Dr. Crude and the bystander effect

Before taking a faculty position, I was employed as a psychiatric nurse/therapist specializing in adolescent mental health, substance-abuse intervention and recovery, and violence prevention. I had the good fortune of working with an amazing team of mental health professionals who treated a variety of conditions and disorders. Many of our patients were violent, adjudicated youth with long histories of severe substance abuse and criminal activity.

Our work was challenging and sometimes dangerous. I have often been asked, “Were you or members of your team ever injured by one of your clients?” And the answer is no, although there were some close calls. Like the time a gang of violent youth drove onto the campus of our treatment center and circled the building while wielding a sawed-off shotgun and threatening to shoot one of our African-American counselors. It was terrifying, but, fortunately, the police responded, handled the situation without incident, and no one was hurt.

But if someone asked me if a co-worker ever harmed me, the answer would be yes. Unbelievably, the assault came from a psychiatrist. Here’s what happened.

Who do you think you are?

Years ago, as the nurse manager of an inpatient adolescent unit, one of my many responsibilities included organizing and facilitating treatment planning for our clients and their families. Each psychiatrist met individually with the team to review his or her clients’ treatment plans. The team consisted of the lead psychiatrist, psychologists, nurses, social workers, recreational therapists, teachers, occupational therapists, and nutritionists. My job was to organize each session so that the team was assembled and ready to go. They were busy and eventful days, with planning and coordination key.

Katarzyna Bialasiewicz/iStock

One particularly busy day, as I was preparing for our meeting, I noticed that one of our patients was struggling with what appeared to be symptoms from excessive dosage of her prescribed antidepressant. The patient—I will call her Anna, not her real name—was complaining of nausea, headache, agitation, and restlessness. She was clearly anxious and diaphoretic. Of course, we were concerned about her, but comforted by the fact that we planned to discuss her treatment plan later that morning. In the meantime, we withheld her morning dose of the medication, recorded her vital signs, and closely monitored her condition.

When her psychiatrist—I will call him Dr. Crude—arrived on the unit, I was relieved because Anna was still not feeling well. As Dr. Crude entered the treatment-planning room, I quietly mentioned that Anna might be experiencing symptoms related to heightened dosage of her antidepressant and expressed a need to discuss her condition first during morning rounds.

Imagine my shock—and fear—when he grabbed me forcibly by the shoulders, threw me angrily against the wall, jammed his finger into my chest, and, with spittle spraying from his mouth, accused me of “playing doctor,” chastised me for my audacity and impertinence, and asked in an enraged tone, “Who do you think you are?” He was beyond angry—furious, in fact—as he continued to berate me in front of my teammates.

I was certain one or more of them would come to my aid, but that did not happen. They sat stunned and silent, looking on with horrified expressions. After what seemed like forever, Dr. Crude let go of me and stormed out of the unit. Moments later, the tears came, and my teammates rushed to console me. When I asked what kept them from intervening, each one immediately apologized, stating that they were so stunned by what they observed they were completely immobilized.

Observers of violence

As I reflect on that experience and the lack of response from my teammates, I’m intrigued by their behavior. What kept a top-notch group of individuals, all highly trained, highly educated, and well-schooled in behavioral health and conflict de-escalation, from intervening on my behalf? There is a term used in psychology for people’s failure to help a person in distress. It’s called the bystander effect, a term coined by social psychologists to study if and how the presence of others discourages a person from intervening in an emergency situation. Researchers found that the greater the number of bystanders, the less likely any one of them will help.

There are various terms to describe bystanders. They are also called witnesses, accomplices, and indirect victims. I prefer the term “witness,” defined as someone who sees, hears, or knows about incivility, bullying and/or violence happening to someone else. Regardless of the term, actions of witnesses, whether intentional or not, contribute to the outcome of an uncivil or bullying event. The impact of bullying on witnesses is clear: Observing uncivil or bullying behavior, particularly over time, can have detrimental effects on one’s health, including mental health. Like targets of workplace bullying, witnesses of bullying may develop symptoms of guilt, anxiety, and depression. In some cases, they may disengage or leave unhealthy workplaces altogether.

