18 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com
“I believe we can change the world if we start listening to one another again. Simple, honest, human con- versation…a chance to speak, feel heard, and [where] we each listen well…may ultimately save the world.” Margaret J. Wheatley,
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GIVEN the stressful healthcare workplace, it’s no wonder nurses and other healthcare professionals sometimes fall short of communi- cating in respectful, considerate ways. Nonetheless, safe patient care hinges on our ability to cope with stress effectively, manage our emo- tions, and communicate respectful- ly. Interactions among employees can affect their ability to do their jobs, their loyalty to the organiza- tion, and most important, the deliv- ery of safe, high-quality patient care.
The American Nurses Associa- tion (ANA) Code of Ethics for Nurses with Interpretive Statements clearly articulates the nurse’s obli- gation to foster safe, ethical, civil workplaces. It requires nurses “to create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, em- ployees, students, and others with
dignity and respect” and states that “any form of bullying, harassment, intimidation, manipulation, threats, or violence will not be tolerated.” However, while nurses need to learn and practice skills to address
uncivil encounters, or- ganization leaders and managers must create an environment where nurses feel free and empowered to speak up, especially regard- ing patient safety issues.
All of us must strive to create and sustain civil, healthy work en- vironments where we
communicate clearly and effectively and manage conflict in a respectful, responsible way. The alternative— incivility—can have serious and lasting repercussions. An organiza- tion’s culture is linked closely with employee recruitment, retention, and job satisfaction. Engaging in clear, courteous communication fos- ters a civil work environment, im- proves teamwork, and ultimately enhances patient care.
In many cases, addressing inci- vility by speaking up when it hap- pens can be the most effective way to stop it. Of course, mean- ingful dialogue and effective com- munication require practice. Like bowel sound auscultation and na- sogastric tube insertion, communi- cation skills can’t be mastered overnight. Gaining competence in civil communication takes time, training, experience, practice, and feedback.
LEARNING OBJECTIVES 1. Identify components of a healthy
workplace. 2. Discuss how to prepare for a chal-
lenging conversation. 3. Describe models for conducting a
The planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit. The author has disclosed that she receives royalties and consulting fees pertaining to this topic. The article was peer reviewed and determined to be free of bias.
CNE 1.0 contact hours
Conversations to inspire and promote a
more civil workplace Let’s end the silence that surrounds incivility.
By Cynthia M. Clark, PhD, RN, ANEF, FAAN
www.AmericanNurseToday.com November 2015 American Nurse Today 19
What makes for a healthy workplace? The American Association of Criti- cal-Care Nurses has identified six standards for establishing and sus- taining healthy work environ- ments—skilled communication, true collaboration, effective decision- making, appropriate staffing, mean- ingful recognition, and authentic leadership.
In my own research, I’ve found that healthy work environments al- so require: • a shared organizational vision,
values, and team norms • creation and sustenance of a
high level of individual, team, and organizational civility
• emphasis on leadership, both formal and informal
• civility conversations at all orga- nizational levels. I have developed a workplace
inventory that individuals and groups within organizations can use as an evidence-based tool to raise awareness, assess the perceived health of an organization, and de- termine strengths and areas for im- provement. The inventory may be completed either individually or by all team members, who can then compare notes to determine areas for improvement and celebrate and reinforce areas of strength. (See Clark Healthy Workplace Inventory.)
How to engage in challenging conversations One could argue that to attain a high score on nearly every invento- ry item, healthy communication must exist in the organization. So leaders need to encourage open discussion and ongoing dialogue about the elements of a healthy workplace. Sharing similarities as well as differences and spending time in conversation to identify strategies to enhance the workplace environment can prove valuable.
But in many cases, having such conversations is easier said than done. For some people, engaging
directly in difficult conversations causes stress. Many nurses report they lack the essential skills for hav- ing candid conversations where emotions run high and conflict- negotiation skills are limited. Many refrain from speaking with uncivil individuals even when a candid conversation clearly is needed, be- cause they don’t know how to or because it feels emotionally unsafe. Some nurses lack the experience and preparation to directly address incivility from someone in a higher position because of the clear power differential or a belief that it won’t change anything. The guidelines be- low can help you prepare for and engage in challenging conversations.
