A question I regularly ask students before delivering a session that identifies what incivility is and explores how it feels to experience incivility or rudeness is ‘Can you remember a situation when someone was rude to you at work?’ The session explores a range of strategies that encourage practitioners to manage such situations in the future, to find their ‘voice’, to challenge rudeness and, ultimately, to ensure that person-centred patient care and safety is not compromised.
During these sessions, a myriad of examples of incivility are easily recalled and shared by the students. Many of the issues cited could be considered microaggressions. These are ‘low grade’ interactions that often go unchallenged, even though they are acknowledged to be frustrating, unsettling and upsetting. In the sessions, participants remember how the episode made them feel, discuss strategies to manage similar situations in the future and reflect on how the situation might have been managed better.
The seminal definition of incivility is a ‘low intensity deviant behaviour with ambiguous intent to harm the target, in violation of workplace norms for mutual respect’ (Andersson and Pearson, 1999). It was identified as an emerging concept in the 1990s, although known to be an issue for many years and thought to range from rudeness to a lack of respect (Pearson and Porath 2004; Cortina et al, 2022).
‘The seminal definition of incivility is a ‘low intensity deviant behaviour with ambiguous intent to harm the target, in violation of workplace norms for mutual respect (Andersson and Pearson, 1999). It was identified as an emerging concept in the 1990s, although known to be an issue for many years and thought to range from rudeness to a lack of respect.’
(Pearson and Porath 2004; Cortina et al, 2022)
Incivility is a negative behaviour from a person or group directed at another individual and is perceived by the receiver as harmful, disruptive or emotionally disturbing (Aebersold and Schoville, 2020). Where incivility is aligned to nursing, it might include blaming someone for something that goes wrong, gossiping or forming a clique where others feel excluded (Layne et al, 2019). Farrell (2022), outlined the range of behaviours that can be categorised as incivility (Table 1).
Table 1. Incivility
| Verbal | Non-verbal | Actions |
|---|---|---|
| Name callingSnide remarksYellingTeasingCriticismIntimidationBlaming | Eye rollingIgnoringWalking awayWithholding informationWithholding assistance | Unfair patient assignmentSabotageFabricationGossipOstracising |
All of the behaviours outlined by Farrell (2022) have a considerable impact on the recipient's wellbeing, the culture in the workplace and the quality of patient care (Martin and Zadinsky, 2022). While the episodes of incivility and microaggression are often personal, difficult to identify, or describe to others, they have significant ramifications for the receiver, including emotional and physical distress. As a result, incivility can have an impact on the care that the recipient delivers.
Incivility impacts performance, morale, patient safety and can lead to the receiver choosing to leave that work environment (Armstrong, 2018; Edmonson and Zelonka, 2019; Townsley et al, 2023; Tate and Chalhoub, 2024).
Ekici and Beder (2014) highlighted a significant relationship between workplace incivility and a reduction in motivation for work from the recipient. Credland and Whitfield (2022) advise that even ‘minor’ acts of incivility accumulate, they ‘erode staff morale, reduce confidence and negatively impact wellbeing’, predisposing burnout and increasing the chances of leaving the profession. In addition to incivility from colleagues, nurses also experience rudeness from patients, their families and visitors. This is often exacerbated by the high-pressure environments that all of them are working in (Townsley et al, 2023).
‘Primary care, district and community nursing staff are not exempt from the challenges of incivility. Tense interprofessional communication, limited access to resources and an ‘overloaded’ system puts additional pressure on interactions between the range of primary care services required to support patients out of hospital. This makes incivility common in the delivery of out-of-hospital care.’
Whilst incivility is seen in every line of work to an extent, it is frequently documented in healthcare professions and, most frequently, in nursing. Here, it is often accepted, expected and tolerated (Farrell, 2022). ‘Nurses eat their young’—a phrase first proposed in a 1986 in an article by Judith Meissner—is a phenomenon that many nurses have experienced either as students or as qualified professionals.
Sahay et al (2015)a found that many newly qualified nurses experienced unsupportive, ‘incivil’ work environments, which increased their propensity to make medication errors. The vulnerability of being ‘newly’ qualified, combined with working in an unwelcoming clinical area exacerbated risks to patient safety (Sahay et al, 2015). People who experience incivility report job stress, psychological distress, depression and, for some, suicidal ideation as a result of incivility (MacIntosh, 2005; Cortina, 2008).
Porath and Pearson (2009) aimed to quantify the impact of incivility. They recorded that 66% of employees reported a decline in their work performance as a direct result of colleagues being rude to them, 78% were less committed to their work and 80% stated that they became preoccupied with the incident, which further impacted on their work. Katz et al (2019) established a link between incivility, diagnostic accuracy by the recipient, their ability to effectively communicate and patient management.
Healthcare environments appear to be particularly susceptible to incivility. This was thought to be directly related to the perceived level of ‘pressure’ within a particular work environment. There are widespread reports of incivility in emergency departments, critical care environments, neonatal units and other clinical areas that typically fit the accepted ‘high pressure’ description (Hesketh et al, 2003; Atashzadeh et al, 2021). These are known to be challenging and fast-paced units, with large staff groups who regularly experience multiple diverse interactions with colleagues, patients and their carers. Primary care, district and community nursing staff are not exempt from the challenges of incivility. Tense interprofessional communication, limited access to resources and an ‘overloaded’ system puts additional pressure on interactions between the range of primary care services required to support patients out of hospital. This makes incivility common in the delivery of out-of-hospital care.
Incivility is widespread for student nurses; this jeopardises their career choice and professional future, their learning and intent to remain on their programme of study (Heydari et al, 2015). Smith et al (2010) surveyed new nurses in Canada and demonstrated that over 90% reported experiencing some incivility from colleagues in their short careers.
Data show that incivility towards newly qualified nurses is common. They are at the peak of their vulnerability in the early months, often exacerbated by unfamiliarity with colleagues (Farrell, 2022). A global survey evidenced that 50% of participants of their study reported being treated rudely at work at least once a month (Porath, 2022). Porath (2022) showed a worrying trend in the prevalence of incivility. In a survey of 2000 workers across 25 industries, findings revealed 55% of participants reported incivility in 2011, 62% in 2016, increasing to 76% in 2022.
Armstrong (2018) advocates the implementation of educational interventions and training to effectively prepare nurses to manage rude or uncivil behaviours. Simulation is a powerful learning tool in the context of incivility. Levett-Jones and Lapkin (2014) used simulated scenarios of incivility to generate learning experiences for students focused on interpersonal communication and incivility, employing debriefing as a significant element of the overall experience.
Another innovative approach to developing specific skills to manage incivility is the use of a technique known as cognitive rehearsal (Griffin, 2004; Razzi and Bianchi, 2019). Cognitive rehearsal is an evidence-based technique that prepares individuals for challenging situations; it discourages an impulsive reaction to incivility, with the training advocating a pause for the recipient to process the situation and then to formulate a healthy response. This process uses simulation and role play (Razzi and Bianchi, 2019). Griffin (2004) also embedded examples of assertive responses to incivility, with participants practicing assertive responses in a simulated environment. Griffin's (2004) innovative study used novel approaches with student nurses. The study evidenced a 100% reduction in bullying behaviours on the units where the nurses worked and effectively enhanced their ability to respond to and mange incivility in the workplace.
Incivility in clinical practice is common, increasing and is known to be damaging to the recipient and to colleagues, impacting on patient safety and the quality of patient care that is delivered. Learning specific skills to manage incivility is key to staff wellbeing, retention, mental health, positive communication and team working in the effective management of patients across all clinical environments.