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Confronting Incivility: Dr. Cynthia Clark's Blueprint for Healthier Workplaces

• Deb Tauber • Season 3 • Episode 109

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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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The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the opinions or positions of anyone at Innovative Sim Solutions or our sponsors. Welcome to The Sim Cafe, a podcast produced by the team at Innovative Sim Solutions, edited by Shelly Houser. Join our host, deb Tauber, and co-host Jared Jeffries as they sit down with subject matter experts from across the globe to reimagine clinical education and the use of simulation. So pour yourself a cup of relaxation, sit back, tune in and learn something new from The Sim Cafe. Thanks to Innovative Sim Solutions for sponsoring this week's episode.

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Deb Tauber:

Welcome to another episode of The Sim Cafe. Welcome to another episode of the Sim Cafe Today. Unfortunately J is not with us. He's in Copenhagen. Today we have the esteemed privilege of interviewing Dr Cynthia Clark. She's the founder of Civility Matters, professor Emeritus at Boise State University and an award-winning tenured professor, scholar and author. She serves as a fellow in the American Academy of Nursing, the NLN Academy of Nursing Education and the American Nurses Association Professional Panel on Preventing Incivility and Bullying in Nursing. Dr Clark is internationally recognized for her groundbreaking work on fostering civility and creating healthy work and learning environments. Her assessment tools have been translated into 18 languages and used by most scholars in 33 countries to measure and address incivility in academic and practice settings. Her most recent workbook, creating and Sustaining Civility in Nursing Education, third edition, 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 about defining civility and explaining why civility and respect matter in nursing about?

Dr.Clark:

defining civility and explaining why civility and respect matter in nursing. Yes, first of all, let me say thank you. Thank you so much. Thank you for having me. It's really a pleasure and such an honor to be part of this podcast series, and so I'm pleased to be here, and I just want to say hello to the listeners who are tuning in. So thanks so much.

Dr.Clark:

So, as to your question, you know why civility matters and what it is, and so let me start by just mentioning this, first of all, that I have always I think even as a child been fascinated by human behavior. Why do people act the way they do? Why do they make the choices they make? I'm especially curious about what makes each of us unique and how our minds and motivations work. So human behavior is absolutely central to my work because it helps us understand and we'll be talking later today about cognitive rehearsal. It helps us understand and address those complex interactions that happen between and among people.

Dr.Clark:

So for more than two decades, and maybe even getting closer to three, I've been studying the science of civility and what it means, and if we go back to 2008 for just a moment, that was the year that my colleague and I published the first concept analysis on civility, and it stood the test of time for quite a while.

Dr.Clark:

But when the pandemic hit, I began to get really deeply curious about whether or not the concept of civility had changed over time, and so my research team and I came together and we decided to do an update on the concept of civility and compare that to the previous concept analysis, and what was so interesting is that we discovered that not a lot has changed over time relative to this concept.

Dr.Clark:

And what we found is this is that, first of all, civility is quite analogous with respect, even though they're not exactly the same. But what was also profound for us in terms of our discovery is that civility is a choice. It's a decision we make every single day, with every encounter, with every interaction. It means that we're respecting the dignity of other people, their perspectives, their well-being, and it helps us create those healthy work environments where all of us feel like we're welcome, like we belong. It helps us build meaningful relationships, especially when we disagree. And so one final thought on that is that civility is not about liking. So, for instance, if you and I like each other, that's awesome. It's really a bonus. It's not requisite to us treating one another with the dignity each of us deserves.

Deb Tauber:

Yeah, I totally can see that and agree with that. Can you provide some examples of incivility in nursing and explain how these behaviors manifest in healthcare settings?

Dr.Clark:

Yeah, so, yeah, so great question I like to think about and have, you know, really illustrated this on what I call the continuum of workplace aggression. So if you sort of imagine, if our listeners can think about any kind of continuum, that on the left side of this particular continuum that I'm referring to in terms of behaviors we might see in a workplace, on the left side, those are more sort of distracting, annoying, irritating behaviors. Those would be things like rude nonverbals, like eye rolling, finger pointing, arm waving. And then I want to take us all the way to the right side of the continuum where we would see very hostile or violent behaviors, in other words acts of violence or tragedy. That would be something like a campus or a workplace shooting and then all those behaviors in between. So when we think about rude nonverbals, as I mentioned a few of those, you know the eye rolling and so forth I mentioned those because in our world of nursing and healthcare, even though we might say those are lesser forms of incivility, I can tell you this that recently there was a beautiful paper published by a group of physicians who were studying what are some of the uncivil behaviors that occur in our patient care areas that ultimately impact patient care, patient safety, and what was very interesting about what they were able to determine was that one of the most common incivilities that occur within the healthcare environment is this walking away before a conversation is over. So that is a nonverbal. We are walking away Now.

