31 March 2015

Life sentence

My beautiful, intelligent, activist, mildly irreverent, and—may I add—favorite Aunt Ellen died peacefully a few weeks ago, following a valiant battle against cancer. As her loved ones gathered, we witnessed her painful, wrenching, lingering death sentence play out in sometimes despicable ways and, at other times, amazingly beautiful ways. While cancer dealt my aunt a sentence of death, it is her “life sentence” that provides the context for this post.

My aunt faced death with unwavering courage, staying strong and resolute as she waged a fearless crusade against an ugly and detestable enemy she knew, ultimately, she could never defeat. Her fervent wish was to forgo an official memorial service. Instead, she wanted to live her final weeks and days engaged in intimate dialogue about her legacy and how her time on earth made a difference in the lives of those who loved her most. Neither she—nor we—were to be denied fulfillment of that desire.

But how would we go about doing this? How would we gather memories and impressions from countless members of our large Irish Catholic family, located far and wide around the globe, that would capture in words the impact of my aunt’s life? It was my cousin—Aunt Ellen’s daughter—who came up with an incredible and meaningful way to document the impact of someone so deeply and dearly loved. Considering that time was of the essence, her idea was an incredible way to chronicle a life well lived.

No more than six words
My cousin asked each of us to consider the following question: “How could we capture the essence of Aunt Ellen’s life—her legacy—in a single “life sentence” of six words or less?" Wow, this seemed like a nearly impossible mission! To get us started, my cousin asked us to reflect on a “story” by Ernest Hemingway who wrote “For sale: Baby shoes. Never worn.” In six words, Hemingway illustrated how an entire story could be told using only a half-dozen words. Hemingway believed you don’t need a lot of words to tell a story and demonstrated that six words can be sufficient.

They say flowers are for the living. So are loving words.
Ruta Saulyte-laurinaviciene/Hemera/Thinkstock

Using Hemingway’s story as an example of brevity, my cousin asked each of us to describe the impact of my aunt’s life. How were we changed by having Aunt Ellen in our lives? What was our unique connection with her? What did we remember most about her life? Six words, just six measly words.

74 years, six words
My cousin wanted to receive our responses within three days so she could share them with her mother as she lay dying. How do you sum up an entire life of 74 years in a few words? And how do you do that for someone who is still alive, knowing that your words will be shared and discussed with that person? While no single truth or perspective can summarize an individual’s life, a collection of them, written by various people—spouse, son, daughter, grandchild, niece, nephew, brother, sister, friend, neighbor, student, and others—offers a surprisingly meaningful portrayal of a life well lived. My aunt was adamant that, when the time came, she did not want us to dwell on her death. Rather, she wanted us to remember how she lived.

My cousin collected hundreds of reflections, encapsulated in no more than six words, that described her mother’s life. We discovered, to our collective amazement, that, when taken together, these pithy phrases truly expressed the multidimensional layers of my aunt’s life, providing a beautiful and loving mosaic.

Below is a sampling of the responses my cousin received and shared with her mother, who, elated and humbled by the outpouring of love, savored our words as she took her last breath. Later, my cousin told us that her mother laughed, cried, and ultimately took her family for a walk down memory lane as she added details to the quips we provided.

And the Oscar goes to, Ellen!
Mom: The house that built me
A mosaic of love and sassiness
She’s always a woman to me
(as sung by Billy Joel)
Danced to her own drummer
Fierce champion for children and animals
Taught me to love butter again
Petite stature, giant heart, tender soul
Keep your elbows off the table
Growing old is optional
More complicated than a Rubik’s cube
A life lived in confident rebellion
Always question the status quo

Perhaps my sister summed it up best when she said our aunt was surrounded by those who loved her most, she was content in knowing she was loved completely, her life mattered, and a sacred place is held for her in heaven. Privy to our myriad warts and wrinkles, she loved us nonetheless.

One day, a phrase will be uttered, a music lyric will be heard, an old movie will be watched, a dog will leap with joy in the presence of his human, or a young woman riding freely on her horse with the wind in her hair will remind us of Aunt Ellen, and we will be filled with laughter and joy! That’s when the healing will begin and the pain will lessen.

Family and friends are our biggest supporters and our most sought-after rescue in a storm. Maybe these six words will summarize this post: Rest in peace. You’ve earned it.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

10 February 2015

Our daughter called today

Our daughter called today. She is a somewhat newly graduated nurse, having completed her nursing degree just a little over three years ago. Since then, she has been working on a very busy oncology unit, caring for extremely ill patients with medically challenging conditions. Her recent need to share stemmed from events surrounding a young mother dying from advanced and untreatable breast cancer.

