Clearly, diagnosis is a critical aspect of healthcare. However, the ultimate purpose of a diagnosis is the development and application of a series of treatments or protocols. Isolated recognition of a health issue does little to resolve it.

In this module’s Discussion, you applied the Clark Healthy Workplace Inventory to diagnose potential problems with the civility of your organization. In this Portfolio Assignment, you will continue to analyze the results and apply published research to the development of a proposed treatment for any issues uncovered by the assessment.

To Prepare:

  • Review the Resources and examine the Clark Healthy Workplace Inventory, found on page 20 of Clark (2015).
  • Review the Work Environment Assessment Template.
  • Select and review one or more of the following articles found in the Resources:
    • Clark, Olender, Cardoni, and Kenski (2011)
    • Clark (2018)
    • Clark (2015)
    • Griffin and Clark (2014)

The Assignment (3-6 pages total):

Part 1: Work Environment Assessment (1-2 pages)

  • Review the Work Environment Assessment Template you completed for this Module’s Discussion.
  • Describe the results of the Work Environment Assessment you completed in your workplace.
  • Identify two things that surprised you about the results and one idea you believed prior to conducting the Assessment that was confirmed.
  • Explain what the results of the Assessment suggest about the health and civility of your workplace.

Part 2: Reviewing the Literature (1-2 pages)

  • Briefly describe the theory or concept presented in the article(s) you selected.
  • Explain how the theory or concept presented in the article(s) relates to the results of your Work Environment Assessment.
  • Explain how your organization could apply the theory highlighted in your selected article(s) to improve organizational health and/or create stronger work teams. Be specific and provide examples.

Part 3: Evidence-Based Strategies to Create High-Performance Interprofessional Teams (1–2 pages)

  • Recommend at least two strategies, supported in the literature, that can be implemented to address any shortcomings revealed in your Work Environment Assessment.
  • Recommend at least two strategies that can be implemented to bolster successful practices revealed in your Work Environment Assessment.

535The Journal of Continuing Education in Nursing · Vol 45, No 12, 2014


Revisiting Cognitive Rehearsal as an
Intervention Against Incivility and Lateral
Violence in Nursing: 10 Years Later
Martha Griffi n, PhD, RN, PMHCNS-BC, FAAN; and Cynthia M. Clark, PhD, RN, ANEF, FAAN

According to a recent survey conducted by the Work-place Bullying Institute (2014), 27% of Americans
have suffered abusive conduct or incivility at work.
Another 21% have witnessed such behaviors, and 72%
are aware that workplace incivility happens. The im-
pact of these behaviors can be devastating and lasting.
For example, workplace incivility can negatively impact
employee physical and mental health, job satisfaction,
productivity, and commitment to the work environment

Dr. Griffin is Director of Nursing Research, Education, and Simu-
lation, Boston Medical Center, Boston, Massachusetts; and Dr. Clark
is Professor, Boise State University, School of Nursing, Boise, Idaho,
and Nurse Consultant, Ascend Learning/ATI Nursing Education,
Leawood, Kansas.

The authors have disclosed no potential conflicts of interest, finan-
cial or otherwise.

Address correspondence to Cynthia M. Clark, PhD, RN, ANEF,
FAAN, Professor, Boise State University, School of Nursing, 1910 Uni-
versity Drive, Boise, ID 83725; e-mail: [email protected].

Received: June 5, 2014; Accepted: September 12, 2014; Posted On-
line: November 22, 2014


Ten years ago, Griffi n wrote an article on the use of
cognitive rehearsal as a shield for lateral violence. Since
then, cognitive rehearsal has been used successfully in
several studies as an evidence-based strategy to address
uncivil and bullying behaviors in nursing. In the original
study, 26 newly licensed nurses learned about lateral vio-
lence and used cognitive rehearsal techniques as an inter-
vention for nurse-to-nurse incivility. The newly licensed
nurses described using the rehearsed strategies as dif-
fi cult, yet successful in reducing or eliminating incivility
and lateral violence. This article updates the literature on
cognitive rehearsal and reviews the use of cognitive re-
hearsal as an evidence-based strategy to address incivility
and bullying behaviors in nursing.
J Contin Educ Nurs. 2014;45(12):535-542.


