Nursing Incivility and Leadership: A Missing Link?
The American Nurses Association Code of Ethics implores nurses to maintain caring and professional relationships with colleagues as well as with patients and their families. Provision 1.5 of this code specifically states that the nurse must "create a culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect" (American Nurses Association, 2015, p. 4). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the primary authority in healthcare regulation. The Joint Commission has issued a mandate for institutions to address uncivil behaviors in healthcare as they create a threat to patient safety.
Despite these directives, nurse-to-nurse hostility is a known problem according to the past 25 years of professional literature (Embree & White, 2010). Inter-collegial hostility, or incivility, is particularly prevalent in the nursing profession versus non-nursing vocations. This is an enigma, as the nursing profession is based upon interpersonal relationships and the care of others.
Civility is defined as the display of polite and courteous acts and expressions that show regard for others (Clark & Carnosso, 2008). Clark & Carnosso, in a concept analysis of civility, find that civil behavior includes tolerance, listening, accepting other viewpoints without negativity, respecting differences, treating one another with dignity and honor, and engaging in social discourse (2008). Civility not only denotes particular behaviors but also describes an attitude of respect for other persons. The word civility has Latin roots in the word 'civilitas' meaning community or city. Civility is more than just polite behavior; it is a prerequisite for humans to live together and function as a community. Thus, civility has been described as active engagement in creating and participating in a group or community (Clark & Carnosso, 2008).
Conversely, incivility can then be understood to delineate impolite, discourteous, rude conduct that shows a disregard or disrespect for others. Common forms of incivility in nursing are non-verbal innuendos, verbal affronts, condescending language, impatience, reluctance or refusal to answer questions, disrespect, and undermining (Embree & White, 2010; Weinand, 2011). Unlike civility, uncivil behavior purposely keeps others out of the in-group, e.g. the community.
Nursing has been considered the primary occupation at risk for horizontal violence and workplace bullying. Studies estimate that approximately 85 percent of nurses are victims of incivility and up to 93 percent of nurses' report witnessing incivility in the workplace (Christie & Jones, 2014; Lachman, 2014). Studies comparing nursing versus non-nursing work environments find a rate of incivility at 85 percent in nursing work environments, compared to 75 percent in non-nursing occupations (Hunt & Marini, 2012). Additionally, non-nursing occupations generally report managers as the perpetrators of bullying in a top-down relationship of power (Hoel et al., 2010). Unique to nursing is the prevalence of incivility between workers with equivocal levels of power. Patient care environments may be particularly susceptible to incivility due to high-emotions, stressful conditions, challenging and difficult work, and diverse roles and interactions. Nonetheless, nurses as a distinct sector of the healthcare team have a particular propensity toward uncivil treatment of each other.
Causes of Incivility in Nursing
A perceived power imbalance is most often a requisite to bullying. Bullying appears to be particularly prevalent in institutions where hierarchy and power imbalances are strongly emphasized (Salin, 2003). Nursing was founded as a predominantly female profession in a patriarchal society with a cultural standard of gender oppression (Bartholomew, 2006). Additionally, in Western healthcare, nursing is practiced in a medically-dominant environment, where work structures are traditionally hierarchal in nature. Patients are admitted under the treating physician's name and nameless nurses will execute physician's orders. Furthermore, the organizational model of nursing is derived from historical roots in the military. This hierarchal system is thought to place nurses in a position of inferiority of rank and subordination. Literature supports the subordinate role of nurses, finding that nurses lack autonomy, control, and self-esteem (Freshwater, 2000). As a result, nursing has been described as a culture characterized by obedience, servitude, dedication, and adherence to hierarchy (Hutchinson, Vickers, Jackson, and Wilkes, 2010).