Dr.Clark:

If we put that in context, if you and I say are working in an engineering firm and you and I have a conversation or attempt to have that, and you're conversing with me and what I do instead is just sort of turn on my heel and walk away, now you might say, wow, that was rude or that was pretty unfriendly. The likelihood of anyone being harmed or even dying is slim and none. When, however, we put that in the patient care environment now, it's a whole new ballgame. In the patient care environment now it's a whole new ballgame Because if you approach me as a colleague, as a healthcare colleague, and you have important information to impart relative to a patient condition, and I just walk away now we have the potential for some very serious problems in terms of what that might do as it impacts patient care. So I guess I mentioned that because, even though those nonverbals are on the far left of that continuum, they can have devastating effects depending on the context.

Dr.Clark:

Just a couple of the other behaviors you might see on that continuum One is bullying, you know, which is more intense. Rather than uncivil acts, bullying is a repeated, persistent pattern of abusive behavior that is characterized not always but almost always by asserting real or perceived power over another person, and that's usually done to intimidate or humiliate. And under that major header of bullying we see now more and more experiences with cyberbullying, where digital devices and online media sites are used to post often harmful, false or malicious content. Sometimes those behaviors are serious enough to be considered criminal. So because of the ubiquitousness and easy access and anonymity of the internet, some really bad stuff can end up happening, and we may be completely unaware of it if we are not tuned in to whatever site that might be whatever site that might be.

Deb Tauber:

So those are just a few of the experiences that some people might have. Well, and I think it's insidious, it starts, you know, you don't really even realize it's happening and then, before you know it, you kind of open your eyes and you think, my goodness gracious, this is incivility right now. Yeah, yeah, in my career I was, you know, bullied by nurses and it left marks on me. In fact, we talked about that the last time that we chatted and you suggested that I read, and I will suggest to our listeners, you know, if they've been bullied, that they might want to think about reading the book. The body keeps the score, as you suggested to me.

Dr.Clark:

Yes, yes, it's an. It's an excellent resource relative to how trauma, unless it's managed well and dealt with in healthy ways, can really overwhelm and overcome our mental health, our physical health. You mentioned the term insidious, and I think that's so interesting because one of the other behaviors, if you will, a subcategory of bullying, is gaslighting, and I think that's a little bit about what you're describing here. It's sort of that insidious, subtle form of bullying where what's what's really happening there is that someone who might be gaslighting me or you is attempting to convince us that what we saw or what we heard didn't really happen. It didn't really happen.

Dr.Clark:

And we begin to question our own thoughts, our own perceptions, our own reality, our own memories, and so we lose confidence. And the other thing we often do is we blame ourselves. Must be me, because gaslighters who are really good at it will say things like if we call the behavior into question, you might hear things like what, can't you take a joke? I was only kidding, you know that's a very common response. Or I didn't say that. What Are you crazy? Or you're crazy. That never happened, are you okay? You seem unstable, you know all of these. And so we begin to question our own thoughts and literally our own reality. So those can be really hard behaviors to first of all assess, because we're blaming ourselves, and second of all address.

Deb Tauber:

Wow, Thank you. Yeah, Now you've written extensively about the use of cognitive rehearsal as a strategy to prevent and address these types of uncivil behaviors. Can you tell us talk about cognitive rehearsal? It's? This is essentially a form of simulation.

Dr.Clark:

Yes, yes, thank you for that, because I didn't know that in the very beginning. You know, I just knew what cognitive rehearsal was and why I was doing it, and it wasn't until later when my good pal Susie Kardon-grin helped me understand that this is a form of sort of live simulation. So let me tell you what it is first. Well, before I do that, I want to give a shout out to Dr Martha Griffin. Martha's now retired, but she wrote a seminal piece. Maybe lots of listeners have read it. It was published over 20 years ago now, in 2004. And Martha wrote an article where she used cognitive rehearsal with newly graduated nurses to help them understand and deal with instability in practice environments, and it was hugely successful. I read that paper in 2004, reached out to Martha. In fact, she and I have co-authored an update to that. Ten years later, in 2014, we published together to do kind of a refresh of cognitive rehearsal.

