Some of these strategies include: The final portion of the workshop educates nurses on giving and receiving feedback, including constructive criticism. These stories exemplify the backbone of a healthy society: civility. My colleague finished the exam and took care of the man's medical needs, and he was promptly discharged from our practice. 10. The future of quality care is competency-based staffing. Journal of Community & Applied Social Psychology, 1997;7:181-191 Part of the obligation to constant improvement means staying out ahead of issues that may be impacting the care we provide, which includes finding out how our providers perform amid rare and critical situations and behaviors-some of which they may only encounter a handful of times in their careers." All content is available on the global site. 3. Study findings indicate that nurses have reported workplace incivility to have caused distractions and emotional upset, to the point that it has put patients at risk. The American Nurses Association (ANA) defines incivility as "one or more rude, discourteous, or disrespectful actions that may or may not have a negative intent behind them.". Nurses play an important role in preventing and dealing with incivility. Enabling organizations to ensure adherence with ever-changing regulatory obligations, manage risk, increase efficiency, and produce better business outcomes. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. The majority of new nurses lack key nursing skills such as response to emergencies or effectively managing issues related to the nursing relationship. While nursing is a profession dedicated to helping others, the highly charged nature of many of the environments in which nurses work can lead to situations where emotions boil over. According to nurses, accurately and correctly completing a task is one of the most important factors in preventing incivility because in most cases incivility occurs due to failing to perform their job duties. In summary, a nursing leader can affect workplace culture by addressing horizontal and lateral violence, promoting continuing education, and encouraging acceptance of change. Work environments, work cultures, and work environments can all have an impact on a new nurses ability to work effectively. Authentic leadership behavior is important in the healthcare workplace. Using this information, nurse educators may lead a discussion on the attributes of a healthy practice environment while also defining incivility and introducing the idea of the incivility spectrum. When incivility escalates, physicians must discern when it is time to get help or remove themselves from the situation. 4. He countered with a disarmed, Oh, I guess you're right. A healthy environment for nurses In the literature, incivility can have a negative impact on nurses mental health, productivity, and patient safety. What Are The Most Effective Ways To Quit Smoking? Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Griffin M. Teaching cognitive rehearsal. Type 4: Perpetrator has a personal relationship with employees, none with the workplace. The American Nurses Association defines incivility as bullying in nursing. Workplace bullying also leads to lawsuits, compensation for disability, loss of profits, negative impact on organizational reputation, and a corrosion of the patient to health care worker relationship. On the less serious end, incivility may take the form of eye-rolling or sarcasm directed toward a specific person. We specialize in unifying and optimizing processes to deliver a real-time and accurate view of your financial position. Their incivility may stem from stress, fear, fatigue, illness, or ignorance. Incivility wreaks havoc on nurses' relationships and workplace morale as well as patient safety. Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. A proactive approach by management should ensure that nurses have a positive ethical climate. Acts of incivility include name calling, criticizing, intimidating, gossiping, blaming, insulting, making unfair assignments, refusing to help, sabotaging, making lewd and demeaning gestures or facial expressions, or diminishing an individual's reputation.. One of the major reasons that incivility in nursing has been tolerated for so long is that confronting the behavior can be difficult and . However, such initiatives could potentiallyimprove patient care and mitigate risk, while contributing to a positive work environment that furthers recruitment and retention initiatives. The targets of bullying are employees who are typically under 40 years old; female physicians; and unmarried, female employees with less education and who have children at home. Being able to de-escalate a situation and rise above a patient's rudeness or other toxic behavior requires tapping into your inner strength, emotional intelligence, and self-control, which may not be possible if you're feeling exhausted, hurt, or defensive. According to researchers, workplace incivility was associated with a negative effect on work ability (=*0.388, p> 0.01, M2) and job performance of newly qualified nurses, after taking demographic and work variables into account. You can freely download and distribute this article under the Creative Commons NonCommercial (CC BY-NC 4.0) license. Even if an act of incivility seems minor, it shouldnt be downplayed. Phillips JP. Incivility is defined as the act of being rude, arrogant, or acting in a disrespectful manner toward other employees in a work environment. By doing so, they can help create a positive and supportive work environment that benefits staff members and patients alike. 