Why civility matters

Second in a series of articles on civility in nursing education and practice—why it matters and what can be done to foster it.

In the first installment of this series, I told the story of my experience with faculty incivility while a young nursing student. I have learned many lessons since then, and one of the most important is the critical role nurses play in creating a culture of civility and respect in nursing education and clinical practice.

Since education and practice are inextricably linked, all members of the nursing community share responsibility for creating and sustaining cultures of civility. My purpose in this article is to describe incivility and its impact on nursing, discuss why civility matters and present myriad rationale for cultivating civility in the nursing profession.

A short walk
It can be a short walk from incivility to aggressive behavior and violence. While campus homicides are rare, unfortunately, they do happen. We will never forget the shocking events that occurred in 2002, when three nursing professors from the University of Arizona were shot and killed by a troubled nursing student who then turned the gun on himself. Less than five years later, 32 students and faculty members died at Virginia Tech in the deadliest campus shooting in American history. The following year, five students were gunned down on the campus of Northern Illinois University by a shooter who also took his own life. Just a week earlier, a nursing student killed two classmates at Louisiana Technical College before fatally wounding herself.

These episodes are chilling reminders that people in higher education are not immune to violent acts. After such events, we yearn for understanding, grieve for the victims and their loved ones, and search for ways to prevent these tragedies from happening again. Clearly, emergency response systems are essential. However, since some acts of aggression begin with lesser forms of incivility, effective prevention strategies are critical.

I define incivility as rude or disruptive behavior that may result in psychological or physiological distress for the people involved and, if left unaddressed, may progress into threatening situations. Incivility can be plotted on a continuum that ranges from irritating, annoying and distracting behavior—such as texting in class, making rude remarks or gossiping—to bullying, menacing and potentially violent behavior, such as withholding vital patient information, intimidating others or making threats of physical harm. Therefore, we must address lesser acts of incivility before they reach a tipping point and degenerate into much worse situations that are irreversible.  

But tipping points can also be turning points. When nursing faculty, students and clinical practitioners engage in meaningful dialogue and work together to resolve conflict, the potential for civility is enhanced, and safer learning and practice environments are created.

What is civility and why does it matter?
With a better understanding of incivility, we might ask, “What is civility, and why does it matter?”

Civility is an authentic respect for others that requires time, presence, willingness to engage in genuine discourse and intention to seek common ground. Civility matters because treating one another with respect is requisite to communicating effectively, building community and creating high-functioning teams. Without civility, we miss opportunities to really listen and understand other points of view. 

This does not mean that college classrooms should be devoid of lively debate or spirited discussion. In fact, institutions of higher education exist to foster intellectual discovery, provoke critical thinking, inspire argument and challenge opinions. Requiring civility is not equivalent to censorship. Civility brings decorum to discourse. The academy must foster a culture of civility where members of a campus community feel safe to express themselves, free from discrimination, harassment, threats and intimidation. It is my fundamental belief that, by promoting civility among nursing students, nursing education plays a pivotal role in fostering civility in academic and practice environments.

Rationale and motivation
Futurist Joel Barker (1991) stresses the power of vision—that having a positive vision is the most powerful motivator for change. Barker believes that when people think together, dream together and act together to make a difference, great things happen. Because civility and respectful conduct are necessary for creating and sustaining healthy work environments, it is important to align these values with the organization’s vision and mission.

To foster civility, each member of the organization must live by an established code of conduct and agree upon a desired way of behaving and treating one another. When it comes to a health care organization, members must also commit to acting in ways that are ethical and professional, and that lead to safe, high-quality patient care.

In addition to a positive vision of civility, the International Council of Nurses Code of Ethics requires nurses to maintain standards of personal conduct that reflect well on the profession and enhance public confidence. Similarly, the American Nurses Association (ANA) Code of Ethics compels nurses to treat colleagues, students and patients with dignity and respect and states that any form of harassment, disrespect or threatening action will not be tolerated. The ANA’s Standards of Nursing Care and Performance (2004) also provide a framework of objective guidelines to promote accountability of nurses for their actions, including how they relate to patients and peers. Vision statements, codes of conduct and standards of care give strong rationale and motivation to foster cultures of civility. And recently, regulatory agencies have weighed in as well.

