Systems Perspective for Incivility in Academia

Systems Perspective for Incivility in Academia: An Integrative Review Ann M. Stalter, Janet M. Phillips, Jeanne S. Ruggiero, Carol M. Wiggs, Josette Brodhead, and Kathleen Swanson Abstract AIM The purpose of this integrative review was to identify evidence of systems thinking on civility in academic settings. BACKGROUND Incivility is present in academic systems, including nursing education. What is learned in academia translates to the workplace. Systems-based solutions may promote quality and safety in health care. METHOD Whittemore and Knafl’s integrative approach guided this study. RESULTS Forty-nine articles were reviewed. Themes emerged describing incivility in nursing as embedded within layers of a performance-driven, oppressive hostile bureaucracy, trickling down, instilling fear, and reinforcing uncivil behavior among and between members. Other themes defined faculty-to-faculty and faculty-to-student incivilities, reasons for it, reactions to it, and suggestions for improved civility. CONCLUSION The systems awareness model is offered as a means of promoting civility in nursing education. A lack of evidence to support how incivility in academia transfers to quality and safety in practice settings is identified as a gap for future study. KEY WORDS Academia – Faculty-to-Faculty – Incivility – Nursing – Systems Thinking F or nearly two decades, Gallup (2017) has recognized the nursing profession as possessing the “highest in ethics.” However, working in the nursing profession has a contrary reality: Incivility exists (Heinrich, 2017a). Incivility within nursing is especially evident among nurse educators working within academic settings (Clark, Olender, Kenski, & Cardoni, 2013). Members of the International Quality and Safety Education for Nurses Institute charged with advancing the science of systems thinking (ST) set out to explore literature relevant to incivility within academic settings. The rationale was to consider civility as a facilitating precursor for systems-based solutions that promote quality and safety in health care. The purpose of this About the Authors Ann M. Stalter, PhD, MEd, RN, is an associate professor, Wright State University Department of Nursing, Dayton, Ohio. Janet M. Phillips, PhD, RN, ANEF, is director, RN to BSN Degree Completion Option and a clinical associate professor, Indiana University School of Nursing, Indianapolis, Indiana. Jeanne S. Ruggiero, PhD, RN, CNE, is an associate professor, New Jersey City University Nursing Department, Jersey City, New Jersey. Carol M. Wiggs, PhD, RN, CNM, AHN-BC, is an associate professor, University of Texas Medical Branch School of Nursing, Galveston, Texas. Josette Brodhead, PhD, MSHS, RNC-MNN, CNE, is an assistant professor of nursing, Daemen College, Amherst, New York. Kathleen Swanson, DNP, RN, is an assistant professor, School of Nursing College of Health Professions, North Dakota State University, Fargo, North Dakota. For more information, contact Dr. Stalter at [email protected]. The authors have declared no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.neponline.net). Copyright © 2019 National League for Nursing doi: 10.1097/01.NEP.0000000000000466 144 May/June 2019 integrative review was to answer the question: “What is the evidence of ST on the study of civility in academic settings?” For the purpose of this study, several definitions were adopted. Theoretically, ST is defined as a method of analysis whereby forethought considers the interconnectedness of people, processes, and outcomes as they relate to an encompassing whole system (Stalter et al., 2016). Operationally, ST is defined as the awareness that one’s action can impact a whole organization (Dolansky & Moore, 2013). Incivility is defined as intended or nonintended, uncivil or rude and discourteous actions that, when experienced, have far reaching effects for the receivers/targets, bystanders, peers, stakeholders, and organizations (American Nurses Association, 2015b). Clark (2013) defined uncivil behaviors that exemplify incivility and proposed that, if left unattended, they can progress to hostility and violence. Hostility is defined as a state condition of ongoing opposition to a person or group that, when acted upon, results in violence (Kelly, 1969). Oppression is defined as a state whereby one has experienced unjust restrictions (mentally or physically) from persons of formal or informal authority (Dong & Temple, 2011). Academic settings are defined as institutions of higher learning that may or may not award nursing degrees. BACKGROUND Literature focusing on higher education provides historical and sociopolitical contexts for uncivil behavior on college campuses (Faucher, Cassidy, & Jackson, 2015), manifesting itself to advance free speech within a bureaucratic hierarchy (Hollis, 2012). Extensive research exists, exploring incivility within nursing education. Studies focus on individual and group-level data, heightening the awareness of incivility among administrators, faculty, staff nurses, graduate