Civility Matters! Strategies to Inspire Healthy, Productive Work Environments Nursing CE Course

1.0 ANCC Contact Hours


Objectives: Upon completion of this activity, participants should be able to:

  • Describe the evidenced-based standards of a healthy work environment for nurses
  • List strategies that inspire and sustain a healthy work environment
  • Compare the implications of an unhealthy work environment
  • Determine ways nurses can be a professional role model for civility


The World Health Organization (2017), defines a healthy work environment as one where employees and management collaborate on a plan of improvement that continually promotes the health, safety and wellbeing of all employees. In the healthcare setting, a healthy work environment promotes productivity and collaboration between nurses and other healthcare providers. In addition, it protects them from psychosocial and physical harm. As a result, they are more likely to provide safe, quality care and experience a more satisfying work experience.

This module will explore the attributes and strategies that inspire a healthy, productive work environment for nurses. It will also compare the implications of an unhealthy work environment. Lastly, sustaining a healthy work environment as well as ways nurses can be a professional role model for civility will also be presented.


Attributes of a Healthy Work Environment for Nurses

Data from the American Association of Critical Care Nurses (2016), found six standards that nurses listed as being integral to attaining and sustaining a healthy work environment. The standards represent evidence-based and relationship-centered principles of professional performance and align directly with the core competencies for health professionals recommended by the Institute of Medicine. Working collaboratively, within an organization, nurses should determine the priority and depth of application required to implement each standard.

The findings are listed in the table below:

Evidence-Based StandardRequired for Implementation
Skilled CommunicationNurses must be as proficient in communication skills as they are in clinical skills
True CollaborationRelentless pursuit and fostering of true collaboration
Effective Decision-makingValued and committed partners in leading organizational operations
Appropriate StaffingEffective match between patient needs and nurse competencies
Meaningful recognitionAuthentic acknowledgement of the value each person brings to the work of the organization
Authentic LeadershipAdoption of the healthy work environment is imperative and includes engagement of others to achieve it

These standards support “American Nurses Association (2015), Code of Ethics for Nurses” and provide a framework in which to uphold their obligation to practice in ways consistent with appropriate ethical behavior. These nine provisions are summarized below and include:

  1. The nurse practices with compassion and respect for each person.
  2. The nurse’s primary commitment is to the patient (including groups).
  3. The nurse promotes and protects the rights, health and safety of the patient.
  4. The nurse has authority, accountability and responsibility for nursing practice.
  5. The nurse owes the same duty to self as to others.
  6. The nurse promotes a safe and ethical work environment.
  7. The nurse advances the profession through scholarly research and inquiry.
  8. The nurse collaborates with other members of the health care team and helps to reduce health care disparities.
  9. The profession of nursing, though professional organizations must promote the integrity of nursing values that integrate justice into healthcare policy.

In addition, the American Nurses Association (ANA, 2015) released “The Nurses Bill of Rights” which states that nurses have a right to see seven basic principals fulfilled in the work place. These seven basic principals allow nurses to perform to the best of their ability and include having the right to:

  1. Practice in manner that fulfills their obligations to society and to those who receive nursing care.
  2. Practice in environments that allow them to act within legally authorized scopes of practice.
  3. A work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses with Interpretive Statements.
  4. To freely and openly advocate for themselves and their patients, without fear of retribution.
  5. To fair compensation for their work, consistent with their knowledge, experience, and professional responsibilities.
  6. To a work environment that is safe for themselves and for their patients.
  7. To negotiate the conditions of their employment, either as individuals or collectively, in all practice settings.

Strategies to inspire and sustain healthy productive work environment  

In order for nurses to provide optimal care to patients and families, a healthy work environment must be a priority. There is a positive correlation between having a healthy working environment, safety, productivity, nurse retention and recruitment. According to WHO (2017), A healthy workplace should protect and promote the health, safety and wellbeing of all workers and the sustainability of the workplace by considering the following, based on identified needs:

  • Health and safety of the physical and psychosocial work environment
  • Personalized health resources and support (healthy lifestyle promotion by the employer)
  • Community engagement to promote the health of employees, family members and community members

In addition, WHO (2017) suggests steps to take to ensure sustainability for a positive work environment including gaining the support of senior management in committing to using a health, safety and well-being filter for all decisions. In addition, the healthy work place initiatives should be incorporated in the organization’s business plan.  It’s also essential to establish a health and safety committee and a work place wellness committee to assist with promoting integration of ideas between work groups. Lastly evaluation should promote continual improvement.