Witnesses react to bad behaviors in various ways. Some take the side of the offender by doing nothing, laughing at the target, or encouraging the offender to mistreat the target. Others give silent approval by simply looking on and doing nothing. In my situation with Dr. Crude, the witnesses were so horrified and shocked by his behavior they were rendered helpless. As noted earlier, some social psychologists believe that the more observers there are to a bad situation, the less likely they are to intervene. That’s known as the “diffusion of responsibility” effect—believing someone else will step in and help.

Reward for silence

In some cases, the offender or bully is protected. That’s what happened with me. When I reported the incident to the medical director and the CEO of the facility, I was told to “let it go” because Dr. Crude topped the list of psychiatrists admitting patients to the facility and we “wouldn’t want to upset him.” Not only was I encouraged to let it go, I was offered a salary increase, which, to me, was hush money in return for my silence. Soon after, when my reports went unacknowledged, I left the organization knowing I could not be party to this type of behavior. Exposure to acts of incivility and bullying impacts everyone involved: the target, witnesses, patients, other co-workers, families of those being targeted, and, ultimately, the organization.

While there is no universal formula for effective intervention and being a supportive witness, here are some suggestions. Take a personal stand against incivility and bullying behavior. Make it clear to your friends and co-workers that you will not be a participant. Set a positive example. Do not tease, spread gossip and rumors about others, or laugh at off-color jokes or distasteful comments. Beware of offensive emails and/or social media postings. Do not forward them to others or respond to them in a conspiring manner.

In the workplace, witnesses may be useful and even compassionate when incivility or bullying occurs. They may listen to the victim and offer a sympathetic ear. However, it is the rare co-worker who puts his or her own well-being or job security on the line by giving an objective, detailed account of the incident to supervisors or HR representatives. Many co-workers—concerned about becoming a target themselves, or being identified as a complainer— are unwilling to address the situation. Also, many workplaces lack guidelines to deal with offenders as well as clear policies regarding confidentiality, so there is no roadmap and, sadly, a lack of support for reporting uncivil behavior. Even worse, rather than showing support, the person reporting the incident may be labeled a troublemaker or “whistle-blower,” a term that, for many, has a negative connotation.

Fortunately, there are witnesses who take immediate action to stop the offender and support the target by using words and/or actions to intervene. Evidence suggests that when witnesses take safe and effective action to support targets of incivility, there is greater likelihood that the behavior stops.

Practice, practice, practice

In an ideal world, witnesses intervene when each incident of incivility and bullying occurs. However, each situation is unique and complex, and stepping in to intervene is not as easy as some would like. Intervening on another’s behalf and, ultimately, mastering this type of intervention take courage, skill, and practice, practice, practice.

For instance, let’s imagine that you witness a colleague (Belle) berating another colleague (Alice) in the presence of a patient and his family. You determine that the incident calls for an immediate response, but what can you say? How comfortable do you feel saying something like, “Belle, it’s not OK to yell at Alice, especially in front of patients. If you have concerns, let’s discuss them in private.” In my experience, individuals often express a desire to intervene, but lack the appropriate skills.

Effective intervention requires practice and skill building, which may be accomplished through workshops, online modules, role-playing, and simulation. But most of all, successful intervention requires support from leadership at all levels of the organization.

Every organization must take a stand against negative and disruptive behavior by developing, implementing, and widely disseminating clear, confidential, and comprehensive policies and procedures that foster a healthy work environment. Supervisors and HR representatives must take reports of incivility and bullying seriously and conduct thorough, confidential investigation, protecting all identified parties. Implementing team charters that reinforce civility and norms for respectful interactions and protection of patient safety are crucial steps toward creating and sustaining healthy work environments.

Organizations must invest in educational programs that raise awareness about the negative impact of incivility on workplaces while simultaneously reinforcing and building upon existing organizational strengths. Positive role modeling at all levels of the organization is essential. For workers to intervene, leaders must model the way and reward others who bear active witness to bad behavior. The bottom line is, we can no longer stay silent.

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.

When people behave badly: How to recover if you're the target

For well over a decade, I have studied and contributed to the body of science on fostering civility, and creating and sustaining healthy workplaces. The utter cruelty of certain individuals never ceases to amaze me. Fortunately, the vast majority of people are respectful and civil. Yet, sadly, others treat people with disdain and contempt. I am often asked what motivates people to behave badly. It’s not a simple question to answer. Although there are reasons behind negative and harmful acts, some of which make sense, others simply fail to explain disrespectful human interaction.

