By Crystal Tillman Harris, RN, MSN, CPNP IN

. laws prevent other types of 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 . about the impact of incivility, and lateral violence, horizontal violence, According to Zolby (2007) many of strategies to promote a culture of or simply what it us are affected by / really is -“.” Many nurses know bullying: . 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 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 . 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 stress alone crossing and walking away - the kind of involved. If incivility is left unaddressed, due to incivility at US 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, , and such as stress, anxiety, exhaustion, personal categories such as race, religion, are more apparent and most reported sleeplessness, , anger, and gender or disability. However, no in media. However, as shown in the

Nursing 16 Bulletin { Official Publication of the N o r t h C a r o l i 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 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 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 “” organizational trust and . 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 (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 and enhance • using , 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 , disrespect, or • undermining of work occurring. The behavior needs to be threatening action will not be tolerated. • 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 o r t h C a r o l i 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 may leave one position, only to wreak target of incivility, then it is important havoc someplace else. Their perception INDIVIDUAL LEVEL to document when each incident occurs. truly becomes their reality. Incivility can It is always best if you can come Write down the date and time of the become the norm for a workplace, which to a resolution between you and the incident, along with the details of the makes it harder to change. Dealing person exhibiting incivility. Start out interaction. Continue doing this until with the behavior in a timely manner, by describing how the behavior makes you see a pattern emerge. A single will prevent incivility from becoming you feel. Sometimes dealing directly incident may not get attention, but the norm. Once incivility is allowed to with the person might not be an option. a pattern of behavior will have to be become the norm, it takes time to get Take a time out and walk away from the addressed. Consider copying any letters, the workplace back to a positive, healthy situation whenever you cannot discuss memos or emails that have a bullying or environment. Most experts agree that the behavior and come to a resolution. rude tone to them. As nurses we know it takes 2-5 years for an organization to An objective third party may need to be the importance of documentation. change its culture. involved. Don’t try to speak and defend Set up a meeting with a human Policies are a must to prevent and/ yourself unless you feel it is absolutely resources representative or someone or improve incivility. A code of conduct necessary. Doing so may encourage the who is higher in the organization than is necessary to describe the behaviors incivility. The bully is looking for you the uncivil person. Only do this after that are considered disruptive. The to add fuel to the fire - do not give him you have established a documented code needs to address all employees or her satisfaction. Practice some slow pattern of behavior. Ask people who in an organization such as nurses, and relaxation breathing and put things into have witnessed the behavior to stand up nonemployees such as providers. In order perspective. If worries start to build up, for you. If they agree, give their names for a code of conduct to be effective, it do not hesitate in seeking professional to your nurse leader or human resources must be applied in all circumstances. counseling. Many have representative, along with the evidence Leadership needs to be not only employee assistance programs available you have collected. There is power in involved in the process, but committed to you. numbers and those not directly involved to modeling civility and reinforcing its Role modeling and showing great offer an objective perspective. importance. Without this enforcement, 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

