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

Clark, Cynthia M., PhD, RN, ANEF, FAAN

doi: 10.1097/NNE.0000000000000563
Feature Articles

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.

Author Affiliation: Strategic Nursing Advisor, ATI Nursing Education, Boise, Idaho.

The author declares no conflicts of interest.

Correspondence: Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (

Accepted for publication: April 21, 2018

Published ahead of print: July 13, 2018

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

Incivility 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 Nurses 7 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 environment.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 address uncivil behaviors. Using evidence-based approaches to structure responses using a deliberate practice model provides an effective communication tool to protect patient safety and enhance teamwork within health care organizations. The author describes how the combination of CR, simulation, evidence-based scripting, deliberate practice, and debriefing can be used to address workplace incivility.

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Cognitive Rehearsal

Cognitive rehearsal is a technique used in behavioral science whereby individuals work with a skilled facilitator to discuss and rehearse effective ways to address a particular problem or social situation.8 It is designed to decrease anxiety, heighten confidence, and improve impulse control by practicing effective ways to address potentially stressful situations.9 The use of CR has been reported to be an effective strategy to address incivility in practice and educational settings.8,10-14 Using a planned, rehearsed response helps to create an opportunity to communicate expectations for appropriate 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 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 learning, (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 simulated scenarios of uncivil encounters.

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Prebriefing and Preparatory Learning

Prebriefing and preparatory learning include readings focused on the relationship between incivility, staying silent when uncivil encounters occur, and the subsequent potential 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 communication and conflict negotiation skills, which leads to improved patient outcomes.

Another preparatory reading includes the ANA position paper on incivility, bullying, and workplace violence,11 which articulates individual and shared roles and responsibilities of nurses and employers to create and sustain a culture of respect across the health care continuum. According 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 consumers, families, and communities.

Other suggestions for preparatory readings include select articles from nursing practice and academe such as the ANA Code of Ethics for Nurses 7 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.

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Identifying and Describing Uncivil Scenarios for Simulation

After completing preparatory readings, faculty may engage students in a deepened understanding of the topical material 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 information 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 experts on the topic of incivility and bullying,20,21 or developed by students who identify real or potential uncivil encounters that may occur in health care settings.

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Using Evidence-Based Approaches to Role-Play and Script Responses

Once students establish a solid foundation and working 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 responses 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 communication is the use of “I” messaging.22 Helping students learn and practice using “I” messages to address incivility 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 address 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 defensiveness, 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 encounter. If addressed in an uncivil manner, one might reply, “I provide the best patient care when I'm treated with respect.” Responding with an assertive “I beg your pardon?” 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 to hone communication skills to function effectively as confident, assertive team members; however, reinforcing the importance of communication requires more than discussion. It requires simulating, demonstrating, practicing, and rehearsing these fundamental skills over and over again.16 Simulations can be used to create uncivil, high-anxiety situations that give students a safe place to make mistakes, practice addressing uncivil encounters, and observe firsthand how a gesture or word choice can influence the outcome of the situation.16 Participating in simulated scenarios allows students to sharpen their communication 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 of “I” messaging and other evidence-based approaches may be used to develop scripts to address uncivil situations.

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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.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

Table 5

Table 5

After gaining experience using an “I” messaging approach, 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 following steps: (1) state your positive intent/purpose; (2) describe 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.

The next scenario is based on the approach suggested by 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 illustrates Caspersen's approach when responding to an uncivil 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 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 safety is in jeopardy. The scenarios depicted in Table 5 illustrate 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 encounters and to ultimately improve patient safety in health care organizations.

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Using Deliberate Practice to Repeat the Simulated Scenarios

Deliberate repetitive practice (DRP) is a process for learning and mastering psychomotor skills by progressing through 3 primary phases: (1) understanding the skill and learning how to perform it accurately, (2) refining the skill until it becomes 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 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, practice, 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 encounters occur, nurses are more apt to use a practiced and patterned response.

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Debriefing Simulated Scenarios of Uncivil Encounters

Rehearsal of the simulated scenarios and scripted responses should be followed by a comprehensive coaching 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 individuals identify aspects of individual and team performance 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, encourage 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 active role during the learning process.29

Examples of debriefing questions for uncivil encounters 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 several benefits of this approach including learning to speak up in stressful situations, communicating more effectively, and advocating for safe patient care.

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In health care, the need to effectively address uncivil situations 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 collaboration 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 experiences to effectively address incivility. Debriefing sessions help to create safe spaces for reflective practice and exploring effective ways to address future situations.

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The author acknowledges Dr Suzan Kardong-Edgren for her review.

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civility; cognitive rehearsal; debriefing; deliberate practice; incivility; simulation

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