For example, do you consider yourself a reasonably respectful or civil person? Most of us would say yes. If this is true for you, here’s another question: Have you ever been rude or disrespectful to someone? If you are like every other human being, the answer to the second question is also yes. So then the question becomes, why would an otherwise civil or respectful person behave rudely or badly?

Stressed out

Very often, the answer is, “Because I’m stressed out.” I agree; heightened levels of stress brought on by any number of life’s demands often account for much incivility. Stress may be caused by the challenges of managing the myriad roles and responsibilities associated with family, work, and life in general. Being overworked, underpaid, and sometimes unappreciated also may contribute to increased stress. While not acceptable, responding rudely in highly stressful situations is more easily understood than other forms of incivility.

–  People Images

In the workplace, incivility can add tension to an already highly stressed environment, and its potential impact cannot be overestimated. Being treated badly or in an uncivil manner, particularly over time, can have devastating results. In a practice-based discipline, such as nursing, this is especially troubling, because incivility can weaken confidence and moral courage, impair clinical judgment and reasoning, create vulnerability and self-doubt, and cause anxiety, resentment, and anger. Ultimately, it can negatively impact patient care.

Stress is not the only contributor to incivility. I’m reminded of a story told to me by a nursing instructor in her mid-50s. She was so excited because she had finally, after much soul-searching and research, decided to pursue a doctoral degree. She could hardly wait to share her excitement and ideas with her program director. When she had an opportunity to meet with the director and disclose her scholarly intentions, the director laughed and said: ‘‘Are you kidding, at your age? You can’t be serious. By the time you finish your degree, you’ll be ready to retire. We prefer to invest in younger faculty.”

The exchange left the instructor feeling demoralized and diminished, and she decided to forgo pursuing the doctoral degree. Whether the director’s comments were intentionally or unintentionally delivered, the result was the same. A talented and energetic faculty member was left to feel devalued and unimportant.

Rank rankism

This example illustrates the negative impact that low emotional intelligence, ineffective communication skills, and an attitude of superiority—a sense of power over—can have. The instructor in this story is the target of rankism, a term coined by Robert W. Fuller, PhD, former president of Oberlin University. In his book, Somebodies and Nobodies: Overcoming the Abuse of Rank, Fuller tells us that "rankism" lies at the heart of discriminatory behavior, is evident in nearly every institution in society, and occurs when people abuse their power to demean and disadvantage those they outrank.

Intended or not, disrespectful and rude behavior toward others may indicate prejudice and rise to the level of discrimination—in some cases, outright abuse. The antidote to rankism is to foster work environments based on human dignity for all. It is abuse of power and rank—not power and rank per se—that damages relationships and puts people at a disadvantage.

Those who are targets of rankism and other forms of incivility often describe their experiences in vividly emotional ways. Many are still negatively impacted by their uncivil experiences, even when the encounters occurred years before. Some people describe intense psychological symptoms, such as feeling traumatized, helpless, and powerless. Many feel caught in a no-win situation, with little possibility of successful resolution. The lingering effects of incivility can cause serious and sometimes lasting psychological and physiological effects.

Although each of us deserves to be treated with dignity and respect, people report varying degrees of discomfort when addressing conflict and incivility. For further discussion of this topic, read my two-part series on conflict negotiation.

If you have been the target of repeated incivility or bullying, attending to your physical, emotional, and spiritual health is a critical first step. It may be necessary to see your healthcare provider or seek counsel from a mental health expert. Getting yourself physically and emotionally prepared to deal with the problem will require you to be in a healthy state. When reporting a problem, it’s important to follow confidential policies, procedures, and guidelines (assuming they exist). In any case, inform your employer or supervisor about the problem, and request institutional support. Be sure that human resource and employee-assistance program personnel have your best interest in mind and are poised to assist you in following healthy workplace policies and procedures.

10 tips for recovery

For anyone who experiences incivility, either inside or outside the workplace, it is imperative to reverse the negative effects it can have on his or her physical, emotional, and spiritual well-being. If you have been the target of bad behavior, here are 10 tips for successful recovery.

