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Nurse Educator

Nurse Educator

Combining Cognitive Rehearsal, Simulation, and Evidence-Based Scripting to Address Incivility

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Corre clark





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 detrimentalimpact on individuals, teams, and organizations. In thepatient 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 AmericanNurses 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: StrategicNursingAdvisor, ATINursing Education, Boise, Idaho. uthor declares no conflicts of interest.

spondence: Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (cindy. @atitesting.com).

ted for publication: April 21, 2018

hed ahead of print: July 13, 2018


Nurse Educator • Vol. 44 • No. 2, pp. 64–68 • Copyright © 2018 Wolters Kluwer

Copyright © 2019 Wolters Kluwer

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 Cognitiverehearsal isatechniqueusedinbehavioralscience 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 effectiveways to address potentially stressful sit- uations.9TheuseofCRhasbeen reported tobe an effective strategy toaddress incivility inpractice andeducational set- 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 situationby repeatedly rehearsing the situation to strengthen the probability of a favorable outcome.UsingCRas a strategy to prepare forwhatmight be considered a stressful encounter includes preparing for the encounter by rehearsing specific phrases that might be usedduring themeeting, 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 andpoor 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 theANA,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 ANACode 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 After completingpreparatory readings, 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

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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 FeedbackModel23 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 otherwords, 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 ademeaning 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 tohone communication skills to function effectively as con- 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 amongnursing students assigned to collaborate on a group project is presented in Table 1, alongwith 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.

Thenext scenario isbasedontheapproachsuggestedby Caspersen,24which includes the following elements: “When (the triggering event) happened, I felt/believed (feeling/ belief ) becausemy (need/interest) is important tome.Would you bewilling 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


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.”

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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 approachwas 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 safety is in jeopardy.The scenariosdepicted inTable5 illus- 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 Deliberate repetitivepractice (DRP) isaprocess for learning andmasteringpsychomotor skillsbyprogressing through3 primary phases: (1) understanding the skill and learning howtoperformit accurately, (2) refining the skill until it be- comesmore 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


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.”

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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 fromdeficiencies 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’mUncomfortable 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 CRwith evidence-based scriptingwithin a deliberate practicemodel 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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