Civility is characterized by an authentic respect for others involving time, presence, engagement, and an intention to seek common ground.1 Treating one another with respect and civility is requisite to effective communication, team building, and constructive conflict negotiation. According to Clark,2 incivility is the display of rude or disruptive behavior that can result in psychological or physiological distress for the people involved and, if unaddressed, may progress into unsafe or threatening situations. Acts of incivility can take various forms including uncivil nonverbal and verbal behaviors and failing to act when warranted, especially when patient safety is at risk.
Incivility in academic and clinical settings can have a harmful impact on nursing students, faculty, and members of the health care team and interferes with the important work nurses do. Uncivil encounters are particularly critical in health care environments since incivility and other forms of relational aggression can result in life-threatening mistakes, preventable complications, and patient harm.3-7 Therefore, it is critical for all members of the nursing profession to raise awareness about the importance of fostering civility to promote and protect patient safety. In a high-stress work environment where change is constant and where complex and demanding workloads are common, decisions made by nurses and other members of the health care team can mean the difference between harm or no harm to patients. Unfortunately, clinical judgment and sound decision making may be negatively impacted by acts of incivility.8
As students enter a nursing program, they have limited knowledge and experience about what it means to be a safe, proficient, professional nurse. In some cases, students lack positive role models to demonstrate the importance of caring, empathy, and compassion for patients, and unfortunately, some students encounter uncivil situations with peers, faculty, or preceptors that they are unprepared to manage effectively. This lack of experience may lead students to develop unclear perceptions of how to behave as a professional nurse. Both the stress caused by and examples set by these conflicted encounters may carry throughout school and into students' nursing careers, creating worrisome cycles of incivility that can threaten patient safety, cause vulnerability, and result in nurses leaving the organization or the profession altogether.9 Some of the most vulnerable groups to experience incivility in nursing include nursing students, newly graduated or inexperienced nurses, and nurses new to different positions or areas of practice.10,11 Studies reveal that incivility in the work environment is a major source of nurse job dissatisfaction resulting in higher rates of turnover among newly graduated nurses12 and an increased intention to leave.13
To prevent and address these concerns, nurses are called on to foster safe, ethical, civil workplaces where all members are valued and treated with respect.14,15 Nurse educators have a fundamental responsibility to educate students about the importance of professionalism, civility, ethical conduct, and effective communication throughout their nursing program and as they transition into practice. This article describes an innovative learning experience designed to prepare students to prevent and address incivility in academic and health care environments and reports assessment data from student users.
Civility Mentor: A Virtual Learning Experience
Civility mentor is a virtual learning experience designed to educate nursing students about the consequences of incivility, develop essential skills to foster civility, communicate more assertively, and address uncivil encounters in academic and health care environments. Civility mentor utilizes a series of on-screen simulations to illustrate the nurse's professional role and the critical importance of collaborating as members of an interprofessional health care team. A variety of peer-to-peer, student-to-preceptor, nurse-to-charge nurse, and other simulations are designed to build nursing students' skills and confidence as they learn, practice, and apply techniques in conflict negotiation, effective communication, stress management, reflective practice, and professional, ethical conduct.
Civility mentor is delivered using an online platform where students interact with emotionally responsive virtual humans within each simulation. Students engage in virtual, real-time conversations; receive in-the-moment feedback from virtual coaches; and explore various pathways to better understand the impact of the communication choices they selected. The virtual coach (Supplemental Digital Content 1, Virtual Coach, http://links.lww.com/NE/A708) is built into the software and provides immediate feedback to help students become more aware of their communication style and the impact on others and suggests ways to improve conflicted interactions. The learning experience is designed to promote empathy and perspective taking for patient-centered care, clarify the ethical obligation of nurses, develop self-awareness of desired professional behaviors, understand the impact of incivility on patient safety, provide skill building for effective communication and constructive conflict management to address conflicted situations, and foster understanding of professional conduct necessary in academic and work environments. Some examples of effective communication techniques used in civility mentor include the use of “I” messaging, open-ended questioning, appreciative inquiry, principled negotiation, and evidence-based approaches to script respectful responses to address uncivil encounters. For more information on communication techniques, see Clark.16
Virtual Human Interactions
Learning is traditionally categorized into 3 domains.17 The cognitive domain relates to mental skills or the acquisition of knowledge. The affective domain relates to attitudes about and enthusiasm toward learning, including feelings and emotions about learning. The psychomotor domain relates to performance of motor and physical skills. Civility mentor addresses all 3 domains of learning (acquisition of knowledge, emotional response to the scenarios, and practicing communication and conflict negotiation skills) to provide a deeper learning experience.
