Healthy work environments change—and save—lives!

I was recently traveling home to Boise, Idaho [USA], on a long flight from Florida. Throughout the trip, the flight attendants kept us entertained with their witty retorts and humorous comments. After we landed, one of them issued the usual “Welcome to Boise” and then said: “If you are in a negative relationship or working at a job you don’t enjoy, remember, life’s too short, so it may be time for a change. Take it from me, a 20-something who clearly understands the way the world works and has the infinite wisdom to advise you on these important matters.”

The comment was intended to elicit a chuckle, and I found myself grinning along with most of the other passengers. But later, as I reflected upon his remark, I realized I often meet people who don’t like what they are doing for a living. In fact, many express deep displeasure with their current work conditions, often disclosing that they can hardly wait for retirement or a new experience. Many say they are keeping their heads down, flying under the radar, doing the least amount possible, or waiting for the next best thing to come along. This, clearly, is a sad state of affairs.

I am blessed!

 This past summer, Molly Clark, BSN, RN, was
promoted to the rank of lieutenant, U.S. Navy Nurse
Corps, while serving at Guantánamo Bay, Cuba. 

I count myself among those truly fortunate individuals who genuinely enjoy their work. I’m convinced I have one of the best jobs in the world. My work as a strategic nursing adviser and consultant takes me to schools and practice settings across the country. I am blessed to meet faculty members, practice-based nurses, and other healthcare professionals, as well as students, in just about every nook and cranny of the United States. Meeting people and listening to their stories energizes me and reminds me that my work is not only important, but I am making a difference.

This was recently pointed out to me by our daughter, Molly, a lieutenant in the U.S. Navy Nurse Corps stationed in Guantánamo Bay, Cuba. [Lt. Molly Clark, BSN, RN, is the author of a 2014 RNL article in which she describes what she learned in her first job after nursing school.] Prior to her deployment to Cuba, she sailed on the USNS Comfort as part of a healthcare team on a humanitarian mission. I was praising her for the awesome work she and her team accomplish every day and how they are saving and changing lives around the world. She was pensive for a moment and then said, “Yes, the work we do is important, but your work is important, too. You’re also changing lives, only in a different way.”

I was a bit taken aback at first, then realized that perhaps she was right. When people make changes to their work environments by transforming the culture and dedicating themselves to deliver safe patient care, it’s pretty amazing. My work matters, and I am deeply affected by the people I meet on my travels.

All hands on deck: Negative work environment!

I recently facilitated, for a group of nurse executives and managers, a workshop on evidence-based strategies to foster positive, healthy work environments. Toward the end of the day, a nurse manager of a busy ED stood to address the group. She said she had been frustrated with unsupportive people who contributed to a negative work environment where teamwork and relationships were second-rate, and, as a consequence, patient care had suffered. As the leader of her department, she decided to do something about it.

She began the process by supervising—individually and deliberately—each offending nurse. Over the course of a 12-month period, 11 nurses were removed from their positions and asked to leave the organization. One by one, she replaced each negative worker with a carefully vetted nurse committed to teamwork, collegiality, and collaboration as part of a high performing team dedicated to delivering the best and safest patient care possible. Life today in that ED, she enthused, is extraordinary! While the work continues to be challenging and demanding, every day is now an energizing experience as the team works together in a highly functional, united, and mutually satisfying way.

Talk about a civility champion! Her bold declaration motivated others in the room to agree that now is the time to lead a coalition for change and mobilize teams to create and sustain healthy, positive work environments where civility flourishes and where workers band together to fulfill a collective and unequivocal commitment to safe patient care.

Wanted: More civility champions!

Road to civility

This dedication to civility—and ultimately patient care—requires principled, ethical, and authentic leadership, as well as unambiguous adherence to nursing’s responsibility to fulfill the obligations set forth in our code of ethics and other professional statements. To hold employees accountable, managers must first establish clear, specific expectations for acceptable work performance and desired behaviors. Next, managers need to discuss each employee’s commitment to fulfilling those expectations and secure his or her assurance that achievement of the desired behaviors will be supported.

It is imperative for managers to provide necessary resources for each employee to meet work-performance expectations and offer ongoing feedback regarding employee performance. Setting clear expectations coupled with quality feedback are hallmarks of holding someone accountable. Although providing constructive feedback about areas of strength and improvement isn’t foolproof, it opens the door for problem-solving and follow-up action. In many cases, giving objective, sincere feedback while expressing desire to support the employee are sufficient to change behavior. When employees meet work-performance expectations, their actions should be rewarded and celebrated.

