility is primarily perpetrated by peers (e.g., gossip or being excluded). The last category of incivility, physical intimidation, involves being encroached upon, threatened, or subjected to physical violence.
Significance of the Problem
To some observers, many forms of incivility may seem inconsequential (e.g., eye rolling, teasing); however, uncivil behaviors can undermine workplace culture, client care, employee health, and organizational productivity (Andersson & Pearson, 1999). For example, Porath and Pearson (2013) reported that when employees encountered rudeness, 80% of recipients lost productive time thinking about the rudeness, 38% reported lower quality of work, 48% reduced their time at work, and 25% took it out on clients. Incivility also threatens the victim’s perceived status, belongingness, and perceived ability to contribute (Hershcovis et al., 2017), and sequelae may include increased stress, physiological and psychological symptoms, absenteeism, errors, and disengagement (Cortina et al., 2017). Even indirect incivility affects workplace performance, because witnesses to incivility reportedly become less helpful and less productive (Cortina et al., 2017). Incivility has also been shown to contribute to decreased patient outcomes and satisfaction as well as higher health care costs related to loss of productivity, employee errors, and turnover (Joint Commission, 2016).
Incidences of incivility and bullying in health care professions have been reported to range from 33% to 47% (Joint Commission, 2016). Information related to incivility in occupational therapy settings is limited; however, in one study, the rate of bullying of occupational therapy fieldwork students was reported to be 16% (Bolding et al., 2020). The purpose of this study was to explore the prevalence and types of incivility experienced by occupational therapy practitioners and the relationship between demographic attributes and perceived incivility.
Method
Design
We collected cross-sectional data from occupational therapy practitioners residing in the United States using a web-based survey. The study design was reviewed by the San José State University Human Subjects Institutional Review Board, which registered the study protocol and deemed it exempt from further review.
Participants
Participants were recruited through announcements on occupational therapy social media groups, state association websites, and emails to occupational therapy educators and practitioners. Practitioners must have been working at least part time in the 6 mo before completing the survey to be eligible.
Instruments
The Negative Acts Questionnaire–Revised (NAQ–R; Einarsen et al., 2009) was used to measure incivility and bullying. Prior research on the instrument demonstrated that it has good internal consistency (Cronbach’s α = .90). Pearson product–moment correlation coefficients between raw sum scores and a respondent’s perception of being bullied demonstrated a strong positive correlation (r = .54, p < .001), which supports the tool’s reliability (Einarsen et al., 2009). We determined construct validity using analysis of variance (ANOVA), which demonstrated that victims of bullying scored higher than nonvictims (p < .001; Einarsen et al., 2009). The scale is correlated (at the .001 level) with measures of mental and physical health, use of sick leave, self-rating of work performance, and thoughts about leaving the job (Einarsen et al., 2009).
The NAQ–R contains 23 items; the first 22 questions use a 5-point ordinal scale to measure the frequency of negative behaviors in the workplace (never, now and then, monthly, weekly, and daily). Possible scores range from 22 to 110, with lower scores representing less incivility. The last question on the test defines bullying and asks participants whether they have been bullied at work over the past 6 mo.
Procedure
Participants opened the electronic link and completed an agreement to participate before starting the survey. All responses were anonymous. The survey was available online in February and March 2020. Respondents who did not complete all questions on the NAQ–R were excluded from the analysis; data were used if they completed the NAQ–R but did not answer all the demographic questions.
Data Analysis
We summarized demographic data and NAQ–R categories using descriptive methods. One-way ANOVA and two-sample t tests were used to examine potential differences between demographic characteristics and mean scores on the NAQ–R. Two-sample t tests were used for demographic variables that comprised two groups. ANOVA was used for demographic variables that had more than two groups and was followed by Tukey’s post hoc tests if the ANOVA result was significant. We performed all analyses using the IBM SPSS Statistics (Version 26; IBM Corp., Armonk, NY).
