Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treatments or protocols. Isolated recognition of a health issue does little to resolve it.
In this module’s Discussion, you applied the Clark Healthy Workplace Inventory to diagnose potential problems with the civility of your organization. In this Portfolio Assignment, you will continue to analyze the results and apply published research to the development of a proposed treatment for any issues uncovered by the assessment.
Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).
Review the Work Environment Assessment Template.
Reflect on the output of your Discussion post regarding your evaluation of workplace civility and the feedback received from colleagues.
Select and review one or more of the following articles found in the Resources:
Clark, Olender, Cardoni, and Kenski (2011)
Griffin and Clark (2014)
The Assignment (3-6 pages total):
Part 1: Work Environment Assessment (1-2 pages)
Review the Work Environment Assessment Template you completed for this Module’s Discussion.
Describe the results of the Work Environment Assessment you completed on your workplace.
Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.
Explain what the results of the Assessment suggest about the health and civility of your workplace.
Part 2: Reviewing the Literature (1-2 pages)
Briefly describe the theory or concept presented in the article(s) you selected.
Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.
Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.
Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (1–2 pages)
Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.
Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.
By Day 7 of Week 9
Submityour Workplace Environment Assessment Assignment.
18American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com
“I believe we can
change the world if we
start listening to one
another again. Simple,
honest, human con-
versation…a chance to
speak, feel heard, and
[where] we each listen
save the world.”
Margaret J. Wheatley,
GIVEN the stressful healthcare
workplace, it’s no wonder nurses
and other healthcare professionals
sometimes fall short of communi-
cating in respectful, considerate
ways. Nonetheless, safe patient care
hinges on our ability to cope with
stress effectively, manage our emo-
tions, and communicate respectful-
ly. Interactions among employees
can affect their ability to do their
jobs, their loyalty to the organiza-
tion, and most important, the deliv-
ery of safe, high-quality patient
The American Nurses Associa-
tion (ANA) Code of Ethics for
Nurses with Interpretive Statements
clearly articulates the nurse’s obli-
gation to foster safe, ethical, civil
workplaces. It requires nurses “to
create an ethical environment and
culture of civility and kindness,
treating colleagues, coworkers, em-
ployees, 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, or-
ganization leaders and
managers must create
an environment where
nurses feel free and
empowered to speak
up, especially regard-
ing patient safety
All of us must strive
to create and sustain
civil, healthy work en-
vironments where we
communicate clearly and effectively
and manage conflict in a respectful,
responsible way. The alternative—
incivility—can have serious and
lasting repercussions. An organiza-
tion’s culture is linked closely with
employee recruitment, retention,
and job satisfaction. Engaging in
clear, courteous communication fos-
ters a civil work environment, im-
proves teamwork, and ultimately
enhances patient care.
In many cases, addressing inci-
vility by speaking up when it hap-
pens can be the most effective
way to stop it. Of course, mean-
ingful dialogue and effective com-
munication require practice. Like
bowel sound auscultation and na-
sogastric tube insertion, communi-
cation skills can’t be mastered
overnight. Gaining competence in
civil communication takes time,
training, experience, practice, and
1. Identify components of a healthy
2. Discuss how to prepare for a chal-
3. Describe models for conducting a
The planners of this CNE activity have disclosed no
relevant financial relationships with any commercial
companies pertaining to this activity. See the last page
of the article to learn how to earn CNE credit. The
author has disclosed that she receives royalties and
consulting fees pertaining to this topic. The article
was peer reviewed and determined to be free of bias.
to inspire and promote a
more civil workplace
Let’s end the silence that surrounds incivility.
By Cynthia M. Clark,
PhD, RN, ANEF, FAAN
www.AmericanNurseToday.com November 2015 American Nurse Today 19
What makes for a healthy
The American Association of Criti-
cal-Care Nurses has identified six
standards for establishing and sus-
taining healthy work environ-
ments—skilled communication, true
collaboration, effective decision-
making, appropriate staffing, mean-
ingful recognition, and authentic
In my own research, I’ve found
that healthy work environments al-
• 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 orga-
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 de-
termine strengths and areas for im-
provement. 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
One could argue that to attain a
high score on nearly every invento-
ry 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 hav-
ing 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, be-
cause 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 be-
low can help you prepare for and
engage in challenging conversations.
