The Downward Spiral: Does it apply to cyberspace?

 Incivility in Nursing: To Respond or Not Respond: Dealing With Incivility

Laura A. Stokowski, RN, MS

 

Civility and Incivility in Nursing

Good manners. Consideration. Graciousness. Respect. Courtesy.These synonyms of “civility” sound sadly as though they come from a bygone era. If they describe your work environment, or if you are a student, your learning environment, consider yourself lucky — very lucky.

Yet, civility is more than polite words. A person can easily say “please and thank you,” and still stab you in the back. Clark defines civility as “an authentic respect for others that requires time, presence, willingness to engage in genuine discourse, and intention to seek common ground” that governs both speech and behavior toward others.^[1]

Cynthia Clark, RN, PhD, and Sara Ahten, RN, MSN.

What has happened to the civilized world? That is perhaps too big a question to tackle here, but we can narrow it down to our own profession. Why does so much incivility exist in the nursing profession (and make no mistake, it does exist), and what can be done to reverse this trend?

Two leaders in the area of research into incivility in nursing are Cynthia Clark, RN, PhD, and Sara Ahten, RN, MSN, from Boise State University in Boise, Idaho. I was happy to be able to speak with them about incivility and civility and to ask them how nurses (especially new graduates and students — the most common targets of incivility) should respond to uncivil behavior in the workplace or classroom.

 

 

The Continuum of Incivility in Nursing

Medscape: How do you conceptualize incivility in nursing interactions?

Cynthia (Cindy) Clark RN, PhD, and Sara Ahten, RN, MSN:Incivility is one term used to describe rude, disruptive, intimidating, and undesirable behaviors that are directed toward another person. Other terms found in the literature include lateral violence, horizontal violence, relational aggression, and bullying. Commonalities and intersections exist in the various definitions of these terms. A highly important shared attribute is the effect of these behaviors on the recipient and the organization, if left unchecked. As Forni so eloquently stated in 2008, “Incivility often occurs when people are stressed, unhappy, and rushed. When these coincide, anything can happen. Incivility erodes self-esteem, damages relationships, increases stress, contaminates the work environment, and may escalate into violence.”^[2] These behaviors may be intentional or unintentional. By unintentional, we mean that in some cases, the person exhibiting the uncivil behaviors is unaware of how his/her behaviors, words or actions may be affecting another.

Although commonalities exist among terms and definitions reflecting uncivil behavior, it is important when reading any literature to focus on how the author/authors define their terminology. Uncivil behavior exists along a continuum ranging from disruptive behaviors on one end, to threatening behaviors on the other (Figure 1). The many nuances and manifestations of the behaviors compel the reader to understand the context in which the information is being presented.

 

 

 

Figure 1. Continuum of incivility. Published with permission from Cynthia Clark.

 

With all of the attention that bullying has received, nurses have learned to recognize this behavior when it occurs and no longer believe that it is acceptable or excusable. Clark’s graph, however, shows that incivility at the left end of the scale can be expressed by some fairly subtle behaviors — the kind of things that nurses often excuse by saying “so and so is having a bad day.”

Medscape: In your opinion, what behaviors represent incivility in nurses?

Clark and Ahten: Overt expressions of incivility, such as taunting, racial/ethnic slurs, and bullying are most apparent and most reported in media. However, as shown in the Continuum of Incivility graphic, this can begin in what appears to be a relatively benign manner, with behaviors such as eye rolling, sarcastic comments, or dominating conversation in a group. We believe it is essential, and ultimately beneficial to any organization, to recognize the behaviors at the left end of the continuum. In an ideal world, people would interact with each other respectfully and thoughtfully. In the real world, what we wish is to prevent the potential escalation to more damaging and disruptive manifestations.

