ATI 0001 Beyond bullying: The Serious Impact of Incivility in Nursing

] Welcome to the first episode of ATI's series on civility and nursing. I'm Gina Kellogg, the senior manager of marketing content strategy for ATI. We are extremely lucky today to gain some insights from Dr. Cynthia Clark. Many of you may know Dr. Clark as the world's leading expert on fostering civility and healthy work environments. Her research has proven that when incivility exists, it puts both nurses and patient safety at risk. Dr. Clark has built her reputation on decades of research into the topic of civility. Most recently she's focused on examining effective ways of preparing nursing students and addressing incivility in both academic and practice settings, and this is a topic gaining greater momentum in today's world.

] Dr. Clark, thank you for helping us better understand this issue. Let's start by asking you to explain why nursing faculty must address civility with their students. Why must students be taught about civility?

] Sometimes students come to us without a clear realization of how their behaviors might impact other people. What's expected of a professional nurse? What does it mean to advocate for patients? What does it even mean to communicate within the healthcare setting in the patient care environment? And so, a lot of times, we just need to really engage our students in conversation about what it means to behave in ways and interact in ways that are respectful, that speak to being a strong role model, to advocate for patients -particularly in patient safety situations. So, to your question about why is it important for faculty to address this, at the end of the day, it really comes down to patient safety. That, if our behaviors aren't expressed in ways that -- again -- are respectful, and if we are unable to advocate or call the question in a patient care situation, then somebody could be injured. Patients can actually die.

] I'm sure students can understand how incivility impacts them, but they may be less familiar with how it impacts patients. What are the aspects students need to understand in regard to patient care.

] Well, again, you know, coming back to this idea of advocacy, of speaking up, of having the skills and -really -- the moral courage to address situations, particularly if you're new to the profession or you're in the student role -- you know -- how do I find that courage to speak up? To stand up? To advocate when my patient needs me to do that -- especially if you're surrounded by healthcare professionals who have been in the business a very long time? Sometimes, there's an intimidation factor around seasoned nurses or our physician colleagues or others. So, at the end of the day, we need to really understand that the patient safety issues are really critical to us learning and mastering some of these skills.

] What are some of the techniques an educator can use to help their students develop that kind of courage?

] Yeah, it's a great question. So, one of the techniques that's really steeped in evidence and is gaining a lot of momentum and -actually -- a teaching strategy that I've been using probably since about, I want to say, about 2008 -- so for at least 10 years -- and it's called cognitive rehearsal. Cognitive rehearsal essentially consists of about five different steps. So, the first step is to think about what preparatory material do I need to have my students learn before we take on this learning experience? What kind of prebriefing do they need to learn about this concept? So, let's say we're talking about incivility or, you know, disruptive healthcare settings or academic environments -- whatever that might be. What do we need to know about that topic? Because, essentially, what cognitive rehearsal does, it comes to us from behavioral science. And it makes some assumptions, and some of the assumptions -- and I'll go back to the steps in a moment -- but some of the assumptions that it makes is that any of us, if we anticipate that we're going to be in a certain situation -- particularly if it's stressful or, in this case, may be uncivil or really disruptive or maybe even intimidating. So, if we think about that before it happens, and sort of consider, "What's that going to look like? Who might be there?" Let me put it in sort of a layperson's example. So, I'm the mother of three children. Our oldest child is an engineer. He works for a private engineering firm, and there came a time when he really believed it was time to ask for a raise. So, kind of stressful, right? Young man, asking for a raise. So, if he thinks about using cognitive rehearsal, one of the things he can do is go, "Okay. What might that meeting look like? Who's going to be there? Where will it be? Will it be private? Will there be people passing by? Is it an office that's just partitioned or is it, you know, more secluded? What will that look like?".

] So, there's some thinking about that situation. Now I begin to go, "Okay, how do I prepare for that kind of stressful ... What are some things I can say? How might I script it?" And I don't mean being scripted but to sort of script through your mind. What am I going to say when I get to that meeting? How might I tee this up for success? What might that interaction go like if I anticipate what my boss might say? And I've practiced doing that, and I've been coached a little bit by somebody in this cognitively rehearsed experience, and I practice, practice, practice with good coaching, and I debrief that a little bit, the likelihood -this is the belief using cognitive rehearsal -- that the likelihood of that going well is heightened. Makes sense. So, when we're doing it with students for incivility, or I've done it with physicians and nurses and, really, you know lots of different people. But, in the case of incivility, we think about, "What are some scenarios you might find yourself in?" And we think about and we role play those, and we practice those. "What am I going to say if I'm faced with this type of situation? How can I frame that? How can I approach that?" So I find that courage to speak up on behalf of my patients. And then being able later to debrief that.

] So, I know that's a kind of a long way to get around it. But giving students that ability to practice is essential. So, let me give you one more thought about that. So, if I were to ask a group of nursing students -let's say I have 100 nursing students. "Think about the very first time you started an I.V." And I do this a lot when I'm meeting with students. "Raise your hand if the very first time you did it, you were perfect at it. You did not breach sterile fields. You hit that vein. Everything was perfect. Patient was happy. How many? Raise your hand." And, of course, almost no one raises their hand. I wouldn't raise my hand if I think back on my first skills. Same thing with a Foley catheter insertion. How many of us got that perfect the first time? No hands. Or maybe one go up. Then I say, "How many now, at the end of your nursing program, feel like, 'You know what? I could do that with a level of competence.'" Lots more hands go up, right? So, the question then becomes: How did you get from no hands going up to at least a large number of hands going up -- or halfway up if they're students. And, of course, the response is practice. They've practice. They've gained experience. They've done it over time.

] So, my belief is, if we need that much kind of deliberate practice for psycho motor skills, we probably need that same experience when we're talking about resolving conflict. Communicating effectively-particularly if it's a surgeon who's pretty mad.

] How do we do that? Practice, practice, practice, and coaching, and debriefing.

] So you had talked about five specific aspects of using cognitive rehearsal effectively. Can you discuss those in more detail?

] Yes. So you would want to, again, go back to sort of, "What is that preparatory work that needs to be done to learn about the concept in this case?" So, incivility or civility, and then the next thing you would do -So maybe there would be some readings. Or maybe there's a lecture at that I might do as a professor. But there could be some way of helping the students sort of get their gray matter in the game. The next thing we're going to do is think about some scenarios. What are some of those potentials or real scenarios that could happen next? We say, "Okay, let's think about applying some evidence-based approaches to responses I might give in those scenarios." Practice, practice, practice, practice, practice -- with coaches and, then, the final one being debriefing. Let's debrief that through our coaching experience.

] That is great advice. But now you have to tell us what happened with your son.

] My son, first of all, felt very prepared, as much as he could. And, yes, he did get a raise. And he also got a little bonus at the end of the year. So he felt pretty confident going into that experience.

] Well, we've run out of time. But thank you so much, Dr. Clark, for sharing your expertise.

] We've covered quite a lot today, from what students don't understand about and why they must due to its impact on patient safety. We also got some great advice on how to use cognitive rehearsal to improve our communication skills. And we've got an example of how effective it is with your son's personal experience.