WORKPLACE ENVIRONMENT ASSESSMENT

44 Journal of Nursing Regulation

Fostering a Culture of Civility and Respect in Nursing Cynthia M. Clark, PhD, RN, ANEF, FAAN

Harm from disrespect has been identified as the next frontier in patient safety efforts. Disrespectful and uncivil behaviors

in healthcare settings can have detrimental effects on individuals, teams, organizations, and patient safety—including life-

threatening mistakes, preventable complications, or harm to a patient. This article focuses on the impact of incivility on the

patient care environment; explores ethical, legal, regulatory, and educational implications of workplace incivility; and provides

evidence-based strategies to promote a culture of civility and respect in healthcare.

Keywords: Civility, incivility, healthy work environment, workplace bullying

Objectives ⦁ Explain the impact of incivility on the patient care environment. ⦁ Identify evidence-based strategies to prevent and address the

problem of incivility in the patient care environment. ⦁ Describe a progressive step-by-step process to promote a culture

of civility and respect in healthcare.

The goal of nursing regulation is to safeguard the public and ensure patient safety. Unfortunately, incivility and other forms of workplace aggression pose a serious threat

to patient safety. The 2018 National Council of State Boards of Nursing environmental scan highlighted important social issues impacting the U.S. nursing workforce, which included the det- rimental impact of incivility, bullying, and violence (National Council of State Boards of Nursing, 2018). The consequences of workplace incivility and related aggressive behaviors have a sig- nificant impact on the work life of healthcare professionals as well as the patients and families they serve. In response, healthcare institutions, regulatory agencies, and professional nursing orga- nizations are paying careful attention to the impact of workplace incivility, bullying, and violence and developing and implementing evidence-based strategies and best practices to prevent and address the issues.

Incivility is defined as rude or disruptive behavior that can result in psychological or physiological distress for the people involved; if unaddressed, it may progress into unsafe or threaten- ing situations (Clark, 2017a). Acts of incivility among colleagues may include nonverbal behaviors, such as eye-rolling, refusing to listen, and walking away, or more overt behaviors, such as mak- ing rude comments, making belittling remarks, or intentionally excluding others. Incivility also includes failing to act when war- ranted (American Nurses Association [ANA], 2015a), such as with- holding important information about a patient’s care, refusing to

assist a colleague, or silently standing by while others are treated with disrespect. In other words, incivility includes not only what we do, but also what we do not do to intervene when incivility occurs, especially when patient safety is at risk.

A decade ago, the Center for American Nurses (2008) strongly recommended nurses and nursing students be made aware of the incidence and prevalence of incivility in healthcare, educated to recognize and address incivility in the workplace, and equipped with effective strategies to mitigate uncivil behavior. This article focuses on the impact of incivility on the patient care environment today; explores ethical, legal, regulatory, and educational implica- tions of workplace incivility; and provides evidence-based strategies to promote a culture of civility and respect in healthcare.

Impact of Incivility on Patient Care and Safety Incivility in healthcare settings can have a detrimental impact on individuals, teams, and organizations. In the patient care envi- ronment, uncivil encounters with co-workers can provoke uncer- tainty and self-doubt, weaken self-confidence, compromise moral courage, and jeopardize patient safety. In some cases, incivility can lead to life-threatening mistakes, preventable complications, harm, or death of a patient (Maxfield & Grenny, 2017; Laschinger, 2014; Hutchinson & Jackson, 2013; Rosenstein & Naylor, 2012; Maxfield, Grenny, Lavandero, & Groah, 2011). Laschinger (2014) further noted that incivility from nurses, physicians, and supervi- sors has significant direct and indirect effects on nurse-assessed adverse events and perceptions of patient care quality, primarily through perceptions of increased patient safety risk. Kusy and Holloway (2014) described the impact of incivility on healthcare organizations and noted that 70% to 80% of medication errors are due to disruptive behaviors, 65% of nurses reported abuse from

Continuing Education

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other nurses, 77% of nurses reported abuse from physicians, and 31% of nurses left their position because of toxic abuse.

