Healing from the Bitter Pill of Incivility

Not long ago, I was facilitating a workshop on fostering civility in nursing education when a faculty member approached me during the break. The soft-spoken professor related her thoughts in a quiet voice, her eyes reflecting a certain sadness as she spoke. She said, “Please think about us—the clinical faculty, I mean—when you are speaking about incivility in nursing education. I am a member of the clinical faculty, and I can tell you, unequivocally, that we are a marginalized group. We are not considered part of the ‘real faculty’ and are often referred to as ‘minions and underlings.’ We are frequently told that we have no clout nor can we provide input into the theoretical courses or exams.” I asked the faculty member how she responded to these incivilities. She said, “I just take it—it’s like swallowing a very bitter pill.”

What I call the in-group and the out-group of nursing faculty teams—and I use the word “team” lightly—is further illustrated by a story described in a study I recently conducted to examine faculty-to-faculty incivility and ways to effectively address the problem. Approximately 13% of the respondents reported experiencing racial, ethnic, sexual, gender, or religious slurs within the past 12 months. One respondent wrote, “During a faculty workshop, faculty members were asked to work in small groups. One group contained four minority faculty members. A non-minority faculty member asked, ‘Do I have to paint my face black to be in this group?’”

Another faculty member related the incivility of perceived ageism that exists in her nursing program. She explained that when she met with her dean to seek advice about returning to graduate school to complete her doctoral degree, the dean laughed and said, “Are you kidding, at your age? You can’t be serious. By the time you finish your degree, you’ll be ready to retire. We prefer to invest in younger faculty.” Other forms of discrimination are also apparent: a student recently commented on faculty bias in the classroom, saying, “Students are often subjected to religious, racial, and anti-gay/lesbian content. We [students] feel vulnerable and do not know how faculty and administrators will react if they complain. It’s appalling and inexcusable.”

Regardless of their origin, uncivil encounters are an affront to human dignity and an assault on a person’s intrinsic sense of self-worth. The effects can be devastating and longlasting. Incivility may come from myriad sources; it is complex, disordered, and multidimensional. Taking time to engage, communicate, and listen with intention has a profound effect on preventing and healing the effects of incivility.

I often refer to incivility as a dance, an expression of feeling and social interaction that gets articulated through a variety of movements, gestures, and actions.1 Each observer and participant interprets the dance within the context of his or her personal experiences, through the lens of his or her own world-view. Because of this individual perception and interpretation, it becomes essential to actively listen, consider the intent of the action, and engage in meaningful and solutionbased conversation.

More than two decades ago, Ernest Boyer asserted that institutions of higher education play a vital role in helping students develop a sense of civic and social responsibility, and become productive citizens of the academy and the community.2 The promotion of civility and good citizenry is especially important in nursing and other health-related disciplines where the risk assumed by not addressing uncivil behavior reaches well beyond the college campus and can negatively impact patient safety, recruitment and retention, and commitment to the nursing profession. Because nursing programs are places where students and faculty provide direct care to patients through clinical experiences, uncivil and disruptive acts must be addressed so that such behaviors do not spiral into aggression and jeopardize the learning and practice environment.

While promoting civility is one of the primary functions of higher education, in some respects the system is failing. This failure may be related to a lack of understanding about the topic in general, and ways to prevent and address incivility in particular. I define incivility as rude or disruptive behaviors that often result in psychological or physiological distress for people involved, and if left unaddressed, may progress into threatening situations.3 Exposure to uncivil behaviors can result in physical symptoms such as headaches, interrupted sleep, and intestinal problems and can cause psychological conditions like stress, anxiety, irritability, and depressive symptoms. Thus, it is important to foster civility—an authentic respect for others requiring time, presence, a willingness to engage in genuine discourse, and an intention to seek common ground.4

Similarly, it is important to raise awareness about the importance of fostering a civil and healthy academic work environment. According to researchers, a healthy academic environment consists of a number of factors, including a clear mission with shared values and norms; high morale, job satisfaction, and an esprit de corps; competitive salaries and benefits; reasonable workloads; positive employee recruitment and retention; policies to eliminate incivility; respectful communication, teamwork, and shared decision making; organizational support and collegial relationships; and competent, honest leaders who collaborate with faculty to share decision making.5,6,7

Awareness may be raised by describing specific rationale for establishing and sustaining healthy academic work environments. First, the costs of incivility are vast. Uncivil behavior adds to employees’ stress level, erodes self-esteem, damages relationships, and threatens workplace safety and quality of life.8 Incivility also lowers morale, causes illness, and leaves workers feeling stressed, vulnerable, and devalued. The human and financial costs of these behaviors may be disastrous.9 Second, the recent Institute of Medicine Report10 includes several recommendations that call for nurses and other health care workers, such as physicians, to collaborate to advance the nation’s health. To fulfill these recommendations, we must establish civil and respectful relationships and interactions. Third, the American Nurses Association Code of Ethics for Nurses with Interpretive Statements Provision 1.5 promotes a civil, healthy work environment by requiring nurses to treat colleagues, students, and patients with dignity and respect, and states that any form of harassment, disrespect, or threatening action will not be tolerated.11 Similarly, the American Nurses Association Standards of Practice reinforce the need for objective standards such as collaboration, ethical conduct, and communication for nurses to be accountable for their actions, their patients, and their peers.12 These rationales and fostering a healthy academic work environment are difficult, if not impossible to achieve in the absence of skilled, ethical leadership. Successful change requires both formal and informal leadership—leaders who hold formal positions as well as individuals without a formal title or authority, but who have significant influence with members throughout the organization.

