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Civility has been described by many aspects of business, political and healthcare environments.  It entails behaviors that help to preserve the norms for mutual respect and shows concern for others. Civility is the ability to politely disagree without disrespect, and the maturity to listen to counter-views, to seek out common grounds, before making preconceptions, and to participate in respectful dialogue over differences.

I recently read an article authored by a physician, Nurse Practitioner Diploma Mills Not the Answer to Physician Shortage (Bernard, 2020). I read with the intent to explore her perspective of the issue in order to understand the opinion of a colleague. She points out that the increase in the nursing scope of practice has led to two very dangerous consequences: a decline in bedside nurses, and the growth of diploma mills. Exploring further, the author perceives that the most critical components of our health care system, referring to nurses, are choosing to become more educated at the masters and doctorate level, rather staying at an associate level that is minimally required to become a nurse. I can’t help but think of the medieval times when literacy was discouraged for workers and in more modern times, women were chastised if working outside the home. The author further expressed concern that doctoral-prepared nurse who achieved an advanced education, often not federally funded like their medical doctoral colleagues, were not accepting less lucrative career as an academic educator, but instead entering clinical practice to seek comparable pay for their services. This display of motivation was perceived by the author as detrimental to the number of bedside nurses and, perhaps the intent inappropriately extrapolated by myself, the downfall of primary care healthcare.

The second concern the author addressed was the growth of nurse programs who train nurses, referred to as diploma mills.  She states that newer studies demonstrate that the programs do not have standardized curriculum and that physician supervision is not being used; although I am not aware that nursing organizations have relinquished control over the nursing curriculums. Clinical rotations do vary, however, based on availability of preceptors. There has also been an increasing trend for the development of nurse practitioner residencies and fellowships across the nation based upon the use of standardized competencies and curriculum development to augment clinical preparation for independent NP practice (Farquhar-Snow, 2020). The article refers to indicators used in various comparative studies regarding primary care physician to NP practice, citing that NPs have an increase in unnecessary skin biopsies, increased diagnostic imaging, increased prescriptions, increased antibiotic prescribing. Indicators can be chosen by researchers with unconscious bias as well as the negative studies cited, so this is difficult to decipher but I appreciate the disparities. The author expressed concern that a larger percentage of NPs have chosen to work in specialty areas rather than in rural areas where physicians numbers have dwindled and have not significantly improved despite changes in physician recruitment efforts. Without the support from physician groups to allow NPs to work independent in rural areas and bill for services, there is little doubt why the percentage of NP practicing in rural areas in comparatively low to physicians receiving higher percentage of CMS funding. Perhaps the physicians wanting to improve the patient access to rural health care can assist NPs in their education and legislative challenges. In conclusion, there seams to be a frustration by the physician author regarding the decreasing numbers of both bedside nurses and primary care physicians, but it is unclear if this is a cause-effect relationship.

 

To understand differing insights or opinions, I suggest using the 10 actions Barbara Richman recommends to promote civility (Richman, 2015):

  1. Focus on how your words or actions will impact others – What is the perceived intent of the other person’s perceptive? Consider how the words and actions you plan to use will impact others.
  1. Use intentional communication – Utilize active listening skills to listen to the other person’s concerns before making judgements. Display respect in not only what you say, but how you say it including your voice tone, and body language.
  1. Create an inclusive environment – Incorporate diversity and respect individual differences. For example, tt was my hope when creating a NP fellowship new to our organization that showcasing what a NP could do within our scope of practice would help explore ways to promote workflow processes once the entire healthcare team became aware of our strengths and learning needs.
  1. Appreciate the value of diverse opinions – Clarify your understanding of each person’s opinions and potential intent. It is OK to “agree to disagree” respectfully. Be cognizant that new approaches can be developed with diverse opinions.
  1. Recognize that conflicts will occur – Focus on the overall objective rather than getting caught up in the drama of a situation. Use a solution-focused mindset to facilitate a team-focused approach to reach resolution to a common goal.
  1. Practice self-restraint when acting upon negative assumptions about the other person’s intent – Guard against acting impulsively but take responsibility if your negativity is displayed. For example, “Sorry if I appear disappointed, but I had hoped to enroll more patients in this study before the abstract is submitted in March.” Analyze relevant facts before making your own assumptions. Is there some truth to the conflict? Will you recognize the disparity or hide it?
  1. Avoid tendencies to become caught up negativity – Recognize that positivity or goal-drive actions on your part can influence how others perceive you as a leader.
  1. How does the difference of opinions rank in the overall scheme of things – Will the difference of opinions change the overall functioning of the team? Will they impact your practice? For example, will having more associate degree nurses than nurse educators improve the hospital readmission of heart failure patients, or will having more educated NPs in clinical practice improve the mortality of African Americans with hypertension. How can these goals be achieved?
  1. Be supportive of your healthcare colleagues, both inside and outside of the nursing profession – Yes, despite negativity or differences in opinions identified, your actions and comments should focus on how to improve or redesign the healthcare team.  As stated before, you can “agree to disagree”, but there may be some work on how to clarify perspective or the need to look in the mirror and make change based on reality.
  1. Re-evaluate your civility on an ongoing basis – Periodically identify opportunities for improvement in your approach to conflict and communication style.  Practice civility and refine these skills.

 

A lack of civility can impact workplace productivity and in our healthcare realm the achievement towards a larger common goal of patient health. Likewise incivility can encroach other settings such as online messaging, schools, and workplaces. This points out a growing need for strategies to improve effective communication that develop high-functioning healthcare teams.

During the Covid-19 pandemic I’ve had a lot of time to cook. I tried some new recipes that I tried out on myself and family before I deemed the recipe a failure or success. I even tweaked a few old recipes that i thought  in the past gave the best results but found sometimes it turned out even better based on input I learned from outside cooks through online searching. Perhaps healthcare should try a similar approach.

 

Marci Farquhar-Snow, M.S., CCRN CMC A.C.N.P-BC AACC. has been a nurse for over 30 years. She is board certified, licensed in the states of Arizona and California as an Acute Care Nurse Practitioner. Over the years, Marci has worked in multiple aspects of cardiovascular care in the inpatient and outpatient settings including critical care, clinical education, program development, and research. Previously, Marci practiced at the Mayo Clinic as a Cardiovascular Nurse Practitioner in outpatient interventional cardiology clinic. She developed and is the Past Program Director for the Cardiology Nurse Practitioner Fellowship at Mayo Clinic that is accredited by ANCC at a PTAP program. Marci has presented at local, national, and international conferences on a variety of cardiovascular clinical topics and education related topics, and is a frequent speaker for ThriveAP. She is actively involved in many committees of the American College of Cardiology and is the national chair of the Cardiovascular Team State Liaisons.

References: Rebekah Bernard. (2020). Nurse Practitioner Diploma Mills Not the Answer to Physician Shortage. Physicians for Patient Protection.June 21, 2020.  https://www.physiciansforpatientprotection.org/nurse-practitioner-diploma-mills-not-the-answer-to-physician-shortage/ Accessed July 10, 2020. / Farquhar-Snow, M. , Bartow, A. and Lucas, C. (2020). Nurse Practitioner Fellowships: Program Planning and Curriculum Development. HCPro: A Simplify Compliance Brand. ISBN: 978-1-68308-946-9 / Richman, B. (2015). 10 Actions You Can Focus on to Influence Culture of Respect, Civility in your Workplace. March 13th, 2015 Legacy Business cultures.https://legacycultures.com/10-actions-you-can-focus-on-to-influence-culture-of-respect-civility-in-your-workplace/ Accessed July 22, 2020.

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