1. Modic, Mary Beth DNP, APRN-CNS, CDE

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Don Berwick, MD, former administrator for the Centers for Medicare and Medicaid and President Emeritus of the Institute for Healthcare Improvement, asked those listening to his keynote address at the Institute for Healthcare Improvement National Meeting in 2016 to consider nine behaviors that he believed were necessary to move into a new era for health care. One of his recommendations was to protect civility (Berwick, 2016).


Incivility has insidiously infiltrated many aspects of society. Some cite the media and political rancor for its rise. In polls conducted regarding the breadth of incivility in the workplace, 98% of the respondents reported that they had experienced rudeness at least once a week, compared with only 25% polled in 1998 (Porath & Pearson, 2013). The nursing literature is replete with studies detailing horizontal hostility, lateral violence, and disruptive relationships (Lewis & Malecha, 2011; Moore, Sublett, & Leahy, 2017; Stagg, Sheridan, Jones, & Speroni, 2011; Wilson, Diedrich, Phelps, & Choi, 2011). Incivility impedes work productivity, impairs cognitive ability, undermines collegiality, strains personal relationships, diminishes a person's self-worth, and contributes to unhealthy coping (Porath, 2016). Researchers Lewis and Malecha (2011) suggested that the yearly cost of incivility to organizations from lost productivity was $11,851 per nurse. Pearson and Porath (2009) published their findings of incivility on performance outcomes:


* 48% intentionally decreased their work effort;


* 47% intentionally decreased their time spent at work;


* 38% intentionally decreased the quality of their work;


* 80% lost work time worrying about the incident;


* 63% lost work time avoiding the offender;


* 66% said their performance declined;


* 78% said their commitment to the organization declined;


* 12% said they left their job because of the uncivil treatment; and


* 25% admitted to taking their frustration out on customers (p. 55).



The word civility is derived from the Latin "civilis," meaning "citizen." Civility is characterized by engagement, respect, and common purpose. Incivility is the exchange of seemingly inconsequential inconsiderate words and deeds that violate conventional norms of workplace conduct (Pearson & Porath, 2009). Incivility is characterized by behaviors that violate respectful workplace norms and often appear vague in terms of intent to harm. The accumulation of these behaviors over time can have far reaching consequences. Seventy-one percent of physicians, nurses, and other caregivers stated that abusive, condescending, and belittling behaviors contributed to medical errors, and 27% of the 4,500 respondents attributed incivility to adverse patient outcomes (Porath, 2015). In a separate study, the most frequently cited uncivil behaviors by managers included interrupting, being judgmental, and sharing minimal interest in ideas of others, and the most frequently self-identified uncivil behaviors included focusing attention on electronic devices, using jargon to exclude others, and not responding to invitations (Porath, 2015).


How do preceptors and nursing professional development practitioners protect civility? In reviewing the literature, three overarching themes emerged: engage in self-reflection, embrace the ladder of inference, and thrive affectively.


* Engage in self-reflection: We have all experienced incivility at work, but how often have we recognized when we were the perpetrators of incivility? We can recall moments when we were not at our best. We rushed to judgment, responded in the moment with intense emotion, or failed to speak up when we witnessed belittling, ridiculing, or dismissive behaviors. As nurses welcoming new colleagues, we must do better. Our daily work life is filled with micro moments, opportunities for small gestures of kindness and support (Barsade & O'Neill, 2016). Caring for acutely ill people is cognitively demanding, physically exhausting, and emotionally depleting work yet simultaneously profoundly rewarding. Reminding ourselves of the attributes that drew us to the profession of nursing is helpful in promoting joy in the workplace. We must find the time to share the joy in our work and cultivate it in each other. Joy, incidentally, is one of the most significant influences of employee satisfaction (Barsade & O'Neill, 2016).