If employees do not meet performance goals, they require additional education and training. If it is a motivation problem or refusal to comply with a performance-improvement plan, imposing a fair and appropriate consequence might be in order. This should not be viewed as a punitive measure, but an approach to encourage employees to take commitments seriously and focus on delivering safe patient care.

Remember: While managers play an important role in fostering healthy work environments, it is ultimately every one’s responsibility to model the way and be civility champions!

Editor’s note: Cindy Clark will be presenting at the Creating Healthy Work Environments conference, slated for 17-19 March 2017 at the JW Marriott in Indianapolis, Indiana, USA. The theme of the conference is “Building a Healthy Workplace: Best Practices in Clinical and Academic Settings,” and Clark’s Plenary 1 presentation is titled “Creating Healthy Work Environments: Powered by Civility, Leadership, and Ethical Practice.” The early registration deadline is 25 January. To learn more and to register.

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.

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.

Planting seeds of kindness

It’s a stunningly gorgeous morning in the high desert of Boise, Idaho, USA. I just returned from an early morning hike with three of our energetic and high-spirited rescue dogs. They run with abandon and enthusiasm to greet the morning, leaping with the utter joy of being alive! I share their exuberance as I listen to the meadowlarks fill the morning air with their catchy and melodious song.

When we arrive at the top of the knoll where we turn to go home, we pause for many moments to take in the panoramic view of mountain ranges that encircle our home. None of the mountains bears even a remnant of the snows that fell and blanketed them earlier this spring. Instead, they stand bare and tall against the blue sky, beckoning elk and other wild critters that inhabit the region, as well as hikers.

The view from our front yard.

When we return from our hike, I attend to the usual morning chores before starting a day of writing, tending the garden, looking after pets, and watering flowers. There’s a particular little flower patch that I planted shortly after last month’s commencement. I dug the patch myself. I could’ve asked my husband to assist me, but digging the small plot was a chore I relished and wanted to do. So one day, I tilled the soil, enriched it with nutrients, and lovingly planted seeds given to me by one of my nursing students. The package of seeds was tucked inside a lovely card in which she thanked me for inspiring her. It included this entry: “Dear Dr. Clark, plant these seeds and watch them bloom, as so many students have bloomed under your guidance.”

I was deeply touched by the sentiment. Today, as seedlings poke through the earth and reach for the sky, I am humbled by the influence we have on the lives of our students. As faculty members, we are and always will be one of their most formidable and influential role models. Therefore, we must always be cognizant of the way we speak and act. The importance of modeling the way cannot be overestimated. Students are watching our every move. It’s a daunting thought, as well as a wonderful opportunity.

"Dear Dr. Clark, plant these seeds and watch them bloom ..." 

— SachmaDeluxe/iStock/Thinkstock

As nurse educators around the globe, we have an important responsibility to prepare and mobilize our nations’ nursing workforces. This is no easy task, and we must not take our students’ professional role development lightly. One of the most important nursing roles is that of a “civilist."

What is a civilist, you may ask? Contending that being civil takes self-discipline, practice, and commitment, Kenneth Maxey (2011) coined the term civilist (p. 10) to describe the attributes and habits of a civil person. I couldn’t agree more! It is incumbent upon nurse educators and academic nurse leaders to intentionally grow the next generation of civilists—nurses well-prepared to create positive change and promote a safe, healthy workplace.

While it is important to establish civility as an organizing value in any organization, it is equally important for each individual to self-reflect and take an accurate inventory of one’s own behavior. Each of us needs to evaluate our interactions and display behaviors that support the dignity of others. It is tempting to return incivility for incivility, to respond in a ‘tit for tat’ manner. Instead, we must be prepared and practiced in the art of addressing uncivil behavior. For example, a demeaning comment or sarcastic remark could be responded to in this way: “I learn best from individuals who address me with respect and value me as a member of the team. Is there a way we can structure this type of interaction?”

I realize that creating a totally civil society is a utopian ideal. Yet, devoting time and attention to being a civilist can make a significant difference. Crafting a personal civility credo, along with developing—and living out—a list of life principles and daily habits, is a good starting point. For instance, my personal civility credo is “to lead the coalition for change by raising awareness, amplifying the civility conversation, and inspiring civil action.” Some of my life principles include living with purpose and meaning, leading an examined life, assuming goodwill, and nurturing my body, mind, and spirit. These life principles are made operational by practicing daily habits, such as smiling and greeting others by name, expressing and living in gratitude, and striving to make a positive difference in the lives of others.

