WORKPLACE INCIVILITY AND TURNOVER INTENTION AMONG NURSES OF PUBLIC HEALTHCARE SYSTEM IN PAKISTAN

 

Abdul Samad

Muhammad Ali Jinnah University Karachi, Pakistan

E-mail: Dahriabdulsamad@gmail.com

 

Salman Bashir Memon

Shaheed Benazir Bhutto University, Pakistan

E-mail: salman.bashir@sbbusba.edu.pk

 

Ayaz Ali Maitlo

Sindh University, Larkana Campus, Pakistan

E-mail: ayazalimaitlo@gmail.com

 

Submission: 8/9/2020

Revision: 9/1/2020

Accept: 9/14/2020

 

ABSTRACT

Though workplace incivility is a negative behavioral phenomenon that has infiltrated almost every sector, yet, less investigated in the healthcare sector. The healthcare sector is the backbone for economic and well-being for any nation and mainly composed of nurses. Turnover among nurses is a serious challenge to public healthcare facilities in terms of management, financing, and service quality. Based on the COR theory, this study capitalizes investigation on the effects of incivility on turnover intention through burnout and occupational stress. Simple random sampling was deployed on a sample of 265 nurses from 24 public hospitals of Sindh in Pakistan. Data analysis through partial least square and results revealed that workplace incivility has insignificant relation with turnover intention. Whereas, incivility has a significant indirect relationship with turnover intention through burnout and occupational stress. This study suggests that emotional and occupational depletion in public healthcare is high due to incivility at the workplace. Thus, HR managers must devise policies to practice civil behavior to curtail turnover intention problem among nurses. Besides practical benefits, some limitations with potential future research directions are discussed in the end.

Keywords: Workplace incivility, occupational stress, turnover intention, healthcare system

1.        INTRODUCTION

Understanding employee behavior is a major concern of behavioral science over the decades to make future predictions and control employee behavior, so as to enhance employee efficiency and organizational efficacy. From an organizational perspective, organizational performance is vital that including many factors and variables (Çelik et al., 2011). Moreover, contemporary organizations contain a diverse workforce that poses numerous challenges regarding quality interpersonal interaction at the workplace (Andersson & Pearson, 1999).

A diverse workforce means one must input more effort to understand, interpret, and act to different social norms. In such a situation, prominent policies must prevail to hold quite clear and mutual norms for reverent behavior at the workstation (Mor Barak et al., 2001). Where, lack of non-verbal cues, or because of physical absence (in case of distant communication) may be perceived negatively that leads to an exhibition of negative behaviors which are assumed as incivility at the workplace (Pearson et al., 2000).

Accordingly, organizational psychology literature depicts frequent instances of rude and discourteous behaviors and are on the rise (Pearson et al., 2000). Statistically, Cortina et al., (2000) found that 71% of employees experienced ‘uncivilized behavior’ during the past five years. Other studies found 75% of university employees, 79% law enforcement employees, 71% court employees, and 85% nurses experienced incivility at the workplace (Cortina & Magley, 2009; Lewis & Malecha, 2011).

Literature shows that employees who experience incivility may involve in negative ‘emotional responses’ to the situation. For instance, Bibi et al. (2013) found positive relations between incivility and production deviance, absenteeism (Porath & Pearson, 2012), burnout (Welbourne et al., 2015), reduced creativity (Porath & Erez, 2009), and ‘turnover intention’ (Laschinger et al., 2009). That results in a $50,000 loss to organizations per employee quit from a job in the USA (Sanchez & Levine, 2000). Incivility experience was observed to associate negatively with ‘turnover intention’ among nurses by Dion (2006).

Moreover, incivility may escalate to more violent behavior (Andersson & Pearson, 1999) especially the harassment that prevails in a number of industries (Einarsen et al., 2011). All of these devastate organizational performance and profitability. Where, these experiences undermine employee self-confidence and often their ‘emotional health’ (Randle, 2003).

Likewise, Hoel et al., (2007) found incivility experienced by nurses in clinical nurses. Yet, Gallo (2012) argue that less is known about nurses’ experience of incivility and its outcomes. However, high psychological risk can also lead to poor interpersonal relationships at work (Harvey et al., 2017). While, negative health effects among nurses such as burnout are well documented (Schaufeli et al., 2009). Incivility has more deleterious results for employees when they fall in dejection and stumpy self-respect (Estes & Wang, 2008).

Laschinger et al., (2009) argued incivility has a strong negative impact on employee emotions, by depleting employee emotional resources leading to burnout that ends at the increased turnover intention. Therefore, incivility is positively linked by many researchers as a major cause of burnout (e.g., Giumetti et al., 2012; Leiter et al., 2015) which ultimately leads to raising employee turnover in an organization (Arshadi &  Damiri, 2013).

Similarly, job stress among employees is conceptualized as a complex process that consists of three major elements a) source of stress, b) perception and appraisal of the stressor by an individual, and c) the emotional reaction when the stressor becomes a threat (Spielberger et al., 2003). It was also conceptualized as the misbalance between job demands that employees are subject to and undesirable experiences that threaten their well-being (Treven & Potocan, 2005).

As occupational stress damages individual physical (Van & Kleber, 2003) as well as mental health and well-being (Sarafis et al., 2016). Likewise, stress decreases concentration, attention, and decision-making skills (Shapiro et al., 2005). Accordingly, incivility is one of the chronic reasons as micro-stressors at the workplace (Cortina et al., 2001). With given complexity of disease treatment, and uncertainty treating patients, propagation of disease from patients, while dealing with death and dying people (Stordeur et al., 2001; Mcvicar, 2003). This makes healthcare service riskier and stressful for nurses to perform even routine work and increases incidences of mistakes and practice errors as reported by Teng et al. (2010) among 229 nurses in Taiwan.

