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Open in new tab By Crystal Tillman Harris, RN, MSN, CPNP
INCIVILITY
I N N Ur sI Ng
Purpose:
To provide nurses with information
about the impact of incivility, and
strategies to promote a culture of
civility.
Objectives: After reading this
article and on-line references, the
nurse should be able to:
1. Describe the impact of incivility
on nursing practice, patients,
and health care settings.
2. Identify the range of behaviors
associated with incivility.
3. Discuss strategies to promote
a culture of civility in nursing
practice.
WHAT EXACTLY IS INCIVILITY?
Incivility is one term used to
describe rude, disruptive, intimidating,
and undesirable behaviors that are
directed toward another person (Clark,
2011). Incivility is any action that is
offensive, intimidating, or hostile that
interferes with the learning or practice
environment. Although incivility has
always been around, incivility seems to be
an increasing problem for organizations
and is getting worse.
Incivility often results in psychological
or physiological distress for the people
involved. If incivility is left unaddressed,
it may progress into more threatening
situations or behaviors. Victims of
incivility may experience symptoms
such as stress, anxiety, exhaustion,
sleeplessness, depression, anger, and
embarrassment.
Searching the literature will produce
numerous articles with terms such as:
lateral violence, horizontal violence,
relational aggression or simply what it
really is -“bullying.” Many nurses know
colleagues, nursing faculty or nursing
leaders who practice incivility. People
who engage in incivility use abnormal,
aggressive behaviors to gain control and
power. Unfortunately, these people have
not developed healthy coping behaviors
and/or skills in their relationships with
others.
Incivility occurs in groups or
individual interactions. Listed are some
various incivility combinations which are
possible:
• provider or management bullying a
nurse
• nurse bullying another nurse
• nurse bullying a patient
• patient bullying a nurse
• nursing faculty bullying a student
THE IMPACT OF INCIVILITY
Incivility wreaks havoc on nurses’
relationships and workplace morale, as
well as the bottom line – patient safety.
Incivility is far more widespread than
most of us realize, and incivility in health
care settings has devastating effects.
Being a victim of incivility is also
costly to organizations. Nurses put in less
effort, produce lower quality, and can
even burn out. According to Banishing
Burnout by M. Leiter and C. Maslach
(2005), the annual cost of job stress alone
due to incivility at US corporations is
$300 billion. Incivility is a major cause of
workplace frustration and stress.
Incivility is illegal if based on protected
personal categories such as race, religion,
gender or disability. However, no
laws prevent other types of workplace
incivility, unless it verges on mental or
physical abuse.
According to Zolby (2007) many of
us are affected by workplace incivility/
bullying:
• 37% US workers directly
experienced bullying
• 12% witnessed bullying
• 45% had their health affected due to
stress from bullying
• 3% file lawsuits related to bullying
• 40% experience bullying but never
complain
Dr. P. M. Forni is the co-founder of the
Johns Hopkins Civility Project, author of
Choosing Civility, and also a leader in in-
civility research. As Forni (2008) stated,
“incivility often occurs when people are
stressed, unhappy, or rushed. When these
coincide, anything can happen. Incivil-
ity erodes self-esteem, damages relation-
ships, increases stress, contaminates the
work environment, and may escalate into
violence.” It is important to note that
many times the person exhibiting the
uncivil behavior is unaware of how his
or her behavior, words or actions may be
affecting others.
According to Clark, uncivil behaviors
exist along a continuum ranging from
disruptive behaviors on one end, to
threatening behaviors on the other (See
Figure 1). The graph illustrates that
incivility at the left end of the scale
can be expressed by some fairly subtle
behaviors such as eye-rolling, arm-
crossing and walking away – the kind of
actions that nurses often excuse by saying,
“so and so is having a bad day.”
Overt expressions of incivility, such
as bullying, taunting, and intimidation
are more apparent and most reported
in media. However, as shown in the
16
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{ Official Publication of the N o r t h C a r o l i N a B oard of Nu rsin g } . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Continuum of Incivility graphic, this can
begin in what appears to be a relatively
benign manner, with behaviors such
as sarcastic comments or dominating
conversation in a group. It is essential
to any organization to recognize
the behaviors at the left end of the
continuum, to name them, and ultimately
address them to prevent more aggressive
acts of anger or violence from occurring.
