Nurses in all settings have an ethical and professional obligation to foster civility and cultures of respect in health care (American Nurses Association, 2015). A decade ago, Clark and Carnosso (2008) conducted a concept analysis to construct a common understanding of the concept of civility and to clarify its meaning. The authors noted that “civility is characterized by an authentic respect for others when expressing disagreement, disparity, or controversy. It involves time presence, a willingness to engage in genuine discourse and a sincere intention to seek common ground” (Clark & Carnosso, 2008, p. 13). Fundamentally, civility is synonymous with respect, whereas incivility is closely associated with disrespect.
Harm from disrespect (incivility) in health care has been identified as the next challenge in patient safety efforts (Sokol-Hessner et al., 2018). These authors also noted that disrespect is associated with a worse patient experience, lower perceptions of quality of care, lower likelihood of seeking care again in the same facility, higher risk of physical harm, and higher levels of staff disengagement, absenteeism, and turnover. Commitment to respect and civility is a critical step toward achieving high-quality patient care and high reliability.
In a large mixed-methods study examining healthy work environments, Ulrich, Barden, Cassidy, & Varn-Davis (2019) concluded that respect was positively associated with job satisfaction, communication, and intent to stay in one's current position. Alarmingly, 6,017 participants reported 198,340 incidents of physical and mental well-being issues, with one third of the nurses expressing intent to leave their current position within the next 12 months. The authors concluded that creating healthy work environments where nurses are empowered to speak up, where they have the confidence to be heard, and where actions will be taken to resolve unsafe conditions is essential.
Incivility is detrimental in academic settings as well. Several studies have supported the detrimental impact of faculty incivility on nursing students (Altmiller, 2012; Clark, 2008; Clark, Barbosa-Leiker, Gill, & Nguyen, 2015; Clark et al., 2012; Del Prato, 2013; Lasiter, Marchiondo, & Marchiondo, 2012; Mott, 2014). Clark and Fey (in press) reported that incivility experienced by students triggers fear and humiliation, impairs clinical judgment, reduces psychological safety, and increases cognitive load. The authors further noted that students are less likely to speak up when a practice error or patient safety issue occurs and that incivility triggers reactions in the brain that make task completion and problem solving much more difficult. Ongoing scrutiny and evaluation can create undue stress, place students in a position where they feel vulnerable, and create a context where students may be hesitant to ask questions or request assistance. This may result in impaired learning and unsafe patient care.
Nursing students and new graduate nurses are particularly vulnerable to the effects of incivility. New graduate nurses who were exposed to incivility reported negative effects on their emotional and physical well-being, their professional identity, and patient safety (Kerber, Woith, Jenkins, & Shafer Astroth, 2015). New graduate nurses who experienced incivility reported lower career satisfaction and greater intent to leave (Laschinger & Read, 2016) and higher levels of turnover within the first 2 years of new graduate employment (D'Ambra & Andrews, 2014). Although new graduate nurse transition programs improve satisfaction and retention overall, the programs did not adequately address the problem of incivility.
Civility education is viewed as an effective strategy to prevent and address this serious safety issue (Bartholomew, 2006; Clark, 2017a, 2017b, 2019a, 2019b; Clark & Fey, in press; Filipova, 2018; Laschinger, 2014; McGonagle, Walsh, Kath, & Morrow, 2014; Nelson, Nichols, & Wahl, 2017; Sauer & McCoy, 2018). In addition, addressing issues of burnout and promoting resilience may enhance health care professional wellness and respect for others, and it may contribute to positive changes in the work environment (Bodenheimer & Sinsky, 2014; Raso, 2015).
The purpose of this study was to demonstrate how an innovative, evidence-based educational strategy incorporating civility and resilience training can be used to prepare nursing students to foster healthy work environments. Educational elements helped students understand the basis of incivility, its relationship to safe patient care, and self-care practices associated with resilience. A multifaceted educational approach was undertaken using cognitive rehearsal (CR), HeartMath (HM), and simulation using the TeamSTEPPS™ Concerned, Uncomfortable, and Safety (CUS) model (Agency for Healthcare Research and Quality, 2019) to help a cohort of prelicensure nursing students learn and practice skills to build resilience and address incivility.