I encourage you to take the time to consider principles and daily habits that shape your life. Writing a personal life statement provides clarity and insight, and helps strengthen your commitment. Putting pen to paper or keyboarding your ideas into a thoughtfully composed statement helps solidify your plan. Share the plan with a family member, friend, or trusted colleague, if you wish. When we share ourselves with others, it strengthens our commitment and resolve.

So, go forth, plant seeds of civility and kindness, and watch them bloom!

Reference:

Maxey, K. (2011). Civil business: Civil practice in Corporations and society. Denver, CO: Colorado Writing Services.

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.

The power and promise of storytelling

Once upon a time, there was a college professor who loved stories. She loved listening to them; retelling them; creating, writing, and sharing them. As a young child, riveted by some of the world’s best storytellers (her family and friends), she quickly learned that a powerful, absorbing story can mobilize action, influence thinking, stir emotions, and sometimes move us to tears. And that every now and then, a gripping story can teach us lessons that change our lives. That college professor is me! I grew up witnessing and embracing the magical power of a compelling story.

Stories not only illuminate a topic, but tell us something about the storyteller, too. Telling a simple, powerful, relevant story breathes life and relevance into even the most uninteresting topics. Stories help make the forgettable and unexciting memorable and significant. The ancient art of storytelling grabs us and refuses to let go. The lessons learned and the morals taught provide fodder for reflection, self-discovery, and inspiration.

Devonyu/iStock/Thinkstock

When we share our stories, we provide context for understanding and sorting out our experiences. Here’s a story that was recently passed along to me by a recently graduated nurse. [I’ll call her Holly, not her real name]. Holly was 23 years old when she had her first month of orientation on an oncology unit and was inexperienced in end-of-life care. Here’s her story.

During my nursing education, I had never experienced the death of a patient. As a brand-new nurse, that changed dramatically. It didn't take long for me to realize that death on an oncology unit is a common occurrence.

I struggled to deal with the range of emotions that quickly became part of my day-to-day working life. One extremely busy night, several very ill patients required complex procedures while they and their families also needed emotional and spiritual comfort and support. Learning my new role while simultaneously administering holistic care to clearly compromised patients, I felt torn in so many directions. I struggled to do my best, and, since every member of the health care team was stretched to the max, was determined to function as independently as possible.

One of my patients, Mr. Brown (not his real name), was in especially critical condition and had a DNR/DNI order. I had been checking him constantly throughout the night and, during a final round, found him surrounded by family and taking his last breath. After checking Mr. Brown’s heart rate and confirming he was deceased, I reported his passing to the physician, who then came and pronounced him dead.

Since Mr. Brown was my patient, it was my responsibility to provide postmortem care. After giving the family time at the bedside, I found myself alone in the room with the deceased and quickly realized I had no idea what to do. I had not been introduced to this type of care during my nursing program, nor had I received postmortem training during orientation. Despite the busyness of the night, I knew I needed help. I explained the situation to my charge nurse, who was immediately supportive and guided me gently through the process. Being a new nurse can be challenging, but knowing when to ask for help and having a collegial and responsive team make all the difference in the world.

Sharing our stories with others helps us deconstruct and interpret new experiences. Stories help us organize our thoughts, make sense of events, and assist us in making decisions and determining courses of action.

What do we learn from Holly’s story? First, reach out to others, and don't be afraid to ask for help. Ultimately, our patients’ safety and care depend on it. Second, the impact of a traumatic experience is eased when we share our thoughts and feelings with trusted and more experienced colleagues. Third, seasoned nurses have the capacity to model caring and supportive behaviors for less experienced colleagues. By serving as a positive role model and sharing knowledge, experience, and wisdom, experienced nurses guide the professional development of those with less experience. Positive role models are generous, competent, and focused on collegiality and collaboration. Nurses at all levels of experience need to encourage initiative and curiosity, foster desire to learn, and promote willingness to seek guidance.

Storytelling is an incredibly powerful tool for opening the nooks and crannies of our minds and makes room for fresh ideas and points of view to take up residence. Stories have the potential to ignite our senses and fill our grey matter with creative ideas and new ways of knowing. So, boldly share your stories and experiences with others, and use those stories as catalysts to create personal, professional, and transformational change. The results might just change the world.

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.

