JONA
Volume 43, Number 10, pp 536-542
Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Relationship of Workplace Incivility,
Stress, and Burnout on Nurses’ Turnover
Intentions and Psychological
Empowerment
Olubunmi Oyeleye, DNP, RN
Patricia Hanson, PhD, RN
This study explored the relationships among per-
ceived workplace incivility, stress, burnout, perceived
turnover intentions, and perceived level of psychologi-
cal empowerment among acute care nurses (medical-
surgical and critical care) in community and tertiary
hospitals through the lens of complexity science. An
exploratory study was conducted, and findings dem-
onstrate significant relationships among workplace
incivility, stress, burnout, turnover intentions, total
years of nursing experience, and RN education levels.
Creating targeted retention strategies and policies that
will be sensitive to the needs and interests of nurses at
high risk for leaving their organizations is imperative
for nurse executives.
Nurses’ turnover and empowerment have become
priorities in healthcare. Studies report the cost of
nursing turnover ranging from about $22,000 to more
than $64,000 per nurse.1 Nurses’ turnover intention
refers to nurses considering leaving the organization
and is considered to be part of a cognitive withdrawal
process.2 In 2010, the American Nurses Association
reported that 53% of nurses were considering leaving
their current position.3 Empowered employees report
Author Affiliations: Director, Patient Care Services (Dr Oyeleye);
Professor (Drs Hanson, O’Connor, and Dunn), School of Nursing,
Madonna University, Livonia, Michigan.
The authors declare no conflicts of interest.
Correspondence: Dr Oyeleye, Detroit Medical Center, Detroit,
MI 48201 (ooyeleye@dmc.org).
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s Web site
(www.jonajournal.com).
DOI: 10.1097/NNA.0b013e3182a3e8c9
536
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nancy O’Connor, PhD, RN
Deborah Dunn, EdD, RN
less intention to turn over their jobs4 and less job
stress.5 Psychological empowerment is defined as a
cognitive state characterized by a sense of perceived
control, competence, and goal internalization that em-
ployees must experience for interventions to be suc-
cessful.6 Several studies have linked empowerment
to factors identified as important to retaining nurses.7,8
There has not been any study on acute care nurses
as it relates to the impact of workplace incivility (WI),
stress, and burnout on their intention to leave their
jobs and levels of perceived psychological empower-
ment; however, studies on individual or a combina-
tion of the variables have been addressed.2,9-16
Nursing is 1 of the most stressful and challeng-
ing professions because of the need for specialization,
complexity, and requirement to handle emergency
situations.17 Negative influences creating increased
stress for nurses and caregivers are staff conflict and
turnover.17 People have different innate abilities to
adapt to stress.18 Previous studies have identified
sources of job stress for nurses,9,10 including their de-
mographics,11 and stress responses.12 Sources of stress
in nursing include conflicts with other employees.13
Prolonged job stress has been shown to result in burnout.14
Burnout is a syndrome of emotional exhaustion,
depersonalization, and personal accomplishment (lack
of) that occurs frequently among individuals who do
people work.19 As burned out individuals’ emotional
resources are depleted, workers feel they are no longer
able to give of themselves at a psychologically healthy
level.14 Depersonalization results from the develop-
ment of negative, cynical attitudes and feelings. The
lack of personal accomplishment results from the ten-
dency to evaluate oneself negatively, particularly with
JONA  Vol. 43, No. 10  October 2013
regard to one’s work with clients.19 Workers may feel
unhappy about themselves and dissatisfied with their
personal job accomplishments, thereby transferring
the frustration to their coworkers.14 Exposure to emo-
tionally distressing dilemmas on a frequent basis
followed by insurmountable fatigue and exhaustion
increases the risk of nurses leaving the profession.14
Working in an unfriendly workplace, a result of a per-
ception of conflict in the workplace, has been identi-
fied as a precursor to nurses leaving organizations.20
Workplace incivility is defined as ‘‘low intensity
deviant behavior’’ with ambiguous intent to harm
the target, and violates workplace norms for mutual
respect.21(p457) Organizational culture may contrib-
ute to the presence of WI by either rejecting or em-
bracing incivility. An organization’s cultural norms
for coworker treatment must be supported by a strong
positive culture that evolves among nurses.15 If cultural
