|Students, Jedi Knights and the promise of civility
First of a three-part series on fostering civility in nursing education and practice.
|By Cynthia Clark|
Some readers may know I am a professor in the School of Nursing at Boise State University and a fellow in both the American Academy of Nursing and the National League for Nursing’s Academy of Nursing Education. I am also the founder of Civility Matters. For more than a decade, I have studied incivility in academic and practice environments to develop evidence-based strategies to create and sustain cultures of civility. Very often, I am asked how I got involved in this topic. Here’s my story.
Before I accepted my faculty position at the university, I worked for more than a dozen years as a psychiatric nurse, specializing in adolescent and family mental-health issues. I was blessed to be a member of a hotshot crew of adolescent mental-health workers who treated teenagers living with a variety of mental-health and substance-abuse disorders. Many of our patients were gang members, adjudicated youth with a long history of violence and addiction-related problems.
Using a primary prevention approach, we helped teenagers settle disputes and disagreements with words and other nonviolent means, instead of resorting to weapons and physical violence. We also considered protective factors and resilience measures to equip our patients with effective ways to deal with stress and to recover from traumatic life events, including trauma resulting from exposure to violence. My clinical work with aggressive and violent youth has fully informed my program of research on preventing personal and organizational violence and continues to fuel my passion for creating communities of civility, not only on college campuses but everywhere.
After leaving my clinical practice and assuming my role as a university professor, things were fairly status quo—in the beginning. Students seemed to focus on learning, and faculty, for the most part, enjoyed teaching. However, in the early 2000s, I began to witness a shift. I noticed attitudinal and behavioral changes in our nursing students. Some of the changes were subtle, but they set off alarm bells in my “gut,” because they reminded me of my earlier experiences with angry youth. Although my college students weren’t outwardly hostile, I noticed more and more rude and disruptive behaviors, and I wondered, “Is it just me?” I also wondered if my observations were even accurate; perhaps they were colored somewhat by my previous clinical work.
Armed with a probing and curious mind, I began my quest to learn all I could about this troubling phenomenon. I started asking other professors, reminiscent of a man- or woman-on-the-street interview. I engaged in some very provocative conversations, and what I discovered was fascinating. Several professors were witnessing disruptive student behaviors, such as students consistently being late for class, holding distracting side conversations, misusing cellphones, challenging faculty knowledge and credibility, and making harassing and demeaning comments. Some professors told me they were retiring or moving on to other employment opportunities, because the toxic classroom behavior and these uncivil encounters were psychologically and physically impacting their lives.
“I know where you live!”
About the same time, two major events happened that forever changed my life and set the course for my program of study on incivility. One event involved a very angry nursing student who failed a nursing course and, for some reason that still perplexes me, held me responsible for the failure. Another faculty member had issued the failing grade but, because I was the course coordinator, I had to make the final decision about the grading outcome. I upheld the failure, but the student grieved the grade.
My clinical work … continues to fuel my passion for creating communities of civility, not only on college campuses but everywhere.Over the course of the student’s attempts to appeal the failing grade, he made personal threats that, to this very day, make my heart race. In his anger and rage, he threatened me with statements such as, “You need to change my grade to a passing grade because I know where you live, I know where you park your car, and I know where your kids go to school.” It was a terrifying experience and, in retrospect, after a decade has passed, I see how far we’ve come in being able to deal with these situations and prevent them from happening in the first place. Fortunately, this situation was safely resolved, but it left me a bit shell-shocked and questioning if I should stay in my faculty role.
The second event, which happened about the same time, was much more chilling. It involved the killing of three university nursing professors, two of whom were shot in cold blood in a large lecture hall while students were taking their midterm exam. A third nursing professor was later found dead in her office. The shooter, a disturbed nursing student, was apparently enraged over being barred from the exam. After killing the three professors, he turned the gun on himself and took his own life. Prior to the killings, the shooter mailed a lengthy manifesto to an area newspaper, detailing his plan to pull the trigger. I knew then that I was on to something, and I began to study this very important issue in earnest. Eventually, my interest extended beyond student behaviors to include faculty incivility and our potential contribution to this incivility problem.
