Assignment: workplace environment assessment

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Assignment: Workplace Environment Assessment

Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treatments or protocols. Isolated recognition of a health issue does little to resolve it.

In this module’s Discussion, you applied the Clark Healthy Workplace Inventory to diagnose potential problems with the civility of your organization. In this Portfolio Assignment, you will continue to analyze the results and apply published research to the development of a proposed treatment for any issues uncovered by the assessment.

To Prepare:

· Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).

· Review the Work Environment Assessment Template*. You have done this for me I have attached it as well

· Reflect on the output of your Discussion post regarding your evaluation of workplace civility and the feedback received from colleagues.

· Select and review one or more of the following articles found in the Resources:

· Clark, Olender, Cardoni, and Kenski (2011)

· Clark (2018)

· Clark (2015) I Have attached this for you to review

· Griffin and Clark (2014) I Have attached this for you to review

*Template completed in the Week 7 discussion should not be submitted with this assignment.

The Assignment (3-6 pages total):

Part 1: Work Environment Assessment (1-2 pages)

· Review the Work Environment Assessment Template you completed for this Module’s Discussion. I have attached this which you have done for me

· Describe the results of the Work Environment Assessment you completed on your workplace.

· Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.

· Explain what the results of the Assessment suggest about the health and civility of your workplace.

Part 2: Reviewing the Literature (1-2 pages)

· 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.

Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (1–2 pages)

· Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.

· Recommend at least two strategies that can be implemented to bolster successful practices revealed in your


Workplace Environment Assessment

Name of Student

Walden University


Interprofessional Organization & System Leadership

Dr. EG. P

(Due date)

Workplace Environment Assessment

Introductory paragraph. The introduction presents the problem that the paper addresses. Write an introductory paragraph. Do not write the word Introduction as a level heading because the first paragraph under the title of the paper functions as your paper’s introduction. Include the purpose of the paper.

The purpose of this paper is to…… (continue stating the purpose of the paper).

Work Environment Assessment

Review the Work Environment Assessment Template you completed for this

Module’s Week 7 Discussion.

Do not include the assessment template in the paper. Just discuss the topics.

Describe the results of the Work Environment Assessment you completed

on your workplace.

Identify two things that surprised you about the results and one idea you believed prior

to conducting the Assessment that was confirmed and explain what the results of the Assessment

suggest about the health and civility of your workplace.

Reviewing the Literature

Briefly describe the theory or concept presented in the article you selected.
Explain how the theory or concept presented in the article relates to the results of your Work Environment Assessment.
Explain how your organization could apply the theory highlighted in your selected article to improve organizational health and/or stronger work teams.

Specific and detailed examples are provided which fully support the responses.

Evidence-Based Strategies to create High-Performance Interprofessional Teams

Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.

Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.

Summary or Conclusion

Conclusion on major points. The conclusion allows you to have the final say on the issues you have raised in your paper, to synthesize your thoughts and ideas, consider broader issues, elaborate on the significance of your findings and give your reader a new view of the subject, see things differently and enrich the reader’s way of thinking and perspective.


The School of Nursing requires that all papers submitted include
a title page, introductory paragraph, discussion topics, summary, and references.
The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at

). All papers submitted must use this formatting.


NOTE: The following references are intended as examples only. Observe current, peer-reviewed and evidenced-based (not more than 5 years old.

Per the APA manual 7th edition, do not include “Retrieved from.” The words “Retrieved from” or “Accessed from” are no longer necessary before a URL.

American Association of University Professors. (2018, October 11). Data snapshot: Contingent faculty in US higher ed. AAUP Updates.

Bachen, C. M., McLoughlin, M. M., & Garcia, S. S. (2019). Assessing the role of gender in college students’ evaluations of faculty. Communication Education, 48(3), 193–210.

Cashin, W. E. (2018). Students do rate different academic fields differently. In M. Theall, & J. L. Franklin (Eds.), Student ratings of instruction: Issues for improving practice. New Directions for Teaching and Learning (pp. 113–121).

Howard, G., Conway, C., & Maxwell, S. (2018). Construct validity of measures of college teaching effectiveness. Journal of Educational Psychology, 77(2), 187–96.

Laureate Education, Inc. (Producer). (2020). How to cite a video: The city is always Baltimore [DVD]. Baltimore, MD: Author.

Laureate Education, Inc. (Producer). (2018). Name of program [Video webcast].

Smasfaldi, H., Wareumph, I., Aeoli, Q., Rickies, F., Furoush, P., Aaegrade, V., … Fiiel, B. (2019). The art of correcting surname mispronunciation. New York, NY: Supportive Publisher Press.

Work Environment Assessment


Work Environment Assessment Template

Use this document to complete the Module 4
Workplace Environment Assessment

Summary of Results – Clark Healthy Workplace Inventory

The overall civility score is 55. This suggests that my workplace is unhealthy.

Identify two things that surprised you about the results. Also identify one idea that you believed prior to conducting the Assessment that was confirmed.

The first thing that surprised me about the results is that my workplace does not have a positive environment as I initially thought. The second thing is how large the gap is between the leadership and the rest of the employees in terms of decision-making.

One idea that I believed before taking the assessment that was confirmed is the workload of the staff is not fairly distributed and that most employees are overworked.

What do the results of the Assessment suggest about the health and civility of your workplace?

The results suggest that my workplace is unhealthy and has a low level of civility.

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.

The theory presented in the article is the DESC model. It presents an effective way to address specific incivility incidents (Clark, 2015). It can help alleviate the problems in my workplace that have been identified in the 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.

The organization can use the DESC model to improve staff to patient ratios. Specifically, it will provide the staff members with an opportunity to describe and express their concerns to the management, state alternatives to the current work model, and the consequences of these actions discussed between all the stakeholders.

General Notes/Comments


Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18-23.

© 2018 Laureate Education Inc. 1

18 American Nurse Today Volume 10, Number 11

“I believe we can
change the world if we
start listening to one
another again. Simple,
honest, human con-
versation…a chance to
speak, feel heard, and
[where] we each listen
well…may ultimately
save the world.”
Margaret J. Wheatley,


GIVEN the stressful healthcare
workplace, it’s no wonder nurses
and other healthcare professionals
sometimes fall short of communi-
cating in respectful, considerate
ways. Nonetheless, safe patient care
hinges on our ability to cope with
stress effectively, manage our emo-
tions, and communicate respectful-
ly. Interactions among employees
can affect their ability to do their
jobs, their loyalty to the organiza-
tion, and most important, the deliv-
ery of safe, high-quality patient

The American Nurses Associa-
tion (ANA) Code of Ethics for
Nurses with Interpretive Statements
clearly articulates the nurse’s obli-
gation to foster safe, ethical, civil
workplaces. It requires nurses “to
create an ethical environment and
culture of civility and kindness,
treating colleagues, coworkers, em-
ployees, students, and others with

dignity and respect” and states that
“any form of bullying, harassment,
intimidation, manipulation, threats,
or violence will not be tolerated.”
However, while nurses need to
learn and practice skills to address

uncivil encounters, or-
ganization leaders and
managers must create
an environment where
nurses feel free and
empowered to speak
up, especially regard-
ing patient safety

All of us must strive
to create and sustain
civil, healthy work en-
vironments where we

communicate clearly and effectively
and manage conflict in a respectful,
responsible way. The alternative—
incivility—can have serious and
lasting repercussions. An organiza-
tion’s culture is linked closely with
employee recruitment, retention,
and job satisfaction. Engaging in
clear, courteous communication fos-
ters a civil work environment, im-
proves teamwork, and ultimately
enhances patient care.

