barriers to civility paper
TRANSCRIPT
Running head: BARRIERS TO CIVILITY 1
Barriers to Civility:
Increasing Awareness, Improving Outcomes
Jenny D. Erkfitz
Aspen University
BARRIERS TO CIVILITY 2
Table of Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Significance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Research Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Concept Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Literature Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Incivility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Workplace Incivility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Incivility in Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Incivility in Nursing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Incivility is Serious. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Promoting Civility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Simulation in Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Education in an Online Format. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Theoretical Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Educational Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Goals and Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Instructional Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Instructional Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Learner and Context Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
BARRIERS TO CIVILITY 3
Performance Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Teaching Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Teaching and Learning Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Instructional Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Components of the Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Pre-course Assignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Didactic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Simulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Debriefing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Evaluation Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Course Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Learner Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Discussion of Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Appendix I – Summary of Research Articles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Appendix II – Dick and Carey‟s Systems Approach Model. . . . . . . . . . . . . . . . . . . . 86
Appendix III – Bloom‟s Taxonomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Appendix IV – New Bloom‟s Image. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Appendix V – Course Syllabus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Appendix VI – Learner Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Appendix VII – Teaching Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Appendix VIII – Pre-Instructional Course Materials. . . . . . . . . . . . . . . . . . . . . . . . 96
Appendix IX – Didactic Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
BARRIERS TO CIVILITY 4
Appendix X – Exam Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Appendix XI – Answers to Exam Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Appendix XII – NLN/Jeffries Simulation Framework . . . . . . . . . . . . . . . . . . . . . . 158
Appendix XIII – Written Outline of Simulation Exercises . . . . . . . . . . . . . . . . . . . 159
Appendix XIV – Debriefing Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Appendix XV – Evaluation Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Appendix XVI – Evaluation Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
BARRIERS TO CIVILITY 5
Abstract
Incidents of incivility in nursing are costly and can result in harm to patients. Even
though nursing is known as a „caring‟ profession, incivility abounds. Therefore,
preventing incivility should be a priority for healthcare organizations. Providing
new nurses and nursing students with the knowledge, skills, and confidence to
overcome incidents of incivility is one step towards a culture of civility and a move
towards more positive patient outcomes. A teaching plan was developed for a
course for asynchronous online delivery over four weeks. The course includes pre-
course assignments, didactic to be delivered via a recorded lecture and slides, an
examination to ensure objectives were achieved after the didactic, a simulation, and
two discussion board debriefing assignments. The teaching plan was evaluated by a
nurse educator working in a multiple-hospital network in central Indiana. Changes
were made to the plan to reflect data received from this qualitative evaluation.
Keywords: incivility, horizontal violence, lateral violence, disruptive behavior,
online simulation
BARRIERS TO CIVILITY 6
Barriers to Civility: Increasing Awareness, Improving Outcomes
Introduction
The foundation of nursing is the principle of caring (Watson, 1994). This is a
widely recognized fact, and one reason why the public view of the profession of
nursing is high. The professional nurse is also held accountable to a code of ethical
standards. The American Nurses Association (ANA) charges nurses to extend these
compassionate and caring relationships to colleagues (AANA, 2007). Indeed, nurses
are to treat others, including colleagues, fairly and with respect. The Code of Ethics
as established by the ANA prohibits harassment, any type of behavior that could be
deemed threatening, and disregard for others (AANA, 2007; Clark & Carnosso,
2008). However, this atmosphere of civility and respect does not always exist.
Background
This project is designed to educate nursing students and new nursing
graduates regarding incivility in nursing. The objective is to raise awareness of the
problem, sharpen coping skills, develop new skills for managing incidents of
incivility, and assist individuals to ensure they are part of the solution and not part
of the problem. Although the education is currently aimed at nursing students and
new graduates, nurses at all levels would benefit from this education.
Multiple current research studies have demonstrated the value of simulation
in nursing education. Therefore, simulation will be incorporated into this project.
Students will have the opportunity to experience firsthand how the decisions they
make impact civility on the nursing unit. Simulation will give students experience
BARRIERS TO CIVILITY 7
in diffusing incivility and provide them with both the skills and confidence to
effectively manage incivility in the workplace.
Significance
Approximately 55% of the nursing workforce today will retire by 2020 (Long,
2011). At today‟s rates of new nurses entering the profession that leaves a
substantial shortage. The profession of nursing perpetuates the nursing shortage
through bullying and incivility. Many new nurses become disillusioned, and even
choose to leave the profession. This could cause the nursing shortage to become an
even greater crisis, and lower the perception of the nursing field in the eyes of the
public.
Another reason for addressing the issue of incivility has to do with the cost of
such behavior to healthcare organizations. Pearson and Porath (2009) estimate the
annual cost of incivility in healthcare organizations to be about $300 billion.
However, the true total cost cannot really be estimated because there is much more
involved than out-of-pocket expenses, and it is impossible to estimate the damage to
staff and team morale. The toxic environment created by incivility results in loss of
productivity, stress and burnout, turnover of valuable experienced employees,
absenteeism, and damage to the reputation of the organization.
Increasing awareness of incivility will result in a move towards improved
patient outcomes. There have sentinel events directly related to violence and
incivility in health care settings each year between 2008 and 2010 (Joint
Commission, 2008, 2009, 2010; Center, 2011). Therefore, a culture of civility is
BARRIERS TO CIVILITY 8
essential to improving patient outcomes and healthcare as a whole. Organizational
cultures must change to reflect the appropriate acceptable and unacceptable
behaviors in a culture of civility. A light must be shined on incivility to increase
awareness of it and begin to root it out of healthcare organizations. Nurses must
come together to protect both patients and colleagues from the damaging effects of
incivility.
Purpose
It is essential to put an end to uncivil behavior when it first begins to rear its
head not once the pattern of incivility has been ingrained. Prevention efforts will
help to preserve the professionalism of nursing and ensure a safe practice
environment for future graduates. As new nurses experience a more nurturing
environment, their positive perception of nursing as a career will be reinforced,
making it more likely that they will remain in the field of nursing. This will help
alleviate the staffing issues caused by the nursing shortage. In turn, with fewer
staffing shortages, there will be less stress on nurses. This will lead to greater
civility. Thus, a positive circle of increased teamwork and respect on the nursing
unit is created.
Finally, and possibly the most important reason for this project is to provide
nurses with the skills necessary to manage incidents of incivility and promote
civility in the nursing unit. This will help move towards improved patient outcomes
as the unit functions as a team for the benefit of the patients. Therefore, the
purpose of this educational project is to begin a move towards improved patient
BARRIERS TO CIVILITY 9
outcomes by increasingawareness of incivility, providing nurses with the skills
necessary to diffuse incivility, and giving individuals the knowledge to assess
whether they are part of the solution or part of the problem.
Research Design
Outcomes research is an appropriate design for this project (Burns & Grove,
2005). This type of research focuses on the end result of patient care, the patient
outcomes, which must be clearly linked to processes. Identifying these outcomes
requires communication between patients and caregivers, and is time dependent.
Time frame for analyzing outcomes is essential, as some may fade or disappear
altogether over time. Additionally, outcomes must directly relate to the
organization‟s and individual‟s goals.
Utilizing a modified version of outcomes research, the focus of this project is
on the outcome of reducing incidents of incivility or promoting an environment of
civility in healthcare. Communication is essential, and is the central theme of the
teaching plan. To be successful, the desired outcome must be clearly linked to the
student‟s goals. Outcomes are influenced by a number of factors (Burns & Grove,
2005). These factors must be identified through research in the literature. They
must then be considered when developing the teaching plan. This will lead to a
successful educational intervention that will promote an environment of civility.
Concept Analysis
Webster‟s New World College Dictionary defines civility as politic behavior,
politeness, or a polite act or utterance, and carries a degree of formality (Neufeldt,
BARRIERS TO CIVILITY 10
1997). By contrast, incivility is a lack of courtesy or politeness, a rude or
discourteous act. Clark and Carnosso (2008) worked to create an operational
definition of civility, in order to clarify the meaning of the concept and add to the
growing body of literature regarding civility. After an extensive conceptual
analysis, the definition they arrived at was as follows (p. 13):
“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.”
There are also other issues involved in incivility that need to be taken into
consideration when describing the concept of civility. These include cultural issues,
power differences, and the reciprocal nature of incivility (Clark & Carnosso, 2008).
Cultural differences play a role in how incivility is perceived, and often a lack of
cultural awareness complicates the issue and may even be the source of the
disparity. Webster‟s New World College Dictionary defines culture as the ideas,
customs, skills, arts, and other knowledge of a people or group that are transferred,
communicated, or passed along to succeeding generations (Neufeldt, 1997). Culture
is a tradition among some that is deeply ingrained, and may differ greatly from that
of others. Therefore, cultural differences and worldview must be taken into
consideration.
Real or perceived power differences also impact incidences of incivility (Clark
& Carnosso, 2008). Some power differences may be due to an individual‟s long-held
BARRIERS TO CIVILITY 11
discriminations such as racism or sexism. However, some differences in power and
rank may truly exist. The real issue is when these differences are abused to create
a disadvantage to another individual, and thus incivility.
Incidents of incivility also breed incivility (Clark & Carnosso, 2008). When
one individual begins uncivil behavior, the victim may very well respond in kind.
The situation escalates and may quickly turn into a crisis. Disrespect and blame
become the focus, and communication breaks down.
It must be noted that incivility is perceptual, based on the view of an
individual. Therefore, when considering the definition of civility, it is important to
take into consideration these other issues (culture, power differences, and reciprocal
incidents) that impact perception. What one individual perceives as incivility may
be viewed by another individual as normal civil behavior, or „blowing off steam.‟
However, applying respect for the other person and the principle of caring will
certainly help to delineate what is truly civil behavior.
Education can help promote an environment of civility within the nursing
workplace by increasing awareness of behaviors that could be perceived as uncivil.
By giving nurses the tools necessary for self-examination, they will be able to
determine if they are a part of the problem of incivility or a part of the solution. In
turn, they will be able to change behaviors to promote civility and strengthen
relationships with peers. This will lead to increased teamwork, a healthier work
environment, and a step towards improving patient outcomes.
BARRIERS TO CIVILITY 12
Literature Review
A literature review was conducted utilizing ProQuest, Ovid,and ERIC
database searches for key words. The literature search was then broken down and
categorized into articles involving workplace incivility, incivility in nursing and
nursing education, simulation in education, and education in an online format.
Each of these topics was deemed essential to review for the validity and framework
of this project.
Incivility
Workplace Incivility
Workplace incivility is also called horizontal violence, disruptive behavior,
discourtesy, and bullying in the literature. It carries a substantial impact on
workers. One in five Americans has an anger management problem, and over two
million workers are the victim of incivility annually (Tunajek, 2007). This leads to
annual cost of $4.2 billion to organizations. In one hospital, the loss of productivity
caused by incivility was determined to cost $1.2 million each year (Hutton & Gates,
2008).
A recent qualitative study examined the impact workplace incivility has on
the organization, on the victims, and on the bullies themselves (Georgakopoulos,
Wilkin, & Kent, 2011). The participants perceived 251 problems which were then
grouped into ten categories. The top category was negative outcomes, and included
items such as negative financial outcomes (legal actions by employees and employee
turnover), unsafe environment, and negative organizational climate (disrupted
BARRIERS TO CIVILITY 13
workplace, lack of respect). Perceived impact to the victim included sustained
injury, physical trauma, damaged self-esteem, feelings of isolation and helplessness,
stress from workplace carried home.
The second phase of this study examined root causes of bullying
(Georgakopoulos, Wilkin, & Kent, 2011). There were 142 root causes identified,
broken down into 10 major categories. Perception and awareness were discussed as
reasons why an individual may be uncivil without even realizing it. Other root
causes included discrimination, organizational culture (never reprimanded for the
behavior), policy and procedures (not addressing the behavior), education and
training (lack of proper training), power (misuse of power and lack of checks and
balances). Finally, the participants developed solutions for the perceived problems.
Of respondents to one survey in 2011, over half reported they had heard of
one to five incidents of workplace incivility in a six month time period (Dobson,
2011). Nineteen percent had heard of six to ten such complaints during the same
time frame. The same report linked perceptions of incivility to an individual‟s self-
esteem, meaning that if an individual suffers from low self-esteem he or she may be
more likely to view an incident as hurtful or uncivil behavior.
The same Canadian survey also found that respondents felt incivility has a
greater impact on productivity than absenteeism, talent retention, or customer
service (Bar-David, 2011). The risk to organizations is clear as over half of those
surveyed felt incivility can even damage the brand‟s reputation. It could easily be
thought that organizations would quickly work to ensure their human resources
BARRIERS TO CIVILITY 14
employees have all the tools necessary to stop incidents of incivility. However, most
of those surveyed felt their organization‟s management did not fully recognize the
impact incivility has on productivity, and 77% did not feel they had the knowledge
or tools to deal with incivility properly.
A recent qualitative study of workplace bulling used content analysis to find
themes in 67 written stories of bullying (Gumbus & Lyons, 2011). Tactics in these
stories included verbal humiliation (including email), instilling fear, public
embarrassment, inappropriate use of power, work related retaliation, and physical
behaviors. While only 16% of these victims complained to human resources, 42%
left the organization where the bullying occurred. These results demonstrate the
need for an organizational policy to address workplace values and a zero tolerance
policy when it comes to incivility.
Owens (2012, p. 33) describes workplace incivility as “low-intensity deviant
behavior with ambiguous intent to harm the target.” This behavior can take many
forms, from dirty looks and condescending comments to being disruptive or time-
consuming at meetings. The stresses caused by workplace incivility add up until
they begin to affect organizational commitment, job performance, and turnover and
retention. The author encourages organizations to screen personality styles and
management styles during interviewing to ensure good fit. Additionally, strong
organizational policies and codes of conduct can foster respect.
An extensive study of workplace incivility supported the claim that it erodes
the very foundation of strong organizations (Pearson & Porath, 2005). The authors
BARRIERS TO CIVILITY 15
found that as incidents of incivility increase, employees begin to decrease their work
effort, time on the job, productivity, and performance. Left unresolved, job
satisfaction and organizational loyalty are also damaged. Some employees may
leave simply because of workplace incivility. However, many organizations
continue to be unaware of these consequences.
Looking at incivility from a legal standpoint, isolated incidents may not be a
violation of law. However, a pattern of such behavior is unlawful (AANA, 2007).
Legal precedence has been established. Employers can be held liable if it can be
proven they were aware of the pattern of behavior and took no actions to end it or
prevent it. Therefore, healthcare institutions should be very concerned with this
issue and provide education to their employees to help alleviate or prevent the
problem.
Direct costs of incivility and workplace bullying to organizations includes
litigation fees, early retirement pay-outs, long-term absenteeism, and worker‟s
compensation and counseling costs (Bond, Tuckey, & Dollard, 2010). However,
indirect costs can mount up as well. These include damaged employee morale, loss
of productivity and motivation, increased absenteeism, and employee turnover. For
this reason, chronic incivility is an organizational crisis. An organizational crisis is
some type of disruption that undermines and challenges employee opinions and
views of the organization for which they work and poses a threat to the survival of
an organization (Carmeli, 2008). Workplace violence certainly fits within this
definition.
BARRIERS TO CIVILITY 16
Workplace incivility becomes especially concerning in light of the results of
one study that found that incidents of workplace bullying trigger symptoms of
posttraumatic stress (Bond, Tuckey, & Dollard, 2010). Symptoms of posttraumatic
stress usually include three clusters of symptoms. The first cluster is intrusions,
such as flashbacks, nightmares, and intrusive thoughts. The second cluster
includes avoidance of people, places, objects, and thoughts associated with the
traumatic event. The third cluster is physiological and psychological hyper-arousal.