* Embrace the ladder of inference: The ladder of inference describes the spontaneous thinking we go through in making decisions or taking actions. Argyis (1990), a respected Harvard business theorist, proposed a process to determine if the conclusions or judgments we make are grounded in accurate facts. He suggested that many of us take a giant leap from observing a specific behavior to making a decision based on limited information. He offered the ladder as a visual representation of the way we make inferences that can reinforce our flawed thinking. Starting at the bottom of the ladder, we (a) have reality and facts, (b) selectively reflect on data from what we have observed coupled with our prior experiences, (c) add meaning to the data, (d) draw conclusions based on assumptions, (e) develop beliefs based on these conclusions, and (f) take actions based on these beliefs. Getting off the ladder or climbing down its rungs is essential to protecting civility. Consider the following scenario: A nurse in orientation asks her preceptor a question about the significance of a basic assessment finding. The preceptor is surprised by what she perceives is a substantial lack of understanding of basic pathophysiology. She begins to reflect on the other questions the new nurse has asked and starts to wonder if the new nurse has the knowledge and decision-making skills to be safe on their nursing unit. The preceptor decides that she needs to be more attentive to what the new nurse is doing. The preceptor begins interrogating the new nurse about the items she overlooked in bedside report and a medication that was late. She changes the way she asks questions of the new nurse, shifting from "tell me about[horizontal ellipsis]" or "what do you think[horizontal ellipsis]?" to "did you do[horizontal ellipsis]?" and "when are you going to[horizontal ellipsis]?" The new nurse becomes more anxious and uncomfortable. The new nurse begins to make more mistakes and becomes withdrawn. She begins to ask herself if nursing was the right career. Several days later, the preceptor confides in another nursing colleague that the new nurse is "not going to pass orientation because she is not safe." The preceptor went to the top rung of the ladder and allowed her assumptions to influence her perspective on the new nurse's potential and performance. Embracing the ladder of inference encourages us to examine the facts and expand our thinking to consider a multitude of possible explanations, thus avoiding a rush to judgment.


* Thrive affectively: Think of incivility as an infectious pathogen that requires an uncompromised immune system. You can promote civility when you sleep well, eat healthfully, are physically active, and surround yourself with people who you love and who love you (Porath, 2016). Sleeping well is a powerful antidote to incivility as it allows the body to rejuvenate. Adequate sleep, 7-9 hours for adults between the ages of 18 and 25 years, decreases the risk of diabetes, improves memory, helps control body weight, and reduces levels of stress and inflammation. Moreover, adequate sleep enhances our ability to recognize important social cues and process emotional information accurately. Sleep can help us to maintain civility in the workplace. We discuss with our patients strategies to eat more mindfully, move every 90 minutes, and develop support systems. We need to heed our own advice! Preceptors also need to be attentive to the healthy self-care practices of their orientee by encouraging them to eat lunch, express emotions, and enjoy their time away from work. The overall health of the nursing profession has prompted the American Nurses Association to designate 2017 as the Year of the Healthy Nurse (American Nurses Association, 2017) The campaign also addresses incivility as one of its major focuses.



Preceptors are pivotal to the well-being of new staff members. They observe a new nurse's clinical shortcomings, vulnerabilities, and desire to be included. Preceptors can show respect, joy, and gratitude or can demean, exclude, and withhold information, impeding the success of the new nurse. Preceptors protect civility by modeling authentic listening, displaying respect, and expressing appreciation to all. In every interaction, preceptors can help their orientees thrive or feel diminished[horizontal ellipsis]. What do you choose?




American Nurses Association. (2017). Healthy nurse, healthy nation. Retrieved from[Context Link]


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Barsade S., & O'Neill O. (2016). Manage your emotional culture. Harvard Business Review, 94(1), 58-66. [Context Link]


Berwick D. M. (2016). Era 3 for medicine and healthcare. Journal of the American Medical Association, 315(13), 1329-1330. [Context Link]


Lewis P. S., & Malecha A. (2011). The impact of workplace incivility on the work environment, manager skill and productivity. Journal of Nursing Administration, 41(1), 41-47. [Context Link]


Moore L. W., Sublett C., & Leahy C. (2017). Nurse managers speak out about disruptive nurse to nurse relationships. Journal of Nursing Administration, 47(1), 24-29. [Context Link]


Pearson C., & Porath C. (2009). The cost of bad behavior: How incivility is ruining your business and what to do about it. New York, NY: Penguin Books. [Context Link]


Porath C. (2015). No time to be nice. The New York Times, SR1. June 21, 2015. [Context Link]


Porath C. (2016). Managing yourself: An antidote to incivility. Harvard Business Review, 94(4), 108-111. [Context Link]


Porath C., & Pearson C. (2013). The price of incivility. Harvard Business Review, 91(1-2), 114-146. [Context Link]


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Wilson B. L., Diedrich A., Phelps C. L., & Choi M. (2011). Bullies at work: The impact of horizontal hostility in the hospital setting and intent to leave. The Journal of Nursing Administration, 11(41), 453-458. [Context Link]