Magazine — Edition 22
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Incivility In Nursing
Crystal Tillman harris

WHAt EXActly IS IncIVIlIty?

Incivility is one term used to describe rude, disruptive, intimidating, and undesirable behaviors that are directed toward another person (Clark, 2011). Incivility is any action that is offensive, intimidating, or hostile that interferes with the learning or practice environment. Although incivility has always been around, incivility seems to be an increasing problem for organizations and is getting worse.

Incivility often results in psychological or physiological distress for the people involved. If incivility is left unaddressed, it may progress into more threatening situations or behaviors. Victims of incivility may experience symptoms such as stress, anxiety, exhaustion, sleeplessness, depression, anger, and embarrassment.

Searching the literature will produce numerous articles with terms such as: lateral violence, horizontal violence, relational aggression or simply what it really is -“bullying.” Many nurses know colleagues, nursing faculty or nursing leaders who practice incivility. People who engage in incivility use abnormal, aggressive behaviors to gain control and power. Unfortunately, these people have not developed healthy coping behaviors and/ or skills in their relationships with others.

Incivility occurs in groups or individual interactions. Listed are some various incivility combinations which are possible:

• provider or management bullying a nurse

• nurse bullying another nurse

• nurse bullying a patient

• patient bullying a nurse

• nursing faculty bullying a student

the impact of incivility

Incivility wreaks havoc on nurses’ relationships and workplace morale, as well as the bottom line - patient safety. Incivility is far more widespread than most of us realize, and incivility in health care settings has devastating effects.

Being a victim of incivility is also costly to organizations. Nurses put in less effort, produce lower quality, and can even burn out. According to Banishing Burnout by M. Leiter and C. Maslach (2005), the annual cost of job stress alone due to incivility at US corporations is $300 billion. Incivility is a major cause of workplace frustration and stress.

Incivility is illegal if based on protected personal categories such as race, religion, gender or disability. However, no laws prevent other types of workplace incivility, unless it verges on mental or physical abuse.

According to Zolby (2007) many of us are affected by workplace incivility/bullying:

• 37% US workers directly experienced bullying

• 12% witnessed bullying

• 45% had their health affected due to stress from bullying

• 3% file lawsuits related to bullying

• 40% experience bullying but never complain

Dr. P. M. Forni is the co-founder of the Johns Hopkins Civility Project, author of Choosing Civility, and also a leader in incivility research. As Forni (2008) stated, “incivility often occurs when people are stressed, unhappy, or rushed. When these coincide, anything can happen. Incivility erodes self-esteem, damages relationships, increases stress, contaminates the work environment, and may escalate into violence.” It is important to note that many times the person exhibiting the uncivil behavior is unaware of how his or her behavior, words or actions may be affecting others.

According to Clark, uncivil behaviors exist along a continuum ranging from disruptive behaviors on one end, to threatening behaviors on the other (See Figure 1). The graph illustrates that incivility at the left end of the scale can be expressed by some fairly subtle behaviors such as eye-rolling, arm-crossing and walking away - the kind of actions that nurses often excuse by saying, “so and so is having a bad day.”

Overt expressions of incivility, such as Bullying, taunting, and intimidation are more 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 sarcastic comments or dominating conversation in a group. It is essential to any organization to recognize the behaviors at the left end of the continuum, to name them, and ultimately address them to prevent more aggressive acts of anger or violence from occurring.

During the NC Board of Nursing 2011 Education Summit, Dr. Cindy Clark stated, “Bullying is allowed to occur for 3 reasons: because it can; because it is modeled; because it is left unchecked.”

What does incivility look like?

As Clark stated in the incivility continuum, there are a range of uncivil behaviors. Dellasega (2009) came up with common uncivil behaviors which include:

• using the “silent treatment”

• spreading rumors

• rude or obnoxious behavior

• badgering or back-stabbing

• sabotaging a project

• damaging someone’s reputation

• using humiliation, put-downs, and intimidation

• failing to support a co-worker

• setting up someone for failure

• undermining of work

• verbal abuse

• public reprimands

• sarcasm

• destroying confidence

• losing one’s temper or yelling at someone

• continual criticism

• encouraging others to turn against a coworker

The effects of incivility take a toll on all of us. It erodes our self-esteem by wearing down our mental defenses. When we feel vulnerable, there is an increase in anxiety, which can lead to resentment and anger. It also damages our relationships by causing feelings of failure, isolation and loss. It also increases stress, which weakens the immune system, causes wear and tear on the body, spirit and soul. Even worse the effects can lead to depression and post-traumatic stress disorder (PTSD). It also contaminates the workplace by lowering morale, organizational trust and job satisfaction.

