You may think your current organization operates seamlessly, or you may feel it has many issues. You may experience or even observe things that give you pause. Yet, much as you wouldn’t try to determine the health of a patient through mere observation, you should not attempt to gauge the health of your work environment based on observation and opinion. Often, there are issues you perceive as problems that others do not; similarly, issues may run much deeper than leadership recognizes.
There are many factors and measures that may impact organizational health. Among these is civility. While an organization can institute policies designed to promote such things as civility, how can it be sure these are managed effectively? In this Discussion, you will examine the use of tools in measuring workplace civility.
To Prepare:
· Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).
· Review and complete the Work Environment Assessment Template in the Resources.
By Day 3 of Week 7
Post a brief description of the results of your Work Environment Assessment. Based on the results, how civil is your workplace? Explain why your workplace is or is not civil. Then, describe a situation where you have experienced incivility in the workplace. How was this addressed? Be specific and provide examples.
6053 Discussion Learning Resources
Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). New York, NY: Springer.
· Chapter 9, “Creating and Shaping the Organizational Environment and Culture to Support Practice Excellence” (pp. 247–278)
· Chapter 10, “Building Cohesive and Effective Teams” (pp. 279–298)
Select at least ONE of the following:
Clark, C. M., Olender, L., Cardoni, C., & Kenski, D. (2011). Fostering civility in nursing education and practice: Nurse leader perspectives. Journal of Nursing Administration, 41(7/8), 324–330. doi:10.1097/NNA.0b013e31822509c4
Note: You will access this article from the Walden Library databases.
Clark, C. M. (2018). Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educator. doi:10.1097/NNE.0000000000000563
Note: You will access this article from the Walden Library databases.
Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18–23. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2015/11/ant11-CE-Civility-1023
Griffin, M., & Clark, C. M. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. Journal of Continuing Education in Nursing, 45(12), 535–542. doi:10.3928/00220124-20141122-02
Note: You will access this article from the Walden Library databases.
Document: Work Environment Assessment Template
Video Transcript.
Work Environment Assessment
Template
Use this document to complete the Module 4
Workplace Environment Assessment
.
Summary of Results – Clark Healthy Workplace Inventory
Identify two things that surprised you about the results. Also identify one idea that you believed prior to conducting the Assessment that was confirmed.
What do the results of the Assessment suggest about the health and civility of your workplace?
Briefly describe the theory or concept presented in the article(s) you selected.
Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.
Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.
Combining Cognitive Rehearsal, Simulation, and
Evidence-Based Scripting to Address Incivility
Autho
The a
Corre
clark
Accep
Publis
DOI:
64
Cynthia M. Clark, PhD, RN, ANEF, FAAN
ABSTRACT
Background: Nurses have a professional and ethical obligation to foster civility and healthy work environments to protect
patient safety. Evidence-based teaching strategies are needed to prepare nursing students to address acts of incivility that
threaten patient safety.
Problem: Incivility in health care must be effectively addressed because the delivery of safe patient care may depend on these
vital skills.
Approach: Cognitive rehearsal (CR) is an evidence-based technique where learners practice addressing workplace incivility
in a nonthreatening environment with a skilled facilitator. The author describes the unique combination of CR, simulation,
evidence-based scripting, deliberate practice, and debriefing to prepare nursing students to address uncivil encounters.
Outcomes: Learners who participated in CR identified benefits using this approach.
Conclusions: Combining CR with simulation, evidence-based scripting, repeated dosing through deliberate practice, and skillful
debriefing is an effective method to provide nursing students with the skills needed to address incivility, thereby increasing the
likelihood of protecting patient safety.
Keywords: civility, cognitive rehearsal, debriefing, deliberate practice, incivility, simulation
Cite this article as: Clark CM. Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educ.
2019;44(2):64–68. doi: 10.1097/NNE.0000000000000563
I
ncivility in health care settings can have a detrimental
impact on individuals, teams, and organizations. In the
patient care environment, uncivil encounters can provoke
uncertainty and self-doubt, weaken self-confidence, and
compromise critical thinking and clinical judgment skills.
If poorly managed, incivility can lead to life-threatening
mistakes, preventable complications, harm, or death of a
patient.1-6 Therefore, innovative and evidence-based teaching
strategies are needed to prepare nursing students to foster
healthy work environments and address acts of incivility
that threaten teamwork and patient safety.
The American Nurses Association (ANA) Code of Ethics
for Nurses7 clearly emphasizes nurses’ moral and ethical
obligation to ensure patient safety by fostering healthy
work environments and cultures of civility. Cognitive
rehearsal (CR) is an evidence-based technique whereby
individuals work with a coach or facilitator to practice
addressing stressful situations in a nonthreatening environ-
ment.8,9 Being well prepared, speaking with confidence,
and using respectful expressions to address incivility can
empower nursing students and nurses to speak up and ad-
dress uncivil behaviors. Using evidence-based approaches
r Affiliation: Strategic Nursing Advisor, ATI Nursing Education, Boise, Idaho.
uthor declares no conflicts of interest.
spondence: Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (cindy.
@atitesting.com).
to structure responses using a deliberate practice model
provides an effective communication tool to protect patient
safety and enhance teamwork within health care organiza-
tions. The author describes how the combination of CR,
simulation, evidence-based scripting, deliberate practice,
and debriefing can be used to address workplace incivility.
Cognitive Rehearsal
Cognitiverehearsalisatechniqueusedinbehavioralscience
whereby individuals work with a skilled facilitator to dis-
cuss and rehearse effective ways to address a particular
problem or social situation.8 It is designed to decrease anx-
iety, heighten confidence, and improve impulse control by
practicing effective ways to address potentially stressful sit-
uations.9 Theuseof CR hasbeen reportedtobean effective
strategytoaddressincivilityinpracticeandeducationalset-
tings.8,10-14 Using a planned, rehearsed response helps to
create an opportunity to communicate expectations for ap-
propriate behaviors and future interactions.15 Put simply,
CR is a behavioral strategy used to prepare an individual
for a potentially stressful situation by repeatedly rehearsing
the situation to strengthen the probability of a favorable
outcome. Using CR as a strategy to prepare for what might
be considered a stressful encounter includes preparing for
the encounter by rehearsing specific phrases that might be
used during the meeting, being coached by someone skilled
at effective communication, and rehearsing the encounter
using deliberate practice, followed by a debriefing session.
This series of activities is likely to lead to a more successful
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outcome because the individual has thoughtfully prepared
for the encounter.
Although the use of CR can take various forms, the
author describes the technique as consisting of 5 essential
elements including (1) prebriefing and preparatory learn-
ing, (2) identifying and describing uncivil scenarios for
simulation, (3) using evidence-based approaches to role-
play and rehearse responses, (4) using deliberate practice
to repeat the simulated scenarios, and (5) debriefing sim-
ulated scenarios of uncivil encounters.
Prebriefing and Preparatory Learning
Prebriefing and preparatory learning include readings fo-
cused on the relationship between incivility, staying silent
when uncivil encounters occur, and the subsequent po-
tential impact on patient safety. Examples include a series
of articles highlighting how staying silent and failing to
advocate for patient safety can lead to errors and poor patient
outcomes.4-6 These studies also describe how education, role-
play, practice, and “scripting” can improve communica-
tion and conflict negotiation skills, which leads to improved
patient outcomes.
