Barriers to civility paper

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


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


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


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: 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


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


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


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,


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


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.


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


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


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


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.


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


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


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


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


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


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


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


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


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


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


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


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


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


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.


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.


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


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.


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


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


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


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


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


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


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


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


(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


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


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-


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


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


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:


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


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


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.


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.


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


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.


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.


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.


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


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


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


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


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.


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.


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


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


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


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.


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.


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


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


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.


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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.


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.


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.


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


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.


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.


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.


Appendix II

Dick and Carey Systems Approach Model for Designing Instruction

(University of Missouri St. Louis, 2009)


Appendix III

Bloom‟s Taxonomy

(Alcorn, 2012)


Appendix IV

New Bloom‟s Image


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:

mailto:[email protected]


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.


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.


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


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


Students will identify the importance of civility in the nursing workplace. "Civility in the Workplace" Didactic


Implement conflict management skills to address incidents of incivility through a simulation exercise.

Students will compare conflict management skills. "Conflict Management" section Didactic



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


After contrasting different communication techniques, students will demonstrate effective communication techniques by selection of appropriate behavioral choices. Simulation experiences Simulation

Simulation Exercise


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


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


After a simulation exercise, students will identify methods of maintaining self-worth for victims of incivility. First part of reflective writing

Discussion Board



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.


Appendix IX

Didactic Presentation


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.


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


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


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


Appendix XII

NLN/Jeffries Simulation Framework

(Jeffries, 2012)


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


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


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


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


“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.


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?


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


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!”


“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.


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.


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


3. Does the instruction provided lead students to objective achievement?

Yes No


4. Does the syllabus provide clear directions? Yes No


5. Is the plan clear for instructors? Yes No


6. Are the test items appropriate? Yes No


7. Are the evaluation methods appropriate? Yes No


8. What does the plan do well?

9. What improvements can be made?


Appendix XVI

Evaluation Results

Barriers to civility paper

Documents

Transcript of Barriers to civility paper