Incivility and bullying are significant issues in nursing education and health care practice. Implications from these problems include ineffective academic learning, unprofessional nursing practice, and negative impact on patient care outcomes (Clark, 2008; The Joint Commission, 2016; Rawlins, 2017). A faculty and student research team at a midwestern baccalaureate nursing program used the Action Research (AR) methodology (Moch, Vandenbark, Pehler, & Stombaugh, 2016) to evaluate a quality improvement (QI) project focused on increasing effective learning and student success (Sperstad et al., 2020). Results from the Incivility in Nursing Education Revised (INE-R) tool (Clark, Barbosa-Leiker, Gill, & Nguyen, 2015) indicated that 84% of faculty and students rated incivility as a mild to moderate problem in the college of nursing. Both faculty and students suggested effective communication as one of the strategies to promote civility. In response to these results, a second faculty and student AR team was formed to create a QI project focused on effective interventions to promote a culture of civility. This article describes the planning, implementation, and evaluation of an educational project, Creating a Culture of Civility QI.
AR methodology was used to plan, implement, and evaluate this project. According to Moch et al. (2016), AR is a systematic process involving data collection, data analysis, reflection, and discussion among co-researchers with the goal of creating change. A team of five faculty and five students representing different cohorts in a midwestern undergraduate baccalaureate nursing program started the project by conducting a literature review for evidence on interventions to address incivility and bullying in nursing education and practice. Intervention strategies commonly associated with positive outcomes in prior research studies included the following: education to increase awareness of incivility (Armstrong, 2018; Egues & Leinung, 2014; Kile, Eaton, deValpine, & Gilbert, 2019; Lasater, Mood, Buchwach, & Dieckmann, 2015); cognitive rehearsal (Armstrong, 2018; Lasater et al., 2015; Sanner-Stiehr, 2018); role-play (Gillespie, Brown, Grubb, Shay, & Montoya, 2015; Kile et al., 2019; Lasater et al., 2015; Ulrich, Gillespie, Boesch, Bateman, & Grubb, 2017); and reflection (Egues & Leinung, 2014; Gillespie et al., 2015; Hogan, Orr, Fox, Cummins, & Foureur, 2018). These strategies, the Civility Toolkit developed by Robert Wood Johnson nurse fellows (PACERS©, 2015), and data from the department incivility survey were used to develop a two-part incivility training program for nursing students and faculty.
Two theoretical frameworks were selected to guide the project: social-ecological model (McLeroy, Bibeau, Steckler, & Glanz, 1988) and the model of empowerment (Worrell, McGinn, Black, Holloway, & Ney, 1996). Social-ecological models suggest behavior is influenced by complex, reciprocal relationships between factors at intrapersonal, interpersonal, institutional, community, and policy levels (McLeroy et al., 1988). The Creating a Culture of Civility training focused on intrapersonal awareness and interpersonal skills for preventing and addressing incivility. The model of empowerment suggests one's ability to prevent or address incivility can be enhanced through collegiality, communication, autonomy, and accountability (Worrell et al., 1996). These four concepts were integrated in the Creating a Culture of Civility QI training objectives.
All college of nursing faculty, staff, and prelicensure undergraduate nursing students were invited to participate in the QI project via e-mail, classroom, and meeting announcements. Faculty and staff (n = 24) and students (n = 69) voluntarily self-enrolled in an online module located within the university's learning management system. An explanation of the QI project and agreements to participate in each phase of the training were imbedded in the module. The chair of the university's Institutional Review Board (IRB) was consulted prior to implementation of the QI project, resulting in a nonresearch project classification. Subsequently, an IRB application was submitted, and exempt status was obtained prior to dissemination of the deidentified project evaluation results. Institutional-level support from the college dean and leadership was attained.
The Creating a Culture of Civility training was delivered in two parts. Training for faculty and staff was separate but similar to student training, differing only according to relevant role-specific self-reflections and scenarios. Part one was an independent, self-paced e-learning module created by the research team that was administered through the university's learning management system. Part one consisted of an introductory video produced by student research team members and a cameo from the college dean. Information on incivility was presented through fact sheets and links to videos from the PACER website (Bolick et al., 2015a; Porath, 2016). Participants were prompted to complete Clark's (2017) incivility indexes and reflect on responses. Part two of the training was an interactive face-to-face session also held separately for faculty and students.
