It Costs Nothing

It has been 10 years since Dr. P. M. Forni published the book Choosing Civility: The Twenty-Five Rules of Considerate Conduct. ¹ In this short, practical guide, Dr. Forni outlines essential rules for civilized behavior, which at their root are based on life and relationships among human beings. Some fundamental principles of relationships include listening and speaking respectfully, being accountable, and treating others with kindness. This book has become required reading for many, including employers, employees, and students, and it has been referenced extensively in both the national and international media.

In the same 10 years, there has been an increase in the development of both academic and community-based civility projects. Unfortunately, the increase in organizations and the subsequent increased public awareness has not been associated with improving perceptions of civility. A recent national report claims that Americans perceive that civility in society is getting worse. ² More than 85% of Americans report being victims of incivility, and surprisingly, about 60% of people admit that they have been perpetrators of uncivil behavior. Incivility in the workplace is often at the forefront of the civility discussion. Recent literature demonstrates that disruptive behavior in the workplace influences turnover, work efficiency, and quality. In addition, there is research to show that these effects impact more than the financial position of a particular organization, and in fact may be damaging to the overall American economy. ³ Lastly, and probably of most importance to the readership of this Journal, healthcare is not immune to disruptive behaviors. In the healthcare setting, these behaviors are associated with adverse events, poor patient outcomes, increased costs of care, and employee turnover. ⁴

The causes of uncivil behavior are complex and diverse. Dr. Forni purports that the goal-oriented, self-gratifying, stressed, and anonymous culture of today's society predisposes individuals to these behaviors. ¹ The Joint Commission reports that personal factors, such as fatigue and stress from working in high-emotion, high-risk environments, and system factors, such as formal and informal hierarchies, are the root causes and contributing factors to disruptive behavior in healthcare. ⁴ Regardless of the root causes and contributing factors, it is becoming clear that such behaviors have an adverse effect not just on individuals but on society; unfortunately it is unlikely that society can continue to bear the consequences.

Disruptive behavior is a generic term that describes a continuum of behavior, with uncivil and rude behavior representing one end of the continuum and physical violence representing the other end. ⁵ Bullying, either verbal, physical, or cyber, is located within this continuum. According to the American Academy of Child and Adolescent Psychiatry, about half of all children are bullied at some point during the school age years, and at least 10% of children are subjected to regular bullying. ⁶ In overweight and obese children, the problem is more significant. Recent data report that more than 90% of children with overweight and obesity are victims of bullying. ⁷

In this issue of Bariatric Nursing and Surgical Patient Care, author Nancy Browne discusses the concepts of bullying, bias, and stigmatization as it relates to obese adolescents. In this timely article, Ms. Browne not only discusses the impact of bullying on the obese adolescent, but she also makes recommendations for screening and addressing the issue. This topic is further explored in the Roundtable Discussion, where experts in the field of adolescent obesity and bariatric surgery speak about their experiences caring for children who have been bullied and share strategies for supporting the adolescent. This is really quite a revealing and eye-opening discussion for providers who do not routinely care for children with overweight and obesity.

There is no doubt that the issue of disruptive behavior and bullying has the attention of various people and stakeholders. In addition to the growth of community and academic civility projects, the federal government is currently supporting research trials that seek to investigate the various components of disruptive behaviors, including bullying in children. ⁸ Attitudes, values, triggering events, and the relationship of mental health diagnoses and psychosocial correlates to bullying behaviors are currently under investigation. Although research is ongoing, it will not provide us with quick or easy solutions.

In the meantime, as leaders and clinicians we have a responsibility to our colleagues, our patients, and our communities to recognize and address the disruptive behaviors we encounter in our personal and professional lives. Furthermore, given that 60% of people freely report being the perpetrators of uncivil behaviors, we also have a responsibility to examine ourselves and our own actions. While we may quickly acknowledge that we do not bully or engage in physical violence, it is important to acknowledge the existence of a slippery slope. ⁵ Behaviors that we may have started accepting and taking for granted, such as being perpetually tardy, repeatedly forgetting to silence cell phones and pagers, engaging in disparaging conversation about others, or even routinely making excuses, slowly erode our interactions and relationships and can cross the line between civility and incivility; awareness and self-awareness is essential. In the words of the 18th-century writer Mary Wortley Montagu, “Civility costs nothing, but buys everything.” Therefore choosing civility should be an easy decision.