Another preparatory reading includes the ANA posi-
tion paper on incivility, bullying, and workplace violence,11
which articulates individual and shared roles and respon-
sibilities of nurses and employers to create and sustain a
culture of respect across the health care continuum. Accord-
ing to the ANA,11 all nurses in all settings are responsible for
creating a culture of respect and implementing evidence-
based best practices to prevent and mitigate incivility and
bullying and to foster a healthy and safe work environment
for all members of the health care team, health care con-
sumers, families, and communities.
Other suggestions for preparatory readings include
select articles from nursing practice and academe such
as the ANA Code of Ethics for Nurses7 and excerpts from
Clark,16 or students may conduct a review of the relevant
literature to identify and summarize scholarly works on
civility and incivility in nursing and health care.
Identifying and Describing Uncivil
Scenarios
for Simulation
Aftercompletingpreparatoryreadings,facultymayengage
students in a deepened understanding of the topical mate-
rial by using active learning strategies such as narrative
pedagogy, storytelling, learning circle discussions,17-19 and
small and large group activities. These teaching strategies
may also be used to introduce students to CR and how
the technique may be used to address uncivil encounters
in the practice setting, especially those that compromise
patient care. Common examples of uncivil behaviors that
may occur in a health care environment include refusing
to help a colleague in need, withholding important infor-
mation during a patient handoff, or engaging in gossip
and spreading rumors.8,12,16 Uncivil scenarios for student
role-playing may be written by faculty, obtained from ex-
perts on the topic of incivility and bullying,20,21 or
developed by students who identify real or potential un-
civil encounters that may occur in health care settings.
Using Evidence-Based Approaches to Role-Play
and Script Responses
Once students establish a solid foundation and work-
ing knowledge about civility and incivility in nursing
education and practice, faculty can introduce students
to evidence-based approaches such as “I” messaging22
and the Caring Feedback Model23 and to script responses
to address uncivil encounters. Because no 1-size-fits-all
approach exists for every individual and because each
individual has a unique way of expressing themselves,
evidence-based approaches offer a structured procedure
and a common language for scripting personalized re-
sponses rather than being rigidly “scripted.” In other words,
students use the approaches to develop scripts crafted in
their own words.
One evidence-based approach for effective commu-
nication is the use of “I” messaging.22 Helping students
learn and practice using “I” messages to address incivil-
ity is a beneficial learning activity. Using “I” messages
does not guarantee that a conflict will be successfully
resolved; however, “I” messages provide a means to ad-
dress conflict in a constructive manner and to preserve
relationships rather than making them worse. If possible,
“You” messages should be avoided because they may
sound critical or accusatory and often trigger defensive-
ness, retreat, or confrontation. Examples of “I” messages
include “I believe you are saying” or “I understand your
position to be” when seeking clarification of the encoun-
ter. If addressed in an uncivil manner, one might reply, “I
provide the best patient care when I’m treated with re-
spect.” Responding with an assertive “I beg your par-
don?” in response to a demeaning or condescending remark
can prompt the offender to step back, think about his/her
comment, and perhaps reconsider his/her approach. It is
also important to describe objective, observable behaviors,
as well as the real or potential impact of the behavior, rather
than to focus on the individual and personalize the event.
Nursing students need ongoing, realistic opportunities
tohonecommunicationskillstofunctioneffectivelyascon-
fident, assertive team members; however, reinforcing the
importance of communication requires more than discussion.
It requires simulating, demonstrating, practicing, and re-
hearsing these fundamental skills over and over again.16
Simulations can be used to create uncivil, high-anxiety situ-
ations that give students a safe place to make mistakes,
practice addressing uncivil encounters, and observe first-
hand how a gesture or word choice can influence the out-
come of the situation.16 Participating in simulated
scenarios allows students to sharpen their communica-
tion skills by listening for understanding, attending to
both verbal and nonverbal cues, interpreting interactions,
and reflecting on their view of the uncivil encounter. The
next section describes how the evidence-based approach
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Table 1. Scenario: The Case of Conflicted Classmates
Scenario Response Using an “I” Message Approach
Alex is a member of a class project where the final grade is based on
each student’s ability to contribute equitably to the project’s completion.
The stakes are high because individual grades are based on the overall
performance of the group and how the group performs as a team. One of
the members (Abby) is frequently late for meetings, fails to complete her
share of the work, and sends text message to friends when she seems
bored with the group work. The deadline is approaching, and several
members of the group are concerned that the project will not be
completed on time or be of good quality. On behalf of the group, Alex
decides to discuss their concerns with Abby.
“Abby, I appreciate the opportunity to meet with you to discuss our
class project. The project is nearly due, and I’m concerned about
the outcome. When the project started, we all agreed to complete
our individual parts on time and in a quality way. If you need help
completing your part, we need to know so we can problem-solve as
a team. I welcome your ideas about ways to meet the deadline and
still produce a quality project.”
of “I” messaging and other evidence-based approaches
may be used to develop scripts to address uncivil situations.
Exemplars of Uncivil Encounters in Academic
and Practice Environments
Several examples of uncivil scenarios with corresponding
responses using evidence-based approaches are presented
in Tables 1 to 5. A scenario depicting an uncivil situation
among nursing students assigned to collaborate on a group
project is presented in Table 1, along with a response using
an “I” message approach to address the issue.
After gaining experience using an “I” messaging ap-
proach, students are introduced to other evidence-based
approaches. The next scenario and corresponding script
uses the Caring Feedback Model23 as an evidence-based
approach to address an uncivil nurse-to-nurse encounter
(Table 2). The Caring Feedback Model includes the fol-
lowing steps: (1) state your positive intent/purpose; (2) de-
scribe the specific behavior you noticed or heard about;
(3) explain the consequence for you, your team, the patients,
or the organization; (4) offer “a pinch” of empathy; and
(5) make a suggestion or request.
Thenextscenarioisbasedontheapproachsuggestedby
Caspersen,24 which includes the following elements: “When
(the triggering event) happened, I felt/believed (feeling/
belief) because my (need/interest) is important to me. Would
you be willing to (request a doable) action?” Table 3 illus-
trates Caspersen’s approach when responding to an un-
civil encounter occurring among coworkers.
The next evidence-based approach was developed
by the Agency for Healthcare Research and Quality
(AHRQ)25 as part of the TeamSTEPPS approach designed
Table 2. Scenario: The Case of the Impatient Nurse
Scenario
Connie is an experienced nurse who has made it abundantly clear that
she has little or no patience when it comes to dealing with new or less
experienced nurses. Kim is a newly graduated nurse and reaches out to
Connie asking for her help with a complex patient situation. Connie
responds rudely stating, “I don’t have time to deal with novices. I’ve got
more important things to do.”
to equip health care workers with the essential skills
needed to address uncivil encounters when they happen,
thus increasing the likelihood of success in stopping the
behavior and protecting patient safety. The next scenario
uses the DESC approach—an acronym for (D) describe
the situation, (E) express your concerns, (S) suggest other
alternatives, and (C) consequences stated (Table 4)—to
illustrate an uncivil encounter between a staff nurse and
the nurse manager.