My work encompasses student perceptions of academic incivility and garners student opinions on ways to address and resolve the problem. Incivility is an issue that, to some extent, all of us face in American society. Whether it’s road rage, desk rage or just plain rudeness, we are impacted by these behaviors. Incivility is an affront to human dignity and an assault on a person’s intrinsic sense of self-worth. The effects can be devastating and long-lasting. Exposure to uncivil behaviors can result in physical symptoms, such as headaches, interrupted sleep and intestinal problems. They can also cause psychological conditions, including stress, anxiety, irritability and depressive symptoms. Thus, it is important to raise awareness about the importance of fostering a civil and healthy academic work environment.
A little bit of cancer?
Sometimes, people make statements such as, “You know, Dr. Clark, in our organization, incivility isn’t really a problem because only one or two individuals are uncivil to or bully others.” Here’s my response: “Imagine you are a patient sitting with your primary care provider after undergoing a series of tests, and he or she says to you, ‘No worries. You are one of the lucky ones; you only have one or two malignant cells circulating in your body.’” Yes, of course, this is a ridiculous response, but I suggest to you that the same level of absurdity relates to incivility in the workplace.
It is my fervent belief, and the evidence bears this out, that one or two toxic employees can devastate an organization. For example, Pearson and Porath (2009) report that managers and executives of Fortune 1000 firms spend as much as 13 percent of their total work time—seven full weeks per year—addressing problematic employee relationships or replacing workers who leave the organization because of incivility. The authors cite one example where a hospital spent more than $25,000 dealing with just one uncivil episode.
The costs of incivility are vast. Uncivil behavior adds to employer and employee stress levels, erodes self-esteem, damages relationships and threatens workplace safety and quality of life (Forni, 2008). Incivility also lowers morale, causes illness and leaves workers feeling stressed, vulnerable and devalued. Therefore, creating and sustaining communities of civility is an imperative and a call to action for all of us. It is also my life’s work.
Civility does matter!
My primary thesis is this: If we identify and address lesser acts of incivility before they escalate into aggression or violence, we are far better off and, in the end, quality of life on all levels will be improved. And here’s what I believe to my very core: Civility does matter! It’s worth fighting the good fight to create and sustain healthy academic and practice workplaces where respect is highly regarded and where benevolence carries the day.
Healthy workplaces do not occur by accident. Creating them requires intention, purpose and bold leadership from all levels of an organization. Incivility takes a tremendous physical, emotional, spiritual and financial toll on everyone. We must do better. One of the most-read articles in Reflections on Nursing Leadership in 2010, the fourth of a five-part series, was one I co-authored with one of my nursing students, titled “What students can do to foster civility.”
In the next installment of this three-part series, I will readdress what students can do to foster civility in nursing education. Nursing students are our promise and our hope, the Jedi Knights who will lead our noble profession to a bright future where civility reigns and respect rules the day. I am excited to share their suggestions for a civil tomorrow. RNL
Part Three: Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES’ (article by Cindy Clark's daughter)
For another article by Cindy Clark on civility and nursing students, see What students can do to promote civility.
Cynthia “Cindy” Clark, PhD, RN, ANEF, FAAN, professor at Boise State University School of Nursing and founder of Civility Matters, is a psychiatric nurse/therapist with advanced certification in addiction counseling. She is the author of “Musing of the great blue,” a blog written for Reflections on Nursing Leadership.
Forni, P.M. (2008). The civility solution: What to do when people are rude. New York, NY: St. Martin’s Press.
Pearson, C., & Porath, C. (2009). The cost of bad behavior: How incivility is damaging your business and what to do about it. New York, NY: Penguin Group.
ANA, others encourage nurses to take that ounce of preventionLike the long-running ad campaign that urges women to use a certain product because they are “worth it,” the American Nurses Association (ANA) is encouraging all nurses to view their own health, safety and wellness as a priority and not something that falls last on their to-do list.
More than a year ago ANA launched its HealthyNurse™ initiative to provide nurses with educational programs and online resources to become, or remain, healthy by eating nutritious foods, participating in physical activity, getting enough sleep and managing their stress (www.nursingworld.org/healthynurse). Another key part of this health-focused initiative centers on nurses receiving the immunizations and preventive care and screenings they need — just like the general population they advise.
“A healthy work environment, health promotion activities and preventive care contribute to nurses’ overall health and well-being,” said Suzy Harrington, DNP, RN, MCHES, director of ANA’s Department of Health, Safety and Wellness. “We know nurses lead busy lives and are doing the best they can. But they — as we all — have a right to be healthy too, and that means prioritizing self-care and taking time to support their own healthy choices and preventive care.”
Other nurses expressed a similar perspective on RNs and self-care.
