September 2, 2025 • 33 mins
Dr. Cynthia Clark opens up about the hidden epidemic affecting healthcare environments nationwide: workplace incivility. Drawing from decades of research and practical experience, she paints a compelling picture of how seemingly minor behaviors like eye-rolling or walking away mid-conversation can create serious patient safety risks when they occur in clinical settings.
What makes this conversation particularly illuminating is Dr. Clark's nuanced understanding of workplace dynamics. She introduces listeners to her "continuum of workplace aggression" framework, which helps identify problematic behaviors ranging from subtle nonverbal cues to outright bullying and gaslighting. Her explanation of how victims often blame themselves rather than recognizing manipulative behaviors provides a wake-up call for anyone who's experienced that unsettling feeling of questioning their own reality after an interaction with a difficult colleague.
The heart of this episode focuses on cognitive rehearsal—a simulation-based technique that transforms how healthcare professionals respond to incivility. Through a practical five-step process, Dr. Clark demonstrates how professionals can prepare for and address difficult conversations rather than avoiding them. Her PAIL framework (Preview, Advocacy, Inquiry, Listen) offers a structured approach that anyone can implement immediately. The example scenario featuring "Iris," a domineering colleague who derails meetings, provides a masterclass in how to approach uncomfortable but necessary conversations.
Whether you're a nursing educator, a healthcare professional, or anyone who's experienced workplace tension, this episode delivers practical strategies for creating more respectful environments. Dr. Clark's insistence on calling communication competencies "power skills" rather than "soft skills" underscores their critical importance in healthcare settings where lives literally depend on effective collaboration. Ready to transform your workplace interactions? This episode provides the blueprint.
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Episode Transcript
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Disclaimer/ Innlvation Sim (00:00):
The views and opinions expressed in
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Welcome to The Sim Cafe, apodcast produced by the team at
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Deb Tauber (01:39):
Welcome to another episode of The Sim Cafe.
Welcome to another episode ofthe Sim Cafe Today.
Unfortunately J is not with us.
He's in Copenhagen.
Today we have the esteemedprivilege of interviewing Dr
Cynthia Clark.
She's the founder of CivilityMatters, professor Emeritus at
(02:00):
Boise State University and anaward-winning tenured professor,
scholar and author.
She serves as a fellow in theAmerican Academy of Nursing, the
NLN Academy of NursingEducation and the American
Nurses Association ProfessionalPanel on Preventing Incivility
and Bullying in Nursing.
Dr Clark is internationallyrecognized for her
(02:23):
groundbreaking work on fosteringcivility and creating healthy
work and learning environments.
Her assessment tools have beentranslated into 18 languages and
used by most scholars in 33countries to measure and address
incivility in academic andpractice settings.
Her most recent workbook,creating and Sustaining Civility
(02:46):
in Nursing Education, thirdedition, is an essential
resource for educators worldwide.
Please welcome, dr Clark.
Thank you so much for being on,and why don't you begin by
telling our listeners aboutdefining civility and explaining
why civility and respect matterin nursing about?
Dr.Clark (03:05):
defining civility and explaining why civility and
respect matter in nursing.
Yes, first of all, let me saythank you.
Thank you so much.
Thank you for having me.
It's really a pleasure and suchan honor to be part of this
podcast series, and so I'mpleased to be here, and I just
want to say hello to thelisteners who are tuning in.
So thanks so much.
So, as to your question, youknow why civility matters and
(03:30):
what it is, and so let me startby just mentioning this, first
of all, that I have always Ithink even as a child been
fascinated by human behavior.
Why do people act the way theydo?
Why do they make the choicesthey make?
I'm especially curious aboutwhat makes each of us unique and
(03:51):
how our minds and motivationswork.
So human behavior is absolutelycentral to my work because it
helps us understand and we'll betalking later today about
cognitive rehearsal.
It helps us understand andaddress those complex
interactions that happen betweenand among people.
(04:13):
So for more than two decades,and maybe even getting closer to
three, I've been studying thescience of civility and what it
means, and if we go back to 2008for just a moment, that was the
year that my colleague and Ipublished the first concept
analysis on civility, and itstood the test of time for quite
(04:36):
a while.
But when the pandemic hit, Ibegan to get really deeply
curious about whether or not theconcept of civility had changed
over time, and so my researchteam and I came together and we
decided to do an update on theconcept of civility and compare
(04:59):
that to the previous conceptanalysis, and what was so
interesting is that wediscovered that not a lot has
changed over time relative tothis concept.
And what we found is this isthat, first of all, civility is
quite analogous with respect,even though they're not exactly
(05:24):
the same.
But what was also profound forus in terms of our discovery is
that civility is a choice.
It's a decision we make everysingle day, with every encounter
, with every interaction.
It means that we're respectingthe dignity of other people,
their perspectives, theirwell-being, and it helps us
(05:47):
create those healthy workenvironments where all of us
feel like we're welcome, like webelong.
It helps us build meaningfulrelationships, especially when
we disagree.
And so one final thought onthat is that civility is not
about liking.
So, for instance, if you and Ilike each other, that's awesome.
(06:11):
It's really a bonus.
It's not requisite to ustreating one another with the
dignity each of us deserves.
Deb Tauber (06:23):
Yeah, I totally can see that and agree with that.
Can you provide some examplesof incivility in nursing and
explain how these behaviorsmanifest in healthcare settings?
Dr.Clark (06:36):
Yeah, so, yeah, so great question I like to think
about and have, you know, reallyillustrated this on what I call
the continuum of workplaceaggression.
