Bullying and incivility frequently have been examined in the nursing literature, and although recognition of the epidemic has increased (Wilson, 2016), the cycle still continues. In a frantic and stressful environment, such as an academic medical center, incidents of violence have a cumulative adverse effect on nursing staff (Longo, Cassidy, & Sherman, 2016). When situations become volatile, tempers rise, and conditions become unbearable, nurses can use learned skills to hold critical conversations. These skills can prevent further disruptive and harmful behaviors.
Incivility, interpersonal hostility, lateral and horizontal violence, and toxic work environments are issues many nurses deal with daily (Park, Cho, & Hong, 2015) and continue to be ranked highest among reasons for nursing turnover and overall intent to leave the profession (Copeland & Henry, 2017). Bullying is an attempt to remove someone else's power. Providing the ability to return this power may lower the levels of incivility and bullying (Blackstock, Harlos, Macleod, & Hardy, 2015; Sauer & McCoy, 2018). Although there are different definitions and meanings for terms such as bullying, incivility, interpersonal hostility, lateral violence, and horizontal violence, for purposes of this article, these terms will be used synonymously.
Bullying and uncivil behaviors can lead to serious adverse outcomes for nurses, including an intent to leave the profession (Al-Hamdan, Manojlovich, & Tanima, 2017). Some sources estimate that nearly 28% of nurses leave within the first year of their professional career (Nursing Solutions Inc., 2018). The causes of nursing turnover are complex (Flinkman & Salanterä, 2015); however, issues surrounding incivility and bullying are becoming more rampant globally (Blackstock et al., 2015).
Bullying and incivility have a significant impact on nurses' intent to leave the profession in multiple countries such as Canada and the United States (Blackstock et al., 2015; Sauer & McCoy, 2018). In a random sampling of 300 nurses, Armmer and Ball (2015) found nurses who experienced bullying expressed their intent to leave the profession at higher rates than other nurses.
In a sample of more than 500 nurses (n = 508) from eight hospitals in Korea, a direct relationship was found between workplace bullying and decreased job satisfaction, and intent to leave the profession (Oh, Uhm, & Yoon, 2016). In a study involving 884 baccalaureate Australian nursing students, Birks, Budden, Biedermann, Park, and Chapman (2018) noted more than half of the participants stated they experienced some form of bullying or harassment by health care providers.
Communication issues are a component of bullying and workplace incivility (Brockman-Weber, 2016). Communicating thoughts and feelings about bullying and interpersonal hostility can be challenging. Staff members may revert to silence or violence, which only perpetuates bullying behaviors (Patterson, Grenny, McMillan, & Switzler, 2011). Patterson et al. (2011) studied communication between individuals and developed strategies that individuals can use to hold conversations effectively.
Expressing bullying in words often is complicated for individuals who are bullied, although recognizing the effects of bullying is critical (Dzurec, Kennison, & Gillen, 2017). Communicating with or confronting a coworker who is a bully is a seemingly abnormal undertaking (Blosky & Spegman, 2015); however, a positive work culture, as well as safe patient care, rely on effective and civil communication between coworkers (Brockman-Weber, 2016), particularly nurse-to-nurse communication (Blosky & Spegman, 2015).
Effective communication is one of the most basic nursing skills (Ulrich, 2016). Active nurse-to-nurse communication contributes to creating a civil culture and a secure climate (Stanton, 2015). Productive communication is key to a civil culture, and interventions must be developed to improve nurse communication. Practicing communication strategies before experiencing uncomfortable situations has been effective in improving nurse communication (Schwartz, El-Banna, Conroy, & Browne, 2019). The purpose of this study was to examine whether an educational intervention can increase awareness and knowledge of incivility and bullying and enhance communication skills.
This study used a pretest–posttest quasiexperimental mixed-method design to improve dialogue and interpersonal engagement to create behavior change. After obtaining permission from Cynthia Clark, PhD, RN, ANEF, FAAN, the Workplace Civility Index (WCI) was administered to measure the effectiveness of the intervention. With a Cronbach's alpha of .82, the WCI is a validated, psychometrically sound, evidence-based questionnaire constructed to assess nurses' sense of civility and to increase awareness related to personal actions and intentions (Clark, 2017; Clark, Sattler, & Barbosa-Leiker, 2018). Effective communication and the ability to manage conflict productively is necessary to decrease an individual's susceptibility to bullying acts (Clark et al., 2018).
