There is a phenomenon of hostility among nurses and certified nursing assistants (CNAs), commonly referred to as “nurses eating their young.” This incivility is pervasive, often seen as a rite of passage, and directed at both peers and those at different levels in the organization. Those who demonstrate this hostility justify it by asserting that a nurse or CNA must be initiated through a trial by fire to be included in the facility’s team. Sadly, bullying has been the acceptable form of initiation for too long. This article will address incivility and its devastating effects and offer solutions to help leaders change this cultural norm to make facilities more welcoming and safer places to work.
Dr. Cynthia Clark, PhD, RN, ANEF, FAAN, an expert in fostering civility and healthy work environments, describes incivility as behaviors that are directed toward another person which are rude, disruptive, intimidating, and undesirable. These behaviors may be expressed in numerous ways. While some expressions are passive and subtle with an undercurrent of negativity, others are blatant displays of contempt.
All of the accounts of incivility in this article are real; however, we decided to keep the identities of the nursing professionals who disclosed these situations anonymous.
A CNA says, “I felt like I was getting picked on and singled out just because I wasn’t part of the group. It was like being the new kid at school. Nobody sat with me at lunch or cared how I was doing. They rolled their eyes at me and made rude comments when I asked a question.”
A night charge nurse relays, “The day charge nurse decided she didn’t like me and found every single thing I messed up. Instead of telling me about it, she reported it to the Director of Nursing Services. She never once offered to help me, and the Director of Nursing Services never called her on it.”
A RN consultant shared “I was a new LPN working five or six 12-hour night shifts a week while the other full-time nurse was out on medical leave. By the fourth week of this I was burning out. An RN offered to pick up a couple of the night shifts, but the DNS said she would rather I work them, since I was the ‘cheaper LPN.’ I enrolled in school to get my RN that fall.
These accounts are cringeworthy displays of incivility. The table below provides additional examples of uncivil behaviors.
|finding fault||unfair work assignments|
|sarcastic or condescending remarks||hostile or rude physical gestures|
|alienating and ignoring||withholding information|
|attacking and punishing||scapegoating or backstabbing|
|gossiping and spreading rumors||refusing to help|
Aren’t Nurses Supposed to Be Caring?
Care for others is the core tenet of the nursing profession—so it is counterintuitive to think of a nurse behaving in an opposite manner. In a study, Nancy Walrafen and colleagues found that the majority of nurses engaging in incivility were surprised that it was a form of hostility. Until participating in the study, some even felt justified in their actions because they believed they were being helpful by providing constructive criticism or upholding a standard of quality care. A major theme emerged in which nurses felt “caught up in the moment” and expressed “it’s just part of the culture.” After becoming aware of how these behaviors were perceived, many expressed sadness that their behavior violated their personal and professional ethics.
The lack of awareness that an individual’s behavior is hostile or uncivil is further perpetuated by groupthink. Psychology Today defines groupthink as a “phenomenon that occurs when a group of well-intentioned people makes irrational or non-optimal decisions spurred by the urge to conform or the belief that dissent is impossible.” One of the consequences of groupthink is a lack of personal responsibility; the individual feels less responsible since there are many people reinforcing the faulty reasoning, so the burden of responsibility is shared. When groupthink takes over a nursing team, the nurse or CNA who observes incivility becomes a silent witness because he or she does not speak out or intervene to stop the behavior. The person performing the behavior continues to do so, and the group accepts the behavior as part of the culture.
One CNA recalls “I was still a nurse aide, not even certified yet, and the CNA who was supposed to be training me left me alone to figure out how to take care of half the residents assigned to us while she was taking care of the other half. The charge nurse never said anything. I quit after I finished the shift, and no one even asked why.”
Effects of Incivility
Facility leaders across the nation are desperate to recruit staff, but those who continue to ignore the devastating effects of incivility will find it extremely difficult to retain the staff they are able to recruit. In addition to poor recruitment and retention, high turnover rates, job dissatisfaction, lack of engagement, and low morale are organizational effects in a culture where incivility is the norm (Samnani & Singh, 2016). In short, people do not want to work in a place where they are belittled, unwelcome, and alienated. With so much complexity in the field, nurses and CNAs who are new to the healthcare profession or to long-term and post-acute care (LTPAC) are especially susceptible to feeling insecure and incapable of caring for residents. If these feelings of insecurity are reinforced by incivility, they are at high risk of leaving the facility, or even the profession. In addition to the impact on the facility, individuals may experience stress that produces physical and psychological effects, such as feeling irritable, depressed, and anxious as well as increased susceptibility to illness, insomnia, hypertension, and weight gain or loss.
