Defining Key Concepts€¦ · Fostering Healthy Work Environments: Powered by Civility, Teamwork, and Ethical Practice Ohio League for Nursing Cynthia Clark PhD, RN, ANEF, FAAN OBJECTIVES

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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