Incivility in nursing is a well-documented phenomenon. Nursing students (NSs) have frequently reported incivility in their clinical learning environment (CLE). Incidences of incivility are not often overtly aggressive but are manifested as subtle and disrespectful behaviors not meant to harm the subject.1-6 These behaviors negatively impact learning, communication, job satisfaction, physical and mental health, and patient safety and care.7-9 Incivility is often a learned and modeled behavior and may become a norm for professional relationships.10 While there is a plethora of literature on the effects of incivility, few evidence-based interventions to combat this behavior can be found in the literature, particularly targeted toward NSs.
After receiving anecdotal feedback from NSs and observing uncivil behaviors between direct care nurses (DCNs) and NSs, a group of hospital-based clinical nursing instructors at a Midwest, Magnet®-designated, pediatric hospital identified a need to understand the prevalence of incivility and its effect on learning objectives and outcomes for NSs in the CLE. The clinical instructors pursued evidence-based clarification of this issue and developed a valid and reliable research tool entitled Nursing Student Perception of Civil and Uncivil Behaviors (NSPCUB) in the Clinical Learning Environment Survey11 that quantified NSs’ perceptions of incivility. Upon further literature review, no evidence-based interventions that address these experiences were found. The primary objectives of this study were to measure student perceptions of incivility in the CLE and test interventions that improve civility in this environment. The secondary objective was to further test the reliability of the NSPCUB.
Review of Literature
Extensive research is available on the concepts of incivility, bullying, lateral and horizontal violence in the nursing profession.6,8,9,12-15 A literature review was conducted to explore incivility toward NSs in the CLE. Despite the wealth of research on incivility in nursing, there is little involving the incivility that is experienced by NSs from DCNs in the CLE. Furthermore, there were limited studies that identified interventions to combat incivility, bullying, and horizontal violence in nursing toward NSs.16-18
A descriptive phenomenological study by Mott19 described the student perception of bullying. While 1 student described a faculty member’s behavior as unprofessional, another student considered it as bullying, based on the lived experiences of the student encountering the behavior. Mott19 also found that a student’s comfort level in the learning environment impacted his/her ability to learn. Learning environments where staff were described as unresponsive or unreceptive to student needs were detrimental to the student’s learning experience, whereas approachability, accessibility, and caring by the faculty led to more positive learning environments. Similarly, Honda et al20 found supportive and welcoming hospital environments enhanced student feelings of belonging, which increased their motivation for learning. The students’ feelings of isolation and alienation from the team on the unit had a negative impact on their willingness and ability to learn. Conversely, acceptance by and support of the nurse preceptor were vital influences on the student’s motivation to learn.
Organizations with uncivil work environments often have difficulty recruiting and retaining new graduates.16-18 Although nurse managers may recognize and address overt incidents of bullying, they often lack tools or guidelines to aid in the more covert incidents of incivility.16,18 Positive clinical experiences on the part of NSs may influence an organization’s ability to recruit these graduates as new employees. Therefore, the purpose of this study was to measure NSs’ perceptions of incivility in the CLE and test interventions to improve civility in the CLE. The creation of evidence-based interventions to combat incivility will provide hospital leaders with means to create a more supportive CLE that may lead to improved recruitment and retention of graduate nurses.
The theoretical framework supporting this research is the model implemented by the participating facility to guide nursing clinical practice: Duffy’s21 Quality Caring Model. The model focuses on caring relationships based on 8 caring factors. Many of the factors, such as mutual problem solving, attentive reassurance, human respect, and encouraging manner, can be precursors to establishing a positive student-centered learning environment.21 The feeling of being cared for can facilitate learning, risk taking, and follow-through and influence future interactions. Positive relationships can lead to professional growth, improve patient care, and have a positive impact on student learning. In short, the attitudes of nurses influence the students’ learning experiences.2,3,10
Design, Sample, and Procedure
This was a single-site, quasi-experimental, nonequivalent pre-post design research study conducted in a Magnet®-designated pediatric hospital. A convenience sample of NSs was recruited on the 1st day of their clinical experience on 10 inpatient units. The preintervention data collection was performed August 2015 to February 2016, and postintervention data were collected August 2016 to February 2017. The primary investigator identified recruitment locations and times, and investigators met with students to invite them to participate. Recruitment occurred during the clinical post conference. After the researcher exited, students were given an opportunity to use computers and personal cell phones to complete the tool using SurveyMonkey. Alternately, NSs were given the option to complete the survey within 1 week at their convenience.
