18 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com

“I believe we canchange the world if westart listening to oneanother again. Simple,honest, human con-versation…a chance tospeak, feel heard, and[where] we each listenwell…may ultimatelysave the world.” Margaret J. Wheatley,

EdD

GIVEN the stressful healthcareworkplace, it’s no wonder nursesand other healthcare professionalssometimes fall short of communi-cating in respectful, considerateways. Nonetheless, safe patient carehinges on our ability to cope withstress effectively, manage our emo-tions, and communicate respectful-ly. Interactions among employeescan affect their ability to do theirjobs, their loyalty to the organiza-tion, and most important, the deliv-ery of safe, high-quality patientcare.

The American Nurses Associa-tion (ANA) Code of Ethics forNurses with Interpretive Statementsclearly articulates the nurse’s obli-gation to foster safe, ethical, civilworkplaces. It requires nurses “tocreate an ethical environment andculture of civility and kindness,treating colleagues, coworkers, em-ployees, students, and others with

dignity and respect” and states that“any form of bullying, harassment,intimidation, manipulation, threats,or violence will not be tolerated.”However, while nurses need tolearn and practice skills to address

uncivil encounters, or-ganization leaders andmanagers must createan environment wherenurses feel free andempowered to speakup, especially regard-ing patient safety issues.

All of us must striveto create and sustaincivil, healthy work en-vironments where we

communicate clearly and effectivelyand manage conflict in a respectful,responsible way. The alternative—incivility—can have serious andlasting repercussions. An organiza-tion’s culture is linked closely withemployee recruitment, retention,and job satisfaction. Engaging inclear, courteous communication fos-ters a civil work environment, im-proves teamwork, and ultimatelyenhances patient care.

In many cases, addressing inci-vility by speaking up when it hap-pens can be the most effectiveway to stop it. Of course, mean-ingful dialogue and effective com-munication require practice. Likebowel sound auscultation and na-sogastric tube insertion, communi-cation skills can’t be masteredovernight. Gaining competence incivil communication takes time,training, experience, practice, andfeedback.

LEARNING OBJECTIVES1. Identify components of a healthy

workplace. 2. Discuss how to prepare for a chal-

lenging conversation.3. Describe models for conducting a

challenging conversation.

The planners of this CNE activity have disclosed no relevant financial relationships with any commercialcompanies pertaining to this activity. See the last pageof the article to learn how to earn CNE credit. The author has disclosed that she receives royalties andconsulting fees pertaining to this topic. The article was peer reviewed and determined to be free of bias.

Expiration: 11/1/18

CNE1.0 contact hours

Conversationsto inspire and promote a

more civil workplaceLet’s end the silence that surrounds incivility.

By Cynthia M. Clark, PhD, RN, ANEF, FAAN

www.AmericanNurseToday.com November 2015 American Nurse Today 19

What makes for a healthyworkplace?The American Association of Criti-cal-Care Nurses has identified sixstandards for establishing and sus-taining healthy work environ-ments—skilled communication, truecollaboration, effective decision-making, appropriate staffing, mean-ingful recognition, and authenticleadership.

In my own research, I’ve foundthat healthy work environments al-so require:• a shared organizational vision,

values, and team norms• creation and sustenance of a

high level of individual, team,and organizational civility

• emphasis on leadership, bothformal and informal

• civility conversations at all orga-nizational levels.I have developed a workplace

inventory that individuals andgroups within organizations can useas an evidence-based tool to raiseawareness, assess the perceivedhealth of an organization, and de-termine strengths and areas for im-provement. The inventory may becompleted either individually or byall team members, who can thencompare notes to determine areasfor improvement and celebrate andreinforce areas of strength. (SeeClark Healthy Workplace Inventory.)

How to engage in challengingconversationsOne could argue that to attain ahigh score on nearly every invento-ry item, healthy communicationmust exist in the organization. Soleaders need to encourage opendiscussion and ongoing dialogueabout the elements of a healthyworkplace. Sharing similarities aswell as differences and spendingtime in conversation to identifystrategies to enhance the workplaceenvironment can prove valuable.

But in many cases, having suchconversations is easier said thandone. For some people, engaging

directly in difficult conversationscauses stress. Many nurses reportthey lack the essential skills for hav-ing candid conversations whereemotions run high and conflict-negotiation skills are limited. Manyrefrain from speaking with uncivilindividuals even when a candidconversation clearly is needed, be-cause they don’t know how to orbecause it feels emotionally unsafe.Some nurses lack the experienceand preparation to directly addressincivility from someone in a higherposition because of the clear powerdifferential or a belief that it won’tchange anything. The guidelines be-low can help you prepare for andengage in challenging conversations.