The health care team had worked tirelessly, trying to control the patient’s agonizing pain with little success. It took nearly an entire 12-hour shift for a team of oncology experts to find the right combination of pain medication and comfort measures to help the patient find relief. To make matters worse, the patient’s husband was so compromised by the experience that he suffered a cardiac event and was rushed to the emergency department. He was later admitted to the hospital for his own health issues.

Mom?
Our daughter was profoundly affected by the day’s events and needed to debrief to gain a deeper understanding of what had happened and to decrease her stress level because, the very next day, during her next shift, the stress of caring for very ill patients with complex issues would begin anew. We talked for the better part of an hour, discussing effective ways of coping, managing stress, and engaging in self-care.

Alliance/iStock/Thinkstock
The conversation with my daughter took place just one day after a nurse with 43 years of experience disclosed to me that she had abruptly handed in her keys, cleared her locker, and, without giving notice, had walked off the job at the end of her shift. She had simply “had enough” of dealing with an incompetent and bullying nurse manager, who seemed to care little about the nurses under her supervision.

With tears in her eyes, this seasoned and highly experienced nurse explained that, while she enjoyed the work and caring for her patients, what she couldn’t abide was working for a manager who demeaned her and her colleagues—sometimes even the patients. Though we had just met, she poured her heart out as I offered an impartial ear. She said that she missed the work, but the stress of the job was killing her. Sadly, she is yet another casualty of workplace incivility.

A soft place to land
On the surface, these stories seem unrelated, but they are bound by a common theme: The work of nursing—regardless of the setting—can be very stressful and demanding. Each of us needs a “soft place to land” and a caring mentor with whom we can share our worries and concerns; someone with whom, when needed, we can speak the unspeakable, to help us sort things out so we can clear our heads and refresh our commitment. All of us need mentors and other caring individuals who can lend support and offer sage guidance and experience-based wisdom. Being a nurse is hard work and certainly not for the faint of heart. Nursing requires fortitude, compassion, and a commitment beyond what most people ever possess.

Think about it from the perspective of a newly graduated nurse, or even from the viewpoint of an experienced nurse, for that matter. The life of a nurse is challenging. Minute by minute, nurses deal with life and death situations that affect not only the patients they care for, but their families and loved ones and, ultimately, the nurses themselves. After talking with our daughter and the seasoned nurse who quietly walked away from a profession she loves, I came away from those conversations absolutely convinced, once again, that we must provide a nurturing place to debrief and a safe space to express the myriad emotions that nurses experience every day when caring for others. In caring for others, they often forget to care for themselves. It is important for each of us to reach out to one another and listen—I mean really listen—to the voices of our colleagues and to provide that soft place to land.

Debriefing for perspective
Sharing our nursing experiences provides a platform for collective understanding, improves problem-solving, and builds collegiality, collaboration and teamwork. Nurse managers must be especially alert to the need for debriefing members of their health care team. Often, the mood of staff members following a critical incident will indicate the need for pulling the team together to process the event. But, in my experience, debriefing and the cathartic need to share often are most effective when the nurse is out of the immediate situation and away from the stressful pace of the work environment. Once home, he or she is more mentally ready to process the day’s events.

Having a mentor or colleague to discuss feelings and concerns helps facilitate critical reflection on our nursing practice and helps nurses find continued—often, lasting—meaning in their work. So reach out to your colleagues and listen with an open heart. Maybe, just maybe, they will return the favor when you need it most.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

08 January 2015

Pursuing the promise of a new year

I woke up on New Year’s Day morning with a sense of renewal and rejuvenation, just as it is supposed to be at the dawn of a new year. It was a glorious day in the high desert of southwest Idaho, frosty, nippy, and fantastically sunny!

Winter birds gathered around the feeders, and multiple coveys of quail feasted merrily on wild birdseed distributed along the back fence as both human and furry friends warmed themselves near the living room’s toasty fireplace. As I gazed out the window, enjoying a freshly brewed cup of Italian roast coffee and sharing quiet moments with my husband, my mind wandered to the promise of a new year.

For many, New Year’s is a time of letting go of the past and looking toward the future and some of us make New Year’s resolutions. Sometimes, we are successful in keeping resolutions throughout the year, and other times, we maintain them for only a week or so. Some people don’t make resolutions at all. Commonly made commitments include losing weight, saving money, reducing stress, organizing closets, and getting more sleep.

Focused and simply stated
While these are all worthy goals, the resolutions I have been most successful in maintaining are those that are well aligned with my personal, professional vision of the future. For example, each year, I make one personal and one
professional (or work-related) resolution. I like to keep them focused and simply stated so that each reads like a mantra. That way, I am more likely to be reminded of my resolutions and more motivated to achieve them as the days, weeks, and months pass.

