Using Cognitve Rehearsal to Address Nurse-to-Nurse Incivility: Six Months Later, How Are They Doing?

Sunday, 30 July 2017

Jennette S. Logan, DNP, RN
School of Community and Health Policy, Nursing Program, Morgan State University, Baltimore, MD, USA


Despite the expectation that nurses behave in civil and caring manners towards patients and other nurses, incivility persists. Research supports however, that there are evidenced based strategies to address uncivil behavior among nurses. Cognitive rehearsal is one of the best evidenced based strategies utilized successfully to address incivility in nursing and to prepare new graduate nurses for a successful career. Nikstaitis, and Simko(2014) conducted training about incivility over a 12 week period and consequently 100% of the population of intensive care nurses were able to successfully use cognitive rehearsal.  However, Clark and Griffin (2014) reported that newly licensed nurses described using the rehearsed strategies as difficult, yet successful in reducing or eliminating incivility and lateral violence. The purpose of this research project was to obtain data from new graduate nurses to determine the effectiveness of a workshop and role play about incivility, six months following the training.


In October 2015, the researcher obtained IRB approval to conduct an educational intervention to address incivility in nursing. The educational intervention was a workshop which consisted of didactics about the definition, prevalence and impact of incivility in nursing. This was followed by a role play demonstrating incivility with time allotted for nursing students to practice Cognitive Rehearsal using cue cards developed by Martha Griffin. At the end of the workshop, 100% of the sample stated that they felt confident that they would be able to utilize cognitive rehearsal to effectively address incivility. The students further agreed to be contacted periodically after graduation regarding the use of Cognitive Rehearsal as new nursing graduates.

 Six months following graduation, the researcher conducted the first follow up survey. The following 3 questions were asked. 1) Are you currently employed in nursing? 2) Have you experienced incivility while in the nursing setting? If so describe. 3) Were you able to use Cognitive Rehearsal to address the uncivil behavior? Why or why not?

Comparative analysis was used to analyze and categorize the findings.


A six month follow up revealed the following: Eighty percent of the new nurse graduates experienced incivility in their new employment environments. This is consistent with research findings that suggested somewhere been 27-85% of nurses experience incivility.  Fifty percent of the new graduate nurses who experienced incivility used Cognitive rehearsal to address the uncivil behavior whereas 50% did not successfully use Cognitive Rehearsal. The new graduates who did not use Cognitive Rehearsal explained that because they were new to the job, they felt uncomfortable addressing the uncivil behavior. One new graduate stated “I decided to just let it go since I had only been on the job a few weeks.”

The uncivil behaviors experienced were categorized as rude, dismissive behavior and withholding information. One new graduate nurse stated” I called the charged nurse to give report at the end of my shift and she yelled at me… “not now”… and hung up the phone” I confronted her the following day and documented it in the discussion forum.” Another nurse graduate stated," I made a suggestion to the nurse manager about a procedure and she dismissed my suggestion without consideration. I approached her later in a calm manner and she apologized for her behavior. Other uncivil acts were categorized as withholding information. The nurse giving report ignored the new graduate and gave report only to the preceptor. The new graduate confronted the nurse and stated, “ I am a part of the health care team also and I need report in order to provide quality patient care.”

Conclusion:   Evidenced based strategies to address incivility such as Cognitive rehearsal are effective but should be threaded throughout the nursing curriculum to increase efficacy and confidence in new graduates. Research by Warner (2016) demonstrated that a series of workshops over a 12- week period enabled 100% of the participates to successfully utilize incivility. A single workshop conducted by this researcher enabled 50% of the new graduate nurses to use Cognitive rehearsal to address uncivil behavior. The researcher concurs with Clark (2014) that new graduate nurses find that Cognitive rehearsal is effective in reducing or eliminating incivility but it is extremely difficult for some new graduates to utilize this strategy. The researcher would further recommend that Cognitive Rehearsal training should be threaded throughout the curriculum as part of orientation, transition classes, mental health class and simulation/lab scenarios. More training and practice may boost confidence in using the strategy. Additionally, policies should be developed to reflect a “no tolerance stance” for incivility in the class room as well as the clinical setting. The researcher would further recommend a collaborative approach to addressing incivility which would involve academia as well as new nurse residency programs. Generalization of these findings is limited due to a small sample size.