So if you sort of imagine, ifour listeners can think about
any kind of continuum, that onthe left side of this particular
continuum that I'm referring toin terms of behaviors we might
(07:01):
see in a workplace, on the leftside, those are more sort of
distracting, annoying,irritating behaviors.
Those would be things like rudenonverbals, like eye rolling,
finger pointing, arm waving.
And then I want to take us allthe way to the right side of the
(07:21):
continuum where we would seevery hostile or violent
behaviors, in other words actsof violence or tragedy.
That would be something like acampus or a workplace shooting
and then all those behaviors inbetween.
So when we think about rudenonverbals, as I mentioned a few
(07:44):
of those, you know the eyerolling and so forth I mentioned
those because in our world ofnursing and healthcare, even
though we might say those arelesser forms of incivility, I
can tell you this that recentlythere was a beautiful paper
published by a group ofphysicians who were studying
(08:07):
what are some of the uncivilbehaviors that occur in our
patient care areas thatultimately impact patient care,
patient safety, and what wasvery interesting about what they
were able to determine was thatone of the most common
incivilities that occur withinthe healthcare environment is
(08:29):
this walking away before aconversation is over.
So that is a nonverbal.
We are walking away Now.
If we put that in context, ifyou and I say are working in an
engineering firm and you and Ihave a conversation or attempt
(08:55):
to have that, and you'reconversing with me and what I do
instead is just sort of turn onmy heel and walk away, now you
might say, wow, that was rude orthat was pretty unfriendly.
The likelihood of anyone beingharmed or even dying is slim and
(09:16):
none.
When, however, we put that inthe patient care environment now
, it's a whole new ballgame.
In the patient care environmentnow it's a whole new ballgame
Because if you approach me as acolleague, as a healthcare
colleague, and you haveimportant information to impart
relative to a patient condition,and I just walk away now we
(09:40):
have the potential for some veryserious problems in terms of
what that might do as it impactspatient care.
So I guess I mentioned thatbecause, even though those
nonverbals are on the far leftof that continuum, they can have
devastating effects dependingon the context.
(10:02):
Just a couple of the otherbehaviors you might see on that
continuum One is bullying, youknow, which is more intense.
Rather than uncivil acts,bullying is a repeated,
persistent pattern of abusivebehavior that is characterized
not always but almost always byasserting real or perceived
(10:26):
power over another person, andthat's usually done to
intimidate or humiliate.
And under that major header ofbullying we see now more and
more experiences withcyberbullying, where digital
devices and online media sitesare used to post often harmful,
(10:52):
false or malicious content.
Sometimes those behaviors areserious enough to be considered
criminal.
So because of theubiquitousness and easy access
and anonymity of the internet,some really bad stuff can end up
(11:13):
happening, and we may becompletely unaware of it if we
are not tuned in to whateversite that might be whatever site
that might be.
Deb Tauber (11:32):
So those are just a few of the experiences that some
people might have.
Well, and I think it'sinsidious, it starts, you know,
you don't really even realizeit's happening and then, before
you know it, you kind of openyour eyes and you think, my
goodness gracious, this isincivility right now.
Yeah, yeah, in my career I was,you know, bullied by nurses and
(11:52):
it left marks on me.
In fact, we talked about thatthe last time that we chatted
and you suggested that I read,and I will suggest to our
listeners, you know, if they'vebeen bullied, that they might
want to think about reading thebook.
The body keeps the score, asyou suggested to me.
Dr.Clark (12:12):
Yes, yes, it's an.
It's an excellent resourcerelative to how trauma, unless
it's managed well and dealt within healthy ways, can really
overwhelm and overcome ourmental health, our physical
health.
You mentioned the terminsidious, and I think that's so
(12:33):
interesting because one of theother behaviors, if you will, a
subcategory of bullying, isgaslighting, and I think that's
a little bit about what you'redescribing here.
It's sort of that insidious,subtle form of bullying where
what's what's really happeningthere is that someone who might
(12:55):
be gaslighting me or you isattempting to convince us that
what we saw or what we hearddidn't really happen.
It didn't really happen.
And we begin to question our ownthoughts, our own perceptions,
our own reality, our ownmemories, and so we lose
confidence.
And the other thing we often dois we blame ourselves.
(13:16):
Must be me, because gaslighterswho are really good at it will
say things like if we call thebehavior into question, you
might hear things like what,can't you take a joke?
I was only kidding, you knowthat's a very common response.
Or I didn't say that.
What Are you crazy?
Or you're crazy.
(13:38):
That never happened, are youokay?
You seem unstable, you know allof these.
And so we begin to question ourown thoughts and literally our
own reality.
So those can be really hardbehaviors to first of all assess
(13:59):
, because we're blamingourselves, and second of all
address.
Deb Tauber (14:04):
Wow, Thank you.
Yeah, Now you've writtenextensively about the use of
cognitive rehearsal as astrategy to prevent and address
these types of uncivil behaviors.
Can you tell us talk aboutcognitive rehearsal?
It's?
This is essentially a form ofsimulation.
Dr.Clark (14:34):
Yes, yes, thank you for that, because I didn't know
that in the very beginning.
You know, I just knew whatcognitive rehearsal was and why
I was doing it, and it wasn'tuntil later when my good pal
Susie Kardon-grin helped meunderstand that this is a form
of sort of live simulation.
So let me tell you what it isfirst.
(14:56):
Well, before I do that, I wantto give a shout out to Dr Martha
Griffin.
Martha's now retired, but shewrote a seminal piece.
