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.