By Crystal Tillman Harris, RN, MSN, CPNP INCIVILITY IN NURSING embarrassment. laws prevent other types of workplace Purpose: Searching the literature will produce incivility, unless it verges on mental or To provide nurses with information numerous articles with terms such as: physical abuse. about the impact of incivility, and lateral violence, horizontal violence, According to Zolby (2007) many of strategies to promote a culture of relational aggression or simply what it us are affected by workplace incivility/ really is -“bullying.” Many nurses know bullying: civility. colleagues, nursing faculty or nursing • 37% US workers directly leaders who practice incivility. People experienced bullying Objectives: After reading this who engage in incivility use abnormal, • 12% witnessed bullying article and on-line references, the aggressive behaviors to gain control and • 45% had their health affected due to nurse should be able to: power. Unfortunately, these people have stress from bullying not developed healthy coping behaviors • 3% file lawsuits related to bullying 1. Describe the impact of incivility and/or skills in their relationships with • 40% experience bullying but never on nursing practice, patients, others. complain and health care settings. Incivility occurs in groups or Dr. P. M. Forni is the co-founder of the 2. Identify the range of behaviors individual interactions. Listed are some Johns Hopkins Civility Project, author of associated with incivility. various incivility combinations which are Choosing Civility, and also a leader in in- possible: civility research. As Forni (2008) stated, 3. Discuss strategies to promote • provider or management bullying a “incivility often occurs when people are a culture of civility in nursing nurse stressed, unhappy, or rushed. When these practice. • nurse bullying another nurse coincide, anything can happen. Incivil- • nurse bullying a patient ity erodes self-esteem, damages relation- • patient bullying a nurse ships, increases stress, contaminates the • nursing faculty bullying a student work environment, and may escalate into WHAT EXACTLY IS INCIVILITY? violence.” It is important to note that Incivility is one term used to THE IMPACT OF INCIVILITY many times the person exhibiting the describe rude, disruptive, intimidating, Incivility wreaks havoc on nurses’ uncivil behavior is unaware of how his and undesirable behaviors that are relationships and workplace morale, as or her behavior, words or actions may be directed toward another person (Clark, well as the bottom line - patient safety. affecting others. 2011). Incivility is any action that is Incivility is far more widespread than According to Clark, uncivil behaviors offensive, intimidating, or hostile that most of us realize, and incivility in health exist along a continuum ranging from interferes with the learning or practice care settings has devastating effects. disruptive behaviors on one end, to environment. Although incivility has Being a victim of incivility is also threatening behaviors on the other (See always been around, incivility seems to be costly to organizations. Nurses put in less Figure 1). The graph illustrates that an increasing problem for organizations effort, produce lower quality, and can incivility at the left end of the scale and is getting worse. even burn out. According to Banishing can be expressed by some fairly subtle Incivility often results in psychological Burnout by M. Leiter and C. Maslach behaviors such as eye-rolling, arm- or physiological distress for the people (2005), the annual cost of job stress alone crossing and walking away - the kind of involved. If incivility is left unaddressed, due to incivility at US corporations is actions that nurses often excuse by saying, it may progress into more threatening $300 billion. Incivility is a major cause of “so and so is having a bad day.” situations or behaviors. Victims of workplace frustration and stress. Overt expressions of incivility, such incivility may experience symptoms Incivility is illegal if based on protected as bullying, taunting, and intimidation such as stress, anxiety, exhaustion, personal categories such as race, religion, are more apparent and most reported sleeplessness, depression, anger, and gender or disability. However, no in media. However, as shown in the NURSING 16 BULLETIN { Official Publication of the N ORTH C AROLI N A Board of Nursing } . NC Continuum of Incivility graphic, this can • sarcasm behavior has probably been reported by begin in what appears to be a relatively • destroying confidence another nurse. benign manner, with behaviors such • losing one’s temper or yelling at Incivility also occurs with student nurses