“I believe we can change the world if we start listening to one another again. Simple, honest, human conversation…a chance to speak, feel heard, and [where] we each listen well…may ultimately save the world.”
Margaret J. Wheatley, EdD
Given the stressful healthcare workplace, it’s no wonder nurses and other healthcare professionals sometimes fall short of communicating in respectful, considerate ways. Nonetheless, safe patient care hinges on our ability to cope with stress effectively, manage our emotions, and communicate respectfully. Interactions among employees can affect their ability to do their jobs, their loyalty to the organization, and most important, the delivery of safe, high-quality patient care.
The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements clearly articulates the nurse’s obligation to foster safe, ethical, civil workplaces. It requires nurses “to create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, 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 to learn and practice skills to address uncivil encounters, organization leaders and managers must create an environment where nurses feel free and empowered to speak up, especially regarding patient safety issues.
All of us must strive to create and sustain civil, healthy work environments where we communicate clearly and effectively and manage conflict in a respectful, responsible way. The alternative—incivility—can have serious and lasting repercussions. An organization’s culture is linked closely with employee recruitment, retention, and job satisfaction. Engaging in clear, courteous communication fosters a civil work environment, improves teamwork, and ultimately enhances patient care.
In many cases, addressing incivility by speaking up when it happens can be the most effective way to stop it. Of course, meaningful dialogue and effective communication require practice. Like bowel sound auscultation and nasogastric tube insertion, communication skills can’t be mastered overnight. Gaining competence in civil communication takes time, training, experience, practice, and feedback.
What makes for a healthy workplace?
The American Association of Critical-Care Nurses has identified six standards for establishing and sustaining healthy work environments—skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.
In my own research, I’ve found that healthy work environments also 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, both formal and informal
- civility conversations at all organizational levels.
I have developed a workplace inventory that individuals and groups within organizations can use as an evidence-based tool to raise awareness, assess the perceived health of an organization, and determine strengths and areas for improvement. The inventory may be completed either individually or by all team members, who can then compare notes to determine areas for improvement and celebrate and reinforce areas of strength. (See Clark Healthy Workplace Inventory.)
How to engage in challenging conversations
One could argue that to attain a high score on nearly every inventory item, healthy communication must exist in the organization. So leaders need to encourage open discussion and ongoing dialogue about the elements of a healthy workplace. Sharing similarities as well as differences and spending time in conversation to identify strategies to enhance the workplace environment can prove valuable.
But in many cases, having such conversations is easier said than done. For some people, engaging directly in difficult conversations causes stress. Many nurses report they lack the essential skills for having candid conversations where emotions run high and conflict-negotiation skills are limited. Many refrain from speaking with uncivil individuals even when a candid conversation clearly is needed, because they don’t know how to or because it feels emotionally unsafe. Some nurses lack the experience and preparation to directly address incivility from someone in a higher position because of the clear power differential or a belief that it won’t change anything. The guidelines below can help you prepare for and engage in challenging conversations.
Reflecting, probing, and committing
Reflecting on the workplace culture and our relationships and interactions with others is an important step toward improving individual, team, and organizational success. When faced with the prospect of having a challenging conversation, we need to ask ourselves key questions, such as:
- What will happen if I engage in this conversation, and what will happen if I don’t?
- What will happen to the patient if I stay silent?
In the 2005 report “Silence Kills: The Seven Crucial Conversations for Healthcare,” the authors identified failing to speak up in disrespectful situations as a serious communication breakdown among healthcare professionals, and they asserted that such a failure can have serious patient-care consequences. In a subsequent report, “The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives,” the authors suggested a multifaceted organizational approach to creating a culture where people speak up effectively when they have concerns. This approach includes several recommendations and sources of influence, including improving each person’s ability to be sure all healthcare team members have the skills to be “200% accountable for safe practices.” Ways to acquire safe practice skills include education and training, script development, role-playing, and practicing effective communication skills for high-stakes situations.
Creating a safe zone
If you’ve decided to engage in a challenging conversation with a coworker who has been uncivil, choose the time and place carefully. Planning wisely can help you create a safe zone. For example, avoid having this conversation in the presence of patients, family, and other observers. Choose a setting where both parties will have as much emotional and physical safety as possible.
Both should agree on a mutually beneficial time and place to meet. Ideally, the place should be quiet, private, away from others (especially patients), and conducive to conversation and problem-solving. Select a time when both parties will be free of interruptions, off shift, and well-rested. If a real or perceived power differential exists between you and the other person, try to have a third party present.
You may need to initiate the conversation by asking the other person for a meeting. Suppose you and your colleague Sam disagree over the best way to perform a patient care procedure. You might say something like, “Sam, I realize we have different approaches to patient care. Since we both agree patient safety is our top concern, I’m confident that if we sit down and discuss possible solutions, we can work this out. When would you like to get together to discuss this?”
Before the meeting, think about how you might have contributed to the situation or conflict; this can help you understand the other person’s perspective. The clearer you are about your possible role in the situation, the better equipped you’ll be to act in a positive way. Rehearsing what you intend to say also can help.
Preparing for the conversation
Critical conversations can be stressful. While taking a direct approach to resolving a conflict usually is the best strategy, it takes fortitude, know-how—and practice, practice, practice. Prepare as much as possible. Before the meeting, make sure you’re adequately hydrated and perform deep-breathing exercises or yoga stretches.