During the NC Board of Nursing 2011
Education Summit, Dr. Cindy Clark
stated, “Bullying is allowed to occur for
3 reasons: because it can; because it is
modeled; because it is left unchecked.”
WHAT DOES INCIVILITY LOOK LIKE?
As Clark stated in the incivility
continuum, there are a range of uncivil
behaviors. Dellasega (2009) came up with
common uncivil behaviors which include:
• using the “silent treatment”
• spreading rumors
• rude or obnoxious behavior
• badgering or back-stabbing
• sabotaging a project
• damaging someone’s reputation
• using humiliation, put-downs, and
intimidation
• failing to support a co-worker
• setting up someone for failure
• undermining of work
• verbal abuse
• public reprimands
• sarcasm
• destroying confidence
• losing one’s temper or yelling at
• continual criticism
• encouraging others to turn against a
someone
co-worker
The effects of incivility take a toll
on all of us. It erodes our self-esteem
by wearing down our mental defenses.
When we feel vulnerable, there is an
increase in anxiety, which can lead to
resentment and anger. It also damages
our relationships by causing feelings of
failure, isolation and loss. It also increases
stress, which weakens the immune system,
causes wear and tear on the body, spirit
and soul. Even worse the effects can lead
to depression and post-traumatic stress
disorder (PTSD). It also contaminates
the workplace by lowering morale,
organizational trust and job satisfaction.
Nurse leaders can be in a difficult
situation too. For nurses in a leadership
role, to remain silent is to condone
the behavior. If leadership accepts the
behavior, it makes it harder for others
to report the same type of behavior.
The nurse may feel his or her leadership
approves of the behavior. When in reality,
leadership may not realize incivility is
occurring. The behavior needs to be
brought to the nurse leader’s attention
for further action. Do not assume the
Continuum of Incivility
Distracting,
annoying,
irritating
behaviors
Low Risk
Disruptive Behaviors
Aggressive,
potentially
violent
behaviors
High Risk
Threatening Behaviors
Behaviors range from:
eye-rolling sarcastic comments bullying taunting racial/ethnic slurs intimidation physical violence
Clark © 2009, revised 2011
NC
behavior has probably been reported by
another nurse.
Incivility also occurs with student nurses
by nurses in practice and nursing faculty.
It results in students having decreased
confidence, anger, frustration, sleeplessness,
anxiety, stress and worry. When student
nurses are subjected to bullying by nurses
in practice, they are more apt to emulate
the behaviors and engage in bullying
activities themselves. Modeling of expected
professional behaviors is the responsibility of
each nurse.
NURSING PROFESSIONALISM
The Essentials of Baccalaureate
Education for Professional Nursing
Practice (2008) states that inherent in
professionalism is accountability and
responsibility for individual actions and
behaviors, including civility. Civility must
be present for professionalism to occur.
The American Nurses Association
(ANA) Nursing Code of Ethics (2001)
states the nurse at all times maintains
standards of personal conduct which
reflect well on the profession and enhance
public confidence. Provision 1.5 requires
nurses to treat colleagues, students, and
patients with dignity and respect and that
any form of harassment, disrespect, or
threatening action will not be tolerated.
The Joint Commission takes the
position that incivility is a safety issue,
and issued a standard on intimidating
and disruptive behaviors at work. The
Joint Commission cited concerns about
increased medical errors, poor patient
satisfaction, adverse outcomes, higher
costs, and loss of qualified staff. The Joint
Commission Sentinel Event Alert (July,
2008) states that health care is a “high-
stakes, pressure-packed environment
that can test the limits of civility in the
workplace.” The rude, disruptive behavior
among health care professionals can pose
a serious threat to patient safety and the
overall quality of care. All health care
settings need to create behavioral codes of
conduct and establish a formal process for
managing unacceptable behavior.
{ Offi ci al P ubli cati on of the N o r t h C a r o l i N a Bo ard of N urs ing } . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure 1. Continuum of incivility. Published with permission from Cynthia Clark.
continued on page 18 >>>
ignoring co-workers concerns, thoughts
or input are all examples of more subtle
types of incivility.