The next evidence-based approach was also developed
by AHRQ25 as part of the TeamSTEPPS approach. CUS is
an acronym for Concerned, Uncomfortable, and Safety—
an approach designed to script a response to use during an
uncivil or conflicted situation, particularly when patient
safetyisinjeopardy.ThescenariosdepictedinTable5illus-
trate 2 different uncivil experiences occurring in the patient
care environment and corresponding responses using the
CUS approach. These evidence-based approaches provide
a helpful structure to script responses to address uncivil en-
counters and to ultimately improve patient safety in health
care organizations.
Using Deliberate Practice to Repeat the Simulated
Scenarios
Deliberaterepetitivepractice(DRP)isaprocessforlearning
andmasteringpsychomotorskillsbyprogressingthrough3
primary phases: (1) understanding the skill and learning
howtoperformitaccurately,(2)refiningtheskilluntilitbe-
comes more consistent, and (3) practicing the skill until it is
automatic and the learner does not need to consciously
think about each step.26 Oermann27 further noted that, to
master skills, students need opportunities to practice them
Response Using the Caring Feedback Model
“Connie, I respect your experience and hope to learn from you. Earlier
today, when I asked for help, it didn’t seem to go well. Without your
support, I’m concerned that patient care might suffer. I realize you’re
busy and have a lot going on. Still, I need to ask some important
questions. When can we meet to discuss them?”
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Table 3. Scenario: The Case of the Gossiping Coworkers
Scenario Response Using the Caspersen Approach
You are a nurse working on the telemetry unit. Some of your coworkers
engage in negative gossip and spreading rumors. You believe you have
been the target of these behaviors, and one day when you approach
the break room, you hear your name mentioned in a derogatory and
negative way. As you enter, the voices fall silent. This is not the first
time this has happened, so you decide to address the situation.
“When I approached the break room, I heard my name mentioned. It
concerns me because being accepted as a valued member of the team
is important to me. In the future, please speak with me directly if you
have something to say.”
Table 4. Scenario: The Case of the Frustrated Manager
Scenario Response Using the DESC Approach
Hey Kathy, Nicole called in sick. We’re shorthanded, so you need to
stay and cover her shift. You may not like the decision, but we all need
to suck it up and deal with it.
“Alice, I appreciate the need to cover the unit. However, I’d like to
discuss other options since I’m unable to work an additional shift. I’m
exhausted, and because I’ve recently covered other shifts, I’m not
rested enough to provide safe patient care. Can we discuss other ways
to cover the shift?”
repetitively and to receive ongoing feedback to guide their
performance. Without DRP, many skills may decay or be
lost altogether. Like psychomotor skill-building, this same
process may be applied to addressing uncivil encounters.
Learning these new skills takes training, experience, prac-
tice, and feedback. Students require more than 1 practice
session to become proficient using CR to address incivility.
Repeated opportunities to practice these strategies over an
extended period are critical so that, if and when uncivil en-
counters occur, nurses are more apt to use a practiced and
patterned response.
Debriefing Simulated Scenarios of Uncivil
Encounters
Rehearsal of the simulated scenarios and scripted re-
sponses should be followed by a comprehensive coaching
Table 5. Scenarios and Responses Using the CUS Approach
Scenarios
The case of the uncivil nurse preceptor
Chris is a senior level nursing student assigned to Mr Brown, a patient
recently diagnosed with diabetes. Although Mr Brown has orders for
the laboratory to draw a glucose level, he is not included on the list of
patients to have a glucose level drawn. Chris notices the omission and
brings it to the attention of his clinical preceptor. She’s clearly annoyed,
rolls her eyes, and reprimands him in front of other nurses stating that
he is out of line for questioning her. Despite his discomfort, Chris
decides to advocate for Mr Brown using the CUS approach.
The case of the hurried handoff
“Geez, Katy, where have you been? You’re late as usual. It’s been a
really busy shift, and I can’t wait to get out of here. See if you can
manage to get this information straight for once. You should know the
patient in 402 since you took care of her yesterday. She has a bunch of
treatments and medications that need to be done. You need to check
her vital signs too—I’ve been way too busy to do them. I’m outta here.
If I forgot something, check the chart.”
and debriefing session. Successful debriefing requires
creating safe spaces for reflection and exploring effective
ways to address future situations. According to AHRQ,28
debriefing is an important learning strategy to help indi-
viduals identify aspects of individual and team perfor-
mance that went well and those that did not. Through
debriefing, students learn from deficiencies to improve their
performance. The goal of debriefing is to discuss the actions
and thought processes involved in a particular situation, en-
courage reflection on those actions and thought processes,
and incorporate improvement into future performance.26
Simulation debriefing has also been described as a
structured and guided reflection process in which students
actively appraise their cognitive, affective, and psychomotor
performance, giving them an opportunity to assume an ac-
tive role during the learning process.29
Response Using the CUS Approach
“Nurse Adams, Mr Brown has been diagnosed with diabetes, and I’m
Concerned that he isn’t on the list for glucose testing. I’m Uncomfortable
administering insulin until his lab results are back to be sure he’s
receiving a Safe dose.”
“Terry, I realize being late is not OK, and we can talk about that later.
For now, I’m Concerned about Mrs. Jones and Uncomfortable rushing
through report. For her Safety, please provide a complete report before
you go.”
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Examples of debriefing questions for uncivil encoun-
ters include the following14:
Ask each student participant: What was it like to be part of
this experience?
Ask observers: What was it like to observe the experience?
Ask student participants and observers: How would you
describe the experience? What went well, and what would
you do again? What did you learn? How might you apply
what you have learned in your clinical practice? What
might be done differently next time?
Learners participating in the CR experience identified sev-
eral benefits of this approach including learning to speak
up in stressful situations, communicating more effectively,
and advocating for safe patient care.
Conclusion
In health care, the need to effectively address uncivil situa-
tions is critical because the delivery of safe patient care
depends on these vital skills. Nurses and nursing students
must be well equipped to effectively address incivility in
a variety of situations to promote teamwork and collab-
oration and to protect patient safety. Combining CR with
evidence-based scripting within a deliberate practice model
and with skilled debriefing is an effective method to provide
nurses and nursing students with the essential skills needed
to effectively address uncivil encounters when they happen,
thereby increasing the likelihood of success in stopping the
behavior and protecting patient safety. Role-playing actual
scenarios provides nursing students with real-life experi-
ences to effectively address incivility. Debriefing sessions
help to create safe spaces for reflective practice and explor-
ing effective ways to address future situations.
Acknowledgment
The author acknowledges Dr Suzan Kardong-Edgren for
her review.
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www.nurseeducatoronline.com
Health, Inc. All rights reserved.
Combining Cognitive Rehearsal, Simulation, and
Evidence-Based Scripting to Address Incivility
Autho
The a
Corre
clark
Accep
Publis
DOI:
64
Cynthia M. Clark, PhD, RN, ANEF, FAAN
ABSTRACT
Background: Nurses have a professional and ethical obligation to foster civility and healthy work environments to protect
patient safety. Evidence-based teaching strategies are needed to prepare nursing students to address acts of incivility that
threaten patient safety.
Problem: Incivility in health care must be effectively addressed because the delivery of safe patient care may depend on these
vital skills.
Approach: Cognitive rehearsal (CR) is an evidence-based technique where learners practice addressing workplace incivility
in a nonthreatening environment with a skilled facilitator. The author describes the unique combination of CR, simulation,
evidence-based scripting, deliberate practice, and debriefing to prepare nursing students to address uncivil encounters.