Rewarding civility

I am so impressed with the Allegheny College Prize for Civility in Public Life. The award recognizes individuals who foster appreciation for the vital link between an engaged, active citizenry and a healthy democracy. The first Allegheny College Prize for Civility in Public Life was awarded to David Brooks and Mark Shields for their remarkable commitment to civil discourse. Despite their very different political views, these two gentlemen are consistently respectful and civil in their communications.

It’s my belief that the civility landscape can be shifted for the better by incorporating an important lesson from Parenting 101: When we catch our children doing something right, they need to be rewarded. B.F. Skinner taught us that lesson long ago when he concluded that positive reinforcement makes a difference and, if delivered in a meaningful way, will likely result in the behavior being repeated.

Using this principle as a starting point, my husband and I discussed various ways to reward nursing students for commitment to civility and professionalism. After several conversations, we decided to establish the Clark Civility Award to recognize nursing students who demonstrate sustained commitment to civility. The award is given each semester to a qualifying senior nursing student who exemplifies civility, respect, and professionalism at Boise State University School of Nursing, College of Health Sciences, and beyond.

There are several criteria for the award, including being a contributing member of student organizations and other relevant teams and committees, having a minimum GPA of 3.0, providing a record of service to the community and the profession, and demonstrating respect and civility toward classmates, faculty, nursing staff, patients, and families. Students receiving the award must also show collegiality, trustworthiness, and responsibility. Recipients may be self-nominated or nominated by someone else.

Mark McLaughlin and Yours Truly

Last week, Mark McLaughlin became the first recipient of the Clark Civility Award. He was nominated by a faculty member, who eloquently described McLaughlin’s contributions of outstanding service to the School of Nursing and the broader community, his unwavering respect toward others, and his commitment to teamwork and ethical conduct of the highest order. An excellent student who actively participates in his community, he shows great promise as a professional nurse and consistently goes the extra mile to provide exceptional patient care.

On Wednesday, 11 December 2013, McLaughlin accepted the award, presented by the dean of the College of Health Sciences, during a ceremony attended by his classmates, faculty members, and academic leaders from the School of Nursing. In addition to a monetary award, McLaughlin received a signed copy of my book and a professional plaque commemorating his achievements.

I hope others will be inspired to create similar awards or other ways to reward those who practice civility by catching them doing something right. Perhaps you will be inspired as I am by the words of two very influential women who encourage each of us to make a difference. The first quote comes from Anne Frank, who stated, “How wonderful that no one need wait a single moment to improve the world,” and the other from Helen Keller, who reminded us, “Alone we can do so little, but together we can do so much.”

Let’s all strive to make a difference in the lives of others. By doing so, we make a difference in our own. Here’s wishing you and the people you love—and those who love you back—the happiest of holidays.

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

Civility rising!

I have always been an optimist! As a child, I dreamed of playing second base for the Chicago Cubs. I imagined myself deftly scooping up ground balls like a Hoover vacuum and whipping the ball to turn a double—or even triple—play. No one ever told me I couldn’t become the next great major-league infielder. As an adolescent, I dreamed of attending Harvard University, being first in my class, and becoming our country’s first female president. No one ever told me I couldn’t become the leader of the free world.

As a young adult, I dreamed I could change the world. Working with challenging and violent youth, as a member of an adolescent mental-health team, reinforced my belief that a strength-based approach to treatment, mixed with a little bit of luck, often resulted in positive life changes in our clients. A core belief of our team was, to give up hope is to give up everything. We believed that each adolescent deserved another chance, and it was our goal to make it happen. Hope was the glue that kept us going and inspired us to keep fighting the good fight. No one ever told me to lower my expectations or to let go of my unlimited idealism. Instead, I was encouraged by nearly everyone around me to dream big and believe in something greater than myself.

Today, in my middle-adult years, I find myself still burning with passionate optimism and believing that things can and will get better, that faith and being open to possibilities are part of my DNA. I am a firm believer in amplifying the civility conversation to strengthen the human infrastructure of civility and respect and to stimulate optimism and hope that relationships matter and that workplaces can be venues of collegiality. To think otherwise is to surrender and admit defeat.

