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• To read an action plan for nurse managers to assist their colleagues, team and organisation to recognise and act on workplace incivility
• To contribute towards revalidation as part of your 35 hours of CPD (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Incivility is a major concern in healthcare, and it is vital that uncivil behaviour is recognised and addressed. Manifestations of incivility are wide ranging and can take the form of microaggressions, which are difficult to pinpoint but have significant repercussions. Research has demonstrated the negative effects of incivility on staff and patients. Uncivil acts and behaviour can create conflict, reduce performance, affect morale, decrease retention and jeopardise patient safety. The role of nurse managers in reducing incivility and promoting civility includes providing leadership, fostering psychological safety, creating a shared understanding of civil behaviour and managing uncivil behaviour as soon as it occurs. The input of employers is crucial to promote a compassionate and inclusive organisational culture and to support nurse managers to acquire the knowledge, skills and confidence to prevent and reduce incivility.
Nursing Management. doi: 10.7748/nm.2024.e2138
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencecolleen.wedderburn-tate@nhs.net
Conflict of interestNone declared
Wedderburn Tate C, Chalhoub S (2024) Managing uncivil behaviour in the workplace. Nursing Management. doi: 10.7748/nm.2024.e2138
Published online: 12 September 2024
The aim of this article is to support nurse managers to identify and address incivility in the workplace. After reading this article and completing the time out activities you should be able to:
• Cite examples of uncivil acts or behaviour in the workplace.
• Describe the effects of incivility on staff, teams, patients, organisations and healthcare services.
• Reflect on your attitudes and behaviour to determine how others may perceive them.
• Develop an action plan to help your colleagues, team and organisation recognise and act on incivility.
• Recognise the importance of taking steps to maintain your well-being when managing uncivil behaviour in the workplace.
Defining incivility is challenging, not only because of its many associated terms and concepts – such as rudeness, disrespect, inappropriate behaviour, disruptive behaviour, bullying, harassment and so on – but also because of the broadness of the topic, since incivility can manifest all the way from individual behaviour to organisational culture (Young and Gifford 2022). The word ‘incivility’ comes from the Latin ‘incivilitas’, which itself comes from ‘civilis’ which means ‘belonging to a citizen, civic, political, urbane, courteous, civil’. The Merriam-Webster online dictionary defines incivility as ‘the quality or state of being uncivil’ or ‘a rude or discourteous act’. By contrast, it defines civility as ‘civilized conduct’ or ‘a polite act or expression’.
Incivility in the workplace is not covered in policy or legislation as such. However, national policies such as the NHS Long Term Plan (NHS England 2019) and People Plan (NHS England 2020) focus on reducing bullying and harassment and putting compassion and inclusivity at the centre of NHS culture. Furthermore, there are several pieces of legislation that prohibit bullying, harassment and all forms of discrimination in the workplace. Outlined in sections 149-157 of the Equality Act 2010, the Public Sector Equality Duty (PSED) applies to all public authorities, including the NHS (Government Equalities Office 2023). The case of Cox vs NHS Commissioning Board (HM Courts & Tribunals Services and Employment Tribunal 2023) is, however, a reminder that policy and legislation are not always heeded in practice.
There is increasing awareness of the need to equip managers with the knowledge and skills they need to develop and maintain a psychologically safe workplace, where inappropriate behaviour is instantly addressed (Remtulla et al 2021). This is especially important in healthcare, where incivility can directly affect clinical outcomes (Riskin et al 2015) and job performance (Katz et al 2019). Furthermore, managers need to be supported so that their own well-being is not affected by exposure to, and having to address, inappropriate behaviour in the workplace (NHS England 2022).
Watch this video about Civility Saves Lives: https://www.youtube.com/watch?v=Ta-Ve9E9lZE&t=5s. Does it chime with your experience? Have you witnessed anything similar to what is described in the video? How does it make you feel?
