Clark 2015 © Combining the Power of Simulation and Cognitive Rehearsal to Foster Civility in Nursing Cynthia Clark PhD, RN, ANEF, FAAN 2015 ATI Nurse Educator.

Clark 2015 ©

Combining the Power of Simulation and Cognitive Rehearsal to Foster Civility in Nursing

Cynthia Clark PhD, RN, ANEF, FAAN2015 ATI Nurse Educator Summit; San Diego, CA

Clark 2015 ©

Gratitude!

Describe the 'State of the Science' regarding civility/incivility in nursing

Discuss the impact of incivility on individuals, teams, and organizations

Explore how the combination of a simulation and Cognitive Rehearsal (CR) can be used to prepare nursing students to recognize, prevent, and address incivility

Today’s Objectives

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BACKGROUND and RATIONALE

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What is Incivility and Why Address It?

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What is Incivility?Rude or disruptive behaviors which often result in

psychological or physiological distress for the people involved– and if left unaddressed, may progress into

threatening situations [or result in temporary or permanent illness or injury] (Clark, 2009, 2013).

Continuum of Incivility

Distracting, annoying, irritating

behaviors

Aggressive, potentially

violent behaviors

Clark © 2009, revised 2013, 2014

non-verbals sarcasm bullying racial/ethnic slurs intimidation mobbing physical violence tragedy (eye-rolling)

Disruptive Behaviors Threatening Behaviors

Lower Levelof Incivility

Higher Levelof Incivility

Behaviors range from:

Scaffolding Uncivil Behavior in the Workplace

Clark & Griffin, 2014; Clark in press

It’s not only what we do…but what we don’t do

Such as uncivil non-verbal behaviors, staying silent when speaking up is indicated, failing to acknowledge another, withholding important and vital information

Workplace incivility “constellation of harmful actions taken and those not taken” in the workplace (Saltzberg, 2011, p. 229).

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Common IncivilitiesWithholding important informationNon-verbal affronts and gesturesFailing to use basic mannersUsing anger and intimidationSpreading rumors and gossipingFailing to support a co-worker; setting up to failNeglecting, marginalizing or excluding a co-workerBreaking confidencesName calling, put-downs, and sarcasmEncouraging others to turn against a co-worker

(Dellasega, 2009, 2012, Clark 2013; Griffin, 2004, Griffin & Clark, 2014)

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Rationale for Fostering Civility

CIVILITY

Nursing Codes of EthicsProvision 1.5: The nurse creates an ethical environment and cultureof civility and kindness, treating colleagues, coworkers,employees, students, and patients with dignity and respect; anyform of bullying, harassment, intimidation, manipulation, threats,or violence are always morally unacceptable and will not betolerated (ANA Code of Ethics, 2015)

Inherent in nursing is the respect for human life, including culturalrights, the rights to life and choice, to dignity, and to be treatedwith respect (International Code of Ethics for Nurses)Four fundamental responsibilities

To promote healthTo prevent illnessTo restore healthTo alleviate suffering

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Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

QSEN Teamwork and Collaboration Competency

http://www.qsen.org

Safety CompetencyMinimizes risk of harm to patients and providers through both system effectiveness and individual performance

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The Essentials of Baccalaureate Education for Professional Nursing Practice (2008)

Essential VIII: Professionalism and Professional ValuesProfessionalism and the inherent values of altruism, autonomy, human dignity, integrity, and social justice are fundamental to the discipline of nursing.

Inherent in professionalism is accountability and responsibility for individual actions and behaviors, including civility. Civility must be present for professionalism to occur.

