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Workplace incivility

Nurse leaders as change agents

Green, Cheryl Ann, DNP, PhD, RN, LCSW, CNE, CNL, MAC, FAPA

doi: 10.1097/01.NUMA.0000550455.99449.6b
Department: Performance Potential

In New Haven, Conn., Cheryl Ann Green is an assistant professor at Southern Connecticut State University and an off-shift nurse leader at Yale-New Haven Hospital.

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

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Incivility in the workplace can include making demeaning facial expressions, such as rolling eyes or raising eyebrows; withholding information; rudeness; communicating in a passive-aggressive manner; gossiping; breaking confidences; and scapegoating.1 Historically, nursing is a profession that's lacked diversity.2 Exclusionary behaviors in the workplace and nurses feeling disempowered can lead to incivility, bullying, and violence. Exclusionary behaviors may include a violation of Equal Employment Opportunity laws, such as sexual harassment or discrimination due to age, genetic information, disability, race, national origin, religion, or gender.3 Despite their likely emotional and psychological origins, uncivil behaviors constitute disruptions to patient care when nurses are affected within the clinical environment, impacting nurse retention and patient safety.4,5

By acknowledging the problem of incivility and making the intentional decision to engage staff in the change process, nurse leaders can resolve conflict while promoting transformation. The purpose of this article is to encourage nurse leaders to identify uncivil conduct within their immediate work environments and be empowered to intervene, report the alleged perpetrator(s), and assist the victimized nurse(s) in receiving support.

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Becoming a change agent

The American Nurses Association (ANA), in its position statement “Incivility, Bullying, and Workplace Violence,” notes that it's the responsibility of both employers and RNs within clinical and academic settings to maintain workplace cultures in which incivility, bullying, and violence aren't tolerated.4 It's the legal, ethical, and moral responsibility of employers to create safe work environments that are conducive to nurses' health and well-being, as well as other healthcare team members, patients, and patients' families.

However, the decision to lead the charge against workplace incivility can be complex. Nurse leaders themselves may be aligned with the bullying employee(s) and it can be difficult to stand up to a fellow nurse(s) who's contributed to a toxic work environment for several years. But failure to do so may eventually affect the nurse leader's reputation as an effective manager. Nurse leaders are professionally obligated to acknowledge the presence of workplace incivility, bullying, and violence and actively seek resolution.4

If you're a nurse leader who's tolerated uncivil conduct by your staff members or if you've just been made aware of the presence of incivility on your unit, it isn't too late to change the work environment. Consider the causative factors associated with workplace incivility in the literature. Talk about the problem with administration and your human resources department. Schedule staff meetings to discuss concerns and potential solutions using a brainstorming approach. After eliciting feedback from your staff, you can develop a plan of resolution.

While reviewing the literature, conduct an honest inventory of your own strengths and weaknesses within your leadership role(s). Review leadership styles to determine the style you most often use in your interactions with your staff. For example, the democratic leader uses constructive criticism to institute change among the group and encourages the group to make decisions together.6 With this leadership style, staff members experiencing uncivil conduct are more likely to feel comfortable discussing their concerns and can anticipate some degree of change to occur within the workplace environment. Transformational leaders motivate staff members to accomplish a goal or an initiative.7 They exhibit organizational citizenship behaviors, use listening skills, and pay attention to their staff members' needs and identified goals, which can positively impact staff engagement, team member collaboration and relationships, and patient care.8 The quantum leader manages complex dynamics at the unit and organizational level, responding with interventions to address issues.9 Within quantum leadership theory, team collaboration is imperative to establishing interconnectedness and, ultimately, resolving identified problems.

On the other hand, laissez-faire leaders avoid criticism of others' behaviors and have difficulty with providing direction.10 Under this style of leadership, the staff member experiencing uncivil conduct is left to cope with the problem alone. The autocratic leader is punitive in his or her criticism of others' behaviors and right or wrong decisions are made with minimal to no group input.11 This can be problematic when the leader is a participant within the culture of incivility.