Reflecting, probing, and committing Reflecting on the workplace culture and our relationships and interac- tions with others is an important step toward improving individual, team, and organizational success. When faced with the prospect of having a challenging conversation, we need to ask ourselves key ques- tions, such as: • What will happen if I engage in
this conversation, and what will happen if I don’t?
• What will happen to the patient if I stay silent? In the 2005 report “Silence Kills:
The Seven Crucial Conversations for Healthcare,” the authors identi- fied failing to speak up in disre- spectful situations as a serious com- munication breakdown among healthcare professionals, and they asserted that such a failure can have serious patient-care conse- quences. In a subsequent report, “The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives,” the authors suggest- ed a multifaceted organizational ap- proach to creating a culture where people speak up effectively when they have concerns. This approach includes several recommendations and sources of influence, including
improving each person’s ability to be sure all healthcare team mem- bers have the skills to be “200% ac- countable for safe practices.” Ways to acquire safe practice skills in- clude education and training, script development, role-playing, and practicing effective communication skills for high-stakes situations.
Creating a safe zone If you’ve decided to engage in a challenging conversation with a coworker who has been uncivil, choose the time and place careful- ly. Planning wisely can help you create a safe zone. For example, avoid having this conversation in the presence of patients, family, and other observers. Choose a set- ting where both parties will have as much emotional and physical safety as possible.
Both should agree on a mutual- ly beneficial time and place to meet. Ideally, the place should be quiet, private, away from others (especially patients), and con- ducive to conversation and prob- lem-solving. Select a time when both parties will be free of inter- ruptions, off shift, and well-rested. If a real or perceived power differ- ential exists between you and the other person, try to have a third party present.
You may need to initiate the conversation by asking the other person for a meeting. Suppose you and your colleague Sam dis- agree over the best way to per- form a patient care procedure. You might say something like, “Sam, I realize we have different approaches to patient care. Since we both agree patient safety is our top concern, I’m confident that if we sit down and discuss possible solutions, we can work this out. When would you like to get to- gether to discuss this?”
Before the meeting, think about how you might have contributed to the situation or conflict; this can help you understand the other per-
20 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com
You can use the inventory below to help determine the health of your workplace. To complete it, carefully read the 20 statements below. Using a scale of 1 to 5, check the response that most accurately represents your perception of your workplace. Check 5 if the statement is completely true, 4 if it’s somewhat true, 3 if it’s neutral, 2 if it’s somewhat untrue, and 1 if it’s completely untrue. Then total the number values of your responses to determine the overall civility score. Scores range from 20 to 100. A score of 90
to 100 indicates a very healthy workplace; 80 to 89, moderately healthy; 70 to 79, mildly healthy; 60 to 69, barely healthy; 50 to 59, unhealthy; and less than 50, very unhealthy.
Completely Somewhat Neutral Somewhat Completely Statement true (5) true (4) (3) untrue (2) untrue (1)
Members of the organization “live” by a shared vision □ □ □ □ □ and mission based on trust, respect, and collegiality.
There is a clear and discernible level of trust □ □ □ □ □ between and among formal leadership and other members of the workplace.
Communication at all levels of the organization □ □ □ □ □ is transparent, direct, and respectful.
Employees are viewed as assets and valued □ □ □ □ □ partners within the organization.
Individual and collective achievements are celebrated □ □ □ □ □ and publicized in an equitable manner.
There is a high level of employee satisfaction, □ □ □ □ □ engagement, and morale.
The organizational culture is assessed on an ongoing □ □ □ □ □ basis, and measures are taken to improve it based on results of that assessment.
Members of the organization are actively engaged in □ □ □ □ □ shared governance, joint decision-making, and policy development, review, and revision.
Teamwork and collaboration are promoted and evident. □ □ □ □ □ There is a comprehensive mentoring program for □ □ □ □ □ all employees.
There is an emphasis on employee wellness and self-care. □ □ □ □ □ There are sufficient resources for professional growth □ □ □ □ □ and development.
Employees are treated in a fair and respectful manner. □ □ □ □ □ The workload is reasonable, manageable, and fairly □ □ □ □ □ distributed.
Members of the organization use effective conflict- □ □ □ □ □ resolution skills and address disagreements in a respectful and responsible manner.