The employee begins to develop an adverse attitude towards job after realizing that the current conditions of deployment are unmatched with ones’ expectations (Mano-Negrin & Kirschenbaum, 1999) which definitely defines ones’ intention to work under any longer or turnover intention. The term ‘turnover intention’ is defined as to how long an individual is willing to stay in the organization (Cotton & Tuttle, 1986).

Likewise, other researchers (e.g., Tett & Meyer, 1993) suggested this as the perceived probability of perception of employees to stay or leave the organization. Whereas, in nursing turnover among nurses may escalate more severely as to leave the hospital environment alone (Tai et al., 1998) or to leave the organization or nursing profession completely (Hayes et al., 2006). Turnover of an employee is either non-voluntary where the organization itself requires no further service of that employee.

Or involuntary when an employee leaves the job. Particularly in nursing, the cost of turnover per nurse ranges from $22,000 to more than $64,000 in the USA alone (Jones; Gate, 2007). Nurses’ turnover intention refers to nurses leaving the job (Dam et al., 2011) which was also reported more than half (53%) among nurses by the American Nurses Association (2010).

Whereas; the voluntary turnover intention is the intentional decision of an employee to leave the organization while physical or emotional resources remain intact to perform or to adjust with the job (Haw & Dickerson, 1998). This turnover intention in the nursing profession is reflected as the shortfall for the past many years (Keenan & Kennedy, 2003). Mirrored in W.H.O reports 2006 depicts a global deficiency of 4.3 million healthcare workers. Moreover, it was suggested to rise by 20% in the upcoming two decades. Similarly, Bobbio and Manganelli (2015) therefore argued to tackle turnover that may help retention.

Hence, it is not surprising to expect negative incivility experience to increase employee psychological risk (Harvey et al., 2017), negative employee career choice (Curtis et al., 2007) which ultimately forces damaging involuntary results for the organization as employee’s intention to leave (Cortina et al., 2001). Furthermore, workplace incivility is also associated with job stress (Day & Leiter, 2014), burnout (Welbourne et al., 2015), which both positively raises turnover among employees (Arshadi & Damiri, 2013; Labrague et al., 2018). It is; therefore, the influence of ‘workplace incivility’ is necessary to investigate for managerial intervention through conceptual factors that tackle turnover intention among nurses.

2.        LITERATURE REVIEW AND HYPOTHESIS

2.1.            Workplace Incivility

Andersson and Pearson (1999) defined ‘workplace incivility’ as the “…low-intense deviant behaviors with ambiguous intent to harm the target, in violation of norms for mutual respect…” These are acts of rudeness, insolent, and showing a lack of regard. Incivility is a mild, asymmetrical, and equivocal at nature that varies in terms of high-intensity violent acts for which incivility can be a major source at the workplace (Andersson & Pearson, 1999).

In other words, ‘workplace incivility’ is shaped by cultural norms, traditions, and formal or informal rules. Thus, socially acceptable or unacceptable behaviors may vary among organizations, industries, or countries (Andersson & Pearson, 1999). Where, communication norms may differ and cultures may increase misunderstandings as potential disrespect (Pearson & Porath, 2005). Though, ‘workplace incivility’ is underestimated (Cortina et al., 2001). Yet, its presence is increasing and scholars revealed that it may damage individual, group, organizational outcomes (Porath & Pearson, 2013; Schilpzand et al., 2016).

Empirically, the ‘workplace incivility’ is negatively connected with customs of ‘mutual respect’ and workplace cooperation (Andersson & Pearson, 1999) and effectiveness (Pearson et al., 2000). Likewise, the mediating relationship of informal climate on incivility and job satisfaction found to be negative among nurses in Pakistan (Samad et al., 2020). Besides, Porath and Pearson (2012) indicated the association between ‘workplace incivility’ and concentrated work efforts, squat performance, job dissatisfaction, stumpy organizational commitment, and high intended turnover. Thus, ‘workplace incivility’ reflected the organization’s image and repute (Bavik & Bavik, 2015) and negatively impact profitability (Porath & Pearson, 2013).

2.2.            Burnout

Maslach et al. (1996) coined burnout as a syndrome consisting of ‘emotional exhaustion’; when a person is no longer able to settle job demands physically or emotionally, professional inefficacy; when an individual feels low achievement, competence, and productivity, and cynicism; when employee detaches from a job based on a negative attitude towards job, clients, or organization. Burnout captures prolonged exposure to chronic work-related demands in any occupation (Maslach & Leiter, 2008).

Also, literature reveals negative outcomes of burnout such as anxiety and depression (Hakanen & Schaufeli, 2012), physical disorders (Armon et al., 2010) and heart diseases (Toker et al., 2012). Literature revealed the toxic effect of burnout on ‘physical’ and ‘emotional wellbeing’ that makes burnout a grave public-health disorder (Bauer & Hämmig, 2014). Besides, the increasing level of burnout let down ‘employee motivation’ and increase ‘dysfunctional attitudes’ and behaviors (Schaufeli & Buunk, 2004). While, at the organizational level burnout leads to high ‘employee turnover’ (Leiter & Maslach, 2009) which is also a serious fear for any organization.

2.3.            Occupational Stress

Organizational stress model was proposed by Ivancevich and Matteson (1980) depicted several reasons for occupational stress. These may include intra-organizational stressors (environment, role conflicts, workload, climate, and organizational structure) and extra-organizational stressors (family relations, economic problems, race, and social status). Where stress with negative consequences may range from blood pressure to various behavioral and organizational negative outcomes such as turnover.

