Evaluating the Dynamic Combination of Simulation and Cognitive Rehearsal to Foster Civility and Transform Practice

Purpose: Innovative and evidence-based teaching-learning initiatives are urgently needed to prepare nursing students to foster healthy, ethical practice settings, and to address acts of incivility that can negatively impact individuals, teams, organizations, and safe patient care. In health care, the consequences of incivility can be especially devastating resulting in life-threatening mistakes, preventable complications, and harm to or death of a patient. This presentation highlights lessons learned from the implementation of a multi-year, learner-centered teaching-learning initiative and provides the results of two empirical qualitative studies conducted in 2011 and 2012.  The overall purpose of the two studies was to evaluate the combination of a simulated Problem-Based Learning (PBL) scenario and ‘scripting’ using Cognitive Rehearsal (CR) as an effective strategy to prepare students to recognize and address incivility and to effect positive change in the practice setting.

Background: There are several important rationales for teaching and reinforcing civility; first, all nurses regardless of setting or position have an ethical imperative to create and sustain healthy work places and to foster an atmosphere of dignity and respect (ANA, 2015a; ANA, 2015b). The American Nurses Association (ANA) Code of Ethics for Nurses (2015a) clearly articulates nurses’ obligation to foster safe, ethical, civil workplaces. Specifically, Provision 1.5  requires nurses “to create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect…and that any form of bullying, harassment, intimidation, manipulation, threats or violence will not be tolerated” (p. 4). Further, Provision 7.2 speaks directly to nursing faculty, stating “academic educators must ensure that all graduates possess the knowledge, skills, and moral dispositions that are essential to nursing” (p. 28). Essential VIII: of the AACN Essentials of Baccalaureate Education for Professional Nursing Practice (2008) emphasizes the inherent values of altruism, autonomy, human dignity, integrity, and social justice, and stresses that “civility must be present for professionalism to occur” (p. 26). Further, the Center for American Nurses (2008) recommends disseminating information to nurses and nursing students that specifically address conflict and provide ways to recognize, address, and change disruptive behavior in the workplace. The Center also advocates for the development and implementation of teaching strategies and curricula that educate nursing students on the incidence and prevalence of disruptive behaviors and to incorporate ways to eradicate this behavior.

Methods: To address these recommendations, the author implemented a multi-year, learner-centered initiative using a combination of a simulated PBL scenario and ‘scripting’ using CR to prepare nursing students to recognize and address incivility and to effect positive change in the practice setting. The multi-year initiative began in 2010 with a written Problem-Based Learning (PBL) scenario, which expanded to the use of ‘live’ actors from a university-based Theater Department (2011), to nursing students acting as Standardized Participants (2012), to a nursing student-produced YouTube video (2013). Effectiveness of the learning initiative was measured using Kirkpatrick’s Model for Evaluation which includes 4 Levels; Level 1 measures participants’ satisfaction with the activity, Level 2 measures participants’ learning during the activity, Level 3 measures participants’ ability to apply what they have learned from the activity, and Level 4 measures the impact of the learning on the organization.

Results: After obtaining institutional approval to conduct the two studies, 64 senior level students participated in the 2011 study. Kirkpatrick’s Level 2 was used to evaluate the level of learning after observing a PBL scenario using live actors to depict an uncivil nurse-to-nurse encounter and the use of CR as a means to address the uncivil behavior. Key findings included 1) students described the uncivil encounter as common, offensive, and requiring supervision, 2) the scenario allowed students to reflect on their own behaviors and how they might handle the situation if faced with a similar event, 3) the scenario was described as realistic, bringing learning ‘alive,’ and heightening awareness of incivility and its impact, and 4) reinforced the importance of teamwork, effective communication, and the need for ongoing education to address incivility.

In 2012, a 10-month follow-up study was conducted with 18 newly graduated nurses who participated in the first study in 2011. The follow-up study used Kirkpatrick’s Level 3 Model of Evaluation to measure the newly graduated nurses’ ability to apply what they learned from the PBL activity into the practice environment. Key findings from the 2012 study included 1) 61% newly graduated nurses reported experiencing and/or observing incivility in the practice setting consisting of rude remarks, gossiping, yelling, berating others, and making disparaging remarks about members of the healthcare team, 2) 61% reported using the information learned in class to address incivility in the practice setting and commented that the learning scenario helped them depersonalize and address the behavior, and 3) 77.7% reported changes in their behavior and a heightened ability to address incivility and to communicate more clearly particularly in patient safety situations.

Conclusions: This multi-year, learner-centered initiative was an effective teaching strategy for preparing students and newly graduated nurses to recognize and address incivility and to effect positive change in the practice setting. Graduates with minimal experience and limited familiarity with the professional nursing role were able to identify uncivil behavior, and in many cases, effectively address incivility and effect positive change. Findings from these studies were subsequently used to 1) develop an evidence-based comprehensive civility curriculum for pre-licensure students and 2) to inform a study using biomarkers to measure the stress experienced during a nurse-to-nurse uncivil encounter and whether the use of a cognitively rehearsed, scripted response was effective in mitigating stress to the extent that nurse performance and patient safety were unaffected.