A positive outlook must be balanced, however, with a realistic perspective. I am not naive to the fact that there are challenges many of which may seem insurmountable—sadly, in a few cases, they may be—and that the only way to stay healthy and motivated is to leave that situation, take our passion with us, and infuse it into a more welcoming venue. But most of all, I see pockets of civility rising! They are brave and courageous individuals who refuse to settle for the status quo and, instead, work together to effect change and bring civility into the light. As Louis Brandeis, former U.S. Supreme Court associate justice, stated, “Sunlight is said to be the best of disinfectants,” meaning that transparency matters and that raising awareness about our challenges and identifying ways to address them helps shed light on them, thereby making them less prone to continuation. In my view, being open and honest with others is requisite to civility. Organizations that embrace and encourage a free flow of dialogue and communication are masters at creating and sustaining a culture of civility.

Let me share a couple examples of why I believe civility is rising. Each semester, my students and I co-create our classroom norms. This semester, in addition to our usual norms, among others, of engaging in respectful interactions, assuming goodwill, respecting differences, and making thoughtful contributions to the teaching-learning environment, we decided to add modeling the type of nurse each of us aspires to be. When we formally evaluated our classroom norms during midterm, we discovered that we are doing an excellent job of abiding by our norms and staying accountable to them. Certainly, we are not perfect, but by having a clear code of desired behavior, we are coming much closer to being the professional nurse we aspire to be.

Similarly, a group of students from Florida has developed and committed itself to a “civility pledge,” with each student signing a promise to work toward positive behavior. The pledge was presented at the school’s All College Day earlier this semester, and students, faculty members, and administrators signed the document. In doing so, students promised, among other civil interactions, to respect others, listen carefully, celebrate diversity, be considerate of others, advocate for the profession of nursing, and promote collaboration. Making this pledge and living by its code has transformed this group of students. Following their example, other students in the school are planning to make a similar pledge. Wouldn’t it be terrific if all faculty members and students committed themselves to a similar set of principles?

Here’s another example of civility rising. I was recently presenting a workshop to a group of practicing nurses, students, nursing faculty, and other nurse leaders. One of the interactive exercises involved completing the Clark Workplace Civility Index (Clark, 2013), a self-reflective activity designed to raise awareness, inspire conversation, and achieve a better understanding of oneself and others with regard to civility and respectful behavior. This eclectic and engaging group thoroughly immersed themselves in the activity and generated several ideas to foster civility in their various settings.

One of the most intriguing ideas resulting from the exercise had to do with using the index as a model to create a family-specific index that would include desirable civil behaviors within families. I encouraged the person suggesting this to use her creativity and imagination to do just that. What a fantastic idea! It’s amazing what we can do individually and collectively when we allow ourselves to think beyond the usual way of doing things and engage in important and provocative discussions on issues that matter.

A final note: A subhead in a recent Time magazine article (Newton-Small, 2013) describing the relationship among some of the women in the U.S. Senate declared, “Civility Above All.” The piece reinforced the importance of establishing norms and adhering to rules of civility. What a wonderful concept!

Reference:

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

Newton-Small, J. (2013, October 16). Women are the only adults left in Washington. Time.

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

Organizational culture matters

Just before the current semester began, I received a phone call from a nursing professor exuding delight about her new faculty appointment. In her enthusiasm and joy, she exclaimed, “I just accepted the most remarkable faculty position. The school has a civility statement, a code for respectful behavior and interactions, and, most of all, members of the campus community actually live by their code of civility and shared values. I can hardly wait to get started!”

I was delighted for my friend and for the students who will reap the benefits of such a rich, engaged teaching-learning environment. After congratulating her, I asked, “What courses will you be teaching?” I laughed out loud when she responded, “Who cares? I’m just so excited to be part of such an incredible experience. I am happy to teach anything!”

Our conversation validated one of my foundational beliefs about workplaces—that culture trumps everything. In other words, no matter how wonderful one’s job description, it pales if the workplace is unhealthy, toxic, or uncivil. It is important for workplaces to have a vision and mission statement, with explicit reference to civility and respect. If an organization lacks such a reference, it is unlikely it will live by these essential values. There must be an established and reciprocal trust between the leaders and all members of the organization—including students, if it’s an educational environment. Each member must be viewed as an asset and appreciated for the value he or she brings to the workplace.

Healthy workplaces embody emotional safety, and they create and encourage “safe spaces” for dialogue and meaningful conversation. Such organizations recruit the best and the brightest and, more importantly, make every effort to retain them. Healthy workplaces exude high morale, job satisfaction, collegiality, and high-performing teamwork. Respectful communication and shared decision-making is evident. In healthy organizations, trust is the glue that holds it together, civility its lifeblood, and leadership at all levels the heart that pumps it throughout the organization.

