Review Article

Incivility toward nurses: a systematic review and meta-analysis


One important part of a nurse’s job is to create and help maintain a safe work environment. Evidence shows that negative behaviors such as incivility are not uncommon in the nursing profession. This systematic review and meta-analysis aimed to examine the prevalence of incivility toward nurses. 
For this purpose, all observational studies that primarily investigated the rate of incivility toward nurses were selected. The electronic databases PubMed, Embase, Web of Sciences, Magiran, IranDoc, and Scopus were searched for studies published during the period of January 1, 1996 to December 31, 2019. The quality of studies was assessed using Hoy’s Critical Assessment Checklist. The study was undertaken using the random effects model, and data were analyzed using STATA14. 
Data on 60 articles, including data on 30801 individuals, published between 1997 and 2019, entered the study. The findings showed the prevalence of incivility to be 55.10% (95%, CI: 48.05, 62.06).

Due to the high prevalence of uncivil behavior, especially of the verbal type, nursing managers should identify risk factors in the workplace. Planners should develop programs to increase workplace safety, especially in centers that are most exposed to these behaviors. It is also recommended that future studies focus on implementation of effective evidence-based interventions based on organizational culture.

Gopalkrishnan P. Workplace incivility and employee strain in reactions: The moderating effects of perceived organisational support and job insecurity. [cited on Aug 2021];

Bjorkqvist K, Osterman K, Hjelt‐Back M. Aggression among university employees. Aggressive Behavior. 1994; 20(3): 173-84.

Duncan S, Estabrooks CA, Reimer M. Violence against nurses. Alta RN. 2000; 56(2): 13-4.

Andersson L.M, Pearson C.M. Tit for tat? the spiraling effect of incivility in the workplace. The Academy of Management Review. 1999; 24(3): 452-71.

Hosseinpour Dalenjan L, Atashzadeh Shoorideh F, Hosseini M, Mohtashami J. The correlation between nurses’ work engagement and workplace incivility. Iranian Red Crescent Medical Journal. 2017; 19(4): 26.

Hershcovis MS, Barling J. Towards a relational model of workplace aggression. In Langan-Fox J, Cooper CL, Klimoski RJ, Eds. Research Companion to The Dysfunctional Workplace: Management Challenges and Symptoms. UK: Edward Elgar Publishing; 2008.

Lim S, Cortina LM, Magley VJ. Personal and workgroup incivility: Impact on work and health outcomes. J Appl Psychol. 2008; 93(1): 95-107.

Hoffman RL, Chunta K. Workplace incivility: promoting zero tolerance in nursing. Journal of Radiology Nursing. 2015; 34(4): 222-7.

Clark CM, Springer PJ. Academic nurse leaders’ role in fostering a culture of civility in nursing education. J Nurs Educ. 2010; 49(6): 319-25.

Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006; 203(1): 96–105.

Estes B, Wang J. Workplace incivility: impacts on individual and organizational performance. Human Resource Development Review. 2008; 7(2): 218-40.

Montalvo L. An evidence based synthesis of civility and incivility literature: a model to explain civil and uncivil behaviors in the workplace. [cited on Aug 2021];

Arab N, Hashemi Sheykhshabani E, Beshlideh K. Antecedents of workplace incivility: investigating some personal and organizational variables. Journal of Psychology. 2013; 17(3): 294-309.

Azami M, Moslemirad M, YektaKooshali M.H, et al. Workplace violence against Iranian nurses: a systematic review and meta-analysis. Violence Vict. 2018; 33(6): 1148-75.

Dalvand S, Gheshlagh RG, Najafi F, Zahednezhad H, Sayehmiri K. The prevalence of workplace violence against iranian nurses: a systematic review and met-analysis. Shiraz E Medical Journal. 2018; 19: 9.

D'ambra AM, Andrews DR. Incivility, retention and new graduate nurses: an integrated review of the literature. J Nurs Manag. 2014; 22(6): 735-42.

Edward Kl, Ousey K, Warelow P, Lui S. Nursing and aggression in the workplace: a systematic review. Br J Nurs. 2014; 23(12): 653-9.

Hawkins N, Jeong S, Smith T. New graduate registered nurses’ exposure to negative workplace behavior in the acute care setting: an integrative review. Int J Nurs Stud. 2019; 93: 41-5.

Zhu Z, Xing W, Lizarondo L, Gue M, Hu Y. Nursing students’ experiences with faculty incivility in the clinical education context: a qualitative systematic review and meta-synthesis. BMJ Open. 2019; 9: e024383.