nurses, and nursing students (Altmiller, 2012; Clark, 2017; Luparell, 2011; Marchiondo, Marchiondo, & Lasiter, 2010). Systems perspectives are lacking. www.neponline.net Copyright © 2019 National League for Nursing. Unauthorized reproduction of this article is prohibited. Systems Perspective for Incivility Internationally, the World Health Organization (2009) identified ST as a means of improving and ensuring safe, quality care for the world’s population. In the US health care system, the need for systems research is crucial because an ongoing quality and safety crisis exists (National Patient Safety Foundation, 2015). The Institute of Medicine (1999) report To Err Is Human: Building a Safe Health System indicated that medical errors caused up to 98,000 preventable deaths. Today, medical errors are the third leading cause of US deaths (Makary & Daniel, 2016), contributing to an estimated 400,000 deaths annually (James, 2013). Error trends are associated with inadequate systems to improve safety (Emergency Care Research Institute, 2017). Seminal work by nurse educators indicates understanding system complexity is essential for safe practice (American Association of Colleges of Nursing, 2008; Orsolini-Hain, 2011; Quality and Safety Education for Nurses, 2014). Gaps linking ST education (Stalter, Phillips, & Dolansky, 2017) with practice partnerships may negatively impact quality and safety (Clark, 2017; Phillips et al., 2018). Incivility is associated with poor patient outcomes, such as patient falls, delayed care, medication and treatment errors, adverse events, patient mortality, altered thinking, communication inhibition, and patient complaints (Houck & Colbert, 2017). ST advances quality and safety in practice (Dolansky & Moore, 2013). If incivility disturbs quality and safety and is present in nursing education, evidence of how ST fosters civility in the academic preparation of health professionals must be identified to break error trends. METHOD Integrative review consists of empirical and nonempirical evidence used to fully understand the phenomenon that analyzed it serves a wide range of purposes, such as assessing research quality for the use of future study (Souza, Silva, & Carvallo, 2010). Whittemore and Knafl’s (2005) five-stage process for conducting an integrative review guided this study as it is the most current approach to integrative reviews for knowledge synthesis (Whittemore, Chao, Jang, Minges, & Park, 2014). Stage 1 establishes the purpose and research question. Stage 2 develops literature search strategies and inclusion/exclusion criteria. Stage 3 identifies data evaluation and results. Stage 4 describes data analysis and interpretation. Stage 5 presents findings in the form of a model. Databases used for the literature search included the Cumulative Index of Nursing and Allied Health (CINAHL) with full text, Academic Search Complete, PsychINFO, Educational Resources Information Center, ScienceDirect, and Google Scholar. Peer-reviewed articles published between January 1, 2000, and May 1, 2017, and written in English were included. Inclusion of expert opinion articles was justified if the research question was answered. MeSH terms were used to delimit results and advance the search. Key words (n = 12) used in the integrative review included faculty-to-faculty, academia, incivility, bullying, nursing, nurses, practice, health care, organizations, systems, systems thinking, and systems practice. Additional keywords uncovered in the search included lateral or horizontal violence, workplace harassment, and oppression. The terms incivility, bullying, lateral or horizontal violence, workplace harassment, and oppression were used interchangeably in the literature. For the purposes of inclusivity, the encompassing term incivility was used. See Supplemental Digital Content 1, available at http://links.lww.com/NEP/A123, for Figure that illustrates the process of article selection. Articles were placed Nursing Education Perspectives into an Internet warehouse with shared drive access so the authors could analyze the findings. RESULTS The 49 selected articles were grouped into four categories: general academic (n = 6), faculty-to-faculty (n = 22), faculty-to-student (n = 16), and systems (n = 5) and ST (n = 0). Categories were selected based on themes identified from abstract reviews. Of the 49 articles reviewed, 33 were research articles. The nonresearch articles (n = 16) consisted of scholarly crafted, theory-driven articles (n = 8), literature reviews (n = 3), a concept analysis, systematic reviews, and expert opinions (n = 3). Of the research articles, a mix of designs addressed incivility within academic settings among administrators, faculty, and students. Methods consisted of quantitative descriptive, correlational, or cross-sectional survey (n = 19), qualitative (n = 8), and mixed (n = 6). A variety of academic systems were studied, including private and public US universities with a combined sample of 8,545 administrators, faculty, and students affiliated within 112 programs awarding a variety of