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Do Environments Influence Human Behavior, Actions and Civility?

January/February 2021


Elizabeth CardElizabeth Card, MSN, APRN, FNP-BC, CPAN, CCRP, FASPAN
ASPAN President 2020-2021

"Don't discount the power of your words. The thought that they might cause unnecessary hurt or discomfort should inform every conversation.”1

We are all drawn to healthy environments. There is a reason we visit beautiful places that give us peace and rejuvenation: art galleries, theaters, symphony halls, museums, gardens, places of worship, national or state parks, spas, lakes, beaches or mountains. These environments feed our souls and influence or elevate our mood and behaviors. Nursing is the science and art of caring for others. Nurses are inherently empathetic and thrive in environments that provide opportunities for partnering in collaborative supportive teams, while also creating ability for growth and professional development.

Impact of Nurse Incivility on the Work Environment
Incivility and workplace violence are very powerful influences on the environment. The impact of incivility can decrease worker creativity and job satisfaction, increase perceptions of intent to leave with emotional exhaustion, and additionally negatively impact nurses’ health and well-being and the safety of the unit’s patients.2 Workplace incivility is defined as deviant behavior coupled with an ambiguous intent to harm.3

There is both a human and monetary cost associated with workplace incivility. Estimates suggest up to 98 percent of employees have experienced workplace incivility, and sadly, up to 50 percent report experiencing this behavior at least weekly.2 These experiences all contribute to burnout, lack of job satisfaction and decreased perceptions of personal accomplishments. The monetary cost of workplace incivility is estimated to be as high as $14,000 annually per employee, measured by delays in project completion and task related distractions.4

ASPAN’s Role in Addressing Workplace Environments
As an organization, ASPAN is uniquely positioned to explore, create, test and implement strategies that can result in healthier workplace environments and contribute to nurse resiliency. I am happy to share that ASPAN, along with the American Association of Nurse Anesthetists (AANA) and the Association of periOperative Registered Nurses (AORN) Workplace Civility Task Force, has successfully created a draft for a joint statement on workplace civility. It was shared first with the ASPAN Board of Directors and then was sent out to the Representative Assembly for voting. A multiorganizational position statement can provide the foundation to improve civility within our workplaces and improve the work environment. For more information on this upcoming position statement, go to page four of this issue of Breathline.

Creating an Environment for Nursing Innovation
Nursing is a science and an art. Nurses use this artistic creativity in the application of the science when customizing patient care to meet special needs or circumstances. A recent example is a Vanderbilt University Medical Center (VUMC) nurse working in the Vanderbilt University Adult Hospital COVID-19 unit and another nurse in a Washington State hospital COVID-19 unit, miles apart. Both came up with an innovative idea of using FaceTime to connect a dying patient with the patient’s family. Both nurses provided much-needed connectivity, comfort, and dignity during a time of vulnerability and isolation for their respective patients. What a beautiful creative application of nursing science!5,6

Nurse Innovation
This creative artistic application of nursing science often happens through an innovation. The concept of innovation has been explored and embedded within the business world for some time now. However, innovation is still fairly new in nursing.

Creative ideas are the sparks to ignite innovation. But these ideas require an environment in which to nurture the new concept into an innovation. There is a process for innovation, and certain environmental factors can improve the process.

Model for Innovative Environment
There are three key components in the literature related to highly innovative environments. When these components are present, innovation emerges/is born (Figure 1).  

Figure 1. Model of an innovative environment.
Copyright 2020. Elizabeth Card.

Autonomous Practice
The first component of an innovative environment is autonomous practice. An innovative environment includes both intrinsic and extrinsic components. Intrinsic components are brought to the environment by the environment’s individuals. These components are beliefs and application of nursing as an autonomous practice, including creative thinking and problem-solving. These skills can all be learned and honed. A recent research article reported the strong relationship between high levels of perceptions of professional autonomy and innovative behavior within a convenience sample of 322 nurses.7 This underlines nurse innovation and can provide value and improve-ments to both patient care and healthcare systems.8 However, individual perception of autonomous practice alone is not effective. It must be a shared value.

Extrinsic components are found within the culture of the environment outside of individuals. These components can be supported and nurtured by leaders, teams, and colleagues. The extrinsic components include a culture that values and supports nursing as an autonomous practice.7 Leadership and the team that value autonomous nursing practice inspire innovative behavior.7-8 These nurses then approach barriers to practice differently by thinking critically, creatively problem-solving, and sometimes incorporating design thinking and generating innovative solutions.

The second component of innovation is creativity. Work environments that encourage and embrace creative approaches to new solutions fuel nurse innovation.9-11 There is evidence examining the relationship between a work culture that engages the individual’s creative process, and results from the individual’s innovative behaviors.9-11 Nurses are the end-users of the largest aspects within any healthcare system. And yet, nurses are not consistently involved in the design of these systems. Innovation opportunities are visible to those who recognize the gaps or barriers in the system and creatively problem solve. This happens more naturally in creative work environments.9-11

Culture Tolerant of Failure
The final environmental element for innovation is a culture displaying high levels of risk-taking and acceptance or tolerance of failure.12-15 Acceptance or tolerance of failure means interpreting failure differently, as a natural part of the learning process. Innovation is a process that includes small tests and revisions, or, stopping the process completely if results are unfavorable. A famous quote on accepting failure: “…contentment in the thrill of action, knowing success was never final and failure never fatal. It was courage that counted. Isn’t opportunity in America today greater than it was in the days of our grateful forefathers?”16