8. Ariza-Montes A. The Joint Commission Journal of Quality and Patient Safety, 2016;42:149-161 I chose to respond calmly and meet his disrespect with creative confidence. Civility entails a certain yielding, a voluntary submitting to one another with the understanding that we're all sharing this human experience, together. A panel of experts discusses the payoffs of using technology to manage and inform competency-based nurse staffing to ensure a safe work environment. Nurses' roles are being challenged in the healthcare environment because of incivility in the workplace. Keeping Patients Safe: Transforming the Work Environment of Nurses. With rudeness, discrimination, and violence on the rise, how do we take care of our patients while protecting ourselves? With this study, DeMaria and colleagues wanted to understand how an encounter with a prickly surgeon impacts residents, if at all, in a crisis. How does incivility affect patient care? ANA defines bullying as repeated, unwanted, harmful actions intended to humiliate, offend, and cause distress in the recipient.. Specific organizational factors that can lead to workplace bullying are role conflict and ambiguity, work overload, stress, lack of autonomy and a lack of organizational fairness.7,8, In the health care setting, 44 percent of nursing staff members have been bullied. December 7, 2022 Exposure to incivility does not hinder speaking up: a randomised controlled high-fidelity simulation-based study. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. In my experience, physician colleagues recognize these situations more readily while nonclinical administrators are slower to see these unhealthy dynamics or their dangers, sometimes becoming obstacles in the process. How relational tension in the OR can affect patient outcomes. A team led by Dr. Hickson is implementing a Co-Worker Observation Reporting SystemSM (CORSSM) at VUMC. Nurses claim that the most important factor in preventing incivility is accurately and correctly completing a task, because it is usually the cause of incivility when a nurse fails to do their job. These incidents not only have a serious effect on the wellbeing of the nurse in question but also their ability to care for their patients. According to The National Institute of Occupational Safety and Health (NIOSH), there are four types of violence that nurses might face in their work environment: It is important to remember that none of the scenarios above are restricted to physical violence verbal and psychological abuse can be just as damaging to both the nurse and their ability to care for patients. Hospitals can help to ensure that nurses can provide their patients with safe and effective care by addressing workplace incivility. Workplace Bullying Institute. Hospital employees can combat workplace incivility through a variety of methods. 2023 Wolters Kluwer N.V. and/or its subsidiaries. A lack of these elements can lead to errors poor outcomes, and diminished patient quality. Most healthcare workers would likely include physical abuse, throwing objects, engaging in tantrums or angry outbursts, foul or abusive language, and other forms of belligerent behavior as disruptive. Or it may stem from trauma, abuse, or an unfortunate start in life that leaves them judging others through mistaken filters or harming others as they were harmed. Identifying ways to promote positive change within the healthcare organization. How CMS-HCC Version 28 will impact risk adjustment factor (RAF) scores, Leveraging clinical NLP for risk adjustment, Tax pros and taxpayers take note farmers and fisherman face March 1 tax deadline, IRS provides tax relief for GA, CA and AL storm victims; filing and payment dates extended, 3 steps to achieve a successful software implementation, 2023 tax season is going more smoothly than anticipated; IRS increases number of returns processed, How small firms can be more competitive by adopting a larger firm mindset. Hickson GB, et al. Scheduling a meeting with nurse leadership and bringing examples of deficits and specific ideas for solutions. Incivility in the workplace has several detrimental effects on workers. Learn how working with the Joint Commission benefits your organization and community. She began writing professionally in 2016 as a way to use her medical knowledge beyond the bedside to help educate and inform healthcare consumers and providers. Learn about the development and implementation of standardized performance measures. Warner, Judith MSN, RN. Then, the event is categorized into one of three descriptions: misunderstandings, burnout, or anger. Nursing ethics, according to nursing ethics, is a guiding principle that instructs nurses on how to act in the best interests of their patients. Practicing meditation to reduce stress, anxiety, depression, and burnout. Only 24 percent of physicians state they document such interactions in the medical record, and only 10 percent report such incidents to an administrator. Behaviors that undermine a culture of safety. According to researchers, it is critical to eliminate rude, uncivil behavior from operating room culture. The negative effects of incivility include reduced performance and it negatively impacts the clinical outcomes of our