undergraduate nursing degrees (associate, baccalaureate, and RN-BSN). Data were obtained through survey and interview methods. The primary survey used was the Incivility in Nursing Education-Revised. Thematic and content analysis was used to analyze qualitative data. Research articles were rated for quality using the Mixed-Methods Assessment Tool (Chu, Ploeg, Wong, Blain, & McGilton, 2016). The three-part questionnaire was used to evaluate qualitative, quantitative, and/or mixed-method studies by a “yes (high quality)/no (low quality)” impression of quality. Quality criteria for qualitative studies included six questions related to a description of the research question, design/approach, study context and how findings relate to it, sample and justification for sampling, data collection and analysis processes, and reflexivity. Quality criteria for nonrandomized control quantitative studies included three questions related to a description of sampling and justification, measurements with reported validity and reliability, control for confounding variables when applicable, contingent on a response rate of 60 percent or greater. Quality criteria for mixed-method studies included three questions related to a description of a combination of qualitative and quantitative data collection techniques and data analysis procedures, justification for design, and the integration of qualitative findings and quantitative results (Chu et al., 2016). Two authors reviewed the studies and scored them using the Mixed-Methods Assessment Tool quality criteria. A third author served as an objective reviewer to discuss any scoring conflicts. Conflicts were resolved by consensus among all authors. Table 1 provides an overview of the high-quality research articles (n = 20 out of 49 selected articles) grouped into the four categories: general academic (n = 1), faculty-to-faculty (n = 9), faculty-to-student (n = 9), and ST (n = 1). (See Supplemental Digital Content 2, available at http://links.lww.com/NEP/A124.) General Academic Incivility From the entire list of all articles, findings revealed themes related to sociopolitical context, power and bullies, and oppression of immigrant and nursing faculty. SOCIOPOLITICAL CONTEXT Universities are nested within a societal infrastructure, funded through political agendas and bureaucratic policies. Permeating within the American social-academic culture are VOLUME 40 NUMBER 3 Copyright © 2019 National League for Nursing. Unauthorized reproduction of this article is prohibited. 145 Stalter et al the notions that a college education yields a pathway to both social and financial success and that system disruption provides opportunities for progression (Hughes, 2015). Uncivil behavior, extreme rudeness, or violence is ubiquitous in contemporary society and manifests itself on college campuses (Piotrowski & King, 2016). The guiding forces of social interaction within academic settings involve a mission to aim for excellence in teaching and scholarship. The purpose of scholarship is generation of new knowledge, procurement of competitive grants, and peer-reviewed dissemination (Cleary, Walter, Horsfall, & Jackson, 2013; Gheorghiu & Stephens, 2016). Uncivil behavior is experienced among academic scholars to advance personal sociopolitical agendas, such as with curriculum change (Lagemann, 2002). An example might be, instead of developing a course on interprofessional collaboration to improve health outcomes, modifying an entire curriculum for specialization in teamwork and collaboration without completing a community needs assessment. POWER AND BULLIES Consistent in the reviewed literature was the idea that uncivil behavior in the form of bullying was demonstrated to attain power, control, and influence over others (Peters, 2014; Peters & King, 2017). In academic settings, performance-driven reward is seen in promotion and tenure (P&T), a political process where the power to succeed is held by administration and senior faculty (Reed, 2016). Incivility is pervasive in higher education due to the pressures to meet P&T requirements and interpersonal aberrations of faculty (Piotrowski & King, 2016). Oppression is an ongoing issue within academia, as it serves to elevate many of those who have seniority or access to publications and grant dollars, while stripping victims of human dignity (Gheorghiu & Stephens, 2016). Yet, within the formal business of academia is an added pressure to secure tuition dollars through increased enrollment and preparing graduates for the workforce (Cleary et al., 2013). Reed (2016) described nontenured university faculty effects of incivility on emotional well-being. Faculty confirmed the predominant themes of fear and confusion. Fear was expressed in subthemes: job loss, physical/mental harm, the unknown, and loss of selfworth. Confusion sets in as participants attempted to determine answers to the questions: “Is it them? or Is it me?” (p. 123). Hughes (2015) and Reed (2016) studied incivility as a campuswide phenomenon and discovered the corporatizing of academic institutions