Occupational stress among employees is often inflicted by excessive rules and lack of participation (Larson, 2004), lack of social support at workplace (Chandola, 2010), work-over load (De Graaf, 2003), role conflict (Manshor et al., 2003), working environment (Spreckelmeyer, 1993), and physical stressor such as, lights and ventilation (Thayer et al., 2010) which ultimately induce turnover among employees (Mor Barak et al., 2001; Chandola, 2010).

Occupational stress occurs when there is an imbalance between the demands or expectations and employee capability to cope with those (Ullrich & Fitzgerald, 1990). Occupational stress also plays a crucial role in employee job satisfaction and later commitment towards organizational goals. Given healthcare is a stressful profession with long working hours, harsh working conditions, patient and family dealings, and countless health and safety risks (O'connor et al., 2000). Whereas, nursing is a high-risk job being responsible for patient outcomes where nurses play a vital role in healthcare services and often encountered with critical incidents or acute stressors.

2.4.            Turnover Intention

Employee turnover is the voluntary withdrawal from the job in any given organization (Shaw et al., 2005). The decision to leave the job is costly not only to the employee but also organization (Lee et al., 2004). For example, ‘employee turnover’ involves three components when computing the cost, it includes ‘separation cost’, ‘replacement cost’, and ‘training cost’. In the USA alone, an average ‘employee turnover’ is 15% which varies among organizations (Tai et al., 1998).

From an Asian perspective, for example, Singapore, HR Asia (2018) reported that: ‘more than half (56 percent) Singapore finance executives said they have witnessed an increase in staff resignation in the past three years, with the average turnover currently staying at 10%. Despite almost all (99 percent) CFOs surveyed currently have a staff retention program in their organizations, the majority still expected that employee turnover will increase over the next 12 months.

Evidence revealed that organizations with high interpersonal interactional cultures (healthcare) had high turnover rates as compared to others who don’t have much work cultures (Sheridan, 1992). Employees with experiencing work abuse (incivility) were likely to resign voluntarily from a job (Hansen, 1993). As mentioned earlier above, that experiencing incivility at the workplace leads to burnout that results in turnover intention among employees.

2.5.            Theoretical Grounding

Hobfoll’s (1989) ‘conservation of resource’ (COR) theory postulates threat (uncivil behavior) from any source (supervisor, co-worker) at the workplace would lead to emotional depletion that leads to burnout if the subject employee cannot match the threat with the available emotional resource. Therefore, the COR theory supports the hypothesis of this study between workplace incivility and burnout.

Moreover, workplace incivility works as a micro-stressors (Cortina et al., 2001) as the stress typically produced whenever an individual perceives a threat or actual loss to employee valued resources. Whereas, incivility can activate additional loss to emotional reserves (e.g. dignity, identity, health, and emotional well-being). Therefore, workplace incivility is documented as a source of stress at work (Nitzsche et al., 2018).

In both conditions, COR theory magnifies the impact of incivility that causes burnout and stress at the workplace that affects one’s job evaluation and eventually increases the intention to change or quit the job. Thus, hypothesized relationships (see Figure 1) has been formed by keeping in view the underlying shreds of evidence in literature.

Figure 1: Hypothesized framework

Source: Authors own work

2.6.            The hypothesis of research:

·         H1: Workplace incivility positively influences employee burnout.

·         H2: Workplace incivility positively influences employee occupational stress.

·         H3: Workplace incivility is negatively related to turnover intention.

·         H4: Workplace incivility is negatively related to burnout.

·         H5: Occupational stress mediates between workplace incivility and turnover intention.

3.        METHODOLOGY

3.1.            Sample and Procedure

The response for the current study has collected by using simple random sampling (SRS) from a population of 1503 officially registered nurses in 24 district government hospitals in Sindh. A sample of 265 nurses remained valid for analysis. The average age of respondents was 25 years and belonged to different departments at hospital facilities such as emergency, trauma, and burn centers. Where more than half (76%) of the nurses were female and as compared to (34%) male nurses. The collected data was further analyzed measurement and structural model and assessed for results of the research.

3.2.            Measurement

Workplace incivility was measured through 7-item developed by Cortina et al. (2001) with a 5-point Likert scale from (1= never to 5= all the time). Sample items include a statement that shows experience from sources of ‘uncivil behavior’ (e.g. ‘made demeaning remarks about you’ and ‘put you down or was condescending to you’). For measure the burnout, Burnout Measure Short (BMS) of Pines and Aronson (1988) version with a 10-item construct with 5-point Likert type scale (1= never, 5= daily). Sample items were: I feel emotionally drained from my work,” and “I feel I’m working too hard at my job”.

Whereas; occupational stress is work related perception of employees’ and measured by Perceived Stress Scale (PSS) with 10-items developed by Cohen et al. (1983) on 5-point Likert type scale. The turnover intention construct was measured with 3-items developed by Mobley et al. (1978) with 5-point Likert scale (1=strongly agree, 5= strongly disagree) and sample items were: ‘I will probably look for a new job in the next year” had scored highest mean among the three items’ and “I often think about quitting my present job”.

4.        ANALYSIS AND RESULTS

The first phase was a screening of data for any outlier, missing data, or incomplete responses through SPSS. The screened data analyzed through the partial least square method developed by Wold (1992). PLS-SEM has gained significant exposure for guesstimating multifarious path models with latent variables and their connections (Sarstedt et al., 2017). Also, ‘structural equation modeling’ has proved robust results in the testing and development of theoretical concepts (Hair et al., 2012; Bashir et al., 2017).