In many cases, addressing inci-
vility by speaking up when it hap-
pens can be the most effective
way to stop it. Of course, mean-
ingful dialogue and effective com-
munication require practice. Like
bowel sound auscultation and na-
sogastric tube insertion, communi-
cation skills can’t be mastered
overnight. Gaining competence in
civil communication takes time,
training, experience, practice, and

1. Identify components of a healthy

2. Discuss how to prepare for a chal-

lenging conversation.
3. Describe models for conducting a

challenging conversation.

The planners of this CNE activity have disclosed no
relevant financial relationships with any commercial
companies pertaining to this activity. See the last page
of the article to learn how to earn CNE credit. The
author has disclosed that she receives royalties and
consulting fees pertaining to this topic. The article
was peer reviewed and determined to be free of bias.

Expiration: 11/1/18

1.0 contact

to inspire and promote a

more civil workplace
Let’s end the silence that surrounds incivility.

By Cynthia M. Clark,
PhD, RN, ANEF, FAAN November 2015 American Nurse Today 19

What makes for a healthy
The American Association of Criti-
cal-Care Nurses has identified six
standards for establishing and sus-
taining healthy work environ-
ments—skilled communication, true
collaboration, effective decision-
making, appropriate staffing, mean-
ingful recognition, and authentic

In my own research, I’ve found
that healthy work environments al-
so require:
• a shared organizational vision,

values, and team norms
• creation and sustenance of a

high level of individual, team,
and organizational civility

• emphasis on leadership, both
formal and informal

• civility conversations at all orga-
nizational levels.
I have developed a workplace

inventory that individuals and
groups within organizations can use
as an evidence-based tool to raise
awareness, assess the perceived
health of an organization, and de-
termine strengths and areas for im-
provement. The inventory may be
completed either individually or by
all team members, who can then
compare notes to determine areas
for improvement and celebrate and
reinforce areas of strength. (See
Clark Healthy Workplace Inventory.)

How to engage in challenging
One could argue that to attain a
high score on nearly every invento-
ry item, healthy communication
must exist in the organization. So
leaders need to encourage open
discussion and ongoing dialogue
about the elements of a healthy
workplace. Sharing similarities as
well as differences and spending
time in conversation to identify
strategies to enhance the workplace
environment can prove valuable.

But in many cases, having such
conversations is easier said than
done. For some people, engaging

directly in difficult conversations
causes stress. Many nurses report
they lack the essential skills for hav-
ing candid conversations where
emotions run high and conflict-
negotiation skills are limited. Many
refrain from speaking with uncivil
individuals even when a candid
conversation clearly is needed, be-
cause they don’t know how to or
because it feels emotionally unsafe.
Some nurses lack the experience
and preparation to directly address
incivility from someone in a higher
position because of the clear power
differential or a belief that it won’t
change anything. The guidelines be-
low can help you prepare for and
engage in challenging conversations.

Reflecting, probing, and
Reflecting on the workplace culture
and our relationships and interac-
tions with others is an important
step toward improving individual,
team, and organizational success.
When faced with the prospect of
having a challenging conversation,
we need to ask ourselves key ques-
tions, such as:
• What will happen if I engage in

this conversation, and what will
happen if I don’t?

• What will happen to the patient
if I stay silent?
In the 2005 report “Silence Kills:

The Seven Crucial Conversations
for Healthcare,” the authors identi-
fied failing to speak up in disre-
spectful situations as a serious com-
munication breakdown among
healthcare professionals, and they
asserted that such a failure can
have serious patient-care conse-
quences. In a subsequent report,
“The Silent Treatment: Why Safety
Tools and Checklists Aren’t Enough
to Save Lives,” the authors suggest-
ed a multifaceted organizational ap-
proach to creating a culture where
people speak up effectively when
they have concerns. This approach
includes several recommendations
and sources of influence, including

improving each person’s ability to
be sure all healthcare team mem-
bers have the skills to be “200% ac-
countable for safe practices.” Ways
to acquire safe practice skills in-
clude education and training, script
development, role-playing, and
practicing effective communication
skills for high-stakes situations.

Creating a safe zone
If you’ve decided to engage in a
challenging conversation with a
coworker who has been uncivil,
choose the time and place careful-
ly. Planning wisely can help you
create a safe zone. For example,
avoid having this conversation in
the presence of patients, family,
and other observers. Choose a set-
ting where both parties will have as
much emotional and physical safety
as possible.

Both should agree on a mutual-
ly beneficial time and place to
meet. Ideally, the place should be
quiet, private, away from others
(especially patients), and con-
ducive to conversation and prob-
lem-solving. Select a time when
both parties will be free of inter-
ruptions, off shift, and well-rested.
If a real or perceived power differ-
ential exists between you and the
other person, try to have a third
party present.

You may need to initiate the
conversation by asking the other
person for a meeting. Suppose
you and your colleague Sam dis-
agree over the best way to per-
form a patient care procedure.
You might say something like,
“Sam, I realize we have different
approaches to patient care. Since
we both agree patient safety is our
top concern, I’m confident that if
we sit down and discuss possible
solutions, we can work this out.
When would you like to get to-
gether to discuss this?”

Before the meeting, think about
how you might have contributed to
the situation or conflict; this can
help you understand the other per-

20 American Nurse Today Volume 10, Number 11

You can use the inventory below to help determine the health of your workplace. To complete it, carefully read the 20 statements
below. Using a scale of 1 to 5, check the response that most accurately represents your perception of your workplace. Check 5 if
the statement is completely true, 4 if it’s somewhat true, 3 if it’s neutral, 2 if it’s somewhat untrue, and 1 if it’s completely untrue.
Then total the number values of your responses to determine the overall civility score. Scores range from 20 to 100. A score of 90

to 100 indicates a very healthy workplace; 80 to 89, moderately healthy; 70 to 79, mildly healthy; 60 to 69, barely healthy; 50 to 59,
unhealthy; and less than 50, very unhealthy.

Completely Somewhat Neutral Somewhat Completely
Statement true (5) true (4) (3) untrue (2) untrue (1)

Members of the organization “live” by a shared vision □ □ □ □ □
and mission based on trust, respect, and collegiality.

There is a clear and discernible level of trust □ □ □ □ □
between and among formal leadership and
other members of the workplace.

Communication at all levels of the organization □ □ □ □ □
is transparent, direct, and respectful.

Employees are viewed as assets and valued □ □ □ □ □
partners within the organization.

Individual and collective achievements are celebrated □ □ □ □ □
and publicized in an equitable manner.

There is a high level of employee satisfaction, □ □ □ □ □
engagement, and morale.

The organizational culture is assessed on an ongoing □ □ □ □ □
basis, and measures are taken to improve it based on
results of that assessment.

Members of the organization are actively engaged in □ □ □ □ □
shared governance, joint decision-making, and policy
development, review, and revision.

Teamwork and collaboration are promoted and evident. □ □ □ □ □
There is a comprehensive mentoring program for □ □ □ □ □
all employees.