has led to a competitive, enrollment-driven, self-promoting work environment. Academic leaders play a pivotal role in promoting a safe workplace, and if they do not have the skills to manage unprofessional behavior, the work environment can become toxic (Cleary et al., 2013). OPPRESSION OF IMMIGRANT AND NURSING FACULTY Another source of incivility in academia occurs with immigrant faculty members who experience incivility and use acculturation strategies to offset conflict in the workplace (Gheorghiu & Stephens, 2016). Foreignborn women faculty, for example, those from Asia, Columbia, and the Middle East, are especially prone to incivility. Incivility is related to gender (female), racial (nonwhite) and income inequality (<$90,000/year), years living in the United States (<18 years), with a nonleadership job position, and working in a research-oriented university (Gheorghiu & Stephens, 2016). Immigrant faculty often feel competition with colleagues, oppression, and a perceived threat of dignity, leading to obstacles for career success. Incivility in the academic setting, related to oppression, has been widely reported among nursing faculty (Clark, 2017). Nursing has been a leader in research related to faculty and student incivility, 146 May/June 2019 revealing that incivility is evident between faculty themselves and between faculty and students (Wright & Hill, 2015). Faculty-to-Faculty Incivility From the 22 articles reviewed in the faculty-to-faculty category, findings revealed prevalent themes: what faculty-to-faculty incivility is, reasons for it, reactions to it, and suggestions for improved civility. WHAT IS FACULTY-TO-FACULTY INCIVILITY? In a national study, Clark et al. (2013) defined characteristics of faculty-to-faculty incivility as berating, sabotaging, excluding, refusing, blaming, taking credit for the work of others, and disrupting meetings. In a concept analysis of incivility, Peters (2015) found the attributes as disrespectful, belittling, condescending, insolent, threatening, intimidating, and undermining. Resilience to incivility describes personal reaction, behaviors, observations, and strategies (Wieland & Beitz, 2015). Study findings indicate faculty-to-faculty incivility is a moderate to severe problem in nursing education (Clark et al., 2013), regardless of program type or faculty position (Amos, 2013) or faculty age (Ziefle, 2014). Beckmann, Cannella, and Wantland (2013) found 36 percent of surveyed faculty reported experiences of incivility. Senior faculty and administrators were identified as the perpetrators in 60 percent of the instances. Sills (2016) found 80 percent of nurse faculty (associate [ASN], baccalaureate [BSN], graduate) from 64 different programs reported incivility in their programs. REASONS FOR FACULTY-TO-FACULTY INCIVILITY Several qualitative studies explored aspects of the lived experience of incivility (Peters, 2014; Peters & King, 2017; Wieland & Beitz, 2015). Power imbalance and the lack of the formal leader’s ability to manage incivility were primary reasons for the phenomenon (Peters & King, 2017). Peters (2014) investigated novice faculty members’ experiences and identified possessiveness of territory from senior faculty and sensing a power struggle as commonalities. Heinrich (2007, 2017a, 2017b) explained that uncivil faculty work within groups to organize and alienate victims, thus strategizing to steal joy. She described mean games played by faculty and categorized them as joy stealing. Games included setup, devalue and distort, misrepresent and lie, shame, betrayal, broken boundaries, splitting, mandate, blame, and exclusion. Envy and jealousy precipitated faculty-to-faculty incivility due to demands for high productivity, intense competition for limited resources, preferences for particular assignments, and opportunities for promotions (Cleary, Walter, Halcomb, & Lopez, 2016). This has negative and positive implications. Negative implications include damaged relationships and the undermining of colleagues’ performance. However, jealousy and envy can stimulate healthy competition benefitting the organization when faculty cooperate with one another and share ambitious goals (Cleary et al., 2016; Heinrich, 2017a). REACTIONS TO FACULTY-TO-FACULTY INCIVILITY Candela, Gutierrez, and Keating (2013) identified that faculty having experienced incivility cope through avoidance, not speaking up, and having an increased intent to leave. Themes identified were rejection from colleagues, sensing that others wanted new faculty to fail, and struggling with a decision to remain in academia (Peters, 2014); consequences of incivility included decreased time spent at work and increased attrition (Peters, 2015). Other emergent themes included inappropriate faculty behaviors, consequences of faculty behaviors on administrative targets, and administrators’ call for action (LaSala, Wilson, & Sprunk. 