If you find you are becoming the
target of incivility, then it is important
to document when each incident occurs.
Write down the date and time of the
incident, along with the details of the
interaction. Continue doing this until
you see a pattern emerge. A single
incident may not get attention, but
a pattern of behavior will have to be
addressed. Consider copying any letters,
memos or emails that have a bullying or
rude tone to them. As nurses we know
the importance of documentation.
Set up a meeting with a human
resources representative or someone
who is higher in the organization than
the uncivil person. Only do this after
you have established a documented
pattern of behavior. Ask people who
have witnessed the behavior to stand up
for you. If they agree, give their names
to your nurse leader or human resources
representative, along with the evidence
you have collected. There is power in
numbers and those not directly involved
offer an objective perspective.
ORGANIZATIONAL LEVEL
Usually “bullies” never recognize their
own behavior as being uncivil. They
may leave one position, only to wreak
havoc someplace else. Their perception
truly becomes their reality. Incivility can
become the norm for a workplace, which
makes it harder to change. Dealing
with the behavior in a timely manner,
will prevent incivility from becoming
the norm. Once incivility is allowed to
become the norm, it takes time to get
the workplace back to a positive, healthy
environment. Most experts agree that
it takes 2-5 years for an organization to
change its culture.
Policies are a must to prevent and/
or improve incivility. A code of conduct
is necessary to describe the behaviors
that are considered disruptive. The
code needs to address all employees
in an organization such as nurses, and
nonemployees such as providers. In order
for a code of conduct to be effective, it
must be applied in all circumstances.
Leadership needs to be not only
involved in the process, but committed
to modeling civility and reinforcing its
importance. Without this enforcement,
<<< continued from page 17 HOW TO DEAL WITH INCIVILITY So let us take a time-out and learn how to deal with incivility at an individual and organizational level. INDIVIDUAL LEVEL It is always best if you can come to a resolution between you and the person exhibiting incivility. Start out by describing how the behavior makes you feel. Sometimes dealing directly with the person might not be an option. Take a time out and walk away from the situation whenever you cannot discuss the behavior and come to a resolution. An objective third party may need to be involved. Don’t try to speak and defend yourself unless you feel it is absolutely necessary. Doing so may encourage the incivility. The bully is looking for you to add fuel to the fire - do not give him or her satisfaction. Practice some slow relaxation breathing and put things into perspective. If worries start to build up, do not hesitate in seeking professional counseling. Many workplaces have employee assistance programs available to you. Role modeling and showing great passion for the nursing profession is important, as well as mentoring other nurses. Colleagues disagree with each other at times, but it is important to maintain respect for each other. Respect is basic to communicating with others on a daily basis. Experienced nurses can model how to confront others in a positive, constructive manner. Remember, none of us start out to become marginal or mediocre nurses. We work very hard to become highly proficient and expert nurses (Clark, 2010). Incivility can be difficult to determine from the small, subtle acts that many people experience. Sometimes we even question ourselves. Is our perception correct of the other person’s behavior? Incivility can take us off guard, because we simply are not expecting the behavior to occur. Little things such as showing up late to meetings, texting or checking emails during meetings, dismissing or 18 NursiNg B NursiNg Bulletin ulletin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NC the code is useless. All team members, including leadership, need to be accountable for modeling and enforcing the code of conduct. Equally important is addressing incidents and complaints in a timely manner, and taking corrective action so employees see it is not condoned or tolerated. Nurse leaders need to set the tone and expectations for the type of professional interactions that will occur in the workplace. Words can be typed in a mission statement, but the truth is that nurses and students will model the behaviors they observe and experience from their nurse leaders and faculty. If my nurse leader does not “walk the talk,” I am going to ignore the rules and do what I know I can get away with. We all drift occasionally and that is human nature. However as nurses, we are ultimately accountable for our own professional behaviors. Education is the key to helping others. Some health care settings are seeking to educate nurses on how to improve social interactions, enact proper business etiquette, and foster positive people skills in