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Fostering Civility and Healthy Work Environments in Nursing and Health Care Nursing CE Course

1.0 ANCC Contact Hour

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This article details the impact of incivility and other workplace aggressions in healthcare and offers several interventions to foster civility and build and sustain healthy work environments.

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This article details the impact of incivility and other workplace aggressions in health care and offers several interventions to foster civility and build and sustain healthy work environments.    

At the conclusion of this activity, the learner should be prepared to: 

  • define civility, incivility, and forms of workplace aggression and describe their impact on individuals, teams, organizations, and patient care
  • discuss core competencies needed to foster civility and healthy work environments
  • detail the evidence-based Pathway for Fostering Organizational Civility© (PFOC)  

What is Civility and Why Does it Matter in Health Care?

Over the past decade, several professional nursing organizations have highlighted the importance of fostering civility and healthy work environments in nursing and health care. In 2015, the American Nurses Association (ANA, 2015b) issued a position statement on incivility, bullying, and workplace violence outlining individual and shared roles and responsibilities of nurses and employers to create and sustain a culture of respect across the healthcare continuum. During the same year, the ANA published the revised Code of Ethics for Nurses (2015a), stating that all nurses have a moral obligation and ethical imperative to create and sustain healthy work environments and to foster an atmosphere of dignity and respect. The ANA Code of Ethics for Nurses is consistent with the International Council of Nurses (ICN) Code of Ethics (2012), which emphasizes each nurse’s obligation to respect human rights, treat people with dignity and respect, and provide respectful and unrestricted care. This position was amplified in the ICN Workplace Violence Position Statement (2017), which supported zero-tolerance policies to prohibit violence in any form, including workplace bullying and lateral violence among nurses. 

In 2016, the American Association of Critical-Care Nurses (AACN) reaffirmed six standards for establishing and sustaining healthy work environments. They concluded that unhealthy work environments and relationship issues “can become the root cause of medical errors, hospital-acquired infections, clinical complications, patient readmissions, and nurse turnover” (AACN, 2016, p. 8). Shortly thereafter, the Tri-Council for Nursing (2017) proclaimed civility as essential for building healthy, inclusive work environments that protect patient safety.

More than a decade ago, Clark and Carnosso (2008) conducted a concept analysis to construct a common understanding of civility and clarify its meaning; the operational definition of civility stemming from this analysis noted that “civility is characterized by authentic respect for others when expressing disagreement, disparity, or controversy. It involves time presence, a willingness to engage in genuine discourse, and a sincere intention to seek common ground” (p. 13). Since then, Clark and colleagues (2021) updated the original concept analysis and revised the operational definition of civility to the following: “choosing to engage respectfully when contrary opinions or opposing views are expressed to promote community, the common good, and meaningful connections.” In both concept analyses, civility was synonymous with respect and emphasized an intention to engage meaningfully in resolving disagreements and seeking common ground. This preliminary operational definition affirms that civility is a choice and that being merely civil is not enough. In other words, remaining silent and polite while doing nothing to intercede is unacceptable and reinforces uncivil behaviors. Being civil means choosing to engage respectfully, particularly in response to contrary opinions or opposing views. Furthermore, civility involves speaking up and supporting others, acting intentionally to promote understanding and meaningful connections, and fostering inclusion, diversity, and equity (Clark, 2020).

