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.

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.

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.

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.

Knowing better and doing better in uncertain and uncivil times

I recently completed a national study on faculty perceptions of faculty-to-faculty incivility in nursing education and was struck by the extent to which faculty perceive this to be a serious problem. It is a sad commentary on the state of affairs in our daily work lives and a phenomenon that requires attention, because lack of civility can cause stress, emotional pain, physical complaints and spiritual distress. The effects of uncivil encounters can be devastating and long-lasting.

Several faculty members wrote stories for my study about the perceived “in groups” and “out groups” of nursing faculty teams (I use the word “team” lightly.) One participant wrote: “We have a faculty member who takes pleasure in targeting new faculty by sabotaging their ability to do their job. She went so far as to completely erase the contents of an online-learning course, so the new faculty taking it over had to start from scratch. The new faculty member was very busy learning the ropes of academe and orienting to the faculty role. She was told by the seasoned faculty member that, since she [the senior faculty member] originally developed the class, she [the new faculty member] could get busy and do the same thing.”

Another participant described interactions during faculty meetings: “One of the senior faculty members routinely cuts others off or talks over the less-senior members she appears to be targeting. She is openly condescending and rude, speaks ill of other faculty members when they are not present and is openly antagonistic to the person she is targeting. At times, the environment is quite tense, yet no one confronts the behavior. At this juncture, I am still in a probationary period and fear that trying to address it could jeopardize the position that I have worked so hard to obtain.” Other participants described experiences with ageism, sexism, racism and being “treated like a second-class citizen” because their academic degrees were in a field other than nursing.

Though these stories vary in content, they possess common features. All of the uncivil encounters resulted in an affront to human dignity and an assault on the person’s intrinsic sense of self-worth. Many believed that directly addressing the situation may be the best approach, though most feared that doing so could result in retaliation, reprisal and lack of administrative support. Others felt ill-equipped to deal with incivility and requested information about specific measures to deal with the problem, including implementing clear policies and procedures, ongoing faculty development and “civility” education, and elimination of power-based hierarchies that perpetuate “in groups” and “out groups” in nursing education. Many suggested the need for taking steps to improve relationship building, including positive mentoring, faculty collaborations, celebrating faculty accomplishments and promoting faculty achievements.

As I was reading some of these faculty accounts, I was reminded of one of my favorite quotes by Maya Angelou, who writes, “We do the best we can with what we know, and when we know better, we do better.” While I appreciate Dr. Angelou’s wisdom, I wonder sometimes if it’s true. Do we really do better when we know better, or is it wishful thinking? I choose to believe it’s true because, given what we are learning about faculty incivility, we must do better.

I am constantly amazed to learn that some faculty members are unaware of how their behaviors affect others. We must make civility a priority, therefore, and raise awareness about the myriad consequences of incivility. With the current nursing faculty shortage, we can ill afford to lose qualified educators. So what shall we do?

If you are experiencing incivility, carefully consider the nature of your situation, especially if you are part of the “out group.” Power differentials can be real or perceived and, in either case, can take a devastating toll on your emotional and physical health. So, take steps to improve your self-care and engage in stress-reducing activities. Surround yourself with positive people, and bask in the light of those you love and those who love you back.

I was recently chatting with a colleague in a non-nursing academic discipline who was experiencing relentless workplace incivility. I asked him how he dealt with the negativity. He smiled and said, “I conjure up a vision of my wife and children and my beloved family dog, and I feel immediate relief.” The conversation reminded me of one way I cope with stressful work situations. I have a number of greeting cards that I have received from family and friends over the years. I keep some of my favorite cards on my desk and select certain ones to cheer me up when needed. At present, I have a delightful valentine from my husband propped up on my desk. It features two adorable yellow labs wrapped up with each other, sheer love and joy written all over their faces. As silly as it sounds, it works for me. The picture takes me to a “happy place’ where I feel safe and wanted and stress free for just a little while.

I realize that more active measures are needed, so I highly suggest and urge all nursing programs to co-create and implement behavioral norms. As Ken Blanchard reminds us, “A river without banks is a pond.” Similarly, I believe an organization without norms is a rudderless ship. Without functional norms, desired behavior is ill defined and, thus, faculty and staff are left to “make things up as they go along.”

To co-create norms, dedicate sufficient time to ask all members of the faculty (and staff) to brainstorm behaviors that lead to effective team functioning and contribute to a healthy work environment. Avoid critiquing the suggestions—let the ideas flow. Some common examples of norms include how each team member will communicate, resolve conflicts and conduct themselves in meetings. Then brainstorm behaviors that do not lead to effective team functioning.

Once the norms are determined, discuss how each team member will “live” the norms and what will happen if the norms are violated. When faculty and staff co-create norms together, they are more likely to approve of and conform to these behaviors. Once the norms are agreed upon, they become the standard for faculty and staff interactions. To keep them dynamic, they will need to be reviewed, revisited and revised on a regular basis.

Fostering civility in nursing programs, or any program for that matter, is difficult, if not impossible, to achieve in the absence of skilled, ethical leadership. Leaders who hold formal positions as well as those without a formal title or authority, but who have significant influence throughout the organization, are called upon to effect and sustain civil, respectful workplaces. In addition to taking action to raise awareness, leaders must discuss acceptable and unacceptable behaviors, as well as model and practice civil interactions. It is also important to reward civility and collegiality, thereby reinforcing efforts to build positive relationships between and among all members of the nursing education community.

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