1. Share your story with a good friend, family member, mentor, counselor, or member of the clergy. Avoid sharing your experience with co-workers. Instead, seek support from those who can offer a more objective perspective, such as an ombudsperson, conflict negotiator, or civility coach. Relating the experience and sharing it with others can provide healing. However, avoid dwelling on it too long. Tell your story, validate that it occurred, and make a plan to move forward.

2. Journal about your experience. For many people, writing their story and reflecting on it can be therapeutic and may help provide insight.

3. Engage in activities you enjoy, and don’t retreat from relationships that matter to you. Continue to make time for exercise, friends, family, pets, and social activities.

4. Enjoy a massage, meditation, yoga, deep breathing exercises, and other relaxation techniques.

5. Get plenty of sleep, stay hydrated, and eat a well-balanced diet.

6. Get (or stay) involved by helping a friend, neighbor, or co-worker. Volunteer in the community, or champion one of your favorite causes.

7. Focus on building resiliency. No one size fits all, so find the plan that works for you. Surround yourself with positive people and with those who bring you joy.

8. Try to find meaning in stressful or traumatic events and experiences, and incorporate this meaning into moving forward.

9. Recognize what makes you uniquely strong, and own it! Don’t let others define you. Memorize and practice reciting a positive script, such as: “I am poised, balanced, and in control of my life. I am talented, courageous, and confident in my ability to succeed.”

10. Remember, symptoms of distress can last from a few days to many months, and recovery takes time and progresses at varying paces and degrees. If symptoms are persistent, you may need to talk with an expert. Don’t hesitate to reach out for support if you need it.

References:

Clark, C.M. (2008). Student perspectives on incivility in nursing education: An application of the concept of rankism. Nursing Outlook, 56(1), 4-8.

Fuller, R.W. (2003). Somebodies and nobodies: Overcoming the abuse of rank. British Columbia, Canada: New Society Publishers.

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.

Beating the burden of burnout

It’s amazing to me that, not long after the start of a new academic year, many nursing faculty members are overwhelmed by stress with some nearing a state of burnout. During a lunch break at a recent nursing conference, I chatted with nurse educators from around the country. The conversation centered on their myriad work responsibilities and heightened levels of stress. Seated around the table, they described how each minute of every day seems to be filled with an endless list of family, life, and work responsibilities. They lamented the long work hours invested in preparing for classes, grading assignments and exams, meeting with students, engaging in committee work, working on scholarly activities, providing service, teaching—both classroom and clinical—and fulfilling a number of other responsibilities.

Manuel Faba Ortega

One professor commented: “It’s only the first month of classes, and I am completely exhausted. I’m teaching two 12-hour clinical days and an extra class as an overload assignment because we have unfilled faculty positions, and there is no one else to teach the class. I’m also enrolled in a DNP program, because our university requires all faculty members to obtain a doctoral degree. We have a new director, and she has asked me to take on some of the school’s administrative responsibilities, which I have agreed to do. On top of everything, our current cohort of students is more challenging than ever, and I am completely drained.”

Too busy for self-nurturing
Concerned for her, I asked: “What are you doing for yourself? How are you nurturing your body and spirit?” She looked at me with a perplexed expression and said, “To be perfectly honest, I am doing very little, if anything, to nurture myself. I’m just too busy.”

Unfortunately, this story is not uncommon. I often ask nurses, nurse faculty members, and nursing students the same question, “What are you doing to nurture yourself?” Sadly, the vast majority of respondents say they are working so hard and moving in so many directions that self care has taken a back seat to responsibilities that often overwhelm them.

This is deeply concerning, because lack of self care takes a significant toll on personal, physical, emotional, and spiritual well-being, and it can have a potentially negative impact on our ability to care for others, including patients. The pressure created by competing demands from family, work, and life responsibilities can cause stress and maybe even burnout.

Obviously, stress will always be a part of our lives, and mild stress levels can actually give us an edge and help us mobilize for action and achievement. However, too much stress, especially if prolonged and coupled with poor coping habits, can cause physical, emotional, and spiritual fatigue as well as ill health. Common signs and symptoms of stress overload include accumulation of belly fat, interrupted sleep, fatigue, irritability and anger, and lack of interest. Mental health problems, such as increased anxiety and depression, may result, and it’s not uncommon for stomachaches, headaches, intestinal problems, and cardiac changes to manifest when stress levels are heightened and prolonged.