Maybe lots of listeners haveread it.
It was published over 20 yearsago now, in 2004.
And Martha wrote an articlewhere she used cognitive
(15:16):
rehearsal with newly graduatednurses to help them understand
and deal with instability inpractice environments, and it
was hugely successful.
I read that paper in 2004,reached out to Martha.
In fact, she and I haveco-authored an update to that.
Ten years later, in 2014, wepublished together to do kind of
(15:43):
a refresh of cognitiverehearsal.
But here's what cognitiverehearsal is it's an
evidence-based technique, it'ssteeped in behavioral science
and what happens is that anindividual or a group of
individuals work with a skilledfacilitator in order to practice
(16:04):
addressing stressful situationsin a non-threatening
environment.
In other words, we use roleplay or simulation, where people
practice addressing in my case,the work that I do with them
uncivil events and that the goalis that, if they are, because
(16:24):
they've had practice, becausewe've debriefed it, if they're
faced with a similar situationin the future, they've had some
rehearsal, thus cognitiverehearsal or practice addressing
it, and I've worked withmultiple groups, whether it's
(16:44):
students, faculty practice-basednurses, physicians, other
academics.
I like to use a five-stepprocess and I'll keep it very
brief, but the first step for me, and so the sim folks out there
are going to go, yeah, yeah,now I get it.
That's why it's simulation.
So step one is that wepre-brief and we prepare, and so
(17:11):
that means in my case that I'mreviewing with the participants
the topic of civility,incivility, providing a summary
of what they're going to expectin our time together.
It includes establishing andco-creating norms.
It includes establishing andco-creating norms.
Often, I'll use the basicassumption from Harvard Sim
(17:34):
Center and I'll also providewhat we like to call some people
call them trigger warnings, nota fan.
What I like to call them arecontent advisories or content
forecasts.
Letting people know hey, youknow what we're going to be role
playing into debriefing someencounters that could evoke some
(17:55):
discomfort Maybe you knowyou've experienced trauma in
this regard and letting peopleknow that it's important that
they take care of themselves,that they might need to step out
.
In some cases, depending on mygroup, we've actually had a
counselor outside the room toassist folks if, in fact, they
(18:20):
want to, you know, touch basewith that individual before
coming back in or not comingback in to the role play
environment.
And then step two is I havethem either work individually or
in groups almost always ingroups because we're going to
eventually role play on civilencounters that they've
(18:44):
experienced.
Now, that's key because I canprovide them scenarios that are
common, and sometimes I do thatto get us jump-started.
But I'm drawing on the work ofCarol Gillian, who studied under
Kohlberg, and what CarolGillian found and she wrote in a
different voice relative toethics is that the scenarios
(19:09):
that Colbert wrote were helpful.
But what Gillian said is youknow what, if you're
deconstructing your ownexperiences, you're going to
have a very different attachmentemotionally to those
experiences.
So step two is to have themidentify what those potential or
(19:30):
real uncivil encounters mightbe and then asking folks to role
play those during cognitiverehearsal, always provide
evidence-based framework forthem to script some responses
and reminding them you're notscripted, you're scripting,
(20:00):
which is really kind of adeparture from Dr Griffin's work
, who likes to provide thescripts that people practice.
I prefer to provide them with aframework to develop their own
scripts so that it's morenatural and authentic.
And then step four is when weactually do the role play, and I
have to tell you it'sastounding to watch the actors
(20:20):
come up and role play theirexperiences.
And then step five, of course,is for me to go into that deep
debrief and reflectiveexperiences, to talk about the
scenario itself, powerimbalances that might have
existed and so forth, andcertainly many other forms of
(20:43):
debriefing queries.
So that's kind of it in anutshell, and it's a pretty
profound experience for thosewho participate, and me, as the
facilitator, totally love it,you know, to see the change in
people.
Deb Tauber (21:01):
It's an enlightenment for the
individuals.
Dr.Clark (21:04):
Absolutely, absolutely .
Deb Tauber (21:07):
I mean, we do so many simulations for high risk,
low frequency events or you knowthings like central line
insertions and postpartumhemorrhage, but I think that to
include incivility training,essentially cognitive rehearsal,
in nursing education and inmedical education is really
(21:28):
something that really needs tobe included in the curriculum
100% because, think about it,every single situation, though
it might be similar, is alwaysdifferent.
Dr.Clark (21:41):
The context is different, the people involved
in different are different.
The tone, the delivery, theverbiage, all of that is
different.
So as much practice as we canpossibly have, for that, I think
, is paramount to our practice.
Some people like to call thosesoft skills, and I'm not a fan
(22:03):
of that term.
I call them power skills withcapital letters, because for us
to hone and master the abilityto effectively manage, maybe
even prevent, those kinds ofsituations is absolutely, I
think, essential to our practiceand to our profession to our
(22:32):
profession?
Deb Tauber (22:32):
Absolutely.
It's that saying people won'tremember what you did, they
won't remember what you said,they'll remember how you made
them feel is so true.
Dr.Clark (22:39):
Yes, yes, and part of the cognitive rehearsal too is,
you know, because I just sort ofwent over it very quickly, you
know, as a former well, let meput it this way there are
cognitive strategies that we canuse to help us prepare to
de-stress in the moment prior toentering a conversation.
(23:02):
So there's a lot more that goesinto it.
It's teaching those skills,techniques, practicing those
together, finding ways to, youknow, sort of come back to some
homeostasis or equilibriumbefore entering into that
conversation.
All of that is part of theexperience.