4.1.            Assessment of Measurement Model

Hair et al. (2016) recommended assessing measurement model for valid analysis results that include item reliability: in terms of factor loading (outer loadings) of individual items in the measurement construct with a value between 0.4 and 0.7 (leguina, 2015), internal consistency: that items of construct measures the same concept for that Hair et al. (2011) suggested a minimum 0.7 value of composite reliability (CR), convergent validity: it is the degree of an item to represent the construct as well as correlate with other construct items with a cut-off value of 0.5 or above suggested by Chin (1998), and discriminant validity: it is the degree of distinctiveness of one construct from the other (duarte & raposo, 2010) with hetero-trait-mono-trait (HTMT) values must be below 0.9 (gold et al., 2001). Below Table 1 reveals measurement model values that are acceptable while the BO10 item from the burnout measurement scale was eliminated due to lower factor loadings. Whereas; values in bold inside small brackets shows (HTMT) acceptable values for the discriminant validity of the measurement.

Table 1: Cross Loading, Composite Reliability, Average Variance Extracted, HTMT

Construct

 Item

BO

OS

TOI

WI

CR

AVE

Burnout

BO1

0.68

0.423

-0.353

0.47

0.956

0.709

BO2

0.843

0.525

-0.417

0.5

BO3

0.841

0.557

-0.399

0.5

BO4

0.854

0.439

-0.385

0.429

BO5

0.889

0.555

-0.47

0.513

BO6

0.924

0.513

-0.474

0.508

BO7

0.862

0.417

-0.415

0.403

BO8

0.85

0.44

-0.443

0.423

BO9

0.816

0.352

-0.409

0.308

Occupational Stress

OS1

0.299

(0.607)

0.746

-0.345

0.51

0.92

0.564

OS2

0.325

0.77

-0.347

0.545

OS3

0.426

0.764

-0.375

0.516

OS4

0.469

0.84

-0.421

0.598

OS5

0.413

0.791

-0.409

0.601

OS6

0.458

0.795

-0.383

0.62

OS7

0.443

0.737

-0.323

0.552

OS8

0.506

0.635

-0.319

0.43

OS9

0.479

0.656

-0.43

0.475

Turn Over Intention

TOI1

-0.443

(0.541)

-0.434

(0.553)

0.911

-0.357

TOI2

-0.427

-0.416

0.896

-0.337

0.932

0.82

TOI3

-0.48

-0.494

0.906

-0.385

Workplace Incivility

 

Wi2

0.464

(0.569)

0.639

(0.784)

-0.37

(0.436)

0.853

0.944

0.705

Wi3

0.444

0.587

-0.312

0.825

Wi4

0.491

0.638

-0.346

0.849

Wi5

0.428

0.589

-0.273

0.859

Wi6

0.496

0.636

-0.373

0.87

Wi7

0.468

0.571

-0.319

0.806

Wi1

0.378

0.574

-0.344

0.814

 

 

Source: Authors own work.

4.2.            Assessment of Structural Model

The research aim was to assess the effect of WI on TOI through BO and OS underpinned on COR theory. The hypothesized relationship(s) was measured using SmartPLS software. The PLS model measures R2, beta values, t-values, the effect size f2, and Q2 on 5000 samples resampling by the bootstrapping process in Smart-PLS following the Hair et al. (2014) recommendations (see Figure 2).

Figure 2: Structural Model

Source: Authors own work.

The results depicted in Table 2 shows that workplace incivility has positive significant relationship with burnout (β= 0.541, t= 11.38, p <0.001) under lower and upper limit of confidence interval [LL=0.456, UP= 0.632], and occupational stress (β= 0.722, t= 16.197, p<0.001) with (LL= 0.626, UL= 0.803) supporting H1 and H2. While, an insignificant relation with turnover intention (β= 0.007, t= 0.069, p> 0.05) with [LL= -0.2, UL= 0.195] not supporting H3. Whereas, workplace incivility has negative significant relation with turnover intention through mediation of burnout (β= -0.174, t= 4.383, p< 0.001, LL= -0.255, UL=-0.1) and occupational stress (β= -0.232, t= 3.169, p< 0.05, LL= -0.367, UL=-0.083) which shows support for H4.

 

Table 2: Structural Model Assessment

Path

Beta

St. Dev

T value

LL

UL

P Values

BO -> TOI

-0.322

0.069

4.637

-0.455

-0.183

0.000

OS -> TOI

-0.321

0.1

3.21

-0.511

-0.108

0.001

WI -> BO

0.541

0.048

11.38

0.456

0.632

0.000

WI -> OS

0.722

0.045

16.197

0.626

0.803

0.000

WI -> TOI

0.007

0.101

0.069

-0.2

0.195

0.945

Indirect Effect

WI -> BO -> TOI

-0.174

0.04

4.383

-0.255

-0.1

0.000

WI -> OS -> TOI

-0.232

0.073

3.169

-0.367

-0.083

0.002

Source: Authors own work.

Hair et al. (2014) suggested evaluating the change in R2 values to find the effect size. Finally, the R2 value for burnout is 0.293, occupational stress is 0.521, and turnover intention is 0.318.  Workplace incivility effect size on burnout is 0.414 on occupational stress is 1.089 and turnover intention is 0. Whereas; f2 values of burnout are 0.098, and of occupational stress is 0.066 on turnover intention.