the workplace environment. Some people may not realize they exhibit uncivil behavior. Many people believe this is “not about me.” Many times people lack insight or self-awareness, and have no idea how to change behavior that may be ingrained. Educating everyone on the new policies will help create an open, friendly and accepting environment. It may be necessary to provide coaching and mentoring as needed to help improve the behaviors of others. There should be a zero tolerance for incivility. It is important for all of us to teach civility and educate others to recognize and respond to incivility. Nurse leaders must take complaints seriously and not shoot the messenger. It takes great courage to report incivility. Do not make excuses such as “that is just the way she is, but you will get used to it” or “the unit cannot afford to lose him even though he creates tension on the unit.” As a nurse leader it is important to gather data quickly, sort out the facts, and take action when necessary. It is also important to conduct post-departure interviews, not at the time an employee leaves, but several weeks after leaving. This will give you a better picture as to what other factors may have been involved in the employee leaving his or her position. It is important to sustain the new culture by encouraging open communication so that civility becomes the norm. Nurse leaders need to guide responsibly and create a safe environment so nurses are not fearful when sharing concerns or reporting incidents. Nurse leaders also need to promote constructive and open feedback so nurses learn how to demonstrate respect and common courtesy. It is important to be accepting of each other’s ideas and opinions. Nursing education programs need to include incivility topics in the curriculum. It is also helpful to have students role play various situations. It has been found that new graduates are able to handle uncivil behaviors in a more appropriate manner, with the use of role play. WRAPPING IT ALL UP Kupperschmidt (2006) talks about the term care-fronting in nursing. It is when nurses care enough about themselves and their patients to confront uncivil behavior face-to-face immediately, directly, and respectfully to foster mutual respect. One question we should all ask ourselves: What if nurses respected ourselves as much as we respect our patients? It is up to each one of us to take care of ourselves and others. As Forni stated, “encouraging civility in the workplace is becoming one of the fundamental corporate goals in our diverse, hurried, stressed and litigation- prone society.” A civil workplace is good for health care providers, since our quality of life is improved in such an environment. But a civil workplace is also good for the patients, since the quality of care they receive from happier and more relaxed health care providers is improved. Our shared goal should be the creation of a safe, respectful place for nurses to practice. Nurses can be ambassadors and leaders for change. With more than 3 million nurses in the US, no other licensed healthcare profession has the potential power that nurses hold as a group. It is important for us to agree upon and unite behind common expectations for how we are treated and how we treat others… we have the ability to change our workplace. As Dr. Clark stated at the NC Board of Nursing 2011 Education Summit “Choosing civility is important and the right thing to do.” REFLECTION QUESTIONS scenario #1: You are a new graduate nurse practicing on a medical unit. There is a colleague that has been on the unit for seven years. One day after orientation you hear her grumbling that “you need to pick up your pace; you are not pulling your weight.” How might you handle this situation? A direct approach is to acknowledge the offensive behavior head-on without offering excuses or opinions. You might say, “You criticize me a lot about my pace, and it distracts me from caring for my patients. I want you to stop making these comments so that I can focus on my patients.” Confrontation can be challenging, but it often puts an end to the problem by directly addressing the offensive behavior. scenario #2: You are sitting with several other colleagues catching-up on charting for the day. One of your colleagues starts gossiping and slamming another one of your colleagues. How might you handle this situation? If someone is gossiping and slamming your colleague, do not join in or give approval by saying nothing. Have the courage to say, “I do not feel right talking about this behind his or her continued on page 20 >>>