Institutional review board approval was obtained to conduct a mixed-methodological study to evaluate the effectiveness of CR, HM, and simulation using the CUS model by Team-STEPPS™ with 188 incoming, upper division, prelicensure nursing students from a school of nursing in the western United States. Most (58.3%) had some previous health care experience, ranging from 2 hours to more than 10,000 hours; 85% identified as female; 15% identified as male; and 40.5% had earned a prior bachelor's degree. The learning experience was allotted 2.5 hours in the afternoon on the last day of orientation. All students agreed to participate in a learning experience that combined CR, a HM technique, and simulation using the CUS model, to identify and address uncivil encounters in the health care environment.
The Institute of HeartMath (2014) defines resilience as the capacity to prepare for, recover from, and adapt in the face of stress, challenge, or adversity. Resilience is not the act of ignoring stress, challenge, or adversity; rather, it is the personal ability to positively address stress, adversity, and challenges with cognitive strategies. HM is an evidence-based set of tools used to develop personal and professional resilience. The goal of HM is to provide individuals with valuable self-care skills, allowing them to rebalance, rejuvenate, and self-regulate emotions. HM uses evidence-based methodology, validated by independent researchers, to develop and teach these tools to foster personal resilience. HM has over 25 years of research and has been used in more than 2,500 schools, 200 universities, and 50 countries globally to mitigate stress and build personal resilience (Institute of HeartMath, 2014). The HM tool used in this training was heart-focused breathing, which helps individuals promote self-regulation and composure when not only facing challenging situations in the workplace but also in daily life. This technique includes breathing slower and deeper than usual with a focus on the area of the heart to decrease the emotive effects on higher brain functioning. This allows the frontal cortex to be engaged when responding to stressful situations.
CUS Model by TeamSTEPPS
The CUS model is an evidence-based model developed by the Agency for Healthcare Research and Quality (2019) as part of the TeamSTEPPS approach to script a response to use during an uncivil or conflicted situation, particularly when patient safety is in jeopardy. In this study, simulated scenarios were used to demonstrate how the CUS model could be implemented to help students script an optimal response to address uncivil encounters.
Adult learning theory and principles of constructivism were used to structure the learning experience. The session began with a large group didactic presentation by defining and exposing the students to the concepts of civility, CR, HM, and simulation using the CUS model. Background, definitions, exemplars, and context for these concepts were provided. Following the didactic session, students participated in a multiphased learning process. First, students were asked to participate individually in a free-write activity to describe a actual uncivil situation that did occur or a hypothetical uncivil situation that could occur in nursing or health care. Upon completion of the free-write, students gathered into groups of five or six and shared their actual or hypothetical uncivil situation within the group. Group members selected one scenario to create a simulation experience, crafted a script using the CUS model, and practiced using heart-focused breathing to address the situation. Individuals within each group were assigned specific roles to enact the uncivil encounter and time was provided for groups to practice and prepare for the role-play experience. Using the scripting skills of the CUS model and using resilience training from HM, selected groups of students role-played their uncivil situation to the larger group.
Given the time allowed, four groups role-played uncivil situations for faculty and peers. Immediately following each role-play presentation, faculty with extensive expertise in CR, HM, and simulation facilitated a debriefing session by posing thought-provoking questions and encouraging peer and self-reflection. The time allotted for each phase of the learning experience is noted in Table 1.
Learning Activities and Time Allotments
Evaluative data were collected immediately following and 6 months after the intervention. Textual content analysis was used to analyze the qualitative narrative responses stemming from the free-write activity and with one item included in the 6-month follow-up survey (Graneheim & Lundman, 2004). Descriptive statistical analysis was used to evaluate students' quantitative responses related to the impact of the learning activity in both assessments.
In the analysis of the free-write activity, keywords or phrases were quantified by the researcher (C.M.C.), inferences were made about their meanings, and then they were organized into themes and ranked in order of the number of responses in each free-write narrative (Table 2). The same analytic process was used in the 6-month follow-up survey related to whether the learners applied the learning tools into their nursing practice (Table 3).
Survey Results Immediately Following Learning Activity
Quantitative evaluation of the learning activity was also completed by the participants immediately following the intervention. The confidential survey consisted of seven items based on Kirkpatrick's Model of Evaluation (Kirkpatrick & Kirkpatrick, 2005, 2006) and used a 5-point Likert scale (5 = strongly agree; 4 = agree; 3 = neither agree nor disagree; 2 = disagree; 1 = strongly disagree) to assess learning and application to practice. The survey was administered using a secure web-based platform (Qualtrics®).
