Civility is not situational. What a leader must manifest all day, every day, is civility, because civility is—or at least should be—an expectation and imperative for all of us…especially in health care.
—Michael S. Woods, MD, MMM, author and healthcare consultant
Recognizing, addressing, and preventing incivility calls for a systematic organizational approach to fostering healthy workplaces that deliver safe patient care. Failing to note and deal with uncivil behaviors causes at least as much damage as the incivility itself. Especially if perpetuated in a patterned way over time, uncivil behaviors can cause lasting harm to individuals, teams, and organizations. Perhaps most important, they can jeopardize patient care, leading to life-threatening mistakes, preventable complications, and patient injury or even death.
What’s more, incivility taxes an already stressful healthcare environment by potentially jeopardizing nurses’ health, well-being, and job satisfaction and imposing a heavy financial burden for healthcare organizations. Implementing measures to address and prevent uncivil behavior is imperative for both the nursing profession and the organization.
Incivility includes a range of rude, disruptive, or intimidating behaviors, including both nonverbal behaviors (such as eye rolling, smirking, and walking away in disgust) and overt behaviors (for instance, making demeaning remarks, spreading rumors, gossiping, and excluding or marginalizing others). Incivility also includes failing to act when action is warranted, such as by refusing to share important information about a patient’s care, failing to speak up when indicated, or refusing to assist or support a coworker. An uncivil act (or failure to act) that’s ignored or left unaddressed is, in essence, being sanctioned or condoned.
Strategic role of nursing leadership
Nurse leaders play a key role in fostering healthy workplaces. Some hold formal positions with official titles; others have informal positions without titles. In either case, they have a powerful impact on team functioning, communication, and patient care; their influence can’t be overestimated.
Ethical, principled, collaborative, and trustworthy leaders make a significant contribution to the organization. They set the tone for the types of professional interactions expected by role-modeling civility, professionalism, and ethical conduct. Although all nurses serve as role models, leaders play an especially significant role by consistently modeling professional behaviors and addressing unacceptable behaviors. (See ANA’s position on workplace civility.)
Strategies for fostering civil workplaces
Nurse leaders can leverage staff meetings and similar venues to raise awareness about the need for civility, discuss acceptable and unacceptable behaviors, and simulate and practice ways to effectively prevent and address incivility, particularly where patient safety is at stake. Three key strategies for fostering civil workplaces are:
- crafting a shared and compelling organizational vision and statement of shared values
- co-creating and abiding by team norms (ground rules)
- developing and implementing policies and procedures that address workplace health.
Organizational vision and shared values
Nurse leaders can start by conducting a careful, comprehensive review of the organization’s foundational statements to ensure its mission, vision, and philosophy align with the principles of civility and respect. A clear organizational vision helps everyone understand the organization’s purpose and articulates a collective sense of a desirable future. Here’s an example of a vision statement based on the tenets of a healthy, civil workplace:
Our organization is dedicated to creating and maintaining a healthy work environment that includes respectful behavior, civility, honest communication, openness to opposing viewpoints, and an unequivocal commitment to patient safety and quality care.
A corresponding statement of shared values supports the organization’s vision and is crucial for successful team functioning, high-quality care, and patient safety. Examples of shared values include superior patient safety and quality care, holistic and ethical practice, integrity, accountability, respect, and collaboration.
Team norms that promote civility
Team norms originate from the organization’s vision and shared values. Without them, desired behavior is ill-defined, leaving team members to make things up as they go along. In contrast, when norms are established, affirmed, and operationalized, teams and organizations have a clearer vision of the future and are well positioned for success. Examples of functional team norms include:
• assuming that others bear goodwill and the best intentions
• thinking the best of others
• speaking up when appropriate to ensure patient safety
• fostering a work environment that promotes respect, communication, and collaboration
• listening well with the intention to understand
• maintaining respectful interactions with all team members
• avoiding gossip and spreading rumors.
Team members need to determine how norms can be operationalized and how each team member will abide by them. This requires individual and collective accountability. Employees’ willingness to hold themselves and others accountable is critical to every successful organization.
Policies and procedures that address workplace health
Other crucial steps to reduce incivility include incorporating policies and procedures for preventing and addressing uncivil, disruptive, and bullying behaviors and evaluating professional behavior standards in yearly personnel reviews. Organizational change must include a confidential nonpunitive system of event reporting and swift intervention to mitigate issues. Policies must be clear, fair, consistent in terms of expectations, and widely disseminated.
Rewarding civility and addressing incivility
Having processes in place to reward civility can serve as a powerful motivator to encourage desired behaviors, especially speaking up to ensure patient safety. Although positive motivators are preferred, consequences for incivility must be stated clearly and followed through.
Uncivil behavior is best addressed privately, if possible, and in a respectful manner. You might use the following script when addressing a team member who has exhibited eye rolling or other uncivil nonverbal behaviors: “I noticed from your facial expressions that you might have something to say to me. It’s okay to speak with me directly. That’s how I learn.” Nurses’ vital role in creating and sustaining cultures of civility can’t be underestimated. At all levels, we must raise awareness, individually and collectively, about the existence and consequences of incivility and role-model professionalism to achieve lasting change.
Cynthia M. Clark is the strategic nursing advisor for ATI Nursing Education and a professor emeritus at Boise State University in Boise, Idaho.
American Nurses Association. Position statement: Incivility, bullying, and workplace violence. 2015.
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Washington, DC: Author; 2015.
Clark CM. Creating & Sustaining Civility in Nursing Education. Indianapolis: Sigma Theta Tau International; 2013.
Griffin M, Clark CM. Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. J Contin Educ Nurs. 2014;45(12):535-42.
Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.
Woods MS. Civil Leadership: The Final Step to Achieving Safety, Quality, Innovation, and Profitability in Health Care. Oakbrook Terrace, Ill: Joint Commission Resources; 2011.