A few questions to ask
For some, burnout may also occur. Burnout is a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress. When we are burned out, we feel overwhelmed, depleted, unproductive, unhappy, unappreciated, and too tired to function. To determine if you might be experiencing burnout, ask yourself a few questions:

• Do you have difficulty getting out of bed and feeling excited about your day?
• Do you become irritable or impatient with students, coworkers, or patients?
• Do you lack energy and feel disillusioned about your work?
• Are you using unhealthy coping strategies, such as spending hours watching TV or browsing the Internet, or using drugs, food, or alcohol to feel better?

If so, you may be experiencing or approaching a state of burnout.

While eliminating stress is impossible, minimizing it and engaging in self-care techniques can be extremely helpful and ultimately important in achieving an overall state of wellness. So, take a minute to jot down your favorite stress busters and most effective stress-reducing techniques. Some of us benefit from physical exercise and activities, such as yoga, meditation, progressive relaxation, deep breathing, and enjoying music or the outdoors. Spending time with family, friends, and pets, eating nutritious foods, and getting enough rest also help reduce stress.

While these stress-management techniques can be helpful—and I certainly recommend them—real and lasting change comes from identifying the sources of our stress and creating an intentional plan to deal with them. It may be helpful to carry a small notebook or make a note using your smartphone to record events or situations that cause you stress. After a week or two, you will likely gain a clear picture of where your stress is coming from and how you might address it.

Putting yourself first essential
After reviewing your personal list of stressors, identify those that you can do something about and those that are out of your control. For example, you may be stressed by your work commute. Is there a way to change the method, timing, or route of your commute to reduce your stress? If so, this is something within your control. If you identify a stressor that you cannot effectively eliminate—caring for a child with a disability, for example—perhaps there are ways to reduce the stress involved. In the case of a child with a disability, are there other people or community resources available that can share your care responsibilities and thereby lessen your stress?

Regardless of the sources of your stress—whether you can change them or not change them—putting yourself first is essential. This is not a selfish endeavor. By taking care of yourself, you can better attend to the needs of others. Enter “me time” into your calendar and regard that time as important as any other work meeting or event. Resist the urge to cancel “me time,” because the healthiest way to cope with stress and burnout is to take excellent care of yourself.

Managing your time well and staying organized can also be stress-reducing. Start each day with a “to-do” list and arrange them by priority—from high to low. Consider dropping low priority tasks altogether by rescheduling them for completion sometime in the future, or better yet, when possible, delegate those tasks to someone else. Resist multitasking and the urge to immediately respond to every text or email message you receive. Prioritize the messages, and, if possible, save them to a folder to be addressed when you have more time.

“Unplug” from your phone, television, computer, and other distractions to enjoy a moment of peace and quiet. Take a deep breath, and clear your mind. When life is busy, we often get distracted and lose connection with those we care about most. Schedule a date night with your partner, enjoy lunch or a power walk with a friend, or spend time with your furry friends. Avoid negative people as much as possible, and surround yourself with those who bring fun and laughter into your life. Take time off, or schedule a mini-vacation. Whatever you decide to do to de-stress, remember, you deserve 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 b posted.

Civility, an ethical imperative

Everyone should choose to practice civility. For nurses and the nursing profession, however, it is imperative, an ethical requirement. According to the American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements (2015), all nurses regardless of setting or position have an ethical responsibility to create and sustain healthy work places and to foster an atmosphere of dignity and regard for all. The code is clear: “The nurse creates an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect. … Disregard for the effects of one’s actions on others, bullying, harassment, intimidation, manipulation, threats, or violence are always morally unacceptable behaviors” (p. 4).

Moreover, Provision 7.2 of the code states: “Academic educators must also seek to ensure that all their graduates possess the knowledge, skills, and moral dispositions that are essential to nursing” (p. 28). Therefore, it is incumbent upon nurse educators in all levels of nursing programs to model ethical conduct, professionalism, inclusion, and civility. They must take the lead in preventing and addressing acts of incivility, set the tone by incorporating civility as a shared value within their programs, and prepare students to effectively address incivility and foster safe, healthy work environments. The stakes are high. Safe patient care hinges on our ability to self-reflect and accurately assess our own behaviors, effectively manage our emotions, and communicate respectfully.

mumininan/iStock

For several years, I have intentionally integrated professionalism and civility content into my courses. Students and faculty members must engage in deliberate conversation about these topics, identifying and practicing specific strategies to foster civility. One exercise I like to use is having students complete the Clark Workplace Civility Index. During this carefully arranged activity, each student assesses his or her own perceived level of civility as well as the perceived civility level of another student with whom he or she is familiar and has built an adequate level of trust. They then candidly—and privately—share their insights with one another.

