Civil behavior in cyberspace is an important element of online communications. However, it is challenging to define and teach due to subjectivity and personal bias on what constitutes cybercivility and cyberincivility. Obvious examples of misbehavior take various forms in online interaction and include trolling (making rude remarks), flaming (posting or sending offensive messages over the internet) or cyberbullying (sending mean, threatening or embarrassing messages to or about another person).1 Defined as disrespectful, insensitive or disruptive online misbehavior, cyberincivility has been documented in health professions education (HPE) as having implications for students’ psychological, physical and social wellbeing, as well as academic outcomes.2 Teaching cybercivility requires thoughtful attention to both curriculum development and the delivery of content. Providing students with specific knowledge and skills, as well as an understanding of consequences of uncivil behaviors, helps them establish a practice of cybercivility.3 As such, it is critical to implement a well-designed program of instruction with the intention of promoting ethical knowledge and skills through both formal and informal curricula.3
While research confirms that cyberincivility has a negative impact on learning in HPE, the effectiveness of interventions is not well known. Some core competencies of interprofessional education (IPE) are closely related to cybercivility, yet interprofessional cyberincivility in health professions is not well studied.4 In recent years, efforts have been made to fill this gap in the literature. In a review that synthesized evidence-based guidelines to enhance the online learning environment, De Gagne et al.3 suggested that fostering professional development requires not only the cultivation of knowledge and skills but also the socialization of students within ethical and moral frameworks. Evidence suggests that health professions’ students lack this knowledge and could benefit from online courses, resources and formats that facilitate discussions about misbehavior in the cyber environment.3 The literature recommends development of cybercivility education, including interprofessional training, especially for healthcare professionals. There is a need for research to explore the effectiveness of role modeling, as well as training, at both the individual and organizational levels.3 Given the increasing prevalence of online learning platforms, social networking and digital communication, the need has never been greater for educators to adopt effective strategies.
In an effort to better understand students’ needs for cybercivility learning, a team of education researchers conducted a gap analysis with 205 students in medicine, nursing, physician assistant and physical therapy programs at a large, private university in the United States.4 Overall, participants reported that they believed they would benefit from lessons about cybercivility in IPE programs. Findings from studies by Chretien et al.5 and Marnocha et al.6 found most of their participants experienced cyberincivility and saw it as a moderate to serious problem. In a study by De Gagne et al.,4 participants had a high level of knowledge about cyberincivility, but had difficulty differentiating between cyberincivility and cyberbullying. There was also variation in the type, degree and frequency of cyberincivility experiences. However, scholars maintained that cyberbullying is a form or a subset of cyberincivility, a more general misbehavior in cyberspace.7-8 In this review, cyberincivility is used as an umbrella term to include cyberbullying and cyberaggression. Participants indicated that learning about cybercivility in IPE would be highly beneficial, especially within the domain of values/ethics.4 Participants preferred learning within the context of existing courses, but also endorsed a variety of other learning formats.4
Other studies2,9 have confirmed the importance and need of incorporating cybercivility into ethical and professional standards, and curricula for health professions education. A qualitative study with 25 health professions’ students9 used semi-structured, web-based interviews to gain an understanding of how participants defined cyberincivility and their views on ways to incorporate teaching on cybercivility into educational curricula. The interviews revealed a variety of definitions, attributable in part to the lack of required cybercivility training within any of the professions. The interviews confirm findings from previous studies that students of health professions frequently experience uncivil communication.2 This study provides evidence that the development and implementation of curriculum for cybercivility across healthcare professions may be beneficial in improving interprofessional communication. To that end, educators of health professions should devise conceptual frameworks and models that facilitate formal assessment and evaluation of learning objectives in cybercivility instruction.
While the literature clearly documents the need and importance of education on cybercivility in IPE, the best method for providing this instruction is less clear. Conceptual models or frameworks often provide useful guidance when new knowledge and skills need to be integrated into existing professional practice.10-17 Referred to as sets of general concepts and propositions, conceptual frameworks illustrate the logic, relationships and structure between ideas and concepts.18,19 Conceptual frameworks are also called conceptual models or systems.19 Sets of values or beliefs, as in a particular philosophical stance, are reflected in conceptual frameworks.19 These theoretical frameworks, also referred to as philosophical frameworks or paradigms of a specific school,20 are derived from theories that have been validated.18 Although theoretical frameworks are considered more abstract than conceptual frameworks, conceptual frameworks and theoretical frameworks will be used interchangeably in this review.21
Conceptual frameworks play an important role in the practice of HPE.10 In HPE, conceptual frameworks offer a means for developing the depth and breadth of competencies and behaviors essential to health professions’ students.10 The effectiveness and efficiency of curriculum can be facilitated by conceptual frameworks that are open, flexible and agile.10 Therefore, the aim of this scoping review is to examine conceptual and theoretical models that are relevant to the pedagogical aspects of teaching cybercivility to students of health professions. Based on a preliminary search of PubMed and CINAHL, no scoping reviews on this topic exist. The findings of this review will inform educators in health professions about relevant models to develop, implement and evaluate cybercivility instruction in HPE. The review may also help identify theoretical gaps for researchers wishing to construct their own theories or models, which are then put into practice.
What conceptual and theoretical models are relevant to the pedagogical aspects of cybercivility in HPE?
The review will consider studies that include students of health professions exposed to disrespectful, insensitive or disruptive behavior in email communications, online courses or on social networking sites. Students’ narratives on academic dishonesty, misuse of social media and failure of accountability and responsibility in the online learning environment are powerful resources to develop formal and hidden curricula of cyberincivility.3 For this scoping review, students of health professions are defined as undergraduate medical students, pre- or post-licensure nursing students, dentistry students, pharmacy students, allied health professions students or students enrolled in other healthcare-related educational programs. Interns or residents are not included, and if they account for more than 50% of the subjects in a study, that study will be excluded from the review.