These effect sizes according to Cohen (1988) guidelines support the hypothesis except the direct effect of workplace incivility on turnover intention. Finally, model predictiveness was assessed by Q2 values through a blindfolding procedure as suggested by Hair et al. (2014). The Q2 values for burnout are 0.189, occupational stress is 0.273, and for turnover intention is 0.238 which suggests that the model has sufficient predictive relevance.

5.        DISCUSSION

In the case of healthcare sector of developing nations, behavioral rudeness is presumed to be a part of job among nurses. Besides the flaws and discrepancies, incivility at workplace consequently increases burnout, occupational stress that results in increased turnover intention among registered nurses of healthcare sector. This study was conducted to observe the direct and mediated effect of workplace incivility among nurses serving in the Pakistani healthcare sector.

The structural model results show the insignificant effect between direct effects of workplace incivility and turnover intention. This seems to serve one of the main objectives of this study of evaluating the indirect effect of workplace incivility on turnover intention. These results are also in line with Cingöz and Kaplan (2015), Dahri and Hamid (2018), and Alola et al. (2019) who also found insignificant direct relation between workplace incivility and other different variables.

For instance, Andersson and Pearson (1999) found workplace incivility is the harmful yet subtle and ambiguous intention that directly affects the mental and emotional state of individual and reaction is also indirect which supports the results of this study. This argument is reflected in results as a higher significant positive increase in burnout and occupational stress due to workplace incivility. Though less, yet reflected also an increase in turnover intention indirectly rather in a direct relationship.

5.1.            Conclusion

One of the grounding assumptions of COR theory is that an uncivil act observed or experienced by an individual will induce subtle or internal accumulation of negative feelings or energy. This negativity results in adverse organizational outcomes. These assumptions were tested in the healthcare sector and were found valid as per COR theory. For instance, the effect of incivility experienced by an employee leads to emotional burnout as well as increases occupational stress.

This result induces turnover intention among healthcare sector employees. One of the assumptions of this study was the direct effect of incivility and an extension of basic COR theory assumptions as H3. This hypothesis was found insignificant. Indicating that there is no direct effect of incivility on turnover intention. This reaffirms the indirect negative impact on non-favored organizational attitudes revealed by employees at a later stage. Thus, extending the boundaries of existing COR theory. Therefore, the results of this study affirm the negative influence of incivility through burnout and occupational stress on employee turnover intention in healthcare sector organizations.

5.2.            Implications

This study unearthed the facts that are immensely important to HR managers and nurse supervisors that how subtle uncivil acts at the workplace may end up in more deleterious events mentally, emotionally, financially, and in terms of deprived service quality and workforce deficiency. Indeed, uncivil behavior was observed in many local context studies (e.g., Bibi et al., 2013; Laeeque et al., 2018) which affected nurses mentally, physically, and emotionally. This also increased the shortage of nursing staff globally (Oulton, 2006) as well as in Pakistan (Nizar & Chagani, 2016).

Whereas; authors urged for further explorations to develop interventional policies in this regard. In this regard, this study explored relations between workplace incivility that increased turnover intention through burnout and occupational stress among nurses in public healthcare facilities. Through results of this study scholars and stakeholders are enlightened towards deeper mental and emotional devastation due to incivility at the workplace. This also helps HR managers, policymakers, and executives or supervisors to maintain civility in public hospital ambiance and intervention for reducing turnover intention among nurses and patient satisfaction through quality services.

5.3.            Future Direction

Further research is needed to enhance our understanding of incivility and its direct effects on turnover intention. Another criterion may include variables that carry negative effects on nurses at the workplace. Further studies may derive HR practices that may help dampen incivility and turnover intention. Scholars may also specify major sources of incivility that may help nip incivility in the bud to overcome ultimate turnover among nurses.

5.4.            Limitation

This study deployed simple random sampling which however advantageous to avoid biases. Even though, common method biases may occur due to a single source may flatter analyses results. Scholars may capitalize on these shortfalls. Further, more rigorous sampling technique such as stratifies sampling may be utilized for more inclusive results. As cross-sectional studies are good to know the current situation yet lack chronic approach and responses may be affected by other excluded variable with respect to a different context that may have affected respondents’ responses. To overcome this limitation researchers may benefit from a longitudinal approach. By overcoming these limitations will enable neat and generalizable results.

REFERENCES

Adib-Hajbaghery, M., Khamechian, M., & Alavi, N. M. (2012). Nurses’ perception of occupational stress and its influencing factors: A qualitative study. Iranian journal of nursing and midwifery research, 17(5), 352.

Alola, U. V., Olugbade, O. A., Avci, T., & Öztüren, A. (2019). Customer incivility and employees' outcomes in the hotel: Testing the mediating role of emotional exhaustion. Tourism Management Perspectives, 29, 9-17.

American Nurses Association. (2010). The nurse’s role in ethics and human rights: Protecting and promoting individual worth, dignity, and human rights in practice settings. Silver Spring, MD: Nursebooks. org.

Andersson, L. M., & Pearson, C. M. (1999). Tit for tat? The spiraling effect of
incivility in the workplace. Academy of management review, 24(3), 452-
471.

Anjazab, B., & Farnia, F. (2002). The relationship between job stress and behavioural and mental responses of obstetricians in Yazd public hospitals. The Journal of Shahid Sadoughi University of Medical Sciences, 10, 32-8.

Arshadi, N., Damiri, H. (2013). The relationship of job stress with turnover intention and job performance: Moderating role of OBSE. Procedia-Social and Behavioral Sciences, 84, 706-710.

Bashir, S., Syed, S., & Qureshi, J. A. (2017). Philosophical and methodological aspects of mixed-methods research: A review of the academic literature. Journal of Independent Studies and Research, 15(1), 32-50.

