Civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, ATI Strategic Nursing Advisor, digs deeper into the topic of incivility in nursing. She discusses some behaviors you may not recognize as being negative. Over time, however, they can have seriously negative impacts on your colleagues. In fact, you may be exhibiting these behaviors yourself without even realizing it! Learn what these words and actions -- or lack of actions -- are.

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Gina Kellogg [00:00:19] Welcome back to episode two of our series on civility and nursing. Today's topic is "Beyond bullying: The serious impact of incivility in nursing." Once again, we're lucky to be speaking with Dr. Cynthia Clark who is recognized as the leading expert in the area of civility. Dr. Clark's recent research has included examining effective ways to prepare nursing students and addressing incivility in academic and practice settings. It's a topic that's becoming increasingly important. Dr. Clark, most people tend to think of incivility in terms of obvious bullying behavior. But you've researched other forms of incivility that people may not initially think of as bullying. Behavior that's more subtle but is just as harmful. Can you tell us more about that.

Cynthia Clark [00:01:04] Yeah, it's a great question. So, sometimes, I like to think of incivility -- usually, we think about it in terms of the things that we do. So, maybe I disrespect you where I make a demeaning comment, or I call you a name, or I -- you know -- do any number of things. Maybe it's even nonverbal. I roll my eyes at you, or I -- you know -- "Harrumph" and I cross my arms. Or I turn on my heel or do any number of things, right? Those tend to be a little bit more obvious and a little less subtle. But then there are others where, what I often say is, incivility can be what we do and what we don't do. Like if I pass you in the hallway and just blow you off. If I don't even extend a welcome or hello, even if I'm in a hurry, at least to say, "How you doing?" If I'm on a team, and everybody's working really hard and I'm not pitching in, I'm not doing my part. So we ignore people, or we don't do our part, or  one of the ones that really concerns me, in general, but especially when I think about healthcare, is when we withhold valuable information. Because some people believe, if I'm the keeper of that information, then I'm kind of the hero in this story. So, I don't tell you about a patient condition, because -- you know what? "Figure it out. Check the chart. I'm tired I'm going home." So those kinds of lack of information-giving, lack of extending even a quick greeting -- because you're another person who matters -- and, unfortunately, you know, in my work with students -- and I see them all over the country and Canada -- and many students will say, "You know, Dr. Clark, I'm walking down the hall, and the faculty will pass me in the hall and say nothing. What am I? Am I invisible? Do I not matter?" So those kinds of microaggressions can have a real impact on people over time.

Gina Kellogg [00:02:58] You've mentioned some of the other types of incivility as mobbing and rankism. Can you describe what those are?

Cynthia Clark [00:03:04] Yeah. So let me begin by saying a little bit about what bullying is, because by building on that concept it makes it easier for me to explain mobbing. So, when I think about bullying, and there are various definitions, the one I like to use comes from NIOSH. And it talks about bullying being a persistent, over time, targeted type of behavior, usually with some power gradient that exists. So, if I'm bullying someone, I'm going to target that individual, usually to demean, demoralize, to marginalize. But one of the reasons I like that particular definition from NIOSH is that, in that definition, it doesn't say it's intentional. So we know that, sometimes, bullying occurs intentionally. I may intentionally do something and get some great joy out of it. Sadly, there are people who do that. But there are others who bully without intent. And it's often because it's become ingrained behavior. It's worked for them. They've gotten their way. It's just how they roll. And, so, intentional or not, it can have some very devastating effect. So, when we think about bullying, it's often one person on another person or one person on a group of people. When we begin to think about mobbing, and I often call mobbing "bullying on steroids," and what I mean by that is that, rather than one individual targeting another such, as me bullying another person, instead, what I've done is have a coalition of people around me -- a team of what I call, you know, this triumvirate of evil who has made it my goal to work with this group to now demean another individual or group of individuals. So that's workplace mobbing, where you have that kind of group or social mentality going after another individual or group of individuals. And it can be devastating to a workplace. And some people have paid a lot of money in legal fees and mental health fees. I hear thousands of stories from people, and many of them include this idea of mobbing. You asked about rankism. Rankism is an interesting concept coined by Dr. Robert Fuller who was the previous president of Oberlin University, and I've had the pleasure of collaborating with Dr. Fuller. He's amazing. He coined that term, rankism, which he describes or defines as an abuse of power or position to demean, to diminish, or to disadvantage another. And what he says is that rankism is sort of like the big cancer. So we have big cancer, and underneath that big concept of cancer, we might have breast cancer, prostate cancer, colon cancer, and so forth. He says rankism is like the big cancer. He says it's the mother of all -isms. So you have rankism, and underneath that you have things like ageism and sexism and racism. Interestingly, he says that the antidote to all of that is to restore dignity and respect to each individual.

