Incivility in Nursing


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Incivility in nursing. Given by Dr. Sheila Davis and USM Ph.D. students.

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  • TITLE: When you consider incivility among nurses… what do you think of??
    University of Alabama
  • Measures to Free Nursing Education of Incivility
    Creation of a civil workplace in nursing education requires participation by students, faculty, and administration. Everyone involved in the nursing education workplace must be aware of the concept of incivility in the workplace. Self evaluation of participation in precipitating or actual behaviors of incivility is required to take steps to change the environment of nursing education. A zero-tolerance approach to incivility is the most important action to stop and prevent the occurrence. Implementation of zero-tolerance also will require communication between students, faculty, and administration to understanding civil and uncivil behaviors (Longo & Sherman, 2007).

    The issue of incivility is impacting nursing education. Short and long term consequences of uncivil behaviors are expanding. Shortages of nurses and nursing faculty demand actions to correct the problem of incivility in nursing education toward faculty members and students. With the critical need for nurses and nursing educators, the profession of nursing cannot allow the behaviors of incivility to continue in nursing education. Individual students, faculty, and administrators nurses must take personal accountability in recognizing incivility and creating a civil environment. Nursing education should not tolerate incivility, but model civil behaviors to create a productive, pleasant academic environment.
  • Faculty to student.
    Uncivil behaviors from faculty toward students cannot be tolerated in nursing education. Zero-tolerance policies concerning incivility by nursing faculty members and clear communication of faculty expectations of civility must be documented (Clark, 2008; DalPezzo & Jett, 2010; Pearson & Porath, 2005). Students have to be comfortable with feeling able to talk to faculty about uncivil behaviors and follow appropriate steps if retaliation is a perception. Active involvement of faculty with students to create strategies to stop incivility will encourage faculty to be leaders and role model civility (Clark, 2008; DalPezzo & Jett, 2010; Pearson & Porath, 2005). Nursing faculty must be aware of uncivil behavior perceptions of students and continually reflect of behaviors to evaluate faculty participation in incivility (Clark, 2008; DalPezzo & Jett, 2010; Longo & Sherman, 2007; Pearson & Porath, 2005). Reports of faculty incivility must be quickly addressed and violations by faculty cannot be overlooked (Longo & Sherman, 2007; Pearson & Porath, 2005; Rau-Foster, 2004).
  • Faculty to student.
    Uncivil behaviors from faculty toward students cannot be tolerated in nursing education. Zero-tolerance policies concerning incivility by nursing faculty members and clear communication of faculty expectations of civility must be documented (Clark, 2008; DalPezzo & Jett, 2010; Pearson & Porath, 2005). Students have to be comfortable with feeling able to talk to faculty about uncivil behaviors and follow appropriate steps if retaliation is a perception. Active involvement of faculty with students to create strategies to stop incivility will encourage faculty to be leaders and role model civility (Clark, 2008; DalPezzo & Jett, 2010; Pearson & Porath, 2005). Nursing faculty must be aware of uncivil behavior perceptions of students and continually reflect of behaviors to evaluate faculty participation in incivility (Clark, 2008; DalPezzo & Jett, 2010; Longo & Sherman, 2007; Pearson & Porath, 2005). Reports of faculty incivility must be quickly addressed and violations by faculty cannot be overlooked (Longo & Sherman, 2007; Pearson & Porath, 2005; Rau-Foster, 2004).
  • Student to faculty.
    Actions to prevent and intervene for behaviors of incivility from students include establishing and communicating clear policies including zero tolerance regarding conduct in classroom and clinical (Clark, 2008; DalPezzo & Jett, 2010; Pearson & Porath, 2005). Those interacting with students must understand and role model civility. Civility is shared and faculty should not provoke students. Students should be guided to self-reflect and be accountable for uncivil behaviors committed (Clark, 2008; DalPezzo & Jett, 2010; Longo & Sherman, 2007; Pearson & Porath, 2005). Criminal background checks before admission to the nursing program can assist in evaluating behaviors that may be considered uncivil (DalPezzo & Jett, 2010; Pearson & Porath, 2005). Faculty education on manifestation of uncivil behaviors will equip faculty and administration to notice warning signals (DalPezzo & Jett, 2010; Longo & Sherman, 2007). Quick intervention for uncivil behaviors is needed by faculty and administration with enforcement of policies consistently. A shared governance approach with students can assist with interventions to reduce incivility (Clark, 2008; DalPezzo & Jett, 2010; Pearson & Porath, 2005).