When addressing workplace incivility, the democratic leadership style can be effective. This style allows for objectivity when discussing environmental dysfunction within the workplace, with multiple views being shared within the group. Sharing viewpoints may potentially decrease staff members' fear and anxiety, facilitating honest discussion. In collaboration with your staff members, you can begin to address the negative behaviors associated with uncivil conduct. You can also set a regularly scheduled time to meet with staff members to discuss behavioral expectations and the consequences of engaging in incivility.

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Breaking the pattern

Education about changes to the way the unit will function must include the ANA's stance of zero tolerance for incivility. Organizational support of unit-based initiatives to correct the culture of incivility will further substantiate and sustain adoption of positive change. You'll need formal and informal resources as you facilitate the restoration of civility on your unit(s). Resources can include an organizational development specialist, chaplain, clinical nurse specialist, clinical nurse leader, or employee-assistance counselor. With the involvement of other professionals within the organization, you'll be better supported to sustain the culture change of zero tolerance for workplace incivility.

Maintenance of a civility intervention can include weekly staff meetings to address conflicts, every-other-week education sessions on conflict resolution for all shifts, and counseling/coaching followed by progressive discipline for staff members who don't adhere to the zero tolerance for workplace incivility initiative. When you encounter unit-based incivility issues, you must communicate with and have referrals readily available for affected staff members who need counseling and support during and after the incident. (See Helpful tips.)

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Change is possible

Today's nurse leaders are innovative decision-makers within their clinical environments. Nurse leaders mentor expert nurses and novices alike, while working to align complex changes on their unit(s) with the healthcare facility's mission, vision, and strategic plan. Workplace incivility can be disruptive to the overall function of clinical units; however, instituting a zero-tolerance policy for incivility will begin a positive change and lead to better outcomes for our staff and our patients.

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Helpful tips

  1. Inform all nursing staff members that incivility within the healthcare environment isn't only harmful to their colleagues, but also to patient safety. Adopt a zero tolerance for incivility, bullying, and violence.
  2. Don't circumvent the problem because this invalidates the affected nursing staff, allowing the culture of incivility to continue.
  3. Use the terminology of incivility, bullying, and violence when discussing the negative interactions reported and observed on the unit.
  4. Avoid blaming and/or identifying the affected individuals—both victims and perpetrators—in front of other staff members. Meet privately with these nurses to provide support and insight into the resolution of the problem. For example, realizing that both the perpetrator and victim can benefit from counseling, an employee-assistance referral can be instituted.
  5. When counseling fails, place nurses who are perpetrators of workplace incivility on a progressive discipline plan to document any repeated episodes of the behaviors.
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REFERENCES

1. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J Contin Educ Nurs. 2004;35(6):257–263.
2. Schmidt BJ, MacWilliams BR, Neal-Boylan L. Becoming inclusive: a code of conduct for inclusion and diversity. J Prof Nurs. 2017;33(2):102–107.
3. US Equal Employment Opportunity Commission. Types of discrimination. 2017. http://www.eeoc.gov/laws/types.
5. Khadjehturian RE. Stopping the culture of workplace incivility in nursing. Clin J Oncol Nurs. 2012;16(6):638–639.
6. Tomey AM. Guide to Nursing Management and Leadership. 8th ed. Saint Louis, MO: Mosby Elsevier; 2009.
7. Breevaart K, Bakker A, Hetland J, Demerouti E, Olsen OK, Espevik R. Daily transactional and transformational leadership and daily employee engagement. J Occup Organ Psychol. 2014;87(1):138–157.
8. Jun SY. Mediating effect of social capital between transformational leadership behavior and organizational citizenship behavior in hospital nurses. J Korean Academy Nurs Adm. 2017;23(5):558–566.
9. Porter-O'Grady T., Malloch K. Quantum Leadership: A Textbook of New Leadership. Boston, MA: Jones & Bartlett; 2003.
10. Roussel LA. Management and Leadership for Nurse Administrators. 4th ed. London, England: Jones and Bartlett Publishers; 2006.
11. Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing: Theory and Application. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
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