Literature Review
Introduction
The terminology is ever-changing depending on the institution: incivility, bullying, lateral violence, workplace harassment, horizontal hostility, or horizontal violence (Crawshaw, 2009) but at the end of the day it virtually the same set of negative behaviors. Incivility in nursing can look different depending on the person or organization involved. Incivility is viewed as "hostile, aggressive, and harmful behavior by a nurse or a group of nurses toward a co-worker or group of nurses via attitudes, actions, words, and/or other behaviors" (Thobaben, 2007, p. 83). Incivility in nursing can be further defined as the rolling of eyes or making faces at a co-worker, unrealistic work assignments, hiding of or hoarding of supplies, setting a co-worker up for failure, making rude or demeaning comments, placing blame for negative outcomes, withholding important information, and backstabbing or gossiping behind a co-workers back (Taylor, 2016).
Implications of incivility
Uncivil behaviors in healthcare can cause extreme issues for both employees, employers, and patients. Not only does it cause a decrease in employee morale (Faletta, 2017) research finds that these poor behaviors can be linked to nursing burn out, increased employee turnover, unsafe working environments, increased use of sick time or use of paid or non-paid time off, and a decrease in patient quality of care (Taylor, 2016). Negative behaviors are often directed at nurses who are new to the floor or newly graduated nurses (Faletta, 2017). These negative behaviors can cause increased turnover which puts a significant burden on the employer due to the cost of training and the additional cost of the re-training of new employees.
A literature review was conducted from the National University database and the National Library of Medicine PubMed website. All articles were free to access through university credentials or free to view on PubMed. The collection of articles was taken from July 2019 to July 2020. Search terms used were focused on nursing, hospital, incivility, lateral violence, workplace harassment, horizontal hostility, or horizontal violence. The purpose of the literature review was to define incivility in nursing, look to see why it occurs, analyze any education or programs implemented to stop it from occurring, and finally to look for any significant findings outlined by the authors.
Perceptions of Horizontal Violence.
Labeled as horizontal violence, Rosemary Taylor explored the perceptions of incivility in nursing. Taylor looked at two units in a hospital each with twenty-eight beds and sought to develop a better understanding of the phenomenon (Taylor, 2016). Taylors research outlined five themes to be a common occurrence. The five themes are “behaviors are minimized and not recognized, fear inhibits reporting, avoidance and isolation are coping strategies, lack of respect and support, and organizational chaos” (Taylor, 2016, p. 1). Looking at the findings it was suggested that only the management and nurse educators were aware of policies and procedures in place to educate and combat the negative behaviors in the workplace. The nurses on the floor had no clear understanding of the policies, no knowledge of an organizational Code of Conduct, or formal education on how to report occurrences of negative horizontal violence. It was also reported that the hospital's human resources representative had little success in perusing the complaints of negative behaviors unless they fell into discrimination based on Equal Employment Opportunity Laws. Taylor described using overt observation to see that horizontal violence was present on both units in public and private areas with verbal remarks occurring most frequently (Taylor, 2016).
Looking further at the five themes present it was clear that the unit's nurses were unaware of clear expectations of their employer for a code of conduct and the reporting of the behaviors. There was also a fear of reporting behaviors with over half of the nurses expressing fears of being labeled for telling on a coworker, feeling that no one will listen to their concerns, or feeling that no one will help them. The feeling of being alone with no support also made the nurses feel there was some disorganization within the organization and further reduced the amount of reporting. The study suggests that the lack of knowledge of the behaviors of horizontal violence allows it to keep occurring. In theory with proper education, resources, and support from co-workers, the instances would decrease. The findings suggested that organizational policies need to be clearly outlined to all levels of staff (Taylor, 2016).
Culture of Safety
According to The Joint Commission, disruptive behaviors, which include both overt and covert actions can create an environment that undermines the culture of safety in health care (Joint Commission, 2008). In a 2008 sentinel event alert, The Joint Commission explored behaviors in the workforce that can lead to preventable negative patient outcomes such as medication errors, poor patient satisfaction, and increased employee turnover. Identified causes were lack of coping and conflict management skills, inadequate addressing of the negative behaviors from the organizational leadership, and the everyday stressors of working in an environment dealing with high stressors. Suggestions made by The Joint Commission to combat these behaviors are to fully educate all team members on professional boundaries and hold all team members accountable for their behaviors. Next, an organization should monitor interactions with employees and have an open-door policy for encouraging dialogue between all team members (Joint Commission, 2008).