Approximately 6 months after the learning experience and after their first medical–surgical clinical experience, students completed a similar survey using the same secure online platform to assess whether the learning experience had an effect on their provision of direct patient care in an acute care setting. Students were asked to reflect on the learning experience and respond to questions related to skills they acquired during orientation. The wording of the questions was slightly modified to reflect whether CR, HM, and the simulation using the CUS model were used in the acute patient care environment. Responses from both evaluations were collected anonymously and reported as aggregate data.
All students (N = 188) completed the free-write activity. They assembled into 37 small groups consisting of approximately five learners per group. Each student participating in the free-write activity was asked to identify whether the uncivil situation they described was real or hypothetical. Twenty-nine of 37 groups (78.3%) described real uncivil situations—in other words, situations that they directly experienced as a patient or family member of a patient, whereas six student groups described hypothetical situations (16.2%) and two student groups did not indicate either real or hypothetical situations. Themes stemming from the free-write narratives are displayed in Table 2. Numbers in parentheses following each theme denote the number of times the theme was identified by learners; the themes are displayed in descending order. One hundred forty-six participants (78%) responded to the initial survey administered immediately following the learning experience. Results of the survey are displayed in Table 3 in the order in which the questions were asked.
Approximately 6 months following the learning experience, after being engaged in direct patient care in an acute care setting, students were asked to reflect on the learning experience and respond to questions related to what they had learned during orientation—and whether they had used the information in their nursing practice. The response rate for the second survey was 36%, with 67 of the 188 participants completing the survey. The questions and responses for strongly agree and agree are noted in Table 4 in the order in which the questions were asked and in alignment with the initial survey.
Survey Results 6 Months After Learning Activity
In response to the question related to whether students had applied the tools stemming from the learning experience into their nursing practice, nearly 70% (69%) reported that they had done so. Seventeen of 67 respondents provided narrative comments describing how they applied what they learned into their nursing practice. Eight respondents reported using HM or other forms of deep breathing or mindfulness activities to calm themselves during stressful situations. Five respondents described taking time to gather their thoughts; consciously discarding biases; and practicing patience to address challenging situations. Three respondents addressed uncivil encounters using the tools developed from the learning activity, and one respondent reported having no recollection of the learning activity.
This study addressed the unambiguous call for civility education in nursing. The innovative combination of CR, HM, and simulation using the CUS model provided nursing students with an evidence-based approach to address patients, families, and other health care professionals during uncivil or conflicted encounters. This combination of tools is one that educators can consider to address the call for civility education.
As educators seek to provide nurses and nursing students with tools to improve levels of civility and respect within the patient care environment, moving to the upstream context of academic education is a promising approach. The opportunity for nursing students to learn effective ways to interact with patients, co-workers, physicians, and other health care providers during their orientation to their nursing program holds significant potential to address civility education. The nursing students are provided a safe environment to recognize that all communication should be respectful, particularly in patient safety situations. However, when communication is disrespectful or uncivil, students need to be prepared to successfully navigate the situation.
This study emphasized the importance of using stress-reducing activities and evidence-based communication tools to address uncivil encounters in the patient care environment. Major components of the study included CR, HM, and simulation using the CUS model. CR has been shown to be an effective teaching strategy in nursing education and practice (American Nurses Association, 2015; Clark, 2019a; Griffin, 2004; Griffin & Clark, 2014; Longo, 2017; Sanner-Stiehr, 2017; Stagg, Sheridan, Jones & Speroni, 2011, 2013). Researchers using CR training (O'Connell, Garbark, & Cavanaugh Nader, 2018) found that overt lateral violence does occur in nursing within a military medical facility; however, CR did not significantly reduce lateral violence in this population. The authors concluded that further studies are needed to understand the value of CR among perioperative military nurses.
