32 American Nurse Journal Volume 15, Number 8 MyAmericanNurse.com

Creating a healthy working environment is every nurse’s responsibility

How clinical faculty and practicing clinicians can collaborate to help students learn professionalism By Kimberly Dimino, DNP, RN, CCRN, Joset Brown, EdD, MSN, RN, and Bea Fernandes, BSN, RN

STRICTLY CLINICAL

PROFESSIONALISM (the integration of profes-sional values in the workplace via words and conduct), which is embedded in the Code of Ethics for Nurses With Interpretive Statements and nurse practice acts, creates the foundation for civil and healthy work environments that are safe, empowering, and satisfying. Healthy work environments, which are cultivated through open and purposeful communication among interprofessional groups, support opti-mal care delivery and ensure positive patient outcomes.

Essential competencies—such as effective,

efficient communication and collaboration among interprofessional healthcare teams—have been cited by the Institute of Medicine and others as lacking in many new graduate nurses. Preparing new nurses for practice re-quires dedicated and coordinated responses from academic and practice organizations. Ac-cording to Clark, professional skills are similar to clinical skills; both can be learned and im-proved upon over time using strategies and ap-propriate role modeling. (See Model behaviors.)

By understanding shared responsibilities and building effective teams, faculty, clini-cians, and students can collaborate to instill professionalism and build healthy work envi-ronments.

Shared responsibility Rather than feeling mentored and nurtured, many students report feeling unwelcome in the clinical environment, which leads to iso-lation, emotional distress, depression, and fear about their career future. Unhealthy work environments pose a threat to nursing student learning, new graduate transition, job satisfaction, employee retention, professional development, and patient safety. We stand little chance of breaking the chain of work-place incivility if the next generation of nurs-es believes this type of behavior is accept-able. Reasons behind our current dilemma are multifaceted, and everyone—clinical fac-ulty, nurse managers, staff nurses, and stu-dents—plays a role.

Clinical faculty Clinical faculty, even when they’re on the unit, may not always be “present” for students

LIFE AT WORK

(continued on page 34)

34 American Nurse Journal Volume 15, Number 8 MyAmericanNurse.com

because students may feel their instructors are unapproachable. This frequently is a result of perceived incivility. For example, some faculty may reprimand students in the presence of others, leaving students feeling insecure and belittled. In addition, faculty may be responsi-ble for eight to 10 students at a time, which can be overwhelming, especially during med-ication administration, creating stress that can carry over to how faculty respond to students.

Nurse managers Different nursing programs have varying num-bers of clinical hours and objectives. With sev-eral clinical groups assigned to one unit, nurse managers may struggle to keep track of them, creating a hurdle when managers need to speak to instructors about student issues. In addition, some nurse managers may not trust faculty, may believe students are disruptive to unit workflow, and may not see themselves as having a stake in educating future nurses. And if nurse managers speak inappropriately to or discipline staff or students, they foster the im-pression that incivility is allowed.

Staff nurses Staff nurses may not see themselves as stake-holders in educating future nurses. Staff may believe that teaching professionalism is the clinical instructor’s job, not theirs, making them less likely to participate in the process.

Students Students may have an idealized view of nurs-ing and struggle when reality doesn’t fit that view, which can be a barrier to open commu-nication.

Building partnerships When clinical faculty and clinicians use the form, storm, norm, perform, adjourn method of team formation, they can collaborate to cre-ate a partnership built on professional stan-dards and a shared vision, while teaching stu-dents professionalism.

Forming Initially, clinical staff may be unclear about their roles and responsibilities with regard to nursing students or view their work with them as an unpaid burden. At this first stage of team development, clinical faculty and practicing clinicians must be clear about tasks and de-bunk the myths (for example, about how nurs-es only follow physicians’ orders, that learning ends when you get your degree, and that male nurses are needed mainly for the heavy work) that contribute to unprofessionalism. (See Tips for forming faculty-staff teams.)

Storming At this stage, conflict may exist between facul-ty and staff team members. Some staff may even rebel against assigned tasks because they don’t trust the faculty member’s clinical skills and they aren’t certain of a student’s ability to safely care for patients. Open com-munication is essential to create an atmos-phere for sharing ideas, building mutual re-spect, and solving problems. Because approximately 80% of communication is non-verbal, everyone must be coached to be mindful not only of verbal communication, but also of body language (for example, facial expressions and posture) when collaborating with each other and caring for patients.

Everyone also should learn to use conflict constructively; it should never become per-sonal. Instead, for example, if conflict arises about how to approach a learning experience, staff, students, and the clinical instructor should brainstorm to establish alternative, mu-tually agreed upon plans. TeamSTEPPS®, a tool created by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Qual-

Model behaviors

Clinical faculty and practicing clinicians can model professional behaviors by being:

willing to listen and

learn

respectful of others’

views

self-reflective

accountable

transparent

prepared

punctual

engaged

MyAmericanNurse.com August 2020 American Nurse Journal 35

ity, can help identify possible reasons for con-flict and support the team through this stage. (See The perfect storm.)

Norming Generally accepted procedures and communi-cation patterns are established during this stage to promote bonding and group identity. The team begins to identify each member’s strengths and build on them together, and everyone understands their roles and begins working together for the greater good—in-vesting in nursing’s future and ultimately im-proving patient outcomes. As committed part-ners, the team is relentless in pursuing and fostering true collaboration. Performing The team begins to focus all of its attention on achieving shared goals. Everyone is close and supportive, open and trusting, resource-ful and effective. Leaders meaningfully recog-nize and celebrate the accomplishments of the whole team, which fully embraces the im-perative of a healthy work environment—au-thentically living it and engaging others in its achievement.

Adjourning At the end of the student’s clinical experience, all team members should have the opportunity to reflect on the experience, objectively cri-tique successes, evaluate areas for improve-ment, and identify best practices for the future.

Benefits of teaching professionalism Incorporating strategies to develop profession-alism into every aspect of clinical education has far-reaching, positive implications. Not only can healthcare teams pre-empt problems be-fore they arise, but also teamwork prepares students for a future in which they model pro-fessionalism, work to create and sustain healthy work environments, and learn the skills to diffuse conflict. Teaching professional be-havior also prepares students for practice by helping them realize and accept the full breadth of nursing, including the values, morals, and attitudes embraced by the profes-sion. Socializing future nurses into the profes-sion, which is the responsibility of clinical fac-ulty and practicing nurses, benefits nursing and patient care in a variety of ways. Students will: • assimilate knowledge, use skills learned in

clinical, and carry both into the workplace • receive mentoring, observe role models,

and engage in meaningful learning oppor-tunities

• develop professional skill sets that decrease incivility and increase healthy work envi-ronments

• continue to develop professionally through-out their careers—a key factor in obtaining positive patient outcomes.

Potential challenges Some clinical faculty or staff may be unable or unwilling to adhere to the team-building process because of staff shortages, increased patient acuity, limited knowledge of learning

Forming a team that models and prioritizes professionalism for nurs-ing students requires that clinical faculty:

• meet with clinicians (including the nurse manager and ancillary staff ) to share their credentials and experiences, ask questions about the unit’s culture, and become familiar with routines and equipment on the unit

• review course objectives, students’ education levels, and clinical learning goals (including time frame and experience) with clinicians

• collaborate with clinicians to establish a shared vision and goals for the clinical rotation

• discuss with clinical staff the importance of students having a sense of belonging and encourage staff to identify strategies that will help them accomplish that

• help staff recognize themselves as role models and stakeholders in the professional development of future nurses

• ensure staff nurses who work directly with students have learned evaluation and feedback skills via preceptor courses.

Tips for forming faculty-staff teams

36 American Nurse Journal Volume 15, Number 8 MyAmericanNurse.com

outcomes, or an unwillingness to participate. However, without consistency and collabora-tion between clinical faculty and staff, the team-building process will lack cohesiveness and continuity. The National League for Nurs-ing proposed promoting academic partner-ships to enhance collaboration between facul-ty and clinical staff, ensure all team members feel valued, and establish clear roles. Clear communication, mutual respect, and faculty willingness to support students and staff facil-itate a cohesive work environment.

Preparing tomorrow’s colleagues Creating healthy clinical work environments leads to more engaged nurses, decreased burnout, reduced turnover, and better patient care. In addition, staff nurses will recognize themselves as mentors and stakeholders in preparing future nurses for practice. As the saying goes, today’s students are tomorrow’s colleagues. AN Kimberly Dimino is an assistant professor in the department of nursing at William Paterson University in Wayne, New Jersey, and a nurse scientist at Hackensack Meridian Health in Hackensack, New Jersey. Joset Brown is an assistant professor in the department of nursing at William Paterson University. Bea Fernandes is a nurse manager at St. Joseph’s Children’s Hospital in Paterson, New Jersey.

References Agency for Healthcare Research and Quality. About TeamSTEPPS. June 2019. ahrq.gov/teamstepps/about-teamstepps/index.html

American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Am J Crit Care. 2005;14(3):187-97.

American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. 2015. nursingworld.org/ practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only

Babiker A, El Husseini M, Al Nemri A, et al. Health care professional development: Working as a team to im-prove patient care. Sudan J Paediatr. 2014;14(2):9-16.

Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francis-co, CA: Jossey-Bass; 2010.

Blake N, Collins M. Importance of healthy work envi-ronment education in nursing schools. AACN Adv Crit Care. 2017;28(3):289-90.

Clark CM. Fostering a culture of civility and respect in nursing. J Nurs Regul. 2019;10(1):44-52.

Dimino K, Louie K, Banks J, Mahon E. Exploring the im-pact of a dedicated education unit on new graduate nurses’ transition to practice. J Nurses Prof Dev. 2020;36(3):121-28.

Everyone—clinical faculty, students, staff nurses, and nurse man-agers—has a role to play in establishing a team that prioritizes and models professionalism and collaboration to promote effective com-munication and problem-solving. Tips for clinical faculty • Be approachable. • Seek input from the nurse manager and nursing staff about student

nurse pairing and patient assignments. • Encourage conversations where clinical staff feel free to give honest

feedback about clinical and communication skills and developing effective collegial relationships.

• Acknowledge the prevalence and effects of incivility and implement policies and strategies to reduce incivility toward nursing students.

• Perform a daily formative evaluation of the clinical environment and a summative evaluation at the end of the clinical rotation.

• Check in with nurses and students; ask, “How’s it going? How can I help?”

Tips for students • Be engaged, assertive, and respectful. • Prepare an elevator speech (short, succinct, effective, and delivered

enthusiastically) so you can introduce yourself to busy unit nurses and communicate intentions, passions, and learning goals.

• Take responsibility for meeting clinical objectives. • Demonstrate an inquiring mind by asking questions and seeking

clarification. • Contribute meaningfully to the unit’s routine by offering assistance

to both staff and patients. Tips for staff nurses • Encourage students. • Share your expertise and experiences. • Speak up. If you’re overwhelmed with patient care, let the charge

nurse, nurse manager, or clinical instructor know. They’re there to support you.

• Be honest, but kind, when providing feedback. Remember, you’re preparing your future colleagues for professional practice.

Tips for nurse managers • Be present and available. Be visible on the unit; establish an open-

door policy; allot time to spend with staff, students, and faculty; lis-ten and speak with intention; and be engaged.

• Listen and maintain open lines of communication with the clinical instructor, staff, and students.

• Share past student clinical experiences with staff and students. • Clearly define roles and boundaries that adhere to scope of practice

and organizational policies early in the rotation to ensure expecta-tions are understood.

• Pause before you speak, so information is delivered calmly and thoughtfully.

• Model professional behavior. • Remember the Platinum Rule: Treat others the way they would like

to be treated.

The perfect storm

MyAmericanNurse.com August 2020 American Nurse Journal 37

Edgecombe K, Wotton K, Gonda J, Mason P. Dedicated education units: 1. A new concept for clinical teaching and learning. Contemp Nurse. 1999;8(4):166-71.

Hofler L, Thomas K. Transition of new graduate nurses to the workforce: Challenges and solutions in the chang-ing health care environment. N C Med J. 2016;77(2):133-6. ncmedicaljournal.com/content/77/2/133.full

Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.

Kavanagh JM, Szweda C. A crisis in competency: The strategic and ethical imperative to assessing new gradu-ate nurses’ clinical reasoning. Nurs Educ Perspect. 2017; 38(2):57-62.

Knight CC, Hamilton SH. Getting students to value lead-ership early in the nursing curriculum: Innovation makes it possible. Nurs Educ Perspect. 2019;40(4):254-6.

National League for Nursing. Interprofessional Collabora-tion in Education and Practice. December 2015. nln.org/ docs/default-source/default-document-library/ipe-ipp- vision.pdf?sfvrsn=14

Natvig D, Stark NL. A project team analysis using Tuck-man’s model of small-group development. J Nurs Educ. 2016;55(12):675-81.

Oja KJ. Incivility and professional comportment in criti-cal care nurses. AACN Adv Crit Care. 2017;28(4):345-50.

Pagana KD. Ride to the top with a good elevator speech. Am Nurse Today. 2013;(3). myamericannurse.com/ride- to-the-top-with-a-good-elevator-speech

Simpson KR. Incivility, bullying, and workplace vio-lence: New recommendations for nurses and their em-ployers from the American Nurses Association. MCN Am J Matern Child Nurs. 2016;41(1):68.

Segal J, Smith M, Robinson L, Boose G. Nonverbal com-munication. June 2019. helpguide.org/articles/relationships- communication/nonverbal-communication.htm

Tecza B, Boots BK, Mains BC, et al. Incivility toward nursing students in clinical rotations: Measuring the inci-dence and testing interventions. J Nurs Admin. 2018; 48(11):585-90.

Tuckman BW, Jensen MAC. Stages of small-group devel-opment revisited. Group & Organization Studies. 1977; 2(4):419-27.

Woolforde L. Beyond clinical skills: Advancing the healthy work environment. J Nurses Prof Dev. 2019;35(1):48-9.

World Health Organization. Being an Effective Team Player. who.int/patientsafety/education/curriculum/ who_mc_topic-4.pdf

Zhu Z, Xing W, Lizarondo L, Guo M, Hu Y. Nursing stu-dents’ experiences with faculty incivility in the clinical education context: A qualitative systematic review and meta-synthesis. BMJ Open. 2019;9(2):e024383.