Training for Toxic Work Culture Should Start in Nursing School
Preparing for incivility, bullying, preventing violence
By Gary Evans, Medical Writer
While often seen as separate and disturbingly distinct, incivility, bullying, and violence in healthcare are actually connected across a common culture of toxicity, says a researcher and author on the subject.
“They are not separate issues — they are related,” says Cynthia Clark, PhD, RN, ANEF, FAAN, professor emeritus of nursing at Boise (ID) State University. “By definition. they are somewhat different, but they exist along a continuum of harmful and aggressive behaviors. You can have a person who behaves badly and never gets to the point of violence. Incivility and bullying, are tragically awful, but generally, people don’t die. So violence takes us to a whole new level, but that, to me, is the far right end of a continuum of aggressive behaviors.”
The author of a recently published book1 on this issue, Clark also co-chaired an American Nurses Association committee that linked incivility, bullying, and violence in an ANA position paper. Clark’s committee concluded that civility in the workplace is an ethical imperative and should be demonstrated by such behaviors as the following:
- Treat others with respect, dignity, collegiality, and kindness.
- Consider how personal words and actions affect others.
- Take personal responsibility or accountability for one’s own actions.
- Recognize that abuse of power or authority is never acceptable.
- Listen to others with interest and respect.2
Unfortunately, such attributes are conspicuously absent in some healthcare work cultures. A common denominator across unsocial and aggressive behaviors is work stress.
“Here’s the thing in nursing and in healthcare — we are never going to get away from a stressful environment,” Clark says. “Let’s face it. We’re in the business of life and death, so that in and of itself creates a stressful work environment that we need to diminish.”
While work culture change takes time, individual healthcare workers must cope with the environment in the moment. To deal with stress in healthcare, Clark recommends setting aside time to center yourself and contemplate gratitude. A metaphor that applies is the common airline safety advice to put on your own oxygen mask before attempting to help others.
“One thing we need to cope well are ‘just-in-time’ strategies that we can use on the job immediately for about 30 seconds or a minute — just sort of regroup,” she says.
For example, Clark advises a quick triple-technique using stretching, breathing, and positive imaging. As described in her book, the technique involves extending the arms upward and standing on tiptoes, drawing deep breaths while thinking a positive affirmation like, “Stress is leaving my body. My work is very important. I am making a positive difference in the lives of my patients.”1
Another important strategy is “learning how to speak up in a respectful way,” she says. “That’s tough stuff. That is not an easy skill to build or to master.”
Remaining silent about witnessing or suffering toxic behavior can normalize incivility in the work culture. By way of example, consider this comment recently submitted to OSHA, which is promulgating a violence prevention regulation for healthcare. It was submitted to the OSHA docket by Stacy Maitha, RN, of the Indiana Emergency Nurses Association in Bloomington:
“‘What are you doing, Kelli?’ I asked our patient care tech as I saw her round the corner in our emergency department for the second time in just a few minutes. ‘I have to step away for a few minutes from the verbal assault I’m receiving back there,’ she said. ‘Oh you get used to it,’ I heard myself say. Her stunned facial expression in response to my flippant comment snapped me out of my autopilot mode and caused me to think about what I had just said. I myself have only been an emergency RN for three and a half years. Kelli has been an emergency department patient care technician for about two years. In that time, I have been kicked, hit, spit on, cursed at and threatened by patients and their visitors. Like most of the people I work with, I have come to expect this behavior from the people we serve in our community hospital. But that day, Kelli’s face reminded me that I shouldn’t expect it, and that I absolutely shouldn’t be telling my co-workers to just ‘get used to it.’”
Can verbal attacks culminate in violence? Establishing direct cause and effect may be elusive in many cases, but healthcare, in general, suffers a toxic continuum where insult can, indeed, be followed by injury. In comments to OSHA, the National Institute of Occupational Safety and Health (NIOSH) cited the importance of encouraging the reporting of “verbal violence.” (For more information, see related story in this issue.)
In the aforementioned ANA paper, Clark recommends nurses consider the following strategies when subjected to abuse:
- When RNs experience incivility and bullying, either they can respond directly to the perpetrator, or they can seek out guidance and support through the appropriate channels. When possible, perpetrators of incivility and bullying should be addressed privately.
- RNs are encouraged to use pre-established code words or other mechanisms to seek support when they feel threatened. This outreach may involve the targeted individual or a bystander using a predetermined phrase that signals all available nurses to move toward the target both to provide nonverbal support and to witness the harmful actions taking place.2
The Next Wave
Incivility and related aggressive behaviors should be acknowledged and addressed in nursing school to prepare the next wave of healthcare workers to enter a work environment where their resilience will be tested, Clark says. She shared some further insights on this timely topic in an interview with Hospital Employee Health.