HM, as an example of personal resilience, has been shown to reduce physician stress (Lemaire, Wallace, Lewin, de Grood, & Schaefer, 2011), improve personal resilience (Edwards, Edwards, & Highley, 2015), and increase the ability to self-regulate emotions, behaviors, and thoughts (McCraty & Shaffer, 2015). Additionally, Lemaire et al. (2011) found that when consistent use of HM is incorporated into daily activities, stress levels are significantly decreased. In nursing, Reyes, Andrusyszyn, Iwasiw, Forchuk, and Babenko-Mould (2015) conducted an integrative review of resilience in the context of nursing education. The authors highlighted the need for more resilience research in nursing education because little is known about evidence-based processes that promote the development and enhancement of resilience of nursing students. In an integrative review conducted by Cleary, Visentin, West, Lopez, and Kornhaber (2018), the authors concluded that developing resilience skills during nursing education programs better prepared students to cope with the unique challenges in nursing practice. Lekan, Ward, and Elliott (2018) explored resilience in senior-level baccalaureate nursing students and underscored the need for nurse educators to help nursing students develop resilience to better prepare them for academic success and a smooth transition into their professional nursing role.
Role-playing and facilitated debriefing of uncivil scenarios provide opportunities and safe spaces to practice addressing uncivil encounters and explore effective ways to address future situations. In this study, students were highly engaged and enthusiastic about the learning activity. None had difficulty identifying uncivil encounters in health care, and nearly all described actual uncivil encounters they personally experienced. Students actively participated in small- and large-group discussions and student questions and comments extended beyond the time allotted for the learning activity. Evaluative feedback from learners was positive. In the postassessment, more than 70% of the students reported being aware of the consequences of incivility on patient care, and 69% reported applying what they learned from the activity into their clinical practice. These findings highlight students' willingness and ability to use the tools practiced during new student orientation in the patient care environment. The potential exists for nursing students and new graduate nurses to benefit from this learning experience by actively seeking employment opportunities and that support civility and foster healthy work environments.
Feedback obtained at the 6-month mark from the students indicated that although the tools were helpful, they had forgotten some of the key points. The concept of providing learning and then reinforcing it is not new and has been shown to be beneficial for students. The opportunity for repeated learning experiences may also decrease the skill decay (Aziza et al., 2013), and repeated exposure to HM in the educational setting can be an effective tool for reducing anxiety and positively affecting academic performance (Aritzeta et al., 2017). Successful learning requires repetitive practice of CR, HM, and simulation using the CUS model accompanied by skilled debriefing sessions from an experienced faculty member or coach. Without deliberate practice, skills may decay or be lost altogether. Learning new skills takes training, experience, practice, and feedback from highly skilled individuals. Participants in this study and in future studies will require lengthier and more frequent sessions to practice interventions to achieve a level of confidence and ability. Ideally, students need expert modeling of these techniques by nursing faculty coupled with repeated opportunities to practice these strategies over an extended period. More research in this area will be needed to determine the dose and timing required for mastery of the technique.
Application for Educators
In this study, combining CR, HM, and simulation using the CUS model was successful in introducing students to the importance of using stress reducing activities and evidence-based communication tools to address uncivil encounters in the patient care environment. These are lifelong self-care skills for all nurses and health care professionals that need to be introduced early and reinforced throughout the nursing curriculum and entry into practice. However, just as nurse educators would not expect students to read about a skill (e.g., sterile dressing changes) without ample opportunity to physically practice the necessary skills to perform the sterile dressing change, likewise students need opportunities to practice stress-reduction and communication skills that have been discussed and taught. Students need repeated dosing and opportunities to practice communication skills over an extended period so that if and when uncivil encounters occur, nurses are more apt to use a practiced and patterned response. Providing students with repeated opportunities to practice these skills throughout their nursing program, from orientation through entry into practice, and combined with meaningful debriefing sessions facilitated by skilled nurse educators is recommended. Nurse educators play a vital role in helping our students learn about nursing care and practice, as well as how to effectively address incivility. Teaching students how to create a positive response using simulation with the CUS model and CR when they are approached in an uncivil manner can address the linkage between incivility and negative impact on patient care.
Limitations and Recommendations
Although this study was conducted in only one school of nursing with limited follow-up teaching, the results are promising for this type of educational intervention to mitigate uncivil behaviors in patient care areas. Because the study included only one cohort of prelicensure students from one school of nursing in the United States, the findings may lack generalizability to other academic settings and student populations. Self-report studies, especially those measuring perceptions, lack external validation. Additionally, the study did not have subsequent training/practice sessions to refresh and reinforce tool usage and application. More work is needed to build on this study using training/practice sessions to not only expose the students to the tools but to create extended opportunities for practice and debriefing sessions. Baseline knowledge, skills, and attitudes (KSA) of the learners related to civility, CR, HM, and CUS were not assessed prior to the intervention. Assessing baseline KSAs of the learners prior to implementing the intervention may strengthen further studies. Continued evaluation is needed to determine the long-term impact of this learning activity on nursing practice and patient safety.