Often, I hear people say that lack of civility and organizational trust is not necessarily a problem if it involves only one or two individuals within the organization. I beg to differ. Think about it this way: If multiple small incisions occur in an organism, it will eventually bleed out, causing its demise. The same is true for organizations. Even if there are only one or two toxic members in the organization, the results can be devastating and far-reaching.

And what if the one or two uncivil individuals hold formal leadership positions and their uncivil acts include an abuse of power? Such behavior can drastically change the organizational culture and have a serious impact on people and the bottom line. According to Porath and Pearson (2013), managers of Fortune 1000 firms spend 13 percent of their time—the equivalent of seven weeks a year—dealing with the aftermath of incivility. In some cases, the financial cost can be ruinous.

So what can we do to create cultures of civility? Here are a few ideas.

First, each member of the organization, including leaders, needs to take a candid and thoughtful look in the mirror, making an honest and accurate inventory of how well he or she is behaving and interacting with others in the organization. This assessment includes asking for candid feedback from colleagues, so each member can get a reality check on how he or she is coming across.

Positive and professional role-modeling is also essential to creating and sustaining cultures of civility. Knowing how to effectively communicate and negotiate conflict are essential skills that must be practiced, honed, and utilized. Too often, we avoid addressing issues that matter, thinking that “nothing will change” or that, in doing so, we might make matters worse. Or we simply don’t believe we have the skills needed to successfully address the situation. We need to change our mind-set, harness our courage to learn, and utilize the skills needed to promote a healthy workplace.

However, stepping up, communicating, and addressing conflict are best accomplished in organizations that embrace civility, respect, and transparency. Thus, establishing unambiguous vision and mission statements, statements of shared values, and co-creating behavioral and organizational norms are foundational to healthy workplaces. Positive behavior needs to be reinforced and celebrated. Being recognized for civility and collegiality can be highly motivating and have a significant impact on morale and job satisfaction. Promoting and rewarding interprofessional teamwork and collaborative initiatives can also enhance job fulfillment and deepen esprit de corps.

Unfortunately, in some cases, despite attempts to respectfully address issues of concern and effect positive organizational change, such efforts may fall short—or fall upon deaf ears. When that happens, we need to carefully reflect on the situation and decide whether we will stay in an uncivil workplace or move on.

On the other hand, if you are fortunate enough to be working in a civil, healthy workplace, celebrate and share the good news. Keep up the great work, and tell about your experiences and strategies so others can gain from your successes. Like the nursing professor who excitedly told me about her new job, each of us deserves a wonderful place to work.

Reference:

Porath, C., & Pearson, C. (2013, Jan.-Feb.). The price of incivility: Lack of respect hurts morale and the bottom line. Retrieved from http://hbr.org/2013/01/the-price-of-incivility/

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

Attention, page turners, tappers and swipers!

I grew up among a family of readers. I have deep and vivid mental images of my father relaxing in his slightly tattered recliner and reading books ranging from Dale Carnegie’s How to Win Friends and Influence People to Homer’s The Iliad and The Odyssey, epic poems about the siege of Troy and the return home, 10 years after the Trojan War, of the Greek hero Odysseus.

My mother, on the other hand, loved fiction. With a book propped open on the kitchen counter, she would read while cooking supper or fulfilling any number of motherly responsibilities. My big sister was and is an avid reader who peruses works that encompass an extensive span of genres.

Click photo to order.

As a teenager, my favorite books included biographies of famous sports figures like Lou Gehrig, Knute Rockne, and Cassius Clay (before he became Mohammed Ali). I enjoyed sports biographies so much that, finally, my high school English teacher declared, “Enough, Cindy, you need to expand your horizons!” and would not accept any more reports from me about books based on sports figures. As I reflect on that time—and my teacher’s mandate—I am grateful for her insistence that I broaden my taste for books, because I started reading just about everything I could get my hands on.

Years later, I met my father-in-law, who always seemed to have a book in hand. When visiting, he would arrive with an extra suitcase filled with his beloved books. He enjoyed a wide variety of subjects, and I loved the way his glasses perched on the end of his nose as he read, how he marked the pages with a folded corner and then entered notes in the margins with his thick, black, felt pen. Even more, I basked in the conversation that ensued as we discussed the author and his or her thesis. It didn’t matter what the subject matter was; what mattered more was the banter and repartee that filled the room and the mind-stimulating dialogue.

As a child and, later, as I grew into adulthood, I hoped to be an author someday, not an author of just any book but one that made a difference in the lives of others. My mother believed I would write a book for children, because I love to tell stories that delight the young of heart. I always thought that my mother was right, so who would have thought I would write a book for colleagues?