HEH: This issue certainly seems appropriate to address in nursing school. Why did you decide to advocate civility training as part of healthcare education?
Clark: As faculty, we have a responsibility in educating our nurses the moment they walk into one of our pre-licensure programs on these important issues. What is their professional role in creating a positive work environment? As you begin to unfold that, you look at things such as how to communicate more effectively among members of the healthcare team, particularly when patient safety issues are at stake. How do we negotiate conflict in an effective way? There is a lot of skill-building that students can learn in the academic environment [in conjunction] with their clinical experiences.
HEH: In a nutshell, you define civility in terms of respect and seeking common ground, while incivility is marked by disregard for the other and, in its worst forms, “an assault on human dignity.” Are these behaviors being commonly taught in nursing school today?
Clark: Is it being done universally? No. It’s being done in some schools, but not in others. It is being done on a grand scale in some [schools] and very little or none in others. I really recommend that we integrate — not change the curriculum, because some faculty are really resistant to adding more to what they already see as a jam-packed curriculum. Instead, we can be smarter or more thoughtful about how we integrate concepts of civility, professionalism, ethical practice and so forth into an already existing curriculum. Those, strategically speaking, need to be active, engaging, with use of simulation, role playing, and those kinds of things. I advocate that schools adopt this as part of their curriculum. Some have; some have not.
HEH: This seems somewhat analogous to nursing schools using safe patient lifting equipment, not only honing their students’ skills, but creating the expectation that this should be part of their work culture.
Clark: Yes, some of my students have said to me, you know [this training] is a resumé builder — to go into an interview and be able to say, “Here are the skill sets that I bring.” In addition to [clinical skills], they bring these additional [work culture] skills that many recruiters and employers are looking for. The ability to manage conflict, build tools, lead by example. Those kind of skills are in high demand, particularly in a multigenerational workforce.
HEH: You argue that there is a link between incivility, bullying, and even violence.
Clark: Yes, it is a continuum of these behaviors or lack of behaviors — because sometimes it is not only what we do, it’s what we don’t do. For example, especially in the healthcare field, if we are not speaking up when we ought to be speaking up, when we are disregarding or shunning co-workers, when we are walking away from dealing with a family. Those behaviors can be very detrimental.
HEH: You certainly describe the detrimental effects of bullying, with the account of one nurse in your book who developed post-traumatic stress disorder.
Clark: Yes, he did. Despite his efforts to take measures within that organization at each juncture, he was sort of thwarted and he didn’t really recover from the symptomology until he left that organization and started working in another one, where it was much healthier and people were much more collegial and collaborative.
HEH: There has been a somewhat begrudging acceptance of what might be described as a kind of “hazing” culture, including the phrase we have all heard: “Nurses eat their young.”
Clark: Well, certainly that is a concept that has been in the literature a long time. You’ll notice my book does not include that phrase. I’m trying very hard to move away from those kinds of oppressive statements about our profession, suggesting instead that we heal from that and move on. Of course I’ve heard that, but this book and my research work is really about how we are going to change the culture — not only in nursing, but in the [healthcare environment]. I believe that nursing faculty can have a key role in doing the heavy lifting on this on the front end — starting at the very nanosecond when students enter our colleges and universities. Start having that conversation.
HEH: You include tools to evaluate one’s own civility, like assessing on a scale how often you are rude or discourteous to others. It seems you are suggesting that self-knowledge can then lead to developing skills for resilience in the healthcare environment.
Clark: That’s absolutely spot-on. As I got into the research on this, one of the findings that kept coming up over and over, no matter how I measured it, is that in many cases people had no clue how to talk [respectfully] to another individual or a group of people. That’s why I developed several indices — one for students to take a look at themselves in their role as learners, one for faculty to take a look at themselves in terms of how we are educating. But the workplace civility [index] is for all of us. I kept it general enough that anyone in any workplace can do that, and take a look at how they might be coming across to people and how they might find ways to enhance and improve interactions.
HEH: The quote you cite from the poet Rumi seems to sum it up: “Yesterday I was clever, so I wanted to change the world. Today I am wise, so I am changing myself.”
Clark: Yes, don’t you love that, and it goes all the way the way back to Socrates, who I believe first said “know thyself.” So I think we need to take a look in the mirror before we can address other people’s behaviors.
- Clark, C. Creating and Sustaining Civility in Nursing Education, Second Edition. 2017: Honor Society of Nursing, Sigma Theta Tau International (STTI). Indianapolis.
- American Nurses Association. Professional Issues Panel on Incivility, Bullying, and Workplace Violence. Position Statement 2015: http://bit.ly/1O5zHQl.
While often seen as separate and disturbingly distinct, incivility, bullying, and violence in healthcare are actually connected across a common culture of toxicity.
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