Creating a Healthy Environment for a Nonprofit Organization
Similarly, non-profit organizations also require an environment to delicately balance and maintain authority, responsibilities, accountability, and clear lines of communication. Guiding principles can increase the ability of board members to understand their duties and to create an environment to achieve governance excellence. The Imperfect Board Member, a book written by Jim Brown, sums up these duties in several disciplines17:

Disciplines and Duties of Board Members

  • Direct the organization to achieve a high level of performance.17 Directing is a consistent pro-active, future focus, purpose-driven discipline, and includes defining the mission, vision and strategic planning for the organization. ASPAN recently updated its strategic plan with these elements in mind
  • Second, reflect on the organization’s result. Understand the operations and the reasons for changes in projections, maintaining a purpose-driven course17
  • Third, respect members’ expectations.17 ASPAN is a member-driven organization where eve-ryone’s voice is heard through the Representative Assembly
  • Fourth, expect great interactions between the board of directors and management or the chief executive officer (CEO).17 This includes maintaining clear communication and a respectful relationship between the board and the CEO, including confirmation of the CEO’s performance
  • The final element in creating a healthy environment is the knowledge and application of fiduciary responsibilities. These include three primary duties18:
  1. Duty of Loyalty18: This is accomplished with loyalty to the best interest of ASPAN and its members through transparent disclosure of any conflicts of interest, evaluation and compensation-setting of ASPAN’s executives, and reviewing financial statements and the tax form 990 prior to filing
  2. Duty of Care18: This means every board member acts with care and diligence in serving ASPAN. This includes preparing and participating in meetings, completing assignments on time and in sharing information or facts relevant to any board decisions
  3. Duty of Obedience18: This is the expectation that all board members are in compliance with the law and with ASPAN’s Articles of Incorporation, Bylaws, and other corporate policies. This duty is accomplished through abiding by the Conflict of Interest policy, and, consulting independent expert advice when there are significant doubts regarding course of action

Nurses are the largest discipline in the healthcare system. Work cultures that expect and demand civility can improve the care environment for staff and patients. Environments that value autonomous nursing practice, embrace creativity, and are tolerant of failures also nurture nurse innovation. Organizations are healthier when the environment includes leaders who are aware of and understand how to exercise oversight and implement the vision of an organization.


  1. Forni PM. Choosing Civility: The Twenty-five Rules of Considerate Conduct. St. Martin's Press. 2010:27.
  2. Pearson C, Porath C. The Cost of Bad Behavior: How Incivility is Damaging Your Business and What to Do About It. Penguin; 2009.
  3. Schilpzand P, De Pater IE, Erez A. Workplace incivility: a review of the literature and agenda for future research. J Organ Behav. 2016;37:S57-S88.
  4. Porath CL. Pearson C. The price of incivility. Har Bus Rev. 2013;91(1–2):115–121.
  5. VUAH nurse providing comfort and connecting family to a dying patient. July 9, 2020. Ac-cessed August 28, 2020.
  6. Washington State nurse uses facetime connecting family to dying patient. March 31, 2020. Accessed August 28, 2020.
  7. Kaya N, Turan N, Aydin GO. A concept analysis of innovation in nursing. Procedia Soc Behav Sci. 2015;195:1674-78.
  8. Sönmez B, Yildirum A. The mediating role of autonomy in the effect of pro-innovation climate and supervisor supportiveness on innovative behavior of nurses. European Journal of Innovation Management. 2019;22(1):41-58.
  9. Uddin MA, Priyankara HR, Mahmood M. Does a creative identity encourage innovative behaviour? Evidence from knowledge-intensive IT service firms. European Journal of Innovation Management. 2019;23(5):877-894.
  10. Turnipseed D. The relationship between the social environment of organizations and the cli-mate for innovation and creativity. Creativity and Innovation Management. 1994;3(3): 184-195.
  11. Cohen A, Ehrlich S. Exchange variables, organizational culture and their relationship with constructive deviance. Management Research Review. 2019;42(12):1423-1446.
  12. Van der Vegt GS, Van de Vliert E, Huang X. Location-level links between diversity and inno-vative climate depend on national power distance. Acad Manage J. 2005;48(6):1171-1182.
  13. Yuan F, Woodman RW. Innovative behavior in the workplace: The role of performance and image outcome expectations. Acad Manage J. 2010;53(2):323-342.
  14. Crenshaw JT, Yoder-Wise PS. Creating an environment for innovation: The risk-taking leadership competency. Nurse Lead. 2013;11(1):24-27.
  15. Kalkan M, Odacı H, Koç HE. Innovativeness, risk taking, focusing on opportunity attitudes on nurse managers and nurses. International Journal of Human and Social Sciences. 2010;5(10):622-5.
  16. You can’t tell him there’s no fishin.’ Anheuser-Busch advertisement. Trenton Evening Times. September 21, 1938. GenealogyBank.
  17. Brown J. The Imperfect Board Member: Discovering the Seven Disciplines of Governance Excellence. John Wiley & Sons; 2010:14.
  18. National Council for Nonprofits fiduciary responsibilities for nonprofit board of directors. Accessed November 1, 2020.

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