A 3-year study conducted by the ANA (2017), which included more than 14,000 nurses from various settings and locations, found that registered nurses and nursing students identified workplace stress as the top work environment health and safety risk, and nearly half of respondents had been bullied in some manner in the workplace. Sokol-Hessner and colleagues (2018) concluded that harm from disrespect (e.g., incivility) in health care is associated with a worse patient experience, lower likelihood of perceiving care as high-quality, lower likelihood of seeking care again in the same facility, higher risk of physical harm, and higher levels of staff disengagement, absenteeism, and turnover. Ulrich and colleagues (2019) conducted a study with 8,080 critical care nurses in the US to evaluate the current state of critical care work environments. While the study provided evidence of positive outcomes when implementing AACN healthy work environment standards, other findings included 198,340 incidents of physical and mental well-being issues reported by 6,017 participants (e.g., verbal abuse, physical abuse, sexual harassment, and discrimination). In the portion of the study designed to measure respect and meaningful recognition, the authors concluded that respect was positively associated with job satisfaction, communication, and intent to stay in one’s current position. The authors further noted that respect is required for effective communication, collaboration, and patient safety (AACN, 2016; Ulrich et al., 2019). Results from the AACN study offer a critical call to action to improve the physical and mental safety of nurses. Healthcare leadership must help create healthy work environments where nurses are empowered to speak up, have the confidence to be heard, and trust that actions will be taken to resolve unsafe conditions. 

Civility in the work environment involves treating others professionally and respectfully, taking collective responsibility for tasks, and using effective communication and conflict negotiation skills to promote interprofessional teamwork and protect patient safety (Clark, 2019).

Defining Incivility, Bullying, and Mobbing in the Workplace

Several terms are used to describe uncivil and intimidating interactions that occur in the workplace. This section provides working definitions for 3 of the more common examples— incivility, bullying, and workplace mobbing. Clark (2017) defines incivility as a range of rude or disruptive behaviors that, if unaddressed, can escalate into more harmful or threatening situations. These uncivil behaviors, especially if they progress over time, can result in psychological and physiological distress. Some examples include nonverbal behaviors, such as eye-rolling, finger-pointing, door slamming, or walking away. Incivility may also consist of spreading rumors, engaging in negative gossip, name-calling, making belittling remarks, or demeaning somebody’s race, ethnicity, weight, gender, religion, or age. It also can involve posting insulting comments on digital or social media sites (Clark, 2017). 

Incivility includes both actions and inactions. Staying silent, failing to acknowledge or support a coworker, ignoring or marginalizing others, or withholding important information—especially in relation to patient safety—are examples of workplace incivility that can result in threats to patient safety, nurse safety, and the nursing profession (ANA, 2015b). According to the Workplace Bullying Institute (n.d.), bullying is defined as repeated, health-harming mistreatment of one or more persons (targets) by one or more offenders. This mistreatment is often severe enough to negatively impact a worker's health, career, and relationships with friends and family (Workplace Bullying Institute, n.d.). Bullying behaviors take many forms, including intimidating or threatening verbal or non-verbal behaviors, cyberbullying or posting disparaging comments on social media sites, and using digital media to demean a


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coworker. Edmonson and Zelonka (2019) concluded that a bullying culture contributes to a poor nursing work environment, increased risk to patients, lower patient satisfaction scores, and higher nurse turnover, which can cost a hospital $4 million to $7 million a year.  

In a pivotal paper, Leymann (1990) described “workplace mobbing” as employees “ganging up” (p. 119) and inflicting psychological terror on a targeted employee by subjecting them to persistent harassment that may result in physical, psychological, emotional, and spiritual damage. Simply stated, workplace mobbing occurs when an individual or a group of individuals collude against a coworker or a group of coworkers with the intent to ridicule, humiliate, harass, or intimidate. At times, incivility and other forms of aggression are deliberate, but in other cases, the behavior is unconscious or unintended. Regardless of intent, the impact can be devastating and far-reaching. 

Competencies to Foster a Healthy Work Environment

Several key competencies foster a healthy work environment. The first is leadership development. Whether leaders are titled, formal leaders or untitled, informal leaders in any capacity, all should aspire to be PEAK leaders. PEAK is an acronym for 

  • principled
  • ethical 
  • authentic
  • kind (Clark, 2016)

PEAK leaders enact values to engender trust and respect and to guide decisions, particularly in turbulent times. Ethical leaders act in an honorable fashion rather than doing what is simply expedient, convenient, or based on self-interest. To be authentic means to examine personal motives, goals, and core values carefully; to be aware of strengths and limitations; and to recognize and appreciate the impact we have on others. Kind leaders lead with benevolence and compassion; they refuse to see kindness as a weakness but instead a sign of strength, courage, and conviction (Clark, 2016).