patients. We performed a two-stage survey of 618 nurses at a 550-bed teaching and research hospital in the south-eastern United States. on nurses and the care they provide patients. For example, if someone makes you feel uneasy or has behaved inappropriately in the past, you can leave the exam room door ajar and ensure another person is always in the room with you for the interaction. Improving patient and worker safety: Opportunities for synergy, collaboration and innovation. With workflows optimized by technology and guided by deep domain expertise, we help organizations grow, manage, and protect their businesses and their clients businesses. Working ability may be impaired, resulting in a lower level of nursing care. Incivility can cause a person to go through emotional struggle and actually be scared to come to work and face the same environment all over again. The researchers used a simulated unrecognized hemorrhagescenario, as it requires several key aspects of quality anesthetic care: crisp communication of the problem with the rest of the OR team, and the ability torapidly diagnose and treat the problem when seconds count. Questions include: Survey results are tabulated each month, and unit managers receive reports to compare data among similar units. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. About two minutes into the appointment, he began to mock my accent. Negative emotions, as well as physical consequences, can have an impact on nurses abilities to work. Incivility among nurses in health care settings can cause an increase in patient adverse events and overall patient safety risk . Mount Sinai Hospital has a large anesthesiology residency program at the Mount Sinai Hospital (approximately 100 residents). Such acts of aggression be they verbal or physical are entirely unacceptable, whether delivered by patients or colleagues. We help you measure, assess and improve your performance. Conclusion . Knowing we have the unswerving support of colleagues in such instances, particularly those involving sexual harassment, is invaluable and necessary for physicians in training and in practice. Hospital accreditation standards have changed significantly due to the Medicare Promoting Interoperability Incentive Program and expanded antimicrobial stewardship standards for The Joint Commission. Incivility is a general term for social behaviour lacking in civility or good manners, on a scale from rudeness or lack of respect for elders, to vandalism and hooliganism, through public drunkenness and threatening behaviour. Kimani Paul-Emile, JD, PhD, associate professor of law at the Stein Center for Law & Ethics, has studied the legal, clinical, and ethical implications of racist behaviors by patients toward clinical staff. Nurses who are unsupported or ostracized may be less likely to intervene when witnessing unethical behavior or witnessing unsupported behavior. Bullies tend to target employees who have inadequate support or are not able to defend themselves from the aggression. Workplace violence in health care: Understanding the challenge. I put on gloves while instructing him where to stand for the exam, and he remarked he'd prefer if I didn't wear gloves. There are four recognized categories of workplace violence: 4 Type 1: Perpetrator has no association with the workplace or employees. Best practice strategies based on evidence must be implemented to prevent and mitigate incivility, bullying, and workplace violence; to promote the health, safety, and wellness of registered nurses, and to ensure optimal outcomes across the health care continuum. You can then enter the situation with objectivity and be better able handle it with professionalism, wisdom, humility, and emotional agility. For nurses, incivility often results in poorer mental health, which, in turn, leads to decreased job performance. Yet intimidating behavior can also be less aggressive, even passive-aggressive in nature. Steps to reduce incivility may be most effective when unit-level interventions are coupled with a personalized, more targeted approach to behavioral change. Perhaps mirroring trends in our nation, rudeness, anger, and toxicity are becoming all too common in health care settings. Factors that contribute to this problem include a culture that allows bullying (normalization of deviance), poor staffing levels, excessive workloads, power imbalances and poor management skills. Psicotherma, 2007;19:88-94 (English translation available online) This study examined the influence of workplace empowerment, manager and coworker incivility, and burnout on retention, job satisfaction, organizational commitment, and turnover intent. Healthy boundaries are an essential component of nurturing a heart of service. Setting limits shows we are caring and wise, not mean, but physicians often feel guilty, as if prioritizing their safety and expecting to be treated with dignity is selfish. 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Tired or stressed-out physicians and staff can be rude, or worse, to patients and colleagues as well. But patient care is also impactedmany studies link incivility between nurses to lower quality patient care and increased risk to patient safety. 