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TRANSCRIPT
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Fostering Healthy Work Environments: Powered by Civility, Teamwork, and Ethical Practice
Ohio League for Nursing Cynthia Clark PhD, RN, ANEF, FAAN
OBJECTIVES
Explore the “State of the Science” regarding civility and incivility.
Discuss the impact of workplace incivility on individuals, teams, organizations, and patient care.
Discuss empirical studies related to faculty and student incivility
Participate in exercises to assess workplace health and civility acumen.
Apply and practice a variety of evidence-based strategies to promote healthy workplaces.
Defining Key Concepts
Authentic respect for others requiring time,
presence, engagement, and an intention to seek
common ground. Clark & Carnosso (2008)
CIVILITY
Workplace Aggression:
Incivility, Bullying, and Mobbing
Workplace Incivility
A range of lower intensity acts of aggression (including failing to take
action when action is warranted) which results in psychological or
physiological distress for the people involved. And, if left unaddressed,
may spiral into more purposeful efforts to harm another, increased
aggression, and threatening situations.
Pearson & Porath; 2005, 2009, 2013; Clark, 2009, 2013, ANA, 2015; Clark & Kenski, 2017
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It’s not only what we do…but what we don’t do
Staying silent when speaking up is indicated, failing to
acknowledge or support a co-worker, ignoring others,
withholding important or vital information
Continuum of Incivility
Distracting, annoying, irritating
behaviors
Aggressive, potentially
violent
behaviors
Clark © 2009, 2013, Clark, Barbosa-Leiker, Gill, & Nguyen, 2015
non-verbal sarcasm bullying racial/ethnic slurs intimidation mobbing physical violence tragedy
behaviors(eye-rolling)
Disruptive Behaviors Threatening Behaviors
Lower Level
of IncivilityHigher Level
of Incivility
Behaviors range from:
Repeated, persistent, targeted pattern of abusive
behavior designed to intimidate, degrade, and
humiliate another. Usually characterized by a person behaving in a certain way to gain power over another.
The National Institute for Occupational Safety and Health (cdc.gov/niosh)
Workplace Bullying“Ganging up”—Malicious campaign by supervisors or co-workers to exclude,
marginalize, and target another—often initiated by a person(s) in a position of power.
Causes psychological, physical, social, spiritual, and emotional damage; resulting in
loss of reputation, professional identity, position, career, and economic livelihood.
Leymann, 1992; Davenport, Schwartz, and Elliott, 1999; Westhues, 2004; Harper, 2013; Castronovo, Pullizzi, & Evans, 2016
Workplace Mobbing
The Envy of Excellence
Outstanding employees or top performers are
ridiculed for their achievements—based on
resentment and jealousy of their accomplishments.
Tall Poppy Syndrome
Those of genuine merit and accomplishment are
resented and criticized because of their talents or
achievements that distinguish them from their peers.
Westhues (2004)
Mouly, Suchitra, & Sankaran (2002)
What Motivates Uncivil Behavior?
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What Motivates Uncivil Behavior
Lack of self-awareness and emotional intelligence
Learned behavior (“it works”)—because it’s often left unaddressed
Rankism—abuse of power or position to diminish another
Tit for Tat—’save face’, retaliation, need to ‘win’
Poor communication and conflict negotiation skills
Find pleasure in demeaning others
Believe bullying needed to change behavior or motivate others
Institutional acceptance of incivility and bullying
Jealousy and envy (often of high-achievers)
Social influence (online environment, reality TV)
Aligning with those perceived to have power
Rationale and Evidence for
Fostering Civility in Nursing
CIVILITY
Creating a Culture of Safety:
High Reliability Organizations (HROs)
An industry that does complex, high-stakes work where
mistakes can equal great harm. HROs have systems in place
that make them exceptionally consistent in accomplishing their
goals and avoiding potentially catastrophic errors.
Commitment to safety at ALL levels,
from ALL workers, providers, managers,
and executives.
Oster & Braaten, 2016; TJC, 2016; AHRQ, 2017
Inter-professional Teamwork and Implementing
the 200% Rule
Everyone is 100% accountable for following safety practices and
100% accountable for making sure others follow safe practices
(Maxfield et al, 2011;Lyndon et al, 2015)
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Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice:
Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; IPE Education Collaborative, 2011
.
