Civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, ATI Strategic Nursing Advisor, continues our conversation about incivility in nursing. She helps us gain insight into being more self-aware and identifying where we may be failing to treat others with respect and kindness. Then she helps us create a path to civility within our nursing programs.  START A CONVERSATION Visit ATI on Facebook, LinkedIn or the ATI blog to comment and share your thoughts. ATI Educator Facebook Page ATI Educator LinkedIn Page ATI blog DOWNLOAD FOR LATER No time now? Click the download button at the bottom of this box to save and listen at your leisure. LIKE & SHARE Tell colleagues and friends about this podcast. Use the links at the bottom of this box. CONTACT US Website: www.atitesting.com Email: aticommunications@atitesting.com Phone: (800) 667-7531  READ THE FULL TRANSCRIPT Gina Kellogg [00:00:18] Welcome back to our conversation with Dr. Cynthia Clark. We're on episode three of our series on civility. And, once again, we're fortunate to have the world's leading expert on civility to lead us in gaining a better understanding of its importance within the nursing profession. Dr. Clark, some of your research has delved into being self-aware and how it's such a crucial part of creating civil and healthy workplaces. Can you give us some insight into this area? Cynthia Clark [00:00:43] Oh boy, you're singing my song now. So, when I was a very novice researcher on this topic -- oh, gosh, probably 15, 16, maybe even another year, but beyond that, in some of my early studies -- I was shocked to discover -- and I no longer am -- but I was shocked to discover that people didn't have a clue how they were coming across to other people. And I should have known that, because I'm also a behavioral health nurse and a trained cognitive therapist. So I should have known some of that. But, in my early works, that was that early finding is that when people were asked to self reflect, it wasn't really part of their DNA. It wasn't really on the radar of how I might be coming across to other people. So, years ago, I started developing self-reflection tools to take a look at that -- not only how I might be coming across to others, so I can self-reflect using that tool. And we now know it's a valid and reliable tool. The paper on all of its psychometric and development will be published later this year in the Journal of Continuing Nursing Education and looking at this whole idea of of self-awareness. But it's one thing for me to do a self-evaluation and go, "Okay, this is kind of how I must be coming across to people." But I encourage -- and did this with my students for many semesters -- had students pair up. And I would coach them along the semester that they knew that, eventually, about week 9 or 10 of the semester, they were going to do a self-reflection of themselves and a reflection of their classmate. That classmate would do a self reflection of themselves and of their classmate. And then sit down together and talk about, "Here's how I perceive you. Here's how I think you have great strengths in these areas." And I would have them identify just one area that, maybe, their classmate could improve. And then I had them switch and then begin to have a conversation. Now, the question becomes when we've heard Dr. Banner and others for years talk about the importance of bringing classroom to the clinical and clinical to the classroom, so always making those connections with our students. So, suggesting to them, "Why would I ask you to do this kind of experience? What -- why would I want you to engage in this kind of dialogue?" And, ultimately, there's myriad reasons, but one of them is -- is that every single day, on that patient floor, or in that community setting, or in that school -- wherever we find ourselves -- there will be conflict. Being able to give and receive feedback in a respectful way is a highly valued skill, and you will be asked to do that. Second point, you may be asked to do peer review or a 360 evaluation of one of your colleagues. You now will have had some experience doing that. Gina Kellogg [00:03:35] Well, when a program starts taking steps in the new cultures they're building, are there any specific steps they can take that will encourage further growth? Cynthia Clark [00:03:44] So, yeah, that's a great question. So, many years ago -- I'm thinking about 2011-ish or so -- I started creating more formidably a pathway for fostering organizational civility. And it has eight steps, and it's not always linear like that, because change is very messy. Change takes time. But I'll give you the eight steps very quickly. No. 1: We have to get leadership on board. And I'm not just talking about all of us as leaders at all levels of our organization, but we really need to engage our executive leadership, our deans, our directors, our chairs, our V.P.s. Are they on board? And there are schools where that is one of their major initiatives -- is to start a civility campaign that is campus-wide, that spreads into the community. And, so, we have very strong leaders. But we must get our leadership on board. The second thing we need to do is we need to measure the problem as I measure -- mentioned before. We need good data. What's going on in that school? The third thing is that we need to create a team. In different places we call them different things. In the school that I worked -- one of the schools where I worked -- we called it an organizational design team. I'm working with a school in Canada that calls it the Spirit of Well-Being Team. But, the point is, that we need to have a dedicated team -- not one that does all the heavy lifting in the work to transform the workplace, but the nucleus to be certain that we keep our eye on the ball -- that we're using our data to begin to put together step four, which is an action plan. What is our data-driven, evidence-based action plan and the interventions we're going to take to move the needle? Step five, now we've got to do it. So we have our action plan. Now we need to implement it. And there's multiple ways that organizations can think about investing and implementing best practices to do that. Step six, we absolutely need to evaluate it. How are we doing? Are we making change? Are we moving in the right direction? So all that evaluation piece and using that data to keep the change moving. The seventh -- and my personal favorite is -- you celebrate. Short-term gains, long-term gains, informal, formal -- but to really cheer ourselves on and, as we make those changes, it really allows us to say, "Hey, we've got this! We can keep that momentum going." So that's step seven. And eight, really, is what needs to be done next to keep this going. So, that is the pathway. It's been implemented in many places with great success. But it takes strong leadership, and it takes a strong team. Gina Kellogg [00:06:35] Well, when a program starts taking steps in the new cultures they're building, are there any specific steps they can take that will encourage further growth? Cynthia Clark [00:06:43] Yes. As I -- as I mentioned, you know, celebrations big and small -- with students especially. And I know that people are on tight budgets, so I'm not talking about a huge thing that's going to cost a lot of money. But, how can we build in -- without much expense -- to celebrate what's going on? Here's one example that I've seen implemented, and have done myself, which is to have kind of a civility summit within your school. Students can present their projects -- maybe their posters of what they've done to create healthy work environments, either in the academic side and the practice side -- how they're doing that -- to showcase their work in their efforts. And maybe it's just tea and homemade cookies? But a way to really showcase that without spending a lot of money. Gina Kellogg [00:07:35] Meanwhile, every step we take in helping to build a world where everyone treats everyone with respect and kindness -- that's really a step in the right direction. So thank you, Dr. Clark, for helping to inspire each of us moving toward that direction. Cynthia Clark [00:07:49] All right! Well, thank you very much. Gina Kellogg [00:07:52] It's been a great experience learning about this important topic, and today's discussion was especially helpful as we talked about how to become more self-aware and how we can foster organizational civility. We have more information from Dr. Clark on this topic at the ATI blog, which you can find by clicking on the blog link at the top of the page. Simply visit www.atitesting.com/educator/blog, and you'll see articles, infographics, and videos. This is an important subject, and we'll be continually adding to the conversation. Thank you for listening.