Outcomes: Learners who participated in CR identified benefits using this approach.
Conclusions: Combining CR with simulation, evidence-based scripting, repeated dosing through deliberate practice, and skillful
debriefing is an effective method to provide nursing students with the skills needed to address incivility, thereby increasing the
likelihood of protecting patient safety.
Keywords: civility, cognitive rehearsal, debriefing, deliberate practice, incivility, simulation
Cite this article as: Clark CM. Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educ.
2019;44(2):64–68. doi: 10.1097/NNE.0000000000000563
I
ncivility in health care settings can have a detrimental
impact on individuals, teams, and organizations. In the
patient care environment, uncivil encounters can provoke
uncertainty and self-doubt, weaken self-confidence, and
compromise critical thinking and clinical judgment skills.
If poorly managed, incivility can lead to life-threatening
mistakes, preventable complications, harm, or death of a
patient.1-6 Therefore, innovative and evidence-based teaching
strategies are needed to prepare nursing students to foster
healthy work environments and address acts of incivility
that threaten teamwork and patient safety.
The American Nurses Association (ANA) Code of Ethics
for Nurses7 clearly emphasizes nurses’ moral and ethical
obligation to ensure patient safety by fostering healthy
work environments and cultures of civility. Cognitive
rehearsal (CR) is an evidence-based technique whereby
individuals work with a coach or facilitator to practice
addressing stressful situations in a nonthreatening environ-
ment.8,9 Being well prepared, speaking with confidence,
and using respectful expressions to address incivility can
empower nursing students and nurses to speak up and ad-
dress uncivil behaviors. Using evidence-based approaches
r Affiliation: Strategic Nursing Advisor, ATI Nursing Education, Boise, Idaho.
uthor declares no conflicts of interest.
spondence: Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (cindy.
@atitesting.com).
to structure responses using a deliberate practice model
provides an effective communication tool to protect patient
safety and enhance teamwork within health care organiza-
tions. The author describes how the combination of CR,
simulation, evidence-based scripting, deliberate practice,
and debriefing can be used to address workplace incivility.
Cognitive Rehearsal
Cognitiverehearsalisatechniqueusedinbehavioralscience
whereby individuals work with a skilled facilitator to dis-
cuss and rehearse effective ways to address a particular
problem or social situation.8 It is designed to decrease anx-
iety, heighten confidence, and improve impulse control by
practicing effective ways to address potentially stressful sit-
uations.9 Theuseof CR hasbeen reportedtobean effective
strategytoaddressincivilityinpracticeandeducationalset-
tings.8,10-14 Using a planned, rehearsed response helps to
create an opportunity to communicate expectations for ap-
propriate behaviors and future interactions.15 Put simply,
CR is a behavioral strategy used to prepare an individual
for a potentially stressful situation by repeatedly rehearsing
the situation to strengthen the probability of a favorable
outcome. Using CR as a strategy to prepare for what might
be considered a stressful encounter includes preparing for
the encounter by rehearsing specific phrases that might be
used during the meeting, being coached by someone skilled
at effective communication, and rehearsing the encounter
using deliberate practice, followed by a debriefing session.
This series of activities is likely to lead to a more successful
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outcome because the individual has thoughtfully prepared
for the encounter.
Although the use of CR can take various forms, the
author describes the technique as consisting of 5 essential
elements including (1) prebriefing and preparatory learn-
ing, (2) identifying and describing uncivil scenarios for
simulation, (3) using evidence-based approaches to role-
play and rehearse responses, (4) using deliberate practice
to repeat the simulated scenarios, and (5) debriefing sim-
ulated scenarios of uncivil encounters.
Prebriefing and Preparatory Learning
Prebriefing and preparatory learning include readings fo-
cused on the relationship between incivility, staying silent
when uncivil encounters occur, and the subsequent po-
tential impact on patient safety. Examples include a series
of articles highlighting how staying silent and failing to
advocate for patient safety can lead to errors and poor patient
outcomes.4-6 These studies also describe how education, role-
play, practice, and “scripting” can improve communica-
tion and conflict negotiation skills, which leads to improved
patient outcomes.
Another preparatory reading includes the ANA posi-
tion paper on incivility, bullying, and workplace violence,11
which articulates individual and shared roles and respon-
sibilities of nurses and employers to create and sustain a
culture of respect across the health care continuum. Accord-
ing to the ANA,11 all nurses in all settings are responsible for
creating a culture of respect and implementing evidence-
based best practices to prevent and mitigate incivility and
bullying and to foster a healthy and safe work environment
for all members of the health care team, health care con-
sumers, families, and communities.
Other suggestions for preparatory readings include
select articles from nursing practice and academe such
as the ANA Code of Ethics for Nurses7 and excerpts from
Clark,16 or students may conduct a review of the relevant
literature to identify and summarize scholarly works on
civility and incivility in nursing and health care.
Identifying and Describing Uncivil
Scenarios
for Simulation
Aftercompletingpreparatoryreadings,facultymayengage
students in a deepened understanding of the topical mate-
rial by using active learning strategies such as narrative
pedagogy, storytelling, learning circle discussions,17-19 and
small and large group activities. These teaching strategies
may also be used to introduce students to CR and how
the technique may be used to address uncivil encounters
in the practice setting, especially those that compromise
patient care. Common examples of uncivil behaviors that
may occur in a health care environment include refusing
to help a colleague in need, withholding important infor-
mation during a patient handoff, or engaging in gossip
and spreading rumors.8,12,16 Uncivil scenarios for student
role-playing may be written by faculty, obtained from ex-
perts on the topic of incivility and bullying,20,21 or
developed by students who identify real or potential un-
civil encounters that may occur in health care settings.
Using Evidence-Based Approaches to Role-Play
and Script Responses
Once students establish a solid foundation and work-
ing knowledge about civility and incivility in nursing
education and practice, faculty can introduce students
to evidence-based approaches such as “I” messaging22
and the Caring Feedback Model23 and to script responses
to address uncivil encounters. Because no 1-size-fits-all
approach exists for every individual and because each
individual has a unique way of expressing themselves,
evidence-based approaches offer a structured procedure
and a common language for scripting personalized re-
sponses rather than being rigidly “scripted.” In other words,
students use the approaches to develop scripts crafted in
their own words.
One evidence-based approach for effective commu-
nication is the use of “I” messaging.22 Helping students
learn and practice using “I” messages to address incivil-
ity is a beneficial learning activity. Using “I” messages
does not guarantee that a conflict will be successfully
resolved; however, “I” messages provide a means to ad-
dress conflict in a constructive manner and to preserve
relationships rather than making them worse. If possible,
“You” messages should be avoided because they may
sound critical or accusatory and often trigger defensive-
ness, retreat, or confrontation. Examples of “I” messages
include “I believe you are saying” or “I understand your
position to be” when seeking clarification of the encoun-
ter. If addressed in an uncivil manner, one might reply, “I
provide the best patient care when I’m treated with re-
spect.” Responding with an assertive “I beg your par-
don?” in response to a demeaning or condescending remark
can prompt the offender to step back, think about his/her
comment, and perhaps reconsider his/her approach. It is
also important to describe objective, observable behaviors,
as well as the real or potential impact of the behavior, rather
than to focus on the individual and personalize the event.
