Running head: INCIVILITY AND BULLYING 1
Incivility and Bullying in Nursing
Michelle A. Stimson
Ferris State University
INCIVILITY AND BULLYING
Abstract
A culture of incivility and bullying has plagued the profession of nursing for decades. Such a
culture degrades the work environment resulting in decreased job satisfaction, job turnover,
impaired team dynamics, and poor patient outcomes. In the academic environment, nursing
faculty are leaving their positions due to uncivil encounters with students and fellow colleagues.
Nurse leaders have failed to address this complex issue leaving the profession of nursing stuck in
a web of toxic, reoccurring patterns threatening the viability of healthcare, academia, and the
profession of nursing altogether.
INCIVILITY AND BULLYING
Incivility and Bullying in Nursing
A pervasive and complex problem facing nurse leaders today, nurse-to-nurse incivility
and bullying threatens the viability of healthcare, academia, and the profession of nursing
(American Nurses Association [ANA], 2015b). Nurse-to-nurse bullying, also known as
horizontal or lateral violence, degrades the integrity of the work environment leading to job
turnover, impaired professional collaboration, and poor patient outcomes (Luparell, 2011). In the
academic setting, it contributes to faculty attrition and lower academic standards (Luparell,
2011). The purpose of this paper is to identify causes of incivility and bullying, discuss how they
impact healthcare, the profession of nursing, and academia, and explain why addressing this
problem in an urgent and aggressive fashion is paramount to the survival of all three entities.
Literature Support and Discussion
A culture of incivility and bullying has plagued the profession of nursing for decades.
The problem is so pervasive that it has grabbed the attention of governing bodies such as the
American Nurses Association (ANA) and The Joint Commission (TJC). Incivility and bullying
occurs in all types of practice and academic settings and has been referred to as professional
terrorism and workplace mobbing (ANA, 2015b; Griffin, 2004). According to Condon (2015),
eighty percent of nurses have experienced some form of incivility or bullying. Even worse, one
in three nurses have left their position due to uncivil encounters and reports of suicide exist due
to bullying (Griffin, 2004).
Some experts believe incivility and bullying stems from oppressed group behaviors.
Nurse are believed to be an oppressed group (Condon, 2015; Griffin, 2004). Oppressed groups
feel excluded from the power structure, therefore, exert whatever power they have on the lowest
ranking members of their group (Condon, 2015; Griffin, 2004). Others believe incivility and
bullying stems from high-stress situations, heavy workloads, lack of interpersonal and conflict
management skills, generational differences, and ineffective nurse leaders (Condon, 2015). At
INCIVILITY AND BULLYING
the point of matriculation, nurses are socialized into a culture of bullying carrying the culture
with them upon graduation (Condon, 2015). Breaking the cycle of violence is rather difficult
because the behaviors are shrouded in secrecy and viewed as a rite of passage (Condon, 2015).
Definitions of incivility and bullying vary, however, many agree they are patterns of
behavior stemming from an individual or a group of individuals with the purpose of shaming,
dishonoring, and/or intimidating others (Condon, 2015). The behaviors can take the form of
physical, verbal, and/or emotional abuse (Condon, 2015). Some behaviors are overt such as eye
rolling, snide comments, and outright professional sabotage (Griffin, 2004; Purpora & Blegen,
2015). However, most often, behaviors are covert in nature. Covert behaviors include spreading
rumors, withholding information, undermining, and backstabbing (Griffin, 2004).
Need for Change
For nurse leaders, effectively addressing a culture of incivility and bullying is critical to
maintaining healthy work environments, sustaining an adequate nursing workforce, and keeping
patients safe from harm. Poor work environments are associated with job dissatisfaction, nurse
turnover, medication errors, and healthcare associated infections (Ulrich, Lavandero, Woods, &
Early, 2014). A direct link exists between incivility and job dissatisfaction (Purpora & Blegen,
2015). Job dissatisfaction directly impacts nursing turnover (Aiken, Clark, Sloane, Lake, &
Cheney, 2008). Evidence shows when there are more nurses caring for patients, patients
experience fewer complications, shorter lengths of stay, and decreased mortality rates (Aiken et
al., 2008). Recruiting and retraining nurses is a financial burden for healthcare organizations.
Costs can reach as high as 92,000 dollars to recruit and train just one nurse (Saber, 2014).
Successful teamwork is the cornerstone of safe, patient-centered care (Sherwood &
Barnsteiner, 2012). The quality of nurse-nurse relationships has a direct impact on patient safety
(Manojlovich et al., 2014). Incivility and bullying destroys team dynamics, impedes mutual
respect, and inhibits collaboration (Luparell, 2011). As a result, communication breakdowns
INCIVILITY AND BULLYING
occur leading to adverse outcomes. A majority of healthcare-related sentinel events are a result
of communication failures (Beckett & Kipness, 2009).
Academic nurse leaders are not immune to the effects of uncivil faculty-faculty and
student-faculty encounters. Behaviors such as inattentiveness, tardiness, rude and sarcastic
comments, and professional sabotage destroy the integrity of the academic environment
(Luparell, 2011). Uncivil behaviors erode an educator's self esteem, destroys their confidence,
and decreases their desire to maintain high educational standards (Luparell, 2011). Faculty
attrition occurs as a result (Luparrell, 2011).