as sarcastic comments or dominating someone by nurses in practice and nursing faculty. conversation in a group. It is essential • continual criticism It results in students having decreased to any organization to recognize • encouraging others to turn against a confidence, anger, frustration, sleeplessness, the behaviors at the left end of the co-worker anxiety, stress and worry. When student continuum, to name them, and ultimately The effects of incivility take a toll nurses are subjected to bullying by nurses address them to prevent more aggressive on all of us. It erodes our self-esteem in practice, they are more apt to emulate acts of anger or violence from occurring. by wearing down our mental defenses. the behaviors and engage in bullying During the NC Board of Nursing 2011 When we feel vulnerable, there is an activities themselves. Modeling of expected Education Summit, Dr. Cindy Clark increase in anxiety, which can lead to professional behaviors is the responsibility of stated, “Bullying is allowed to occur for resentment and anger. It also damages each nurse. 3 reasons: because it can; because it is our relationships by causing feelings of modeled; because it is left unchecked.” failure, isolation and loss. It also increases NURSING PROFESSIONALISM stress, which weakens the immune system, The Essentials of Baccalaureate WHAT DOES INCIVILITY LOOK LIKE? causes wear and tear on the body, spirit Education for Professional Nursing As Clark stated in the incivility and soul. Even worse the effects can lead Practice (2008) states that inherent in continuum, there are a range of uncivil to depression and post-traumatic stress professionalism is accountability and behaviors. Dellasega (2009) came up with disorder (PTSD). It also contaminates responsibility for individual actions and common uncivil behaviors which include: the workplace by lowering morale, behaviors, including civility. Civility must • using the “silent treatment” organizational trust and job satisfaction. be present for professionalism to occur. • spreading rumors Nurse leaders can be in a difficult The American Nurses Association • rude or obnoxious behavior situation too. For nurses in a leadership (ANA) Nursing Code of Ethics (2001) • badgering or back-stabbing role, to remain silent is to condone states the nurse at all times maintains • sabotaging a project the behavior. If leadership accepts the standards of personal conduct which • damaging someone’s reputation behavior, it makes it harder for others reflect well on the profession and enhance • using humiliation, put-downs, and to report the same type of behavior. public confidence. Provision 1.5 requires intimidation The nurse may feel his or her leadership nurses to treat colleagues, students, and • failing to support a co-worker approves of the behavior. When in reality, patients with dignity and respect and that • setting up someone for failure leadership may not realize incivility is any form of harassment, disrespect, or • undermining of work occurring. The behavior needs to be threatening action will not be tolerated. • verbal abuse brought to the nurse leader’s attention The Joint Commission takes the • public reprimands for further action. Do not assume 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 Continuum of Incivility satisfaction, adverse outcomes, higher Distracting, Aggressive, costs, and loss of qualified staff. The Joint annoying, potentially Commission Sentinel Event Alert (July, irritating violent 2008) states that health care is a “high- behaviors behaviors stakes, pressure-packed environment Low Risk High Risk that can test the limits of civility in the workplace.” The rude, disruptive behavior Disruptive Behaviors Threatening Behaviors among health care professionals can pose a serious threat to patient safety and the Behaviors range from: overall quality of care. All health care settings need to create behavioral codes of eye-rolling sarcastic comments bullying taunting racial/ethnic slurs intimidation physical violence conduct and establish a formal process for Clark © 2009, revised 2011 managing unacceptable behavior. Figure 1. Continuum of incivility. Published with permission from Cynthia Clark. continued on page 18 >>> { Official Publication of the N ORTH C AROLI N A Board of Nursing } . .17 <<< continued from page 17 HOW TO DEAL WITH INCIVILITY ignoring co-workers concerns, thoughts ORGANIZATIONAL LEVEL So let us take a time-out and learn or input are all examples of more subtle Usually “bullies” never recognize their how to deal with incivility at an types of incivility. own behavior as being uncivil. They individual and organizational level. If you find you are becoming the