Chapter 17 Incivility: The Antithesis of Caring Cheryl Taylor Sharon Bator Edna Hull Jacqueline J. Hill Wanda Spurlock Joseph T. Catalano

What Is Civility? Having good manners and being polite Respecting others Based on recognizing that all human beings are important Protection from discrimination

Civility in Nursing The basis for caring Promotes emotional health Creates a positive environment for learning and the promotion of healing Develops emotional intelligence in nurses Transforms negative attitudes

Communication and Civility Positive interpersonal relationships are a key aspect of civility. Health and well-being of clients are predicated on excellence in communication and a culture of civility in the workplace. The Institute of Medicine (IOM) states: “new strategies to improve communications is critical in promoting a culture of civility.”

Incivility Any type of speech or behavior that disrupts the harmony of the home, work, or educational environment Other names in health care Nurses eating their young The doctor–nurse game Aggressive communication

Incivility (cont’d) Pervasive in American society Incivility increases when people are under stress. Includes Cyber-harassment Vicious anonymous e-mails Hate text messaging Acts of rudeness Social rejection

Incivility Continuum Incivility can be viewed as a continuum of impolite behaviors. They have a lot of overlap between them. All of the individual stages usually begin with some type of covert, subtle type of psychological behavior, however, they all can lead to physical violence if taken to their extremes. Impoliteness/ Psychological Bullying Lateral or Overt Physical Rudeness Violence Vertical Violence Violence—Homicide

Bullying Defined as any behavior that could reasonably be considered humiliating, intimidating, threatening, or demeaning to an individual or group of individuals Can occur anywhere Can become habitual, being repeated over and over

Bullying (cont’d) A complex concept that includes Physical abuse Emotional abuse Verbal abuse Any combination of the three

Bullying (cont’d) Goal of bullying To coerce or intimidate another person into doing something that they do not want to do To merely humiliate a person or group because of some perceived difference or weakness Hazing and initiation rites are forms of bullying.

Bullying (cont’d) Characteristics of bullies Have low self-esteem and poor self-image Use bullying to make themselves feel more powerful Seek the approval of others Were the target of bullying themselves as children or early in their careers

Bullying (cont’d) Victims of bullying are called “targets.” Characteristics of targets Anything that makes them “different” Religion, looks, race, skills, etc. Project an attitude of weakness Feel powerless and helpless Don't know how to stop it Timid personality

Bullying (cont’d) May include subtle methods of coercion Intimidating comments on social media (cyber bullying) Being ostracized from the group Being the butt of practical jokes

Bullying (cont’d) One-on-one bullying from peers is sometimes called peer abuse or lateral violence. In groups, the primary bully may have helpers that contribute to or prolong the bullying activities. A bullying culture may develop in the workplace.

Lateral or Horizontal Violence Has many of the same characteristics as bullying except that it takes place almost exclusively in the work setting among peers Can be either covert or overt Overt lateral violence includes Name calling Threatening body language Physical hazing Bickering Fault finding Negative criticism Intimidation

Lateral or Horizontal Violence (cont’d) Overt lateral violence includes (cont’d) Gossip or divulging confidential information Shouting Blaming Put-downs Raised eye brows and rolling of the eyes Verbally abusive sarcasm with rude tones Physical acts such as Pounding on a table Throwing objects Shoving a chair against a wall

Lateral or Horizontal Violence (cont’d) Covert lateral violence More difficult to identify Includes Unfair assignments Marginalizing a person Refusing to help someone Ignoring Making faces behind someone’s back Refusing to work with certain people Whining, sabotage, exclusion, and fabrication

Lateral or Horizontal Violence (cont’d) Not a new phenomenon for nurses A part of the health-care culture almost from the beginning Those experiencing lateral violence include Nursing students Pharmacists Unit secretaries (and others) Nurses sometimes use horizontal violence to attack one another as a means of venting their frustrations and anger against a supervisor or institution they feel helpless to change.

