Cognitive Rehearsal Interventions: Strategies for Responding to Incivility Pamela A. Minarik, PhD,...

Cognitive Rehearsal Interventions: Strategies for

Responding to IncivilityPamela A. Minarik, PhD, RN, CNS, FAANProfessorSamuel 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 Statementhttp://www.nursingworld.org/

MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Incivility-Bullying-and-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 frameworkSelf-awarenessPermission to be realRolling with resistanceCognitive rehearsal strategies Pulling it all together

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Compassionate FrameworkFrame 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 dataBehavior is meaningful—your thoughts &

feelings can be a clue to the other’s feelingsUse of self is your primary toolIndirect & direct communicationKnow your pattern of responses and

communication stylesIdentify 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 ResistanceResistance= argues, interrupts,

denies, ignoresSignal to you to listen more carefully

Avoid arguments & power strugglesUse empathic responsesAsk open-ended questionsOffer reframe of the issue

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A Shield for Lateral Violence: Interventions

from ResearchGriffin, M. (2004). Teaching cognitive

rehearsal researchNewly registered nurses; educational

program and follow-up focus groups100% confronted person; difficult &

emotional -->Behavior stoppedMost 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 strategyAll nurses must be equipped to address

uncivil behaviorsSpeaking up is often an effective interventionEssence is rehearsing & practicing ways to

deal with situation when incivility occurs

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Cognitive Rehearsal: Strategies for

ResponsesNonverbal 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

ResponsesVerbal 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

ResponsesUndermining 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

ResponsesWithholding 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

ResponsesSabotage (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

ResponsesInfighting (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

ResponsesScapegoating (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

ResponsesBackstabbing (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

ResponsesFailure 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

ResponsesBroken 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 

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