Nursing students must have effective education and practice opportunities to prepare for solving real world problems to best prepare for entering professional practice. Incivility, lateral violence, and bullying behaviors are frequently endured as a “rite of passage” for new nurses (Condon, 2015; Szutenbach, 2013). Lateral violence (also termed horizontal violence) includes uncivil behaviors directed toward peers (Griffin, 2004; Roberts, 2015). It thus seems feasible that use of peer training may have benefit as an early and necessary educational method (McKenna & French, 2011). Collegiality and teamwork are critical to patient safety (Griffin, Bartholomew, & Robins, 2016), so there must be a professional responsibility to foster these accountabilities in nurses and nursing students. As incivility may be covertly experienced in clinical settings, there are limited venues for reflective response training. Educational experiences designed to promote incivility recognition and skilled response are essential (Clark, Ahten, & Macy, 2014) and cognitive rehearsal methods offer a simulation method to experientially practice critical responses when not under duress.
A project was developed to increase nursing students’ awareness of incivility, provide communication techniques to respond appropriately, and reinforce positive behaviors that promote a culture of safety. Effectiveness of a one-hour interactive and student peer-led civility training was compared to a three-hour didactic/interactive training provided by a nursing incivility expert. Key components as espoused by Clark, Ahten, & Macy (2014) including problem-based learning scenarios to foster experiential learning were included in the design. Use of cognitive rehearsal and different level peer training were also design elements. First semester (sophomore) baccalaureate nursing (BSN) students and the final semester (senior) students in upper division nursing at a public university in the southeastern United States served as participants.
Method
Two training methods were compared for effectiveness. The first method involved training provided by a nursing incivility expert consisting of two-hour didactic followed by a one-hour interactive session using cognitive rehearsal.. This session was provided for senior BSN students. The introduction of the training included a history of incivility among nurses and theoretical underpinnings. Using examples of experienced incivility from students, the trainer encouraged students to form a response utilizing the prompting cards provided (Griffin, 2014). As the students practiced, the trainer provided feedback to the students.
The second training method involved a one-hour peer training provided by the previously expert-trained seniors for sophomore students. Working in teams, senior students conducted one-hour interactive training using cognitive rehearsal with prompting cards for the sophomore nursing students. Prompting cards included 10 types of incivility experiences with suggested responses for pre-rehearsal. Incivility situations included nonverbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect, and broken confidences.
Evaluation
Two surveys utilizing a 5-point Likert rating scale were administered to evaluate effectiveness of education based on Kirkpatrick’s Four-Level Training Evaluation Model (Kirkpatrick & Kirkpatrick, 2006). The first survey, containing six statements, was administered immediately following each method of training session and assessed the first two levels of Kirkpatrick’s model (Level 1 - Reaction and Level 2 – Learning). A second survey, containing five statements, was administered to both groups at the end of the semester to evaluate Kirkpatrick’s model (Level 3 - Behavior and Level 4 –Results). Open-ended comments were also encouraged in a comment section.
Results
Quantitative Data Analysis
Descriptive statistics were evaluated using both survey results to compare responses between groups on both survey items (Table 1 and Table 2).
Table 1: Comparison of Satisfaction & Learning between Expert and Peer Training
|
Training... |
Kirkpatrick Level |
% Rating Senior Students (n=20) |
% Rating Sophomore Students (n=58) |
|
Was relevant to a student nurse |
1 |
95% |
97% |
|
Was helpful in identifying uncivil behaviors |
2 |
100% |
98% |
|
Enhanced their understanding of the effects of uncivil behavior |
2 |
100% |
98% |
|
Helped in the realization of their role in promoting a culture of civility |
2 |
90% |
93% |
|
Provided skills to help respond to incivility |
2 |
100% |
93% |
|
Made them more likely to appropriately respond to incivility as a result of the training |
2 |
75% |
90% |
Table 2: Comparison of Application & Results between Expert and Peer-Training
|
Training resulted in... |
Kirkpatrick Level |
% Rating Senior Students (n=31) |
% Rating Sophomore Students (n=42) |
|
More awareness of incivility/lateral violence in personal/professional experiences |
3 |
90% |
93% |
|
Practicing skills learned in training when incivility is anticipated |
3 |
71% |
71% |
|
Using the skills learned in training to respond to incivility |
3 |
58% |
69% |
|
Noticeable decline in incivility incidence in school of nursing this semester over previous semesters |
4 |
55% |
57% |
|
More positive attitude about importance of promoting civil behavior and prevention of incivility/lateral violence |
3 |
90% |
93% |
Inferential statistics using SPSS 22 were completed. To evaluate expert versus peer training on satisfaction/learning summed scores, an independent-samples t-test was used. A significant difference in scores for peer training [M = 27.53, SD = 3.37] and expert training was found [M = 25.70, SD = 2.08; t(53.8) = 2.86, p = .006]. The magnitude of the differences was .096, between moderate (.06) and large (.14) effect size (Cohen, 1988), with peer training accounting for 9.6% of the variance.
To evaluate the potential influence of the expert versus peer training on application sum scores, again, an independent-samples t-test showed no significant difference in scores for peer training [M = 20.69, SD = 3.31] and expert training [M = 19.55, SD = 3.48; t(77) = 1.43, p = .158]. These two analyses indicate that peer training provided to sophomore students was potentially perceived as more satisfying with higher learning achieved than the three-hour didactic/interactive training for seniors provided by an expert trainer, yet peer training was just as beneficial for application of training.
Qualitative Data Analysis
Participants’ written comments qualitatively analyzed by the research team identified four consistent themes for both groups: 1) interactive training; 2) role play; 3) incivility recognition; and 4) prepared responses. The participants enjoyed the interactive method used to complete the training. Student statements regarding these themes are provided to illustrate themes further.
Discussion/Conclusions
Results of descriptive, inferential, and qualitative statistics support these two training methods for incivility. These findings are consistent with the literature indicating that peer learning contributed to decreased anxiety (Kurtz, Lemley, & Alverson, 2010; McQuiston & Hanna, 2015, Stone, Cooper, & Cant, 2013) and increased satisfaction (Stone, Cooper, & Cant, 2013). Peer trainers conveyed meaningfulness and value of the training through comments such as, “We wish we had gotten this training when we were sophomores.” and “This training would really have helped me when I was starting upper division.” Peer trainers were able to share real situations from their own clinical experiences, providing guidance on how they wish they had resolved previous situations with the new knowledge they had achieved.
Peer bullying continues to be high at 48% (Carpenter, 2017), even with national data and stated key initiatives (ANA, 2014) for improving incivility. Interactive peer training can be a powerful way to prepare nursing students to recognize and respond to incivility in the healthcare setting. Peer training and cognitive rehearsal also affords other benefits such as leadership and confidence to the trainers and may have potential to establish a zero tolerance model within a nursing program or healthcare community over time (ANA, 2015). Finally, perpetual peer training after initial expert training may provide an expert system for civility training cost-effectively with the added benefit of self-perpetuating high quality student outcomes.
Limitations
This study was confined to one nursing program in the southeast and needs to be replicated. Longitudinal study of program perpetuation would be potentially beneficial in determining whether learning gains are sustained. The training methods were provided to two different levels of students within a nursing program, therefore prior knowledge may have influenced learning or data results.