The concept of interest for the proposed scoping review is a framework, model, system or paradigm that has guided the education of students of health professions related to cyberincivility. King12 established that conceptual frameworks offer a method of categorizing the information, skills and values of a discipline in a manner that shows the association between the essential knowledge and the procedures that activate that knowledge. Huckabay11 further asserted that the use of conceptual frameworks in education offers the medium for conceptual consistency, theoretical development, unity and continuity within the profession, in addition to student performance evaluation as a criterion. Similarly, the use of frameworks provides educators direction for building a curriculum by demonstrating the knowledge or skills students need to attain.11 As such, it is important for educators to assess, use, improve and test the conceptual model they select.11
The context of the review is the academic setting, hospital, community, clinic, skills laboratory and virtual classroom, and platforms such as virtual communications including emails and blogs, online courses, discussion forums or any other settings where cyberincivility takes place or has been explored. The specific contextual focus will be on conceptual, theoretical or philosophical frameworks or models relevant to the pedagogical aspects of cybercivility in curricula for health professions students.
Types of studies
This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, interrupted time-series studies, analytical observational studies (including prospective and retrospective cohort studies), case-control studies and analytical cross-sectional studies. This review will also consider inclusion of descriptive observational study designs including case series, individual case reports, descriptive cross-sectional studies and qualitative studies that focus on qualitative data including designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, feminist research and systematic reviews. Dissertations may also be considered, but not conference abstracts and posters due to their brevity. Editorials, commentaries and opinion papers will be excluded due to potential bias. The search will be limited to studies published in English. The date of the search will be limited to studies published after 2007 since a previous integrative review of cybercivility in health professions education, which began in the year 2000, found that the first reference to cyberincivility was published in 2007.2
This review will adhere to the JBI methodology for scoping reviews.22
The search strategy will follow a three-phase approach with an aim to identify both published and unpublished studies. In the first phase, a draft search was conducted in PubMed (MEDLINE) and CINAHL (via EBSCO) followed by an analysis of text words in the titles and abstracts as well as index terms. During this process, the authors experimented with adding the concept of curriculum to the HPE part of the search. This did not yield relevant results, so the terms were removed. Additionally, the authors decided not to limit the search unnecessarily by using keywords for framework or model. A full search strategy for PubMed (MEDLINE) and CINAHL (via EBSCO) is detailed in Appendix I. In the second phase of the search, a final search strategy will be adopted for each information source. The reference lists of all selected studies will be screened for additional studies during the third phase of the search.
The databases to be searched include PubMed (MEDLINE), CINAHL (via EBSCO), Education Resources Information Center (ERIC), Embase, PsycINFO (via EBSCO) and Education Full Text (H.W. Wilson).
The search for unpublished studies will include the ProQuest Dissertations and Theses Global database, OpenGrey, and PaperFirst. The authors will also review reference lists for all included studies.
All citations identified in the search results will be uploaded into EndNote X9 (Clarivate Analytics, PA, USA), and duplicates removed. The citations will then be imported into Covidence online software (Veritas Health Innovation, Melbourne, Australia) for screening. Two independent researchers will examine titles and abstracts for inclusion. The full text of selected studies will be retrieved and assessed. Full-text studies that do not meet the inclusion criteria will be excluded, and the reasons for exclusion will be provided in an appendix in the final scoping review. Any disagreements that arise between the researchers during either title and abstract screening or full text screening will be resolved through discussion, or with a third reviewer. Included studies will undergo a process of data extraction. The results of the search will be reported in full in the final article and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.23
Assessment of methodological quality
A formal assessment of methodological quality will not be performed as the purpose of this research is to provide an overview of frameworks and models that have been used to theoretically conceptualize cybercivility in education in health professions. The goal of this review is to provide a map of the evidence produced as opposed to selecting quality evidence to answer a research question.22
The data extraction instrument was adapted from the standardized JBI data extraction tool (Appendix II) in JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (JBI, Adelaide, Australia) to answer the research question. Data will be extracted from the papers included in the review by two independent researchers using the data extraction instrument (Appendix III). The data will include specific details about the population, concept, context, study methods and key findings relevant to the review objective. Any disagreements that arise between the researchers will be resolved through discussion or with a third researcher. For automated qualitative data analysis, NVivo 12 (QSR International Pty Ltd, Doncaster, Australia) will be used. In this computerized method, each document stored in JBI SUMARI will be imported into NVivo as a “case” to manage text data in references, synthesize and report the results.24 Each case will be assigned “attributes” (e.g. author, study year, country, study design, keywords). Texts pertinent to the review questions will be recorded in a data extraction form, and each document will be coded, analyzed and synthesized for main themes to emerge. The draft data extraction tool will be modified and revised as necessary during the process. Modifications will be detailed in the full scoping review.
The extracted data will be presented in tabular form and as a narrative summary that aligns with the aim of this scoping review. The table will report: i) distribution of studies by authors/year/countries of origin/study design; ii) health discipline(s)/participants/sample size; iii) domains of cyber environment identified in articles; iv) purpose of framework/model; v) framework/model details; vi) framework/model contribution to the body of knowledge in cybercivility; and vii) framework/model value in cybercivility curriculum, as detailed in Appendix III. This table may be further refined at the review stage. Graphical representations may be used, including bar charts, line charts, pie charts and diagrams.
The current review is supported by a 2018–19 Duke AHEAD Supporting Health Professions Educators (DASHE) grant awarded to the first author (JCDG).
Appendix I: Search strategy
Database: PubMed (MEDLINE)
Database: CINAHL Complete (via EBSCO)
Appendix II: Standardized JBI data extraction tool
Appendix III: Data presentation form
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