Incivility in nursing

Overview of Incivility in Nursing

The key concept to eliminate incivility entails evidence-based practice, which is the research applied to clinical expertise to set forth quality improvements in health care by reviewing the best clinical evidence to resolve an issue. The evidence-based practice research is the scientific systematic collection of relevant data of both quantitative and qualitative data, to view a potential need of improvement to best deal with incivility at its core (Conner, 2014). Evidence-based practice has served the nursing profession in many areas of quality improvements that improve their functions and the way nurse’s orient, implement care and improve outcomes. Research is needed to generate new knowledge or validate an existing know how, using a systemic approach of testing hypothesis to gain a better insight. 

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Evidence-based nursing differs from research, as it does not try to develop a new method of how-to. Instead, it serves to collect data that will translate the evidence and apply it to clinical making decisions to improve a previous practice. By utilizing both concepts, knowledge, as well as the best clinical decisions, can help to address the acts of incivility of seasoned lead nurses towards new nurses, which has caused many units across America to become toxic. 

Identification of Nursing Concern to be Improved

In my specialty, my focus is Nurse Executivewitha career prospect of becoming a Chief Nursing Officer, to empower change and eliminate incivility in nursing. Ideally, the solution to incivility requires empowering all staff to comfortably report incivility, and have it eliminated through progressive discipline, as “one in three nurses in all care settings have been a victim of lead nurse role incivility” (Abdollahzadeh, Asghari, Ebrahimi, Rahmani, &Vahidj, 2017). In this case, my specialty track will enforce the most effective educational training as well as the policies to best deal with incivility. I will also be responsible for ensuring that clinical, patient care and staffing standards within the healthcare organization are met. 

My role will also involve advising senior management on best practices in nursing, recruitment, training, retention, managing nursing budgets, among other functions of a CNO. Moreover, my responsibilities extend to ensuring a healthful workplace environment. In particular, it will be my responsibility to educate nurses and ensure that they understand they are accountable for their behavior. To achieve this, the introduction of in-service programs to help train new nurses on the right way to handle disruptive behavior is necessary. Quarterly surveys that monitor for incivility among nurses in all areas will be adopted. These will be sent to the human resource and the unit director to help monitor the corrective action taken to fix all inappropriate behaviors. Another thing is to model a nursing culture that exhibits appropriate behaviors, by first being a role model, and ensuring nurses follow my example. 

PICOT/Pico question and Literature Search Process

P- Incivility amongst lead roles nurses unto new nurses on a unit 

I – Use of progressive write-ups as the framework to deal with cases of incivility

C- zero-tolerance policy against incivility and workplace bullying

O-  Reduced incidences of incivility and workplace bullying amongst new nurse thereby enhancing their longevity within their current role with growth and development 

T- Within an annual timeline, through random staff survey’s, policy changes, and addressing the behaviors will create a friendly and resourceful environment for all new nurses

Research Question

When dealing with incivility among lead role nurses to the new nurses in a unit, does the use of progressive write-ups a better framework than a zero-tolerance policy help in reducing the incidences of incivility and workplace bullying among new nurses? Does it enhance their longevity within their current role with growth and development within a time of one-year?

A literature review will be relevant for this research since it offers a summary of what has been done on the topic of interest. It assists the research to make sense of a body of research and is effective in providing the reader with the information done without the need to access the individual research report highlighted. The vast amount of literature on literature makes it important to provide a summary of the information on a certain topic of interest. A literature review is important when carrying out an evidence-based research as it provides the evidence to researches that promote the development of the evidence-based practices. The literature review provides an explanation of the background of research on a certain topic. It helps justify why the certain topic being researched on is an important subject area. The process of carrying out literature review helps identify the relationship between different studies. The analysis of different studies on a certain topic area is an effective way of identifying major themes, concepts, and researcher. Through the investigation of the available literature, a research is able to identify critical gaps in knowledge and areas where evidence provided conflict with each other.

PubMed Health and PubMed.gov were journals selected as being appropriate for carrying out the literature search. This was informed due to their vast quantity of articles that can be accessed from their database. PubMed has more than 21 million research articles for biomedical based on the US National Library of Medicine. This qualifies it as a credible database for journals. Among its database’s index, there are more than 5000 journals published within the United States and over 80 journals published in other nations. The research articles found within the database are range from the disciplines of medicine, nursing, dentistry, healthcare systems and other preclinical sciences. 