Hodgins M, MacCurtain S, Mannix-McNamara P. Workplace bullying and incivility: a systematic review of interventions. International Journal of Workplace Health Management. 2014; 7(1): 54-72.

Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. Int J Evid Based Healthc. 2015;13(3):147–53.

Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000; 283(15); 2008-12.

Hoy D, Brooks P, Woolf A, et al. Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol. 2012; 65(9): 934-9.

Chen KP, Ku YC, Yang HF. Violence in the nursing workplace–a descriptive correlational study in a public hospital. J Clin Nurs. 2013; 22(5-6):798-805.

Khademloo M, Moonesi FS, Gholizade H. Health care violence and abuse toward nurses in hospitals in north of Iran. Global Journal of Health Science. 2013; 5(4): 211-6.

Fallahi Khoshknab M, Tamizi Z, Ghazanfari N, Mehrabani G. Prevalence of workplace violence in psychiatric wards, Tehran, Iran. Pak J Biol Sci. 2012; 15(14): 680-4.

Pai HC, Lee S. Risk factors for workplace violence in clinical registered nurses in Taiwan. J Clin Nurs. 2011; 20(9‐10): 1405-12.

Abualrub RF, Al-Asmar AH. Psychological violence in the workplace among Jordanian hospital nurses. J Transcult Nurs. 2014; 22(2): 157-65.

Hsieh YH, Wang HH, Ma SC. The mediating role of self-efficacy in the relationship between workplace bullying, mental health and an intention to leave among nurses in Taiwan. Int J Occup Med Environ Health. 2019; 32(2): 245-54.

Zhao S, Xie F, Wang J, et al. Prevalence of workplace violence against Chinese nurses and its association with mental health: a cross-sectional survey. Arch Psychiatr Nurs. 2018; 32(2): 242-7.

Zhang L, Wang A, Xie X, et al. Workplace violence against nurses: a cross-sectional study. Int J Nurs Stud. 2017; 72: 8-14.

Jafree SR. Workplace violence against women nurses working in two public sector hospitals of Lahore, Pakistan. Nurs Outlook. 2017; 65(4): 420-7.

Esmaeilpour M, Salsali M, Ahmadi F. Workplace violence against Iranian nurses working in emergency departments. Int Nurs Rev. 2011; 58(1): 130-7.

Fujishiro K, Gee GC, de Castro AB. Associations of workplace aggression with work-related well-being among nurses in the Philippines. Am J Public Health. 2011; 101(5): 861-7.

Shiao JSC, Tseng Y, Hsieh YT, Hou JY, Cheng Y, Guo YL. Assaults against nurses of general and psychiatric hospitals in Taiwan. Int Arch Occup Environ Health. 2010; 83(7): 823-32.

Honarvar B, Ghazanfari N, Shahraki HR, Rostami S, Lankarani KB. Violence against nurses: a Neglected and health threatening epidemic in the university affiliated public hospitals in Shiraz, Iran. Int J Occup Environ Med. 2019; 10(3): 111-23.

Jiao M, Ning N, Li Y, et al. Workplace violence against nurses in Chinese hospitals: a cross-sectional survey. BMJ Open. 2015; 5(3): e006719.

Park M, Cho SH, Hong HJ. Prevalence and perpetrators of workplace violence by nursing unit and the relationship between violence and the perceived work environment. J Nurs Scholarsh. 2015; 47(1):87-95.

Obeidat RF, Qan’ir Y, Turaani H. The relationship between perceived competence and perceived workplace bullying among registered nurses: a cross sectional survey. Int J Nurs Stud. 2018; 88: 71-8.

Al-Shamlan NA, Jayaseeli N, Al-Shawi MM, Al-Joudi AS. Are nurses verbally abused? a cross-sectional study of nurses at a university hospital, Eastern Province, Saudi Arabia. J Family Community Med. 2017; 24(3): 173-80.

Heydari A, Rad M. Evaluating the incivility between staff nurses and matrons employed in Iran. Acta Facultatis Medicae Naissensis. 2015; 32(2):137-46.

Lu L, Lok KI, Zhang L, et al. Prevalence of verbal and physical workplace violence against nurses in psychiatric hospitals in China. Arch Psychiatr Nurs. 2019; 33(5): 68-72.

Jaradat Y, Nielsen MB, Kristensen P, et al. Workplace aggression, psychological distress, and job satisfaction among Palestinian nurses: a cross-sectional study. Appl Nurs Res. 2016; 32: 190-8.

Cheung T, Yip PS. Workplace violence toward nurses in Hong Kong: prevalence and correlates. BMC Public Health. 2017; 17(1): 196.