2016). www.neponline.net Copyright © 2019 National League for Nursing. Unauthorized reproduction of this article is prohibited. Systems Perspective for Incivility SUGGESTIONS FOR IMPROVED FACULTY-TO-FACULTY CIVILITY Leaders can improve the academic environment by supporting faculty development, scholarly productivity, and application of teaching expertise. Empowering interprofessional teams with civility education through orientation programs and mentoring may help create supportive work environments (Wright & Hill, 2015). Academic environments harnessing the creativity and substantive diversity related to acculturation may bring about workplace civility solutions, especially among immigrant faculty (Gheorghiu & Stephens, 2016). Heinrich (2017a) suggested ways to avoid joy stealing through confrontation, shifting from competition to cooperation rules, and initiating a community of faculty-student scholars. Burger, Kramlich, Malitas, Page-Cutrara, and Whitfield-Harris (2014) proposed that bioethical, practice-based theory can facilitate decision-making during difficult interactions, sustaining a focus on central agreements foundational to nursing education. Faculty-to-Student Incivility Of the 16 articles selected in the faculty-to-student category, four prevalent themes were identified: what faculty-to-student incivility is, reasons for it, reactions to it, and suggestions for improved civility. WHAT IS FACULTY-TO-STUDENT INCIVILITY? Clark (2008) reported that students identified major themes regarding faculty uncivil behaviors, including faculty belittling students, treating students unfairly, and pressuring students to conform to unreasonable demands. Gallo (2012) reported that incivility can lead to a weakened learning environment, poor workforce behaviors, and violence. Of the articles reviewed, all nursing education programs were embedded within a university system. Incivility within nursing education is widespread among students, faculty, and administration (Clark, 2017). A culture of incivility within academia negatively impacts students, faculty, and leadership in a trickle-down effect whereby the most vulnerable are affected, that is, the students (Young, Anderson, & Stewart, 2015). Clark and Springer (2007) indicated both students and faculty perceived incivility as a problem inside and outside the classroom. Lasiter, Marchiondo, and Marchiondo (2012) reported four areas in which students experience incivility from faculty: 1) incivility in the presence of others, 2) talking about one student to others, 3) comments making the student feel stupid, and 4) comments making the student feel belittled. Goldberg, Beitz, Wieland, and Levine (2013) reported that students felt both physical and psychological effects of faculty-induced incivility. Vickous and Young (2015) described that BSN students perceived disruptive faculty behaviors (being late for class, arriving unprepared, or refusing to answer questions) as more discourteous than ASN counterparts. REASONS FOR FACULTY-TO-STUDENT INCIVILITY Clark and Springer (2010) studied the perspectives of leaders regarding incivility and reported stressors such as juggling multiple roles and meeting demands contributed to uncivil behavior. The authors also found that leaders (86 percent) are responsible for preventing and dealing with incivility. Goldberg et al. (2013) found that some leaders allowed incivility to occur because they did not have skills to manage perpetrators of incivility. Seibel (2014) described the complexity of incivility between both faculty and students. For example, faculty may not be knowledgeable about understanding their clinical role, and students may perceive they are not being respected by faculty. Wallace, Bourke, Tormoehlen, and Poe-Greskamp (2015) reported that students experience stress in the clinical setting when teacher behaviors Nursing Education Perspectives are perceived as confrontational, such as questioning everything the student does or correcting students in front of patients. They surmised that use of confrontation may be employed due to time constraints in the clinical setting. REACTIONS TO FACULTY-TO-STUDENT INCIVILITY Both online and traditional college students react to faculty-to-student incivility. For example, Byrnes (2015) found that as online faculty incivility (FI) increased, student satisfaction with the nursing program decreased. In another example, Alt and Itzkovich (2015) indicated that students reporting higher levels of exposure to uncivil faculty encounters in the classroom reported poorer adjustment to college life. Itzkovich and Alt (2016) found four student responses to FI: 1) Exit (E), whereby students voluntarily drop out of class/college; 2) Voice (V), whereby students complain to remedy the situation; 3) Loyalty (L), whereby students’ nonresponses show a willingness to endure unfavorable conditions; and 4) Neglect (N), whereby students either passively or actively manifest behaviors resulting in destructive interpersonal relations. Minority students are more exposed to FI and more inclined to elicit EVLN responses. Students who chose the exit response to FI were influenced by its severity. SUGGESTIONS FOR IMPROVED FACULTY-TO-STUDENT CIVILITY Clark (2017) used an evidence-based