Incivility in health care

Incivility in health care

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 Incivility in health care

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 Incivility in health care

r Affiliation: StrategicNursingAdvisor, ATINursing Education, Boise, Idaho. author declares no conflicts of interest.

spondence: Dr Clark, 279 E Danskin Dr, Boise, ID 83716 (cindy.

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. Incivility in health care

Cognitive Rehearsal Cognitive rehearsal is a technique used in behavioral science 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 Incivility in health care

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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. Incivility in health care

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. Incivility in health care

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. Incivility in health care

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 Incivility in health care

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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. Incivility in health care

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. Incivility in health care

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 Incivility in health care 65

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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. Incivility in health care


“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. Incivility in health care

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. Incivility in health care

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 ) 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. Incivility in health care

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.” Incivility in health care

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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. Incivility in health care

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 Incivility in health care

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 Incivility in health care

Also check: Theoretical Framework to Support Evidence-based Practice