Nurse leaders can be in a difficult situation too. For nurses in a leadership role, to remain silent is to condone the behavior. If leadership accepts the behavior, it makes it harder for others to report the same type of behavior. The nurse may feel his or her leadership approves of the behavior. When in reality, leadership may not realize incivility is occurring. The behavior needs to be brought to the nurse leader’s attention for further action Do not assume the behavior has probably been reported by another nurse.

Incivility also occurs with student nurses by nurses in practice and nursing faculty. It results in students having decreased confidence, anger, frustration, sleeplessness, anxiety, stress and worry. When student nurses are subjected to bullying by nurses in practice, they are more apt to emulate the behaviors and engage in bullying activities themselves. Modeling of expected professional behaviors is the responsibility of each nurse.

nursing Professionalism

The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) states that inherent in professionalism is accountability and responsibility for individual actions and behaviors, including civility. Civility must be present for professionalism to occur.

The American Nurses Association (ANA) Nursing Code of Ethics (2001) states the nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. Provision 1.5 requires nurses to treat colleagues, students, and patients with dignity and respect and that any form of harassment, disrespect, or threatening action will not be tolerated.

The Joint Commission takes the position that incivility is a safety issue, and issued a standard on intimidating and disruptive behaviors at work. The Joint Commission cited concerns about increased medical errors, poor patient satisfaction, adverse outcomes, higher costs, and loss of qualified staff. The Joint Commission Sentinel Event Alert (July, 2008) states that health care is a “high-stakes, pressure-packed environment that can test the limits of civility in the workplace.” The rude, disruptive behavior among health care professionals can pose a serious threat to patient safety and the overall quality of care. All health care settings Need to create behavioral codes of conduct and establish a formal process for managing unacceptable behavior.

how to deal with incivility

So let us take a time-out and learn how to deal with incivility at an individual and organizational level.

individual level

It is always best if you can come to a resolution between you and the person exhibiting incivility. Start out by describing how the behavior makes you feel. Sometimes dealing directly with the person might not be an option. Take a time out and walk away from the situation whenever you cannot discuss the behavior and come to a resolution. An objective third party may need to be involved. Don’t try to speak and defend yourself unless you feel it is absolutely necessary. Doing so may encourage the incivility. The bully is looking for you to add fuel to the fire - do not give him or her satisfaction. Practice some slow relaxation breathing and put things into perspective. If worries start to build up, do not hesitate in seeking professional counseling. Many workplaces have employee assistance programs available to you.

Role modeling and showing great passion for the nursing profession is important, as well as mentoring other nurses. Colleagues disagree with each other at times, but it is important to maintain respect for each other. Respect is basic to communicating with others on a daily basis. Experienced nurses can model how to confront others in a positive, constructive manner. Remember, none of us start out to become marginal or mediocre nurses. We work very hard to become highly proficient and expert nurses (Clark, 2010).

Incivility can be difficult to determine from the small, subtle acts that many people experience. Sometimes we even question ourselves. Is our perception correct of the other person’s behavior? Incivility can take Us off guard, because we simply are not expecting the behavior to occur. Little things such as showing up late to meetings, texting or checking emails during meetings, dismissing or ignoring co-workers concerns, thoughts or input are all examples of more subtle types of incivility.

If you find you are becoming the target of incivility, then it is important to document when each incident occurs. Write down the date and time of the incident, along with the details of the interaction. Continue doing this until you see a pattern emerge. A single incident may not get attention, but a pattern of behavior will have to be addressed. Consider copying any letters, memos or emails that have a bullying or rude tone to them. As nurses we know the importance of documentation.