Bullying is a more serious form of incivility and is defined as repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient (ANA, 2015a). It often involves an abuse or misuse of power and presents serious safety and health concerns. Bullying may be directed from the top down (supervisors against employees), from the bottom up (employees against supervisors), or horizontally (employee-to-employee such as nurse-to-nurse) (ANA, 2015a). Harm from disrespect (incivil- ity) in healthcare has been identified as the next frontier in patient safety efforts (Sokol-Hessner et al., 2018) and is associated with a worse patient experience, lower likelihood of perceiving care as high quality, lower likelihood of seeking care again in the facility, higher risk of physical harm, and higher levels of staff disengage- ment, absenteeism, and turnover.

Bullying has resulted in disruption to meeting patients’ needs (Kerber, Woith, Jenkins, & Schafer-Astroth, 2015). Houck and Colbert (2017) conducted an integrative review of 11 research studies on the relationship between patient safety and work- place bullying and healthcare. The authors noted that workplace bullying is associated with negative nursing outcomes such as work dissatisfaction, turnover, and intent to leave. In the same review, several findings related to the impact of workplace bul- lying on patient safety were identified, including errors in treat- ment or medication administration, delayed care, and patient falls. Similarly, Adams and Maykut (2015) concluded that bul- lying interferes with teamwork, collaboration, and communica- tion, all key essentials to the provision of accurate, timely, and safe patient care.

Ethical, Legal, and Regulatory Implications The fact that all nurses are morally obligated to foster civil, safe, and productive work environments is well supported. For exam- ple, the International Code of Ethics for Nurses (International Council of Nurses, 2012) emphasizes the nurse’s responsibility to respect human rights, treat others with dignity and respect, and provide respectful and unrestricted care. The International Council of Nurses (2017) recently revised their workplace violence position statement to support development of “zero tolerance” policies of violence in any form, including those associated with such issues as workplace bullying and lateral violence of nurses to each other.

The ANA Code of Ethics for Nurses (2015b) clearly articu- lates that all nurses have a moral obligation and ethical impera- tive to create and sustain healthy work environments and to foster an atmosphere of dignity and respect. Specifically, provision 1.5 requires nurses:

. . . to create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect . . . and that any form of bullying,

harassment, intimidation, manipulation, threats or violence will not be tolerated (p. 4).

The ANA’s position paper on incivility, bullying, and work- place violence advocates for the adoption and implementation of a zero-tolerance policy for all forms of workplace aggression and outlines individual and shared roles and responsibilities of nurses and employers to create and sustain a culture of respect across the healthcare continuum (ANA, 2015a). The ANA position also emphasizes the ethical, moral, and legal responsibility of health- care employers to create a healthy and safe work environment for nurses, other healthcare team members, patients, families, and communities. The following year, the American Association of Critical-Care Nurses (2016) reaffirmed six standards for establish- ing and sustaining healthy work environments and concluded that unhealthy work environments and relationship issues “can become the root cause of medical errors, hospital-acquired infections, clini- cal complications, patient readmissions, and nurse turnover” (p. 8). Although the standards were not developed specifically to address incivility, they provide a solid foundation for fostering civility and developing healthy work environments.

In addition to ethical considerations, legal efforts are evolv- ing. In the early 2000s, the Healthy Workplace Bill (HWB) was drafted by David Yamada; since then, it has been considered in more than half of the United States, with more than 100 versions, and sponsored by more than 400 legislators (Clark & Ritter, 2018). Although there have been partial victories in Utah, California, and Tennessee, no state has passed the full version of the HWB that holds employers accountable for fostering an abusive work environ- ment (Workplace Bullying Institute, 2014). Massachusetts Senate Bill 1013, which petitions for An Act Addressing Workplace Bullying, Mobbing, and Harassment (2017), provides a detailed description of the HWB. Although there are currently no laws in the United States specifically targeting workplace bullying, perpetrators and employers who do not address the issue may be subject to legal consequences. For example, individuals who spread rumors about a coworker might be sued based on defamation if the rumor is proven to be false and determined to cause injury (Matt, 2012).

In their mission to safeguard the public, Boards of Nursing and other regulators are challenged to address important questions related to the issue of incivility in nursing practice. For example, should an error stemming from incivility among nursing staff be reported to state boards of nursing for possible disciplinary action, and, if so, how should it be acted upon? The ANA Code of Ethics (2015b) provides some guidance to nurse regulators regarding a violation of the ethical standard of care. One recommendation is to incorporate rules to the nurse practice act to address issues of workplace incivility. In the District of Columbia, the responsibility of nurses to adhere to the standards in the Code of Ethics is incorpo- rated into the municipal regulations (Stokes, 2015).

