1. Warrner, Judith MSN, RN
  2. Sommers, Kathleen EdD, RN
  3. Zappa, Mary DPT, ATC
  4. Thornlow, Deirdre K. PhD, RN, CPHQ

Article Content

A problem in many healthcare institutions, workplace incivility is often referred to as bullying, lateral/horizontal violence, or harassment.1-3 It can be defined as "repeated offensive, abusive, intimidating, or insulting behavior, abuse of power, or unfair sanctions that make recipients upset and feel humiliated, vulnerable, or threatened, creating stress and undermining their self-confidence."4 Uncivil behaviors can range from lack of support to rude or humiliating comments, and may even include verbal threats.5 Determining the actual incidence and prevalence of workplace incivility is difficult because it's often unrecognized and underreported.6 However, studies examining workplace incivility assert that the percentage of nurses experiencing some form of incivility ranges from 27% to 85%.6,7

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Acts of incivility are devastating to nurses, affecting their performance, mental health, and intention to remain with an organization or even within the profession of nursing.5,6,8 Hospitals and healthcare organizations experience additional consequences from an uncivil work environment through increased costs related to nursing turnover, absenteeism, and decreased work performance.6 According to one report, the average hospital will spend an estimated $379,500 for every percentage point increase in turnover rates.9 In addition, healthcare organizations spend an estimated $30,000 to $100,000 per year for each employee experiencing workplace incivility due to costs related to absenteeism, decreased work performance, staff treatment for depression and/or anxiety, and increased nursing turnover.6


Although the effects on nurses and healthcare organizations are clearly detrimental, a more dangerous consequence of incivility comes from its threat to patient safety. One study demonstrated a connection between incivility toward nurses and behaviors that may lead to compromised patient safety.10 The study included 130 nurses and delineated specific unsafe nurse practices that were directly related to instances of incivility. These unsafe practices included interpreting an unreadable order rather than asking for clarification, lifting or ambulating heavy patients without asking for help, and carrying out orders not considered to be in the best interest of the patient without challenging them.


In 2009, realizing that intimidating behavior affects morale, staff turnover, and patient care, The Joint Commission put standards in place that require leaders to maintain a culture of safety.11 According to The Joint Commission, organizations that fail to address unprofessional behavior are indirectly promoting such behavior. Uncivil behavior undermines the healthcare team's effectiveness and can lead to medical errors and preventable adverse patient outcomes.12 Interventions aimed at reducing incivility in the workplace are beneficial to nurses, healthcare organizations, and patients.


Literature review

It has been pointed out that many perpetrators of incivility are unaware of the effects of their behaviors.13 In order to change the behaviors associated with incivility, nurses first must be able to recognize these behaviors and the negative consequences they cause.14


An interventional study was conducted to determine if training on incivility and cognitive rehearsal responses to such behavior influenced the awareness of levels of incivility.2 The study utilized a pre- and postsurvey, with a training intervention completed between the surveys. The training included a didactic session explaining incivility and the use of cognitive rehearsal as a way to address the behavior. To supplement the training, handouts for dealing with confrontation and conflict, cue cards of responses to incivility, and a list of expected professional behaviors were provided to participants. To measure the respondent's sense of empowerment, the Nurse Workplace Scale (NWS) was used.15 A higher score on the NWS equates to a greater sense of empowerment. The total NWS scores increased slightly, although not statistically significant. However, the authors concluded that nurses felt more empowered when confronted with incivility.2


Another study was conducted to determine if a training intervention would increase awareness of incivility.16 This study consisted of three phases: a pretraining survey, training sessions, and a posttraining survey. All three phases were completed in a 12-week period. Training sessions utilized case studies, presented the literature regarding the effects of incivility, and provided recommendations for a healthy work environment. A total of 21 nurses completed all three phases of the study. Although not statistically significant, the instances of incivility were perceived to be higher after the intervention. The authors concluded that after the nurses were provided with training on the concept of incivility, awareness and, thus, perception of its occurrence increased.


After awareness of the problem is raised, strategies can be put into place to combat uncivil behavior. Utilizing a systematic review of the literature, one group of authors identified that the most effective workplace incivility intervention programs included cognitively rehearsed responses to incivility.3 Cognitive rehearsal was used in one qualitative study with 26 newly licensed RNs hired into their first nursing position.14 The study was designed to examine the effects of cognitive rehearsal on workplace incivility. Educational sessions were provided describing incivility and its effect on nursing practice, the profession of nursing, and the nurses themselves. In addition, the nurses were instructed on the use of cognitive rehearsal, offering appropriate responses to frequent forms of incivility. Laminated cue cards were provided that delineated behavioral expectations for professionals, the most common forms of incivility, and suggested responses. A focus group session was held with all participants 1 year after the intervention.