Domain 1: Values/Ethics: Mutual respect and shared values
Domain 2: Roles/Responsibilities: Understand and value roles and
responsibilities of other professions
Domain 3: Interprofessional Communication: Communication that
supports team approach and patient-centered care
Domain 4: Teams and Teamwork: Relationship building, shared values and principles
Interprofessional Collaborative Practice Competencies Standards for Establishing and Sustaining
Healthy Work Environments
Skilled Communication*
True Collaboration*
Effective Decision Making
Appropriate Staffing
Meaningful Recognition
Authentic Leadership*
American Association of Critical Care Nurses (2016)
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ANA Code of Ethics
Provision 1.5: The nurse creates an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and patients with dignity and respect; any form of bullying, harassment, intimidation, manipulation, threats, or violence are always morally unacceptable and will not be tolerated.
Provision 7.2: Academic educators must ensure that all graduates possess the knowledge, skills, and moral dispositions that are essential to nursing
ANA, 2015
ANA Position Statement:
Incivility, Bullying, and Workplace Violence
ANA, 2015
American Nursing Credentialing Center
14 Forces of Magnetism
Force 13: Interdisciplinary Relationships
Collaborative working relationships
Mutual respect
Conflict management strategies
http://www.nursecredentialing.org
Bookends of Civility
PRACTICE EDUCATION
The Joint Commission Sentinel Event Alert (Issued July 2008 — Effective January 2009)
Health care is “high-stakes, pressure-packed environment that can
test the limits of civility in the workplace.”
Rude, uncivil behavior among health care professionals poses a
serious threat to patient safety and the overall quality of care.
All accredited health care organizations need to create behavioral
codes of conduct and establish a formal process for managing
unacceptable behavior.
Boards of Nursing
Sanctions for Academic Incivility Nursing programs are required to develop a defined set of expectations,
interventions, strategies and written policies “to improve the culture of academic
civility.”
And to produce evidence of a “respectful, confidential, positive and productive
academic environment and improved student-faculty relationships and
communication to ensure student success.”
Clark, 2011
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Develop and implement teaching strategies and curricula to
educate nursing students on the incidence of disruptive
behaviors and steps to address and eradicate this behavior.
The Center for American Nurses (2008)
Inexplicable Link Between
Stress and Incivility
Student Stressors Demanding workload
Juggling family, work, school, personal lives
Financial concerns
Incivility, decreased program satisfaction, and retention
Competition for grades, high passing threshold, NCLEX
Ineffective or outdated teaching strategies
(unclear assignments, course expectations, passive methods)
Finding a job, fear of failure, or harming a patient
Clark, 2008, 2011, 2013; Clark et al, 2014: Lasiter et al 2010; Marchiondo et al, 2012; Twenge 2006
Faculty Stressors Juggling home, work, family, other competing demands
Unmanageable workloads and workload inequity
Ineffective or incompetent leadership
Advancement issues (P&T, pursuing a doctoral degree)
Publications, grants, and other scholarly works
Power imbalances (non-tenured, PT, adjunct, clinical)
Maintaining clinical or practice competence
Problematic students and workplace incivility
Low salary and financial pressures
Keeping pace with technology
Clark et al, 2013, Clark 2013; Cipriano, 2011; Pearson & Porath, 2009, 2013
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INCIVILITY
IS NOT A
ONE-WAY
STREET
Common Student Incivilities
Displaying a sense of entitlement (‘owed’ a grade)
Misusing cell phones and media devices
Making rude remarks, using sarcasm, profanity
Showing a lack of respect and regard for others
Pressuring faculty to agree to demands
Speaking negatively/gossiping about others
Clark 2007, 2008, 2011; Altmiller, 2012; Luparell 2007
Common Faculty Incivilities
Exerting position and power over students
Setting unrealistic student expectations
Assuming a “know it all” attitude
Threatening to fail or dismiss students
Devaluing students’ previous life, work, academic experience
Clark 2007, 2008, 2011
Faculty-to-Faculty (and administrator) Incivility
MIXED METHODS STUDY
588 Nursing Faculty from 40 States
67.4% Moderate to Serious Problem
8 THEMES
Civility
Clark, 2013; Clark, Olender, Kenski, & Cardoni, 2013
Berating, Insulting, and Allowing [Verbal and Non-Verbal]