norms include sanctioning an atmosphere of general
workplace disrespect or arrogance, it can be referred
to as the ‘‘dance of incivility.’’15 Developing a more
civil workplace environment and better interpersonal
skills includes refusals to take part in an act of inci-
vility, intolerance of rudeness, and perpetrators apol-
ogizing to peers for disrespectful behaviors. Refusals
and apologies set the standard for others to emulate
and promote a civil relationship, which is referred to
as the ‘‘dance of civility.’’15 Organizations and leaders
must be vigilant to prevent the conditions leading to
disempowerment and turnover intentions as nurses
are constantly challenged to adapt to complex and
chaotic healthcare environments. Complexity science
can guide a greater understanding of the healthcare
systems.22
Healthcare is constantly changing, with a high
degree of complexity. Complexity science, as related
to healthcare, is the science of moving in a nonlin-
ear and interactive manner where unpredictable out-
comes are often realized; organizations are described
as ever-changing collections of individuals and condi-
tions in the organization; and patterns of interaction
among individuals and connections are made in day-to-
day practices among and between individuals.22 Com-
plexity principles explain the unpredictable and often
chaotic nature of organizations.23 Healthcare orga-
nizations are complex adaptive systems (CASs) or a
group of individuals interacting with their environment
in ways that are interconnected and unpredictable.24
Complex Adaptive Systems
Complexity science encompasses systems thinking,
which investigates patterns and structures. This un-
derscores the ability to fully see, integrate, and ap-
preciate the emerging view of unity and wholeness,
reciprocity, interdependence, and cocreation in the
JONA  Vol. 43, No. 10  October 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
web of life.25 One’s actions will continue to influ-
ence the actions of the other, no matter how far they
are separated by time or distance.26 In the nursing pro-
fession, a nurse’s negative attitude can have a lasting
negative impression on other nurses, even if removed
from the negative environment.
Nurses integrate the complementary functions of
both science and art into a larger whole. They have
learned to harness and distribute energy while work-
ing with new forms of technology and systems. The
spiritual side of humanity (adaptive mechanisms) has
been slower to develop.27 Self-awareness, a spiritual
component for humanity, can lead to psychological
empowerment fostering civility in the workplace. Self-
awareness encompasses knowing one’s self and the
self of others. An adaptive strategy to promote civil-
ity is developing a method to find deeper meaning in
one’s life and more comprehensive solutions to di-
lemmas.27 Bolstered with the interconnectedness of
their personal lives and professional practice, nurses
are able to propagate the culture of civility in the face
of heightened level of stress and burnout. The appli-
cation of the understanding of healthcare as a CAS
involves cultivating an environment of collegial work
relationships by allowing even small nonthreaten-
ing interactions that attract and retain nurses.26 The
purpose of this study was to explore the relationships
and differences among WI, stress, burnout, turnover
intentions, and level of psychological empowerment
on acute care nurses in the hospital settings using
CAS as the theoretical framework.
Study Framework
In this study, encounters with missed or avoided op-
portunities for psychological empowerment are seen
as maladaptive modes that increase WI occurrences,
stress, and burnout, leading to turnover intentions.
On the other hand, encounters with seized opportu-
nities for psychological empowerment are seen as
adaptive modes that propagate civil behavior with
decreased stress and burnout levels among nurses,
leading to a decrease in turnover intention and high
psychological empowerment (Figure 1).
This framework guided the study examining the
dynamic environment in community and tertiary hos-
pitals among acute care in relation to (a) perceived
WI, (b) levels of stress and burnout, (c) nurses’ turn-
over intention, (d) turnover, and (e) level of perceived
psychological empowerment. The implication of this
framework is that the heightened level of stress can
lead to burnout and WI; likewise, burnout can lead
to heightened levels of stress, which can foster WI
(Figure 2).
537
Figure 1. Conceptual framework modified, depicting relationship of study variables.4,26,28
Research Questions
1. Are there differences between acute care nurses’
perceived WI, stress levels, burnout, intent to
leave, and levels of psychological empowerment?
