Nurses in healthcare settings face numerous challenges, such as economic and reimbursement constraints, fast-paced technologic advances, the need to retrieve and report high quantities of data, and the increased demand to care for patients with complex medical needs, to name a few. These challenges, among others, create stressful and emotionally charged environments. The American Nurses Association (ANA) acknowledges that the environments in which nurses often work can “lead to situations where emotions boil over.”1 According to the ANA, incivility and bullying are “widespread in all settings.”2 And The Joint Commission reports that incivility in the form of bullying is at epidemic levels.3
Workplace incivility and bullying are topics frequently talked about in our offices, hallways, stairwells, and cafeterias, yet they may be hard to address in action. The effects of incivility, bullying, and violence in our work environments put everyone in the institution at risk for physical and emotional harm. In fact, incivility, bullying, and workplace violence are so prevalent that The Joint Commission issued a Sentinel Event Alert for all “behaviors that undermine a culture of safety.”4
In one study polling 800 managers and employees in 17 industries, it was found that the financial loss and negative effects of incivility were enormous, including decreased motivation, creativity, and team spirit and one-third less quality of work being accomplished.5 Eighty percent of those polled spent time worrying at work about the incidence of incivility, 60% spent time at work avoiding the offender, and 78% admitted to being less committed to the organization.5 The effects of incivility can stifle employee motivation and communication, cause mistrust and a liberal use of sick time, decrease productivity, create staff burnout, increase legal liability, and drive employees to leave their jobs at greater turnover rates, resulting in human resources costs and affecting the company's bottom line. When incivility occurs in the healthcare workplace, it may lead staff members to be less likely to report both safety and quality issues, which can increase errors causing patient harm.4 Furthermore, incivility causes talented staff to leave, making it harder for organizations to implement the improvements needed in healthcare today.4
Personal experience and countless research confirm the crisis of incivility in nursing. If these behaviors go unaddressed and have no repercussions, it creates environments where incivility can run rampant in our organizations. When we encounter incivility and bullying, it has a five times greater effect on our mood than a positive encounter, and it takes many positive encounters to counteract the damage done by the incident.6 One-third of people who witness incivility and bullying want to intervene but are afraid to do so and eventually may leave the organization as a result.6 As a nursing supervisor, it isn't uncommon to hear of an employee's personal encounter with or witnessing of incivility and/or bullying at work. Unfortunately, the employee is often reluctant to formally report the incident. In fact, when encouraging employees to speak up against incivility and bullying, a common response is, “Why bother, nothing changes anyway.”
Working in healthcare for over 30 years, I have firsthand experience with incivility and bullying at work both toward me personally and as a bystander. With each of these experiences, I was left asking myself: What should I do about the incident? Should I report it and to whom? Will anything be done? Will I ultimately reap the wrath of reporting it? Thoughts of these incidents lasted for days, weeks, and even months later, and I'm actively recounting some of them as I write this article. Incivility poisons our workplaces and steals our joy, motivation, and job satisfaction, leading to poor work performance and a negative impact on our profession, our organizations and, most important, our patients. But what can we do about it?
Organizations aren't in the dark about incivility and bullying; most workplaces have zero-tolerance policies for this behavior. Yet, research shows that incivility continues to rise. Nurse leaders need clear, evidence-based, achievable strategies to ensure that incivility has no place in our organizations. The ANA's position statement on incivility, bullying, and workplace violence includes primary, secondary, and tertiary prevention strategies.2 Primary prevention strategies address existing vulnerabilities, with the goal of improving interpersonal and intraprofessional relationships. Secondary prevention strategies are aimed at reducing the negative impacts of incivility, bullying, and workplace violence. Tertiary prevention strategies can be used to decrease the consequences of these behaviors.
The ANA recommends that all employees should:2
- make a commitment to create and foster cultures of safety individually and through the implementation of evidence-based strategies
- be committed to establishing and promoting the ability to work as healthy intraprofessional teams
- model respectful, effective communication and professional codes of conduct
- be cognizant and responsible for their own interactions, open to receiving constructive intervention, respectful of feedback from others, and able to apologize and make amends
- receive mandatory education on zero-tolerance policies and action plans for incivility, bullying, and workplace violence, including definitions, assessment, recognition, response, prevention strategies, and consequences for negative behavior
- adhere to zero-tolerance policies with a strict, enforceable, and specific timeline for all corrective action plans
- receive mandatory education on therapeutic communication, diversity and inclusiveness, conflict resolution, stress reduction and management, assessing and addressing fatigue and burnout, enhancing psychological hardiness and resilience, self-care and reflection measures and practices, personal health and wellness strategies that minimize workplace stressors, de-escalation techniques, self-defense, and situational awareness with mock drills
- collaborate with academic institutions to develop curricula that foster cultures of civility
- encourage, protect, and provide policy guidance to those reporting incivility, bullying, and workplace violence
- encourage timely, detailed written reporting by both the victim and witnesses of the incident and transparency with all parties involved
- frequently track, asses, analyze, and respond to data sources such as incident reports related to safety and security
- provide support through peers, leadership, employee assistance programs, counseling, and even legal counsel if warranted
- ensure that all work environments have safety controls, policies, and training in place.
The role of nursing leadership is vital to eliminate incivility, bullying, and violence from our workplaces. All nurse leaders must have competencies to build healthy intraprofessional team relationships and implement and adhere to zero-tolerance policies. Nurse leaders set the organizational tone by modeling good behavior, hiring for civility, creating group norms, seeking out employee feedback, following up on repercussions for negative employee behavior, and even knowing when it's time to let the bullies in the organization go. We need to ensure that zero-tolerance policies are more than just pieces of paper. Implementing evidence-based strategies can help eliminate incivility in the workplace.
With the use of the mnemonic CIVIL, we can promote civil environments for all employees:
- C: Create zero-tolerance environments by ensuring that individuals are accountable for incivility and policies are in place, understood, followed, and updated as necessary.
- I: Institute true zero-tolerance policies and repercussion for negative behavior.
- V: Value employee feedback and reporting by ensuring that incivility is confronted when reported; support is provided; and all employees, including new hires, model professional behaviors aligned with the organization. Also value the hiring process by checking reliable references and assessing candidates for not only their work qualifications, but also for their “soft” skills such as kindness toward others.
- I: Intervene early when reports of incivility occur, demonstrate a persistent intolerance for bad behavior, and provide resources to educate and prevent incivility.
- L: Leadership is essential to enforcing zero-tolerance policies by role modeling good behavior, demonstrating effective intraprofessional teamwork, excelling at the use of therapeutic communication, and mentoring all employees to create civil work environments.
Moving forward together
All employees deserve to work in an environment where civility is promoted and embraced. Although policies are foundational, they're only part of the solution to eliminate incivility, bullying, and workplace violence. We must work collaboratively as a team to address this issue. Nurses have an opportunity to unite the intraprofessional team to create work environments that motivate, inspire, and bring joy to our work so we can continue our mission of providing safe, competent, and quality care to our patients, their families, and our communities.