Rude, insulting, demeaning remarks and gestures…in front of others
Often occurred in faculty and committee meetings where the behavior was
tolerated, ignored, and allowed to occur
Screaming, fist pounding, door slamming, throwing items, putting fist through wall
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Setting-up, Undermining, and Sabotaging
Intentionally undermining, sabotaging, setting others up to fail
Using improper channels or questionable methods [e.g. blind
copied e-mails] to subvert, misrepresent, or undermine others
Power Playing, Derailing, and Disgracing
Power plays, abusing position or authority, ganging up, joining forces
Treating junior, adjunct, new, clinical or faculty without the ‘right’
degree with distain and disrespect
Rankism
IN OUT
Excluding, Gossiping, Degrading
Ignoring, marginalizing, shunning, avoiding, and excluding
Conducting secretive and exclusive meetings
Gossiping, spreading rumors, degrading others
Refusing, Not doing, Justifying [Favoritism]
Refusing to do ones share of the workload or being
assigned an easier or inequitable workload
Justify ‘not doing’ … by having more urgent, pressing, or
important work to do
Blaming and Accusing
Faculty blamed and falsely accused of something they did not do;
often with no evidence of wrong-doing
Accusations often ill-founded, but taken as truth. The accused felt
powerless to ‘prove’ their innocence
Taking Credit (Ripping Off) Others Work
Subtle and blatant attempts [and successes] at taking
intellectual property or course content for their own gain or
without obtaining permission or giving credit
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Distracting and Disrupting Meetings
Using computers, mobile devices, and engaging in other non-
meeting related activities [grading papers, side conversations] Fear of retaliation
Lack of administrator support
No clear policies to address incivility
It takes too much time and effort
Lack of skill to address incivility
Makes matters worse
Feel powerless (new, non-tenured, adjunct, clinical faculty)
Want to be liked—don’t rock the boat
Reasons for Avoiding Addressing Incivility
AVOID
78.5% of respondents avoid addressing incivility
Negative Impact of Incivility Low morale, low productivity, high turn-over, and early retirement
Increased absenteeism, tardiness, ‘presenteeism’—leaving without leaving
Diminished quality of work—especially of once highly productive people
Lack of meaningful participation in governance activities
Working at home more than usual
Increased isolation—flying under the radar
Increased illness and health issues
(Clark, 2013; Grust, 2013; Twale & DeLuca, 2008; Cipriano, 2001; Davenport, Schwartz, & Elliott 1999)
Impact of Faculty-Faculty Incivility
Negative Impact on the
Learning Environment
Increases stress and anxiety
Impairs faculty and student well-being
Weakens relationships
Impedes effective teaching and learning
Decreases motivation and student engagement
Decreases quality of patient care/safety in the clinical setting
Patient Safety and Quality Care
Nurse Performance, Clinical Judgment, Advocacy
Recruitment and Retention
Collegiality, Collaboration, and Teamwork
Job Satisfaction—Intent to Leave
The ‘Bottom Line’
Laschinger et al 2013; Brunt, 2011; Dellasega, 2009, 2011; Dellasega & Volpe, 2013; Johnston, Phanhtharath, & Jackson
2010; Clark & Springer, 2010; Cleary, Hunt, & Horsfall 2010; Felblinger 2009; TJC, 2009; Forni 2008; Clark, 2008
Negative Impact on the Practice Environment
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Foster and Sustain Healthy Work Environments
G O A LClark Healthy Work Environment Inventory©
EVIDENCED-BASED
STRATEGIESPositive Role Modeling
Developing Self AwarenessSelf
Awareness
Self-Management
Relationship Management
Social Awareness
EMOTIONAL
INTELLIGENCE
ME
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Self-Assessment
Clark Workplace Civility Index©
Dream lofty dreams, and as you dream, so shall you
become James Allen
Let’s Consider the Power of a
Personal, Professional Vision
Crafting a Personal, Professional
Vision of the Future
Today
(Current
Reality)
Action Steps
Tomorrow
(Desired
Future)
Thoughts to Consider
What am I doing today that will help me achieve my goals?
How am I doing focusing on and meeting my goals?
How and where am I committing my time?
What are my next steps towards career success?
What parts of my life can I simplify—what can I say ‘no’ to?
How will my plans affect my family and friends?
If I could change something about my life, what would it be?
Am I satisfied with the direction of my career/life?
What is missing in my career/life?
Will my chosen profession bring me joy and accomplishment?