• Acts of incivility adversely affect people subjected to them and those who witness them
• For nurse managers, it is critical to recognise the manifestations of incivility in themselves and in others
• Nurse managers have a crucial role in reducing incivility and promoting civility in the workplace
• Nurse managers who witness, experience and/or address incivility need to maintain their well-being
Civility creates a sense of respect, harmony, trust and inclusivity. It helps make people feel valued, which in turn helps them perform more effectively (Dekker and Edmondson 2022). This is particularly important in healthcare, where staff are exposed to high levels of stress. Healthcare staff need to evaluate and adjust their behaviour to decrease incivility and therefore enhance psychological safety and reduce stress levels (Loh et al 2023). Civility aligns with nurses’ values and with their professional standards of practice and behaviour (Nursing and Midwifery Council (NMC) 2018), which require them to ‘treat people fairly and without discrimination, bullying or harassment’.
Further reasons why civility in the workplace is important include (Smallwood 2018):
• Promoting respect – civility encourages people to listen to one another, understand differing perspectives and communicate in a respectful manner.
• Reducing conflict – when people communicate in a civil manner, the likelihood of misunderstanding is reduced, resulting in a more peaceful and harmonious environment. Conversely, uncivil communication, for example name-calling or insults, makes a breakdown in communication and conflict more likely.
• Building trust – civility helps create an environment of trust and psychological safety.
• Fostering inclusivity and diversity – civility contributes to an environment where everyone feels valued and respected regardless of their background, beliefs or opinions.
• Encouraging positive change – civility promotes effective communication, which in turn fosters innovation and supports openness to change.
A group of healthcare professionals created Civility Saves Lives, a self-funded collaborative project aimed at providing ‘a collective voice for the importance of respect, professional courtesy and valuing each other’ and at raising awareness of ‘the negative impact that rudeness (incivility) can have in healthcare’. The Civility Saves Lives website (www.civilitysaveslives.com/) features evidence of the links between incivility, decreased job performance and suboptimal patient care.
Workplace incivility has been described as the ‘cancer’ of many healthcare organisations (Agarwal et al 2023) and is a major problem in healthcare worldwide (Erkfitz 2013). Its effects on patients can be far-reaching; for example, it may deter people from seeking treatment (Vargas et al 2021). Several reports into failures of care in the NHS – see for example Francis (2013), Kirkup (2022) and Ockenden (2022) – have described the harmful effects of unsafe practice, suboptimal leadership culture, discrimination, bullying and harassment on patients, staff and organisations. The 2023 annual NHS staff survey showed a decrease in staff experiencing bullying and harassment from colleagues at work, but 26% of staff still experienced them (NHS 2024).
In a study into the effects of workplace empowerment, incivility and burnout on nurse recruitment and retention, supervisor incivility and cynicism appeared to be strong predictors of job dissatisfaction and staff turnover (Spence Laschinger et al 2009). Incivility from patients and families can have similar effects, especially when staff experience it regularly (Campana and Hammoud 2015).
All members of the healthcare team can be exposed to incivility, which will affect how they interact with each other. As an example, 76 anaesthetists participated in a simulated operating theatre crisis and were randomly allocated to experience civility or incivility (Katz et al 2019). Those who experienced incivility scored lower in terms of clinical performance and interpersonal behaviour. Furthermore, they were unaware of the effects of their behaviour on others (Katz et al 2019).
Acts of incivility affect not only people subjected to them, but also those who witness them. Porath and Pearson (2013) conducted a poll of 800 managers and employees in 17 industries, including healthcare, and found that incivility had a range of negative effects on staff, both those subjected to incivility and those who witnessed it (Box 1).
Among staff who had been subjected to incivility, Porath and Pearson (2013) found that:
• 80% spent time worrying about rudeness
• 78% reduced their commitment to work
• 75% had less enthusiasm for the organisation than before
• 63% spent time avoiding the person who had shown incivility towards them
• 61% experienced a reduction in cognitive ability
• 48% spent less time at work
• 38% showed a reduction in the quality of their work
• 25% took it out on others, including service users
• 20% showed decreased performance
• 12% had left their job
Among staff who had witnessed incivility, Porath and Pearson (2013) found that:
Disruptive behaviour at work causes significant and unnecessary distress among colleagues, affects decision-making, undermines professionalism and adversely affects patient care (Royal College of Surgeons of England 2021). Incivility may take the form of ‘microaggressions’, which are often subtle behaviours that are difficult to pinpoint but have significant effects. As Hollowood (2022) put it, ‘micro refers to its subtle delivery – not its impact’. The dignity of staff exposed to acts of incivility is diminished, their physical health is affected and their levels of stress increase (West and Coia 2019). Incivility is costly for teams and organisations in terms of morale, absenteeism, staff turnover, employment tribunal claims and damage to the organisation’s reputation (NHS Resolution 2023). Box 2 summarises the potential effects of incivility in healthcare.