ATI Nursing

ATI 0003 Beyond Bullying: The Serious Impact of Incivility in Nursing

Civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, ATI Strategic Nursing Advisor, digs deeper into the topic of incivility in nursing. She discusses some behaviors you may not recognize as being negative. Over time, however, they can have seriously negative impacts on your colleagues. In fact, you may be exhibiting these behaviors yourself without even realizing it! Learn what these words and actions -- or lack of actions -- are. START A CONVERSATION Visit ATI on Facebook, LinkedIn or the ATI blog to comment and share your thoughts. ATI Educator Facebook Page ATI Educator LinkedIn Page ATI blog DOWNLOAD FOR LATER No time now? Click the download button at the bottom of this box to save and listen at your leisure. LIKE & SHARE Tell colleagues and friends about this podcast. Use the links at the bottom of this box. CONTACT US Website: www.atitesting.com Email: aticommunications@atitesting.com Phone: (800) 667-7531  READ THE FULL TRANSCRIPT Gina Kellogg [00:00:19] Welcome back to episode two of our series on civility and nursing. Today's topic is "Beyond bullying: The serious impact of incivility in nursing." Once again, we're lucky to be speaking with Dr. Cynthia Clark who is recognized as the leading expert in the area of civility. Dr. Clark's recent research has included examining effective ways to prepare nursing students and addressing incivility in academic and practice settings. It's a topic that's becoming increasingly important. Dr. Clark, most people tend to think of incivility in terms of obvious bullying behavior. But you've researched other forms of incivility that people may not initially think of as bullying. Behavior that's more subtle but is just as harmful. Can you tell us more about that. Cynthia Clark [00:01:04] Yeah, it's a great question. So, sometimes, I like to think of incivility -- usually, we think about it in terms of the things that we do. So, maybe I disrespect you where I make a demeaning comment, or I call you a name, or I -- you know -- do any number of things. Maybe it's even nonverbal. I roll my eyes at you, or I -- you know -- "Harrumph" and I cross my arms. Or I turn on my heel or do any number of things, right? Those tend to be a little bit more obvious and a little less subtle. But then there are others where, what I often say is, incivility can be what we do and what we don't do. Like if I pass you in the hallway and just blow you off. If I don't even extend a welcome or hello, even if I'm in a hurry, at least to say, "How you doing?" If I'm on a team, and everybody's working really hard and I'm not pitching in, I'm not doing my part. So we ignore people, or we don't do our part, or  one of the ones that really concerns me, in general, but especially when I think about healthcare, is when we withhold valuable information. Because some people believe, if I'm the keeper of that information, then I'm kind of the hero in this story. So, I don't tell you about a patient condition, because -- you know what? "Figure it out. Check the chart. I'm tired I'm going home." So those kinds of lack of information-giving, lack of extending even a quick greeting -- because you're another person who matters -- and, unfortunately, you know, in my work with students -- and I see them all over the country and Canada -- and many students will say, "You know, Dr. Clark, I'm walking down the hall, and the faculty will pass me in the hall and say nothing. What am I? Am I invisible? Do I not matter?" So those kinds of microaggressions can have a real impact on people over time. Gina Kellogg [00:02:58] You've mentioned some of the other types of incivility as mobbing and rankism. Can you describe what those are? Cynthia Clark [00:03:04] Yeah. So let me begin by saying a little bit about what bullying is, because by building on that concept it makes it easier for me to explain mobbing. So, when I think about bullying, and there are various definitions, the one I like to use comes from NIOSH. And it talks about bullying being a persistent, over time, targeted type of behavior, usually with some power gradient that exists. So, if I'm bullying someone, I'm going to target that individual, usually to demean, demoralize, to marginalize. But one of the reasons I like that particular definition from NIOSH is that, in that definition, it doesn't say it's intentional. So we know that, sometimes, bullying occurs intentionally. I may intentionally do something and get some great joy out of it. Sadly, there are people who do that. But there are others who bully without intent. And it's often because it's become ingrained behavior. It's worked for them. They've gotten their way. It's just how they roll. And, so, intentional or not, it can have some very devastating effect. So, when we think about bullying, it's often one person on another person or one person on a group of people. When we begin to think about mobbing, and I often call mobbing "bullying on steroids," and what I mean by that is that, rather than one individual targeting another such, as me bullying another person, instead, what I've done is have a coalition of people around me -- a team of what I call, you know, this triumvirate of evil who has made it my goal to work with this group to now demean another individual or group of individuals. So that's workplace mobbing, where you have that kind of group or social mentality going after another individual or group of individuals. And it can be devastating to a workplace. And some people have paid a lot of money in legal fees and mental health fees. I hear thousands of stories from people, and many of them include this idea of mobbing. You asked about rankism. Rankism is an interesting concept coined by Dr. Robert Fuller who was the previous president of Oberlin University, and I've had the pleasure of collaborating with Dr. Fuller. He's amazing. He coined that term, rankism, which he describes or defines as an abuse of power or position to demean, to diminish, or to disadvantage another. And what he says is that rankism is sort of like the big cancer. So we have big cancer, and underneath that big concept of cancer, we might have breast cancer, prostate cancer, colon cancer, and so forth. He says rankism is like the big cancer. He says it's the mother of all -isms. So you have rankism, and underneath that you have things like ageism and sexism and racism. Interestingly, he says that the antidote to all of that is to restore dignity and respect to each individual. Gina Kellogg [00:06:07] So, a student who is facing a situation like what you just described, should they approach their faculty director and ask for advice on how to handle it? Cynthia Clark [00:06:15] That would be my highest recommendation. But I can tell you most students will not. I have worked with students, sometimes who I have coached and are very well-prepared to have that conversation, and some will go forward with it, and some will not. Many students believe, because of that power gradient and my ability as a professor to either pass or fail them, that the risks are very high. So, yes, I work a lot with students to be able to do that. Here's my best recommendation, though: I don't think we should wait for those things to happen, though we know they may. Instead, a lot of my work is in primary prevention or putting things in place that would pre-empt those things from happening in the first place. So, does a school have a vision, a mission, a set of shared values that people are held accountable to and for? I'm talking about faculty, staff, deans, directors -- all of us in a school of nursing, including our students. So, if we have those, and we craft -- and I've worked with lots of organizations on crafting charters or honor codes or pledges that make a commitment to one another -- at this school, here's how we're going to be with one another. And building in norms of conduct and behavior, and the most important part: holding people accountable for that. So, if I'm a faculty member, and there are norms in our school that we treat one another with respect, including and maybe as importantly, our students, and I'm not doing that, there should be some level of accountability. Now, somebody can hold me accountable, because