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Research Library

Cognitive Rehearsal, HeartMath, and Simulation: An Intervention to Build Resilience and Address Incivility

    • Published: 2019
    • Cynthia M. Clark, Ph.D., R.N., A.N.E.F., F.A.A.N.1, and Karen L. Gorton, Ph.D., R.N., F.N.P.2
    • Journal of Nursing Education, 2019; 58(12):690–697. DOI: 10.3928/01484834-20191120-03.1. Strategic Nursing Advisor, ATI Nursing Education, Boise, Idaho. 2. Associate Professor, School of Nursing and Health Studies, University of Missouri Kansas City, Kansas City, Missouri.
    • Expanded version available as journal: Cognitive Rehearsal, HeartMath, and Simulation.



The detrimental impact of incivility in health care is well documented. Nursing students and new graduate nurses are particularly vulnerable to its effects. Evidence-based civility education strategies are urgently needed to address incivility, which can protect patient safety.


Using a mixed methodology, 188 incoming, upper division, prelicensure nursing students participated in an intervention study that combined cognitive rehearsal, HeartMath, and simulation using TeamSTEPPS™ Concerned, Uncomfortable, and Safety model to address acts of incivility that threaten patient safety.


Student evaluations immediately following the intervention and 6 months postintervention rendered positive results. Eight themes emerged describing uncivil experiences occurring in the patient care environment.


This intervention provided nursing students with evidence-based tools to build resilience to effectively address incivility in the patient care environment. Nurse educators are urged to provide civility education in conjunction with tested techniques to build resilience and address uncivil encounters in health care.