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Where Do You Think You Are? A Grounded Theory Study of the Critical Factors Triggering the Existence and Fueling the Persistence of Incivility in Nursing

Samson-Mojares, Roselle Ann; Chin, Claudette R.; Colvin, Mary K.; Umadhay, Tony

doi: 10.1097/01.NEP.0000000000000397
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BACKGROUND Incivility in health care settings was first identified in 1976. The Institute of Medicine has called for a safer health care environment, and the Joint Commission emphasizes that disruptive behavior compromises patient safety. Incivility in nursing is a topic of interest, yet it had not been explored as a social process.

AIM The purpose of this study was to acquire an understanding and develop a theory to address incivility in nursing.

METHOD Twenty-nine RNs were interviewed based on Charmaz’s constructionist grounded theory.

RESULTS Four categories emerged (neglecting, alienating, relinquishing, and finding oneself) that developed into the theory of self-positioning.

CONCLUSION To understand incivility in nursing, one must, immersed within the institution, profession, and society, find and position the self. It is only then that we can address the health and well-being of RNs, provide quality care, and ensure patient safety.

About the Authors The authors are faculty at Barry University College of Nursing and Health Sciences, Miami Shores, Florida. Roselle Ann Samson-Mojares, PhD, RN, is an assistant professor, Undergraduate Program. Claudette R. Chin, PhD, ARNP, is an assistant professor, Graduate Program. Mary K. Colvin, PhD, RN, CNE, is an associate professor and the program director, Undergraduate Program. Tony Umadhay, PhD, CRNA, ARNP, is an associate dean. This study was funded by the Florida Nurses Foundation, 2014 Undine Sams and Friends Research Grant Fund, and a Sigma Theta Tau International-Lambda Chi Chapter 2016 Research Grant. The authors are grateful to the RNs who volunteered to be part of this study. For more information, contact Dr. Samson-Mojares at rsamson-mojares@barry.edu.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.neponline.net).

The authors have declared no conflict of interest.

“Nurses eat their young!” is an alarming remark that began to circulate in the 1980s (Meissner, 1986). This longstanding observation, uttered by most nurses, should make all nurses shudder in protest. Although many who use this phrase do not have insight into what nursing is truly all about, the phrase evokes strong emotion in nurses who have grown to appreciate the uniqueness of the nurse’s role; the vastness of nursing’s influence in society; and the discipline, science, and art of nursing’s embodiment and execution. Understanding incivility in nursing as a social process is the initial rung in our flight as a profession to ascend above our current predicament.

In 1976, Krebs published an article on disrespectful conduct in the health care industry that revealed that workplace incivility was 10 times more prevalent than workplace violence in health care settings (Hutton & Gates, 2008). In 1986, Meissner, who had witnessed nurse educators, administrators, and seasoned nurses devour novice nurses with their severe teaching stance, unrealistic expectations, and discouraging attitudes, gave a label to the social phenomenon that was poisoning the nursing profession. Incivility has been defined in management as a “low-intensity deviant behavior with ambiguous intent to harm the target…. Uncivil behaviors are characteristically rude and discourteous, displaying lack of regard for others” (Andersson & Pearson, 1999, p. 457). This definition has been used by other disciplines including nursing.

In 2000, the Institute of Medicine (IOM) reported that as many as 98,000 people die annually due to medical errors in US hospitals. Generally, errors originate from flawed systems, methods, and environments that are conducive for making mistakes or failing to prevent them. At the core of the solution is the creation of a safer environment. Eight years after the IOM report was issued, the Joint Commission on Accreditation of Health Care Organizations released a sentinel event alert, calling attention to intimidating and disruptive behaviors between health care professionals that undermine a culture of safety (Joint Commission, 2008). Such behaviors deflate teamwork, affecting the quality of care and jeopardizing patient safety. Since then, a body of literature has acknowledged the impact of incivility in the workplace due to its role in leading to workplace violence.

There is also a growing concern surrounding the link between workplace incivility and detrimental health outcomes for employees (Hutton & Gates, 2008). Disturbingly, in 2012, Sauer authored a continuing education article titled “Do Nurses Eat Their Young? Truth and Consequences,” a testimony that Meissner’s 1986 call to action had not been heeded.

