Civility in Nursing and Health Care

During your nursing education, you learn everything from Anatomy to Z-track injections. One topic that isn’t always emphasized is the absolute need for civility, how important it is when you enter the workplace, and how it can impact your ability to provide excellent care.

What is civility?

The dictionary defines civility in two words: courtesy and politeness. But in the high-pressure environment of today’s healthcare, we need a better definition.

Cynthia Clark, PhD, RN, ANEF, FAAN is a nurse educator who has studied civility in health care for 15 years. In 2021, she and her colleagues defined civility as “choosing to engage respectfully when contrary opinions or opposing views are expressed to promote community, the common good, and meaningful connections.”

The crucial difference between these two definitions: RESPECT. The dictionary definition describes a superficial behavior. Dr. Clark’s definition describes a proactive behavior that is displayed even during difficult events. It also includes speaking up and supporting others.

Yale law professor Stephen L. Carter has written extensively about civility in all areas of life. He defines it as the total of all the sacrifices we must make if we are going to live together in society. Being civil doesn’t depend on whether we like someone. We can disagree, but we should resolve our differences in a respectful way. It means thinking before speaking.

What happens when the work environment is bad?

Creating and maintaining a healthy workplace for nurses and their colleagues has become a priority for more than a decade. The American Nurses Association conducted a 3-year study that included more than 14,000 nurses from a variety of settings. The results showed that nurses and nursing students said that workplace stress was their #1 environment and safety risk. A different study published in MEDSURG Nursing Journal reported that about 85% of nurses experience incivility during their career. Sadly, experienced nurses are often the bullies.

Yet another study (Sokol-Hessner, 2018) found that organizations often focus on preventing physical harm or violence, neglecting the “nonphysical” harm of disrespect and lack of dignity, for patients, families, and healthcare professionals.

Sokol-Hessner concluded that when incivility was tolerated in the workplace, the following occurred:

• Worse overall patient experience
• Patients felt the quality of care was low
• Patients were less likely to seek care again at the facility
• Higher risk of physical harm
• Higher level of staff disengagement
• Higher staff absenteeism and turnover rates

Besides the negative impact on staff morale and performance, patient safety can be affected when nurses face incivility. Wilson and Phelps (2013) determined that “horizontal hostility” led to potentially dangerous actions like:

• Interpreting a written order, rather than contacting the provider for clarification
• Trying to lift or ambulate a heavy patient without asking for assistance
• Not questioning orders that could harm a patient

Incivility, Bullying, and Mobbing: What’s the difference?

Several terms are used to describe rude or disruptive behavior in the workplace. Although they are used interchangeably, there is a difference. Let’s examine at each one and how it looks.

INCIVILITY: Actions that go without being addressed or confronted can become harmful or threatening. These behaviors can actually cause both psychological and physiological stress. Incivility can be displayed in verbal and nonverbal ways.
Nonverbal: Door slamming, walking away, pointing fingers, eye-rolling.
Verbal: Demeaning remarks, belittling, spreading rumors, name-calling, or rude comments about gender, weight, age, ethnicity, or religion. It also includes posting damaging remarks on social media.

BULLYING: Ongoing and deliberate attacks by one or more people against another person, the target. This is a misuse of power, meant to intimidate someone who feels unable to stop the assaults. Bullying is not random or a single episode. It is constant harassment that affects the target’s self-esteem.
Nonverbal: Dirty looks, avoiding eye contact, not providing space to sit or work, excluding the target in conversation or activities.
Verbal: Remarks about appearance or work methods, sexual comments, interrupting, criticizing in front of others, making offensive jokes within the target’s earshot.

MOBBING: Sometimes called “group bullying” or “ganging up,” done by a group against an individual. Because of the isolation and stress of the individual target, the group behavior is considered psychological terrorism, worse than bullying by one or two people.
Nonverbal: Stonewalling (ignoring suggestions or projects), leaving the target off of group emails, failing to invite the target to meetings, relocating the target’s workspace away from the group.
Verbal: Malicious gossip, revealing embarrassing personal information unrelated to job performance, organized campaigns to discredit the target outside of the workplace.

“Bystanders” are not innocent

When we witness an act of incivility or bullying, what should we do? Often, we avoid the situation, because we’re afraid to speak up. We don’t want to get involved or we’re afraid of retaliation by the bully. Maybe we don’t know the target very well or we think someone else should intervene. Sometimes we simply don’t know what to say at that moment.

A bystanders is anyone—whether in person, on social media, or by texting—who observes or witnesses the bullying or incivility episode. Bystanders are present at 80% of bullying events and can impact the situation, whether they take action or do nothing.