Usually these symptoms occur after a single traumatic event when the individual is
exposed to a threat to their physical integrity. However recent research suggests
prolonged exposure to recurrent negative events, such as workplace bullying, can
also trigger these three clusters of symptoms.
One recent study was the first to reveal a correlation between certain social
competencies and the likelihood of an individual to become abusive when faced with
interpersonal conflict (Kisamore, et al., 2010). Specifically, individuals who are
politically skilled or are highly self-monitored may be more likely to abuse others at
work when personally faced with interpersonal conflict. These behaviors are
generally considered to be positive attributes for employees. However, as this study
demonstrates, there is a need for organizations to address conflict management
skills and workplace civility.
Incivility in Nursing
Nursing is a caring profession. It is built on the caring theories of such
individuals as Florence Nightingale and Jean Watson. One might think incivility
BARRIERS TO CIVILITY 17
could not occur in a profession with caring as a foundation. Yet, a recent study
found that 70% of nurses in the United States report being bullied at work (Vassey,
et al., 2009). Incivility impacts both retention of bedside nurses and patient safety
(Broome & Williams-Evans, 2011). Therefore, incivility is a serious concern for the
profession of nursing. The victims of incivility have symptoms, both psychological
and physical, of increased stress. Mental and physical stress impacts an
individual‟s decision to leave a job or even leave the profession of nursing. There
have even been reports of suicide among nurses who have experienced high stress
levels at work (Hastie, 1996).
Nurses themselves must deal with burnout, frustration, increased job stress
and decreased job satisfaction that lead to absenteeism (McNamara, 2012). Nurses
may suffer from physical symptoms such as weight fluctuations, cardiac
palpitations, headaches, hypertension, sleep disorders, and fatigue. They may also
suffer from psychological symptoms of anxiety, depression, insecurity, low self-
esteem, substance abuse, and suicidal or homicidal thoughts. Nurses may even
suffer from posttraumatic stress disorder stemming from incidences of incivility
from colleagues or others.
According to the United States Bureau of Labor Statistics, those who work in
healthcare and social assistance are five times more likely to be the victim of an
assault or violent act than average workers in all the other industries combined
(Bowen, Privitera, & Bowie, 2011). It is important to not simply focus on the
individuals who are „bad apples,‟ when there is a very real possibility that the
BARRIERS TO CIVILITY 18
organization itself may be a „bad barrel.‟ Organizations with oppressive or violent
climates may trigger violence by staff, patients, or others. As already noted, there
are various levels of workplace violence and incivility, ranging from intent to harm
another to behavior that is rude, discourteous, and displays a lack of regard for
others. It has recently been calculated that lost productivity due to incivility may
cost an organization $11,581 per nurse (Lewis & Malecha, 2011).
In the spring of 2011, a survey went out to identify the frequency with which
nurses experience horizontal violence, or incidents of incivility (Dumont, et al.,
2012). Of the 950 respondents the overall frequency was determined to be more
than monthly. The most frequent uncivil behavior was complaining about someone
to other, closely followed by eye-rolling. Rounding out the top five behaviors were
pretending not to notice someone struggling, belittling in front of others, and
harshly criticizing. In fact, 82% of the respondents reported experiencing or
witnessing these behaviors weekly or daily. The personal effects of these behaviors
included feeling discouraged due to of a lack of positive feedback, leaving work
feeling bad about interactions with coworkers, not speaking up for fear of
retaliation, physical symptoms (inability to sleep, headaches, abdominal pain), and
not asking questions for fear of ridicule. Nurse peers were the most frequent
perpetrators of incivility, followed by nurse supervisors, and then unlicensed
assistive personnel and physicians.
Incivility in nursing finds its roots in a number of places. It can come from
patients, physicians, supervisors, and, as noted by the saying that nurses eat their
BARRIERS TO CIVILITY 19
young, it comes from colleagues (AANA, 2007). Disruptive behavior impacts not
only the nurse it is directed at, but also the quality of care provided by the nursing
unit and thus patient safety (Tunajek, 2007).
Tunajek (2007) described disruptive behavior as any inappropriate or hostile
behavior, including confrontations, conflict, rude or angry language, facial
expressions, threatening manners, and physical abuse. Incivility, therefore, can be
expressed verbally, nonverbally, or in both manners. Other types of incivility
include harmful words, actions, or attitudes, lack of respect, and any behavior that
humiliates, denigrates, or injures the dignity of another individual. It includes acts
of unkindness, discourtesy, sabotage, lack of cohesiveness, and unconstructive
criticism. Left unaddressed, the victim may suffer loss of self-esteem and serious
stress-related illnesses.
Of respondents to one recent survey, 27.3% reported being victims of
workplace incivility or bullying in the prior six months (Johnson & Rea, 2009). This
same study found incidents of incivility were highly positively correlated with an
individual‟s intent to leave their job or even the field of nursing. Interestingly, this
study found that incidents of incivility occurred among nurses who were highly
experienced and educated, rather than new nurses or nursing students. This
suggests that incivility is a problem across the career, rather than only at the
beginning.
In an editorial in Nursing Management a description of how to identify a
victim of bullying is given (Hader, 2009). This is important because often a victim
BARRIERS TO CIVILITY 20
of bullying and incivility will not report the issue, but will begin looking for work
elsewhere. To help with retention of valuable staff members, managers should be
alert to these indicators and step in to resolve the issue. Indicators of victimization
include a high rate of absenteeism, disinterest in the organization, displaying signs
of stress, and overall loss of productivity. It is also important to plan well for a
discussion with this staff member because the manager needs to create a sense of
trust and empathy. Once the staff member reports the incivility, the manager must
balance being supportive of the victim with remaining objective until the
investigation is complete. Nurse leaders should encourage their staff to report
incidents of incivility immediately, and should be role models in promoting an
environment of civility.
Nurses and patients are not the only ones hurt by incivility in nursing.
Johnston (2009) warns that organizations who do not address this issue and take
measures to prevent it will suffer from the effects of a toxic work environment.
Factors that foster bullying and incivility in a nursing workplace include
occupational stress, lack of leadership, and oppression. The theory behind
oppression as a cause of bullying in nursing is that nursing is an oppressed
discipline with a very strict hierarchy (Leiper, 2005). Those who are at or near the
bottom of the hierarchy feel the oppression the most, so they take out their tensions
on inferiors through bullying. New nurses and students are easy targets because of
their insecurity and dependence upon other staff members (Johnston, 2009). As
BARRIERS TO CIVILITY 21
they internalize the bullying, these behaviors create a norm, and they, in turn bully
others.
Even witnesses to incivility are affected (Johnston, 2009). Those who witness
incidents of incivility and are moved to feel pity for the victim face increased stress
levels, fear of taking action and becoming a target themselves, and some may even
change jobs to get out of the situation. Thus, incivility increases organizational
costs for retention and recruitment even if it is a witnessed event.
The authors of a recent article sought to explain why bullying occurs in
nursing by creating a model (Hutchinson, et al., 2008). Their model includes
organizational antecedents such as organizational tolerance and reward, informal
organizational alliance, and misuse of legitimate authority, processes, and
procedures that come together to foster bullying acts. These bullying acts could be
in the form of a personal attack, an attack upon one‟s reputation and competence,
and/or an attack through work tasks. The consequences of these bullying acts are
normalization of bullying in work teams, distress and avoidance at work, health
effects, and interruption to work and career.
The effect of incivility on patient outcomes is not always clearly evident
(Johnston, 2009). Since quality nursing requires teamwork and bad behaviors
break down teams, incivility does impact patient outcomes even if it is not clearly
evident. When nurses become dissatisfied either with their job or their work
environment, they do not fully engage in their work or may not show up for work at
all. This leads to an unstable and disengaged workforce which creates poor patient
BARRIERS TO CIVILITY 22
care conditions. It is in these poor conditions that patient outcomes are
compromised. Therefore, maintaining civil work environments in health care is an
essential step towards improving patient outcomes.
Incivility in Nursing Education
Incivility does not simply start in the healthcare workplace. Rather, it is a
pattern that is present even in educational settings. A small, recent study
discovered that incivility from staff nurses directed at students in clinical settings
does occur, but positive experiences are far more frequent (Anthony & Yastik,
2011). However, despite the difference in frequency, the impact is significant.
Students experienced a loss of self-confidence and were left with a negative attitude
towards nursing as a career. This same study recommended utilization of
simulation to address workplace incivility and development of conflict resolution
skills.
A large study determined students recognize incivility in the classroom from
other classmates (Bjorklund & Rehling, 2010). The students in this study perceived
mid-level incivility from classmates on a regular basis. This would include texting
during class, eating or drinking during class, displaying inattentive posture,
packing up to leave class early, using technology for non-class activities, arriving
late and/or leaving early, fidgeting that distracts others, and getting up leaving and
returning during class. The authors recommend directly addressing at least the top
five uncivil behaviors that disrupt class, allowing a cell phone to ring; using a Palm
BARRIERS TO CIVILITY 23
Pilot, iPod, or computer for non-class activities; arriving late or leaving early;
packing up books before class is over; and text messaging during class.
Victims of incivility in nursing education are not limited to students.
Incivility has been noted in all modalities of educational delivery, in the classroom,
in the clinical settings, and online (Suplee, Lachman, Siebart, & Anselmi, 2008).
Students are not only victims; they are also the perpetrators of incivility. Student
incivility includes breaches of common rules of courtesy, such as inattentiveness in
class, arriving late, leaving early, yelling by students, and even physical contact
(Lashley & deMenses, 2001). This behavior results in disruptions in the learning
environment for the other students (Luparell, 2007). It also impacts faculty
through loss of self-esteem and confidence, time expenditure, and both a physical
and emotional toll.
Incivility is not limited to face-to-face educational programs. Rude, impolite,
or unkind conversations occur in online educational settings, stunting the
development of social presence and connectedness. Rieck and Crouch (2007) found
that 35% of students encountered incivility from peers and 60% reported incivility
from instructors. Communication perceived as rude is a big part of incivility in an
online setting. The authors suggested addressing the behavior privately,
establishing netiquette guidelines, and defining rude behavior to make everyone
more aware of incivility.
Clark and Springer (2007) researched the behaviors interpreted as uncivil,
both from the student and faculty point of view. Faculty perceived uncivil student
BARRIERS TO CIVILITY 24
behaviors to include disapproving groans, sarcastic remarks or gestures,
dominating class discussions, using cell phones during class, cheating on
examinations, and not paying attention in class. Students also perceived some
behaviors by faculty as being uncivil. These included cancelling class without
warning, being unprepared, not allowing open discussion, being disinterested or
cold, belittling students, delivering fast-paced lectures, and not being available
outside of class.
While faculty who participated in the study viewed incivility as a rare
problem, student participants felt it was a moderate problem (Clark & Springer,
2007). However, over 70% of respondents felt that incivility in academia in general
is a moderate or serious problem. This underscores the need to address incivility at
the nursing education level, prior to the workplace.
There are a number of ways a nurse educator can prevent incivility in the
classroom, ingraining civil behaviors and ultimately positively impacting the
workplace. Griffin (2004) encourages nurse educators to raise awareness about the
existence of incivility and the dangers such behavior presents. Teaching students to
ask questions and address the problem behaviors can do much in reducing the
incidence and effects of incivility.
Clark and Ahten (2012) place classroom incivility on a continuum, with the
far left including annoying and irritating disruptive behaviors, such as rude
comments and eye-rolling. As one moves further to the right, the behavior escalates
into bullying, intimidation, and psychological abuse. The far right is reserved for
BARRIERS TO CIVILITY 25
threatening and potentially violent behavior. It is essential to stop the behavior
from escalating, while it is still on the far left side of the continuum. Meaningful
conversations with students can do much to accomplish this goal.
Some faculty may hesitate to address behaviors that seen merely as annoying
(Clark & Ahten, 2012). First, the faculty member must recognize the behavior as a
form of incivility, and then prepare him or herself to address the behavior.
Consider the worst-case scenario and best-case scenario outcomes. Addressing the
problem is most likely well worth the effort. Next, the faculty member should
consider potential barriers to the conversation. Then, approach the student,
choosing a mutually appropriate time and place. During the conversation, attention
should be placed on the interest of learning, and not who is right or wrong.
Academic nurse leaders (deans, directors, and chairpersons) play a major role
in both the prevention and addressing of incivility in nursing education (Clark &
Springer, 2010). A study investigating the perceptions of 126 academic nurse
leaders asked five open-ended questions aimed at the stressors of educators and
students, uncivil behaviors exhibited by both, and the role of academic leaders in
incivility. Stressors for both faculty and students were perceived to include heavy
workloads, financial pressures, and lack of support. Recognition of these stressors
by academic nurse leaders is the first step in ending uncivil behaviors.
Organizational support serves to reduce stress and may also increase the coping
abilities of individuals. Suggestions made by academic nurse leaders to reduce
incidents of incivility included role modeling by leaders, gathering information
BARRIERS TO CIVILITY 26
through surveys thus prompting conversations, providing forums for open
discussion for students and faculty, and counseling, coaching, and mentoring.
Indeed, incivility permeates all levels of the nursing profession, from
educational to organizational settings. The ramifications of this behavior are also
felt across the profession. Decreased productivity, decreased morale, and increased
turnover rates impact healthcare organizations significantly (Hutton & Gates, 2008;
McNamara, 2012). Patients are affected by increased distractions and errors
leading to adverse events, impaired quality of care, increased mortality,
compromised patient safety, delays in proper treatment, misdiagnosis,
mistreatment, and pain or prolonged pain (McNamara, 2012).
The literature has clearly demonstrated a link between nursing incivility and
the cost of healthcare, poor patient outcomes, and the increasing nursing shortage.
As noted, the concept of incivility has numerous labels in the literature, including
horizontal violence, disruptive behavior, bullying, and discourtesy.
Incivility is Serious
“She was hurt and embarrassed when he chastised her in front of everyone
saying how she could not even take a message correctly” (Gumbus & Lyons, 2011,
pg. 77). “He used verbal humiliation and character assassination to reprimand my
co-worker for making a tiny mistake with an ad that wasn‟t going to be published
for a week.” “He got in an argument and started screaming and yelling and saying
„stupid women like you are secretaries because you are not smart enough to get a
better job!‟” “He demeaned me, embarrassed other employees in front of each other
BARRIERS TO CIVILITY 27
and customers.” “(He) singles someone out and continues to push them until they
break.” These are a few comments about how incivility in the workplace affects the
feelings of victims and witnesses.
A 50-year-old nurse and grandmother is waiting for shoulder surgery after
being physically assaulted by a patient(Wilson, 2012). But that is not the worst
part of it for her. She is dealing with the psychological after affects as well. The
patient threatened to kill all the staff and their families. When her four-year-old
grandson saw the bruises, it frightened him, so she lied and said she fell. She says,
“I went into nursing to help people, not to get hurt and be threatened. What is
going to happen if I won‟t be able to work?” (Wilson, 2012, p. 1).
One Monday, students were taking a midterm exam at the University of
Arizona College of Nursing, nothing out of the ordinary (CNN, 2002). Except, today
one man had been barred from taking the exam. His response? He showed up
anyway, but with a gun. He killed three professors before shooting himself. One
witness stated, “It was silent while he was shooting our teachers. I was afraid that
I was going to get shot” (CNN, 2002, p. 2).