The hospital’s institutional review board approved this study. Data were collected using the NSPCUB in the Clinical Learning Environment Inventory.11 NSPCUB is a valid and reliable instrument to measure NSs’ perceptions of uncivil and civil behaviors displayed by DCNs in the hospital clinical environment. The instrument consists of 12 items, with each researcher-generated construct (mutual respect, guided participation, and student centeredness) having 4 items. The Cronbach’s α scores for the instrument and its constructs were greater than 0.70. Validity was obtained via literature, representatives of the population (focus group), and content experts (faculty). The responses were reported on a 4-point Likert scale ranging from “strongly disagree” to “strongly agree.” The NSPCUB includes demographic data including age, gender, previous work experience, primary language, type of nursing program, prior post–secondary school degree, ethnicity, and race. Two open-ended questions, “Were there any experiences on this unit today that made you feel welcomed as part of the patient care team?” and “Were there any experiences on this unit today that made you feel ignored, unwanted, or disrespected?” allowed the respondent to provide additional qualitative data regarding his/her clinical experience.
The preintervention data helped to identify overall organizational and unit-specific areas for improvement. Collective preintervention results were presented hospital-wide, and unit-specific results were shared with the shared governance councils of each participating unit.
Mandatory education for the nursing staff was presented through “Seasons of Learning,” the facility’s educational blitzes that are broadcasted 4 times a year (with each season). This session, broadcasted in summer 2016, included presentation of quantitative and qualitative hospital-wide survey results, educational strategies for working with students, and video depicting examples of scenes of incivility between NSs and DCNs. The video was created prior to this research and was based on information gathered from the literature review, previous focus groups, and experientially shared and/or observed interactions by full-time hospital-based clinical instructors. The behaviors portrayed in the video were consistent with themes of preintervention data results.
The unit councils consist predominately of RNs, with the purpose of promoting shared governance by providing autonomy, accountability, and ownership to address unit-specific concerns. Councils were given only their unit results to compare with the hospital’s collective results. Themes drawn from the qualitative data were shared with unit councils as well as the number of positive and negative comments. Researchers then partnered with unit councils to facilitate unit-specific intervention strategies, addressing areas of lowest scores. Each unit was asked to create 1 interactive and 1 educational intervention. For example, 1 unit chose to create a Student Welcome Card (a student interactive intervention). Educational materials were disseminated via an informational paper strategically located in the rest room (“potty paper”) and on the unit’s video slide board in the break room entitled “Nurses Help Us Welcome Our Student Nurses” (a staff educational intervention). A list of interventions by unit is provided in Figure 1. Once interventions were complete, postintervention data were collected using the same procedure as the preintervention data, with a different group of students.
For preintervention data collection, of the 652 eligible students, 320 participated (49.1%). In the postintervention data collection period, of the 591 eligible students, 422 students responded (71.4%). The mean of each item, the mean of all 12 items, and the mean of the 3 constructs were calculated. Before analysis, applicable items were reverse scored. Table 1 provides a summary of the hospital-wide cumulative result, including a listing of the survey item, the number of preintervention and postintervention surveys completed, and the P value for each item. The preintervention and postintervention means were compared using an independent-sample t test. P values are bolded if significant at <.05. A high score is desired, with 4.0 being the best score, denoting the least incivility. There was a statistically significant mean increase for 7 of the 12 items, as well as for the overall total score. There was also a statistically significant increase in the mean for 2 of the 3 constructs, guided participation and student centeredness (Supplemental Digital Content 1, http://links.lww.com/JONA/A647).
The same analysis was conducted for each of the 10 units. The results are summarized in Table 2 showing preintervention n, postintervention n, whether there was improvement in total score, the number of items that showed any improvement, and the number of items that were statistically significant. The total postintervention scores were improved for all but 1 unit. This unit, designated as D, dropped from a total score of 3.48 to 3.39, which was not a statistically significant difference. Five of the units had a statistically significant mean increase for at least 1 item. Unit J had improvement in all 12 items, with a statistically significant increase in 11 items.
Demographic data were collected and analyzed using independent-sample t tests (variables with 2 choices) and 1-way analysis-of-variance tests (variables with >2 choices). One demographic difference worth noting was the student’s age. In the preintervention data collection, students 25 years or younger showed statistically significantly better scores (P < .05) for “RN was disrespectful to me,” “RN calmed my anxieties,” and “RN embarrassed me” (Supplemental Digital Content 2, http://links.lww.com/JONA/A648). This suggested that older students perceived more incivility than did those students who were 25 years or younger. These differences were not apparent during the postintervention data collection, with no items showing statistically significant differences between age groups.
