Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review.

Background: Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim: To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources: Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results: Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions: Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations. Future work: Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations: This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration: This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a 'realist review', which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature ­ not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour.

Psychometric properties of the Incivility in Nursing Education - Revised Survey - Brazilian version.

OBJECTIVE: to analyze the psychometric properties of the Incivility in Nursing Education - Revised Survey - Brazilian version with undergraduate nursing students. METHOD: methodological study conducted in a nursing school in São Paulo state. It is the analysis of the psychometric properties (reliability and construct validity) of the items in the INE-R survey - Brazilian version. Construct validity was performed by Confirmatory Factor Analysis, and reliability by test-retest in order to verify the instrument's stability, as calculated by the Intraclass Correlation Coefficient and the Internal Consistency of the items according to Cronbach's alpha, ordinal alpha and McDonalds's omega coefficients. RESULTS: Confirmatory Factor Analysis fitted the proposed model with two factors (low and high incivility), with a suggestion to exclude one of student items. Most of the fitting values for the student items and all of the faculty-member items complied with the references established in the literature; the values for Internal Consistency Coefficients were greater than 0.80, and Intraclasss Correlation Coefficients were greater than 0.75. CONCLUSION: the Brazilian version of the Incivility in Nursing Education - Revised Survey is validated for the studied context, as it has shown satisfactory reliability and validity by means of factor analysis, which has confirmed the original two-factor model, with 23 items addressing student behaviors and 24 items applied to faculty behaviors. HIGHLIGHTS: (1) Incivility is a global and growing phenomenon in higher education.(2) An uncivil environment interferes with learning and health indicators.(3) A validated survey to measure incivility in nursing education is presented.

Educator-to-student incivility in online nursing education during COVID-19 as reported by nursing students: A descriptive cross-sectional study.

BACKGROUND: Educators' incivility in online nursing education is a serious academic issue; much of it is still unknown as it occurs in a less supervised environment. AIM: This study examined variables and differences in educator-to-student incivility in online nursing education during COVID-19, as reported by nursing students. METHODS: Utilizing the Incivility in Online Learning Environments (IOLE) online survey, a cross-sectional design was used to collect data in 2021 from a convenience sample of 163 nursing students studying in different universities in Jordan. Version 25 of the Statistical Package for the Social Sciences (SPSS) was used to generate descriptive and inferential statistics. RESULTS: As reported by nursing students, there was a low degree of incivility among nursing educators in online nursing education, 45(range 23-92), and a moderate frequency in the past 12 months, 63(range 23-92). Around 37.00 % of students thought incivility in online nursing education was a mild problem. On a scale of 0-100, 63.00 % of the students reported the level of nursing educators' civility in online nursing education ranged from 50.00 % to 70.00 % (an average of 60.00 %). Differences in students' reporting of online nursing educators' incivility and its' frequencies were significantly influenced by students' grade point averages (GPA) and genders, respectively. CONCLUSIONS: Although nursing students have a positive sense of civility among their nursing educators, incivility in online nursing education should be zero-level and disclosed and treated at its early signs.

Using Cognitive Rehearsal to Address Faculty Incivility in Nursing Academe.

BACKGROUND: Faculty-to-faculty incivility is a national and global problem. Recent studies examining faculty incivility in nursing academe found that respondents expressed emotional and physical distress stemming from workplace incivility, and most avoid dealing with the problem. A top strategy for improving workplace civility includes providing ongoing education to improve communication skills. PROBLEM: Faculty and academic nurse leaders require evidence-based strategies to prevent and address the range of uncivil behaviors occurring in academic work environments. APPROACH: Cognitive Rehearsal (CR) is a primary prevention and intervention communication strategy used to address incivility in health care and educational settings. Working with a skilled facilitator, participants practice addressing stressful situations in a non-threatening environment. This is the first known publication using CR to address faculty-to-faculty incivility. CONCLUSIONS: The author uses real-life situations derived from faculty-to-faculty incivility research studies and in-person conversations to describe each step of the CR process.

The antecedents, drivers and outcomes of employee family incivility in the workplace: A systematic review and future research avenues.

Family Incivility has emerged as an important construct that may impact the employee's mental wellbeing and thus affect various organizational outcomes including financial and market related outcomes. The construct however is nascent stage of scholarly research. Thus through a systematic literature review we organise the scholarship till date on the theories, contexts and methods used to explore the construct We also propose a unique framework for employee family incivility and its impact on workplace that identifies and maps the antecedents, drivers and outcomes of family incivility. These two contributions would help both scholars and practitioners in further development of theory and practice. The study follows the PRISMA method for literature review which is an established and rigorous protocol to minimise the errors and biases. That identified 34 articles for the review that were analysed and synthesised for the findings. The third unique and novel contribution of the study is the identification of specific future research questions with reference to employee family incivility and workplace, based on the analysis done in the review.

The relationship between faculty diversity and workplace civility in nursing education: A correlational analysis.