Set up a meeting with a human resources representative or someone who is higher in the organization than the uncivil person. Only do this after you have established a documented pattern of behavior. Ask people who have witnessed the behavior to stand up for you. If they agree, give their names to your nurse leader or human resources representative, along with the evidence you have collected. There is power in numbers and those not directly involved offer an objective perspective.

organizational level

Usually “bullies” never recognize their own behavior as being uncivil. They may leave one position, only to wreak havoc someplace else. Their perception truly becomes their reality. Incivility can become the norm for a workplace, which makes it harder to change. Dealing with the behavior in a timely manner, will prevent incivility from becoming the norm. Once incivility is allowed to become the norm, it takes time to get the workplace back to a positive, healthy environment. Most experts agree that it takes 2-5 years for an organization to change its culture.

Policies are a must to prevent and/or improve incivility. A code of conduct is necessary to describe the behaviors that are considered disruptive. The code needs to address all employees in an organization such as nurses, and nonemployees such as providers. In order for a code of conduct to be effective, it must be applied in all circumstances. Leadership needs to be not only involved in the process, but committed to modeling civility and reinforcing its importance. Without this enforcement, the code is useless. All team members, including leadership, need to be accountable for modeling and enforcing the code of conduct.

Equally important is addressing incidents and complaints in a timely manner, and taking corrective action so employees see it is not condoned or tolerated. Nurse leaders need to set the tone and expectations for the type of professional interactions that will occur in the workplace. Words can be typed in a mission statement, but the truth is that nurses and students will model the behaviors they observe and experience from their nurse leaders and faculty. If my nurse leader does not “walk the talk,” I am going to ignore the rules and do what I know I can get away with. We all drift occasionally and that is human nature. However as nurses, we are ultimately accountable for our own professional behaviors.

Education is the key to helping others. Some health care settings are seeking to educate nurses on how to improve social interactions, enact proper business etiquette, and foster positive people skills in the workplace environment. Some people may not realize they exhibit uncivil behavior. Many people believe this is “not about me.” Many times people lack insight or self-awareness, and have no idea how to change behavior that may be ingrained. Educating everyone on the new policies will help create an open, friendly and accepting environment. It may be necessary to provide coaching and menToring as needed to help improve the behaviors of others.

There should be a zero tolerance for incivility. It is important for all of us to teach civility and educate others to recognize and respond to incivility. Nurse leaders must take complaints seriously and not shoot the messenger. It takes great courage to report incivility. Do not make excuses such as “that is just the way she is, but you will get used to it” or “the unit cannot afford to lose him even though he creates tension on the unit.” As a nurse leader it is important to gather data quickly, sort out the facts, and take action when necessary. It is also important to conduct post-departure interviews, not at the time an employee leaves, but several weeks after leaving. This will give you a better picture as to what other factors may have been involved in the employee leaving his or her position.

It is important to sustain the new culture by encouraging open communication so that civility becomes the norm. Nurse leaders need to guide responsibly and create a safe environment so nurses are not fearful when sharing concerns or reporting incidents. Nurse leaders also need to promote constructive and open feedback so nurses learn how to demonstrate respect and common courtesy. It is important to be accepting of each other’s ideas and opinions.

Nursing education programs need to include incivility topics in the curriculum. It is also helpful to have students role play various situations. It has been found that new graduates are able to handle uncivil behaviors in a more appropriate manner, with the use of role play.

Wrapping it all up

Kupperschmidt (2006) talks about the term care-fronting in nursing. It is when nurses care enough about themselves and their patients to confront uncivil behavior face-to-face immediately, directly, and respectfully to foster mutual respect. One Question we should all ask ourselves: What if nurses respected ourselves as much as we respect our patients? It is up to each one of us to take care of ourselves and others.

As Forni stated, “encouraging civility in the workplace is becoming one of the fundamental corporate goals in our diverse, hurried, stressed and litigation-prone society.” A civil workplace is good for health care providers, since our quality of life is improved in such an environment. But a civil workplace is also good for the patients, since the quality of care they receive from happier and more relaxed health care providers is improved.

Our shared goal should be the creation of a safe, respectful place for nurses to practice. Nurses can be ambassadors and leaders for change. With more than 3 million nurses in the US, no other licensed healthcare profession has the potential power that nurses hold as a group. It is important for us to agree upon and unite behind common expectations for how we are treated and how we treat others…we have the ability to change our workplace.

