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.
• 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 (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.
• Describe the results of the Work Environment Assessment you completed in 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 Work Environment Assessment.

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

CNE ARTICLE

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: cclark@boisestate.edu.

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

doi:10.3928/00220124-20141122-02

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.

abstractHOW TO OBTAIN CONTACT HOURS BY
READING THIS ISSUE

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 http://goo.gl/gMfXaf. 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

CNE ARTICLE

(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.

DEFINING INCIVILITY, BULLYING, AND WORKPLACE
MOBBING

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

CNE ARTICLE

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.

THEORETICAL BACKGROUND: OVERVIEW OF
OPPRESSION THEORY

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

CNE ARTICLE

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

CNE ARTICLE

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-

TABLE 1

COMMITMENT TO MY COWORKERS

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 (http://www.chcm.com).
Reprinted with permission.

540 Copyright © SLACK Incorporated

CNE ARTICLE

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

TABLE 2

COMMON UNCIVIL BEHAVIORS AMONG NURSES WITH ASSOCIATED COGNITIVE REHEARSAL RESPONSESa

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

CNE ARTICLE

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

CNE ARTICLE

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

REFERENCES
Adams, A. (1992). Bullying at work—How to confront and overcome

it. London, England: Virago Press.
Agency for Healthcare Research and Quality. (2014). TeamSTEPPS:

National implementation. Retrieved from http://teamstepps.ahrq.
gov

Clark, C.M. (2013a). Creating and sustaining civility in nursing educa-
tion. Indianapolis, IN: Sigma Theta Tau International.

Clark, C.M. (2013b). National study on faculty-to-faculty incivility:
Strategies to foster collegiality and civility. Nurse Educator, 38, 98-
102. doi:10.1097/NNE.0b013e31828dc1b2

Clark, C.M., Ahten, S.M., & Macy, R. (2013). Using problem-based
learning scenarios to prepare nursing students to address incivil-
ity. Clinical Simulation in Nursing, 9, e75-e83. doi:10.1016/j.
ecns.2011.10.003

Clark, C.M., Ahten, S.M., & Macy, R. (2014). Nursing graduates’ abil-
ity to address incivility: Kirkpatrick’s level-3 evaluation. Clinical
Simulation in Nursing, 10, 425-431.

Dellasega, C.A. (2009). Bullying among nurses. American Journal of
Nursing, 109, 52-58.

Dunn, H. (2003). Horizontal violence among nurses in the operating
room. Association of Operating Room Nurses Journal, 78, 977-988.

Embree, J.L., Bruner, D.A., & White, A. (2013). Raising the level
of awareness of nurse-to-nurse lateral violence in a criti-
cal access hospital. Nursing Research and Practice, 2013, 1-7.
doi:10.1155/2013/207306

Fanon, F. (1963). The wretched of the earth. New York, NY: Grove
Press.

Fanon, F. (1967). Black skin, white masks. New York, NY: Grove
Press.

Freire, P. (1971). Pedagogy of the oppressed. Harmondsworth, Eng-
land: Penguin.

Glod, C.A. (1998). Contemporary psychiatric–mental health nursing:
The brain behavior connection. Philadelphia, PA: F.A. Davis.

Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral
violence: An intervention for newly licensed nurses. The Journal of
Continuing Education in Nursing, 35, 257-263.

Griffin, M. (2014). A modicum of lateral violence education leads to
nurse self-accountability. Manuscript submitted for publication.

Hutchinson, M., Vickers, M., Jackson, D., & Wilkes, L. (2006). Work-
place bullying in nursing: Towards a more critical organisational
perspective. Nursing Inquiry, 13, 118-126.

Lewis, M. (2006). Nurse bullying: Organizational considerations in
the maintenance and perpetration of health care bullying cultures.
Journal of Nursing Management, 14, 52-58.

Lewis, P.S., & Malecha, A. (2011). The impact of workplace incivil-
ity on the work environment, manager skill, and productivity.
The Journal of Nursing Administration, 41, 41-47. doi:10.1097/
NNA.0b013e3182002a4c

Leymann, H. (1990). Mobbing and psychological terror at workplaces.
Violence and Victims, 5, 119-126.