approach to integrate civility, professionalism, and ethical practice into nursing education, thus reinforcing student empowerment. Schools of nursing should establish ways for students to voice complaints of FI and promote a zero tolerance for FI (Itzkovich & Alt, 2016), allowing for safe teaching-learning environments and promoting positive personal and professional growth (Clark & Davis-Kenaly, 2011). Furthermore, students need education on how to cope with their poor performance, and academic policies need to be in place for student complaints (Seibel, 2014). Continuing education for faculty and students based on the American Nurses Association’s (2015a) Code of Ethics was proposed to improve civility in academia (Vickous & Young, 2015). For example, faculty need civility education, opportunities to share stressors, and support for good teaching practices. Faculty need to be role models with good clinical reasoning and conflict resolution skills that will help students manage their stress to be more competent care providers (Wallace et al., 2015). Finally, Itzkovich and Dolev (2017) recommended that classroom size be taken into consideration when preventing faculty-to-student incivility because of the impersonal, hierarchical, and temporary status of student-faculty relationships in large classrooms. Systems and ST From the five articles impacting academic systems, one article was identified; no articles were identified regarding incivility impacting ST in academic systems. Three themes emerged from the systems literature: trickle down and trickle across, hostile culture, and successful approaches to incivility management. TRICKLE DOWN AND TRICKLE ACROSS Mawritz, Mayer, Hoobler, Wayne, and Marinova (2012) tested a trickle-down model of supervisory abuse across managers, supervisors, and employees. Findings revealed that uncivil manager behavior led to employee incivility. Abusive, uncivil manager behavior trickles down two levels (Mawritz et al., 2012). Luparell (2011) explained that, although poor clinical outcomes were a result of practice setting incivility, resolution skills must transfer across academic to practice settings, beginning with school admission and ceasing with retirement. Young et al. (2015) propose the trickle-across perspective by defining how rankism in higher VOLUME 40 NUMBER 3 Copyright © 2019 National League for Nursing. Unauthorized reproduction of this article is prohibited. 147 Stalter et al Figure 1. Academia within Socio-political Context of Incivility and Uncivil Behavior. education is related to P&T as a trickling down of incivility through faculty to vulnerable student. From there, students translate the learned experiences to practice settings. HOSTILE CULTURE Mawritz et al. (2012) identified that hostile culture moderates uncivil supervisor and employee behavior, predicting that safety may be at risk within uncivil workplaces. Condon (2015) examined the impact of incivility in nursing education by studying historical and lived human experiences of victims. Intimate details of the betrayal and shame of human dignity and of the dishonoring of human worth resulting from the violating of human trust are associated with the ever-present existence of both horizontal and lateral violence within nursing academia. SUCCESSFUL APPROACHES Zero tolerance policies are recommended to help nurse educators begin honoring the living quality of developing professionals (Condon, 2015). Fischer (2017) recommended the use of transformational leaders as a solution to address incivility. Williams and Lauerer (2013) used Plan-Do-Study-Act to implement a nursing civility code among students. They proposed policies, shared governance, and arbitration of violations or grievances as best practice for integrating a civility improvement plan. Successful approaches describe a Just Culture or a safe systems approach intolerant of blame, gross negligence, willful violations, and/or destructive acts (Boysen, 2013). DISCUSSION The evidence related to the general academic category affirmed that incivility exists within a sociopolitical system and is based on power. This assertion is consistent with Neuman’s (1980) theory that a person’s interaction with his or her environment is based on layering inputs, throughputs, and outputs across groups, communities, and systems. Findings are also consistent with Stocum (2013), who described the race for research and prestige as the demise of higher education. Young et al. (2015) defined rankism in higher education related to P&T as a trickling down of incivility to vulnerable members. In some instances, suppression of scholarly contributions by powercentric groups penalize the credibility of advancing scholars (i.e., Figure 2. Social-Political Context of Civility in an Open Culture. 