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PRISMA Study flow diagram.
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Figure 1

PRISMA Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies using the Downs 1998 checklist.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies using the Downs 1998 checklist.

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Risk of bias summary: review authors' judgements about each risk of bias item for included studies.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for included studies.

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Comparison 1 CREW intervention vs no intervention, Outcome 1 Self‐reported civility.
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Analysis 1.1

Comparison 1 CREW intervention vs no intervention, Outcome 1 Self‐reported civility.

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Comparison 1 CREW intervention vs no intervention, Outcome 2 Self‐reported co‐worker incivility.
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Analysis 1.2

Comparison 1 CREW intervention vs no intervention, Outcome 2 Self‐reported co‐worker incivility.

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Comparison 1 CREW intervention vs no intervention, Outcome 3 Self‐reported supervisor incivility.
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Analysis 1.3

Comparison 1 CREW intervention vs no intervention, Outcome 3 Self‐reported supervisor incivility.

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Comparison 1 CREW intervention vs no intervention, Outcome 4 Self‐reported frequency of incivility perpetration.
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Analysis 1.4

Comparison 1 CREW intervention vs no intervention, Outcome 4 Self‐reported frequency of incivility perpetration.

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Comparison 1 CREW intervention vs no intervention, Outcome 5 Self‐reported absenteeism in previous month.
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Analysis 1.5

Comparison 1 CREW intervention vs no intervention, Outcome 5 Self‐reported absenteeism in previous month.

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Comparison 2 Expressive writing vs. control writing, Outcome 1 Incivility victimisation (25th percentile pre‐test).
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Analysis 2.1

Comparison 2 Expressive writing vs. control writing, Outcome 1 Incivility victimisation (25th percentile pre‐test).

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Comparison 2 Expressive writing vs. control writing, Outcome 2 Incivility victimisation (50th percentile pre‐test).
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Analysis 2.2

Comparison 2 Expressive writing vs. control writing, Outcome 2 Incivility victimisation (50th percentile pre‐test).

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Comparison 2 Expressive writing vs. control writing, Outcome 3 Incivility victimisation (75th percentile pre‐test).
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Analysis 2.3

Comparison 2 Expressive writing vs. control writing, Outcome 3 Incivility victimisation (75th percentile pre‐test).

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Comparison 2 Expressive writing vs. control writing, Outcome 4 Incivility victimisation (pooled).
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Analysis 2.4

Comparison 2 Expressive writing vs. control writing, Outcome 4 Incivility victimisation (pooled).

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Comparison 2 Expressive writing vs. control writing, Outcome 5 Incivility perpetration.
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Analysis 2.5

Comparison 2 Expressive writing vs. control writing, Outcome 5 Incivility perpetration.

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Comparison 3 Cognitive Behavioural intervention vs. no intervention, Outcome 1 Victimisation.
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Analysis 3.1

Comparison 3 Cognitive Behavioural intervention vs. no intervention, Outcome 1 Victimisation.

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Comparison 3 Cognitive Behavioural intervention vs. no intervention, Outcome 2 Perpetration.
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Analysis 3.2

Comparison 3 Cognitive Behavioural intervention vs. no intervention, Outcome 2 Perpetration.

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Summary of findings for the main comparison. Organisational level workplace culture intervention versus no intervention

Controlled before and after study

Patient or population: Employees
Setting: Workplaces in US and Canada
Intervention: CREW: complex group‐based, at the organisational level
Comparison: no intervention

Outcomes

Absolute effects*

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with no intervention

Risk with CREW (95% CI)

Self‐reported workplace civility, on a scale of 1 to 5; higher score more civility
Follow‐up: 6 to 12 months

Mean civility score was 3.58 points

Mean civility score was 0.17 higher (0.07 higher to 0.28 higher)

2969
(2 studies)

⊕⊝⊝⊝1
VERY LOW

Self‐reported co‐worker incivility, on a scale of 0 to 6; higher score more frequent incivility

Follow‐up: 6 months

Mean coworker incivility score was 0.76 points

Mean co‐worker incivility score was 0.08 lower (0.22 lower to 0.06 higher)

907
(1study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported supervisor incivility, on a scale of 0 to 6; higher score more frequent incivility

Follow‐up: 6 months

Mean supervisor incivility score was 0.57 points

Mean supervisor incivility score was 0.17 lower (0.33 lower to 0.01 lower)

907
(1 study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported frequency of incivility instigation, on a scale of 0 (never) ‐ 6 (daily) **; higher score more frequent incivility

Follow‐up: 6 months

Mean incivility instigation score was 0.50

Mean incivility instigation score was 0.05 lower (0.15 lower to 0.05 higher)

907
(1 study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported days of absenteeism in previous month. Follow‐up: 6 months

Mean absenteeism in previous month was 0.83 days

Mean absenteeism in previous month was 0.63 days lower (0.92 lower to 0.34 lower)

907
(1 study)

⊕⊝⊝⊝1
VERY LOW

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
** 0‐6 scale confirmed by email correspondence from author
CI: Confidence interval.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 We would have downgraded the quality of evidence twice due to high risk of bias caused by study limitations (lack of randomisation and blinding, and use of self‐reporting instrument) and once due to imprecision (limited sample available for outcome measurement, limited matching pre‐ and post intervention). However, once was enough to reach very low quality evidence as we started at low quality evidence because the included studies used a controlled before‐after design. We found no reason to upgrade the quality of the evidence.

