One particular specialty in nursing known for high pressure, high risk, and a high incident of WI is the operating room (OR), where “30% of all observed relevant communication events could be categorized as communication failures” (Sydor et al., 2012, 463-464). Some of those communication failures presented as opportunities for patient advocacy that remained unfulfilled. For example, OR nurses routinely face ethical dilemmas during the course of their daily practice such as the violation of a patient’s rights during a procedure, the committing of surgical errors, and contamination of the sterile field to name a few. When acted upon, these opportunities for advocacy are known to OR nurses as exercising surgical conscience. “In its strictest sense, surgical conscience is about much more than just using good surgical technique or not taking shortcuts. It’s about consistently exhibiting ethical behavior and promoting patient safety all the time, in every circumstance—and doing the “right thing” in a surgical setting ….” (Sadler, 2012, para. 5). Unfortunately, it was found that only “one in ten (nurses) speak up and share their full concerns” when potentially unsafe practice occurs (American Association of Critical Care Nurses, 2005b).
Matters of uncivility, such as fear of a counterattack and/ or disruptive reactions, may be to blame for OR nurses failing to speak up when necessary. Compounding this issue could be the perceived dynamics of the perioperative setting. “The pronounced hierarchy of the OR may also make preoperative communication by a nurse…more challenging than in other clinical settings” (Berlinger & Dietz, 2017, p.927). When OR nurses fail to advocate and protect a surgical patient, the consequences can be fatal. Currently, there is attention and curricula devoted to the development of the cognitive and psychomotor skills required of a perioperative nurse, but very little time or attention is spent on promoting civility and positive communication. “While there is a growing body of literature in nursing education and practice, as well as other health care disciplines, on the topic of incivility, very few studies provide specific teaching strategies to address the ‘‘reality shock’’ between what students learn about the practice of nursing and the interactions they may experience in the workplace” (Clark, Ahten, & Macy, 2013, p.77).
Knowing that one of the “standards for establishing and sustaining healthy work environments are skilled communication” (AACN, 2005a, p. 189), 25 students were intentionally trained to practice communication skills in an “uncivil” OR setting. The students were part of a second degree BSN perioperative elective course, and the simulation exercise took place in May of 2018. The participants responded to possible compromises in patient safety, and experienced having to communicate undesirable, yet critical, information to surgeons and anesthesiologists as needed. At times, when communication from the other caregivers became negative and uncivil, the students practiced using techniques from Griffin’s (2004) cognitive rehearsal. Pre-planned phrases were used to de-escalate the uncivil communication and helped the students navigate the difficult situation in a positive way. The exercise strengthened their ability to perform their required duties with increased confidence, and 100% of the students felt they were better prepared to deal with potential matters of incivility after participating in the simulation.
Civility, collaboration, and positive communication are the cornerstones for healthy work environments. To insure future nurses have the capability to promote civility in nursing, it is essential to “develop and implement curricula that educate nursing students on the incidence of disruptive behaviors including lateral violence and bullying, along with steps to take to eradicate this behavior” (Center for American Nurses, 2008, p.6). This exercise had a positive impact on nursing education, nursing practice, and patient outcomes. By strengthening the way in which healthcare professionals communicate with one another, civility is promoted, and a healthy work environment can be maintained.