Reflecting, probing, and
Reflecting on the workplace culture
and our relationships and interac-
tions 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 ques-
tions, 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 identi-
fied failing to speak up in disre-
spectful situations as a serious com-
munication breakdown among
healthcare professionals, and they
asserted that such a failure can
have serious patient-care conse-
quences. In a subsequent report,
“The Silent Treatment: Why Safety
Tools and Checklists Aren’t Enough
to Save Lives,” the authors suggest-
ed a multifaceted organizational ap-
proach 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 mem-
bers have the skills to be “200% ac-
countable for safe practices.” Ways
to acquire safe practice skills in-
clude 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 careful-
ly. 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 set-
ting where both parties will have as
much emotional and physical safety
Both should agree on a mutual-
ly beneficial time and place to
meet. Ideally, the place should be
quiet, private, away from others
(especially patients), and con-
ducive to conversation and prob-
lem-solving. Select a time when
both parties will be free of inter-
ruptions, off shift, and well-rested.
If a real or perceived power differ-
ential exists between you and the
other person, try to have a third
You may need to initiate the
conversation by asking the other
person for a meeting. Suppose
you and your colleague Sam dis-
agree over the best way to per-
form 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 to-
gether 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 per-
20American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com
You can use the inventory below to help determine the health of your workplace. To complete it, carefully read the 20 statements
below. Using a scale of 1 to 5, check the response that most accurately represents your perception of your workplace. Check 5 if
the statement is completely true, 4 if it’s somewhat true, 3 if it’s neutral, 2 if it’s somewhat untrue, and 1 if it’s completely untrue.
Then total the number values of your responses to determine the overall civility score. Scores range from 20 to 100. A score of 90
to 100 indicates a very healthy workplace; 80 to 89, moderately healthy; 70 to 79, mildly healthy; 60 to 69, barely healthy; 50 to 59,
unhealthy; and less than 50, very unhealthy.
Completely Somewhat Neutral Somewhat Completely
Statementtrue (5)true (4)(3) untrue (2) untrue (1)
Members of the organization “live” by a shared vision□ □ □ □□
and mission based on trust, respect, and collegiality.
There is a clear and discernible level of trust□ □ □ □□
between and among formal leadership and
other members of the workplace.
Communication at all levels of the organization □ □ □ □□
is transparent, direct, and respectful.
Employees are viewed as assets and valued □ □ □ □□
partners within the organization.
Individual and collective achievements are celebrated □ □ □ □□
and publicized in an equitable manner.
There is a high level of employee satisfaction, □ □ □ □□
engagement, and morale.
The organizational culture is assessed on an ongoing□ □ □ □□
basis, and measures are taken to improve it based on
results of that assessment.
Members of the organization are actively engaged in□ □ □ □□
shared governance, joint decision-making, and policy
development, review, and revision.
Teamwork and collaboration are promoted and evident. □ □ □ □□
There is a comprehensive mentoring program for □ □ □ □□
There is an emphasis on employee wellness and self-care.□ □ □ □□
There are sufficient resources for professional growth□ □ □ □□
Employees are treated in a fair and respectful manner. □ □ □ □□
The workload is reasonable, manageable, and fairly□ □ □ □□
Members of the organization use effective conflict- □ □ □ □□
resolution skills and address disagreements in a
respectful and responsible manner.
The organization encourages free expression of diverse□ □ □ □□
and/or opposing ideas and perspectives.
The organization provides competitive salaries, benefits,□ □ □ □□
compensations, and other rewards.
There are sufficient opportunities for promotion and □ □ □ □□
The organization attracts and retains the□ □ □ □□
“best and the brightest.”