Once awareness is raised and leaders agree that changes are needed to foster a civil workplace, it is highly desirable to use empirical measures to determine levels, types, and frequency of civil and uncivil factors, and to reveal strategies for fostering a healthy workplace. Some examples of empirical measures include the Organizational Civility Scale (OCS)13 and the Culture/Climate Assessment Scale (CCAS).14 Other data sources are also helpful, such as formal and informal reports, evaluations, satisfaction surveys, performance evaluation information, regulatory reports, and information from focus groups and open forums. Once a comprehensive organizational assessment has been conducted, strategies can be implemented to improve areas of concern and to reinforce efforts already in place to enhance areas of strength and excellence.

Specific strategies include aligning the organizational mission and values with a focus on civility and respect. Successful organizations intentionally focus their vision for the future so that employees are able to meet organizational objectives as well as achieve personal satisfaction in their work. Organizational values undergird the formulation and implementation of norms of decorum. Without functional norms, desired behavior is ill defined and thus, members of the campus community are left to “make things up as they go along.”

Healthy academic work environments do not occur by accident—creating them requires intentional and purposeful focus. Unfortunately, many faculty, students, and administrators are unaware of how their behaviors affect others, and many are ill equipped to deal with incivility. Thus, strategies to prevent and address incivility must be taught, practiced, reinforced, and supported. We must make civility a priority. Faculty and staff meetings are excellent venues to raise awareness, discuss acceptable and unacceptable behaviors, establish norms of behavior, and practice and role-play civil interactions. When faculty and staff collectively co-create norms for behavior, they are more likely to approve of and conform to these behaviors. Once the norms are agreed upon, they become the standard for faculty and staff interactions. It is also important to establish, implement, and widely disseminate confidential, non-punitive policies and procedures for addressing incivility. This includes enforcing sanctions if indicated, and perhaps more importantly, to reward civility and collegiality. Although positive motivators are preferred, the consequences for violating the agreed-upon norms must be clearly stated and enforced. Ignoring or failing to address the uncivil behavior damages the organization as much, if not more, than the incivility itself.

Acting civilly and respectfully isn’t always easy, especially in a high-stress learning environment where constant change is the norm, and where faculty and students experience complex and demanding workloads. Yet, we must make civility a priority for our students, colleagues, practice partners, and ourselves. Incivility takes a tremendous toll on everyone throughout the campus and practice community. In a fast-paced work environment, patience is often in short supply, yet it remains a virtue we should value and uphold. Each individual must set a positive example to lead the transformation for cultivating civility in nursing education.

References

  1. C.M. Clark, “The Dance of Incivility in Nursing Education as Described by Nursing Faculty and Students,” Advances in Nursing Science (2008), 31(4), E37–E54.
  2. E. Boyer, Campus Life: In Search of Community. Princeton: The Carnegie Foundation for the Advancement of Teaching, 2009.
  3. C.M. Clark, “Faculty Field Guide for Promoting Student Civility,” Nurse Educator, 34(5),194–197.
  4. C.M. Clark and J. Carnosso, “Civility: A Concept Analysis,” Journal of Theory Construction and Testing, 12(1), 11–15.
  5. C.M. Clark (in progress), “Pathway for Fostering Organizational Civility.”
  6. M. Brady, “Healthy Nursing Academic Work Environments,” OJIN: The Online Journal of Issues in Nursing (2010), 15(1),Manuscript 6.
  7. National League for Nursing. “Healthful work environments for nursing faculty.” Retrieved February 26, 2012, www.nln.org/newsletter/healthfulworkenv.pdf.
  8. P.M. Forni, The Civility Solution, New York, NY: St. Martin’s Press, 2008.
  9. C. Pearson and C. Porath, The Cost of Bad Behavior: How Incivility is Damaging Your Business and What to do About it. New York, NY: Penguin Group, Inc, 2009.
  10. Institute of Medicine Report (2010). “The future of nursing: Leading change, advancing health,” Robert Wood Johnson Foundation Publisher.
  11. American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements. Washington, D.C.: American Nurses Association.
  12. American Nurses Association. (2010). Nursing Scope and Standards of Practice. (2nd ed). Silver Spring, MD: American Nurses Association.
  13. C.M. Clark and R.E. Landrum, “Organizational Civility Scale.” Retrieved February 26, 2012, http://hs.boisestate.edu/civilitymatters/
  14. C.M. Clark, M. Belcheir, P. Strohfus, and P.J. Springer, “Development and Description of the Culture and Climate Assessment Scale, Journal of Nursing Education (2012), 51(2), 75-80.