I often say, if your resolution is pithy enough to fit on a coffee cup or T-shirt, you’re more likely to remember it and remain inspired. For example, my personal resolution for 2015 is: Be grateful everyday. This means I need—and want—to pay attention to the blessings in my life and live as much as possible in a state of gratitude, knowing that, if I do this, I will likely accomplish other important goals, such as being present, living a healthy life, valuing relationships, and reducing my overall stress level.

For my professional resolution, I aspire to: Make a meaningful difference. To make a difference to my team, organization, and the people we serve, I must be thoughtful and mindful, so that my contributions add value and make a positive impact. As with my personal resolution, achieving this goal helps me achieve other goals. My work with faculty members, students, and nurses will thrive, and my writing and presenting will create positive momentum and change.

Passion and purpose
What are your New Year’s resolutions? If you are focusing on one or two goals in 2015, be sure they stem from a sense of passion and purpose and fit with your personal, professional vision of your future. Set goals based on something you love, not on something you dread. For example, if you love to write, make a commitment to submit at least one paper for publication, or write an editorial for your local newspaper. 

If your goal is somewhat lofty, break it down into achievable measures, and celebrate each accomplishment along the way. Creating resolutions based on issues that really matter to you will likely result in accomplishments that positively influence your workplace, your community, and your life. Certainly, there will be setbacks and days when we fall short of our goals. We must be prepared to put those days in the rearview mirror, look forward to the future, and strive to make the next day even better.

Celebrate success
So, whether it’s starting a new workout regime, nutrition plan, or organizing your office, do not expect complete and immediate results. Set achievable short-term goals that can be accomplished along the way, and celebrate them with gusto! Perhaps you can make a small sign to hang next to your work area, or use your smartphone to send yourself daily reminders or inspirational quotes that help you achieve your goals. However, the way you choose to remind and motivate yourself to accomplish your goals is less important than celebrating short-term wins and keeping the momentum going.

Real change takes time and commitment to the long term. If you struggle with self-doubt, keep a journal of small and large accomplishments, and periodically reflect on them to keep you motivated and moving forward. Consider sharing your resolutions with others. This makes them more real, more likely to be accomplished. Garnering support from family, friends, and colleagues can help you reach your goals, but be aware of individuals who may sabotage your efforts and keep you from making progress.

My genuine and sincere hope for all of you is to have a fulfilling and memorable 2015! Stretch yourself to experience the joy that awaits, and know that a few speed bumps may lie in your path, but, as Albert Einstein stated, “A person who never made a mistake never tried anything new.”

Happy New Year!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

26 November 2014

Showing gratitude. What a gift!

During one of my recent traveling adventures, I was browsing a bookstore in the Minneapolis airport. As I approached the checkout stand to make my purchase, I was pleased to see a generous stack of P.M. Forni’s book Choosing Civility (2002) piled high and prominently displayed right next to the cash register. I was delighted to see that the topic of civility is one that still resonates with readers. It is my hope that the concept will continue to be a focus of attention, not only in nursing and health care, but in American society and beyond.

One of my favorite quotes by Forni is, “When we are on the receiving end of an act of civility, we feel validated, valued, and it gives our life meaning.” If you prefer a more colloquial version of this observation, you may enjoy a quote from Mark Twain who quipped, “I can live for two months on a good compliment.” Whichever quote strikes you most, each author makes a similar and compelling point—that we feel valued when we are recognized and appreciated by others.

Reflect for a moment on a recent or past experience when you felt affirmed and validated. Perhaps the affirmation came from a co-worker, student, family member, supervisor, or friend. As you contemplate the affirmation, consider the thoughts and feelings associated with the experience. My hunch is that they are enjoyable and pleasant. That’s because affirmations and words of encouragement add meaning to our lives and can lift us up during challenging times. They are like a port in the storm or a buoy on the choppy ocean. They situate us in the sweet spot of contentment. Unfortunately, when the opposite happens and we are treated rudely with disdain or disrespect, we feel dismissed, diminished, unimportant, and insignificant.

iStock/Thinkstock
During one of my recent workshops, a nurse in the audience commented that the effects of incivility last far longer than the two months of gratification cited by Mark Twain. The nurse observed that the impact of incivility can be crippling, while a genuine affirmation penetrates like a warm, welcoming, soothing salve.

A few months ago, just before our youngest daughter left to study at a university in England, we were visiting one evening—simple family talk, really—when she gazed at me for a moment, and declared, “You know what, Mama? You have always been a good mama, but I want you to know that I think you are also a very impressive woman.” Wow! What an unexpected and always-to-be cherished affirmation. Since her departure for Europe, I have reflected on that sweet, yet powerful pronouncement, and it lifts my spirits every time.