Bauer, G. F., & Hämmig, O. (2014). Bridging occupational, organizational and public health: A transdisciplinary approach. In bridging occupational, organizational and public health (1-11). Springer, Dordrecht.

Bavik, A., & Bavik, Y. L. (2015). Effect of employee incivility on customer retaliation through psychological contract breach: The moderating role of moral identity. International journal of hospitality management, 50, 66-76.

Bibi, Z., Karim, J., & Ud Din, S. (2013). Workplace incivility and counterproductive work behavior: Moderating role of emotional intelligence. Pakistan Journal of Psychological Research, 28(2).

Boamah, S. A., & Laschinger, H. (2016). The influence of areas of worklife fit and work‐life interference on burnout and turnover intentions among new graduate nurses. Journal of Nursing Management, 24(2), E164-E174.

Bobbio, A., & Manganelli, A. M. (2015). Antecedents of hospital nurses’ intention to leave the organization: A cross sectional survey. International Journal of Nursing Studies, 52(7), 1180-1192.

Çelik, M., Turunç, Ö., & Begenirbaş, M. (2011). The role of organizational trust, Burnout and interpersonal deviance for achieving organizational performance. International Journal of Business and Management Studies, 3(2), 179-189.

Cingöz, A., & Kaplan, A. (2015). The effect of workplace incivility on job satisfaction and organizational trust: A study of industrial enterprises in turkey. In WEI International Academic Conference Proceedings, Vienna, Austria (12-15).

Cortina, L. M., Magley, V. J., Williams, J. H., Langhout, R. D. (2001). Incivility in the workplace: incidence and impact. Journal of occupational health psychology, 6(1), 64.

Cortina, L. M., & Magley, V. J. (2009). Patterns and profiles of response to
incivility in the workplace. Journal of occupational health psychology,
14(3), 272.

Chandola, T. (2010). Stress at Work: A Report Prepared for the British Academy. [Brochure]. London: The British Academy

Cotton, J. L., & Tuttle, J. M. (1986). Employee turnover: A meta-analysis and review with implications for research. Academy of management Review, 11(1), 55-70.

Chin, W. W. (1998). The partial least squares approach to structural equation modeling. Modern methods for business research, 295(2), 295-336.

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of health and social behavior, 385-396.

Curtis, J., Bowen, I., & Reid, A. (2007). You have no credibility: Nursing students’ experiences of horizontal violence. Nurse education in practice, 7(3), 156-163.

Dahri, A. S., & Ab Hamid, K. (2018). Effect of Workplace Incivility on Job Satisfaction Among Nurses: Mediating Role of Emotional Exhaustion. The Journal of Social Sciences Research, 80-90.

Day, A., & Leiter, M. P. (2014). The good and bad of working relationships: Implications for burnout. In Burnout at work (64-87). Psychology Press.

De Graaf, J. (Ed.). (2003). Take back your time: Fighting overwork and time poverty in America, San Francisco: Berrett-Koehler.

Dion, M. J. (2006). The impact of workplace incivility and occupational stress on the job satisfaction and turnover intention of acute care nurses.

Duarte, P. A. O., & Raposo, M. L. B. (2010). A PLS model to study brand preference: An application to the mobile phone market. In Handbook of partial least squares (449-485). Springer, Berlin, Heidelberg.

Estes, B., & Wang, J. (2008). Integrative literature review: Workplace incivility: Impacts on individual and organizational performance. Human Resource Development Review, 7(2), 218-240.

Espnes, G. A., & Byrne, D. G. (2008) Occupational stress and cardiovascular disease. Stress Health. 24, 231-8.

Gallo, V. J. (2012). Incivility in nursing education: A review of the literature. Teaching and learning in Nursing, 7(2), 62-66.

Gandham, S. R. (2000). Occupational stress: Time for a policy. The Health & Safety Practitioner, 18, 20-1

Giumetti, G. W., Mckibben, E. S., Hatfield, A. L., Schroeder, A. N., & Kowalski, R. M. (2012). Cyber incivility@ work: The new age of interpersonal deviance. Cyberpsychology, Behavior, and Social Networking, 15(3), 148-154.

Gold, A. H., & Arvind Malhotra, A. H. S. (2001). Knowledge management: An organizational capabilities perspective. J. Manag. Inf. Syst., 18(1), 185–214.

Golubic, R., Milosevic, M., Knezevic, B., & Mustajbegovic, J. (2009). Work‐related stress, education and work ability among hospital nurses. Journal of advanced nursing, 65(10), 2056-2066.

Harvey, S. B., Modini, M., Joyce, S., Milligan-Saville, J. S., Tan, L., Mykletun, A., &  Mitchell, P. B. (2017). Can work make you mentally ill? A systematic meta-review of work-related risk factors for common mental health problems. Occup Environ Med., 74(4), 301-310.

Hair, J. F., Ringle, C. M., & Sarstedt, M. (2011). PLS-SEM: Indeed a silver bullet. Journal of Marketing theory and Practice, 19(2), 139-152.

Hair, J. F., Sarstedt, M., Pieper, T. M., & Ringle, C. M. (2012). The use of partial least squares structural equation modeling in strategic management research: a review of past practices and recommendations for future applications. Long range planning, 45(5-6), 320-340.

Hair, Jr, J. F., Hult, G. T. M., Ringle, C. M., & Sarstedt, M. (2016). A primer on partial least squares structural equation modeling (PLS-SEM). Sage Publications.