2. Are there relationships among perceived WI,
stress levels, burnout, turnover intention, and
levels of psychological empowerment in acute
care nurses in the community and tertiary
hospitals?
Methods
This quantitative study used exploratory, correlational
methods. All statistical procedures were performed
using SPSS version 20.0. Statistically significant as-
sociations and correlations were considered at a
P value of .05.
Setting and Sample
After institutional review board approval was ob-
tained from Wayne State University and Madonna
University, a convenience sample of acute care nurses
from 2 community hospitals and 1 tertiary hospital
in a healthcare system located in the Midwest region
of the United States was obtained. Four hundred sur-
538
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veys were distributed; 200 surveys were sent to the
tertiary hospital and 100 surveys were sent to each of
the 2 community hospitals. Reminders were sent to
nonresponders at weeks 3 and 5. The final survey
response rate was 15% (n = 61). Three quarters (72%;
n = 44) of the respondents were from the tertiary
hospital, whereas the remaining quarter (28%; n = 17)
were from the community hospitals.
Respondents were mostly women (87%, n = 53),
with a minority of male respondents (13%, n = 8).
Ages ranged from 23 to 61 years, with a mean of
40 years. Most respondents were white (82%, n =
50), with 11 respondents identifying as nonwhite
(Asian, 12%, n = 7; African Americans, 5%, n = 3;
other, 2%, n = 1). The sample represents experienced
nurses, ranging from 1 to 40 years of experience;
more than half of the sample had 8 years or more of
nursing experience (mean [SD], 11 [9.3] years). Of
the respondents, 59% (n = 36) worked in medical-
surgical settings, whereas 41% (n = 25) worked in
critical care. Most (90%) respondents worked full-
time. Highest level of nursing educational prepara-
tion was queried; most respondents were associate
degree prepared (62%; n = 38), whereas more than
one-third of the respondents were bachelor prepared
(38%; n = 23).
JONA  Vol. 43, No. 10  October 2013
Figure 2. Research and measurement model.
Data Collection Instruments
Data collection instruments included 5 tools to mea-
sure stress, burnout, WI, turnover intentions, and
psychological empowerment. Stress was measured
using the Perceived Stress Scale (PSS10), a 10-item,
5-point Likert scale (0 = never to 4 = very often),
with total scores ranging from 0 to 40.27 The PSS10
exhibited construct validity (P G .0001) with other
stress measures, health, health service utilization,
health behaviors, life satisfaction, and help-seeking
behaviors.27 Burnout was measured using the Maslach
Burnout Inventory (MBI; 3rd edition), a 22-item
7-point Likert scale (0 = very strongly disagree to
6 = very strongly agree), with total scores ranging
from 0 to 132.19 The MBI exhibited internal con-
sistency and convergent and discriminant validity
with behavioral ratings, job characteristics, and other
psychological constructs at P G .001.19 Workplace
incivility was measured using a combination and
modification of 2 instruments, the Uncivil Workplace
Behaviors questionnaire16 and the Workplace Inci-
JONA  Vol. 43, No. 10  October 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
vility Scale (WIS).29 The reliability and validity of the
modified scale are unknown; however, the WIS has
reported reliability (! = .89).29
Turnover intention was measured using a 4-item
tool with a 5-point Likert scale (0 = strongly disagree
and 5 = strongly agree), with total scores ranging
from 0 to 16.30 Psychological empowerment was mea-
sured using the Spreitzer Psychological Empowerment
Scale (PES), a 16-item Likert scale tool (0 = strongly
disagree to 6 = very strongly agree), with scores rang-
ing from 0 to 96.31 Convergent and discriminant
validity with self-esteem, locus of control, social de-
sirability, information, effectiveness, and innova-
tion was established for the PES with a reported
! of .72.31
Results
The 1st study question examined whether there were
differences between acute care nurses on the study
variables (incivility, stress, burnout, turnover intentions,
539
and psychological empowerment levels). Descriptive
statistics were initially examined. Results demonstrated
that perceived stress scores ranged from 15 to 31 (n =
61; mean [SD], 21.5 [3.78]), burnout scores ranged
from 42 to 91 (n = 54; mean [SD], 64 [12.0]), and
scores for WI ranged from 19 to 74 (n = 61; mean
[SD], 40.5 [12.2]). Turnover intention scores ranged
from 0 to 16 (n = 61; mean [SD], 4.9 [2.9]), and
psychological empowerment scores ranged from 15 to
96 (n = 61; mean [SD], 75.2 [13.5]).