Although participants found confrontation difficult, 100% of those who experienced instances of incivility confronted the offender. The responses from the perpetrators included shock that the new nurse felt offended (75%), apologies for the behavior (58%), and shunning of the accuser for a short period (25%). However, 100% of the instances of incivility stopped after confronting the perpetrators. The author concluded that knowledge of lateral violence, combined with behavioral responses to halt it, functioned as an empowering tool for the nurses to confront the perpetrators.


In order to measure incivility in the nursing workplace, a reliable tool specific for nursing incivility is needed. In 2010, the Nursing Incivility Scale (NIS) was developed. (See Table 1.) The NIS is a measurement tool designed to capture nursing-specific workplace incivility prevalence. Forty-two items are included in the scale, which are then grouped into five subscales of sources of incivility: general, nursing, supervisor, physician, and patient/visitor. In a sample of 163 hospital nurses, alpha statistics demonstrated reliability for all subscales, with scores ranging from 0.81 to 0.94. Validity estimates demonstrated distinction from each other, having only moderate intercorrelations (r = 0.11 to 0.57).1

Table 1: Nursing Inc... - Click to enlarge in new windowTable 1: Nursing Incivility Scale

Presentation of the organization's policies on conduct and behavior during training on incivility can also be beneficial. These presentations provide participants with an understanding of the organization's stance on such behavior and prepare them to manage instances as they occur, as well as how to report such instances.11 In one study on the nature and extent of healthcare workplace incivility in Australia, of the 478 (32%) respondents who experienced this behavior, only 91 (19%) felt that their organization dealt with the situation in a manner that was "very good" or "good."17 Management has a responsibility to identify and decrease factors that allow incivility to occur.18 In any organizational intervention aimed at decreasing incivility, management should receive parallel training to that of the staff. Teaching staff members how to respond to incivility is futile if management neither sees nor admits that the problem exists, or if leadership lacks the tools required to address it.19

Table 1: Nursing Inc... - Click to enlarge in new windowTable 1: Nursing Incivility Scale (


The inpatient unit of a 60-bed orthopedic surgical specialty hospital located in the Midwestern United States was the setting for a quality improvement project that provided training to elevate staff and management's awareness of incivility and its consequences, and decrease the instances of perceived incivility.


Stakeholders from the hospital were interviewed about the existence of incivility at the organization. All stakeholders agreed that the problem of incivility did exist within the organization both at the lateral (peer to peer) and the hierarchical (supervisor/physician to staff) levels. They agreed that a program to reduce incivility would demonstrate the organization's commitment to a quality work environment for staff to provide safe, effective care.



Permission to use the cognitive rehearsal cue cards was received from Dr. Martha Griffin; permission to use the NIS was received from Dr. Ashley Guidroz. The quality improvement project was approved by both the hospital and Duke University's institutional review boards. A time series study design was used.


The sample consisted of all care providers on the 60-bed inpatient unit, including RNs, multiskilled technicians, unit secretaries, physical therapists, respiratory therapists, case manager nurses, and members of the management team. The project included both management and staff in incivility training, cognitive rehearsal techniques, and the use of visual cue cards.


Initial training sessions were held for the management team to ensure that managers would have the same understanding of incivility as the staff, and the same tools to address it. All remaining staff training was completed during a 2-week time frame. The 45-minute training sessions were conducted by the principal investigator to ensure consistency in the presentation. Sessions were scheduled to cover all shifts and multiple days of the week for staff convenience. Participation in the training was mandatory.


To ensure that all participants recognized uncivil behaviors, the planned training started with providing definitions and examples of incivility, and the different ways it can manifest.14 An explanation of cognitive rehearsal techniques preceded examples of appropriate ways to respond to incivility. Data were presented on the potential effects of incivility on patient safety, the costs of incivility to organizations, and the effects on nursing personnel. The training sessions concluded with specific examples of common forms of uncivil behavior and provision of assertive responses that the victims can feel comfortable using without undermining working relationships with the perpetrators. Laminated cue cards were used and provided to all attendees as a resource to use in everyday work encounters.14 The first of these cards provided a list of behaviors that are expected of professionals. The second cue card listed the common forms of uncivil behavior aligned with appropriate responses to deal with each type of behavior as it occurs in a manner that promotes teamwork and simultaneously decreases future occurrences of uncivil actions.


Data collection and analysis

Participants completed the NIS immediately before training, immediately after training, and 2 months after training. Presurveys were taken before the training to assess initial awareness of incivility. A post-1 survey was administered immediately after the training to measure changes in awareness of incivility and capture baseline data on the frequency of perceived instances of incivility. A post-2 survey was given to all staff members 2 months after the last training session to determine if the intervention was successful in decreasing perceived instances of incivility. And, finally, participants were surveyed in the post-2 survey on the frequency of confronting the perpetrators of incivility and/or being confronted about uncivil behavior. Data were analyzed using a software program. Outcome measures included the change in awareness of uncivil behavior and the change in the frequency of perceived instances of incivility.