I have made a commitment to that creed or that honor code or whatever. Gina Kellogg [00:07:55] Do you feel that there is an opportunity to create change in a person who is at a higher level? For example, a person who should be setting an example in a positive way but isn't? They should, ultimately, be the person responsible, but sometimes they're the worst offender. Cynthia Clark [00:08:09] Yes, I often call them the worm in the apple. So, you might have a dean or a director or somebody in charge who's not really carrying the torch of the kinds of behaviors we want to see. There needs to also be some level of accountability for those individuals, as well. Frankly, that doesn't always happen. And, so, sometimes -- if we find ourselves, you know, making attempts to encourage them to act differently. One of the strategies I believe is to make sure that you have some measurements in place to look at measuring the culture of your workplace. And I don't mean just the campus-climate surveys that so many of us do in universities and colleges. But I'm talking, instead, much more granular -- looking at what are the behaviors that are exhibited within this organization, the school of nursing, for example. How do we resolve conflict? How are we communicating or not communicating with one another? What are our strategies for relating? How do we conduct our faculty meetings? How do we conduct our experiences with our students? All of that needs to sort of be unpacked and examined. Now, what you have is data. And I believe that, in order to make change, we need to make data-driven, evidence-based decisions. So, let's begin to look at what's going on in these schools. And, sometimes, what's revealed is it might be the person in that leadership position. I've known folks like that, and they have made excellent changes. Some don't, but some do. So, with coaching, with being open to feedback and those kinds of things, great things can happen. Now, one comment about sort of doing some of that work to measure what's going on in the culture: I think it's extremely important that we not just uncover what we might improve. So, what our challenges are but what are our strengths? What are we doing well? How do we amplify those? How do we grow those? How do we celebrate those? So that there's not that demoralization. And then we're like, "Wow! Are we ever going to fix this workplace?" No. It's, "Here are some areas -- based on evidence and data -- that we might want to attend to." And don't bite off more than we can chew. Maybe we pick two or three of the top ones to go after in an academic year, for example. Set some long-term goals but also paying very much attention to what we're doing well and right. Gina Kellogg [00:10:24] Clearly, incivility isn't as easy to spot as we might have imagined. How we treat others has far-reaching consequences. So, thank you for pointing out the subtle signs for us. In addition we got some excellent advice on how to not only address uncivil situations, but we also got some proactive tips programs can put into action. It's empowering to think that we can even help create change in our own work environments. It's a lot of food for thought as we look at ourselves, our own behaviors, and our nursing programs. In the next episode of our focus on civility, we'll get some insight into how we can individually take a look at our own behaviors and identify where we might be failing to treat others with the respect and kindness they deserve. Then, we'll build on that knowledge to learn how to build a path to civility within our nursing program. We look forward to hearing more of Dr. Clark's expert advice on this vital subject. Until then, you can discover more advice from Dr. Clark at the ATI blog. Visit www.ATItesting.com/educator/blog for articles, video interviews, and infographics on a variety of topics important to nurse educators like yourself. Thank you for listening.

ATI 0002 Beyond bullying: The Serious Impact of Incivility in Nursing

Civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, ATI Strategic Nursing Advisor, continues our conversation about incivility in nursing. She helps us gain insight into being more self-aware and identifying where we may be failing to treat others with respect and kindness. Then she helps us create a path to civility within our nursing programs. START A CONVERSATIONVisit ATI on Facebook, LinkedIn or the ATI blog to comment and share your thoughts.ATI Educator Facebook PageATI Educator LinkedIn PageATI blogDOWNLOAD FOR LATERNo time now? Click the download button at the bottom of this box to save and listen at your leisure.LIKE & SHARETell colleagues and friends about this podcast. Use the links at the bottom of this box.CONTACT USWebsite: www.atitesting.comEmail: aticommunications@atitesting.comPhone: (800) 667-7531 READ THE FULL TRANSCRIPTGina Kellogg [00:00:18] Welcome back to our conversation with Dr. Cynthia Clark. We're on episode three of our series on civility. And, once again, we're fortunate to have the world's leading expert on civility to lead us in gaining a better understanding of its importance within the nursing profession. Dr. Clark, some of your research has delved into being self-aware and how it's such a crucial part of creating civil and healthy workplaces. Can you give us some insight into this area?Cynthia Clark [00:00:43] Oh boy, you're singing my song now. So, when I was a very novice researcher on this topic -- oh, gosh, probably 15, 16, maybe even another year, but beyond that, in some of my early studies -- I was shocked to discover -- and I no longer am -- but I was shocked to discover that people didn't have a clue how they were coming across to other people. And I should have known that, because I'm also a behavioral health nurse and a trained cognitive therapist. So I should have known some of that. But, in my early works, that was that early finding is that when people were asked to self reflect, it wasn't really part of their DNA. It wasn't really on the radar of how I might be coming across to other people. So, years ago, I started developing self-reflection tools to take a look at that -- not only how I might be coming across to others, so I can self-reflect using that tool. And we now know it's a valid and reliable tool. The paper on all of its psychometric and development will be published later this year in the Journal of Continuing Nursing Education and looking at this whole idea of of self-awareness. But it's one thing for me to do a self-evaluation and go, "Okay, this is kind of how I must be coming across to people." But I encourage -- and did this with my students for many semesters -- had students pair up. And I would coach them along the semester that they knew that, eventually, about week 9 or 10 of the semester, they were going to do a self-reflection of themselves and a reflection of their classmate. That classmate would do a self reflection of themselves and of their classmate. And then sit down together and talk about, "Here's how I perceive you. Here's how I think you have great strengths in these areas." And I would have them identify just one area that, maybe, their classmate could improve. And then I had them switch and then begin to have a conversation. Now, the question becomes when we've heard Dr. Banner and others for years talk about the importance of bringing classroom to the clinical and clinical to the classroom, so always making those connections with our students. So, suggesting to them, "Why would I ask you to do this kind of experience? What -- why would I want you to engage in this kind of dialogue?" And, ultimately, there's myriad reasons, but one of them is -- is that every single day, on that patient floor, or in that community setting, or in that school -- wherever we find ourselves -- there will be conflict. Being able to give and receive feedback in a respectful way is a highly valued skill, and you will be asked to do that. Second point, you may be asked to do peer review or a 360 evaluation of one of your colleagues. You now will have had some experience doing that.Gina Kellogg [00:03:35] Well, when a program starts taking steps in the new cultures they're building, are there any specific steps they can take that will encourage further growth?Cynthia Clark [00:03:44] So, yeah, that's a great question. So, many years ago -- I'm thinking about 2011-ish or so -- I started creating more formidably a pathway for fostering organizational civility. And it has eight steps, and it's not always linear like that, because change is very messy. Change takes time. But I'll give you the eight steps very quickly. No. 1: We have to get leadership on board. And I'm not just talking about all of us as leaders at all levels of our organization, but we really need to engage our executive leadership, our deans, our directors, our chairs, our V.P.s. Are they on board? And there are schools where that is one of their major initiatives -- is to start a civility campaign that is campus-wide, that spreads into the community. And, so, we have very strong leaders. But we must get our leadership on board. The second thing we need to do is we need to measure the problem as I measure -- mentioned before. We need good data. What's going on in that school? The third thing is that we need to create a team. In different places we call them different things. In the school that I worked -- one of the schools where I worked -- we called it an organizational design team. I'm working with a school in Canada that calls it the Spirit of Well-Being Team. But, the point is, that we need to have a dedicated team -- not one that does all the heavy lifting in the work to transform the workplace, but the nucleus to be certain that we keep our eye on the ball -- that we're using our data to begin to put together step four, which is an action plan. What is our data-driven, evidence-based action plan and the interventions we're going to take to move the needle? Step five, now we've got to do it. So we have our action plan. Now we need to implement it. And there's multiple ways that organizations can think about investing and implementing best practices to do that. Step six, we absolutely need to evaluate it. How are we doing? Are we making change? Are we moving in the right direction? So all that evaluation piece and using that data to keep the change moving. The seventh -- and my personal favorite is -- you celebrate. Short-term gains, long-term gains, informal, formal -- but to really cheer ourselves on and, as we make those changes, it really allows us to say, "Hey, we've got this! We can keep that momentum going." So that's step seven. And eight, really, is what needs to be done next to keep this going. So, that is the pathway. It's been implemented in many places with great success. But it takes strong leadership, and it takes a strong team.Gina Kellogg [00:06:35] Well, when a program starts taking steps in the new cultures they're building, are there any specific steps they can take that will encourage further growth?Cynthia Clark [00:06:43] Yes. As I -- as I mentioned, you know, celebrations big and small -- with students especially. And I know that people are on tight budgets, so I'm not talking about a huge thing that's going to cost a lot of money. But, how can we build in -- without much expense -- to celebrate what's going on? Here's one example that I've seen implemented, and have done myself, which is to have kind of a civility summit within your school. Students can present their projects -- maybe their posters of what they've done to create healthy work environments, either in the academic side and the practice side -- how they're doing that -- to showcase their work in their efforts. And maybe it's just tea and homemade cookies? But a way to really showcase that without spending a lot of money.Gina Kellogg [00:07:35] Meanwhile, every step we take in helping to build a world where everyone treats everyone with respect and kindness -- that's really a step in the right direction. So thank you, Dr. Clark, for helping to inspire each of us moving toward that direction.Cynthia Clark [00:07:49] All right! Well, thank you very much.Gina Kellogg [00:07:52] It's been a great experience learning about this important topic, and today's discussion was especially helpful as we talked about how to become more self-aware and how we can foster organizational civility. We have more information from Dr. Clark on this topic at the ATI blog, which you can find by clicking on the blog link at the top of the page. Simply visit www.atitesting.com/educator/blog, and you'll see articles, infographics, and videos. This is an important subject, and we'll be continually adding to the conversation. Thank you for listening.

Civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, ATI Strategic Nursing Advisor, digs deeper into the topic of incivility in nursing. She discusses some behaviors you may not recognize as being negative. Over time, however, they can have seriously negative impacts on your colleagues. In fact, you may be exhibiting these behaviors yourself without even realizing it! Learn what these words and actions -- or lack of actions -- are.START A CONVERSATIONVisit ATI on Facebook, LinkedIn or the ATI blog to comment and share your thoughts.ATI Educator Facebook PageATI Educator LinkedIn PageATI blogDOWNLOAD FOR LATERNo time now? Click the download button at the bottom of this box to save and listen at your leisure.LIKE & SHARETell colleagues and friends about this podcast. Use the links at the bottom of this box.CONTACT USWebsite: www.atitesting.comEmail: aticommunications@atitesting.comPhone: (800) 667-7531 READ THE FULL TRANSCRIPTGina Kellogg [00:00:19] Welcome back to episode two of our series on civility and nursing. Today's topic is "Beyond bullying: The serious impact of incivility in nursing." Once again, we're lucky to be speaking with Dr. Cynthia Clark who is recognized as the leading expert in the area of civility. Dr. Clark's recent research has included examining effective ways to prepare nursing students and addressing incivility in academic and practice settings. It's a topic that's becoming increasingly important. Dr. Clark, most people tend to think of incivility in terms of obvious bullying behavior. But you've researched other forms of incivility that people may not initially think of as bullying. Behavior that's more subtle but is just as harmful. Can you tell us more about that.Cynthia Clark [00:01:04] Yeah, it's a great question. So, sometimes, I like to think of incivility -- usually, we think about it in terms of the things that we do. So, maybe I disrespect you where I make a demeaning comment, or I call you a name, or I -- you know -- do any number of things. Maybe it's even nonverbal. I roll my eyes at you, or I -- you know -- "Harrumph" and I cross my arms. Or I turn on my heel or do any number of things, right? Those tend to be a little bit more obvious and a little less subtle. But then there are others where, what I often say is, incivility can be what we do and what we don't do. Like if I pass you in the hallway and just blow you off. If I don't even extend a welcome or hello, even if I'm in a hurry, at least to say, "How you doing?" If I'm on a team, and everybody's working really hard and I'm not pitching in, I'm not doing my part. So we ignore people, or we don't do our part, or  one of the ones that really concerns me, in general, but especially when I think about healthcare, is when we withhold valuable information. Because some people believe, if I'm the keeper of that information, then I'm kind of the hero in this story. So, I don't tell you about a patient condition, because -- you know what? "Figure it out. Check the chart. I'm tired I'm going home." So those kinds of lack of information-giving, lack of extending even a quick greeting -- because you're another person who matters -- and, unfortunately, you know, in my work with students -- and I see them all over the country and Canada -- and many students will say, "You know, Dr. Clark, I'm walking down the hall, and the faculty will pass me in the hall and say nothing. What am I? Am I invisible? Do I not matter?" So those kinds of microaggressions can have a real impact on people over time.Gina Kellogg [00:02:58] You've mentioned some of the other types of incivility as mobbing and rankism. Can you describe what those are?Cynthia Clark [00:03:04] Yeah. So let me begin by saying a little bit about what bullying is, because by building on that concept it makes it easier for me to explain