(23:24):
And I wanted to mention,because I think it's so very
important, is that if folks arethinking about facilitating
cognitive rehearsal, you wantthat facilitator not only to be
(23:53):
skilled at building trust,establishing rapport, but I
always see my job as creatingthat safe space, that safe
environment for the kind ofexperiences we're going to have.
And the facilitator also needsto have an excellent working
(24:15):
knowledge, as you know, someexpertise in the content, the
subject matter of civility andincivility and being prepared
that some of the participantsmay be really impacted by
memories of previous acts and beable to address those.
So it really does take thatspecial education and experience
(24:41):
and coaching.
Deb Tauber (24:44):
Absolutely.
I think when you think aboutany, essentially any simulations
, you need that subject matterexpert present to you know, help
the learners obtain theobjectives that you're reaching
for.
Dr.Clark (25:00):
Totally totally.
Deb Tauber (25:02):
Can you provide a specific example of how
cognitive rehearsal can be usedto an address in uncivil
situation?
Dr.Clark (25:11):
Yes, okay, so I have so many, but I'm going to talk
about Iris, a person that I callIris.
I wrote this scenario becauseit is such a common situation
that nursing faculty talk about.
(25:31):
It's also been the scenariothat has shown up in my research
studies as well, when I ask forpersonal narratives about their
personal experiences.
So here's Iris.
So imagine if you have an Irisin your work environment.
(25:52):
So Iris is a faculty member whodominates conversations and
meetings, voices strong opinionsat the exclusion of others,
often escalates disagreementsinto verbal attacks, often
escalates disagreements intoverbal attacks, uses an
aggressive tone, body language,word choice.
Now here's the kicker.
(26:14):
We may have an iris, butobviously in this description of
iris, the behavior is prettytroublesome, right, but here's
the real problem that peoplearen't addressing it.
They're allowing this behaviorto continue.
So now let's think aboutsomeone in that group who's had
(26:41):
time to reflect on it and saysyou know what?
I'm going to go have aconversation with Iris, and I
can imagine if there arelisteners who are thinking about
putting themselves in the placeof the person who's about to
address Iris.
I mean, that can be prettynerve wracking.
Right, you're going to go havea conversation with someone
whose communication style is,you know, pretty offensive at
(27:03):
times.
So in cognitive rehearsal, whatI would do is, if we were role
playing that, we would role playit, and one of the evidence
based frameworks that I mightuse in part to folks that they
A2, so PAIL is P-A-A-I-L, sopreview Advocacy 1 is something
(27:39):
like I saw, I heard or I noticed.
Advocacy 2 would be I'mconcerned, or I think.
I believe Inquiry is where youpose a question or a probe, and
then L is my favorite because itstands for listen.
So here's how PALE might beused with IRIS.
(28:03):
So P for preview, iris.
I'd like to talk aboutyesterday's team meeting.
Okay, advocacy one there weremoments when the discussion
became intense and some commentstook the conversation away from
the main topic.
Advocacy two I'm concernedbecause these actions could
(28:26):
affect our ability to worktogether and discuss issues in
an open manner that's respectful, and discuss issues in an open
manner that's respectful.
I, which is that probe orquestion.
What are your observations?
How do you think the meetingwent?
And then L is we listen.
(28:47):
We listen to Iris's responsebefore we respond.
So that's just one example ofhow we might address that
situation.
Deb Tauber (29:04):
Okay, let me take this.
This is fantastic, but let mejust go ahead and push this a
little bit further.
What?
Dr.Clark (29:08):
if iris stonewalls you , yeah, well, that that's likely
to happen.
That's likely to happen withsome irises, right?
And so let's say that, first ofall, you want to prepare iris,
and that might be done in anemail Iris, I'd like to get
together and talk so that irishas time to prepare as well,
setting a mutual time for us toget together.
(29:31):
Hopefully she says yes.
If not, that's a differentexperience.
But let's say she says yes,because I want to get to your
question about now.
What so?
You have this time set up, youintroduce your concern and let's
say it goes immediately off therails, doesn't want to hear it,
(29:52):
which, by the way, let me justsay here that very often, in
many cases, a person is unawareof how they're coming across to
other people, and it's hopefuland sometimes possible that they
will listen, but let's say itgoes off the rails.
(30:12):
I often suggest that you haveanother sort of script ready in
your mind which might gosomething like you know, I'm
wondering if we might rescheduleour meeting because I'm not
sure we, either of us, have hadenough time to really prepare
for it.
Let's reschedule and give itanother whirl Now.
(30:36):
Let's go into that secondmeeting.
You're going to make thatsecond attempt, having rehearsed
it, prepared, done all thethings that we mentioned in
terms of preparation andpractice and debrief, practice
(30:59):
and debrief, and it goesreasonably well, but let's say
it doesn't.
Now I believe that you've givenit an excellent go at it twice
without much reconciliation orresolution.
Now is the time where we mightinvite that neutral third party
in to negotiate the conflict.
So it's not going to work 100%of the time, but very often it
(31:22):
does.
Deb Tauber (31:23):
Thank you, thank you very much for providing these
examples of how, specifically,we can address some of this
incivility in the workplace.
Dr.Clark (31:36):
Yeah, you're so welcome and I just want to thank
you again, your listeners,everyone out there who has been
a part of today's experience.
So thank you.
Deb Tauber (31:46):
Thank you Now, Dr.
Clark, if our listeners wantto get a hold of you and I know,
being the subject matter expertinternationally, and this
subject might be hard, but howcould they get a hold of you?