  • Faculty to faculty.

    Incivility in nursing education between nursing faculty is prevalent. Measures to stop horizontal violence in the academic workplace are required to make nursing education a civil environment. Nursing faculty should be knowledgeable of the concept of incivility in the workplace including manifestations and interventions. Self-awareness for acts of incivility is required for nursing faculty. Zero tolerance expectations should be communicated to all faculty and excuses not accepted for leaders of incivility. Policy should be clear, consistent and timely enforced for uncivil behaviors (DalPezzo & Jett, 2010; Longo & Sherman, 2007; Pearson & Porath, 2005). The academic environment must be caring, supportive and respectable to have a civil culture. Cooperation and collaboration between nursing faculty is needed to expand nursing knowledge development for students and coworkers. Careful selection of faculty and heeding warning signals will prevent creation of an uncivil environment. Faculty recognizing uncivil behaviors must refuse to become a victim and intervene to stop incivility (DalPezzo & Jett, 2010; Pearson & Porath, 2005). Monitoring group formation to support bullying is essential to preventing an uncivil environment (Hutchinson, Wilkes, Jackson, & Vickers, 2010; Longo & Sherman, 2007).
  • Administration to faculty and students.
    Administration responsibility in creating and maintaining civility in the workplace of nursing education includes self-awareness and reflection of administrative acts of incivility toward faculty and students and enforcement of zero tolerance policies for uncivil behaviors. Administration actions to prevent incivility include ensuring nursing faculty feel respected and valued for their knowledge and work. Acknowledgement of quality work and not just critique will build confidence and a healthier work environment. Kindness and respect for faculty time and office space facilitates civility in the workplace (Rau-Foster, 2004). Listening to faculty is important to hear reports and impact of incivility on individual faculty and the academic environment. Development, implementation, and enforcement of policies for zero tolerance of uncivil behaviors in the academic environment is expected from administration. Dealing with uncivil behaviors is mandatory and instigators on incivility cannot be excused. Faculty and students must be clearly educated on the concept of incivility and understand uncivil behaviors will not be tolerated (Longo & Sherman, 2007; Pearson & Porath, 2005; Rau-Foster, 2004). Teaching civility and promotion of positive behavior encourages faculty and students to enhance the academic environment (Pearson & Porath, 2005; Rau-Foster, 2004). Other important administrative measures to create a civil workplace include acknowledgement of warning signals of incivility, looking at the organizational structure on the nursing education workplace to decrease power structures which can support bullying, and listening to the interviews of faculty that leave the organization (DalPezzo & Jett, 2010; Longo & Sherman, 2007; Pearson & Porath, 2005).
  • Incivility in Nursing

    1. 1. The University of Southern Mississippi PhD Program of Nursing
    2. 2. • Sheila P. Davis, PhD, RN, FAAN • Mary Friend – PhD Student • Charlotte Gore- PhD Student • Danny Tige Lantrip- PhD Student • Melissa Martin- PhD Student • Sharon McDonald- PhD Student • Melinda Sills – PhD Student
    3. 3. Define incivility and state statistics to its manifestation in the academic and practice setting Be aware of the range of behaviors associated with incivility Provide input into a conceptual model for recognition and reduction of incivility in nursing. state at least three precipitating indices related to incivility State at least three alleviating indices related to incivility Be aware of resources to aid in formation in policies and procedures related to incivility
    4. 4. • Definition – any action that is offensive, Intimidating, or hostile that interferes with the Learning and/or practice environment (CRLT). Such behavior may be increasing, thus jeopardizing the welfare of the educational and/or practice setting of nurses.
