Interprofessional Organizational And Systems Leadership HW

Incivility in healthcare can lead to unsafe working conditions, poor patient care, and increased medical costs. The authors discuss a study that examined factors that contribute to adverse working relation- ships between nursing education and practice, effective strategies to foster civility, essential skills to be taught in nursing education, and how education and practice can work together to foster civility in the profession.

The work of nursing is 4 times more dangerous than most other occupations,1 and nurses experience work- related crime at least 2 times more often than any other healthcare provider.2 Root causes for workplace violence are multifaceted and include work-related stress due in part to an increasingly complex patient population and workload and deteriorating interper- sonal relationships at the bedside.1 When normalized or left unaddressed, these uncivil and disruptive be- haviors may emerge into an incivility spiral,3 depicted along a continuum from an unintentional act leading to intentional retaliation, escalating to workplace bul- lying and even violence.4 Incivility and disruptive be- haviors have been identified both in the academic5-7

ORDER CUSTOM, PLAGIARISM-FREE PAPER

and clinical settings8-10; however, no direct study of incivility between the 2 environments has been made.

Review of the Literature

Incivility and disruptive behavior in nursing educa- tion and practice are common,4,9 on the rise,11 and frequently ignored.12 Two decades ago, Boyer13

noted several challenges facing institutions of higher education, including academic incivility. Although incivility in the academic setting is not a new phe- nomenon, the types and frequency of misbehavior are increasing and have become a significant prob- lem in higher education, including nursing educa- tion. Clark and Springer14,15 explored faculty and student perceptions of incivility in nursing education and found negative behaviors to be commonplace and exhibited by students and faculty alike. The ma- jority of respondents (71%) perceived incivility as a moderate to serious problem and reported that stress, high-stake testing, faculty arrogance, and student en- titlement contributed to incivility.14 More than half of the respondents reported experiencing or know- ing about threatening student encounters between students or faculty.14

A small but growing body of research suggests that incivility and disruptive behaviors are particu- larly commonplace to the new graduate nurse or nursing student within the clinical setting.10 Paral- leling incivility in the academic setting, staff nurses are also vulnerable to bullying, defined as negative behavior that is systematic in nature and purpose- fully targeted at the victim over a prolonged time frame with the intent to do harm.16 These findings are also supported by a recent Joint Commission (TJC) survey17 reporting that more than 50% of nurses are victims of disruptive behaviors includingInterprofessional Organizational And Systems Leadership HW

324 JONA � Vol. 41, No. 7/8 � July/August 2011

Author Affiliations: Professor (Dr Clark) and Research Assistants (Mss Cardoni and Kenski), School of Nursing, Boise State University, Idaho; Doctoral Candidate (Ms Olender), Seton Hall University, South Orange, New Jersey, and Executive Con- sultant and Nurse Researcher (Ms Olender), James J. Peters VA Medical Center, Bronx, New York.

The authors declare no conflict of interest. Correspondence: Dr Clark, School of Nursing, Boise State Uni-

versity, 1910 University Dr, Boise, ID 83725 (cclark@boisestate.edu). DOI: 10.1097/NNA.0b013e31822509c4

incivility and bullying, and more than 90% of nurses stated witnessing abusive behaviors of others in the workplace. Likened to the concept of nurses ‘‘eating their young’’,18 the findings of several studies suggest that these negative behaviors are a learned process, transferred through staff nurses to new nurses and student nurses via interaction within the hierarchi- cal nature of the profession.10

Incivility and disruptive behaviors may also be normalized or perpetuated by organizational cul- ture,12,18 particularly during times of restructuring or downsizing. This is suggested to be secondary to unclear roles and expectations, professional and per- sonal value differences, personal vulnerabilities, and power struggles common within organizations dur- ing periods of change.18 Other consequences of inci- vility include heightened stress levels, physiological and psychological distress,5 job dissatisfaction,10,19

decreased performance,20 and turnover intention.21

Bartholomew18 noted that uncivil behaviors may contribute to the exodus of new graduates leaving their first job within 6 months. If disruptive behav- iors are tolerated, nurses may leave the profession altogether.21 Disruptive and bullying behaviors have been identified as a root cause of more than 3,500 sentinel events over a 10-year time frame22 and con- tribute to an annual estimate of 98,000 to 100,000

patients dying secondary to medical errors in hos- pitals.23,24 Collectively, these findings led TJC17 to intervene and release a sentinel event alert calling for zero tolerance of intimidating and bullying behaviors.