Virtual human interactions as a learning modality provide some of the same benefits as practice with real humans, but without some of the drawbacks. When students interact with a virtual human, they adopt typical social behaviors and assumptions and respond to nonverbal behaviors, expressions, and intonation on the part of the virtual human (Supplemental Digital Content 2, http://links.lww.com/NE/A709 and http://links.lww.com/NE/A710, Virtual Humans). These findings make a virtual human a reasonable substitute for a human actor in a role-play scenario. Virtual humans have the added benefit of being able to maintain “anonymity, confidentiality, and objectivity” when dealing with a human learner, which may make the user more apt to take risks without fear of embarrassment and more able to focus on the learning goals rather than worry about saving face with the role-play partner.18(p27)
Civility mentor consists of 4 learning modules to educate students about the consequences of incivility and develop essential skills to promote civility, communicate more effectively, and address uncivil encounters in academic and health care environments. Each module has its own set of specific learning outcomes for students and module-specific assessments related to the specific learning outcomes.
Module 1: Foundations of Professionalism and Civility
This module emphasizes use of empathy, reflective practice, perspective taking, and norms setting to support safe patient care. The student plays the part of a nurse colleague who helps her coworker focus on the importance of quality patient care while refocusing her attention on the team norms they have created that emphasize quality care, avoiding workplace drama, and supporting their teammates. Learning outcomes include recognizing the impact of incivility on patient safety and reinforcing the nurses' role in advocating for safe, quality patient care.
Module 2: Professionalism and Civility in the Academic Environment
The second module describes some of the stressors of nursing school and highlights how heightened levels of stress can lead to incivility. Students interact with a fellow nursing student who has been stressed, irritable, and disruptive. Students play the role of the classmate to offer support, suggest ways to effectively cope with stress in a healthy manner, and provide information about accessing campus resources when needed.
Module 3: Civility and Patient Safety in the Clinical Environment
This module takes place between a nursing student and a clinical preceptor while caring for a patient. The nursing student performs a procedure on a patient, and during the procedure, the clinical preceptor displays uncivil nonverbal behaviors (eg, eye rolling, arm crossing, head tossing, etc). Both the student and patient recognize that something is wrong. The nursing student, while sensing the patient's anxiety and concern, verbally addresses the clinical preceptor to assist in the care of the patient. Learning outcomes emphasize evidence-based approaches to address uncivil encounters in the clinical setting.
Module 4: Professionalism and Civility in Nursing Practice
This module takes place between a newly graduated nurse and the charge nurse in the patient care area. The student plays the role of the newly graduated nurse concerned about a patient safety issue and uses evidence-based approaches to respond to the unsafe situation and to initiate a follow-up conversation with the charge nurse to constructively resolve a conflict they are experiencing and to improve their overall communication. Learning outcomes include using evidence-based strategies to constructively address conflict “in the moment” and in subsequent conversations.
More than 22 000 students evaluated civility mentor by responding to a set of global questions that asked about their overall perceptions of the learning experience. Responses were positive and an indicator of the potential the learning experience possesses to educate students about the consequences of incivility and provide them with the skills needed to communicate effectively. More than 90% of respondents indicated they were satisfied with the learning experience and were made aware of the consequences of incivility and its effects on patient safety. Each module was evaluated individually by more than 6200 students, with 89% to 91% reporting that they had a better understanding of the consequences of incivility and its impact on colleagues, classmates, and patient care; recognizing sources of stress; and using evidence-based communication techniques to address patient safety issues (Table).
Application to Nursing Education
Civility mentor modules may be threaded sequentially throughout the nursing curriculum or used independently in a variety of ways including use in new student orientation; introduction to health sciences courses (prenursing), fundamentals, and other level 1 courses; professional issues and nursing leadership and management courses; and behavioral health courses. Modules may also be assigned early in a nursing program and then reassigned for deeper reflection and discussion once students have gained clinical experience. Civility mentor may also be used as clinical preparation, make-up time, or remediation; foundational learning material assigned prior to a simulation activity or in-class activity; or as independent study content.