This study demonstrated how an evidence-based educational strategy can be used to prepare nursing students to foster healthy work environments and address acts of incivility that threaten patient safety. The combination of CR, HM, and simulation using the CUS model to address uncivil behaviors and mitigate the potential negative effect of these on patient safety is promising. Evidence-based teaching strategies to minimize the negative impact of uncivil behaviors on patient safety are clearly needed in nursing programs. Therefore, nurse educators are urged to provide civility education in conjunction with tested techniques to build resilience and address uncivil encounters, especially those that compromise patient care. This approach is an effective strategy to address these critical needs; however, for the approach to be effective, it must be facilitated by experienced faculty and integrated throughout the nursing curriculum using principles of repetitive practice. Teaching the next generation of nurses lifelong self-care skills at the start of their professional education has the potential to positively influence the delivery of safe patient care, build stronger interprofessional relationships, and foster healthy work environments.
- Agency for Healthcare Research and Quality. (2019). TeamSTEPPS national implementation. Retrieved from http://teamstepps.ahrq.gov
- Altmiller, G. (2012). Student perceptions of incivility in nursing education: Implications for educators. Nursing Education Perspectives, 33(1), 15–20 https://doi.org/10.5480/1536-5026-33.1.15 PMID: doi:10.5480/1536-5026-33.1.15 [CrossRef]22416535
- American Nurses Association. (2015). Position statement: Incivility, bullying, and workplace violence. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/
- Aritzeta, A., Soroa, G., Balluerka, N., Muela, A., Gorostiaga, A. & Aliri, J. (2017). Reducing anxiety and improving academic performance through a biofeedback relaxation training program. Applied Psycho-physiology and Biofeedback, 42(3), 193–202 https://doi.org/10.1007/s10484-017-9367-z PMID: doi:10.1007/s10484-017-9367-z [CrossRef]
- Aziza, W., Wang, W., Kesaf, S., Abdelhamid Mohamed, A., Fukazawa, Y. & Shigemoto, R. (2013). Distinct kinetics of synaptic structural plasticity, memory formation, and memory decay in massed and spaced learning. Proceedings of the National Academy of Sciences, 111(1), E194–E202. doi:10.1073/pnas.1303317110 [CrossRef]
- Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HC Pro.
- Bodenheimer, T. & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576 https://doi.org/10.1370/afm.1713 PMID: doi:10.1370/afm.1713 [CrossRef]25384822
- Clark, C. M. (2008). Faculty and student assessment of and experience with incivility in nursing education. Journal of Nursing Education, 47(10), 458–465 https://doi.org/10.3928/01484834-20081001-03 PMID: doi:10.3928/01484834-20081001-03 [CrossRef]18856100
- Clark, C. M. (2017a). Creating and sustaining civility in nursing education (2nd ed.). Indianapolis, IN: Sigma Theta Tau International Publishing.
- Clark, C. M. (2017b). An evidence-based approach to integrate civility, professionalism, and ethical practice into nursing curricula. Nurse Educator, 42(3), 120–126 https://doi.org/10.1097/NNE.0000000000000331 PMID: doi:10.1097/NNE.0000000000000331 [CrossRef]
- Clark, C. M. (2019a). Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educator, 44(2), 64–68 https://doi.org/10.1097/NNE.0000000000000563 PMID: doi:10.1097/NNE.0000000000000563 [CrossRef]
- Clark, C. M. (2019b). Fostering a culture of civility and respect in nursing. Journal of Nursing Regulation, 10(1), 44–52 https://doi.org/10.1016/S2155-8256(19)30082-1 doi:10.1016/S2155-8256(19)30082-1 [CrossRef]
- Clark, C. M., Barbosa-Leiker, C., Gill, L. M. & Nguyen, D. (2015). Revision and psychometric testing of the Incivility in Nursing Education (INE) survey: Introducing the INE-R. Journal of Nursing Education, 54(6), 306–315 https://doi.org/10.3928/01484834-20150515-01 PMID: doi:10.3928/01484834-20150515-01 [CrossRef]26057424
- Clark, C. M. & Carnosso, J. (2008). Civility: A concept analysis. Journal of Theory Construction & Testing, 12(1), 11–15.