Nursing 18 Bulletin ...... NC the code is useless. All team members, to gather data quickly, sort out the facts, relaxed health care providers is improved. including leadership, need to be and take action when necessary. It is also Our shared goal should be the accountable for modeling and enforcing important to conduct post-departure creation of a safe, respectful place the code of conduct. interviews, not at the time an employee for nurses to practice. Nurses can be Equally important is addressing leaves, but several weeks after leaving. ambassadors and leaders for change. incidents and complaints in a timely This will give you a better picture as With more than 3 million nurses in manner, and taking corrective action to what other factors may have been the US, no other licensed healthcare so employees see it is not condoned or involved in the employee leaving his or profession has the potential power that tolerated. Nurse leaders need to set the her position. nurses hold as a group. It is important tone and expectations for the type of It is important to sustain the for us to agree upon and unite behind professional interactions that will occur new culture by encouraging open common expectations for how we are in the workplace. Words can be typed communication so that civility treated and how we treat others… in a mission statement, but the truth is becomes the norm. Nurse leaders need we have the ability to change our that nurses and students will model the to guide responsibly and create a safe workplace. behaviors they observe and experience environment so nurses are not fearful As Dr. Clark stated at the NC Board from their nurse leaders and faculty. when sharing concerns or reporting of Nursing 2011 Education Summit If my nurse leader does not “walk the incidents. Nurse leaders also need to “Choosing civility is important and the talk,” I am going to ignore the rules and promote constructive and open feedback right thing to do.” do what I know I can get away with. so nurses learn how to demonstrate We all drift occasionally and that is respect and common courtesy. It is REFLECTION QUESTIONS human nature. However as nurses, we important to be accepting of each other’s Scenario #1: are ultimately accountable for our own ideas and opinions. You are a new professional behaviors. Nursing education programs need practicing on a medical unit. There is a Education is the key to helping to include incivility topics in the colleague that has been on the unit for others. Some health care settings are curriculum. It is also helpful to have seven years. One day after orientation seeking to educate nurses on how to students role play various situations. It you hear her grumbling that “you need improve social interactions, enact has been found that new graduates are to pick up your pace; you are not pulling proper business , and foster able to handle uncivil behaviors in a your weight.” How might you handle positive people skills in the workplace more appropriate manner, with the use this situation? environment. Some people may not of role play. A direct approach is to acknowledge realize they exhibit uncivil behavior. the offensive behavior head-on without Many people believe this is “not about WRAPPING IT ALL UP offering excuses or opinions. You might me.” Many times people lack insight or Kupperschmidt (2006) talks about say, “You criticize me a lot about my self-awareness, and have no idea how to the term care-fronting in nursing. pace, and it distracts me from caring for change behavior that may be ingrained. It is when nurses care enough about my patients. I want you to stop making Educating everyone on the new policies themselves and their patients to these comments so that I can focus on will help create an open, friendly and confront uncivil behavior face-to-face my patients.” Confrontation can be accepting environment. It may be immediately, directly, and respectfully challenging, but it often puts an end to necessary to provide and to foster mutual respect. One question the problem by directly addressing the mentoring as needed to help improve we should all ask ourselves: What if offensive behavior. the behaviors of others. nurses respected ourselves as much as we There should be a zero tolerance respect our patients? It is up to each one Scenario #2: for incivility. It is important for all of of us to take care of ourselves and others. You are sitting with several other us to teach civility and educate others As Forni stated, “encouraging civility colleagues catching-up on charting for to recognize and respond to incivility. in the workplace is becoming one of the day. One of your colleagues starts Nurse leaders must take complaints the fundamental corporate goals in our gossiping and slamming another one of seriously and not shoot the messenger. It diverse, hurried, stressed and litigation- your colleagues. How might you handle takes great courage to report incivility. prone society.” A civil workplace is this situation? Do not make excuses such as “that is just good for health care providers, since our If someone is gossiping and slamming the way she is, but you will get used to quality of life is improved in such an your colleague, do not join in or give it” or “the unit cannot afford to lose him environment. But a civil workplace is also approval by saying nothing. Have the even though he creates tension on the good for the patients, since the quality of courage to say, “I do not feel right unit.” As a nurse leader it is important care they receive from happier and more talking about this behind his or her