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Fostering Civility in Academic and Practice Environments In 2017, the Tri-Council for Nursing—an alliance between the American Association of Colleges of Nursing, the ANA, the American Organization of Nurse Executives, and the National League for Nursing—issued a proclamation on nursing civility. The Tri-Council noted that civility is key to promoting healthy, inclusive work environments to safeguard patient safety. The fol- lowing year, the National League for Nursing (2018) released a vision statement on creating community to build a civil, healthy academic work environment, stressing that faculty play an impor- tant role in co-creating and maintaining academic and practice environments that foster civility. The statement underscores how uncivil behavior within the academic environment can lead to learned negative behaviors by students and, ultimately, newly graduated nurses.

Nursing faculty must take the lead to model professionalism and ethical practice and set the tone for civility as a shared value within nursing programs. A culture of civility must be embed- ded in the vision, mission, and shared values of all nursing edu- cation programs and integrated throughout all nursing curricula (Clark, 2017a, 2017b). Consideration must be given to developing and implementing admission criteria and learning activities that stress the importance of respectful and professional conduct for all incoming and continuing students. For example, simulation, role-play, problem-based learning, case-based scenarios, and other teaching-learning strategies may be implemented to illustrate the relationship between civility and safe patient care and the conse- quences of incivility on individuals, teams, and organizations.

Several factors affect the culture of any organization, includ- ing level of job satisfaction, employee commitment, and turnover rates. These factors are directly related to the interaction between employees and their ability to do the job, their loyalty to the orga- nization, and the level of support they experience from the leaders of the organization (Mathis & Jackson, 2008).

Incremental changes are generally inadequate to renovate a workplace culture. Transforming the organizational culture requires hard work, focus, commitment, and strong, effective lead- ership at all levels of the organization. Transformational change involves redesigning how the organization is structured and man- aged, redefining its vision and goals, and establishing new norms, systems, and practices (Bigelow & Arndt, 2005). Although no one- size-fits-all framework exists, several essential components can be implemented to help foster organizational civility and achieve a healthy workplace. Any model or pathway to foster civility must be considered within the context of the organization’s unique culture and climate and must be nimble and flexible to use in a variety of work environments.

A Framework for Fostering Civility The Pathway for Fostering Organizational Civility (PFOC) is one framework that may be implemented to create healthier and more civil workplaces (Clark, 2017a). This comprehensive and dynamic approach to workplace improvement provides a progressive step- by-step process to promote a culture of civility and respect and can be implemented by an individual department, academic setting, or organization.

Step 1: Raise Awareness and Build Leadership Support

The first step of the PFOC is to raise awareness about the posi- tive impact of civility; educate key stakeholders about the deleteri- ous effects of incivility on individuals, teams, organizations, and patient care; and enlist leadership support at all levels to imple- ment a compelling vision to foster a healthy work environment. Because transformational and sustained change requires broad- based collaboration, individuals need leadership support and the necessary resources to promote change.

Raising awareness about the types and frequency of inci- vility is a vital step in fostering a civil organizational culture and can be done by helping leaders and other members of the organi- zation understand and appreciate the costs of uncivil actions and embrace a desire for positive change. Sharing stories and experi- ences of incivility and civility is an effective tactic to raise aware- ness and engage leaders in making a commitment to a culture of respect and dignity (Sokol-Hessner et al., 2018).

Step 2: Assemble and Empower a Civility Team and Seek Broad-Based Support

Note: Steps 2 and 3 can be reversed depending on whether an organizational assessment has been conducted. If one has not been done, Step 2, developing a civility team (organizational culture team), can be extremely helpful in moving the civility initiative forward. If an organizational assessment has been completed, the assessment results, Step 3, provide objective information about the scope of the problem, strengths of the organization, and direction for positive change.

The main purpose of a civility team is to lead the transition to a more civil, healthy organizational culture. The team can con- sist of employees who are trusted, committed, and empowered to measure the problem, develop a compelling vision of the organiza- tion’s future, and carry out the steps of the PFOC. Although civil- ity team members might be volunteers or selected from a pool of formal and informal leaders, representation from various interpro- fessional disciplines, including nurses, physicians, assistive person- nel, therapist, and human resource professionals, is critical.

Information about the civility initiative and its progress can be communicated internally and externally via face-to-face meet- ings, web pages, memos, newsletters, and formal meeting minutes. With broad-based support and ownership, the civility initiative is more likely to succeed.

