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An Integrative Review of Nurse-to-Nurse Incivility, Hostility, and Workplace Violence

A GPS for Nurse Leaders

Crawford, Cecelia L., DNP, RN; Chu, Frances, MLIS, MSN, RN; Judson, Lorie H., PhD, RN, NP; Cuenca, Emma, DNP, RN, CCRN, CSC, CNS; Jadalla, Ahlam A., PhD, RN; Tze-Polo, Lisa, BSN, RN; Kawar, Lina Najib, PhD, RN, CNS; Runnels, Cindy, MLIS; Garvida, Roque Jr, MSN, RN

Nursing Administration Quarterly: April/June 2019 - Volume 43 - Issue 2 - p 138–156
doi: 10.1097/NAQ.0000000000000338
Original Articles
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Bullying, lateral violence, and incivility are real phenomena in the nursing workplace and remain widespread across all care settings. The American Nurses Association recommends zero tolerance for any form of violence from any source and adopting evidence-based strategies to mitigate incivility and bullying. This integrative review examined the evidence regarding nurse-to-nurse incivility, bullying, and workplace violence for 4 nurse populations—student, new graduate, experienced, and academic faculty. Ganong and Cooper's review methodology structured the evidence synthesis. Twenty-one articles pertained to the clinical inquiry. The evidence consistently described the incidents, instigators, and targets of incivility/bullying, which contributes to 84 negative academic, organizational, work unit, and personal outcomes. A safe and just organizational culture demands a comprehensive systems-level approach to create civil environments. The evidence-based structures, processes, and recommendations serve as a Global Positioning System for practice and academic leaders to use in creating a healthy work environment where nurses are encouraged and empowered. The critical choices by nurse leaders will determine not only the future of 21st century professional nursing practice but how the public views the nursing profession for many years to come.

Academy of Evidence-Based Practice, Kaiser Permanente Southern California Patient Care Services, Regional Nursing Research Program, Pasadena (Dr Crawford); Gonzaga University, Foley Center Library, Spokane, Washington (Ms Chu); California State University, Los Angeles, Chin Family Institute for Nursing, Los Angeles (Dr Judson); University of California, Los Angeles, School of Nursing, Los Angeles (Dr Cuenca); School of Nursing, California State University, Long Beach (Dr Jadalla); Kaiser Permanente Woodland Hills Medical Center, Medical-Surgical/Oncology Unit, Woodland Hills, California (Ms Tze-Polo); Kaiser Permanente Southern California Patient Care Services, Regional Nursing Research Program, Kaiser Permanente, Pasadena (Dr Kawar); Health Science/Medical Library, Southern California Permanente Medical Group, Downey (Ms Runnels); and Kaiser Permanente Panorama City Medical Center, Nursing Administration, Panorama City, California (Mr Garvida Jr).

Correspondence: Cecelia L. Crawford, DNP, RN, Academy of Evidence-Based Practice, Kaiser Permanente Southern California Patient Care Services, Regional Nursing Research Program, 393 E Walnut St, Pasadena, CA 91188 (Cecelia.L.Crawford@kp.org).

This manuscript was made possible with a 2017 Mapping the Landscape, Journeying Together grant from the Arnold P. Gold Foundation.

This review was supported by the Kaiser Permanente Southern California Regional Nursing Research Program.

The authors declare no conflict of interest.

CURRENT CONVERSATIONS within complex health care environments are focusing on health professional burnout, retention, and a healthy work environment. The Institute for Healthcare Improvement's recent white paper noted that staff burnout and its negative effects impact both patient care and an organization's fiscal vitality.1 Recognizing that bullying and incivility are widespread across all patient care settings, the American Nurses Association (ANA) made the work environment a top priority. In 2015, the ANA convened a panel to develop a position statement regarding incivility, bullying, and workplace violence. Key points of the statement were zero tolerance for violence in any form from any source, creating a respectful culture for all health care professionals, and adopting evidence-based strategies to prevent and mitigate incivility and bullying.2

Healthy work environments demand evidence-based strategies for optimal patient and staff relationships and outcomes. An academic-service collaborative, the Academy of Evidence-Based Practice (EBP), was tasked with investigating the evidence to identify the scope of the literature on incivility, bullying, and workplace violence. This article examines these phenomena within the nursing profession for 4 nursing populations—student nurses, new graduate nurses, experienced nurses, and academic faculty. Review results offer best practices, pragmatic solutions, and evidence-based recommendations for nurse leaders in academia and practice as they seek to create civil cultures and work environments.