A strategy that nurses can use to promote and sustain a healthy work environment includes utilizing the nursing process:

  • Assessment: Assessment of the work environment is the mutual responsibility of leadership and nurses. Together they should work together to communicate values that support a healthy work environment as a priority.
  • Planning: The role of leadership is to create a healthy work environment for staff by listening to concerns and working together to foster an environment in which nursing and other staff thrive. It’s the responsibility of both leadership and nurses to report practices that do not promote a healthy work environment.
  • Implementation: Leadership is the gatekeeper for a healthy work environment via modeling and implementation of a healthy workplace. Nurses are responsible for delivering safe, high quality patient care and ensuring professional communication with patients and colleagues.
  • Evaluation: Both leadership and nurses are responsible for evaluation of goals. Evaluation is ongoing using the nursing process in order to assure that a healthy work environment is sustained.

A current study (Smith & Lake, 2018) found that an unhealthy work environment in nursing was significantly associated with coworker incivility. Nurse manager qualities were the principal factor of the nurse work environment associated with incivility. Another study found (White & Schoonover, 2016) that implications of an unhealthy work environment negatively impact the patient, the nurse and the organization.  Some of the implications and impacts of this study, as well and other findings are listed below.


Job stress

Increased staff turn over

Excessive work demands

Burn out

Poor staffing

Ineffective delivery of patient care (injury/death)

Over abundance of physical demands of work

Unsafe working conditions

Sick systems

Frustration and powerlessness

Toxic leaders

Confusion about what is right or normal, and decreased morale

Dysfunctional colleagues

Blame and insecurity

Ways to be a professional nurse role model for civility 

Merriam-Webster’s Dictionary (2018), defines civility as “polite, reasonable and respectful behavior.” An expanded definition entails honoring one’s personal values, while listening to disparate points of view to reach a common ground. Prioritizing civility promotes effective communication, high-functioning teams, inclusive and productive communities and civic engagement. In contrast, incivility is defined as “a rude or impolite behavior, lack of civility.” As a nurse, the key factor in addressing incivility in an unhealthy work environment is to address the issues assertively when they occur, especially when the safety of the patient is threatened. Current research (American Academy of Medical-Surgical Nurses, 2013) found that incivility is under reported by nurses and occurs frequently in the clinical nursing. Incivility occurs laterally between nurses, and between members of the health care team. Examples of ways nurses can be a role model for civility includes:

  • Professional role modeling
  • Self-reflection: The Clark Workplace Civility Index ©
  • Stress relief and self-care
  • Honoring your communication and conflict-negotiation skills
  • Using a tool such as the DESC model for conflict resolution

Professional role modeling occurs by demonstrating civility and respect. As a nurse, being a positive role model requires mindfulness and accountability for behaviors with others while consistently displaying ethical, principled conduct based on acceptable standards of professional practice. It’s imperative for nurses to pay attention to detail, encourage collaboration, share important information, and admit mistakes. In addition, nurses should engage in thoughtful self-reflection as an important step toward improving competence as a nurse, colleague, and team member.

The Clark Workplace Civility Index© (2015), is a tool for self-reflection that assesses civility level. It’s designed to raise awareness and identify civility strengths and areas for improvement. Using the tool, nurses can obtain colleague and/or mentor feedback on their own ‘Civility Index’ and perhaps providing feedback on other co worker’s ‘Civility Index’. Doing so can improve your awareness and aids in identifying strengths and areas for improvement. The index using a likert scale (1) Never (2) Rarely (3) Sometimes (4) Usually (5) Always) and assesses “how often do I?” or “How often do they?) There are twenty questions that assess work place civility issues and provides a civility score based on answers given to the questions. The score results vary from:

  • Very civil
  • Moderately civil
  • Barely civil
  • Uncivil
  • Very uncivil

Stress and incivility have a positive correlation. Nurses who are working in high stress environments are more prone to be on either end of incivility. Additional stress results from caring for high-acuity patients, managing demanding workloads, and dealing with incivility. Stress coupled with poor coping skills not only causes personal stress, but also can jeopardize patient care. Acknowledging stress as a reality of life, while working to decrease the reaction to is it is the goal. It’s imperative to know and practice stress-management techniques. A couple of the most powerful tools in promoting civility are engaging in meaningful conversations and negotiating conflict successfully. Yet many nurses struggle with these vital skills. In many cases, nurses feel inexperienced or ill- prepared to engage in critical conversations, much less deal with and address incivility, especially with peers and supervisors. There’s no universal technique that addresses every situation successfully, but there are a few guiding suggestions that include:

  • “What will happen if I stay silent?”
  • “Do I feel equipped to address the issue directly, or is it best to report my observations to my supervisor?”
  • “Is there a protocol or a set of guidelines to assist me in this process?”