Setting and Participants
This study was conducted at an academic medical center in the Midwestern United States. The study received institutional review board (IRB) approval from the appropriate hospital and universities (Eskenazi Health, Indiana University, and Northern Kentucky University). Recruitment of participants occurred primarily during a 5-week period via e-mail sent to nurses who had completed general nursing orientation within a year of study initiation and nurses who were currently in nursing orientation. Some direct appeals were made to orientation groups per IRB approval guidelines. The control group consisted of nurses who had completed general nursing orientation within the past calendar year, and the experimental group comprised nurses who were enrolled in general nursing orientation at the time of the study.
The educational activity used for the intervention was “Bullying in the Workplace: Solutions for Nursing Practice.” This asynchronous provider-directed, learner-paced e-learning educational activity was developed in conjunction with Sigma Theta Tau International Honor Society of Nursing (Sigma). The interactive educational intervention was designed to encourage productive communication and dialogue. The intervention aimed to increase the participants' awareness and knowledge of incivility and bullying. A secondary goal was to increase participants' ability to engage in difficult conversations successfully.
The content for the intervention, which was developed collaboratively by several international authors in the field of incivility, was divided into five distinct modules (Table 1) that featured branching scenarios. The online educational activity required approximately 2.5 hours to complete. When discussing communication and communication techniques, participant interaction is needed. Because the intervention was an online learning activity, the educational activity used branching scenarios to provide participants with the ability to practice what they learned.
Educational Content of Modules
Branching scenarios are an efficient and interactive way to present case study information (Lala, Jeuring, van Dortmont, & van Geest, 2017). The branching scenarios begin as case studies. However, the scenarios allowed participants to choose how they would respond to given situations through the use of avatars or graphic illustrations that represented the participant and other characters in the case study (Kunc & O'Brien, 2017; Lala et al., 2017). The scenarios provided participants the ability to explore real-world options in a safe, simulated environment and required participants to actively think through the steps of their decision-making process (Lala et al., 2017). These scenarios accounted for subjective judgments or expectations about the random future of the scenario and allowed participants to use what they learned to better prepare for future complex, real-time interactions.
Data were analyzed using Excel®. A total of 168 nurses were invited to participate, and 49 nurses agreed to participate for a 29% response rate. Of these nurses, 21 met the criteria for the experimental group, and 28 met the criteria for the control group. Both quantitative and qualitative data were analyzed. Descriptive statistics and a paired two-sample t test were used to evaluate data.
Participants included 46 females (94%) and three males (6%). Participants identified themselves as Millennials (n = 25, 51%), Generation X (n = 15, 30.6%), and Post-Millennials (n = 7, 14.3%). Participants worked in the intensive care unit (n = 11, 22.4%), emergency department (n = 10, 20.4%), and telemetry/medical-surgical floor (n = 10, 20.4%), as well as other units. The majority of participants had a baccalaureate degree (n = 30, 61.2%,) with less than 3 years of experience as a nurse (n = 33, 67.3%) (Table 2).
Demographic Characteristics of Participants
After all of the participants completed the post-WCI, the WCI results were analyzed using the scoring key provided by the instrument author (Clark, 2017). Scores ranged from 20 to 100. A low score (<50) signifies very uncivil behavior, whereas a score between 90 and 100 exhibits very civil behavior. Paired t test results are listed in Table 3. The mean for the experimental group increased from 91.6 to 95.4, and the mean for the control group decreased from 88.2 to 80.2; these changes were statistically significant (t = −6.16 and p ⩽ .00001; t = 3.99 and p = .000227, respectively). No further analysis was necessary given the relatively small sample size.
T Test: Paired Two Sample for Means by Group
This study sought to assess whether an educational intervention could increase nurses' awareness and knowledge of incivility and bullying, and enhance their communication skills. The study had two objectives to measure success. The first measure of success was for participants to increase their WCI score. In the experimental group, WCI score increased for all of the participants (preintervention M = 91.6 versus postintervention M = 95), which met the first objective for the study.
For participants in the control group, the WCI scores did not remain the same, which was unexpected. The control group showed a decrease from preintervention scores (M = 88.2143) to postintervention scores (M = 80.2143, SD = 10.6075). After discussions with facility leadership, there were no issues during the time period of the study to specifically account for the decrease in WCI scores. It is believed that self-awareness is one possible reason for this decrease in the control group's civility scores (Clark et al., 2018). The control group participants could have become aware of their activities and how they relate to their perceived civility. Self-reflection and self-awareness of their uncivil behavior could have led to introspection on how they acted versus how they thought they acted. Additional research around the rationale for the control group findings could be conducted to explore this finding.