AIM: The aim of this study was to explore the relationship between faculty diversity and workplace civility in nursing programs. BACKGROUND: Diversity is needed in healthcare and in nursing education. A diverse workforce contributes to positive organizational culture and optimal learning environments for students and faculty in nursing programs. However, nursing faculty with diverse backgrounds often experience incivility more often than the rest of the population. Effects of incivility for all faculty can be detrimental and commonly include both physical and emotional symptoms. Civility encompasses respect for diversity and inclusion. It involves consistent, intentional acts to welcome and celebrate individual differences as well as different ways of thinking and acting. The relationship between level of faculty diversity and workplace civility has not previously been studied. Understanding this relationship will be an important step in increasing workplace civility in nursing education. DESIGN: Correlational design METHODS: Nursing faculty (n=528) from across the United States completed the Workplace Incivility/Civility Survey (WICS). Participants were grouped based on their self-reported level of faculty diversity at the nursing program where they were employed. Several questions from the WICS were analyzed to determine the experience and perceived incidence of incivility by the faculty participants. Descriptive statistics were used to calculate means and frequencies for the survey questions and Pearson correlation coefficient was calculated to determine if significant relationships existed between variables. RESULTS: A significant negative correlation was found between the level of faculty diversity and workplace incivility. As faculty diversity increased, workplace incivility decreased. CONCLUSIONS: Nursing programs with more diverse faculty tend to have lower levels of workplace incivility. Nursing program administrators should make every effort to diversify their faculty body.

Challenges of Incivility in Dental Practice and Education.

Professional collaboration is a key component of patient care and a source of fulfilment for oral health care providers. However, reports of incivility in employment as well as education are increasing impacting individuals in all settings including patients. Uncivil behavior implies a disregard for others and creates an atmosphere of disrespect, conflict, and stress. In contrast, civility towards others implies polite, respectful behavior towards others. This short report presents case studies in dental hygiene clinical practice and in dental hygiene education with strategies for approaching uncivil behavior.

Incivility, Mobbing, and Abusive Supervision: A Tripartite Scale Development Study.

Using qualitative and quantitative methodologies, in three consecutive studies with employed samples, we developed measures of workplace incivility, mobbing, and abusive supervision sensitive to the nuances of a non-Western context (i.e., Türkiye). In Study 1, we first conducted 15 focus groups (N = 149), identified culture-specific and universal themes underlying the focal mistreatment types, and developed the initial scales. We then pilot-tested (N = 427) and refined the scales using exploratory factor analytic procedures. In Study 2, confirmatory factor analyses (N range = 456-524) and associations between the new scales and their widely used counterparts (N = 353) yielded evidence for the construct validity of the scales. Study 2 also involved the development of short forms of relatively long incivility and abusive supervision scales. In Study 3 (N = 482), we first examined the extent to which the three scales were operationally distinct. Second, we examined the scales' ability to predict burnout and organizational commitment. Results supported operational distinctiveness as well as the criterion-related validity of the scales. A dominance analysis revealed that the three scales had equivalent contributions in explaining the two outcome variables, further justifying their distinctiveness. We argue that the use of present scales is not necessarily restricted to the Turkish context and may prove useful more broadly in other neo-traditional contexts.

Toxic work climates: An integrative review and development of a new construct and theoretical framework.

Research and the media demonstrate the profound impact hostile work environments have on organizations and their members. Often, the term "toxic work climate" is used to describe patterns of aggressive behaviors that harm individuals and manifest in the broader workplace. However, despite these common references, scholars still know relatively little about what a toxic work climate actually entails, the processes by which they emerge, and their influence on organizational outcomes. The research domain is complex. Within the organizational literature alone, toxic work climates have been described as those that harbor abusive bosses, aggressive employees, and those that show signs of bullying or incivility. Our aim in this integrative conceptual review is to add precision and focus to this multidisciplinary and fragmented literature. Grounding our efforts in multilevel theories, we first introduce an overarching definition of the toxic work climate construct and review research on existing hostile climate types that can appropriately be consolidated under this new heading. We then develop a new theoretical model that outlines the dominant causes and mechanisms by which toxic work climates form, and the main pathways by which they influence employees, teams, and organizations. Finally, we provide a unified path forward for advancing theory, research, and practice, including advice on how toxic climates might be combated in years to come. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Predicting frontline employees' emotional labor after suffering customer incivility: A job passion perspective.

The phenomenon of customer incivility poses significant challenges for frontline employees whose expression of emotion determines the service experience. Few studies have explored the mediating mechanisms linking customer incivility to frontline employees' emotional labor. Drawing on the dualistic model of job passion theory, we proposed job passion as a feasible mediator of the links from customer incivility to frontline employees' emotional labor. Using data from 1040 frontline employees across the retailing, banking, and hospitality sectors, the results indicate that job passion acts as the psychological mechanism underlying the relationships between customer incivility and frontline employees' emotional labor. Specifically, customer incivility is positively associated with frontline employees' surface acting through both obsessive passion and harmonious passion. Conversely, customer incivility is negatively linked with deep acting only through harmonious passion. Our findings clarify the psychological mechanisms through which customer incivility affects frontline employees' emotional labor from the perspective of job passion. Furthermore, the current study also extends the job passion model to the boundary-spanning context to explain how frontline employees respond to customer incivility. This study sheds light on how service practitioners can support frontline employees in dealing with customer incivility.