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REVIEW OF LITERATURE

Although there have been several studies exploring workplace violence, bullying, lateral violence, horizontal violence, and mobbing, this researcher found no studies that examined the phenomenon of incivility as a social process. Rather, there are borrowed theories explaining these phenomena as they occur in the nursing profession. However, incivility is distinct from other types of workplace misbehavior due to its elusive negative aim. In addition, although it can be argued that incivility is insignificant compared to bullying and other actions, the counter argument this study offers is that, in a continuum of organizational disruption, incivility ensues at the lowest level, bullying at the middle level, and battery or physical violence at the highest level (Felblinger, 2008). Incivility has been known to be an antecedent to discrimination, belligerence, and physical violence. It is the spark that can ignite a global war.

In the last two decades, incivility in nursing has been a widely documented concept (Wilson, Diedrich, Phelps, & Choi, 2011), but mostly from a quantitative research point of view (Gallo, 2012). The focus of studies was predominantly on the results of incivility. The National Survey of Registered Nurses reported a significant increase in antagonistic work environment from 19 percent in 2006 to 23 percent in 2008 (Buerhaus, DesRoches, Donelan, & Hess, 2009). In a more recent study conducted in the Pacific Northwest, 35 percent of nurses reported they experienced incivility on a weekly basis, and 28 percent reported to have had experienced incivility on a daily basis (Etienne, 2014).

Apart from these statistics, incivility is linked to negative patient outcomes (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011), rising costs for the health care industry (Laschinger, Leiter, Day, & Gilin, 2009), and wounding consequences for nurses (Felblinger, 2008; Garrosa, Moreno-Jimenez, Rodriguez-Munoz, & Rodriguez-Carvajal, 2011) that tarnish the reputation of the nursing profession (Lachman, 2014). Incivility in nursing is also a global phenomenon: the incidence rises to nearly 77 percent in Africa (Khalil, 2009); between 40 percent and 86 percent in European countries (Hahn et al., 2010; Yildirim & Yildirim, 2007); 62 percent to 72 percent in Asia (Lin & Liu, 2005; Natan, Hanukayev, & Fares, 2011); 14.7 percent to 65 percent in Australia (Roche, Diers, Duffield, & Catling-Paull, 2010); and 49 percent in North America (Budin, Brewer, Chao, & Kovner, 2013). There is a chasm between the literature, the IOM (2000) thrust to create a safe environment, and the 2008 Joint Commission standard addressing behaviors that undermine a culture of safety.

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METHOD

Purpose and Conceptual Framework

The purpose of this grounded theory study was to adopt an abductive process to acquire an in-depth understanding of the critical factors that trigger the existence and fuel the persistence of incivility in nursing and to develop a substantive theory to address the concept of incivility. The overarching research questions were: What are the critical factors that influence nurses’ perceptions, attitudes, and behaviors about incivility? How do nurses make sense of their experiences with incivility in nursing? Utilizing the constructionist grounded theory approach by Charmaz (2006) and applying the principles of symbolic interactionism and pragmatism, data collection and analysis commenced after obtaining Barry University’s Institutional Review Board approval.

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Procedure

RN participants were recruited through purposive and snowball sampling. Phase I included 60-minute individual, face-to-face, semistructured interviews with 25 RNs: 60 percent (n = 15) had more than 20 years of nursing experience; 48 percent (n = 12) were BSN and 36 percent (n = 9) were MS/MSN prepared; 28 percent (n = 7) were in their current position for 10 to 15 years and 24 percent (n = 6) for 4 to 6 years; and 64 percent (n = 16) were staff nurses.

Phase II was a 90-minute face-to-face, semistructured focus group interview with four RNs who were nurse administrators (n = 2) and educators/researchers (n = 2). One had a BSN, two had an MSN, and one had a PhD. Participants were in their current positions from 1 to 15 years; three had more than 20 years of nursing experience. The four nurses had dealt with issues of incivility in nursing and were considered experts on the topic.

The 29 participants were RNs in Florida, and all were women. Each RN chose a pseudonym, signed an informed consent, and completed a researcher-designed demographic questionnaire; each was given a $20 gift card as a token of appreciation. All interviews were audiotaped, transcribed, and analyzed by the researcher right after each interview. Phase I participants were provided the opportunity to review the transcript. Data gathered from Phase II substantiated the findings from Phase I. The data collection process took place parallel to data analysis, memo writing, and reflective journaling.