    5. 5. • “I was typing my patient assignment on the computer and began humming to myself. The instructor approached me angrily and told me that if I hummed again, she would kick me out of clinical. .. She really let me have it in front of other students……inside, I was ready to burst.” (Clark, 2008)
    6. 6. • “ Faculty who realize that they will likely face inappropriate behavior during lectures may begin devoting time and energy to planning coping ( survival) strategies rather than focusing on lecture material. Further, faculty who dread going to a particular class and having to deal with particular students can become demoralized and disillusioned with the overall teaching process.” (Morrissette,
    7. 7. Luparell( 2008) • Moderate problem in nursing ( Clark & Spring, 2007) • Tardiness, talking in class, and other inattentiveness was experienced by 100% of faculty • One half of faculty reported being yelled at in the classroom • 43% of faculty reported being yelled at in clinical setting • Faculty report having serious emotional and physical consequences
    8. 8. Jane Legacy • Incivility appears to be an increasing dilemma for organizations. • Incivility is getting worse and more exaggerated • Incivility is a business issue – expensive $$ – Victims suffer from increased stress, anxiety, exhaustion, sleeplessness, depression, anger and embarrassment. Lost of work time, sickness, extreme reactionary actions, and lawsuits can result from incivility.
    9. 9. • According to Gary and Ruth Namie, authors of The Bully at Work, bullying is ‘the repeated malicious, health-endangering mistreatment of one employee (the target) by one or more employees (the bully, bullies). The mistreatment is psychological violence, a mix of verbal and strategic assaults to prevent the target from performing well. It is illegitimate conduct in that it prevents work getting done. Thus an employer’s legitimate business interests are not met.
    10. 10. • Almost 38% of shootings in the workplace happened in "white collar" situations. This makes up over 30% of all fatal shootings at work. • Florida and California were the most dangerous states involving shootings on the job. • 24% of workplace shooters were laid off or fired. • about 9% of those shooting showed warning signs beforehand that were commonly ignored when others noticed them. • There were about 13% of shootings in the workplace that involved a former or current intimate relationship. • Over 13% of cases revealed the workplace shooter had a history of mental health issues
    11. 11. • Patients yelling, using vulgarities at the nurse and throwing things? • Physicians being discourteous and obnoxious? • Experienced nurses leaving new nurses to fend for themselves? • Anger, jealousy and strife between nurses or units? • School/College /University shootings/ most recently faculty on faculty- February 2010
    12. 12. • The previous are all blatant acts of Horizontal Incivility and Violence! • But incivility is not always that easy to identify.
    13. 13. • Arriving late to a meeting or leaving early. • Sending an e-mail without a greeting. • Not using uncivil words- but using accompanying harsh tones or body language. • Dismissing or ignoring co-workers concerns, thoughts, or input.
    14. 14. Please don’t answer Just Think… Have you ever been guilty of any of these?
    15. 15. • Perhaps incivility is more common than we think. • Perhaps incivility exist in places we are afraid to consider. • In fact, incivility has permeated all areas of society and nurses are no exception.
    16. 16. Objective 3 Provide input into a conceptual model for recognition and reduction of incivility in nursing.
    17. 17. ….. A dynamic interaction between faculty and students. When viewed as a ‘dance’ rather than a struggle for power and control, the potential for healing is enhanced. (Clark 2008)
    18. 18. • Crowded working conditions • Overworking conditions • Too many demands • Fundamental mistrust between students and faculty that faculty are trying to “weed them out” • Fundamental mistrust between subordinate and supervisor • Ineffective classroom and/or practice management skills ( Luparell, 2008)
    19. 19. • Requires – Nurses – Students – Faculty – Administration
    20. 20. • Zero-tolerance • Clear communication • Non-threatening environment • Shared involvement • Self-reflection • Cooperate • Collaborate • Monitor for bullying groups • Carefully select employees
    21. 21. • Zero-tolerance • Clear communication • Non-threatening environment • Shared involvement • Self-reflection
    22. 22. • Zero-tolerance • Clear communication • Role-models • Shared involvement • Self-reflection • Criminal background checks • Act on warning signals
    23. 23. • Zero-tolerance • Clear communication • Self-reflection • Cooperate • Collaborate • Carefully select faculty • Refuse to be a victim • Monitor for bullying groups
    24. 24. • Zero-tolerance • Clear communication • Self-reflection • Respect subordinates • Listen • Educate subordinates on incivility and civility • Acknowledge warning signals • Evaluate organizational structure
    25. 25. • Anti-bullying legislation was enacted in Sweden in 1993, Great Britain in 1997, Belgium in 2002 and Australia in the mid- to late-1990’s (Leymann & Gustafsson 1996; Namie 2004). • Targets in the U.S. find few avenues of legal redress available.