mobbing. So, when I think about bullying, and there are various definitions, the one I like to use comes from NIOSH. And it talks about bullying being a persistent, over time, targeted type of behavior, usually with some power gradient that exists. So, if I'm bullying someone, I'm going to target that individual, usually to demean, demoralize, to marginalize. But one of the reasons I like that particular definition from NIOSH is that, in that definition, it doesn't say it's intentional. So we know that, sometimes, bullying occurs intentionally. I may intentionally do something and get some great joy out of it. Sadly, there are people who do that. But there are others who bully without intent. And it's often because it's become ingrained behavior. It's worked for them. They've gotten their way. It's just how they roll. And, so, intentional or not, it can have some very devastating effect. So, when we think about bullying, it's often one person on another person or one person on a group of people. When we begin to think about mobbing, and I often call mobbing "bullying on steroids," and what I mean by that is that, rather than one individual targeting another such, as me bullying another person, instead, what I've done is have a coalition of people around me -- a team of what I call, you know, this triumvirate of evil who has made it my goal to work with this group to now demean another individual or group of individuals. So that's workplace mobbing, where you have that kind of group or social mentality going after another individual or group of individuals. And it can be devastating to a workplace. And some people have paid a lot of money in legal fees and mental health fees. I hear thousands of stories from people, and many of them include this idea of mobbing. You asked about rankism. Rankism is an interesting concept coined by Dr. Robert Fuller who was the previous president of Oberlin University, and I've had the pleasure of collaborating with Dr. Fuller. He's amazing. He coined that term, rankism, which he describes or defines as an abuse of power or position to demean, to diminish, or to disadvantage another. And what he says is that rankism is sort of like the big cancer. So we have big cancer, and underneath that big concept of cancer, we might have breast cancer, prostate cancer, colon cancer, and so forth. He says rankism is like the big cancer. He says it's the mother of all -isms. So you have rankism, and underneath that you have things like ageism and sexism and racism. Interestingly, he says that the antidote to all of that is to restore dignity and respect to each individual.Gina Kellogg [00:06:07] So, a student who is facing a situation like what you just described, should they approach their faculty director and ask for advice on how to handle it?Cynthia Clark [00:06:15] That would be my highest recommendation. But I can tell you most students will not. I have worked with students, sometimes who I have coached and are very well-prepared to have that conversation, and some will go forward with it, and some will not. Many students believe, because of that power gradient and my ability as a professor to either pass or fail them, that the risks are very high. So, yes, I work a lot with students to be able to do that. Here's my best recommendation, though: I don't think we should wait for those things to happen, though we know they may. Instead, a lot of my work is in primary prevention or putting things in place that would pre-empt those things from happening in the first place. So, does a school have a vision, a mission, a set of shared values that people are held accountable to and for? I'm talking about faculty, staff, deans, directors -- all of us in a school of nursing, including our students. So, if we have those, and we craft -- and I've worked with lots of organizations on crafting charters or honor codes or pledges that make a commitment to one another -- at this school, here's how we're going to be with one another. And building in norms of conduct and behavior, and the most important part: holding people accountable for that. So, if I'm a faculty member, and there are norms in our school that we treat one another with respect, including and maybe as importantly, our students, and I'm not doing that, there should be some level of accountability. Now, somebody can hold me accountable, because I have made a commitment to that creed or that honor code or whatever.Gina Kellogg [00:07:55] Do you feel that there is an opportunity to create change in a person who is at a higher level? For example, a person who should be setting an example in a positive way but isn't? They should, ultimately, be the person responsible, but sometimes they're the worst offender.Cynthia Clark [00:08:09] Yes, I often call them the worm in the apple. So, you might have a dean or a director or somebody in charge who's not really carrying the torch of the kinds of behaviors we want to see. There needs to also be some level of accountability for those individuals, as well. Frankly, that doesn't always happen. And, so, sometimes -- if we find ourselves, you know, making attempts to encourage them to act differently. One of the strategies I believe is to make sure that you have some measurements in place to look at measuring the culture of your workplace. And I don't mean just the campus-climate surveys that so many of us do in universities and colleges. But I'm talking, instead, much more granular -- looking at what are the behaviors that are exhibited within this organization, the school of nursing, for example. How do we resolve conflict? How are we communicating or not communicating with one another? What are our strategies for relating? How do we conduct our faculty meetings? How do we conduct our experiences with our students? All of that needs to sort of be unpacked and examined. Now, what you have is data. And I believe that, in order to make change, we need to make data-driven, evidence-based decisions. So, let's begin to look at what's going on in these schools. And, sometimes, what's revealed is it might be the person in that leadership position. I've known folks like that, and they have made excellent changes. Some don't, but some do. So, with coaching, with being open to feedback and those kinds of things, great things can happen. Now, one comment about sort of doing some of that work to measure what's going on in the culture: I think it's extremely important that we not just uncover what we might improve. So, what our challenges are but what are our strengths? What are we doing well? How do we amplify those? How do we grow those? How do we celebrate those? So that there's not that demoralization. And then we're like, "Wow! Are we ever going to fix this workplace?" No. It's, "Here are some areas -- based on evidence and data -- that we might want to attend to." And don't bite off more than we can chew. Maybe we pick two or three of the top ones to go after in an academic year, for example. Set some long-term goals but also paying very much attention to what we're doing well and right.Gina Kellogg [00:10:24] Clearly, incivility isn't as easy to spot as we might have imagined. How we treat others has far-reaching consequences. So, thank you for pointing out the subtle signs for us. In addition we got some excellent advice on how to not only address uncivil situations, but we also got some proactive tips programs can put into action. It's empowering to think that we can even help create change in our own work environments. It's a lot of food for thought as we look at ourselves, our own behaviors, and our nursing programs. In the next episode of our focus on civility, we'll get some insight into how we can individually take a look at our own behaviors and identify where we might be failing to treat others with the respect and kindness they deserve. Then, we'll build on that knowledge to learn how to build a path to civility within our nursing program. We look forward to hearing more of Dr. Clark's expert advice on this vital subject. Until then, you can discover more advice from Dr. Clark at the ATI blog. Visit www.ATItesting.com/educator/blog for articles, video interviews, and infographics on a variety of topics important to nurse educators like yourself. Thank you for listening.