There is an emphasis on employee wellness and self-care. □ □ □ □ □
There are sufficient resources for professional growth □ □ □ □ □
and development.

Employees are treated in a fair and respectful manner. □ □ □ □ □
The workload is reasonable, manageable, and fairly □ □ □ □ □

Members of the organization use effective conflict- □ □ □ □ □
resolution skills and address disagreements in a
respectful and responsible manner.

The organization encourages free expression of diverse □ □ □ □ □
and/or opposing ideas and perspectives.

The organization provides competitive salaries, benefits, □ □ □ □ □
compensations, and other rewards.

There are sufficient opportunities for promotion and □ □ □ □ □
career advancement.

The organization attracts and retains the □ □ □ □ □
“best and the brightest.”

The majority of employees would recommend the □ □ □ □ □
organization as a good or great place to work to
their family and friends.

© 2014 Cynthia M. Clark

Clark Healthy Workplace Inventory November 2015 American Nurse Today 21

son’s perspective. The clearer you
are about your possible role in the
situation, the better equipped you’ll
be to act in a positive way. Re-
hearsing what you intend to say al-
so can help.

Preparing for the conversation
Critical conversations can be stress-
ful. While taking a direct approach
to resolving a conflict usually is the
best strategy, it takes fortitude,
know-how—and practice, practice,
practice. Prepare as much as possi-
ble. Before the meeting, make sure
you’re adequately hydrated and
perform deep-breathing exercises
or yoga stretches.

On the scene
When the meeting starts, the two
of you should set ground rules,
such as:
• speaking one at a time
• using a calm, respectful tone
• avoiding personal attacks
• sticking to objective information.

Each person should take turns
describing his or her perspective in
objective language, speaking di-
rectly and respectfully. Listen ac-
tively and show genuine interest in
the other person. To listen actively,
focus on his or her message in-
stead of thinking about how you’ll
respond. If you have difficulty lis-
tening and concentrating, silently
repeat the other person’s words to
yourself to help you stay focused.

Stay centered, poised, and fo-
cused on patient safety. Avoid be-
ing defensive. You may not agree
with the other person’s message,
but seek to understand it. Don’t in-
terrupt or act as though you can’t
wait to respond so you can state
your own position or impression.

Be aware of your nonverbal
messages. Maintain eye contact and
an open posture. Avoid arm cross-
ing, turning away, and eye rolling.

The overall goal is to find an
interest-based solution to the situa-
tion. The intention to seek com-
mon ground and pursue a com –

promise is more likely to yield a
win-win solution and ultimately im-
prove your working relationship.
Once you and the other person
reach a resolution, make a plan for
a follow-up meeting to evaluate
your progress on efforts at resolv-
ing the issue.

Framework for engaging in
challenging conversations
Cognitive rehearsal is an evidence-
based framework you can use to
address incivility during a challeng-
ing conversation. This three-step
process includes:
• didactic and interactive learning

and instruction
• rehearsing specific phrases to

use during uncivil encounters
• practice sessions to reinforce in-

struction and rehearsal.
Using cognitive rehearsal can

lead to improved communication, a
more conflict-capable workforce,
greater nurse satisfaction, and im-
proved patient care.

DESC model
Various models can be used to
structure a civility conversation.
One of my favorites is the DESC
model, which is part of Team-
STEPPS—an evidence-based team-
work system to improve communi-
cation and teamwork skills and, in
turn, improve safety and quality
care. Using the DESC model in
conjunction with cognitive rehears-
al is an effective way to address
specific incivility incidents. (See
DESC in action: Three scenarios.)

Other acceptable models exist
for teaching and learning effective
communication skills and becom-
ing conflict-capable. In each mod-
el, the required skills are learned,
practiced, and reinforced until re-
sponses become second nature.
Another key feature is to have the
learner make it his or her own; al-
though a script can be provided, it
should be used only to guide de-
velopment of the learner’s personal

Nurturing a civil and
collaborative culture
Addressing uncivil behavior can be
difficult, but staying silent can in-
crease stress, impair your job per-
formance and, ultimately, jeopard-
ize patient care. Of course, it’s
easier to be civil when we’re re-
laxed, well-nourished, well-hydrat-
ed, and not overworked. But over
the course of a busy workday,
stress can cause anyone to behave

When an uncivil encounter oc-
curs, we may need to address it by
having a critical conversation with
the uncivil colleague. We need to
be well-prepared for this conversa-
tion, speak with confidence, and
use respectful expressions. In this
way, we can end the silence that
surrounds incivility. These encoun-
ters will be more effective when
we’re well-equipped with such
tools as the DESC model—and
when we’ve practiced the required
skills over and over until we’ve
perfected them.

Effective communication, con-
flict negotiation, and problem-solv-
ing are more important than ever.
For the sake of patient safety,
healthcare professionals need to
focus on our higher purpose—pro-
viding safe, effective patient care—
and communicate respectfully with
each other. Differences in social-
ization and educational experi-
ences, as well as a perceived pow-
er differential, can put physicians
and nurses at odds with one an-
other. When we nurture a culture
of collaboration, we can synthesize
the unique strengths that health-
care workers of all disciplines
bring to the workplace. In this
way, we can make the workplace
a civil place. �

Cynthia M. Clark is a nurse consultant with ATI
Nursing Education and professor emeritus at Boise
State University in Boise, Idaho. Names in scenarios
are fictitious.

For a list of selected references, visit American

22 American Nurse Today Volume 10, Number 11

DESC in action: Three scenarios
The DESC model for addressing incivility has four elements:
D: Describe the specific situation.
E: Express your concerns.
S: State other alternatives.
C: Consequences stated.

The scenarios below give examples of how to use the DESC
model to address uncivil workplace encounters.

Nurses Sandy and Claire
At the beginning of her shift, Sandy receives a handoff report
from Claire, who has just finished her shift.

“Geez, Sandy, where have you been? You’re late as usual. I can’t
wait to get out of here. See if you can manage to get this informa-
tion straight for once. You should know Mary Smith by now. You
took care of her yesterday. She was on 4S forever; now she’s our
problem. You need to check her vital signs. I’ve been way too busy
to do them. So, that’s it—I’m out of here. If I forgot something, it’s
not my problem. Just check the chart.”

Not only is Claire rude and disrespectful, but she also is put-
ting the patient at risk by providing an incomplete report.
Here’s how Sandy might address the situation.

Describe:“Claire, I can see you’re in a hurry, and I understand
you’re upset because I’m late. We can talk about that when we
have more time. For now, I don’t feel like I’m getting enough
information to do my job effectively.”
Explain: “Talking about Mrs. Smith in a disrespectful way and
rushing through report can have a serious impact on her care.”
State: “I know we’re both concerned about Mrs. Smith, so
please give me a more detailed report so I can provide the
best care possible.”
Consequence:“Without a full report, I may miss an important
piece of information, and this could compromise Mrs. Smith’s

Nurse manager Alice and staff nurse Kathy
The anxiety level may rise for a nurse who experiences incivili-
ty from a higher-up. The following scenario illustrates an unciv-
il encounter between Alice, a nurse manager, and Kathy, a staff

“Hey Kathy, I just found out Nicole called in sick, so you’re going to
have to cover her shift. We’re totally shorthanded, so you need to
stay. You may not like the decision, but that’s just the way it is.”