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RESULTS AND DISCUSSION

Four distinct categories emerged that developed into the theory of self-positioning: neglecting, alienating, relinquishing, and finding oneself.

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Neglecting

Neglecting characterizes the institution’s failure to care for or attend to patients and nurses as stakeholders. It paints a picture of overlooking a responsibility that is not accidental. The concept of social exchange (Parzefall & Salin, 2010) indicates that, between an employer and its employees, there exists a mutual exchange of benefits and trusts that takes place without any formal contract. Nurses expect the institution to provide resources, support, and structure to facilitate their ability to deliver quality and safe nursing care while also keeping them safe. The institution counts on nurses to provide the human resources and deliver quality and safe nursing care in compliance with regulatory standards to keep the facility open for public service.

Throughout the interview, Rose 1 made several references: “Yes you do the charting, but it’s not really like a rule”; “It was only me…on the schedule so with nine patients”; and “there’s no consistency from one nursing supervisor to the other…they make their own rules.” Kanter’s theory of social power asserts that conduct and perspectives are largely molded by a person’s status and circumstances (Laschinger, Sabiston, & Kutszcher, 1997). The institution and nurses are on opposite ends of the spectrum when it comes to status and circumstances. When nurses are the recipients of incivility, their confidence in the establishment’s commitment to look after their best interest and well-being plunges (Miner-Rubino & Reed, 2010).

Nurse participants shared how they felt unheard and vulnerable when their supervisors failed to intervene when they reported incivility. Pomegranate constantly missed dinner and left work late due to the uneven distribution of patient admissions during her shift. She shared: “She [supervisor] would say, ‘Oh, it’s because of your lack of confidence…it’s your fault.’” Her grievances were addressed neither by the supervisor nor the nurse manager.

Cookie felt the charge nurse possessed the status and power to withhold help. She felt neglected and said: “When we’re busy and we need help…she [charge nurse] cuts you off…does not even come to see what’s going on.” Surgincer, a new nurse, reported that a senior nurse screamed at her during orientation. She felt let down by this response from the nurse manager: “I [nurse manager] know she [senior nurse] has that kind of personality…so I’m going to put you with another nurse, so we’re not going to do anything about it.” The nurse manager exhibited a lack of familiarity with institutional policies on bullying and failed to encourage open communication among nurses.

Institutions also neglect to protect nurses from the wrath of physicians. Zoey witnessed how, in the presence of a patient, a surgeon became overly upset with a nurse when the supplies he needed were not at the bedside five minutes after his request. When her efforts to address the rudeness and unprofessional behavior of a surgeon failed, Franscesca, a nurse manager, sent a report to the hospital administrators, who took the surgeon out for dinner and charged it to her unit budget. Flaca expressed how as a young nurse she felt degraded and worthless when frustrated surgeons threw instruments.

Nurses who experience incivility are being neglected by their institution of employment. There is a breach in the unspoken agreement between employer (institution) and employees (nurses) that is built on mutual trust, loyalty, and protection. As the institution neglects to provide resources, guidance, structure, and support to nurses, frustration, tension, and stress intensify.

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Alienating

Alienating characterizes the attitudes and behaviors of nurses toward each other. Nurses who alienate are unsupportive, competitive, and critical toward their peers. To alienate means “to make unfriendly; to cause to be withdrawn or detached, as from one’s society” (Webster’s New World, 2016). Nurses who alienate make other nurses feel distant or they don’t belong.

Nursing is a profession distinct from all other professions with its own code of ethics, standards, and guidelines, and it contributes to political agitation to push forward public well-being (Fowler, 2015a). It can be argued that, because the profession is an organic amalgam of human beings, incivility is inevitable. Yet, it is important that nurses carry themselves in a respectful and professional manner to patients, other health care providers, and the community. This must be a manner that communicates care and compassion, honoring the first provision of the American Nurses Association Code of Ethics for Nurses that states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (Fowler, 2015a, p. 1). This provision pertains to everyone, including nurses.