Manthey, M. (1988). Commitment to my co-workers. Minneapolis,
MN: Creative Health Care Management.

Memmi, A. (1965). The colonizer and the colonized. Boston, MA: Bea-
con Press.

Memmi, A. (1968). Dominated man: Notes towards a portrait. New
York, NY: Prentice Hall.

Pearson, C., & Porath, C. (2009). The cost of bad behavior: How inci-
vility is damaging your business and what to do about it. New York,
NY: Penguin.

Randall, P. (2003). Adult bullying: Perpetrators and victims. New York,
NY: Brunner-Routledge.

Randle, J. (2003). Bullying in the nursing profession. Journal of Ad-
vanced Nursing, 43, 395-401.

Roberts, S.J. (1983). Oppressed group behavior: Implications for nurs-
ing. Advances in Nursing Science, 5(4), 21-30.

Roberts, S.J. (1996). Breaking the cycle of oppression: Lessons for
nurse practitioners? Journal of the American Academy of Nurse
Practitioners, 8, 209-214.

Roberts, S.J. (1997). Nurse executives in the 1990s: Empowered or op-
pressed? Nursing Administration Quarterly, 22, 64-71.

Roberts, S.J. (2000). Development of a positive professional identity:
Liberating oneself from the oppressor within. Advances in Nursing
Science, 22(4), 71-82.

Roberts, S.J., Demarco, R., & Griffin, M. (2009). The effect of op-
pressed group behaviours on the culture of the nursing workplace:
A review of the evidence and interventions for change. Journal of
Nursing Management, 17, 288-293.

Simons, S.R., & Mawn, B. (2010). Bullying in the workplace—A
qualitative study of newly licensed registered nurses. AAOHN
Journal, 58, 305-311.

Skillings, L. (1992). Perceptions and feelings of nurses about horizontal
violence as an expression of oppressed group behavior. NLN Publi-
cations, 14-2504, 167-185.

Smith, C.M. (2011). Scripts: A tool for cognitive rehearsal. The
Journal of Continuing Education in Nursing, 42, 535-536.
doi:10.3928/00220124-20111118-03

Spence-Laschinger, H.K., Wong, C.A., Cummings, G.G., & Grau,
A.L. (2014). Resonant leadership and workplace empowerment:
The value of positive organizational cultures in reducing workplace
incivility. Nursing Economic$, 32(1), 5-15, 44.

Stagg, S.J., & Sheridan, D. (2010). Effectiveness of bullying and vio-
lence prevention programs: A systematic review. AAOHN Journal,
58, 419-424. doi:10.3928/08910162-20100916-02

Stagg, S.J., Sheridan, D., Jones, R.A., & Speroni, K.G. (2011). Evalua-
tion of a workplace bullying cognitive rehearsal program in a hos-
pital setting. The Journal of Continuing Education in Nursing, 42,
395-401. doi:10.3928/00220124-20110823-45

Stagg, S.J., Sheridan, D.J., Jones, R.A., & Speroni, K.G. (2013).
Workplace bullying: The effectiveness of a workplace program.
Workplace Health & Safety, 61, 333-338. doi:10.3928/21650799-
20130716-03

Tarkan, L. (2008, December 1). Arrogant, abusive and disruptive—
And a doctor. The New York Times. Retrieved from http://www.
nytimes.com/2008/12/02/health/02rage.html

Westhues, K. (2004). The envy of excellence: Administrative mobbing
of high-achieving professors. Lewiston, NY: Edwin Mellen Press.

Workplace Bullying Institute. (2014). 2014 WBI U.S. workplace bul-
lying survey. Retrieved from http://workplacebullying.org/multi/
pdf/WBI-2014-US-Survey

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.

18 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com

“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,

EdD

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

www.AmericanNurseToday.com 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 www.AmericanNurseToday.com

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

www.AmericanNurseToday.com 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
NurseToday.com/?p=21641.

22 American Nurse Today Volume 10, Number 11 www.AmericanNurseToday.com

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.”

www.AmericanNurseToday.com 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 http://www.americannursetoday.com/continuing-education/

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

CNE

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

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

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 (cclark@boisestate.edu).
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.