The profession of nursing abides by a code of ethics (ANA, 2015a). According the Code
of Ethics, nurses are responsible for protecting their patients from harm and injury (ANA,
2015a). The Code of Ethics is nursing's contract with society (ANA, 2015a). Allowing a culture
of incivility and bullying to exist breaks nursing's promise to the individuals it has promised to
protect.
A Vision for Change
Nurse leaders are critical to maintaining a healthy work environment. Without proper
leadership, job satisfaction, workforce stabilization, and patient safety suffers (Ulrich et al.,
2014). Nurse leaders must abandon reductionist thinking in order to solve problems within
complex systems such as healthcare and academia (Marshall, 2011). Nurse leaders can no longer
be one-dimensional or stuck (Marshall, 2011). Otherwise, patient safety and the integrity of
healthcare will be jeopardized. Embracing uncertainty and interconnectedness allows leaders to
solve problems that are entangled, multifaceted, and ever-evolving (Weberg, 2012).
Using the ecological model of health, nurse leaders can identify potential interventions
for addressing incivility and bullying in nursing. Recognizing problems such as incivility and
bullying are complex and multifaceted, the ecological framework addresses multiple levels of
interactions and the interplay each interaction has on the end result (World Health Organization
[WHO], 2015). After looking at the individual, interpersonal, institutional, community, and
INCIVILITY AND BULLYING
societal levels of influence, risk factors such as personal attitudes, social isolation, conflict
management skills, and cultural norms can be identified (WHO, 2015). Once identified,
strategies can be created and implemented. The ecological model has been used by the World
Health Organization to address the complex issue of domestic violence. Bullying and incivility
are forms of workplace violence on occur in patterns similar to domestic violence (ANA, 2015b;
WHO, 2015).
Conclusion
The profession of nursing has an ethical obligation to eliminate incivility and bullying.
In order for incivility and bullying to be eliminated, the complexity of the problem must be fully
appreciated. A one-sided solution would not measure up to the breadth and depth of this
complex phenomenon. Although complicated and pervasive, nurse leaders must abandon old
ways of thinking and join forces with leaders in the practice, academic, and research setting. As
in situations of domestic violence, the impact of incivility and bullying reaches much further
than the immediate perpetrator and victim. If allowed to continue, incivility and bullying has the
potential to destroy the integrity of healthcare, academia, and the profession of nursing
altogether.
INCIVILITY AND BULLYING
References
Aiken, L. H., Clark, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital
care environments on patient mortality and nurse outcomes. Journal of Nursing
Administration, 38(5), 223-229
American Nurses Association [ANA]. (2015a). Code of ethics for nurses with interpretive
statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/
EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html
American Nurses Association [ANA]. (2015b). The American Nurses Association position
statement on incivility, bullying, and workplace violence. Retrieved from http://
www.nursingworld.org/DocumentVault/Position-Statements/Practice/Position-Statementon-Incivility-Bullying-and-Workplace-Violence.pdf
Beckett, C. D., & Kipness, G. (2009). Collaborative communication: Integrating SBAR to
improve quality/patient safety outcomes. Journal for Healthcare Quality,31(5), 19-28.
Condon, B. B. (2015). Incivility as bullying in nursing education. Nursing Science Quarterly,
28(1), 21-26. doi: 10.1177/0894318414558617
Griffin, D. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention
for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257263.
Luparell, S. (2011). Incivility in nursing: The connection between academia and clinical settings.
Critical Care Nurse, 31(2), 92-95. doi: 10.4037/ccn2011171
Manojlovich, M., Kerr, M., Davies, B., Squires, J., Mallick, R., & Rodger, G. L. (2014).
Achieving a climate for patient safety by focusing on relationships. International Journal
for Quality in Healthcare, 26(6), 579-584.
Marshall, E. (2011). Transformational leadership in nursing: From expert clinician to influential
leader (1st ed.). New York, NY: Springer Publishing Company, LLC.
Purpora, C., & Blegen, M. A. (2015). Job satisfaction and horizontal violence in hospital staff
registered nurses: Mediating the role of peer relationships. Journal of Clinical Nursing,
24(15-16), 1-9. doi: 10.1111/jocn.12818
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Saber, D. A. (2014). Frontline registered nurse job satisfaction and predictors over three decades:
A meta-analysis from 1980 to 2009. Nursing Outlook, 62(6), 402-414. doi: http://
dx.doi.org/10.1016/ j.outlook.2014.05.004
Sherwood, G, & Barnsteiner, J. (2012). Quality and safety in nursing. West Sussex, UK: WileyBlackwell.
Ulrich, B. T., Lavandero, R., Woods, D., & Early, S. (2014). Critical care nurse work
environments 2013: A status report. Critical Care Nurse, 34(4), 64-79. doi:10.4037/
ccn2014731
Weberg, D. (2012). Complexity leadership: A healthcare imperative. Nursing Forum, 47(4), 268277.