Michelle shared: “You know, they [nurses] will actually order food and not ask if I want anything.” Feeling left out or ridiculed was a resounding sentiment during the interviews. Brick felt belittled when nurses questioned her skills in front of patients. She said: “The incoming shift will look at the (IV) tubings and will say ‘this is not changed!’” Teresita shared how nurses made her feel uneasy and unsure of her skills that she began to wonder if it is because of her culture. She articulated: “I felt I was alone especially with the talking, about the culture and the race…you feel excluded.”

People who feel underestimated in an environment where only the values of the powerful are promoted develop self-hate and hate others. They become convinced of their inferiority and dependence on the people who hold the power with no accountability when that power is abused (Roberts, De Marco, & Griffin, 2009). Oppressed people feel helpless to retaliate against their oppressors. Their frustration turns into anger; anger turned inward, toward their own, the same people who are also oppressed. Focus group participant Julia referred to this: “We compete among ourselves and if we were to use a theory…you are oppressed so you would want to oppress another person.” Purple stated: “We are the models…instructors or staff nurses…and if we model this behavior [incivility], students are going…into the workforce acting like this because it’s the only thing they’ve ever seen.”

Sandy Shore described how her former nurse manager addressed her: “She would treat me in this manner, it was, ‘I am your boss. You do what I say whether it made sense or not.’” Professional organizational membership was mentioned by focus group participant Cats Mom as a catalyst to bringing nurses together in a collaborative and constructive way. She said: “As long as each nurse remains a little solitary island and does not join together and become a continent,” alienating behaviors are more likely to continue.

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Relinquishing

Relinquishing addresses the nurses’ perceptions, attitudes, and behaviors surrounding the contributions of society to incivility. Society includes the individual’s surroundings, culture, and upbringing with the context of time. To relinquish means “to give up, to let go”; it implies “a voluntary refusal to insist on one’s rights as for reasons of convenience” (Webster’s New World, 2016).

Beyond the profession of nursing, nurses are an integral part of society. The care a nurse provides an individual affects the family and community. In the same manner, anything and everything that occurs in society affects the nurse. Relinquishing indicates that society has been waning on its primary responsibility to be diligent and vigilant when it comes to raising and nurturing younger generations. With exponential advances in technology and shifting personal values, the most basic unit of society — the family — has been redefined, which increasingly contributes to the breakdown of the solid foundation of parent-child relationships. The mutuality between society and nursing, which involves expectations and responsibilities, has been suffering a breach as indicated by the nurses in this study. Participants did not fail to mention society’s role in incivility.

Brick cited how 21st century parents are busy making a living with young children and children of all ages exposed to unfiltered media and a considerable reduction in family time and parental guidance. Franscesca shared how she was brought up to be respectful and to pay attention when someone is speaking. Mo expressed the same sentiments. Dinner with her family was a time for fellowship. Today, she observed, the families sit together for dinner with cell phones in their hands, barely speaking with one another.

Nursing’s Social Policy Statement expresses the social contract between society and the nursing profession (American Nurses Association, 2010). Among the document’s 16 elements (Fowler, 2015b) are the nursing profession’s provision of compassionate, competent, ethical care free from prejudice that is collaborative, altruistic, and transparent with the intent to foster public well-being. Society will accord the nursing profession title and autonomy to practice to the full extent of its education, exercise self-regulation, and provide decent wages and a safe work environment. This contract is fractured when much of nursing care becomes standardized rather than individualized.

Such was Flaca’s experience when nursing supervisors expected all nurses to complete their electronic documentation by a certain time. She emphasized that each patient has unique needs, and setting a time constraint takes the nurse “away from the true essence of nursing.” Brick pointed to societal pressures that push nurses to work more than one job, work overtime, or work three 12-hour shifts in a row. She argued: “If you choose that then you have no reason to be cranky, to be grouchy, snap at people…. You want…the nice car or live in a big house. So you work your…off and you become cranky.”

Ocean expressed her concern over the proliferating culture of regulations: “We [have become] a highly regulated industry so there are more and more requirements…in order to get money [reimbursement].” Lola pointed out how culture, age, and upbringing shape how people interact with others. These factors affect one’s appraisal of oneself and society. Today’s economic challenges have witnessed an influx of nurses who might have not had considered becoming a nurse had the economy been more robust. Julia made an unsettling observation: “I think nursing is also a victim of job availability and that quite a number of persons who had become nurses [were not called to nursing].”