Another database used for the literature research was the Medline Plus database, which is useful in the medical field. It is an important source of consumer health information-based. It is made available by the National Library of Medicine. Its user-friendly design facilitates a well-organized and selective search of appropriate and relevant research articles. The database is structured in terms of dictionaries, organizations, directories, organization, and libraries, which simplifies the overall process of searching for health-related information.  

Key search words: Major-Incivility in Nursing, Incivility, Leadership on how to address Incivility, 

The key search words used during the literature research included minor-  Settings of Incivility, Differentiating Evidence-based practice from research, policies to effectively discipline, Instigated Incivility, PDSA Change Model, progressive write-ups, zero tolerance to incivility and workplace bullying. 

`Theoretical Framework

One of the theories that best applies to this research is the Theory of the Nurse as Wounded Healer. This theory indicates that nurses and other nursing professionals become wounded after recognizing, transforming, and transcending the pain of trauma in their lives. As the traumatized nurses attempt to find wholeness, they pass through the stage of walking wounded to being a wounded healer. Walking wounded are people who remain physically, emotionally, and spiritually attached to a past trauma. The wounded nurses who may have experienced incidences of incivility and workplace bullying normally have limited consciousness related to how the pain manifests in their lives. Wounded healers through self-reflection and spiritual growth are able to attain expanded consciousness that facilitates the manner in which it is processed, converted, and healed. Wounded healers are able to use their personal experiences therapeutically to assist others (Wanda, 2014).

Another model that may be used to understand the issue of incivility among the nurses is the Freire’s Model of oppressed group behavior. Roberts, a nurse scholar, made the proposition that submissive and dependent behaviors of nurses developed through the course of history to respond to the domination by authoritative groups such as the hospital administrators and physicians (Hedin, 1986). 

Heider’s attribution theory may also help to understand the issue of incivility among nurses. The theory indicates the reasons why some events and certain behaviors occur, to help predict and control subsequent events or behaviors (Wagner, 2014). This theory is relevant in exploring differences in the perceptions of incivility among nurses. Wagner effectively applied the theory in a study that focused on individual’s perceptions of incivility as they observe the behaviors and actions of self and others. In this study, the theory provided new knowledge that indicated that students attach attributions as the reason as to why faculty incivility happens (Wagner, 2014). 

The social exchange theory is concerned with the social relationships and associations that take place between behaviors and rewards. The social exchange theory indicates that incivility is less likely to take place where faculty members offer good rewards for exemplary performance (Cropanzano & Mitchell, 2005).

Research Literature Support

Research Question

When dealing with incivility among lead role nurses to the new nurses in a unit, does the use of progressive write-ups offer a better framework than a zero-tolerance policy in reducing the incidences of incivility and workplace bullying among new nurse? Does it enhance their longevity within their current role with growth and development within a time of one-year?

The study by Natarajan, Muliira& Van-der-Colff (2017) focused on identifying the perception and the level of academic incivility among nursing students and nursing faculty members undertaking a university-based undergraduate program in nursing in Oman. The cross-sectional survey used a sample of 155 nursing students and 40 nursing faculty to collect data through nursing education surveys. The results indicated an agreement between the students and faculty members on the behaviors perceived to be disruptive. Moderate incidents of academic incivility were noted among the nursing students. It was also clear that the nursing faculty and nursing students perceived the incidences of incivility behavior differently. One of the strengths of using survey is that it offered a wider picture of the issue of academic incivility. A crucial limitation of the research is that it was based on data that was gathered from a convenient sample comprised of nursing faculty and nursing students from a single learning institution and program in Oman. 

The purpose of the study by Abdollahadeh et al. (2017) was to establish the mechanism to prevent workplace incivility based on the nurse’s perspective. The researchers used qualitative study based on a conventional content analysis approach. The data came from a sample of 34 nurses from seven training hospitals in Tabriz using semi-structured interviews and field notes. The results pointed to a theme of a need for a comprehensive attempt in dealing with incivility. The results indicated that it was essential to put in place attempt of an organization, nurse, and public to prevent workplace incivility. The strength of this research is the generalization of the results to the situation facing nurses and what was experienced in hospitals. The limitation of this study arises from the complex nature of the textual analysis.

The research by Kirk, Schutte, & Hine (2011) examined the effect of an expressive-writing paradigm meant to increase the emotional self-efficacy in employees. The data was collected from participants to determine pre-test self-efficacy scores. The results indicated that among the participants in the writing intervention condition there was reduced workplace incivility perpetration relative to the participants in the control writing condition. The results indicated the importance of having an expressive-writing intervention may be an effective strategy for increasing positive workplace outcomes. 