The second measure of success, related to communication skills, was the participants' ability to implement at least one positive conflict management strategy after completing the educational activity. All of the participants in the experimental group (n = 21) stated they had effectively performed at least one positive conflict management strategy. One participant noted, “I felt comfortable having a conversation that needed to happen a long time ago.” Another participant noted, “I took the opportunity to have a conversation with a tech that has been very dismissive. The conversation went well, but time will tell.” Another participant noted, “The course did give me the tools to speak with a physician in a positive way.” Thus, the educational activity met the second measure of success.
The increase in civility scores after the educational intervention was consistent with findings from previous studies (Armstrong, 2017; Stoddard, 2017); however, no studies using an asynchronous e-learning educational intervention were found in the literature. Stoddard (2017) used several interventions from the PACERS civility tool-kit to study the prevalence of civility in the workplace (n = 48). Armstrong (2017) implemented a provider-paced, provider-directed civility training program (n = 9) that also showed a postintervention increase in the WCI. Similar to findings reported by Wright (2017), the current study found that an evidence-based educational intervention could positively alter nursing staff's perception and actions.
Strengths and Limitations
One strength of the study is the overwhelming support provided by the study facility's nursing administration. As supported in the literature, institutional support is key to participant involvement in performance improvement projects (Mackinson et al., 2018). Nursing administrative staff eliminated some barriers for participants to complete the study, such as allowing participants to complete the educational intervention while at work.
The development of the educational intervention in conjunction with an international nursing organization, Sigma, is an additional strength of the study. Using Sigma's instructional designers and technology enabled the development of branching scenarios. This is a unique feature of this educational activity. One of the participants wrote: “I enjoyed the activity at the end [the branching scenarios]. Covering all topics of bullying, not just the obvious. Different real-life situations.”
In conjunction with the subject matter experts and authors, the instructional designers at Sigma planned and created interactive branching scenarios that stimulated participant learning. In addition, the global reach of Sigma, including authors and intervention reviewers from several countries, enhanced the appeal and depth of the educational activity and study as noted by participant evaluations.
There are several limitations to this study. The sample size was small compared with other similar studies; the response rate of the current study was 29% (49 of 168 individuals who were invited to participate completed the study). Participant recruitment at the facility was difficult, even with administrative support for the study. Experimental group participants also were engaged in patient care and did not take the time to complete the study during work hours; however, they may have felt obligated to complete the study given the support from administration. Additional studies, with larger sample sizes, are recommended to improve insights on the effect of this educational activity on nursing communication and civility.
Participants in the experimental group noted the time required to complete the educational activity was excessive. Facility leaders allowed participants to complete the educational activity during their orientation work hours; however, participants still had difficulty finding the time to complete the intervention. One participant noted that the educational activity was “too long to do at work. I couldn't hear the [audio while] at work.”
An additional limitation of the study was the limited years of nursing experience. More than 65% (n = 33) of the participants had less than 3 years of nursing experience, and more than 40% (n = 20) of participants had 1 year or less of experience as a nurse. As nurses gain experience in the profession, they develop coping mechanisms for dealing with and handling incivility and bullying in the clinical setting (Fang, Huang, & Fang, 2016). This may represent a potential threat to the reliability of the study—namely, participant error and participant bias. The study had no control for participants who personally had or had not experienced bullying or uncivil behaviors. This could ultimately skew the data, depending on the participants' personal perception of bullying.
Incivility and bullying have been an issue for decades (Wilson, 2016). One way to break the cycle of violence is through increasing awareness of incivility and education regarding critical conversations (Vagharseyyedin, 2016). Although further research is recommended, the implementation of Sigma's “Bullying in the Workplace: Solutions for Nursing Practice” provided evidence to support that an asynchronous provider-directed, learner-paced e-learning educational activity may be an effective way to encourage productive communication and increase awareness and knowledge of incivility and bullying.