The evidence-based, 20-item questionnaire is designed to assess civility, increase self-awareness, generate discussion, and identify ways to enhance individual and collective civility acumen. The index includes assessing behaviors such as treating others with respect, keeping confidences, avoiding gossip and spreading rumors, using respectful communication, taking personal responsibility, and being accountable for one’s actions.

In addition to completing the index and discussing the issues it raises, each individual makes a firm commitment—in writing—to behave in a civil, respectful, and ethical manner. After completing the index, I recently asked a group of approximately 100 nursing students the following question: “What specific individual action can you take to foster a civil, healthy work environment?” The responses were impressive and, in some cases, inspirational.

Here are the top 10 responses:

• Always focus on the patient; this will keep us centered and respectful.
• Listen well and welcome other points of view.
• Offer to help and be supportive of others.
• Assume good will and exercise patience.
• Model professionalism, kindness, and respect.
• Speak up, set the bar high, and be a crusader for civility.
• Strive to be the very best person possible.
• Value differences and avoid judgment.
• Take good care of myself, de-stress, and live well.
• Practice the Golden Rule; treat others the way we wish to be treated.

Engaging in reflective exercises and candid conversation about ways to foster civility are helpful strategies to prepare students—and others—to address incivility, establish and sustain healthy workplaces, foster positive interpersonal and intrapersonal relationships, and enhance ethical practices that contribute to the ongoing success of top-performing work teams and highly effective organizations. Addressing incivility can be challenging, but remaining silent not only impairs nurse performance, it ultimately jeopardizes patient care.

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.

Uncivil semester: The nursing class that didn't seem to care!

Just before spring semester began—for many of us in the Northern Hemisphere, spring semester begins in January—I received an email message from a nursing professor (I’ll call her Beth) who expressed extreme distress stemming from a series of ongoing uncivil encounters with a class of nursing students. Attempting to resolve her problem, Beth had availed herself of several civility resources before contacting me, but, despite her efforts, had been unsuccessful in managing the disruptive and intimidating student behaviors.

Beth was very concerned about the situation, made worse by the fact that she would be teaching the same class of students during the spring semester. With permission, I share Beth’s story:

Aggressive and abusive
Fall semester was disastrous. From August into December, Beth experienced ongoing incivility in one of her nursing classes that involved multiple students. She described the students as highly stressed, aggressive, and verbally abusive. Exposure to this incivility began the first day of classes while Beth was facilitating discussion on accelerated heart rates. In the middle of Beth’s explanation, a student rudely interrupted her, stating that Beth didn’t know what she was talking about, and that the correct term was tachycardia. 

Jupiter Images/Photos.com/Thinkstock

Beth agreed with the student and attempted to explain that she, indeed, was planning to discuss the medical term. Before she could finish her response, however, the student made a sarcastic remark loud enough to be heard by the entire class. Some students responded by rolling their eyes and grimacing, and one of them glared at Beth for the remainder of the class. These and similar behaviors continued throughout the semester. Not equipped to address the situation, Beth tried to ignore it, which only made things worse.

To rectify the problem, Beth approached an experienced and tenured faculty member to seek her counsel. Sadly, the colleague acknowledged her own inexperience and lack of ability to address student incivility and offered no assistance. Consequently, the problem went unaddressed and, like pebbles rippling in a pond, continued to expand and intensify. 

Other students also became rude and disruptive, muttering under their breath during class and making disrespectful or aggressive comments to Beth and fellow students. One student openly and consistently challenged Beth during class, often snapping at her, shooting hostile glares, and vehemently arguing with her. At one point, Beth snapped back at the student and, after several unproductive back and forth exchanges, informed the student that she refused to argue with her. This interaction was followed by confrontation with another student, who accused Beth of refusing to satisfactorily answer class members' questions.