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THE REVIEW

Aim

The main aim of the literature review was to examine the quantity, quality, and consistency of the evidence regarding nurse-to-nurse incivility, bullying, and workplace violence for the 4 aforementioned nurse populations. A secondary aim was to meaningfully translate the evidence to offer guidance to executive nurse leaders, managers, and academic faulty.

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Design

This integrative evidence review was conducted using techniques developed by Ganong,3 Cooper,4 Stetler et al,5 Torraco,6 and Whittemore and Knafl.7 The review phases included creation of the clinical and searchable questions, data retrieval, literature appraisal, data interpretation and synthesis, and a narrative summary. The literature review question was crafted during phase 1 by 13 members of the Academy of EBP8 and a nurse scientist. The review was conducted from March 2016 to June 2017. This review was supported by the Kaiser Permanente Southern California Regional Nursing Research Program and a 2017 Mapping the Landscape, Journeying Together grant from the Arnold P. Gold Foundation.

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Search methods

The second phase of the review was the structured database search. The search was done by 2 Kaiser Permanente librarians and an academic librarian. The search terms were broad and included “bullying,” “hostility,” “incivility,” “workplace violence,” “lateral violence,” and “eat their young,” combined with the distinct nurse population, either alone or in combination. The databases searched included CINAHL, Cochrane Library, EMBASE, ERIC, PsycINFO, and PubMed. Searches were limited to 2010 to 2016, English, and humans. Three librarians ran the search during the months of December 2015 to March 2016.

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Search outcome

The search retrieved 1495 records. After excluding nonrelevant titles and deduplication of records, the final yield was 336. Further deduplication eliminated another 43 records resulting in 293 abstracts to review. Five rounds of detailed abstract/full-text article examination eliminated 272 articles, as they did not answer the clinical question, were outside the acute care environment, were based in countries other than United States or Canada, included health care professionals other than nurses, or did not focus on the concepts of incivility, hostility, and/or workplace violence. The remaining 21 articles pertained to the clinical question and were evaluated for quality, with a subsequent content analysis.

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Quality appraisal and evidence abstraction

Evidence evaluation took place during the third phase. Article ranking was accomplished using the Academy of EBP Evidence Leveling System8 and graded using the Johns Hopkins Evidence Appraisal tools.9 The evidence consisted of 1 integrative review,10 1 randomized controlled trial,11 6 qualitative descriptive survey studies,12–17 8 quantitative descriptive studies,18–25 1 concept analysis,26 3 mixed-methods survey studies,27–29 and 1 theory/model testing.30 Articles were examined for more than 7 months (Table 1). The strength of the evidence was graded as low-to-moderate quality.

Table 1

Table 1

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Evidence synthesis

Data analysis and interpretation took place during the fourth phase to establish common categories and topics. Final synthesis included a narrative overview, key summary, and evidence-based recommendations. The lack of clear terminology and universal definitions may have resulted in missed articles.10,12,13,15–21,23,25–30 Other limitations included lack of generaliza-bility12,15,18,19,25,27,29; little evidence for sub-populations such as male gender,12,19,21,25,27,28 race,12,16,19,21,28 and culture10; small sample size12,15,18,19,25,27,29,30; limited settings15,17,27; low survey responses15,29,30; self-report data25,27; and difficulty locating nurses who are bullied.16 Finally, there were little data supporting specific interventions10,12,15–17,21,25–30 and difficulty making causal connections.23

The information in this review provides the best available evidence to date for nursing leaders regarding bullying, incivility, and hostility for 4 nurse populations in the acute care setting. Review results could potentially be translated to other health care settings such as ambulatory care and home health/hospice.

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THE UNCIVIL ELEPHANT IN THE ROOM: REVIEW RESULTS

Bullying, lateral violence, and incivility are real phenomena in the nursing workplace. The evidence is consistent in its description of the incidents, instigators, and targets of incivility/bullying10–12,16,19,21,24,25,27–30 (Table 2). Historically, lateral violence may have been an unavoidable component of nursing.26 Bullying prevalence rates have not changed in more than 20 years,21 which perpetuates a destructive rite of passage where nurses “eat their young”17,26 (Figure 1).