Potential effects on staff
• Decreased productivity
• Reduced confidence
• Reduced ability to make safe decisions
• Increased mental distress
• Increased risk of mental health issues
Potential effects on teams
Potential effects on patients
• Decreased patient safety
• Increased risk of morbidity and mortality
• Loss of trust in healthcare services
• Decreased willingness to seek treatment
Potential effects on organisations
• Challenges to recruitment and retention
• Increased costs due to sickness leave, staff recruitment and litigation claims
• Reduced credibility and damaged reputation
Potential effects on the healthcare system
Manifestations of incivility in the workplace include (Bar-David 2018):
• Spreading rumours or gossip.
• Talking over or interrupting people.
• Making rude or belittling gestures, such as eye rolls.
• Using condescending language.
• Making belittling comments, being sarcastic or mocking colleagues.
• Not attending meetings.
• Excluding or avoiding colleagues.
• Intimidating colleagues.
• Gaslighting – a form of emotional abuse which causes a person to doubt themselves.
A study by Howick et al (2020) found a direct correlation between kind and empathic behaviour and improved patient outcomes; in contrast, incivility resulted in inadequate communication, staff burnout and patient safety errors. It is critical that nurses understand how their attitudes and behaviour can influence how others perceive them, as well as the attitudes and behaviour others adopt. Nurses need to use all forms of communication responsibly and take care not to express personal beliefs or opinions inappropriately (NMC 2018). In this way, positive attitudes and behaviour are reinforced within the team, which has a direct effect on nurses’ ability to co-operate with each other.
For nurse managers, it is critical to recognise the manifestations of incivility in themselves and in others (Atashzadeh Shoorideh et al 2021). Self-reflection enables managers and leaders to refine their leadership style and develop their emotional intelligence (Bailey and Rehman 2022). Self-reflection is necessary for nurse managers to recognise potential incivility in their own attitudes and behaviour. A useful tool to support reflection is Gibbs’ (1988) reflective cycle (Figure 1). Gibbs’ reflective cycle can be used to support the individual to explore their experiences and feelings and acknowledge the positive and negative effects of their behaviour on others. Evaluation and analysis then help the individual to determine what they could have done differently and what they can learn. Finally, the individual is prompted to develop an action plan aimed at improving how they will manage similar situations in the future.
Listen to this Nursing Standard podcast with Chris Turner on how to (politely) call out rudeness at work: rcni.com/nursing-standard/newsroom/podcast/how-to-call-out-rudeness-politely-work-198671
How would you implement Chris’ suggestions in your workplace?
Organisational climate is a crucial factor in the smooth running of an organisation (Chartered Institute of Personnel and Development 2023). In a suboptimal organisational climate, incivility often goes unchallenged and therefore persists. This leads to normalisation of incivility, which may bring about suboptimal working relationships, increased sickness leave, lack of accountability and lack of trust. Nurse managers have a crucial role in reducing incivility and promoting civility in the workplace. That role includes providing leadership, fostering psychological safety, creating a shared understanding of civil behaviour and managing uncivil behaviour.
If unchallenged, incivility creates a vicious circle whereby one act of incivility breeds another (Bar-David 2018). Small acts of incivility or microaggressions that are not addressed can spiral into horizontal violence – which refers to non-physical and aggressive, harmful and/or hostile behaviour between co-workers (Smallwood 2018). Addressing these discreet acts of incivility promptly sets clear boundaries between acceptable and unacceptable behaviour.