148 May/June 2019 www.neponline.net Copyright © 2019 National League for Nursing. Unauthorized reproduction of this article is prohibited. Systems Perspective for Incivility violations of academic integrity; Bretag, 2016). Mikaelian and Stanley (2016) described nursing as “doubly” oppressing due to gender bias within dysfunctional workplaces (p. 963). Figure 1 illustrates a systems perspective of incivility within academia. Systems evidence in academic settings is related to both facultyto-faculty and faculty-to-student categories. Findings are consistent with Clark’s (2017) work, which asserts that incivility in nursing education exists. The findings from this study expand the notion that relationships are the internal core of a macrosystem exhibiting dynamic patterns (Trbovich, 2014), mostly of bidirectional negentropy among administrators, faculty, and students. The potential for synergy exists through caring, respectful relationships within systems (Condon, 2015). Systems evidence related to faculty-to-faculty incivility reveals that reasons for and reactions to incivility are meshed within the system. Peters (2015) reported that workload and a greater degree of informality at work are identified system-level antecedents to incivility. Systems evidence related to faculty-to-student incivility shows incivility exists in many schools of nursing across the globe and in all educational levels (Johnson, 2009; Lasiter et al., 2012; Seibel, 2014; Vickous & Young, 2015). In the United States, Clark (2017) and Condon (2015) recommend zero tolerance policies and incivility education based on the American Nurses Association’s Code of Ethics. Several authors suggest the use of good teaching practices to prevent faculty-to-student incivility (Itzkovich & Alt, 2016; Lasiter et al., 2012, Seibel, 2014; Vickous & Young, 2015). From a ST perspective, of the literature reviewed, a culture of incivility existed in academic nursing departments/units. This is consistent with Peters’ (2014) findings that novice faculty sense power struggles, for example, possessiveness of territory from senior faculty. Many successful system approaches were identified to reduce incivility, such as empowerment through transformational leadership, quality improvement through Plan-Do-Study-Act (PDSA), and safety via a Just Culture. Nurses work in a dual system (academic and practice) where systems and ST approaches can be used to improve civility and patient safety (Stalter et al., 2017). A gap in the literature emerged regarding how incivility trickles across from academic to practice settings. The authors of this study propose the systems awareness model (SAM) be considered to advance civility in systems, bridging academia to practice. This proposed solution is aligned with Phillips, Stalter, Winegardner, Wiggs, and Jauch’s (2018) recommendations to employ SAM to intervene with incivility in practice settings, reinforcing civility as a facilitating precursor for systems-based solutions that promote quality and safety in health care (Stalter et al., 2017). The SAM’s seven-step process is an educational intervention framework offering a progressive awareness of ST. Educators use SAM to influence personal effort, reliance on authority, and critical reasoning and interdependences, culminating in the ability for nurses to lead in complex health care systems (Phillips, Stalter, Dolansky, & Lopez, 2016). SAM has been used in academia to advance ST across curricula to foster leadership in quality and safety (Phillips et al., 2016). It is aligned with the Systems Thinking Scale (Dolansky & Moore, 2013), which measures and evaluates nurses’ systemsrelated knowledge and skills, specific to quality and safety. Figure 2 integrates suggestions for improvement by addressing civility as a sociopolitical context, integrating empowerment, quality improvement, safety, and systems awareness into academia. Limitations of this review are that Level 1 studies (predictive or experimental) were lacking on incivility in education. Some articles may have been overlooked as only articles written in English were reviewed. Nursing Education Perspectives CONCLUSION This integrative review offers a system perspective on incivility, especially in nursing education. Two schematics depict the whole academic system and rippling effects of incivility between people and system layers. Common themes update the incivility literature. More research is needed related to 1) use of ST in academic settings (e.g., curriculum), 2) transference of incivility from academic to practice settings, 3) incivility and ST in practice settings, and 4) use of SAM as a substantive conceptual model in expanding a systembased practice competency to educate nurses on civility. Nurses should not be afraid to learn and work in academic settings because worldwide, professional nurses must be able to operate within cultures of civility to lead quality and safety in complex health care systems. REFERENCES Alt, D., & Itzkovich, Y. (2015). Adjustments to college and perceptions of faculty incivility. Current Psychology, 35, 657-666. Altmiller, G. (2012). Student perceptions of incivility in nursing education: Implications for educators. Nursing Education Perspectives, 33(1), 15-20. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. 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