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Welcome to this episode of NLN podcast Nursing EDge Unscripted. I'm your host, Dr. Steven Palazzo, a member of the editorial board of Nursing Education Perspectives. In this episode, we will discuss how integrating cognitive rehearsal training into pre-licensure education may decrease the effects of incivility in the profession. My guest today is Dr. LisaMarie Wands, an associate professor at the Nell Hodgson Woodworth School of Nursing at Emory University in
Atlanta. We will discuss her innovative article, Implementing Cognitive Rehearsal Training with Nursing Students to Counter Incivility in the Clinical Setting as Students and New Nurses, A Sequential Mixed-Methods Study. This article can be found in the July August issue of Nursing Education Perspectives. Well, Dr. Wands, welcome. We appreciate having you today. Thank you. Happy to be here. Let's begin by having you briefly describe the study and a little about cognitive
rehearsal training. Sure. So, first of all, I'd like to have the disclosure that this was actually funded by NLN. We were very happy to have received an educational research grant to do this project.
And this this project was trying to focus on the experience of incivility for both nursing students and into their transition into professional practice, which is unfortunately a known problem and one that leads to burnout and attrition, all of the things that we don't want to happen to new
nurses. So, a colleague of mine who was embedded in the health care side as well as in the school Dr. Carrie McDermott and I wanted to see if we could help nursing students learn some scripting techniques to counter incivility if encountered in the clinical setting. And so that's where cognitive rehearsal training comes into place. This work comes out of authors Cynthia Clark and Griffin, forget her first name. But their work,
they do a lot of work with incivility. And so cognitive rehearsal training, the very first step of cognitive rehearsal training is to teach people how to pause if they are on the receiving end of uncivil behaviors, which can include verbal, non-verbal, facial expressions, those kinds of things. And so it's just a pause and try to get yourself to not react in the moment, which can just escalate the whole situation
in negative ways. And then it is to teach people some scripting that they could potentially use to counter very specific actions that they might receive. So for instance, eye rolling is a pretty well-known uncivil behavior. And so if you are a person who is on the receiving end of an eye roll, your response could be to pause and then to say something to the person to the effect of, it looks, you know, from your facial expression, I am sensing that what I just did, you know,
didn't meet your expectations. So, can we talk about that a little bit more so that I can do, you know, do what needs to be done to meet your expectations? So, it kind of calls out the person to say, you know, not to let it slide. Calls them out and then kind of says like, where do we go from here, right? So, it's kind of starting a conversation, right? Thank you for that
description. Can you tell us a little bit about how students perceived incivility in the clinical setting and what are the results of the simulation-based learning experience? So unfortunately nursing students are one of the big parties of perceiving uncivil behavior and from their perspective they're low man on the totem pole. They have no power whatsoever in the situation. So even teaching them the scripting
you know is is difficult for them to enact. But we conducted this study actually during the pandemic. We started it before we were interrupted during it and then resumed it afterwards. And of course they were they noticed increased instability during the pandemic because obviously everybody was just under tremendous amount of stress. But the nursing students who participated in this study were on their independent practicum for their clinical capstone
course. And so they work one- on-one with nurses, nurse preceptors. And unfortunately 29 students so close to 14% of the students out of the study reported that they experienced incivility in some way and that the most common perpetrator was their preceptor which is just terrible. So again trying to teach them some tools but understanding they're
in a really low power kind of position. So what we tried to do was embed some incivility in a simulation-based learning experience that's this kind of chaotic multi-patient kind of simulation and we had someone portray an uncivil charge nurse and so that person went into the room and kind of got in their face and asked them things like, do you even know what you're doing and you know
things like that. And honestly, we didn't record this objectively in any measure, but what I noticed students doing was they were just ignoring it, which I thought was interesting. So you know, some of them did try to implement some of the scripting, but for the most part they were like
just ignoring it and going on their way. And when I asked him about it during debriefing, one of the things they said was we weren't sure if that was on purpose or if that was that person's teaching style, which just made my heart sink. Yeah. Because I'm like, well, so now you're saying this idea about encountering incivility during your educational experience is just a thing, an experience, right? It wasn't it wasn't unexpected like, well, this could possibly
just be how this person is. Right. Right. So, yeah. So, we we didn't pursue that line because it was so anecdotal, but it was one of the things that I found so disheartening about it, and then otherwise, like I said, they just kind of went about their business and they didn't really, respond. I did a little followup with some seven people after they had already started professional practice. They were about a year in, and I did one-on-one interviews with them. They all had
experienced incivility in some manner. Most of it was coming from nurse colleagues. And most of it was very blatant, being yelled at in front of patients, being questioned in front of patients. And so I asked them, you know, did what kind of strategies did you employ? And most of them had some kind of response. A lot of them did the