Nursing students need ongoing, realistic opportunities
tohonecommunicationskillstofunctioneffectivelyascon-
fident, assertive team members; however, reinforcing the
importance of communication requires more than discussion.
It requires simulating, demonstrating, practicing, and re-
hearsing these fundamental skills over and over again.16
Simulations can be used to create uncivil, high-anxiety situ-
ations that give students a safe place to make mistakes,
practice addressing uncivil encounters, and observe first-
hand how a gesture or word choice can influence the out-
come of the situation.16 Participating in simulated
scenarios allows students to sharpen their communica-
tion skills by listening for understanding, attending to
both verbal and nonverbal cues, interpreting interactions,
and reflecting on their view of the uncivil encounter. The
next section describes how the evidence-based approach
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Table 1. Scenario: The Case of Conflicted Classmates
Scenario Response Using an “I” Message Approach
Alex is a member of a class project where the final grade is based on
each student’s ability to contribute equitably to the project’s completion.
The stakes are high because individual grades are based on the overall
performance of the group and how the group performs as a team. One of
the members (Abby) is frequently late for meetings, fails to complete her
share of the work, and sends text message to friends when she seems
bored with the group work. The deadline is approaching, and several
members of the group are concerned that the project will not be
completed on time or be of good quality. On behalf of the group, Alex
decides to discuss their concerns with Abby.
“Abby, I appreciate the opportunity to meet with you to discuss our
class project. The project is nearly due, and I’m concerned about
the outcome. When the project started, we all agreed to complete
our individual parts on time and in a quality way. If you need help
completing your part, we need to know so we can problem-solve as
a team. I welcome your ideas about ways to meet the deadline and
still produce a quality project.”
of “I” messaging and other evidence-based approaches
may be used to develop scripts to address uncivil situations.
Exemplars of Uncivil Encounters in Academic
and Practice Environments
Several examples of uncivil scenarios with corresponding
responses using evidence-based approaches are presented
in Tables 1 to 5. A scenario depicting an uncivil situation
among nursing students assigned to collaborate on a group
project is presented in Table 1, along with a response using
an “I” message approach to address the issue.
After gaining experience using an “I” messaging ap-
proach, students are introduced to other evidence-based
approaches. The next scenario and corresponding script
uses the Caring Feedback Model23 as an evidence-based
approach to address an uncivil nurse-to-nurse encounter
(Table 2). The Caring Feedback Model includes the fol-
lowing steps: (1) state your positive intent/purpose; (2) de-
scribe the specific behavior you noticed or heard about;
(3) explain the consequence for you, your team, the patients,
or the organization; (4) offer “a pinch” of empathy; and
(5) make a suggestion or request.
Thenextscenarioisbasedontheapproachsuggestedby
Caspersen,24 which includes the following elements: “When
(the triggering event) happened, I felt/believed (feeling/
belief) because my (need/interest) is important to me. Would
you be willing to (request a doable) action?” Table 3 illus-
trates Caspersen’s approach when responding to an un-
civil encounter occurring among coworkers.
The next evidence-based approach was developed
by the Agency for Healthcare Research and Quality
(AHRQ)25 as part of the TeamSTEPPS approach designed
Table 2. Scenario: The Case of the Impatient Nurse
Scenario
Connie is an experienced nurse who has made it abundantly clear that
she has little or no patience when it comes to dealing with new or less
experienced nurses. Kim is a newly graduated nurse and reaches out to
Connie asking for her help with a complex patient situation. Connie
responds rudely stating, “I don’t have time to deal with novices. I’ve got
more important things to do.”
to equip health care workers with the essential skills
needed to address uncivil encounters when they happen,
thus increasing the likelihood of success in stopping the
behavior and protecting patient safety. The next scenario
uses the DESC approach—an acronym for (D) describe
the situation, (E) express your concerns, (S) suggest other
alternatives, and (C) consequences stated (Table 4)—to
illustrate an uncivil encounter between a staff nurse and
the nurse manager.
The next evidence-based approach was also developed
by AHRQ25 as part of the TeamSTEPPS approach. CUS is
an acronym for Concerned, Uncomfortable, and Safety—
an approach designed to script a response to use during an
uncivil or conflicted situation, particularly when patient
safetyisinjeopardy.ThescenariosdepictedinTable5illus-
trate 2 different uncivil experiences occurring in the patient
care environment and corresponding responses using the
CUS approach. These evidence-based approaches provide
a helpful structure to script responses to address uncivil en-
counters and to ultimately improve patient safety in health
care organizations.
Using Deliberate Practice to Repeat the Simulated
Scenarios
Deliberaterepetitivepractice(DRP)isaprocessforlearning
andmasteringpsychomotorskillsbyprogressingthrough3
primary phases: (1) understanding the skill and learning
howtoperformitaccurately,(2)refiningtheskilluntilitbe-
comes more consistent, and (3) practicing the skill until it is
automatic and the learner does not need to consciously
think about each step.26 Oermann27 further noted that, to
master skills, students need opportunities to practice them
Response Using the Caring Feedback Model
“Connie, I respect your experience and hope to learn from you. Earlier
today, when I asked for help, it didn’t seem to go well. Without your
support, I’m concerned that patient care might suffer. I realize you’re
busy and have a lot going on. Still, I need to ask some important
questions. When can we meet to discuss them?”
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Table 3. Scenario: The Case of the Gossiping Coworkers
Scenario Response Using the Caspersen Approach
You are a nurse working on the telemetry unit. Some of your coworkers
engage in negative gossip and spreading rumors. You believe you have
been the target of these behaviors, and one day when you approach
the break room, you hear your name mentioned in a derogatory and
negative way. As you enter, the voices fall silent. This is not the first
time this has happened, so you decide to address the situation.
“When I approached the break room, I heard my name mentioned. It
concerns me because being accepted as a valued member of the team
is important to me. In the future, please speak with me directly if you
have something to say.”
Table 4. Scenario: The Case of the Frustrated Manager
Scenario Response Using the DESC Approach
Hey Kathy, Nicole called in sick. We’re shorthanded, so you need to
stay and cover her shift. You may not like the decision, but we all need
to suck it up and deal with it.
“Alice, I appreciate the need to cover the unit. However, I’d like to
discuss other options since I’m unable to work an additional shift. I’m
exhausted, and because I’ve recently covered other shifts, I’m not
rested enough to provide safe patient care. Can we discuss other ways
to cover the shift?”
repetitively and to receive ongoing feedback to guide their
performance. Without DRP, many skills may decay or be
lost altogether. Like psychomotor skill-building, this same
process may be applied to addressing uncivil encounters.
Learning these new skills takes training, experience, prac-
tice, and feedback. Students require more than 1 practice
session to become proficient using CR to address incivility.
Repeated opportunities to practice these strategies over an
extended period are critical so that, if and when uncivil en-
counters occur, nurses are more apt to use a practiced and
patterned response.
Debriefing Simulated Scenarios of Uncivil
Encounters
Rehearsal of the simulated scenarios and scripted re-
sponses should be followed by a comprehensive coaching
Table 5. Scenarios and Responses Using the CUS Approach
Scenarios
The case of the uncivil nurse preceptor
Chris is a senior level nursing student assigned to Mr Brown, a patient
recently diagnosed with diabetes. Although Mr Brown has orders for
the laboratory to draw a glucose level, he is not included on the list of
patients to have a glucose level drawn. Chris notices the omission and
brings it to the attention of his clinical preceptor. She’s clearly annoyed,
rolls her eyes, and reprimands him in front of other nurses stating that
he is out of line for questioning her. Despite his discomfort, Chris
decides to advocate for Mr Brown using the CUS approach.