Kathy is unable—and frankly, unwilling—to work a double
shift. Exhausted, she’d planned to spend time with her family
this evening. Also, she has worked three extra shifts this
month. She decides she needs to deal with this situation now
instead of setting up a meeting with Alice later in the week.
Here’s how she might use the DESC model with her manager.

Describe:“Alice, I can appreciate the need to cover the unit
because of Nicole’s illness. We all agree that having adequate
staff is important for patient care.”
Explain:“I’m exhausted, and because I have recently covered
other shifts, I’m less prepared to administer safe, high-quality
State:“I realize that as manager, it’s your responsibility to
make sure we have adequate staff for the oncoming shift. But

I’d like to talk about alternatives because I’m unable to work an
additional shift today.”
Consequence:“Let’s work together to discuss alternatives for
covering Nicole’s shift. It’s important for me to have a voice in
decisions that affect me.”

For a staff nurse, addressing a manager can be daunting. To
have a critical conversation with an uncivil superior in an effort
to put an end to the problem, you need the courage to be as-
sertive. Engaging in stress-reducing and self-care activities and
practicing mindfulness can boost your courage so you’ll be
prepared. Most of all, you need to practice and rehearse effec-
tive communication skills until you feel comfortable using
A 2014 study by Laschinger et al. found a compelling rela-

tionship between meaningful leadership and nurse empower-
ment and their impact on creating civility and decreasing
nurse burnout. This study underscores the need for leadership
development to enable nurse managers to foster civil work en-
vironments. To create and sustain a healthy environment, all
members of the organization need to receive intentional and
ongoing education focused on raising awareness about incivil-
ity; its impact on individuals, teams, and organizations; and
most important, its consequences on patient care and safety.

Nurse Tom and Dr. Jones
This scenario depicts an uncivil encounter between a nurse
and a physician.

Tom is concerned about Mr. Brown, a patient who’s 2 days postop
after abdominal surgery for a colon resection. On the second
evening after surgery, Mr. Brown’s blood pressure increases. Tom
watches him closely and continues to monitor his vital signs. As
the night wears on, Mr. Brown’s blood pressure continues to rise,
his breathing seems more labored, and his heart rate increases.
Tom calls Dr. Jones, the attending physician, to report his find-

ings. Dr. Jones chuckles and says, “He’s just anxious. Who wouldn’t
be in his condition?” and hangs up. Undaunted, Tom calls back
and insists Dr. Jones return to the unit to assess Mr. Brown. Reluc-
tantly, Dr. Jones comes to the unit, peeks into Mr. Brown’s room
without assessing him, and chastises Tom in front of his col-
leagues and other patients about his “ridiculous overreaction.”
Tom politely asks Dr. Jones to meet with him in an empty meeting
room. Here’s how Tom uses DESC to address the situation.

Describe: “Dr. Jones, I’d like to explain something. Please hear
me out before you comment. I am a diligent nurse with exten-
sive patient care experience.”
Explain:“I know that as Mr. Brown’s attending physician,
you’re committed to his safety. I assure you that everyone on
the healthcare team shares your concern, including me. I
called you immediately after determining persistent and no-
table changes in Mr. Brown’s vital signs.”
State:“Because we are all concerned about Mr. Brown’s care, it
would be best if you conducted an assessment and addressed
me in a respectful manner so we can provide the best care
possible. I will show you the same respect.”
Consequence:“Disregarding important information or allow-
ing your opinion of me to influence your response could com-
promise Mr. Brown’s care. We need to work together as a team
to provide the best care possible.” November 2015 American Nurse Today 23

Please mark the correct answer online.

1. The American Association of
Critical-Care Nurses does not identify
which of the following as a
characteristic of a healthy workplace?

a. Skilled communication
b. Informal leadership
c. True collaboration
d. Meaningful recognition

2. A healthy work environment

a. civility conversations at the highest
level of the organization.

b. emphasis on formal rather than
informal leadership.

c. shared organizational vision, values,
and norms.

d. individualized values and norms.

3. When considering whether to have
a challenging conversation, which key
question should you ask yourself?

a. Is the person I need to talk to a full-
time employee?

b. Do I have enough experience to
have the conversation?

c. How many years have I worked at
this facility?

d. What will happen to the patient if I
stay silent?

4. Which of the following helps to
create a safe zone for a challenging

a. Agreeing on a mutually beneficial
time to meet

b. Having the conversation in the
presence of patients

c. Having the conversation in the
presence of family members

d. Choosing a time immediately after
the other person’s shift

5. If a power differential exists
between you and the other person, an
effective approach is to:

a. keep the matter between the two of

b. have a third party present.
c. have a security officer attend the

d. refrain from having the

6. Which of the following is an
appropriate action during a challenging

a. Interrupt as needed.
b. Talk quickly.
c. Cross your arms.
d. Maintain eye contact.

7. The first step of cognitive rehearsal

a. describing your position in objective

b. rehearsing specific phrases to use
during uncivil encounters.

c. undergoing didactic and interactive
learning and instruction.

d. having a practice session to
reinforce instruction and rehearsal.

8. What is the first element of the
DESC model?

a. Describe the specific situation.
b. Discuss your concerns.
c. Define your solution.
d. Detail the alternatives.

9. What is the last element of the DESC

a. Coordinate your response.
b. Consider the setting.
c. Consequences stated.
d. Concerns stated.

10. Which statement about challenging
conversations is correct?

a. Nurses have an innate ability to
have these conversations.

b. The person who called the meeting
should dominate the discussion.

c. Agreeing with the other person’s
message is important.

d. After the resolution, the participants
should schedule a follow-up

POST-TEST • Conversations to inspire and promote a more civil workplace
Earn contact hour credit online at

Provider accreditation
The American Nurses Association’s Center for Continuing Edu-
cation and Professional Development is accredited as a
provider of continuing nursing education by the American
Nurses Credentialing Center’s Commission on Accreditation.
ANCC Provider Number 0023.

Contact hours: 1.0

ANA’s Center for Continuing Education and Professional Devel-
opment is approved by the California Board of Registered Nurs-
ing, Provider Number CEP6178 for 1.2 contact hours.

Post-test passing score is 80%. Expiration: 11/1/18

ANA Center for Continuing Education and Professional Devel-
opment’s accredited provider status refers only to CNE activi-
ties and does not imply that there is real or implied endorse-
ment of any product, service, or company referred to in this
activity nor of any company subsidizing costs related to the
activity. The author and planners of this CNE activity have dis-
closed no relevant financial relationships with any commercial
companies pertaining to this CNE. See the last page of the
article to learn how to earn CNE credit.

CNE: 1.0 contact hours


535The Journal of Continuing Education in Nursing · Vol 45, No 12, 2014


Revisiting Cognitive Rehearsal as an
Intervention Against Incivility and Lateral
Violence in Nursing: 10 Years Later
Martha Griffi n, PhD, RN, PMHCNS-BC, FAAN; and Cynthia M. Clark, PhD, RN, ANEF, FAAN

According to a recent survey conducted by the Work-place Bullying Institute (2014), 27% of Americans
have suffered abusive conduct or incivility at work.
Another 21% have witnessed such behaviors, and 72%
are aware that workplace incivility happens. The im-
pact of these behaviors can be devastating and lasting.
For example, workplace incivility can negatively impact
employee physical and mental health, job satisfaction,
productivity, and commitment to the work environment

Dr. Griffin is Director of Nursing Research, Education, and Simu-
lation, Boston Medical Center, Boston, Massachusetts; and Dr. Clark
is Professor, Boise State University, School of Nursing, Boise, Idaho,
and Nurse Consultant, Ascend Learning/ATI Nursing Education,
Leawood, Kansas.