 

To Respond or Not Respond: Dealing With Incivility

When confronted with an uncivil comment or behavior, many nurses struggle with how they should respond, or even if they should respond at all. In a recent article,^[3] Clark and Ahten offer the following suggestions for what to do if you are the target of incivility in the workplace or the classroom. “If you have experienced an uncivil encounter, reflect on the experience, take time to cool off, and think about your response. After careful deliberation, you may choose not to respond at all. Ask yourself these questions: “If I do not respond, what is the worst (or best) thing that can happen? If I do respond, what is the worst (or best) thing that can happen?” Once you have given careful consideration to responding or not, in either case, put yourself in the other person’s position. Consider how you may have contributed to the problem, as this may help you develop clearer understanding and resolution of the issue.”^[3]

Medscape: It sounds, once again, like we are making excuses for incivility. Let’s say the uncivil nurse ishaving a bad day. Does this give him or her the right to be uncivil to colleagues?

Clark and Ahten: We want to stress very strongly that we are not and would never condone blaming the victim of bullying for his/her experience. That behavior is owned by the one who is bullying, period. The bully needs to know that the behavior is not acceptable. We agree with Forni when he states, “You want to impress upon the bully that he or she will not get away with pushing you around.” The variable in this situation, depending on your level of comfort and feeling of safety, is whether this encounter takes place between the 2 of you in a private place, in the presence of a third party mediator, or in a formal session with a member of management.

Back to the question, what we are suggesting is to be mindful in your interactions with others. Be aware, when you engage people, of their present activities and responsibilities. It is as simple as asking, “Do have a moment?” before starting a conversation or interrupting their work. If someone is abrupt or rude, you should absolutely hold them accountable for that response. What we are suggesting is that mindfulness of others before engaging them can lower stress and irritability in that communication, hopefully reducing the opportunity for uncivil behavior. Each of us is personally responsible for our behaviors as we engage others.

  

Exposing Nurse Incivility

When we were interviewed for the article The Downward Spiral: Incivility in Nursing , we must admit that we did not anticipate the volume and passionate intensity of the responses from Medscape readers. When we learned how many individuals had read the article in the first few weeks after publication, the huge numbers were a surprise, but the stories were regrettably familiar.

Our intent in participating in the original interview was to initiate thoughtful conversation about civility and incivility in nursing. We believe that the end goal of this conversation should be the creation of a safe, respectful place for nurses to practice. We completely agreed with Susan Yox, RN, EdD, Editor, and many readers who see a need to focus on creating positive, proactive organizational changes in both the workplace and the academic setting. (See Incivility in Nursing — Is That All There Is to Talk About?)

 

Civility: Putting a Name to It

 

 

In this article, we hope to raise awareness of the existence and consequences of incivility, which we view as a necessary first step in resetting the conversation to the topic of civility. The essential empowering activities for us as nurses are to define, encourage, model, and embed the desired behaviors into our organizations.

We believe that nursing must amplify the national dialogue on creating civil work and learning environments. Nurses can be ambassadors and leaders for change. With more than 3 million nurses in the United States, no other licensed healthcare profession has the potential power that nurses hold as a group. If we could agree upon and unite behind common expectations for how we are treated and how we treat others, we have the ability to change school and workplace interactions.

Eradicating bullying behavior starts at the top because an organization “reflects the values, attitudes, and actions of its leaders.”^[1] It takes deliberate and conscious decision on the part of leadership to eliminate uncivil behaviors, create norms and expectations for schools and workplaces, and hold all participants — including themselves — accountable.

Change can only occur following public recognition of what behavior must be changed. Griffin^[2] stated that nursing “cannot fix the problem until we put a name to it. Throughout history, nursing has condoned intimidating behavior that has now become an ‘acculturated bad behavior’ that we don’t really talk about.” After our interview was published, hundreds of readers on the article’s discussion board put a name to — and told a story about — their experiences with condoned intimidating behaviors.

What we found most upsetting about these stories were the obvious feelings of fear, loneliness, intimidation, and self-doubt that persisted for the nurses who were targets of uncivil, bullying behaviors, even years after the incident. The profound and far-reaching effects of these experiences cannot be minimized or marginalized. Griffin said it best: “Bullying is allowed to occur for 3 reasons: because it can; because it is modeled; because it is left unchecked.”^[2]