Health, Spirituality and Medical Ethics

Original Article                                                                                                                    Health, Spirituality and Medical Ethics. 2021;8(1):28-34

 

Implementation of the Training Course of Student’s Manners in Management of Nursing Students’ Incivility
Received 17 Apr 2020; Accepted 07 Mar 2021
http://dx.doi.org/10.29252/jhsme.8.1.28
Zahra Abedini¹ , Kobra Akhoundzadeh¹ , Ashraf Khoramirad^1* , Ali Mohammadiveldani^{2, 3}
1 Department of Nursing, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran.
2 Department of Islamic sciences, School of Medicine, Qom University of Medical Sciences, Qom, Iran.
3 School of Nursing, Qom University of Medical Sciences, Qom, Iran.

Abstract Background and Objectives: Uncivil behaviors against morals in nursing students are increasing and it can be transferred to the nursing professional environment. Therefore, it is necessary to manage the incivility of students through appropriate strategies. The purpose of this study was to determine the effect of student manner's training on the uncivil behavior of nursing students in Qom University of Medical Sciences. Methods: This quasi-experimental study was performed by participation of 83 second and third year nursing students from February to March 2019. Students were divided into two experimental and control groups. Intervention of student manner's training was conducted during four weeks. Questionnaire of incivility in nursing education was used for data collection. Data were analyzed by independent and paired t-test. Results: The mean scores of students’ incivility before intervention in the experimental and control groups were 45.37 ± 10.56 and 42.80 ± 13.50, respectively. After intervention, these values ​​were 38.23 ± 13.28 and 41.94 ± 8.25, respectively. The difference between the mean incivility of the intervention group in the pre and post training stages was significant (p<0.05). Conclusion: Student manner's training through free thinking was effective in managing incivility. It is suggested to use this method in managing the incivility of nursing students. Keywords: Discussion, Incivility, Nursing, Student.

*Correspondence: Should be addressed to Dr. Ashraf Khoramirad. Email: parsian_ins_kh@yahoo.com

 
 
 
 
 
 
 
 
 
 
 
 
 

Please Cite This Article As: Abedini Z, Akhoundzadeh K, Khoramirad A, Mohammadiveldani A. Implementation of the Training Course of Student’s Manners in Management of Nursing Students’ Incivility. Health Spiritual Med Ethics. 2021;8(1):28-34.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License

 
 
 