Conceptual Framework

Clark5 developed a conceptual model to illustrate how heightened levels of nursing faculty and student stress, combined with attitudes of student entitle- ment and faculty superiority, work overload, and a lack of knowledge and skills, contribute to incivility in nursing education. This conceptual model has been adapted to reflect the stressors that contribute to incivility in both nursing education and practice (Figure 1). Factors that contribute to stress in nurs- ing practice are similar to the stressors experienced in nursing education including work overload, un- clear roles and expectations, organizational condi- tions, and a lack of knowledge and skills. Moreover, in both practice and academia, stress is mitigated by leaders who role model professionalism and utilize effective communication skills.25 The importance of modeling effective communication and related edu- cation to address incivility cannot be underestimated, can reduce its incidence and effects,26 and can assist in fostering cultures of civility.6

Figure 1. Conceptual model for fostering civility in nursing education (adapted for nursing practice).

JONA � Vol. 41, No. 7/8 � July/August 2011 325

Nurse Leaders’ Survey

Mindful of the need to enhance the culture of civility both in the academic and clinical settings, a descrip- tive qualitative study was conducted. The purpose of the study was to gather practice-based nursing lead- ers’ perceptions about factors that contribute to an adverse working relationship between nursing ed- ucation and practice, the most effective strategies needed to foster civility, the skills needed to be taught in nursing education, and how nursing education and practice can work together to foster civility in the nursing workplace.

Procedure and Analysis

The survey was developed by the author (C.M.C.) and included 4 open-ended questions designed to garner nurse leaders’ perceptions on ways to foster civility in nursing education and practice. The ques- tions were constructed based on a comprehensive review of the literature on incivility and numerous empirical studies. Two other researchers reviewed the survey for content validity and logical construc- tion. Institutional approval to conduct the study was obtained. The surveys were administered to nurse leaders attending a statewide nursing conference using a paper method for gathering narrative, hand- written responses. Once the study was clearly ex- plained, the respondents provided consent and voluntarily completed the survey. Aside from indi- cating their employment position, no demographic information was gathered about the participants. The survey contained 4 questions: Interprofessional Organizational And Systems Leadership HW

1. What factors contribute to an adverse working relationship between nursing edu- cation and practice?

2. What are the most effective strategies for fostering civility in the practice setting?

3. What essential skills need to be taught in nurs- ing education to prepare students to foster ci- vility in the practice setting?

4. How can nursing education and practice work together to foster civility in the prac- tice setting?

The sample consisted of 174 nurse leaders: 68 (39.1%) nurse executives and 106 (60.9%) nurse managers who were attending a statewide conference held in a large western state. The respondents were recruited by the researcher (C.M.C.), who explained the purpose of the study during the keynote address. The surveys were collected and prepared for analysis.

Textual content analysis was used to manually analyze the respondents’ narrative responses. Key words or phrases were quantified by the researchers;

inferences were made about their meanings and cat- egorized into themes. Two members of the research team reviewed the nurse leaders’ comments indepen- dently to quantify the recurring responses and orga- nize them into themes. Then, 2 other research members reviewed the comments. Areas of theme agreement and disagreement were discussed, and verbatim com- ments were reviewed until all researchers were con- fident that the analysis was a valid representation of the comments.

Findings

Analyses of the narrative responses from the partici- pants were organized into themes, ranked in order of the number of responses, and described according to each research question. The first research ques- tion asked nurse leaders to identify factors that con- tribute to an adverse working relationship between nursing education and practice. Both groups identi- fied a noticeable gap between nurses in education and practice (Table 1). Nurse executives reported nurse educators failing to keep pace with practice changes, lacking familiarity with practice regulations and standards, being slow to respond with curricular changes, and a lack of shared goals between nurses in education and practice. Nurse managers reported similar findings, but suggested that a limited number of nursing faculty, a highly stressed work environ- ment, and lack of adequate resources also contributed to adverse working relationships. These reported defi- cits resulted in the perception that students were not being adequately prepared for practice.

The second research question asked the respon- dents to identify the most effective strategies for fos- tering civility in the practice setting. Nurse executives identified 4 major themes, and nurse managers iden- tified 7 themes, listed in Table 2. Strategies that ren- dered less than 10 responses are not listed in the table. For nurse executives, these themes included holding self and others accountable for acceptable behaviors, addressing incivility in nursing education programs, implementing stress reduction strategies, making ci- vility a requirement for hiring, and conducting in- stitutional assessments to measure incivility. Nurse managers’ responses to this question were similar to those of nurse executives. Notable differences between the 2 groups were nurse executives’ recommendations for civility teaching starting at the education level, civility as a requirement for hiring, and ongoing ci- vility assessment. Nurse managers’ responses differing from executives were establishing a healthy work en- vironment, ongoing practice-preparedness education, and reinforcing positive behavior. Interprofessional Organizational And Systems Leadership HW