Like me, you have received affirmations that you treasure and hold onto tightly. But I wonder how many of us have to ponder a while to recall a time when we felt affirmed and validated. It’s perplexing that, while we know how great a positive comment feels, we are slow to affirm others—even those in our closest circle for whom we care the most. For whatever reason—busyness, stress, lack of face-to-face connection, or believing that a real “thank you” costs money—we often miss opportunities to affirm others. I would like to suggest several ways to acknowledge and express gratitude that cost very little, yet render high-impact results.

Smiling and greeting others by name can go a long way in helping colleagues and students feel welcome and significant. Make a point to say ”Good morning,” or extend a similar greeting as you go about your day. As Lady Mary Wortley Montagu reminds us, “Civility costs nothing, and buys everything.” Say “Thank you” often, and offer praise in front of others. Be specific with your praise. It’s good to praise, even when you express it in general terms, but it’s better to be specific, and it’s best to extend praise beyond the confines of the current setting.

Suppose you are a nurse working on an oncology unit. You have just put in a very long day attending to very ill patients, many of whom suffer from terminal conditions and are receiving palliative and end-of-life care. You are an attentive and compassionate nurse, but clearly exhausted and ready to go home. Just as you are leaving the unit, your charge nurse approaches you and says, “Great job today! I really appreciate you.” Obviously, this comment feels good—in fact, it might feel very good.

Now, what if your charge nurse is a bit more specific with her feedback and addresses you by saying, “Chris, I am so impressed with the care you provided today. I especially appreciate how you collaborated with Dr. Bailey to find the right combination of medications to relieve Mrs. Jones’ pain. Her family is deeply grateful, and because of you, she is going to have a restful night. Thank you for being such a great nurse. You are a valued member of the team.” Wow, what an incredible message! It’s specific, unambiguous, and, clearly, your charge nurse is appreciative and observant. You will likely remember this personal affirmation for a long time.

What if we take this expression of gratitude one step further and elevate the message beyond the work setting? In his book, Creating Magic: 10 Common Sense Leadership Strategies from a Life at Disney, Lee Cockerell (2008), former executive vice president of operations at Walt Disney World Resort, suggests sending a note of recognition to a family member. For example, in the above situation, the charge nurse might take a few minutes to mail a handwritten thank-you note to your family member or significant other that reads something like this: “Dear Terry, I want to take a moment to let you know how much we appreciate Chris. She is a caring, talented, and gifted nurse who takes great pride in the care she provides for every one of her patients. She is a joy to work with, and I can’t begin to fully explain how much she means to our team, and most especially to our patients and their families. Thank you for sharing her with us. She is a very special person.”

Now that is a powerful message! It’s a low-cost reward with high-impact results. And it takes only a few minutes of time and the price of a postage stamp. There are many other creative ways to say thank you. We can treat a colleague to lunch, leave a note of appreciation on their car or in a public place; give them a lottery or movie ticket or a gift card to their favorite coffee shop.

Shortly after delivering a plenary address at a nursing conference where we discussed the power of acknowledging others, I was approached by a nurse who shared a personal experience. She said, “I have worked in the neonatal intensive care unit for 16 years. Every day, I come to work, caring for very sick babies and tending to families terrified of losing their greatest treasure. Many of our babies don’t make it, and the toll it takes on the people in their lives is nearly unbearable. 

So, a few years ago, I started a support group. It is a safe space for loved ones to share thoughts and feelings and, in many cases, to express the pain of their devastating loss. I facilitate the group on my own time, but it is worth every minute. While my teammates appreciate what the group means to families, for years it went largely unnoticed by my manager and others throughout the hospital. But, of course, I wasn’t doing it for the recognition.

“And then one day, a colleague showed me a brief write-up in the hospital newsletter. On the front page of the newsletter was a short paragraph describing the support group and the positive impact it was making on the families of our babies. One of the families had sent a letter to the CEO expressing their gratitude for the support group. I had no idea, but there it was in black and white on the front page of the newsletter! My name was even mentioned! I decided right then and there, I can do this another 16 years!”

Let this holiday season begin a long tradition of inspiring others by affirming their value and giving them the glorious gift of gratitude.

Reference:
Cockerell, L. (2008). Creating Magic: 10 Common Sense Leadership Strategies from a Life at Disney, New York, NY: Double Day Publishing Group.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

14 October 2014

It was the nurses!

Last month, I had the privilege and high honor of delivering the endnote address to hundreds of neonatal nurses who attended the 30th Annual Educational Conference of the National Association of Neonatal Nurses (NANN). Asked to speak on the topic of civility and healthy workplaces, my presentation was titled “Igniting the power and passion of civility in nursing: Creating healthy workplaces.