The organization encourages free expression of diverse □ □ □ □ □ and/or opposing ideas and perspectives.
The organization provides competitive salaries, benefits, □ □ □ □ □ compensations, and other rewards.
There are sufficient opportunities for promotion and □ □ □ □ □ career advancement.
The organization attracts and retains the □ □ □ □ □ “best and the brightest.”
The majority of employees would recommend the □ □ □ □ □ organization as a good or great place to work to their family and friends.
© 2014 Cynthia M. Clark
Clark Healthy Workplace Inventory
www.AmericanNurseToday.com November 2015 American Nurse Today 21
son’s perspective. The clearer you are about your possible role in the situation, the better equipped you’ll be to act in a positive way. Re- hearsing what you intend to say al- so can help.
Preparing for the conversation Critical conversations can be stress- ful. While taking a direct approach to resolving a conflict usually is the best strategy, it takes fortitude, know-how—and practice, practice, practice. Prepare as much as possi- ble. Before the meeting, make sure you’re adequately hydrated and perform deep-breathing exercises or yoga stretches.
On the scene When the meeting starts, the two of you should set ground rules, such as: • speaking one at a time • using a calm, respectful tone • avoiding personal attacks • sticking to objective information.
Each person should take turns describing his or her perspective in objective language, speaking di- rectly and respectfully. Listen ac- tively and show genuine interest in the other person. To listen actively, focus on his or her message in- stead of thinking about how you’ll respond. If you have difficulty lis- tening and concentrating, silently repeat the other person’s words to yourself to help you stay focused.
Stay centered, poised, and fo- cused on patient safety. Avoid be- ing defensive. You may not agree with the other person’s message, but seek to understand it. Don’t in- terrupt or act as though you can’t wait to respond so you can state your own position or impression.
Be aware of your nonverbal messages. Maintain eye contact and an open posture. Avoid arm cross- ing, turning away, and eye rolling.
The overall goal is to find an interest-based solution to the situa- tion. The intention to seek com- mon ground and pursue a com –
promise is more likely to yield a win-win solution and ultimately im- prove your working relationship. Once you and the other person reach a resolution, make a plan for a follow-up meeting to evaluate your progress on efforts at resolv- ing the issue.
Framework for engaging in challenging conversations Cognitive rehearsal is an evidence- based framework you can use to address incivility during a challeng- ing conversation. This three-step process includes: • didactic and interactive learning
and instruction • rehearsing specific phrases to
use during uncivil encounters • practice sessions to reinforce in-
struction and rehearsal. Using cognitive rehearsal can
lead to improved communication, a more conflict-capable workforce, greater nurse satisfaction, and im- proved patient care.
DESC model Various models can be used to structure a civility conversation. One of my favorites is the DESC model, which is part of Team- STEPPS—an evidence-based team- work system to improve communi- cation and teamwork skills and, in turn, improve safety and quality care. Using the DESC model in conjunction with cognitive rehears- al is an effective way to address specific incivility incidents. (See DESC in action: Three scenarios.)
Other acceptable models exist for teaching and learning effective communication skills and becom- ing conflict-capable. In each mod- el, the required skills are learned, practiced, and reinforced until re- sponses become second nature. Another key feature is to have the learner make it his or her own; al- though a script can be provided, it should be used only to guide de- velopment of the learner’s personal response.
Nurturing a civil and collaborative culture Addressing uncivil behavior can be difficult, but staying silent can in- crease stress, impair your job per- formance and, ultimately, jeopard- ize patient care. Of course, it’s easier to be civil when we’re re- laxed, well-nourished, well-hydrat- ed, and not overworked. But over the course of a busy workday, stress can cause anyone to behave disrespectfully.
When an uncivil encounter oc- curs, we may need to address it by having a critical conversation with the uncivil colleague. We need to be well-prepared for this conversa- tion, speak with confidence, and use respectful expressions. In this way, we can end the silence that surrounds incivility. These encoun- ters will be more effective when we’re well-equipped with such tools as the DESC model—and when we’ve practiced the required skills over and over until we’ve perfected them.