Reflecting, probing, andcommittingReflecting on the workplace cultureand our relationships and interac-tions with others is an importantstep toward improving individual,team, and organizational success.When faced with the prospect ofhaving a challenging conversation,we need to ask ourselves key ques-tions, such as:• What will happen if I engage in

this conversation, and what willhappen if I don’t?

• What will happen to the patientif I stay silent? In the 2005 report “Silence Kills:

The Seven Crucial Conversationsfor Healthcare,” the authors identi-fied failing to speak up in disre-spectful situations as a serious com-munication breakdown amonghealthcare professionals, and theyasserted that such a failure canhave serious patient-care conse-quences. In a subsequent report,“The Silent Treatment: Why SafetyTools and Checklists Aren’t Enoughto Save Lives,” the authors suggest-ed a multifaceted organizational ap-proach to creating a culture wherepeople speak up effectively whenthey have concerns. This approachincludes several recommendationsand sources of influence, including

improving each person’s ability tobe sure all healthcare team mem-bers have the skills to be “200% ac-countable for safe practices.” Waysto acquire safe practice skills in-clude education and training, scriptdevelopment, role-playing, andpracticing effective communicationskills for high-stakes situations.

Creating a safe zoneIf you’ve decided to engage in achallenging conversation with acoworker who has been uncivil,choose the time and place careful-ly. Planning wisely can help youcreate a safe zone. For example,avoid having this conversation inthe presence of patients, family,and other observers. Choose a set-ting where both parties will have asmuch emotional and physical safetyas possible.

Both should agree on a mutual-ly beneficial time and place tomeet. Ideally, the place should bequiet, private, away from others(especially patients), and con-ducive to conversation and prob-lem-solving. Select a time whenboth parties will be free of inter-ruptions, off shift, and well-rested.If a real or perceived power differ-ential exists between you and theother person, try to have a thirdparty present.

You may need to initiate theconversation by asking the otherperson for a meeting. Supposeyou and your colleague Sam dis-agree over the best way to per-form a patient care procedure.You might say something like,“Sam, I realize we have differentapproaches to patient care. Sincewe both agree patient safety is ourtop concern, I’m confident that ifwe sit down and discuss possiblesolutions, we can work this out.When would you like to get to-gether to discuss this?”

Before the meeting, think abouthow you might have contributed tothe situation or conflict; this canhelp you understand the other per-

20 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com

You can use the inventory below to help determine the health of your workplace. To complete it, carefully read the 20 statementsbelow. Using a scale of 1 to 5, check the response that most accurately represents your perception of your workplace. Check 5 ifthe statement is completely true, 4 if it’s somewhat true, 3 if it’s neutral, 2 if it’s somewhat untrue, and 1 if it’s completely untrue. Then total the number values of your responses to determine the overall civility score. Scores range from 20 to 100. A score of 90

to 100 indicates a very healthy workplace; 80 to 89, moderately healthy; 70 to 79, mildly healthy; 60 to 69, barely healthy; 50 to 59,unhealthy; and less than 50, very unhealthy.

Completely Somewhat Neutral Somewhat CompletelyStatement true (5) true (4) (3) untrue (2) untrue (1)

Members of the organization “live” by a shared vision □ □ □ □ □and mission based on trust, respect, and collegiality.

There is a clear and discernible level of trust □ □ □ □ □between and among formal leadership and other members of the workplace.

Communication at all levels of the organization □ □ □ □ □is transparent, direct, and respectful.

Employees are viewed as assets and valued □ □ □ □ □partners within the organization.

Individual and collective achievements are celebrated □ □ □ □ □and publicized in an equitable manner.

There is a high level of employee satisfaction, □ □ □ □ □engagement, and morale.

The organizational culture is assessed on an ongoing □ □ □ □ □basis, and measures are taken to improve it based on results of that assessment.

Members of the organization are actively engaged in □ □ □ □ □shared governance, joint decision-making, and policy development, review, and revision.

Teamwork and collaboration are promoted and evident. □ □ □ □ □There is a comprehensive mentoring program for □ □ □ □ □all employees.

There is an emphasis on employee wellness and self-care. □ □ □ □ □There are sufficient resources for professional growth □ □ □ □ □and development.

Employees are treated in a fair and respectful manner. □ □ □ □ □The workload is reasonable, manageable, and fairly □ □ □ □ □distributed.