Structural-functionalism theory (Turner, 2014) has been widely adopted for family studies. Its current use rests on the strength of its assumptions central to family sociology. The theory suggests that the family is the basic unit of society where every individual is introduced to social interactions. The family serves as a small-scale version of society and has the function of teaching the individuals their roles. The breakdown of any family unit has the potential to negatively affect how we carry ourselves in the workplace, in society, with resulting incivility.

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Finding Oneself

Finding oneself echoes the participants’ emphasis on the values and choices the self makes in the face of incivility in nursing. It is a process that is not without challenges. However, it will and must take place as the permeable self, with influences from an evolving society and a maturing profession, develops within an organic institution. Finding oneself involves the individual’s ability to construct an understanding of the self based on how one sees the self, how others see it, effects of relationships, and self-acceptance (Inder et al., 2011). It is the practice of reflecting on experiences, integrating how other people react to the self, interactions with others, and coming to terms with the self, which include acknowledging one’s strengths and limitations. The construction of self is dependent on the construction of other — one’s self is formed through a process of being able to focus on both the internal and external (Duff & Flattery, 2014).

Franscesca emphasized: “I don’t think I can exclude myself…I don’t think any person can exclude themselves.” She acknowledged that she must have been guilty of incivility. Mary did not hesitate to admit she was not always pleasant to others. Her willingness to look within and consider her shortcomings may be the beginning of growth. Julia exhorted: “I think that we have to reflect and understand that we are in charge of our own destiny. That that’s just us. The change must come from within us.” Franscesca agreed: “It starts with you.” Pam emphasized: “Know yourself.” They determined that, although the self is inundated by the voices and impressions of the institution (neglecting), profession (alienating), and society (relinquishing), the self finds its way through. If anything has to change with regard to incivility in nursing, it must start from the self.

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THEORY OF SELF-POSITIONING

The four main categories come together to construct the theory of self-positioning (see Supplemental Digital Content at http://links.lww.com/NEP/A98 for figure) (Samson-Mojares, 2016) This theory influenced the nurses’ perceptions, attitudes, and behaviors when faced with incivility, the substance of how nurses made sense of their experiences.

Where to locate the self within the social process that is incivility is a subjective experience and decision. Embedded in the nurses’ narratives is the recurring theme that the occurrence of incivility in nursing is multifaceted and moved by elements from the institution, profession, and society. The connections between the self, institution, profession, and society determine how the self evolves, positions itself, and possibly evolves again. In positioning the self, there are three possibilities: self-doubt, self-indulgence, and self-awareness.

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Self-Doubt

Self-doubt represents “lack of confidence or faith in oneself” (Webster’s New World, 2016). This can occur during the transition to practice for new nurses (Ortiz, 2016) due to snowballing regulatory standards that incite a competitive atmosphere (Yeo & Marquardt, 2015) and when there is a sense of threat to one’s position (Williams 2014). Incivility around a nurse or directed at the nurse can cause confusion and uncertainty, an experience described by male social workers who worked closely with male perpetrators of battery (Bailey, Buchbinder, & Eisikovits, 2011).

Prior knowledge or expectations about being in a caring profession has been disrupted. Nurses begin to question their knowledge, skills, and capabilities; develop self-pity; and feel they have failed. Not likely to stand up for themselves, internalizing their pain, and prone to self-destruction, they become easy targets. Bewildered, they mimic their peers and managers. These factors trigger the existence of incivility.

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Self-Indulgence

Individuals in self-indulgence have been shattered by incivility; in refusing to once again become prey, they become predators. To indulge implies “yielding to the desires of oneself because of a weak will, which emphasizes harm done to the personality or character” (Webster’s New World, 2016). The nurse becomes detrimental to both self and others. As self-regulatory behaviors have been worn out (Sharma, Sivakumaran, & Marshall, 2014), they become self-absorbed, reactive, and impulsive (aan Het Rot, Moskowitz, & Young, 2015), and they feed their low self-esteem by stepping on others (Shoham, Gavish, & Segev, 2015). Their lack of cognition and self-control lead to the perpetuation of incivility, thus fueling its persistence.