Share your Vision
With Mentors and Coaches
M
Transforming the Organizational CultureTaking your Workplace to the Next Level
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8-Step Pathway for Fostering
Organizational Civility© [PFOC]
Step 1—Raise Awareness and
Enlist Leadership Support
Civility
Incivility StressCoping
Step 2—Measure Civility
and Workplace Health Appreciative Inquiry
What are your strengths?
What’s going well?
What initiatives should be continued/strengthened?
What can be tweaked or fine-tuned to perform better?
Step 3—Assemble and Empower a
Civility (Organizational Culture) Team
Clark, 2017, 2013; Maxfield et al, 2011
Step 4—Develop an Evidence-Based
Civility Action Plan
Evidence-
Based Civility
Action Plan
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Step 5—Implement an
Evidence-Based Civility Action Plan
Establish and Implement
Unambiguous Foundational Statements
To create a campus culture that values civility, inclusion,
respectful discourse, and affirms the contributions of
each member of the campus community.
Vision/Mission Statement: Exemplar Statement of Shared ValuesExemplar
Academic Excellence
Global Citizenship
Caring and Ethical Practice
Integrity and Accountability
Civility and Respect
Social Justice
Collegiality and Collaboration
CIVILITY
Team (School/Department) Charter [Commitment, Pledge, Promise, Creed]
Overarching Goal
Preamble
Creed/Commitment
Norms/Ground Rules
Ground Rules (Norms): Exemplar
Fulfill our commitment to student success and workplace health
Assume goodwill and best intentions
Be respectful in our interactions
Use direct communication (Take and send the mail to the right address)
Role model professionalism, civility, and ethical conduct
Listen carefully and with intention to understand
Honor and respect diversity
Be open to other points of view
Hold self and each other accountable for abiding by our norms
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Achieving Accountability Hire for Civility Robust Vetting of Candidates
Miller’s SIMPLE Solution
for Accountability S-Set Expectations
I-Invite Commitment
M-Measure Progress
P-Provide Feedback
L-Link to Reward or Consequences
E-Evaluate Effectiveness
Miller, n.d.
Policies, Procedures, and Guidelines
Confidential Reporting Systems
Addressing Incivility; Rewarding Civility
Linking Healthy Work Environment Criteria to
Performance Assessment
360° Evaluation Based On:Vision, Mission, Values, Charter, Norms
Additional Thoughts for Managers and
Supervisors
Maintain confidentiality and avoid favoritism
Take complaints seriously; avoid making excuses for bad behavior
Invest in post-departure interviews
Matice, 2016; Clark et al, 2012; Clark, 2013; Cipriano, 2011; Pearson & Porath, 2009
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Skill Building Effective communication
Conflict management
Interpersonal and organizational trust
Teamwork and collaboration
Effective Communication
Building Conflict
Capable Teams
Individual Conflict Competence ModelRunde & Flanagan 2013
Cool Down
Constructively Engage Slow Down and Reflect
Frameworks for Successful Resolution
Cognitive Rehearsal and ‘Scripting’
Caring Feedback Model (Language of Caring LLC)
Casperson Model (2014)
DESC and CUS (TeamSTEPPS)
Frameworks
CI
V
IL
Griffin 2004; Griffin & Clark, 2014; Willhaus, Clark, & Kardong-Edgren, in review)
Cognitive Rehearsal: Evidence-Based Strategy to address
uncivil behavior: Consists of 4 parts:
1. Learning and didactic instruction
2. Rehearsing specific phrases to use during uncivil encounters
(creating a personalized statement)—Scripting!
3. Practice sessions to reinforce instruction and rehearsal
4. De-briefing and reflection
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Caring Feedback Model
State Positive Intent/Purpose
Describe Behavior
Explain Consequences
Offer Pinch of Empathy
Make Suggestion/Request
http://www.languageofcaring.com/resource/model-for-caring-feedback-holding-each-other-accountable
Nurse-to-Nurse Scenario: Connie is an experienced nurse
educator who has made it abundantly clear that she has little
or no patience when it comes to dealing with new or less
experienced faculty. Kim is a new faculty member and reaches
out to Connie asking for her help to prepare a course that
Connie has previously taught. Connie responds rudely stating
“Why should I help you—I had to do it on my own, so can you.”
State Positive Intent: Connie, I respect your teaching experience and hope to learn
from you.
