An older nurse rolls her eyes at a younger one and calls her an "idiot" behind her back. A frustrated eye surgeon pushes a female nurse and sends her flying. A frustrated nurse slaps a colleague. Sound familiar? Most of us know that we have an incivility problem in health care.

The journal Academic Medicine recently reported that 100% of the physicians interviewed in their study had witnessed or been personally affected by incivility. A Joint Commission survey in 2008 nurses found that 90% of nurses had witnessed workplace bullying — and 50% had been bullied themselves.

Friction between staffers and staffers and surgeons costs us big — in absenteeism, loss of productivity and turnover. Estimates are that nurse-on-nurse and surgeon-on-nurse bullying costs healthcare facilities upwards of $14,000 per employee per year — a staggering $4 billion annually in the aggregate. Worse, bullying affects outcomes. Incivility in health care has been linked to an alarming 71% of medical errors and to increased mortality in 27% of cases, according to a report in The Joint Commission Journal on Quality and Patient Safety. The OR is a particularly high-stress, high-risk environment, and the one place in health care where physician-on-nurse bullying is more common than the nurse-to-nurse variety.

Why can't we be nicer to one another? There are many reasons. One is that doctors and nurses learn very early on in their careers that toughness is a virtue. The barriers to entry in our field are high, and stress is endemic. To get into a practice or to work on a hospital floor, you must endure long, grueling years of training. When things get stressful and rushed, as they so often do in our field, senior staffers take out their frustrations on lower-level employees. The mentality is, "I survived it and now it's your turn." Too frequently the victims become perpetrators and the cycle starts anew.

Civility should be exemplified from the top down in every organization.

Incivility manifests differently depending on gender. Many men were raised with a "boys will be boys" attitude — they roughhoused on the playground in an environment of overt aggression. In women, generally, bullying is subtler. Many of us learned very early on to bully by excluding other girls. We see both forms of incivility manifesting in health care. A man may express anger by throwing something, whereas a woman may quietly backstab a colleague to peers. If you feel your facility may be suffering from incivility, it's critical to diagnose and solve it promptly or it could cost you.

Here are 10 tips to help your team start acting civil to one another.

If you suspect you may have an incivility issue, a great first step is to conduct a written or online anonymous survey of your staff. You will quickly identify the issues. I have created my own with Survey Monkey, but it may be wisest to work with your in-house or contract IT staff to build a secure one. You can adapt the Nursing and Civility Scale for these purposes; you don't need to use a branded tool to get the information you need.

There is a great starter questionnaire in Shelley Cohen's excellent "From Sheep to Lion: Confronting Nurse Bullying," in the July 2014 Nursing Management. She suggests asking staffers how frequently incidences like these occur:

• A coworker yelled at me in front of others.
• I was the source of gossip or rumors.
• I was purposely given a patient assignment others didn't want.
• I was blamed for something I didn't do.

In your survey data, look for subtleties. Cynthia Clark, PhD, RN, a behavioral nurse therapist and a leader in the field of creating healthy workplaces, likes to describe uncivil behavior as a continuum. Incivility can include such seemingly harmless actions as leaving emails unanswered, eye-rolling, cliques and gossiping, all the way up to consciously undermining a co-worker's reputation, verbal abuse, and outright physical violence. Keep in mind that even one or two people can have a significant impact on an entire unit. Sometimes terminating those people can make a huge difference in staff retention and sick out calls.

Every organization should have a clear explanation of the level of civility expected from employees, and the vast majority do. Even if yours doesn't, the American Nurses Association instructs us to "create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect." This code of conduct should clearly communicate the ramifications if the terms are violated, delineating the exact sequence of consequences for each infraction.

The trick is to get employees to adhere to the code. Aside from requiring every employee to read it, we find it's helpful to keep our team aware of the positive influence of civility and the negative consequences of its opposite. Engage an experienced HR staffer or a contracted seminar leader to conduct regular training, and post reminders of the code of conduct throughout your institution.

Every single staffer should establish a group of peers — or at least an individual co-worker — with whom they can talk out civility questions in confidence. Whether a nurse, technician or a physician, each team member needs someone to "bounce things off" when situations become stressful, whether they have been uncivil to someone else or when they've been on the receiving end. This type of trustful peer-to-peer dialogue can often defuse situations before they turn into crises.

