Chapter 2The Costs and

Consequences of Incivility: Rationale for Change

“Civility costs nothing and buys everything.” –Mary Worley Montagu

This chapter discusses:

• Thehumanandfiscalcostsofincivility

• Reasonsforaddressingincivility

• Civilityandadvancingournation’shealth

The High Cost of IncivilityThecostsofincivilityarevastandimpactusinmyriadways.Disruptiveandintimidatingbehaviorscanhavenegativeandlastingeffectsonindividuals,teams,andorganizations.Recently,IwasdeeplymovedwhilereadingtheforewordofanexcellentbookauthoredbyPearsonandPorath(2009),The Cost of Bad Behavior: How Incivility Is Damaging Your Business and What to Do About It.TheforewordiswrittenbyWarrenBennis,ascholarlygiantandconsultantinthefieldoforganizationalleadership.Bennistitlestheforeword“LittleMurders”andwritesagrippingaccountofhisobservationsofincivilityintheworkplaceinthelate1950swhilestudyingdoctor-nurserelationships.Thestory

18 Creating & Sustaining Civility in Nursing Education

takesplaceinanoperating-roomtheaterbetweenagiftedsurgeonandanORnurse.Duringaparticularlygruelingandlengthysurgicalprocedure,thesurgeongrewmoreandmoreinfuriatedanddemandingofthenurse.Inhisestimation,thenursewastooslowandfailedtohandhimthesurgicalinstrumentsinaproperway.Thesurgeonscreamedatthenurseinaprofaneandextremelydemeaningmanner.Thenurserespondedwithherownlevelofragebyslammingtheinstrumentsintothesurgeon’shandwithsuchviolentforcethatthedoctor’spalmwasrawandreddened.Bennisandhiscolleagueslaterdescribedthenurse’sbehavioras“spitefulobedience”andconcludedthatincivilityisapervasiveconditioninworkplacesaroundtheworld,onethattendstobeheightenedwhentheworldissufferingfromdiscontentanduncertainty.

Bennis’graphicandvividdescriptionofdoctor-nurseincivilitymadealastingimpressiononme.First,Bennischosetofocusonthebusinessofhealthcaretoillustratethecostsandimpactofincivility.Forme,thiswasajarringaspectofthestory,becauseeventhoughitwasindirect,itwasastoryaboutus—thedoctorsandnurseswhosejobitistodeliverqualitypatientcareandtoadvocateforpatientsafety.Second,tothisday,Iwonderwhathappenedtothepatient.Whatwastheimpactofsuchafierceandaggressiveencounteronthepatient?Iwasleftreelingfromtheaccountandwasremindedonceagainabouttheseriousconsequencesofincivility,particularlyinhealthcare,wherethestakesarehighandtheoutcomecanresultinlifeordeath.

PearsonandPorath(2009)foundthat95%ofAmericanworkersreportedexperiencingincivilityfromcoworkersandconcludedthatincivilityoccursin“nearlyallsettings,bypeopleofallages,aspartoftheirdailyroutine”(p.23).Asaresult,manyworkersareactivelydisengagedandlessproductive,andsomeintentionallyunderminetheirorganizationandtheircoworkers.Theauthorspresentasetofactionstepsandmathematicalequationstocalculatethecostofevenoneuncivilemployeeinanorganization.Asanexample,theauthorsdescribetheimpactofoneuncivilemployeeinahospital—thecostsofincivilityescalatewhenoneincludestheexpensesassociatedwithsupervisingtheemployee,managingthesituation,consultingwithattorneys,andinterviewingwitnesses(doctors,nurses,patients,andothersimpactedbytheoffenderorwhowitnessedtheincivility).Inthiscase,thehospitallostmorethan$25,000asaresultofoneuncivilepisode.

19Chapter 2: The Costs and Consequences of Incivility

the Costs of InCIvIlIty

35% of workers in the United States have experienced bullying firsthand.

62% of the bullies are men.

58% of the targets are women.

80% of the time, women bullies target other women.

30% of bullied employees will resign from their jobs, and 20% of those who witness bullying will also leave the organization.

The annual cost to U.S. organizations is around $300 billion.

Center(2011);TheWorkplaceBullyingInstitute(2010)

Thisimportantinformationshouldbeofinteresttoallemployersandemployees.AsImentionedinChapter1,Ioftenhearpeoplesay,“Wedon’treallyhaveanincivilityproblem,becauseweonlyhaveoneortwotoxicemployees,orjustafewstudentswhobehavebadly,oronlyacoupleofuncivilfacultyinournursingschool—soit’snobigdeal.”Again,Istronglycontendthatthecostofevenoneuncivilindividualcanhaveadeeplysystemiceffectandpotentiallydevastateaworkplace.