Gina Kellogg [00:06:07] So, a student who is facing a situation like what you just described, should they approach their faculty director and ask for advice on how to handle it?

Cynthia Clark [00:06:15] That would be my highest recommendation. But I can tell you most students will not. I have worked with students, sometimes who I have coached and are very well-prepared to have that conversation, and some will go forward with it, and some will not. Many students believe, because of that power gradient and my ability as a professor to either pass or fail them, that the risks are very high. So, yes, I work a lot with students to be able to do that. Here's my best recommendation, though: I don't think we should wait for those things to happen, though we know they may. Instead, a lot of my work is in primary prevention or putting things in place that would pre-empt those things from happening in the first place. So, does a school have a vision, a mission, a set of shared values that people are held accountable to and for? I'm talking about faculty, staff, deans, directors -- all of us in a school of nursing, including our students. So, if we have those, and we craft -- and I've worked with lots of organizations on crafting charters or honor codes or pledges that make a commitment to one another -- at this school, here's how we're going to be with one another. And building in norms of conduct and behavior, and the most important part: holding people accountable for that. So, if I'm a faculty member, and there are norms in our school that we treat one another with respect, including and maybe as importantly, our students, and I'm not doing that, there should be some level of accountability. Now, somebody can hold me accountable, because I have made a commitment to that creed or that honor code or whatever.

Gina Kellogg [00:07:55] Do you feel that there is an opportunity to create change in a person who is at a higher level? For example, a person who should be setting an example in a positive way but isn't? They should, ultimately, be the person responsible, but sometimes they're the worst offender.

Cynthia Clark [00:08:09] Yes, I often call them the worm in the apple. So, you might have a dean or a director or somebody in charge who's not really carrying the torch of the kinds of behaviors we want to see. There needs to also be some level of accountability for those individuals, as well. Frankly, that doesn't always happen. And, so, sometimes -- if we find ourselves, you know, making attempts to encourage them to act differently. One of the strategies I believe is to make sure that you have some measurements in place to look at measuring the culture of your workplace. And I don't mean just the campus-climate surveys that so many of us do in universities and colleges. But I'm talking, instead, much more granular -- looking at what are the behaviors that are exhibited within this organization, the school of nursing, for example. How do we resolve conflict? How are we communicating or not communicating with one another? What are our strategies for relating? How do we conduct our faculty meetings? How do we conduct our experiences with our students? All of that needs to sort of be unpacked and examined. Now, what you have is data. And I believe that, in order to make change, we need to make data-driven, evidence-based decisions. So, let's begin to look at what's going on in these schools. And, sometimes, what's revealed is it might be the person in that leadership position. I've known folks like that, and they have made excellent changes. Some don't, but some do. So, with coaching, with being open to feedback and those kinds of things, great things can happen. Now, one comment about sort of doing some of that work to measure what's going on in the culture: I think it's extremely important that we not just uncover what we might improve. So, what our challenges are but what are our strengths? What are we doing well? How do we amplify those? How do we grow those? How do we celebrate those? So that there's not that demoralization. And then we're like, "Wow! Are we ever going to fix this workplace?" No. It's, "Here are some areas -- based on evidence and data -- that we might want to attend to." And don't bite off more than we can chew. Maybe we pick two or three of the top ones to go after in an academic year, for example. Set some long-term goals but also paying very much attention to what we're doing well and right.

Gina Kellogg [00:10:24] Clearly, incivility isn't as easy to spot as we might have imagined. How we treat others has far-reaching consequences. So, thank you for pointing out the subtle signs for us. In addition we got some excellent advice on how to not only address uncivil situations, but we also got some proactive tips programs can put into action. It's empowering to think that we can even help create change in our own work environments. It's a lot of food for thought as we look at ourselves, our own behaviors, and our nursing programs. In the next episode of our focus on civility, we'll get some insight into how we can individually take a look at our own behaviors and identify where we might be failing to treat others with the respect and kindness they deserve. Then, we'll build on that knowledge to learn how to build a path to civility within our nursing program. We look forward to hearing more of Dr. Clark's expert advice on this vital subject. Until then, you can discover more advice from Dr. Clark at the ATI blog. Visit www.ATItesting.com/educator/blog for articles, video interviews, and infographics on a variety of topics important to nurse educators like yourself. Thank you for listening.

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