Describe Behavior: Earlier today, when I asked for help, it didn’t seem to go well.
Explain Consequences: Without support to prepare the course, I’m concerned
student learning may be affected.
Offer Pinch of Empathy: I realize you’re busy and have a lot of responsibility.
Make Request: Still, I need to ask some important questions. When can we meet to
discuss them?
Language of Caring
Heart-Head-Heart™ Model
Connie, I value the work that went into
developing this course, and it’s very well done.
However, I’m still on a learning curve, so I’d like
to discuss your ideas for preparing the course.
I’d really appreciate your input.
Casperson’s Framework
Resist the urge to attack (Casperson, 2014)
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When (the triggering event) happened,
I felt/believed (my feeling or belief)
because my (need/interest) is really important to me.
Would you be willing to (request a doable) action?
Student Scenario: Carmen is consistently late
and poorly prepared for her clinical experience.
Lately, her clinical performance has deteriorated,
patient care has suffered, and her decision-
making is faulty. As her clinical instructor, you
address these concerns with Carmen.
Carmen, when I see you arrive late for clinical and fail to
deliver quality patient care, it concerns me because the role of
a professional nurse includes being punctual and above all,
providing safe care. I’d like to meet with you to discuss ways to
improve your timeliness and clinical performance.
Co-worker-to-Co-worker Scenario: In the department where you
work, some employees engage in negative gossip and spreading
rumors—you believe you have been the target of these behaviors,
and one day when you approach the break room, you hear your
name mentioned in a negative way—as you enter the room, your
co-workers fall silent. You decide to address the situation.
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When I approached the break room, I heard my name
mentioned. Being viewed as a valued member of the team is
important to me. In the future, please speak with me directly if
you have something to say about me.
Evidence-based teamwork system to improve communication and
teamwork skills among health care professionals.
http://teamstepps.ahrq.gov/
TeamSTEPPSTeam Strategies and Tools to Enhance
Performance and Patient Safety
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DESC Model
Describe the specific situation
Express your concerns
Suggest other alternatives
Consequences stated
Manager-to-Nurse Scenario
Hey Kathy, Nicole called in sick. We’re totally shorthanded, so you
need to stay and cover her shift. You may not like the decision, but
that's just the way it is. We all need to suck it up and deal with it.
Using the DESC Model
Describe: Alice, I appreciate the need to cover the unit.
Explain: However, I’d like to discuss other options since I’m unable to work an
additional shift today.
State: I’m exhausted and because I’ve recently covered other shifts, I’m not rested
enough to administer safe patient care.
Consequence/Question: Can we discuss other ways to cover the shift?
CUS(sing): To get attention when
you really need it: CUS!
I am Concerned
I am Uncomfortable
This is a Safety issue
EXEMPLAR: Case-Based Scenario
“Nearly every day we are faced with the hand-off allergy list.
Frequently the surgeons will order an antibiotic the patient is
allergic to according to the checklist. When the patient is out of
surgery, nurses have to call the surgeon, the anesthesiologist,
and sometimes even the pharmacist trying to get someone to
listen. It’s so frustrating, that sometimes we go ahead and give
the drugs anyway knowing it’s not the right thing to do.”
The Silent Treatment; Maxfield D, Grenny J, Lavendro R. & Groah L. (2011)
Using the CUS Model
I’m Concerned about (name) and Uncomfortable
administrating this medication until we check her
record for allergies to be sure it is Safe to give.
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Faculty Scenario: You and your colleague, Terri are team teaching a
nursing course. You vehemently disagree on the subject matter to
include and ways to deliver the course. Working together is becoming
very stressful…and to make matters worse, students are becoming
confused and frustrated due to the ongoing conflict. You realize that
something needs to be done to resolve the situation.
Using the CUS Model
(For the Sake of …
Terri, I’m Concerned about our recent interactions and
Uncomfortable with our lack of teamwork. For the
Sake of our relationship and the success of our
students, let’s make a plan to work things out.
Step 6—Evaluation and ReassessmentStep 7—Reward Civility
and Reinforce Success
Step 8—Expand, Modify, and
Continue the Civility Initiative
CIVILITY
C I V I L I T Y
Cynthia Clark PhD, RN, ANEF, FAAN
Strategic Nursing Advisor | ATI Nursing Education
Founder of Civility Matters®[email protected]
Thank You