Abstract
Workplace incivility is a well-documented issue in nursing in the health care setting. It has the potential to cause emotional and physical distress in victims and potentially affects the quality of care provided. The purpose of this study was to critique and summarize the most recent, available evidence related to interventions in assisting nursing staff working in health care settings in managing incivility. This systematic review of literature yielded 10 studies meeting the criteria. The studies were mostly identified as lower quality research. Despite the lower quality of research, the collection of evidence suggests the use of a combination of educational training about workplace incivility, training about effective responses to uncivil workplace behaviors, and active learning activities to practice newly learned communication skills, in assisting nurses in improving their ability to manage incivility in the workplace.
Keywords
Workplace incivility, defined as low-intensity social behaviors that are generally considered unacceptable in the workplace, may intend to cause harm (Andersson & Pearson, 1999). The Washington State Department of Labor and Industries (2011) defines incivility as behaviors that are repetitive and are aimed at intimidating and undermining another person or group. Nursing incivility directed at coworkers (lateral violence) can be a form of bullying that is, unfortunately, a common occurrence in the health care setting. Smith, Andrusyszyn, and Laschinger (2010) surveyed 117 novice Canadian nurses and found that 90.4% reported that they had experienced some form of coworker incivility in their young careers. In a survey of 303 American nurses from a variety of experience levels and areas, Vessey, Demarco, Gaffney, and Budin (2009) found that 76% of the respondents had experienced incivility in their careers.
Incivility can have a destructive effect on the workplace and patient care. Study findings indicate that nurses have reported workplace incivility to have caused distractions and emotional upset, to the point that it has put patients at risk. For example, Sahay, Hutchinson, and East (2015) found a relationship between experiences with unsupportive work relationships and unsafe medication administration practices among new graduate nurses. In addition, Laschinger (2014) found a significant correlation between practicing nurses’ experiences with workplace incivility and the quality of care the nurses provided. Nurses in this study reported that incivility increased their risk of making errors in patient care. Laschinger and Nosko (2015) found a relationship between workplace incivility and posttraumatic stress disorder in nurses. As well, there has been a statistically significant relationship found between increased workplace incivility and nurses’ loss of motivation at work (Ekici & Beder, 2014).
Workplace incivility has been linked to adverse outcomes that could cause a financial strain on health care organizations. Workplace incivility has been found to be a potential contributor to nursing turnover (Berry, Gillespie, Fisher, Gormley, & Haynes, 2016). Researchers also found that nurses who were frequently exposed to workplace incivility were at a 92% higher risk of having a long-term absence related to illness (Ortega, Christensen, Hogh, Rugulies, & Borg, 2011). With nursing incivility potentially decreasing the quality of care provided, it could affect a hospital’s financial status.
The management of nursing workplace incivility is a new area of study relative to decades of workplace violence research, with most incivility management research occurring after 2000. In the seminal work by Griffin (2004), a program was developed to help 26 novice nurses learn how to recognize and respond effectively to workplace incivility. The program involved general education about workplace incivility and examples of assertive responses to workplace incivility behaviors. The nurses in the program then used cognitive rehearsal, a form of mental practice, to run through assertive responses to incivility scenarios provided by the researchers. The participants were given cue cards to attach to their work badges with reminders about how to respond effectively to workplace incivility. Interviews with the participants 1 year following the intervention revealed a 100% stoppage of bullying behaviors on the units in which the nurses worked. The success of this program led to many of the subsequent research studies involving cognitive rehearsal or other related means of actively practicing assertive, effective responses to workplace incivility case studies or scenarios. The purpose of this study was to critique and summarize the available evidence related to interventions to assist nursing staff working in health care settings to manage incivility, so that nurses and health care leaders can have ready access to the best available evidence to combat this problem. Managing incivility, in this case, refers to the nurses’ ability to cope with and respond to workplace incivility effectively.
Search Strategies
The focus of the systematic review was on intervention-based research designed to help nurses manage nursing incivility in health care settings. An extensive search was performed of multiple health care–related databases: including CINAHL, PubMed, Google Scholar, MEDLINE, and Cochrane Database of Systematic Reviews. This review also included studies found in the citations of the discovered literature. The search was limited to research that was available in English and to articles published since 2010, because a systematic review focusing on the management of nursing workplace incivility was found that covered research published prior to that date (Stagg & Sheridan, 2010). The search was not limited to randomized trials or more rigorous study designs.
The search included the terms “nursing” along with “incivility,” “bullying,” “lateral violence,” and “horizontal violence,” as multiple terms are used to describe uncivil behavior in the workplace. As well, searches included the terms “interpersonal relations” and “interprofessional communication.”