Effective communication, con- flict negotiation, and problem-solv- ing are more important than ever. For the sake of patient safety, healthcare professionals need to focus on our higher purpose—pro- viding safe, effective patient care— and communicate respectfully with each other. Differences in social- ization and educational experi- ences, as well as a perceived pow- er differential, can put physicians and nurses at odds with one an- other. When we nurture a culture of collaboration, we can synthesize the unique strengths that health- care workers of all disciplines bring to the workplace. In this way, we can make the workplace a civil place. �
Cynthia M. Clark is a nurse consultant with ATI Nursing Education and professor emeritus at Boise State University in Boise, Idaho. Names in scenarios are fictitious.
For a list of selected references, visit American NurseToday.com/?p=21641.
22 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com
DESC in action: Three scenarios The DESC model for addressing incivility has four elements: D: Describe the specific situation. E: Express your concerns. S: State other alternatives. C: Consequences stated.
The scenarios below give examples of how to use the DESC model to address uncivil workplace encounters.
Nurses Sandy and Claire At the beginning of her shift, Sandy receives a handoff report from Claire, who has just finished her shift.
“Geez, Sandy, where have you been? You’re late as usual. I can’t wait to get out of here. See if you can manage to get this informa- tion straight for once. You should know Mary Smith by now. You took care of her yesterday. She was on 4S forever; now she’s our problem. You need to check her vital signs. I’ve been way too busy to do them. So, that’s it—I’m out of here. If I forgot something, it’s not my problem. Just check the chart.”
Not only is Claire rude and disrespectful, but she also is put- ting the patient at risk by providing an incomplete report. Here’s how Sandy might address the situation.
Describe: “Claire, I can see you’re in a hurry, and I understand you’re upset because I’m late. We can talk about that when we have more time. For now, I don’t feel like I’m getting enough information to do my job effectively.” Explain: “Talking about Mrs. Smith in a disrespectful way and rushing through report can have a serious impact on her care.” State: “I know we’re both concerned about Mrs. Smith, so please give me a more detailed report so I can provide the best care possible.” Consequence: “Without a full report, I may miss an important piece of information, and this could compromise Mrs. Smith’s care.”
Nurse manager Alice and staff nurse Kathy The anxiety level may rise for a nurse who experiences incivili- ty from a higher-up. The following scenario illustrates an unciv- il encounter between Alice, a nurse manager, and Kathy, a staff nurse.
“Hey Kathy, I just found out Nicole called in sick, so you’re going to have to cover her shift. We’re totally shorthanded, so you need to stay. You may not like the decision, but that’s just the way it is.”
Kathy is unable—and frankly, unwilling—to work a double shift. Exhausted, she’d planned to spend time with her family this evening. Also, she has worked three extra shifts this month. She decides she needs to deal with this situation now instead of setting up a meeting with Alice later in the week. Here’s how she might use the DESC model with her manager.
Describe: “Alice, I can appreciate the need to cover the unit because of Nicole’s illness. We all agree that having adequate staff is important for patient care.” Explain: “I’m exhausted, and because I have recently covered other shifts, I’m less prepared to administer safe, high-quality care.” State: “I realize that as manager, it’s your responsibility to make sure we have adequate staff for the oncoming shift. But
I’d like to talk about alternatives because I’m unable to work an additional shift today.” Consequence: “Let’s work together to discuss alternatives for covering Nicole’s shift. It’s important for me to have a voice in decisions that affect me.”
For a staff nurse, addressing a manager can be daunting. To have a critical conversation with an uncivil superior in an effort to put an end to the problem, you need the courage to be as- sertive. Engaging in stress-reducing and self-care activities and practicing mindfulness can boost your courage so you’ll be prepared. Most of all, you need to practice and rehearse effec- tive communication skills until you feel comfortable using them. A 2014 study by Laschinger et al. found a compelling rela-
tionship between meaningful leadership and nurse empower- ment and their impact on creating civility and decreasing nurse burnout. This study underscores the need for leadership development to enable nurse managers to foster civil work en- vironments. To create and sustain a healthy environment, all members of the organization need to receive intentional and ongoing education focused on raising awareness about incivil- ity; its impact on individuals, teams, and organizations; and most important, its consequences on patient care and safety.
Nurse Tom and Dr. Jones This scenario depicts an uncivil encounter between a nurse and a physician.