Regulatory response
Boards of nursing are beginning to sanction nursing programs for uncivil conduct among faculty and students. In one state, a nursing program was cited for incivility and required to develop a defined set of expectations, interventions, strategies and written policies “to improve the culture of academic civility.” The program was also required to produce evidence of a “respectful, confidential, positive and productive academic environment and improved student-faculty relationships and communication to ensure student success.”* In addition to boards of nursing, The Joint Commission (TJC) is also concerned about the impact of incivility on patients, staff and organizations.

In July 2008, TJC issued a sentinel event alert titled “Behaviors that undermine a culture of safety” (The Joint Commission, 2008b). Effective 1 January 2009, The Joint Commission (2008a) promulgated a new leadership standard (LD.03.01.01) to address intimidating, disruptive and inappropriate behavior in accredited health care organizations. This sentinel alert addresses behavior that undermines a culture of safety, since it seriously threatens patient safety and employee satisfaction. According to a TJC report (2008b), uncivil, disruptive and intimidating behavior in health care can lead to medical errors, poor patient care and satisfaction, preventable adverse patient outcomes and increased costs of care. It also causes qualified clinicians, administrators and managers to seek new positions in more professional environments.

The new leadership standard addresses a continuum of disruptive behavior that includes covert actions, such as withholding important information from others and failing to cooperate with colleagues, as well as overt actions, such as verbal threats and blatant acts of intimidation. Overt acts of intimidation and coercion constitute bullying and are clearly unacceptable.

Nurses, physicians, administrators, nonclinical staff or other members of the organization may be instigators or targets of uncivil or bullying behavior. In some cases, this behavior becomes embedded in the organizational culture and has direct impact on employees, as well as patients entrusted to their care. As a result, TJC requires health care organizations to recognize and address behavior that threatens patient safety and performance of the health care team.

While most members of health care teams are responsible professionals, some are not. Health care organizations that ignore unacceptable behavior indirectly promote it, and expose themselves to litigation from employees, patients and family members (TJC, 2008b).

Civility is a choice 
Acting civilly and respectfully isn’t always easy, especially in a stressful environment of high-stakes testing and heavy workloads, and where lives often hang in the balance. Yet, we must make civility a priority for our patients, colleagues and classmates. Incivility takes a tremendous toll on staff, patients and organizations. Choosing civility is important and the right thing to do. It requires courage, concern for others, presence and patience.

In our rushing around, patience is often in short supply, yet patience is a virtue that makes all of us better. So, I challenge myself, and all of us, to lead by example, to join the revolution for cultivating civility, to lead with our hearts as well as our heads and to continue to make nursing the most trusted profession. RNL

*Reference omitted to protect confidentiality.

Other articles in Cynthia Clark’s series on civility in nursing education and practice:

The sweet spot of civility: My story
What educators can do to promote civility
What students can do to promote civility
From incivility to civility: Transforming the culture

References:
American Nurses Association. (2004). Standards of clinical nursing practice. Washington, D.C.: Author.
Barker, J. (1991). Discovering the future series: The power of vision [DVD]. United States: Star Thrower.

The Joint Commission (2008a, July 2).  Applicable Joint Commission standards. Retrieved 18 March 2010 from http://www.jointcommission.org/NewsRoom/PressKits/
Behaviors+that+Undermine+a+Culture+of+Safety/app_stds.htm

The Joint Commission (2008b, July 2). Behaviors that undermine a culture of safety. Retrieved 18 March 2010 from http://www.jointcommission.org/SentinelEvents/
Sentineleventalert/sea_40.htm

Cynthia Clark, PhD, RN, ANEF, FAAN,  is an award-winning professor in the School of Nursing at Boise State University in Boise, Idaho, USA. Clark’s principal body of research is in the area of fostering civility in nursing education and practice. She is a fellow in the American Academy of Nursing, a fellow in the National League for Nursing Academy of Nursing Education, and the recipient of NLN’s 2011 Excellence in Educational Research Award. Clark has conducted numerous empirical studies to better understand issues related to incivility and to develop best practices to foster civility and respect in the nursing profession. Her current research includes the role of nursing education in preparing future nurses to address incivility in the practice setting, faculty-to-faculty incivility, and intervention studies. Her work has stimulated national and international dialogue on these critical issues.