The majority of employees would recommend the□ □ □ □□
organization as a good or great place to work to
their family and friends.
© 2014 Cynthia M. Clark
Clark Healthy Workplace Inventory
www.AmericanNurseToday.com November 2015 American Nurse Today 21
son’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. Re-
hearsing what you intend to say al-
so can help.
Preparing for the conversation
Critical conversations can be stress-
ful. 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 possi-
ble. 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,
• 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 di-
rectly and respectfully. Listen ac-
tively and show genuine interest in
the other person. To listen actively,
focus on his or her message in-
stead of thinking about how you’ll
respond. If you have difficulty lis-
tening and concentrating, silently
repeat the other person’s words to
yourself to help you stay focused.
Stay centered, poised, and fo-
cused on patient safety. Avoid be-
ing defensive. You may not agree
with the other person’s message,
but seek to understand it. Don’t in-
terrupt 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 cross-
ing, turning away, and eye rolling.
The overall goal is to find an
interest-based solution to the situa-
tion. The intention to seek com-
mon ground and pursue a com –
promise is more likely to yield a
win-win solution and ultimately im-
prove 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 resolv-
ing the issue.
Framework for engaging in
Cognitive rehearsal is an evidence-
based framework you can use to
address incivility during a challeng-
ing conversation. This three-step
• didactic and interactive learning
• rehearsing specific phrases to
use during uncivil encounters
• practice sessions to reinforce in-
struction and rehearsal.
Using cognitive rehearsal can
lead to improved communication, a
more conflict-capable workforce,
greater nurse satisfaction, and im-
proved patient care.
Various models can be used to
structure a civility conversation.
One of my favorites is the DESC
model, which is part of Team-
STEPPS—an evidence-based team-
work system to improve communi-
cation and teamwork skills and, in
turn, improve safety and quality
care. Using the DESC model in
conjunction with cognitive rehears-
al 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 becom-
ing conflict-capable. In each mod-
el, the required skills are learned,
practiced, and reinforced until re-
sponses become second nature.
Another key feature is to have the
learner make it his or her own; al-
though a script can be provided, it
should be used only to guide de-
velopment of the learner’s personal
Nurturing a civil and
Addressing uncivil behavior can be
difficult, but staying silent can in-
crease stress, impair your job per-
formance and, ultimately, jeopard-
ize patient care. Of course, it’s
easier to be civil when we’re re-
laxed, well-nourished, well-hydrat-
ed, and not overworked. But over
the course of a busy workday,
stress can cause anyone to behave
When an uncivil encounter oc-
curs, we may need to address it by
having a critical conversation with
the uncivil colleague. We need to
be well-prepared for this conversa-
tion, speak with confidence, and
use respectful expressions. In this
way, we can end the silence that
surrounds incivility. These encoun-
ters 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
Effective communication, con-
flict negotiation, and problem-solv-
ing are more important than ever.
For the sake of patient safety,
healthcare professionals need to
focus on our higher purpose—pro-
viding safe, effective patient care—
and communicate respectfully with
each other. Differences in social-
ization and educational experi-
ences, as well as a perceived pow-
er differential, can put physicians
and nurses at odds with one an-
other. When we nurture a culture
of collaboration, we can synthesize
the unique strengths that health-
care 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
For a list of selected references, visit American
22American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com
DESC in action: Three scenarios
The DESC model for addressing incivility has four elements:
D: Describe the specific situation.
E: Express your concerns.
S: State other alternatives.
C: Consequences stated.
The scenarios below give examples of how to use the DESC
model to address uncivil workplace encounters.
Nurses Sandy and Claire
At the beginning of her shift, Sandy receives a handoff report
from Claire, who has just finished her shift.
“Geez, Sandy, where have you been? You’re late as usual.I can’t
wait to get out of here. See if you can manage to get this informa-
tion straight for once. You should know Mary Smith by now. You
took care of her yesterday. She was on 4S forever; now she’s our
problem. You need to check her vital signs. I’ve been way too busy
to do them. So, that’s it—I’m out of here. If I forgot something, it’s
not my problem. Just check the chart.”