As Dr. Clark stated at the NC Board of Nursing 2011 Education Summit “Choosing civility is important and the right thing to do.”

reflection Questions

Scenario #1:

You are a new graduate nurse practicing on a medical unit. There is a colleague that has been on the unit for seven years. One day after orientation you hear her Grumbling that “you need to pick up your pace; you are not pulling your weight.” How might you handle this situation?

A direct approach is to acknowledge the offensive behavior head-on without offering excuses or opinions. You might say, “You criticize me a lot about my pace, and it distracts me from caring for my patients. I want you to stop making these comments so that I can focus on my patients.” Confrontation can be challenging, but it often puts an end to the problem by directly addressing the offensive behavior.

Scenario #2:

You are sitting with several other colleagues catching-up on charting for the day. One of your colleagues starts gossiping and slamming another one of your colleagues. How might you handle this situation?

If someone is gossiping and slamming your colleague, do not join in or give approval by saying nothing. Have the courage to say, “I do not feel right talking about this behind his or her back. Have you talked with him or her?” It is important to hold each other accountable for our chosen behaviors.

Scenario #3:

You just came out of a patient’s room, when suddenly you hear a provider screaming and yelling at one of your colleagues. How might you handle this situation?

If you see someone being bullied, do not stand by quietly or pretend you do not see it. Unless each nurse names uncivil behavior when it occurs, it continues without any consequences. The behavior exhibited by the provider is unprofessional, and should not be tolerated. One hospital uses a “code incivility” for each unit. When one of your colleagues is being bullied by another person, the rest of the nurses come and stand by the nurse being bullied, without saying a word. This action is usually enough to stop the behavior of the uncivil person, and draws attention to their inappropriate behavior.

time for reflection:

Remember a time when you have been bullied by a nursing faculty member, peer or someone in leadership.

• How did the situation make you feel?

• Did you experience any of the listed feelings stated in the article?

• How did you resolve the situation?

• Was it an assertive approach or did you leave your position to get away from the incivility?

• How would you do things differently now?

• How do you manage stress reduction and taking care of yourself?

For More information Cindy Clark, PhD, RN website:

Incivility in the College Classroom:

P. M. Forni, PhD website:


American Nurses Association (2001). Code of ethics for nurses with interpretive statements. American Nurses Association: Washington, D.C.

American Psychological Association (October 24,2007) . Stress in America. Retrieved from http:// Stress+in+America+REPORT+FINAL.doc

Clark, C.M. (2011). Incivility Presentation at the NC Board of Nursing Education Summit, Chapel Hill, NC.

Clark, C.M. & Springer, P.J. (2010). Academic nurse leaders’ role in fostering a culture of civility in nursing education. Journal of Nursing Education, 49(6), 319-325.

Clark, C.M. (2010). Five-part series: Fostering civility in nursing education and practice, Reflections on Nursing Leadership, 36(1), Sigma Theta Tau International.

Clark, C.M. (2008). The dance of incivility in nursing education as described by nursing faculty and students. ANS Advanced Nursing Science, 31(4), 37-54.

Dellasega, C. A. (2009). Bullying among nurses. American Journal of Nursing, 109(1), 52-58.

Forni PM. The Civility Solution. New York, St. Martin’s Press, 2008.

Joint Commission (July 2, 2009). Behaviors that undermine a culture of safety. Retrieved August 10, 2009 from Sentineleventalert/sea_40.htm

Kolanko, KM., Clark, C., Heinrich, KT., Olive, D., Serembus, JF., Sifford, KS. (2006). Academic Dishonesty, bullying, incivility, and violence: difficult challenges facing nurse educators. Nursing Education Perspective, January: 27 (1), 34-43.

Kupperschmidt, BR. (2006.) Addressing multigenerational conflict: mutual respect and carefronting as strategy. Online Journal Issues in Nursing. May 31:11(2):4.

Laschinger, H. K. S., & Leiter, M. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/ engagement. The Journal of Nursing Administration, 36(5), 259-267.

Leiter, M. & Maslach, C. (2005). Banishing Burnout. San Francisco: Jossey-Bass.

Lim, S., Cortina, L.M., & Magley, V.J. (2008).Personal and workgroup incivility: Impact on work and health outcomes. Journal of Applied Psychology, 3(1), 95-107.

Lower, J. (2007). Creating a culture of civility in the workplace. American Nurse Today, 2 (9), 49-52.

Zolby (2007). America’s Debate. Retrieved from