Instructions: 1.2 contact hours will be awarded by Villanova
University College of Nursing upon successful completion of this
activity. A contact hour is a unit of measurement that denotes
60 minutes of an organized learning activity. This is a learner-
based activity. Villanova University College of Nursing does
not require submission of your answers to the quiz. A contact

18 American Nurse Today Volume 10, Number 11

“I believe we can
change the world if we
start listening to one
another again. Simple,
honest, human con-
versation…a chance to
speak, feel heard, and
[where] we each listen
well…may ultimately
save the world.”
Margaret J. Wheatley,


GIVEN the stressful healthcare
workplace, it’s no wonder nurses
and other healthcare professionals
sometimes fall short of communi-
cating in respectful, considerate
ways. Nonetheless, safe patient care
hinges on our ability to cope with
stress effectively, manage our emo-
tions, and communicate respectful-
ly. Interactions among employees
can affect their ability to do their
jobs, their loyalty to the organiza-
tion, and most important, the deliv-
ery of safe, high-quality patient

The American Nurses Associa-
tion (ANA) Code of Ethics for
Nurses with Interpretive Statements
clearly articulates the nurse’s obli-
gation to foster safe, ethical, civil
workplaces. It requires nurses “to
create an ethical environment and
culture of civility and kindness,
treating colleagues, coworkers, em-
ployees, students, and others with

dignity and respect” and states that
“any form of bullying, harassment,
intimidation, manipulation, threats,
or violence will not be tolerated.”
However, while nurses need to
learn and practice skills to address

uncivil encounters, or-
ganization leaders and
managers must create
an environment where
nurses feel free and
empowered to speak
up, especially regard-
ing patient safety

All of us must strive
to create and sustain
civil, healthy work en-
vironments where we

communicate clearly and effectively
and manage conflict in a respectful,
responsible way. The alternative—
incivility—can have serious and
lasting repercussions. An organiza-
tion’s culture is linked closely with
employee recruitment, retention,
and job satisfaction. Engaging in
clear, courteous communication fos-
ters a civil work environment, im-
proves teamwork, and ultimately
enhances patient care.

In many cases, addressing inci-
vility by speaking up when it hap-
pens can be the most effective
way to stop it. Of course, mean-
ingful dialogue and effective com-
munication require practice. Like
bowel sound auscultation and na-
sogastric tube insertion, communi-
cation skills can’t be mastered
overnight. Gaining competence in
civil communication takes time,
training, experience, practice, and

1. Identify components of a healthy

2. Discuss how to prepare for a chal-

lenging conversation.
3. Describe models for conducting a

challenging conversation.

The planners of this CNE activity have disclosed no
relevant financial relationships

Volume 41, Number 7/8, pp 324-330
Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins


Fostering Civility in Nursing
Education and Practice
Nurse Leader Perspectives

Cynthia M. Clark, PhD, RN, ANEF

Lynda Olender, MS, RN, ANP, NEA-BC

Cari Cardoni, BSN

Diane Kenski, BSN

Incivility in healthcare can lead to unsafe working
conditions, poor patient care, and increased medical
costs. The authors discuss a study that examined
factors that contribute to adverse working relation-
ships between nursing education and practice, effective
strategies to foster civility, essential skills to be taught
in nursing education, and how education and practice
can work together to foster civility in the profession.

The work of nursing is 4 times more dangerous than
most other occupations,1 and nurses experience work-
related crime at least 2 times more often than any
other healthcare provider.2 Root causes for workplace
violence are multifaceted and include work-related
stress due in part to an increasingly complex patient
population and workload and deteriorating interper-
sonal relationships at the bedside.1 When normalized
or left unaddressed, these uncivil and disruptive be-
haviors may emerge into an incivility spiral,3 depicted
along a continuum from an unintentional act leading
to intentional retaliation, escalating to workplace bul-
lying and even violence.4 Incivility and disruptive be-
haviors have been identified both in the academic5-7

and clinical settings8-10; however, no direct study of
incivility between the 2 environments has been made.

Review of the Literature

Incivility and disruptive behavior in nursing educa-
tion and practice are common,4,9 on the rise,11 and
frequently ignored.12 Two decades ago, Boyer13

noted several challenges facing institutions of higher
education, including academic incivility. Although
incivility in the academic setting is not a new phe-
nomenon, the types and frequency of misbehavior
are increasing and have become a significant prob-
lem in higher education, including nursing educa-
tion. Clark and Springer14,15 explored faculty and
student perceptions of incivility in nursing education
and found negative behaviors to be commonplace
and exhibited by students and faculty alike. The ma-
jority of respondents (71%) perceived incivility as a
moderate to serious problem and reported that stress,
high-stake testing, faculty arrogance, and student en-
titlement contributed to incivility.14 More than half
of the respondents reported experiencing or know-
ing about threatening student encounters between
students or faculty.14

A small but growing body of research suggests
that incivility and disruptive behaviors are particu-
larly commonplace to the new graduate nurse or
nursing student within the