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Self-Awareness

To become aware implies “having the knowledge through alertness or (the ability to) interpret what one sees, hears, feels” (Webster’s New World, 2016). It also requires the awareness of other (Duff & Flattery, 2014) because it is multifaceted and all-encompassing (Llorens, Noe, Ferri, & Alaniz, 2015). It is symbolic interactionism in action: the self is a participant in the experience and the cognitive discourse at the very same time (Chadna, 2011). Self-awareness creates a balance and empowers the nurse to change the self and the surroundings. An individual in the self-awareness position acknowledges personal strengths and limitations. The individual is empowered yet humbled, thus diminishing the occurrence of incivility.

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RECOMMENDATIONS AND CONCLUSION

The findings of this study entail clearly defining incivility in nursing curricula, specifying knowledge and skills in identifying, responding, and preventing incivility by emphasizing interpersonal aspects of being a nurse and becoming socialized into the profession. More importantly, urging students to engage in self-reflection and personal knowing exercises may result in positive self-esteem and empowerment.

The inclusion of communication techniques and self-awareness exercises will stretch and strengthen the student’s character, priming the student to cope with the complex social structures and challenges in health care institutions, the profession of nursing, and society. The benefits to nursing practice may be translated through comprehensive and well-defined institutional policies on staffing, floating, and civility. More importantly, partnering with nurses in decision-making cohorts impacts nursing practice and patient care across specialties.

When nurses actively serve or sit on committees, the institutional mission and vision become holistic. Joining a professional organization keeps nurses abreast of educational, professional, political, social, and global changes and advances. Personal knowing strengthens a nurse’s character and secures self-identity, threatened by neither innovations in technology nor younger nurses, physicians, and demanding patients; educational advancement; and updates in practice.

With the emergence of this new theory, others may be inspired to test it and embark on quantitative and qualitative studies. This study’s findings may be utilized by public policy officials to guide legislation mandating lower nurse-patient ratios that will ease the workload of direct patient care nurses and affect better patient outcomes. Pioneering regulations uphold society’s reciprocal obligations to the nursing profession and include the nurses’ rights, duties, responsibilities, and safety as indicated in the Nursing’s Social Policy Statement (Fowler, 2015b). Public and private agencies that regulate health care institutions and professional organizations are urged to revisit levels of standards and expectations, taking into consideration the shrinking nursing workforce, the aging population, advances in technology, and economic challenges while honoring individualized care delivered at the bedside.

The strengths of this study include the voices of 29 volunteer RNs, triangulation, member checking, purposive sampling, transcription by the researcher, bracketing, the researcher as an instrument and an RN, and support from the researcher’s family and friends and the academic and professional communities. The study findings can be adapted to any arena that involves human interaction. Limitations include the participants’ truthfulness and ability to recall their experiences, the researcher being a novice, and the fact that some participants were known to the researcher.

Recommendations include replicating this study with a larger sample size and specific demographic groups, testing the theory through a quantitative study, applying the theory outside the nursing profession, and exploring factors affecting nurses’ willingness to participate in research studies. Incivility has been researched since the 1970s and there is a wealth of information about it, yet it continues. Is it a necessary evil? Toward the end of data analysis, this researcher began to wonder if incivility has any benefits. If there are benefits to incivility, what are they? And who are the beneficiaries? Is incivility necessary in a caring profession such as nursing? Does incivility bear characteristics that ironically keep an institution, the nursing profession, and society secure? Might we begin to look at incivility from a different perspective?

The emergent categories — neglecting, alienating, relinquishing, and finding oneself and the theory of self-positioning — identified the critical factors that influence nurses’ perceptions, attitudes, and behaviors about incivility and how they make sense of their experiences. To understand incivility in nursing, one must, immersed within the institution, profession, and society, find and position the self. It is only then that we can begin to design and execute pragmatic strategies to indisputably alleviate the wounding effects of incivility; ease health care costs; address the health and well-being of RNs; and behold better patient outcomes, institutional protection, an embracing nursing profession, a cradling society, and individuals who are self-aware. Finally, one must ask: Where do you think you are?

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      Keywords:

      Constructionist Grounded Theory; Incivility in Nursing; Theory of Self-Positioning

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