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Step 3: Assess Organizational Civility at All Levels

Because every organization possesses a unique history, culture, and workforce, careful and thorough assessment of the organiza- tional culture can yield meaningful information to individualize the PFOC data-driven action plan. Data derived from empirical tools to conduct pre- and posttest assessments of the organizational culture along with information gleaned from satisfaction surveys, interviews, focus groups, and open forums can be used to imple- ment change.

There are several empirical instruments used to measure organizational culture, climate, and civility, including the Civility, Respect, Engagement in the Workforce (CREW) Scale (Osatuke, Moore, Ward, Dyrenforth, & Belton, 2009), Organizational Civility Scale (OCS) (Clark, Landrum, & Nguyen, 2013), and the Healthy Work Environment Inventory (HWEI) (Clark, Sattler, & Barbosa-Leiker, 2016). CREW was developed by the U.S. Veterans Hospital Association to improve the work climate through more civil and respectful interactions (National Center for Organization Development, n.d.). In addition to measuring incivility, CREW was designed to enhance civility in the workplace by strengthen- ing and improving workplace relationships. The OCS measures the extent to which incivility is perceived to be a problem in an orga- nization, to identify the factors that contribute to it, and to gener- ate solutions. In addition to incivility, the OCS measures civility, stress, coping, and job satisfaction. HWEI is a 20-item instrument used to measure perceptions of workplace health, determine areas of strength and improvement, and form the basis for vetting and interviewing potential employees and employers.

Step 4: Develop a Data-Driven Action Plan

During this step, the assessment information obtained from Step 3 is synthesized and translated into a data-driven action plan to be implemented in Step 5. The assessment findings are reviewed to identify areas of strength and excellence, reinforce efforts already in place to enhance a positive workplace, and implement specific strategies to improve areas of concern and deficit. Each strategy should include clear objectives, expected timelines, and necessary resources (financial, human, and organizational) to implement and evaluate the strategies.

Policy development and implementation is critical to orga- nizational change and to the success of the civility initiative. The establishment and implementation of a healthy workplace policy may lead to a healthier and more productive workforce and should be aligned with other policies and procedures within the organiza- tion. The SMART policy (see Table 1) was developed as a frame- work to report and address incivility, to reward civility, and to evaluate progress (Clark, 2017a). It applies to acts of incivility and other forms of workplace aggression and provides a mechanism for documenting and rewarding civility. Clark and Ritter (2018) pro- vide a more detailed description of this policy.

Step 5: Implement the Data-Driven Action Plan

This step includes implementing the evidence-based strategies. Depending on the assessment data, key strategies may include co- creating and implementing a civility charter with clear norms and ground rules for social engagement, improving effective communi- cation skills, developing a conflict-capable workforce, and enhanc- ing teamwork and collaboration.

Co-creating and Implementing Team Norms

Co-creating and implementing team norms is essential for team- work, collaboration, and high performance. Nurse managers can facilitate the co-creation of team norms by describing the insti- tution’s vision, mission, and shared values; defining civility; and discussing the negative impact of incivility and other workplace aggressions on patient safety. However, because the goal is co- creation of norms, the nurse manager may not be the person to take the lead. Although role-modeling is important, encouraging staff nurses to facilitate the co-creation of norms is an opportunity for staff to take a leadership role and meaningfully contribute to building a healthy work environment.

Institutional documents provide a foundation upon which team charters and norms can be developed and implemented. After explaining the value and importance of co-creating norms and their positive impact on patient safety (McGonagle, Walsh, Kath, & Morrow, 2014), nurse managers/leaders can facilitate the co-creation of team norms. Overarching aspirations set the stage for norm co-creation. To begin the process, managers may ask staff members, “Which behaviors do you wish to avoid on this unit, and which behaviors do you want to see on this unit that will support teamwork, collaboration, and patient safety?” An impor- tant follow-up question is, “How will we hold ourselves and one another accountable for norm adherence?” Ideas are generated, agreed upon, and displayed throughout the unit. Norms must also be periodically reviewed, revised as needed, and reaffirmed on a regular basis. Team norms are living documents that provide a “civility” touchstone for all members of the healthcare team by providing a framework for working, collaborating, and learning with and from one another.