    26. 26. Two federal statutes that spell out the affirmative duty of managers to provide a safe, non-hostile working environment. 1. Occupational Safety and Health Act of 1970 2. Title VII,Civil Rights Act
    27. 27. • Case law associated with Title VII of the U. S. Civil Rights Act of 1964 has established employer liability for the consequences of a hostile work environment. Title VII prohibits discrimination on the basis of “race, color, religion, sex, and national origin” which renders it inadequate to protect against generalized workplace bullying.
    28. 28. • The U. S. Occupational Safety and Health Act of 1970 (OSHA) was primarily designed to respond to physical hazards in the workplace (Yamada 2000). OSHA’s protections do not generally extend to psychological or stress- related hazards in the workplace.
    29. 29. • Few, if any, States recognize psychological or stress-related claims as compensable under their Workers’ Compensation programs. Because the vast majority of workplace bullying is verbal in nature, there is often no direct physical injury to the target.
    30. 30. • New York is the only state that forbids abusive conduct in the workplace. • In May 2010, the New York State Senate passed the Healthy Workplace Bill, a measure that would allow workers to sue for physical, psychological, or economic harm from abusive treatment at work.
    31. 31. • There are many ways that you can contribute to the Healthy Workplace Bill Campaign, from a simple letter to the editor or become a state coordinator, everything helps • Citizen lobbying as opposed to professional lobbying is appreciated by most politicians. • Gary Namie, PhD • Director of the Healthy Workplace Bill Legislative Campaign.
    32. 32. • Taking the perspective that bullying is a safety issue, in 2008, the Joint Commission issued a standard on intimidating and disruptive behaviors at work, citing concerns about increased medical errors, poor patient satisfaction, adverse outcomes, higher costs, and loss of qualified staff.
    33. 33. • The ANA Code of Ethics states nurses have a responsibility to establish, maintain and improve health care environments and conditions of employment conducive to the provision of quality healthcare.
    34. 34. • American Association of Critical Care Nurses’ Healthy Work Environment Initiative (2004). • AACN’s Healthy Work Environment initiative is a multipronged, multiyear effort to engage nurses, employers and the nursing profession in recognizing the urgency and importance of working collaboratively to improve the environments in which nurses work.
    35. 35. • The American Organization of Nurse Executives has stated that collaboration and communication are some of the characteristics that are needed in a healthy workplace.
    36. 36. Principles and elements of a healthful practice/work environnent. (2008.) 1. Collaborative Practice Culture 2.Communication Rich Culture 3. A Culture of Accountability 4. The Presence of Adequate Numbers of Qualified Nurses
    37. 37. The Presence of Expert, Competent, Credible, Visible Leadership Shared Decision-Making at All Levels The Encouragement of Professional Practice & Continued Growth/Development Recognition of the Value of Nursing’s Contribution Recognition by Nurses for Their Meaningful Contribution to Practice
    38. 38. • The National League for Nursing has focused on work environments in academia and has published the Healthful Work Environment Tool Kit© that can be used by applicants for faculty positions, current faculty members, and nurse administrators to assess an academic work environment.
    39. 39. • The tool kit addresses the following nine work-related areas: salaries, benefits, workload, collegial environment, role preparation and professional development, scholarship, institutional support, marketing and recognition, and leadership. These areas are used to frame the discussion of how nursing faculty and administrators can work together to assess and enhance the health of nursing academic workplaces
    40. 40. • Center for American Nurses. Lateral violence and bullying in the workplace. 2008. • It is the position of the CENTER that there is no place in a professional practice environment for lateral violence and bullying among nurses or between healthcare professionals. All healthcare organizations should implement a zero tolerance policy related to disruptive behavior, including a professional code of conduct and educational and behavioral interventions to assist nurses in addressing disruptive behavior.
    41. 41. • In the NLN/Carnegie Foundation Survey, Nurse Educators: Compensation, Workload and Teaching Practices, nurse educators reported working just over 56 hours per week while school was in session.
    42. 42. • To maintain a healthy work environment, nurse administrators should ensure that faculty members have options for nine, ten, and twelve month contracts. Another benefit could be joint-appointment contracts allowing faculty to fulfill both education and practice role responsibilities.
    43. 43. • First, it is important to develop a code of conduct describing the types of behavior that are considered disruptive .The code needs to address all workers in an organization, including employees, such as nurses, and nonemployees, such as physicians (Barnsteiner, Madigan, & Spray, 2001).