Competency can also be attained by improving emotional intelligence and heightening self-awareness. Ways to improve self-awareness go beyond simple self-assessments, although those can be helpful. Emotional intelligence is strengthened through knowing and growing our strengths, practicing empathy, genuinely asking for and incorporating feedback, and intentionally examining and addressing our conscious and unconscious biases that can impact others in the workplace (Clark et al., 2018; FitzGerald et al., 2019; Marini et al., 2021).

Implementing the Pathway to Foster Organizational Civility© 

Transforming the organizational culture of a workplace requires time, commitment, and effective leadership at all levels. While there is no universal, one-size-fits-all approach for transforming workplace culture, several essential components can be implemented to increase this potential. Any model that seeks to foster a healthy work environment must consider the organization’s unique culture and be flexible to suit a variety of work environments. The Pathway for Fostering Organizational Civility© (PFOC; Clark, 2017, 2019) is an evidence-based, systematic, 8-step process designed to create and sustain a culture of civility and workplace health. 

Step 1: Raise Awareness and Enlist Leadership Support

The first step of the PFOC is to raise awareness about the positive impact of civility, reveal the harmful effects of workplace aggression, and enlist leadership support to implement a system-wide, evidence-based action plan to foster a healthy work environment. Leadership support and broad-based collaboration are essential for transformational, sustained change. Raising awareness about the harmful effects of workplace aggression can be a powerful motivator to enlist leadership and system-wide support. Leadership support is essential since leaders have a vested interest in the organization, frequently possess a broader view of workplace issues, and can provide resources for organizational change. Furthermore, their institutional knowledge and experience with workplace incivility may provide insight into possible solutions (Clark, 2019). 

Step 2: Assess Organizational Civility 

A comprehensive organizational assessment can yield useful information to develop and implement a system-wide, data-driven action plan. Information may also be gathered from formal and informal reports, satisfaction surveys, interviews, focus groups, listening sessions, and open forums. If desired, external researchers may be engaged to collect, analyze, and report the assessment findings on behalf of the Civility Team and organization. Assessment data should be used to develop, implement, and evaluate a data-driven action plan. Ongoing assessments should be conducted at various intervals to measure progress and identify success. Results of the cultural assessment can provide information about the scope of the problem, strengths of the organization, and intervention strategies for positive change. Once data are collected and analyzed, the Civility Team enlists broad-based support by engaging people at all levels of the organization, communicating the civility mission, and encouraging participation in the civility initiative. By gaining broad-based support, the civility initiative is more likely to succeed (Clark, 2017, 2019). 

Step 3: Assemble and Empower a Civility Team 

Once the organizational assessment has been conducted, establishing a Civility Team of trusted, committed, and empowered employees is integral to assess the culture, develop a compelling vision of the organization’s future, and carry out the steps of the PFOC (Clark, 2017, 2019). Note: Steps 2 and 3 can be reversed if an organizational cultural assessment has not already been conducted.

Step 4: Develop a Data-Driven Action Plan

During this step, the assessment information obtained from Step 3 is formulated into an evidence-based, data-driven action plan that will be implemented in Step 5. The action plan includes areas of strength and excellence, areas for improvement and growth, and measurable interventions to transform the organizational culture. Each intervention should include clear objectives, expected timelines, and necessary resources (financial, human, time, and organizational) to implement and evaluate the identified interventions. Establishing policies and procedures to foster workplace civility and a healthy work environment should be included in the action plan (Clark, 2017, 2019). 