The authors have disclosed no potential conflicts of interest, finan-
cial or otherwise.

Address correspondence to Cynthia M. Clark, PhD, RN, ANEF,
FAAN, Professor, Boise State University, School of Nursing, 1910 Uni-
versity Drive, Boise, ID 83725; e-mail: [email protected]

Received: June 5, 2014; Accepted: September 12, 2014; Posted On-
line: November 22, 2014


Ten years ago, Griffi n wrote an article on the use of
cognitive rehearsal as a shield for lateral violence. Since
then, cognitive rehearsal has been used successfully in
several studies as an evidence-based strategy to address
uncivil and bullying behaviors in nursing. In the original
study, 26 newly licensed nurses learned about lateral vio-
lence and used cognitive rehearsal techniques as an inter-
vention for nurse-to-nurse incivility. The newly licensed
nurses described using the rehearsed strategies as dif-
fi cult, yet successful in reducing or eliminating incivility
and lateral violence. This article updates the literature on
cognitive rehearsal and reviews the use of cognitive re-
hearsal as an evidence-based strategy to address incivility
and bullying behaviors in nursing.
J Contin Educ Nurs. 2014;45(12):535-542.


Instructions: 1.2 contact hours will be awarded by Villanova
University College of Nursing upon successful completion of this
activity. A contact hour is a unit of measurement that denotes
60 minutes of an organized learning activity. This is a learner-
based activity. Villanova University College of Nursing does
not require submission of your answers to the quiz. A contact
hour certificate will be awarded after you register, pay the
registration fee, and complete the evaluation form online
at In order to obtain contact hours you
1. Read the article, “Revisiting Cognitive Rehearsal as an
Intervention Against Incivility and Lateral Violence in Nursing:
10 Years Later,” found on pages 535-542, carefully noting
any tables and other illustrative materials that are included to
enhance your knowledge and understanding of the content. Be
sure to keep track of the amount of time (number of minutes)
you spend reading the article and completing the quiz.
2. Read and answer each question on the quiz. After completing
all of the questions, compare your answers to those provided
within this issue. If you have incorrect answers, return to the
article for further study.
3. Go to the Villanova website to register for contact hour cred-
it. You will be asked to provide your name, contact information,
and a VISA, MasterCard, or Discover card number for payment
of the $20.00 fee. Once you complete the online evaluation, a
certificate will be automatically generated.
This activity is valid for continuing education credit until
November 30, 2016.
Contact Hours
This activity is co-provided by Villanova University College of
Nursing and SLACK Incorporated.
Villanova University College of Nursing is accredited as a pro-
vider of continuing nursing education by the American Nurses
Credentialing Center’s Commission on Accreditation.
• Describe the value of cognitive rehearsal as an appropriate
framework to use in addressing uncivil encounters.
• Explain the effects of incivility and lateral violence on individu-
als, teams, and organizations.
Disclosure Statement
Neither the planners nor the authors have any conflicts of inter-
est to disclose. Dr. Clark has disclosed authorship of the book
Creating and Sustaining Civility in Nursing Education.

536 Copyright © SLACK Incorporated


(Clark, 2013a; Spence-Laschinger, Wong, Cummings, &
Grau, 2014). Workplace incivility also creates a heavy
financial burden for health care organizations. Some
estimates suggest that the annual cost of lost employee
productivity due to workplace incivility may be as high
as $12,000 per nurse (Lewis & Malecha, 2011). In addi-
tion, the costs of incivility escalate when the expenses
associated with supervising the employee, managing the
situation, consulting with attorneys, and interviewing
witnesses (i.e., doctors, nurses, patients, and others im-
pacted by the offender or who witnessed the incivility) are
included (Clark, 2013a; Pearson & Porath, 2009). Clearly,
incivility in the workplace is a serious problem and must
be addressed—especially since incivility by health care
professionals can result in serious mistakes, preventable
complications, and even death (Tarkan, 2008).

One evidence-based strategy to address incivility
and lateral violence is through the use of cognitive re-
hearsal, a behavioral technique generally consisting of
three parts:
● Participating in didactic instruction about incivility

and lateral violence.
● Identifying and rehearsing specific phrases to address

incivility and lateral violence.
● Practicing the phrases to become adept at using them.


There are several terms in the nursing literature used
to describe undesirable and intimidating behaviors and
interactions that occur between and among nurses and
other health care workers. This section provides working
definitions for three of the more common examples—
incivility, bullying, and workplace mobbing. Histori-
cally, many nurse scholars have housed these terms all
under the rubric of horizontal (also known as lateral)
violence (Roberts, Demarco, & Griffin, 2009); however,
although these terms are sometimes used interchange-
ably, each definition is distinctive and unique.

Clark (2013a, 2013b) defines incivility as rude or dis-

ruptive behaviors that often result in psychological or
physiological distress for the people involved (including
targets, offenders, bystanders, peers, stakeholders, and
organizations), and if left unaddressed, these behaviors
may progress into threatening situations or even result
in temporary or permanent illness or injury. Typically,
incivility is generally considered to be a one-on-one ex-
perience and perceived to be less threatening than bully-
ing or mobbing behavior. Some examples of uncivil be-
haviors include eye-rolling, making demeaning remarks,

excluding and marginalizing others, and issuing sarcastic
remarks (Clark, 2013a).

Although considered to be a lesser form of intimida-
tion, if perpetuated in a patterned way over time, inci-
vility can have serious detrimental effects on individu-
als, teams, and organizations. In health care, the results
of incivility can be devastating by negatively impacting
team performance and the delivery of safe patient care,
ultimately putting self and others at risk. How one per-
ceives and responds to the uncivil encounter affects the
level and intensity of the impact (Clark, 2013a). The
same is true for bullying.

In her influential work on bullying in nursing, Randle

(2003) citing Adams (1992), defined bullying as the “per-
sistent, demeaning and downgrading of humans through
vicious words and cruel acts that gradually undermine
confidence and self-esteem” (p. 399). In essence, bully-
ing is considered to be an ongoing, systematic pattern of
behavior designed to intimidate, degrade, and humiliate
another. Some examples of bullying behaviors include
threatening and abusive language, constant and unrea-
sonable criticism, deliberately undermining another per-
son, hostile verbal attacks, and rumor spreading. Lateral
violence, also referred to as horizontal violence, is a form
of bullying based on the theoretical construct of oppres-
sion theory and contextualized by viewing nursing as an
oppressed group (Roberts et al., 2009).

Workplace Mobbing
In 1990, Leymann described “workplace mobbing” as

employees “ganging up” (p. 119) on a target employee
and subjecting him or her to psychological harassment
that may result in severe psychological and occupational
consequences for the victim. Simply stated, workplace
mobbing is a type of bullying in which more than one
person commits egregious acts to control, harm, and
eliminate a targeted individual. In some cases, targets
of mobbing may be excellent and exceptional workers.
For example, Westhues (2004) suggested that mobbing
behaviors among faculty in academic workplaces may be
related to the envy of excellence and jealousy associated
with the achievements of others. The authors further
noted that some of the most common mobbing tech-
niques are completely nonviolent, such as words spoken
or written, while delivered politely with a smile.

