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

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

3. 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

4. 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.”

5. 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

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

7. 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

8. 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

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

10. 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.

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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.

37. 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.

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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.

50. 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.

51. 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.

52. 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.

53. 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.