A 25-year-old midwife is passionate about her work, and works hard to learn
as much as she can (Hastie, 1995). She attends every workshop, and seeks to
influence practice at her organization to improve patient care. However, instead of
the support and encouragement she needed, she faced hostility from her institution
and her management. Criticism and intimidation came in comments such as, „what
would you know, you are only a graduate‟ and „I have been doing it this way for
BARRIERS TO CIVILITY 28
years.‟ Her self-esteem destroyed, she went home after an early shift and ended her
life. She left a suicide note that clearly demonstrated her hopelessness and
frustration. The response from some of her coworkers is disheartening as they
dismissed her feelings saying „there must have been something wrong with her.‟
Promoting Civility
In a study of workplace bullying and symptoms of posttraumatic stress, the
authors concluded that psychosocial workplace climate is directly related to the
occurrence of workplace bullying and can help lessen the impact of bullying on
symptoms of posttraumatic stress (Bond, Tuckey, & Dollard, 2010). Therefore,
attention should be given to establishing a psychosocial climate of safety in the
workplace. The authors posit that organizations with strong psychosocial climates
are committed to the psychological safety and well-being of their employees;
therefore the factors that underpin bullying are unlikely to exist, making incidents
of incivility rare. In contrast, organizations with low psychosocial climates are
conducive to bullying and incivility by creating stressful work conditions. These
organizations are more likely to increase job demands and decrease job resources,
adding to the stress and creating an ideal situation for incivility.
To increase the psychosocial climate of the organization it is essential to
relieve stress on employees and make it clear that incidences of incivility and
bullying will not be tolerated (Bond, Tuckey, & Dollard, 2010). Participative
management styles can do much to create a culture of civility in the workplace.
First, senior management must show support for stress prevention by
BARRIERS TO CIVILITY 29
demonstrating involvement and commitment to the organization. Second, all
individuals in all layers of the organization must be involved in stress prevention.
Third, occupational health and safety issues should be discussed with employees,
unions, and occupational health and safety representatives. All must be involved
and aware of these issues. Finally, the organization must listen to the contributions
of and suggestions from its employees.
In considering a response to workplace incivility and aggression, it is
imperative to first determine the type of aggression (Bowen, Privitera, & Bowie,
2011). Instrumental aggression stems from an internal cue, and its motive is
personal gain. It is premeditated. The perpetrator has low impulsivity and is
usually calm. Actions are typically morally discounted. Reactive aggression is
another form that is common in workplace incivility. This type of aggression stems
from an external cue, and its motive is to escape or harm the stimulant. There is no
premeditation involved with reactive aggression, and impulsivity is high with angry
emotions. Actions are considered to be justified or deserved.
Just as primary prevention has been demonstrated to be more cost effective
than treating symptoms or secondary prevention in medical care, the same is true of
workplace incivility (Bowen, Privitera, & Bowie, 2011). Primary prevention of
workplace incivility means creating a healthy work environment and a healthy
organization. Rather than coercion and punishment, policy and procedures should
incorporate positive practice models. Also, employees should regularly be asked for
their input, such as through quality assurance surveys.
BARRIERS TO CIVILITY 30
De-escalation is a type of secondary prevention (Bowen, Privitera, & Bowie,
2011).A situation has occurred and needs to be handled properly so the symptoms
are resolved. To accomplish this, organizations need to give their employees the
skills to affirm their emotions and choose proper behaviors. Supervisors and
managers should be taught to proactively address these incidents. Finally, tertiary
prevention or intervention becomes necessary when there is an employee that has
become an instigator of workplace incivility. The human resources department
should be involved at this point, and conflict management strategies need to be used
to immediately handle incidents of incivility. Even if termination is warranted,
dignity and respect must be maintained. It is not enough to simply put these steps
into policy and procedure manuals. It is imperative that all employees be given the
skills and confidence to work appropriately through each step. Managers and
supervisors should receive specialized training in de-escalation and conflict
management techniques.
Despite the recognition in the literature of the prevalence and cost, both in
dollars and to employees and patients, of workplace incivility in nursing, the
problem remains. Holding crucial conversations to maintain civility and diffuse
incivility is essential. Yet, less than 10% of nurses and physicians have the
knowledge, skills, and confidence, to hold crucial conversations (American
Association of Critical Care Nurses, 2005). Center (2010) recommends using the
three A‟s of civility to begin the healing process and create a more civil workplace
and profession.
BARRIERS TO CIVILITY 31
The three A‟s of civility are acknowledgment, authentic conversations, and
action (Center, 2010). Acknowledgement means to recognize uncivil behaviors and
identify our role in these behaviors, as perpetrator, victim, or silent witness. The
author outlined eight steps to holding authentic conversations, but these steps must
be learned in safe environments where it is ok to make a mistake. The eight steps
are as follows:
1. Pause, breath, set your intention
2. Invite the „right‟ people – the meeting should be face-to-face, private,
and informal.
3. Express concerns compassionately
4. Ask clarifying questions
5. Listen compassionately
6. Ask more questions
7. Make requests and set an agreement
8. Genuinely acknowledge gratitude
Once the problem of incivility has been acknowledged and employees have
the skills and confidence to hold authentic conversations, it is time to take action
(Bowen, Privitera, & Bowie, 2011). Zero tolerance policies must be put in place to
ensure a fair and just culture. The impact of this action can be determined by
measuring patient safety outcomes, quality, and nurse and patient satisfaction.
More strategies to combat incivility have recently been suggested by Broome
and Williams-Evans (2011). Education is the first step, both of staff nurses and
BARRIERS TO CIVILITY 32
nurse leadership. A strong code of conduct and zero-tolerance policy will assist a
healthcare organization to gain control over incivility. Documentation of events
when they occur is essential to rooting out this problem. Finally, victims must
receive holistic care to ensure they return to normal functioning.
Simulation in Education
Jeffries (2006) points out that simulations can be used to teach facts,
principles, and concepts; assess skill or intervention competency; integrate
technology; and assist students to develop problem-solving and diagnostic reasoning
skills in a safe and nonthreatening environment. This project will utilize
simulation to teach the concepts of effectively managing incidents of incivility. It
will also be utilized to practice these new skills, allowing students to develop
confidence in a safe and nonthreatening environment. Other benefits to simulation
include allowing students the flexibility to practice their skills in a way convenient
to their schedules, getting students more involved in the learning process, and
promoting a higher order of skill sets (Jeffries, 2006).
Burke and Mancuso (2012) recognize that “nurses function in a constant state
of controlled chaos” (p. 544). Utilizing simulation as an active learning strategy
assists students to develop problem-solving and critical thinking skills. Simulation
can incorporate any activities from role play to a high-fidelity manikin. For
simulation to be effective, it must occur in an environment conducive to learning
and must support symbolic coding operations and mastery of new skills. The level
of complexity of the simulation should match the learning objectives of the course.
BARRIERS TO CIVILITY 33
Does simulation assist in knowledge acquisition along with increasing
problem-solving and critical thinking skills? In a study of 104 undergraduate
nursing students, those who participated in high-fidelity simulation scenarios
scored significantly higher on examinations than those who did not participate in
these scenarios (Gates, Parr, & Hughen, 2011). This study utilized a pulmonary
embolism scenario and a gastrointestinal bleed scenario for the high fidelity
simulations. Students who participated in these simulations had an 8% increase in
examination performance over those who did not participate. The results of this
study provide valuable data regarding the use of simulations as a viable substitute
to traditional clinical learning.
Education in an Online Format
Both the nursing shortage and the shortage of nursing faculty have combined
to create what Neuman (2006) describes as a need for redesign, restructuring, and
recognition of the innovation strategies presented through technology. Current
innovations include the use of handheld computers and wireless phones, along with
web-based education, electronic drills and practice, digital hospitals, humanoid
robots, and wireless health-monitoring systems. Distance learning in an online
environment can be enhanced through the use of many innovations. Electronic
games and simulations can be incorporated into education to assist in transmitting
nursing content. Virtual reality and electronic health care can be used for skill
practice and assessment. However, the author also discusses the need for increased
technology to provide universal access. Classroom lectures and dialogues provided
BARRIERS TO CIVILITY 34
electronically increase the ease with which potential students with heavy schedules
can access their courses. Specialty-designed curricula should be developed that will
change the role of the teacher to an educator, mentor, and coach. This makes the
student responsible for learning. Neuman also visualizes customized testing, and
rolling timeframes that would allow students to seamlessly move from one set of
objectives to the next.
Studies have provided much support for distance education provided through
an online format. Some studies have discovered that online education promotes
greater critical thinking skills than its counterpart in face-to-face education (Larson
& Sung, 2008). One study found that improved learning outcomes in online courses
are the result of a higher degree of active participation (Mitchell, et al., 2007). Even
a fear that students ask fewer questions in online learning is unfounded. Dye
(2007) found that students tend to ask more questions when they are online than in
face-to-face classrooms, if the technology is reliable, they have received adequate
training to use the software, and proper instructional designs are in place.
Online educational formats can no longer be considered “new.” Many
students are familiar with this type of instructional delivery, and may in fact prefer
it. In the academic year 2000 to 2001, 90% of public two-year institutions and 89%
of public four-year institutions offered distance education courses (Tallent-Runnels,
et al, 2006). During this year, over 2.8 million individuals were enrolled in college-
level, credit-granting distance education courses. Online courses have high overall
satisfaction rates and perceptions become even more favorable over time (Halter, et
BARRIERS TO CIVILITY 35
al., 2006; Mitchell, et al., 2007; Wills & Stommel, 2002). Of course, some students
do still prefer traditional face-to-face courses over web-based courses (Stiffler, 2008).
One recent study examined the relationship between social presence and
perceived learning in online educational environments (Cobb, 2011). The study
revealed that relationships, comfort, and community had greater impact on course
satisfaction and quality of the learning experience than the communication medium
itself. The study also corroborated the results of earlier studies that found there is
a high correlation between perceived learning and social presence (Richardson &
Swan, 2003). Therefore, establishing comfort and a sense of community early in a
course is essential to the learning experience.
A recent study examined the benefits and challenges of online learning
environments as perceived by both faculty and students (Clark, Ahten, & Werth,
2012). Both faculty and students reported the major benefits of online learning
environments are flexibility, convenience, and self-paced learning. Faculty also
reported an ability to make a deeper connection with student learning as a benefit.
Faculty perceived challenges to online learning included the time-consuming work
of reading, writing, and responding to student postings and assignments, creating a
sense of community, maintaining a supportive teaching-learning environment, the
lack of face-to-face interactions when addressing student concerns, and anonymity
that may foster uncivil behaviors. Student perceived challenges of online learning
environments included excessive group work and lack of full participation, lack of
clarity regarding objectives and assignments, self-disciple necessary to remain
BARRIERS TO CIVILITY 36
focused, lack of face-to-face communication with faculty and peers, excessive
reading and writing assignments, lack of familiarity with technology, delayed
faculty response times, and group grades regardless of individual contribution.
Some students complained that online learning environments were boring and
uninteresting.
Online education is not immune to incivility, also called cyber-bullying
(Clark, Werth, & Ahten, 2012). This type of incivility may show up as rumors or
misinformation posted on a discussion board or other online environment, gossiping,
or publishing any type of materials that defame or humiliate others. Thirty-nine
percent of faculty in one online baccalaureate completion program perceived
incivility to be a mild problem, and another 38.9% found it to be a moderate
problem.
In this same university, 44.5% of students perceived incivility to be a mild
problem, while only 6.6% reported it as a moderate problem (Clark, Werth, &
Ahten, 2012). Most respondents, both faculty members and students, reported
students to be much more likely than faculty to engage in incivility in an online
learning environment. The top four uncivil faculty behaviors were unclear
expectations, failure to respond in a timely manner, group grades that were
inclusive of individual work, and failure to post grades in a timely manner. The top
four reported uncivil student behaviors were failing to complete assignments in a
timely manner, posting vague responses that do not add meaning to the class
discussion, posting short and terse responses, and failing to fulfill group
BARRIERS TO CIVILITY 37
responsibilities. Creating civil learning environments online will take careful
planning and diligent work. Creating norms and establishing respectful teacher-
student relationships are critical to the success of online programs.
Theoretical Framework
There are a number of learning theories that can be applied to this project.
The main five theories include behaviorist, cognitive, social learning,
psychodynamic, and humanist. Each of these learning theories can be used to alter
student behaviors.
Watson and Pavlov defined behaviorist learning theory as a change in
behavior as a result of learning (DeYoung, 2009). According to this theory, emotion
and thought are attributed to behaviors learned through conditioning, while
behaviors are more or less conditioned reflexes. Conditioning occurs when a
stimulus is followed by a response thus influencing future behavior. For example,
an individual enters a hospital and is exposed to smells (stimulus) that cause him to
become nauseated (response) (Bastable, 2008).
Reward and punishment are reinforcements that can also affect behavior
(DeYoung, 2009). For example, rewarding a child for putting away the dishes will
cause the child to put away the dishes again. One educator made an interesting
application of this theory (Jackson, 2009). Each high school teacher decorates the
classroom according to the subject he or she teaches. For example, the French
teacher chose pictures of Paris and the French countryside in the hope that the
BARRIERS TO CIVILITY 38
environment would stimulate in her students a burning desire to learn the
language.
Cognitive learning theory stresses the internal workings of the learner
(Bastable, 2008). Cognition is perception, thought, memory, and ways of processing
and structuring information and is the key to learning and changing. Cognitive
theorists hold that learner goals and expectations are more important to the
learning process than reward.
There are several perspectives of cognitive learning theory, each emphasizing
a different facet of cognition (Bastable, 2008). Gestalt perspective emphasizes the
perception of the learner, assuming that each learner perceives, interprets, and
responds to a situation in his own way. Gestalt perspective highlights the need for
simplicity in teaching and the selectiveness of individual perception. A simple and
clear explanation will assist the learner in relating the new information to past
information and experiences. Also, learners may have multiple stimuli at any given
point. Determination of which stimuli will receive their attention is based on their
past experiences, needs, motives, and attitudes. Therefore, it is important to assess
distractions in the learning environment.
The information processing perspective of cognitive learning theory
emphasizes the thinking process, and how information is perceived, interpreted,
and remembered (Bastable, 2008). This perspective suggests four stages to
memory. Stage one is an external process that involves paying attention to a
particular stimulus. Stage two is the internal processing of information by the
BARRIERS TO CIVILITY 39
senses. The student-preferred mode of sensory processing (visual, auditory, or
motor) is an important consideration for educators at this step. The third stage is
internal memory storage, where the information is briefly stored in short-term
memory and then either forgotten or moved to long-term memory. Information is
moved to long-term memory through the learner‟s preferred method of storage, such
as imagery, association, rehearsal, or breaking into units. The fourth and final
stage is an external process involving the action or response of the learner.
A third perspective on cognitive learning theory is cognitive development
(Bastable, 2008). This perspective focuses on the changes in perception, thinking,
and reasoning that occur as learners grow and mature. Educators should be aware
that children and adults learn differently. However, not all adults will reach
Piaget‟s formal operations stage, the final stage in his cognitive development theory.
On the other hand, some adults have advanced even beyond the formal operations
stage and are able to deal with contradictions, synthesize information, and more
effectively integrate what they have learned. This perspective does not allow for the
impact social experiences has on a learner. Social constructivism and social
cognition are two perspectives that do consider the effects social factors may have
on perception, thoughts, and motivation. Also, the cognitive-emotional perspective
of cognitive learning theory considers the part emotion plays in learning.
Bandura‟s social learning theory incorporates personal characteristics of the
learner, behavior patterns, and the environment (Bastable, 2008). Role modeling is
a main concept in this theory. It involves providing compelling examples, or role
BARRIERS TO CIVILITY 40
models, to demonstrate to the students how to think, feel, and act. Another central
concept is vicarious reinforcement, and displays a role model‟s behavior as
achieving a perceived reward or punishment.