Employees who have recognised they have behaved in an uncivil manner have reported that they modelled their behaviour on that of leaders in their organisation (Murrell 2018). Effective leaders shape the team’s behaviour by acting as role models for civility (Chartered Institute of Personnel and Development 2023), establishing clear standards and showing no tolerance for incivility. Power dynamics are commonly at the centre of incivility in the workplace, since people who are targeted are often below those, within the hierarchy, displaying incivility. However, incivility must not be ignored even when it comes from people in the higher tiers of the organisation (Murrell 2018).
Providing positive leadership is therefore vital in creating a civil workplace. However, it has been acknowledged that leadership in the NHS is inconsistent and that there is a need for clear development pathways and support systems for people in leadership roles (Messenger and Pollard 2022).
Removing barriers to addressing incivility enables staff to feel a sense of psychological safety, since they can be confident that uncivil behaviour will be managed promptly. This in turn contributes to the provision of better and safer patient care (Oppel et al 2019). By actively listening to staff, nurse managers can create an environment where staff feel free to raise concerns. This enhances psychological safety, the absence of which leads staff to fear humiliation or punishment if they speak up (Dekker and Edmondson 2022), with negative effects on their performance and ability to make effective decisions (Porath and Pearson 2013).
Team debriefs support the process of fostering psychological safety (Kolbe et al 2020); ‘hot debriefs’ – held in the immediate aftermath of an incident – can highlight the effects of uncivil behaviour, de-escalate conflict and generate learning; ‘cold debriefs’ – held some time after an incident – can help develop a culture of transparency and restore trust in managers (Burman 2018).
Civility and incivility are subjective concepts that are influenced by culture and life experiences. It is important to establish, in collaboration with the team, a shared understanding of what constitutes civil and uncivil behaviour in the workplace. Price (2024) posited that nurse managers need to investigate potential problematic behaviour from staff towards colleagues and conduct a collective exploration of the team’s values. The Clark Workplace Civility Index (NHS England 2021a) can support nurse managers in this exploratory process.
The Clark Workplace Civility Index, devised by Cynthia Clark and adopted by the Capital Midwife programme as part of its ‘civility toolkit’ (NHS England 2021a), can be used to gauge levels of civility within the team. It is often completed confidentially on a one-to-one basis but can also be used for a collective reflection exercise aimed at sharing perceptions about workplace culture and to generate ideas on how to reduce incivility.
Box 3 explains how the Clark Workplace Civility Index works.
Go through the following 20 statements and answer them ‘yes’ or ‘no’:
• You assume goodwill and think the best of others
• You include and welcome new and current colleagues
• You communicate respectfully (online, email, phone, face to face) and really listen
• You avoid gossip and spreading rumours
• You keep confidences and respect others’ privacy
• You encourage and mentor others
• You avoid abusing your position or authority
• You use respectful language (no age, racial, ethnic, sexual or religiously biased terms)
• You arrive on time for meetings, participate, volunteer and do your share of the work
• You avoid distracting others (misusing media, holding side conversations) during meetings
• You avoid taking credit for someone else’s ideas or work or contributions
• You acknowledge others and praise their ideas or work or contributions
• You take personal responsibility and accountability for your actions
• You speak directly to the person with whom you have an issue
• You share pertinent or important information with others
• You uphold the vision, mission and values of your organisation
• You seek and encourage constructive feedback from others
• You demonstrate openness, approachability and flexibility to other points of view
• You bring your ‘A’ game and a strong work ethic to your workplace
• You apologise, and mean it, when the situation calls for this
Add your ‘yes’ responses and calculate your civility as follows:
• 18-20 (90% of ‘yes’ responses) – very civil
• 16-17 (80% of ‘yes’ responses) – civil
• 14-15 (70% of ‘yes’ responses) – moderately civil
• 12-13 (60% of ‘yes’ responses) – minimally civil
• 10-12 (50% of ‘yes’ responses) – uncivil
• <10 (<50% of ‘yes’ responses) – very uncivil
(Adapted from NHS England 2021a)
The Vanderbilt Model was developed by the Vanderbilt University Medical Centre for Patient and Professional Advocacy as part of its management of unprofessional and disruptive behaviour (Hickson et al 2007). The model provides a clear structure for open and honest discussion, feedback, support and decision-making when managing uncivil behaviour and represents a practical and accessible method of addressing the anger and frustration caused by incivility (Hickson et al 2007).
