The Downward Spiral: Incivility in Nursing

Laura A. Stokowski, RN, MS


March 24, 2011

In This Article

The Continuum of Incivility in Nursing

Medscape: How do you conceptualize incivility in nursing interactions?

Cynthia (Cindy) Clark RN, PhD, and Sara Ahten, RN, MSN: Incivility is one term used to describe rude, disruptive, intimidating, and undesirable behaviors that are directed toward another person. Other terms found in the literature include lateral violence, horizontal violence, relational aggression, and bullying. Commonalities and intersections exist in the various definitions of these terms. A highly important shared attribute is the effect of these behaviors on the recipient and the organization, if left unchecked. As Forni so eloquently stated in 2008, "Incivility often occurs when people are stressed, unhappy, and rushed. When these coincide, anything can happen. Incivility erodes self-esteem, damages relationships, increases stress, contaminates the work environment, and may escalate into violence."[2] These behaviors may be intentional or unintentional. By unintentional, we mean that in some cases, the person exhibiting the uncivil behaviors is unaware of how his/her behaviors, words or actions may be affecting another.

Although commonalities exist among terms and definitions reflecting uncivil behavior, it is important when reading any literature to focus on how the author/authors define their terminology. Uncivil behavior exists along a continuum ranging from disruptive behaviors on one end, to threatening behaviors on the other (Figure 1). The many nuances and manifestations of the behaviors compel the reader to understand the context in which the information is being presented.

Figure 1. Continuum of incivility. Published with permission from Cynthia Clark.

With all of the attention that bullying has received, nurses have learned to recognize this behavior when it occurs and no longer believe that it is acceptable or excusable. Clark's graph, however, shows that incivility at the left end of the scale can be expressed by some fairly subtle behaviors -- the kind of things that nurses often excuse by saying "so and so is having a bad day."

Medscape: In your opinion, what behaviors represent incivility in nurses?

Clark and Ahten: Overt expressions of incivility, such as taunting, racial/ethnic slurs, and bullying are most apparent and most reported in media. However, as shown in the Continuum of Incivility graphic, this can begin in what appears to be a relatively benign manner, with behaviors such as eye rolling, sarcastic comments, or dominating conversation in a group. We believe it is essential, and ultimately beneficial to any organization, to recognize the behaviors at the left end of the continuum. In an ideal world, people would interact with each other respectfully and thoughtfully. In the real world, what we wish is to prevent the potential escalation to more damaging and disruptive manifestations.


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