Workplace Bullying Among Nurses
Over the year’s incivility has been looked at as bullying in the workplace, in “Psychological Distress and Workplace Bullying Among Registered Nurses” the authors looked at the behaviors in healthcare organizations which lead to difficult work environments (Berry, Gillespie, Fisher, Gormley, & Haynes, 2016). It was found that emotions and stress were high during the confrontation of the aggressor so at times confrontation was just avoided altogether. The confrontation was avoided at times because the nurses reported not wanting to have others see them cry or become angry. Nurses need to address the behaviors when they occur as to not form an emotional response from the incident. The research stressed that new nurses and even seasoned nurses who were being bullied in the workplace needed to be mindful when responding to the behaviors since it can bring out an emotional response (Berry et al., 2016).
Prevalence and Related Factors
Looking further at the negative interactions between nurses in the literature review entitled "Workplace Incivility, lateral violence, and bullying among nurses. A review of their prevalence and related factors", the authors explored the prevalence of these issues, related factors, and the psychological impact on the victims (Bambi, Foà, De Felippis, Lucchini, Guazzini, Rasero,2018). The authors focused on the term bullying in their research and found that 10% of nurses who had been bullied at work displayed Post-Traumatic Stress Disorder symptoms with 75% of bullied nurses demonstrating either physical or mental symptoms related to the negative behaviors (Bambi et al., 2018). It was further noted that nurses with less than 5 years of employment were more likely to resign from their current position and move to a new position causing increases in employee turnover and decreased job satisfaction (Bambi et al., 2018). Risk factors identified for becoming a target of the negative behaviors included nurses who were looked at as less competitive or assertive, more conscientious, less extroverted, and nurses who are young or newer to the field (Bambi et al., 2018). Organizational risk factors included organizational flaws such as frequent changes within the organization, lack of control over tasks or time, and uncertainty in the workplace (Bambi et al., 2018).
It was discovered that the bullying was found more often in the clinical practice setting where more technical clinical skills were required and in high demand verses in the clinical office setting where building nurse-patient relationships are more the focus (Bambi et al., 2018). The behaviors of bullying were exhibited more by nurses who had previously learned these behaviors and the behaviors were never corrected. The authors concluded the bullying behaviors can lead to high stress at work, psychosomatic disorders such as stomach aches or insomnia, overreactions to mental stress such as wanting to frequently cry, depression, or feelings of guilt or rage, and finally behavioral issues such as excessively double-checking every action over fears of being judged or self-isolating (Bambi et al., 2018).
Stopping these behaviors in the workplace will require support from all levels of the team. Educational opportunities to stop bullying need to include techniques to stop the behavior when it occurs, how to report to nurse leaders, and how to become more aware of the issue. Implementing a zero-tolerance policy and improvement of communication skills to prevent conflict. It is suggested that nursing educational institutes look at these behaviors and implement education into the curriculum to stop these learned behaviors from occurring (Bambi et al., 2018). By teaching nursing students about these behaviors during their education it will educate the students on the identification of the behaviors and how to react if they become a victim of the behaviors in the workplace (Bambi et al., 2018). In conclusion, the authors found a distinct lack of evidence of organizational policies and programs in place to end bullying and incivility in the workplace. Recommendations were that the key to stopping the behaviors is through information in educational settings and during nursing training courses (Bambi et al., 2018).
Incivility, Bullying, and Workplace Violence
The American Nurses Association (ANA) released a statement on incivility in the workplace in 2008. The ANA statement reads as follows:
ANA’s Code of Ethics for Nurses with Interpretive Statements states that nurses are required to “create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” (ANA, 2015a, p. 4). Similarly, nurses must be afforded the same level of respect and dignity as others. Thus, the nursing profession will no longer tolerate violence of any kind from any source. All RNs and employers in all settings, including practice, academia, and research, must collaborate to create a culture of respect that is free of incivility, bullying, and workplace violence. Evidence-based best practices must be implemented to prevent and mitigate incivility, bullying, and workplace violence; to promote the health, safety, and wellness of RNs; and to ensure optimal outcomes across the health care continuum. This position statement, although written specifically for RNs and employers, is also relevant to other health care professionals and stakeholders who collaborate to create and sustain a safe and healthy interprofessional work environment. Stakeholders who have a relationship with the worksite also have a responsibility to address incivility, bullying, and workplace violence. (ANA Position Statement, 2015)
Nurses and other healthcare professionals need to set the behavior standards in the workplace to be viewed as a professional. The ANA urges education within nursing educational programs, within the workplace, and ongoing education for all members of the healthcare team. The ANA cites issues resulting from incivility in the workplace to include job dissatisfaction, increased employee turnover, reduced commitment to the organization, and decreased personal health (ANA Position Statement, 2015).