Statistical analyses were applied to the presurvey, post-1 survey, and post-2 survey perceived instances of incivility. Demographic data were presented using descriptive statistics. Fidelity was measured by calculating attendance at the sessions, using a log of all attendees, and comparing it with the departmental roster.



A total of 99 out of 114 staff members (86.8%) participated in the presurvey, with 98 out of 114 (86.0%) participating in the post-1 survey and 41 out of 114 (36%) in the post-2 survey. Participation was higher in the first two surveys because they were administered in conjunction with the training sessions. As noted in Table 2, for all three surveys, the majority of respondents were female, full-time RNs employed with the organization between 1 and 5 years.


The survey utilized a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The survey was constructed in a manner that equated lower scores with a more civil environment and higher scores with an uncivil environment; thus, the higher the score, the more uncivil the environment. T-tests were run to compare the presurvey with the post-1 survey and the post-1 survey with the post-2 survey.

Table 2: Demographic... - Click to enlarge in new windowTable 2: Demographics

Increased awareness

To determine if there was an increased awareness of uncivil occurrences after the training intervention, the presurvey results were compared with the post-1 survey results. None of the scores for the five subscales of sources of incivility were statistically significant. However, a trend was noted with all five subscales (general, nursing, supervisor, physician, and patient/visitor) demonstrating an increase in their mean, which may indicate a mild increase in awareness. (See Figure 1.)

Figure 1:. Compariso... - Click to enlarge in new windowFigure 1:. Comparison of awareness of incivility mean scores, presurvey to post-1 survey

Decreased occurrences

To measure if there was a change in occurrences of incivility 2 months after completion of the training, results of the post-1 survey were compared with the results of the post-2 survey. Two of the five subscales demonstrated a statistically significant decrease in instances of perceived incivility: general incivility (2.75 to 2.24, p = 0.00) and physician incivility (2.79 to 2.43, p = 0.04). The other three subscales also demonstrated a decrease in the occurrences of incivility, although not statistically significant. (See Figure 2.)

Figure 2:. Compariso... - Click to enlarge in new windowFigure 2:. Comparison of perceived incivility in post-1 survey to perceived incivility in post-2 survey

Confrontation frequency

Of the 41 respondents in the post-2 survey, 27.5% (11) stated that they had confronted someone about uncivil behavior after receiving training on incivility, whereas only 7.5% (3) responded that someone had confronted them about uncivil behavior. Although a comment section was provided, none of these respondents gave information about the confrontation or its results.



Review of the scores indicated that three of the subscales-general incivility, physician incivility, and patient/visitor incivility-had mean scores above a 2.5 for both the presurvey and the post-1 survey, which is the midpoint of the scale. This indicates greater incivility from these sources. The mean scores for all three of these subscales dropped below the midpoint on the post-2 survey. The subscale of nursing incivility, close to the midpoint of mean scores in the presurvey (2.37) and post-1 survey (2.42), dropped to 2.16 in the post-2 survey. The subscale of supervisor incivility had the lowest mean scores on all three surveys (pre = 1.56, post-1 = 1.59, post-2 = 1.58), indicating higher civility from this source. The use of incivility training and cognitive rehearsal techniques appears to be most effective in the areas of greater incivility. The low scores for the supervisor incivility subscale contradict other studies that show supervisors exhibiting more incivility toward staff than others.19,20


This project adds strength to previous studies that demonstrated increased awareness of incivility after training.2,16 Previous literature on the use of cognitive rehearsal as a tool to decrease incivility presented mixed results.2,14 This project provides additional information on the effectiveness of cognitive rehearsal.


The increased awareness of incivility in the post-1 survey should be treated with caution because findings weren't statistically significant. Consideration should be given to the possibility of response bias for the post-2 survey because the response rate was only 41.4% of the presurvey and 41.8% of the post-1 survey. Given the positive findings, perhaps only those who felt the program had worked completed the final survey.


Lessons learned

No time was provided to the participants to practice real-life scenarios in the training sessions. This may have contributed to the low rates of confrontation exhibited in the post-2 survey. Participants may have felt more comfortable about addressing uncivil behavior if they had more time to practice the new skills in a safe environment.


Because the response rate was remarkably lower for the post-2 survey, consideration should be given to the method of providing the survey. Participants were provided with the presurvey and post-1 survey individually in conjunction with the training class. Perhaps handing out the final survey to each staff member individually instead of having the surveys available at a common location may have increased the return rate on the post-2 survey.


Toward a healthy environment

Providing an atmosphere where nurses can perform at their best to provide quality, safe patient care is the responsibility of all healthcare organizations. As demonstrated in the literature, incivility in nursing can affect nurses' mental health, decrease their productivity, and lead to potential patient safety concerns.5,6,8,10 The results from this quality improvement project demonstrate that a program that raises awareness of incivility, provides cognitive rehearsal techniques and resources, and incorporates management can help decrease the perceived instances of uncivil behavior.


INSTRUCTIONS Decreasing workplace incivility



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