Lateral or Horizontal Violence (cont’d) Results of lateral violence Decreased communication Poor quality of care Reduced safety of clients Poor staff morale Excessive “sick days” High turnover of staff Nurses leaving the profession Physical symptoms Insomnia, hypertension, depression, GI upset

Vertical Violence Any behavior conducted by a superior or supervisor that could reasonably be considered humiliating, intimidating, threatening, or demeaning to an individual or group of individuals. Can permeate the entire organization Has a detrimental effect on the entire organization Originates from concept of inappropriate use of coercive power Bullies are in a position of power or perceived to have power

Vertical Violence (cont’d) The targets of vertical violence Are in a constant state of fear Work in a defensive mode Avoid contact with the supervisor Avoid anything that may bring attention from the supervisor Feel anger toward the supervisor Have a lower self-esteem because they don’t know what to do about it

Vertical Violence (cont’d) Results of vertical violence Decreased productivity Decreased innovation Poor morale among workers The best workers seek employment elsewhere Employee may go postal

Vertical Violence (cont’d) Vertical violence can move in both directions. Bosses may become the targets of bottom-up vertical violence. Employees have considerable power. Employees can use passive-aggressive methods to sabotage the supervisor and undercut his or her power.

Bullying Vicious Circle Occurs when employees who were bullied when they first start working later move into supervisory positions Perpetuates a culture of vertical violence

Bullying Vicious Circle (cont’d) Common in health care and education Comes from the attitude of “I went through it, now it’s your turn to pay your dues” In nursing = “eating your young” phenomenon

Incivility in the Classroom Any type of activity that creates an unpleasant or negative learning atmosphere Takes the form of horizontal violence when faculty, students, and staff are demeaning to their peers

Incivility in the Classroom (cont’d) Takes the form of vertical violence when faculty demeans students and new faculty Is destructive to the emotional and physical well-being of those affected.

Incivility in the Classroom (cont’d) Student-to-faculty incivility includes Harassing and threatening behaviors by students towards certain instructors over grades Cutting classes because students consider them boring or the instructor stupid Cheating on tests and home work assignments to get better grades Refusing to participate in class activities

Incivility in the Classroom (cont’d) Student-to-faculty incivility includes (cont’d) Being unprepared for classes by not doing reading assignments or written work Cell phone use during class Talking out of turn or to other students during lecture

Incivility in the Classroom (cont’d) Student-to-faculty incivility includes (cont’d) Distracting teachers and other students by asking irrelevant or confrontational questions Complaining behind the teacher’s back to the teacher’s superiors

Incivility in the Classroom (cont’d) Faculty-to-student incivility includes Rigid attitudes Unfair treatment of students Expectation of too much conformity Discrimination Negative or demeaning remarks Insinuations Harassment in class Aggressive behavior

Incivility in the Classroom (cont’d) Student-to-student incivility includes Obtaining study notes from the previous year’s classes and using them as bargaining chips with their classmates Ridicule (bullying) of students who were considered outcasts by their classmates because they didn’t fit the model of the majority in terms of clothing, hairstyle, and disposable income Two-faced behavior, where students acted nice to a classmate’s face but nasty behind his or her back

Incivility in the Classroom (cont’d) Caused by Excessive stress levels Juggling multiple roles Financial pressures The student’s own emotional issues Low levels of teacher enthusiasm Lack of teacher clarity and organization Discomfort with expressions of empathy Unapproachable faculty

Incivility in the Classroom (cont’d) Consequences of classroom incivility Fosters an atmosphere of hostility and aggression Impersonalizes faculty and students Creates highly toxic environment Poor student learning Failure to reach educational goals and outcomes High turnover rates of faculty High drop-out and failure rates of students Poor results on the NCLEX

Workplace (Clinical) Incivility Broad term that includes workplace hostility, bullying, lateral violence, horizontal violence, vertical violence, and workplace violence It is the threat of violence or the actual causing of physical harm to workers either inside or outside of the workplace.

