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From incivility to civility: Transforming the culture

Fifth in a series of articles on civility in nursing education and practice—why it matters and what can be done to foster it.

By Cynthia Clark

“Cultural change occurs only after people alter their behavior, performance improves, and once the change produces benefits to the organization” (Kotter, 1996).

From incivility to civility: Transforming the culture

Organizations everywhere are undergoing significant change. Nursing education and practice are no exceptions. Nursing organizations face several challenges, including pressure to manage costs while improving quality, identifying opportunities for growth, dealing with financial uncertainty, stewarding limited resources and contributing to the health and well-being of society. Thus, nurse leaders must act boldly to transform the culture of the organization. This bold approach is not for the feeble or faint of heart. Transforming an organization’s culture is not only time-consuming and complex; it requires a strong commitment to long-term change.

In the second installment of this series, I discussed why civility matters and asserted that it’s a choice. Ultimately, transforming an uncivil culture to one of civility requires choice, decisive action and resolve. Changing the culture also requires changing the conversation. Margaret Wheatley (2002) contends that, if we engage one another in earnest and honest conversation and sufficiently re-engage with the purpose of our work, we can change the world. In their thought-provoking book, Authentic Conversations, Showkeir and Showkeir (2008) assert that organizational transformation depends on changing our conversations, revising our assumptions about people, respecting one another’s point of view and creating a meaningful vision of the future.

How do we get the conversation started, and how do we sustain the conversation once it has begun? One way is to use a theoretical model to guide the process. Several change theories and models are available, and one of my favorites is John Kotter’s (1996) eight-stage process for transformational change. Whether we are nurses in the practice setting or in the academy, Kotter’s eight steps provide a framework for changing the conversation and ultimately transforming the organizational culture. In this installment, I illustrate how his process for leading change can be applied to nursing and our pursuit of creating cultures of civility in nursing education and practice.

Kotter’s process comprises the following stages: 1) establishing a sense of urgency, 2) creating a guiding coalition, 3) developing a vision and strategy, 4) communicating the change vision, 5) empowering broad-based action, 6) generating short-term wins, 7) consolidating gains and producing more change, and 8) anchoring new approaches in culture. Kotter contends that all eight stages are essential, that change is dynamic and messy, and that effective leadership is critical to successful change. Leaders of change play a key role in defining the future, aligning people with a compelling vision and inspiring action to achieve the new vision.

The first stage in Kotter’s model is establishing a sense of urgency. Complacency and unchallenged acceptance of the status quo are significant impediments to change. To create a sense of urgency, leaders who want to foster civility must boldly name and address the issue of incivility and disrupt the status quo.

One way to do that is to provide empirical evidence about the scope of the problem by conducting an institutional assessment. Some organizational leaders are in denial about the potential for incivility. By not addressing its effects, they contribute to further escalation of the problem. Measuring and identifying the presence and extent of incivility and having an open, honest and convincing dialogue about what’s happening can change the status quo and move an organization toward the second stage of Kotter’s change process. Real change requires buy-in, however, from the majority of the members. Thus, we need to spend significant time and energy on building urgency before proceeding to the next steps. Moving forward too soon can thwart your best-intentioned efforts and set your organization up for a very bumpy ride.

The second stage of achieving transformational change includes creating a guiding coalition of formal and informal leaders who are trusted and empowered to develop a compelling vision of the organization’s future. A strong, high-performance team can utilize data gleaned from the institutional assessment to mobilize change within the organization. Members of the guiding coalition must share a common purpose; possess the skills, credibility and influence to effect change; be empowered with the responsibility to lead the change process; and be genuinely committed to the organizational vision for change. Strong leadership within the guiding coalition is needed to encourage and promote broad-based change.

The third and fourth stages of Kotter’s process include developing and communicating a shared vision for creating meaningful change. A clear vision helps everyone understand what the organization is trying to achieve, assists in overcoming forces that support the status quo and clearly articulates a collective sense of what a desirable future looks like. Creating and reaching agreement on a shared vision take time, continual communication and an ardent commitment to long-term cultural change. Once the vision is firmly established, communicate your vision frequently and convincingly—not just in meetings. Talk about it and share it in hallways, classrooms and clinical settings. You must also “walk the talk” and live the vision. Lead by example.

