Using Cognitive Rehearsal to Address Incivility in Nursing Education

Background/Significance

Nurse-to-nurse incivility is a global issue and is considered by working nurses to be the most common and most disturbing type of workplace aggression (Vessey, Demarco, & Difazio, 2010; Almost, Doran, McGilliss Hall, & Spence Laschinger, 2010). Incivility is a term used to describe rude, disruptive, intimidating, and undesirable behaviors that are directed toward another person (Stokowski, 2011).  Similar terms that related to uncivil behavior include lateral violence, horizontal violence and bullying. Despite the professional expectation that nurses should show caring behavior towards patients and co-workers, uncivil behavior persists (Eggerstone, 2011; Griffin, 2004; Johnson, 2009). Eighty-eight percent of nurses admit knowing a coworker who engages in nurse-to-nurse incivility (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005). Student nurses are exposed to incivility in their academic programs from other students, faculty, and staff nurses in the clinical area.  There is a need to provide nursing students with skills on how to engage in civil ways that support nurse-to-nurse collegial relationships (Berry, Gillespie, Gates, & Schafer, 2012; Randle, 2003).  Learning how to engage in a civil manner by treating one another with respect is a prerequisite to communicating effectively, building community and creating high-functioning teams. These skills greatly improve the chances of student nurses being successful in the nursing program and of newly graduated nurses being successful at their jobs. The academic environment is an ideal place for nursing students to gain the skills to engage in civil collegial relationships with the guidance of nurse educators. Role play has been shown as a strategy that assists students in gaining self-confidence in how to address incivility in the workplace. This study uses the educational strategy of role play to help nurses learn how to recognize and address nurse-to-nurse incivility.

Statement of the Problem:

Despite the expectation that nurses exhibit caring and professional behavior towards patients and coworkers, incivility still persists.  According to a The Joint Commission Report (2008), “uncivil, disruptive and intimidating behavior in health care can lead to medical errors, poor patient care and satisfaction, preventable adverse patient outcomes and increased costs of care.” It also causes qualified clinicians, administrators and managers to seek new positions in collegial and safe environments.  According to Robertson (2010), there is an abundance of evidenced based knowledge about the prevalence and impact of incivility in nursing, however research regarding strategies to address the problem is inconspicuously lacking.

The question this study seeks to address is:

 In senior nursing students, how does the use of a workshop addressing nurse-to-nurse incivility through role play and cognitive rehearsal affect student perception of incivility and how to address it?

Methodology:

            This study used a descriptive qualitative design which is appropriate for this study as it purposed to obtain data about the perceptions of the workshop and role play experiences. 

The intervention for this capstone was developed following a model proposed by Griffin(2004).  Institutional IRB approval was received from the Capstone University and the host University. Students were consented prior to the implementation of the project. Demographic information regarding, gender, age, college status was collected and students were asked if incivility had been encountered in the nursing classroom or clinical setting.     

Students then listened to didactics about the definition of incivility, prevalence and impact.  Additionally, they were introduced to the concept of cognitive rehearsal and evidenced based findings to support the effectiveness of this strategy in addressing nurse to nurse incivility.  Cue cards developed by Griffin (2004) which addressed the ten most common types of incivility and appropriate responses were distributed. Nursing actors followed the didactics with a role play demonstrating common acts of nurse to nurse incivility.  Students were then given the opportunity to practice addressing incivility using the cue cards. Nursing actors then repeated the role play and included examples of how to effectively use cognitive rehearsal to address incivility. 

Data Collection and Analysis:

Data collection was done through written surveys with open ended questions given to students following the workshop and role play.  Analysis of data will be completed using constant comparative analysis. The survey questions were:

1.    What is your understanding of the definition of nurse- to- nurse incivility?

2.     What were your feelings of observing a nurse being treated uncivilly in the role play?

3.     What were your personal feelings of being treated uncivilly in the role play?

4.     Describe your experience of using cognitive rehearsal to respond to being treated uncivilly?

5.     Describe your confidence about using the cognitive rehearsal approach to address uncivil behavior in the future?

6.     What more do you want to know about how to address nurse-to-nurse incivility?

Summary of Results

       

Ten senior nursing students from a university located in the northeast region of the United States were surveyed in this study.  Ninety percent of the participants were females and 10% male.  Ages ranged from 22- 44 years of age.  Ninety percent of the students surveyed had experienced incivility while matriculating through the nursing program.  One hundred percent of the students stated that they felt confident in using cognitive rehearsal to address uncivil behavior in nursing in the future.  Five survey questions are currently being analyzed to identify themes and subthemes related to student perceptions about nurse-to-nurse incivility following a role play using cognitive rehearsal.

 

Recommendations:

Nurse to nurse incivility creates barriers to learning and affects all involved both physiologically and psychologically, Clark& Kenaley, (2013).  The nursing school environment is an excellent forum and opportunity to address nurse to nurse incivility.  Zero tolerance policies for incivility should be developed for the university setting and incivility education should be incorporated into the nursing curriculum.

 

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