My objectives were to emphasize the imperative of fostering civility in nursing and provide several evidence-based, ready-to-use strategies for creating and sustaining healthy workplaces. The organizers of the conference asked that I deliver a message of optimism and highlight positive aspects of transforming practice environments, a request that fit easily and comfortably with my views on the topic. Clearly, the dedicated, hardworking nurses in attendance wished to end the conference and return to their busy, high-stress working places refreshed and invigorated by a message of hope and inspiration. I was determined to do just that, because they deserved my best.

What the organizers didn’t know—and what I chose not to disclose until the day of the event—is that, just over 30 years ago, I was the mother of a high-risk infant, a baby who spent nearly two months in a neonatal intensive care unit. Conceived during a northern Illinois winter, known for its frigid, tundra-like conditions, my firstborn child was due to be delivered in early August, associated in our hemisphere with sunny summer days. Who knew, instead, he would enter the world in the spring, almost 10 weeks before his due date?

Eric’s story is one I had never shared outside our family and close circle of friends, and, as I prepared for the NANN conference, I wondered if the moment had finally arrived to share a small piece of Eric’s early beginnings. There would likely never be a more fitting audience than this group of exceptional neonatal nurses, so, with Eric’s permission, I closed my endnote address by sharing this story. After all, had it not been for the unwavering, exceptional care provided by the entire NICU team, especially the nurses, Eric might not be with us today. One of NANN’s core values is advocating for quality patient and family care. Eric's neonatal nursing team took this value very seriously and lived it—every minute of every day.

I was young and inexperienced. I read just about everything I could on the topic of pregnancy, and talked with my mother and grandmother frequently about my pregnancy and pending delivery. Like most young mothers, I was thrilled and a bit fearful—all at the same time. Most of my pregnancy progressed normally, but long before the due date, I began to feel sluggish and nauseated. I became quite edematous and easily fatigued. I kept thinking something was wrong, so I visited my physician, who assured me I was fine. Somehow, I knew that wasn’t true, but I forced my worries to the back of my mind and allowed myself to think only about delivering a healthy child. In my way of thinking, if I thought it, it would happen.

When it became evident Eric would be coming much too early, I was rushed—following a flurry of examinations and ER visits—to a nearby medical center that boasted an excellent neonatal intensive care center. I remember arriving terrified. Immediately, I was swarmed by members of the medical team, all of them trying to determine the best course of action. Tests were run, examinations completed, and consultations made, all in a hurried attempt to save Eric’s life. Specialists agreed that the only chance Eric had of surviving was to prepare me for vaginal delivery.

Tests had determined that Eric suffered from a rare condition that included an in utero bowel perforation, an enlarged liver, and gross abdominal ascites, so we knew going into the delivery room that the odds for his survival were poor. The delivery room was packed with nurses, physicians, medical students, respiratory therapists, and just about anyone else who might be needed to save our baby’s life. The delivery itself was excruciating, and the level of infection I incurred post-delivery kept me hospitalized for nearly two weeks. But the real story is about Eric. A tiny, vulnerable infant, his Apgar score was 1, but only because he had a weak and thready pulse.


Eric then—a tiny, vulnerable infant with a weak and thready pulse.
He was rushed to the OR, where surgeons fought to save his life, conducting a procedure so revolutionary it had only been performed twice before. Chances of Eric’s survival were grim, particularly when, six days later, his bowel reperforated in another area of the colon. Over the course of the next 10 weeks, I experienced a roller coaster of emotions—fear, hope, worry, and yes, a love so deep it is unexplainable—all juxtaposed, layer upon layer. Through it all, the nurses—yes, those glorious, wonderful, highly skilled nurses—took care of every one of us, not just Eric, while our devoted family and friends stood vigil, hoping and praying for Eric’s health and recovery.

It was the nurses who, day in and day out, held my hand, accepted my tears, and encouraged me to never give up hope. It was the nurses who loved my son nearly as much as I did and inspired me with stories of other babies who had graduated from the NICU and were living healthy lives. It was the nurses who gave me hope, who never grew tired of my need to talk, who found a way to help me through every second, minute, and hour of each challenging and exhausting day. And finally, it was the nurses who helped me prepare for that most glorious of days—taking our son home. I have never forgotten, nor will I ever forget, the kindness, caring, and dedication shown to our son, our entire family, and me. Because of the nurses, our son is alive today and leading an incredible life. Though he has some physical limitations and lasting deficits, none of them has affected Eric’s beautiful and brilliant mind. He has earned a master’s degree in civil engineering and works as a professional environmental engineer. He is funny, witty, highly intelligent, and an incredible role model, not only for his two younger sisters but for all who have the privilege of knowing him.
Eric today—an environmental engineer with a
master's degree in civil engineering.
I told this story to the audience of neonatal nurses at the NANN conference for the sole purpose of expressing my deepest gratitude for the tireless and important work they do every day. I shared the photos included in this blog to illustrate the incredible life that Eric now leads largely because of their efforts. I also shared with them a note, written in Eric’s voice, that we gave to his nurses the day we finally left the NICU. It’s funny, but I still have the original note. Why, you might ask. It's because Eric’s thoughtful, unselfish nurses made a copy of the note for their notebook and returned the original to me, knowing that someday we would probably wish to have it in its original form. They were right. The note has been tucked away in Eric’s baby book for more than 30 years. It reads:

My dearest friends,

Almost 10 weeks have passed since I entered the world. I leave you all today with great admiration and gratitude. In the first two months of my life, my parents and I have come to understand and realize the fragility and sacredness of life. From your hands and hearts came the loving and professional care which has enabled me to leave here with the potential for a very long and eventful life. The greatest gift we can ever give another is the gift of ourselves. You have given of yourselves over and over, and goodness knows, how much I have appreciated that most precious gift. Thank you so much for your knowledgeable assistance and prayers; and thank you for loving me as much as you have. Perhaps someday we'll meet again and I can do something wonderful for all of you. We will keep you posted on my progress, and I promise to stop by and visit whenever I am in town. May God bless you all, and may your remarkable work continue to benefit all of the little children who pass through this center. You are and always will be so dear and wonderful to me.

Thank you again,

Eric

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

02 September 2014

Hardwired for the 'soft skill' of civility

For nearly 15 years of my recent adult life, I spent three to four evenings a week learning and practicing self-defense and cardio kickboxing in a traditional karate dojo under the tutelage of Sensei Pon Inthatarath, world-champion martial artist and self-defense practitioner. The dojo became my second home. The lessons I learned then and since have shaped my life in myriad ways beyond the scent of sweat and the smack of leather.

More than three years ago, I blogged about some of the important life lessons learned from my dojo experiences, such as how to survey my surroundings, how fitness extends well beyond physical capacity, and being alert for risky encounters. Sensei reinforced discipline, hard work, and training. We ran, punched, kicked, and performed countless plyometric and boxing drills—and then did it all over again. The countless hours of training taught me confidence, courage, and the importance of standing strong on the side of right. The seemingly endless drills and relentless training improved my ability to respond to challenges, learn from my mistakes, and be a model of courage and integrity.

Like muscle memory honed in the dojo, responding
effectively to disrespectful behavior is a skill that
can be learned.
Much of what we practiced, studied, and ultimately learned was a result of “muscle memory”—teaching our physical bodies to repeat movements and techniques over and over until they became routine and eventually stored in our grey matter, to be retrieved when needed. Our muscles grow accustomed to certain types of movement, and the more often an activity is rehearsed and reinforced, the more likely it is to be performed without putting much thought into it. For example, one of the lessons I learned from the dojo is to scan a room upon entering, locate the exits, and sit with a view of the door. The muscle memory of this lesson has resulted in rote, unconscious behavior on my part. It’s automatic, reflexive, and involuntary. Because we learned the skill, practiced it over and over again, and received ongoing and constructive feedback from our teacher, it became second nature.

To me, muscle memory is akin to deliberate repetitive practice (DRP), a process for learning and mastering psychomotor skills by progressing through three primary phases: 1) understanding the skill and learning how to perform it accurately, 2) refining the skill until it becomes more consistent, and 3) practicing the skill until it is automatic and the learner does not need to consciously think about each step. Oermann noted that, to master skills, learners need op­portunities to practice them repetitively and receive feedback to guide their per­formance. Without deliberate repetitive practice, many skills may decay or be lost altogether.

Consider just about any type of nursing skill, such as ausculating lung sounds, taking a blood pressure reading, or deescalating a client living with bipolar disorder who is experiencing a rapid cycling phase of their condition. None of these skills are mastered overnight. In fact, many need to be practiced and practiced and practiced some more. The same is true for engaging in meaningful dialogue and using effective communication skills. We don’t wake up one morning fully proficient at addressing challenging encounters. Learning and becoming communication-competent and conflict-capable take time, training, experience, practice, and feedback. And guess what—no encounter is the same, so the skills we develop and practice are a continuous work in progress and must be rehearsed until we become comfortable and composed in similar situations.

Just like muscle memory honed in the dojo and use of DRP in nursing programs, learning, practicing, and retaining skills to effectively address uncivil or disrespectful behavior are essential skill sets. One evidence-based technique used to address incivility is cognitive rehearsal (CR). Similar to DRP, CR typically consists of three parts: 1) learning and instruction, 2) rehearsing specific phrases to use during uncivil encounters, and 3) practice sessions to reinforce instruction and rehearsal.