When the publishers of Sigma Theta Tau International contacted me with the prospect of authoring a book on “fostering civility in nursing education,” I was a bit taken aback, but not for long, because I soon realized I had been writing just such a book in my head for a long time. I couldn’t wait to put my stories and thoughts down on the pages of a manuscript that has now become a published book with the title Creating and Sustaining Civility in Nursing Education. What a thrill! I wrote the book with you in mind—nurse educators who each and every day rise to the challenge of educating and mentoring our students and future nursing workforce.

I must admit, I love the feel and smell of an old tome, cracking the binding and turning the pages of a book to discover unlimited possibilities, experiencing an incredible intellectual or entertaining journey that transports me to any place my mind can travel. Now, I invite you to experience the feel and smell of a new tome and to have fun delving into a book that offers myriad ideas and reflections on ways to foster civility in nursing education, your lives, and beyond. Enjoy the journey!

Oh, you prefer E-books? Well, start downloading!

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

Living the joy of authentic conversations

For many of us, the world is a busy and noisy place, a high-tech, digital environment—often stressful—where we are besieged with text, e-mail, phone calls and other instant messaging. We madly check, send, receive, exchange and process a vast amount of information every day. And, if we teach in the virtual environment, our days are filled with managing and responding to an incredible amount of complex and multifaceted data. This explosion of technology and our preoccupation with it can interfere with our privacy, disrupt our relationships and create yet another venue for incivility.

At a recent community event, I was seated next to a civic leader who expressed concern about the impact of technology on relationships. She told me about having an important conversation with her grown son who, in the middle of their discussion, took a call that lasted several minutes. Annoyed, she asked her normally well-mannered son why he chose to take the call when they were obviously engaged in an important dialogue. He thought for a moment and then said, “I think it’s because I wanted to stop the noise, to quiet the jarring disturbance of a ringing cell phone.” Ah, there it is again. We are torn between our desire to silence the noisy din of our busy, hurried world and our preoccupation with responding in “real time” simply because technology makes it possible.

What will it take for us to engage in meaningful, genuine, face-to-face conversation; to carve out time from our hectic schedules to seek and savor the quiet and calm that often comes with open, honest communication? Margaret Wheatley (2002) reminds us that we can “change the world if we start listening to one another. Simple, honest, human conversation … a chance to speak, to feel heard, and where we each listen well. The simple art of conversation may ultimately save the world (p. 3).” If Wheatley’s assertion is true, and I believe it is, then faculty play a key role in facilitating this process with students by creating learning environments for teaching, learning and practicing the complex skills needed for authentic conversations.

My students and I spend a good deal of time practicing and improving our skills for engaging in conversation with patients, members of the health care team, one another and with the people who matter most in our lives. We discuss mental and cognitive preparation for critical conversations, how to gauge and create emotional safety, setting goals and determining mutual interests, and seeking common ground. We practice giving and receiving constructive feedback, and we use that feedback to set realistic short- and long-term goals for life and for nursing practice.

I challenge my students to use their newly acquired skills to engage in meaningful conversation with others. I ask students to select someone in their lives with whom they wish to have an important conversation, using the skills we’ve practiced in class, and then, if comfortable, to share their experiences with the class. If students agree to report back, I have them briefly describe the situation and the person or people involved, key issues and reasons for the conversation, and steps used to engage in the conversation. I also ask them to describe how the conversation started, progressed and ended. Many students rise to the challenge and openly share their experiences, which, of course, help all of us learn and improve.

I challenge my students to use their newly acquired skills
to engage in meaningful conversation with others.

This semester, I had a very interesting experience. After our “critical conversations” class, I was working in my office when one of my students—I’ll call him Harry—knocked on the door and asked if I had time to meet for a few moments. I did, so invited him to have a seat. Taking the chair across from me, he sat quietly for a few moments, seemingly to compose his thoughts, and then said, “Dr. Clark, you suggested that we find someone with whom we would like to engage in a critical conversation, right?” I nodded, and he continued, “Well, I picked you!”

I was surprised and flattered, all at the same time, but more than that, I was very curious, so I asked him to proceed. Harry seemed to gather himself, and then asked, “Do you remember a couple of weeks ago when I was playing computer games and not paying attention to the class discussion?” I nodded, asked him to continue, and he said, “What I did was wrong. My behavior was rude, and I came to apologize. You deserve better—and you deserve more respect. I promise that, from here on out, I am going to do better. You will see a different me. I am going to be more involved in class, pay closer attention and show you that I mean it.” I thanked him, expressed how impressed I was with our conversation, and then he left.