Alkorashy HAE, Al Moalad FB. Workplace violence against nursing staff in a Saudi university hospital. Int Nurs Rev. 2016; 63(2): 226-32.

Suhaila O, Rampal KG. Prevalence of sexual harassment and its associated factors among registered nurses working in government hospitals in Melaka State, Malaysia. Med J Malaysia. 2012; 67(5): 506-17.

Ahmed AS. Verbal and physical abuse against Jordanian nurses in the work environment. East Mediterr Health J. 2012; 18(4), 318-24.

Zahra AN, Feng JY. Workplace violence against nurses in Indonesian emergency departments. Enfermeria clinica. 2018; 28: 184-90.

Yun S, Kang J, Lee YO, Yi Y. Work environment and workplace bullying among Korean intensive care unit nurses. Asian Nursing Research. 2014; 8(3): 219-25.

Niu SF, Kuo SF, Tsai HT, Kao CC, Traynor V, Chou KR. Prevalence of workplace violent episodes experienced by nurses in acute psychiatric settings. PLoS ONE. 2109; 14(1): e0211183.

Chang HE, Cho SH. Workplace violence and job outcomes of newly licensed nurses. Asian Nurs Res (Korean Soc Nurs Sci). 2016; 10(4): 271-6.

An Y, Kang J. Relationship between organizational culture and workplace bullying among Korean nurses. Asian Nurs Res (Korean Soc Nurs Sci). 2016; 10(3): 234-9.

Kwok RPW, Law YK, Li KE, et al. Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Med J. 2006; 12(1): 6-9.

Dehghan-Chaloshtari S, Ghodousi A. Factors and characteristics of workplace violence against nurses: a study in Iran. J Interpers Violence. 2020; 35(1-2): 496-509.

Sauer PA, McCoy TP. Nurse bullying: Impact on nurses’ health. West J Nurs Res. 2017; 39(12): 1533-46.

Budin WC, Brewer CS, Chao YY, Kovner C. Verbal abuse from nurse colleagues and work environment of early career registered nurses. J Nurs Scholarsh. 2013; 45(3): 308-16.

Tsukamoto SAS, Galdino MJQ, Robazzi MLCC, et al. Occupational violence in the nursing team: prevalence and associated factors. Acta Paulista de Enfermagem. 2019; 32(4): 425-32.

Lemelin L, Bonin JP, Duquette A. Workplace violence reported by Canadian nurses. Can J Nurs Res. 2009: 41(3): 152-67.

Manderino MA, Berkey N. Verbal abuse of staff nurses by physicians. J Prof Nurs. 1997; 13(1): 48-55.

Berry PA, Gillespie GL, Gates D, Schafer J. Novice nurse productivity following workplace bullying. J Nurs Scholarsh. 2012; 44(1): 80-7.

Hampton D, Tharp‐Barrie K, Rayens MK. Experience of nursing leaders with workplace bullying and how to best cope. J Nurs Manag. 2019; 27(3):517-26.

Ridenour M, Lanza M, Hendricks S, et al. Incidence and risk factors of workplace violence on psychiatric staff. Work. 2015; 51(1): 19-28.

Estes BC. Abusive supervision and nursing performance. Nurs Forum. 2013; 48 (1): 3-16.

Johnson SL, Rea RE. Workplace bullying: concerns for nurse leaders. J Nurs Adm. 2009; 39(2): 84-90.

Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2005; 13(3): 242-8.

Campbell JC, Messing JT, Kub J, et al. Workplace violence: prevalence and risk factors in the safe at work study. J Occup Environ Med. 2011; 53(1): 82-9.

May DD, Grubbs LM. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs. 2002; 28(1): 11-7.

Hanrahan NP, Kumar A, Aiken LH. Adverse events associated with organizational factors of general hospital inpatient psychiatric care environments. Psychiatr Serv. 2010; 61(6): 569-74.

Cook JK, Green M, Topp RV. Exploring the impact of physician verbal abuse on perioperative nurses. AORN J. 2001; 74(3): 317-31.

Boafo IM, Hancock P, Gringart E. Sources, incidence and effects of non‐physical workplace violence against nurses in Ghana. Nurs Open. 2016; 3(2): 99-109.

Fute M, Mengesha ZB, Wakgari N, Tessema GA. High prevalence of workplace violence among nurses working at public health facilities in Southern Ethiopia. BMC Nurs. 2015; 14: 9.