The purpose of this study by Armstrong (2018) was to analyze and summarize the most recent, available data related to interventions in assisting the nursing staff in the healthcare settings in managing incivility. The research method used for the study was a systematic review of relevant literature. The collection of evidence indicated that it is important to use a mix of education training in dealing with workplace incivility, training on effective response to uncivil workplace behaviors, and active learning activities as effective mechanisms in improving the ability of nurses in managing incivility in the workplace. Among the strengths of the research approach used in this study is that it helps reduce the implicit researcher bias through the adoption of extensive search strategies, and standard inclusion and exclusion criteria. One of the limitations of this study was the use of low-quality research thereby may affect the credibility and reliability of the research findings.

The purpose of this study by Shi et al. (2018) was to investigate the impact of workplace incivility on job burnout among new nursing staff, verify the partial mediating role of anxiety in the relationship between workplace and job burn-out, and establish the resilience that manages the relationship between workplace incivility and job burn-out. The research was carried out through a cross-sectional online survey form of questionnaires for data collection. The results indicated that workplace incivility positively correlated with anxiety and job burnout of new nurses. It was indicted facing workplace incivility by new nurses is likely to generate in the victims. The strengths of this research approach are on the reliability of the data due to the vastness of participants. The cross-sectional online survey research design has a limitation of being prone to non-response biases. 

A research by Kang, Jeong, and Kong (2018) sought to explore the experiences of incivility among the nursing students. The research was carried out through a qualitative study approach where a grounded theory approach of Corbin and Strauss was adopted. Data was collected through a one-on-one interview. The results indicated that incivility takes place in the context of a hierarchical organizational culture that results from the situation of nurses as outsiders, non-systematic clinical education, and poor nursing work environment. The students were found to respond to incivility through reality shock, passive action, and submissive acceptance. The strength of this research approach is in its theoretical approach, which helps in the understanding and explaining human behavior through inductive reasoning processes. One limitation of the research approach is that it fails to consider the embeddedness of the researcher. 

The purpose of the research by Oja (2017) was to examine the relationship between perception of nurse-nurse incivility, professional behavior among critical care nurses, and the level at which nurse characteristics affect their perceptions. The research approach used for this research was a quantitative research. Data were collected from nurses in 14 critical care units and was analyzed through correlation analysis to establish the relationship between nurses’ perceptions of nurse-to-nurse incivility and professional attitude. Regression analysis was used to establish the predictors of nurse-to-nurse incivility. The results indicate that there was reduced perceptions of nurse-nurse incivility were connected with increased perceptions of behavior. It was thus, established that professional behavior education for critical care nurses is essential and may be an effective way of reducing the levels of incivility, and enhances healthy work environments for nurses. One of the strengths of this research approach is the generalizability of results from the sample to the entire population. The limitation of this research design is that the use of structured questionnaire causes an unnatural situation that creates a tendency to alienate respondents.

The objective a study by Babenko and Laschinger (2014) was to establish whether there was any relationship between nursing between the nurse students’ exposure to different forms incivility within acute care practice setting and their experience of burnout. The experiences of incivility experienced by staff nurses and new nurse graduates in the workplace informed the study. The research used a cross-sectional survey design with a sample of 126 students. Data was collected through having students’ complete instruments to assess the level of uncivil behaviors experienced during the past six months from nursing staff, clinical instructors, and other healthcare professionals in the acute care practice setting and to measure the level of student burnout. The result from the research indicated that there reported incidences of incivility in the practice setting connected to burnout. Higher rates, especially from staff nurses, were connected with higher levels of emotional exhaustion and cynism, which are components of burnout. The strength of the research design used is that it is relatively quick and easy to carry out, as it does not require long periods of follow-up. Among the limitation of cross-sectional survey design is that it does not measure the incidences.

The research by Johnson, Boutain, and Tsai (2015) aimed to establish how hospital nursing unit managers and organizational policies deal with workplace bullying. It was based on the fact that workplace bullying to organizations and by the situation where the managers do not deal with the issue in a consistent manner. The study used a discourse analysis to analyze interview data and policy documents. The results indicated that there existed differences in the method that managers used and the policy indicated as policy documents labeled bullying-type and highlighted the roles and responsibilities of staff and managers. Notably, the policies did not clearly delineate the method in, which managers should deal with the workplace. Unclear policy language provided insufficient guidance to managers, resulting in differential enforcement of policies. The strength of the research method is that it binds the researchers to the tradition of social constructionist that indicates that reality does not exist in isolation, but rather founded on its subjects. One of the limitations of the research approach is that fails to take into consideration the actual content of the matter.  