To explore if there were differences between acute
care nurses on the 5 study variables, unpaired t tests
were conducted. Results demonstrated no statistically
significant differences in mean scores (Table 1).
The 2nd study question explored relationships
among the 5 study variables. Correlations revealed
statistically significant relationships between stress
and incivility (P = .001), stress and burnout (P = .000),
burnout and incivility (P = .005), and burnout and
turnover intention (P = .005). In addition, turnover
intention and incivility were significantly related
(P = .000), whereas psychological empowerment
scores did not correlate with any study variables. Ad-
ditional tests were done with demographic character-
istics as related to their potential relationship with
the 5 study variables. Total years of nursing experience
was significantly correlated with burnout (P= .045),
incivility (P = .007), and turnover intention (P = .047),
whereas education levels correlated with burnout
(P= .038) (see Table, Supplemental Digital Content 1,
http://links.lww.com/JONA/A252).
The results of the data analyses are depicted in
Figure 2. The theoretical framework guided the study
examining the dynamic environment in community and
tertiary hospitals among acute care nurses in relation to
(a) perceived WI, (b) levels of stress and burnout, (c)
nurses’ turnover intention, and (d) level of perceived
psychological empowerment. Findings support that a
heightened level of stress and burnout can lead to WI.
Discussion
The conceptual model guiding this research study
posited that stress, burnout, and incivility are factors
that may contribute to nurses’ turnover intention and
level of psychological empowerment. In this sample
of 61 acute care nurses, moderate levels of stress, burn-
out, and incivility were found, whereas turnover in-
tention was low. Examining the relationships among
the variables in this sample supported relationships
between stress and burnout. Both stress and burnout
were related to WI. Factors relating to turnover in-
tention included incivility and burnout, whereas psy-
chological empowerment was not found to be related
to any study variable. Findings are consistent with
the literature9-14,17,18,20,21,28,30,32 documenting re-
lationships among burnout, stress, and incivility and
linking them to nurse turnover. These data thus sup-
port previous evidence of the importance of work en-
vironments that enable nurses to practice in collegial
work settings in which nurses respect each other and
refrain from uncivil behaviors in daily practice and use
appropriate tools to decrease job stress and burnout.
Research has demonstrated that nursing leader-
ship is crucial to ensuring elements of supportive pro-
fessional practice environments.4-8,11,12,21,28 Nurse
administrators can monitor for the dance of incivil-
ity and the associated cognitive dissonance that prompt

Table 1. t-Test Differences Between MS and CC Nurses on Study Variables

Group/Variable n Mean SD t Test df P (2 tailed)

Stress
MS 36 21.31 3.76
CC 25 21.76 3.85 j0.459 59 .648
Burnout
MS 30 62.1 13.3
CC 24 66.79 9.69 j1.458 52 .151
Incivility
MS 36 39.72 12.34
CC 25 41.44 12.06 j0.539 59 .592
Turnover intention
MS 36 4.44 2.82
CC 25 5.48 2.99 j1.376 59 .174
Empowerment
MS 36 73.72 13.98
CC 25 77.28 12.73 j1.014 59 .315

Abbreviations: CC, critical care; MS, medical-surgical.

540 JONA  Vol. 43, No. 10  October 2013

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nurses to leave their jobs. Conversely, nurse adminis-
trators can work toward fostering the dance of civility
until it becomes the norm for organizational culture.
The consequences of unmanaged stress and burnout
are costly; therefore, it is important to proactively iden-
tify factors that contribute to the development of stress
and burnout in the workplace.
From a theoretical perspective, actualizing em-
powerment is linked to nurses’ perceptions of psycho-
logical empowerment. Nurses in this study reported
moderate levels of perceived psychological empower-
ment; however, psychological empowerment was not
found to be associated with stress, burnout, or WI.
