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.
  • 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)
    • Griffin and Clark (2014)

The Assignment ( 6-7 pages total):

Part 1: Work Environment Assessment (2-3pages)

  • Review the Work Environment Assessment Template you      completed for this Module’s Discussion.
  • 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 (2-3 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 (2-3 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 Work      Environment Assessment.

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 care.

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 issues.

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 feedback.

LEARNING OBJECTIVES 1. Identify components of a healthy

workplace. 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

CNE 1.0 contact hours

Conversations 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 workplace? 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 leadership.

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 conversations 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 committing 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 □ □ □ □ □ distributed.

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 response.

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 disrespectfully.

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 care.”

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 nurse.

“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 care.” 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 them. 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 requires:

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 conversation?

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 you.

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

d. refrain from having the conversation.

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

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

7. The first step of cognitive rehearsal is:

a. describing your position in objective terms.

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 model?

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 meeting.

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


JONA Volume 41, Number 7/8, pp 324-330 Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins


Fostering Civility in Nursing Education and Practice Nurse Leader Perspectives

Cynthia M. Clark, PhD, RN, ANEF

Lynda Olender, MS, RN, ANP, NEA-BC

Cari Cardoni, BSN

Diane Kenski, BSN

Incivility in healthcare can lead to unsafe working conditions, poor patient care, and increased medical costs. The authors discuss a study that examined factors that contribute to adverse working relation- ships between nursing education and practice, effective strategies to foster civility, essential skills to be taught in nursing education, and how education and practice can work together to foster civility in the profession.

The work of nursing is 4 times more dangerous than most other occupations,1 and nurses experience work- related crime at least 2 times more often than any other healthcare provider.2 Root causes for workplace violence are multifaceted and include work-related stress due in part to an increasingly complex patient population and workload and deteriorating interper- sonal relationships at the bedside.1 When normalized or left unaddressed, these uncivil and disruptive be- haviors may emerge into an incivility spiral,3 depicted along a continuum from an unintentional act leading to intentional retaliation, escalating to workplace bul- lying and even violence.4 Incivility and disruptive be- haviors have been identified both in the academic5-7

and clinical settings8-10; however, no direct study of incivility between the 2 environments has been made.

Review of the Literature

Incivility and disruptive behavior in nursing educa- tion and practice are common,4,9 on the rise,11 and frequently ignored.12 Two decades ago, Boyer13

noted several challenges facing institutions of higher education, including academic incivility. Although incivility in the academic setting is not a new phe- nomenon, the types and frequency of misbehavior are increasing and have become a significant prob- lem in higher education, including nursing educa- tion. Clark and Springer14,15 explored faculty and student perceptions of incivility in nursing education and found negative behaviors to be commonplace and exhibited by students and faculty alike. The ma- jority of respondents (71%) perceived incivility as a moderate to serious problem and reported that stress, high-stake testing, faculty arrogance, and student en- titlement contributed to incivility.14 More than half of the respondents reported experiencing or know- ing about threatening student encounters between students or faculty.14

A small but growing body of research suggests that incivility and disruptive behaviors are particu- larly commonplace to the new graduate nurse or nursing student within the clinical setting.10 Paral- leling incivility in the academic setting, staff nurses are also vulnerable to bullying, defined as negative behavior that is systematic in nature and purpose- fully targeted at the victim over a prolonged time frame with the intent to do harm.16 These findings are also supported by a recent Joint Commission (TJC) survey17 reporting that more than 50% of nurses are victims of disruptive behaviors including

324 JONA � Vol. 41, No. 7/8 � July/August 2011

Author Affiliations: Professor (Dr Clark) and Research Assistants (Mss Cardoni and Kenski), School of Nursing, Boise State University, Idaho; Doctoral Candidate (Ms Olender), Seton Hall University, South Orange, New Jersey, and Executive Con- sultant and Nurse Researcher (Ms Olender), James J. Peters VA Medical Center, Bronx, New York.

