Civility, the respectful behaviors that contribute to positive interpersonal interactions and social engagement (Sauer et al., 2017), is crucial to safe and effective patient care (The Joint Commission, 2016). Incivility, the disrespectful or disruptive behaviors that can cause physiological or psychological distress (Babenko-Mould & Laschinger, 2014), may jeopardize patient care, increase health care costs, and reduce employee satisfaction (The Joint Commission 2008).
Civility in nursing education is the compilation of language, communication techniques, and actions that positively influence student-to-student and student-to-educator relationships (Woodworth, 2016). Educators contribute to healthier academic environments by teaching students to recognize and mitigate the effects of incivility (Babenko-Mould & Laschinger, 2014; Clark, 2017) and by modelling professional behaviors for students to emulate (Woodworth, 2016).
Semi-virtual reality simulation (SVRS) is a technique that allows students to actively participate in a two-dimensional computerized world (Cooper et al., 2015; Green et al., 2014), in which they may observe the actions of others and engage in professional role-play (Tschannen et al., 2012). SVRS provides students with meaningful, authentic learning experiences in a low-stress environment that is free of negative repercussions for patients (Green et al., 2014; Tschannen et al., 2012). In an attempt to utilize SVRS to promote civility in nursing, we developed a civility-related active learning intervention (C-RALI) to raise students' awareness of civility and incivility.
Innovative Education Strategy
As nurse educators who have conducted civility-related research and incorporated the results into our teaching, we developed the innovative C-RALI to raise senior-level baccalaureate nursing students' awareness of civility and incivility. The C-RALI was based on an extensive review of the literature related to civility, incivility, and simulation in nursing education. Although nursing programs are incorporating more computer technology into student-focused learning activities (Caylor et al., 2015; Thompson & George, 2016), we found no literature describing educators' experiences in developing and implementing SVRS interventions related to civility. We designed the C-RALI to teach nursing students civil communication in professional practice. Our intervention consisted of three phases: a faculty-led discussion, an asynchronous C-RALI experience, and, finally, a web-conferenced C-RALI debriefing.
After receiving approval from course faculty, we presented our intervention to the students. In the first phase of the intervention, we led a 30-minute, face-to-face discussion on civility. Students discussed their perceptions of civility and incivility, the importance of civility in professional communication, and how to recognize and manage incivility. The first half of the discussion addressed Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™), a program developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), to improve teamwork through effective and professional communication (AHRQ, 2016). We discussed four specific TeamSTEPPS communication strategies: Situation-Background-Assessment-Recommendation (SBAR), call-out, check-back, and hand-off (AHRQ, 2016). Students practiced SBAR, a standardized framework for effective communication, by providing pertinent background and critical assessment findings on a fictional patient and verbalizing their recommendations or requests. Unlike SBAR, which is used during daily practice, call-out is a technique designed for communicating critical information during an emergent event; it assists caregivers in anticipating the next steps during a crisis situation (AHRQ, 2016). The check-back involves health care providers verifying information with each other to ensure that the relay of information from person to person is accurate (AHRQ, 2016). The final technique, hand-off, is performed during the transition of care and provides for the accurate provision of pertinent patient information in order to mitigate ambiguity (AHRQ, 2016). During the second half of the discussion, we provided students with techniques for addressing incivility, including positive self-talk, defusing negativity, maintaining healthy boundaries, and continually showing kindness to others (Clark, 2017). Students were encouraged to be empathetic listeners, maintain a positive attitude, show respect for others, and disagree graciously (Clark, 2017).
Civility-Related Asynchronous SVRS
Given that SVRS had not yet been used to enhance students' awareness of civility and incivility, our options were limited. Time and budgetary constraints prevented the development of our own SVRS program. Instead, we looked for existing programs that complemented the discussion portion of our intervention and were interactive, easy to navigate, affordable, and accessible outside the classroom. We eliminated the three most popular advanced simulation learning platforms described in the nursing literature: Virtual Heroes®, VSim®, and Second Life®. These platforms were either too expensive, costing $99.95 to $518.85 per student (Laerdal Medical & Wolters Kluwer Medical, 2019), or too difficult to navigate.
Because we were experienced with using nurse-based, interactive, computer tablet applications to enhance students' clinical education, we decided to investigate this option. We found no applications portraying incivility. Those applications that demonstrated civil behavior ranged from free to $26.99 per student. We chose VNurse Lite version 1.0.1 (Morsi, 2012) because it modeled professional communication and behaviors, thereby potentially enhancing students' civility.
Set in a virtual hospital, the free application VNurse Lite version 1.0.1 (Morsi, 2012) took 10 minutes to complete and allowed users to observe professional, civil interactions. The day after the faculty-led discussion, we emailed students instructions on accessing, downloading, and using VNurse Lite. Three computer tablets with the SVRS application were placed on loan in the college library for those students who did not own tablets. At the onset of the program, students created nurse avatars, completed the orientation to the application, and activated an orthopedic patient scenario. As their nurse avatars, the students received TeamSTEPPS (AHRQ, 2016) hand-off report on an elderly patient who had sustained a hip fracture. They completed the patient's assessment and medication reconciliation and used SBAR to notify the attending physician about the patient's condition.
