COMMENTARY

Nurses: Resetting the Civility Conversation

Cynthia M. Clark, PhD, RN; Sara M. Ahten, MSN, RN

Disclosures

August 19, 2011

In This Article

A Reader's Rejoinder

Both of us received numerous personal emails in response to the article. One reader sent a thoughtful message that was representative of many of the themes expressed on the article's discussion board. We would like to share excerpts from her message, which so clearly embodied the thoughts of many readers. Like many of those who commented on the article, she speaks from years of experience in a variety of workplace settings. With her permission, we abbreviated her comments and removed any identifying information to ensure her privacy.

Two points in your article on which I agree are that incivility exists in nursing and that it is hurting our profession. I have had a variety of work experiences in my nursing career, in hospitals and occupational health. Many times I held 2 jobs, working in both hospital and industrial settings at the same time on different days. The bullying in nursing has become worse in the last 10+ years. Today, only the sickest patients are admitted to the hospital. Nurses are expected to be everything from phlebotomists to dieticians, nursing assistants, housekeepers, and managers. At times, it is overwhelmingly hard to work as a bedside nurse, and bullying makes it much worse. Some nurses are bullied and "kept in their places" so the work on their floor can be assigned and completed.

I believe that incivility will not stop until hospital leaders and managers take charge of the situation. Change has to start at the top. Maybe nursing schools can be pioneers in today's society by showing their students, "Yes you have to be tough, and you need to not only be kind to the patients but also to yourself and each other."

Our Response

What a powerful statement on the challenges faced by so many nurses who are working to provide professional care to patients and families and at the same time dealing with managerial and organizational demands that are frequently overwhelming. Responding to her email message gave us the opportunity to discuss ideas that we believe would have a significant impact on improving both civility in nursing practice and quality patient care. A paraphrase of our answer to her is as follows.

What we took away from your message was the need to examine "how we do business" in nursing practice. A first step is an in-depth analysis of what nurses are being asked to do in the course of a typical shift. We believe very strongly that those in leadership/management need to contrast this analysis with a realistic appraisal of what a professional nurse can actually be expected to do. Nothing will suffice but an objective assessment of current role responsibilities along with the honest feedback of experienced bedside nurses. The expectation of what constitutes nursing practice suffers from a phenomenon similar to what we in education call the "additive curriculum." As more knowledge is added to the body of nursing science and more becomes known about the functioning, needs, cares, and concerns of patients and families, more content is simply piled on to existing nursing courses. The problem arises when the curriculum isn't reviewed at the same time to see if other content can be de-emphasized, revised, or eliminated because it is no longer of primary importance to nursing. Neither a nursing program nor a nursing professional can offer all things to all people at all times.

We believe that the exhaustion and overload of bedside nurses has as much to do with outdated perceptions and old models of care, and a reluctance to examine and evaluate the "sacred cows" of traditional nursing practice, as it does with understaffing of units.

This brings us to another of your major points: the need for nursing managers and leaders to set the tone and expectations for the type of professional interactions that will occur in the workplace. This rings true not only for nursing practice leaders but also for leaders in nursing education. No matter what words are typed in a mission statement or human relations memo, staff and students will model the behaviors they observe and experience from their leaders and faculty. If my manager doesn't "walk the talk," I am going to ignore the official rules and do what I know I can get away with. That is human nature.

Leaders and managers give cues and clues all day long as to what they consider to be acceptable behavior. If I'm the manager, even if I don't exhibit incivility, I condone it if I don't address it when I see or hear about it. This is especially true if I don't let my staff know clearly what I expect in their workplace interactions. If I convey a continuous, consistent message in my words and actions, they will know that it is a priority and an expectation of professional behavior.

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