Implementing Cognitive Rehearsal Training with Nursing Students to Counter Incivility in the Clinical Setting as Students and New Nurses: A Sequential Mixed-Methods Study

In this episode of Nursing EDge Unscripted, host Dr. Steven Palazzo interviews Dr. LisaMarie Wands about her research on integrating cognitive rehearsal training into nursing education to counteract incivility. Dr. Wands explains how incivility, from dismissive behaviors to overt hostility, harms nursing students and new nurses and contributes to burnout and attrition. Her study, funded by the NLN, used simulation to teach students strategies like pausing and scripted responses when encountering uncivil behavior. Findings revealed that students often struggled to act on these strategies because of their low power in clinical settings, but some reported applying the training once in professional practice. The conversation emphasizes the need for nursing programs to introduce even small-scale training or role-play to prepare students for the realities of incivility in the workplace.

Wands, L., McDermott, C., Bernard, N., Wolf, R., & Kimble, L. P. (2025). Implementing Cognitive Rehearsal Training With Nursing Students to Counter Incivility in the Clinical Setting as Students and New Nurses: A Sequential Mixed-Methods Study. Nursing education perspectives, 46(4), 243–245. https://doi.org/10.1097/01.NEP.0000000000001325

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Transcript

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[Music] 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]