Building Effective Communication and Constructive Conflict

Negotiation Skills

In their sentinel work, The Silent Treatment, Maxfield et al. (2011) remind readers not to make the mistake of assuming people have the skills they need to “just do it” (p. 10) as it relates to the skills needed to provide safe practices. The authors conclude that effec- tive organizations use training, education, script development, and role play to improve communication and constructive conflict negotiation skills. The use of “cognitive rehearsal,” role-playing, and evidence-based scripts as learning strategies to improve com- munication during uncivil encounters has been well documented (Clark, 2019; Sanner-Stiehr, 2017; Longo, 2017; Griffin & Clark, 2014; Stagg, Sheridan, Jones, & Speroni, 2013, 2011; Griffin,

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2004). Cognitive rehearsal is a behavioral strategy used to prepare an individual for a potentially stressful and/or uncivil situation by rehearsing ways to approach the situation to strengthen the prob- ability of a favorable outcome. Cognitive rehearsal includes rehears- ing specific phrases that might be used during the encounter and being coached and debriefed by a skilled facilitator (Clark, 2019). Implementing evidence-based approaches such as the Concerned, Uncomfortable, and Safety (CUS) model from TeamSTEPPS™ (Agency for Healthcare Research and Quality, 2014) provides a helpful structure to script responses to address uncivil encounters and ultimately protect patient safety.

Role-playing and simulating events in the safe setting of a skills laboratory could also allow members of the interdisci- plinary team to practice civil interactions in stressful conditions (Johnson, Boutain, Tsai, & de Castro, 2015). Honing communica- tion and conflict negotiation skills is critical to the delivery of safe patient care. Using staff meeting time, using simulation space, and addressing incivility in “real time” will help nurses learn about and practice effective ways of dealing with uncivil encounters.

Step 6: Evaluation and Reassessment

The PFOC is a cyclical process that includes assessing, planning, educating, strategizing, evaluating, and reassessing. As part of the PFOC cycle, evaluation and reassessment do not complete the pathway, but they are necessary steps to review the effectiveness of the change process to foster organizational civility and health. Ongoing and periodic re-administration of the empirical tools to measure progress, goal achievement, and effectiveness of civility interventions is highly recommended to determine whether aspects of civility have changed over time.

Step 7: Reward Civility and Consolidate Successes

Recognizing and celebrating individual and collective achieve- ments fuel momentum for change and reward individual and organizational efforts. Celebrations honor and reward successes, achievements, and accomplishments. Evidence of success includes achieving long- and short-term goals, enjoying high levels of morale and job satisfaction, improving communication and con- flict negotiation skills, giving and receiving meaningful recog- nition, growing new programs and initiatives, and increasing community visibility and recognition.

TABLE 1

Summary of the SMART Policy

System for Confidential Reporting

An online confidential reporting system is needed to collect reports of incidents related to incivility and ci- vility. Contact information is collected for statistical and follow-up purposes only. Report should include time, date, and location of occurrence; description of the incident; impact of incivility; the reporter’s per- ception of and response to the issues; and suggestions for follow-up. These reports are valuable in tracking incidents of incivility and, if indicated, imposing sanctions and/or follow-up actions for the offender.

Managing Report Information

Entities such as human resources personnel are well suited to examine the validity of the report by inter- viewing the individuals involved and providing follow-up procedures, if needed. This ensures confidentiali- ty of all parties involved.

Addressing Incivility To the individual who bears witness or is affected by uncivil behaviors: After filing the incivility report, the individuals involved meet with a supervisor or mediator to address and resolve the problem. The goal is that each person details their view of the situation, agrees on an interest-based resolution with clear expec- tations and timelines, and agrees to a plan to evaluate progress on efforts to resolve the issue. To the individual displaying uncivil behaviors: The emphasis for corrective actions is placed on the behav- ior and not the person. The first violation of the policy results in a verbal warning without written documen- tation placed in their employee file. Upon the second incivility infraction, a performance improvement plan (PIP) is initiated with specific behavioral requirements and associated time frames. If the person makes minimal or no improvement or if repetitive incidents are reported against them, disciplinary actions (e.g., suspension, temporary leave) may be warranted.

Rewarding Civility An online confidential reporting system collects reports of civility and acts of kindness and regard in the workplace. Reporters can identify themselves or remain anonymous. Contact information is collected so that rewards can be rendered. Specific fields include time, date, description of the civil or respectful act, the reporter’s perception of and response to the issues, and suggestions for follow-up. Individuals can se- lect a desired “civility” reward from a “wish list” of rewards and incentives.