Results
Incivility and Bullying
Responses on the NAQ–R were gathered from 1,320 participants. The frequency and types of exposure to incivility based on NAQ–R questions are presented in Table 1. Normalized mean scores for the categories of work-related incivility, person-related incivility, and physical intimidation revealed that work-related incivility was most frequent (M = 1.8 on a scale ranging from 1 to 5), followed by person-related incivility (M = 1.4) and physical intimidation (M = 1.2). The most commonly reported type of work-related incivility (i.e., occurring daily or weekly) was “being exposed to an unmanageable workload” (17.5%). The most common person-related incivility was “being ignored or excluded” (9.5%), and the most common type of physical intimidation was “being shouted at or being the target of spontaneous anger (or rage)” (2.6%).
Percentage of Exposure to Incivility Based on NAQ–R Responses
Note. Survey N = 1,320. Question numbers refer to the question order in the Negative Acts Questionnaire–Revised (NAQ–R).
For the final question on the NAQ–R, participants read a description of bullying and were then asked, “Have you been bullied at work?” The responses were never (84.7%), now and then (7.4%), monthly (5.8%), weekly (1.4%), and daily (0.1%). Because bullying is often underreported by self-report, total raw scores on the NAQ–R were also used as a measure of bullying. A raw score of 33 to 44 constitutes occasional bullying, and higher scores fall in the victim category (Notelaers & Einarsen, 2013). On the basis of participants’ individual scores on the NAQ–R, 66% (n = 870) did not experience bullying, 23% (n = 298) experienced occasional bullying, and 12% (n = 152) were victims of workplace bullying. When asked to identify the perpetrator of incivility (n = 200), the most frequently cited person was a superior (supervisor, 25%; another manager, 23%), followed by colleagues (33%), a patient or student (12%), and a subordinate (7%), with some participants citing multiple perpetrators.
Negative Acts Questionnaire–Revised Scores and Demographic Factors
We examined NAQ–R total scores and subscores (work-related incivility, person-related incivility, and physical intimidation) using one-way ANOVA (for comparisons of more than two groups) or two-sample t tests (for comparisons of two groups), with an α of .05. No significant differences were found in total NAQ–R scores by age, gender, sexual minority identification, race, or size of workplace. Respondents from the Midwest region had significantly lower scores (representing less incivility) than those from the South and Northeast. Occupational therapy practitioners reported significantly less incivility than occupational therapy assistants, and practitioners with more than 20 yr of experience had significantly lower scores than those with less than 2 yr of experience. Practitioners working in skilled nursing and long-term care facilities reported significantly higher scores (representing a greater incidence of incivility) on the NAQ–R than all other practice settings except for mental health and academia; however, fewer respondents were included for the latter two settings (Table 2).
Negative Acts Questionnaire–Revised Scores by Category
Note. Survey N = 1,320. Numbers are adjusted by category for participants who gave no response or preferred not to reply. Differences in scores for gender and sexual identity were assessed with t tests; no significant differences were found between groups. NAQ–R = Negative Acts Questionnaire–Revised.
Reference groups for Tukey’s post hoc tests. bOnly scores for men and women were calculated because of the small number of respondents in gender minority categories (n = 4). cNative American/Alaskan Native (n = 2), Native Hawaiian/Pacific Islander (n = 1), Black (n = 12), bi- and multiracial (n = 40), other (n = 12).
Analysis of subscale scores on the NAQ–R demonstrated that people who identified as a sexual minority (M = 3.9, SD = 2.0) reported significantly higher subscale scores for physical intimidation than sexual majority respondents (M = 3.5, SD = 1.2) on the basis of a two-sample t test, t(6) = 2.71, p = .007. A one-way ANOVA indicated that occupational therapy practitioners with 20 or fewer years of experience were significantly more likely to encounter physical intimidation, F(3, 1319) = 4.8, p = .003, and work-related incivility, F(3, 1316) = 7.4, p = .001, than practitioners with more than 20 yr of experience. Tukey’s post hoc tests showed that the difference was significant for all three younger age groups.
Discussion
Results from this survey demonstrated that although the incidence of incivility is relatively low in occupational therapy settings compared with reports from research with other health professionals, as many as 11% of practitioners may be bullied at work. The perpetrators are often supervisors, other managers, or colleagues; infrequently, they include clients, subordinates, or students. Less experienced practitioners and those working in skilled nursing and long-term care facilities experienced the most incivility, and occupational therapy assistants experienced more incivility than occupational therapy practitioners. In this study, we did not find a significant link between incivility and age, gender, race, sexuality, or size of workplace. Other researchers have also failed to find consistent links to incivility on the basis of gender, ethnicity, and age but have noted that higher status and experience are protective factors (Keller et al., 2020).