Incivility, bullying, and workplace mobbing exact a
heavy toll on individuals, teams, and organizations by
negatively impacting employee retention, recruitment,
and job satisfaction (Clark, 2013a; Spence-Laschinger et
al., 2014). In addition, these behaviors can have devas-

537The Journal of Continuing Education in Nursing · Vol 45, No 12, 2014


tating and lasting effects on self-worth, self-confidence,
clinical judgment, and ultimately patient safety. For
example, when a nurse who is giving a hand-off report
uses an abrupt or antagonistic communication style with
an oncoming nurse, and the oncoming nurse feels in-
timidated or ill-equipped to deal with this type of com-
munication, he or she may not ask for a full patient re-
port, which in turn may negatively impact patient care.
Workplace incivility within the nursing profession is
of particular concern as the nursing shortage becomes
more critical and the profession is called on to lead the
advancement of the nation’s health. Therefore, creating
and sustaining civil workplaces is an imperative for the


The conceptualization of the profession of nursing as
an oppressed group is and has been held by many nurs-
ing scholars (Dunn, 2003; Roberts, 1983, 1997, 2000;
Roberts et al., 2009; Skillings, 1992) and is theoretically
grounded in the original work on oppressed group be-
havior (Fanon, 1963, 1967; Freire, 1971; Memmi, 1965,
1968). In Freire’s (1971) sentinel work, Pedagogy of the
Oppressed, he described the psychological and socio-
logical behaviors that are often manifested by those who
are oppressed and as such are marginalized and con-
trolled by others perceived to have more power. The
theory contends that nurses lack power and control in
their workplaces as a result of health care moving into
a physician-controlled hospital setting. Thus, the theory
serves to connect nurses to other oppressed groups based
on their similarly predictable interrelationship behav-
iors related to how they treat each other. The terminol-
ogy used to describe the strife and communication style
within oppressed groups often has been applied to those
in the nursing profession. Oppressed group behavior has
a negative impact on nurses in the workplace, and the
act of not speaking up (known as silencing) is one of the
most frequently described oppressed group behaviors in
nursing (Roberts et al., 2009).

The terms horizontal violence and lateral violence
evolved from oppression theory and refer to the behav-
iors often seen and described as bullying type behaviors
that members of the oppressed group manifest toward
each other as a result of being members of a powerless
group. The descriptor language of lateral and horizontal
refers to the relationship each of the members has to each
other and in that context it is considered as all the same
and linear.

Currently, the contemporary nursing scholars who
study oppressed group behaviors in nursing (Hutchison,

Vickers, Jackson, & Wilkes, 2006; Lewis, 2006; Randle,
2003; Roberts, 1983, 1996, 2000; Roberts et al., 2009),
particularly as it relates to these bullying type behaviors
(lateral and horizontal violence), have suggested two per-
spectives to be considered in conceptualizing the nursing
profession in this context. The first is to understand that
to solely ascribe these behaviors as willful acts of nurses
alone would be incorrect. The understanding of context
is essential. Thus, a more collective understanding that
these behaviors can be and often are an expression of the
character of the workplace and its inherent perception
and treatment of the nurses is indicated. Roberts et al.
(2009) sought support and understanding for the neces-
sity to view oppressed group behavior theory, as it is de-
scribed, and recognition that it does not attribute blame
to flawed nurses but rather attempts to explain the nega-
tive behaviors and uncivil environments manifested by
an unequal power balance in the nurses’ workplace.

The quest to equilibrate the power gradient in any work
environment starts with the individual, and in this case, it
begins with the individual nurse who plays an important
role in establishing the tenor of the workplace. Nurses
most vulnerable to uncivil work environments are most
often of a particular cohort, such as new to nursing prac-
tice, new to a particular area of practice, transitioning to
a new health care environment, and floating and per diem
nurses (Griffin, 2014). Therefore, establishing respectful,
professional communication in health care environments
leads to better outcomes for patients and more civil, col-
legial nurses (Clark, 2013a; Simons & Mawn, 2010).

As a result, all nurses, especially those most vulner-
able to incivility, must be equipped to effectively ad-
dress uncivil behaviors as they occur. The simple act of
speaking up is often an effective intervention. Through
the use of cognitive rehearsal, nurses can learn prere-
hearsed phrases designed to confront and stop bullying
behaviors. The rehearsed and learned retort is matched
in some fashion to the offense that has occurred. Grif-
fin (2004) found that by rehearsing a preprogrammed
retort to a colleague’s uncivil affront or an individual
uncomfortable situation, the level of both personal com-
fort and confidence in a cohort of new to practice nurses
was raised. Smith (2011) also found the use of scripted
language within many health care settings led to greater
patient satisfaction because it allows nurses to use words
and phrases already understood to express a specific
meaning or to ask for additional information.

In 2004, Griffin published the findings of her ground-

breaking exploratory descriptive study using cognitive
rehearsal as a tool against lateral violence for a cohort of

538 Copyright © SLACK Incorporated


26 newly licensed nurses. During general orientation to
the hospital, the newly licensed nurses learned the his-
tory and construction of lateral violence and its impact
on patient care and nursing practice. Participants were
given interactive instruction on cognitive rehearsal and
practiced appropriate responses to frequent forms of
lateral violence. The newly licensed nurses also received
laminated cards that summarized accepted behavioral
expectations for professionals and appropriate responses
to the 10 most frequent forms of lateral violence. At the
end of the 1-year study, 96.1% of newly licensed nurses
stated that they had witnessed lateral violence on the
units, and 46% reported being direct victims of lateral
violence. Most important, the newly licensed nurses who
used cognitive rehearsal to address lateral violence re-
sulted in a complete stoppage of behaviors against newly
licensed nurses.

Griffin (2004) concluded that the use of cognitive
rehearsal as a tool for practicing intervention strategies
in a safe and nonthreatening environment can be highly
effective in preparing newly licensed nurses to address
uncivil behaviors in the workplace. For example, a newly
licensed nurse involved in the study was scheduled to
work the evening shift during her first week of orien-
tation and was somewhat unfamiliar with the unit and
patient population. The nurse reported anecdotally:

I had four patients in three different rooms, but fortu-
nately, they had the same attending physician so I felt
pretty confident with my ability to provide quality care.
However, just as the shift was beginning, the charge
nurse changed my assignment and reassigned two
patients with two different attending physicians. I had
received only a minimal report, and when I got one of
the patients up in a chair upon his [the patient’s] request,
the attending physician entered the room and screamed
“everybody knows I need my patients in bed so I can
complete my exam.” Because of my CR [cognitive re-
hearsal] class, I responded “the individuals I learn the
most from are clearer in their directions and feedback. Is
there some way we can structure this type of learning?”
It sounded contrite but it came out maybe not exactly as
it was on my card, but it got out!