As part of the AR process, student research team members requested that student sessions be held separately from faculty to create a more comfortable environment for students to share their experiences. Sessions were held in a university classroom and facilitated by faculty and student research team members. The 2-hour session focused on skill development, emphasizing communication in difficult situations. After briefly reflecting on insights from part one of the training, participants were trained in the five-step approach for Respectful Conversations for Difficult Situations© (Bolick et al., 2015b). This approach was practiced using cognitive rehearsal after viewing a video vignette (Bolick et al., 2015c) and through small group role-play scenarios. The scenarios differed for faculty and staff, and students, targeting events that were more likely to transpire in each role. Small- and large-group reflection and discussion were integrated throughout the process.
Data Collection and Analysis
An anonymous program evaluation survey addressing both the eLearning and face-to-face sessions was administered electronically to participants after completion of both phases of training. The nine-item survey generated both quantitative and qualitative feedback on the knowledge and communication skills participants gained, perceptions on training methods used, and additional learning needs that should be considered for future programming. The four quantitative items measured participants' perspectives with either a 3-point (yes, somewhat, or no) or a 5-point Likert scale format. The five qualitative items collected open text responses. Quantitative data were analyzed descriptively with frequency counts and percentages. Qualitative data from the open-ended evaluation questions were analyzed for themes.
A total of 69 (21%) students across the five semesters of the nursing program and 24 (64%) faculty and administrative staff completed the anonymous survey after participating in both the eLearning and in-person sessions. Quantitative results specific to the evaluation of the QI programing showed some variation between faculty and staff, and students. Following are key results of the program evaluation survey showing the consistency as well as contrasts between faculty and staff, and students.
When asked whether participants thought this information would be useful in their practice, 96% of students and 80% of faculty and staff thought it would be very to extremely useful in their practice. In a follow-up question asking how they would use the information, students shared an increased understanding, recognition, and strategies to deal with an uncivil situation. Students had an enhanced confidence to address incivility and gained skills for respectful communication. One student commented, “The information we learned will be helpful when dealing with a variety of situations in the workforce. It is good to have these tools to feel better prepared to handle incivility and challenging situations.” Faculty and staff identified communication strategies during difficult situations, integrating teaching strategies to promote student learning, and an increased self-awareness and importance of role modeling. One faculty participant said:
I see myself paying more attention to my own actions and how they are being perceived and felt by others. I can hopefully learn tactful ways to take care of situations that are not civil instead of just being uncomfortable and trying to avoid situations.
Another question asked participants to identify information they felt was missing from the program. Students identified wanting more “starter phrases” to start a conversation, more scenarios, inclusion of practice and work environments, uncivil people in positions of authority (i.e., providers, faculty, and supervisors), and strategies outlining what steps or strategies to use if incivility continued. One student commented, “I think this program could have included more ‘catch phrases’ to take with for practice. I have an overall better understanding but still feel nervous about having that sort of conversation because it's difficult.”
Faculty and staff also requested more examples and strategies, as well as more information on how to deal with non-teaching and coworker incivility, changing the culture, and recognizing the impact of context, emotion, and diversity. One participant said, “Perhaps discussing more cases and intervention strategies for those particular cases would be helpful. Some discussion on how very subjective and contextual this content can be would [be] appreciated.”
Future programing was another area that was explored; responses mirrored some of the comments on what participants felt was missing. The additional ideas students brought forward included providing more facts and figures on civility, adding the information to a course, and creating a “cheat sheet” of key phrases to use. One student noted, “I really enjoyed the examples/role-playing. I would just like more because it takes practice to have these conversations effectively, and I am definitely still a novice.” Faculty and staff wanted information on how other schools deal with incivility, more discussion of actual situations and how they could be addressed, combined discussion and activities with students, and how things would move forward in the future. One faculty participant said, “Maybe faculty and students having part of the training at the same time, together? [It] could increase the sense of all being on the ‘same team, same dream.’”
