Every student must be able to use and apply knowledge as well as clinically reason before they graduate from nursing school.  If they are able to do this, they will pass the NCLEX®.

But there is something that is almost as important that every student who graduates must also know, but it is not even tested on the NCLEX®. As a result, not every nursing program addresses it and prepares students for this lived reality that can result in new nurses who leave nursing and even cause them to question why they ever became a nurse.

Almost every nurse will observe it in their first year of practice and almost half will personally experience it.

Once experienced, it can cause a whole range of devastating emotions including depression, anxiety, and feelings of failure.

But this lived reality does not only impact the new nurse, but patients on the care unit. Adverse consequences to patient safety include preventable complications and even patient death!

What is the one thing that every student must know before they graduate?

How to be empowered to respectfully and directly address incivility and bullying once they are in clinical practice.

The most important weapon and the ONE THING that every student must know before they graduate to address nurse-to-nurse incivility?

Cognitive rehearsal.

Nurses at Risk

Health care occupations such as nursing have the highest rates of incivility and bullying (Johnson & Rea, 2009)

Though incivility is also a documented problem in nursing education (see last week’s blog “How to Address Student Incivility”), it continues to be endemic in clinical practice. (Could there a relationship between these two lived realities?)

Who is most likely to be an “incivility magnet?”

According to the literature it is the following:

• New graduate nurses
• New nurses to a unit
• Ethnic minorities
• Men

Knowing that new nurses are most at risk for personally experiencing incivility after graduation, how is your program not only educating them about incivility, but more importantly EMPOWERING them to identify it, and once experienced, how to DIRECTLY and RESPECTFULLY address it! This is essential because incivility must first be correctly identified before it can be addressed.

Bad Behavior Defined

Bullying can be defined as a consistent pattern of inappropriate, abusive, aggressive behavior toward another colleague that is designed to accomplish the following:

• Intimidates
• Diminishes
• Devalues
• Disrespects

The most common overt bullying behaviors in nursing include patterns of faultfinding, intimidation, gossip, put-downs, and nonverbal innuendo such as raising eyebrows or sighing. More subtle bullying behaviors include isolation, exclusion, ignoring/refusing to help, and unfair assignments (Bartholomew, 2006).

Other categories of bullying behavior include the resentful nurse who holds grudges and encourages others to join in as well as the cliquish nurse who intentionally excludes others from the “group” (Dellasega, 2009).

One New Nurse’s Pain

When I asked a new nurse who had just come off orientation in ICU how she was doing, she broke down and began to cry. Not good.

She put her lived experience in writing and gave me permission to share the following:

“I started on the unit with a fresh and positive attitude directly out of school. I thought I had found my dream job. I find the unit to operate under a ‘good old boys’ mentality, where new staff fall victim to senior staff until they have ‘proved themselves’ or ‘done their time’ like they had to do. I can honestly say that I cried every shift I worked for the first 6 months, and the only reason I stopped crying was not because it got any better, but because I had to change my expectations about the unit and accept my reality. I cannot put into words what it feels like to have nurses laugh in your face and belittle you when you ask a clinical question, roll their eyes and walk out on your report before it is finished, to literally have a back turned on you when trying to discuss a concern, or to be scolded or yelled at in front of your other colleagues until you are apologizing profusely with tears streaming down your cheeks. At this time I am not interested in making things any more difficult for myself. I would just like to get off of the unit before I lose my passion for nursing altogether.”

Empower Your Students with Cognitive Rehearsal

The article “Teaching Cognitive Rehearsal as a Shield for Lateral Violence: An Intervention for Newly Licensed Nurses” is a must-read for every educator, student or new nurse. It defines professional behaviors as well as the most common uncivil behaviors.

But more importantly, “cognitive rehearsal” teaches nurses to have a prepared plan to respond respectfully when specific uncivil behaviors are directed toward them. Because incivility thrives in an environment of passivity, incivility can often be stopped in its tracks when it is directly addressed in an assertive, DIRECT, and RESPECTFUL way (Griffin, 2004).

Three Simple Steps

When any interaction is perceived as being uncivil, Griffin states that it is imperative for the nurse to do the following:

1. Process what just happened…do NOT immediately react or respond. Was this encounter uncivil or was it  something else. If you felt disrespected by the encounter, it was likely incivility!
2. Do NOT own or make uncivil behaviors personal…you did not deserve it!
3. Recognize and follow through to address the colleague directly and respectfully

Practical Example

For example, if a nurse has a pattern of raising eyebrows or sighs deeply when asked for help, the empowered nurse has practiced and is prepared to respond in the following manner, “I sense (I see from your facial expression) that there may be something you want to say to me. Please speak directly to me” (Griffin, 2004).

Effectiveness

In one study where nurses were empowered by this strategy, 100 percent of the nurses reported that when the perpetrator was confronted, the bullying behavior stopped (Coursey, Rodriguez, Dieckmann, & Austin, 2013). Though this was a small sample size, it clearly demonstrates that cognitive rehearsal empowers nurses to effectively address incivility when it is encountered.

In Closing

Encourage your students that they can not only be empowered to effectively address incivility, but they can also bring needed change by living out CIVILITY.

Encourage every student to be a leader and role model respect for all colleagues, value the diversity of others, never criticize another colleague publicly, work as a team, and accept your share of the workload (Griffin, 2004).

By teaching your students cognitive rehearsal, you too will be making a difference by better preparing them for the realities of real-world professional practice and empowering the next generation of nurses to be a part of the needed change in the nursing profession!

What do you think?
What strategies have you found effective to directly address incivility in your practice?
Comment below and let the conversation begin!

References

• Bartholomew, K., (2006), Ending nurse to nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro Incorporated.
• Coursey, J. H., Rodriguez, R.E., Dieckmann, L.S., & Austin, P.N. (2013). Successful implementation of policies addressing lateral violence. AORN Journal, 97(3), 101–109.
• Dellasega, C. A. (2009). Bullying among nurses. American Journal of Nursing, 109, 52–58.
• Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35, 257–263.
• Johnson, S. J. & Rea, R. E. (2009). Workplace bullying: Concerns for nurse leaders. The Journal of Nursing Administration, 39(2), 84–90.