Teaching and coordinating the nursing leadership and management cluster of courses at Boise State University comprise my primary teaching responsibilities. There are several faculty members on our clinical teaching team and, over the years, we have created vision and mission statements to frame our team goals and philosophies. We publish them in our course syllabus and discuss them with students the first day of clinicals. Our vision statement reads, “We strive to develop ethical, principled nurses who possess leadership and management skills to effect meaningful change in a variety of health care settings and organizations.” Our mission statement stems from our vision statement: “We demonstrate professionalism, inclusion, collaboration and civility through open dialogue, civil discourse, engagement and essential conversation to promote learning, professional growth and career development.” Our teaching team refers to these statements throughout the semester, but they would be empty, meaningless words if we failed to lead by example and to role model the traits they encompass.

The fifth and sixth stages of Kotter’s process include empowering broad-based action and generating short-term wins. We must work together to remove obstacles to desired change and empower and encourage all members of the organization to participate. We must eliminate “silos” that discourage communication and reconsider the status of sacred cows, so that “the way we’ve always done things” does not impede achieving the desired vision. We may need to redesign our systems to support a desired change and provide incentives. Generating short-term wins improves the chances of implementing long-term successful change.

An example of a short-term win may be an increase in faculty or student satisfaction, or a practice partner recognizing the nursing education program for improved safety and performance. After every win, analyze what went right and what needs to be improved. Use the momentum to set new, achievable goals. Goal achievement calls for celebration that is highly visible and connected to the vision for change. Celebrations create excitement, momentum and enthusiasm, but Kotter warns against claiming victory too soon, which can result in a false sense of security.

This leads to the seventh and eighth stages in the change process: to consolidate gains to produce more change and to anchor new approaches in the organizational culture. This requires “keeping our eye on the ball” and continuing to focus on the desired vision and strategic steps to achieve it. Once we are living our shared vision, we must anchor it in the culture by deeply embedding civility and teamwork in that culture, adopting a statement of shared values and guiding principles, having a working set of cultural norms, and implementing effective policies and procedures to support the new vision.

Successful and lasting change of an organization’s culture can take years. Transforming a culture of incivility to one of civility takes time, patience, courage and commitment. It also requires strong leadership, ongoing support, shared vision and ambitious planning. Yet, failing to do so can lead to stagnation, burnout and program closures. Lasting change is a team effort that depends on transforming the culture itself. RNL

Cynthia Clark
Cynthia Clark

Cynthia Clark, PhD, RN, ANEF, FAAN, is an award-winning professor in the School of Nursing at Boise State University in Boise, Idaho, USA. Clark’s principal body of research is in the area of fostering civility in nursing education and practice. She is a fellow in the American Academy of Nursing, a fellow in the National League for Nursing Academy of Nursing Education, and the recipient of NLN’s 2011 Excellence in Educational Research Award. Clark has conducted numerous empirical studies to better understand issues related to incivility and to develop best practices to foster civility and respect in the nursing profession. Her current research includes the role of nursing education in preparing future nurses to address incivility in the practice setting, faculty-to-faculty incivility, and intervention studies. Her work has stimulated national and international dialogue on these critical issues.

This article is the fifth in a series on civility in nursing education and practice. Other articles:

The sweet spot of civility: My story
"Why civility matters
What students can do to promote civility
"What educators can do to promote civility"

Kotter, J.P. (1996). Leading change. Boston, MA: Harvard Business School Press.

Showkeir, J., & Showkeir, M. (2008). Authentic conversations: Moving from manipulation to truth and commitment. San Francisco: Berrett-Koehler Publishers.

Wheatley, M.J. (2002). Turning to one another: Simple conversation to restore hope to the future. San Francisco: Berrett-Koehler Publishers.

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