Step 5: Implement the Data-Driven Action Plan 

Step 5 involves implementing evidence-based strategies and interventions to foster and sustain civility and a healthy work environment. While all action plans will be different because each culture is unique, some interventions are common across most organizations. Essential interventions include evaluating the institution’s foundational documents and statements, co-creating and implementing a civility charter with clear norms and ground rules, improving communication and conflict negotiation skills, and enhancing teamwork and collaboration (Clark, 2017, 2019). 

The organizational vision, mission, philosophy, and statement of shared values need to be examined to ensure a commitment to patient safety, civility, equity, and inclusion. If these statements do not reflect the core mission of the institution, they may need to be revised to reinforce an unequivocal, shared commitment to fostering civility and a healthy work environment (Clark, 2017, 2019). 

A civility charter includes team norms, rules of engagement, and accountability measures. An example of a civility charter (or pledge/commitment to coworkers) may read like this: 

All members of the department or unit commit to fostering a healthy work environment that promotes respect, teamwork, professionalism, inclusion, and emphasizes patient safety. We pledge to abide by our vision, mission, shared values, and team norms and to communicate and interact with professionalism and respect. When we disagree, we will restrict our differences to the issue while continuing to respect the person with whom we disagree.

A civility charter should also include team norms. Team members should be encouraged to collaborate, share their perspectives, and agree to a list of desired behaviors that support teamwork, productivity, and high performance. In this manner, the charter becomes a living document that provides a touchstone for desired behaviors. Co-creating and implementing these norms takes time and courageous conversations. This process should include all members of the healthcare team and may be facilitated by a nurse manager or any member of the healthcare team (Clark, 2017, 2019). 

While there are many ways to facilitate team norms, the following example is adapted from the Center for Creative Leadership (n.d.). Each member is asked to describe the worst team (e.g., sports, work) they have experienced where members have been dependent on each other. While considering their experiences, each member should describe for the group what made the experience difficult or conflicted. Next, each team member is asked to think about the best, most high-performing team of which they have been a member and share with the group what made the experience productive and high-performing. As the discussion ensues, one team member should keep track of suggested norms and establish a list of behaviors by which the team agrees to interact and communicate with one another. The discussion should also include how team members will hold one another accountable, including themselves, for following and abiding by the norms. The agreed-upon norms need to be documented and displayed, such as on a small, laminated card or a poster on the wall of the unit. Also, the norms should be periodically reviewed, revised, and reevaluated, as well as regularly reaffirmed (Clark, 2017, 2019). 

Some examples of team norms include the following: 

  • affirm an unequivocal commitment to patient care and safety;
  • assume goodwill and best intentions;
  • be considerate in our interactions;
  • use direct and respectful communication;
  • model professionalism, civility, and ethical conduct;
  • listen carefully with the intention to understand;
  • honor and respect diversity and inclusion;
  • be open to other points of view; and
  • hold oneself and each other accountable for abiding by team norms (Clark, 2017, 2019).

The co-creation of team norms promotes collaboration, collegiality, and productive relationships. Building connections by sharing stories, celebrating team and program successes, being present in conversations, and supporting and empathizing with others helps build high-performing teams, trust, and goodwill. To accomplish these outcomes, nurses must hone their communication and conflict-negotiation skills to address incivility effectively in a variety of situations, promote teamwork, and protect patient safety. Using staff meeting time, simulation space, and addressing incivility in “real-time” will help nurses learn about and practice effective ways of dealing with uncivil encounters, thus increasing the likelihood of success in stopping these behaviors. Using evidence-based frameworks to structure conversations increases the likelihood of a positive outcome. PAAIL is a conversational strategy to help foster respectful communication that consists of: 

  • preview
  • advocacy1
  • advocacy2
  • inquiry
  • listening (Clark & Fey, 2020)

PAAIL expands on the Basic Assumption from the Center for Medical Simulation (2004). The Basic Assumption extends positive regard for the other person, laying the groundwork for effective communication. It consists of the belief that everyone is intelligent, is capable, cares about doing their best, and wants to improve. The PAAIL method is operationalized as follows (Clark & Fey, 2020):

  • Preview: I'd like to talk to you about ___.
  • Advocacy1: I saw___, I heard ___, or I noticed___. 
  • Advocacy2: I think, or I'm concerned because___. 
  • Inquiry: I wonder what was on your mind. 
  • Listen carefully and intentionally before responding. 