The authors declare no conflict of interest. Correspondence: Dr Clark, School of Nursing, Boise State Uni-

versity, 1910 University Dr, Boise, ID 83725 ( DOI: 10.1097/NNA.0b013e31822509c4

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

incivility and bullying, and more than 90% of nurses stated witnessing abusive behaviors of others in the workplace. Likened to the concept of nurses ‘‘eating their young’’,18 the findings of several studies suggest that these negative behaviors are a learned process, transferred through staff nurses to new nurses and student nurses via interaction within the hierarchi- cal nature of the profession.10

Incivility and disruptive behaviors may also be normalized or perpetuated by organizational cul- ture,12,18 particularly during times of restructuring or downsizing. This is suggested to be secondary to unclear roles and expectations, professional and per- sonal value differences, personal vulnerabilities, and power struggles common within organizations dur- ing periods of change.18 Other consequences of inci- vility include heightened stress levels, physiological and psychological distress,5 job dissatisfaction,10,19

decreased performance,20 and turnover intention.21

Bartholomew18 noted that uncivil behaviors may contribute to the exodus of new graduates leaving their first job within 6 months. If disruptive behav- iors are tolerated, nurses may leave the profession altogether.21 Disruptive and bullying behaviors have been identified as a root cause of more than 3,500 sentinel events over a 10-year time frame22 and con- tribute to an annual estimate of 98,000 to 100,000

patients dying secondary to medical errors in hos- pitals.23,24 Collectively, these findings led TJC17 to intervene and release a sentinel event alert calling for zero tolerance of intimidating and bullying behaviors.

Conceptual Framework

Clark5 developed a conceptual model to illustrate how heightened levels of nursing faculty and student stress, combined with attitudes of student entitle- ment and faculty superiority, work overload, and a lack of knowledge and skills, contribute to incivility in nursing education. This conceptual model has been adapted to reflect the stressors that contribute to incivility in both nursing education and practice (Figure 1). Factors that contribute to stress in nurs- ing practice are similar to the stressors experienced in nursing education including work overload, un- clear roles and expectations, organizational condi- tions, and a lack of knowledge and skills. Moreover, in both practice and academia, stress is mitigated by leaders who role model professionalism and utilize effective communication skills.25 The importance of modeling effective communication and related edu- cation to address incivility cannot be underestimated, can reduce its incidence and effects,26 and can assist in fostering cultures of civility.6

Figure 1. Conceptual model for fostering civility in nursing education (adapted for nursing practice).

JONA � Vol. 41, No. 7/8 � July/August 2011 325

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

Nurse Leaders’ Survey

Mindful of the need to enhance the culture of civility both in the academic and clinical settings, a descrip- tive qualitative study was conducted. The purpose of the study was to gather practice-based nursing lead- ers’ perceptions about factors that contribute to an adverse working relationship between nursing ed- ucation and practice, the most effective strategies needed to foster civility, the skills needed to be taught in nursing education, and how nursing education and practice can work together to foster civility in the nursing workplace.

Procedure and Analysis

The survey was developed by the author (C.M.C.) and included 4 open-ended questions designed to garner nurse leaders’ perceptions on ways to foster civility in nursing education and practice. The ques- tions were constructed based on a comprehensive review of the literature on incivility and numerous empirical studies. Two other researchers reviewed the survey for content validity and logical construc- tion. Institutional approval to conduct the study was obtained. The surveys were administered to nurse leaders attending a statewide nursing conference using a paper method for gathering narrative, hand- written responses. Once the study was clearly ex- plained, the respondents provided consent and voluntarily completed the survey. Aside from indi- cating their employment position, no demographic information was gathered about the participants. The survey contained 4 questions:

1. What factors contribute to an adverse working relationship between nursing edu- cation and practice?

2. What are the most effective strategies for fostering civility in the practice setting?

3. What essential skills need to be taught in nurs- ing education to prepare students to foster ci- vility in the practice setting?

4. How can nursing education and practice work together to foster civility in the prac- tice setting?

The sample consisted of 174 nurse leaders: 68 (39.1%) nurse executives and 106 (60.9%) nurse managers who were attending a statewide conference held in a large western state. The respondents were recruited by the researcher (C.M.C.), who explained the purpose of the study during the keynote address. The surveys were collected and prepared for analysis.

Textual content analysis was used to manually analyze the respondents’ narrative responses. Key words or phrases were quantified by the researchers;

inferences were made about their meanings and cat- egorized into themes. Two members of the research team reviewed the nurse leaders’ comments indepen- dently to quantify the recurring responses and orga- nize them into themes. Then, 2 other research members reviewed the comments. Areas of theme agreement and disagreement were discussed, and verbatim com- ments were reviewed until all researchers were con- fident that the analysis was a valid representation of the comments.


