Introduction to the Civility Tool-Kit:

Truth, Wisdom, Courage, and Renewal


Historically, strategies to eliminate bullying and create respectful, civil, supportive, and safe environments have largely centered on individuals, while ignoring the broader context of its occurrence that includes influences from interpersonal, community, environmental, and policy sources. Theory and research establishes bullying as a complex interplay of influences between individuals and their broader environments. Bullying is a group phenomenon, reciprocally influenced by the individual, peers, the immediate environment/institution, community, and /or society (Swearer & Espelage, 2004). Human behaviors are not isolated events; they are linked with and influenced by other behaviors and social norms. Hutchinson, Wilkes, Jackson, & Vickers (2010) reported that organization factors serve as a mechanism through which bullying becomes embedded in the culture. While individual factors may play a major role that contributes to bullying, the environment is a powerful force that consciously or unconsciously enables acts of bullying (Bronfenbrenner, 1994; Katrinli, Atabay, Gunay, & Cangarli, 2010). Educating individuals to be civil when environments are not supportive can be ineffective, making sustainable behavioral change elusive. Emerging evidence and anecdotal reports suggest leaders’ conscientiousness in implementing comprehensive, cohesive, and integrated bullying prevention and intervention programs is critical to promote environments of respect, and enhance sustainability of cultures of civility (Cleary, Hunt, & Horsfall, 2010; McNamara, 2012). With a grounded understanding of the scientific etiologies of bullying and the potential solutions to the issues, the civility tool-kit employs the social ecological model (SEM) as a framework to mitigate the complex, and multiple influence etiologies of bullying.


  • Discuss the socio-ecological model as an effective framework to address the complex, and multiple influence etiologies of bullying
  • Describe the application of SEM to the four buckets (Truth, Wisdom, Courage, and Renewal) of the Civility Tool-kit, serving as a comprehensive, cohesive, and integrated solution to support, create, and sustain cultures of civility and respect in the healthcare organization/environment
  • Provide guiding principles for effective utilization of the Civility Tool-kit


The Social-Ecological Model (SEM)

The SEM offers a useful and applicable framework that combines individual, interpersonal, community, environmental, and policy level solutions to address bullying and create and sustain environments of respect and civility. The SEM evolved from the fields of sociology, psychology, education, and health focusing on the nature of people’s interactions with others and their environments. SEM is grounded in research, including but not limited to the work of: Bronfenbrenner (1979), Ecological Systems Theory that focused on the relationship between the individual and the environment; McLeroy, Bibeau, Steckler, & Glanz (1998), Ecological Model of Health Behaviors, which classified five different levels of influence on health behavior, and Stokols (1992, 1996) Social Ecology Model of Health Promotion that identified the core assumptions which underpin the social-ecological model. SEM posits that human behavior does not happen in a vacuum, as individuals exist and interact within a complex ecological system. Behavior is a complex interaction between individuals, their families, their communities and the society in which they live. The model asserts that the human natural environment includes not only the corporeal surroundings, but also social and cultural forces (Swearer & Espelage, 2004). Thus, individual behavioral competence or problems are reflected properties of an integrated system, and not just their individual characteristics. SEM theorizes bullying occurs not only because of the individual bully characteristics, but also the actions of peers, bystanders, leaders, acceptable norms in the environment, culture, community, and/or society that either serve to reinforce acts of bullying behaviors or eradicate it. The environment, in turn, is mediated by remote forces in the larger community and society. Thus SEM has been used to better understand and address challenging behaviors that arise from multiple levels of influence including violence, abuse, and harassment. Indeed, some have argued the limited success of current anti-bullying programs is a result of failure to direct solutions that address the social-ecology of bullying that goes beyond the individual including peers, families, and the broader environment. SEM underscores the imperative for a multi-level and multi-pronged approach. Therefore, solutions such as the Civility tool-kit are targeted to all levels (individual, interpersonal, community, environmental, and policy), using multi-pronged strategies for assessment, prevention, monitoring, intervention, and recovery.

