1. 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

2. 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-and- Resolutions/ANAPositionStatements/Position- Statements-Alphabetically/Incivility-Bullying- and-Workplace-Violence.html P. Minarik2

3. 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. P. Minarik3

4. Preview  Compassionate framework  Self-awareness  Permission to be real  Rolling with resistance  Cognitive rehearsal strategies  Pulling it all together P. Minarik4

5. 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 P. Minarik5

6. 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 P. Minarik6

7. 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 P. Minarik7

8. 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 P. Minarik8

9. 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 P. Minarik9

10. 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 P. Minarik10

11. 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.)” P. Minarik11

12. 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?” P. Minarik12

13. 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?” P. Minarik13

14. 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.” P. Minarik14

15. Let’s Practice P. Minarik15

16. 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?” P. Minarik16

17. 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). P. Minarik17

18. 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.” P. Minarik18

19. 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?” P. Minarik19

20. 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.” P. Minarik20

21. 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.” P. Minarik21

22. Let’s Practice P. Minarik22

23.  “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) P. Minarik23

24. 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. P. Minarik24

25. 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 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 P. Minarik25