Analyses of the narrative responses from the partici- pants were organized into themes, ranked in order of the number of responses, and described according to each research question. The first research ques- tion asked nurse leaders to identify factors that con- tribute to an adverse working relationship between nursing education and practice. Both groups identi- fied a noticeable gap between nurses in education and practice (Table 1). Nurse executives reported nurse educators failing to keep pace with practice changes, lacking familiarity with practice regulations and standards, being slow to respond with curricular changes, and a lack of shared goals between nurses in education and practice. Nurse managers reported similar findings, but suggested that a limited number of nursing faculty, a highly stressed work environ- ment, and lack of adequate resources also contributed to adverse working relationships. These reported defi- cits resulted in the perception that students were not being adequately prepared for practice.

The second research question asked the respon- dents to identify the most effective strategies for fos- tering civility in the practice setting. Nurse executives identified 4 major themes, and nurse managers iden- tified 7 themes, listed in Table 2. Strategies that ren- dered less than 10 responses are not listed in the table. For nurse executives, these themes included holding self and others accountable for acceptable behaviors, addressing incivility in nursing education programs, implementing stress reduction strategies, making ci- vility a requirement for hiring, and conducting in- stitutional assessments to measure incivility. Nurse managers’ responses to this question were similar to those of nurse executives. Notable differences between the 2 groups were nurse executives’ recommendations for civility teaching starting at the education level, civility as a requirement for hiring, and ongoing ci- vility assessment. Nurse managers’ responses differing from executives were establishing a healthy work en- vironment, ongoing practice-preparedness education, and reinforcing positive behavior.

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The third research question asked the respon- dents to identify essential skills that need to be taught in nursing education programs to prepare students to foster civility in the practice setting (Table 3).

Nurse executives identified 4 major themes, and nurse managers identified 8 themes. Strategies that rendered less than 10 responses are not listed in the table. For nurse executives, these themes included re- flective practice and critical thinking, respect for di- versity, and stress reduction strategies. Nurse mangers had similar responses for essential skills and also sug- gested critical-thinking skill sets (time management, decision-making, and problem-solving skills), organi- zational culture of civility, and civility education.

The final research question asked nurse leaders for strategies about how nursing education and prac- tice can work together to foster civility in the prac- tice setting (Table 4). Both groups identified 5 major

themes. Once again, strategies that rendered less than 10 responses are not listed in the table. For nurse executives, these themes included making civility a requirement for hiring, teaching conflict resolution and managing difficult situations, implementing stress reduction strategies, and conducting institutional as- sessments to measure incivility. Teaching civility was identified only by nurse executives, and themes iden- tified only by nurse managers were mentorship, pro- fessionalism, and reinforcing and rewarding civility. Nurse managers also suggested focusing on patient care and safety and implementing stress reduction strategies (G10 responses).

At both the organizational level and unit levels, nurse leaders in practice noted the importance of having a shared vision of civility and underscored the importance of adopting and implementing codes of conduct and effective policies and procedures. Both

Table 2. Strategiesa for Fostering Civility in the Practice Setting

Nurse Executives (n = 64 of 68 [94.11%])b Nurse Managers (n = 95 of 106 [85.62%])b

1. Conducting joint meetings to develop a shared vision and a culture of civility (49)

1. Conducting joint meetings to develop a shared vision and a culture of civility (38)

2. Establish codes of conduct with and policies with clearly expected behaviors (40)

2. Establish codes of conduct and policies with clearly expected behaviors (32)

3. Provide ongoing education (conflict resolution, problem solving, respectful communication) (23)

3. Establish a healthy practice environment, emphasizing workplace civility (32)

4. Positive role modeling by all members of the healthcare team (20)

4. Positive role modeling by all members of the healthcare team (30)

5. Provide ongoing education (conflict resolution, problem solving, respectful communication) with a focus on practice preparedness (20)

6. Hold self and others accountable for acceptable behaviors (19) 7. Reinforce positive behavior (11)

aStrategies identified by less than 10 respondents are not included; please see text. bThe number in parentheses following the strategies indicates the number of times the strategy was identified. The number exceeds the number of respondents because of suggestions of multiple strategies.