Limitations of the study include the low response rate
and the nonrepresentativeness of the sample to the pop-
ulation of employees. Approximately 82% of the respon-
dents were white/non-Hispanic, demonstrating limited
diversity in the sample. Further research is needed.
Conclusions and Recommendations
Nurse administrators can intervene to lead organi-
zational cultural change toward the dance of civility.
A zero-tolerance policy for incivility must be man-
datory, and employees should be aware of the exis-
tence of the policy and related processes. Nurse
leaders must be provided with tools for conflict man-
agement. Research shows that when managers are ill-
equipped for addressing WI conflicts, the tendency to
ignore those conflicts is high.21 Because WI is used as
a litmus test for workplace violence, managers must
be fluent in identifying factors that predispose their
environment to dance of incivility. Connecting WI
References
1. Jones CB, Gates MG. The costs and benefits of nurse turn-
over: a business case for nurse retention. Online J Issues Nurs.
2007;2(3):1-12.
2. van Dam K, Meewis M, van Der Heijin BIJM. Securing intensive
care: towards a better understanding of intensive care nurses’
perceived work pressure and turnover intention. J Adv Nurs.
2012;69(1):31-40. doi:10.1111/j.1365-2648.2012.05981.x
3. American Nurses Association. The Nurse’s Role in Ethics and
Human Rights: Protecting and Promoting Individual Worth,
Dignity, and Human Rights in Practice Setting. Silver Spring,
MD: Nursebooks.org; 2010.
4. Koberg CS, Boss W, Senjem JC, Goodman EA. Antecedents
and outcomes of empowerment: empirical evidence from the
health care industry. Group Organ Manag. 1999;34(1):71-91.
5. Spreitzer GM, Mishra AK. Giving up control without losing
control: trust and its substitutes’ effects on managers’ involv-
ing employees in decision making. Group Organ Manag.
1997;24(2):155-187.
6. Laschinger HKS, Finegan J, Shamian J, Wilk P. Impact of
structural and psychological empowerment on job straining
JONA  Vol. 43, No. 10  October 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to nurses’ stress and burnout reinforces the nurse’s
accountability for attitude and behavior through self-
awareness. A code of professionalism and mutual
respect must be enforced by nursing administrators
and can result in organizational cultural change to a
dance of civility. To cultivate a dance of civility in the
work environment, managers must create an open
communicative environment where nurses feel free
to express their concerns without feelings of power-
lessness, intimidation, and oppression. Nurse leaders
are encouraged to provide stress-reducing interven-
tions that can help in alleviating job stress and sub-
sequently decrease or prevent the incidence of work
place incivility.
On the basis of this research, further investigation
should explore interventions that nurse leaders can
use to positively influence WI, stress, and burnout and
play a meaningful role in reducing/preventing turnover
intentions. As previously mentioned, self-awareness,
a key concept to psychological empowerment, is im-
portant for nurses’ psychological well-being. The ability
for nurses to develop greater self-awareness increases
their ability to manage and use emotions to respond
more appropriately to one’s needs and those of others.
Because psychological empowerment is a predictor
of positive work behaviors leading to positive work
environment,31 managers must support nurses as
they exhibit psychological power-based work relations
with their coworkers, thereby promoting positive or-
ganizational culture by propagating a dance of civil-
ity, while nurses have the tools to use stress-reducing
interventions.
in nursing work settings: expanding Kantar’s model. J Nurs
Adm. 2001;31(5):260-272.
7. Laschinger HKS, Almost J, Tuer-Hodes D. Workplace em-
powerment and Magnet hospital characteristics: making the
link. J Nurs Adm. 2003;33:410-422.
8. Laschinger HKS, Finegan J. Using empowerment to build
trust and respect in the workplace: a strategy for addressing
the nursing shortage. Nurs Econ. 2005;23(1):6-13.
9. Welsh D. Predictors of depressive symptoms in female med-
ical surgical hospital nurses. Issues Ment Health Nurs. 2009;
30:320-326.
