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Incivility in critical care nursing

Perregrini, Michelle MSN, RN-BC, CAPA, CPAN

doi: 10.1097/01.NME.0000577616.12761.5f
Department: On the Horizon

Michelle Perregrini is a Supervisor at Providence Portland Medical Center, Oregon.

The author has disclosed no financial relationships related to this article.



Nurses are exposed to incivility in all facets of the nursing profession, from nursing school through frontline nursing and into leadership positions. This article discusses the incidence of incivility in the critical care area, strategies for preceptors to mitigate risk, and approaches for new graduate nurses entering the ICU environment.

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The American Nurses Association (ANA) defines incivility as “one or more rude, discourteous, or disrespectful actions that may or may not have a negative intent behind them.” The ANA defines bullying as “repeated, unwanted, harmful actions intended to humiliate, offend, and cause distress in the recipient.”

The prevalence of incivility and bullying in the nursing profession has drawn much awareness; however, it continues to occur. Consider the results of a recent Occupational Safety and Health Administration report on workplace violence in the healthcare environment: In a 1-year period, 21% of RNs and nursing students reported being physically assaulted and more than 50% indicated that they were verbally abused. During a 1-week period, 12% of emergency nurses experienced physical violence and 59% were subjected to verbal abuse.

Nurses working on ICUs may be exposed to incivility given the high stress levels in the environment—a factor thought to increase the risk of incivility and bullying. Graduate nurses entering the critical care area are often told “nurses eat their young” or warned that they can't survive on an ICU without previous medical-surgical experience. Generally, graduate nurses begin with the night shift on an ICU during which time there are less resources available, such as leadership, case management, attending physicians, ancillary staff, satellite pharmacy, transport, and additional team members for support.

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Negative outcomes

Critical care nurses are exposed to heightened chaos, stress, grief, and a sense of urgency to complete tasks. New graduates rely heavily on experienced nurses who know how to respond rapidly; however, experienced nurses are also often expected to manage their own patients, take charge of the unit, and guide new nurses while under increased levels of stress. The impact of this amplified stress may result in the novice being hesitant to ask time-sensitive questions, jeopardizing patient safety and placing him or her at risk for cultivating incorrect practices. In addition, nurses who are new to critical care may be exposed to hazing by ancillary staff and, as a result, may attempt to demonstrate that they're capable of full patient care without calling on anyone to assist them. That's why civility among critical care nurses is important for achieving positive patient outcomes.

Research suggests that incivility and bullying create more stress for nurses in an already stressful environment, negatively impacting nurse satisfaction. Nurses who are exposed to incivility and bullying are at risk for increased callouts on days the known bully is working, depression, burnout, and increased turnover. Culturally, a new nurse who experiences incivility and bullying is also learning that this is acceptable behavior on the unit and may progress to becoming uncivil to newcomers over the years.

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Reducing the incidence

Frontline nurses who've been exposed to or witnessed incivility and bullying during their own initiation are integral when creating mentorship relationships between new graduates and experienced nurses because they're aware of what it feels like to be unwelcomed into the unit culture. Conti-O'Hare's theory of the nurse as a wounded healer can be used in situations of workplace violence, incivility, and bullying to resolve personal and/or professional pain, promote the process of healing, and create an environment that disenables these behaviors. As nurses promote health in their patients, they must also promote health in themselves and one another.

To mitigate incivility in the critical care area, there should be a focus on the nurse-preceptor connection during orientation, an ongoing supportive collaboration with nursing management and nursing professional development, and experienced nurses who have an interest in mentoring new nurses. Strategies for preceptors to employ during orientation include:

  • practicing handoff report with the orientee and roleplaying a scenario in which another nurse attempts to interrupt with criticisms
  • allowing the new nurse to observe a global view of the responsibilities of all team members and providing unit-based simulation to practice skills from novice to expert level
  • assigning a secondary preceptor to increase advocacy for the orientee and help him or her maintain consistency with streamlined objectives, planning and evaluation of progress, and supportive assimilation into unit culture.
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A supportive work environment

When a new graduate nurse considers a position on an ICU, the interview generally begins with the nurse manager and continues with a staff panel interview. This is an opportunity to gauge the level of support from coworkers and leadership, as well as observe team dynamics and congruity between staff and management. Asking what support is offered to new ICU nurses after orientation can help distinguish an uncivil environment from a supportive one. If the answer is “We generally like to give the toughest assignment to see you sink or swim,” it's a red flag. Other red flags during the interview process include noting negative nonverbal behavior such as eyerolling, sidebar commentary between clinical nurses, inside jokes, or someone deliberately pointing out that not everyone makes it through orientation.

A supportive environment will have transparency during the interview process in which clinical nurses may point out the degree of difficulty transitioning to an ICU, followed by a description of the level of support they've offered to other new nurses in addition to the support received by leadership during their own orientation struggles (see Supportive resources).



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Change for the better

When we foster focused preceptorship and supportive collaboration between nursing management, nursing professional development, and clinical nurses, we can mitigate incivility in the critical care area for better patient outcomes and increased nurse satisfaction.

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American Nurses Association. Violence, incivility, and bullying.
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