Table 1. Factors Contributing to an Adverse Working Relationship Between Nursing Education and Practicea

Nurse Executives (n = 67 of 68 [98.53%])b Nurse Managers (n = 101 of 106 [95.28%])b

1. Educators not keeping current with practice changes (standards and regulations) (39)

1. Limited number of faculty and disconnected from practice (40)

2. Lack of communication, collaboration, and mutual curriculum planning between nursing faculty and staff (16)

2. Highly stressed work environments plagued by rude, uncivil behaviors among members of the health care team (32)

3. Lack of preceptor engagement due to stress and workload (23)

3. Faculty and staff workload and being stretched too thin (29)

4. Lack of shared vision, mission, and goals between practice and education (11)

4. Lack of communication, collaboration, and mutual curriculum planning between nursing faculty and staff (21)

5. Lack of adequate resources (human and financial) (18)

aFactors identified by less than 10 respondents are not included; please see text. bThe number in parentheses following the factors indicates the number of times the factor was identified. The number exceeds the number of respondents because of suggestions of multiple factors.

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nurse executives and managers expressed the need for effective communication and collaboration, pos- itive role modeling, and the importance of vigilant and purposeful hiring with civility in mind.


The applicability of Clark and Olender’s (Figure 1) conceptual model for fostering civility in nursing academic and clinical practice environments is supported by the results of this study. Indeed, results suggest an increased awareness of stressors likely contributing to a culture of incivility by these nurs- ing leaders. As depicted in the model, and as Table 2 denotes, the implementation of strategies to reduce stressors (such as policy and procedure, education, and self-care initiatives) is a key objective for the establishment of a culture of civility. A high percent- age of nursing leaders emphasized the importance of a collaborative vision and partnership between educa- tion and practice to meet this goal. This vision could emerge via joint education and practice meetings

that focus on designing up-to-date and relevant cur- ricula that reflect current practice standards with em- phasis on civility education and teamwork. Ideally, this would result in the development and implemen- tation of comprehensive, well-defined, nonpunitive policies and procedures that focus on civility, are widely disseminated, and have measurable outcomes. An emphasis on individual accountability at all or- ganizational levels, as well as organizational adop- tion of a culture of civility, would be required for policies to be effective. In addition, leadership mind- fulness and intentionality toward positive role mod- eling, professionalism, collaboration, teamwork, and ethical conduct would be required. Related com- petencies would be reinforced and practiced through simulation and role playing, in real time, and in- clusion of these skills within competency assessment systems.

Our findings lend support to studies indicating that stress is a major contributor to incivility1,5,14,15,19; thus, it is important to integrate self-care and stress reduction into daily activities. The American Holistic

Table 4. How Nursing Education and Practice Can Work Together to Foster Civility in the Practice Settinga

Nurse Executives (n = 58 of 68 [85.29%])b Nurse Managers (n = 84 of 106 [79.24%])b

1. Improve communication and partnerships between education and practice (33)

1. Improve communication and partnerships between education and practice (55)

2. Develop a shared vision for a culture of civility (14) 2. Integrate civility into the nursing curriculum (30) 3. Integrate civility into the nursing curriculum (13) 3. Develop codes of conduct with expected behaviors (23) 4. Foster leadership and positive role modeling (11) 4. Foster leadership, professionalism, positive role

modeling, and mentoring (16) 5. Teach civility and behavioral expectations (11) 5. Reinforce and reward civility (11)

aStrategies identified by less than 10 respondents are not included; please see text. bThe number in parentheses following the strategies indicates the number of times the strategy was identified. The number exceeds the number of respondents because of suggestions of multiple strategies.

Table 3. Essential Skillsa Needed to Prepare Students to Foster Civility in the Practice Setting

Nurse Executives (n = 61 of 68 [89.70%])b Nurse Managers (n = 99 of 106 [93.39%])b

1. Conflict resolution, negotiation, assertiveness, learning to address incivility (43)

1. Effective communication, teamwork, and collaboration (57)

2. Effective communication, teamwork, and collaboration (31) 2. Conflict resolution, negotiation, assertiveness (38) 3. Professionalism and leadership skills (24) 3. Professionalism and leadership skills (35) 4. Personal accountability and patient safety (22) 4. Time management, organizational skills, and

decision-making and problem-solving skills (17) 5. Creating a healthy work environment and

organizational culture (17) 6. Civility education (13) 7. Patient-focused care and patient safety (11)

aSkills identified by less than 10 respondents are not included; please see text. bThe number in parentheses following the skills indicates the number of times the skill was identified. The number exceeds the number of respondents because of suggestions of multiple skills.

