Practice Matters

Seeking civility

Chris’s story: My unhappy journey with workplace incivility began years ago when I became the target of a psychologically abusive coworker; I’ll call her Liz. I was bullied, ostracized, and made the victim of false and malicious rumors. I became anxious and insecure, and I developed eating problems, head­aches, and disturbed sleep. My judgment and concentration suffered, and I was terrified my symptoms would somehow lead to a patient injury.

Liz’s incivility got so extreme that I reported the problem to my supervisor. Fortunately, she took the situation seriously and set up a meeting between Liz and me. My supervisor was skilled in principled conflict negotiation, and she had us co-create ground rules for the meeting. She started the meeting by confirming that patient safety is the most important goal, then reviewed hospital policies for professional conduct. Next, Liz and I took turns explaining our views of the situation, and together we generated mutually beneficial solutions. I was astonished to hear her say she wasn’t aware of the impact of her behavior. She pledged to be more respectful and asked for feedback about her prog­ress. We ended the meeting by making a plan to meet again in a few weeks to review our progress.

To me, civility is like handwashing: It needs to be taught, reinforced, and given constant attention and reminders.

Chris’s experience with workplace incivility—rude behaviors that violate norms of mutual respect—is far too common. Although most nurses and other healthcare pro­viders strive to foster respectful relationships and positive working conditions, some behave in an uncivil and unprofessional manner. Workplace incivility reduces employee retention, recruitment, and job satisfaction, and it can have devastating and lasting effects on a nurse’s sense of self-worth, confidence, and commitment to nursing. In healthcare workplaces, incivility can lead to medical errors, poor patient care, and increased costs. It’s especially concerning in the nursing profession, with the nurse shortage growing more critical and the profession increasingly called on to lead the advancement of our nation’s health.

Creating and sustaining a civil workplace is an imperative. Fortunately, most nurses and nurse leaders are eager to learn ways to prevent and address workplace in­civility and to implement evidence-based strategies to create and sustain healthy workplaces. This article describes evidence-based tools and strategies to prevent and address workplace incivility.

Professional role modeling

Professional role modeling lays the foundation for civility and respect. Positive role models are mindful of and accountable for the impact of their behaviors on others and consistently display ethical, principled conduct based on acceptable standards of professional practice. They pay attention to detail, encourage collaboration, share important information, and admit mistakes. They foster an atmosphere of collegiality and respect, inspire others to be the best they can be, and are contemplative. In other words, they reflect and seek an accurate reading of their civility level and the quality of their interactions with others. Engaging in thoughtful self-reflection is an important step toward improving your competence as a nurse, colleague, and team member.


Self-reflection: The Clark Workplace Civility Index©

The Clark Workplace Civility Index is a tool for self-reflection that assesses your civility level. It’s designed to raise awareness and identify civility strengths and areas for improvement. (See Clark Workplace Civility Index by clicking the PDF icon above.)

Stress relief and self-care

Stress and incivility are inextricably linked. Nurses confront constant and rapid change, complex care conditions, inadequate staffing patterns, downsizing, and cost-cutting efforts—all while being expected to deliver safe, high-quality care. Additional stress results from caring for high-acuity patients, managing demanding workloads, and dealing with incivility. Stress coupled with poor coping ability not only causes wear and tear on the nurse but also can jeopardize patient care. But stress is a reality of life, and eliminating it is impossible. So it’s important to know and practice stress-management techniques. (See Stress reducers and self-care measures by clicking the PDF icon above.)

Honing your communication and conflict-negotiation skills

Two of the most powerful tools in the civility toolbox are engaging in meaningful conversations and negotiating conflict successfully. Yet many nurses lack these vital skills. I’ve asked hundreds of nurses what keeps them from speak­-ing directly with colleagues when a conversation clearly is needed. Many tell me, “I would, but I really don’t know how” or “The thought of speaking with her about this issue feels emotionally unsafe” or “Are you kidding? How can I possibly speak with my supervisor when he’s the problem?”

In many cases, nurses feel inexperienced or ill-prepared to engage in critical conversations, much less deal with and address incivility, especially with peers and supervisors. There’s no universal technique that addresses every situation successfully, but there are a few guiding principles. Ask yourself:

  • “What will happen if I stay silent?”
  • “Do I feel equipped to address the issue directly, or is it best to report my observations to my supervisor?”
  • “Is there a protocol or a set of guidelines to assist me in this process?”