Chris, a friend who works in my facility, is someone to whom I can tell anything and know that it will be kept completely confidential. Chris recently asked me about a confrontation I had with another staffer, "Do you think that was the right action to take in this situation?" After reflecting, I said, "No, I do not." Chris's feedback spurred me to go back to the person I treated poorly and say, "I should never have said that to you. I had concerns and I was frustrated, but that is no excuse for my behavior." These types of conversations almost always end up being productive. Every healthcare professional needs at least one peer to go to for honest, unvarnished, consequence-free feedback.

A 2011 study on improving physician-nurse relationships in Archives of Surgery showed that accountability is key to stemming physician-to-nurse incivility. When doctors or staff are held accountable for bullying behavior it sends a message to them, their colleagues and to staff that the institution will not tolerate it.

I was once in the OR with a pediatric surgeon performing open-heart surgery on an infant — clearly a stressful case. At one point, the surgeon became so frustrated that he threw a prep bottle across the room. After the operation was over, I told him, calmly, "If that bottle had struck me, I would have reported you to the police." He was flabbergasted and said that he hadn't thrown it at anyone; however, his action was intimidating and alarming to everyone in the OR. The possession of elite surgical skill does not excuse treating others inhumanely.

When an employee violates your code for the first time, have a casual chat with that person about why the actions were improper. Reassure the employee that the event will not go "on the record." Be empathetic and work with the staffer to solve any underlying problems that led to the incivility.

For me, a conversation might begin this way: "You know, Robin, when Christy suggested an idea to the committee meeting last week, you rolled your eyes. What was going on there?" Then I would try to have an honest discussion about how Robin might have handled the moment more productively, always reminding her that our common goal is always good patient care. Uncivil behavior does not help us achieve our goals and our mission.

Interestingly, bullies often have no awareness that they're bullying. In 2005, our facility experienced an influx of international nurses, and a group of female nurse bullies in the PICU began targeting this new group. One morning I encountered a couple nurses literally yelling about one of the international nurses. They complained that on the previous evening she had hummed to a baby who was in a low-stimulation environment. Ironically, they told me this story very loudly and angrily in the same room with the same baby present.

When an issue with an uncivil employee reaches a crisis level, there can often be a panic to invoke a zero-tolerance policy in order to correct it. However, institutional confusion about such policies is rampant. I was once consulting with an organization and someone in their education department told me, "We don't like to say, 'zero tolerance,' because that means that the first time you do it, you're out."

That's not how I see zero tolerance. To me, zero tolerance means that I am going to mentor you, I am going to cheer you on and lift you up, do the best that I can to help you live the values that our organization stands for. If you make a conscious effort not to align with that — you do things that lead to patient harm, staff burnout and the inability to retain employees — that's when zero tolerance leads to disciplinary action and termination.

If counseling has not been effective in curbing a staffer's incivility, it is often wise to recommend a leave of absence. In some cases, it's wise to require counseling during this leave. I know of one physician who was required to attend anger-management classes during his leave of absence, and I'm aware of a nurse who had to receive treatment for alcohol abuse. Leaves of absence can be remarkably successful. I have seen staffers and physicians return from leave with an entirely new outlook on life.

If none of the above is successful and damaging behavior continues, it may be time to let the employee go. Remember, no matter how high they are in the institutional hierarchy, no one is immune from consequences. Showing your team that bullying will not be tolerated is a net positive.

So often, physicians especially are recruited solely on the basis of where they went to school and who they trained with; seldom does their willingness and ability to collaborate with others come into the picture. Thoroughly assessing a potential hire's emotional maturity and respect for others will pay more dividends in the long run.

Organizations really need to invest time and money into training their employees at all levels. We need to teach nurses how to navigate difficult conversations with each other, management how to handle conflict on their units and executive-level administrators how to be respectful. Civility should be exemplified from the top down in every organization.

Ultimately, the solution to an incivility problem has to include a culture change. It really does have to be infused throughout the staff — not just teaching young nurses how to handle bullying, not just training surgeons how to channel their frustrations into productive conversations, but teaching whole organizations how to recognize the humanity in one another. The great reward of good behavior? Positive patient outcomes, reduced costs from bullying and the retention of a healthy, experienced team. OSM

Footnotes to this article can be found here.