Various frameworks are used to structure a ‘civility conversation” using CR, but, for years, I have used the TeamSTEPPS approach with my nursing students to prepare them for addressing potential uncivil interactions and, more importantly, to act as role models for civility and decorum. TeamSTEPPS is a communication system that provides a powerful evidence-based framework to improve patient safety between and among health care professionals in practice settings. The model my students prefer most is CUS. An acronym for concerned, uncomfortable, and safety, CUS is a communication structure used to assist with conflict negotiation.

When a health care professional uses CUS, it issues an alert that a patient-safety problem has been identified. For example, if a nurse encounters an uncivil experience, they may respond in the following way: “I am Concerned about the tone of this interaction. I am Uncomfortable, because the stress resulting from this exchange could impact the Safety of our patients. Please address me in a respectful way.” There are several other acceptable models for teaching and learning effective communication skills and becoming conflict-capable. However, the essential ingredient is to use a CR (or DRP) framework where skills are learned, practiced, and reinforced until responses become second nature.

Another key component is to have learners “make it their own.” In other words, we can provide a script, but it should only be used to guide the development of a learner’s own, personal response. For example, in an upcoming article by Martha Griffin, PhD, RN, CS, and me —pending publication in Journal of Continuing Education in Nursing (JCEN)— we provide scripted responses to nine common uncivil encounters that include nonverbal behaviors such as eye rolling, deep sighing, and arm crossing. For example, our suggested response to eye rolling is to politely address the individual in this way: “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.” We offer this and other responses as starting points for practicing a retort until the words flow and become natural and spontaneous. I encourage my students to practice these and other related responses in front of a mirror until they feel prepared and ready to use them when needed.

Our pending JCEN article builds on the early work of Griffin, who used CR as a shield for lateral violence and details the use of CR as an effective intervention against incivility and bullying behaviors. We firmly believe, and remain steadfastly convinced, that CR as a strategy for addressing incivility and bully-like behaviors in nursing is a valuable tool. Being well prepared, speaking with confidence, and using respectful expressions to address incivility can empower nurses to break the silence of incivility and oppression.

So, whether you are refining your boxing skills, sharpening your auscultation ability, or polishing your communication capacity, using a framework for deliberate, repetitive practice or cognitive rehearsal is highly recommended—because it works!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

11 August 2014

Landed that faculty interview? 20 questions YOU should ask!

I recently received the following message from a colleague starting a new teaching position: Today was the first day of my new faculty position at Acme College [not the real name], and it was awesome! I can tell already that it will be a great place to work, teach, and learn. Everyone is very supportive and respectful. I even have a mentor who will be working with me over the course of the next few years. My new director is amazing and has eagerly invited feedback and ideas. I feel motivated and inspired to do my best work. I feel thrilled and privileged to be a member of such a forward-thinking team.

Contrast that positive and optimistic message with this one: I will be leaving my faculty position as soon as I can. I can’t stand the pressure anymore. I am spending money I don’t have to consult a health coach to assist me in dealing with my negative work situation. The effects of a hostile workplace are taking their toll. I am having difficulty sleeping, concentrating, and focusing. I’m distracted and preoccupied with worry about my work situation and, perhaps more importantly, how the fallout might negatively impact my students and co-workers. I feel like I am running for my professional life.

The above examples are representative and vary by degree with nursing faculty around the country. What accounts for these discrepancies? Although reasons for these contrasting experiences differ—budget constraints and increasing job competition from clinical sites, to name two—in many cases, ineffective leadership is a decisive factor. For better or worse, leaders make a significant impact on the workplace by setting the environmental tone and tenor of the milieu. It is often said that people don’t leave companies; they leave managers and leaders. If this is true, leadership matters if nursing education is to successfully recruit and retain qualified faculty members who, in turn, will prepare the nurse workforce of tomorrow.

When they ask if YOU have any questions, say yes!
— Digital Vision/Thinkstock
Ethical, effective, and supportive leadership styles are essential to fostering healthy workplaces and creating engaged learning environments where everyone thrives. A supportive work environment improves mental and physical health, decreases emotional exhaustion, increases organizational commitment, lowers absenteeism, and reinforces faculty members’ intent to stay. Certainly, it is everyone’s responsibility at all levels of an organization to positively impact the work culture. Leaders, however, play a crucial role in this process by defining the future, aligning people with a compelling vision, and inspiring action to achieve sustained and long-term cultural change. The heavy lifting of leadership requires vision, effective and continual communication, willingness to engage in and successfully negotiate conflict, and openness to other points of view.