“We often talk about women being the health managers of their families,” said Catherine Ruhl, MS, CNM, director, Women’s Health Programs at the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN), an organizational affiliate of ANA. “A side effect of that is we manage others until something happens to us that gets our attention. And then a whole lot of things that seemed so important before, aren’t.
“I’d love to say women and all nurses are getting better about looking after their health. But it can be a challenge — even for us as health care professionals — to keep up to date with the various preventive care guidelines.”
Betty McGinty, MS, RN, CGRN, HSA, president-elect of the Society of Gastroenterology Nurses and Associates, Inc. (SGNA), sees generational differences in nurses’ approaches to managing their health.
“My experience is that generations X and Y and younger nurses tend to not work when ill and take better care of themselves,” said McGinty, also an ANA member. “And that’s a good trend.”
The following is a general overview of some of the preventive care activities that nurses should consider on their road to better health.
Starting with the heart
“As an advanced practice nurse with cardiology expertise, many nurses share with me their concern of developing heart disease,” said Joanna Sikkema, DNP, ANP-BC, FAHA, FPCNA, a member of the Preventive Cardiovascular Nurses Association (PCNA) Board of Directors and Florida Nurses Association member. “They often request information for cardiovascular disease risk reduction and request consultation for hypertension management.
“Nurses are so busy multitasking and taking care of others that finding the time to exercise and eat a healthy diet can be difficult, especially for those who are working odd shifts. Often due to work demands, nurses will skip meals or eat fast foods, which in general are high in cholesterol and sodium.”
These unhealthy practices, as well as not getting enough sleep, place nurses at risk for cardiovascular disease.
Sikkema noted that shift work and rotating shifts contribute to nurses getting less quality sleep, and those same work practices disturb their sleep cycles. That interference can set up inflammation in the body that can lead to cardiovascular complications, including hypertension and metabolic syndrome.
Cardiovascular risk increases with age, particularly in women who are peri- or post-menopausal, and many nurses are in this age group, she said. And although nurses are generally active in their daily work routine, the role of many is changing. They may be more sedentary in their work responsibilities, such as sitting and performing chart reviews, telemetry monitoring or telephone triage. These nurses can face a risk of hypercoagulation if they are sedentary for long periods of time, and at added risk if they are on birth control pills, she pointed out.
To promote cardiovascular health, Sikkema advises nurses to engage in the same traditional methods of preventive care that they frequently advise to their patients: maintain a healthy blood pressure, weight and BMI, and avoid tobacco use. One strategy to achieve appropriate levels includes eating a heart-healthy diet — not one based on extremes often found in many fad diets.
“I cannot overemphasize the benefits of daily exercise for collateral and coronary circulation and general heart health,” she said. “Stress management is also extremely important for nurses. Techniques such as guided imagery, relaxation breathing and yoga have been shown to lower blood pressure and improve overall health. Nurses need to take a few minutes daily to care for themselves.”
When it comes to screening, Sikkema said, routine cholesterol and blood pressure checks are critical.
Sikkema and PCNA, also an ANA organizational affiliate, are calling for more workplace-based healthy lifestyle initiatives which, she said benefit both the nursing workforce and employers. (PCNA offered a free live webinar examining these workplace initiatives May 15 to launch their “Walk the Talk” campaign. To view the archived webinar, “Creating a Heart-Healthy Workplace: The Job Begins with Us!,” go to: www.pcna.net/walkthetalk.)
“Like most busy people today, nurses spend a lot of time in the workplace,” Sikkema said. “These simple, daily lifestyle initiatives help promote a healthier and more stable workforce and can decrease costly emergency room visits and diagnostic testing.”
Although there are some slight — and controversial — differences in some preventive guidelines, AWHONN’s Ruhl said nurses need to be proactive when it comes to addressing their own primary care needs.
For example, the U.S. Preventive Services Task Force (USPSTF) suggests that most women receive biennial breast cancer screening — mammograms — beginning at age 50; the American Cancer Society recommends yearly mammograms beginning at age 40.
“When considering which mammogram guidelines to follow, people need to be very thoughtful and talk over the decision with a trusted provider,” Ruhl said. “They need to look at their family history, personal history, whether they smoke, and what level of risk they are willing to take on. If they are going to sleep better at night by getting an annual mammogram after age 40, then get one.”
Even self-breast examination is a source of differing opinions. The American Cancer Society considers it an option for women in their 20s. Other groups talk about the importance of self-knowledge — having an awareness of one’s own breast tissue and the changes that can happen, which is a viewpoint that AWHONN supports, according to Ruhl.