Findings

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.

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

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

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.

JONA � Vol. 41, No. 7/8 � July/August 2011 327

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

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.

Discussion

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.

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

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

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.

Conclusion

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).

References

1. Gallant-Roman M. Strategies and tools to reduce workplace

violence. AAOHN J. 2008;56(11):449-455.
2. Dunhart DT. National Crime Victimization Survey: Violence

in the Workplace, 1993-1999. Washington, DC: US Depart-
ment of Justice; 2001:1-12. Available at http://bjs.ojp.usdoj.

gov/index.cfm?ty=pbdetail&iid=693.

Accessed

June 19, 2011.

3. Anderson LM, Pearson CM. Tit for tat? The spiraling effect

of incivility in the workplace. Acad Manage Rev. 1999;24(3):
452-471.

4. Hutton S, Gates D. Workplace incivility and productivity losses
among direct care staff. AAOHN J. 2008;56(4):168-175.

5. Clark CM. The dance of incivility in nursing education as de-

scribed by nursing faculty and students. Adv Nurs Sci. 2008;
31(4):E37-E54.

6. Clark CM. Faculty and student assessment and experience

with incivility in nursing education: a national perspective.

J Nurs Educ. 2008;47(10):458-465.
7. Luparell S. The effects of student incivility on nursing faculty.

J Nurs Educ. 2007;46(1):15-19.
8. Olender-Russo L. Reversing a bullying culture. RN. 2009;

72(8):26-29.
9. Randle J. Reducing bullying in healthcare organisations.

Nurs Stand. 2007;21(22):49-56.

10. Simons S. Workplace bullying experienced by Massachusetts

registered nurses and the relationship to intention to leave the
organization. Adv Nurs Sci. 2008;31(2):48-59.

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.

Nurs Educ Perspect. 2007;28(2):93-97.
16. Hutchinson M, Vickers M, Jackson D, Wilkes L. Workplace

bullying in nursing: towards a more critical organisational

perspective. Nurs Inq. 2006;13(2):118-126.
17. The Joint Commission. Behaviors that undermine a culture of

safety. Sentinel Event Alert. July 9, 2008; issue 40. Available
at http://www.jointcommission.org/assets/1/18/SEA_40 .

Accessed June 19, 2011.

JONA � Vol. 41, No. 7/8 � July/August 2011 329

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

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

transformation of hostile to healthy workplace environments.

J Prof Nurs. 2009;25(5):299-306.
20. Cortina LM, Magley VJ, Williams JH, Langout RD. Incivility

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

21. Duffield C, O’Brien-Pallas L, Aitken L. Nurses who work
outside of nursing. Nurs Health Care Manage Policy. 2004;
47:664-667.

22. Healthgrades, Inc. Healthgrades Seventh Annual Patient

Safety in American Hospitals Study. March 2010. Avail-
able at http://www.healthgrades.com/media/DMS/pdf/

PatientSafetyinAmericanHospitalsStudy2010 . Accessed

June 19, 2011.

23. Institute of Medicine. To Err Is Human: Building a Safer

Health System. Washington, DC: National Academy Press;
2000.

24. Institute for Safe Medication Practices. Results from ISMP

survey on workplace intimidation. Available at http://ismp.org/
Survey/surveyresults/Survey0311.asp. Accessed June 19, 2011.

25. Shirey MR. Authentic leadership, organizational culture, and

healthy work environments. Crit Care Nurs Q. 2009;32(3):
189-198.

26. Griffin M. Teaching cognitive rehearsal as a shield for lateral
violence: an intervention for newly licensed nurses. J Contin
Educ Nurs. 2004;35(6):257-263.

27. American Holistic Nurses Association. Holistic stress manage-
ment for nurses. Available at http://www.ahna.org/Resources/

StressManagement/tabid/1229/Default.aspx. Accessed

June 19, 2011.

28. Olender-Russo L. creating a culture of regard: an antidote
to workplace bullying. Creat Nurs. 2009;15(2):75-81.

29. Clark CM, Landrum RE. Organizational Civility Scale. Avail-

able at http://nursing.boisestate.edu/civility/research-instr.htm.

Accessed June 19, 2011.

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

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