    44. 44. • In order for a code of conduct to be effective, it must be applied in all circumstances where there is a possible breach. Without this enforcement, the code is meaningless. All team members, including hospital administrators, chief nursing officers, and other nursing leaders, need to be accountable for modeling and enforcing the code.
    45. 45. Provide coaching and mentoring as needed to help improve behaviors. Provide mediation services in instances of unresolved disputes between parties . If well-documented efforts at changing the behaviors are not adequate, take disciplinary action.
    46. 46. • Griffin (2004) reported that newly licensed nurses who had been taught about the use of cognitive rehearsal techniques to address disruptive behaviors were better able to confront nurses who displayed lateral violence.
    47. 47. • One strategy that has been used by nurses to show support for other nurses is by calling a “Code Bully” or a “Code Pink” (Childers, 2004; Namie & Namie, 2009). If a nurse is being yelled at by another healthcare worker, a code can be called by word of mouth or by a more formal method, and the nurses can unify by physically standing behind the nurse so as to let the disrupter know that the disruptive behavior is unacceptable (Childers, 2004).
    48. 48. • American Medical Association: www.ama- people/member-groups-sections/organized- medical-staff-section/helpful- resources/disruptive-behavior.shtml • HC Pro: ail/225618.cfm
    49. 49. • For those nurses wishing to learn more about disruptive behaviors, the Center for American Nurses (CAN) has a free webinar titled 10 Tips for Addressing Disruptive Behavior at Work that can be accessed at mmon.cfm?an=1&subarticlenbr=195.
    50. 50. • Employers can reduce risks by identifying and controlling workplace incivility before it gets out of hand. • Have a civility in the workplace policy that requires the exercise of self-control at work and professionalism in dealing with coworkers. Make sure employees are aware of any anti-stress programs you have. Walking paths, exercise rooms and anger management classes are examples
    51. 51. • Provide a quiet area that employees may use to get away when needed. • Make sure that employees are aware of job related resources • Keep in mind that ignorance is not bliss where desk rage is concerned and have a good plan for dealing with it.
    52. 52. • American Association of Critical-Care Nurses (2005). AACN Standards for establishing and sustaining healthy work environments. Available: • Center for American Nurses. February 2008. Position statement on lateral violence and workplace bullying. ns/lateralviolence.pdf • (accessed July 15, 2010).
    53. 53. • American Organization of Nurse Executives (2006). AONE guiding principles for excellence in nurse/physician relationships. Retrieved June 17, 2009, from
    54. 54. • Center for Research on Learning and Teaching (2010). Teaching strategies: Incivility in the college classroom. Retrieved September 30, 2010, from • Childers, L. (2004, April 26). Bullybusters: Nurses in hostile work environments must take action against abusive colleagues. Nurseweek. Retrieved August 19, 2009, from 04/bullies_print.html
    55. 55. • Clark, C. (2008). Student voices on faculty incivility in nursing education: A conceptual model. Advances in Nursing Science, 31 (4), E37-E54. • Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35, 257-263. • Grover, S.M. (2005). Shaping effective communication skills and therapeutic relationships at work. AAOHN Journal, 53(4), 177-182
    56. 56. • Healthy Workplace Bill. Available at: Accessed July 20, 2010. • The Joint Commission. Sentinel Event Alert #40. Behaviors that undermine a culture of safety. July 9, 2008. Available at: nts/SentinelEventAlert/sea_40.htm Accessed September 22, 2010.
    57. 57. • Lazoriz, S., and P. J. Carlson. 2008. Don’t tolerate disruptive physician behavior. American Nurse Today 3 : p?sid . • Legacy, J. , Incivility in the workplace. Retrieved July 7, 2010 from • Luparell, S. (2008). Incivility in nursing education: Let’s put an end to it. NSNA Imprint, April/May, 42 – 46.
    58. 58. References • Morrissette, P. (2001). Reducing incivility in the university/college classroom. Retrieved, July 7, 2010 from • Yamada, David C., Crafting a Legislative Response to Workplace Bullying (2004). Employee Rights and Employment Policy Journal, Vol. 8, p. 475, 2004. Available at SSRN:
    59. 59. The University of Southern Mississippi 118 College Drive, #5095 Hattiesburg, MS 39406-0001 601-266-5457