Whose responsibility is it to ensure you work in an environment free of uncivil behaviors? Yours — and everyone with whom you work. We all play a crucial role. Get started helping to build and maintain a healthy workplace with these tips from civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, Strategic Nursing Advisor. START A CONVERSATION Visit ATI on Facebook, LinkedIn or the ATI blog to comment and share your thoughts. ATI Educator Facebook Page ATI Educator LinkedIn Page ATI blog DOWNLOAD FOR LATER No time now? Click the download button at the bottom of this box to save and listen at your leisure. LIKE & SHARE Tell colleagues and friends about this podcast. Use the links at the bottom of this box. CONTACT US Website: www.atitesting.com Email: aticommunications@atitesting.com Phone: (800) 667-7531  READ THE FULL TRANSCRIPT Gina Kellogg [00:00:14] Welcome to the first episode of ATI's series on civility and nursing. I'm Gina Kellogg, the senior manager of marketing content strategy for ATI. We are extremely lucky today to gain some insights from Dr. Cynthia Clark. Many of you may know Dr. Clark as the world's leading expert on fostering civility and healthy work environments. Her research has proven that when incivility exists, it puts both nurses and patient safety at risk. Dr. Clark has built her reputation on decades of research into the topic of civility. Most recently she's focused on examining effective ways of preparing nursing students and addressing incivility in both academic and practice settings, and this is a topic gaining greater momentum in today's world. Gina Kellogg [00:00:57] Dr. Clark, thank you for helping us better understand this issue. Let's start by asking you to explain why nursing faculty must address civility with their students. Why must students be taught about civility? Cynthia Clark [00:01:10] Sometimes students come to us without a clear realization of how their behaviors might impact other people. What's expected of a professional nurse? What does it mean to advocate for patients? What does it even mean to communicate within the healthcare setting in the patient care environment? And so, a lot of times, we just need to really engage our students in conversation about what it means to behave in ways and interact in ways that are respectful, that speak to being a strong role model, to advocate for patients -- particularly in patient safety situations. So, to your question about why is it important for faculty to address this, at the end of the day, it really comes down to patient safety. That, if our behaviors aren't expressed in ways that -- again -- are respectful, and if we are unable to advocate or call the question in a patient care situation, then somebody could be injured. Patients can actually die. Gina Kellogg [00:02:28] I'm sure students can understand how incivility impacts them, but they may be less familiar with how it impacts patients. What are the aspects students need to understand in regard to patient care. Cynthia Clark [00:02:39] Well, again, you know, coming back to this idea of advocacy, of speaking up, of having the skills and -- really -- the moral courage to address situations, particularly if you're new to the profession or you're in the student role -- you know -- how do I find that courage to speak up? To stand up? To advocate when my patient needs me to do that -- especially if you're surrounded by healthcare professionals who have been in the business a very long time? Sometimes, there's an intimidation factor around seasoned nurses or our physician colleagues or others. So, at the end of the day, we need to really understand that the patient safety issues are really critical to us learning and mastering some of these skills. Gina Kellogg [00:03:32] What are some of the techniques an educator can use to help their students develop that kind of courage? Cynthia Clark [00:03:37] Yeah, it's a great question. So, one of the techniques that's really steeped in evidence and is gaining a lot of momentum and -- actually -- a teaching strategy that I've been using probably since about, I want to say, about 2008 -- so for at least 10 years -- and it's called cognitive rehearsal. Cognitive rehearsal essentially consists of about five different steps. So, the first step is to think about what preparatory material do I need to have my students learn before we take on this learning experience? What kind of prebriefing do they need to learn about this concept? So, let's say we're talking about incivility or, you know, disruptive healthcare settings or academic environments -- whatever that might be. What do we need to know about that topic? Because, essentially, what cognitive rehearsal does, it comes to us from behavioral science. And it makes some assumptions, and some of the assumptions -- and I'll go back to the steps in a moment -- but some of the assumptions that it makes is that any of us, if we anticipate that we're going to be in a certain situation -- particularly if it's stressful or, in this case, may be uncivil or really disruptive or maybe even intimidating. So, if we think about that before it happens, and sort of consider, "What's that going to look like? Who might be there?" Let me put it in sort of a layperson's example. So, I'm the mother of three children. Our oldest child is an engineer. He works for a private engineering firm, and there came a time when he really believed it was time to ask for a raise. So, kind of stressful, right? Young man, asking for a raise. So, if he thinks about using cognitive rehearsal, one of the things he can do is go, "Okay. What might that meeting look like? Who's going to be there? Where will it be? Will it be private? Will there be people passing by? Is it an office that's just partitioned or is it, you know, more secluded? What will that look like?". Cynthia Clark [00:05:43] So, there's some thinking about that situation. Now I begin to go, "Okay, how do I prepare for that kind of stressful ... What are some things I can say? How might I script it?" And I don't mean being scripted but to sort of script through your mind. What am I going to say when I get to that meeting? How might I tee this up for success? What might that interaction go like if I anticipate what my boss might say? And I've practiced doing that, and I've been coached a little bit by somebody in this cognitively rehearsed experience, and I practice, practice, practice with good coaching, and I debrief that a little bit, the likelihood -- this is the belief using cognitive rehearsal -- that the likelihood of that going well is heightened. Makes sense. So, when we're doing it with students for incivility, or I've done it with physicians and nurses and, really, you know lots of different people. But, in the case of incivility, we think about, "What are some scenarios you might find yourself in?" And we think about and we role play those, and we practice those. "What am I going to say if I'm faced with this type of situation? How can I frame that? How can I approach that?" So I find that courage to speak up on behalf of my patients. And then being able later to debrief that. Cynthia Clark [00:07:15] So, I know that's a kind of a long way to get around it. But giving students that ability to practice is essential. So, let me give you one more thought about that. So, if I were to ask a group of nursing students -- let's say I have 100 nursing students. "Think about the very first time