Nursing Student Perceptions of Incivility in Academia.

ABSTRACT: Compassion is an essential value held by the nursing profession, but many nurses demonstrate incivility that may originate from their experiences in nursing academia. The Incivility in Nursing Education-Revised tool was used at a community college nursing program to gain student perspectives on incivility. Watson's theory of human caring influenced this study. Participants were surveyed about types and frequencies of perceived faculty incivility. At least 77.8 percent of participants observed some degree of incivility in the program. No correlations between incivility and age or health care experience were identified.

Role of workplace bullying and workplace incivility for employee performance: Mediated-moderated mechanism.

Workplace events play a significant role in shaping the performance of employees and organizations. Negative events, in particular, require careful attention due to their severe impact on employee wellbeing and performance. Workplace bullying and incivility are two negative events that can cause significant harm to employees and contribute to poor performance. This study examines the effects of workplace bullying and incivility on employee performance in the presence of perceived psychological wellbeing (PWB), with the moderating role of perceived organizational support (POS) considered for both independent variables and employee performance (EP). The study focuses on female nurses working in the healthcare sector of Azad Jammu and Kashmir. The results of the study indicate that workplace bullying and incivility have adverse effects on employee performance and that PWB mediates these relationships. Moreover, perceived organizational support moderates the relationship between both predictors and the employee performance criterion. In conclusion, the findings of this study highlight the importance of creating a positive and supportive work environment to mitigate the negative effects of workplace bullying and incivility on employee performance.

"It is Essentially About Treating Each Other Well": Insights from Faculty on Incivility in Nursing Education.

STUDY BACKGROUND: Incivility in nursing educational institutions, which may be perpetrated by both students and faculty, is troubling given that such institutions have a mandate to prepare students for caring, relational nursing practice. PURPOSE: The purpose of this study was to contribute to understanding nursing academic incivility through an examination of nursing faculty's perspectives on student and faculty incivility. METHODS: The study was conducted using a mixed methods, descriptive, survey design with collection and analysis of quantitative and qualitative data. The sample consisted of 52 faculty members. RESULTS: A large majority of faculty thought that incivility in the nursing academic environment is a problem, with most considering it to be a mild or moderate problem. Students acted unprofessionally by showing disrespect, displaying superiority, engaging in disruptive behaviors, or not taking responsibility for their role in their learning. Faculty acted unprofessionally by showing disrespect, displaying superiority, or not being supportive. Faculty perceived that stress, personality, failure to deal with incivility, and an attitude of entitlement contributed to incivility. They thought that educational interventions, policies, and an academic environment that is conducive to civility are needed to address the problem. CONCLUSION: Until evidence is available to support the effectiveness of interventions for academic incivility, nursing educational institutions are encouraged to implement strategies suggested by faculty in this study.

Does adolescent incivility longitudinally predict future bullying?

INTRODUCTION: Adolescent bullying is a complicated behavior that is difficult to prevent. Understanding factors that predict bullying during adolescence can help us minimize such behavior. Classroom incivility is a low-level antisocial behavior that has been discussed in the literature as being a potential predictor of bullying in adolescence. Therefore, the goal of the present study was to examine the longitudinal link between classroom incivility and bullying. METHODS: Data for the current study was collected using quantitative surveys at two-time points, three years apart (November 2019 and November 2022) in southern Ontario, Canada. Our sample comprised 349 adolescents (51.3% boys, 46.4% girls, 0.6% other, and 1.7% preferred not to say) between the ages of 9 and 14 years old (M = 11.92 years; SD = 1.42). We utilized cross-lagged analyses to examine the stability of classroom incivility in adolescence, and the longitudinal association between classroom incivility and bullying. RESULTS: Classroom incivility at Time 1 predicted bullying behavior at Time 2, while bullying at Time 1 did not predict classroom incivility at Time 2. Our results not only support the stability of levels of classroom incivility across time, but also provide empirical support for classroom incivility as a precursor to bullying behavior. CONCLUSION: Our study suggests that classroom incivility can not only negatively impact the learning environment but may also be implicated in contributing to the circumstances that promote bullying behavior in adolescence, highlighting the importance of limiting uncivil behavior before it escalates into more severe forms of behavior.

Incivility in the Online and Hybrid Learning Environment During the COVID-19 Pandemic Era.

ABSTRACT: With the surge in online learning since the onset of the COVID-19 pandemic, fostering civil behavior in this environment is essential. This mixed-methods study examined online incivility among faculty and students at two schools of nursing using a quantitative survey instrument with several open-ended questions addressing the impact of the pandemic. Survey results suggested that faculty ( n = 23) and students ( n = 74) experienced a low frequency of online incivility that remained potentially disruptive. Qualitative analyses suggested that the pandemic placed considerable strain on nursing faculty and students while providing increased flexibility for working and learning.