Figuras y tablas -
Summary of findings for the main comparison. Organisational level workplace culture intervention versus no intervention
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Summary of findings 2. Multilevel educational intervention versus no intervention

Five‐arm cluster randomised trial

Patient or population: employees
Setting: workplaces in several locations in the UK
Intervention: education and policy development, at organisational level
Comparison: no education

Outcomes

Effect of the intervention

№ of participants
(studies)

Quality of the evidence
(GRADE)

Bullying
assessed with: Self report
Follow up: mean 6 months

Insufficient data reported for analysis

1041

(1 study)

⊕⊝⊝⊝
VERY LOW 1

Absenteeism
assessed with: organisational data

Insufficient data reported for analysis

1041

(1 study)

⊕⊝⊝⊝
VERY LOW 1

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 We would have downgraded the quality of evidence once due to high risk of bias caused by study limitations (lack of blinding and use of self‐reporting instrument) and twice due to imprecision (study conducted in mixed settings and with unclear number of participants). However, once was enough to reach very low quality evidence as we started at low quality evidence because the included studies used a controlled before‐after design. We found no reason to upgrade the quality of the evidence.

Figuras y tablas -
Summary of findings 2. Multilevel educational intervention versus no intervention
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Summary of findings 3. Individual level expressive‐writing versus control‐writing

Controlled before and after study

Patient or population: employees
Setting: New South Wales and Queensland, Australia
Intervention: expressive writing, at the individual level
Comparison: control writing

Outcomes

Absolute effects* (95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with Control writing

Risk with Expressive‐Writing

Self‐reported frequency of incivility victimisation.
Follow up: 2 weeks

Mean number of incivility victimisations was 26

Mean incivility victimisation in the intervention group was 3.3 fewer occurrences (5.4 fewer to 1.2 fewer)

46
(1 study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported frequency of incivility perpetration.
Follow up: 2 weeks

Mean number of incivility perpetrations was 23

Mean incivility perpetration in the intervention group was 3.5 fewer occurrences (6.2 fewer to 0.8 fewer)

46
(1 study)

⊕⊝⊝⊝1
VERY LOW

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1. We would have downgraded the quality of evidence twice due to high risk of bias caused by study limitations (lack of randomisation and blinding, and use of self‐reporting instrument) and once due to imprecision (small sample size). However once was enough to reach very low quality evidence as we started at low quality evidence because the included studies used a controlled before‐after design. We found no reason to upgrade the quality of the evidence.

Figuras y tablas -
Summary of findings 3. Individual level expressive‐writing versus control‐writing
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Summary of findings 4. Individual level cognitive behavioural intervention versus no intervention

Controlled before and after study

Patient or population: Adult workers with a learning disability
Setting: three work centres in South West Ireland
Intervention: cognitive behavioural intervention, at the individual level
Comparison: waiting‐list control (i.e. no treatment)

Outcomes

Absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with no intervention

(Waiting‐list control)

Risk with cognitive

behavioural intervention

Self‐reported victimisation.
Post intervention.

39 per 100

(18 to 64)

21 per 100

(11 to 37)

RR 0.55

(0.24 to 1.25)

60
(1 study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported victimisation.
Three‐month follow‐up.

39 per 100

(18 to 64)

19 per 100

(9.1 to 35)

RR 0.49

(0.21 to 1.15)

60
(1 study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported perpetration.

Post intervention.

33 per 100

(14 to 59)

21 per 100

(11 to 37)

RR 0.64

(0.27 to 1.54)

60
(1 study)

⊕⊝⊝⊝1
VERY LOW

Self‐reported perpetration.

Three‐month follow‐up.

28 per 100

(11 to 54)

17 per 100

(7.5 to 32)

RR 0.69

(0.26 to 1.81)

60
(1 study)

⊕⊝⊝⊝1
VERY LOW

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group Grades of Evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1. We would have downgraded the quality of evidence twice due to high risk of bias caused by study limitations (lack of randomisation and blinding, and use of self‐reporting instrument) and once due to imprecision (small sample size). However, once was enough to reach very low quality evidence as we started at low quality evidence because the included studies used a controlled before‐after design. We found no reason to upgrade the quality of the evidence.

Figuras y tablas -
Summary of findings 4. Individual level cognitive behavioural intervention versus no intervention
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Comparison 1. CREW intervention vs no intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Self‐reported civility Show forest plot

2

Mean Difference (Random, 95% CI)

0.17 [0.07, 0.28]

2 Self‐reported co‐worker incivility Show forest plot

1

Mean Difference (Random, 95% CI)

Totals not selected

3 Self‐reported supervisor incivility Show forest plot

1

Mean Difference (Random, 95% CI)

Totals not selected

4 Self‐reported frequency of incivility perpetration Show forest plot

1

Mean Difference (Random, 95% CI)

Totals not selected

5 Self‐reported absenteeism in previous month Show forest plot

1

Mean Difference (Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 1. CREW intervention vs no intervention
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Comparison 2. Expressive writing vs. control writing

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incivility victimisation (25th percentile pre‐test) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Incivility victimisation (50th percentile pre‐test) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

3 Incivility victimisation (75th percentile pre‐test) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

4 Incivility victimisation (pooled) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

5 Incivility perpetration Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 2. Expressive writing vs. control writing
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Comparison 3. Cognitive Behavioural intervention vs. no intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Victimisation Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.1 Pre‐intervention

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Post‐intervention

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Follow‐up at three months

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Perpetration Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1 Pre‐intervention

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Post‐intervention

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 Follow‐up at three months

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 3. Cognitive Behavioural intervention vs. no intervention
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