When a bystander stands up to a bully in support of the target, the target is less likely to become depressed or anxious. And when bystanders defend the target, bullying stops within 10 seconds, almost 60% of the time.

Bystanders can either defuse or escalate a situation, depending on what they choose to do. An “active” bystander steps in to support the target. Here are the four steps to standing up to a perpetrator:

1. Notice the situation or the perpetrator’s behavior. Does it seem inappropriate?
   Observe what’s going on and compare to what you know is unacceptable.
2. Interpret the event or behavior as a problem. Is the target being intimidated?
   Just because the target is silent doesn’t mean the problem is solved.
3. Prepare to take responsibility. Are you waiting for someone else to intervene?
   If you’re present, it’s up to you to feel empowered to support the target.
4. Get the necessary skills or training to act. Are you prepared to help? If not, ask your employer to provide methods to handle the situation, whether immediately or later.

7 ways you can help be part of the solution

Everyone wants a pleasant workplace. We want to enjoy our shift and do our best to care for our clients. We want to foster collaboration and even have fun with our co-workers. By agreeing to act appropriately, we can prevent incivility, bullying, and mobbing at work.

Here are seven ways to do your part to create and maintain a congenial environment:

1. 1

   Be a good listener.

   Give the other person your full attention, instead of thinking about what you’re going to say. Often you can determine what the other person is feeling and what they’re actually trying to communicate.

2. 2

   No gossip. Period.

   Civility demands that we stand together and refuse to engage in any rumors or negative stories. Simply turn away and be a role model for appropriate behavior.

3. 3

   Remember your manners.

   It’s surprising how a genuine “please” and “thank you” can change someone’s mood. Everyone has a hundred tasks to do, but it only takes a second to be polite.

4. 4

   Be adaptable.

   Change comes quickly in healthcare. Instead of joining the complainers who grumble about “how we used to do it,” remain open and flexible about learning, even if it’s difficult or seems pointless. It’s going to happen again and again.

5. 5

   Admit when you’re wrong.

   It can be tough to apologize after a mistake. Learn to acknowledge your error right away, learn from your experience, and move on. Be humble if you receive constructive criticism.

6. 6

   Pick your battles.

   Face it, some co-workers can be challenging. Before you speak up, ask yourself if the issue is something you really care about, or if you’re about to argue for its own sake.

7. 7

   Stay calm and carry on.

   It can be so tempting to fling a rude comment to a team member, especially when you’re tired, hungry, or over-extended. Take five minutes to collect yourself. Later, you’ll be glad you didn’t strike out at the co-worker.

The ANA Code of Ethics for Nurses

The American Nurses Association (ANA) has had a Position Statement regarding civility since 2015: Incivility, Bullying, and Workplace Violence. The statement is part of the ANA’s Code of Ethics, and states that nurses are required to “create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect…and that any. Form of bullying, harassment, manipulation, threats, or violence will not be tolerated.” (Read the entire Position Statement here.)

The ANA Position Statement then lists the responsibilities of every Registered Nurse:

• Commit to, and take responsibility for, establishing and promoting healthy interpersonal relationships with all members of the health care team.
• Be aware of your own actions and communication with others. RNs should insist on training in diversity and inclusiveness, conflict negotiation, and effective communication.
• Co-create norms for a civil workplace.
• Be familiar with incivility and bullying prevention policies and procedures. If these do not exist, RNs are obligate to participate in their development.
• Determine an agreed-upon code word or signal to get help when feeling threatened.
• Demonstrate respect and a professional demeanor at all times to reinforce civility and positive norms.

The ANA Position Statement also includes a list of responsibilities for employers and educators:

• Organizational vision, mission, philosophy, and shared values include a culture of respect and safety.
• Orientation for new employees must include presentation of existing policies and procedures.
• Zero-tolerance policy regarding incivility and bullying; all cases of these are to be treated in the same manner, regardless of who is involved.
• RNs must have a mechanism for support when they feel threatened.
• Strategies for conflict resolution and respectful communication must be provided.
• Nurse leaders and faculty members must provide initial education on a culture of civility, including it throughout the curriculum and policy development.
• Nursing curricula should include communication, crisis theory, conflict negotiation and resolution.

It is the most respected profession

For 19 straight years, the Gallup Poll has shown that Americans rate nursing as the number one most ethical and honest profession. In fact, nurses have been first since Gallup began its poll, except in 2001, when Americans gave 9/11 firefighters top ranking.

With public trust so high, nurses must find a way to lead the way in workplace civility. If every nurse does their part, the rewards will be great: more job satisfaction and better client care.

About the Author

Winona Suzanne Ball

Nursing Adviser, RN | MHS, Governors State University, IL
Full member of the American Nurses Association. Learn more