D 02 D 02 SPECIAL SESSION: Combining the Power of Cognitive Rehearsal, Simulation, and Evidence-Based Scripting to Foster Healthy Work Environments

Friday, 22 February 2019: 2:35 PM-3:20 PM
Incivility in health care can have detrimental effects on individuals, teams, organizations, and patient care. This engaging session highlights the unique combination of Cognitive Rehearsal, simulation, and evidence-based scripting to address incivility. Working together, participants will utilize a unique and exciting approach to foster healthy work environments.
Incivility in health care settings can have a detrimental effect on individuals, teams, and organizations. In the patient care environment, uncivil encounters can provoke uncertainty and self-doubt, weaken self-confidence, compromise moral courage, and jeopardize patient safety. In some cases, incivility can lead to life-threatening mistakes, preventable complications, harm, or death of a patient (Hutchinson & Jackson, 2013; Laschinger, 2014; Maxfield & Grenny, 2017; Maxfield, Grenny, Lavandero, & Groah, 2011; Rosenstein & Naylor, 2012). Therefore, innovative and evidence-based strategies are needed to prepare nurses and other health care professionals to foster healthy work environments and address acts of incivility that threaten teamwork and patient safety.

There are several important reasons for fostering civility and healthy work environments. A decade ago, the Center for American Nurses (2008) strongly recommended that nurses and nursing students be made aware of the incidence and prevalence of incivility in health care, educated to recognize and address incivility in the workplace, and equipped with effective strategies to mitigate uncivil behavior. The American Nurses Association (ANA) Code of Ethics for Nurses (2015) clearly articulated that regardless of setting or position, all nurses have a moral obligation and ethical imperative to create and sustain healthy work environments and to foster an atmosphere of dignity and respect. Specifically, Provision 1.5 requires nurses “to create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect…and that any form of bullying, harassment, intimidation, manipulation, threats or violence will not be tolerated” (p. 4). The following year, the American Association of Critical-Care Nurses (AACN) reaffirmed six standards for establishing and sustaining healthy work environments and concluded that unhealthy work environments and relationship issues “can become the root cause of medical errors, hospital acquired infections, clinical complications, patient readmissions, and nurse turnover” (AACN, 2016, p. 8). In this session, the presenter focuses primarily on the standards of skilled communication, true collaboration, effective decision-making, and authentic leadership.

Cognitive rehearsal (CR) is an evidence-based strategy to address these critical needs. Based in behavioral science theory, CR is a technique whereby individuals work with a coach or facilitator to practice addressing stressful situations in a nonthreatening environment. CR is specifically designed to decrease anxiety, heighten confidence, and improve impulse control by practicing effective ways to address potentially stressful situations. Put simply, CR is a behavioral strategy used to prepare an individual for a potentially stressful situation by anticipating and rehearsing ways to address the situation thereby strengthening the probability of a favorable outcome. CR has been reported to be an effective strategy to address incivility in health care and educational settings (Clark, in press; Griffin, 2004; Griffin & Clark, 2014; Stagg, Sheridan, Jones, & Speroni, 2011, 2013; Sanner-Stiehr, 2017). Being well-prepared, speaking with confidence, and using respectful expressions to address incivility can empower nurses and other health care professionals to speak up, address uncivil behaviors, and advocate for patient safety (Clark, 2017; Clark, in press).

Using CR as a strategy to prepare for an uncivil encounter includes 1) prebriefing and preparatory learning, 2) identifying uncivil scenarios for simulation, 3) using evidence-based approaches to role play and rehearse responses, 4) using deliberate practice to repeat the simulated scenarios, and 5) debriefing the simulated scenarios of uncivil encounters. These critical steps will be presented during the session in the following ways:

Prebriefing and preparatory learning

Prebriefing and preparatory learning will include a didactic presentation focused on the relationship among incivility, staying silent when uncivil encounters occur, and the potential impact on team collaboration and patient safety.

Identifying and describing uncivil scenarios for simulation

After prebriefing, participants will learn about CR and how this technique may be used to address uncivil encounters in the practice setting, especially those that compromise patient care. Common examples of uncivil behaviors that may occur in a health care environment include refusing to help a colleague in need, withholding important information during a patient hand-off, or engaging in gossip and spreading rumors. Participants will work in small groups to identify real or potential uncivil encounters that may occur in health care settings.

Using evidence-based approaches to role-play and script responses

Participants will be introduced to several evidence-based approaches to script responses to address uncivil encounters. Evidence-based approaches offer a structured procedure and common language for scripting personalized responses in one’s own words rather than being rigidly “scripted.” This interactive experience provides a safe venue for participants to simulate, role-play, and practice communication skills and advocating for patient safety.

Using deliberate practice to repeat the simulated scenarios

Participants will discuss deliberate repetitive practice (DRP) in the context of CR; however, this step will be abbreviated. DRP is a process for learning and mastering psychomotor skills by progressing through three primary phases: 1) understanding the skill and learning how to perform it accurately, 2) refining the skill until it becomes more consistent, and 3) practicing the skill until it is automatic and the learner does not need to consciously think about each step. Without DRP, many skills may decay or be lost altogether. Learning these new skills takes training, experience, practice, and feedback. Students require more than one practice session to become proficient using CR to address incivility. Repeated opportunities to practice these strategies over an extended period of time is critical so that if and when uncivil encounters occur, nurses are more apt to use a practiced and patterned response.

Debriefing simulated scenarios of uncivil encounters

Rehearsal of the simulated scenarios and scripted responses will be followed by a debriefing session. Successful debriefing requires creating safe spaces for reflection and exploring effective ways to address future situations and an important learning strategy to help participants identify aspects of individual and team performance that went well, and those that did not. The goal of debriefing is to discuss the actions and thought processes involved in a particular situation, encourage reflection on those actions and thought processes, and incorporate improvement into future performance.

This series of activities is likely to lead to a more successful outcome because the individual has thoughtfully prepared for the potential encounter (Clark, in press). In this interactive and engaging session, the presenter describes how the combination of CR, simulation, evidence-based scripting, and debriefing can be used to address workplace incivility, protect patient safety, and foster civility and healthy work environments.

Organizers:  Cynthia Clark, PhD, RN, ANEF, FAAN, Strategic Nursing Advisor, ATI Nursing Education, Boise, ID, USA
Moderators:  Juli Maxworthy, DNP, MBA, School of Nursing and Health Professions, University of San Francisco, Orinda, CA, USA