The following week, I arrived at my classroom early, as usual, to give me time to visit with my students before class began. I immediately noticed that Harry was sitting in a different seat. Instead of his normal spot in the last row in a far corner, he had selected a new seat—just a bit off center and only two rows from the front of the classroom. I approached him and said, “Good morning, Harry. I see you have a new seat.” He smiled and said, “I promised you that I would make every effort to be involved in class, and that’s what I’m doing. Sitting here helps.”

Since the day of our critical conversation, Harry has lived up to his promise. He is fully engaged and participates in small and large classroom discussions. He is a very impressive young man and well on his way to becoming an excellent nurse.

Engaging in critical conversation is an art that must be developed and honed over time. Being a positive role model and teaching this important skill is integral to preparing our students for successful nursing careers. The end goal is to create a safe space for authentic dialogue, to treat one another with civility and respect, to seek common ground, to give a little, pursue a win-win outcome and, ultimately, to improve our relationships.

Reference:

Wheatley, M.J. (2002). Turning to one another: Simple conversation to restore hope to the future. San Francisco, CA: Berrett-Koehler Publishers.

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

Reflections in The Cathedral of the Blue Dome

I am a firm believer in the power of reflection and introspection. Finding quiet time to think, contemplate and wonder restores the soul. For me, being outdoors and experiencing the elements brings me considerable joy.

Our family recently moved to the country, several miles outside of Boise, Idaho. Our new home is nestled within thousands of acres of public land, surrounded by several mountain ranges, inhabited by herds of deer, antelope and elk. Above all this marvelous splendor is a big, bold, wide-open sky, what my husband and I affectionately call The Cathedral of the Blue Dome.

During the recent Thanksgiving holiday, I hiked many miles along the hilly terrain that surrounds our property and took time to reflect on some of the pivotal events of my life and how they impacted my choice to become a nurse. Along my hiking journey, a story came to mind. It begins many years ago. I was 16 years old and working as a nurse’s aide in a nursing home. An elderly man whom I will call James lived in the home. I didn’t know it at the time, but James would change the course of my life.

As a younger man, he was severely injured in a construction accident, leaving him a multiple amputee and wheelchair-bound. Later, James suffered a debilitating stroke, but he fought the good fight and refused to yield to the physical limitations of his condition. I was inspired by his spirit, tenacity and determination. The highlight of my working day was spending time with him, listening to his stories as he recounted the history of his life.

Each day was a journey into the existence of a man who loved life and feared little. He taught me to believe in goodness and kindness, and he challenged me to think big, to dream in living color. He encouraged me to make a difference in the world and to leave an indelible footprint on this earth, a footprint I would be proud to leave, one of decency, compassion and integrity. James inspired me to reach higher than I ever believed I could, to soar at 60,000 feet. Most importantly, he encouraged me to become a nurse. He loved nurses, he loved the profession and I know he loved me. As an adolescent, I gave little thought to my future, but I listened to James and his deliberations about the journey of life with its many twists and turns. I took note of his insightful lessons. They mattered deeply to me.

One day, when I arrived at work, I saw the ambulance pulling away. I knew from experience that one of the residents had died, and I wondered who it could be. The night nurse met me at the door and embraced me. Hugging me tightly, she whispered softly that James had died quietly during the night. I was devastated by the news. It was a defining moment in my life, and it made a significant impact on my future career. I decided then that I would become a nurse, that I would strive to make a difference and that I would do everything I could to leave that much discussed and highly treasured indelible footprint.

Many people like James come into our lives and influence us in ways that are deeply felt and shape the person we are; indeed, the person we are becoming. Many of these people are our role models, mentors and heroes. They challenge us every day to make an important difference in the world, to set the bar high and to “pay it forward” by becoming mentors to others, inspiring them to lead mindful and purposeful lives, lives that matter.

Each day, I challenge myself to advocate for a more just and humane world, solidly embedded in the principles of social justice, veracity and equality. I believe that each of us is called upon to serve the common good and to cultivate hope, to be reflective and contemplative when making decisions, to find quiet moments to restore and rejuvenate the spirit, to promote and celebrate the lives and accomplishments of others, and to shine the spotlight brightly on those who are a voice for the marginalized and less fortunate. In the end, it is truly what really matters.

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