Because of the potential sensitive nature of the topic, the team wanted to be sure a safe environment was created to facilitate discussion and learning. Although 98% of students reported feeling somewhat or extremely comfortable during the in-person sessions, only 46% of faculty and staff reported feeling somewhat or extremely comfortable. This difference may be explained by how the faculty and staff answered the follow-up question, “What made you feel uncomfortable during the in-person session, and how could the organizers have improved the session?” Responses may have reflected the participants' assigned group; for instance, two participants identified the discussion was centered around the classroom but they did not teach. Response also may have reflected the physical environment, where there were multiple groups talking at the same time.
Participants also were asked if they felt they accomplished their own learning goals developed during the eLearning Phase 1 of the program. All of the students indicated they believed they had accomplished their goals, identifying an increased understanding, recognition of, and helpful strategies to deal with an uncivil situation. Students had enhanced confidence to address incivility and gained skills for respectful communication. One student stated, “I believe that I have gotten better information out of this program than what my original goals were. Scenarios were helpful, and I feel more comfortable in approaching situations after having discussions.” For faculty and staff, 75% felt they met their goals of increased knowledge, self-awareness, and skills and tools to deal with incivility. For the three faculty and staff who did not feel their goals were met, they indicated that they wanted more information on constructive conversation and identified awareness of need for improvement. One participant said, “I believe this is a very good start to learning about incivility. There will probably always be room to improve so I do not consider my self-learning goals to be done.”
This two-part incivility training for nursing students and faculty was effective in increasing knowledge and communication skills for recognizing and dealing with incivility. Most identified was the increased ability to use the communication strategies practiced during the face-to-face part of the intervention. This further supports the focus of the intervention on communication strategies, as identified in the PACERS Civility Toolkit (2015).
Student evaluations were highly positive, whereas faculty and staff evaluations showed more variation. This may have been due to discussion being centered on classroom scenarios, whereas not all of the participants in the group had teaching responsibilities. Qualitative feedback indicated the need for development of incivility interventions tailored specifically for administrative support staff.
When offered on a voluntary basis, only 21% of nursing students opted to complete the incivility training. Potential explanations for the low participation rate may be lack of formal exposure to incivility content until the senior year of the nursing program. However, feedback from the students who participated in the intervention indicated they recognized the importance and significance of incivility. These results identified a need for incivility interventions that are integrated in required course-work and have led to the development of training sessions that could be delivered in the curriculum at sophomore, junior, and senior levels.
Several limitations of the QI project were identified. Despite offering multiple training sessions for students, voluntary participation resulted in a lower turnout of student attendance (21% of total possible students attended versus 64% of total possible faculty and staff). Voluntary participation also could have had some bias on the survey results. This was a pilot program with a small sample size; therefore, results cannot be generalized to all baccalaureate nursing students or faculty. Finally, outcome measures focused on program evaluation. Additional research is needed to determine whether the training changed behavior or the overall department culture.
This educational innovation based on a prior student and faculty research project was a culmination of strategies and methods found in the literature and in an online resource (PACERS, 2015), resulting in a successful two-phase QI project to enhance civility within a college of nursing. Although meeting initial goals, the team also is aware of the ongoing need to continue this work. Future goals for curricular and policy development projects were identified to address higher levels and truly shift the culture. The college of nursing has included civility as part of its vision and mission statements. The college of nursing's strategic plan will help guide further educational initiatives and sessions to provide additional strategies and practice to enhance civility for students, faculty, and administrative staff. Plans include resurveying faculty and staff and students using Clarke's (2015) INE-R to measure progress toward creating a culture of civility.
It is well documented that incivility in health care can begin during a student's time in school. By using free resources, a college of nursing was able to implement a cost-effective program to begin the conversation and offer a communication strategy to address incivility for faculty, staff, and students. This program design can be readily adopted by others for use in their organization.
- Armstrong, N. (2018). Management of nursing workplace incivility in the health care settings: A systematic review. Workplace Health & Safety, 66(8), 403–410.