The social learning theory involves a six-step process (Bastable, 2008). The
first is an external process where the role model demonstrates the behavior which
may be reinforced vicariously. The next four steps are internal processes of self-
regulation and control. In the attentional phase, the student observes the role
model. Next, the retention phase, involves processing and representation in
memory. The reproductive phase occurs when the student‟s memory replays a
performance of the model‟s actions. In the motivational phase the student may be
influenced by vicarious reinforcement and punishment. The final step is an
external process; that of the student actually performing the behavior modeled.
The psychodynamic learning theory is largely based on the work of Freud and
his followers (Bastable, 2008). The central principle of this theory is that behavior
may be conscious or unconscious, so a student may not be aware of his motivations
and why he thinks, feels, or acts in a certain way. One key is the pleasure principle,
the desire to seek pleasure and avoid pain. This is the id or primitive drive. It
conflicts with the conscience or superego. The ego, based in reality, mediates
between the two. When the ego is threatened by harsh realities, defense
mechanisms are used to protect the self from the perceived threats.
Humanistic Learning Theory is based on the assumption that everyone is
different. Each individual is unique, but all want to grow in a positive way
BARRIERS TO CIVILITY 41
(Bastable, 2008). Motivations are controlled by a hierarchy of needs, as identified
by Maslow. The hierarchy of needs begins with physiological needs such as food,
water, warmth, and sleep. Once those have been met, the individual continues
along the hierarchy to safety needs, then belonging and love, followed by esteem,
and finally self-actualization. The hierarchy of needs may make sense intuitively,
but it has not held out in research. Some individuals have lacked basic necessities,
but have offered of themselves to other people and enjoyed learning. However, in
applying this theory to education, the emphasis is fostering curiosity, enthusiasm,
initiative, and responsibility, rather than simple mastering of facts and information.
Another appropriate learning theory to consider is systems theory. A system
is a set of interrelated components (Dechant & Dechant, 2010). In this case, those
components include the educator, students, materials, learning environment, and
technology. Each component is crucial to successful learning, and must be carefully
considered in the teaching plan.
While parts of each of these theories will be considered and applied,
transformational learning theory is the most appropriate theory to guide
development of a teaching plan for this course. This detailed theory helps to
describe how learners construct, validate, and reformulate the meaning of their
learning experience (Mezirow, 2000). It is a way of solving a problem by first
defining the problem and then reframing it. It involves critical reflection of the
individual learner‟s assumptions, and those of the other learners in the learning
BARRIERS TO CIVILITY 42
community. Transformative insight is arrived at through discourse and
justification of the new perspective.
The purpose of transformative learning is to create a more autonomous
thinker (Baran, Correia, & Thompson, 2011). This means students should be able
to critically reflect upon their beliefs, values, ways of thinking, and feelings, and
those of others. After reflection and validation, the autonomous thinker can
determine best course of action. This is exactly what the course in civility should do
for new nurses and nursing students. Students of this course should be able to
critically review their own beliefs, feelings, and way of thinking about civility,
compare it to the examples they receive in this class. They can then select the most
appropriate behavioral choice, whether they are witnessing incivility, the victims of
incivility, or tempted to become uncivil themselves.
Educational Model
Dick and Carey‟s systems approach model will be utilized for this project
(Dick, Carey,& Carey, 2009).The authors hold that instruction is a systematic
process, containing many interrelated variables that are essential to learning, as
supported by systems theory. The instructional process itself is the system, and the
components are the learners, the instructor, the instructional materials, and the
learning environment. These components work together to achieve the goal. There
are ten steps to this systems approach model, as illustrated in Appendix II. These
steps are:
1. Identify an instructional goal
BARRIERS TO CIVILITY 43
2. Conduct an instructional analysis
3. Analyze learners and contexts
4. Write performance objectives
5. Develop assessment instruments
6. Develop an instructional strategy
7. Develop and/or select instructional materials
8. Design and conduct the formative evaluation
9. Revise instruction
10. Conduct summative evaluation
Method
Goals and Objectives
Instructional Goals
The first step to planning instruction according to Dick and Carey‟s systems
approach model is to identify the instructional goal (Dick, Carey, & Carey, 2009).
Goals are quite different from objectives (Bastable, 2008). Goals are final outcomes
of the teaching and learning process. A goal statement describes the ultimate finale
in the future. Goals are broad, multidimensional, long-term targets for both the
learner and the educator. They are the desired outcomes of learning that are
realistically achievable in weeks or months.
On the other hand, an objective is specific, one-dimensional, and short-term
in nature (Bastable, 2008). An objective is what the student should learn as a
result of the teaching. Objectives are specific, short-term behaviors that lead step-
BARRIERS TO CIVILITY 44
by-step to achieving a goal. In this way, objectives and goals work together in
education. I liked the analogy used by the textbook. If learning is a map, the
destination is the goal while the directions are the objectives.
A good instructional goal must contain a clear but general statement of
learner outcomes (Dick, Carey, & Carey, 2009). In other words, it is a statement of
behaviors the student will demonstrate as a result of the instruction. It must be
related to the problem and needs assessment. Also, it must be able to be achieved
through instruction. The identified problem for this project is incivility in the
nursing workplace. The needs of the students include knowledge of what could be
considered to be uncivil behaviors, how to identify whether one‟s own behaviors
could be perceived as uncivil, and how to maintain self-worth in the face of incivility
and bullying. Additionally, students are in need of effective communication and
conflict management strategies to promote a culture of civility. The original
instructional goal is: Learners will know the value of a culture of civility.
The next step is to refine the goal (Dick, Carey, & Carey, 2009). There are six
steps to this process. First, write the goal down. Second, identify behaviors
learners would demonstrate to reflect they have achieved the goal. Third, select the
behaviors that best represent the goal. Fourth, select indicators of the behaviors.
Fifth, write statements connecting those indicators with what the learner will do.
Finally, evaluate the new goal for clarity and relationship to the original goal. The
behaviors that best represent the goal of civility in the workplace are effective
BARRIERS TO CIVILITY 45
communication techniques and conflict management strategies. The instructional
goal for this project is:
Students will identify behaviors associated with incivility, complete a self-
assessment to ensure they are a part of the solution, and demonstrate
effective communication skills and conflict management strategies, as victim,
witness, and perpetrator of incivility, through appropriate selection of
behavioral choices in an online simulation.
Instructional Analysis
Instructional analysis is the next step in the planning of the education (Dick,
Carey, & Carey, 2009). First, the instructional goal should be analyzed and
classified into a domain of learning and then broken down into a series of steps
required to perform the goal. For the chosen instructional goal, there are really two
learning domains. Learning the concept of incivility and discriminating between
behavioral choices falls within the intellectual learning domain. Demonstrating
communication skills and conflict management strategies through an appropriate
selection of behavioral choices requires an underlying belief or preference that has
caused the individual to make the choice. This is an example of the attitudes
learning domain.
Other items to consider are subordinate skills to be included in the
instruction and entry skills learners will need prior to the instruction (Dick, Carey,
& Carey, 2009). For this instruction, learners will need basic computer skills and
may need a tutorial prior to beginning the instruction. A tutorial for the program
BARRIERS TO CIVILITY 46
should be written to familiarize students with the program utilized for course
delivery. This tutorial will be made available to students prior to the start of the
course. The best plan for designing a tutorial is to complete the course first and
then design the tutorial to fit exactly what students will need to know for the
course. Learners are either student nurses or recent nursing graduates so it is
expected they will have the intellectual skills needed to reason appropriately.
However, attitude towards the course needs to be considered. Attitude will be
addressed in a pre-course assignment designed to foster enthusiasm.
Put another way, Robert Mager (1997c) describes this analysis phase as the
steps taken to answer three questions. First, is there a problem worth solving?
Second, is instruction a relevant part of the solution? Third, what should the
instruction accomplish? The answer to the first two questions was discovered
through the literature search. There is a problem with incivility in nursing, and
instruction can be a part of the solution. The intent of the instruction is assist
students to recognize behaviors associated with incivility, analyze themselves for
the presence of these behaviors, and develop the skills necessary to extinguish these
behaviors, whether the student is a victim, a witness, or a perpetrator of incivility.
A course description tells what a course is about, its content and procedures
(Mager, 1997c). However, the course description does not explain the criteria of
acceptable performance. The course description is intended for a course catalog,
and not for describing the results of the course. The course description for this
project is as follows:
BARRIERS TO CIVILITY 47
This course will assist individual nurses to remove the barriers to civility by
increasing awareness of incivility and its effects, including negative patient
outcomes. Students will learn to recognize the signs of incivility, the steps to
take in addressing the behavior, effective communication and conflict
management skills, and how to maintain personal self-worth even in adverse
environments. Students will be prepared to examine themselves to ensure
they are part of the solution and not part of the problem. The students will
be given an opportunity to practice their new skills to develop confidence.
Analyze Learners and Contexts
In the previous step learner skills needed prior to instruction were
considered. During this step the characteristics of the learner will be analyzed,
along with the context in which the instruction is to be delivered, and the context in
which the skills will be used (Dick, Carey, & Carey, 2009). To analyze the
characteristics of the learner the instructional designer needs to know the learners‟
entry skills, prior knowledge of topic area, attitudes towards content and potential
delivery system, academic motivation, and group characteristics. The designer can
obtain general information about nursing students and recent graduates, or can use
a survey of the actual learners in the course in order to tailor the information to
them.
Tailoring the information to the learners is the best method of obtaining
accurate information so as to design the course for this set of learners (Dick, Carey,
& Carey, 2009). Items to consider when analyzing the target population for
BARRIERS TO CIVILITY 48
education include their interests, reason for taking the course, age ranges, whether
they want to be in the course, gender, if they have families, attitudes and biases,
training and experience, skills they already possess, and tools and equipment they
already know how to use (Mager, 1997a).
There are two main unknowns about the learners that would reshape this
course. First, how familiar and comfortable are students with online learning
environments? A tutorial could assist students to gain comfort and skill with online
learning prior to the start of the course. Access to tutorials for each portion of the
course may be necessary for students who have never taken an online course before.
Second, how do the students prefer to learn? Do they wish to hear the information
or to read the information? The simulation and debriefing are both interactive
assignments. However, the didactic can be tailored to fit the needs of the student.
A lecture could be recorded to go with the slides or the slides could be presented on
their own.
A survey was developed to be sent out to students one month prior to the
start of the course. The students are given one week to complete the anonymous
survey. There are actually twopurposes in the survey. First, it gives the instructor
the information necessary to tailor the instruction to the learners. Second, it whets
the learners‟ appetites for what is to come in the course. The survey tool can be
found in Appendix VI.
Just as important as instructional and learner analysis is context analysis
(Dick, Carey, & Carey, 2009). The instructional designer must ensure there is
BARRIERS TO CIVILITY 49
appropriate managerial and supervisor support. If an organization‟s managerial
styles creates an environment that supports incivility, the course will have much
less affect than if the managers and supervisors are supportive. Physical aspects of
the instructional site can be considered, but since this is an online course the
learners are responsible for the physical location. Social aspects of the instructional
site should be considered, especially because this is an online course. A degree of
social connectedness could be lost if not carefully planned. The discussion board
assignments for the debriefing serve to connect students and create an atmosphere
of collegiality. Finally, the skills the students will learn are very relevant to their
workplace, and may be put into practice immediately.
Learning context analysis requires the instructional designer to carefully
consider adaptability of the learning site to simulate the workplace, adaptability for
delivery approaches, and constraints of the learning site that affect design and
delivery (Dick, Carey, & Carey, 2009). Simulation activities are designed to
replicate workplace environments. Delivery can be varied and is made more
convenient for students. One constraint of online learning is social connectedness,
as addressed previously. Another possible constraint is lack of interaction with the
instructor during the didactic portion of the course, making that portion seem
boring to students. The instructor will need to make the instructional delivery
dynamic and engaging to students, even when he cannot visualize the students
directly during the delivery.
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Performance Objectives
Course objectives are the destination, or behavioral outcomes one expects to
meet at the end of a course (Mager, 1997c). A clear, precise statement of what
students should be able to do at the end of a course sets a solid foundation for
communicating instructional intent, selecting instructional content, and creating
evaluation instruments to determine competence.At least one objective can be
written for each of the skills identified in the instructional analysis (Dick, Carey, &
Carey, 2009).
A well-prepared objective has three components: performance, conditions,
and criteria of acceptable performance (Dick, Carey, & Carey, 2009). The first
component, performance, describes the skill or behavior identified in the
instructional analysis. The second component describes what conditions will be
present while the learner carries out a task. For example, will students be given a
case study to analyze or a series of behavioral choices from which to select? The
third component describes the criteria that will be utilized to evaluate student
performance. In other words, must the student be completely precise or is a margin
of error allowed?
Bloom‟s taxonomy is a classification of levels of intellectual behavior
necessary for learning, organized into a triangle (Overbaugh & Schultz, 2012). It
was revised in the 1990‟s to reflect relevance to current work. One main change
was from nouns to verbs at each level. Bloom‟s revised taxonomy can be found in
Appendix III.
BARRIERS TO CIVILITY 51
As one moves up from the base of the triangle to its apex the behaviors
become more complex (Overbaugh & Schultz, 2012). At the base of the triangle, or
the lowest level of intellectual behavior, is remembering. This requires a student to
recall information. The next step is understanding, or asking the student to explain
ideas or concepts. Applying requires the student to use the information in a
different manner. Analyzing requires students to distinguish between different
elements. Evaluating is asking a student to justify a decision. Finally, creating
requires the student to create a new product or point of view. Each of these
behavioral processesis used when necessary, and an individual learner may move
up and down the triangle many times as they create new knowledge. Schrock
(2012) put these behaviors into a cogwheel formation rather than a triangle to
demonstrate their interconnectedness. An example of this is found in Appendix IV.
The objectives for this course are as follows:
Having received information regarding incivility, students will:
Recognize and provide examples of incivility during a test at the end of
the didactic portion of the course.
Implement conflict management skills to address incidents of incivility
through a simulation exercise.
Model effective communication techniques as demonstrated by
selection of appropriate behavioral choices.
Write about their experiences during the simulation as a victim,
witness, and perpetrator of workplace incivility during a discussion
BARRIERS TO CIVILITY 52
board-based debriefing, defining methods of maintaining self-worth in
each adverse environment.
Recognize is a behavior associated with analyzing (Overbaugh & Schultz,
2012). This will require students to analyze behaviors to determine if incivility is
present. This objective will be assessed through an online quiz at the end of the
didactic portion of the course. Implement is a behavior that corresponds with
applying, or using the information in a new way. Students will demonstrate
through the online simulation that they can use the information received about
conflict management skills to extinguish uncivil behaviors. Model also falls under
the applying category of Bloom‟s taxonomy. For the third objective, students will
take the knowledge they have gained regarding effective communication skills to
address incivility. Finally, writing is a creating behavior. This means students will
need to take the knowledge and experience they have gained throughout the course
and formulate a new point of view. Evidence of achieving this objective will be clear
through the reflective writing assignment and discussion board responses.
Evaluation of objectives is essential (Dick, Carey, & Carey, 2009). The
objectives should contain each of the three essential elements; performance,
conditions, and criteria. Additionally, a good method of evaluating the clarity and
feasibility of an individual objective is to design a test item to measure the learner‟s
accomplishment.
BARRIERS TO CIVILITY 53
Teaching Plan
Once goals and objectives have been defined, the teaching plan can be written
because there is now a clear direction for the course (Bastable, 2008). The teaching
plan is the blueprint or map that will be used to assist students to achieve the
coarse objectives. The teaching plan should include the purpose, content, methods
and tools, timing, and evaluation of the instruction. It should clearly define each
step in the educational process. There are three reasons for creating a teaching
plan. First, it forces the educator to consider the coherence of the education,
ensuring a logical order and keeping the content on target. Second, the teaching
plan is a plan of action that communicates what is to be taught, how the material
will be delivered, how it will be evaluated, and the time allowed for achievement of
the behavioral objectives. Third, the teaching plan serves to provide documentation
that the education is being properly implemented. The teaching plan for this course
can be found in Appendix VII.
