Aims and learning outcomes

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:

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).

Understanding the importance of civility

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):

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.

Acknowledging the harm caused by incivility

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).

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.

Recognising incivility in oneself and in others

Manifestations of incivility in the workplace include (Bar-David 2018):

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.

Figure 1.

Gibbs’ reflective cycle

Reducing incivility and promoting civility

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.

Managing uncivil behaviour

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).

Figure 2.

Promoting Professionalism Pyramid

Time Out 5

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?

Further Resources

NHS England – Civility and Respect

Suggested action plan for nurse managers

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:

Self-care for nurse managers

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:

Conclusion

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.