The following case study offers a scenario of how PAAIL can be used to address conflicted or uncivil situations.

 

While several excellent frameworks offer a structure for conflicted or uncivil conversations, PAAIL is one of the most effective because it stresses the essential skills of showing respect and listening well.

Another important intervention for the data-driven action plan is to develop and implement policies that foster and sustain a healthy work environment. Establishing a well-defined, confidential, step-by-step plan for addressing incivility and recognizing civility and other desired behaviors is essential. Policies and procedures must ensure strict confidentiality, fairness, and consistency and must be easily accessible and widely disseminated (Clark & Ritter, 2018; Makic, 2018).

Step 6: Evaluation and Reassessment

The PFOC is a cyclical, iterative process that should continue to repeat. Evaluation and reassessment do not complete the pathway, but they are necessary steps to review the effectiveness of the civility and healthy workplace initiative. Information gleaned from periodic reassessment of the organizational culture can help measure progress, goal achievement, and the effectiveness of the actionable interventions. Ongoing assessment data can also be used to make recommendations for continuing the current measures and/or implementing revisions to the PFOC action plan (Clark, 2017, 2019). 

Step 7: Reward Civility and Consolidate Successes

Although the PFOC is an ongoing process, nursing leadership should recognize and celebrate individual and collective achievements regularly. Honoring accomplishments fuels momentum for change and reinforces individual, team, and organizational efforts. Victories include achievement of long- and short-term goals; heightened morale and job satisfaction; recruitment and retention of high-performing employees; improved communication and decision-making; growth of new programs, endowments, and revenue; career advancement; and increased visibility and community credibility. Celebrations can be formal or informal: the goal is to honor successes and acknowledge examples of civility and workplace health (Clark, 2017, 2019). 

Step 8: Expand the Civility Initiative: Sharing Knowledge, Lessons, and Experiences

To expand the civility initiative and sustain organizational transformation, some members of the Civility Team should remain while new members rotate onto the team to continue facilitating the change process and implementing the PFOC initiative. This transition phase may include determining leadership and team commitment; selecting new and promising leaders committed to the civility initiative; discussing the individual, team, and organizational accomplishments; reviewing the progression and assessment of the civility plan; and sharing lessons learned. Discussion points should also address areas for continued improvement and additional strategies to advance the civility initiative (Clark, 2017, 2019). 

Conclusion

Incivility and other workplace aggressions negatively impact individuals, teams, organizations, and patient care. These behaviors can result in life-threatening mistakes, preventable complications, near misses, and patient harm. The implementation of individual and organizational core competencies for fostering civility and healthy work environments is imperative for nurses and all members of the healthcare profession. 


References

American Association of Critical-Care Nurses. (2016). AACN standards for establishing and sustaining healthy work environments: A journey to excellence, 2nd ed. http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf  

American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

American Nurses Association. (2015b). Position statement: Incivility, bullying, and workplace violence. https://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/Incivility-Bullying-and-Workplace-Violence.html

American Nurses Association. (2017). Health risk appraisal (HRA) 2013-2016, Executive summary. https://www.nursingworld.org/~4aeeeb/globalassets/practiceandpolicy/work-environment/health--safety/ana-healthriskappraisalsummary_2013-2016.pdf

Center for Creative Leadership. (n.d.). The real-world guide to team norms. Retrieved March 16, 2021 from https://www.ccl.org/articles/leading-effectively-articles/the-real-world-guide-to-team-norms/

Center for Medical Simulation. (2004). Basic assumption [class handout]. Center for Medical Simulation. 