Recommended interventions include primary prevention techniques that address the liabilities and help improve professional and interpersonal relationships among nurses. This can be done by education about incivility and the consequences of the behaviors, by registered nurses committing to stopping the behaviors if they are seen, and by employers having a clear organizational vision with policies and procedures in place to curb the negative behaviors (ANA Position Statement, 2015).
Next, secondary prevention includes all interventions to diminish the adverse impacts of incivility. Secondary prevention can be nurses who respond directly to the behaviors or report the behaviors to their supervisor, leaders need to be aware of the behaviors and stop them as they occur and implement measures to help reduce stressors within the work environment (ANA Position Statement, 2015).
Finally, tertiary prevention includes the reduction of the aftereffects of incivility in nursing. This can be done by the nurse obtaining or providing support from others who have experienced the negative behaviors, reporting of the event, or keeping a detailed record of the event (ANA Position Statement, 2015).
Implementation of primary, secondary, and tertiary preventions will help educate nurses on the behaviors and raise awareness of the issues. Allowing the nurse to be a mentor or mentee to a nurse who went through the same experiences will allow the nurses a chance to reduce the emotional baggage of the events.
Conclusion
No one is immune from incivility in nursing, a new nurse on a unit or a new grad can both be victims of these behaviors. Incivility in nursing can cause increased stress on the nurse leading to patient care errors, job dissatisfaction, and increased costs to the organization through increased turnover or the increased need for supervision of employees. Overall research shows that the key to combating incivility in the workplace is through education, leadership, and strong organizational policies. Education should be continuously performed in the workplace and also incorporated within nursing school curriculums to stop the behaviors from occurring during education and then transferring this education into the workplace. By stopping the negative behaviors early, the newly graduate nurse would be equipped with information and resources to be able to confront the behaviors if they occur and stop them. Nursing leadership and management needs to be aware of the issues of incivility on their unit and stop them using a zero-tolerance policy. Education and re-education should be used often so nurses know the policies, procedures, and reporting requirements in place. By creating a safe environment for reporting of events, nurses will feel at ease when coming to their unit leader and know the issues they experienced will be addressed without consequence. Finally, organizations need to implement the policies and procedures for the units to follow; and also provide up to date and ongoing training and education on incivility in nursing. By making incivility an everyday topic, it will be a daily reminder of the training to stop it from occurring.
References
American Nurses Association. (2015a). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Nursesbooks.org.
ANA Position Statement- Incivility, Bullying, and Workplace Violence. (2015). Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position- statements/id/incivility-bullying-and-workplace-violence/
Bambi S, Foà C, De Felippis C, Lucchini A, Guazzini A, Rasero L. Workplace incivility, lateral violence, and bullying among nurses. A review about their prevalence and related factors. Acta Biomed. 2018;89(6-S):51-79. Published 2018 Jul 18.
Berry, P., Gillespie, G., Fisher, B., Gormley, D., Haynes, J., (August 10, 2016) "Psychological Distress and Workplace Bullying Among Registered Nurses" OJIN: The Online Journal of Issues in Nursing Vol. 21, No. 3.
Crawshaw, L. (2009). Workplace bullying? Mobbing? Harassment? Distraction by a thousand definitions. Consulting Psychology Journal: Practice and Research, 61, 263–267.
Falletta, E., (2017, September 13). Lateral Violence in the Workplace. Retrieved from https://magazine.nursing.jhu.edu/2017/09/lateral-violence-workplace/
Joint Commission. (2008). Sentinel event alert, issue 40: Behaviors that undermine a culture of safety. Retrieved from http://www.jointcommission.org/sentinel_event_alert_issue_ 40_behaviors_that_undermine_a_culture_of_safety/
Taylor, R. (2016). Nurses' Perceptions of Horizontal Violence. Retrieved from https://journals.sagepub.com/doi/10.1177/2333393616641002
Thobaben, M. (2007). Horizontal workplace violence. Home Health Care Management & Practice, 20, 82–83.