As simulation moves into the virtual world, webconferencing is becoming increasingly useful as a means for debriefing (Gordon, 2017). Debriefing allows faculty to reframe the simulated scenario, facilitate reflection, evaluate learning, enhance future performance (Gordon, 2017), and heighten self-awareness (International Nursing Association for Clinical Simulation and Learning [INACSL] Standards Committee, 2016). Our goal was to facilitate web-conferenced debriefing to enhance students' awareness of civility and incivility.
We developed the following open-ended questions to encourage group discussion:
- What civil behaviors and communication techniques did you observe that will be useful to you as a practicing nurse?
- How did the scenario influence how you will interact with others in the future?
- Did you observe any behaviors or communication techniques that will help you confront incivility in the future?
Students could choose one of six 30-minute, online Skype™ debriefing sessions. Ideally, debriefing should occur immediately after the simulation (INACSL, 2016), but because students were allowed to complete their simulated scenario at their convenience, this was not possible. Instead, our goal was to have the students join one debriefing session within 1 week of participating in the simulated scenario. Each session was limited to 10 participants to promote active engagement (INACSL, 2016).
The C-RALI provided a risk-free environment that enhanced student learning and provided them with a realistic interpretation of professional practice. The students' survey data and narrative responses to the open-ended question “How has the C-RALI influenced your awareness of civility and incivility?” demonstrated that the intervention increased their awareness of civility and incivility. At the completion of the C-RALI, students said they were more aware of the importance of civility and the dangers of incivility in nursing. Students also said they were more likely to intervene when they witnessed acts of incivility. A detailed report of our findings is described elsewhere. Given that the C-RALI did promote civility among nursing students, we offer the following recommendations for nurse educators who wish to replicate this intervention.
Managing the Technology
Decide what you want students to learn before you begin to search for an SVRS application. By determining essential criteria in advance, we were able to be more focused and efficient in our search. After desired content is determined and the search is initiated, plan to dedicate a significant amount of time analyzing potential SVRS scenarios for ease of use and cost. To simplify your search, use terms relevant to your teaching goals and objectives. Avoid using broad or ambiguous terms; they will produce too many applications for review. The price and accessibility of computer tablet applications vary, but we found them to be a more economical choice than other popular advanced simulation learning platforms.
Verify that the program you choose is compatible with newer editions of computer tablets by reviewing the application's technical requirements. If the developer has not recently updated the application, it will not work on newer editions of computer tablets. Because we wanted a scenario that depicted civility and professional communication, our options were limited. After we chose VNurse Lite, we discovered it was not compatible with the newer editions of computer tablets currently on the market. We purchased refurbished computer tablets that ranged in price from $100 to $400, depending on the brand and edition.
Consider providing your students with earphones to minimize extraneous noise. Students who did not own a computer tablet used one of the three we provided on loan at the college library. However, simulated scenarios may be too noisy for use in a college library. To be respectful to other students using the library to study, we addressed extraneous noise produced by the C-RALI by providing earphones. We recommend supplying disposable, single-user earphones, which can be purchased online at a reasonable cost.
Debriefing after simulation enhances students' learning while heightening their self-awareness (INACSL, 2016). In our case, some students failed to log in for the synchronous, webconferenced, debriefing sessions. We did not make the debriefing a mandatory part of the C-RALI because the intervention itself was voluntary. The lack of participation in debriefing may have negatively affected the effectiveness of this learning intervention. In retrospect, although participation in this intervention was voluntary, we should have required those students who elected to participate in the C-RALI to also complete a debriefing session.
The effectiveness of debriefing sessions may also have been affected by the asynchronous nature of our intervention. The time frame for students to complete the C-RALI scenario ranged from 1 to 5 weeks, so it was not possible to schedule debriefing sessions immediately afterward. In retrospect, we should have set a due date for completing the scenario and scheduled debriefing for within 1 to 2 days after completion of the scenario, so the experience remained fresh in students' minds. If it is necessary to conduct debriefing several days or weeks after the intervention, educators may consider asking students to write a self-reflective post immediately following completion of the scenario (Gordon, 2017). Students could be provided with prompts to guide their reflection—for example, asking students to think about their own past experiences with civility and incivility or to discuss feelings provoked by participation in the scenario.
We also scheduled debriefing sessions for evenings to minimize conflict with students' course schedules. This may have been counterproductive, in that students told us they were fatigued in the evening and therefore less likely to participate. In the future, we will make every effort to find a time earlier in the day that is convenient for students.
Because our students' experience with simulation debriefing was limited to face-to-face interactions, they were unfamiliar with a web-conferencing format. Based on our experience, we suggest that educators explain why debriefing is essential to learning. Many students do not understand that debriefing is vital for the development of knowledge and professional growth (INACSL, 2016). Given that this was a new experience for students, we asked their opinions as to the value of web-conferenced debriefing. Students asserted that the anonymity of the process made them more comfortable in sharing personal experiences than they would have been in a face-to-face interaction.