Guidelines on cervical cancer and HPV screening have nuances based on the recommending group, as well.
The American Cancer Society, American College of Obstetricians and Gynecologists and USPSTF generally agree that women should begin cervical cancer screening at 21 years old. Further, from age 21 to 29, women should get a pap smear every three years. And although there are slight differences among these groups for women aged 30 to 65, who are not at high risk for developing cervical cancer, overall women in this range should have a pap smear every three years or every five years if accompanying it with HPV testing, Ruhl explained. Those over 65 should be screened only based on their health history.
Ruhl suggests other routine screening for all nurses, such as intimate partner violence, skin cancer and HIV status. They also might want to consider genetic testing for breast and ovarian mutations, if they have a strong family history of these cancers, and, if they are baby boomers, screening for hepatitis C.
Another huge area of prevention is immunizations. Ruhl encourages nurses to receive annual influenza immunizations and keep up to date on Pertussis, which is particularly important for nurses working with babies or who have young families themselves.
Controversy also surrounds screening for prostate cancer, specifically the use of the prostate specific antigen test (PSA).
The Centers for Disease Control and Prevention (CDC) and federal agencies promote following the recommendation of the USPSTF.
Based on comments received and up-to-date research, the USPSTF concludes that “many men are harmed as a result of prostate cancer screening and few, if any, benefit.”
Further the task force noted, “A better test and better treatment options are needed. Until these are available, the USPSTF has recommended against [PSA-based] screening for prostate cancer.”
The American Cancer Society recommends that men make informed decisions — based on learning the risks and benefits — with their providers about whether to be tested for prostate cancer generally beginning at age 50. The organization also recommends that African-American men or those who have a close family history of prostate cancer talk with their providers about the test beginning at age 45.
With their recommendation, the American Cancer Society notes: “Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment.”
Looking at GI health
SGNA has a website that is rich in resources to keep nurses, and in turn their patients, healthy — from infection prevention strategies to healthful eating.
But a key message that gastroenterology nurses preach is the importance of colon cancer screening. SGNA has been advocating for a national health care measure that would ensure that everyone in this country has access to colon cancer screening at no cost or low cost, said McGinty, director of Gastroenterology Services for Northside Hospital system in Atlanta, GA.
“I know that some people are afraid of having a colonoscopy — or the preparation for it, or feel that it is too time-consuming,” she said. “But it is the gold standard for colon cancer screening. And an early diagnosis ensures a much higher percentage of recovery.”
For most people, colorectal cancer screening should begin at age 50 and be performed every 10 years, according to current recommendations.
McGinty said that there also are workplace practices that can affect the health of gastroenterology nurses.
“Many members have written in our journal about ergonomic-related issues that gastroenterology nurses experience, and equipment that is available or emerging to prevent or reduce musculoskeletal disorders,” McGinty said. “For example, many GI nurses have upper extremity injuries because they supply abdominal pressure with their hands to enable the passage of scopes.”
One preventive workplace strategy for nurses who work in GI labs and in ORs are anti-fatigue floor mats, which can automatically help shift nurses’ weight and prevent stasis of blood in the lower extremities, McGinty said. She added that there are many position statements that address nurses’ risks and strategies at the SGNA website, www.sgna.org.
And finally, RNs have an advantage over the general public in that they understand health promotion and disease prevention.
Said Harrington, “By participating in routine preventive care and healthy behaviors, nurses are in a strong position to not only be healthier themselves, but also to serve as real role models for their patients, families and communities.”
— Susan Trossman is the senior reporter for The American Nurse.
ResourcesANA’s HealthyNurse™: www.nursingworld.org/healthynurse
United States Preventive Services Task Force (USPSTF) recommendations: www.uspreventiveservicestaskforce.org/adultrec.htm
USPSTF mobile app: https://itunes.apple.com/us/app/ahrq-epss/id311852560?mt=8
Agency for Healthcare Quality and Research guidelines comparison: www.guideline.gov
American Cancer Society guidelines: www.cancer.org/healthy
American Heart Association: www.heart.org
Immunizations: The Centers for Disease Control and Prevention: www.cdc.gov/vaccines/schedules and American Nurses Association www.anaimmunize.org
“Creating a Heart-Healthy Workplace: The Job Begins with Us!” visit: www.pcna.net/walkthetalk.