Clearly,incivilityintheworkplaceisaseriousproblem.Nearlyadecadeago,FarkasandJohnson(2002)foundthat79%ofsurveyrespondentsagreedthatrudenessandincivilityweregrowingandseriousproblemsintheUnitedStates.InamorerecentstudybyKRCResearch(2011),investigatorsfoundthat65%ofrespondentsbelievethattheUnitedStateshasamajorcivilityproblemandthatAmericansexpectcivilitytoerodeevenfurtheroverthenextfewyears.Theresearchersalsofoundthat43%oftherespondentsreportedexperiencingincivilityatwork,and38%believethattheworkplaceisbecomingmoreuncivilanddisrespectfulthanafewyearsago.Theacademicsettingisnoexception.ClarkandSpringer(2010)studiedacademicnurseleaders’perceptionsof incivility and found that student and faculty stressors, such as heavy workdemands,financialpressures,andlackofadministrativesupport,canleadtoincivility.Theacademicnurseleadersinthestudymadeseveral

20 Creating & Sustaining Civility in Nursing Education

suggestions to address incivility and create cultures of civility in nursing education, including:

• Role-modelingcivil,professionalbehavior

• Teachingandmodelingdirect,effectivecommunicationby seizingopportunitiesforengagement

• Creatingculturesofmutualrespectandemotionalsafety

• Encouragingfreedomofexpression

Leadersneedtoinitiateimportantconversationsaboutcivilitybyprovidingforumsforopendiscussionandbeingvisibleandavailabletofacultyandstudents.Additionally,academicnurseleadersplayakeyroleincraftingvisionstatementsandco-creatingnormsthatreflectanemphasisoncivilityandrespect.Olender-Russo(2009)suggestedthatdiscussingthedesiredwaytheorganization’smemberswilltreatthemselves,eachother,andtheorganizationshouldbeembeddedwithintheorganization’sstrategicplan,vision,mission,andvaluestoincreasethelikelihoodthatchangewilloccurandbesustained.

examples of mIssIon statement, statement of CIvIlIty, and shared values

mission: The University strives to create a community of learners and responsible citizens prepared to improve the world and to meet the challenges of work, family, and community through service, leadership, discovery, and imagination.

statement of Civility: All members of the University are dedicated to creating and maintaining a civil community that supports respectful discourse, openness to opposing points of view, and passionate argument. The campus community demonstrates mutual regard, a willingness to listen, compliance with norms of decorum, and respectful communication.

shared values:

• Academicexcellence

• Respect

• Responsibility

• Socialjustice

• Citizenship

21Chapter 2: The Costs and Consequences of Incivility

Inhealthcare,academic,andotherorganizations,uncivilanddisruptivebehaviorsmightbecomeembeddedintheorganizationalcultureandhaveadirectimpactonemployeesaswellasstudentsandpatientsservedbytheorganization.Incivilitymightresultinincreasedemployeeturnover,disruptionofworkteams,poorproductivity,andsignificanteconomicloss(KRCResearch,2011;Pearson&Porath,2009).Further,incivilitybyhealthcareprofessionalscanresultinseriousmistakes,preventablecomplications,andevendeath(Tarkan,2008).Thepsychologicalimpactofincivilityonfacultyandstudentsmaybedevastatingaswell(Clark,2008a,2008b).

RegulatoryResponse—GameOverAnotherstrongrationaleforfosteringcivilityisTheJointCommission(TJC)sentineleventalertreleasedinJuly2008,withago-livedateofJanuary2009.Inthisalert,TJCnotedthathealthcaresettingsarehigh-stakes,pressure-packedenvironmentsthatcantestthelimitsofcivilityintheworkplace—andthatrudeanddisruptivebehavioramonghealthcareprofessionals can pose a serious threat to patient safety and overall quality ofcare.TJCpromulgatedanewleadershipstandard(LD.03.01.01)toaddressintimidating,disruptive,andinappropriatebehaviorinaccreditedhealthcareorganizations.Thissentinelalertaddressesbehaviorthatunderminesacultureofsafety,becauseitseriouslythreatenspatientsafetyandemployeesatisfaction.AccordingtoTJC,uncivil,disruptive,andintimidatingbehaviorinhealthcarecanleadtomedicalerrors,poorpatientcareandsatisfaction,preventableadversepatientoutcomes,andincreasedcostsofcare.Incivilityalsocausesqualifiedclinicians,administrators,andmanagerstoseeknewpositionsinmoreprofessionalenvironments.