Application of SEM to Address Bullying in Healthcare Organizations:

In line with SEM, we conceptualize bullying as a constellation of behavioral interactions and provide guidelines through the civility tool-kit to support nurse leaders to assess, recognize, identify, prevent, intervene, and ultimately eliminate bullying in their organizations and beyond. The tool-kit is comprehensive, cohesive, and an integrated collection of four buckets (Truth, Wisdom, Courage and Renewal) to assist nurse leaders to create a cultural norm of respect, civility, connectedness, acceptance, and support. The four buckets in the tool-kit integrate and unify multiple initiatives that may otherwise operate in a fragmented, uncoordinated, inefficient, and/or ineffective way to address all levels of bullying. The buckets work in tandem, lending to ease of use in addressing the interconnectedness of all the components; who, when, and what, providing specificity to a systematic targeted level of intervention.

Knowledge of the different levels of the etiologies of bullying influenced the development of the comprehensive intervention approaches of the tool-kit to systematically target mechanisms of change at several levels. The tool-kit provides a systematic approach to the appropriate level of intervention, timing of intervention, and focus of the intervention. The below table lists examples of each of the five levels of influence : 1) Individual; 2) Interpersonal; 3) Institutional; 4) Community; and 5) Policy; listing risk factors and identifying comprehensive strategies that can be found within the civility tool-kit to address bullying and promote respectful, civil, and safe environments within healthcare organizations and beyond. Outcomes for positive behavioral change are expected to be maximized when environments and policies support respectful and civil behaviors, strengthening cultural norms and social support for civility.

Examples of each of the Five Levels of SEM in Identifying Bullying and Strategies to Address

Guiding Principles for Effective use of Tool-kit and Sustainability for Healthcare Leaders:

  • Human behaviors, including eliminating acts of bullying can be improved and sustained when environments and policies support civility. Individuals will be motivated, and empowered to be civil when their leaders demonstrate ability and capacity for civility. Nurse leaders have a unique role in eliminating bullying behaviors as their actions have implications for how behaviors are judged. Specifically, within healthcare organizations, nurse leaders serves as important role models upon which nurses and staff base their expectations of future interactions. While this tool-kit can be used by anyone and everyone to create and sustain environments of respect and civility, we have specifically targeted nurse leaders to help drive and create civil and respectful healthcare environments, where nurses share connectedness, acceptance, support, and respect for each other and for other members of the interprofessional care team. Ongoing engagement, evaluation, consistency, and commitment are necessary for sustainability the below guiding principles can further enhance sustainability.
  • Actively engage frontline nurses and organizational leaders in policy development and implementation
  • Establish a Civility team with a point leader to oversee, monitor, and routinely check the pulse of overall unit or organization environment in relations to sustainability of a respectful, civil, and safe environment
  • Use multi-prong approaches’ to include prevention and intervention
  • Integrate bullying prevention and minimization education to system orientation and staff trainings
  • Implement policies to eliminate bullying and increase respect and civility that :

– Are clear, fair, and consistent
– Safeguard the well-being of patients and staff
– Empower staff to use alternate positive behaviors (see Difficult Conversations in Courage Bucket)


Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design Cambridge, MA: Harvard University Press.

Bronfenbrenner, U. (1994). Ecological Models of Human Development International Encyclopaedia of Education (Vol. 3). Oxford: Elsevier.

Cleary, M., Hunt, G. E., & Horsfall, J. (2010). Identifying and addressing bullying in nursing. Issues in Mental Health Nursing, 31(5).

Hutchinson, M., Wilkes, L., Jackson, D., & Vickers, M. H. (2010). Integrating individual, work group and organizational factors: testing a multidimensional model of bullying in the nursing workplace. Journal of Nursing Management, 18(2), 173-181.

Katrinli, A., Atabay, G., Gunay, G., & Cangarli, B. G. (2010). Nurses’ perceptions of individual and organizational political reasons for horizontal peer bullying. Nursing Ethics, 17(5), 614-627.

McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1998). An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351-377.

McNamara, S. A. (2012). Incivility in nursing: unsafe nurse, unsafe patients. AORN Journal, 95(4), 535-540. doi:

Stokols, D. (1992). Establishing and Maintaining Healthy Environments: Toward a Social Ecology of Health Promotion. American Psychologist, 4(2), 6-22.

Stokols, D. (1996). Translating Social Ecological Theory into Guidelines for Community Health Promotion. American Journal of Health Promotion, 10(4), 282–298.

Swearer, S. M., & Espelage, D. L. (2004). Introduction: A social-ecological framework of bullying among youth. . In D. L. Espelage & S. M. Swearer (Eds.), Bullying in American schools: A social-ecological perspective on prevention and intervention (pp. 1-12): Mahwah, NJ: Lawrence Erlbaum.