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Cognitive Rehearsal
Interventions: Strategies for
Responding to Incivility
Pamela A. Minarik, PhD, RN, CNS, FAAN
Professor
Samuel Merritt University School of Nursing,
Behavioral Health Consultant, UCSF Medical Center
Incivility, Bullying, and
Workplace Violence
 “…to create and sustain a culture of
respect, free of incivility, bullying and
workplace violence.”
 2015 ANA Position Statement
http://www.nursingworld.org/MainMenuCateg
ories/Policy-Advocacy/Positions-andResolutions/ANAPositionStatements/PositionStatements-Alphabetically/Incivility-Bullyingand-Workplace-Violence.html
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Bullying
 “Bullying is repeated, unwanted harmful
actions intended to humiliate, offend,
and cause distress in the recipient. “
(p.3)
 “Bullying actions present serious safety
and health concerns…” (p.3)
 The strategies being presented here are
not for bullying.
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Preview
 Compassionate framework
 Self-awareness
 Permission to be real
 Rolling with resistance
 Cognitive rehearsal strategies
 Pulling it all together
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Compassionate Framework
 Frame challenging behaviors as learned
behaviors reinforced by the social
environment (what nurses foster)
rather than people deliberately choosing to be
difficult (Separate the person from the issue.)
 React with compassion & seek
understanding about the issue/interest
(rather than focusing on the person)
 Reacting with compassion does not
preclude setting limits
& boundaries
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Become Aware of Your
Own Reactions
 Everything is data
 Behavior is meaningful—your thoughts &
feelings can be a clue to the other’s feelings
 Use of self is your primary tool
 Indirect & direct communication
 Know your pattern of responses and
communication styles
 Identify your thoughts/feelings so you
can choose how to respond rather
than react
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Give Yourself Permission
to be Real
 Working with and caring for unpleasant
people
Most are doing the best they can
 Appropriate responses to inappropriate
behavior
 Communicate respect
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Rolling with Resistance
 Resistance= argues, interrupts, denies,
ignores
Signal to you to listen more carefully
 Avoid arguments & power struggles
 Use empathic responses
 Ask open-ended questions
 Offer reframe of the issue
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A Shield for Lateral Violence:
Interventions from Research
 Griffin, M. (2004). Teaching cognitive
rehearsal research
 Newly registered nurses; educational
program and follow-up focus groups
 100% confronted person; difficult &
emotional -->Behavior stopped
 Most did not use cognitive strategies
verbatim but they remembered/felt
empowered
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Cognitive Rehearsal as
Intervention Strategy
 Replicated in subsequent studies &
cognitive rehearsal found effective (Griffin
& Clark, 2014)=evidence-based strategy
All nurses must be equipped to address uncivil
behaviors
Speaking up is often an effective intervention
Essence is rehearsing & practicing ways to
deal with situation when incivility occurs
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Cognitive Rehearsal:
Strategies for Responses
 Nonverbal innuendo(raising of
eyebrows, rolling eyes, face-making).
“I see from your facial expression that
there may be something you wanted to say
to me. It’s okay to speak directly to me. (I
would prefer it.)”
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Cognitive Rehearsal:
Strategies for Responses
 Verbal affront (covert or overt, snide
remarks, lack of openness, abrupt
responses).
“The individuals I learn the most from are
clearer in their directions and feedback. Is
there some way we can structure this type
of situation?”
“What happened?”
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Cognitive Rehearsal:
Strategies for Responses
 Undermining activities (turning away,
not available).
“When something happens that is
“different” or “contrary” to what I thought
or understood, it leaves me with questions.
Help me understand how this situation may
have happened.”
“What has happened? Have I done
something that irritates you?”
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Cognitive Rehearsal:
Strategies for Responses
 Withholding information (practice or
about patient).
“It is my understanding that there was (is )
more information available regarding this
situation and I believe if I had known that
(more), it would (will) affect how I learn or
need to know.”
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Let’s Practice
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Cognitive Rehearsal:
Strategies for Responses
 Sabotage (deliberately setting up a
negative situation).
“There is more to this situation than meets
the eye. Could “you and I” (whatever,
whoever) meet in private and explore what
happened?”
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Cognitive Rehearsal:
Strategies for Responses
 Infighting (bickering with peers).
Nothing is more unprofessional than a
contentious discussion in non-private
places. Always avoid.
“This is not the time or the place. Please
stop” (physically walk away or move to a
neutral spot).
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Cognitive Rehearsal:
Strategies for Responses
 Scapegoating (attributing all that goes
wrong to one individual). Rarely is one
individual, one incident, or one situation
the cause for all that goes wrong.
Scapegoating is an easy route to travel,
but rarely solves problems.
“I don’t think that’s the right connection.”
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Cognitive Rehearsal:
Strategies for Responses
 Backstabbing (complaining to others
about an individual and not speaking
directly to that individual).
“I don’t feel right talking about
her/him/situation when I wasn’t there, or
don’t know the facts. Have you spoken to
her/him?”
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Cognitive Rehearsal:
Strategies for Responses
 Failure to respect privacy.
“It bothers me to talk about that without
her/his/their permission.”
“I only overheard that. It shouldn’t be
repeated.”
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Cognitive Rehearsal:
Strategies for Responses
 Broken confidences.
“Wasn’t that said in confidence?”
“That sounds like information that should
remain confidential.”
“She/he asked me to keep that
confidential.”
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Let’s Practice
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 “Being well-prepared, speaking with
confidence, and using respectful
expressions to address incivility can
empower nurses to break the silence of
incivility and oppression.”
(Griffin & Clark, 2014, p. 541)
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Pulling It All Together
 What is your take-home message?
 Take a piece of paper and write a
behavior change commitment to
yourself.
 Turn it in with your email address. I will
send it to you in one month as a
reminder of your commitment.
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References
 American Nurses Association (2015). American Nurses Association
position statement on incivility, bullying, and workplace violence.
 http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-
Nurse/bullyingworkplaceviolence/Incivility-Bullying-and-Workplace-Violence.html
 Griffin, M. (2004). Teaching cognitive rehearsal as a shield for
lateral violence: An intervention for newly licensed nurses. Journal
of Continuing Education in Nursing, 35(6), 77-84.
 Griffin, M., & Clark, C. M. (2014). Revisiting cognitive rehearsal as
an intervention against incivility and lateral violence in nursing: 10
years later. Journal Of Continuing Education In Nursing, 45(12),
535-542 8p. doi:10.3928/00220124-20141122-02

 http://www.alphaeta-ucsf.org/leadership-program-2016-speaker-notes.html
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