One piece of the teaching plan is time allocation. The fifth principle of
Chickering and Gamson‟s classic Seven Principles of Good Practice in
Undergraduate Education is emphasize time on task (DeYoung, 2009). This means
instructors need to ensure students are aware of how much time they should spend
on studying, learning, and practicing. The instruction must determine how much
time students will need to spend on each portion of this course and for the course in
its entirety. This information has been included in the course syllabus.
BARRIERS TO CIVILITY 54
After the didactic portion of the course, there will be a quiz students must
pass before moving on to the online simulation. Therefore, developing criterion-
referenced test items becomes a concern (Dick, Carey, & Carey, 2009). There are
three types of criterion-referenced tests. A pretest is utilized to measure entry
behaviors, or prerequisite skills. In this case, there are no prerequisite skills as this
education is directed at nursing students and recent graduates. An embedded test
is like a practice test question with no feedback, and is only for the benefit of the
designer. A posttest assesses all the objectives, especially focusing on the course
objectives to determine learner achievement. Embedded test questions will be
utilized during the didactic portion of the course to ensure learners are grasping the
concepts. However, feedback will be provided so these questions are beneficial both
to the learner and the designer. A posttest will follow the didactic portion to ensure
all learning objectives have been met up to that point.
Teaching and Learning Strategies
Teaching and learning strategies are the methods used to deliver course
content to the students (Moyer & Wittmann-Price, 2008). Before determining which
teaching and learning strategies should be utilized, it is essential for the educator to
consider seven principles. Teaching and learning strategies should:
1. Clearly relate to the course objectives and competencies, learning
domain, and domain level.
2. Be challenging enough for students to use higher levels of cognitive
and affective development.
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3. Be emotionally satisfying for all students.
4. Assist students to view the problem or issue from other perspectives.
5. Be varied so as to prevent student boredom and allow for the students‟
individual differences and cultural experiences.
6. Link and apply prior learning experiences, both within the course and
from previous and concurrent courses.
7. Provide a solid foundation for future learning.
Teaching and learning strategies can be either passive or active (Moyer &
Wittmann-Price, 2008). Active participation gets students involved in the learning
process through talking, participating, and investing energy. This means there is
less lecture time and students must take an initiative. Examples of active teaching
methods are games, simulations, case studies, and reflective writing. However, this
does not mean there is no longer any room for passive learning strategies. Lecture
notes, handouts, and audiovisual media are examples of passive learning strategies
that allow educators to impart a large amount of content in a relatively short time
frame while maintaining control. However, very little cognitive effort is required of
students.
There are five major components to teaching and learning strategies (Dick,
Carey, & Carey, 2009). These are pre-instructional activities, information
presentation, student participation, testing, and follow-through. Pre-instructional
activities are aimed at motivating the learners, informing them of what they will
learn, and making sure they have the prerequisite knowledge to begin the
BARRIERS TO CIVILITY 56
instruction. When working on information presentation it is essential to consider
sequencing, objectives, and relationship of concepts. For this teaching plan, each
section (didactic, simulation, discussion board) will have its own objectives.
The teaching and learning strategies selected for this teaching plan include
both active and passive learning. A pre-instructional activity will be designed to
capture student‟s attention and enhance their motivation for the course. The
activity will be in the form of an email sent to students prior to the course, and will
require students to think about how they have personally been affected by incivility.
Information presentation will occur mostly in the didactic portion of the course and
will mainly be a passive learning strategy. This content delivery will occur via
slides the students must read. However, some slides will require active
participation, such as embedded test questions, which will work similar to clickers.
Another active learning strategy employed will be an online simulation. Students
will be placed in scenarios where they are a victim, a witness, or a perpetrator of
incivility. Students will then be given a series of behavioral choices from which to
select. Finally, for the follow-through, students will complete a guided reflective
writing assignment after the simulation and post it to a discussion board. They will
also be required to respond to at least three of their peers.
Instructional Materials
One must first have a destination and then can determine the best route to
take to get there. The same applies to teaching. First, you must know what you
want to achieve then you can determine how to achieve it. This means determining
BARRIERS TO CIVILITY 57
course objectives must be completed before selecting content (University of Illinois,
2010). The content and subsequent instructional materials can then be chosen so as
to achieve the established behavioral objectives. The objectives are also the basis
upon which success is measured. Therefore, the effectiveness of instructional
materials can only be determined after the success of meeting the objectives is
calculated.
Instructional materials enhance learning, but only if they are chosen
appropriately (Bastable, 2008). Appropriate materials are determined by
considering the characteristics of the learner, the characteristics of the media, and
the characteristics of the task. The characteristics of the learners are how they
learn best, which can be determined from the learner analysis. The characteristics
of the media in this project are characteristics of online education. The
characteristics of the task include both the learning domains and the complexity of
the tasks that must be mastered to achieve the predetermined behavioral
objectives. Behavioral objectives must be clearly defined before attempting to
choose instructional materials.
For this course, the learning domains were intellectual and attitude.
Intellectual skills are inclusive of discrimination, concrete concepts, utilizing rules,
and problem-solving (Dabbaugh, 2006). Attitude is an internalization that affects
an individual‟s choice of action. Instructional materials will need to be chosen and
adapted for the instructional strategy. Content is needed regarding definitions of
concepts, incidence of incivility to establish the need to develop strategies to
BARRIERS TO CIVILITY 58
promote a culture of civility, self-assessment of bullying behaviors, effective
communication techniques, and conflict management strategies. This content will
derived from a series of sources, as outlined below. However, it will also need to be
tailored to the learning needs of the students and put together in a cohesive
manner.
Components of the Course
Pre-course Assignment
Prior to the start of the course, a reflective writing assignment will be
emailed to students. The point of this assignment is to increase interest in the topic
of civility, and make it personal. This is one way to engage students in the content,
triggering a higher level of accountability for learning and future actions (Center,
2010). Students will need enough time to complete the assignment, emailing it back
to the instructor, but not so much time that they lose interest in the topic.
Therefore, this email will go out one week prior to the start of the course. A copy of
the email and assignment can be found in Appendix VIII. It is modified from an
example used by Center (2010). Following the pre-course assignment, there are
three parts to the course: didactic, simulation, debriefing.
Didactic
The objectives for the didactic portion of the course are sub-objectives
designed to assist students in achieving course objectives. These sub-objectives are:
Identify the importance of civility in the nursing workplace
Recognize examples of incivility
BARRIERS TO CIVILITY 59
Compare conflict management skills
Contrastcommunication techniques
Identify potential self-worth issues for those involved with incidents of
incivility
This portion of the course is a recorded lecture with power point slides. The
lecture is divided into eight sections. Instructors should tailor the recorded lecture
to their students, and alter the slides to reflect the pre-course assignments. The
sections in the lecture are: Incivility; Civility in the Workplace; Self-Esteem; Am I a
Bully?; Effective Communication; Conflict Management; The Witness; The Victim;
and A Final Word on Incivility – What kind of fire ant are you? Each section will
conclude with quiz questions to ensure the students have achieved the objectives up
to that point. Once the student has listened and watched the entire program and
correctly answered the questions, they will be allowed to move on to the exam.
The exam is a20 question multiple-choice and true/false style test. Students
must receive a grade of 80% to pass. The exam questions can be found in Appendix
X and answers to the exam questions are in Appendix XI. Students who do not pass
on their first attempt may remediate and repeat the didactic part of the course. If
students fail the exam a second time, they must first meet with the instructor to
discuss any issues that need clarification. They may then repeat the exam. After
students have passed the exam, they will be given access to the simulation part of
the course. Students will have one week to complete the didactic part of the course.
BARRIERS TO CIVILITY 60
Simulation
There are a number of frameworks that could be applied to the simulation
activity, but the most appropriate is the NLN/Jeffries Simulation Framework
(Jeffries, 2012). This framework can be found in Appendix XII. There are five main
components to the framework, each with associated variables. The components are
students or learners, teachers or instructors, education practices in simulation, a
simulation, and outcomes.
The teacher must serve as a facilitator of learning, which will occur during
the debriefing process in this project (Jeffries, 2012). Learner demographics and
knowledge must be considered prior to designing the simulations. Simulation is an
active learning technique. Students will have high expectations and may have
diverse learning from their experiences. The simulation design characteristics
include objectives, fidelity, problem solving, student support, and debriefing. The
online simulations in this project are full context, medium fidelity computerized
simulations. In other words, it is an online focused experience for the learner to
solve problems, perform skills, and make decisions.
The objectives for the simulation piece are also sub-objectives designed to
lead students to successful achievement of the course objectives. The simulation
objectives are:
After comparing conflict management skills, students will implement
the most appropriate skills to address incidents of incivility.
BARRIERS TO CIVILITY 61
After contrasting different communication techniques, students will
demonstrate effective communication techniques by selection of
appropriate behavioral choices.
The final component, outcome, includes the knowledge or learning gained,
skill performance, learner satisfaction, critical thinking, and self-confidence
(Jeffries, 2012). The three simulations in this activity are designed to assist
students to put into practice the knowledge and skills they have gained, thereby
developing self-confidence. The simulation outlines can be found in Appendix XIII.
Debriefing
Debriefing of simulation exercises is essential. The debriefing for these
exercises will serve to tie the course together and finalize achievement of course
objectives. The objectives for the debriefing are:
After a simulation exercise, students will write about their experiences
as a perpetrator of incivility.
After a simulation exercise, students will compare effective methods of
addressing incivility for witnesses.
After a simulation exercise, students will identify methods of
maintaining self-worth for victims of incivility.
The debriefing will occur through a series of assignments on a group
asynchronous discussion board. First is a reflective writing assignment to be
completed within three days of completion of the simulation exercise. Students are
given prompts to assist their creativity and critical thinking. Then, students are
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required to make a minimum of two substantial posts in response to the reflective
writing assignments of their peers. Students will have two weeks to complete the
discussion board activities. The debriefing assignments can be found in Appendix
XIV.
Reflection helps learners correlate past experiences with the learning
experience (Jeffries, 2012). However, the instructor must carefully assess each
student when utilizing reflective writing, to ensure the student gets the most value
out of the exercise. Some students may require much guidance and have a limited
ability to reflect on the simulation experience. Other students may need less
assistance, but still demonstrate limited self-analysis skills. Finally, the critical
reflectors need very little assistance and are able to identify areas for self-
enhancement. For this reason, the instructor must be very involved with the
discussion board assignments, checking the postings multiple times a day during
the allotted time. Students are required to respond to the responses of both
students and instructors on their original post.
Evaluation Methods
Course Evaluation
There are two types of evaluation to consider for this project. One is
evaluation of the course itself, and the other is evaluation of the learner‟s
achievement of course objectives. The first to be discussed is evaluation of the
course. The two types of course evaluation are formative and summative (Keating,
2011). Formative evaluation is the gathering of feedback to make ongoing
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improvements (Carnegie Mellon, 2012). Formative evaluation was completed
during the creation of this course through meetings between the author and an
experienced nurse educator. Summative evaluation occurs at the end of a project to
ensure standards of learning are met. Summative evaluation for this project was
achieved through a formal review of the teaching plan by two experienced nurse
educators.
Before the course is launched, it is essential to ensure the instruction
matches learner expectations (Mager, 1997b). Qualitative evaluation will allow the
nurse educators to provide specific feedback on areas they notice need improvement.
However, there are also specific areas that must be addressed. These include
ensuring the objectives match the instruction, the conditions are appropriate to the
objectives, and the instruction provided will lead students to objective achievement.
The syllabus should be clear, test items should be appropriate, and the evaluation
methods should be appropriate. Also the teaching plan should be clear for
instructors. Therefore, an evaluation survey tool was developed to answer these
specific questions. This tool can be found in Appendix XV. Any “no” answers are
followed up by asking for further details. The final two questions allow for the
evaluator to provide qualitative input. These questions are: What does the plan do
well? and What improvements can be made?
Learner Evaluation
Next, learner evaluation must be planned, although it will not be
implemented during this project. Formative evaluation is used to ensure students
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are on the „right path,‟ so to speak during the course (Carnegie Mellon, 2012).
Summative evaluation is used to measure learner achievement of course objectives.
Formative evaluation will occur during the didactic portion of the course through
the embedded questions. Summative evaluation is comprised of a test at the end of
the didactic portion, learner demonstration of achieved outcomes by selection of
behavioral choices during the simulation, and through a written debriefing
assignment.
When considering the development of student evaluation, barriers must also
be considered. There are many barriers, real or perceived, to evaluation, but they
can usually be overcome with proper planning (Bastable, 2008). The three
categories into which most barriers fall are 1) lack of clarity, 2) lack of ability, and
3) fear of punishment or loss of self-esteem.
Lack of clarity could mean one of the five components of evaluation was not
identified, available, or clearly understood (Bastable, 2008). These components are
audience, purpose, questions, scope, and resources. Lack of clarity may most often
be due to lack of a clearly stated purpose of the evaluation. There must be a specific
plan for what to do with the data collected from the evaluation.
The usual reason for lack of ability to conduct an evaluation is lack of
knowledge (Bastable, 2008). Educators need to know the steps to take to plan for
and implement an effective evaluation. Once they learn the steps and plan
carefully, they must ensure that all the resources are available to implement the
evaluation.
BARRIERS TO CIVILITY 65
Fear of punishment or loss of self-esteem is another barrier to effective
evaluation, especially with self-evaluations (Bastable, 2008). The evaluation may
be perceived by the students as a judgment of themselves, their self-worth, or their
abilities as learners. This can be one of the more difficult barriers to overcome. The
first step in overcoming this barrier is to recognize that it almost always exists to
some degree. The purpose of the evaluation should be clearly explained. If the
evaluation is not to be graded, this should be made known to the students to reduce
their stress. For evaluations that do receive grades, such as homework
assignments, quizzes, and tests, students should know how many points are
possible and what percentage of their course grade this evaluation will make up.
The second step in overcoming the obstacle of fear of punishment or loss of
self-esteem is to remember that the person is more important than the performance
(Bastable, 2008). Nursing school can be stressful for students, and educators can do
much to ease the stress. Developing a good relationship with students will make it
more likely that they will come to the educator to ask questions and clarify content
they do not understand. This makes evaluation less stress for students and gives
the educator an idea of what points need to be reinforced in the classroom. Students
who score poorly on evaluations should not be left to wonder why, but can be helped
to understand why they did not score as highly as they might have wished.
Additionally, these at-risk students can be given one-on-one assistance to improve
their study habits and skills so they can score higher the next time.
BARRIERS TO CIVILITY 66
The third step in overcoming this obstacle is to point out achievements
(Bastable, 2008). Especially do the at-risk students benefit from this practice.
Students who have scored poorly on evaluations may be considering quitting the
program or at least the class. These students need positive reinforcement. Finally,
clear communication can overcome the barrier of fear. If students know exactly
what to expect from the evaluation, and the content covered, they will be less
fearful, which should lead to higher scores.
Discussion of Findings
The evaluation survey was completed by a professional nurse educator in a
healthcare network. The completed survey can be found in Appendix XVI. In
addition to the survey, a meeting was scheduled to discuss the evaluation of the
teaching plan with the educator, for additional qualitative data collection.
The entire teaching plan was discussed, with an emphasis on what was
completed well and which parts could be improved. Pre-course work, simulation
activities, and the debriefing were items that were considered to be completed well.