A nurse says, “I just got my nursing license, and it was my first day on the job. The nurse orienting me said, ‘Keep up because I don’t have time for you, and I hate having to do orientation.’ She told me this before even saying hello or asking my name. I instantly regretted taking the job.”
Create a Culture of Civility
People want to assimilate into a group and be part of something meaningful. Facility leadership must facilitate a culture where staff can assimilate in a healthy way. Because incivility has been a long-established practice in the nursing profession, there is much work to be done. Leaders can take the following actions to transform the culture from incivility to civility.
- Gain awareness of the depth and pervasiveness of incivility in your facility. To do this, observe interactions between staff, especially those between new and tenured staff.
- Have an open dialogue to discuss the issue. Note that before proceeding, staff will need to be comfortable to share openly and honestly and not be afraid of retribution. The following exploratory questions can facilitate the conversation:
o Have you or have you witnessed any staff members engage in uncivil behavior towards other staff members? Provide examples of incivility.
o Have you been on the receiving end of uncivil behaviors? How has this affected you? What can I do to help you?
- Model civility for all staff to follow.
- Provide education to all staff about what civil behaviors are expected, especially when welcoming and onboarding new staff. Also, provide examples of what behaviors are hostile or uncivil and will not be tolerated.
- Focus on creating an onboarding experience that is welcoming.
- Provide education on conflict management so staff know how to deal with conflict.
- When witnessing hostile or uncivil behaviors, speak one-on-one with the perpetrator, in a calm, non-threatening way. Address what took place and coach them through an alternative approach. See an example of a conversation between an RN unit nurse and a DNS below.
o Mary, DNS: “Sophia, thank you for meeting with me. You’ve been extremely busy today and I appreciate the extra effort it takes to orient a new nurse. How is it going?”
o Sophia, RN: “Mary, I am really busy today and that new nurse can’t keep up. She asked the dumbest questions. I don’t know what you’re going to do with her.”
o Mary, DNS: “It sounds like you’re frustrated. I noticed you rolled your eyes at her and told her to go sit down and you would deal with her later. What happened?”
o Sophia, RN: “Yeah, she just kept asking me about the medications and how to enter them into the computer. I told her a few times, but she just kept asking me stuff. It’s not that hard to figure out.”
o Mary, DNS: “Have you considered her level of experience compared to yours? You’ve been a nurse for five years and know the EHR very well. In fact, you’re so proficient, I count on you to teach our new nurses how to use the system.”
o Sophia, RN: “I didn’t realize that.”
o Mary, DNS: “I wish I would have made it clearer how talented you are and how much I depend on you to teach the EHR. We need to work together to help our new nurse learn the EHR and also feel welcome. We want her to stay and help us take care of our residents. I know you were frustrated, but eye rolling and ignoring her isn’t the solution. Have you considered how that made her feel?”
o Sophia, RN: “I didn’t even think about it, but I’m sure it hurt her feelings. I don’t want to be mean to her.”
o Mary, DNS: “You’re not a mean person, Sophia. How can you show her that and deal with the frustration better? What can I do to help you both?”
o Sophia, RN: “I’m going to apologize to her and let her know I just felt overwhelmed. I can teach her the EHR, but I need another four hours with her tomorrow afternoon.”
o Mary, DNS: “Thank you, Sophia. I’ll check in with both of you later today and again tomorrow to see how it’s going.”
Nurses and CNAs are caring, compassionate people who have a heart for others; help bring out the best in them. By transforming the culture from one where nurses eat their young to one of civility, you can empower nurses to care for and nurture each other.
Nickitas, D. (2014). Fostering Civility: An Interview with Cynthia Clark. Nursing Economic$, 32(6), 306-311.
Walrafen, N., Brewer, M. K., & Mulvenon, C. (2012). Sadly Caught Up in the Moment: An Exploration of Horizontal Violence. Nursing Economic$, 30(1), 6-12.
Samnani, A. & Singh, P. (2016). Workplace Bullying: Considering the Interaction Between Individual and Work Environment. Journal of Business Ethics, 139, 537–549.
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