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<<< continued from page 19 back. Have you talked with him or her?” It is important to hold each other accountable for our chosen behaviors. scenario #3: You just came out of a patient’s room, when suddenly you hear a provider screaming and yelling at one of your colleagues. How might you handle this situation? If you see someone being bullied, do not stand by quietly or pretend you do not see it. Unless each nurse names uncivil behavior when it occurs, it continues without any consequences. The behavior exhibited by the provider is unprofessional, and should not be tolerated. One hospital uses a “code incivility” for each unit. When one of your colleagues is being bullied by another person, the rest of the nurses come and stand by the nurse being bullied, without saying a word. This action is usually enough to stop the behavior of the uncivil person, and draws attention to their inappropriate behavior. Time for reflection: Remember a time when you have been bullied by a nursing faculty member, peer or someone in leadership. • How did the situation make you feel? • Did you experience any of the listed feelings stated in the article? • How did you resolve the situation? • Was it an assertive approach or did you leave your position to get away from the incivility? • How would you do things differently now? • How do you manage stress reduction and taking care of yourself? FOr MOrE iNFOrMATiON Cindy Clark, PhD, RN website: http:// nursing.boisestate.edu/civility/ Incivility in the College Classroom: http:// www.crlt.umich.edu/tstrategies/Incivility.php P.M. Forni, PhD website: http://krieger.jhu. edu/civility/background.html BiBLiOgrAPHY American Nurses Association (2001). Code of ethics for nurses with interpretive statements. American Nurses Association: 20 NursiNg B NursiNg Bulletin ulletin Washington, D.C. American Psychological Asso- ciation (October 24, 2007). Stress in America. Retrieved from http://apahelp- center.mediaroom.com/file.php/138/ Stress+in+America+REPORT+FINAL.doc Clark, C.M. (2011). Incivility Presenta- tion at the NC Board of Nursing Education Summit, Chapel Hill, NC. Clark, C.M. & Springer, P.J. (2010). Aca- demic nurse leaders’ role in fostering a culture of civility in nursing education. Journal of Nursing Education, 49(6), 319-325. Clark, C.M. (2010). Five-part series: Fostering civility in nursing education and practice, Reflections on Nursing Leadership, 36(1), Sigma Theta Tau International. Clark, C.M. (2008). The dance of incivil- ity in nursing education as described by nursing faculty and students. ANS Advanced Nursing Science, 31(4), 37-54. Dellasega, C. A. (2009). Bullying among nurses. American Journal of Nursing, 109(1), 52-58. Forni PM. The Civility Solution. New York, St. Martin’s Press, 2008. Joint Commission (July 2, 2009). Be- haviors that undermine a culture of safety. Retrieved August 10, 2009 from http://www. jointcommission.org/SentinelEvents/Sentine- leventalert/sea_40.htm Kolanko, KM., Clark, C., Heinrich, KT., Olive, D., Serembus, JF., Sifford, KS. (2006). Academic dishonesty, bullying, incivility, and violence: difficult challenges facing nurse educators. Nursing Education Perspective, January: 27 (1), 34-43. Kupperschmidt, BR. (2006.) Addressing multigenerational conflict: mutual respect and carefronting as strategy. Online Journal Issues in Nursing. May 31:11(2):4. Laschinger, H. K. S., & Leiter, M. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/engagement. The Journal of Nurs- ing Administration, 36(5), 259-267. Leiter, M. & Maslach, C. (2005). Banish- ing Burnout. San Francisco: Jossey-Bass. Lim, S., Cortina, L.M., & Magley, V.J. (2008).Personal and workgroup incivility: Impact on work and health outcomes. Journal of Applied Psychology, 3(1), 95-107. Lower, J. (2007). Creating a culture of civility in the workplace. American Nurse Today, 2 (9), 49-52. Zolby (2007). America’s Debate. Re- trieved from http://www.americasdebate.com NC EARN CE CREDIT INSTRUCTIONS Read the article and on-line reference documents (if applicable). There is not a test requirement, although reading for comprehension and self-assessment of knowledge is encouraged. RECEIVE CONTACT HOUR CERTIFICATE Go to www.ncbon.com and select “Events, Workshops & Conferences”; then select “Board Sponsored Workshops”; under “Bulletin Articles”, scroll down to the link “Incivility in Nursing.” Register, complete and submit the evaluation, and print your certificate immediately. registration deadline is November 1, 2013 PROVIDER ACCREDITATION The North Carolina Board of Nursing will award 1.0 contact hours for this continuing nursing education activity. The North Carolina Board of Nursing is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. NCBON CNE Contact Hour Activity Disclosure statement The following disclosure applies to the NCBON continuing nursing education article entitled “Incivility in Nursing”: Participants must read the CE article and online reference documents (if applicable) in order to be awarded CNE contact hours. Verification of participation will be noted by online registration. No financial relationships or commercial support have been disclosed by planners or writers which would influence the planning of educational objectives and content of the article. There is no endorsement of any product by NCNA or ANCC associated with the article. No article information relates to products governed by the Food and Drug Administration. { Official Publication of the N o r t h C a r o l i N a B oard of Nu rsin g } . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .