Cindy’s ‘Five RITES’ for fostering student-driven civility

By Cynthia Clark | 01/01/2013

Second of a three-part series.

Cynthia Clark

Some readers may know I am a professor in the School of Nursing at Boise State University. In June 2010, an article I co-authored with one of my nursing students, titled “What students can do to promote civility,” was published in Reflections on Nursing Leadership (RNL) as part of a five-part series on civility. As I mentioned in the first installment of this present series, nursing students are our promise and our hope. They are the Jedi Knights who will lead our noble profession to a bright future where personal and organizational civility reign. To frame this article, I have developed the Five RITES of Civility:
  • Raise awareness and expose effects of incivility.
  • Inspire action and catalyze change.
  • Take responsibility for creating civility.
  • Engage and commit to personal and organizational change.
  • Sustain results and generate more change.
Raise awareness and expose effects of civility
Raising awareness with students about the power of civility and the negative consequences of incivility in academic and practice settings is an important and vital endeavor. Students at the very beginning of their nursing education need to know what is expected of them regarding professional behavior and what they can expect from others. Schools of nursing can raise awareness in a variety of important ways. As a result, students will better understand what civil, respectful, and professional behavior is; how to promote it; and how to integrate civility into their daily lives.

Consider raising civility awareness for incoming students during general student orientation. This is an excellent venue to introduce a number of ways for students to thrive in their academic pursuits. In our institution, our Statement of Shared Values (SSV), which includes academic excellence, caring, citizenship, fairness, respect, responsibility, and trustworthiness, is woven into the fabric of student orientation. Students learn from the very beginning of their college experience what being a member of the campus university means, why civility matters, and how the SSV provides a touchstone for all members of the university.

In the school of nursing, we also conduct a formal student orientation. Before classes officially begin, newly admitted nursing students participate in a full-day program where we specifically address what it means to be a nurse, professionalism, ethical conduct, and the importance of civility. I am responsible for conducting the civility portion of the orientation process, though all faculty members and administrators in the school of nursing reinforce and extend the message in a variety of interesting and creative ways. I also facilitate a second civility workshop during Week 6 of the students’ first semester, where we reintroduce the concepts of civility, professionalism, and how students can promote a safe and civil teaching-learning environment.

In the initial orientation class, I present an overview of the state of the science on civility and incivility in nursing and engage students in activities focused on what they can do to promote civility throughout their nursing program. One of my favorite activities is to have students participate in slicing the “civility pie.”
                                                                                       
I provide students with a large index card that is blank on both sides. With the students working independently, I ask them to draw a large circle on one side of their index cards. This is the civility pie. Next, I ask each student to slice his or her pie into three pieces—representing students, faculty, and school administrators—according to what he or she believes is the approximate amount of responsibility each group has for promoting civility. After the students divide their pies, I ask them to turn their cards over and provide a rationale for why they sliced their pies the way they did. Most of them divide the pie into three equal parts. I love it when students draw three circles around the perimeter of the pie and comment that all three groups—students, faculty, and administrators—are 100 percent responsible for fostering civility. Awesome!

One of the most enjoyable aspects of this exercise is discussing the students’ rationales for why they sliced—or didn’t slice—their civility pie the way they did. My favorites include: “Civility is a shared responsibility; we are equal partners.” “Civility helps grow and strengthen relationships.” “Leaders are the drivers of civility—and we’re all leaders.” And “Civility starts from the inside out.” In other words, “It starts with me.”

Inspire action and catalyze change
Raising awareness and actively discussing civility and incivility are crucial, but insufficient. We must also inspire action and engage students in making a commitment to create a civil academic environment. In addition to having students share how they slice their civility pie and their rationale for doing so, I ask them specifically what students can do to promote civility. This often results in a spirited and enlightening discussion where students identify specific actions, such as respecting others, being inclusive and collaborative, using open communication, being honest and nonjudgmental, and making a positive difference.

We also identify additional ways students can promote civility, which include engaging in stress-reducing behaviors, assuming personal responsibility for co-creating classroom and clinical norms, and conforming and abiding by those norms. We discuss the importance of modeling civility; engaging in respectful social discourse; and participating on teams, committees, and governance councils. We also reinforce the importance of attending class, being on time, being prepared, avoiding side conversations, and not using media devices in disruptive ways.

One of the new activities I will be using with students is the Clark Academic Civility Index for Students (below). This tool encourages students to think deeply about civil and respectful interactions with others and to engage in thoughtful self-reflection to improve their civility awareness and to identify strengths as well as areas that need improvement. It is important that educators who adopt the Clark Academic Civility Index instruct students to dedicate sufficient time and space to complete it. 
 
Students need to find a quiet place, void of distractions, to carefully consider the behaviors listed in the index and respond truthfully and candidly by answering yes or no regarding each behavior. Once students have completed the index and their civility score has been determined, I ask them to consider their score and identify areas of satisfaction as well as areas for improvement. I also urge students to share their index responses with a classmate, colleague, or mentor and to ask that person to compare the student’s response to the index with his or her assessment of the student. Are there similarities between how the student sees himself or herself with how he or she is viewed by others? Are there differences or gaps? Discuss with your students ways to maintain the positive aspects of their “civility index” and identify strategies to address those areas they wish to improve.


The Clark Academic Civility Index for Students

 Ask yourself the following questions, responding either “Yes” or “No”:
 Do I, the majority of time (80 percent or more) …
  1. Role-model civility, professionalism, and respectful discourse? Yes/No
  2. Add value and meaning to the educational experience? Yes/No
  3. Communicate respectfully (by email, telephone, face-to-face) and really listen? Yes/No
  4. Avoid gossip and spreading rumors? Yes/No
  5. Avoid making sarcastic remarks or gestures (staged yawning, eye-rolling)? Yes/No
  6. Pay attention and participate in class discussion and activities? Yes/No
  7. Use respectful language (avoid racial, ethnic, sexual, gender, and religiously biased terms)? Yes/No
  8. Avoid distracting others (misusing media devices, side-conversations) during class? Yes/No
  9. Avoid taking credit for someone else’s work or contributions? Yes/No
  10. Co-create and abide by classroom and clinical norms? Yes/No
  11. Address disruptive student behaviors and promote a safe, civil learning environment? Yes/No
  12. Take personal responsibility and stand accountable for my actions? Yes/No
  13. Speak directly to the person with whom I have an issue? Yes/No
  14. Complete my assignments on time and do my share of the work? Yes/No
  15. Arrive to class on time and stay for the duration? Yes/No
  16. Avoid demanding make-up exams, extensions, grade changes, or other special favors? Yes/No
  17. Uphold the vision, mission, and values of my school? Yes/No
  18. Listen to and seek constructive feedback from others? Yes/No
  19. Demonstrate openness to other points of view? Yes/No
  20. Apologize and mean it when the situation calls for it? Yes/No
Scoring:
Add up your “yes” responses to determine your Civility Index score:
  • 18-20 (90 percent or more “yes” responses)—Very civil
  • 16-17 (80 percent)—Moderately civil
  • 14-15 (70 percent)—Mildly civil
  • 12-13 (60 percent)—Barely civil
  • 10-11 (50 percent)—Uncivil
  • Less than 10—Very uncivil


Take responsibility for creating civility
The activities described above are just a few of the initiatives that can be implemented to encourage students to take responsibility for creating civility. There are a number of other ways to reinforce the positive focus achieved during orientation. However, I highly recommend collaborating with students to co-create classroom and clinical norms to foster a safe teaching-learning environment and to consistently and intentionally discuss with students the imperative of fostering civility.
 
One of the most effective ways to foster civility is to co-create behavioral norms. I contend that any organization devoid of norms (including the classroom) is a rudderless ship. Thus, co-creating classroom and clinical norms is essential to successful teaching and learning. In classes I teach, we begin co-creating classroom norms by describing the institution’s vision and mission, defining civility, and discussing the university’s Statement of Shared Values (SSV). With regard to the latter, we discuss how each provides a foundation upon which the vision of our college and school of nursing is based. We also co-create classroom norms by asking the following questions: “What behaviors do we want to see in class? What behaviors do we not want to see in class? And, once we determine and agree upon expected behaviors, how will we monitor their effectiveness?”
 
We also co-create norms in our clinical groups and involve our community partners (preceptors) in the process, so they have a voice in how we behave together in our clinical groups. It is everyone’s responsibility to reinforce and monitor adherence to the norms. At midterm, we conduct a formal evaluation of how the norms are working.
 