The case of the hurried handoff
“Geez, Katy, where have you been? You’re late as usual. It’s been a
really busy shift, and I can’t wait to get out of here. See if you can
manage to get this information straight for once. You should know the
patient in 402 since you took care of her yesterday. She has a bunch of
treatments and medications that need to be done. You need to check
her vital signs too—I’ve been way too busy to do them. I’m outta here.
If I forgot something, check the chart.”
and debriefing session. Successful debriefing requires
creating safe spaces for reflection and exploring effective
ways to address future situations. According to AHRQ,28
debriefing is an important learning strategy to help indi-
viduals identify aspects of individual and team perfor-
mance that went well and those that did not. Through
debriefing, students learn from deficiencies to improve their
performance. The goal of debriefing is to discuss the actions
and thought processes involved in a particular situation, en-
courage reflection on those actions and thought processes,
and incorporate improvement into future performance.26
Simulation debriefing has also been described as a
structured and guided reflection process in which students
actively appraise their cognitive, affective, and psychomotor
performance, giving them an opportunity to assume an ac-
tive role during the learning process.29
Response Using the CUS Approach
“Nurse Adams, Mr Brown has been diagnosed with diabetes, and I’m
Concerned that he isn’t on the list for glucose testing. I’m Uncomfortable
administering insulin until his lab results are back to be sure he’s
receiving a Safe dose.”
“Terry, I realize being late is not OK, and we can talk about that later.
For now, I’m Concerned about Mrs. Jones and Uncomfortable rushing
through report. For her Safety, please provide a complete report before
you go.”
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Examples of debriefing questions for uncivil encoun-
ters include the following14:
Ask each student participant: What was it like to be part of
this experience?
Ask observers: What was it like to observe the experience?
Ask student participants and observers: How would you
describe the experience? What went well, and what would
you do again? What did you learn? How might you apply
what you have learned in your clinical practice? What
might be done differently next time?
Learners participating in the CR experience identified sev-
eral benefits of this approach including learning to speak
up in stressful situations, communicating more effectively,
and advocating for safe patient care.
Conclusion
In health care, the need to effectively address uncivil situa-
tions is critical because the delivery of safe patient care
depends on these vital skills. Nurses and nursing students
must be well equipped to effectively address incivility in
a variety of situations to promote teamwork and collab-
oration and to protect patient safety. Combining CR with
evidence-based scripting within a deliberate practice model
and with skilled debriefing is an effective method to provide
nurses and nursing students with the essential skills needed
to effectively address uncivil encounters when they happen,
thereby increasing the likelihood of success in stopping the
behavior and protecting patient safety. Role-playing actual
scenarios provides nursing students with real-life experi-
ences to effectively address incivility. Debriefing sessions
help to create safe spaces for reflective practice and explor-
ing effective ways to address future situations.
Acknowledgment
The author acknowledges Dr Suzan Kardong-Edgren for
her review.
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Combining Cognitive Rehearsal, Simulation, and
Evidence-Based Scripting to Address Incivility
Autho
The a
Corre
clark
Accep
Publis
DOI:
64
Cynthia M. Clark, PhD, RN, ANEF, FAAN
ABSTRACT
Background: Nurses have a professional and ethical obligation to foster civility and healthy work environments to protect
patient safety. Evidence-based teaching strategies are needed to prepare nursing students to address acts of incivility that
threaten patient safety.
Problem: Incivility in health care must be effectively addressed because the delivery of safe patient care may depend on these
vital skills.
Approach: Cognitive rehearsal (CR) is an evidence-based technique where learners practice addressing workplace incivility
in a nonthreatening environment with a skilled facilitator. The author describes the unique combination of CR, simulation,
evidence-based scripting, deliberate practice, and debriefing to prepare nursing students to address uncivil encounters.
Outcomes: Learners who participated in CR identified benefits using this approach.
Conclusions: Combining CR with simulation, evidence-based scripting, repeated dosing through deliberate practice, and skillful
debriefing is an effective method to provide nursing students with the skills needed to address incivility, thereby increasing the
likelihood of protecting patient safety.
Keywords: civility, cognitive rehearsal, debriefing, deliberate practice, incivility, simulation
Cite this article as: Clark CM. Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educ.
2019;44(2):64–68. doi: 10.1097/NNE.0000000000000563
I
ncivility in health care settings can have a detrimental
impact on individuals, teams, and organizations. In the
patient care environment, uncivil encounters can provoke
uncertainty and self-doubt, weaken self-confidence, and
compromise critical thinking and clinical judgment skills.
If poorly managed, incivility can lead to life-threatening
mistakes, preventable complications, harm, or death of a
patient.1-6 Therefore, innovative and evidence-based teaching
strategies are needed to prepare nursing students to foster
healthy work environments and address acts of incivility
that threaten teamwork and patient safety.
The American Nurses Association (ANA) Code of Ethics
for Nurses7 clearly emphasizes nurses’ moral and ethical
obligation to ensure patient safety by fostering healthy
work environments and cultures of civility. Cognitive
rehearsal (CR) is an evidence-based technique whereby
individuals work with a coach or facilitator to practice
addressing stressful situations in a nonthreatening environ-
ment.8,9 Being well prepared, speaking with confidence,
and using respectful expressions to address incivility can
empower nursing students and nurses to speak up and ad-
dress uncivil behaviors. Using evidence-based approaches
r Affiliation: Strategic Nursing Advisor, ATI Nursing Education, Boise, Idaho.
uthor declares no conflicts of interest.
spondence: Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (cindy.
@atitesting.com).
to structure responses using a deliberate practice model
provides an effective communication tool to protect patient
safety and enhance teamwork within health care organiza-
tions. The author describes how the combination of CR,
simulation, evidence-based scripting, deliberate practice,
and debriefing can be used to address workplace incivility.
Cognitive Rehearsal
Cognitiverehearsalisatechniqueusedinbehavioralscience
whereby individuals work with a skilled facilitator to dis-
cuss and rehearse effective ways to address a particular
problem or social situation.8 It is designed to decrease anx-
iety, heighten confidence, and improve impulse control by
practicing effective ways to address potentially stressful sit-
uations.9 Theuseof CR hasbeen reportedtobean effective
strategytoaddressincivilityinpracticeandeducationalset-
tings.8,10-14 Using a planned, rehearsed response helps to
create an opportunity to communicate expectations for ap-
propriate behaviors and future interactions.15 Put simply,
CR is a behavioral strategy used to prepare an individual
for a potentially stressful situation by repeatedly rehearsing
the situation to strengthen the probability of a favorable
outcome. Using CR as a strategy to prepare for what might
be considered a stressful encounter includes preparing for
the encounter by rehearsing specific phrases that might be
used during the meeting, being coached by someone skilled
at effective communication, and rehearsing the encounter
using deliberate practice, followed by a debriefing session.
This series of activities is likely to lead to a more successful
Health, Inc. All rights reserved.
www.nurseeducatoronline.com
Health, Inc. All rights reserved.
http://www.nurseeducatoronline.com
outcome because the individual has thoughtfully prepared
for the encounter.
