1. Alexander, Susan DNP, ANP-BC, ADM-BC

Article Content

Events preceding and following the 2016 presidential election in the United States demonstrated the potential for rude and impolite behaviors that may be manifested when people feel fear or mistrust. Examples of these behaviors, collectively referred to as "incivility," may extend beyond the political arena, permeating the healthcare workplace to negatively influence communication and care between healthcare providers, educators, and patients. In the workplace, incivility has been defined as "[horizontal ellipsis]a behavior of low intensity and ambiguous intent, which lacks mutual respect and physical assault."1(p121) Incivility exists also in healthcare and the education of students in health professions. Although technological and systems aspects are important in improving patient care and safety, the impact of human interactions, particularly those that may encourage the necessary flow of information between clinicians, cannot be overlooked.


The Institute of Medicine (IOM) (now the National Academies, Health and Medicine Division), in its 1999 report To Err Is Human, noted the importance of communication among healthcare providers as a significant source of errors in patient care.2 The IOM further clarified the need for preparing healthcare professionals to deliver patient care in the 21st century, suggesting that educational programs integrate content designed to equip students with skills necessary in complex healthcare environments. Working effectively in interdisciplinary teams, 1 of 5 competencies identified by the IOM, cannot be achieved when incivility persists among students, faculty, and clinicians.3


Incivility in the Environment of Healthcare

Unfortunately, episodes of incivility in healthcare settings may occur frequently. A survey of 4530 healthcare providers and hospital executives from 4 hospitals across the West Coast suggests that episodes of incivility may be witnessed often by healthcare providers and associated with undesirable outcomes for patients. In the study, 77% of respondents reported witnessing disruptive behaviors among physicians, whereas 65% found similar behaviors for nurses employed in the facilities.4 Other findings from the survey framed the impact of the behaviors upon clinical care for the patients, with 78% of respondents identifying a linkage to adverse events and 71% reporting linkages to medical errors for patients.4


Because nursing students must balance the pressures of classroom and clinical practice, they may be at greater risk for feelings of stress and vulnerability. Reports of nursing students' experiences in clinical settings have described the impact of negative behaviors from instructors and other clinical professionals. In the clinical practice setting, incivility from instructors and other personnel may contribute to feelings of burnout and cynicism in nursing students and were significant independent predictors of emotional exhaustion as reported by the students ([beta] = .487 and .193, P < .05, respectively).5


In addition to personally experiencing discourteous and disruptive behaviors, nursing students may themselves exhibit similar behaviors toward faculty, other students, and professionals in the clinical setting. Episodes of incivility may impair relationships with peers and faculty and result in poor school performance; continuing the behaviors into a professional career may create unnecessary risk for patients. Gerry Altmiller, EdD, APRN, ACNS-BC, associate professor at The College of New Jersey School of Nursing, has witnessed the impact of incivility between faculty and nursing students and is concerned about the influence of adverse communication techniques upon patient care. Her interest in promoting teamwork and collaboration among students, faculty, and clinicians has evolved into an active program of research, clinical practice, and consultation that highlights the multiple spheres of influence that clinical nurse specialists (CNS) enjoy.


Changing Expectations for Student and Faculty Behaviors

Altmiller's career as an educator began at a diploma school of nursing in which expectations for nursing student behaviors were firmly defined and managed by faculty. The environment shaped her expectations for classroom and clinical activities. Required attendance at nursing classes was an example of an anticipated behavior necessary for success in the program. Her later transition to a university, wherein student behavior was viewed more moderately, led Altmiller to reexamine her own attitudes and adopt a more thoughtful approach in her interactions with students. "People can be so unkind to each other," states Altmiller, noting that addressing students with caring statements that underscore faculty's goals for students to achieve their best in nursing, such as "[horizontal ellipsis]I'm talking to you today because I want you to be the best nurse you can be," is often a more constructive way to begin and manage difficult conversations (G. Altmiller, personal communication, September 2016).


Altmiller developed an interest in exploring nursing students' perceptions of incivility in the classroom, which became her topic of doctoral study. Using qualitative research methods, she identified themes from conducting focus groups with prelicensure nurses. She found that nursing students shared concerns similar to those of faculty concerning the types of uncivil behavior and their frequent occurrence in the classroom.6 Results of her research characterized the behaviors that faculty may use, even indirectly, that contribute to an episode of incivility in the classroom.6 Developing an understanding of nursing students' perceptions of incivility and disruptive behavior and equipping them with strategies for mitigation present an important step in reducing later incivility in healthcare settings.