The use of cognitive rehearsal as an intervention strat-
egy has been replicated in subsequent studies and found
to be an effective way to prepare nurses to identify and
address incidents of lateral violence (Embree, Bruner, &
White, 2013; Stagg, Sheridan, Jones, & Speroni, 2011,
2013). In Embree et al. (2013), nurses employed in non-
patient care roles, such as nursing leadership, physi-
cians’ offices, and hospital staff, received didactic con-
tent about lateral violence and cognitive rehearsal, and
were provided laminated cue cards containing appro-
priate responses to common forms of lateral violence.

Although there was no statistically significant difference
between pre- and postsurvey data, trends indicated a
positive sense of empowerment and self-esteem; this was
further supported by anecdotal data.

In their pilot study, Stagg et al. (2011) used a similar
cognitive rehearsal method and reported a significant
increase in nurses’ knowledge of workplace bullying
management, nurses’ likelihood to report bullying be-
haviors, and nurses’ preparedness to handle workplace
bullying. In 2013, Stagg et al. replicated the study and
found that among study participants, 50% witnessed
bullying behaviors, 70% changed their own behaviors,
and 40% reported a decrease in bullying behaviors.
However, only 16% actually responded to bullying
at the time the bullying occurred, which indicated the
need to prevent and manage workplace bullying more

Smith (2011) also used scripts and role-playing for
cognitive rehearsal and found that the technique can
prepare staff and students to improve communication in
critical encounters, especially when interpersonal con-
flict existed. In a two-part study conducted by Clark,
Ahten, and Macy (2013, 2014), the researchers used live
actors to simulate an uncivil nurse-to-nurse encounter
using a problem-based learning (PBL) scenario in an
academic setting. Nursing students enrolled in a senior
leadership course participated in the first part of the
study, which included preparatory readings and a 1-hour
faculty-led didactic session on the topic of workplace in-
civility and the use of cognitive rehearsal as a strategy to
counter incivility and bullying in the health care practice
setting. The students observed the scenario, provided
written feedback on its effectiveness, and participated in
small group discussions to debrief the scenarios. This ap-
proach provided the students with effective strategies to
manage conflicts in similar situations they may encoun-
ter as new nurses in the practice setting.

In a 10-month follow-up study, the students, now
newly licensed, were asked to describe how they trans-
ferred the PBL knowledge presented in the classroom
setting to their nursing practice; how their behavior had
changed since participating in the PBL scenario; and
what barriers and benefits they experienced to using
the PBL scenario knowledge in the practice setting. The
participants reported that the classroom-centered PBL
scenario was an effective teaching strategy for preparing
them to recognize and address nurse-to-nurse incivility
in the workplace. Their comments mirrored Griffin’s
(2004) finding that having knowledge of incivility and
bullying and using cognitive rehearsal for countering
uncivil behaviors can empower nurses to confront in-
stigators and episodes of incivility. Despite gaps in the

539The Journal of Continuing Education in Nursing · Vol 45, No 12, 2014


literature, cognitive rehearsal has been identified as a
best practice to prevent and manage workplace bullying
among staff nurses (Stagg & Sheridan, 2010).

Incivility is detrimental in any work setting, and orga-

nizations must take deliberate steps to prevent and eradi-
cate the problem. Putting measures in place to prevent or
preempt the problem of civility is recommended. To do
this, leaders must openly and boldly address the problem
of incivility and bullying; they must call it by name and
encourage shared responsibility to effectively address
the problem. The end goal is to create and sustain a safe,
healthy, and thriving work environment where the orga-
nizational vision, mission, and values are shared, lived,
and embedded in civility and respect (Clark, 2013a).

To begin, health care organizations must ensure that
their foundational documents (i.e., vision, mission, phi-
losophy, and shared values) are closely aligned with the
concepts of civility and respect, and that the spirit and
intent of these foundational documents are shared and
embraced by employees throughout the organization.
Next, making a commitment to coworkers to foster a
healthy work environment can go a long way in foster-
ing civility, especially when the commitment is focused
on patient safety and quality patient care (Table 1).

After a commitment has been made, it is important
to co-create and establish behavioral norms of decorum

that are essential to successful team functioning, quality
patient care, and a safe work environment. Behavioral
norms form the foundation for effective team function-
ing and stem from the organization’s vision, mission,
philosophy, and statement of shared values. Without
functional norms, desired behavior is ill-defined, and
thus, team members are left to make things up as they
go along.

Unfortunately, there are times when prevention mea-
sures are unsuccessful. In such instances, intervention
methods must be relied on to effectively address incivil-
ity and bullying behaviors. Cognitive rehearsal can be
an effective intervention against incivility and bullying

It is imperative to understand the nature of workplace

incivility and lateral violence to prevent and effectively
address the problem. Being treated in an uncivil manner
changes an individual’s natural neurobiological state, and
the impact of this can be felt instantly. Some individuals
flush, sweat, get angry or tear-up, or worse, they become
silent. Griffin (2014) noted that some individuals rumi-
nate internally about the exchange and wish later they
had addressed the offender. These reactions call for an
intervention because the longer the clock ticks after an
uncivil assault, the less of an impact confrontation may
have (Randall, 2003). Cognitive rehearsal is an evidence-



As your coworker and with our shared organizational goal of excellent service to [our patients] and customers, I commit the following:

I will accept responsibility for establishing and maintaining healthy interpersonal relationships with you and every other member of this

I will talk to you promptly if I am having a problem with you. The only time I will discuss it with another person is when I need advice or
help in deciding how to communicate with you appropriately.

I will establish and maintain a relationship of functional trust with you and every other member of this team. My relationship with each of
you will be equally respectful, regardless of job titles or levels of educational preparation.

I will not engage in bickering, back-biting, and blaming (3Bs). I will practice caring, committing, and collaboration (3Cs) in my relationship
with you and ask that you do the same with me.

I will not complain about another team member and ask you not to as well. If I hear you doing so, I will ask you to talk to that person.

I will accept you as you are today, forgiving past problems and ask you to do the same with me.

I will be committed to fi nding solutions to problems rather than complaining about them or blaming someone for them, and ask you to
do the same.

I will affi rm your contribution to the quality of our service.

I will remember that neither of us is perfect, and that human errors are opportunities not for shame or guilt, but for forgiveness and

From “Commitment to My Co-Workers,” by M. Manthey, 1988. Copyright 1988, 2014, by Creative Health Care Management (
Reprinted with permission.

540 Copyright © SLACK Incorporated


based strategy to effectively communicate and deliver a
message to uncivil or laterally violent colleagues that it is
not okay for them to behave in an uncivil manner.

Addressing the uncivil encounter when it happens
may have the greatest success in stopping the behavior.
Randall (2003) noted that confronting bullies grabs their
attention; however, many targets may lack the skill set or
assertiveness to confront a bully and may need to learn
to do so. Most individuals can recall a time or multiple
times when they wish they had spoken up to someone
or at the very least said, “I wish that I had the exact right
words to say in that situation.” Typically, these situa-
tions occur during times of stress when a creative or ef-
fective response is momentarily unavailable. According
to Randall, the strategy for addressing the uncivil behav-
ior should occur “in private, [with] no witnesses, and
when the bully is unprepared” (p. 136).

