Transcript Slide 1

Combining the Power of Simulation and
Cognitive Rehearsal to Foster Civility in Nursing
Cynthia Clark PhD, RN, ANEF, FAAN
2015 ATI Nurse Educator Summit; San Diego, CA
Clark 2015 ©
Gratitude!
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Today’s Objectives
 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
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).
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Continuum of Incivility
Distracting,
annoying,
irritating
behaviors
Aggressive,
potentially
violent
behaviors
Lower Level
of Incivility
Disruptive Behaviors
Higher Level
of Incivility
Threatening Behaviors
Behaviors range from:
non-verbals sarcasm bullying racial/ethnic slurs intimidation mobbing physical violence tragedy
(eye-rolling)
Clark © 2009, revised 2013, 2014
Scaffolding Uncivil Behavior in the Workplace
Mobbing
• Extreme form of intentional and collective [group]
bullying behavior aimed at marginalizing,
excluding, or expelling another
Bullying
• An intentional pattern of abusive, threatening, or
demeaning behavior designed to intimidate,
degrade, and humiliate another
Incivility
• Rude or disruptive behavior often prompted by
thoughtlessness rather than malice. Generally
considered to be a 1:1 experience and perceived
to be less threatening than bullying or mobbing
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).
Common Incivilities
Withholding important information
Non-verbal affronts and gestures
Failing to use basic manners
Using anger and intimidation
Spreading rumors and gossiping
Failing to support a co-worker; setting up to fail
Neglecting, marginalizing or excluding a co-worker
Breaking confidences
Name calling, put-downs, and sarcasm
Encouraging 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
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Nursing Codes 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 (ANA Code of Ethics, 2015)
Inherent in nursing is the respect for human life, including cultural
rights, the rights to life and choice, to dignity, and to be treated
with respect (International Code of Ethics for Nurses)
Four fundamental responsibilities
To promote health
To prevent illness
To restore health
To alleviate suffering
QSEN
Teamwork and Collaboration Competency
Function effectively within nursing and inter-professional teams, fostering
open communication, mutual respect, and shared decision-making to
achieve quality patient care
Safety Competency
Minimizes risk of harm to patients and providers through both system
effectiveness and individual performance
http://www.qsen.org
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The Essentials of Baccalaureate Education for
Professional Nursing Practice (2008)
Essential VIII: Professionalism and Professional Values
Professionalism 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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Negative Impact On:
Patient Safety and Quality Care
Recruitment and Retention
Morale and Collegiality
Job Satisfaction—Intent to Leave
Relationships and Teamwork
Quality of Services
The ‘Bottom Line’
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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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• Year 5: Sp 2013-Fall 2013
• Comprehensive Civility Curriculum
• Year 4: Sp 2013-Fall 2013
• Student-Produced YouTube video
• Year 3: Sp 2012-Fall 2012
• Live actors from the SON
• Year 2: Sp 2011-Fall 2011
• Live Theater Actors
• Year 1: Sp 2010-Fall 2010
• Written Case-Based Scenario
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:
Griffin 2004; Griffin & Clark, 2014
1. Learning and didactic instruction
2. Rehearsing specific phrases to use during uncivil encounters
(creating and preserving a personalized statement)
3. Practice sessions to reinforce instruction and rehearsal
V
C
I
I
L
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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
coworker
That'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 information
I 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 humiliate
I 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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TeamSTEPPS
Team Strategies and Tools to Enhance
Performance and Patient Safety
An evidence-based teamwork system to
improve communication and teamwork skills
among health care professionals.
CUS Model
Concerned
Uncomfortable
Safety
http://teamstepps.ahrq.gov/
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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.”
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Nurse Incivility PBL Scenario
Actors: 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 staff
Situation: 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.
Probing Question
Assume you are a nurse being treated
uncivilly; using the CUS model, write a
response to diffuse an uncivil encounter.
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Example from Dr. Clark’s Class
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.
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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
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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
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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10-Month Follow-up Study—February 2012
(Year 3)
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]
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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 feel
as though it isn’t my place to say anything regarding the
incivility.”
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Question 5: What personal or professional rewards have
you received by using the knowledge you learned in class?
10 of 18 (56%) reported benefits/rewards
• Themes:
• Role modeling and collegiality
• Communicating more effectively
“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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Summary
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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What’s Next?
Future Directions
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Cognitive Rehearsal Intervention Study Using
Biomarkers and Simulation
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Thank You
C
I
V I L
I T Y
Cynthia (Cindy) Clark PhD, RN, ANEF, FAAN
Nurse Consultant: ATI Nursing Education
Professor and Founder of Civility Matters©
[email protected]
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