pausing. They did they couldn't necessarily name a cognitive rehearsal strategy but they most of them said you know I'm pretty sure that training had something to do with the fact that I was able to even be in that situation you know so so that that longitudinal piece definitely needs more focus so how long was the simulation if you don't mind me asking the simulation itself myself. We had students come in for 3 hours and like I said,
it was kind of a chaotic situation. It's a, it's a simulation I designed and I've run for years where students come in in small groups and then they're in a room and they have to care for multiple patients who all have different things going on. It's focused main focus is on priority setting. And so really trying to get students to implement priority setting frameworks in order to make
decisions about patient care. Oh, wonderful. And so I would assume one of the maybe sub-objectives would be to identify how this bullying kind of behavior impacted their ability to prioritize care that we didn't have that as a clear objective, but it was something we potentially anticipated
that it could impact. But like I said, most of the time they just didn't pay attention to the charge nurse and just went about what they were doing, which also isn't a great response either, you know, because you need to have the ability to communicate and collaborate. And so the idea that you're just kind of like there's this noise and you're going to ignore it and kind of go about
with your business. That's like not a very healthy or you know kind of professional court comportment way of dealing with it either. I did have one faculty colleague who was playing this uncivil charge nurse for me and the the nursing students didn't know any of the charge nurses that we used which is why it was so interesting to think that they just thought that one person was just that
was her normal style. But I had one colleague who was like determined to get a reaction out of the students and it was making her like mad that they wouldn't engage with her in this way. So, she kept going in and trying to get them to do something, but either they just kind of was like, you know, we can talk later, which is a which is a cognitive rehearsal strategy. You know, let's talk about this later. This isn't the right time for it. Or are they just ignored?
What part of the program are these students in? Oh, I'm sorry. This is final semester. So we have a four semester pre-licensure program. Some of these were first degree, some of them were second degree students because we did it in different semesters. I wonder if some of them seen I mean obviously I'm sure most of them seen some kind of behavior that was incivil at the very least in
their clinicals up to this point. I wonder if they saw that react that response to the charge nurse is something they are they were modeling from what maybe they saw in their own clinical experience. Could be. It's an it would be an interesting question to ask. What recommendations do you have for a nursing program that doesn't have this type of training in their curriculum or in their simulation who might be interested in embedding it in there? Where would they start
and what would you recommend? Anything. I mean really anything. But the the cognitive rehearsal training that we did was Griffith's model and that is it's didactic. It's not resource intense. It just needs an hour of time. There is the piece about just talking about incivility, you know, bringing it into students awareness, talking about the effects of it, the consequences of it, which include attrition, burnout, you know,
job dissatisfaction, all of those things. So, you know, really making it part of the students awareness to know that. So, so bringing that information to them and then teaching some of the scripting, the the pause and then some of the scripting and then leaving time for a little role play. And so these are this is a published content like a didactic almost like a little training session. And so it should be readily
available. So it doesn't you don't have to have like this involved simulation that we did role play is considered simulation anyway, so you can do it that way. You could do it in simulation. It could be very interesting. Talking to them about their experiences while they're in clinical would be really important to do. Especially helping them helping to arm them with some strategies for when
they they do encounter it. Because if they can figure out how to do it as a nursing student, then they're going to be better prepared in being able to do something about it when they enter professional practice. For sure. Well, it sounds like anything you can do, whether that's a postconference debrief or roleplaying to begin with, is a start to at least get the understanding of the concept and and the response to it. So, no, that's great. I want to thank you,
Dr. Wands, for joining us today. You know, this is bullying and incivility has been, you know, a topic for several years now and and unfortunately we're still talking about it and still new studies are coming out demonstrating that's still pretty pervasive and that's a little disheartening, right? But we all have a role to play in it and in putting a stop to it. So your work highlights this very unfortunate behavior that happens especially in nursing.
I appreciate your time and expertise and the work of the team and you know I'm glad we've got some ideas about how we can simply introduce it into some of the organizations and programs. For those who are watching to our listeners if you've not had an opportunity please look for the author's work, Implementing Cognitive Rehearsal Training with Nursing Students to Counter Incivility in the Clinical Setting as Students and New Nurses, A Sequential Mixed Methods Study.
And the article can be found in the July-August issue of Nursing Education Perspectives. Again, thank you for joining us today and thank you for all the listeners for joining. [Music]