Abou-ElWafa HS, El-Gilany AH, Abd-El-Raouf SE, Abd-Elmouty SM, El-Sayed RESH. Workplace violence against emergency versus non-emergency nurses in Mansoura university hospitals, Egypt. J Interpers Violence. 2015; 30(5): 857-72.

Abbas MA, Fiala LA, Abdel Rahman AG, Fahim AE. Epidemiology of workplace violence against nursing staff in Ismailia Governorate, Egypt. J Egypt Public Health Assoc. 2010; 85(1-2): 29-43.

Pandey M, Bhandari TR, Dangal G. Workplace violence and its associated factors among nurses. J Nepal Health Res Counc. 2017; 15(3): 235-41.

Sisawo EJ, Ouedraogo SYY, Huang SL. Workplace violence against nurses in the Gambia: mixed methods design. BMC Health Serv Res. 2017; 17(1): 311.

Tiruneh BT, Bifftu BB, Tumebo AA, Kelkay MM, Anlay DZ, Dachew BA. Prevalence of workplace violence in Northwest Ethiopia: a multivariate analysis. BMC Nurs. 2016; 15: 42.

Joubert E, du Rand A, van Wyk N. Verbal abuse of nurses by physicians in a private sector setting. Curationis. 2005; 28(3): 39-46.

Bambi S, Becattini G, Giusti GD, Mezzetti A, Guazzini A, Lumini E. Lateral hostilities among nurses employed in intensive care units, emergency departments, operating rooms, and emergency medical services: a national survey in Italy. Dimens Crit Care Nurs. 2014; 33(6): 347-54.

Galian-Munoz I, Ruiz-Hernandez JA, Llor-Esteban B, Lopez-Garcia C. User violence and nursing staff burnout: the modulating role of job satisfaction. J Interpers Violence. 2016; 31(2): 302-15.

Aksakal FNB, Karasahin EF, Dikmen AU, Avci E, Ozkan S. Workplace physical violence, verbal violence, and mobbing experienced by nurses at a university hospital. Turk J Med Sci. 2015; 45(6):1360-8.

Karatza C, Zyga S, Tziaferi S, Prezerakos P. Workplace bullying and general health status among the nursing staff of Greek public hospitals. Ann Gen Psychiatry. 2016; 15(1): 7.

Yıldırım D. Bullying among nurses and its effects. Int Nurs Rev. 2009; 56(4): 504-11.

Fafliora E, Bampalis VG, Zarlas G, Sturaitis P, Lianas D, Mantzouranis G. Workplace violence against nurses in three different Greek healthcare settings. Work. 2016; 53(3): 551-60.

Li P, Xing K, Qiao H, et al. Psychological violence against general practitioners and nurses in Chinese township hospitals: incidence and implications. Health Qual Life Outcomes. 2018; 16(1): 117.

Taylor JL, Rew L. A systematic review of the literature: workplace violence in the emergency department. J Clin Nurs. 2011; 20(7‐8): 1072-85.

Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya M. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six US hospitals. Am J Ind Med. 2015; 58(11): 1194-204.

Phillips J.P. Workplace violence against health care workers in the United States. N Engl J Med. 2016; 374(17): 1661-9.

Elmblad R. Workplace incivility affecting CRNAs: a study of prevalence, severity, consequences with proposed interventions. AANA J. 2014; 82(6): 437-45.

Jenkins SD, Kerber CS, Woith WM. An intervention to promote civility among nursing students. Nurs Educ Perspect. 2013; 34(2): 95-100.

Martinez AJS. Managing workplace violence with evidence-based interventions: a literature review. J Psychosoc Nurs Ment Health Serv. 2016; 54(9): 31-6.

Bergman ME, Henning JB. Sex and ethnicity as moderators in the sexual harassment phenomenon: a revision and test of Fitzgerald et al (1994). J Occup Health Psychol. 2008; 13(2): 152-67.

EL Banan SHA, Abdrbo AA. The Relationship between Workplace Incivility and Work Engagement as Perceived by Staff Nurses at a Selected Hospital. International Journal of Nursing and Health Science. 2020; 6(1): 1-9.

Spence Laschinger H.K, Finegan J, Wilk P. New graduate burnout: the impact of professional practice environment, workplace civility and empowerment. Nurs Econ. 2009; 27(6): 377-83.

IssueVol 14 (2021) QRcode
SectionReview Article(s)
Incivility Uncivil behavior Nurses Workplace violence

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Atashzadeh Shoorideh F, Moosavi S, Balouchi A. Incivility toward nurses: a systematic review and meta-analysis. J Med Ethics Hist Med. 2021;14.