I

ncivility is a common immorality problem in higher education institutions and includes rude behaviors and disrespect for others in the learning environment (1). Unwillingness to listen to others’ opinions, stubbornness and lack of humility, lack of honesty and violence are considered as incivility (2). Such relationships are not desirable in the nursing educational environment, so establishing respectful interaction to spread civic culture in nursing education has always been emphasized (3).
Obviously, proper professional behavior in nursing as one of the key members of the medical team should be learned during the study. The development of moral virtues in students improves learning conditions, creates optimal relationships between nurses and students in the clinical environment and achieves positive outcomes in patient care. (4) If such behaviors are approved in the educational environment, they will continue during the study and work and will affect the quality of patient care, and by providing comfort, lead to their satisfaction (1).
According to the statement of the International Association of Nurses, respect for human rights, including cultural rights, human dignity and respectful behavior, is an inseparable part of nursing (5). In the Iranian nursing ethics, it is stated that all human beings have high human dignity and it is necessary to be respected in any situation (6). The development of moral virtues, planning to improve social behaviors, strengthening work ethics, honesty and contentment are cultural goals in Iran (7).
Evidence of evaluation of nursing students by Rafiee et al. (2016) showed a significant prevalence of uncivil behaviors among nursing students (8). In the study of Joibari et al. (2010), about two thirds of the professors stated that in the past year, they have seen uncivil behavior by students (9). Other researchers showed that 60.2% of students behaved irresponsibly and 47.8% of students behaved aggressively in the educational environment (10).
Uncivil interactions in the organization are likened to cancer and, if it is not controlled, it will spread and affect the entire system. Those who are new to the organization, following others, engage in inappropriate behaviors, imitate and repeat it as the culture of the organization. People are usually afraid to report rude behavior directly and do not trust the organization to declare it (11).
Using appropriate measures are effective in controlling incivility. People should be familiar with moral norms and be obliged to observe them. Understanding the importance of etiquette, respect and moral principles reduces the occurrence of destructive behaviors and eliminates the conflict (12). Creating focus groups with the active participation of individuals and professionals can help investigate and solve behavioral problems. Establishing dialogue sessions to find the root of problems and to investigate disrespectful behaviors is helpful (13). Free thinking session as creating a space for declaring various opinions on challenging topics and achieving results is practical. In this meeting, individuals in a free, systematic, respectful, rational, logical and courageous manner, comment, question and answer, exchange views, argue and present documents on a certain topic (14).
Inappropriate behaviors that have increased in recent years among students and instructors in educational settings (15), has also been observed in the School of Nursing and Midwifery of Qom University of Medical Sciences (16). Therefore, effective action is necessary to prevent and control the current situation. The purpose of this study was to determine the effect of student manner's training on the uncivil behavior of nursing students.
Methods
This quasi-experimental study was performed by participation of 83 second and third year nursing students from February to March 2019. Second year students were selected for the experimental group and third year students were selected as the control group. Sampling was by complete enumeration and all students participated in the study. First and last year students were excluded from the study. To collect data, a questionnaire of incivility in nursing education was used (17). This tool was designed by Clark and the Cronbach's alpha coefficient to confirm its reliability was 0.88 and it measures the incidence of behaviors on a four-point Likert scale (18). To confirm the validity and reliability of the questionnaire, after obtaining permission from the tool maker, the English questionnaire was translated into Persian by two translators. The Persian version was translated into English again and approved by the tool designer. In order to perform qualitative face validity, the questionnaire was given to 10 professors of the School of Nursing and based on their opinions, the validity of the tool was confirmed. The reliability of the questionnaire was approved by calculated alpha coefficient of 0.85.
Incivility free thinking course was conducted in four sessions in coordination with the group director and the professors of the education department. The importance and goals were explained to them. After ensuring of the cooperation of the instructors and the agreement of the director of the education department, educational content of student etiquette was provided to the students in the form of a file in Telegram channel. Students were asked to study the subject and be prepared to participate in free thinking session within two weeks. The students discussed the incivility of their classmates in the educational setting, and in cases where there was a need to respond to doubts and ambiguities, the professor of Islamic education was responsible. Free thinking was conducted in four sessions for 2 hours for students. The researcher attended four free thinking sessions as a facilitator
and worked on presenting the issue and encouraging students to express their opinions. Independent and paired t-tests were used to analyze the data.
Written consent was obtained from the study participants. The intervention was done by presenting a letter of introduction to the director of the School of Nursing. The study
was conducted by receiving the ethics code IR.MUQ.REC.1397.137 from Research Deputy of Qom University of Medical Sciences.
Result
In the present study, 83 nursing students participated. Most students were 19-21 years old (79.8%) and girls (51.81%). The majority of them were local students (76.32%). Table 1 showed that there was no significant difference between the experimental and control groups in terms of age, gender and marital status (p>0.05). Determining the incivility status of nursing students before performing free thinking showed that the mean ± SD (Standard deviation) incidence of students’ incivility in the experimental and control groups were 45.37±10.56 and 42.80±13.50, respectively. After the intervention, the mean incidence of incivility in the experimental group was 38.23±13.28 and in the control group was 41.94 ±8.25. Changes in civic behavior in the intervention group were significant (p<0.05) (Table 2).

 
Table 1. Students’ specifications in experimental and control groups

Demographic variables	Group	Experimental	control	Total	χ² / t	P-value
		Mean (SD)/n(%)	Mean (SD)/n(%)	Mean (SD)/n(%)
Age	years	19.67 (6.21)	20.42 (3.43)	20.41 (4.10)	1.03	0.41
Gender	Male	21 (47.73)	19 (48.71)	40 (48.19)	0.90	0.08
	Female	23 (52.27)	20 (51.29)	43 (51.81)
Marital status	Married	12 (27.26)	10 (25.64)	22 (26.51)	2.06	0.34
	Single	32 (72.74)	29 (74.35)	61 (73.49)
Academic year	Third	20 (45.46)	21 (53.84)	41 (49.39)	0.82	0.19
	Second	24 (54.54)	18 (49.16)	42 (50.61)

 
Table 2. Determining the effect of intervention on mean and standard deviation scores of incivilities in experimental and control groups

Behavior Incidence Score		Before Intervention	After Intervention	Test Results	P-value
		Mean±SD	Mean±SD
Group	Experimental	45.37±10.56	39.23±12.28	3.25	0.00
	Control	42.80±13.50	41.94±8.25	1.26	0.30

 