The simulation case study was “a 10!” The reason this case study is so appropriate
is because it takes the same scenario from three different viewpoints. This enables
the student to make decisions from all three standpoints, while simultaneously
getting the „big picture.‟
Suggestions were made for improvement in the communication skills and
conflict management sections of the didactic portion. An additional suggestion was
made to add to another follow-up activity to the discussion board. Communication
BARRIERS TO CIVILITY 67
skills are a part of a safety course required for all employees of the Community
Health Network in Indianapolis, Indiana. Conflict management strategies are
discussed in a relationship development course required for all employees of the
Community Health Network. The author has taken both courses, and reviewed
course material to add essential content to the didactic. These two courses contain
communication tools that have been developed and utilized successfully by
Community Health Network for over 15 years. In fact, relationship competence
accounts for up to 50% of an employee‟s annual performance evaluation.
The added follow-up activity is a second discussion thread. The assignment
for this thread is for students to relate an example since taking the didactic of when
they were able to utilize specific communication skills or conflict management
techniques. The purpose of this assignment is for students to implement at least
one of these skills and note whether it worked for them. There is no grade for this
assignment. Only participation is required for passing.
Additional changes were made in the didactic to change the wording and
examples given to fit more closely with the students. The targeted audience for this
course is new nursing graduates or nursing students. Therefore, they are more
likely to be young and computer savvy. The pre-course learner survey will validate
these assumptions, and changes can be made as necessary.
Recommendations
There are several recommendations for this teaching plan. First, the didactic
is designed to be a pre-recorded lecture the students can play back at a convenient
BARRIERS TO CIVILITY 68
time. However, it could also be a live class session that is recorded. Students could
be required to attend or encouraged to attend if the session were made available for
replay. It is also advisable that instructors take the pre-course learner survey into
consideration when determining the best method of delivering the didactic piece of
the teaching plan.
Additionally, before launching this type of education, it is essential to gain
the support of upper management. A culture of civility must be supported from the
top down. Once expectations have been set for civility, there must be follow-through
for the education to be truly effective. Establishing effective relationships as a part
of employees‟ annual performance appraisal (and tied to their compensation) is a
positive step in implementing a culture of civility.
BARRIERS TO CIVILITY 69
Bibliography
AANA. (2007). Workplace incivility part II: Managing the dilemma. AANA
NewsBulletin (April): 36-37.
Alcorn, M. (2012). Essential skills for teachers of excellence. Retrieved from
http://www.cpdscotland.org.uk/what/lead/tfe/skillsfortfe.asp.
American Association of Critical Care Nurses. (2005). Silence kills: The seven
crucial conversations in healthcare. Retrieved from www.silencekills.com.
Anthony, M. & Yastik, J. (2011). Nursing students‟ experiences with incivility in
clinical education. Journal of Nursing Education 50(3): 140-144.
Baran, E., Correia, A., & Thompson, A. (2011). Transforming online teaching
practice: Critical analysis of the literature on the roles and competencies of
online teachers. Distance Education 32(3): 421-439.
Bar-David, S. (2011). The incivility risk: It‟s time to connect the dots. Canadian HR
Reporter 24(17): 17.
Bastable, S. B. (2008). Nurse as educator: Principles of teaching and learning for
nursing practice (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.
Becher, J. & Visovsky, C. (2012). Horizontal violence in nursing. MedSurg Nursing
21(4): 210-213, 232.
Bjorkland, W. L. & Rehling, D. L. (2010). Student perceptions of classroom
incivility. College Teaching 58: 15-18.
BARRIERS TO CIVILITY 70
Bond, S. A., Tuckey, M. R., & Dollard, M. F. (2010). Psychosocial safety climate,
workplace bullying, and symptoms of posttraumatic stress. Organizational
Development Journal 28(1): 37-56.
Boothe, B. E. (2010). Fostering the three c‟s of nursing. Journal of Practical
Nursing 60(4): 4-9.
Bowen, B., Privitera, M. R., & Bowie, V. (2011). Reducing workplace violence by
creating healthy workplace environments. Journal of Aggression, Conflict,
and Peace Research 3(4): 185-198.
Broome, B. S. & Williams-Evans, S. (2011). Bullying in a caring profession:
Reasons, results, and recommendations. Journal of Psychosocial Nursing
49(10): 30-35.
Burke, H. & Mancuso, L. (2012). Social cognitive theory, metacognition, and
simulation learning in nursing education. Journal of Nursing Education
51(10): 543-548.
Burns, N. & Grove, S. K. (2005). The practice of nursing research: Conduct, critique,
and utilization (5thed.). St. Louis, MO: Elsevier Saunders.
Carmelli, A. (2008). Organisational – crisis preparedness: The importance of
learning from failures. Long Range Planning 41: 177.
Carnegie Mellon. (2012). Formative vs. summative assessment. Retrieved from
http://www.cmu.edu/teaching/assessment/howto/basics/formative-
summative.html.
BARRIERS TO CIVILITY 71
Center, D. L. (2010). Three A‟s of civility: Acknowledgement, authentic
conversations, and action. Journal of Continuing Education in Nursing
41(11): 488-489.
Center, D. L. (2011). Mandates for patient safety: Are they enough to create a
culture of civility in health care? The Journal of Continuing Education in
Healthcare 42(1): 16-17.
Clark, C. M. & Ahten, S. (2012). Beginning the conversation: The nurse educator‟s
role in preventing incivility in the workplace. Georgia Nursing (August,
September, October): 16-17.
Clark, C. M., Ahten, S., & Werth, L. (2012). Cyber-bullying and incivility in an
online learning environment, part 2: Promoting student success in the virtual
classroom. Nurse Educator 37(5): 192-197.
Clark, C. M. & Carnosso, J. (2008). Civility: A concept analysis. Journal of Theory
Construction & Testing 28(3): 11-14.
Clark, C. M. & Springer, P. J. (2007). Incivility in nursing education: A descriptive
study of definitions and prevalence. Journal of Nursing Education 46(1): 7-
14.
Clark, C. M. & Springer, P. J. (2010). Academic nurse leaders‟ role in fostering a
culture of civility in nursing education. Journal of Nursing Education 49(6):
319-325.
BARRIERS TO CIVILITY 72
Clark, C. M., Werth, L., & Ahten, S. (2012). Cyber-bullying and incivility in the
online learning environment, part 1: Addressing faculty and student
perceptions. Nurse Educator 37(4): 150-156.
CNN. (2002). Three professors killed at University of Arizona. CNN U.S. Retrieved
from http://articles.cnn.com/2002-10-28/us/university.shooting_1_borboa-
barbara-monroe-professors?_s=PM:US.
Cobb, S. C. (2011). Social presence, satisfaction, and perceived learning of RN-to-
BSN students in web-based nursing courses. Nursing Education Perspectives
32(2): 115-119.
Dabbaugh, N. (2006). Gagné‟s five learned capabilities. Retrieved from
http://classweb.gmu.edu/ndabbagh/Resources/Resources2/gagnetax.htm.
Dechant, K. & Dechant, L. (2010). Using systems theory to conceptualize the
implementation of undergraduate online education in a university setting.
Organization Management Journal 7: 291-300.
DeYoung, S. (2009). Teaching strategies for nurse educators (2nd ed.). Upper
Saddle River, NJ: Prentice Hall.
Dick, W. O., Carey, L., & Carey, J. O. (2009). The systematic design of instruction
(7thed.). Upper Saddle River, NJ: Pearson.
Dobson, S. (2011). Incivility common workplace issue, finds survey. Canadian HR
Reporter 24(17): 1, 17.
Dumont, C., Meisinger, S., Whitacre, M. J. & Corbin, G. (2012). Horizontal violence
survey report. Nursing 2012 (January): 44-49.
BARRIERS TO CIVILITY 73
Gates, M. G., Parr, M. B., & Hughen, J. E. (2011). Enhancing knowledge using high-
fidelity simulation. Journal of Nursing Education 51(1): 9-15.
Georgakopoulos, A., Wilkin, L., & Kent, B. (2011). Workplace bullying: A complex
problem in contemporary organizations. International Journal of Business
and Social Science 2(3): 1-20.
Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An
intervention for newly licensed nurses. Journal of Continuing Education in
Nursing 35(6): 257-263.
Gumbus, A. & Lyons, B. (2011). Workplace harassment: The social costs of bullying.
Journal of Leadership, Accountability, and Ethics 8(5): 72-90.
Hader, R. (2009). Bullying isn‟t just found on the playground. Nursing Management
(July): 6.
Halter, M. J., Kleiner, C., & Hess, R. (2006). The experience of nursing students in
an online doctoral program in nursing: A phenomenological study.
International Journal of Nursing Studies 43, 99-105.
Hastie, C. (1996). Dying for the cause. Australian College of Midwives Journal.
Retrieved from
http://uts.academia.edu/CarolynHastie/Papers/355326/Dying_for_the_Cause.
Hutchinson, M., Jackson, D., Wilkes, L., & Vickers, M. H. (2008). A new model of
bullying in the workplace: Organizational characteristics as critical
antecedents. Advances in Nursing Science 31(2): E60-E71.
BARRIERS TO CIVILITY 74
Hutton, S. & Gates, D. (2008). Workplace incivility and productivity losses among
direct care staff. AAOHN Journal 56(4): 168-175.
Jackson, L. D. (2009). Revisiting adult learning through the lens of an adult
learner. Adult Learning 20(3/4), 20-22.
Jeffries, P. R. (2012). Simulation in nursing education: From conceptualization to
evaluation (2nd ed.). New York, NY: National League for Nursing.
Johnson, S. L. & Rea, R. E. (2009). Workplace bullying: Concerns for nurse leaders.
The Journal of Nursing Administration 39(2): 84-90.
Johnston, M., Phanhtharath, P., & Jackson, B. S. (2009). The bullying aspect of
workplace violence in nursing. Critical Care Nursing Quarterly, 32(4): 287-
295.
Joint Commission. (2008). Sentinel event alert, issue 40: Behaviors that undermine
a culture of safety. Retrieved from www.jointcommission.org.
Joint Commission. (2009). Sentinel event alert, issue 43: Leadership committed to
safety. Retrieved from www.jointcommission.org.
Joint Commission. (2010). Sentinel event alert, issue 45: Preventing violence in the
healthcare setting. Retrieved from www.jointcommission.org.
Keating, S. B. (2011). Curriculum development and evaluation in nursing (2nd ed.).
New York, NY: Springer Publishing Company.
Kisamore, J. L., Jawahar, I. M., Liguori, E. W., Mharapara, T. L., & Stone, T. H.
(2010). Conflict and abusive workplace behaviors: The moderating effects of
social competencies. Career Development International 15(6): 583-600.
BARRIERS TO CIVILITY 75
Lashley, F. & deMenses, M. (2001). Student incivility in nursing programs: A
national study. Journal of Professional Nursing 17(2): 81-86.
Leiper, J. (2005). Nurse against nurse: How to stop horizontal violence. Nursing
35(3): 44-45.
Lewis, P. S. & Malecha, A. (2011). The impact of workplace incivility on the work
environment, manager skill, and productivity. Journal of Nursing
Administration 41(1): 41-47.
Long, B. (2011). 21st century nursing shortage. Retrieved from
http://www.seekingsources.com/nursing_shortage.htm.
Luparell, S. (2007). Managing difficult student situations: Lessons learned. Annual
Review of Nursing Education 5: 101-XIII.
Mager, R. F. (1997a). Making instruction work: A step-by-step guide to designing
and developing instruction that works (2nd ed.). Atlanta, GA: Center for
Effective Performance.
Mager, R. F. (1997b). Measuring instructional results: How to find out if your
instructional objectives have been achieved (3rd ed.). Atlanta, GA: Center for
Effective Performance.
Mager, R. F. (1997c). Preparing instructional objectives: A critical tool in the
development of effective instruction (3rded.). Atlanta, GA: Center for Effective
Performance.
McNamara, S. A. (2012). Incivility in nursing: Unsafe nurse, unsafe patients. AORN
Journal 95(4): 535-540.
BARRIERS TO CIVILITY 76
Mezirow, J. (2000). Learning as transformation: Critical perspectives on a theory in
progress. San Francisco, CA: Jossey-Bass.
Mitchell, E. A., Ryan, A., Carson, O., & McCann, S. (2007). An exploratory study of
web-enhanced learning in undergraduate nurse education. Journal of Clinical
Nursing 16(2): 2287-2296.
Moyer, B. A. & Wittmann-Price, R. A. (2008). Nursing education: Foundations for
practice excellence. Philadelphia, PA: F. A. Davis Company.
Neufeldt, V. Ed. (1997). Webster‟s new world college dictionary (3rd ed.). New York,
NY: Simon & Schuster, Inc.
Neuman, L. H. (2006). Creating new futures in nursing education: Envisioning the
evolution of e-nursing education. Nursing Education Perspectives 27(1): 12-
15.
Overbaugh, R. C. & Schultz, L. (2012). Bloom‟s taxonomy. Retrieved from
http://ww2.odu.edu/educ/roverbau/Bloom/blooms_taxonomy.htm.
Owens, D. M. (2012). Incivility rising. HR Magazine 57(2): 33.
Pearson, C. M. & Porath, C. L. (2005). On the nature, consequences, and remedies
of workplace incivility: No time for “nice”? Think again. Academy of
Management Perspectives 19(1): 7-18.
Pearson, C.& Porath, C. (2009). The cost of bad behavior: How incivility is
damaging your business and what to do about it. New York, NY: Penguin
Group.
BARRIERS TO CIVILITY 77
Richardson, J. C. & Swan, K. (2003). Examining social presence in online courses in
relation to students‟ perceived learning and satisfaction. Journal of
Asynchronous Learning Networks 7(1): 68-88.
Rieck, S. & Crouch, L. (2007). Connectedness and civility in online learning. Nurse
Education in Practice 7: 425-432.
Schrock, K. (2012). Bloomin‟ apps. Retrieved from
http://www.schrockguide.net/bloomin-apps.html.
Stiffler, D. J. (2008). A comparison of web-enhanced vs. traditional classroom
teaching in women‟s health nurse practitioner education. Topics in Advanced
Practice Nursing e-Journal 8(3).
Suplee, P. D., Lachman, V. D., Siebart, B., & Anselmi, K. K. (2008). Managing
nursing student incivility in the classroom, clinical setting, and on-line.
Journal of Nursing Law 12(2): 68-77.
Tallent-Runnels, M. K., Thomas, J. A., Lan, W. H., Cooper, S., Ahern, T. C., Shaw,
S. M., et al. (2006). Teaching courses online: A review of the research. Review
of Educational Research 76(1): 93-135.
Tunajek, S. (2007). Workplace incivility – part 1: Anger, harassment, and horizontal
violence. AANA News Bulletin 61(3): 30-31.
University of Illinois. (2010). Developing Course Objectives. Retrieved from
http://www.ion.uillinois.edu/resources/tutorials/id/developObjectives.asp.
BARRIERS TO CIVILITY 78
University of Missouri St. Louis. (2009). Dick and Carey‟s model for instructional
design. Retrieved from
http://www.umsl.edu/services/ctl/DEID/destination3deid/3dickandcarey.html.
Vassey, J. A., DeMarco, R. F., Gaffney, D., & Budin, W. C. (2009). Bullying of staff
nurses in the workplace: A preliminary study for developing personal and
organizational strategies for the transformation of hostile to healthy
workplace environments. Journal of Professional Nursing 25: 299-306.
Watson, J. (1994). Applying the art and science of human caring. New York, NY:
National League of Nursing Publishers.
Wills, C. E. & Stommel, M. (2002). Graduate nursing students‟ precourse and
postcourse perceptions and preferences concerning completely web-based
courses. Journal of Nursing Education 41(5): 193-201.
Wilson, S. (2012). Danger zone: Workplace violence touches many in nursing.
Nurse.com. Retrieved from
http://news.nurse.com/article/20121112/EOS1/111120003.