Tom is concerned about Mr. Brown, a patient who’s 2 days postop after abdominal surgery for a colon resection. On the second evening after surgery, Mr. Brown’s blood pressure increases. Tom watches him closely and continues to monitor his vital signs. As the night wears on, Mr. Brown’s blood pressure continues to rise, his breathing seems more labored, and his heart rate increases. Tom calls Dr. Jones, the attending physician, to report his find-
ings. Dr. Jones chuckles and says, “He’s just anxious. Who wouldn’t be in his condition?” and hangs up. Undaunted, Tom calls back and insists Dr. Jones return to the unit to assess Mr. Brown. Reluc- tantly, Dr. Jones comes to the unit, peeks into Mr. Brown’s room without assessing him, and chastises Tom in front of his col- leagues and other patients about his “ridiculous overreaction.” Tom politely asks Dr. Jones to meet with him in an empty meeting room. Here’s how Tom uses DESC to address the situation.
Describe: “Dr. Jones, I’d like to explain something. Please hear me out before you comment. I am a diligent nurse with exten- sive patient care experience.” Explain: “I know that as Mr. Brown’s attending physician, you’re committed to his safety. I assure you that everyone on the healthcare team shares your concern, including me. I called you immediately after determining persistent and no- table changes in Mr. Brown’s vital signs.” State: “Because we are all concerned about Mr. Brown’s care, it would be best if you conducted an assessment and addressed me in a respectful manner so we can provide the best care possible. I will show you the same respect.” Consequence: “Disregarding important information or allow- ing your opinion of me to influence your response could com- promise Mr. Brown’s care. We need to work together as a team to provide the best care possible.”
www.AmericanNurseToday.com November 2015 American Nurse Today 23
Please mark the correct answer online.
1. The American Association of Critical-Care Nurses does not identify which of the following as a characteristic of a healthy workplace?
a. Skilled communication b. Informal leadership c. True collaboration d. Meaningful recognition
2. A healthy work environment requires:
a. civility conversations at the highest level of the organization.
b. emphasis on formal rather than informal leadership.
c. shared organizational vision, values, and norms.
d. individualized values and norms.
3. When considering whether to have a challenging conversation, which key question should you ask yourself?
a. Is the person I need to talk to a full- time employee?
b. Do I have enough experience to have the conversation?
c. How many years have I worked at this facility?
d. What will happen to the patient if I stay silent?
4. Which of the following helps to create a safe zone for a challenging conversation?
a. Agreeing on a mutually beneficial time to meet
b. Having the conversation in the presence of patients
c. Having the conversation in the presence of family members
d. Choosing a time immediately after the other person’s shift
5. If a power differential exists between you and the other person, an effective approach is to:
a. keep the matter between the two of you.
b. have a third party present. c. have a security officer attend the meeting.
d. refrain from having the conversation.
6. Which of the following is an appropriate action during a challenging conversation?
a. Interrupt as needed. b. Talk quickly. c. Cross your arms. d. Maintain eye contact.
7. The first step of cognitive rehearsal is:
a. describing your position in objective terms.
b. rehearsing specific phrases to use during uncivil encounters.
c. undergoing didactic and interactive learning and instruction.
d. having a practice session to reinforce instruction and rehearsal.
8. What is the first element of the DESC model?
a. Describe the specific situation. b. Discuss your concerns. c. Define your solution. d. Detail the alternatives.
9. What is the last element of the DESC model?
a. Coordinate your response. b. Consider the setting. c. Consequences stated. d. Concerns stated.
10. Which statement about challenging conversations is correct?
a. Nurses have an innate ability to have these conversations.
b. The person who called the meeting should dominate the discussion.
c. Agreeing with the other person’s message is important.
d. After the resolution, the participants should schedule a follow-up meeting.
POST-TEST • Conversations to inspire and promote a more civil workplace Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/
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ANA Center for Continuing Education and Professional Devel- opment’s accredited provider status refers only to CNE activi- ties and does not imply that there is real or implied endorse- ment of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the activity. The author and planners of this CNE activity have dis- closed no relevant financial relationships with any commercial companies pertaining to this CNE. See the last page of the article to learn how to earn CNE credit.
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