The main aim of a study by Cicotti (2012) was to investigate the relationship that exists between engagement and incivility among nursing college students. The research used a quantitative approach. The strength of this research approach is that it was well suited for the current study as it has the ability to establish the correlation between incivility and engagement. Data for the research was collected using CFF student course feedback form. The data analysis sought to determine the most disruptive classroom behavior. The results pointed out to a relationship between incivility and engagement and indicated the most prevalent and disruptive nursing student behaviors. The limitation of this research design is that the use of structured questionnaire causes of unnatural situation that creates a tendency to alienate respondents. 

Workplace incivility has been prevalent in healthcare organizations. The purpose of a study by Schenck (2017) was to explore how successful strategies leaders at healthcare organizations strive to reduce workplace incivility and improve employee retention. The research approach used for this study was a single case study. Data collection used semi-structured interviews with human resource professionals and departmental heads tasked with the responsibility of dealing with employee relations. From the study, it was established that the use of strategies and processes for dealing with workplace incivility. Among the techniques identified was the one-on-one communication technique between managers and employees and dealing with the implantation barriers such as resistance to change. Among the key strengths of qualitative studies used in this study is that it enables the researchers to identify and analyze the emerging themes. The limitation of this research approach is on the risk of researcher bias, which may affect the reliability of the study. 

Workplace incivility has the possibility of causing emotional and physical distress among victims and negatively affects the quality of care provided by the nurses. Armstrong (2015) conducted a study to implement a civility-training program that incorporated the education on incivility by facilitating discussions. The implementation of the project was through a medically focused surgical unit. The results of the project indicated that there was no significant change in the frequency of the nurses’ experiences with incivility in their unit. There was a significant increase in the nurses’ self-assessed ability to identify workplace incivility and confidence as well as the nurses’ ability to deal with incidences of workplace incivility. The limitation of this research approach is that the program is specific to a certain facility. 

The research project by Johnson (2013) purposed to finding out discourses of workplace bullying and workplace bullying management that managers of hospital nursing units used as well as those used by the agencies responsible for regulating. The research approach was critical discourse analysis. Data collection was through interviews of fifteen hospital nursing unit managers. Analysis of data from hospitals and regulatory agency showed that there was not a common label for bullying-type behaviors within or across the documents. The results indicated bullying to be an interpersonal issue connected to the target and perpetrator. In the management of bullying, studies showed some bullying was the responsibility of staff to resolve while some other forms were the task of managers. The managers can use progressive guidance as a solution for solving workplace bullying. One of the limitations of discourse analysis is that the results are not generalizable.

The purpose of the study by Gillian (2015) was to establish the level of incivility among registered nurses in a hospital set up. The research approach used for the study was a non-experimental descriptive quantitative design. The data came from the nursing incivility scale delivered to all registered nurses at the facility through an email. The results showed that the nurses did not have experiences in dealing with incivility. The strength of the research approach used in this study is that the participants were in their natural environment with no manipulation. The limitation of this study was that the scale used for collecting data was in providing ranges for the participants to provide answers to questions.

Research Approach and Design; –

In investigating incivility, the best research approach to identify the problem is a descriptive design, because it locates the core features of the problem in nursing with incivility. The reason for identifying incivility as a nurse executive track issue to resolve is one of the major issues in nursing plaguing all units in every setting throughout the world. The data collection used descriptive quantitative research that entailed the prevalence of incivility within all units in nursing. The study used new “nurse surveys that about their preceptor’s, and new nurses quitting a unit triggered directors and human resource personnel” to find the root of the problem (Meires, 2015).

Sampling

The population selected for the research consisted of new nurses as well as students who were at the mercy of the lead role nurse over them. The sampling of data consisted also of new nurses who exhibited negative behaviors unto lead role nurses that were all parts of negative behaviors. The sampling method used in this study will be convenience sampling. The convenience sampling method is a non-probability sampling method that uses the judgment of the research to select the sample to be included in the research. One advantage of this method is that the researcher will manage to get nurses who are new nurses and thus qualify the inclusion criteria. One disadvantage of this sampling method is the risk of research biases in selecting the sample to include. To protect the confidentiality and anonymity of data from the research, only authorized personnel will access it. 

