The presence of incivility is not new to medicine, and certainly not foreign to us in the NICU environment. Over the past two decades, I have seen several situations develop in different institutions that create an environment where it is uncomfortable, threatening, or unsafe to conduct oneself fluidly as part of a highly functioning team. Incivility can arise simply from people choosing to disregard or disrespect one another’s opinions, or it can manifest more blatantly in the form of harsh public criticism or the deliberate dissemination of misinformation that deteriorates trust levels.
Each time these situations arise, I wonder, “How did we end up here? What could have been done to prevent this?” and, “Is there something special about healthcare that puts individuals at a higher risk of being hurt or slighted by others who choose to be harsh, condescending, or behaviorally inappropriate? Is it that we are just seeing more incivility across society?”
Through social media, we witness a significant amount of cyberbullying on a daily basis in tones and flavors that is otherwise not tolerated. Could it be that social trends are transferring over to the clinical arena? It certainly does not help that some public figures put on an open display of unrepentant bullying, bigotry, and misogyny, all the while drawing large public crowds of support.
The NICU is a special environment in part because of its physical space. Most NICUs are isolated within an adult hospital, making it very natural for the NICU “village” and its culture to be quite different from the rest of the hospital.
This insular existence can be positive, as it brings a sense of closeness that encourages familial behavior. Many of our NICUs, including my own unit, closely replicate the ideal village size of about 150 people (see Malcolm Gladwell’s The Tipping Point). As a village, however, the NICU may be particularly prone to being overly sensitive to different degrees of incivility.
In a close space or in the functional intimacy of the NICU village we may, at times, feel it is challenging to separate familial from professional behaviors. Later this fall, my NICU will leave behind a part of the “old school” NICU design where everything happens in one or two large rooms filled with infant beds. This physical arrangement allows for rapid and direct communication, quick situational awareness of acute events occurring in the unit, and a close physical proximity to one other that encourages the mentoring of younger staff. This physical closeness, however, can generate a certain claustrophobia, not unlike the feeling one experiences after spending too much time with one’s family.
Working in a high stress environment where caregivers’ disposition is to care for infants and families can often lead to the internalization of daily frustrations. Professionalism entails being able to act out a dignified role without buckling to the emotional pressures that are potentially triggered in casual conversations. Nevertheless it can be difficult to prevent the negative stories that come from witnessing or experiencing acts of poor behavior or incivility. News travels quickly in the small NICU village, whether it be positive or negative. Therefore it does not take many negative events before a degree of toxicity permeates the entire village. When one feels the pain, so too does the entire village.
By nature, neonatal care providers care a lot, perhaps too much at times. Caring is part of the DNA of neonatal healthcare provider, especially when it comes to NICU nurses. Taking care of babies brings out the maternal/paternal side in caregivers. Nurses pour out their heart to care for their babies and treat these precious infants often as if they were their own.
Parents forgive easily and sacrifice many things for their child’s well-being. So when a baby blows out more stool than one can imagine, and the entire bed and surrounding environment needs a wipe down, there are only forgiving caregivers cleaning up the mess. But being so sensitive and vulnerable towards your patients, who are the most vulnerable and fragile, may equally sensitize you to react quickly to negative or harsh words or behavior.
Herein lies the challenge of caregivers: to care, but also be resilient to negative behavior or communication. How can we defend ourselves against the emergence or perpetuation of toxicity in our unit? The wrong direction would be to care less, as building up walls of defense and internalizing suffering will not drive towards the creation of a better culture.
So, I look forward to the move of our NICU to a single patient room design later this fall as we will be challenged to take our thriving village culture and regrow it in a completely different physical space. This will be a true test of the strength of our special village, but also an opportunity to embolden new ways of preserving the resilience of a positive culture.
I leave you with some considerations that might help foster and sustain a positive culture to work in:
Take care of yourself first. Make sure that you are in command of your health and well-being. Situations only amplify when one is tired, hungry, or emotionally drained.
Control the negative stories. Commit to taking gossip out of your unit culture.
Develop an open culture of speaking up without reprisals when you have concerns.
Pay it forward. Doing something good or thoughtful for another member of the team is infectious.
Build on strengths rather than dwelling on weaknesses, as emphasis on the negative far too easily takes over the narrative, and only reinforces people’s powerlessness and frustration.
Make everyone accountable for their actions and words. Foster a zero tolerance for incivility in your village. People should not be allowed to behave badly repeatedly and get away with it. It is when we tolerate it that incivility can grow.
Put the patients first. If we discuss matters with that at the center of the table, great things can happen and the proper focus can take place professionally.
Share your experience! Use the comments section below to share your own stories, especially the positive ways you addressed workplace negativity.