Dr.Clark (32:01):
Oh, oh, thank you.
So I'm pretty easy to find.
I'm available on LinkedIn.
I have a profile there.
I don't have a large socialmedia presence on purpose, so
LinkedIn.
I also have a site, a websitethrough my university of where
I'm professor emeritus at BoiseState University, and you can
(32:25):
Google Stability Matters.
That's my website.
It'll pop up.
It's got my information inthere.
So thank you so much for asking.
Deb Tauber (32:35):
Thank you.
Thank you for all that you'redoing.
Dr.Clark (32:39):
You're welcome.
Deb Tauber (32:40):
And happy simulating .
Disclaimer/ Innlvation S (32:43):
Thanks again to Innovative Sim
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Welcome to The Sim Cafe, apodcast produced by the team at
Innovative Sim Solutions, editedby Shelly Houser.
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Deb Tauber (01:39):
Welcome to another episode of The Sim Cafe.
Welcome to another episode ofthe Sim Cafe Today.
Unfortunately J is not with us.
He's in Copenhagen.
Today we have the esteemedprivilege of interviewing Dr
Cynthia Clark.
She's the founder of CivilityMatters, professor Emeritus at
(02:00):
Boise State University and anaward-winning tenured professor,
scholar and author.
She serves as a fellow in theAmerican Academy of Nursing, the
NLN Academy of NursingEducation and the American
Nurses Association ProfessionalPanel on Preventing Incivility
and Bullying in Nursing.
Dr Clark is internationallyrecognized for her
(02:23):
groundbreaking work on fosteringcivility and creating healthy
work and learning environments.
Her assessment tools have beentranslated into 18 languages and
used by most scholars in 33countries to measure and address
incivility in academic andpractice settings.
Her most recent workbook,creating and Sustaining Civility
(02:46):
in Nursing Education, thirdedition, is an essential
resource for educators worldwide.
Please welcome, dr Clark.
Thank you so much for being on,and why don't you begin by
telling our listeners aboutdefining civility and explaining
why civility and respect matterin nursing about?
Dr.Clark (03:05):
defining civility and explaining why civility and
respect matter in nursing.
Yes, first of all, let me saythank you.
Thank you so much.
Thank you for having me.
It's really a pleasure and suchan honor to be part of this
podcast series, and so I'mpleased to be here, and I just
want to say hello to thelisteners who are tuning in.
So thanks so much.
So, as to your question, youknow why civility matters and
(03:30):
what it is, and so let me startby just mentioning this, first
of all, that I have always Ithink even as a child been
fascinated by human behavior.
Why do people act the way theydo?
Why do they make the choicesthey make?
I'm especially curious aboutwhat makes each of us unique and
(03:51):
how our minds and motivationswork.
So human behavior is absolutelycentral to my work because it
helps us understand and we'll betalking later today about
cognitive rehearsal.
It helps us understand andaddress those complex
interactions that happen betweenand among people.
(04:13):
So for more than two decades,and maybe even getting closer to
three, I've been studying thescience of civility and what it
means, and if we go back to 2008for just a moment, that was the
year that my colleague and Ipublished the first concept
analysis on civility, and itstood the test of time for quite
(04:36):
a while.
But when the pandemic hit, Ibegan to get really deeply
curious about whether or not theconcept of civility had changed
over time, and so my researchteam and I came together and we
decided to do an update on theconcept of civility and compare
(04:59):
that to the previous conceptanalysis, and what was so
interesting is that wediscovered that not a lot has
changed over time relative tothis concept.
And what we found is this isthat, first of all, civility is
quite analogous with respect,even though they're not exactly
(05:24):
the same.
But what was also profound forus in terms of our discovery is
that civility is a choice.
It's a decision we make everysingle day, with every encounter
, with every interaction.
It means that we're respectingthe dignity of other people,
their perspectives, theirwell-being, and it helps us
(05:47):
create those healthy workenvironments where all of us
feel like we're welcome, like webelong.
It helps us build meaningfulrelationships, especially when
we disagree.
And so one final thought onthat is that civility is not
about liking.
So, for instance, if you and Ilike each other, that's awesome.
(06:11):
It's really a bonus.
It's not requisite to ustreating one another with the
dignity each of us deserves.
Deb Tauber (06:23):
Yeah, I totally can see that and agree with that.
Can you provide some examplesof incivility in nursing and
explain how these behaviorsmanifest in healthcare settings?
Dr.Clark (06:36):
Yeah, so, yeah, so great question I like to think
about and have, you know, reallyillustrated this on what I call
the continuum of workplaceaggression.
So if you sort of imagine, ifour listeners can think about
any kind of continuum, that onthe left side of this particular
continuum that I'm referring toin terms of behaviors we might
(07:01):
see in a workplace, on the leftside, those are more sort of
distracting, annoying,irritating behaviors.
Those would be things like rudenonverbals, like eye rolling,
finger pointing, arm waving.
And then I want to take us allthe way to the right side of the
(07:21):
continuum where we would seevery hostile or violent
behaviors, in other words actsof violence or tragedy.
That would be something like acampus or a workplace shooting
and then all those behaviors inbetween.
So when we think about rudenonverbals, as I mentioned a few
(07:44):
of those, you know the eyerolling and so forth I mentioned
those because in our world ofnursing and healthcare, even
though we might say those arelesser forms of incivility, I
can tell you this that recentlythere was a beautiful paper
published by a group ofphysicians who were studying
(08:07):
what are some of the uncivilbehaviors that occur in our
patient care areas thatultimately impact patient care,
patient safety, and what wasvery interesting about what they
were able to determine was thatone of the most common
incivilities that occur withinthe healthcare environment is
(08:29):
this walking away before aconversation is over.