Cognitive rehearsal is a technique often used in be-
havioral health for impulse control disorders that calls
for the memorization (learned, although not necessar-
ily “rote verbatim” memorization) of a thought or an
expression designed to help an individual “stop an im-
pulse,” “cue a certain behavior,” or “express a desire to

others” (Glod, 2008, pp. 58-59; Smith, 2011). The use of
cognitive rehearsal in social situations has been proven
to be an effective way for some individuals to control
their environment.

For nurses, cognitive rehearsal is an effective inter-
vention for addressing incivility and workplace bullying
(Griffin, 2004). The cognitive rehearsal process typically
consists of three parts:
● Participating in didactic instruction.
● Learning and rehearsing specific phrases to use during

uncivil encounters.
● Participating in practice sessions to reinforce instruc-

tion and rehearsal.
Cognitive rehearsal can take on various forms. For ex-

ample, the TeamSTEPPS approach (Agency for Health-
care Research and Quality, 2014) is a communication
system designed for health care professionals and pro-
vides a powerful evidence-based framework to improve
patient safety within health care organizations. This ap-
proach helps to improve communication and teamwork
among health care professionals. CUS, an acronym for
Concerned, Uncomfortable, and Safety, is one specific
communication structure provided by TeamSTEPPS to



Uncivil Behavior Verbal Response

Using nonverbal behaviors or innuendo (e.g., eye-rolling, making
faces, deep sighing)

“I sense/see from your facial expression that there may be some-
thing you wish to say to me. It is OK to speak to me directly.”

Name-calling, verbal affronts, demeaning comments, putdowns,
sarcastic remarks

“I learn best from individuals who address me with respect and
who value me as a member of the team. Is there a way we can
structure this type of interaction?”

Using silent treatment or withholding important information “It is my understanding that there was/is more information available
regarding this situation. Please share any other important informa-
tion since patient care depends on a full report.”

Using anger, humiliation, and intimidation “When the words that I hear make me fearful or shamed, I need to
seek a respectful professional explanation. What was your intent?”

Spreading rumors, gossiping, failing to support, sabotaging a co-
worker, or sharing information you were asked to keep private

“I don’t feel right talking about him/her/situation when I wasn’t
there and don’t know the facts. Perhaps the information was taken
out of context. I suggest you check it out with him/her.”

Making fun of another nurse’s appearance, demeanor, or personal-
ity trait

“She/he is a valuable member of the team and deserves our sup-
port. How can we be more inclusive and work more effi ciently as a

Failing to support or encouraging others to turn against a coworker “I am not feeling like a valued coworker. Can we approach this dif-
ferently? What helped you to fi t in here?”

Taking credit for others’ work, ideas, or contributions “I didn’t expect your nonsupport. Behaving this way is unprofes-
sional and makes me feel disrespected. How can we work together
and support one another?”

Distracting and disrupting others during meetings “Can I speak with you about your sense of urgency in our meet-
ings? It distracts me and interrupts my thoughts.”

a Excerpts from Clark, 2013b; Dellasega, 2009; and Griffi n, 2004.

541The Journal of Continuing Education in Nursing · Vol 45, No 12, 2014


assist with conflict negotiation. When a health care pro-
fessional uses CUS, it issues an alert that a patient safety
problem has been identified. For example, a CUS frame-
work may be used in the following way: “I am Con-
cerned about Mr. Jones. I am Uncomfortable with his
recent activity. I think we may have missed something,
and I am worried about his Safety.”

A similar response may be used in the case of incivil-
ity. For example, if a nurse encounters an uncivil experi-
ence, he or she may respond in the following way: “I
am Concerned about the tone of this interaction. I am
Uncomfortable and beginning to feel stressed. I’m wor-
ried that my discomfort and stress may impact the Safety
of our patients. Please address me in a respectful way.”
Table 2 lists some common uncivil behaviors among
nurses and associated cognitive rehearsal responses.

Many of the articles reviewed for this retrospective

article were a synthesis of three decades of research con-
cerning incivility in nursing. It is evident that when nurs-
ing environments harbor uncivil or bullying behaviors,
patients are put at risk, and nursing as a profession is
disparaged and maligned. Although prevention is clearly
the best approach toward minimizing or eliminating in-
civility in the nursing workplace, cognitive rehearsal is
a valuable tool for effective conflict negotiation and a
positive step toward resolving disagreements.

In her original work, situated in the context of oppres-
sion theory, Griffin (2004) raised awareness about the
negative consequences of workplace incivility and lateral
violence in nursing and concluded that cognitive rehearsal
is an effective behavioral technique to address the prob-
lem. Since then, several researchers have used cognitive
rehearsal in a variety of workplace and academic settings
(Clark et al., 2014; Embree et al., 2013; Stagg et al., 2011,
2013) and found the use of cognitive rehearsal to be an
effective intervention in addressing incivility and lateral
violence. In some cases, the use of cognitive rehearsal re-
sulted in a heightened sense of nurse empowerment and
self-esteem, an increased awareness in nurses’ knowledge
of workplace bullying and ability to address the offender
(Stagg et al., 2011), and improved communication (Smith,
2011), and helped prepare new graduate nurses to effec-
tively address incivility (Clark et al., 2014).

The essence of cognitive rehearsal as an intervention
is rehearsing and practicing ways to deal with a situation
between two individuals when incivility occurs. This
is important because in addition to descriptive studies
exploring incivility and bullying in nursing, nurses now
are equipped with an evidence-based strategy to address
some of the specific uncivil behaviors.

How individual nurses treat each other and what
a nursing practice environment looks and feels like is
predicated on what behaviors are fostered by the nurses
themselves. Continued research on the impact of inci-
vility in different domains in nursing practice as well as
in the academic environment produces and informs the
profession. Therefore, the continuation of intervention
studies using cognitive rehearsal is recommended. For
example, one of the authors (C.M.C.) and her research
partners will be conducting an intervention study us-
ing a laboratory-simulated experience to explore how
emotional stress caused by an uncivil nurse-to-nurse
encounter impacts a nurse’s work performance and
patient safety. The researchers will measure the effects
of stress on the participant (nurse) using biomarkers
found in saliva, heart rate, blood pressure readings, and
self-assessment scales to determine whether the prepared
cognitive rehearsal response was effective in countering
the stress effects of the uncivil encounter and was ef-
fective to the extent that work performance and patient
safety were unaffected.

Cognitive rehearsal was revisited as a shield for incivil-

ity and lateral violence, and the use of cognitive rehearsal
as a strategy for addressing incivility and bullying be-
haviors in nursing continues to be a valuable tool. Being
well-prepared, speaking with confidence, and using re-
spectful expressions to address incivility can empower
nurses to break the silence of incivility and oppression.

key points
Revisiting Incivility in Nursing
Griffi n, M., Clark, C.M. (2014). Revisiting Cognitive
Rehearsal as an Intervention Against Incivility and Lateral
Violence in Nursing: 10 Years Later. The Journal of Continu-
ing Education in Nursing, 45(12), 535-542.

1 This article scaffolds working defi nitions for three of the more common examples of undesirable behaviors and interactions
that occur between and among nurses and other health care

workers: incivility, bullying, and workplace mobbing.

2 A historical and updated review of the literature on the use of cognitive rehearsal as an effective, evidence-based intervention
is provided.

3 Common language for addressing uncivil encounters is pro-vided to empower nurses to effect change by focusing on the
unifying and essential need to deliver safe, quality patient care.

542 Copyright © SLACK Incorporated


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