- Clark, C. M. & Fey, M. K. (in press). Fostering civility in learning conversations: Introducing the PAAIL communication strategy. Nurse Educator.
- Clark, C. M., Juan, C. M., Allerton, B. W., Otterness, N. S., Jun, W. Y. & Wei, F. (2012). Faculty and student perceptions of academic incivility in the People's Republic of China. Journal of Cultural Diversity, 19(3), 85–93 PMID:23155894
- Cleary, M., Visentin, D., West, S., Lopez, V. & Kornhaber, R. (2018). Promoting emotional intelligence and resilience in undergraduate nursing students: An integrative review. Nurse Education Today, 68, 112–120 https://doi.org/10.1016/j.nedt.2018.05.018 PMID: doi:10.1016/j.nedt.2018.05.018 [CrossRef]29902740
- D'Ambra, A. M. & Andrews, D. R. (2014). Incivility, retention and new graduate nurses: An integrated review of the literature. Journal of Nursing Management, 22(6), 735–742 https://doi.org/10.1111/jonm.12060 PMID: doi:10.1111/jonm.12060 [CrossRef]
- Del Prato, D. (2013). Students' voices: The lived experience of faculty incivility as a barrier to professional formation in associate degree nursing education. Nurse Education Today, 33(3), 286–290 https://doi.org/10.1016/j.nedt.2012.05.030 PMID: doi:10.1016/j.nedt.2012.05.030 [CrossRef]
- Edwards, S.D., Edwards, D.J. & Highley, J.A. (2015). Evaluation of HeartMath training programme for improving personal resilience and psychophysiological coherence. African Journal for Physical, Health Education, Recreation and Dance, 21, 996–1008.
- Filipova, A. A. (2018). Countering unprofessional behaviors among nurses in the workplace. JONA, 48(10), 487–494 https://doi.org/10.1097/NNA.0000000000000656 PMID: doi:10.1097/NNA.0000000000000656 [CrossRef]
- Graneheim, U. H. & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112 https://doi.org/10.1016/j.nedt.2003.10.001 PMID: doi:10.1016/j.nedt.2003.10.001 [CrossRef]14769454
- Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257–263 https://doi.org/10.3928/0022-0124-20041101-07 PMID: doi:10.3928/0022-0124-20041101-07 [CrossRef]15584678
- Griffin, M. & Clark, C. M. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. The Journal of Continuing Education in Nursing, 45(12), 535–542 https://doi.org/10.3928/00220124-20141122-02 PMID: doi:10.3928/00220124-20141122-02 [CrossRef]25406637
- Institute of HeartMath. (2014). The resilience advantage: Skills for personal and professional effectiveness. Author.
- Kerber, C., Woith, W. M., Jenkins, S. H. & Schafer Astroth, K. (2015). Perception of new nurses concerning incivility in the workplace. The Journal of Continuing Education in Nursing, 46(11), 522–527 https://doi.org/10.3928/00220124-20151020-05 PMID: doi:10.3928/00220124-20151020-05 [CrossRef]26509405
- Kirkpatrick, D. L. & Kirkpatrick, J. D. (2005). Transferring learning to behavior: Using the four levels to improve performance. San Francisco, CA: Berrett-Koehler.
- Kirkpatrick, D. L. & Kirkpatrick, J. D. (2006). Evaluating training programs: The four levels (3rd ed.). San Francisco, CA: Berrett-Koehler.
- Koh, W. M. S. (2016). Management of workplace bullying in hospital: A review of the use of cognitive rehearsal as an alternate management strategy. International Journal of Nursing Sciences, 3(2), 213–222 https://doi.org/10.1016/j.ijnss.2016.04.010 doi:10.1016/j.ijnss.2016.04.010 [CrossRef]
- Laschinger, H. K. (2014). Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes. The Journal of Nursing Administration, 44(5), 284–290 https://doi.org/10.1097/NNA.0000000000000068 PMID: doi:10.1097/NNA.0000000000000068 [CrossRef]24759201
- Laschinger, H. K. & Read, E. A. (2016). The effect of authentic leadership, person-job fit, and civility norms on new graduate nurses' experiences of coworker incivility and burnout. The Journal of Nursing Administration, 46(11), 574–580 https://doi.org/10.1097/NNA.0000000000000407 PMID: doi:10.1097/NNA.0000000000000407 [CrossRef]27779537
- Lasiter, S., Marchiondo, L. & Marchiondo, K. (2012). Student narratives of faculty incivility. Nursing Outlook, 60(3), 121–126, 126.e1. https://doi.org/10.1016/j.outlook.2011.06.001 PMID: doi:10.1016/j.outlook.2011.06.001 [CrossRef]
- Lekan, D. A., Ward, T. D. & Elliott, A. A. (2018). Resilience in baccalaureate nursing students: An exploration. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 46–55 https://doi.org/10.3928/02793695-20180619-06 PMID: doi:10.3928/02793695-20180619-06 [CrossRef]29975398
- Lemaire, J. B., Wallace, J. E., Lewin, A. M., de Grood, J. & Schaefer, J. P. (2011). The effect of a biofeedback-based stress management tool on physician stress: A randomized controlled clinical trial. Open Medicine, 5(4), e154–e163 PMID:22567069
- Longo, J. (2017). Cognitive rehearsal. American Nurse Today, 12(8), 41–43.