Workplace (Clinical) Incivility (cont’d) Workplace incivility runs along the continuum ranging from verbal abuse to physical violence and homicide. Over 2 million workers are targets of workplace abuse each year. It is blamed for the deaths of more than 1,000 people a year in the United States.

Workplace (Clinical) Incivility (cont’d) Two paths when incivility starts Escalation to physical violence End resentment and stop the progression The path chosen depends largely on communication, both at the beginning of the conflict and during its progress. Conflict resolution interventions are essential to the process.

Workplace (Clinical) Incivility (cont’d) Victim of the incivility experiences Loss of face Increasing anger A desire to fight back Leads to a desire for violent revenge Nurses must prevent incivility from turning into violent actions.

Workplace (Clinical) Incivility (cont’d) Results of a hostile health-care work environment Failing to clarify an unreadable order because of fear of the physician Lifting or ambulating heavy or debilitated clients without assistance rather than asking for help Using an unfamiliar piece of equipment without asking for instructions first Carrying out orders that the nurse did not believe were correct

Workplace (Clinical) Incivility (cont’d) Consequences of incivility in the clinical setting Jeopardizes client safety Increases medical and nursing errors Lowers the overall quality of care Creates hostile, toxic workplace environment Causes high turnover rates of nursing staff

Workplace (Clinical) Incivility (cont’d) Actions to help build a positive workplace environment and overcome incivility Building a collaborative culture that includes respectful communication and behavior Establishing a communication-rich culture that emphasizes trust and respect

Workplace (Clinical) Incivility (cont’d) Actions (cont’d) Making accountability central to the culture with clearly defined role expectations Maintaining adequate staffing Training leaders competent in cooperation and communication

Workplace (Clinical) Incivility (cont’d) Actions (cont’d) Sharing decision-making with all those it will affect Continuously developing employee skills and clinical knowledge Recognizing and rewarding employees’ contributions

Workplace (Clinical) Incivility (cont’d) Other identified methods that help reverse horizontal violence include Recognizing and acknowledging that horizontal violence exists in the workplace Adopting a continuous, consistent, integrated approach to promote a culture of cooperation and address instances of horizontal violence

Workplace (Clinical) Incivility (cont’d) Stopping the cycle of workplace violence Naming the problem: call it “horizontal violence” to refer to the situation Raising the issue at staff meetings: bring the light of day to the problem

Workplace (Clinical) Incivility (cont’d) Stopping the cycle (cont’d) Asking supervisors about developing a process for dealing with incivility in the workplace Learning from experience: keeping a journal raises self-awareness about personal values, beliefs, attitudes, and behavior; it is also a good source of documentation

Workplace (Clinical) Incivility (cont’d) Stopping the cycle (cont’d) Pursuing a path of personal growth: finding those things that create happiness and satisfaction and developing them goes a long way to counteract incivility Ensuring the nurse is part of the solution, not part of the problem

Workplace (Clinical) Incivility (cont’d) Stopping the cycle (cont’d) Maintaining self-care behaviors: peer support, good nutrition, adequate sleep, time out, meditation, and exercise Speaking up when “horizontal violence” is witnessed

Solutions to Incivility Develop high-quality preceptor and mentoring programs for students and new nurses. Educate people on how to recognize and deal with bullying.

Solutions to Incivility (cont’d) Screen job applicants in all settings for indications of bullying personalities and behaviors. Make civility and cooperation a key element in the vision, mission statement, and outcomes of the program and institution.

Solutions to Incivility (cont’d) Include how to confront a bully as part of assertiveness training. Develop a culture, climate, and atmosphere of civility throughout the organization.

Solutions to Incivility (cont’d) Recognize bullying behavior early and address it (bullying never stops by itself). Include stress reduction techniques as part of the orientation or curriculum.

Solutions to Incivility (cont’d) Provide rewards for civility. Establish codes of conduct that include civility (HIRRE: honesty, integrity, respect, responsibility, and ethics). Set an example of “civility” by your own behavior. Establish a communication-rich culture that emphasizes trust and respect.