The initial search resulted in 4,025 studies, with significant duplication between databases. Excluding duplicate studies, each study uncovered in the search results was screened via abstract and title for relevance to research related to interventions to manage nursing workplace incivility. Any studies that related to incivility in nursing education, such as faculty or student incivility in classroom and clinical settings, were excluded, with the exception of a study focusing on nursing students nearing graduation (Clark, Ahten, & Macy, 2014). Studies were excluded if they focused on researching the prevalence, causes, or consequences of nursing workplace incivility. Only interventional research related to the management of workplace incivility was included in the full article critique and review.
The strength of the evidence for each qualifying study was scored based on the levels of evidence hierarchy developed by Melnyk and Fineout-Overholt (2011). The levels of evidence in this hierarchy are rated from Level I to Level VII, with Level I being the highest levels of evidence, systematic reviews of literature, or meta-analysis of randomized controlled trials, down to level VII, which are the opinions of experts in the field. The research in this systematic review included two Level III studies (trials with control, but no randomization) and eight Level VI studies (descriptive studies, including quality improvement projects).
Results
A total of 10 studies were captured that met the inclusion criteria (Table 1). Several of the reviewed studies had interventions that included education about workplace incivility, training about effective communication techniques to combat workplace incivility, and active learning strategies to practice the newly learned communication techniques (Armstrong, 2017; Ceravolo, Schwartz, Foltz-Ramos, & Castner, 2012; Dahlby & Herrick, 2014; Lasater, Mood, Buchwach, & Dieckmann, 2015; Laschinger, Leiter, Day, Gilin-Oore, & Mackinnon, 2012; Nicotera, Mahon, & Wright, 2014; Stagg, Sheridan, Jones, & Speroni, 2013; Warrner, Sommers, Zappa, & Thornlow, 2016). Two of these programs also included teambuilding exercises (Armstrong, 2017; Laschinger et al., 2012). Two of the studies included education about incivility and communication techniques in their interventions, but did not provide practice time for the communication skills (Clark et al., 2014; Nikstaitis & Simko, 2014).
Studies of Workplace Violence Incivility Management in Nursing: Review of the Literature (2010-2017)
Note. The level of evidence was measured as defined by Melnyk and Fineout-Overholt (2011). Level VI = single descriptive studies; CREW = civility, respect, and empowerment in the workplace; Level III = well-designed controlled trials without randomization.
Programs
There was a great deal of variation found in the specific program used in the studies’ interventions. However, cognitive rehearsal, as previously discussed in the seminal research by Griffin (2004), and CREW (Civility, Respect, and Engagement in the Workplace), a program developed by the U.S. Department of Veterans Affairs (2017), were both effective in helping nurses manage workplace incivility in more than one of the reviewed studies. The CREW program involves teambuilding exercises, training on recognizing and responding to workplace incivility, and practice responding to workplace incivility scenarios.
Combined Elements
The combination of educational training about workplace incivility, education about effective responses to workplace incivility, and active learning strategies resulted in improvements in the nurses’ self-efficacy in responding or reacting to workplace incivility in six of the studies (Armstrong, 2017; Ceravolo et al., 2012; Lasater et al., 2015; Laschinger et al., 2012; Nicotera et al., 2014; Stagg et al., 2013). Improvement was demonstrated in nine of the studies reviewed in the participants’ ability to recognize and manage workplace incivility (Armstrong, 2017; Ceravolo et al., 2012; Clark, Ahten, & Macy, 2013; Dahlby & Herrick, 2014; Lasater et al, 2015; Laschinger et al., 2012; Nicotera et al., 2014; Rush, Adamack, Gordon, & Janke, 2014; Stagg et al., 2013). However, there was no improvement in the ability to respond to workplace incivility in one study with the same components (Warrner et al., 2016). In addition, three studies including the three components were found to have increases in the nurses’ self-reported recognition of workplace incivility (Armstrong, 2017; Dahlby & Herrick, 2014; Stagg et al., 2013). The length of the training program intervention did not appear to alter the outcomes, nor did the use of a specific program. A study by Rush et al. (2014) had a unique intervention in which they compared new graduate nurses who took part in a program aimed at assisting in their transition to the workforce with recently graduated nurses who did not participate in a transition program. The researchers measured self-reported workplace incivility exposures and the ability to access help when bullied. The nurses who had participated in a transition program had a greater ability to access support regarding incivility when needed.
Strength and Weaknesses of the Evidence
The overall strength of the reviewed evidence, as scored by the Melnyk and Fineout-Overholt hierarchy, was low (Table 1). Eight of the studies were of low research quality, such as quality improvement projects or quasi-experimental studies with no randomization or control group. There were two studies with control groups, but no preceding randomization was used (Laschinger et al., 2012; Nicotera et al., 2014). However, it should be noted that the nature of the types of interventions performed and the outcomes sought, such as changes in self-efficacy and improved workplace communication, lends itself to the type of research that has been performed.
