Nurses are entitled to expect to practice in a healthy and safe work environment. They should not have the need to defend themselves unprofessional colleagues, who engaging in inappropriate uncivil behavior; this behavior includes yelling, rude comments, sabotage, or the eye rolling (Becher & Visovsky, 2012). Nurses and administration must acknowledge the various types of incivility and the prevalence of such behavior. Knowledge and understanding are the first steps of instituting policies and creating a culture of respect, improved safety, and effective communication (ANA, 2015a).
When workplaces address unit culture and empower nurses, they demonstrate greater job satisfaction and organizational commitment. Cognitive rehearsal is an evidence-based communication technique, proven to stop uncivil behavior by using scripted, rehearsed cues as prompts for professional, effective communication. This will, hypothetically, encourage a change in behavior and an improved work environment. The review of literature provided evidence that educating nurses can increase their perception and awareness of incivility. Much of the literature supported education, communication training, and rehearsal as interventions which could raise awareness and potentially decrease the incidence of incivility. Strong nursing leadership and zero-tolerance policies should also be instituted in all practice areas (Berry, Gillespie, Fisher, Gormley, & Haynes, 2016). There have been several studies since that have found cognitive rehearsal to be effective in helping nurses identify and respond to uncivil behavior. Preparing nurses by using common language to react to uncivil comments or behavior can give nurses the confidence they need and empower them to react in an effective manner. There are three parts to cognitive rehearsal: the first is instruction on the method; next, the participants are taught common language, verbal responses to use when encountering uncivil behavior or language; finally, the participants practice using the cognitive training to reinforce the content. Using this trained, common language can empower the victims of incivility to react in a positive manner (Griffin, & Clark, 2014).
The purpose of this program was to improve the workplace environment. The first part involved an assessment and measurement of nursing incivility. The Nursing Incivility Scale (NIS) is an instrument with proven validity used to measure nursing incivility. The survey is broken down to eight subscales; these subscales are: hostile climate (HC), inappropriate jokes (IJ), inconsiderate behavior (IB), gossip or rumors (GR), free riding (FR), abusive supervision (AS), lack of respect (LR), and displaced frustration (DF). It may also be divided to reveal source specific areas of incivility. The NIS consists of forty-three total questions, nine relate to all individuals interacted with at work, ten relate to nurse-nurse interactions, seven relate to interactions with a direct supervisor, seven relate to interactions with a physician, and ten relate to interactions with patients, family members, or visitors. Subscale scores are added and averaged; this allows more specific interventions to be discussed (Guidroz, Burnfield-Geimer, Clark, and Schwetschenau, 2010). The participants completed the Nursing Incivility Scale prior to the program, immediately after the program and a third time 1 month after the program to assess the impact of the education. The second part of the program focused on educating participants on incivility and cognitive rehearsal. The participants were given cue cards with scripted responses to various forms of uncivil behavior. They then had time for role playing to practice using the scripted responses.
Improving the experience and job satisfaction of nurses will help the hospital to retain staff; thereby improve the working conditions for all nurses. Better staffing will improve patient outcomes and decrease the hospital’s cost of continually training new staff. The project coordinator of this program believed that most nurses do not wish to cause patient harm. Most entered the profession wanting to help patients. For some reason, the culture of nursing has made it a common, almost expected practice that nurses should undergo an initiation into the profession. This can be compared to a new sorority or fraternity recruit being forced to undergo hazing to “toughen them up”. Bringing incivility out into the open through an educational quality improvement program, will demonstrate that patients, as well as nurses are being harmed as an outcome of this so called initiation. Victims were taught how to respond to uncivil behavior using an evidence-based, professional communication technique. The goal was to facilitate a transformational change in behavior and an improved work environment.
The results are as follows:
Demographics: Sample size included 24 participants. All participants were female, the majority (63.6%, n=14) of participants reported their age to be between 51 and 60, 27.3% (n=6) reported their age to be between 41 and 50, four participants (1%)reported age between 20 and 30, and , four participants (1%)reported age over 61.Participants reported highest degree obtained as follows: two (9.1%%) diploma, 4.5% (n=1) associate’s degrees, 72.7% (n=16) bachelor's degrees, and 13.6% (n=3) with masters degrees or higher. The majority of participants 86.4% (n=19) had over 10 years nursing experience, two (9.1%) participants had six to ten years, and only one (4.5%) participant had two or less years nursing experience.
The majority of participants (52% n=13) reported the educational content was relevant, eight (34.8%) participants were satisfied, and 2 (8.7%) participants were neutral. Thirteen participant (56.5%) reported the program was met objectives, nine participants (39.1%) reported good, and only one (4.3%) was neutral. Sixteen (69.6%) reported they were very likely to recommend the program, five (21.7%) were likely to recommend the program, and two (8.7%) were neutral.
A one-way repeated measures ANOVA was conducted to compare scores on the NIS at time 1 (prior to intervention implementation), time 2 (following the intervention) and time 3 (one month after implementation of the intervention). Alpha was set at .05. There was a statistical significant difference for effect of total time, Wilk’s Lambda = .44, F (2, 22) = 13.76, p <0.000, multivariate partial eta square = .55.
A one-way repeated measures ANOVA was conducted to compare scores on each of NIS subscales. Alpha was set at .05. There was a statistical significant difference for the following subscales: IJ, Wilk’s Lambda = .73, F (2, 22) = 3.95, p <0.034, multivariate partial eta square = .26; GR, Wilk’s Lambda = .62, F (2, 22) = 6.68, p <0.005, multivariate partial eta square = .37; FR, Wilk’s Lambda = .66, F (2, 22) = 5.66, p <0.010, multivariate partial eta square = .34; AS, Wilk’s Lambda = .48, F (2, 22) = 11.51, p <0.000, multivariate partial eta square = .51; LR, Wilk’s Lambda = .64, F (2, 22) 6.02, p <0.008, multivariate partial eta square = .35. There was a not statistical significant difference for the following subscales: HC, Wilk’s Lambda = .76, F (2, 22) = 3.34, p <0.054, multivariate partial eta square = .23; IB, Wilk’s Lambda = .83, F (2, 22) = 2.14, p <0.141, multivariate partial eta square = .16; DF, Wilk’s Lambda = .82, F (2, 22) = 2.26, p <0.128, multivariate partial eta square = .17.
This was a small scale project; however, based on the feedback and data analysis, it would be recommended to expand the cognitive rehearsal training. It would also be beneficial to have long term follow-up with the participants.