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...... 19 <<< continued from page 19 NC back. Have you talked with him or Washington, D.C. her?” It is important to hold each other American Psychological Asso- accountable for our chosen behaviors. ciation (October 24, 2007). Stress in America. Retrieved from http://apahelp- Scenario #3: center.mediaroom.com/file.php/138/ EARN CE CREDIT You just came out of a patient’s room, Stress+in+America+REPORT+FINAL.doc Clark, C.M. (2011). Incivility Presenta- when suddenly you hear a provider INSTRUCTIONS screaming and yelling at one of your tion at the NC Board of Nursing Education Read the article and on-line reference colleagues. How might you handle this Summit, Chapel Hill, NC. documents (if applicable). There is not situation? Clark, C.M. & Springer, P.J. (2010). Aca- demic nurse leaders’ role in fostering a culture a test requirement, although reading for If you see someone being bullied, of civility in nursing education. Journal of do not stand by quietly or pretend you comprehension and self-assessment of Nursing Education, 49(6), 319-325. knowledge is encouraged. do not see it. Unless each nurse names Clark, C.M. (2010). Five-part series: uncivil behavior when it occurs, it Fostering civility in nursing education and RECEIVE CONTACT HOUR CERTIFICATE continues without any consequences. practice, Reflections on Nursing Leadership, The behavior exhibited by the provider 36(1), International. Go to www.ncbon.com and select is unprofessional, and should not be Clark, C.M. (2008). The dance of incivil- “Events, Workshops & Conferences”; then tolerated. One hospital uses a “code ity in nursing education as described by select “Board Sponsored Workshops”; under incivility” for each unit. When one of nursing faculty and students. ANS Advanced “Bulletin Articles”, scroll down to the link your colleagues is being bullied by another Nursing Science, 31(4), 37-54. “Incivility in Nursing.” Register, complete person, the rest of the nurses come and Dellasega, C. A. (2009). Bullying among and submit the , and print your stand by the nurse being bullied, without nurses. American Journal of Nursing, 109(1), certificate immediately. saying a word. This action is usually 52-58. Registration deadline is November 1, 2013 enough to stop the behavior of the uncivil Forni PM. The Civility Solution. New York, St. Martin’s Press, 2008. person, and draws attention to their PROVIDER ACCREDITATION inappropriate behavior. Joint Commission (July 2, 2009). Be- haviors that undermine a culture of safety. The North Carolina Board of Nursing will award 1.0 contact hours for this continuing Time for reflection: Retrieved August 10, 2009 from http://www. jointcommission.org/SentinelEvents/Sentine- nursing education activity. Remember a time when you have been leventalert/sea_40.htm The North Carolina Board of Nursing is bullied by a nursing faculty member, peer Kolanko, KM., Clark, C., Heinrich, KT., an Approved Provider of continuing nursing or someone in leadership. Olive, D., Serembus, JF., Sifford, KS. (2006). education by the North Carolina Nurses • How did the situation make you feel? Academic dishonesty, bullying, incivility, Association, an accredited approver by the • Did you experience any of the listed and violence: difficult challenges facing nurse American Nurses Credentialing Center’s feelings stated in the article? educators. Nursing Education Perspective, Commission on Accreditation. • How did you resolve the situation? January: 27 (1), 34-43. • Was it an assertive approach or did Kupperschmidt, BR. (2006.) Addressing NCBON CNE Contact Hour Activity you leave your position to get away multigenerational conflict: mutual respect from the incivility? and carefronting as strategy. Online Journal Disclosure Statement • How would you do things differently Issues in Nursing. May 31:11(2):4. The following disclosure applies to the now? Laschinger, H. K. S., & Leiter, M. (2006). NCBON continuing nursing education • How do you manage stress reduction The impact of nursing work environments on article entitled “Incivility in Nursing”: and taking care of yourself? patient safety outcomes: The mediating role Participants must read the CE article and of burnout/engagement. The Journal of Nurs- online reference documents (if applicable) FOR MORE INFORMATION ing Administration, 36(5), 259-267. in order to be awarded CNE contact hours. Cindy Clark, PhD, RN website: http:// Leiter, M. & Maslach, C. (2005). Banish- Verification of participation will be noted by nursing.boisestate.edu/civility/ ing Burnout. San Francisco: Jossey-Bass. online registration. No financial relationships Incivility in the College Classroom: http:// Lim, S., Cortina, L.M., & Magley, V.J. or commercial support have been disclosed www.crlt.umich.edu/tstrategies/Incivility.php (2008).Personal and workgroup incivility: by planners or writers which would influence P.M. Forni, PhD website: http://krieger.jhu. Impact on work and health outcomes. Journal edu/civility/background.html of , 3(1), 95-107. the planning of educational objectives Lower, J. (2007). Creating a culture of and content of the article. There is no BIBLIOGRAPHY civility in the workplace. American Nurse endorsement of any product by NCNA or American Nurses Association (2001). Today, 2 (9), 49-52. ANCC associated with the article. No article Code of ethics for nurses with interpretive Zolby (2007). America’s Debate. Re- information relates to products governed by statements. American Nurses Association: trieved from http://www.americasdebate.com the Food and Drug Administration.

Nursing 20 Bulletin { Official Publication of the N o r t h C a r o l i n a Board of Nursing } ......