Table 2

Table 2

Figure 1

Figure 1

Workplace incivility impacts nurses' physical, emotional, and psychological health13,17,24,26 across all 4 populations and contributes to 84 negative academic, organizational, work unit, and personal outcomes10,12,13,15–17,20,21,23–26,28–30 (Table 3). These outcomes often result from organizational, work environment, and personal triggers (Table 4). As the nursing profession seeks collaborative academic-service partnerships to create healthy and safe learning milieus,12,16,18 health care organizations must assess their own culture, structures, and practices that contribute to negative socialization experiences and uncivil workplaces13,21 (Table 5).

Table 3

Table 3

Table 4

Table 4

Table 5

Table 5

There were multiple concepts, terms, and phrases related to incivility, which were used interchangeably throughout the literature.10,12,13,15–21,23,25–30 The review team had difficulty differentiating between the multiple descriptions, definitions, and terms related to these phenomena. The lack of clearly defined bullying/incivility terminology and definitions may lead to uncertainty in determining whether nurses have or have not been treated appropriately.26,29

Five overarching themes were identified throughout the review (Figure 1). Student nurses are exposed to hostile behaviors by a variety of others such as academic faculty, preceptors, mentors, seasoned nurses, and other students10–12,16,18–21,24,25,27–30 (Table 2). This cycle persists as student nurses acclimate to a possible “eat our young” environment,17,26 which normalizes unacceptable behavior and forces inexperienced nurses to believe that they must “pay their dues.”26 Students and new graduates who have difficulty coping with and alleviating uncivil behaviors often exit the profession.17,20,21,24

Multiple contributing factors of incivility for nursing leadership were identified in the literature (Table 6). Clinical instructors may be perpetrators of bullying (Table 2). This provides unfortunate role modeling for students.12 Executive leaders may use bullying tactics to enforce a hierarchical organization structure, maintain the status quo, and lead from a distance.13 Nurse managers (NMs) may also maintain an arm's length from frontline staff13 and ignore or even participate in uncivil behaviors.28 Other nurses in leadership roles may move outside the limits of their authority and deny vacation requests, give unmanageable patient assignments, or participate in perceived punitive actions.17,29 These actions edge into unethical professional behavior15 that should not be tolerated in any setting.

Table 6

Table 6

Although not directly discussed, the evidence implied that emotional intelligence (EI) may be a component of bullying and incivility not only for student/experienced nurses but also for executive leadership and NMs (Table 6). The lack of interpersonal skills,13 psychological capital,17 and/or management skills13 hampers the development of EI. These skills are learned early in life and may be difficult to change.16 The evidence described how perceptions of bullying gradually abated over time16 and/or as nurses aged,29 suggesting that nurses may be mitigating it by using effective interpersonal skills. On the contrary, nurses may be tolerating incivility as part of professional and environmental dysfunctional norms.15

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Effects on nurses and the work environment

Bullying and incivility exact a toll on all nurse populations, including executive and academic leaders. The work environment may be undermined and ultimately affects the organizational culture, possibly contributing to 84 distinct negative outcomes.10,12,13,15–17,20,21,23–26,28–30 An uninterrupted cycle could lead to the creation of a toxic work environment (Table 3). As a result, the unit environment may experience low staff morale,13,28,29 decreased teamwork,15 and little sense of community.24 Fiscal consequences17 due to increased turnover10,13,17,20,21,24,26 and absenteeism13 could deeply affect the organizational itself (Table 3). Nurse leaders must then strive to restore a healthy work environment where nurses are encouraged and empowered.10,24,26

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Implications for nurse leaders

Nurse manager perspectives related to incivility/bullying were grouped into 6 distinct themes (Figure 2). Inappropriate actions and behaviors are accepted as “That's Just How S/he Is.” Nurse managers also need to address “Old Baggage,” particularly if they manage a unit with long-standing issues of uncivil behavior. Nurse managers may be reluctant to confront bullies, particularly if these individuals are seen as clinical experts. “They Just Take It” describes passive nurses who tolerate uncivil behavior. Although some frontline staff remain silent and passive while being bullied, many nurses do not. They report the event to their NM and describe uncivil behaviors and actions occurring in the work environment.15

Figure 2

Figure 2

When an NM realizes that nurses are experiencing negative workplace behaviors, a moment of discovery ensues that triggers “Ethical Dilemmas.”15 The NM must explore the “Three Sides to a Story” to investigate the bullied nurse's story and the bully's story to determine the story that exists between the two. The NM then has an organizational and ethical obligation to follow policy, procedures, and guidelines to correct inappropriate behaviors. Finally, both NM and staff should realize that these behaviors may be unleashed during times of stress and critical events in “Lots of Things Going On.” Efforts to de-escalate unit tensions could go a long way to relieving the pressures involved in high census, short staffing, and minimal resources. These 6 themes vividly illustrate just 1 small facet of the issues NMs confront on a daily basis.15