So that is a nonverbal.
We are walking away Now.
If we put that in context, ifyou and I say are working in an
engineering firm and you and Ihave a conversation or attempt
(08:55):
to have that, and you'reconversing with me and what I do
instead is just sort of turn onmy heel and walk away, now you
might say, wow, that was rude orthat was pretty unfriendly.
The likelihood of anyone beingharmed or even dying is slim and
(09:16):
none.
When, however, we put that inthe patient care environment now
, it's a whole new ballgame.
In the patient care environmentnow it's a whole new ballgame
Because if you approach me as acolleague, as a healthcare
colleague, and you haveimportant information to impart
relative to a patient condition,and I just walk away now we
(09:40):
have the potential for some veryserious problems in terms of
what that might do as it impactspatient care.
So I guess I mentioned thatbecause, even though those
nonverbals are on the far leftof that continuum, they can have
devastating effects dependingon the context.
(10:02):
Just a couple of the otherbehaviors you might see on that
continuum One is bullying, youknow, which is more intense.
Rather than uncivil acts,bullying is a repeated,
persistent pattern of abusivebehavior that is characterized
not always but almost always byasserting real or perceived
(10:26):
power over another person, andthat's usually done to
intimidate or humiliate.
And under that major header ofbullying we see now more and
more experiences withcyberbullying, where digital
devices and online media sitesare used to post often harmful,
(10:52):
false or malicious content.
Sometimes those behaviors areserious enough to be considered
criminal.
So because of theubiquitousness and easy access
and anonymity of the internet,some really bad stuff can end up
(11:13):
happening, and we may becompletely unaware of it if we
are not tuned in to whateversite that might be whatever site
that might be.
Deb Tauber (11:32):
So those are just a few of the experiences that some
people might have.
Well, and I think it'sinsidious, it starts, you know,
you don't really even realizeit's happening and then, before
you know it, you kind of openyour eyes and you think, my
goodness gracious, this isincivility right now.
Yeah, yeah, in my career I was,you know, bullied by nurses and
(11:52):
it left marks on me.
In fact, we talked about thatthe last time that we chatted
and you suggested that I read,and I will suggest to our
listeners, you know, if they'vebeen bullied, that they might
want to think about reading thebook.
The body keeps the score, asyou suggested to me.
Dr.Clark (12:12):
Yes, yes, it's an.
It's an excellent resourcerelative to how trauma, unless
it's managed well and dealt within healthy ways, can really
overwhelm and overcome ourmental health, our physical
health.
You mentioned the terminsidious, and I think that's so
(12:33):
interesting because one of theother behaviors, if you will, a
subcategory of bullying, isgaslighting, and I think that's
a little bit about what you'redescribing here.
It's sort of that insidious,subtle form of bullying where
what's what's really happeningthere is that someone who might
(12:55):
be gaslighting me or you isattempting to convince us that
what we saw or what we hearddidn't really happen.
It didn't really happen.
And we begin to question our ownthoughts, our own perceptions,
our own reality, our ownmemories, and so we lose
confidence.
And the other thing we often dois we blame ourselves.
(13:16):
Must be me, because gaslighterswho are really good at it will
say things like if we call thebehavior into question, you
might hear things like what,can't you take a joke?
I was only kidding, you knowthat's a very common response.
Or I didn't say that.
What Are you crazy?
Or you're crazy.
(13:38):
That never happened, are youokay?
You seem unstable, you know allof these.
And so we begin to question ourown thoughts and literally our
own reality.
So those can be really hardbehaviors to first of all assess
(13:59):
, because we're blamingourselves, and second of all
address.
Deb Tauber (14:04):
Wow, Thank you.
Yeah, Now you've writtenextensively about the use of
cognitive rehearsal as astrategy to prevent and address
these types of uncivil behaviors.
Can you tell us talk aboutcognitive rehearsal?
It's?
This is essentially a form ofsimulation.
Dr.Clark (14:34):
Yes, yes, thank you for that, because I didn't know
that in the very beginning.
You know, I just knew whatcognitive rehearsal was and why
I was doing it, and it wasn'tuntil later when my good pal
Susie Kardon-grin helped meunderstand that this is a form
of sort of live simulation.
So let me tell you what it isfirst.
(14:56):
Well, before I do that, I wantto give a shout out to Dr Martha
Griffin.
Martha's now retired, but shewrote a seminal piece.
Maybe lots of listeners haveread it.
It was published over 20 yearsago now, in 2004.
And Martha wrote an articlewhere she used cognitive
(15:16):
rehearsal with newly graduatednurses to help them understand
and deal with instability inpractice environments, and it
was hugely successful.
I read that paper in 2004,reached out to Martha.
In fact, she and I haveco-authored an update to that.
Ten years later, in 2014, wepublished together to do kind of
(15:43):
a refresh of cognitiverehearsal.
But here's what cognitiverehearsal is it's an
evidence-based technique, it'ssteeped in behavioral science
and what happens is that anindividual or a group of
individuals work with a skilledfacilitator in order to practice
(16:04):
addressing stressful situationsin a non-threatening
environment.
In other words, we use roleplay or simulation, where people
practice addressing in my case,the work that I do with them
uncivil events and that the goalis that, if they are, because
(16:24):
they've had practice, becausewe've debriefed it, if they're
faced with a similar situationin the future, they've had some
rehearsal, thus cognitiverehearsal or practice addressing
it, and I've worked withmultiple groups, whether it's
(16:44):
students, faculty practice-basednurses, physicians, other
academics.