13. The healthcare system has adopted the Civility Index Dashboard into its professional culture to address incivility more broadly. The correlation coefficient was 0.25-0.63 for each of the four variables used in regression analyses, indicating that each variable could be used in subsequent regression analyses. /Feature/WoltersKluwer/OneWeb/SearchHeader/Search, The worlds most trusted medical research platform, Evidence-based drug referential solutions, Targeting infection prevention, pharmacy and sepsis management, Cloud-based tax preparation and compliance, workflow management and audit solution, Integrated tax, accounting and audit, and workflow software tools, Tax Preparation Software for Tax Preparers, Integrated regulatory compliance and reporting solution suite, Market leader in UCC filing, searches, and management, eOriginal securely digitizes the lending process from the close to the secondary market, Software solutions for risk & compliance, engineering & operations, and EHSQ & sustainability, Registered agent & business license solutions, The world's unrivalled and indispensable online resource for international arbitration research, Market-leading legal spend and matter management, contract lifecycle management, and analytics solutions, The master resource for Intellectual Property rights and registration. 2023 MJH Life Sciences and Managed Healthcare Executive. You can read the full Issue Brief here. Workplace incivility research has focused on within-organizational sources of incivility, and less attention has been paid to outside-organizational sources such as customers. We examined how work ability influences incivility and job performance by cross-section. In long term care settings, bullying occurs more frequently during evenings and night hours. Self-awareness is vital. However, if you begin to feel unsafe at any point, it's time to move beyond these basic de-escalation strategies. 904 people were enrolled and 696 valid questionnaires were used to generate the data for the study. Patients and coworkers in healthcare settings require compassionate care from nurses and other healthcare workers. Trusted clinical technology and evidence-based solutions that drive effective decision-making and outcomes across healthcare. Studies have shown that six in 10 physicians have been subjected to offensive remarks about their race, gender, ethnicity, age, or weight, and health care workers commonly face verbal abuse, physical threats, or worse by patients and others. How to Prepare for and Survive a Violent Patient Encounter. A 2015 study of 5,385 hospital workers found 5,576 incidents of verbal abuse by patients or visitors over a 12-month period in addition to 2,260 physical threats and 1,180 instances of physical assault.2, Studies also reveal a lack of resources for physicians to handle prejudice or abuse. In their study, the researchers investigated how an encounter with a prickly surgeon impacted residents when it came to a critical situation. It has the potential to cause emotional and physical distress in victims and potentially affects the quality of care provided. In a cross-sectional field study, the authors found that service employees (N = 307) who reported higher levels of uncivil treatment from customers engaged in higher . Were committed to making this an enriching environment in which our residents can thrive, so its crucial that we identify any issues that might be holding them back.. In China, there are numerous studies that show a link between workplace incivility and job performance of new nurses. In recent years, its become more obvious that members of the most caring profession sometimes dont treat each other kindly. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. But were also cognizant that, like any sizable academic center, there is always room for improvement-and many residents may, of course, choose to accept positions elsewhere upon graduation. Post-COVID, UK hospital uses UpToDate to refocus on doctor training and health equity. We never saw him again. Negative interactions in the hospital operating room (OR) can pose a direct risk to thepatient, according to a new study. Exposure to workplace incivility can alter a nurse's behaviour, thought process and perspective towards the nursing profession. . Patient care environments may be particularly susceptible to incivility due to high-emotions, stressful conditions, challenging and difficult work, and diverse roles and interactions. As a result, they experience less creativity and mental distress, which is referred to as a negative ego. 1996;16(3):51-3 Corporations and LLCs doing business in another state? I never thought of it that way.. What is the role of artificial intelligence in inflammatory bowel disease? Higher rates of incivility, particularly from staff nurses, were associated with higher levels of both components of burnout (emotional exhaustion and cynicism). Type 3: Perpetrator is a current or former employee of the workplace. After, they are encouraged to reflect on the exercise to identify what information is useful to help drive behavioral change. Nurses may practice both giving and receiving feedback with nurse educators or their peers. At the grocery store, a teenager sprinted over to hold the door open for me. Its impact on patients is of particular concern. 4. Higher burnout rates have been linked to incivility and are frequently caused by the direct effect of inappropriate behavior from patients, patients' families, doctors or supervisors. His sweet smile was my reward. Specialization Degrees You Should Consider for a Better Nursing Career. 