Thenewleadershipstandardaddressesacontinuumofdisruptivebehaviorthatincludescovertactions,suchaswithholdingimportantinformationfromothersandfailingtocooperatewithcolleagues,andovertactions,suchasverbalthreatsandblatantactsofintimidation.Overtactsofintimidationandcoercionconstitutebullyingandareclearlyunacceptable.

Nurses,physicians,administrators,nonclinicalstaff,orothermembersoftheorganizationmightbeinstigatorsortargetsofuncivil

22 Creating & Sustaining Civility in Nursing Education

orbullyingbehavior.Insomecases,thisbehaviorbecomesembeddedintheorganizationalcultureandhasdirectimpactonemployeesaswellaspatientsentrustedtotheircare.Asaresult,TJCrequireshealthcareorganizationstorecognizeandaddressbehaviorthatthreatenspatientsafetyandtheperformanceofthehealthcareteam.TJCrecommendedthatallaccreditedhealthcareorganizationscreatebehavioralcodesofconductandestablishaformalprocessformanagingunacceptablebehaviors.

IliketocallTJC’ssentineleventalertthefirstoftwosignificantandimportantbookendsonthequesttocreatecivilworkplacesforhealthcareworkers.Thesecondofthetwobookendsincludesaregulatoryresponsefromsomestateboardsofnursing(BON)thatarebeginningtosanctionnursingprogramsforuncivilconductamongfacultyandstudents.Inonestate,anursingprogramwascitedforincivilityandrequiredtodevelopadefinedsetofexpectations,interventions,strategies,andwrittenpoliciestoimprovethecultureofacademiccivility.Theprogramwasalsorequiredtoproduceevidenceofarespectful,confidential,positive,andproductiveacademicenvironmentandimprovedstudent-facultyrelationshipsandcommunicationtoensurestudentsuccess.Ifthisdidnothappen,theschoolofnursingmightbeclosed.Iwasfortunatetobeincludedintheinterventionstudythatsubsequentlyensued(Clark,2011).

Inthesummerof2009,thedirectorofthenursingprogramcalledmetoexplainthattheprogramhadbeencitedbytheBONforfaculty,student,andpracticepartnerincivility.Anumberoffacultyandstudentslodgedcomplaintsaboutthetypeandlevelofincivilityoccurringinthenursingprogram,andmembersofthepracticecommunityhadexpressedconcernaboutthedisrespectfulandoccasionallyintimidatingbehaviordisplayedbysomeofthenursingfaculty.Studentsfeltvictimizedbyfacultyandcomplainedabouttheuseofscaretacticsandbullyingbehaviors.Faculty-to-facultyincivilitywasanotherconcern.TheBONrequiredtheprogramtodevelopaclearlydefinedsetofexpectations,strategies,andwrittenpolicies“toenhancestudent-facultyrelationshipsandtoimprovethecultureofacademiccivility.”Further,theconsequencesofnottakingactionweredire.Significantimprovementsneededtobedemonstratedwithin6months;otherwise,theprogramwouldbeclosed.Giventheseriousnessofthesituation,thedirectorrequestedmyassistancetoaddresstheproblem.

23Chapter 2: The Costs and Consequences of Incivility

Theteamdevelopedandimplementedanambitiousandmulti-dimensionalinterventionplantoincludepreinterventionandpostinterventioninstitutionalassessments,anevidence-basedframeworkforestablishingcollaborativepartnerships,andaseriesofdaylongworkshopswithfacultyandstudents.Anactionresearchapproachprovidedastructureforcollaborationandaneffectivemethodtoorganizeourprocesses.Thenursingdirector,faculty,andstudentswerefullmembersintheinterventionplan.Theinstitutionalassessmentsprovidedscientificevidencetounderstandthetypeandfrequencyoffacultyandstudentincivilityanditseffectsonthelearningenvironmentandtodeveloppracticalstrategiestoaddresstheproblem.UsingHeinrich’sframeworkforestablishingcollaborativepartnerships(Heinrich,2010b;Heinrich,Clark,&Luparell,2008)andconductingdaylongfacultyandstudentworkshopswerevitaltothesuccessoftheplan.Theworkshopswerecarefullyplannedtoincludebothstructuredandunstructuredactivities,andvaluabletimewasspentinthoughtfulconversationandproblem-solvingeffortstoidentifyandpracticeindividualandcollectivecivilitystrategies.Withfewexceptions,eachmemberofthefacultyandstudentbodyimplementedstrategiestofulfillthevisiontofostercivilityintheprogram.Intheend,awell-plannedinterventionstrategyhelpedalignadedicatedgroupoffacultyandstudentstotakeinitialstepstowardfulfillingtheirvisionofcivilityandachievinglastingresults.Thisbeginningtransformationservesasanexampleofthepositivechangesthatcanoccurwhenfaculty,students,andacademicleaderscometogethertofosteracultureofcivilityandchange.