DESC model for conflict resolution

After reflecting on these questions, you might choose to engage in a direct conversation with your uncivil colleague. If so, plan wisely, seek assistance if needed, and practice before you meet. You may use one of several models for conflict resolution. I like to use the DESC model suggested by TeamSTEPPS from the Agency for Healthcare Research and Quality (AHRQ). This model is preferred when hostile or harassing behaviors are occurring and are affecting patient safety. DESC is a mnemonic for:

D = Describe the specific situation

E = Express your concerns

S = Suggest other alternatives

C = Consequences stated.

Let’s look at Chris’s situation. The example below illustrates how she might have engaged in a conversation with her uncivil coworker Liz using the DESC model before seeking assistance from her supervisor.

Describe: Liz, I’d like to talk with you about an important matter. It concerns our interactions with one another.

Explain: When I am addressed in a demeaning way, I feel disrespected and stressed out. I’m concerned about the impact of this behavior on my health—and more importantly, on my ability to provide safe patient care.

State: I need you to address me in a respectful manner.

Consequence: It’s important to me that you understand this is a serious concern, and if your disrespectful behaviors continue, I will enlist the support of our supervisor to help us resolve the problem.

Enlisting leadership support

Nurses at all levels of the organization are responsible for developing and maintaining a healthy workplace. However, nurse managers and leaders play a unique role in setting the tone for the professional interactions expected in the workplace. Employees tend to model the behaviors they observe and experience from leaders. Leaders and managers routinely emit clues regarding the behaviors they consider acceptable. Even when they don’t exhibit incivility, managers and leaders condone it if they don’t address it when they see or hear about it. The nurse manager in the opening scenario demonstrated a high level of civility, professionalism, and leadership acumen by role-modeling behaviors of respect and decorum—which others will likely emulate and reinforce. Taking it a step further, desired behaviors need to be articulated clearly in foundational documents and embedded in departmental norms.

Co-creating norms of decorum

Co-creating and abiding by behavioral norms are essential to successful team functioning, high-quality care, and patient safety. Behavioral norms form the foundation for effective team functioning and stem from the organization’s vision, mission, philosophy, and statement of shared values. Without functional norms, desired behavior is ill-defined, so team members are left to make things up as they go.

To promote the norm-creating process, managers can engage team members in a brainstorming exercise by asking, “What behaviors do each of you want to see on our unit, and what behaviors do you not want to see?” Managers should avoid critiquing the suggestions and instead let the ideas flow. For example, if team members believe gossiping and holding private meetings are acceptable behaviors, they’re more likely to treat others with disregard. On the other hand, if treating others with respect and civility is important, people are more likely to assume good will and take a positive view of others. As team members determine and agree on expected behavioral norms, a volunteer can write them on a poster board for everyone to see, which can generate further discussion until agreement is reached.

Once the team agrees on norms, these need to be disseminated, posted around the unit, and discussed on an ongoing basis. Everyone is responsible for reinforcing and monitoring adherence to the norms and periodically evaluating how they are working. Perhaps most important, team members need to determine how norms can be operationalized and how each team member will “live” them.

Holding oneself and others accountable is critical to every successful organization. Behavioral norms need to be reviewed on an ongoing basis and periodically revised and reaffirmed. Norms are living documents that provide a civility touchstone for all team members, providing a framework for working, collaborating, and learning with and from one another.

Celebrating successes

Take time to celebrate individual and collective achievements and successes along the way. This fuels the momentum for change and rewards significant individual, team, andorganizational efforts. Healthcare workplaces are ever-changing, hectic, demanding, and highly stressful. Stress caused by incivility is unacceptable and avoidable. We have a responsibility to ourselves, each other, our patients, and the profession to “look under the hood” to expose incivility, address it head on, and collaborate to create a workplace where everyone experiences meaning, satisfaction, and value.

Names in scenarios are fictitious.

Cynthia M. Clark is a professor in the school of nursing at Boise State University, Idaho.

Selected references

Clark CM. Creating and Sustaining Civility in Nursing Education. Indianapolis, IN: Sigma Theta Tau International Publishing; 2013.

Institute of Medicine (IOM). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. www.nap.edu/catalog.php?record_id=12956

TeamSTEPPS: Fundamentals Course: Module 6. Mutual Support. Agency for Healthcare Research and Quality. Updated March 2014. www.ahrq.gov/professionals/education/curriculumtools/teamstepps/instructor/fundamentals/module6/igmutualsupp.html. Accessed May 1, 2014.

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