Members of the organization use effective conflict- □ □ □ □ □resolution skills and address disagreements in a respectful and responsible manner.

The organization encourages free expression of diverse □ □ □ □ □and/or opposing ideas and perspectives.

The organization provides competitive salaries, benefits, □ □ □ □ □compensations, and other rewards.

There are sufficient opportunities for promotion and □ □ □ □ □career advancement.

The organization attracts and retains the □ □ □ □ □“best and the brightest.”

The majority of employees would recommend the □ □ □ □ □organization as a good or great place to work to their family and friends.

© 2014 Cynthia M. Clark

Clark Healthy Workplace Inventory

www.AmericanNurseToday.com November 2015 American Nurse Today 21

son’s perspective. The clearer youare about your possible role in thesituation, the better equipped you’llbe to act in a positive way. Re-hearsing what you intend to say al-so can help.

Preparing for the conversationCritical conversations can be stress-ful. While taking a direct approachto resolving a conflict usually is thebest strategy, it takes fortitude,know-how—and practice, practice,practice. Prepare as much as possi-ble. Before the meeting, make sureyou’re adequately hydrated andperform deep-breathing exercisesor yoga stretches.

On the sceneWhen the meeting starts, the twoof you should set ground rules,such as:• speaking one at a time• using a calm, respectful tone• avoiding personal attacks• sticking to objective information.

Each person should take turnsdescribing his or her perspective inobjective language, speaking di-rectly and respectfully. Listen ac-tively and show genuine interest inthe other person. To listen actively,focus on his or her message in-stead of thinking about how you’llrespond. If you have difficulty lis-tening and concentrating, silentlyrepeat the other person’s words toyourself to help you stay focused.

Stay centered, poised, and fo-cused on patient safety. Avoid be-ing defensive. You may not agreewith the other person’s message,but seek to understand it. Don’t in-terrupt or act as though you can’twait to respond so you can stateyour own position or impression.

Be aware of your nonverbalmessages. Maintain eye contact andan open posture. Avoid arm cross-ing, turning away, and eye rolling.

The overall goal is to find an interest-based solution to the situa-tion. The intention to seek com-mon ground and pursue a com –

promise is more likely to yield awin-win solution and ultimately im-prove your working relationship.Once you and the other personreach a resolution, make a plan fora follow-up meeting to evaluateyour progress on efforts at resolv-ing the issue.

Framework for engaging inchallenging conversationsCognitive rehearsal is an evidence-based framework you can use toaddress incivility during a challeng-ing conversation. This three-stepprocess includes:• didactic and interactive learning

and instruction• rehearsing specific phrases to

use during uncivil encounters• practice sessions to reinforce in-

struction and rehearsal. Using cognitive rehearsal can

lead to improved communication, amore conflict-capable workforce,greater nurse satisfaction, and im-proved patient care.

DESC modelVarious models can be used tostructure a civility conversation.One of my favorites is the DESCmodel, which is part of Team-STEPPS—an evidence-based team-work system to improve communi-cation and teamwork skills and, inturn, improve safety and qualitycare. Using the DESC model inconjunction with cognitive rehears-al is an effective way to addressspecific incivility incidents. (SeeDESC in action: Three scenarios.)

Other acceptable models existfor teaching and learning effectivecommunication skills and becom-ing conflict-capable. In each mod-el, the required skills are learned,practiced, and reinforced until re-sponses become second nature.Another key feature is to have thelearner make it his or her own; al-though a script can be provided, itshould be used only to guide de-velopment of the learner’s personalresponse.

Nurturing a civil andcollaborative culture Addressing uncivil behavior can bedifficult, but staying silent can in-crease stress, impair your job per-formance and, ultimately, jeopard-ize patient care. Of course, it’seasier to be civil when we’re re-laxed, well-nourished, well-hydrat-ed, and not overworked. But overthe course of a busy workday,stress can cause anyone to behavedisrespectfully.

When an uncivil encounter oc-curs, we may need to address it byhaving a critical conversation withthe uncivil colleague. We need tobe well-prepared for this conversa-tion, speak with confidence, anduse respectful expressions. In thisway, we can end the silence thatsurrounds incivility. These encoun-ters will be more effective whenwe’re well-equipped with suchtools as the DESC model—andwhen we’ve practiced the requiredskills over and over until we’veperfected them.