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NURSE LEADERS' ROLE IN MITIGATING UNCIVIL BEHAVIORS

Abusive nurse behaviors and experiences remain an issue in nursing and continue to impact system, organizational, and patient outcomes.31 The Joint Commission issued a 2008 sentinel event sheet stating, “intimidating behaviors, disrespectful behaviors, use of inappropriate words, shaming, and unjustified comments in the clinical or work environments disrupts the culture of safety.”32 The 2015 ANA position statement deemed lateral violence as unacceptable,2 while the 2015 ANA Code of Ethics for Nurses considers bullying/incivility as unethical.33

Table 6 outlines facilitators for nursing leadership to employ in preventing and managing inappropriate staff behavior. Executive leaders must be seen as authentic22,24 and assume a primary role in addressing bullying.29 Nurse managers must become comfortable in confronting ethical issues related to uncivil behaviors/actions and seek assistance from other leaders and human resources staff.15 Academic instructors and NM should partner to clarify student nurses' current education level and what behaviors are expected during their clinical experiences.12 These 3 groups have an opportunity to set the tone for daily encounters between all 4 nurse populations and create a civil discourse for others to see and model.

Nurse leaders who experience any of the NM themes should consider developing their EI skills, which many leaders need. Emotional intelligence is a common sense method important for personal and professional development. The process promotes skills for self-control, flexibility, and resolution. Using these skills, EI encourages a person to stop, think, and choose an appropriate intervention.34 These interpersonal skills are useful for nurse leaders as they role model civil behavior, particularly during staff conflict, disagreement, and disparity.

Strategic structures and processes (Table 5) provide a Global Positioning System (GPS) for nursing leaders to create an environment that fosters workplace civility13,14,26 and establish zero tolerance for bullying/incivility.10,14,16,20,29 Using regular assessments of practices, perceptions, and policies,10,13,14,20,29 executive leaders can create a work space of civility and respect.16 Processes to increase a culture of acceptance and understanding include open discussion of the issues10,14,16,20,29 and a clear outline of how managers/directors are to respond to unacceptable behaviors.14 Engaging HR, nurse leaders, and staff in exploring current resources and autonomy of nursing practice would go far in establishing an empowering practice environment.13 Implementing new graduate transition programs could potentially decrease stress and acculturate10 novice nurses.25 Nurse leaders who harness these strategies can provide support for frontline staff to feel engaged and confident, and potentially improve communication and clinical competencies—all essential elements for excellent patient care.10,13

All nurses—staff, managers, directors, and executives—should reflect upon the nursing world they wish to live in, what prevents them from achieving it, and how to question the status quo within academic-service institutions.13 Further investigation is warranted to examine the impact of gender and race on the perception of reactive incivility.12,19,27 Review results provide nurse leaders the evidence they need to produce an authentic and just culture for high-quality patient, staff, unit, and organizational outcomes.

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CREATING A CIVIL CULTURE: A GLOBAL POSITIONING SYSTEM FOR NURSE LEADERS

Successfully tackling incivility requires a consistent and uniform response to incivility15,30 and the deployment of civility in the face of ongoing hostility.16 This review provides several evidence-based recommendations to tackle nurse-to-nurse incivility and bullying in acute care settings. Any initiatives aiming to create a civil, safe, and just culture must contain certain characteristics. First, there must be clarity.13–16,21,25,26 All nurses must understand the terms and descriptions associated with incivility and the various ways and degrees it is manifested. A second characteristic is comprehensively addressing civil behaviors on all organizational levels13–16,21 and at each stage of nurse role socialization.10,12,14,16,17,21,25,28 Finally, every nurse is responsible and accountable for ensuring that civility prevails in the workplace.33

Both academic23,30 and practice leaders must create cultures,10,14,16,20,29 structures,10,13–16,26 and processes10,13,20,26 that foster workplace civility. Nursing leaders must ensure that civil behavior descriptions, policies, and care practices are consistent and standardized throughout all organizational levels to minimize interpretative variations and situational responses.13–16,21,26 Leaders at all levels should periodically assess and monitor10,14,16,20,29 their environments in an effort to eliminate risk factors and system inequities that contribute to uncivil behavior.13 These actions have the potential to empower nursing staff23,24 and reduce lateral violence/practices that perpetuate and sustain these negative behaviors.10