I like to use a five-stepprocess and I'll keep it very
brief, but the first step for me, and so the sim folks out there
are going to go, yeah, yeah,now I get it.
That's why it's simulation.
So step one is that wepre-brief and we prepare, and so
(17:11):
that means in my case that I'mreviewing with the participants
the topic of civility,incivility, providing a summary
of what they're going to expectin our time together.
It includes establishing andco-creating norms.
It includes establishing andco-creating norms.
Often, I'll use the basicassumption from Harvard Sim
(17:34):
Center and I'll also providewhat we like to call some people
call them trigger warnings, nota fan.
What I like to call them arecontent advisories or content
forecasts.
Letting people know hey, youknow what we're going to be role
playing into debriefing someencounters that could evoke some
(17:55):
discomfort Maybe you knowyou've experienced trauma in
this regard and letting peopleknow that it's important that
they take care of themselves,that they might need to step out
.
In some cases, depending on mygroup, we've actually had a
counselor outside the room toassist folks if, in fact, they
(18:20):
want to, you know, touch basewith that individual before
coming back in or not comingback in to the role play
environment.
And then step two is I havethem either work individually or
in groups almost always ingroups because we're going to
eventually role play on civilencounters that they've
(18:44):
experienced.
Now, that's key because I canprovide them scenarios that are
common, and sometimes I do thatto get us jump-started.
But I'm drawing on the work ofCarol Gillian, who studied under
Kohlberg, and what CarolGillian found and she wrote in a
different voice relative toethics is that the scenarios
(19:09):
that Colbert wrote were helpful.
But what Gillian said is youknow what, if you're
deconstructing your ownexperiences, you're going to
have a very different attachmentemotionally to those
experiences.
So step two is to have themidentify what those potential or
(19:30):
real uncivil encounters mightbe and then asking folks to role
play those during cognitiverehearsal, always provide
evidence-based framework forthem to script some responses
and reminding them you're notscripted, you're scripting,
(20:00):
which is really kind of adeparture from Dr Griffin's work
, who likes to provide thescripts that people practice.
I prefer to provide them with aframework to develop their own
scripts so that it's morenatural and authentic.
And then step four is when weactually do the role play, and I
have to tell you it'sastounding to watch the actors
(20:20):
come up and role play theirexperiences.
And then step five, of course,is for me to go into that deep
debrief and reflectiveexperiences, to talk about the
scenario itself, powerimbalances that might have
existed and so forth, andcertainly many other forms of
(20:43):
debriefing queries.
So that's kind of it in anutshell, and it's a pretty
profound experience for thosewho participate, and me, as the
facilitator, totally love it,you know, to see the change in
people.
Deb Tauber (21:01):
It's an enlightenment for the
individuals.
Dr.Clark (21:04):
Absolutely, absolutely .
Deb Tauber (21:07):
I mean, we do so many simulations for high risk,
low frequency events or you knowthings like central line
insertions and postpartumhemorrhage, but I think that to
include incivility training,essentially cognitive rehearsal,
in nursing education and inmedical education is really
(21:28):
something that really needs tobe included in the curriculum
100% because, think about it,every single situation, though
it might be similar, is alwaysdifferent.
Dr.Clark (21:41):
The context is different, the people involved
in different are different.
The tone, the delivery, theverbiage, all of that is
different.
So as much practice as we canpossibly have, for that, I think
, is paramount to our practice.
Some people like to call thosesoft skills, and I'm not a fan
(22:03):
of that term.
I call them power skills withcapital letters, because for us
to hone and master the abilityto effectively manage, maybe
even prevent, those kinds ofsituations is absolutely, I
think, essential to our practiceand to our profession to our
(22:32):
profession?
Deb Tauber (22:32):
Absolutely.
It's that saying people won'tremember what you did, they
won't remember what you said,they'll remember how you made
them feel is so true.
Dr.Clark (22:39):
Yes, yes, and part of the cognitive rehearsal too is,
you know, because I just sort ofwent over it very quickly, you
know, as a former well, let meput it this way there are
cognitive strategies that we canuse to help us prepare to
de-stress in the moment prior toentering a conversation.
(23:02):
So there's a lot more that goesinto it.
It's teaching those skills,techniques, practicing those
together, finding ways to, youknow, sort of come back to some
homeostasis or equilibriumbefore entering into that
conversation.
All of that is part of theexperience.
(23:24):
And I wanted to mention,because I think it's so very
important, is that if folks arethinking about facilitating
cognitive rehearsal, you wantthat facilitator not only to be
(23:53):
skilled at building trust,establishing rapport, but I
always see my job as creatingthat safe space, that safe
environment for the kind ofexperiences we're going to have.
And the facilitator also needsto have an excellent working
(24:15):
knowledge, as you know, someexpertise in the content, the
subject matter of civility andincivility and being prepared
that some of the participantsmay be really impacted by
memories of previous acts and beable to address those.
So it really does take thatspecial education and experience
(24:41):
and coaching.
Deb Tauber (24:44):
Absolutely.
I think when you think aboutany, essentially any simulations
, you need that subject matterexpert present to you know, help
the learners obtain theobjectives that you're reaching
for.
Dr.Clark (25:00):
Totally totally.
Deb Tauber (25:02):
Can you provide a specific example of how
cognitive rehearsal can be usedto an address in uncivil
situation?