- Al-Hamdan, Z., Manojlovich, M. & Tanima, B. (2017). Jordanian nursing work environments, intent to stay, and job satisfaction. Journal of Nursing Scholarship, 49(1), 103–110. doi:10.1111/jnu.12265 [CrossRef]
- Armmer, F. & Ball, C. (2015). Perceptions of horizontal violence in staff nurses and intent to leave. Work, 51(1), 91–97. doi:10.3233/WOR-152015 [CrossRef]
- Armstrong, N.E. (2017). A quality improvement project measuring the effect of an evidence-based civility training program on nursing workplace incivility in a rural hospital using quantitative methods. Online Journal of Rural Nursing & Health Care, 17(1), 100–137. doi:10.14574/ojrnhc.v17i1.438 [CrossRef]
- Birks, M., Budden, L.M., Biedermann, N., Park, T. & Chapman, Y. (2018). A rite of passage?: Bullying experiences of nursing students in Australia. Collegian: The Australian Journal of Nursing Practice, Scholarship and Research, 25(1), 45–50 doi:10.1016/j.colegn.2017.03.005 [CrossRef]
- Blackstock, S., Harlos, K., Macleod, M.L. & Hardy, C.L. (2015). The impact of organisational factors on horizontal bullying and turnover intentions in the nursing workplace. Journal of Nursing Management, 23(8), 1106–1114. doi:10.1111/jonm.12260 [CrossRef]
- Blosky, M.A. & Spegman, A. (2015). Let's talk about it: Communication and a healthy work environment. Nursing Management, 46(6), 32–38. doi:10.1097/01.NUMA.0000465398.67041.58 [CrossRef]
- Brockman-Weber, S.J. (2016). A guide to nurse provider collaboration: Skills to improve communication. Retrieved from http://hdl.handle.net/10755/620409
- Clark, C.M. (2017). Creating and sustaining civility in nursing education (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.
- Clark, C.M., Sattler, V.P. & Barbosa-Leiker, C. (2018). Development and psychometric testing of the Workplace Civility Index: A reliable tool for measuring civility in the workplace. The Journal of Continuing Education in Nursing, 49(9), 400–406 doi:10.3928/00220124-20180813-05 [CrossRef]
- Copeland, D. & Henry, M. (2017). Workplace violence and perceptions of safety among emergency department staff members: Experiences, expectations, tolerance, reporting, and recommendations. Journal of Trauma Nursing, 24(2), 65–77. doi:10.1097/JTN.0000000000000269 [CrossRef]
- Dzurec, L.C., Kennison, M. & Gillen, P. (2017). The incongruity of workplace bullying victimization and inclusive excellence. Nursing Outlook, 65, 588–596. doi:10.1016/j.outlook.2017.01.012 [CrossRef]
- Fang, L., Huang, S.H. & Fang, S.H. (2016). Workplace bullying among nurses in South Taiwan. Journal of Clinical Nursing, 25(17–18), 2450–2456. doi:10.1111/jocn.12360 [CrossRef]
- Flinkman, M. & Salanterä, S. (2015). Early career experiences and perceptions–A qualitative exploration of the turnover of young registered nurses and intention to leave the nursing profession in Finland. Journal of Nursing Management, 23(8), 1050–1057. doi:10.1111/jonm.12251 [CrossRef]
- Kunc, M. & O'Brien, F.A. (2017). Exploring the development of a methodology for scenario use: Combining scenario and resource mapping approaches. Technological Forecasting & Social Change, 124, 150–159 doi:10.1016/j.techfore.2017.03.018 [CrossRef]
- Lala, R., Jeuring, J., van Dortmont, J. & van Geest, M. (2017). Scenarios in virtual learning environments for one-to-one communication skills training. International Journal of Educational Technology in Higher Education, 14(1), 1–15 doi:10.1186/s41239-017-0054-1 [CrossRef]
- Longo, J., Cassidy, L. & Sherman, R. (2016). Charge nurses' experiences with horizontal violence: Implications for leadership development. The Journal of Continuing Education in Nursing, 47(11), 493–499. doi:10.3928/00220124-20161017-07 [CrossRef]
- Mackinson, L.G., Corey, J., Kelly, V., O'Reilly, K.P., Stevens, J.P., Desanto-Madeya, S. & Foley, J. (2018). Nurse project consultant: Critical care nurses move beyond the bedside to affect quality and safety. Critical Care Nurse, 38(3), 54–66 doi:10.4037/ccn2018838 [CrossRef]
- Nursing Solutions Inc. (2018). 2018 national health care retention & RN staffing report. Retrieved from https://pdf4pro.com/view/2018-national-health-care-retention-amp-rn-staffing-1292b3.html
- Oh, H., Uhm, D. & Yoon, Y. (2016). Workplace bullying, job stress, intent to leave, and nurses' perceptions of patient safety in South Korean hospitals. Nursing Research, 65(5), 380–388 doi:10.1097/NNR.0000000000000175 [CrossRef]
- Park, M., Cho, S.H. & Hong, H.J. (2015). Prevalence and perpetrators of workplace violence by nursing unit and the relationship between violence and the perceived work environment. Journal of Nursing Scholarship, 47(1), 87–95. doi:10.1111/jnu.12112 [CrossRef]
- Patterson, K., Grenny, J., McMillan, R. & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). New York, NY: McGraw-Hill.
