Unmasking Incivility in Nursing: The Hidden Cost to Patient Care

Incivility in the Nursing Profession

The public perception of nurses has been favorable, but most recently since the COVID -19 pandemia, the nursing profession has garnered considerable attention. For the 21st consecutive year, nursing has been rated the most trusted profession [1]. This honor is certainly well deserved as Perspective nurses are truly skillful, highly competent, and self-less. Also necessary to note, nurses are celebrated for their compassion and caring spirit.

It may be a shock to discover to those that aren’t entrenched in the innermost functions of health care, but, the nursing profession has deep rooted secrets that branch far from being compassionate and caring. For at least four decades the literature has become saturated with anecdotes and evidence of a profession plagued by incivility [2]. There are instances of nurses being uncivil to each other, which is called lateral incivility [3]. The research reveals nurses can be cruel to each other to the point victims experience physical and emotional ailments. There are instances of nurses being targeted by their nurse manager, which is called supervision incivility. This type of incivility is associated with threats of loss of employment and can demonstrate with malicious verbal and non-verbal behaviors. It is shocking to think that those entrusted to care for the ill and infirmed are actually victims of incivility or are part of the problem.

There are many definitions and broad interpretations of incivility and the defining features varied across a spectrum. Subtle acts of incivility demonstrated by the offender may include eye rolling, heavy sighs, and disingenuous remarks. Other actions or behaviors that are deemed uncivil include mocking, name calling, targeting, mobbing, and making false accusations which can be damaging to the victim’s reputation [3]. Other instances of uncivil actions and behaviors aim to belittle an individual which had devasting effects on mental health. Hostilities and aggressions which threaten an individual’s wellbeing and makes it difficult to carry out one’s job responsibilities is considered workplace violence [4]. The mental health consequences correlated with working in an uncivil environment include depression, irritability, fear for their safety, anxiety, self-doubt, and isolation. Lasinger, et al. reported an increase of nurses diagnosed with post- traumatic stress disorder due to mental health ramifications associated with workplace. An uncivil work environment can cause individuals to lack the confidence to do their job and to also have decreased satisfaction with their job [5]. It is horrible to think that incivility can cause such personal chaos and upheaval that the individual has disregard for their self-care and has lack of interest in personal relationships and at times, irrational thoughts. The physical effects are also deeply troubling as nurses who experience or witness incivility have trouble sleeping, have an array of gastrointestinal disturbances, experience lack of energy and extreme fatigues, frequent headaches, and chest pains [6].

The Impact of Nursing Incivility on Health Care Agencies and Patient Outcomes

Uncivil actions and behaviors have negative consequences that extend further than the actual key players involved. Health care agencies are affected by incivility in the nursing profession, and patient outcomes are negatively impacted. When nurses experience incivility, their mental clarity is impaired as they are distracted and or focused on their personal safety rather than on delivering quality nursing care. The physical and mental health effects of incivility are known to attribute to high absenteeism among nursing staff [7]. According to Ekici, et al. [8] nurses who experience workplace incivility lack motivation deliver patient care, which results increased numbers of nursing calling out for this shift. High rates of nurse absenteeism translate to operating an agency floor with less staff, thus contributing the high nurse to patient ratio. When nurses are forced to work in conditions where nurse patient rations are elevated, staff morale plummets and patient safety is jeopardized [9]. In addition, an uncivil work climate leads to decrease in job satisfaction, which may further exacerbate nurse absenteeism as well as negatively affect nurse retention Diaz.

Staffing shortages affect nurses on a personal as well as professional level. When nurses are working in agencies where there are inadequate numbers of staff to care for patients, the nurse has limited time to take care of their personal needs such as taking bathroom breaks or to eat their meals Diaz. In situations where the nurse’s basic needs aren’t being met, nurses are more prone to make mistakes. Other contributing factors associated with nurse errors involve staff relationships and staff communication skills. Effective communication among nursing staff is essential to health care team functioning and decision making. According to Lewis, incivility in the nursing profession inhibits collegial relationships which are necessary for the delivery of quality patient care.

Unfortunately, mistakes in healthcare have devasting consequences to patient outcomes. Lewis noted errors with medication administration compromises patient safety and can be attributed to distractions and breakdown of health care team functioning due to incivility in the workplace. Medication errors can cause significant harm to patients are considered to be highly preventable World Health Association. The World Health Association, reported an estimated $42 billion-dollar annual financial burden due to medication errors in the United States, and the United States Food and Drug Administration reported 100,000 suspected medication errors annually. While it can’t be known with absolute certainty if incivility in the nursing workforce contributed to each error in medication administration, the threat to patient safety evident. The Impact of Nursing Incivility and Nursing Academia The culture of aggression in the nursing profession may originate within nursing academia [10]. While this too may come to a shock to many, nursing academia is also riddled with instances of incivility. The various players in incivility in nursing academia involve nursing students, nursing faculty, and nursing staff from clinical agencies. The literature reviews offer circumstances where nursing students report nursing faculty as uncivil when they refuse to answer student questions, when they are unprepared for class, and when they don’t make time to meet with students to discuss their concerns. Nurse faculty have been reported to be deliver rude and dismissive comments to students and have been abrupt in delivery, which is interpreted as harsh and overly critical. There are high demands placed upon nursing students as the curriculum is content laden and the stakes are high to achieve passing grades for fear of dismissal from the program [10].

Nursing students have also been found to demonstrate bullying and hostile behaviors directed at their student nurse peers as well as nurse faculty. Faculty have been victims of student intimidation, harassment, and have even suffered physical harm such as with the death of nursing faculty at the hands of a disgruntled nursing student [11]. Clinical nurse faculty have been reported to create hostile learning environments for nursing students. The literature suggests their actions and behaviors have been demeaning to student learners and it has been reported that they are unwilling to assist students [3]. Without having a rich learning experience, students are not properly equipped with the knowledge and skills to deliver quality patient care. The destructive tendencies in the workforce and in academia create turmoil for the nursing profession and perpetuates a cycle of dysfunction with equates to horrific ramifications for the profession and to patient care. While nursing student enrollment in undergraduate four-year programs has increased by 3.3% since the pandemic American Association of Colleges of Nursing, there is risk for enrollment decline if the public perception of nurses declines. Negative patient outcomes will contribute to the demise of the nursing image [12]. Addressing nursing incivility is imperative as there are countless consequences causing a vicious cycle; incivility affects physical and mental health of nurses, which causes staff absenteeism and increase in job vacancies, and exacerbate the nursing staff crisis. Limited number of nurses translates to decreased patient satisfaction and higher risk of preventable injury such as medication errors. Ultimately, incivility in nursing is a pervasive and metastatic obstruction which impedes the important role nurses serve- delivering high quality patient care [13].

Future Research Endeavors

Incivility in nursing has long standing roots in the literature. The current climate in the nursing workforce is unhealthy as incivility is rampant, and the consequences affect individual personal health and job satisfaction, the functioning of health care agencies, and patient outcomes. There is inadequate information about the rationale for incivility in nursing. It is recommended that nurse researchers examine incivility in nursing via qualitative and quantitative studies to better understand the intricacies and underlying factors which influence nurses to act and behave in direct contradiction to the role they serve as health care professionals. Compassion and caring are at the core of the nursing profession; however, incivility is in direct opposition. Incivility in nursing has the potential for causing catastrophic effects on individuals and large-scale populations. There should be an open call for funded research to examine the underlying and contributing factors associated with incivility in the nursing profession. Getting to the heart of the matter via mixed methods research studies appears to be the next logical step necessary-the cost to patient care is too dire.