Hair, Jr, J. F., Hult, G.T.M., Ringle, C. M., & Sarstedt, M. (2014). A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). Sage Publication, Los Angeles.

Hakanen, J. J., & Schaufeli, W. B. (2012). Do burnout and work engagement predict depressive symptoms and life satisfaction? A three-wave seven-year prospective study. Journal of affective disorders, 141(2-3), 415-424.

Haw, J., & Dickerson, M. (1998). The effects of distraction on desensitization and reprocessing. Behaviour Research and Therapy, 36(7-8), 765-769.

Hayes, L. J., Orchard, C. A., Hall, L. M., Nincic, V., O'brien-Pallas, L., & Andrews, G. (2006). Career intentions of nursing students and new nurse graduates: a review of the literature. International Journal of Nursing Education Scholarship, 3(1).

Henseler, J., Ringle, C. M., & Sarstedt, M. (2015). A new criterion for assessing discriminant validity in variance-based structural equation modeling. J. Acad. Mark. Sci., 43(1), 115–135

Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American psychologist, 44(3), 513.

Hoel, H., Giga, S. I., & Davidson, M. J. (2007). Expectations and realities of student nurses' experiences of negative behaviour and bullying in clinical placement and the influences of socialization processes. Health Services Management Research, 20(4), 270-278.

Hurst, T. E., & Hurst, M. M. (1997) Gender differences in mediation of severe occupational stress among correctional officers. Am J Crim Justice. 22, 121-37.

HR Asia (July, 14 2018) Increasing Turnover Rates: Thousands Finance Workers to Change Jobs in 2018. Retrieved from http://www.hrinasia.com/recruitment/increasing-turnover-rates-thousands-finance-workers-to-change-jobs-in-2018/ on march, 14 2019.

Ivancevich, J. M., & Matteson, M. T. (1980). Stress and work. Glenview, IL: Scott, Foresman

Jones, C. B., & Gates, M. (2007). The costs and benefits of nurse turnover: A business case for nurse retention. The Online Journal of Issues in Nursing, 12(3).

Katz, D. (1964) The motivational basis of organizational behavior. Behav Sci., 9:131–46.

Keenan, J. F., Kennedy, R. V., & Cote, D. (2003). U.S. Patent No. 6,589,057. Washington, DC: U.S. Patent and Trademark Office.

King, K. A., Vidourek, R., & Schwiebert, M. (2009) Disordered eating and job stress among nurses. J Nurs Manag., 17, 861-9.

Labrague, L. J., Gloe, D., Mcenroe, D. M., Konstantinos, K., & Colet, P. (2018). Factors influencing turnover intention among registered nurses in Samar Philippines. Applied Nursing Research, 39, 200-206.

Laeeque, S. H., Bilal, A., Hafeez, A., & Khan, Z. (2018). Violence breeds violence: burnout as a mediator between patient violence and nurse 204 violence. International journal of occupational safety and ergonomics, (just-accepted), 1-31.

Larson, L. L. (2004). Internal Auditors and Job Stress. Managerial Auditing Journal. 19(9), 1119–1130.

Lee, T. W., Mitchell, T. R., Sablynski, C. J., Burton, J. P., & Holtom, B. C. (2004). The effects of job embeddedness on organizational citizenship, job performance, volitional absences, and voluntary turnover. Academy of Management journal, 47(5), 711-722.

Leiter, M. P., & Maslach, C. (2009). Nurse turnover: the mediating role of burnout. Journal of nursing management, 17(3), 331-339.

Leiter, M. P., Day, A., & Price, L. (2015). Attachment styles at work: Measurement, collegial relationships, and burnout. Burnout Research, 2(1), 25-35.

Lewis, P. S., & Malecha, A. (2011). The impact of workplace incivility on the work environment, manager skill, and productivity. Journal of Nursing Administration, 41(1), 41-47.

Leguina, A. (2015). A primer on partial least squares structural equation modeling (PLS-SEM).

Samad, A., Memon, S. B., & Kumar, M. (2020). Job satisfaction among nurses in Pakistan: The impact of incivility and informal climate. Global Business and Organizational Excellence, 39(4), 53-59.

Taap Manshor, A., Fontaine, R., & Siong Choy, C. (2003). Occupational stress among managers: a Malaysian survey. Journal of managerial psychology, 18(6), 622-628.

Mano-Negrin, R., & Kirschenbaum, A. (1999). Push and pull factors in medical employees' turnover decisions: The effect of a careerist approach and organizational benefits on the decision to leave the job. International Journal of Human Resource Management, 10(4), 689-702.

Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach burnout inventory manual. Mountain View. California: CPP.

Maslach, C., & Leiter, M. P. (2008). The truth about burnout: How organizations cause personal stress and what to do about it. John Wiley & Sons.

Mcgowan, B. (2001). Self-reported stress and its effects on nurses. Nursing Standard (through 2013), 15(42), 33.

Mcvicar, A. (2003). Workplace stress in nursing: a literature review. Journal of advanced nursing, 44(6), 633-642.

Mor Barak, M. E., Nissly, J. A., & Levin, A. (2001). Antecedents to Retention and Turnover Among Child Welfare, Social Work, and Other Human Service Employees: What Can We Learn From Past Research? A Review and Meta-analysis. Social Service Review. 75(4), 625–662.

Mobley, W. H., Horner, S. O., & Hollingsworth, A. T. (1978). An evaluation of precursors of hospital employee turnover. Journal of Applied psychology, 63(4), 408.

Nizar, H., & Chagani, P. (2016). Analysis of health care delivery system in Pakistan and Singapore. International Journal of Nursing, 8(2).