Not only is Claire rude and disrespectful, but she also is put-
ting the patient at risk by providing an incomplete report.
Here’s how Sandy might address the situation.
Describe: “Claire, I can see you’re in a hurry, and I understand
you’re upset because I’m late. We can talk about that when we
have more time. For now, I don’t feel like I’m getting enough
information to do my job effectively.”
Explain: “Talking about Mrs. Smith in a disrespectful way and
rushing through report can have a serious impact on her care.”
State: “I know we’re both concerned about Mrs. Smith, so
please give me a more detailed report so I can provide the
best care possible.”
Consequence: “Without a full report, I may miss an important
piece of information, and this could compromise Mrs. Smith’s
Nurse manager Alice and staff nurse Kathy
The anxiety level may rise for a nurse who experiences incivili-
ty from a higher-up. The following scenario illustrates an unciv-
il encounter between Alice, a nurse manager, and Kathy, a staff
“Hey Kathy, I just found out Nicole called in sick, so you’re going to
have to cover her shift. We’re totally shorthanded, so you need to
stay. You may not like the decision, but that’s just the way it is.”
Kathy is unable—and frankly, unwilling—to work a double
shift. Exhausted, she’d planned to spend time with her family
this evening. Also, she has worked three extra shifts this
month. She decides she needs to deal with this situation now
instead of setting up a meeting with Alice later in the week.
Here’s how she might use the DESC model with her manager.
Describe: “Alice, I can appreciate the need to cover the unit
because of Nicole’s illness. We all agree that having adequate
staff is important for patient care.”
Explain: “I’m exhausted, and because I have recently covered
other shifts, I’m less prepared to administer safe, high-quality
State: “I realize that as manager, it’s your responsibility to
make sure we have adequate staff for the oncoming shift. But
I’d like to talk about alternatives because I’m unable to work an
additional shift today.”
Consequence: “Let’s work together to discuss alternatives for
covering Nicole’s shift. It’s important for me to have a voice in
decisions that affect me.”
For a staff nurse, addressing a manager can be daunting. To
have a critical conversation with an uncivil superior in an effort
to put an end to the problem, you need the courage to be as-
sertive. Engaging in stress-reducing and self-care activities and
practicing mindfulness can boost your courage so you’ll be
prepared. Most of all, you need to practice and rehearse effec-
tive communication skills until you feel comfortable using
A 2014 study by Laschinger et al. found a compelling rela-
tionship between meaningful leadership and nurse empower-
ment and their impact on creating civility and decreasing
nurse burnout. This study underscores the need for leadership
development to enable nurse managers to foster civil work en-
vironments. To create and sustain a healthy environment, all
members of the organization need to receive intentional and
ongoing education focused on raising awareness about incivil-
ity; its impact on individuals, teams, and organizations; and
most important, its consequences on patient care and safety.
Nurse Tom and Dr. Jones
This scenario depicts an uncivil encounter between a nurse
and a physician.
Tom is concerned about Mr. Brown, a patient who’s 2 days postop
after abdominal surgery for a colon resection. On the second
evening after surgery, Mr. Brown’s blood pressure increases. Tom
watches him closely and continues to monitor his vital signs. As
the night wears on, Mr. Brown’s blood pressure continues to rise,
his breathing seems more labored, and his heart rate increases.
Tom calls Dr. Jones, the attending physician, to report his find-
ings. Dr. Jones chuckles and says, “He’s just anxious. Who wouldn’t
be in his condition?” and hangs up. Undaunted, Tom calls back
and insists Dr. Jones return to the unit to assess Mr. Brown. Reluc-
tantly, Dr. Jones comes to the unit, peeks into Mr. Brown’s room
without assessing him, and chastises Tom in front of his col-
leagues and other patients about his “ridiculous overreaction.”