- McCraty, R. & Shaffer, F. (2015). Heart rate variability: New perspectives on physiological mechanisms, assessment of self-regulatory capacity, and health risk. Global Advances in Health and Medicine: Improving Healthcare Outcomes Worldwide, 4(1), 46–61 https://doi.org/10.7453/gahmj.2014.073 PMID: doi:10.7453/gahmj.2014.073 [CrossRef]
- McGonagle, A. K., Walsh, B. M., Kath, L. M. & Morrow, S. L. (2014). Civility norms, safety climate, and safety outcomes: A preliminary investigation. Journal of Occupational Health Psychology, 19(4), 437–452 https://doi.org/10.1037/a0037110 PMID: doi:10.1037/a0037110 [CrossRef]24933595
- Mott, J. (2014). Undergraduate nursing student experiences with faculty bullies. Nurse Educator, 39(3), 143–148 https://doi.org/10.1097/NNE.0000000000000038 PMID: doi:10.1097/NNE.0000000000000038 [CrossRef]24743180
- Nelson, J., Nichols, T. & Wahl, J. (2017). The cascading effect of civility on outcomes of clarity, job satisfaction, and caring for patients. Interdisciplinary Journal of Partnership Studies, 4(2), 1–22 https://doi.org/10.24926/ijps.v4i2.164 doi:10.24926/ijps.v4i2.164 [CrossRef]
- O'Connell, K.M., Garbark, R.L. & Cavanaugh Nader, K. (2018). Cognitive rehearsal training to prevent lateral violence in a military medical facility. PeriAnesthesia Nursing. Advance online publication. doi:10.1016/j.jopan.2018.07.003 [CrossRef]
- Raso, R. (2015). To the triple aim…and beyond. Nursing Management, 46(7), 6 https://doi.org/10.1097/01.NUMA.0000466492.31074.33 PMID: doi:10.1097/01.NUMA.0000466492.31074.33 [CrossRef]
- Reyes, A. T., Andrusyszyn, M.-A., Iwasiw, C., Forchuk, C. & Babenko-Mould, Y. (2015). Resilience in nursing education: An integrative review. Journal of Nursing Education, 54(8), 438–444 https://doi.org/10.3928/01484834-20150717-03 PMID: doi:10.3928/01484834-20150717-03 [CrossRef]26230163
- Sanner-Stiehr, E. (2017). Using simulation to teach responses to lateral violence: Guidelines for nurse educators. Nurse Educator, 42(3), 133–137 https://doi.org/10.1097/NNE.0000000000000326 PMID: doi:10.1097/NNE.0000000000000326 [CrossRef]
- Sauer, P. A. & McCoy, T. P. (2018). Nurse bullying and intent to leave. Nursing Economic$, 36(5), 219–245.
