Spotlight On: Can Civility in Nursing Work Environments Improve Medication Safety? 
Christine L. Covell MSN, RN 

JONA: Journal of Nursing Administration
July/August 2010 
Volume 40 Number 7/8
Pages 300 - 301

In recent years, healthcare organizational leaders have become aware of the importance of promoting a culture of patient safety. Organizations deemed safe have systems to identify high-risk, error-prone situations, supportive atmospheres that discourage blame and encourage civility, and collaboration among all healthcare providers to seek appropriate solutions to hazardous situations.1,2 Many organizations have invested in technologies such as computerized physician ordering and automated medication dispensing systems in an effort to prevent medication errors. Although thought to be effective,3 their safe use relies on the willingness of all healthcare professionals to stringently ensure that patients receive their medications correctly. Because these types of technologies are often cost prohibitive to purchase, implement, and monitor, the traditional method of nurse-initiated incident reports often remains a major source of identifying and reporting medication errors in many hospitals.4 However, empirical evidence indicates that nurses are fearful to report medication errors because of the responses exhibited by their managers, colleagues, and physicians.4-6

Uncivil Behavior

In our study,6 we found that nurses encountered rude or ridiculing comments, gossip, social and professional exclusion, and administrative and professional punishment as the result of reporting medication errors. When we asked nurses what they thought contributed to these uncivil behaviors, they cited the characteristics of poor-quality work environments, such as high workload, poor staffing, and high job stress. When we probed further, the nurses explained that they avoid reporting medication errors because they want to maintain good working relationships with their colleagues. The most alarming effect of incivility that we found was when nurses described how they avoid rather than seek consultation about the appropriate methods to administer medications out of fear that their colleagues would think they are incompetent.

The evidence signifies a civil work environment is an essential component of a well-functioning nursing unit, where because of their proximity to the patient, nurses are often the last in a chain of healthcare providers to identify and prevent a medication error before it occurs. Maintaining a civil environment, treating one another with courtesy, politeness, and respect is essential for creating the conditions where nurses can consult freely with their colleagues, institute surveillance systems, solve problems, and identify and address learning needs, all of which promote medication safety. Civility is also important for teamwork; which has been linked to better patient safety outcomes.7 Because nurses are active members of interdisciplinary teams, respectful communication among all healthcare providers is essential for good-quality patient care.

Civility in the workplace is also thought to increase nurse job satisfaction and reduce turnover8; which is essential for the retention of experienced and knowledgeable nurses. This is important because units that employ a nursing staff with a greater number of years of professional experience have fewer medication errors.9 Researchers have also found a relationship between units with a high percentage of RNs with degrees and less severe medication errors.10 Thus, retaining experienced and knowledgeable nurses by sustaining a civil work environment is important for maintaining safe medication administration practices. In addition, civility can lower human resource costs because nurse turnover is expensive for organizations.11

Promoting Civility

There is very little evidence on the effect of interventions designed to promote civility in healthcare organizations. Belton and Dyrenforth2 reported success after implementing a unit- or group-level customized program that encourages civility, respect, and engagement in the workplace. They reported strong relationships between civility and improved patient satisfaction and quality performance; however, no studies could be located that investigated the effect of civility interventions on medication safety. Drawing on the related literature of teamwork, conflict management, nurse-physician communication, managerial leadership, and patient safety may assist researchers and stakeholders with identifying the key components of interventions aimed at promoting safe medication administration practices and medication error reporting.

The literature does provide some insights into how administrators and managers can encourage civility in nursing work environments in an effort to improve medication safety. They include the following:

* establishing expectations for civil workplace behavior through role modeling including treating the individuals involved in the medication error with respect and communication related to the incident with discretion6,12;

* providing policies, guidelines, and organizational supports that promote and enable the respectful communication and reporting of medication errors and related hazardous situations, such as near misses, among all healthcare providers6,13; and

* offering continuing education that focuses on communication skills, conflict management, and team building7,14 and how they contribute to medication safety.

When work environments are civil, nurses and other healthcare providers feel safe to identify and report medication errors and other safety issues. As a patient advocate, nurses are accountable for ensuring patients receive safe care. However, it is the responsibility of all healthcare providers to ensure the work environment is civil so their colleagues can deliver patient care competently and safely.


1. Pizzi LT, Goldgarb NI, Nash DB. Promoting a culture of safety. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. Rockville, MD: Agency of Healthcare Research and Quality; 2001:447-457. [Context Link]

2. Belton LW, Dyrenforth SR. Civility in the workplace. Healthc Exec. 2007; 22(5):40-43. [Context Link]

3. Institute of Medicine Committee on Identifying and Preventing Medication Errors. Aspen P, Wolcott J, Bootman JL, Cronenwett, LR, eds. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007. [Context Link]

4. Chiang HY, Pepper G. Barriers to reporting medication administration errors in Taiwan. J Nurs Scholarsh. 2006;38(4):392-399. [Context Link]

5. Wakefield DS, Wakefield BJ, Borders T, Uden-Holman T, Blegen M, Vaughn T. Understanding why medication administration errors may not be reported. Am J Med Qual. 1991;14(2):81-88. [Context Link]

6. Covell CL, Ritchie JA. Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting. J Nurs Care Qual. 2009;24(4):287-297. [Context Link]

7. Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471. [Context Link]

8. Spence Laschinger HK, Leiter M, Day A, Gilin D. Workplace empowerment, incivility, and burnout: impact on staff recruitment and retention outcomes. J Nurs Manag. 2009;17(3):302-311. [Context Link]

9. Blegen MA, Vaughn TE, Goode CJ. Nurse experience and education: effect on quality of care. J Adv Nurs. 2001;31(1):33-39. [Context Link]

10. Chang YK, Mark BA. Antecedents to severe and nonsevere medication errors. J Nurs Scholarsh. 2009;41(1):70-78. [Context Link]

11. O'Brien-Pallas L, Griffin P, Shamian J, et al. The impact of nurse turnover on patient, nurse, and system outcomes: a pilot study and focus for a multicenter international study. Policy Polit Nurs Pract. 2009;7(3):169-179. [Context Link]

12. Pearson CM, Andersson LM, Porath CL. Chapter 8. Workplace incivility. In: Fox S, Spector PE, eds. Counterproductive Work Behaviors. Washington, DC: American Psychological Association; 2005:177-220. [Context Link]

13. Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2004;13(3):242-248. [Context Link]

14. Felblinger D. Incivility and bullying in the workplace and nurses' shame responses. JOGNN. 2008;37(2):234-242. [Context Link]