Promoting civility begins with establishing a culture where incivility/bullying is openly rejected.10,14,16,20,29 Nurses must be educated to recognize and prevent these behaviors17,23,25 and be equipped to contain and mitigate them.17,29 Nursing scholars could explore using targeted educational opportunities during student nurses' academic preparation12,14,21 and reinforce these learnings during their clinical training.27 Nursing instructors should introduce civility, respect, and coping strategies as class topics12,14,21 during the formative socialization period of nursing students.27 Finally, academic leaders must role model civility14 and assist student nurses in recognizing uncivil behaviors27 and understanding their detrimental effects.18

Practice leaders can reinforce previous civility education when new graduate nurses enter the workforce and reinforce this education for all nurses on a regular basis.10,17,28 All nurses must be educated in civil behaviors and oriented to the resources, processes, and policies governing professional nursing practice.12–16,21,26 These activities can be incorporated into residency10 and preceptorship28 programs, with nursing peers and leaders providing a supportive mentoring network for all nurses.25 The following additional recommendations are offered for nurse executives, academic faculty, and other clinical leaders to consider when creating a civil and safe just culture:

  • Create a supportive and civil organizational culture.10,14,16,20,29 Confirm that organizational policies contain clear terminology that promotes civil behavior.26,29 Assess organizational infrastructure, nurse perceptions, workplace design, and policies on a regular basis.10,14,16,20,29 Incorporate the ANA Code of Ethics and related topics on workplace bullying during employee orientation and regular staff updates.15,30
  • Support NMs as they ensure that academic faculty, students, preceptors, unit staff, and mentors25 understand the acceptable parameters of workplace behavior12,16,18 to recognize, diffuse, and minimize bullying/incivility.15,23 Assist NM and other leaders in addressing bullying by providing institutional supports, guidance, and a heightened awareness for incivility prevalence.10,14
  • Provide professional development by offering education on assertiveness,15 conflict management,30 EI skills,18 relationship building,29,30 and open dialogue.28 Embed cognitive rehearsal10,26 and role-playing simulations26 into orientation and developmental programs to assist all nurses in building confidence and basic survival skills.10,25 Create teaching moments by using videos and incidents to illustrate negative workplace behaviors.18,28
  • Disrupt the normalization of nurse-to-nurse incivility.13,26 Tactics include the creation of a universal bullying code word,16 designing an official report system16 to halt inappropriate behavior,16,28 and determining behavior for direct confrontation.16 Reduce fears of retaliation by establishing a “hotline” to report inappropriate behaviors.29 Use exit inteviews20 and root cause analyses of incivility incidents to identify and examine triggers and outcomes of uncivil behaviors.19,28,29 Finally, reward staff creativity as well as compliance.13
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COURAGEOUS NURSE LEADERS IN THE 21ST CENTURY

Despite incivility, nursing has remained the most respected profession for the past 16 years.35 Nurses can continue their role as moral agents by effecting positive change to schools of nursing, health care systems, and ultimately to the nursing profession.31,36 Fostering a culture of understanding, patience, and acceptance21 requires executive, middle management, and academic leaders to lean in and assume a primary role in addressing incivility12,13,15,18,22,24,29,37 (Table 5). Nurse leaders can proactively create a joyful work environment where nurses are empowered and engaged in providing optimal patient care1 (Table 6).

Although it is tempting to isolate various aspects of nurse-to-nurse incivility, a safe and just organizational culture demands a comprehensive systems-level approach.31 Strategic structures and processes can assist in creating civil organizations and work units, with improved nursing, environment, and patient outcomes10,11,13–17,19–22,25,26,28–30 (Table 5). Nurses at all institutional levels must first understand how civility, incivility, and bullying are defined and then articulate the numerous triggers, targets, and instigators involved in these phenomena. Only then can nurses determine which specific identification and assessment tools can categorize the types of incivility present in their unique workplaces.

Institutional leaders and clinicians must then decide which path they will take. Will they turn a blind eye to a work environment that fosters hostility, bullying, and uncivil behaviors that eventually generates a toxic organizational culture? Or, will courageous and authentic leaders embark on the enlightened path of determining the customized strategies and facilitators needed for civil organization/unit cultures and the personal behaviors of each nurse population?31 These critical choices will determine not only the future of 21st century professional nursing practice but how the public views the nursing profession for many years to come.

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Keywords:

integrative review; nurse hostility; nurse-to-nurse incivility; organizational culture; workplace violence

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