Nitzsche, M., Ribeiro, L., & Laneiro, T. (2018). Workplace incivility among Portuguese hotel employees: Is lack of respect burning them out? Journal of Spatial and Organizational Dynamics, 6(1), 52-71.

O'connor. B., Rory C. O'connor., Barbara L. White., Peter E., & Bundred D. (2000). The effect of job strain on British general practitioners' mental health. Journal of Mental Health, 9(6), 637-654.

Oulton, J. A. (2006). The global nursing shortage: an overview of issues and actions. Policy, Politics, & Nursing Practice, 7(3_suppl), 34S-39S.

Pearson, C. M., Andersson, L. M., & Porath, C. L. (2000). Assessing and attacking workplace incivility. Organizational dynamics, 29(2), 123-137.

Pines, A., & Aronson, E. (1988). Career burnout: Causes and cures. Free press.

Porath, C. L., Pearson, C. M. (2012). Emotional and behavioral responses to workplace incivility and the impact of hierarchical status. Journal of Applied Social Psychology, 42, E326-E357.

Porath, C., & Pearson, C. (2013). The price of incivility. Harvard business review, 91(1-2), 115-121.Porath, C. L., & Erez, A. (2009). Overlooked but not untouched: How rudeness reduces onlookers’ performance on routine and creative tasks. Organizational Behavior and Human Decision Processes, 109(1), 29-44.

Purcell Sr., Kutash M., & Cobb S. (2011) The relationship between nurses’ stress and nurse staffing factors in a hospital setting. J Nurs Manag., 19, 714-20

Reynolds, S. (1997). Psychological well-being at work: is prevention better than cure? Journal of psychosomatic research, 43(1), 93-102.

Sanchez, J. I., & Levine, E. L. (2000). Accuracy or consequential validity: which is the better standard for job analysis data?. Journal of Organizational Behavior: The International Journal of Industrial, Occupational and Organizational Psychology and Behavior, 21(7), 809-818.

Sarafis, P., Rousaki, E., Tsounis, A., Malliarou, M., Lahana, L., Bamidis, P., & Papastavrou, E. (2016). The impact of occupational stress on nurses’ caring behaviors and their health related quality of life. BMC nursing, 15(1), 56.

Sarstedt, M., Ringle, C. M., & Hair, J. F. (2017). Partial least squares structural equation modeling. Handbook of market research, 1-40.

Schaufeli, W. B., & Buunk, B. P. (2004). Burnout: An overview of 25 years of research and theorizing. In M. J. Schabracq, J. A. M. Winnubst., C. L. Cooper (Eds.), The handbook of work and health psychology (2nd ed., 383–425). Chichester, UK: Wiley. doi: 10.1002/0470013400.ch19

Schmitz, N., Neumann, W., & Oppermann, R. (2000). Stress, burnout and locus of control in German nurses. International Journal of Nursing Studies, 37(2), 95-99.

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: results from a randomized trial. International journal of stress management, 12(2), 164.

Spielberger, C. D., Vagg, P. R., & Wasala, C. F. (2003). Occupational stress: Job pressures and lack of support.

Spreckelmeyer, K. F. (1993). Office Relocation and Environmental Change: A Case Study. Environment and Behavior Journal, 25(2): 181–204.

Stordeur, S., D'hoore, W., & Vandenberghe, C. (2001). Leadership, organizational stress, and emotional exhaustion among hospital nursing staff. Journal of advanced nursing, 35(4), 533-542.

Tai, T. W. C., Bame, S. I., & Robinson, C. D. (1998). Review of nursing turnover research, 1977–1996. Social science & medicine, 47(12), 1905-1924.

Tett, R. P., & Meyer, J. P. (1993). Job satisfaction, organizational commitment, turnover intention, and turnover: path analyses based on meta‐analytic findings. Personnel psychology, 46(2), 259-293.

Teng, C. I., Hsiao, F. J., & Chou, T. A. (2010). Nurse‐perceived time pressure and patient‐perceived care quality. Journal of Nursing Management, 18(3), 275-284.

Thayer, J. F., Verkuil, B., Brosschot, J. F., Kampschroer, K., West, A., Sterling, C., Christie, I.C., Abernethy, D., Sollers, J. J., Cizza, G., Marques, A. H., & Sternberg, E. M. (2010). Effects of the Physical Work Environment on Physiological Measures of Stress. Eur J Cardiovasc Prev Rehabil., 17(4): 431–439.

Toker, S., Melamed, S., Berliner, S., Zeltser, D., & Shapira, I. (2012). Burnout and risk of coronary heart disease: a prospective study of 8838 employees. Psychosomatic Medicine, 74(8), 840-847.

Treven, S., & Potocan, V. (2005). Training programmes for stress management in small businesses. Education+ Training, 47(8/9), 640-652.

Ullrich, A., & Fitzgerald, P. (1990). Stress experienced by physicians and nurses in the cancer ward. Social Science & Medicine, 31(9), 1013-1022.

Van Dam, K., Meewis, M., & Van Der Heijden, B. I. (2013). Securing intensive care: towards a better understanding of intensive care nurses’ perceived work pressure and turnover intention. Journal of advanced nursing, 69(1), 31-40.

Van Der Ploeg E., & Kleber R. J. (2003) Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med., 60, 40-6.

Welbourne, J. L., Gangadharan, A., &Sariol, A. M. (2015). Ethnicity and cultural values as predictors of the occurrence and impact of experienced workplace incivility. Journal of occupational health psychology, 20(2), 205.

Wold, S. (1993). Discussion: PLS in chemical practice. Technometrics, 35(2), 136-139.