Consultation With Quality and Safety in Nursing to Encourage Teamwork and Collaboration

During her tenure as nursing faculty at LaSalle University, Altmiller was introduced to the Quality and Safety in Nursing (QSEN) Initiative in 2006 when the La Salle School of Nursing and Health Sciences was selected as 1 of 15 pilot schools to begin integration of QSEN initiatives into curricula. As a member of the faculty team to begin the integration, Altmiller quickly realized that it was work that she really enjoyed. The QSEN faculty began to integrate the 6 competencies (patient-centered care, quality improvement, teamwork and collaboration, safety, evidence-based practice, and informatics) into prelicensure and graduate programs. Altmiller's interests in promoting civility in nursing led her to develop further expertise in the competency of teamwork and collaboration, publishing and presenting frequently on the topic of using the QSEN competencies to improve communication and provide feedback in both education and the clinical setting.


Altmiller continues her commitment towards improving the culture of safety in healthcare organizations by implementation of the QSEN competencies, focused on aspects of teamwork and collaboration. She maintains service to QSEN as a consultant and Advisory Board Member. She has published many teaching strategies that are freely available to nursing faculty with an interest in integrating QSEN competencies in classrooms and clinical teaching (Table). Her expertise in the integration of the QSEN competencies across all levels of nursing educational programs has generated many requests for oral presentations and workshops since she became involved with the organization.

Table Examples of Qu... - Click to enlarge in new windowTable Examples of Quality and Safety in Nursing Modules Available for Nursing Faculty

Combining Expertise in the Clinical Setting

Altmiller continues her work as a CNS consultant at Albert Einstein Medical Center in Philadelphia, Pennsylvania. Her responsibilities as a practicing CNS include advancing research and evidence-based practice among the nursing staff. "I connect to staff nurses who are trying to do projects and I help them[horizontal ellipsis]. I stand behind the staff nurses and help them figure out the process. I do the work with them, sit with them while they do their literature search, and coach them as they work to improve practice and later disseminate their work through publications," states Altmiller (personal communication, September 2016).


Working with a committee of nurses from the emergency department, Altmiller supported staff members with their quality improvement project to determine an accurate, yet efficient, method of temperature assessment in pediatric patients presenting with noninfectious processes. The result of the 8-month project was the adoption of a practice change to use temporal artery thermometry as a screening measure. This quality improvement evidence-based practice project eliminated the stress and discomfort of rectal temperature measurements for many patients and their families, while increasing patient and nurse satisfaction.7


Maintaining practice in the clinical setting has given her an appreciation for the scalability of QSEN competencies, and their utility across multiple levels of education and clinical practice. The QSEN competencies are applicable for staff nurses providing direct care, or for CNSs who often work with macro-systems, such as whole units or the medical system, to solve problems.


Early Choices Can Sustain a Career

"There are things you learn in life that make you more empathetic and understanding[horizontal ellipsis]. I have seen myself do a 360 turnaround over the 20 years I have been teaching. I approach it completely different now than I did 20 years ago," says Altmiller (personal communication, September 2016). She uses many techniques in working with students, stemming from her own experience and familiarity with the use of QSEN competencies in the classroom. For example, Altmiller frequently employs the technique of reframing with her students. She notes, "If I say to a student 'that was a careless error,' then the student feels that he or she is being criticized." Asking the student, "If you were the patient and you knew this happened, would you feel that you were receiving safe care?" can be a more constructive way to gently alter the student's perspective and help them to better understand the implications of his/her actions and decisions upon patient care (Altmiller, personal communication, September 2016).


Altmiller recognized her love for education early in her career, and finding her interest in encouraging respectful, yet effective, communication between faculty, students, and clinicians, leading her to complete her Doctorate in Education from Widener University in 2008. Her work in quality and safety initiatives for nurses earned her the Linda Cronenwett QSEN Leadership Award in May 2016, which honors an emerging leader in the field of quality and safety education. She has also recently received funding from the Agency for Healthcare Research and Quality to provide a free workshop entitled "Infusing Quality and Safety Education Into Your Curriculum." What advice for other nurses can she take from her own successful career? "Find something you love and stay with it[horizontal ellipsis]something that you could settle into for the rest of your life."




1. Abolfazl Vagharseyyedin S. Workplace incivility: a concept analysis. Contemp Nurse. 2015;50(1):115-125. [Context Link]


2. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. [Context Link]


3. Institute of Medicine. Health Professions Education: A Bridge to Quality. Greiner AC, Knebel E, eds. Washington, DC: National Academies Press; 2003. Accessed November 1, 2016. [Context Link]


4. 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]


5. Babenko-Mould Y, Laschinger HK. Effects of incivility in clinical practice settings on nursing student burnout. Int J Nurs Educ Scholarsh. 2014;11. [Context Link]


6. Altmiller G. Student perceptions of incivility in nursing education: implications for educators. Nurs Educ Perspect. 2012;33(1):15-20. [Context Link]


7. Hurwitz B, Brown J, Altmiller G. Improving pediatric temperature measurement in the ED. Am J Nurs. 2015;115(9):48-55. [Context Link]