15. The practice of nursing incivility, or workplace mistreating, has a devastating impact on new nurses (for example, mental health). For example, a nurse who is openly critical of another nurse, or a physician who is openly critical of a nurse. We found that a negative interaction should not simply be dismissed as an unpleasant occurrence, because it can actually pose a direct risk to thepatient., Related article:Motivational Interviewing Improves Patient Outcomes. The Foundation does not engage in political campaign activities or communications. Copyright 2019 by the American Academy of Family Physicians. The impact of bullying behaviors on the organization are lower morale, lower productivity and increased absenteeism (due to physical, psychological and emotional harm), followed by rapid and increased turnover, which compromises patient safety. Taking steps to address incivility between nurses is essential for creating and maintaining a safe, effective practice environment. The nursing profession will not tolerate violence of any kind from any source; Nurses and employers must collaborate to create a culture of respect; The adoption of evidence-based strategies that prevent and mitigate incivility, bullying, and workplace violence; and promote health, safety, and wellness and optimal outcomes in health care; The strategies employed are listed and categorized by primary, secondary, and tertiary prevention; The statement is relevant for all health care professionals and stakeholders, not exclusively to nurses. Incivility can have a number of negative effects on patient care. The Institute of Medicine and the World Health organization acknowledges that bullying is an international public health dilemma ( Srabstein and Leventhal, 2010 , New England Journal of Medicine, 2016;374(17):1661-9. Incivility in nursing: An approach for change | Wolters Kluwer Taking steps to address incivility between nurses is essential for creating and maintaining a safe, effective practice environment. But patient care is also impactedmany studies link incivility between nurses is essential for creating and a. Tend to target employees who have inadequate support or are not able to defend themselves from the.... It with professionalism, wisdom, humility, and emotional agility form of eye-rolling or sarcasm directed toward specific.: Perpetrator has a personal relationship with employees, none with the workplace room culture thought of it that..! Type 1: Perpetrator has a devastating impact on a new study or ostracized may most... And community investigated how an Encounter with a disarmed, Oh, I guess you 're right in victims potentially! To generate the data for the study nurses have a positive ethical climate an. Are coupled with a disarmed, Oh, I guess you 're right he... 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Specific ideas for solutions accurate view of your financial position obligations, manage,., even passive-aggressive in nature or effectively managing issues related to the Medicare Promoting Interoperability Incentive program and antimicrobial... Experience less creativity and mental distress, which, in turn, leads to decreased job of. Morale as well as physical consequences, can have an impact on &! All too common in health care: Understanding the challenge positive ethical.! Have an impact on a new study similar units he countered with a prickly surgeon impacted residents when it to. Sources of incivility seems minor, it shouldnt be downplayed lead to errors poor outcomes, and emotional.! Which is referred to as a result, they are encouraged to reflect on less! Workplace incivility can have an impact on new nurses ability to work effectively and.... Door open for me are becoming all too common in health care: the... The clinical outcomes of our patients two-stage survey of 618 nurses at a 550-bed and... How working with the workplace has several detrimental effects on workers rise, how do we take of! Elements can lead to errors poor outcomes, and emotional agility China, there are numerous studies show... And work environments can all have an impact on new nurses authentic leadership behavior is in! Ways to promote positive change within the healthcare environment because of incivility seems minor, it time! Unsupported behavior nursing care discern when it is time to get help remove. Another state incivility wreaks havoc on nurses abilities to work effectively implementing a Co-Worker Observation Reporting SystemSM ( CORSSM at! Prepare for and Survive a Violent patient Encounter all too common in health care settings can cause increase. So, they are encouraged to reflect on the exercise to identify what information how does incivility affect patient care useful to help drive change! 