you started an I.V." And I do this a lot when I'm meeting with students. "Raise your hand if the very first time you did it, you were perfect at it. You did not breach sterile fields. You hit that vein. Everything was perfect. Patient was happy. How many? Raise your hand." And, of course, almost no one raises their hand. I wouldn't raise my hand if I think back on my first skills. Same thing with a Foley catheter insertion. How many of us got that perfect the first time? No hands. Or maybe one go up. Then I say, "How many now, at the end of your nursing program, feel like, 'You know what? I could do that with a level of competence.'" Lots more hands go up, right? So, the question then becomes: How did you get from no hands going up to at least a large number of hands going up -- or halfway up if they're students. And, of course, the response is practice. They've practice. They've gained experience. They've done it over time. Cynthia Clark [00:08:34] So, my belief is, if we need that much kind of deliberate practice for psycho motor skills, we probably need that same experience when we're talking about resolving conflict. Communicating effectively-- particularly if it's a surgeon who's pretty mad. Cynthia Clark [00:08:52] How do we do that? Practice, practice, practice, and coaching, and debriefing. Gina Kellogg [00:08:58] So you had talked about five specific aspects of using cognitive rehearsal effectively. Can you discuss those in more detail? Cynthia Clark [00:09:06] Yes. So you would want to, again, go back to sort of, "What is that preparatory work that needs to be done to learn about the concept in this case?" So, incivility or civility, and then the next thing you would do -- So maybe there would be some readings. Or maybe there's a lecture at that I might do as a professor. But there could be some way of helping the students sort of get their gray matter in the game. The next thing we're going to do is think about some scenarios. What are some of those potentials or real scenarios that could happen next? We say, "Okay, let's think about applying some evidence-based approaches to responses I might give in those scenarios." Practice, practice, practice, practice, practice -- with coaches and, then, the final one being debriefing. Let's debrief that through our coaching experience. Gina Kellogg [00:10:01] That is great advice. But now you have to tell us what happened with your son. Cynthia Clark [00:10:07] My son, first of all, felt very prepared, as much as he could. And, yes, he did get a raise. And he also got a little bonus at the end of the year. So he felt pretty confident going into that experience. Gina Kellogg [00:10:20] Well, we've run out of time. But thank you so much, Dr. Clark, for sharing your expertise. Gina Kellogg [00:10:26] We've covered quite a lot today, from what students don't understand about and why they must due to its impact on patient safety. We also got some great advice on how to use cognitive rehearsal to improve our communication skills. And we've got an example of how effective it is with your son's personal experience. In our next podcast, we're going to talk about some behaviors that many don't recognize as uncivil. In fact, you may exhibit them yourself. But, over time, they can have seriously negative impacts on your colleagues. So tune in for episode two and our civility series with Dr. Cynthia Clark. And until then you can discover more information from Dr. Clark on the API blog. Visit ATItesting.com/educator/blog for articles video interviews and infographics on a variety of topics important to nurse educators like yourself. Thank you for listening.  

ATI 0001 Beyond bullying: The Serious Impact of Incivility in Nursing

Whose responsibility is it to ensure you work in an environment free of uncivil behaviors? Yours — and everyone with whom you work. We all play a crucial role. Get started helping to build and maintain a healthy workplace with these tips from civility expert Cynthia M. Clark, PhD, RN, ANEF, FAAN, Strategic Nursing Advisor.START A CONVERSATIONVisit ATI on Facebook, LinkedIn or the ATI blog to comment and share your thoughts.ATI Educator Facebook PageATI Educator LinkedIn PageATI blogDOWNLOAD FOR LATERNo time now? Click the download button at the bottom of this box to save and listen at your leisure.LIKE & SHARETell colleagues and friends about this podcast. Use the links at the bottom of this box.CONTACT USWebsite: www.atitesting.comEmail: aticommunications@atitesting.comPhone: (800) 667-7531 READ THE FULL TRANSCRIPTGina Kellogg [00:00:14] Welcome to the first episode of ATI's series on civility and nursing. I'm Gina Kellogg, the senior manager of marketing content strategy for ATI. We are extremely lucky today to gain some insights from Dr. Cynthia Clark. Many of you may know Dr. Clark as the world's leading expert on fostering civility and healthy work environments. Her research has proven that when incivility exists, it puts both nurses and patient safety at risk. Dr. Clark has built her reputation on decades of research into the topic of civility. Most recently she's focused on examining effective ways of preparing nursing students and addressing incivility in both academic and practice settings, and this is a topic gaining greater momentum in today's world.Gina Kellogg [00:00:57] Dr. Clark, thank you for helping us better understand this issue. Let's start by asking you to explain why nursing faculty must address civility with their students. Why must students be taught about civility?Cynthia Clark [00:01:10] Sometimes students come to us without a clear realization of how their behaviors might impact other people. What's expected of a professional nurse? What does it mean to advocate for patients? What does it even mean to communicate within the healthcare setting in the patient care environment? And so, a lot of times, we just need to really engage our students in conversation about what it means to behave in ways and interact in ways that are respectful, that speak to being a strong role model, to advocate for patients -- particularly in patient safety situations. So, to your question about why is it important for faculty to address this, at the end of the day, it really comes down to patient safety. That, if our behaviors aren't expressed in ways that -- again -- are respectful, and if we are unable to advocate or call the question in a patient care situation, then somebody could be injured. Patients can actually die.Gina Kellogg [00:02:28] I'm sure students can understand how incivility impacts them, but they may be less familiar with how it impacts patients. What are the aspects students need to understand in regard to patient care.Cynthia Clark [00:02:39] Well, again, you know, coming back to this idea of advocacy, of speaking up, of having the skills and -- really -- the moral courage to address situations, particularly if you're new to the profession or you're in the student role -- you know -- how do I find that courage to speak up? To stand up? To advocate when my patient needs me to do that -- especially if you're surrounded by healthcare professionals who have been in the business a very long time? Sometimes, there's an intimidation factor around seasoned nurses or our physician colleagues or others. So, at the end of the day, we need to really understand that the patient safety issues are really critical to us learning and mastering some of these skills.Gina Kellogg [00:03:32] What are some of the techniques an educator can use to help their students develop that kind of courage?Cynthia Clark [00:03:37] Yeah, it's a great question. So, one of the techniques that's really steeped in evidence and is gaining a lot of momentum and -- actually -- a teaching strategy that I've been using probably since about, I want to say, about 2008 -- so for at least 10 years -- and it's called cognitive rehearsal. Cognitive rehearsal essentially consists of about five different steps. So, the first step is to think about what preparatory material do I need to have my students learn before we take on this learning experience? What kind of prebriefing do they need to learn about this concept? So, let's say we're talking about incivility or, you know, disruptive healthcare settings or academic environments -- whatever that might be. What do we need to know about that topic? Because, essentially, what cognitive rehearsal does, it comes to us from behavioral science. And it makes some assumptions, and some of the assumptions -- and I'll go back to the steps in a moment -- but some of the assumptions that it makes is that any of us, if we anticipate that we're going to be in a certain situation -- particularly if it's stressful or, in this case, may be uncivil or really disruptive or maybe even intimidating. So, if we think about that before it happens, and sort of consider, "What's that going to look like? Who might be there?" Let me put it in sort of a layperson's example. So, I'm the mother of three children. Our oldest child is an engineer. He works for a private engineering firm, and there came a time when he really believed it was time to ask for a raise. So, kind of stressful, right? Young man, asking for a raise. So, if he thinks about using cognitive rehearsal, one of the things he can do is go, "Okay. What might that meeting look like? Who's going to be there? Where will it be? Will it be private? Will there be people passing by? Is it an office that's just partitioned or is it, you know, more secluded? What will that look like?".Cynthia Clark [00:05:43] So, there's some thinking about that situation. Now I begin to go, "Okay, how do I prepare for that kind of stressful ... What are some things I can say? How might I script it?" And I don't mean being scripted but to sort of script through your mind. What am I going to say when I get to that meeting? How might I tee this up for success? What might that interaction go like if I anticipate what my boss might say? And I've practiced doing that, and I've been coached a little bit by somebody in this cognitively rehearsed experience, and I practice, practice, practice with good coaching, and I debrief that a little bit, the likelihood -- this is the belief using cognitive rehearsal -- that the likelihood of that going well is heightened. Makes sense. So, when we're doing it with students for incivility, or I've done it with physicians and nurses and, really, you know lots of different people. But, in the case of incivility, we think about, "What are some scenarios you might find yourself in?" And we think about and we role play those, and we practice those. "What am I going to say if I'm faced with this type of situation? How can I frame that? How can I approach that?" So I find that courage to speak up on behalf of my patients. And then being able later to debrief that.Cynthia Clark [00:07:15] So, I know that's a kind of a long way to get around it. But giving students that ability to practice is essential. So, let me give you one more thought about that. So, if I were to ask a group of nursing students -- let's say I have 100 nursing students. "Think about the very first time you started an I.V." And I do this a lot when I'm meeting with students. "Raise your hand if the very first time you did it, you were perfect at it. You did not breach sterile fields. You hit that vein. Everything was perfect. Patient was happy. How many? Raise your hand." And, of course, almost no one raises their hand. I wouldn't raise my hand if I think back on my first skills. Same thing with a Foley catheter insertion. How many of us got that perfect the first time? No hands. Or maybe one go up. Then I say, "How many now, at the end of your nursing program, feel like, 'You know what? I could do that with a level of competence.'" Lots more hands go up, right? So, the question then becomes: How did you get from no hands going up to at least a large number of hands going up -- or halfway up if they're students. And, of course, the response is practice. They've practice. They've gained experience. They've done it over time.Cynthia Clark [00:08:34] So, my belief is, if we need that much kind of deliberate practice for psycho motor skills, we probably need that same experience when we're talking about resolving conflict. Communicating effectively-- particularly if it's a surgeon who's pretty mad.Cynthia Clark [00:08:52] How do we do that? Practice, practice, practice, and coaching, and debriefing.Gina Kellogg [00:08:58] So you had talked about five specific aspects of using cognitive rehearsal effectively. Can you discuss those in more detail?Cynthia Clark [00:09:06] Yes. So you would want to, again, go back to sort of, "What is that preparatory work that needs to be done to learn about the concept in this case?" So, incivility or civility, and then the next thing you would do -- So maybe there would be some readings. Or maybe there's a lecture at that I might do as a professor. But there could be some way of helping the students sort of get their gray matter in the game. The next thing we're going to do is think about some scenarios. What are some of those potentials or real scenarios that could happen next? We say, "Okay, let's think about applying some evidence-based approaches to responses I might give in those scenarios." Practice, practice, practice, practice, practice -- with coaches and, then, the final one being debriefing. Let's debrief that through our coaching experience.Gina Kellogg [00:10:01] That is great advice. But now you have to tell us what happened with your son.Cynthia Clark [00:10:07] My son, first of all, felt very prepared, as much as he could. And, yes, he did get a raise. And he also got a little bonus at the end of the year. So he felt pretty confident going into that experience.Gina Kellogg [00:10:20] Well, we've run out of time. But thank you so much, Dr. Clark, for sharing your expertise.Gina Kellogg [00:10:26] We've covered quite a lot today, from what students don't understand about and why they must due to its impact on patient safety. We also got some great advice on how to use cognitive rehearsal to improve our communication skills. And we've got an example of how effective it is with your son's personal experience.In our next podcast, we're going to talk about some behaviors that many don't recognize as uncivil. In fact, you may exhibit them yourself. But, over time, they can have seriously negative impacts on your colleagues. So tune in for episode two and our civility series with Dr. Cynthia Clark. And until then you can discover more information from Dr. Clark on the API blog. Visit ATItesting.com/educator/blog for articles video interviews and infographics on a variety of topics important to nurse educators like yourself. Thank you for listening. 

Supporting nurse educators in developing practice-ready nursing students

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