On the scene
When the meeting starts, the two of 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 turns describing his or her perspective in objective language, speaking directly and respectfully. Listen actively and show genuine interest in the other person. To listen actively, focus on his or her message instead of thinking about how you’ll respond. If you have difficulty listening and concentrating, silently repeat the other person’s words to yourself to help you stay focused.
Stay centered, poised, and focused on patient safety. Avoid being defensive. You may not agree with the other person’s message, but seek to understand it. Don’t interrupt or act as though you can’t wait to respond so you can state your own position or impression.
Be aware of your nonverbal messages. Maintain eye contact and an open posture. Avoid arm crossing, turning away, and eye rolling.
The overall goal is to find an interest-based solution to the situation. The intention to seek common ground and pursue a compromise is more likely to yield a win-win solution and ultimately improve your working relationship. Once you and the other person reach a resolution, make a plan for a follow-up meeting to evaluate your progress on efforts at resolving the issue.
Framework for engaging in challenging conversations
Cognitive rehearsal is an evidence-based framework you can use to address incivility during a challenging conversation. This three-step process includes:
- didactic and interactive learning and instruction
- rehearsing specific phrases to use during uncivil encounters
- practice sessions to reinforce instruction and rehearsal.
Using cognitive rehearsal can lead to improved communication, a more conflict-capable workforce, greater nurse satisfaction, and improved patient care.
Various models can be used to structure a civility conversation. One of my favorites is the DESC model, which is part of TeamSTEPPS—an evidence-based teamwork system to improve communication and teamwork skills and, in turn, improve safety and quality care. Using the DESC model in conjunction with cognitive rehearsal is an effective way to address specific incivility incidents. (See DESC in action: Three scenarios.)
Other acceptable models exist for teaching and learning effective communication skills and becoming conflict-capable. In each model, the required skills are learned, practiced, and reinforced until responses become second nature. Another key feature is to have the learner make it his or her own; although a script can be provided, it should be used only to guide development of the learner’s personal response.
Nurturing a civil and collaborative culture
Addressing uncivil behavior can be difficult, but staying silent can increase stress, impair your job performance and, ultimately, jeopardize patient care. Of course, it’s easier to be civil when we’re relaxed, well-nourished, well-hydrated, and not overworked. But over the course of a busy workday, stress can cause anyone to behave disrespectfully.
When an uncivil encounter occurs, we may need to address it by having a critical conversation with the uncivil colleague. We need to be well-prepared for this conversation, speak with confidence, and use respectful expressions. In this way, we can end the silence that surrounds incivility. These encounters will be more effective when we’re well-equipped with such tools as the DESC model—and when we’ve practiced the required skills over and over until we’ve perfected them.
Effective communication, conflict negotiation, and problem-solving are more important than ever. For the sake of patient safety, healthcare professionals need to focus on our higher purpose—providing safe, effective patient care—and communicate respectfully with each other. Differences in socialization and educational experiences, as well as a perceived power differential, can put physicians and nurses at odds with one another. When we nurture a culture of collaboration, we can synthesize the unique strengths that healthcare workers of all disciplines bring to the workplace. In this way, we can make the workplace a civil place.
Cynthia M. Clark is a nurse consultant with ATI Nursing Education and professor emeritus at Boise State University in Boise, Idaho. Names in scenarios are fictitious.
American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Aliso Viejo, California: Author; 2005. aacn.org/WD/HWE/Docs/HWEStandards.pdf
American Nurses Association. Bullying in the Workplace: Reversing a Culture. Silver Spring, MD: American Nurses Association; 2012.
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Author; 2015.
American Nurses Association. Incivility, Bullying, and Workplace Violence. 2015. nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Incivility-Bullying-and-Workplace-Violence.html
Clark CM. Creating and Sustaining Civility in Nursing Education. Indianapolis, IN: Sigma Theta Tau International Publishing; 2013.
Clark CM. Hardwired for the ‘soft skill’ of civility. September 2, 2014. musingofthegreat
Clark CM. National study on faculty-to-faculty incivility: strategies to promote collegiality and civility. Nurse Educ. 2013;38(3):98-102.
Clark CM. Seeking civility: strategies to create and sustain healthy workplaces. Am Nurse Today. 2014;9(7):18-21.
Clark CM, Springer PJ. Academic nurse leaders’ role in fostering a culture of civility in nursing education. J Nurs Educ. 2010;49(6):319-25.
Clark CM, Springer PJ. Nurse residents’ first-hand accounts on transition to practice. Nurs Outlook. 2012;60(4):e2-8.
Griffin M, Clark CM. Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. J Contin Educ Nurs. 2014;45(12):535-42.
Laschinger HK, Wong CA, Cummings GG, Grau AL. Resonant leadership and workplace empowerment: the value of positive organizational cultures in reducing workplace incivility. Nurs Econ. 2014;32(1):5-15.
Maxfield D, Grenny J, Lavandero R, Groah L. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. Patient Safety & Quality Healthcare; September 26, 2011. psqh.com/the-silent-treatment-why-safety-tools-and-checklists-arent-enough
Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Silence Kills: The Seven Crucial Conversations for Healthcare. VitalSmarts Industry Watch; 2005. .aacn.org/WD/
TeamSTEPPS®: National Implementation. Agency for Healthcare Research and Quality. teamstepps.ahrq.gov
“When we nurture a culture of collaboration, we can synthesize the unique strengths that healthcare workers of all disciplines bring to the workplace. In this way, we can make the workplace a civil place.”
In a nutshell the above statement said it all. It is high time that finally it is recognized this important interactions between professionals is so crucial. Hope we learn ,listen, and practice this techniques.