Civility,Ethics,andAdvancingOurNation’sHealthSeveralotherorganizationsarehelpingpointthewaybacktocivilityevenastheyhelpadvancethenation’shealthcaresystem.In2008,theRobertWoodJohnsonFoundation(RWJF)andtheInstituteofMedicine(IOM)collaboratedtoassessandtransformthenursingprofessionandtoproduceanaction-orientedblueprintforthefutureofnursing.In2010,theIOMreportcalledforsubstantialtransformationinnursingrolesinallsectorsofhealthcareandfornursingeducationtotakegreaterprofessionalresponsibilitytopreparethisnewgenerationofnurseleaders.

24 Creating & Sustaining Civility in Nursing Education

Asthelargestcomponentofthehealthcarepopulation,nursesareuniquelypositionedtoleadchangeatalllevelsofthehealthcaresystem—includingcreatinghealthyandcivilworkplacesinnursingeducation.Todoso,nursesmustincreasetheirleadershipcapacitytoimplementtransformationalchange,redefinethefuture,alignpeople,andinspireactiontoachieveacompellingvisionandrealizemeaningfulresults.Ultimately,thereportcenteredonfourkeymessages:

1. Nursesshouldpracticetothefullextentoftheireducationandtraining.

2. Nursesshouldachievehigherlevelsofeducationandtrainingthroughanimprovededucationsystemthatpromotesseamlessacademicprogression.

3. Nursesshouldbefullpartners,withphysiciansandotherhealthprofessionals,inredesigninghealthcareintheUnitedStates.

4. Effectiveworkforceplanningandpolicymakingrequirebetterdatacollectionandinformationinfrastructure.

Inadditiontothesekeymessages,theIOMreportissuedeightspecificrecommendations.Iwouldliketohighlightthreeoftheeightrecommendations:

• Recommendation2:Expandopportunitiesfornursestoleadanddiffusecollaborativeimprovementefforts.

• Recommendation7:Prepareandenablenursestoleadchangetoadvancehealth.

• Recommendation8:Buildaninfrastructuretocollectandana-lyzehealthcareworkforcedata.

Iselectedthesethreerecommendationstoproviderationaleforfosteringcivilitybecausetosomeextent,eachrequiresdoctors,nurses,andotherhealthcareprofessionalstoworktogetherandbecausetheyunderscoretheneedforcollaboration,teamwork,andcollegiality—whichareallhighlyrelatedtoestablishingandsustainingrespectfulandcivilinteractions.Noneoftheserecommendationswillbeeasytoaccomplish.Wemustestablishcivilandrespectfulrelationshipsandinteractionstoaccomplishtheseimportantandnecessarygoals.

25Chapter 2: The Costs and Consequences of Incivility

TheAmericanAssociationofCollegesofNursing(AACN)Essentials of Baccalaureate Education for Professional Nursing Practice(2008)includes11essentialsdesignedtotransformbaccalaureatenursingeducationby“providingthecurricularelementsandframeworkforbuildingthebaccalaureatenursingcurriculumforthe21stcentury” (p.4).Oftheseessentials,EssentialVIII:ProfessionalismandProfessionalValuesandbehaviorsassociatedwiththiscategoryarefoundationaltothepracticeofnursing.EssentialVIIIunderscorestheimportanceofprofessionalismandtheinherentunderstanding of the historical, legal, andcontemporarycontextofnursingpractice.Professionalismincludesbeingaccountableandtakingresponsibilityforindividual actions and behaviors,includingcivility.Inotherwords,civilitymustbepresentforprofessionalismtooccur.

Magnetrecognitioninhealthcareorganizationsconveysthatanagencyisanexceptionalplacetowork,asevidencedbythedeliveryofexcellentpatientcare,highlevelsofjobsatisfaction,lowturnoverrates,andcollectivedecision-makingamongmembersofthehealthcareteam.Magnetfacilitiesreflectpositive,dynamic,andresponsiveorganizationalculturesguidedbyleaderswhosupportparticipation,feedback,andcommunication(ANCC,2012;Dumpel,2010).AchievingMagnetstatusinpracticeorganizationsisapinnacleofachievement.The14ForcesofMagnetismincludethemembers’abilitytoworktogetherandtocollaboratetoimprovepatientoutcomesandhealthcaredeliverysystems.Thisisanotherrationaleforpromotingcivility.Ifcivilityisnotpresent,itisunlikelythattheForcesofMagnetismcanbeachievedandultimatelysustained.Insomeway,all14ForcesofMagnetismrequirecivilityandrespect;however,fouroftheforcesstandoutasbeingcloselyrelatedtocivility:

• Force3:ManagementStylereliesonasupportive,participative workenvironmentwherefeedbackisencouraged,valued,andincorporatedatalllevelsoftheorganization.

