Merriam-Webster’s dictionary (2018) defines incivility as “the quality or state of being uncivil or a rude or discourteous act”. It is an unfortunate fact that the majority of those that work in the medical field have either experienced or witnessed acts of incivility. Facilities and staff that experience acts of incivility are likely to have higher rates of anxiety, depression, burnout, absenteeism and high turnover rates (Klingberg et al., 2018). This paper will explore incivility and its effects on nursing.
A scenario related to incivility will be discussed as a means to discover strategies for creating a healthy environment and how family nurse practitioners can implement several of these strategies.
There are many forms and variations of incivility which can range from minor physical representations all the way up to full blown physical and psychological attacks. Some forms of incivility include eye-rolling, making disparaging remarks, or excluding and marginalizing others. Other forms that are not as easily recognizable include the following actions: “lack of actions, failing to share important information about a patient’s care, refusing to assist a coworker, or intentionally neglecting to acknowledge a coworker” (Clark & Kenski, 2017).
Some of the more extreme forms of incivility include bullying and public humiliation. No matter which end of the spectrum the victim is on, incivility can have devastating effects. Staff can experience anxiety, distress, sleep disturbance, panic attacks, low self-esteem, physical illness, feelings of isolation, reduced work performance, deteriorating relationships with family, friends and colleagues and even thoughts of suicide.
Facilities often have employees with low job satisfaction, degraded morale, and engagement and staff retention rates can be negatively affected (Mikaelian & Stanley, 2016).
When acts of uncivility are committed in any workplace it disturbs more than just the intended victim. The results of incivility in nursing can cause effects on the healthcare environment and patients as well. Healthcare facilities are especially susceptible to incivility and bullying. To identify these types of negative actions, one must understand the cause first.
Studies have shown there are four major factors that contribute to incivility, or bullying, in the nursing filed. These four main factors of bullying include “economy and workload, lack of interpersonal skills, lack of management skills, and other factors; generational differences and the hierarchical nature of nurses’ work” (Backer Condon, 2015). Hospitals and healthcare facilities have a higher rate of uncivil actions for a wide variety of reasons. “Staff is often required to respond to complex urgent medical issues with varying degrees of background information on the patient” (Klingberg et al., 2018). Staff in these facilities often contend with high levels of stress and work volume, long work hours, and a lack of communication and clarity between departments and specialty clinics (Klingberg et al., 2018). As nurses contend with stressors in these four areas, negative reactions can cause them to lash out at others with devastating consequences.
Consequences of bullying and uncivil actions can reach all levels of the healthcare environment. When a nurse or co-worker gets bullied it can cause poor mental and physical health, nurse burnout, nurse absenteeism, high turnover rate and lost productivity. (Smith, Morin, & Lake, 2017). Continuously dealing with these actions can cause depression and anxiety to those who fear contending with it on a daily basis. There can also be decreased therapeutic functioning in patient care, diminished team work and poor communication as well as negative impacts on critical thinking and procedural performance (Mikaelian & Stanley, 2016). As bullying continues, a hostile environment is created which is evident to nursing staff and effects patients as well.
Patient safety is the biggest factor affected by incivility. Patients have negative outcomes to include a correlation in an increase in falls, medication delays and errors. Between patient safety concerns and employee concerns, the facility itself, or microsystem work environment, faces consequences as well. Poor nurse performance and productivity costs the facility a great deal of money. Facilities also face high turn over rates and the continual cost of training new employees. With the increase in medication error, falls or other risks there are fines and/or lawsuits that must be paid. These costs and constant changes take a toll on the medical facility and its ability to function properly.
The unfortunate reality is that almost everyone in the healthcare field has dealt with incivility at least once in their career. As a new nurse I witnessed acts of uncivility or even outright bullying on a daily basis. Between senior nurses with-holding information from new nurses so “they could learn on their own” and outright belittling of those nurses it was hard to ignore. Many of us new nurses saw it as a form of hazing that everyone had to go through. I was usually able to ignore this behavior and continue with my tasks, but there was one time that a physician and nursing staff alike acted in a manner that made me almost retaliate against their actions. At the time I worked in the only emergency room for our city.
This emergency room always seems short staffed and has a high volume of patients as it is the only facility for a fairly large population. On this particular shift, my room assignments were the ones right next to the trauma bay rooms. This set of rooms was often difficult because we got the overflow of serious cases when the trauma rooms were filled. On this day the trauma rooms were almost full, and a patient presented in full cardiac arrest. Staff reacted appropriately and helped this nurse. As the code was winding down once the patient was stabilized and prepped for the cath lab, a new patient presented with Super ventricular tachycardia (SVT).
All the trauma rooms were taken so the patient was placed in one of my rooms. I called over the radio for assistance and was told by multiple nurses they were too busy to help. I repeatedly stated that I needed at least one person to help but got no response. While I was calling for help, I was getting the patient hooked up to the monitors and the defibrillator as a precaution since I knew Adenosine would be needed in this case. The doctor for the patient came to the room while I was trying my best to get the patient ready. He started yelling at me to move faster over and over again. Not once did he lay hands on the patient to try and help, but I was at least able to leave the patient with him long enough to pull medications. The whole situation was very frustrating and made me angry. The rest of the shift I had the above-mentioned reactions, I closed myself off to communication with others. I was not a very productive team member either. I did not actively seek to help others and only responded to radio calls for help. In the end, situations like this caused me to seek employment elsewhere. No one wants to continue working in an environment where the people you work with refuse to help you.
There are three major strategies for creating a healthful environment. These strategies include open communication, self-awareness and increased training. “Action should begin with the organization and manager followed by the individual nurse, because establishing a foundation for safe, open communication is critical to creating an atmosphere in which nurses feel free and empowered to speak up, especially concerning patient safety issues.” (Clark & Kenski, 2017). Once a nurse is comfortable in their environment they can begin to assess their own actions. This allows them to take personal accountability for themselves and encourages them to create and maintain interpersonal relationships with coworkers (Clark & Kenski, 2017). Managers are responsible for incorporating procedures, policies and training to staff which addresses incivility. They should then evaluate those staff adherence to those policies and procedures in annual reviews.
Transitioning to the field of family nurse practitioner (FNP) will require understanding which strategies will be most important to cultivating a healthful environment. I feel that self-awareness and communication will be most important to my practice. When moving to a new role, being self-aware of new responsibilities and changing interactions with peers, subordinates and outside resources is paramount. “Collaboration and consultation are concepts embedded in the practice standards of the nurse practitioner’s (NP) practice.” (Heale, Dickieson, Carter, & Wenghofer, 2013). An FNP must have effective communication for successful collaboration. As I take on the role of an FNP, I will be responsible for promoting change in quality of care, promoting excellence through lifelong learning, and implementing best practice policies based on evidence-based practice. In many environments I will be taking on more leadership responsibilities. As such, I will be responsible for monitoring for instances of incivility, re-educating those who perpetrate those actions, and training others in recognition and prevention. I may also be responsible for various annual reviews of subordinates, which would reflect any instances of uncivil behaviors.
In today’s healthcare environment actions of incivility can be crippling to any organization. This inappropriate behavior not only negatively affects employees, but it compromises patient safety as well. Strategies to cultivate a healthful environment can help combat the negative effects of incivility. Opening lines of communication creates an environment of trust and builds relationships within the healthcare team. As an FNP, acting as a team lead who participates in and promotes training programs can help create awareness of this growing issue in our healthcare system.