Dr.Clark (25:11):
Yes, okay, so I have so many, but I'm going to talk
about Iris, a person that I callIris.
I wrote this scenario becauseit is such a common situation
that nursing faculty talk about.
(25:31):
It's also been the scenariothat has shown up in my research
studies as well, when I ask forpersonal narratives about their
personal experiences.
So here's Iris.
So imagine if you have an Irisin your work environment.
(25:52):
So Iris is a faculty member whodominates conversations and
meetings, voices strong opinionsat the exclusion of others,
often escalates disagreementsinto verbal attacks, often
escalates disagreements intoverbal attacks, uses an
aggressive tone, body language,word choice.
Now here's the kicker.
(26:14):
We may have an iris, butobviously in this description of
iris, the behavior is prettytroublesome, right, but here's
the real problem that peoplearen't addressing it.
They're allowing this behaviorto continue.
So now let's think aboutsomeone in that group who's had
(26:41):
time to reflect on it and saysyou know what?
I'm going to go have aconversation with Iris, and I
can imagine if there arelisteners who are thinking about
putting themselves in the placeof the person who's about to
address Iris.
I mean, that can be prettynerve wracking.
Right, you're going to go havea conversation with someone
whose communication style is,you know, pretty offensive at
(27:03):
times.
So in cognitive rehearsal, whatI would do is, if we were role
playing that, we would role playit, and one of the evidence
based frameworks that I mightuse in part to folks that they
A2, so PAIL is P-A-A-I-L, sopreview Advocacy 1 is something
(27:39):
like I saw, I heard or I noticed.
Advocacy 2 would be I'mconcerned, or I think.
I believe Inquiry is where youpose a question or a probe, and
then L is my favorite because itstands for listen.
So here's how PALE might beused with IRIS.
(28:03):
So P for preview, iris.
I'd like to talk aboutyesterday's team meeting.
Okay, advocacy one there weremoments when the discussion
became intense and some commentstook the conversation away from
the main topic.
Advocacy two I'm concernedbecause these actions could
(28:26):
affect our ability to worktogether and discuss issues in
an open manner that's respectful, and discuss issues in an open
manner that's respectful.
I, which is that probe orquestion.
What are your observations?
How do you think the meetingwent?
And then L is we listen.
(28:47):
We listen to Iris's responsebefore we respond.
So that's just one example ofhow we might address that
situation.
Deb Tauber (29:04):
Okay, let me take this.
This is fantastic, but let mejust go ahead and push this a
little bit further.
What?
Dr.Clark (29:08):
if iris stonewalls you , yeah, well, that that's likely
to happen.
That's likely to happen withsome irises, right?
And so let's say that, first ofall, you want to prepare iris,
and that might be done in anemail Iris, I'd like to get
together and talk so that irishas time to prepare as well,
setting a mutual time for us toget together.
(29:31):
Hopefully she says yes.
If not, that's a differentexperience.
But let's say she says yes,because I want to get to your
question about now.
What so?
You have this time set up, youintroduce your concern and let's
say it goes immediately off therails, doesn't want to hear it,
(29:52):
which, by the way, let me justsay here that very often, in
many cases, a person is unawareof how they're coming across to
other people, and it's hopefuland sometimes possible that they
will listen, but let's say itgoes off the rails.
(30:12):
I often suggest that you haveanother sort of script ready in
your mind which might gosomething like you know, I'm
wondering if we might rescheduleour meeting because I'm not
sure we, either of us, have hadenough time to really prepare
for it.
Let's reschedule and give itanother whirl Now.
(30:36):
Let's go into that secondmeeting.
You're going to make thatsecond attempt, having rehearsed
it, prepared, done all thethings that we mentioned in
terms of preparation andpractice and debrief, practice
(30:59):
and debrief, and it goesreasonably well, but let's say
it doesn't.
Now I believe that you've givenit an excellent go at it twice
without much reconciliation orresolution.
Now is the time where we mightinvite that neutral third party
in to negotiate the conflict.
So it's not going to work 100%of the time, but very often it
(31:22):
does.
Deb Tauber (31:23):
Thank you, thank you very much for providing these
examples of how, specifically,we can address some of this
incivility in the workplace.
Dr.Clark (31:36):
Yeah, you're so welcome and I just want to thank
you again, your listeners,everyone out there who has been
a part of today's experience.
So thank you.
Deb Tauber (31:46):
Thank you Now, Dr.
Clark, if our listeners wantto get a hold of you and I know,
being the subject matter expertinternationally, and this
subject might be hard, but howcould they get a hold of you?
Dr.Clark (32:01):
Oh, oh, thank you.
So I'm pretty easy to find.
I'm available on LinkedIn.
I have a profile there.
I don't have a large socialmedia presence on purpose, so
LinkedIn.
I also have a site, a websitethrough my university of where
I'm professor emeritus at BoiseState University, and you can
(32:25):
Google Stability Matters.
That's my website.
It'll pop up.
It's got my information inthere.
So thank you so much for asking.
Deb Tauber (32:35):
Thank you.
Thank you for all that you'redoing.
Dr.Clark (32:39):
You're welcome.
Deb Tauber (32:40):
And happy simulating .
Disclaimer/ Innlvation S (32:43):
Thanks again to Innovative Sim
Solutions for sponsoring thisweek's episode.
Ready to revolutionize how youteach and train?
Then check out the basics ofhealthcare simulations with
Innovative Sim Solutions and DebTauber today.
Thanks for joining us here atThe Sim Cafe.
(33:06):
We hope you enjoyed.
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