- Bolick, B., Edmonson, C., Adeniran, R., Cuming, R., Khan, B., Lawson, L. & Wilson, D. (2015a, August7). Incivility and bullying in health-care: Overview video 1 of 3 [Video file]. Retrieved from https://www.youtube.com/watch?v=4DOQ593cHfE&t=816s
- Bolick, B., Edmonson, C., Adeniran, R., Cuming, R., Khan, B., Lawson, L. & Wilson, D. (2015b, August19). Incivility and bullying in health-care: Practice Vignettes video 3 of 3 [Video file]. Retrieved from https://youtu.be/t8XddfSddzU
- Bolick, B., Edmonson, C., Adeniran, R., Cuming, R., Khan, B., Lawson, L. & Wilson, D. (2015c). Respectful conversations for difficult situations. Retrieved from https://www.youtube.com/watch?v=t8XddfSddzU
- Clark, C., Barbosa-Leiker, C., Gill, L. & 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.
- Clark, C.M. (2008). Faculty and student assessment of and experience with incivility in nursing education. Journal of Nursing Education, 47(10), 458–465.
- Clark, C.M. (2017). Creating and sustaining civility in nursing education (2nd ed.). Indianapolis, IN: Sigma Theta Tau International Publishing.
- Egues, A.L. & Leinung, E.Z. (2014). Antibullying workshops: Shaping minority nursing leaders through curriculum innovation. Nursing Forum, 49(4), 240–246.
- Gillespie, G.L., Brown, K., Grubb, P., Shay, A. & Montoya, K. (2015). Qualitative evaluation of a role play bullying simulation. Journal of Nursing Education and Practice, 5(7), 73–80.
- Hogan, R., Orr, F., Fox, D., Cummins, A. & Foureur, M. (2018). Developing nursing and midwifery students' capacity for coping with bullying and aggression in clinical settings: Students' evaluation of a learning resource. Nurse Education in Practice, 29, 89–94.
- The Joint Commission. (2016, June). Bullying has no place in health care. Quick Safety Issue 24. Retrieved from: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_24_June_2016.pdf
- Kile, D., Eaton, M., deValpine, M. & Gilbert, R. (2019). The effectiveness of education and cognitive rehearsal in managing nurse-to-nurse incivility: A pilot study. Journal of Nursing Management, 27(3), 543–552.
- Lasater, K., Mood, L., Buchwach, D. & Dieckmann, N.F. (2015). Reducing incivility in the workplace: Results of a three-part educational intervention. The Journal of Continuing Education in Nursing, 46(1), 15–24.
- McLeroy, K.R., Bibeau, D., Steckler, A. & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4):351–377.
- Moch, S.D., Vandenbark, R.T., Pehler, S. & Stombaugh, A. (2016). Use of action research in nursing education. Nursing Research and Practice, 2016(8749167). doi:10.1155/2016/8749167 [CrossRef]
- PACERS©. (2015). Civility tool-kit: Resources to empower healthcare leaders to identify, intervene, and prevent workplace bullying. Retrieved from http://stopbullyingtoolkit.org/
- Porath, C. (2016, May24). How incivility shuts down our brains at work [Video file]. Retrieved from https://www.youtube.com/watch?v=AoT-nmSdAOs
- Rawlins, L. (2017). Faculty and student incivility in undergraduate nursing education: An integrative review. Journal of Nursing Education, 56(12), 709–716.
- Sanner-Stiehr, E. (2018). Responding to disruptive behaviors in nursing: A longitudinal, quasi-experimental investigation of training for nursing students. Nurse Education Today, 68, 105–111.
- Sperstad, R., Pehler, S.R., Ackerson, S., Brunsell, K., Gyorog, E. & Sisto, H. (2020). Student voices during Action Research impact outcomes in nursing quality improvement project. Journal of Nursing Education, 59(1), 42–45.
- Ulrich, D.L., Gillespie, G.L., Boesch, M.C., Bateman, K.M. & Grubb, P.L. (2017). Reflective responses following a role-play simulation of nurse bullying. Nursing Education Perspectives, 38(4), 203–205.
- Worrell, J.D., McGinn, A., Black, E., Holloway, N. & Ney, P. (1996). The RN-BSN student: Developing a model of empowerment. Journal of Nursing Education, 35(3), 127–130.