Studies have shown that between 10% and 20% of workers report witnessing incivility and microaggressions daily, while 20% to 50% affirmed that they have been the direct target of such types of mistreatments in their workplace.1 What is incivility? What are microaggressions?

Civility is formal politeness, kindness, good manners, courtesy in speech or behavior, and being respectful even if you do not like the person very much. Civility includes treating others with dignity, respect, and consideration.2 It is the way most of us would like to be treated. On the other hand, incivility is low-intensity deviant behavior with the ambiguous intent to harm the target, in violation of workplace norms for mutual respect.1,3,4 Having work assigned unjustly, disrespect, rude behaviors, having judgments questioned, rationalizing aggression (they deserved it), social manipulation, insulting comments, aggressive behaviors, withholding information, sabotage, and failure to respect privacy are also examples of incivility.4 These mistreatments and rude behaviors have been observed between co-workers, staff and patients, staff and patients' families, students and faculty, faculty and students, all peoples across the gamete as well as across the globe, and unfortunately the neonatal intensive care unit (NICU) is not immune to this behavior.

Microaggressions are comments or behaviors that insult an individual, whether intentional or unintentional. These behaviors and comments communicate hostile, derogatory, or negative attitudes or create environments that stigmatize culturally marginalized groups. Brief everyday exchanges that send denigrating messages, physical intimidation, and insults to certain individuals because of their group membership (gender, culture, and race) are all examples of microaggressions. The persons making the comments may be unaware of the impact of their words or actions. However, these behaviors have negative impact on the recipients.4,5

How many times have you or someone you know made jokes referring to a cultural stereotype or assumption related to race, economic status, gender, culture, religion or because they are different from you? Have you ever treated your patient differently because of something in their background (sexually transmitted disease, and substance use disorder), or because of where they were from or the way they looked, such as they were unkept, or had on the wrong clothes? Have you ever threated someone, been suspicious of or responded to a patient slower because of their race, culture, gender? How many times have you or a colleague made inappropriate comments regarding a patient's situation? If yes then you have engaged in microaggressions.

Did you ever provided a suggestion or present an idea at work only to be told later not to discuss issues related to your work area with others or to keep your mouth shut? Have you ever been threatened that if the numbers/situation does not improve/resolve that “someone is going to lose their job and it won't be me”? Have you ever asked someone where they were from because they were different from you? How many times have you or someone you know made jokes referring to a cultural stereotype or assumption related to race, economic status, gender, culture, religion or because they are different from you? Have you ever held your purse or bag tighter because someone from a different culture/race walked near you? Have you ever told someone who was going through a challenging time to “man up”? Often these types of comments and behaviors seem to slip out and we may not even realize it. Many of us have been the targets these types of comments and behaviors.

Incivility leads to stress and stress leads to incivility. The cycle of uncivil behaviors and stressors lead to negative health consequences and harm one's self-image, decrease self-esteem, self-confidence, self-efficacy, and well-being1 and lead to depression, anxiety, and trauma.6 Microaggressions and incivility have both been linked to headaches, hypertension, sleep difficulties, posttraumatic stress disorder, and burnout. A negative career impact has been documented in employees subjected to this this type of mistreatment including leaving the workplace or even the nursing profession.5–7 The effects of incivility and microaggressions are cumulative and the recipients of incivility and microaggressions often experience ambiguity, which may lead them to dismiss the event and blame themselves as being overly sensitive.4 A higher rate of stress, burnout, lower job performance, theft, and misuse of time and resources has been seen in those who have engaged in uncivil behaviors.5,6 Further impacts of incivility and microaggressions are a reduction in cognitive ability in the recipient, and an increase in diagnostic errors and procedural errors when rudeness was present in the clinical area has also been demonstrated.6

According to a study by Vargas et al,8 patients have reported witnessing hospital staff treating patients and their families with uncivilities and/or microaggressions. A few examples from this study are as follows:

Talking to family members like they were children. Ordering patients/families around. Patients being given conflicting information from the nurse and doctor. Patients requesting that instructions be repeated and the staff stating I do not have time. Statements linked to a person's social identity, social position, or condition.

Patients, feeling they were the victims of microaggressions and incivility, felt anxious dealing with staff, which may prevent a patient from asking for help or reporting a symptom; other studies showed recipients left hospital settings in the middle of treatment, never to return to healthcare again.9 It is important to remember that we are meeting families on what could be characterized as their worst day. Please consider: How do you act on your worse day? Are you more difficult or anxious on your worse day? We need to give families in the NICU grace it is their worst day. Stigmatizing them does not make their worst day better.

Strategies to improve work environments are essential because the long-term consequences of incivility and microaggressions can lead to psychological and physical issues as well as increased patient care errors. What do we need to do? Do you feel equipped to speak up when someone has treated you with or you have witnessed incivility or microaggression? We each need to step up and educate ourselves and others regarding microaggressions and incivility. Counseling needs to be readily available and offered to those who have been the recipients of these behaviors and to the those that have displayed the behaviors.1 We need to create an atmosphere where incivility and microaggressions are discouraged—by creating inclusive, welcoming, and healthy workplaces, which combat microaggressions and incivility. Understand how microaggressions show up and how to respond productively.6 Be aware of your biases, self-reflect. Reflect on how your statements and actions may be impacting others. Be thoughtful about common phrases. Instead of “man up,” “rise to the occasion,” work to unlearn language and actions that are uncivil or microaggressive. Understand each other's lived experiences. Work to unlearn language and actions that are uncivil or microaggressive. We are a helping profession, and we need to support each other and our patients and their families. The common thread is to treat others as you would want to be treated.

—Pamela Harris-Haman, DNP, APRN, NNP-BC
Section Editor, Practice Improvements in Neonatal Care

1. Di Fabio A, Duradoni M. Fighting incivility in the workplace for women and for all workers: the challenge of primary prevention. Front Psychol. 2019;10:1805. doi:10.23389/fpsyg.2019.01805. 2. Spath T, Dahnke C. What is civility? The Institute of For Civility in Government. https://www.instituteforcivility.org. Published 2016. Accessed February 2, 2023. 3. Anderson LM, Pearson CM. Tit for tat? The spiraling effect of incivility in the workplace. Acad Manage Rev. 1999;24(3):452–471. 4. Wikipedia. Incivility. https://en.m.wikipedia.org. Accessed March 12, 2023. 5. Porath C, Pearson C. The Price of Incivility. Harvard Business Review, Quality Management Institute. https://hbr.org/2013/01/the-price-of-incivility. Published January/February 2013. Accessed March 11, 2023. 6. Paul M. Umbrella survey: workplace incivility. Quality Improvement Center for Workplace Development. https://www.qicwd.org/umbrella/workplace-incivility. Published December 5, 2021. Accessed March 11, 2023. 7. Washington EF. Recognizing and responding to microaggressions at work. Harvard Business Review. https://hbr.org. Published May 5, 2022. Accessed March 4, 2023. 8. Vargas EA, Mahalingam R. Experiences of patient incivility: A qualitative study. Journal of Patient Experience. 2020; 7(4):615–620. doi: 10.1177/2374373519878037. 9. Limbong A. Microaggressions are a big deal: how to talk them out and when to walk away. https://www.npr.org/2020/06/08/872371063/microaggressions-are-a-big-deal-how-to-talk-them-out-and-when-to-walk-away. Published June 9, 2020.