Dr.Clark:

But here's what cognitive rehearsal is it's an evidence-based technique, it's steeped in behavioral science and what happens is that an individual or a group of individuals work with a skilled facilitator in order to practice addressing stressful situations in a non-threatening environment. In other words, we use role play or simulation, where people practice addressing in my case, the work that I do with them uncivil events and that the goal is that, if they are, because they've had practice, because we've debriefed it, if they're faced with a similar situation in the future, they've had some rehearsal, thus cognitive rehearsal or practice addressing it, and I've worked with multiple groups, whether it's students, faculty practice-based nurses, physicians, other academics. I like to use a five-step process 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.

Dr.Clark:

That's why it's simulation. So step one is that we pre-brief and we prepare, and so that means in my case that I'm reviewing with the participants the topic of civility, incivility, providing a summary of what they're going to expect in our time together. It includes establishing and co-creating norms. It includes establishing and co-creating norms. Often, I'll use the basic assumption from Harvard Sim Center and I'll also provide what we like to call some people call them trigger warnings, not a fan. What I like to call them are content advisories or content forecasts. Letting people know hey, you know what we're going to be role playing into debriefing some encounters that could evoke some discomfort Maybe you know you've experienced trauma in this regard and letting people know that it's important that they take care of themselves, that they might need to step out. In some cases, depending on my group, we've actually had a counselor outside the room to assist folks if, in fact, they want to, you know, touch base with that individual before coming back in or not coming back in to the role play environment. And then step two is I have them either work individually or in groups almost always in groups because we're going to eventually role play on civil encounters that they've experienced. Now, that's key because I can provide them scenarios that are common, and sometimes I do that to get us jump-started.

Dr.Clark:

But I'm drawing on the work of Carol Gillian, who studied under Kohlberg, and what Carol Gillian found and she wrote in a different voice relative to ethics is that the scenarios that Colbert wrote were helpful.

Dr.Clark:

But what Gillian said is you know what, if you're deconstructing your own experiences, you're going to have a very different attachment emotionally to those experiences.

Dr.Clark:

So step two is to have them identify what those potential or real uncivil encounters might be and then asking folks to role play those during cognitive rehearsal, always provide evidence-based framework for them to script some responses and reminding them you're not scripted, you're scripting, which is really kind of a departure from Dr Griffin's work, who likes to provide the scripts that people practice. I prefer to provide them with a framework to develop their own scripts so that it's more natural and authentic. And then step four is when we actually do the role play, and I have to tell you it's astounding to watch the actors come up and role play their experiences. And then step five, of course, is for me to go into that deep debrief and reflective experiences, to talk about the scenario itself, power imbalances that might have existed and so forth, and certainly many other forms of debriefing queries. So that's kind of it in a nutshell, and it's a pretty profound experience for those who participate, and me, as the facilitator, totally love it, you know, to see the change in people.

Deb Tauber:

It's an enlightenment for the individuals.

Dr.Clark:

Absolutely, absolutely.

Deb Tauber:

I mean, we do so many simulations for high risk, low frequency events or you know things like central line insertions and postpartum hemorrhage, but I think that to include incivility training, essentially cognitive rehearsal, in nursing education and in medical education is really something that really needs to be included in the curriculum 100% because, think about it, every single situation, though it might be similar, is always different.

Dr.Clark:

The context is different, the people involved in different are different. The tone, the delivery, the verbiage, all of that is different. So as much practice as we can possibly have, for that, I think, is paramount to our practice. Some people like to call those soft skills, and I'm not a fan of that term. I call them power skills with capital letters, because for us to hone and master the ability to effectively manage, maybe even prevent, those kinds of situations is absolutely, I think, essential to our practice and to our profession to our profession?

Deb Tauber:

Absolutely. It's that saying people won't remember what you did, they won't remember what you said, they'll remember how you made them feel is so true.

Dr.Clark:

Yes, yes, and part of the cognitive rehearsal too is, you know, because I just sort of went over it very quickly, you know, as a former well, let me put it this way there are cognitive strategies that we can use to help us prepare to de-stress in the moment prior to entering a conversation.

Dr.Clark:

So there's a lot more that goes into it. It's teaching those skills, techniques, practicing those together, finding ways to, you know, sort of come back to some homeostasis or equilibrium before entering into that conversation. All of that is part of the experience. And I wanted to mention, because I think it's so very important, is that if folks are thinking about facilitating cognitive rehearsal, you want that facilitator not only to be skilled at building trust, establishing rapport, but I always see my job as creating that safe space, that safe environment for the kind of experiences we're going to have. And the facilitator also needs to have an excellent working knowledge, as you know, some expertise in the content, the subject matter of civility and incivility and being prepared that some of the participants may be really impacted by memories of previous acts and be able to address those. So it really does take that special education and experience and coaching.

Deb Tauber:

Absolutely. I think when you think about any, essentially any simulations, you need that subject matter expert present to you know, help the learners obtain the objectives that you're reaching for.

Dr.Clark:

Totally totally.

Deb Tauber:

Can you provide a specific example of how cognitive rehearsal can be used to an address in uncivil situation?

Dr.Clark:

Yes, okay, so I have so many, but I'm going to talk about Iris, a person that I call Iris. I wrote this scenario because it is such a common situation that nursing faculty talk about. It's also been the scenario that has shown up in my research studies as well, when I ask for personal narratives about their personal experiences. So here's Iris. So imagine if you have an Iris in your work environment. So Iris is a faculty member who dominates conversations and meetings, voices strong opinions at the exclusion of others, often escalates disagreements into verbal attacks, often escalates disagreements into verbal attacks, uses an aggressive tone, body language, word choice. Now here's the kicker. We may have an iris, but obviously in this description of iris, the behavior is pretty troublesome, right, but here's the real problem that people aren't addressing it. They're allowing this behavior to continue. So now let's think about someone in that group who's had time to reflect on it and says you know what? I'm going to go have a conversation with Iris, and I can imagine if there are listeners who are thinking about putting themselves in the place of the person who's about to address Iris. I mean, that can be pretty nerve wracking. Right, you're going to go have a conversation with someone whose communication style is, you know, pretty offensive at times. So in cognitive rehearsal, what I would do is, if we were role playing that, we would role play it, and one of the evidence based frameworks that I might use in part to folks that they A2, so PAIL is P-A-A-I-L, so preview Advocacy 1 is something like I saw, I heard or I noticed. Advocacy 2 would be I'm concerned, or I think.

Dr.Clark:

I believe Inquiry is where you pose a question or a probe, and then L is my favorite because it stands for listen. So here's how PALE might be used with IRIS. So P for preview, iris. I'd like to talk about yesterday's team meeting. Okay, advocacy one there were moments when the discussion became intense and some comments took the conversation away from the main topic. Advocacy two I'm concerned because these actions could affect our ability to work together 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 or question. What are your observations? How do you think the meeting went? And then L is we listen. We listen to Iris's response before we respond. So that's just one example of how we might address that situation.

Deb Tauber:

Okay, let me take this. This is fantastic, but let me just go ahead and push this a little bit further. What?

Dr.Clark:

if iris stonewalls you, yeah, well, that that's likely to happen. That's likely to happen with some irises, right? And so let's say that, first of all, you want to prepare iris, and that might be done in an email Iris, I'd like to get together and talk so that iris has time to prepare as well, setting a mutual time for us to get together. Hopefully she says yes. If not, that's a different experience. But let's say she says yes, because I want to get to your question about now. What so?

Dr.Clark:

You have this time set up, you introduce your concern and let's say it goes immediately off the rails, doesn't want to hear it, which, by the way, let me just say here that very often, in many cases, a person is unaware of how they're coming across to other people, and it's hopeful and sometimes possible that they will listen, but let's say it goes off the rails.

Dr.Clark:

I often suggest that you have another sort of script ready in your mind which might go something like you know, I'm wondering if we might reschedule our meeting because I'm not sure we, either of us, have had enough time to really prepare for it. Let's reschedule and give it another whirl Now. Let's go into that second meeting. You're going to make that second attempt, having rehearsed it, prepared, done all the things that we mentioned in terms of preparation and practice and debrief, practice and debrief, and it goes reasonably well, but let's say it doesn't. Now I believe that you've given it an excellent go at it twice without much reconciliation or resolution. Now is the time where we might invite that neutral third party in to negotiate the conflict. So it's not going to work 100% of the time, but very often it does.

Deb Tauber:

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:

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:

Thank you Now, Dr. Clark, if our listeners want to get a hold of you and I know, being the subject matter expert internationally, and this subject might be hard, but how could they get a hold of you?

Dr.Clark:

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 social media presence on purpose, so LinkedIn. I also have a site, a website through my university of where I'm professor emeritus at Boise State University, and you can Google Stability Matters. That's my website. It'll pop up. It's got my information in there. So thank you so much for asking.

Deb Tauber:

Thank you. Thank you for all that you're doing.

Dr.Clark:

You're welcome.

Deb Tauber:

And happy simulating.

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