Classroom and clinical norms must be reviewed periodically, revised as needed, and reaffirmed throughout the course of the semester. Norms are living documents that provide a civility touchstone for students, faculty, and clinical partners. They provide a framework for working, collaborating, and learning with and from one another.

Engage and commit to personal and organizational change
To engage students in civility initiatives and encourage their commitment to personal and organizational change, I believe that we, as members of nursing faculties, must “begin at the beginning” with faculty members intentionally preparing students to identify and effectively address incivility in academic and practice settings. In a policy statement on lateral violence and bullying, the Center for American Nurses (2008) addressed the “reality shock” that new graduates experience and made several recommendations for eliminating disruptive behavior, including 1) disseminating information to nurses and students that addresses conflict and provides information about how to change disruptive behavior in the workplace, 2) developing educational programs on how to recognize and address disruptive behavior, and 3) implementing curricula to educate nursing students on ways to address and eradicate such behavior.

In response to these recommendations, I began to integrate, several years ago, civility content into my senior-level leadership course. We use a Problem-Based Learning (PBL) scenario with live actors (standardized patients, or SPs) to portray incivility among nurses in the workplace. Students prepare by reading specific articles on the topic before coming to class. In class, before we observe a “live” scenario, we engage in an interactive didactic presentation and large-group discussion. In the past, students from our university theater department portrayed the scenario, but last semester, I asked three student volunteers to enact it.
 
It was a rousing success! Two of the students acted out a situation in which a staff nurse was extremely uncivil to her co-worker, and a third student played the part of the nurse manager who used an evidence-based framework to address the conflict. After observing the enactment, students analyzed the scenario, developed and practiced specific ways to address the situation, and debriefed the encounter in a whole-class discussion.
 
I asked students about what they had observed, including how the scenario helped them learn about dealing with incivility in nursing practice. The majority of students viewed the enactment as realistic, believed the role of the nurse manager was crucial in addressing incivility, and identified the importance of teamwork, effective communication, and directed education—readings and group discussion, to name two. Students also commented that the scenario raised their civility awareness, provided them with specific ways to prevent and address incivility, and helped them to be more cognizant of their own behavior and how they treat others.

In small-group sessions, I asked students to consider specific ways they could foster civility in nursing education. They came up with some excellent suggestions, including 1) taking an active role in integrating civility into the nursing curriculum, 2) participating in candid discussions and open forums on the topic of incivility, 3) holding themselves and others accountable for uncivil actions, 4) rewarding civility, and 5) identifying helpful phrases to use when incivility occurs. The latter, an excellent suggestion based on the work of Martha Griffin (2004), is discussed briefly below.

Sustain results and generate more change
To counter uncivil behaviors and empower new nurses to address and confront uncivil co-workers, Griffin (2004), drawing upon cognitive rehearsal strategies, suggests identifying phrases to use when incivility occurs. Accordingly, after students observe a live PBL scenario, I have them generate and practice specific responses they can use to address uncivil co-workers in the workplace. The following are two examples of student-generated responses: 1) “It takes teamwork and support to care for our patients, and your behavior toward me is getting in the way. What can we do to resolve our differences?” 2) “I have noticed a conflict between us, and it is affecting our working relationship and caring for our patients. I would like to discuss the situation and resolve our differences.”

Once students have identified potential responses, we practice them and discuss their impact. Students write their responses on an index card, which they keep with them for use when and if a situation calls for it. This helps sustain results and generate more change. Time after time, student feedback reveals a vital need for integrating civility content into courses. More importantly, by adopting civility training into the nursing school curriculum, students are better prepared to foster civility in the academy, in the practice setting, and in life.
 
Part Three: Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES’ (article by Cindy Clark's daughter)
 
For another article by Cindy Clark on civility and nursing students, see What students can do to promote civility

Cynthia Clark, PhD, RN, ANEF, FAAN, nurse consultant for ATI Nursing Education, founder of Civility Matters, and author of Creating and Sustaining Civility in Nursing Education, Second Edition, is a psychiatric nurse/therapist and an expert in fostering civility and healthy workplaces.

References:
Center for American Nurses. (2008). Lateral violence and bullying in the workplace (Policy Brief). Retrieved from http://www.mc.vanderbilt.edu/root/pdfs/nursing/center_lateral_violence_and_
bullying_position_statement_from_center_for_american_nurses.pdf


Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35, 257-263.
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