Effective communication, con-flict negotiation, and problem-solv-ing are more important than ever.For the sake of patient safety,healthcare professionals need tofocus on our higher purpose—pro-viding safe, effective patient care—and communicate respectfully witheach other. Differences in social-ization and educational experi-ences, as well as a perceived pow-er differential, can put physiciansand nurses at odds with one an-other. When we nurture a cultureof collaboration, we can synthesizethe unique strengths that health-care workers of all disciplinesbring to the workplace. In thisway, we can make the workplacea civil place. �

Cynthia M. Clark is a nurse consultant with ATINursing Education and professor emeritus at BoiseState University in Boise, Idaho. Names in scenariosare fictitious.

For a list of selected references, visit AmericanNurseToday.com/?p=21641.

22 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com

DESC in action: Three scenariosThe DESC model for addressing incivility has four elements:D: Describe the specific situation.E: Express your concerns.S: State other alternatives.C: Consequences stated.

The scenarios below give examples of how to use the DESCmodel to address uncivil workplace encounters.

Nurses Sandy and Claire At the beginning of her shift, Sandy receives a handoff reportfrom Claire, who has just finished her shift.

“Geez, Sandy, where have you been? You’re late as usual. I can’twait to get out of here. See if you can manage to get this informa-tion straight for once. You should know Mary Smith by now. Youtook care of her yesterday. She was on 4S forever; now she’s ourproblem. You need to check her vital signs. I’ve been way too busyto do them. So, that’s it—I’m out of here. If I forgot something, it’snot my problem. Just check the chart.”

Not only is Claire rude and disrespectful, but she also is put-ting the patient at risk by providing an incomplete report.Here’s how Sandy might address the situation.

Describe:“Claire, I can see you’re in a hurry, and I understandyou’re upset because I’m late. We can talk about that when wehave more time. For now, I don’t feel like I’m getting enoughinformation to do my job effectively.”Explain: “Talking about Mrs. Smith in a disrespectful way andrushing through report can have a serious impact on her care.”State: “I know we’re both concerned about Mrs. Smith, soplease give me a more detailed report so I can provide thebest care possible.”Consequence:“Without a full report, I may miss an importantpiece of information, and this could compromise Mrs. Smith’scare.”

Nurse manager Alice and staff nurse Kathy The anxiety level may rise for a nurse who experiences incivili-ty from a higher-up. The following scenario illustrates an unciv-il encounter between Alice, a nurse manager, and Kathy, a staffnurse.

“Hey Kathy, I just found out Nicole called in sick, so you’re going tohave to cover her shift. We’re totally shorthanded, so you need tostay. You may not like the decision, but that’s just the way it is.”

Kathy is unable—and frankly, unwilling—to work a doubleshift. Exhausted, she’d planned to spend time with her familythis evening. Also, she has worked three extra shifts thismonth. She decides she needs to deal with this situation nowinstead of setting up a meeting with Alice later in the week.Here’s how she might use the DESC model with her manager.

Describe:“Alice, I can appreciate the need to cover the unitbecause of Nicole’s illness. We all agree that having adequatestaff is important for patient care.”Explain:“I’m exhausted, and because I have recently coveredother shifts, I’m less prepared to administer safe, high-qualitycare.”State:“I realize that as manager, it’s your responsibility tomake sure we have adequate staff for the oncoming shift. But

I’d like to talk about alternatives because I’m unable to work anadditional shift today.”Consequence:“Let’s work together to discuss alternatives forcovering Nicole’s shift. It’s important for me to have a voice indecisions that affect me.”

For a staff nurse, addressing a manager can be daunting. Tohave a critical conversation with an uncivil superior in an effortto put an end to the problem, you need the courage to be as-sertive. Engaging in stress-reducing and self-care activities andpracticing mindfulness can boost your courage so you’ll beprepared. Most of all, you need to practice and rehearse effec-tive communication skills until you feel comfortable usingthem. A 2014 study by Laschinger et al. found a compelling rela-

tionship between meaningful leadership and nurse empower-ment and their impact on creating civility and decreasingnurse burnout. This study underscores the need for leadershipdevelopment to enable nurse managers to foster civil work en-vironments. To create and sustain a healthy environment, allmembers of the organization need to receive intentional andongoing education focused on raising awareness about incivil-ity; its impact on individuals, teams, and organizations; andmost important, its consequences on patient care and safety.

Nurse Tom and Dr. JonesThis scenario depicts an uncivil encounter between a nurseand a physician.