Beth began to dread going to class. Often, she lay awake at night. Unable to sleep, she worried about the hostility she would likely face the next day. Students who did not display uncivil behavior seemed to be feeling the stress as well. Again, Beth sought assistance from more experienced nurse educators, but none offered helpful advice.

Breaking point
One day, Beth’s stress level and inability to cope hit what seemed to be a breaking point, and she experienced a fairly intense hot flash during class. Some students, finding the event hilarious, responded by ridiculing and mocking her. Beth was humiliated and stunned by their insensitivity.

One student reported to Beth that class members maintained a social media site where students would criticize the class and post negative comments. She was told that some students fanned the flames of discontent, which, in turn, intensified the situation, resulting in a mob-type mentality. Although Beth tried to remain pleasant and respectful in class, her nerves were hanging by a thread, and she was relieved when the semester ended.

Her relief was short-lived. In addition to the brutally cruel student evaluations she received, it was then she learned she was scheduled to teach the same student cohort the very next semester. As I read Beth’s desperate message and plea for help, her dread was palpable.

Suggested solutions
I suggested several interventions, emphasizing the importance of role modeling and setting expectations the first day of class. I encouraged Beth to engage the students in conversation about the need for demonstrating civility and professionalism, displaying ethical behavior, and assuming the role and responsibilities of a professional nurse. 

I also suggested to Beth that she reinforce in class the various provisions contained in the American Nurses Association's Code of Ethics for Nurses (2015), in particular, Provision 1.5 which reads: “The nurse creates an ethical environment and culture of civility and kindness, treating colleagues, co-workers, 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,” (p. 4) and Provision 6.3 which reads: “Nurses are responsible for contributing to a moral environment that demands respectful interactions among colleagues” (p. 24).

In addition, I suggested co-creating classroom norms to foster and sustain a safe and civil learning environment. Faculty members need to take the lead in creating safe spaces for students, faculty, and other members of the learning community to express their views and beliefs without insult or other intimidation. Thus, co-creation of class norms is one of the most important activities to accomplish on the first day of class. Establishing, implementing, and reinforcing these norms are foundational to a respectful and civil teaching-learning environment and become living documents that provide a touchstone of civility and professionalism for students and faculty—a framework for working, collaborating, and learning together (Clark, 2013).

Norms need to be reviewed, revised, and reaffirmed on an ongoing basis. Once agreed upon, they can be used to remind students of their commitment to creating a safe teaching-learning environment and can set the stage for future meetings when faculty members may need to address performance or academic issues with students.

Beth’s story, Part 2.

Wearing business attire and striking a professional tone, Beth arrived early on the first day of the new semester. After welcoming the students, she started a dialogue about class expectations, using several foundational documents including the Code of Ethics for Nurses. Next, Beth facilitated co-creation of classroom norms, emphasizing the importance of following the norms and holding one another accountable for their successful implementation. After passing out index cards, she invited students to anonymously pose questions or comments to which she would promptly respond with posts on the students’ online learning platform.

Next, Beth told the class she had reviewed the course feedback she had received from the previous semester and, as a result, would be making several changes to improve the course. She told the students about her background and experience as a professional nurse and encouraged class members to ask questions and share their own experiences.

Welcome, Civility!
An interesting and wonderful thing happened after Beth shared her plans for the course: The class virtually exploded with questions, and students told stories and shared examples from their personal and professional experiences. It was an animated and interactive dialogue. Beth was “pleasantly shocked.”

Lumina Stock/iStock/Thinkstock

In the weeks that followed, Beth addressed some of the questions posed by students on the index cards, and she periodically discussed their compliance with classroom norms and progress toward becoming professional nurses. Overall, the students remained animated, interactive, and respectful. Several made supportive comments on the index cards. In fact, one student apologized for how the class had treated Beth during the previous semester.

Moral of the story 
Preparation, professional role modeling, and open, honest discussion matter and go a long way toward reducing or eliminating uncivil behavior. More importantly, they foster civility and add value to professional growth and development. Beth’s story is an epic success. We can all learn from her courageous response.

References:

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Association.

Clark, C.M. (2013). Creating & sustaining civility in nursing education. Indianapolis, IN: Sigma Theta Tau International.

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.

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.