Tracking and Evaluating Progress

The civility team (or designee) institutes a method to evaluate the SMART policy, monitors progress, and uses evaluation data to modify or improve processes to reach the desired results. Using de-identified infor- mation, the team can keep a record of every action or strategy to evaluate processes and to generate for- mal reports to communicate progress on the SMART policy. The reports are disseminated in aggregate to all members of the organization and are used to keep leaders well informed and to garner ongoing support for “staying on course” with the civility initiative.

Source: Clark, C. M. (2017a). Creating and sustaining civility in nursing education (2nd ed.). Indianapolis, IN: Sigma Theta Tau International Publishing.

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Step 8: Expand the Civility Initiative: Sharing Knowledge, Lessons, and Experience

To expand the civility initiative and sustain organizational trans- formation, the civility team (or designates) can encourage the onboarding of new members and other promising leaders to facili- tate the passage of knowledge, lessons, and experience gained dur- ing implementation of the civility initiatives. This transition phase may include identifying leaders/members from the current civil- ity team; recruiting other interested team members to initiate the next phase of the civility plan; discussing individual, team, and organizational accomplishments; reviewing progression and assess- ment of the civility plan; and sharing lessons learned.

Conclusion Since incivility and disrespect were linked to poor patient out- comes, employee dissatisfaction, and increased turnover rates, harm from disrespect has been identified as the next frontier in patient safety efforts. Therefore, creating and sustaining organi- zational civility using evidence-based strategies to structure best practices and initiatives is an essential consideration for all health- care settings. Responding to the urgent calls to action to foster and maintain civility and respect in healthcare requires all members of the nursing profession and its constituents to work collaboratively to prevent and address the negative consequences of incivility, bul- lying, and other forms of workplace aggression.

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Sokol-Hessner, L., Folcarelli, P. H., Annas, C. L., Brown, S. M., Fernan- dez, L., Roche, S. D., … Rozenblum, R. (2018). A road map for advancing the practice of respect in health care: The results of an interdisciplinary modified Delphi consensus study. Joint Commission Journal on Quality & Patient Safety, 44(8), 463–476.

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Cynthia M. Clark, PhD, RN, ANEF, FAAN, is a Professor Emeritus at Boise State University, Idaho, and Strategic Nursing Advisor for ATI Nursing Education, living in Boise, Idaho.

www.journalofnursingregulation.com 51Volume 10/Issue 1 April 2019

Fostering a Culture of Civility and Respect in Nursing

Objectives ⦁ Explain the impact of incivility on

the patient care environment. ⦁ Identify evidence-based strategies to

prevent and address the problem of incivility in the patient care environment.

⦁ Describe a progressive step-by-step process to promote a culture of civil- ity and respect in healthcare.

Ce

CE Posttest If you reside in the United States and wish to obtain 1.3 contact hours of continuing education (CE) credit, please review these instructions.

Instructions Go online to take the posttest and earn CE credit: Members – courses.ncsbn.org (no charge) Nonmembers – www.learningext.com ($15 processing fee) If you cannot take the posttest online, complete the print form and mail it to the address (nonmembers must include a check for $15, payable to NCSBN) included at the bottom of the form.

Provider accreditation The NCSBN is accredited as a provider of CE by the Alabama State Board of Nursing.

The information in this CE activity does not imply endorsement of any product, service, or company referred to in this activity.

Contact hours: 1.3 Posttest passing score is 75%. Expiration: April 2022

Posttest

Please circle the correct answer.

1. Which of the following definitions describes incivility?

a. Rude or disruptive behavior that can result in psychological or physiological distress for the people involved.

b. Repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient.

c. An abuse or misuse of power, which presents serious safety and health concerns.

d. None of the above.

2. How does incivility impact the patient care environment?

a. Can provoke uncertainty and self-doubt, weaken self-confidence, compromise moral courage, and jeopardize patient safety.

b. Can lead to life-threatening mistakes, preventable complications, harm, or death of a patient.

c. Has significant direct and indirect effects on nurse-assessed adverse events and perceptions or patient care quality, primarily through perceptions of increased patient safety risk.

d. All of the above.