The Vanderbilt Model can support nurse managers to set expectations of civil behaviour and can be used on a one-to-one basis or as a whole-organisation response to incivility in the workplace. It has become increasingly popular since the idea emerged of using informal ‘coffee conversations’ to address uncivil behaviour in a compassionate manner (Inglis 2021) and has been adopted in the NHS as part of the Promoting Professionalism Pyramid (NHS England 2021b) (Figure 2).
Imagine the following situation. You notice that you are anxious when you know that you will be working at the same time as a particular colleague. Staff in your team feel the same. They feel that when that colleague is present they are being watched, criticised and not trusted to do their job. This prompts them to stop taking responsibility and making decisions, reinforcing the colleague’s view that the team shows no initiative and cannot be trusted. What would be your plan to address this situation?
The following is a suggested action plan for nurse managers to help their colleagues, team and organisation recognise and act on incivility in the workplace. Based on their experience, the authors of this article recommend that nurse managers:
• Observe, and listen to, staff and patients to understand what is going on.
• Have individual conversations and/or organise focus groups with staff and with patients to hear about their experiences of incivility.
• Communicate the findings of the individual conversations and/or focus groups to, and discuss with, the whole team.
• Seek the team’s commitment to a plan of action aimed at exploring, agreeing and embedding standards of civil behaviour.
• Provide training for team members so that they are equipped to recognise and challenge incivility. NHS England commissioned the ‘active bystander’ or ‘challenging anti-social behaviour’ training for all trusts in England and should be available through the training and education team.
• Ensure there is a pathway for escalating acts of incivility and that everyone in the team is aware of it.
• Use professional nurse advocates (PNAs) to support staff who have experienced, witnessed or displayed uncivil behaviour. The introduction of PNAs has demonstrated the value of kindness and restorative clinical supervision as part of staff learning, reflection and personal development (Dunkley-Bent 2017).
• Present their findings and plan of action to their organisation’s divisional managers and executive board and ask what steps they will take at organisational level to support the team’s work and address incivility.
• Follow up on the team’s plan of action and evaluate the team’s progress.
• Celebrate success, big or small, in the team’s efforts to reduce and prevent uncivil behaviour.
Managing uncivil behaviour in the workplace is stressful and challenging. Nurse managers who witness, experience and/or address incivility need to maintain their well-being, especially if the uncivil behaviour is longstanding. Self-care for nurse managers who manage incivility in the workplace includes:
• Alerting their line manager to the effects of uncivil behaviour on themselves and on the team and asking for their support.
• Using clinical supervision, coaching and/or mentoring to discuss the effects of uncivil behaviour and how to manage it.
• Networking with colleagues who have had similar experiences. Having conversations with colleagues within or outside the organisation can be beneficial in several ways. They may have developed innovative solutions for addressing uncivil behaviour or they may be looking to others for support and advice. In both cases, talking to colleagues will provide reassurance that others are encountering similar challenges and are similarly committed to addressing incivility.
• Seeking advice and support from a professional body and/or trade union representative.
• Ensuring they ‘recharge’ and ‘unplug’ during their time off, talk to family or friends as needed and take their annual leave entitlement.
• Seeking support with potential physical and/or mental health issues from their GP or occupational health department.
Incivility is pervasive in healthcare and addressing it means it must be recognised, discussed and acted on. Everyone can potentially be uncooperative, use inappropriate language and cause offence to others, whether intentionally or unintentionally. However, recognising, addressing and preventing uncivil behaviour, in oneself and in others, can be challenging. Nurse managers need to be clear about the standards of behaviour expected of team members and challenge uncivil behaviour as soon as it occurs to avoid it becoming the norm. The role of nurse managers includes providing leadership, fostering psychological safety, creating a shared understanding of civil behaviour and managing uncivil behaviour. At organisational level, making the workplace more civil requires healthcare organisations to adopt a compassionate and inclusive culture.
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
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