The NSPCUB was further tested for reliability. The 12 items were analyzed, and the applicable items were reverse scored. Cronbach’s α for the entire instrument was 0.927. Cronbach’s α was performed on the 3 constructs (Table 3). The constructs scored 0.675 (mutual respect), 0.859 (guided participation), and 0.886 (student centeredness). Cronbach’s α scores for the instrument were 0.933, 0.880, and 0.863, respectively, when constructs were deleted. These scores indicate high reliability.
We were able to successfully demonstrate a measured improvement in unit civility with targeted interventions. Cronbach’s α scores for the entire instrument and its constructs continue to indicate high reliability of the NSPCUB as a tool to measure NSs’ perceptions of incivility in the CLE. Data gathered from the NSPCUB surveys were useful in identifying areas of perceived incivility requiring improvement hospital-wide and on each unit. The research team felt that by asking unit councils to create interventions there would be greater buy-in and ownership from staff. Interventions varied per unit as interventions were unique to each CLE and based on individual unit results. The unit that demonstrated the greatest improvement had leaders who were heavily involved and engaged in the implementation process and chose to develop these interventions as a quality improvement project on their unit. It is interesting to note the high rate of survey return. Comments shared verbally during recruitment and in qualitative data revealed students’ appreciation of this research, which may have validated the importance of their experiences related to civility in the CLE.
Of note, there were differences in the perceptions of civility between traditional-age students (<25 years old) and non–traditional-age students (>25 years old). Traditional-age students scored nurses significantly higher (more civil) that did the non–traditional-age students in the preintervention data collection. One might question whether these results reflect differences in expectations between generations or differences in DCN interactions with younger students.
Implications for Nurse Leaders
This study demonstrated that the presence of perceived incivility in the CLE does exist in our hospital learning environment, and the ability to effectively change this perception is possible by creating hospital-wide awareness and empowering DCNs to identify and implement interventions for areas necessitating change. It is vital to understand that the implications of perceived incivility on behalf of a student extend far beyond the clinical experience. In addition to influencing retention by decreasing job dissatisfaction and creating a smooth transition to practice for new graduate nurses, reduction of medication errors and negative patient outcomes are also a resulting factor.7-9 Incivility is often a learned and modeled behavior, necessitating the need to address and manage uncivil behaviors as they are revealed. As the responsibility of addressing and managing these behaviors falls to nursing leadership, important to note is that the unit with the greatest number of areas demonstrating statistically significant change had management involvement and accountability in the implementation of the interventions created by the DCNs.
A limitation of this research includes data collection being isolated to a single pediatric facility. Also, to promote consistency in data collection, the survey was administered to students on their 1st clinical day; however, it is unknown if perceptions might have changed following the 1st clinical day. Although the sample size was relatively large (preintervention n = 314 and postintervention n = 410), lack of diversity in ethnicity, age, and program selection is a limitation, with the majority of respondents identifying themselves as white (92%), between the ages of 20 and 25 years (70%), and enrolled in a BSN program (traditional and accelerated = 87%).
Additional limitations include the variation of interventions between units and the inability of the research investigators to monitor the consistency and sustainability of intervention implementation. Our study included only undergraduate students in the inpatient setting and should not be generalized to advanced practice students or students in community or ambulatory settings.
This study further substantiated the reliability of NSPCUB as a tool to measure perceived incivility by NSs in the CLE. The quantitative and qualitative data collected from this survey were useful in identifying areas requiring improvement and revealed the existence of perceived incivility in our facility. Postintervention data showed significant improvement after implementation of hospital-wide education and unit-specific interventions created by unit councils. Because the unit with the greatest statistically significant improvement was the only unit with management and educator involvement, future research in this area should consider management involvement in the implementation process.
Because incivility is often a learned behavior, as it is witnessed by NSs in the CLE when preparing to transition to the clinical practice, it would be reasonable to infer that these practices of incivility are modeled and accepted as the normal framework of the nursing practice.10 Nurse leaders should consider the NSPCUB tool to identify areas of perceived incivility and involve staff in creating interventions to combat this issue with the end result of creating a positive learning environment. A more supportive CLE will lead to improved recruitment and retention of graduate nurses. Further research is currently underway to test the applicability of NSPCUB for newly licensed nurses during their orientation process.
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