Using a tool for conflict resolution may be helpful in helping nursing to engage in direct conflict with an uncivil colleague. There are several models for conflict resolution. One of the model is the DESC model suggested by TeamSTEPPS from the Agency for Healthcare Research and Quality (US Department of Health and Human Services, 2014). This model is preferred when hostile or harassing behaviors are occurring and are affecting patient safety. DESC is a mnemonic for:

D = Describe the specific situation

E = Express your concerns

S = Suggest other alternatives

C = Consequences stated.

Take a look at an example in the following case study below. The example below illustrates how a nurse could engage in a conversation with an uncivil coworker using the DESC model before seeking assistance from her nurse manager.

Describe:  I’d like to talk with you about an important issue. It concerns our interactions with one another.

Explain: When I am addressed in a demeaning way, I feel disrespected and stressed out. I’m concerned about the impact of this behavior on my physical and mental healthy—and more importantly, on my ability to provide safe patient care.

State: I am asking you to address me in a respectful manner.

Consequence: It’s important to me that you understand this is a serious concern, and if your disrespectful behaviors do not stop, I will enlist the support of our supervisor to help us resolve the problem. It’s imperative to work closely with the nurse manager who sets the tone for civility. Nurse managers working with effected nursing staff can show support by promoting respectful communication between the healthcare team members, while encouraging nurses to continue promoting patient safety. Fortunately, most nurses and nurse leaders are eager to learn ways to prevent and address workplace in­civility and to implement evidence-based strategies to create and sustain healthy workplaces.

Examples of how nurse managers can create and sustain civil workplace include:

  • Set the tone for civility in the workplace
  • Co-create desired norms of behavior
  • Implement policy to reward civility

Organizational change occurs when administrative and managerial buy-in occurs. The culture of the facility can then transform into one of effective communication, safety and civility. Ways that facilities can support a healthy work environment (Becker’s Hospital Review 2017). include:

  • Align organizational culture with principles of civility and respect
  • Utilize yearly reviews to evaluate professional behavioral standards
  • Implement elements of a just culture, such as investigating the motivation or purpose behind uncivil behavior
  • Reward civility within the work place
  • Utilize programs to improve and sustain communication and civility


American Association of Critical Care Nurses (2016).AACN STANDARDS FOR ESTABLISHING AND SUSTAINING A HEALTHY WORK ENVIRONMENT. A Journey to Excellence, 2nd edition EXECUTIVE SUMMARY.

American Academy of Medical-Surgical Nurses (2013). Healthy Work Environments.Personal Civility in Health Care. resources/healthy-practice-environment/MSM-Spencer-Jan13.pdf

American Nurses Association (2015). The Code of Ethics for Nurses with Interpretive Statements. https: // for nurses/.American Nurse Today. Seeking Civility.

American Psychological Society: Psychology Teacher Network (2016). Civility: a core component of professionalism? Civility is relevant to the goals of undergraduate education in psychology.

Becker’s Hospital Review (2017). Incivility in the OR: How hospitals, nurse managers and  frontline nurses should respond.

Civility. (n.d.) In Merriam-Webster’s collegiate dictionary. Retrieved from

Clark Workplace Civility Index (Revised) (2015). Revised-Likert.pdf 

Emergency Nurses Association (2012). Position Paper: Healthy Work Environment.          

Forbes (2015).8 Expert Tips to Having a Healthy Company Environment. healthy-company-environment/#4266214dd7

Smith, J. G., Morin, K. H., & Lake, E. T. (2018, March). Association of the nurse work environment with nurse incivility in hospitals. Journal of Nursing Management 26 (2) retrieved from

U.S. Department of Health & Human Services. (2014). Agency for Healthcare Research And Quality. About TeamSTEPS. Retreived from

White, P.E., & Schoonover-Shoffner,K. (July/September,2016). Surviving (Even Thriving?) in a Toxic Workplace. Journal of Christian Nursing 33(3) retrieved from

World Health Organization (2017): Healthy Work Place Model. Five Keys to a Healthy Workplace. Retrieved from