Incivility: An Invisible Force Behind Nurse Burnout

The Invisible Contributor to Nurse Burnout

Burnout. It's the word used to describe the cumulative stress burden of nursing. But it doesn't even come close to capturing the strange exhaustion, disconnect and numbness from the work that used to bring so much joy and meaning. Solutions often revolve around appropriate staffing ratios or providing adequate support and resources. Improvement in these realms is essential, but is that really all that is contributing to burnout for nurses? If I'm honest with myself, there's another source of burnout that drains my professional battery that has nothing to do with patient care, and has everything to do with my colleagues. It's called incivility. Other names include lateral violence, horizontal violence or nurse-on-nurse hostility. A literature review identified that the prevalence of workplace incivility among peers is 75%-90.4%, specifically highlighting that bullying is a predictive factor for burnout. Enough is enough! We must break this cycle of generational nurse abuse.

What Incivility Looks Like in Nursing

"Aren't you a nurse?" I felt a sense of calm pride well up in my gut as I applied pressure to her sliced finger. It was spring 2023, and a group of us had gathered to celebrate a bride-to-be. As we were preparing strawberries for a charcuterie board brunch, the knife slipped and her skin split. In moments with family or new friends when our expertise as nurses is called upon, this question prompts a sense of honor and respect.

"Aren't you a nurse?" I felt a sense of embarrassment as my face reddened and my stomach turned. It was winter 2023, as the rapid response team gathered around a decompensating patient. We were asked to give an infusion of an unfamiliar, high-risk medication, and my questions about safety and processes resulted in the questioning of my clinical competence. In moments with clinical colleagues, this question - this nurse-to-nurse incivility - prompts self-doubt and distrust, and puts patient safety at risk.

Emotional and Professional Impact on Nurses

After that winter night shift in 2023, I dreaded running into the nurse who questioned my clinical competence in front of respiratory therapists, attending physicians, and a patient and her family. After working as a nurse for over a decade, I've had several moments with colleagues that prompted a silent drive home. I'm not quite sure if I turned right or left at the highway exit, or if there was music playing in the car - because the thoughts in my head were so loud as I replayed the incident over and over again in my mind. Here's the impact on us as humans after moments of professional incivility:

• Calling out sick from work, directly affecting attendance and pay
• Intentionally altering schedules to avoid working with a particular person or a group of people, affecting team dynamics and work-life balance
• Not asking questions, avoiding reaching out for help, or not escalating concerns out of fear that competence will be questioned. This response compromises patient safety and can subsequently result in moral distress.

Why Incivility Is Hard to Identify and Address

Incivility is so difficult to address, because it's often ambiguous. Usually, it's not egregious yelling or throwing things. That behavior, although disturbing, feels easy to identify and report.

Subtle Behaviors That Undermine Team Culture

It's the eyeroll or the lack of eye contact during handoff. It's the long sigh or tone of voice over the phone. Or, in the example above, it's the loaded question in a calm voice meant to shame someone in front of a group of people.

The Role of High‑Acuity Environments in Nurse-to-Nurse Incivility

Literature identifies that the more specialized the care being provided, the higher the rate of incivility. Let that sink in. Take a quick scan of open positions at healthcare organizations near you. Recruiters are constantly looking for nurses in emergency departments and intensive care units, often with sign-on bonuses and incentives. Why? There's no doubt it's because the work is difficult, and the level of expertise required is rare. But there could be another layer - these departments are highly specialized; they are at the highest risk for incivility.

In specialized departments, we take pride in knowing our jobs well, being clinical experts, and being able to intervene to save lives. These departments often require a higher level of collaboration with different subspecialties simply because of the complexity of the patients. This collision of pride, expertise and opinions is fertile soil for the weeds of incivility to take root if there aren't professionals who are empowered to address it.

How Nurse‑to‑Nurse Incivility Affects Patient Care

Let's break down this experience:

You are giving a handoff to the oncoming nurse. As you are sharing details about an extremely busy patient and the care they need, the nurse won't make eye contact with you. They let out a loud sigh and full eyeroll when you mention a task you weren't able to complete on your shift.

Effects on Safety, Communication and Moral Distress

As you're walking into the room together to visualize your patient, your head is spinning - are they frustrated with me? I didn't have time to complete that task, but should I stay over to do it? Maybe they're just having a bad day? This is so awkward.

As you drive home, you continue to replay the scenario over and over. You're back in 12 hours and have to see that same nurse again. You initially have trouble falling asleep, but eventually your thoughts settle and you drift off. On your drive back in, you dread seeing them again. You convince yourself it wasn't that bad... they were probably just having a bad day. Their behavior had nothing to do with you. You pretend the handoff 12 hours prior didn't happen. "How did our patient do today?" you ask, with a halfhearted smile.

Feel all-too familiar?

Real‑World Scenarios of Incivility in Clinical Settings

Next time this scenario plays out, try these three tips instead:

• 1Timing Matters in Difficult Interactions

  Address the situation sooner rather than later, as there is often an emotional or even a physical toll in waiting. If you are able to stay kind and curious, the best time to say something is immediately after incivility is perceived. It allows for clarification of details, context, expectations, emotions and/or behaviors. It will also decrease the overprocessing post-event, trying to make sense of what happened. It also prevents our tendency to discuss moments like this one with other colleagues instead of the individuals involved, which often contributes to larger departmental incivility issues. Some examples of how to address incivility in the moment are in AACN's Voices in Nursing podcast episode 10 "From Bullying to Belonging: Changing Nursing Culture."

• 2Naming Behaviors Instead of Emotions

  In the example above, as you feel tensions rising at the station, you may try to address it by saying, "You seem frustrated." The problem with this reply is that we are assigning emotions to someone's behavior - which may or may not be correct. They could respond, "No, I'm not frustrated at all," leaving the conversation at a dead end. They could be angry, annoyed, exhausted or disappointed - but not frustrated. A better reply would be, "I noticed you rolled your eyes and sighed - can we talk about it?" People can argue what emotion they're feeling, but naming a behavior allows those involved to engage in what actually happened and then name their emotions themselves. It can also bring awareness to some habitual behaviors people may not be aware of and the impact on others.

• 3Why Silence Undermines a Healthy Work Environment

  Not saying anything is your stamp of approval that these behaviors will continue to be tolerated. While it's tempting to avoid potentially awkward conversations by being nice, assuming there was a lack of sleep, or excusing behaviors because of likely external life stressors - this is how we wind up working alongside nurses who are known in their departments for being particularly uncivil... for years. And at that point, since it's been going on for so long, not only do people not feel empowered to address it, but they make excuses and say, "you know... that's just how they are." Be courageous, be curious and say something.

Building a Culture That Prevents Nurse Burnout in Critical Care Settings

We can't control the behaviors of others, but we can control what we will tolerate as individuals, as organizations and as a profession. We need to create the type of work environment that enables nurses to provide the highest level of patient care while finding joy and fulfillment in their work.

Skilled Communication as a Core Competency

Skilled communication requires us to create healthy work environments where nurses work as a team, support each other and communicate respectfully.

Leadership's Role in Reinforcing Civility

Nursing is known for being the most trusted profession. Let's make it known for being the kindest.

Are you ready to be courageous and use skilled communication to challenge incivility?