Effective Change with the PDSA Model Incorporation

In using the PDSA Change Model, in our addressing incivility, the “first steps are to Plan, Do, Act, Study as each focus implements a true insight into the problem while incorporating the best outcome for the organization, unit, facility and discipline methods” to educate and prevent the incivility amongst all units (Donnelly & Kirk, 2015). In the planning phase for incivility, all employees will engage in online education as well as in-person training with incivility and how to report it, along with quarterly surveys to aid in the elimination of incivility within a year from the nursing units who implement these core steps. Next, in the do step, having all employees sign job descriptions annually as well as new hires unto professional behaviors and expectations towards co-workers. Then in the active phase of change model, will consist of improvements to identify, report, and eliminate all incivility in nursing units, by administrative rounds on units talking with all staff and keeping them abroad about the importance of recognizing what is incivility and how to best deal with its negative impact.

Finally, in the last phase of plan, analyzing data from quarterly throughput, and progressive write-ups, staff will be able to see the impacts within the annual review of the situation, while the nurse executives and leaders will round to depict to staff how the changes improved through questionnaire survey’s staff filled out and the actual reports that reflect actual incivility. The report would also demonstrate the instigated incivility reported, as well as false accusations to demonstrate to staff, progress has been made. Ultimately, the units will see the direct impact of the elimination of incivility as the atmosphere will be friendly, full of teamwork, improved longevity amongst all staff, and eagerness to help co-workers as we all strive to improve the quality of care we deliver unto our patients. 

Patient satisfaction will improve as a direct reflection also as a well-run unit provides better care, improved rounding, and looks out for every nurse’s patients on the unit, which “patients sense a friendly unit and improved infrastructure” (Mennella &Balderrama, 2017). As a beneficial end-result, the staff, facility, and patient all began to have a homeostasis within this productive environment. This improves “patient satisfaction scores for facilities and improves reimbursements for remaining within the top 95% in the country according to Center for Medicaid and Medicare Services” (Stein & Newell, 2016).

References 

Abdollahzadeh, F., Asghari, E., Ebrahimi, H., Rahmani, A., &Vahidi, M. (2017). How to Prevent Workplace Incivility? Nurses’ Perspective. Iranian Journal of Nursing and Midwifery Research22(2), 157–163. 

Armstrong, N. (2018). Management of nursing workplace incivility in the health care settings: a systematic review. Workplace health & safety, doi: 2165079918771106.

Armstrong, N. E. (2015). The Effect of a Facilitated Educational Program and Experiential Learning on Nursing Workplace Incivility.

Babenko-Mould, Y., &Laschinger, H. K. (2014). Effects of incivility in clinical practice settings on nursing student burnout. International journal of nursing education scholarship11(1), 145-154.

Cicotti, C. (2012). The relationship between incivility and engagement in nursing students at a state college.

Gillian, L. (2015). Exploring Incivility among Registered Nurses in the Hospital Setting. Gardner-Webb University.

Johnson, S. L., Boutain, D. M., Tsai, J. H.-C., & de Castro, A. B. (2015). Managerial and Organizational Discourses of Workplace Bullying. The Journal of Nursing Administration45(9), 457–461. 

Johnson, S. (2013). An exploration of discourses of workplace bullying of organizations, regulatory agencies and hospital nursing unit managers (Doctoral dissertation).

Kang, J., Jeong, Y. J., & Kong, K. R. (2018). Threats to Identity: A Grounded Theory Approach on Student Nurses’ Experience of Incivility during Clinical Placement. Journal of Korean Academy of Nursing48(1), 85-95.

Kirk, B. A., Schutte, N. S., & Hine, D. W. (2011). The effect of an expressive‐writing intervention for employees on emotional self-efficacy, emotional intelligence, affect, and workplace incivility. Journal of Applied Social Psychology41(1), 179-195.

Natarajan, J., Muliira, J. K., & van der Colff, J. (2017). Incidence and perception of nursing students’ academic incivility in Oman. BMC Nursing16(1), 19.

Oja, K. J. (2017). Incivility and Professional Comportment in Critical Care Nurses. AACN advanced critical care28(4), 345-350.

Shi, Y., Guo, H., Zhang, S., Xie, F., Wang, J., Sun, Z., … & Fan, L. (2018). Impact of workplace incivility against new nurses on job burn-out: a cross-sectional study in China. BMJ Open8(4), e020461.Schenck, K. L. (2017). Strategies for Addressing Workplace Incivility and Retention in a Healthcare System (Doctoral dissertation, Walden University).

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