- Seibel, L. M. & Fehr, F. C. (2018). “They can crush you”: Nursing students' experiences of bullying and the role of faculty”. Journal of Nursing Education and Practice, 8(6), 66–75 https://doi.org/10.5430/jnep.v8n6p66 doi:10.5430/jnep.v8n6p66 [CrossRef]
- Sokol-Hessner, L., Folcarelli, P. H., Annas, C. L., Brown, S. M., Fernandez, L., Roche, S. D. & Sands, K. E.the Practice of Respect Delphi Study Group (2018). A road map for advancing the practice of respect in health care: The results of an interdisciplinary modified Delphi consensus study. Joint Commission Journal on Quality and Patient Safety, 44(8), 463–476 https://doi.org/10.1016/j.jcjq.2018.02.003 PMID: doi:10.1016/j.jcjq.2018.02.003 [CrossRef]30071966
- Stagg, S. J., Sheridan, D., Jones, R. A. & Speroni, K. G. (2011). Evaluation of a workplace bullying cognitive rehearsal program in a hospital setting. The Journal of Continuing Education in Nursing, 42(9), 395–401 https://doi.org/10.3928/00220124-20110823-22 PMID: doi:10.3928/00220124-20110823-22 [CrossRef]21877661
- Stagg, S. J., Sheridan, D. J., Jones, R. A. & Speroni, K. G. (2013). Work-place bullying: The effectiveness of a workplace program. Workplace Health & Safety, 61(8), 333–338 https://doi.org/10.1177/216507991306100803 PMID:23875566
- Ulrich, B., Barden, C., Cassidy, L. & Varn-Davis, N. (2019). Critical care nurse work environments 2018: Findings and implications. Retrieved from http://ccn.aacnjournals.org/search?fulltext=ulrich&submit=yes&x=0&y=0
Learning Activities and Time Allotments
|Introduction to civility and incivility in nursing||10 minutes|
|Didactic session: cognitive rehearsal (CR), HeartMath (HM), and TeamSTEPPS™ Concerned, Uncomfortable, and Safety (CUS)||45 minutes|
|model presented to students using interactive teaching–learning strategies. Objectives for this session included:|
| Briefly define workplace aggression and discuss its impact on individuals, teams, organizations, and patient care.|
| Explain CR, HM, and scripting using the CUS model.|
|Free write: Time allotted for students to write about real or potential uncivil scenarios that might affect patient safety.||10 minutes|
|Small group work using CR: Groups of 5 to 6 students shared free-write outcomes and selected one scenario to be presented as a role-play and debriefed by the facilitators (faculty) with all students. Students selected actors for the role-play and rehearsed using HM and the CUS model.||25 minutes|
|Group role-play and debrief: Skilled faculty coaching and debriefing session conducted after four group role-plays of uncivil encounters using HM and CUS.||60 minutes|
|Themes Stemming From the Free-Write Narratives (n = 37)a|
Nurse ignored patient condition (e.g., not responding to call light, failing to follow up on a rash, refusing to assist with patient repositioning and incontinence change, respiratory problems/distress) (10)
Fall risk (ambulated patient with unrepaired hip fracture, patient fell during stress test because physician refused to stop the test when patient showing signs of distress) (6)
Dealing with combative, violent, intoxicated patients and/or visitors (5)
Wrong medication order/prescription (medication ordered for patient who was allergic, birth control prescription ordered without pregnancy test) (5)
Poor hand hygiene, no hand washing, failing to wear gloves (cut off fingertips) (4)
Ignored possible physical and/or sexual abuse of a patient (3)
Deceit (certified nursing assistant stealing from patient, RN made up vital signs) (2)
RN insisting that certified nursing assistant provide care beyond scope of practice (2)
Survey Results Immediately Following Learning Activity
|Question||Response: Strongly Agree or Agree|
|I am more aware of the consequences of incivility on patient care.a||95.2%|
|Using cognitive rehearsal has increased my ability to address uncivil situations.a||88.4%|
|Using HeartMath has helped me reset my frame of mind.a||83%|
|I have acquired new tools to help me reduce stress.a||82%|
|I have acquired at least one effective tool to deal with uncivil behaviors.a||96%|
|I have acquired at least two effective tools to deal with uncivil behaviors.a||84.4%|
|I will apply what I have learned through this learning experience into my nursing practice.a||96%|
Survey Results 6 Months After Learning Activity
|Question||Response: Strongly Agree or Agree|
|I am more aware of the consequences of incivility on patient care.a||70.2%|
|Participating in the cognitive rehearsal experience has increased my ability to address uncivil situations.a||55.2%|
|I have used HeartMath to help me reset my frame of mind.a||39%|
|I acquired new tools to help me reduce stress.a||60%|
|I have acquired at least one effective tool to deal with uncivil behaviors.a||71.6%|
|I have acquired at least two effective tools to deal with uncivil behaviors.a||51%|
|I have applied what I have learned through this learning experience into my nursing practice: Yes/No.b If yes, please explain.||69%|