Tom is concerned about Mr. Brown, a patient who’s 2 days postopafter abdominal surgery for a colon resection. On the secondevening after surgery, Mr. Brown's blood pressure increases. Tomwatches him closely and continues to monitor his vital signs. Asthe night wears on, Mr. Brown’s blood pressure continues to rise,his breathing seems more labored, and his heart rate increases. Tom calls Dr. Jones, the attending physician, to report his find-

ings. Dr. Jones chuckles and says, “He’s just anxious. Who wouldn’tbe in his condition?” and hangs up. Undaunted, Tom calls backand insists Dr. Jones return to the unit to assess Mr. Brown. Reluc-tantly, Dr. Jones comes to the unit, peeks into Mr. Brown’s roomwithout assessing him, and chastises Tom in front of his col-leagues and other patients about his “ridiculous overreaction.”Tom politely asks Dr. Jones to meet with him in an empty meetingroom. Here’s how Tom uses DESC to address the situation.

Describe: “Dr. Jones, I’d like to explain something. Please hearme out before you comment. I am a diligent nurse with exten-sive patient care experience.”Explain:“I know that as Mr. Brown’s attending physician,you’re committed to his safety. I assure you that everyone onthe healthcare team shares your concern, including me. Icalled you immediately after determining persistent and no-table changes in Mr. Brown’s vital signs.”State:“Because we are all concerned about Mr. Brown’s care, itwould be best if you conducted an assessment and addressedme in a respectful manner so we can provide the best carepossible. I will show you the same respect.”Consequence:“Disregarding important information or allow-ing your opinion of me to influence your response could com-promise Mr. Brown’s care. We need to work together as a teamto provide the best care possible.”

www.AmericanNurseToday.com November 2015 American Nurse Today 23

Please mark the correct answer online.

1. The American Association ofCritical-Care Nurses does not identifywhich of the following as acharacteristic of a healthy workplace?

a. Skilled communicationb. Informal leadership c. True collaborationd. Meaningful recognition

2. A healthy work environmentrequires:

a. civility conversations at the highestlevel of the organization.

b. emphasis on formal rather thaninformal leadership.

c. shared organizational vision, values,and norms.

d. individualized values and norms.

3. When considering whether to havea challenging conversation, which keyquestion should you ask yourself?

a. Is the person I need to talk to a full-time employee?

b. Do I have enough experience tohave the conversation?

c. How many years have I worked atthis facility?

d. What will happen to the patient if Istay silent?

4. Which of the following helps tocreate a safe zone for a challengingconversation?

a. Agreeing on a mutually beneficialtime to meet

b. Having the conversation in thepresence of patients

c. Having the conversation in thepresence of family members

d. Choosing a time immediately afterthe other person’s shift

5. If a power differential existsbetween you and the other person, aneffective approach is to:

a. keep the matter between the two ofyou.

b. have a third party present.c. have a security officer attend themeeting.

d. refrain from having theconversation.

6. Which of the following is anappropriate action during a challengingconversation?

a. Interrupt as needed.b. Talk quickly.c. Cross your arms.d. Maintain eye contact.

7. The first step of cognitive rehearsalis:

a. describing your position in objectiveterms.

b. rehearsing specific phrases to useduring uncivil encounters.

c. undergoing didactic and interactivelearning and instruction.

d. having a practice session toreinforce instruction and rehearsal.

8. What is the first element of theDESC model?

a. Describe the specific situation.b. Discuss your concerns.c. Define your solution.d. Detail the alternatives.

9. What is the last element of the DESCmodel?

a. Coordinate your response.b. Consider the setting.c. Consequences stated.d. Concerns stated.

10. Which statement about challengingconversations is correct?

a. Nurses have an innate ability tohave these conversations.

b. The person who called the meetingshould dominate the discussion.

c. Agreeing with the other person’smessage is important.

d. After the resolution, the participantsshould schedule a follow-upmeeting.

POST-TEST • Conversations to inspire and promote a more civil workplace Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Edu-cation and Professional Development is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.ANCC Provider Number 0023.

Contact hours: 1.0

ANA’s Center for Continuing Education and Professional Devel-opment is approved by the California Board of Registered Nurs-ing, Provider Number CEP6178 for 1.2 contact hours.

Post-test passing score is 80%. Expiration: 11/1/18

ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activi-ties and does not imply that there is real or implied endorse-ment of any product, service, or company referred to in thisactivity nor of any company subsidizing costs related to the activity. The author and planners of this CNE activity have dis-closed no relevant financial relationships with any commercialcompanies pertaining to this CNE. See the last page of the article to learn how to earn CNE credit.

CNE: 1.0 contact hours

CNE