Clark, C. M. (2016, December 19). The imperative of PEAK leadership. Reflections on Nursing Leadership. http://www.reflectionsonnursingleadership.org/features/more-features/Vol42_4_the-imperative-of-peak-leadership

Clark, C. M. (2017). Creating and sustaining civility in nursing education, 2nd ed. Sigma Theta Tau International Publishing.

Clark, C. M. (2019). Fostering a culture of civility and respect in nursing. Journal of Nursing Regulation, 10(1), 44-52.

Clark, C. M. (2020). An ‘upstanding’ approach to address bullying in nursing. American Nurse Journal, 15(9), 31-34.

Clark, C. M., & Carnosso, J. (2008). Civility: A concept analysis. Journal of Theory Construction and Testing, 12(1), 11–15.

Clark, C. M., & Fey, M. K. (2020). Fostering civility in learning conversations: Introducing the PAAIL communication strategy. Nurse Educator, 45(3), 139-143.

Clark, C. M., Gorton, K., & Bentley, A. (2021). Civility: A concept analysis revisited. Nursing Outlook. Unpublished manuscript. 

Clark, C. M. & Ritter, K. (2018). Policy to foster civility and support a healthy academic work environment. Journal of Nursing Education, 57(6), 325-331.

Clark, C. M., Sattler, V., & Barbosa-Leiker, C. (2018). Development and psychometric testing of the Workplace Civility Index: A reliable tool to assess workplace civility. Journal of Continuing Education in Nursing, 49(9), 400-406.

Edmonson, C., & Zelonka, C. (2019). Our own worst enemies: The nurse bullying epidemic. Nursing Administration Quarterly, 43(3), 274–279. https://doi.org/10.1097/NAQ.0000000000000353

FitzGerald, C., Martin, A., Berner, D., & Hurst, S. (2019). Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review. BMC Psychology, 7(1), 29. https://doi.org/10.1186/s40359-019-0299-7

International Council of Nurses. (2012). ICN code of ethics for nurses. https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf

International Council of Nurses. (2017). Position statement: Prevention and management of workplace violence. https://www.icn.ch/sites/default/files/inline-files/ICN_PS_Prevention_and_management_of_workplace_violence.pdf

Leymann, H. (1990). Mobbing and psychological terror at workplaces. Violence and Victims, 5, 119-126. 

Makic, M. B. F. (2018). A culture of civility: Positively impacting practice and patient safety. Journal of PeriAnesthesia Nursing, 33(2), 220-222. https://doi.org/10.1016/j.jopan.2017.12.006

Marini, M., Waterman, P. D., Breedlove, E., Chen, J. T., Testa, C., Reisner, S. L., Pardee, D. J., Mayer, K. H., & Krieger, N. (2021). The target/perpetrator brief-implicit association test (B-IAT): An implicit instrument for efficiently measuring discrimination based on race/ethnicity, sex, gender identity, sexual orientation, weight, and age. BMC Public Health, 21(1), 158. https://doi.org/10.1186/s12889-021-10171-7

Sokol-Hessner, L., Folcarelli, P. H., Annas, C. L., Brown, S. M., Fernandez, L., Roche, S. D., Lee, B. S., Sands, K. E., & the Practice of Respect Delphi Study Group. (2018). A road map for advancing the practice of respect in health care: The results of an interdisciplinary modified Delphi consensus study. Joint Commission Journal on Quality and Patient Safety, 44(8), 463–476. https://doi.org/10.1016/j.jcjq.2018.02.003 PMID:30071966

Tri-Council for Nursing (2017, September 26). Nursing civility proclamation. https://tricouncilfornursing.org/

Ulrich, B., Barden, C., Cassidy, L., & Varn-Davis, N. (2019, April 1). Critical care nurse work environments 2018: Findings and implications. Critical Care Nurse, 39(2), 67–84. https://doi.org/10.4037/ccn2019605

Workplace Bullying Institute. (n.d.). The WBI definition of workplace bullying. Retrieved March 16, 2021 from http://workplacebullying.org/tutorial-2-what-it-is/

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