Although the use of CR can take various forms, the
author describes the technique as consisting of 5 essential
elements including (1) prebriefing and preparatory learn-
ing, (2) identifying and describing uncivil scenarios for
simulation, (3) using evidence-based approaches to role-
play and rehearse responses, (4) using deliberate practice
to repeat the simulated scenarios, and (5) debriefing sim-
ulated scenarios of uncivil encounters.
Prebriefing and Preparatory Learning
Prebriefing and preparatory learning include readings fo-
cused on the relationship between incivility, staying silent
when uncivil encounters occur, and the subsequent po-
tential impact on patient safety. Examples include a series
of articles highlighting how staying silent and failing to
advocate for patient safety can lead to errors and poor patient
outcomes.4-6 These studies also describe how education, role-
play, practice, and “scripting” can improve communica-
tion and conflict negotiation skills, which leads to improved
patient outcomes.
Another preparatory reading includes the ANA posi-
tion paper on incivility, bullying, and workplace violence,11
which articulates individual and shared roles and respon-
sibilities of nurses and employers to create and sustain a
culture of respect across the health care continuum. Accord-
ing to the ANA,11 all nurses in all settings are responsible for
creating a culture of respect and implementing evidence-
based best practices to prevent and mitigate incivility and
bullying and to foster a healthy and safe work environment
for all members of the health care team, health care con-
sumers, families, and communities.
Other suggestions for preparatory readings include
select articles from nursing practice and academe such
as the ANA Code of Ethics for Nurses7 and excerpts from
Clark,16 or students may conduct a review of the relevant
literature to identify and summarize scholarly works on
civility and incivility in nursing and health care.
Identifying and Describing Uncivil
Scenarios
for Simulation
Aftercompletingpreparatoryreadings,facultymayengage
students in a deepened understanding of the topical mate-
rial by using active learning strategies such as narrative
pedagogy, storytelling, learning circle discussions,17-19 and
small and large group activities. These teaching strategies
may also be used to introduce students to CR and how
the technique may be used to address uncivil encounters
in the practice setting, especially those that compromise
patient care. Common examples of uncivil behaviors that
may occur in a health care environment include refusing
to help a colleague in need, withholding important infor-
mation during a patient handoff, or engaging in gossip
and spreading rumors.8,12,16 Uncivil scenarios for student
role-playing may be written by faculty, obtained from ex-
perts on the topic of incivility and bullying,20,21 or
developed by students who identify real or potential un-
civil encounters that may occur in health care settings.
Using Evidence-Based Approaches to Role-Play
and Script Responses
Once students establish a solid foundation and work-
ing knowledge about civility and incivility in nursing
education and practice, faculty can introduce students
to evidence-based approaches such as “I” messaging22
and the Caring Feedback Model23 and to script responses
to address uncivil encounters. Because no 1-size-fits-all
approach exists for every individual and because each
individual has a unique way of expressing themselves,
evidence-based approaches offer a structured procedure
and a common language for scripting personalized re-
sponses rather than being rigidly “scripted.” In other words,
students use the approaches to develop scripts crafted in
their own words.
One evidence-based approach for effective commu-
nication is the use of “I” messaging.22 Helping students
learn and practice using “I” messages to address incivil-
ity is a beneficial learning activity. Using “I” messages
does not guarantee that a conflict will be successfully
resolved; however, “I” messages provide a means to ad-
dress conflict in a constructive manner and to preserve
relationships rather than making them worse. If possible,
“You” messages should be avoided because they may
sound critical or accusatory and often trigger defensive-
ness, retreat, or confrontation. Examples of “I” messages
include “I believe you are saying” or “I understand your
position to be” when seeking clarification of the encoun-
ter. If addressed in an uncivil manner, one might reply, “I
provide the best patient care when I’m treated with re-
spect.” Responding with an assertive “I beg your par-
don?” in response to a demeaning or condescending remark
can prompt the offender to step back, think about his/her
comment, and perhaps reconsider his/her approach. It is
also important to describe objective, observable behaviors,
as well as the real or potential impact of the behavior, rather
than to focus on the individual and personalize the event.
Nursing students need ongoing, realistic opportunities
tohonecommunicationskillstofunctioneffectivelyascon-
fident, assertive team members; however, reinforcing the
importance of communication requires more than discussion.
It requires simulating, demonstrating, practicing, and re-
hearsing these fundamental skills over and over again.16
Simulations can be used to create uncivil, high-anxiety situ-
ations that give students a safe place to make mistakes,
practice addressing uncivil encounters, and observe first-
hand how a gesture or word choice can influence the out-
come of the situation.16 Participating in simulated
scenarios allows students to sharpen their communica-
tion skills by listening for understanding, attending to
both verbal and nonverbal cues, interpreting interactions,
and reflecting on their view of the uncivil encounter. The
next section describes how the evidence-based approach
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Table 1. Scenario: The Case of Conflicted Classmates
Scenario Response Using an “I” Message Approach
Alex is a member of a class project where the final grade is based on
each student’s ability to contribute equitably to the project’s completion.
The stakes are high because individual grades are based on the overall
performance of the group and how the group performs as a team. One of
the members (Abby) is frequently late for meetings, fails to complete her
share of the work, and sends text message to friends when she seems
bored with the group work. The deadline is approaching, and several
members of the group are concerned that the project will not be
completed on time or be of good quality. On behalf of the group, Alex
decides to discuss their concerns with Abby.
“Abby, I appreciate the opportunity to meet with you to discuss our
class project. The project is nearly due, and I’m concerned about
the outcome. When the project started, we all agreed to complete
our individual parts on time and in a quality way. If you need help
completing your part, we need to know so we can problem-solve as
a team. I welcome your ideas about ways to meet the deadline and
still produce a quality project.”
of “I” messaging and other evidence-based approaches
may be used to develop scripts to address uncivil situations.
Exemplars of Uncivil Encounters in Academic
and Practice Environments
Several examples of uncivil scenarios with corresponding
responses using evidence-based approaches are presented
in Tables 1 to 5. A scenario depicting an uncivil situation
among nursing students assigned to collaborate on a group
project is presented in Table 1, along with a response using
an “I” message approach to address the issue.
After gaining experience using an “I” messaging ap-
proach, students are introduced to other evidence-based
approaches. The next scenario and corresponding script
uses the Caring Feedback Model23 as an evidence-based
approach to address an uncivil nurse-to-nurse encounter
(Table 2). The Caring Feedback Model includes the fol-
lowing steps: (1) state your positive intent/purpose; (2) de-
scribe the specific behavior you noticed or heard about;
(3) explain the consequence for you, your team, the patients,
or the organization; (4) offer “a pinch” of empathy; and
(5) make a suggestion or request.
Thenextscenarioisbasedontheapproachsuggestedby
Caspersen,24 which includes the following elements: “When
(the triggering event) happened, I felt/believed (feeling/
belief) because my (need/interest) is important to me. Would
you be willing to (request a doable) action?” Table 3 illus-
trates Caspersen’s approach when responding to an un-
civil encounter occurring among coworkers.