- Sauer, P.A. & McCoy, T.P. (2018). Nurse bullying and intent to leave. Nursing Economic$, 36(5), 219–245.
- Schwartz, L., El-Banna, M., Conroy, J.F. & Browne, J. (2019). What's your style? Enhanced interprofessional communication and practice using the communication wheel. Nurse Educator, 44(1), 20–24 doi:10.1097/NNE.0000000000000509 [CrossRef]
- Stanton, C. (2015). Action needed to stop lateral violence in the perioperative setting. AORN Journal, 101(5), P7–P9. doi:10.1016/S0001-2092(15)00320-8 [CrossRef]
- Stoddard, J.L. (2017). Civility matters: Overcoming workplace incivility using an interactive education intervention. Retrieved from https://digitalrepository.unm.edu/dnp/1
- Ulrich, B. (2016). Communication: The most basic of nursing skills. Nephrology Nursing Journal, 43(5), 375–450.
- Vagharseyyedin, S.A. (2016). Nurses' perspectives on workplace mistreatment: A qualitative study. Nursing & Health Sciences, 18(1), 70–78. doi:10.1111/nhs.12236 [CrossRef]
- Wilson, J.L. (2016). An exploration of bullying behaviours in nursing: A review of the literature. British Journal of Nursing, 25(6), 303–306 doi:10.12968/bjon.2016.25.6.303 [CrossRef]
- Wright, S.M. (2017). Using evidence-based practice and an educational intervention to improve vascular access management: A pilot project. Nephrology Nursing Journal, 44(5), 427–439.
Educational Content of Modules
|1. Defining the problem||Defines the overarching problem and provides common definitions for the terms surrounding bullying and incivility|
|2. Reacting under stress||Discusses how individuals do and should react when conversations become critical|
|3. Identifying conflict management (or mismanagement) styles||Introduces conflict management styles and examines how effective styles relate to creating a trustworthy and secure space for dialogue|
|4. Creating a safe environment||Discusses how to create that safe space; explains the importance of trust and mutual respect in conversations; describes ways to foster those attributes and includes how to work in a multigenerational environment|
|5. Putting it together: how to hold crucial conversations||Presents case studies and the use of branching scenarios to help learners as they practice scenarios with less effective and most effective responses|
Demographic Characteristics of Participants
|Characteristic||Control Group||Experimental Group||Total|
| Associate degree||7||25||5||23.8||12||24.5|
| Baccalaureate degree||17||60.7||13||61.9||30||61.2|
| Master's degree||4||14.3||2||9.5||6||12.2|
| Doctoral degree||0||0||1||4.8||1||2|
|Years of experience as a nurse|
| 0 to 1||11||39.3||9||42.9||20||40.8|
| 2 to 3||10||35.7||3||14.3||13||26.5|
| 4 to 5||2||7.1||1||4.75||3||6.1|
| 6 to 7||2||7.1||3||14.3||5||10.2|
| 8 to 9||0||0||1||4.8||1||2|
| 10 to 15||0||0||1||4.8||1||2|
| 16 to 20||1||3.6||2||9.5||3||6.1|
| 21 to 25||1||3.6||0||0||1||2|
| 26 to 30||1||3.6||1||4.75||2||4.1|
T Test: Paired Two Sample for Means by Group
|Statistic||WCI Pretest Total||WCI Posttest Total|
| Pearson correlation||0.259272206|
| Hypothesized mean difference||0|
t critical one-tailed||1.703288446|
t critical two-tailed||2.051830516|
| Pearson correlation||0.97396356|
| Hypothesized mean difference||0|
t critical one-tailed||1.724718243|
t critical two-tailed||2.085963447|