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Nurses Association27 recommends several stress management techniques including enjoying the com- pany of family, friends, and other supportive people; getting regular exercise and adequate sleep; eating healthy foods; and drinking plenty of water. We also suggest lunchtime walking programs, change of shift aerobic classes, meditation, and 5-minute massages. This may also include implementing caring compe- tencies such as empathy, collaboration, and conflict resolution in the work site. Last, Olender-Russo28

suggests creating forums to share success stories and to communicate evidence-based outcomes such as staff and patient satisfaction, low turnover rates, and patient-related adverse events or avoidances both at the organizational and unit levels to sustain work- place civility and staff motivation.


Recent reports of the increasing prevalence of in- civility and related disruptive behaviors within our nursing academic and clinical settings are alarming, especially when considering the impact on patient and staff safety. The old adage, ‘‘it takes a village,’’ rings true when one considers the complexity of the task of fostering a culture of civility. A comparison study with academic nurse leaders could illuminate shared perceptions or alternative ways to foster ci- vility in nursing education and practice.

The model proposed in this study is newly adapted to practice and requires further empirical testing. For example, evidence-based data obtained through in- stitutional assessments, such as the Organizational Civility Scale,29 are needed to measure the organiza- tional culture so that targeted interventions may be implemented and empirically tested. Case study meth- ods may be beneficial to showcase best practices.

Researchers also suggest that negative behaviors in the workplace may be a learned process and likely exacerbated within stressful academic and clinical set- tings.12 Conversely, fostering civility in nursing edu- cation and practice may also be a learned process and, as such, amenable to positive interventions. Nurse leaders need to be extremely attentive and supportive toward the success of the nursing practice and nurs- ing education partnership for the cocreation and sus- tainment of a healthy work environment. Indeed, the promotion of a positive organizational culture has been shown to be a successful strategy and is asso- ciated with increased nurse manager engagement in authentic leadership.25 As healthcare providers, we all have an ethical responsibility to care for those who care for others. Specifically, nurse leaders must create and promote a work environment conducive to caring. This includes fostering a culture of civility both within the academy (where nursing learning begins) and within practice environments (where learning of nursing continues).


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10. Simons S. Workplace bullying experienced by Massachusetts

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11. Lipley N. Bullying at work on increase, Royal College of

Nursing survey finds. Nurs Manage. 2006;12(10):5. 12. Lewis MA. Nurse bullying: organizational considerations in the

maintenance and perpetration of health care bullying cultures.

Nurs Manage. 2006;14(1):52-58. 13. Boyer EL. Campus Life: In Search of Community. San Francisco,

CA: The Carnegie Foundation for the Advancement of Teaching; 1990.

14. Clark CM, Springer PJ. Incivility in nursing education: descriptive

study on definitions and prevalence. J Nurs Educ. 2007;46(1):7-14. 15. Clark CM, Springer PJ. Thoughts on incivility: student and

faculty perceptions of uncivil behavior in nursing education.

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bullying in nursing: towards a more critical organisational

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18. Bartholomew K. Ending Nurse to Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HCPro; 2006.

19. Vessey JA, DeMarco RF, Gaffney DA, Budin W. Bullying of

staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the

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in the workplace: incidence and impact. J Occup Health Psychol. 2001;6(1):64-80.

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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:

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 must: 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. Objectives • 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.

Incivility 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.

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 profession.


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.

COGNITIVE REHEARSAL 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 effectively.

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).

PRIMARY PREVENTION AS A FRAMEWORK 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 behaviors.

COGNITIVE REHEARSAL AS AN INTERVENTION 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 team.

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 growth.

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 team?”

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.

DISCUSSION 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.

CONCLUSION 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


The intent of the original study was to improve nurse communication in health care settings and to ensure a safer environment for patients.

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Work Environment Assessment TemplateUse this document to complete the Module 4 Workplace Environment Assessment .Summary of Results – Clark Healthy Workplace InventoryIdentify two things that surprised you about the results. Also identify one idea that you believed prior to conducting the Assessment that was confirmed.What do the results of the Assessment suggest about the health and civility of your workplace?Briefly describe the theory or concept presented in the article(s) you selected.Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.General Notes/CommentsWork Environment AssessmetTemplate© 2018 Laureate Education Inc. 4

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