The next evidence-based approach was developed
by the Agency for Healthcare Research and Quality
(AHRQ)25 as part of the TeamSTEPPS approach designed
Table 2. Scenario: The Case of the Impatient Nurse
Scenario
Connie is an experienced nurse who has made it abundantly clear that
she has little or no patience when it comes to dealing with new or less
experienced nurses. Kim is a newly graduated nurse and reaches out to
Connie asking for her help with a complex patient situation. Connie
responds rudely stating, “I don’t have time to deal with novices. I’ve got
more important things to do.”
to equip health care workers with the essential skills
needed to address uncivil encounters when they happen,
thus increasing the likelihood of success in stopping the
behavior and protecting patient safety. The next scenario
uses the DESC approach—an acronym for (D) describe
the situation, (E) express your concerns, (S) suggest other
alternatives, and (C) consequences stated (Table 4)—to
illustrate an uncivil encounter between a staff nurse and
the nurse manager.
The next evidence-based approach was also developed
by AHRQ25 as part of the TeamSTEPPS approach. CUS is
an acronym for Concerned, Uncomfortable, and Safety—
an approach designed to script a response to use during an
uncivil or conflicted situation, particularly when patient
safetyisinjeopardy.ThescenariosdepictedinTable5illus-
trate 2 different uncivil experiences occurring in the patient
care environment and corresponding responses using the
CUS approach. These evidence-based approaches provide
a helpful structure to script responses to address uncivil en-
counters and to ultimately improve patient safety in health
care organizations.
Using Deliberate Practice to Repeat the Simulated
Scenarios
Deliberaterepetitivepractice(DRP)isaprocessforlearning
andmasteringpsychomotorskillsbyprogressingthrough3
primary phases: (1) understanding the skill and learning
howtoperformitaccurately,(2)refiningtheskilluntilitbe-
comes more consistent, and (3) practicing the skill until it is
automatic and the learner does not need to consciously
think about each step.26 Oermann27 further noted that, to
master skills, students need opportunities to practice them
Response Using the Caring Feedback Model
“Connie, I respect your experience and hope to learn from you. Earlier
today, when I asked for help, it didn’t seem to go well. Without your
support, I’m concerned that patient care might suffer. I realize you’re
busy and have a lot going on. Still, I need to ask some important
questions. When can we meet to discuss them?”
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Table 3. Scenario: The Case of the Gossiping Coworkers
Scenario Response Using the Caspersen Approach
You are a nurse working on the telemetry unit. Some of your coworkers
engage in negative gossip and spreading rumors. You believe you have
been the target of these behaviors, and one day when you approach
the break room, you hear your name mentioned in a derogatory and
negative way. As you enter, the voices fall silent. This is not the first
time this has happened, so you decide to address the situation.
“When I approached the break room, I heard my name mentioned. It
concerns me because being accepted as a valued member of the team
is important to me. In the future, please speak with me directly if you
have something to say.”
Table 4. Scenario: The Case of the Frustrated Manager
Scenario Response Using the DESC Approach
Hey Kathy, Nicole called in sick. We’re shorthanded, so you need to
stay and cover her shift. You may not like the decision, but we all need
to suck it up and deal with it.
“Alice, I appreciate the need to cover the unit. However, I’d like to
discuss other options since I’m unable to work an additional shift. I’m
exhausted, and because I’ve recently covered other shifts, I’m not
rested enough to provide safe patient care. Can we discuss other ways
to cover the shift?”
repetitively and to receive ongoing feedback to guide their
performance. Without DRP, many skills may decay or be
lost altogether. Like psychomotor skill-building, this same
process may be applied to addressing uncivil encounters.
Learning these new skills takes training, experience, prac-
tice, and feedback. Students require more than 1 practice
session to become proficient using CR to address incivility.
Repeated opportunities to practice these strategies over an
extended period are critical so that, if and when uncivil en-
counters occur, nurses are more apt to use a practiced and
patterned response.
Debriefing Simulated Scenarios of Uncivil
Encounters
Rehearsal of the simulated scenarios and scripted re-
sponses should be followed by a comprehensive coaching
Table 5. Scenarios and Responses Using the CUS Approach
Scenarios
The case of the uncivil nurse preceptor
Chris is a senior level nursing student assigned to Mr Brown, a patient
recently diagnosed with diabetes. Although Mr Brown has orders for
the laboratory to draw a glucose level, he is not included on the list of
patients to have a glucose level drawn. Chris notices the omission and
brings it to the attention of his clinical preceptor. She’s clearly annoyed,
rolls her eyes, and reprimands him in front of other nurses stating that
he is out of line for questioning her. Despite his discomfort, Chris
decides to advocate for Mr Brown using the CUS approach.
The case of the hurried handoff
“Geez, Katy, where have you been? You’re late as usual. It’s been a
really busy shift, and I can’t wait to get out of here. See if you can
manage to get this information straight for once. You should know the
patient in 402 since you took care of her yesterday. She has a bunch of
treatments and medications that need to be done. You need to check
her vital signs too—I’ve been way too busy to do them. I’m outta here.
If I forgot something, check the chart.”
and debriefing session. Successful debriefing requires
creating safe spaces for reflection and exploring effective
ways to address future situations. According to AHRQ,28
debriefing is an important learning strategy to help indi-
viduals identify aspects of individual and team perfor-
mance that went well and those that did not. Through
debriefing, students learn from deficiencies to improve their
performance. The goal of debriefing is to discuss the actions
and thought processes involved in a particular situation, en-
courage reflection on those actions and thought processes,
and incorporate improvement into future performance.26
Simulation debriefing has also been described as a
structured and guided reflection process in which students
actively appraise their cognitive, affective, and psychomotor
performance, giving them an opportunity to assume an ac-
tive role during the learning process.29
Response Using the CUS Approach
“Nurse Adams, Mr Brown has been diagnosed with diabetes, and I’m
Concerned that he isn’t on the list for glucose testing. I’m Uncomfortable
administering insulin until his lab results are back to be sure he’s
receiving a Safe dose.”
“Terry, I realize being late is not OK, and we can talk about that later.
For now, I’m Concerned about Mrs. Jones and Uncomfortable rushing
through report. For her Safety, please provide a complete report before
you go.”
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Examples of debriefing questions for uncivil encoun-
ters include the following14:
Ask each student participant: What was it like to be part of
this experience?
Ask observers: What was it like to observe the experience?
Ask student participants and observers: How would you
describe the experience? What went well, and what would
you do again? What did you learn? How might you apply
what you have learned in your clinical practice? What
might be done differently next time?
Learners participating in the CR experience identified sev-
eral benefits of this approach including learning to speak
up in stressful situations, communicating more effectively,
and advocating for safe patient care.
Conclusion
In health care, the need to effectively address uncivil situa-
tions is critical because the delivery of safe patient care
depends on these vital skills. Nurses and nursing students
must be well equipped to effectively address incivility in
a variety of situations to promote teamwork and collab-
oration and to protect patient safety. Combining CR with
evidence-based scripting within a deliberate practice model
and with skilled debriefing is an effective method to provide
nurses and nursing students with the essential skills needed
to effectively address uncivil encounters when they happen,
thereby increasing the likelihood of success in stopping the
behavior and protecting patient safety. Role-playing actual
scenarios provides nursing students with real-life experi-
ences to effectively address incivility. Debriefing sessions
help to create safe spaces for reflective practice and explor-
ing effective ways to address future situations.
Acknowledgment
The author acknowledges Dr Suzan Kardong-Edgren for
her review.
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