World Health Organization [WHO]. (2015). The ecological framework. Retrieved from
http://www.who.int/violenceprevention/approach/ecology/en/
Below Expectations
Needs Improvement
Meets Expectations
Exceptional
A.
Introduction
with
Identification
of an Issue
in Nursing
0-7 points
8 points
12 points
15 points
No introduction included,
or the introduction does
not identify an issue that
is clear or current. The
introduction may be far
too brief or lengthy, and
the purpose statement is
missing.
Student identifies an issue
or challenge facing a nurse
leader, but the issue is
unclear and may not
necessarily be relevant to
the current healthcare
environment. The
introduction lacks
conciseness, and a
purpose statement is weak
or not included.
Student identifies an issue or
challenge facing a nurse
leader in the current
healthcare environment. The
introduction is concise, and a
purpose statement is
included.
Student clear
identifies a
relevant issue
challenge fac
nurse leader
current health
environment.
introduction is
concise, but
makes the iss
challenge cle
clear purpose
statement is
included.
B. Literature
Support &
0-17 points
18 points
24 points
30 points
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Discussion
This section is missing or
the student provides little
to no literature support for
the importance and reality
of this issue/challenge as
it relates to the role of a
nurse leader. The issue is
not discussed from the
perspective of how this
issue threatens
healthcare from a broad
perspective, and/or how it
can impact the nursing
workforce or organization.
The student provides little
literature support for the
importance and reality of
this issue/challenge as it
relates to the role of a
nurse leader. The issue is
only minimally discussed
from the perspective of how
this issue threatens
healthcare from a broad
perspective, and/or how it
can impact the nursing
workforce or organization.
One or more of these areas
may not be discussed.
The student provides
literature support for the
importance and reality of this
issue/challenge as it relates
to the role of a nurse leader.
The issue is discussed from
the perspective of how this
issue threatens healthcare
from a broad perspective,
and/or how it can impact the
nursing workforce or
organization.
The student
provides clea
literature supp
for the import
and reality of
issue/challeng
it relates to th
role of a nurs
leader both w
an organizatio
and within the
broader
perspective. T
issue is very
clearly discus
from the
perspective o
this issue
threatens
healthcare fro
broad perspe
and/or how it
impact the nu
workforce or
organization.
C.
Advocating
Need for
Change
0-17 points
18 points
24 points
30 points
This section is missing or
the students written
communication does not
establish a sense of
urgency for the change,
nor does the student
create a vision for the
change. The student does
not communicate the
vision for the change to
the reader. The student
doesnt cite either
leadership or change
theory
The students written
communication does not
effectively establish a
sense of urgency for the
change, nor is the student
able to create a clear vision
for the change. The student
is not able to clearly
communicate the vision for
the change to the reader.
The student doesnt cite
relevant leadership or
change theory
The student utilizes written
communication to establish a
sense of urgency for the
change, and to create a
vision for the change. The
student is able to
communicate the vision for
the change to the reader.
The student cites leadership
or change theory
The student
utilizes effecti
written
communicatio
establish a se
of urgency fo
change, and t
create a clear
vision for the
change. The
student is abl
effectively
communicate
vision for the
change to the
reader. The
student cites
relevant
leadership an
change theor
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D. Summary
E. Data &
Information
10
0-4 points
5 points
8 points
10 points
The summary is missing
or the student writes a
very weak summary
section that does not
cover the main points of
the paper and may or may
not bring in bring in new
information.
The student writes a weak
summary section that does
not cover the main points of
the paper and may or may
not bring in bring in new
information.
The student writes a
summary section that covers
the main points of the paper
without bringing in any new
information.
The student w
a clear summ
section that
effectively cov
the main poin
the paper with
bringing in an
new informati
0-7 points
8 points
12 points
15 points
The student doesnt
include credible
references, and may not
include a research study
or a text source. There
are 2 or less scholarly
sources.
The student includes
references for at least one
original research study but
it is not from nursing, one
text source, and only a total
of 3 or less scholarly
sources.
The student includes
references for at least one
original nursing research
study, two text sources, and
a total of 4 scholarly
sources.
The student
includes stron
references fo
least two orig
nursing resea
studies, two t
sources, and
total of 5 or m
scholarly sou
TOTAL POINTS FOR CONTENT:
DEDUCTIONS OF UP TO 20% will be made to the score received for content for errors in APA formatting, Spelling & Grammar; Clarity o
ideas
No points will be deducted if APA format is excellent, and no errors in grammar, spelling, punctuation, or sentence structure, and ideas are clearly
presented.
The number of points deducted will be determined on the number of errors found within the paper as a whole, and at what point the student is at in th
MSN program.
A general idea is as follows:
APA format is in far below average with > 30 errors in APA/grammar/spelling and ideas are unclearly presented. (20 point deduction).
APA format is below average; >20 errors in grammar or spelling; Ideas are not clearly presented. (15 point deduction)
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APA format is average; <10 errors in grammar or spelling; Ideas are almost always clearly presented. (10 point deduction)
APA format is good; <5 errors in grammar or spelling; Ideas are clearly presented. (5 point deduction)
APA format is excellent; No errors in grammar or spelling; Ideas are clearly presented (0 point deduction.)
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