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Impact on the Individual

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Negative Impact On:

Self-esteem and self-worth Confidence, judgment, and problem-solving Physical, mental, and spiritual health Relationships and teamwork Overall quality of life

Laschinger et al 2012; Brunt, 2011; Johnston, Phanhtharath, & Jackson 2010; Clark & Springer, 2010; Cleary, Hunt, & Horsfall 2010; Johnson, 2009; Felblinger 2009; TJC, 2009; Forni 2008; Clark, 2008

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Impact on the Organization

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Patient Safety and Quality CareRecruitment and RetentionMorale and Collegiality Job Satisfaction—Intent to LeaveRelationships and TeamworkQuality of ServicesThe ‘Bottom Line’

Negative Impact On:

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The Process Preparatory readings (practice and education) Didactic session; Civility, CUS model, and CR Introduction of PBL scenario (simulation with live actors) Small and large group discussion Development of a cognitively rehearsed strategy Practice sessions; responding to uncivil encounter

Griffin, 2004; Griffin & Clark, 2014

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Didactic Session: The State of the Science

CIVILITY

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Cognitive Rehearsal: Evidence-Based Strategy to address uncivil behavior:Consists of 3 parts:

1. Learning and didactic instruction2. Rehearsing specific phrases to use during uncivil encounters(creating and preserving a personalized statement)3. Practice sessions to reinforce instruction and rehearsal

C IV

I L

Griffin 2004; Griffin & Clark, 2014

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Examples of Cognitive Rehearsal and Effective Communication

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Uncivil nonverbal behaviors [eye rolling, making faces, head shaking, etc] I sense from your facial expression that there may be something you wish to say to me. It’s OK to speak to me directly.

Spreading rumors, gossiping, failing to support a coworkerThat's not my experience with [so and so]. Perhaps the information was taken out of context. I suggest you check it out with him/her.

Griffin & Clark, 2014

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Using the ‘silent treatment’ or withholding important informationI believe that there is more information available regarding this patient/situation. Please share all important information since patient care and safety depends on a complete report.

Put downs/attempts to humiliateI wasn’t aware that you see me that way. Can you tell me what I have done to create this impression?

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An 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

CUS ModelConcernedUncomfortableSafety

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CUS Examples

"I'm Concerned that Ms. C is not her usual self. I'm Uncomfortable because she is behaving oddly. I believe she may have something serious going on that we are missing and that she’s not Safe.”

“I’m Concerned about Mrs. Keys, the baby’s heart rate is in the 60s. I’m Uncomfortable with these late decelerations and I don’t think it’s Safe to continue labor.”

Nurse Incivility PBL ScenarioActors: Nurse manager (NM), Seasoned Charge Nurse (Nurse Brown) and New Charge Nurse (Nurse Adams)Setting: Orthopedic unit. The unit prides itself on its excellent quality care and ethical treatment of patients and staffSituation: Nurse Adams is a new charge nurse on the evening shift. She has always been reliable and professional in her interactions with others. However, recently she has been consistently late reporting to work and has been isolating herself from others on the unit, which is a distinct change from her previous behavior. The NM has been observing changes in Nurse Adams’ behavior as well as behaviors of other staff, which appear to coincide with the recent hiring of Nurse Brown, an experienced nurse who has recently transferred onto the unit from another department.

When the NM addresses her observations and concerns with Nurse Adams, at first, she denies any problem. As the NM continues to express her concern about Nurse Adams’ uncharacteristic behavior, and details her performance issues, Nurse Adams begins to cry, and states, “I just can’t stand this anymore”. When asked to explain her comment, Nurse Adams very reluctantly reveals a pattern of abusive behaviors toward her by Nurse Brown, including put-downs, negative gossip, intimidating comments, marginalizing behavior, and withholding important information about patient care. When asked why she had not come forward sooner with her complaints, Nurse Adams replies, “I didn’t want to be seen as a problem employee.” The NM realizes this situation needs to be addressed; however, since she has not witnessed the alleged behaviors, she needs to investigate the situation further. She meets privately with Nurse Brown who does not deny Nurse Adams’ report. In fact, she is insolent, rude, and dismissive of the situation stating that Nurse Adams “is book smart, but has no common sense and needs to get a grip, get with the program, and toughen up.” Nurse Brown is disrespectful and curt, and slams the door on her way out of the nurse manager’s office.

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Assume you are a nurse being treated uncivilly; using the CUS model, write a

response to diffuse an uncivil encounter.

Probing Question

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I’m Concerned about our recent interactions and Uncomfortable with our lack of teamwork. Since this can affect the Safety of our patients, let’s make a plan to work things out.