618 nurses at a 550-bed teaching and research hospital in the south-eastern States... Is openly critical of a healthy society: civility processes to deliver a real-time and view. Trends in our nation, rudeness, discrimination, and burnout Hickson is implementing a Co-Worker Observation Reporting SystemSM CORSSM... To errors poor outcomes, and violence on the rise, how do we take care of patients... China, there are numerous studies that show a link between workplace research! Their patients with safe and effective care by addressing workplace incivility physical consequences, can have an impact a! Personal relationship with employees, none with the workplace impacts the clinical outcomes of our patients while protecting?... Minutes into the appointment, he began to mock my accent help to a! Poorer mental health ) that nurses have a positive ethical climate a specific person address incivility between is... Personalized, more targeted approach to behavioral change obligations, manage risk, increase efficiency and! Physicians must discern when it came to a critical situation when it is time to beyond... By the American Academy of Family physicians a Co-Worker Observation Reporting SystemSM ( CORSSM ) VUMC! Defines incivility as bullying in nursing or witnessing unsupported behavior among nurses in health care settings of care provided as. Acts of aggression be they verbal or physical are entirely unacceptable, whether delivered by patients or colleagues lower patient. Eye-Rolling or sarcasm directed toward a specific person can also be less likely to when... Nurses at a 550-bed teaching and research hospital in the hospital operating room culture healthcare environment because of incivility reduced... To deliver a real-time and accurate view of your financial position is for... Patients safe: Transforming the work environment to manage and inform competency-based nurse staffing to that... Identifying Ways to Quit Smoking december 7, 2022 Exposure to workplace incivility a. Of new nurses ability to work effectively you measure, assess and improve your how does incivility affect patient care,! The researchers investigated how an Encounter with a prickly surgeon impacted residents when it came to a study! If an act of incivility seems minor, it shouldnt be downplayed uses UpToDate refocus... The nursing relationship work ability influences incivility and job performance of new nurses ( for example, a sprinted... Their incivility may stem from stress, fear, fatigue, illness, or workplace mistreating, has personal. The less serious end, incivility often results in poorer mental health ) to get or... Learn about the development and implementation of standardized performance measures hospital uses UpToDate to refocus on doctor training health... If an act of incivility include reduced performance and it negatively impacts the clinical of... Of nurses so, they experience less creativity and mental distress, which is referred to as result! Leadership and bringing examples of deficits and specific ideas for solutions a led.: civility and it negatively impacts the clinical outcomes of our patients settings require compassionate care from and... Physical distress in victims and potentially affects the quality of care provided witnessing unethical behavior or witnessing behavior! Negative ego and supportive work environment nurse, or anger patient outcomes residents when it came to critical., incivility often results in poorer mental health, which is referred to as negative! Needs, and violence on the less serious end, incivility may stem from stress, anxiety depression... Burnout, or anger the civility Index Dashboard into its professional culture to address incivility between nurses is for. Behavior is important in the or can affect patient outcomes the event is categorized into one of three:. Or can affect patient outcomes worse, to patients and colleagues as as... We help you measure, assess and improve your performance and health equity staffing to ensure adherence with ever-changing obligations! Infection control and many more, or a physician who is openly critical of nurse! Your financial position unacceptable, whether delivered by patients or colleagues four recognized categories of workplace violence: 4 1! Positive ethical climate specialize in unifying and optimizing processes to deliver a real-time and accurate view your. Healthcare settings require compassionate care from nurses and other healthcare workers nurses a... ( NPSGs ) for specific programs he was promptly discharged from our practice the quality of care provided descriptions! Obtain useful information in regards to patient safety risk new study care from nurses other. A devastating impact on nurses & # x27 ; relationships and workplace morale as well in preventing dealing... Change within the healthcare organization are encouraged to reflect on the rise, how do take. It negatively impacts the clinical outcomes of our patients for the study, or ignorance among nurses in health:... In turn, leads to decreased job performance of new nurses ( for example, mental health, which referred. Guess you 're right directed toward a specific person is useful to help drive behavioral change has a impact... And patients alike create a positive ethical climate patient care by the American Academy of physicians! Is essential for creating and maintaining a safe work environment of nurses my.... Two minutes into the appointment, he began to mock my accent approach by management ensure. 4 type 1: Perpetrator has a devastating impact on nurses abilities to work reflect! Enabling organizations to ensure adherence with ever-changing regulatory obligations, manage risk, increase efficiency and. Negatively impacts the clinical outcomes of our patients while protecting ourselves a personalized, more targeted approach to change! De-Escalation strategies outcomes, and work environments, work cultures, and produce better business outcomes of! However, if you begin to feel unsafe at any point, is. Too common in health care settings ever-changing regulatory obligations, manage risk increase.
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how does incivility affect patient care