One of my foundational beliefs about workplaces is that culture trumps everything. In other words, if the workplace is unhealthy, toxic, or uncivil, it will be challenging to retain faculty members. Given the current and projected nursing faculty shortage, we cannot afford to lose even one qualified nurse educator. Low faculty salaries, an aging workforce, dissatisfaction with the educator role, pressure to acquire research funding in an era of dwindling resources, and stress from rapid and sustained change are just a few of the stressors that affect nurse educators.

We must do better. As nursing programs place a cap on admissions and, as a result, turn away large numbers of qualified applicants—some of whom might choose to become nurse educators—lack of qualified faculty will result in insufficient numbers of registered nurses to provide patient care. Unfortunately, an uncivil or toxic work environment adds to the dreary list of reasons for faculty exodus. Without question, this is avoidable. The goal for all members of the academic workplace is to reap the benefits of a healthy, respectful work environment. What are the elements of a healthy, respectful workplace?

According to the Chronicle of Higher Education, 12 key features are associated with excellent academic workplaces: collaborative governance, confidence in senior leadership, respectful supervisor or departmental chair relationships, active professional and career-development programs, healthy teaching environments, clarity regarding tenure and promotion processes, fair compensation and benefits, job satisfaction, respect and appreciation, diversity, workplace security, and an emphasis on work-life balance. These features are consistent with the six standards identified by the American Association of Critical-Care Nurses for establishing and sustaining healthy work environments: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

I suggest the addition of three related elements: 1) establishing and living a shared statement of organizational vision, values, and team norms, 2) creating and sustaining a high level of civility, and 3) emphasizing leadership, both formal and informal, throughout all levels of the organization. At a time of unprecedented change and technological and cultural transformation, academic institutions are increasingly being called upon to create cultures of collegiality, collaboration, and civility.

It is vital, therefore, to ask timely, relevant, and important questions about the workplace culture. I contend that employment decisions should not be made lightly because a nurse educator spends an average of 50 hours or more per week fulfilling faculty responsibilities. Moreover, it is concerning that very few faculty members ask key questions about their prospective employment.

For example, over the course of my academic career, while serving as a member of interview teams charged with hiring new and potential faculty members, I have been amazed that applicants, when asked if they have questions, often say no. To me, this is an incredibly lost opportunity. Remember, you—the interviewee—are interviewing the organization as much as the organization is interviewing you. So, be sure to come to interviews equipped with essential questions that help lead to informed decision-making about whether or not to accept a faculty position.

To get you started, here are 20 questions to consider asking when applying for a faculty position. (To evaluate your current workplace, you may also want to ask these questions of yourself.) Each question calls for an explanation, so, for each one, be sure to ask the person or persons interviewing you to provide an example or two.
  1. How does your school live out its organizational vision, mission, shared values, and norms?
  2. How would you describe the level of trust between leaders and those they are assigned to lead?
  3. How do faculty members, staff members, and students describe the culture and character of your school?
  4. What policies has your school established to address incivility and promote civility?
  5. What values are fundamental and important to the school? How are they expressed?
  6. What are the best features of working at this school? How are they being celebrated? What are some of the most common complaints? How are they being addressed?
  7. How are the school’s organizational culture and faculty satisfaction assessed? Are they assessed on a regular basis? Where might I find the assessment results and measures taken to improve the workplace culture?
  8. How would you describe faculty and student engagement and overall morale?
  9. What are the school's vision and strategic goals for the future? How do faculty members participate in these initiatives?
  10. Describe the leader’s leadership style and specific attributes. How does his or her leadership style and attributes influence the workplace culture?
  11. Tell me how faculty contributions are recognized and rewarded.
  12. Describe how faculty members—and others in your organization—know what is expected of them and how people are held accountable for results.
  13. Describe how new faculty members are mentored upon hire and throughout their tenure.
  14. What is your process for shared governance and participative decision-making?
  15. Tell me about the school’s strategic approach to developing and sustaining a healthy workplace.
  16. How is faculty performance assessed? What resources are available for faculty support and development?
  17. Would you recommend this organization to your best friend or a family member as a good place to work?
  18. On a scale from 1 to 10—10 being the most fantastic, amazing, and inspiring workplace—what score would the collective faculty assign to this school?
  19. If this organization could be summed up in one or two words, what would they be?
  20. All things considered, is this is a great place to work?

If you believe, as I do, that culture trumps everything, take a proactive approach and be ready to ask some key questions that will help you make a well-informed and responsible decision about your next faculty position. By doing so, you will be sending messages to colleagues much like the one I received and quoted at the top of this post.

If you are currently in a position where answers to these questions fail to measure up to your desired expectations, perhaps it is time to be an agent for change in your organization or to carefully consider your next move. Either way, take care of yourself. The profession needs you and can’t afford to lose you!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.