Nurse educators can use civility mentor modules to develop role-playing activities that incorporate evidence-based approaches to communicate in a professional and effective manner. Other suggestions for active student learning include viewing the modules in class to prompt small and large group discussions, implementing reflective activities for learners to practice empathy and perspective taking, and having learners identify and share a real or potential uncivil or conflicted situation from their personal experience and discuss ways to effectively address the situation.
While students may practice and learn ways to address uncivil encounters in the academic and practice setting by using civility mentor, it is important for educators to engage students in supplemental activities to reinforce the learning outcomes. For example, a reflection exercise may be implemented to help students think more deeply about the patient experience, empathize with their situation, and understand the impact of incivility on patient safety. Reflecting on nursing practice encourages deeper levels of thinking about patient care, helps students make sense of their practice decisions, and facilitates integration of theory and practice. Nurse educators may ask probing questions, such as the following: What did you learn after completing the learning module? What are some of the main problems or key issues expressed in the module? What were some of the challenging decisions the nurses needed to make? What is the evidence-based rationale for these decisions? How might you respond if this situation occurs in the future? And have you experienced similar situations in your clinical rotations? If so, please explain.
Nurse educators may engage students in a small group classroom or postclinical conference activity to problem solve ways to address a real or potential case-based scenario such as the example provided in Supplemental Digital Content 4, http://links.lww.com/NE/A711, Case-Based Scenario. The nurse educator can lead a large group discussion where students share highlights stemming from small group discussion. These and other classroom and postconference activities can be implemented to strengthen and reinforce the learning outcomes included in civility mentor.
Academic and workplace incivility can weaken teamwork and collaboration, diminish communication, and contribute to patient harm. Civility mentor is an evidence-based, virtual learning experience designed to prepare students to prevent and address incivility in academic and health care environments and has been shown to be effective in educating students about the consequences of incivility, communicating more assertively, and addressing uncivil encounters in academic and health care environments.
1. Clark CM, Carnosso J. Civility: a concept analysis. J Theory Constr Test
2. Clark CM. Creating and Sustaining Civility in Nursing Education
. 2nd ed. Indianapolis, IN: Sigma Theta Tau International Publishing; 2017.
3. Sokol-Hessner L, Folcarelli PH, Annas CL, et al; Practice of Respect Delphi Study Group. A road map for advancing the practice of respect in health care: the results of an interdisciplinary modified Delphi consensus study. Jt Comm J Qual Patient Saf
4. Aiken LH, Sloane DM, Barnes H, Cimiotti JP, Jarrin OF, McHugh MD. Nurses' and patients' appraisals show patient safety in hospitals remains a concern. Health Aff
5. Houck NM, Colbert AM. Patient safety and workplace bullying. J Nurs Care Qual
6. Maxfield D, Grenny J. Crucial moments in healthcare: patient safety and quality of care impacted by silence around five common workplace issues. Available at: https://www.vitalsmarts.com/press/2017/05/crucial-moments-in-healthcare-new-study-shows-staff-drama-puts-patients-at-risk
. Published 2017. Accessed July 24, 2019.
7. Laschinger HK. Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes. J Nurs Adm
8. Clark CM, Fey MK. Fostering civility in learning conversations: introducing the PAAIL communication strategy [published online ahead of print September 6, 2019]. Nurse Educ
9. Kovner CT, Brewer CS, Fatehi F, Jun J. What does nurse turnover rate mean and what is the rate? Policy Polit Nurs Pract
10. Griffin M, Clark CM. Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. J Contin Educ Nurs
11. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J Contin Educ Nurs
12. D'Ambra AM, Andrews DR. Incivility, retention and new graduate nurses: an integrated review of the literature. J Nurs Manag
13. Laschinger HK, Read EA. The effect of authentic leadership, person-job fit, and civility norms on new graduate nurses' experiences of coworker incivility and burnout. J Nurs Adm
14. American Nurses Association. Position statement: incivility, bullying, and workplace violence. Available at: https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/
. Published 2015. Accessed July 24, 2019.
15. Clark CM. Fostering a culture of civility and respect in nursing. J Nurs Regul
16. Clark CM. Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educ
17. Anderson LW, Krathwohl DR, Bloom BS. A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom's Taxonomy of Educational Objectives
. Abridged Edition. New York: Longman; 2001.
18. Swartout W, Artstein R, Forbell E, et al. Virtual humans for learning. AI Magazine