Young, S. (2011). Does nursing school facilitate vertical and horizontal violence?
Tennessee Nurse. Retrieved from
http://www.nursingald.com/Uploaded%5CNewsletterFiles%5CTN9_11.pdf.
Running head: BARRIERS TO CIVILITY 79
Appendix I
Summary of Research Articles
Study Reference Type of Study Purpose Sample Size Findings
Anthony, M. & Yastick, J. (2007). Nursing students' experiences with nursing incivility in clinical education. Journal of Nursing Education 50(3): 140-144.
Qualitative Uncover experiences of nursing students as targets of incivility in clinical settings; student perceptions of specific behaviors by nurses, and how students feel nursing schools should address incivility.
21 pre-licensure students in one university
Incivility has a significant impact on student experiences. Although positive experiences outweighed negative in quantity, negative experiences have greater impact on student self-confidence and attitudes toward nursing as a career.
AlKandari, N. (2011). The level of student incivility: The need of a policy to regulate college student civility. College Student Journal 45(2): 257-268.
Quantitative How often do incidents of student incivility occur? Do demographics affect perception? How do faculty members maintain civility in classrooms?
505 randomly selected students from Kuwait University during academic year 2007/2008
Students perceive incivility from other students such as leaving early, arriving late, talking during the lecture, use of a mobile phone or text messaging, and other behaviors that negatively impact the learning environment. Females perceive a high number of student incivilities in the classroom, while males reported fewer incidences, however perceptions were similar.
Bjorkland, W. L. & Rehling, D. L. (2010). Student perceptions of classroom incivility. College Teaching 58: 15-
Quantitative To determine the behaviors students find uncivil and how often they are experiencing them.
3,616 students at a Midwestern public university
Students recognize and perceive that they are experiencing at least a fair amount of moderately uncivil behaviors in classes on a regular basis.
BARRIERS TO CIVILITY 80
18.
Clark, C. M. & Springer, P. J. (2007). Incivility in nursing education: A descriptive study of definitions and prevalence. Journal of Nursing Education 46(1): 7-14.
Qualitative Determine perceptions of student and faculty behaviors considered uncivil and frequency of occurrence.
32 faculty and 324 nursing students at one university
Faculty reported uncivil student behaviors to include disapproving groans, sarcastic remarks, not paying attention in class, dominating class discussions, use of cell phone during class, and cheating on exam, and these occur sometimes. Students report uncivil faculty behavior includes cancelling class without warning, being unprepared for class, not allowing open discussion, belittling students, being disinterested or cold, delivering fast-paced lectures, and not being available outside of class, and these behaviors are a moderate problem.
Clark, C. M. & Springer, P. J. (2010). Academic nurse leaders’ role in fostering a culture of civility in nursing education. Journal of Nursing
Qualitative To determine the perceptions of academic nurse leaders of incivility from students and faculty in nursing education, stressors affecting this, and the role of leadership in addressing and preventing it.
126 academic nurse leaders - deans, directors, and chairpersons
Perceived faculty and student stressors include heavy work demands, financial pressures, and lack of support. Many suggestions to create a culture of civility were aimed at increasing support for faculty and students.
BARRIERS TO CIVILITY 81
Education 49(6): 319-325.
Cobb, S. C. (2011). Social presence, satisfaction, and perceived learning of RN-to-BSN students in web-based nursing courses. Nursing Education Perspectives 32(2): 115-119.
Quantitative Examine social presence among students in online nursing courses and determine its relationship to satisfaction and perceived learning.
128 students in one RN-to-BSN online program taking web-based nursing courses during one 12-week semester
Social presence is highly correlated to satisfaction and perceived learning. Therefore creating a sense of social presence should be a best practice in online courses. Faculty need to create a feeling of comfort and community.
Rieck, S. & Crouch, L. (2007). Connectedness and civility in online learning. Nurse Education in Practice 7: 425-432.
Descriptive-exploratory
Examine perceptions of connectedness and civility in online nursing courses
96 students in four nursing programs who had completed at least one online nursing course
Discussions that include personal or supportive comments increase connectedness. A sense of connectedness increases civility in online nursing courses. 35% of students reported uncivil or impolite conversation from students. 60% reported uncivil or rude communication from faculty.
BARRIERS TO CIVILITY 82
Clark, C. M., Werth, L., & Ahten, S. (2012). Cyber-bullying and incivility in the online learning environment, part 1: Addressing faculty and student perceptions. Nurse Educator 37(4): 150-156.
Qualitative Examine perceptions of students and faculty of incivility in online learning environments, behaviors considered to be uncivil, and frequency of these behaviors.
152 students and 19 faculty enrolled in or teaching in an online baccalaureate completion program at one university
38.9% of faculty perceived incivility to be a mild problem, 38.9% perceived incivility to be a moderate problem. 44.5% of students perceived incivility to be a mild problem, while 6.6% perceived incivility to be a moderate problem.
Clark, C. M., Ahten, S., & Werth, L. (2012). Cyber-bullying and incivility in an online learning environment, part 2: Promoting student success in the virtual classroom. Nurse Educator 37(5): 192-197.
Quantitative Measure faculty and student perceptions of challenges and advantages of online learning environments, and suggestions for promoting civility.
152 students and 19 faculty enrolled in or teaching in an online baccalaureate completion program at one university
Challenges to online learning include: time for instructors to read, write, respond to student postings and assignments, challenge of creating a sense of community, lack of face-to-face contact to address student issues, anonymity that can encourage incivility, excessive group work for students and lack of participation, lack of clarity for objectives and assignments, self-disciple required to stay focused. The greatest advantages included flexibility, convenience, and self-paced learning. Clearly defined behavioral expectations and consequences for incivility, faculty modeling of civility, and immediately addressing cases of incivility were
BARRIERS TO CIVILITY 83
suggestions for promoting a civil online learning environment.
Johnson, S. L. & Rea, R. E. (2009). Workplace bullying: Concerns for nurse leaders. The Journal of Nursing Administration 39(2): 84-90.
Descriptive Describe nurses' experiences with workplace bullying
249 members of the Washington State Emergency Nurses Association
27.3% of respondents had experienced workplace bullying in the prior six months. This behavior is significantly positively correlated with intent to leave the job or career. Leaders need to focus on the reasons for bullying and how to reduce its occurrence.
BARRIERS TO CIVILITY 84
Dumont, C., Meisinger, S., Whitacre, M. J. & Corbin, G. (2012). Horizontal violence survey report. Nursing 2012 (January): 44-49.
Quantitative To determine the frequency with which nurses experience horizontal violence
955 nurse respondents
82% of respondents reported experiencing or witnessing uncivil behaviors on a weekly or daily basis. Common behaviors were harshly criticizing someone without having heard both sides of the story, belittling a coworker in front of others, complaining about a coworker to others, eye-rolling, and pretending not to notice a coworker struggling.
Gumbus, A. & Lyons, B. (2011). Workplace harassment: The social costs of bullying. Journal of Leadership, Accountability, and Ethics 8(5): 72-90.
Qualitative - content analysis
Enable victims to better understand the situation, help managers learn to alleviate bullying situations, and assist witnesses to react better to bullying incidents
67 written stories of workplace bullying
Bullying tactics included verbal humiliation (including email), instilling fear, public embarrassment, inappropriate use of power, work related retaliation, and physical behaviors.
BARRIERS TO CIVILITY 85
Kisamore, J. L., Jawahar, I. M., Liguori, E. W., Mharapara, T. L., & Stone, T. H. (2010). Conflict and abusive workplace behaviors: The moderating effects of social competencies. Career Development International 15(6): 583-600.
Quantitative Investigate the moderating effects of social competencies (political skill, self-monitoring, emotional intelligence) on workplace incivility
213 graduate and undergraduate students working at least 20 hours per week and enrolled in psychology, management, human resources, or social work courses in two universities over two semesters.
Interpersonal conflict is correlated with counterproductive behaviors; social competencies combined with interpersonal workplace conflict predict the likelihood of abuse of coworkers. Politically skilled workers and highly self-monitored workers were more likely to engage in aggressive and abusive behaviors when faced with interpersonal conflict.
Running head: BARRIERS TO CIVILITY 86
Appendix II
Dick and Carey Systems Approach Model for Designing Instruction
(University of Missouri St. Louis, 2009)
Running head: BARRIERS TO CIVILITY 87
Appendix III
Bloom‟s Taxonomy
(Alcorn, 2012)
BARRIERS TO CIVILITY 88
Appendix IV
New Bloom‟s Image
BARRIERS TO CIVILITY 89
Appendix V
Course Syllabus
Improving Outcomes through Civility
Instructor Contact Information
Name: Jenny Erkfitz
Email: [email protected]
Telephone: (317) 431-1469 Office hours are by appointment only. Feel free to text
this number or email to set up an appointment.
Course Information
Course Length:
This is a four-week asynchronous course with online delivery.
Instructional Goals:
Students will identify behaviors associated with incivility, complete a self-
assessment to ensure they are a part of the solution, and demonstrate
effective communication skills and conflict management strategies, as victim,
witness, and perpetrator of incivility, through appropriate selection of
behavioral choices in an online simulation.
Course Description:
This course will assist individual nurses to remove the barriers to civility by
increasing awareness of incivility and its effects, including negative patient
outcomes. Students will learn to recognize the signs of incivility, the steps to
take in addressing the behavior, effective communication and conflict
management skills, and how to maintain personal self-worth even in adverse
environments. Students will be prepared to examine themselves to ensure
they are part of the solution and not part of the problem. The students will
be given an opportunity to practice their new skills to develop confidence.
Course Objectives:
Having received information regarding incivility, students will:
BARRIERS TO CIVILITY 90
Recognize and provide examples of incivility during a test at the end of
the didactic portion of the course.
Implement conflict management skills to address incidents of incivility
through a simulation exercise.
Model effective communication techniques as demonstrated by
selection of appropriate behavioral choices.
Write about their experiences during the simulation as a victim,
witness, and perpetrator of workplace incivility during a discussion
board-based debriefing, defining methods of maintaining self-worth in
each adverse environment.
Course Outline
Pre-course Assignment
Written reflection to be submitted prior to or on the first day of the
course
This assignment will take 30 minutes
Didactic Coursework
Students will have one week to complete the didactic coursework and
successfully pass the assessment test at the end.
The assessment test may be taken as many times as necessary to
receive a passing grade (80%). If a student receives less than the 80%
passing grade, the didactic portion will be repeated. Students who
have received less than the 80% passing grade more than one time will
need to schedule an appointment with the instructor.
Simulation
Students will have one week to complete the simulation activities.
Debriefing/Discussion board assignment
Students will have two weeks to complete the discussion board
activities.
First posting is due within three days (see course calendar for details).
The remaining postings are due within two weeks. Students are
encouraged to make their postings early and often as this will increase
collaborative learning between peers.
Students must monitor their own original posting and reply to each
student and instructor post in their thread.
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Course Policies
Email Response Time
Normal turnaround for responses to emails is 24 hours, but could be 48 hours
during weekend and holiday hours.
Grading
This course is graded as pass or fail. To achieve a passing grade, students
must successfully complete all sections of the course, and all assignments.
Course Participation
Attendance and participation in the discussion board portion of this course is
expected for a grade of “pass.” Students will be required to make three
postings, but the more discussion the students participate in, the more
collaborative and active the learning.
Respectful Online Communication
Mutually respectful communication is the foundation of an online learning
environment. Respectful communication is expected from students and
instructors alike. Students who do not maintain civility in their
communications will be withdrawn from the course with a grade of “fail.”
Uncivil communications are any communications that disrupt the learning
environment. These include, but are not limited to: insulting or harassing
remarks, use of profanity, and insults. These communications could be in
emails, on the discussion board, or in assignments and may be directed at
either students or instructors. Civility is expected and required.
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Appendix VI
Learner Survey
Please rank your agreement with the following
statements Disagree
Disagree
a little Neutral
Agree a
little Agree
I would rather read a book than listen to a lecture
If I were lost, I would stop and ask for directions rather
than read a map.
I like to talk and listen.
It is hard for me to sit still and pay attention for a class
that is more than 2 hours in length.
I am confident using a computer.
I enjoy surfing the internet.
I prefer to take classes online.
Yes No
Have you ever taken an online course before?
Learner Pre-Course Survey
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Appendix VII
Teaching Plan
Teaching Plan
Objectives Sub-objectives Content Outline Method of Instruction
Method of Evaluation
Having received information regarding civility, students will:
Recognize and provide examples of incivility during a test at the end of the didactic portion of the course.
Having received information regarding civility, students will recognize examples of incivility during a test. "Incivility" section Didactic
Multiple Choice Test
Having received information regarding civility, students will provide examples of incivility during a test. "Incivility" section Didactic
Multiple Choice Test
Students will identify the importance of civility in the nursing workplace. "Civility in the Workplace" Didactic
Multiple Choice Test
Implement conflict management skills to address incidents of incivility through a simulation exercise.
Students will compare conflict management skills. "Conflict Management" section Didactic
Multiple Choice Test
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After comparing conflict management skills, students will implement the most appropriate skills to address incidents of incivility. Simulation experiences Simulation
Simulation Exercise
Model effective communication techniques as demonstrated by selection of appropriate behavioral choices.
Students will contrast different communication techniques. "Effective Communication" section Didactic
Multiple Choice Test
After contrasting different communication techniques, students will demonstrate effective communication techniques by selection of appropriate behavioral choices. Simulation experiences Simulation
Simulation Exercise
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Write about their experiences during the simulation as a victim, witness, and perpetrator of workplace incivility during a discussion board based debriefing, defining methods of maintain self-worth in each adverse environment
Students will identify potential self-worth issues for those involved with incidents of incivility.
Review feeling words from the pre-course assignment - add these to the power point presentation for the didactic. "Self-Esteem" section Didactic
Multiple Choice Test
After a simulation exercise, students will write about their experiences as a perpetrator of incivility. Second part of reflective writing
Discussion Board
Discussion board assignments
After a simulation exercise, students will compare effective methods of addressing incivility for witnesses. Third part of reflective writing
Discussion Board
Discussion board assignments
After a simulation exercise, students will identify methods of maintaining self-worth for victims of incivility. First part of reflective writing
Discussion Board
Discussion board assignments
Running head: BARRIERS TO CIVILITY 96
Appendix VIII
Pre-Instructional Course Materials
The following assignment will be emailed to all students one week prior to start of
the course:
Think about a time you felt “bullied” by another student, an instructor, a
nurse, or another healthcare provider. Can you remember the details? How long
ago did it happen? What happened? Maybe you were harshly criticized in front of
others for a mistake, or ignored when you asked for assistance. Maybe you were
belittled or a nurse rolled her eyes as you spoke. Take a moment to write down
what happened. Then, write three words to express how the incident made you feel.
Email these three words to your course instructor, as a reply to this email.
Resource:
Center, D. L. (2010). Three a‟s of civility: Acknowledgement, authentic
conversations, and action. Journal of Continuing Education in Nursing
41(11): 488-489.
Running head: BARRIERS TO CIVILITY 97
Appendix IX
Didactic Presentation
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Appendix X
Exam Questions
1. Examples of incivility include:
a. Gossiping
b. Eye-rolling
c. Confrontations
d. All of the above
2. True or false: Disruptive behaviors, bullying, and horizontal violence are all
examples of incivility.
a. True
b. False
3. True or false: There is no legal precedent for incivility.
a. True
b. False
4. True or false: All incidents of incivility should be immediately reported to a
supervisor, even if you were a witness and not the target.
a. True
b. False
5. True or false: Incivility does not affect job satisfaction and therefore does not
impact the nursing shortage.
a. True
b. False
6. Which of the following exacerbates incivility in a nursing unit?
a. Adequate staffing
b. Unrealistic scheduling
c. Low patient acuity
d. Availability of appropriate equipment and supplies
7. True or false: Repeated incidents of incivility may cause symptoms similar to
post-traumatic stress disorder.
a. True
b. False
8. Which of the following statements is true:
a. Incivility on the nursing unit may decrease patient mortality.
b. Incivility on the nursing unit decreases medical errors.
c. Incivility on the nursing unit impairs quality of care.
d. Patients have not been misdiagnosed due to incivility.