Uncivil behavior among nurses is posited to result from this culture of oppression and subordination. Horizontal violence and incivility was originally described as an internal manifestation of conflict that resulted from oppression of one group by a more powerful entity (Freire, 2000). An oppressed group is one in which members lack power or control except within the group itself (Peters, in press). Internalized beliefs about their own inferiority prevents the oppressed group from controlling their own destiny, maintaining the status quo and allowing power structures to remain unchallenged. Frustration with these feelings results in aggression toward colleagues within the oppressed group (Hutchinson, Vickers, Jackson, & Wilkes, 2005). Members of the oppressed group direct their frustrations toward each other as they cannot act out directly to those who create the oppression (Freshwater, 2000). From this perspective, incivility in nursing is the reaction to the oppression and subordination experienced by nurses as a collective profession.
Besides a culture of oppression, the socialization of nurses into the profession is said to propagate a culture of incivility. Foundational paramilitary influences are said to have fostered a culture in which insult, humiliation, and hazing are considered part of the on-the-job training (Hutchinson et al., 2005). In fact, the metaphors frequently used in nursing orientation include "earning one's stripes" and "boot camp". A common narrative is to intentionally subject a novice nurse to the same experience seasoned nurses had when they entered practice, with the mentality of "if I had to do it, (s)he can too" (Bartholomew, 2006). Compounding the problem is that most females have been socialized not to react to conflict, to avoid it, and to keep the peace. Nurses too have been socialized not to assert themselves individually or collectively. The result is that nurses often are silent as either targets or witnesses of incivility (Croft & Cash, 2012).
Students and new graduates are particularly at risk to be targets of incivility. In Freire's theory of oppression, any member introduced into a powerless group is at high risk for horizontal violence (Freire, 2000). Additionally, Kanter's Structural Theory of Empowerment finds that when subordinates try to assert their power and authority, only to have it blocked, they usually will seek power over those whom they can dominate. Usually that power is directed downward in the hierarchy (Twale & De Luca, 2008). Incivility is used to acculturate new members into the oppressed group; it is how the unspoken rules are taught (Bartholomew, 2006). Targets of incivility are usually individuals who are different or threaten the status quo (Salin, 2003; Twale & De Luca, 2008). If the status quo is disrupted, fear escalates within the group and is expressed as hostility. Until the newcomer is acculturated as a subordinate group member he or she is considered a threat and treated as such (Bartholomew, 2006). Victims often have done something unknowingly to disrupt the status quo that results in hostility. These acts may range from simply being hired to questioning a philosophy or process of a seasoned organizational member. If someone is introduced to the culture who does not adhere to the group expectations, or worse, challenges the dominant members or cultural norms, they are eliminated, treated uncivilly, bullied, taken advantage of, or marginalized (Twale & De Luca, 2008). As is often heard, the notion of "nurses eating their young" continues to prevail in contemporary nursing.
More recent literature has considered contextual factors such as job conditions, levels of empowerment and the presence of in-groups as explanations for incivility. While some organizational factors have been explored, no studies in any setting involving nurses are found that explore the relationship of the leadership style of a nurse leader with perceived levels of incivility. It is well established that leaders have a profound impact on the culture and interpersonal relationships of a group. A potential explanation for uncivil behaviors that has been little explored is the impact of leadership style on nurse-to-nurse incivility.
Organizational Culture
In the nursing literature, incivility has been predominantly understood as the reactions of an individual agent within a subordinate group exhibiting oppressed group behavior. Oppressed group explanation of incivility provides one consideration, but is not the only factor that impacts incivility in nursing (Hutchinson et al., 2005). Organizational issues contribute to an environment in which incivility is normalized and acceptable. The assumption that incivility is simply a result of the unique socialization of nurses as a subordinate group fails to consider the organizational contexts in which nurses work, as well as the organizational factors that impact incivility (Hutchinson et al., 2005). "Organizations and management structures have been able to remain immune from any further consideration as to their role in perpetuating bullying" (Hutchinson et al., 2005, p. 120).
Organizational culture influences how members perceive their interpersonal interactions and how they manage and respond to such interactions (Keashly & Neuman, 2010). An organization that encourages genuine friendships will have a more positive atmosphere. An organization that promotes boundaries and professional distance may have respectful interactions, but may fall more easily into incivility in times of stress or conflict. Lateral violence has been described as an emotion-based response triggered by factors such as rapid change, pressures for increased productivity, and chaotic work environments (Hutchinson et al., 2010).