The findings underscore the importance of developing a safe and civil workplace, which begins with organizational values, governance, and training that support a culture of safety, respect, and teamwork. Evidence from multiple studies demonstrates that a positive work culture, organizational support, and a climate of diversity are associated with decreased incivility (Keller et al., 2020). Management behaviors that promote employee safety and civility include using supportive, open communication; having frequent interactions with employees; instilling confidence; demonstrating compassion while expecting accountability; acknowledging fallibility; supporting all voices being heard; and using transformational leadership behaviors (Mullen et al., 2018; Williams & Kemp, 2020).
In this study, participants identified supervisors and other managers (48%) as the frequent perpetrators of incivility. Mistreatment by supervisors has been demonstrated to cause stronger negative effects than mistreatment from coworkers, perhaps because of the power differential between their positions (Mullen et al., 2018). This finding suggests a need for enhanced training and accountability at the mid-levels of organizations.
Practitioners are responsible for reflecting on how their behavior influences civility (both positively and negatively) in the workplace and for creating individual professional development plans. One approach is for practitioners to learn to respond assertively to uncivil behaviors, whether as a victim or an observer. Although this behavior may be intimidating at first, cognitive rehearsal training has been shown to help victims respond to uncivil behaviors (Armstrong, 2018; Clark & Gorton, 2019). People who are experiencing incivility in the workplace might try to increase their resilience as a mental defense against the psychological and physical harm caused by incivility (Sanderson & Brewer, 2017). Developing personal and professional resilience strategies might also help victims manage stress and maintain job performance levels (Brown et al., 2020).
Clark (2019) provided a framework for fostering civility that can be used in practice settings. The steps include raising awareness about the problem, assembling a civility team that assesses civility at all levels of the organization, developing and implementing a data-driven plan, and evaluating and reassessing the changes. Final steps include recognizing achievements and sharing and sustaining the changes. One such program, “Bullying in the Workplace: Solutions for Nursing Practice,” engages participants in an educational dialogue to define the problem of incivility, react under stress, identify conflicting management styles, create a safe environment, and respond effectively (Howard & Embree, 2020). This program and similar ones have demonstrated promise for increasing knowledge about the problems caused by incivility, teaching strategies to address disruptive behaviors, and improving team performance (Clancy & Tornberg, 2019). Most educational programs are targeted to nurses, physicians, and health professionals in general. Occupational therapy practitioners might benefit from instructional materials that use examples unique to their own practices.
Study Limitations
In this study, we used a cross-sectional design and cannot address causal relationships. Respondents contacted through occupational therapy social media and alumni groups may overrepresent people who are more engaged in professional issues or more interested in this particular topic. Self-reported data may have errors due to memory, telescoping, attribution, and exaggeration. Nonrespondents may differ from respondents in unknown ways.
Implications for Occupational Therapy Practice
On the basis of our results, we suggest that occupational therapy practitioners consider the following measures:
Examine the practice environment and develop standards for communication and behavior to stop low-level incivility.
Develop workplace interventions to combat incivility (e.g., workshops; training in communication, resilience, civility, and how to respond to incivility).
Embed strategies to help students and less experienced practitioners recognize instances of incivility and cultivate communication and resilience skills because those with less experience appear to be more vulnerable to incivility.
In future studies, researchers should investigate the efficacy of such programs for improving civility, employee satisfaction, teamwork, safety, and patient-care outcomes.
Conclusion
Workplace incivility can lead to decreased quality of patient care, personal consequences for the victim, and increased health care costs. Although incidences of incivility in occupational therapy settings appear to be lower than that reported by other health professions, it remains a significant concern. Occupational therapy practitioners are challenged to develop civil interpersonal relationships and teams that will foster safe and respectful workplaces.
Footnotes
Acknowledgments
We thank Laurie Drabble and Sulekha Anand for their assistance with this project. We also thank Heidi Pendleton for editorial advice.