3. What is the relationship between bullying and incivility?

a. Incivility is a more serious form of bullying.

b. Bullying is synonymous with incivility. c. Bullying is considered a more serious

form of incivility. d. Incivility and bullying are separate and

distinct phenomenon.

4. Nurses at all levels within an organization play a critical role in fostering civility, modeling professionalism and ethical practice, and setting the tone for civility as a shared value within health care environments.

a. True b. False

5. What framework can be implemented within all organizations in order to foster organizational civility and achieve a healthy workplace?

a. The Pathway for Fostering Organizational Civility (PFOC)

b. Any model or pathway to foster civility must be considered within the context of the organization’s unique culture and climate.

c. No one-size-fits-all framework for fostering organizational civility and achieving a healthy workplace exists.

d. B and C

6. How can regulatory agencies, such as the National Council of State Boards of Nursing (NCSBN), advocate for healthier and more civil workplaces?

a. Through sanctions for incivility in the workplace.

b. By collaborating with an interactive network of stakeholders to implement system changes and approaches that collectively contribute to public safety.

c. By completely redesigning how organizations are structured and managed.

d. By creating and sustaining civility and a healthy work environment.

Match the steps of the PFOC with their function:

7. Step 1: Raise awareness and build leadership support

8. Step 2: Assemble and empower a civility team and seek broad-based support

9. Step 3: Assess organizational civility at all levels

10. Step 4: Develop a data-driven action plan

11. Step 5: Implement the data-driven action plan

12. Step 6: Evaluation and reassessment

13. Step 7: Reward civility and consolidate successes

14. Step 8: Expand the civility initiative: sharing knowledge, lessons, and experience

a. Key strategies of this step may include co-creating and implementing a civility charter with clear norms and ground rules for social engagement, improving effective communication skills, developing a conflict-capable workforce, and enhancing teamwork and collaboration.

b. During this step, assessment findings are reviewed to identify areas of strength and excellence, reinforce and celebrate efforts already in place to enhance a positive workplace, and implement specific strategies to improve areas of concern and deficit.

c. This step incorporates ongoing and periodic re-administration of the empirical tools to measure progress, goal achievement, and effectiveness of civility interventions to determine whether particular aspects of civility have changed over time.

52 Journal of Nursing Regulation

d. This step of the PFOC is to raise awareness about the positive impact of civility; educate key stakeholders about the deleterious effects of incivility on individuals, teams, organizations, and patient care; and enlist leadership support at all levels to implement a compelling vision to foster a healthy work environment.

e. The civility team (or designates) encourage the onboarding of new members and other promising leaders to facilitate the passage of knowledge, lessons, and experience gained during implementation of the civility initiatives.

f. The civility team engages people at all levels of the organization by communicating clearly and widely and by encouraging all members of the organization to participate and work together to achieve the desired vision.

g. Evidence of success includes achieving long- and short-term goals, enjoying high levels of morale and job satisfaction, improving communication and conflict negotiation skills, giving and receiving meaningful recognition, growing new programs and initiatives, and increasing community visibility and recognition.

h. Because every organization possesses a unique history, culture, and workforce, careful and thorough assessment of the organizational culture can yield meaningful information to individualize the PFOC data-driven action plan.

15. Incivility has not yet been identified in the NCSBN’s environmental scan as a detrimental issue impacting the United States nursing workforce.

a. True b. False

16. Which of the following choices is NOT a consequence of incivility and disrespect?

a. Harm b. Employee dissatisfaction c. Organizational structure d. Increased turnover rates

17. Who is responsible for transforming work environments to create and sustain organizational civility?

a. Healthcare institutions b. Regulatory agencies c. Professional nursing organizations d. All of the above

Evaluation Form (required)

1. Rate your achievement of each objective from 5 (high/excellent) to 1 (low/poor).

• Explain the impact of incivility on the patient care environment.

1 2 3 4 5

• Identify evidence-based strategies to prevent and address the problem of incivility in the patient care environment.

1 2 3 4 5

• Describe a progressive step-by-step process to promote a culture of civility and respect in healthcare.

1 2 3 4 5

2. Rate each of the following items from 5 (strongly agree) to 1 (strongly disagree):

• The authors were knowledgeable about the subject.

1 2 3 4 5

• The methods of presentation (text, tables, figures, etc.) were effective.

1 2 3 4 5

• The content was relevant to the objectives.

1 2 3 4 5

• The article was useful to me in my work.

1 2 3 4 5

Comments:

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