• Force4:PersonnelPoliciesandProgramsreflectssafeandhealthyworkenvironmentsthatprovideopportunitiesforprofessional growthandthatprovidepoliciesandprogramstosupport professionalnursingpractice,work/lifebalance,andthe deliveryofqualitycare.

26 Creating & Sustaining Civility in Nursing Education

• Force6:QualityofCareprovidesforaworkenvironmentthatpositivelyinfluencespatientoutcomesandwherehigh-qualitycaretopatientsoccurs.

• Force13:InterdisciplinaryRelationshipsemphasizesthevalueofcollaborativeworkingrelationshipswithinandamongthevarioushealthcaredisciplineswheremutualrespectexistsandwhereconflictmanagementstrategiesareinplaceandareusedeffectively.

TheQualityandSafetyEducationforNurses(QSEN,2012)competenciesaredesignedto“preparefuturenurseswiththeknowledge,skills,andattitudes(KSAs)necessarytocontinuouslyimprovethequalityandsafetyofthehealthcaresystemswithinwhichtheywork”(p.1).TheQSENcompetenciesarebasedontheIOM(2003)competencies,andthoughnearlyallofthemrelyoncivilityandrespect,thecompetencyofTeamworkandCollaborationexemplifiescivility—thiscompetencycallsforfunctioningeffectivelywithinnursingandinterprofessionalteamsandfosteringopencommunication,mutualrespect,andshareddecision-makingtoachievequalitypatientcare.Morespecifically,theTeamworkandCollaborationcompetencyrequiresnursestoactwithintegrityandrespectfordifferingviews,toappreciatetheimportanceofintra-andinterprofessionalcollaboration,torespecttheuniqueattributesofteammembers,toinitiateactionstoresolveconflict,andtousecommunicationthatminimizesrisktopatientsafety.Alltheseskillsandattitudesarereliantuponcivilrelationshipsandteamwork.

Otherrationaleforcivilitycomesoutofinternationalandnationalnursingcodesofethics.TheInternationalCouncilofNurses(ICN)Code of Ethics for Nurses(2006)requiresnursestomaintainstandardsofpersonalconductthatreflectwellontheprofessionandenhancepublicconfidence.Similarly,theAmericanNursesAssociation(ANA,2001)Code of Ethics for Nurses With Interpretive Statements,specificallyProvision1.5,compelsnursestotreatcolleagues,students,andpatientswithdignityandrespectandstatesthatanyformofharassment,disrespect,orthreateningactionwillnotbetolerated.Thesecodesofethicssupporttherequirementthatnursesinallareasofnursingeducationandpracticedisplaycivilbehaviorscontinuously.TheANA’sNursing: Scope and Standards of Practice(2010)alsoprovidesaframeworkofobjectiveguidelinestopromoteaccountabilityofnursesfor

27Chapter 2: The Costs and Consequences of Incivility

theiractions,includinghowtheyrelatetopatientsandpeers.Inaddition,theANAstandardsofprofessionalperformanceareclearstandardsandobjectiveguidelinesfornursestobeaccountablefortheiractions,theirpatients,andtheirpeers.Inparticular,theprofessionalperformancestandardofethics,qualityofpractice,communication,andcollaborationiscentraltobuildingandfosteringcommunitiesandculturesofcivility.

FinishingTouchesThecostsandassociatedconsequencesofincivilityarevastandtroubling.Andthetollittakesonindividuals,teams,andorganizationscanbedisturbing.Thoughcivilitymattersformanyimportantreasons,attheendoftheday,itsimplymattersbecauseitistherightthingtodo.Asawisepersononcesaid,“Ifitwereeasy[inthiscase,behavinginacivilmanner],everyonewoulddoit.”Irealizethatourdaysareoftenhectic,theworkloadsometimesseemsunmanageable,andotherdaysourpatienceisinshortsupply,yetpatienceisavirtuethatmakesallofusbetter.Seekingsupportandsettingapositiveexampletoleadthetransformationforcultivatingcivilityinnursingeducationarenoteasybutdefinitelyworththeeffort.

CIvIlIty tIp

Become a catalyst and a change agent in your nursing program. Take the lead to rewrite the narrative on civility and how it can be embedded in your vision and mission statements and shared values and threaded through your everyday interactions with colleagues and students.