Tom politely asks Dr. Jones to meet with him in an empty meeting
room. Here’s how Tom uses DESC to address the situation.
Describe: “Dr. Jones, I’d like to explain something. Please hear
me out before you comment. I am a diligent nurse with exten-
sive patient care experience.”
Explain: “I know that as Mr. Brown’s attending physician,
you’re committed to his safety. I assure you that everyone on
the healthcare team shares your concern, including me. I
called you immediately after determining persistent and no-
table changes in Mr. Brown’s vital signs.”
State: “Because we are all concerned about Mr. Brown’s care, it
would be best if you conducted an assessment and addressed
me in a respectful manner so we can provide the best care
possible. I will show you the same respect.”
Consequence: “Disregarding important information or allow-
ing your opinion of me to influence your response could com-
promise Mr. Brown’s care. We need to work together as a team
to provide the best care possible.”
www.AmericanNurseToday.com November 2015 American Nurse Today 23
Please mark the correct answer online.
1.The American Association of
Critical-Care Nurses does not identify
which of the following as a
characteristic of a healthy workplace?
b. Informal leadership
c. True collaboration
d. Meaningful recognition
2.A healthy work environment
a.civility conversations at the highest
level of the organization.
b. emphasis on formal rather than
c. shared organizational vision, values,
d. individualized values and norms.
3.When considering whether to have
a challenging conversation, which key
question should you ask yourself?
a.Is the person I need to talk to a full-
b. Do I have enough experience to
have the conversation?
c. How many years have I worked at
d. What will happen to the patient if I
4.Which of the following helps to
create a safe zone for a challenging
a.Agreeing on a mutually beneficial
time to meet
b. Having the conversation in the
presence of patients
c. Having the conversation in the
presence of family members
d. Choosing a time immediately after
the other person’s shift
5.If a power differential exists
between you and the other person, an
effective approach is to:
a. keep the matter between the two of
b. have a third party present.
c. have a security officer attend the
d. refrain from having the
6.Which of the following is an
appropriate action during a challenging
a. Interrupt as needed.
b. Talk quickly.
c. Cross your arms.
d. Maintain eye contact.
7.The first step of cognitive rehearsal
a.describing your position in objective
b. rehearsing specific phrases to use
during uncivil encounters.
c. undergoing didactic and interactive
learning and instruction.
d. having a practice session to
reinforce instruction and rehearsal.
8.What is the first element of the
a. Describe the specific situation.
b. Discuss your concerns.
c. Define your solution.
d. Detail the alternatives.
9.What is the last element of the DESC
a.Coordinate your response.
b. Consider the setting.
c. Consequences stated.
d. Concerns stated.
10. Which statement about challenging
conversations is correct?
a.Nurses have an innate ability to
have these conversations.
b. The person who called the meeting
should dominate the discussion.
c. Agreeing with the other person’s
message is important.
d. After the resolution, the participants
should schedule a follow-up
POST-TEST • Conversations to inspire and promote a more civil workplace
Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/
The American Nurses Association’s Center for Continuing Edu-
cation and Professional Development is accredited as a
provider of continuing nursing education by the American
Nurses Credentialing Center’s Commission on Accreditation.
ANCC Provider Number 0023.
Contact hours: 1.0
ANA’s Center for Continuing Education and Professional Devel-
opment is approved by the California Board of Registered Nurs-
ing, Provider Number CEP6178 for 1.2 contact hours.
Post-test passing score is 80%. Expiration: 11/1/18
ANA Center for Continuing Education and Professional Devel-
opment’s accredited provider status refers only to CNE activi-
ties and does not imply that there is real or implied endorse-
ment of any product, service, or company referred to in this
activity nor of any company subsidizing costs related to the
activity. The author and planners of this CNE activity have dis-
closed no relevant financial relationships with any commercial
companies pertaining to this CNE. See the last page of the
article to learn how to earn CNE credit.
CNE: 1.0 contact hours
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