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Witt, Catherine L. MS, NNP-BC

doi: 10.1097/ANC.0b013e31828005df
Letter From the Editor

The author declares no conflicts of interest.



Speak not injurious words neither in jest nor earnest. Scoff at none although they give occasion.

George Washington1

Is society becoming less civil? It would certainly appear so. Decrease in civility in the media, in social networking, and on the road is readily apparent. We cheer for unsportsman like behavior in professional sports. We reward the talk show host who can be the most aggressive and insulting to those we disagree with. It seems that it has become acceptable to say almost anything. This might not be new. After all, even George Washington wrote a list of rules of etiquette to live by. Old or new, incivility at work and life in general seems to be prevalent.

A number of articles speak of the problem of incivility in nursing education, both in the classroom and in the clinical arena.2,3 Problems described include aggressive or hostile remarks, talking in class, coming late or leaving early, gossip about faculty or other students, and inability to work together with classmates. In the clinical setting, problems with students, faculty, and staff nurses were described, creating a stressful and possibly unsafe environment. After students graduate from this environment, is it any surprise that the problem continues into the work setting?

This month we have included a manuscript on horizontal hostility, the creating of a hostile work environment by nurses and other health care workers. In addition to creating enormous stress for those the hostility is directed at as well as those who witness the hostility, it can create an unsafe atmosphere for patients. Stress and frustration can lead to lack of concentration, inability or unwillingness to ask for help, and decreased sharing of information, all of which can lead to increased errors and decreased patient safety.

Workplace bullying by nurses has often been described as a reaction to oppression. The theory is that nurses, being an oppressed group, have low self-esteem, thereby directing their feelings of hostility toward others or themselves.4 However, some studies have suggested that in fact, nurses who are most likely to display hostile behavior to others are popular and influential individuals and are often the “informal leaders” in a unit.4 This is like adolescent bullying behavior, where those who are socially popular or leaders may be the most likely to bully those with less social standing. Most bullies are actually intelligent and articulate and have great influence over others.

This author describes workplace bullying as a process that begins subtly and progresses until it appears to be normal or acceptable within a workplace or culture.4 Gossip, exclusion, and undermining may happen and are most often initiated by those with informal leadership in a group. This can progress to “persuading” or convincing the rest of the group that what the leader says about the victim is true. This leads to rationalizing the behavior, where the bullying begins to be seen as deserved or permissible, as if the victim deserves to be ostracized or treated badly. It may be presented as if the person is incompetent or different in some way. After a while, this becomes normal, and others either participate in the bullying behavior or stand by and allow it to continue.4 Disparaging comments about other's competence, excluding them from social activities, refusal to help with tasks, and gossip become the norm. When thinking of the bully as an informal leader, or at the top of the social hierarchy, is it any wonder that many bystanders fail to act? To act puts one at risk of becoming a target; participating makes one part of the group.

How can we change this culture? If we continue to see ourselves as victims, responding to victim status by victimizing others, there is not much room for progress. We cannot hope, as a profession to stand up for ourselves to outside influences if we cannot stand up for ourselves and our coworkers within our own profession. So how do we manage this behavior? We must first recognize that one bully by themselves could not do much if the rest of us did not support them, allow their behavior, and then exacerbate it by participating ourselves. One study showed that only 1 in 10 health care workers confronted disruptive behavior, whether it came from coworkers, physicians, or others.5 While policies that prohibit disruptive behavior are important, they are most likely to work against outright verbal or physical aggression. They are less effective against subtle behavior that is not readily noticeable by managers. It is much more difficult to prove incidences of withholding information, for instance, or determine whether someone is really “too busy” to help the new graduate with a task.

Confronting disruptive and disrespectful behavior is one way of managing it. This requires courage on the part of the victim or bystander but often results in positive changes—a decrease in the bullying behavior and increased self-esteem on the part of the victim. Confrontation is not easy and training can be helpful in empowering staff to stand up for themselves and others. Management support is important. While most institutions have instituted policies expressing zero tolerance for bad behavior and educate staff on what constitutes workplace bullying or horizontal violence, fewer have provided education on what to do when it happens to you.5

Even more important than individual confrontation is the role of the bystander. Changing the tendency of bystanders to avoid intervening is important. Bystanders who ignore the behavior are participating in escalating the culture of bullying and horizontal violence.4 Has it become so common in our culture, not only at work but in the media, on the road, and on the Internet that we don't recognize it when it occurs? Or, are we so afraid of being ostracized ourselves that we prefer not to get involved?

Becoming aware of our own behaviors, as bully or bystander, is the first step. What do you consider normal in your environment? Constant exposure to uncivil behavior, whether at work, in sports, on talk radio, on the road, or at home, can make it seem normal. While it may be unadvisable to pick the roadway as the first place to confront a bully, we can and should learn to do it at work, at school, or at home. Managers can help by recognizing and addressing subtle behaviors and providing education on confrontation skills. Managers should also pay attention to who the informal leaders are and what kind of leadership they are actually providing. Experience and competence do not always lead to a team that works well together or provides the best care. It requires teamwork and competence together to give the best care we can to our babies and families.

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1. Washington G. Rules of Civility and Decent Behavior in Company and Conversation. Chestertown, MD, Washington College; 2007:12.
2. Clark CM, Springer PJ. Thoughts on incivility: student and faculty perceptions of uncivil behavior in nursing education. Nurs Educ Perspect. 2007;28:93–97.
3. Altmiller G. Student perceptions of incivility in nursing education: implications for educators. Nurs Educ Perspect. 2012;33:15–20.
4. Hutchinson M. Bullying as workgroup manipulation: a model for understanding patterns of victimization and contagion within the workgroup [published online ahead of print May 23, 2012]. J Nurs Manag. 2012. doi:10.1111/j.1365-2834.2012.01390.x
5. Lux KM, Hutcheson JB, Peden AR. Successful management of disruptive behavior: a descriptive study. Issues Mental Health Nurs. 2012;33:342–351.
© 2013 National Association of Neonatal Nurses