Workplace demands are thought to create pressures and opportunity for incivility. Hutchinson et al. notes that contemporary "healthcare organizations are now characterized as transactional climates, strongly focused on productivity and its reward" (2010, p. 27). The central pressure within healthcare organizations is cost containment, with organizational goals described in terms of efficiency and quality. Nurses are under constant surveillance and are challenged daily with providing care in a corporate context (Hutchinson et al., 2005). This added pressure and scrutiny compounds the already complex environments in which nurses work, including a frantic pace, high-stake decisions, and heavy workloads. This type of environment induces frustration and high emotions (Croft & Cash, 2012). The effects of stress contribute to the use of incivility as a reaction to the environment.
In some organizations, incivility is more or less permitted as the way things are done. There exist organizations in which bullying is actually considered acceptable and creates advantages to the perpetrators (Salin, 2003). Furthermore, it is suggested that uncivil behavior amongst nurses is 'accepted' within the profession as part of the metanarrative (Hutchinson et al., 2005), i.e. "nurses eat their young." Often in nursing units, cliques with nursing management and select staff are formed, and this group dictates the norms of the unit. Self-assured of their position in the alliance, these nurses act to enforce the 'rules of work' (Hutchinson et al., 2010). It has been found that bullies within the nursing workforce in particular are often protected by those in power (Croft & Cash, 2012).
The Corollary Role of Leadership
The leader of an organization has a powerful influence on organizational culture. The important role of leadership and organizational structures in influencing a positive workplace is well-documented. In a workplace with a strong sense of team membership and community, incivility is much less likely (Clark & Springer, 2010; Weaver Moore et al., 2013). Leaders are powerful role models, and their actions communicate messages as to what is considered acceptable behavior (Clark, Olender, Kenski, & Cardoni, 2013). Leaders play a key role in establishing the climate and culture of the organization. Ultimately, people are more likely to follow the performance cues of those with social power or social status within an organization (Twale & De Luca, 2008). Organizational culture includes the norms, values, and rituals that characterize an organization, and "serves as a social control mechanism that sets expectations about appropriate attitudes and behaviors of group members, thus guiding and constraining their behaviors" (Bally, 2007, p. 144.). It is vital to identify the effect of leadership and organizational culture on uncivil behaviors among nurse coworkers.
Summary
Incivility in the workplace has far-reaching, damaging effects to both the individual and the organization. Incivility is a particular problem in the nursing profession, which, paradoxically, is founded on caring. Leaders can play a key role in attenuating or contributing to levels of incivility. Hence, it is important to first understand what particular leadership styles or behaviors are more or less associated with worker incivility. From this information, actions by the leader to prevent workplace hostility can be better implemented.
References
American Nurses Association (2015). Code of Ethics for Nurses with Interpretive Statements.
Nursebooks.org publishing program of the American Nurses Association: Silver Springs, MD.
Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc.
Clark, C. M. & Carnosso, J. (2008). Civility: a concept analysis. The Journal of Theory Construction & Testing, 12 (1), pp. 11-15.
Croft, R. K. & Cash, P. A. (2012). Deconstructing contributing factors to bullying and lateral violence in nursing using a postcolonial feminist lens. Contemporary Nurse, 42 (2), pp. 226. Retrieved from Contemporary Nurse - Contemporary Nurse: Healthcare Across the Lifespan.
Embree, J. L. & White, A. H. (2010). Concept analysis: nurse-to-nurse lateral violence. Nursing Forum, 45 (3), pp. 166-173.
Freire, P. (2000). Pedagogy of the oppressed (30th anniversary ed.). New York: Continuum publishers.
Freshwater, D. (2000). Crosscurrents: against cultural narration in nursing. Journal of Advanced Nursing, 32 (2), 481-484.
Hutchinson, M., Vickers, M., Jackson, D., & Wilkes, L. (2005). Workplace bullying in nursing: Towards a more critical organizational perspective. Nursing Inquiry, 13 (2), 118-126.
