Dealing With Incivility In Healthcare

Incivility, bullying, and horizontal violence have become commonplace occurrences in the workplace.

In healthcare, the issue not only affects the individuals involved but has impacts which can be felt at multiple levels. The cost on healthcare is exorbitant; from nurse retention and training costs to lawsuits from medical errors and negative patient outcomes. However, there are strategies for creating a healthy work environment which can be applied to practice settings that, if maintained, can prevent personal issues from becoming anything more than isolated incidents.

Facilities need to take these situations more seriously because ultimately everyone has the same goal and should work together as a team to promote patient safety and positive outcomes.

The American Nurse Association (ANA) defines incivility and bullying rather well. Incivility is defined as “one or more rude, discourteous, or disrespectful actions that may or may not have a negative intent behind them”. While bullying is defined as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient” (American Nurse Association, n.

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d.). These terms should not be used interchangeably. Although another term that may encompass the two is horizontal violence which has been described as intergroup dispute that is shown in obvious and hidden non-physical aggression such as “sabotaging, infighting, scapegoating and bickering”. In the nursing profession an oath is taken to first do no harm. The part which seems to be left out of that statement is to do no harm to all, not just the patients. However, horizontal violence is becoming commonplace occurrences in the workplace. The issue this causes in healthcare is the impact it can have on nurse retention, facility costs, but most importantly, patient care and safety.

The impact of incivility and horizontal violence on nursing affects the profession on multiple levels. Continued exposure can have devastating effects on an individual. The psychological trauma and stress can lead to anxiety, depression, sleep disturbances, low self-esteem and self-worth. The rate of physical illness has also found to be increased in those who are victims of incivility compared to those who do not feel victimized. For the organization this leads to low productivity, poor morale, increased absences from work (due to trying to avoid emotional or physical harm), and increased nursing turnover rates. Patient care is affected on the microsystem level. The multiple problems incivility, bullying, and horizontal violence cause affect the nurse’s ability to provide optimal patient care which in turn effects patient safety. Furthermore, when patients and their families notice the disconnect between staff members they begin to question the level of care they are receiving.

Nurse retention and turnover rates contribute to the nursing shortage issue which already exists in America. The reason being is many nurses have the mentality (and rightly so) that they can leave at any time and most assuredly can get a job on another unit or another facility. Therefore, when the stress becomes too much, and the situation is not addressed effectively, it is easier to leave. While this may not seem like a very big issue it has a greater financial impact on the industry. Training a replacement nurse can cost upwards to $145,000 depending on the specialty. In addition to training costs, the other financial impact is from lawsuits related to patient or employee injury and loss of profits due to reduction of reputation. It is easy to see how this might influence healthcare costs.

Most people start a new job with the intention of liking what they do, where they are and who they work with. It is a sad realization when that does not happen. Take Deena for example, she is an experienced nurse with 22 years behind her. After years of leadership positions, she decided to go back to bedside nursing after her kids were out of high school. A few weeks into her training period she noticed nurses and aides not following proper policies and items that were outside scope of practice. She addressed her director and nurse manager with her observations. Immediately she noticed a change in her work environment, other nurses avoided interaction with her and the aides always found an excuse not to help her when she needed. This became the norm. She was very paranoid and fearful during every shift because it became a hostile work environment.

Deena knew a healthy work environment was vital to positive patient outcomes, and this was not a healthy place to be. Twice more she addressed management with her concerns, but things just got worse for her. It was when one of her patients told her that she overheard the staff talking about Deena in the hallway and they said, “She better straighten up or else.” This confirmed her fears. After taking her concerns to the director of HR, she ended up getting a transfer to a sister facility. She also is unaware if any of the policy issues she informed management about were ever addressed.

Due to all the problems incivility, bullying and horizontal violence can cause it is important to create a healthy work environment. Ultimately, there are two main goals to aim for; one, nurse retention and two, patient safety and care. There are many strategies that could be implemented to help obtain these goals; among them are establishing authentic leadership, skilled communication, and appropriate staffing. Leadership is a skill which continuously needs to be fine-tuned. Hiring the appropriate managers and directors whose values fit the value and mission of the facility is a beginning. For existing leadership, offering continued education, training, and resources in order to enhance leadership skills .

Authenticity in leadership is an achievable outcome and assists with earned respect among staff. A reorganization of management staff could be an option if the training and education fail to provide appropriate results. Skilled communication is also necessary in a healthy work environment. Nurses need to be skilled in proper communication just as much as they are skilled clinically, this includes verbal, nonverbal and written communication. A zero-tolerance policy should be in place for inappropriate actions, along with processes on dealing with disruptive behavior. Education must be available to staff to help facilitate this goal along with appraisals and recognition when effective communication goals are met (Morton, 2015).

Ensuring appropriate staffing availability is vital to work satisfaction and proper patient outcomes. Facilities that are understaffed have employees who are stressed and burned out. This results in staff leaving. Ultimately, if the staff is happy and taken care of, their work is better, and turnover is low. This will reduce facility cost by reducing replacement nurse training. Practice Application As a family nurse practitioner in an office or urgent care setting, Incivility, bullying, and horizontal violence in healthcare are vital issues that need to be addressed in settings due to the impact on patient care and the potential cost to the healthcare industry.

The problem creates an unhealthy work environment that results in morale issues, productivity issues, increased turnover rates, patient safety concerns and financial problems for the facility that can affect healthcare costs. Strategies for addressing this issue include hiring and training leadership to not only handle inappropriate situations but to also lead by example, train and educate staff on how to enhance their communication skill, and work diligently at obtaining appropriate staff. All these methods can be applied to any healthcare setting including a physician’s office or urgent care center. Unfortunately, unlike harassment and racist issues, there are few policies in place to deal with issues in incivility, but it needs to be taken just as seriously. Communicating effectively is a skill. Effective leadership is a skill. Effort must be implemented by each and every one to enhance these skills. Simply put, people need to treat each other with respect, but respect is earned. Earning respect is a skill.