10. Alacacioglu A, Yavuzsen T, Dirioz M, Oztop I, Yilmaz U.
Burnout in nurses and physicians working at an oncology de-
partment. Psychooncology. 2009;18:543-548.
11. von Rueden KT, Hinderer KA, McQuillan KA, et al.
Secondary traumatic stress in trauma nurses: prevalence and
exposure, coping, and personal/environment characteristics.
J Trauma Nurs. 2010;17(4):191-200.
12. Badger JM. A descriptive study of coping strategies used by
medical intensive care unit nurses during transitions from cure
to comfort oriented care. Heart Lung. 2005;34(1):63-68.
541
13. Moola S, Ehlers VJ, Hattingh SP. Critical care nurses’ per-
ceptions of stress and stress related situations in the workplace.
Curationis. 2008;31(2):74-83.
14. Wu S, Zhu W, Wang Z, Wang M, Lan Y. Relationship between
burnout and occupational stress among nurses in China. J Adv
Nurs. 2007;59(3):233-239. doi:10.1111/j.1365-2648-
2007.04301.x.
15. Koerner J. Insight: the application of complexity science to
decision-making. Creat Nurs. 2009;15(4):165-171.
16. Martin RJ, Hine DW. Development and validation of uncivil
workplace behavior questionnaire. J Occup Health Psychol.
2005;10(4):477-490 doi:10.1037/1076-8998.10.4.4.477.
17. Chen C, Lin C, Wang S, Hou T. A study of job stress, stress
coping strategies, and job satisfaction for nurses working in
middle-level operating rooms. J Nurs Res. 2009;17(3):199-210.
18. Iacovides A, Fountoulakis KN, Kaprinis S, Kaprinis G. The
relationship between job stress, burnout and clinical depres-
sion. J Affect Disord. 2003;75:209-221.
19. Maslach C, Jackson SE. The measurement of burnout. J Occup
Behav. 1981;2:99-113.
20. Andersson LM, Pearson CM. Tit for tat?: the spiraling effect of
incivility in the workplace. Acad Manag Rev. 1999;24(3):452-471.
21. Lim S, Cortina LM, Magley V. Personal and workgroup in-
civility: impact on work and health outcomes. J Appl Psychol.
2008;93(1):95-107.
22. Hast AS, DiGioia AM, Thompson D, Wolf G. Utilizing com-
plexity science to drive practice change through patient and
family centered care. J Nurs Adm. 2013;43(1):44-49.
542
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
23. Pslek P, Greenhalgh T. The challenge of complexity in health
care. BMJ. 2001;323:625-628.
24. Nadeau R, Kafatos M. The Non-local Universe: The New
Physics and Matter of the Mind. New York, NY: Oxford
University Press; 2002.
25. Mindel A. The Quantum Mind and Healing. Charlottesville,
VA: Hampton Roads Publishing; 2004.
26. Chinn PL, Kramer MK. Integrated Knowledge Development
in Nursing. St Louis, MO: Mosby; 2008.
27. Cohen S, Williamson GM. Perceived stress in a probability
sample of the United States. In: Spacapan S, Oakamp S, eds.
The Social Psychology of Health. Newbury Park, CA: Sage;
1988:31-67.
28. Clark CM, Olender L, Cardoni C, Kenski D. Fostering civility
in nursing education and practice: nurse leader perspectives.
JONA. 2011;41(7/8):324-330.
29. Cortina LM, Magley VJ. Patterns and profiles of response
to incivility in the workplace. J Occup Health Psychol. 2009;
14(3):272-288.
30. Kelloway EK, Gottlieb BH, Barham L. The source, nature,
and direction of work and family conflict: a longitudinal in-
vestigation. J Occup Health Psychol. 1999;4:337-346.
31. Spreitzer GM. Psychological empowerment in the workplace:
dimensions, measurement, and validation. Acad Manag J. 1995;
38(5):1445-1465.
32. MacKusick CI, Minick P. Why are nurses leaving? Find-
ings from an initial qualitative study on nursing attrition.
Medsurg Nurs. 2010;19(6):335-340.
JONA  Vol. 43, No. 10  October 2013