Despite the low level of research quality, there were noted strengths to the evidence. Many of the studies used psychometrically tested instruments to help validate the results (Armstrong, 2017; Embree, Bruner, & White, 2013; Lasater & Mood, 2014; Laschinger et al., 2012; Nikstaitis & Simko, 2014; Warrner et al., 2016). Another strength of the evidence was that most of the interventions attempted would be fairly easy and economical to reproduce with very little risk, if any, to participants. There does appear to be a pattern as to the type of educational program is effective, based on the results of the review: programs with education about incivility, communication training, and practice in responding effectively to bullying situations. This pattern may be helpful in guiding future interventions.
Aside from the already discussed use of convenience samples in most of the studies, there were other notable weaknesses to the evidence. Many of the studies had a low number of participants (Armstrong, 2017; Nicotera et al., 2014; Stagg et al., 2013), limiting the ability to detect true intervention effects, ultimately reducing the generalizability of the results. In most of the evidence, the researchers relied on self-reported data about the participants’ understanding of workplace incivility, self-efficacy, and numbers of incivility exposures. The subjective data could bias the results. There were occasionally factors that could have increased the likelihood that outside influences may have increased the risk of bias. As an example, sometimes there were long gaps between the time of the intervention and the post-intervention data collection. Ceravolo et al. (2012) collected the data 4 years after initiating their intervention program. There was a fair amount of inconsistency in how the interventions were implemented and what type of program was used. This inconsistency makes it hard to pinpoint the exact program or timeframe that is needed to produce the desired results.
Discussion
The lack of consistency in type of incivility training program implemented and the general weakness of the quality of the research reduce the strength of the evidence available. Although these studies are less robust forms of research, they are still strong enough in combination to use as evidence for practice. There does appear to be key elements to creating an incivility training program that helps nurses manage workplace incivility. Incivility training programs that included education about workplace incivility and its effects, a form of training about how to communicate when conflict arises in an assertive manner, and practice actively responding to incivility scenarios, either through cognitive rehearsal or some form of role-play, appear to be the most effective way to help nurse improve their self-efficacy, as it pertains to workplace incivility. Teambuilding exercises can also be helpful, but do not appear to be necessary for the success of the program. The length of the program does not appear to influence effectiveness of the intervention. As well, a variety of programs, such as assertiveness training or cognitive rehearsal, with the key elements appeared to be effective. Education and active learning seem to be the most important components in helping nurses learn to best respond to workplace incivility. More research needs to be done in this area to strengthen these recommendations. Having a particular program tested multiple times would be helpful, so that there can be more specific recommendations about which program that works best. Also, there needs to be more general research done about interventions to help nurses manage workplace incivility. There is an overall lack of research in these area, while there are many more studies about the prevalence and consequences of workplace incivility in nursing practice.
Conclusion
There is a growing base of evidence available to support the use of a combination of education about workplace incivility and active, experiential learning exercises in assisting nurses in managing incivility in health care settings. The studies in this review were all health care setting based with nurses and other health care team members as participants. In several studies, the outcome of reported confidence in handling incivility or in their ability to manage incivility was directly assessed, with participants reporting improvements after the interventions. This systematic review provides evidentiary support that education about workplace incivility, training related to effective responses to uncivil behaviors in the workplace, and active learning exercises to practice responses to incivility are appropriate and research-supported for use in training nurses in the management of incivility.
Applying Research to Practice
Once a nurse is trained to assertively respond to uncivil behaviors in the workplace, the next important step is to practice those newly learned communication techniques and allow them to become second nature. However, role playing assertive communication can be awkward or intimidating for some nurses. According to the available evidence, one of the most effective methods to assist nurses in effectively responding to workplace incivility is the use of cognitive rehearsal. Cognitive rehearsal consists of mentally rehearsing responses to scenarios involving behaviors commonly associated with workplace incivility, such as gossiping, eye rolling, or backbiting. By using this training method, nurses are able to practice communication techniques in a safe, comfortable environment. Cognitive rehearsal allows nurses to transition the training they receive about effective communication techniques into acquired behaviors to be used in the workplace.
In Summary
Nursing workplace incivility is an ongoing problem in the health care setting. When allowed to become pervasive, it can be problematic for the wellbeing of nurses, the health and safety of the patients they care for, and for the workplace as a whole.
The management of nursing workplace incivility is a relatively new area of study. Much of the research that has been performed is of low quality, with limited generalizability.
Despite the limitations of the research, it appears that the use of a particular set of interventions is helpful in assisting nurses in managing workplace incivility. The combination of education about workplace incivility, training related to effective responses to workplace incivility, and an opportunity to practice those effective responses in a safe environment appears to be an evidence-based approach to assisting nurses in managing workplace incivility.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author Biography
Nancy Armstrong is an assistant professor at Murray State University School of Nursing. Her research has focused on nursing education and nursing incivility.