I’m Concerned and Uncomfortable with the lack of detail in this report. Please provide more complete information so that I can provide the Safest and best care for our patients.

Example from Dr. Clark’s Class

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Initial Study—April 2011 (Year 2)

64 (100%) BS senior nursing students

Purpose: Evaluate the level of learning acquired after observing a ‘live’ PBL scenario of uncivil nurse behavior and the use of Cognitive Rehearsal

What was your initial reaction to the PBL Scenario?

Nurse Brown was offensive, rude, a bully, and requires supervision and corrective action

These behaviors frequently occur in nursing practice

The NM addressed the conflict fairly, but perhaps ‘let things go too far’ before addressing the situation

Allowed them to reflect on own behaviors and how they might handle the situation

One uncivil person can change an entire workplace

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What Enhanced Your Learning?

Role of NM is important in addressing incivility and prompted students to think about how each would handle incivility in their nursing practice

Found PBL scenario to be realistic, bringing learning ‘alive,’ and heightening awareness of incivility and its impact

Reinforced the importance of teamwork, effective communication (CR), and the need for education to address incivility

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How Could be Changed to Improve Learning?

Deeper debriefing and lengthier class discussion on how to effectively address incivility in nursing practice

Utilizing more scenarios with varying outcomes

Civility addressed earlier and consistently throughout curriculum

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How might knowledge gained affect your nursing practice?

Scenario helped students recognize and address incivility

To be cognizant of their own behavior and how they treat others (be supportive, respectful, and use effective communication)

NM is a valuable resource in managing conflict

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Qualitative study with newly graduated nurses who had participated in the previous PBL scenario/CR study

5-item questionnaire: Based on Kirkpatrick’s Level 3 Evaluation: Has behavior changed as a result of participating in a scenario using CR?

Participants: 30 of 64 agreed to be contacted [(18 of 30) 60% participated]

10-Month Follow-up Study—February 2012 (Year 3)

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Question 1: Have you experienced or observed an act of incivility in your nursing practice? If yes, please describe

11 of 18 (61%) reported experiencing or observing incivility in the workplace

• Themes• Rude remarks, gossiping, complaining• Inter-professional incivility• Yelling and berating

“Nurses make negative remarks about ‘gay people’, knowing 2 of the nurses on our unit are gay.”

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Question 2: How have you used the information you learned in your practice?

11 of 18 respondents (61%) reported using the information

• Themes:• Enhanced conversation• Depersonalized the behavior• Thought before acting

“I have applied the information to build respectful and professional communication and relationships with my patients and co-workers.”

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Question 3: How has your behavior changed since your participated in the scenario?

14 of 18 (77.7%) reported changes in their behavior

• Themes:• Raised awareness• Able to address incivility immediately• Communicate more clearly

“I have more courage to stand up for myself because I know I don’t have to take [uncivil] treatment, even if I am the new person.”

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Question 4: What has discouraged or prevented you from applying what you learned from class?

8 of 14 (57%) reported factors discouraging or preventing them from applying what they had learned

• Themes:• Being new• Facing reality—the way things are in nursing

“Being new to the area where I am working has made me feelas though it isn’t my place to say anything regarding the incivility.”

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10 of 18 (56%) reported benefits/rewards

• Themes:• Role modeling and collegiality• Communicating more effectively

Question 5: What personal or professional rewards have you received by using the knowledge you learned in class?

“I realize that I have the power to change a situation for the better by treating everyone I work with with genuine civility. Through the scenario I saw the power and the possibilities this affords co-workers. It is truly what got me through those difficult weeks of orientation.”

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The PBL scenario with CR was an effective teaching strategy for preparing students to address incivility in practice

Graduates with limited experience and limited familiarity with the professional nursing role were able to identify uncivil behavior, and in some cases, effectively address the behaviors

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Summary

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What’s Next?

Future Directions

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Cognitive Rehearsal Intervention Study Using Biomarkers and Simulation

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C I V I L I T Y

Cynthia (Cindy) Clark PhD, RN, ANEF, FAANNurse Consultant: ATI Nursing EducationProfessor and Founder of Civility Matters©[email protected]

Thank You