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9. True or false: Any compliment you give to someone will always increase their
self-esteem.
a. True
b. False
10. Which of the following compliments will most likely raise the recipient‟s self-
esteem?
a. You had a difficult patient assignment today, but you managed to get
everything done on time and help me! You have excellent time
management skills.
b. Good work with that patient!
c. I like the way you charted that note.
d. You did a good job managing your assignment today!
11. Which of the following may be a driving force for bullying?
a. Fear
b. Anger
c. Reaction to difficulties
d. All of the above
12. Which of the following is a true statement?
a. There is not an addictive nature to bullying.
b. Most bullies, once aware of the problem, can change their behaviors
without any help.
c. Posttraumatic stress disorder can trigger bullying.
d. All of the above are true statements
13. Which of the following will increase good communication?
a. Honesty
b. A closed body stance
c. Lack of eye contact
d. A harsh tone of voice
14. ARCC stands for:
a. Act, Respond, Clarify, Chain of Command
b. Act, Reply, Clarify, Chain of Command
c. Ask a question, Request, Concern, Chain of Command
d. Ask a question, Reply, Clarify, Chain of Command
15. When you ask a clarifying question to learn more you are demonstrating
a. Disarming
b. Empathy
c. Inquiry
d. Stroking
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16. Which of the following statements demonstrates an appropriate use of
conflict management strategies?
a. “I think you are being rude. I feel angry, and I want you to go away.”
b. “You have to listen to me, or I won‟t help you.”
c. “I think we all want what is best for the patient. But, I feel frustrated
with the communication. I want to spend a few minutes focusing on
our report.”
d. None of the above
17. True or false: Since healthcare organizations cannot be held liable for the
incivility of their employees, there is no point in documenting incidents.
a. True
b. False
18. If you witness an incident of incivility, which of the following is the best
course of action to take
a. Do nothing and hope the bully doesn‟t pick on you
b. Give the victim a compliment and explain the bully is just having a
bad day
c. Break the silence and acknowledge there is a problem
d. None of the above
19. True or false: If I am a victim of bullying, I should just ignore it.
a. True
b. False
20. True or false: Creating a culture of civility will improve teamwork and lead
towards improving patient outcomes.
a. True
b. False
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Appendix XI
Answers to Exam Questions
1. D
2. True
3. False
4. True
5. False
6. B
7. True
8. C
9. False
10. A
11. D
12. C
13. A
14. C
15. C
16. C
17. False
18. C
19. False
20. True
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Appendix XII
NLN/Jeffries Simulation Framework
(Jeffries, 2012)
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Appendix XIII
Written Outline of Simulation Exercises
Simulation 1 (Abby):
You graduated nursing school six months ago. After passing your boards and
successfully completing the training program, you are working as a registered nurse
on a progressive care, step-down unit. You have been „on your own‟ for a little over
two months now. You subscribe to several professional magazines, and complete as
much continuing education as you can. However, you still feel like you might be „in
over your head.‟ Your assignment of 3-4 patients per day is challenging, and you
are having a difficult time adjusting. You feel like you are always behind. And,
there seems to be a lack of teamwork on the unit. It seems like everyone disappears
when you ask for help. To make matters worse, one of the other nurses, Jennifer, is
always criticizing you. She is always there to point out everything you do wrong.
Sometimes it seems that she is just waiting for you to screw up. Maybe you are not
really cut out to be nurse, you think as you are facing yet another day of four
difficult patients and running an hour behind schedule on medications.
These thoughts are in your head as you walk into Mrs. Green‟s room. She is a
sweet older lady who has been admitted with another heart failure exacerbation.
She is 300 pounds, and despite wearing a CPAP, drops her oxygen saturation when
she tries to move on her own. You have been monitoring her carefully all day,
trying to prevent another visit to the intensive care unit. Twenty minutes ago she
called saying she needed to use the bathroom, while you were administering
medication to another patient. You asked the nurse‟s aide to put her on the bedpan,
but Mrs. Green states she never came. Mrs. Green is incredibly embarrassed to
admit she had an accident in the bed. “That‟s ok,” you say. “I need to do a skin
assessment, so I‟ll just clean you up and change your linens while I‟m at it. Let me
just step outside and get some help so you don‟t get out of breath with all the
turning.”
When you step outside, Jennifer is just walking into the nurse‟ station, and Carrie
is sitting at one of the computers charting.
Do you try to do it yourself?
o You walk back into the room and explain to Mrs. Green there is no one
available to help, but you need to get her cleaned up. Mrs. Green
states she thinks she can at least roll on her own. During the process
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of turning and cleaning, the CPAP slides off Mrs. Green‟s face, but the
alarms have been silenced so you do not notice. The finger probe for
oxygen saturation also has fallen off Mrs. Green‟s finger, and so does
not alarm when her oxygen saturation level falls into the 80‟s. When
you try to roll her back, you notice her lips are blue and she is
unresponsive. You call a code.
Do you ask for help?
o You take a deep breath, and ask, “Hey, could someone come help me
get a patient cleaned up?”
o Jennifer sighs, rolls her eyes, and walks away. Carrie pretends not to
hear you and picks up the phone.
Do you try to do it yourself?
You walk back into the room and explain to Mrs. Green
there is no one available to help, but you need to get her
cleaned up. Mrs. Green states she thinks she can at least
roll on her own. During the process of turning and
cleaning, the CPAP slides off Mrs. Green‟s face, but the
alarms have been silenced so you do not notice. The
finger probe for oxygen saturation also has fallen off Mrs.
Green‟s finger, and so does not alarm when her oxygen
saturation level falls into the 80‟s. When you try to roll
her back, you notice her lips are blue and she is
unresponsive. You call a code.
Do you choose to be assertive? If so, which statement do you
choose?
“Is anyone available to help me? Please?!”
o No one answers, so you try to do it yourself
o You walk back into the room and explain to Mrs.
Green there is no one available to help, but you
need to get her cleaned up. Mrs. Green states she
thinks she can at least roll on her own. During the
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process of turning and cleaning, the CPAP slides off
Mrs. Green‟s face, but the alarms have been
silenced so you do not notice. The finger probe for
oxygen saturation also has fallen off Mrs. Green‟s
finger, and so does not alarm when her oxygen
saturation level falls into the 80‟s. When you try to
roll her back, you notice her lips are blue and she is
unresponsive. You call a code.
“Jennifer, I think you are busy, but I feel like I‟m
drowning and I really need some help. Would you have
some time to assist me in turning this patient in 10
minutes?”
o Jennifer agrees to help you in 10 minutes. You
return to Mrs. Green‟s room and tell her everyone
is busy right now, but help is coming in 10 minutes.
In the meantime, you will give her her medications
and help her with bathe what can be reached
without turning.
Simulation 2 (Jennifer):
You have been a nurse on the progressive care step-down unit for 16 years. You
have watched nurses come and go, some have left the unit, some have left nursing,
and some have been promoted to management. You are frustrated with the fact
that nothing ever changes on your unit. Now they expect you to be a charge nurse
and take an assignment of 2-3 patients. You used to enjoy being charge nurse
because it gave you a break from the challenging patients on the unit. Now, it
seems they are always asking you to do more with less. What‟s more, this new
group of students got even less training than the previous groups, and you feel like
it‟s a danger to the patients to cut back on training. Abby is always reading about
improving her nursing skills, and she has a lot of book knowledge, but she has
difficulty translating that to bedside skills. You feel like you have to point out some
of her bigger mistakes so she can learn from them. It‟s a matter of protecting the
patients. But she does not see it that way. She gets upset every time you bring it
up. Obviously she has a lot of growing up to do.
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On top of all these frustrations, you have started having problems with your back.
By the end of your shift, you can hardly sit still in your car long enough to drive
home. The doctor said you needed to be on lift restrictions, but that would mean
you could not work. You still have bills to pay, and now medical bills on top of it.
Even being a charge nurse is hard work for your back since you now have to take a
patient assignment. Long ago you told upper management you were not interested
in a management position because you love bedside nursing. Now, things have
changed, but no one is willing to give you a chance. Maybe it‟s too late.
And, of course, Abby is working today and you are in charge. She is already behind
in her assignment. You have three patients, and you have managed to stay on top
of their medications. What is wrong with her time management skills? She has
needed help multiple times today. And she never remembers to put the bed up
when moving her patients. Didn‟t her school teach her proper body mechanics?
Finally, all your patients‟ needs are met and you have a few minutes to sit down
and do some charting on this crazy new computer system. You really have to
concentrate on what you are doing when you are using the new system. Some of the
younger nurses just fly through their charting. How can they be thorough? Just as
you start to sit down, you hear Abby‟s voice asking for help . . . again. „Forget it,‟
you think. As you walk off down the hallway to use another computer.
What could you have done differently?
Nothing, Abby needs to learn how to be a better nurse
o Abby decides she can handle caring for the patient herself, finally. A
little bit later you hear her yelling to call a code blue. You run into the
room and find he patient unresponsive with blue lips. Abby is too
upset to even explain what happened. You start chest compressions
while Carrie grabs the crash cart.
Maybe you should have practiced some of those communication techniques.
You walk back down the hall, take a deep breath and say, “Abby, I‟m sorry,
what did you say?”
Abby repeats her request for assistance in turning a patient. Which
statement do you make?
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o “Abby, you have a nurse‟s aide assigned to help you. You need to ask
her for help, that‟s all part of delegating, one of your responsibilities as
a professional nurse.”
As you walk away, Abby is calling the nurse‟s aide like she
should have before asking you for help. You sit down to catch up
your charting, and a few minutes later hear Abby yelling to call
a code blue. You run into the room and find he patient
unresponsive with blue lips. Abby is too upset to even explain
what happened. You start chest compressions while Carrie
grabs the crash cart.
o “Abby, I know you need help and I am caught up on patient care. I
think I can help you right now, but I feel overwhelmed with this new
computer system. I need to do some charting without any
interruptions.”
Abby suggests after you help her, she will sit down and help you
with your computer issues. She seems to always be on top of her
charting, so you agree. Teamwork has won out today.
Simulation 3 (Carrie):
You have been a nurse for 8 years, with 5 of those being on this progressive care
step-down unit. You like your job, and you enjoy taking care of patients, even the
challenging ones. You know Jennifer is one of those nurses who seem to get
pleasure out of putting other nurses down. In fact, when you were new to this unit,
she used to pick on you all the time. However, you put up with it, and now you and
Jennifer are colleagues. However, you wish Jennifer would not always complain to
you about the new nurses. She seems to have such a difficult time trying to find
anything nice to say about them. But you hesitate to say anything because you
don‟t want to become one of her targets again. Besides, you don‟t do so well with
conflict.
Recently, Jennifer has really been picking on Abby, which is a shame because Abby
is so enthusiastic about nursing. Just last week Abby was telling you about an
article she read in a professional magazine. It was a magazine you subscribe to, but
they have been collecting dust on the shelf. You went home and found that article
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and ended up reading the entire magazine. It would be nice to start a journal club
again, especially with young nurses like Abby.
Today Abby was given a very hard assignment. It would have been difficult for a
seasoned nurse to keep up, but Abby has done the very best she could and only
asked for help a couple of times. However, each time she asked for help Jennifer
rolled her eyes and sighed. You are worried because you know if nurses don‟t work
together it is the patient that suffers.
You are just about to call the pharmacy about a missing drug that is due in 30
minutes when Abby sticks her head of a room and asks Jennifer to help her turn a
patient. You watch Jennifer roll her eyes and sigh then head off in the opposite
direction, pretending not to hear. What do you do next?
Pick up the phone and call pharmacy. You don‟t really want to get involved
and after all, she didn‟t ask you for help.
o Abby sighs and goes back into the room. A little while later you are in
another room with one of your patients when you hear Abby yelling to
call a code. You rush to the room and find Abby speechless and white,
and Jennifer doing chest compressions. You go grab the crash cart.
Get up and go help Abby. Your phone call can wait.
o Abby thanks you for your assistance, but seems near tears. As you
walk out of the room, Abby sighs and says maybe she is not really cut
out to be a nurse. Which statement do you make next?
“Abby, you should stand up for yourself to Jennifer. You are a
good nurse.”
“I suppose so,” says Abby. Three months later Abby gives
her two-week notice. She is going back to school for
elementary education.
“Abby, you have a very tough assignment today, but you have
been able to meet all your patients‟ needs. You have only asked
for help three times, which I find impressive. You are doing a
great job!”
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“I suppose so,” says Abby. What do you say next?
o Nothing – your job here is done.
Three months later Abby gives her two-week
notice. She is going back to school for
elementary education.
o “Abby, I have seen the way Jennifer treats you. We
need to report her incivility to the manager. I will
come with you.”
You and Abby speak with the manager, who
sits down with Jennifer. Then, Abby and
Jennifer sit down together with the
manager. Jennifer is horrified. She did not
realize how her attitude was affecting Abby,
and she thought she was really just trying to
help Abby be a good nurse. Abby and
Jennifer may not be best friends, but they
are able to work together, fostering civility
on the unit.
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Appendix XIV
Debriefing Activities
Initial Posting Assignment:
Think about your experiences in the online simulation. You may have had
different experiences than your peers. Take ten minutes to write about your
experiences as Abby, the victim of incivility. How did you feel? How could
effective communication techniques have helped you? Could you have used
any conflict management strategies to improve the situation? What will you
do differently the next time?
Now take ten minutes to write about your experiences as Jennifer, the
perpetrator of incivility. How did you feel? How could effective
communication techniques have helped you? Could you have used any
conflict management strategies to improve the situation? What will you do
differently the next time?
Finally, take ten minutes to write about your experiences as Carrie, the
witness to the incident of incivility. How did you feel? How could effective
communication techniques have helped you? Could you have used any
conflict management strategies to improve the situation? What will you do
differently the next time?
Post your reflective writings to the discussion board under the appropriate
thread.
Second Posting Assignment:
Think about your interactions over the past week. Have you had an
opportunity to use a specific effective communication or conflict management
technique? What went well? What can be improved upon the next time? Did
you notice your “cow path” or automatic reaction?
Take five minutes to write about the experience. Post your reflective writing
to the discussion board under the appropriate thread.
Subsequent Assignments:
Check into the discussion board often, daily if possible, but at least every
other day.
When students or instructors post a reply to your original posting, be sure to
respond.
Reply to at least two of your peers‟ reflective writings. The posts should be
substantive, at least 250 words. They should also be constructive, rather
than a simple “good job.” Remember to apply the principles learned in class
about giving meaningful compliments.
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Appendix XV
Evaluation Tool
1. Are the conditions appropriate to the objectives? Yes No
a. If no, please elaborate:
2. Does the instruction match the objectives? Yes No
a. If no, please elaborate:
3. Does the instruction provided lead students to objective achievement?
Yes No
a. If no, please elaborate:
4. Does the syllabus provide clear directions? Yes No
a. If no, please elaborate:
5. Is the plan clear for instructors? Yes No
a. If no, please elaborate:
6. Are the test items appropriate? Yes No
a. If no, please elaborate:
7. Are the evaluation methods appropriate? Yes No
a. If no, please elaborate:
8. What does the plan do well?
9. What improvements can be made?
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Appendix XVI
Evaluation Results