Discussion
Based on the results, teaching student manners was effective in managing students’ incivility. Appropriate behaviors should be articulated by directors and professors in the classroom, and expectations should be clearly defined. As research shows, some people consider immoral and obscene behaviors to be normal and do not believe in the ugliness of their misconduct. Due to the reciprocal nature of destructive behaviors and its effects on the parties, informing people in the organization should be pursued by directors (19). In
similar research, the emphasis on desirable characteristics such as trust, honesty, truthfulness, integrity and moral values has been introduced as the duties of the organization (1). Unless expectations and civic behaviors are defined and clarified for students and professors, they may not realize the ugliness of their misconduct. Therefore, planning to inform students is among the duties of directors and the first step to improve relationships.
Increasing students’ awareness was the most important factor in reducing incivility. In one similar study, increasing individual awareness using instructional videos on moral challenges and discussing appropriate behaviors in desired situations helped to control students’ incivility (20). According to other researchers, teaching moral virtues and discussing moral challenges has been effective in promoting students’ competence (21). In Clark’s study, increasing students’ awareness was emphasized on promoting appropriate behavior. (22) Other researchers have argued that students should gain self-control and readiness to live up to expectations and behavioral standards (23) and that students’ understanding is necessary for controlling the behavior (24).
Holding discussion and free thinking sessions led to deep thinking about behavioral challenges. Talking about moral challenges can help you make the right decisions and recognize the right behaviors. Findings
of other researchers also showed that understanding the subject has been associated with increased moral sensitivity in students (25). Discussion of appropriate behavioral characteristics to maintain the dignity of others and avoid collusion in interactions with classmates, professors, staff, and patients has reduced incivility (26). In a similar study, learning behavior using case-based learning strategies was found to be useful in strengthening critical thinking and improving appropriate professional relationships of nurses (27). Also, stimulating student thinking in another study caused moral sensitivity and better analysis of issues and appropriate decisions (28). Purposeful dialogue has led to a better understanding of moral issues by sharing opinions on moral issues and how to make decisions (29).
One of the features of the present study was the formation of a training course in semester sessions. Teaching appropriate behaviors
in the formal environment and Islamic education classes was a reason for the need to learn moral principles while studying and integrating the subject in the current program. Experts believe that providing a curriculum based on ethical virtues is one of the educational needs of nursing students (21). In one study, teaching ethics and manner in
the nursing curriculum to identify ethical challenges and experiences was recognized as one of the competencies expected of nursing graduates (30). The opinions of professors and students in a study showed that civic behavior counseling and adding this issue to the educational curriculum was effective in promoting performance and achieving civic culture (31). Formal discussion sessions to improve educational plans, assessment methods, and curriculum have strengthened and improved professional communication (32). Thus, forums and purposeful discussion based on educational content written and approved by experts was one of the benefits of behavior management method.
The aim of this study was to familiarize students with the importance and types
of normal behaviors in the educational environment. Since the preventive approach as the most effective method to control behavior can be used to manage behavior, according to similar studies, teaching policies and rules of interaction in the educational environment promotes positive behaviors in students (33). Focusing on acceptable behaviors instead
of forbidding wrong behaviors, balanced encouragement and punishment, clarifying expectations, warning about the use of equipment, explaining how to use technology and anti-fraud policies are also among the duties of professors (34).
In this study, educational intervention over four weeks was associated with a reduction in incivility. In similar studies, holding six training sessions has been useful to achieve the expected outcomes (35). Holding journal club meetings for 8 weeks has led to good results (36). Holding weekly meetings for a month has also reduced incivility in students (27). Despite the positive results of the present study, in order to maintain appropriate behaviors in students, it is necessary that educational programs continue throughout the study.
One of the limitations of the study was questionnaire whose answers were self-reported and affected by the accuracy of the samples. The generalizability of the results to students of other institutions is limited due to non-random selection of samples. The study was conducted quasi-experimentally in second and third year nursing students and its results can’t be generalized to students of other years. Also, it is not possible to permanently change the religious and cultural beliefs and attitudes of students in the short period of research, and it is necessary to continue the program to institutionalize them.
Conclusion
Teaching student manner through free thinking was effective in managing students’ incivility. The use of 4 training sessions with dialogue and discussion about behavioral challenges in the educational environment with comments and conclusions by the professor of Islamic Education Department was associated with a reduction in incivility. Learning moral principles while studying and integrating the subject in current curricula together with informing students and increasing their moral sensitivity is useful in the management of incivility.
 
Conflict of interest
There was no conflict of interest.
Acknowledgements
Students and faculty members of the Department of Nursing and Islamic Education of Qom University of Medical Sciences who participated in the study are appreciated.
References

1. Woodworth JA. Promotion of nursing student civility in nursing education: a concept analysis. Nurs Forum 2016;51(3):196-203. DOI: 10.1111/nuf.12138
2. Eka NGA, Chambers D. Incivility in nursing education: a systematic literature review. Nurse Educ Pract 2019;39:45-54. DOI: 10.1016/j.nepr.2019.06.00
3. Peters AB. The concept of incivility: a case study. Teach Learn Nurs 2015;10(4):156-60. DOI: 10.1016/j.teln.2015.06.002
4. Clark CM, Olender L, Cardoni C, Kenski D. Fostering civility in nursing education and practice: Nurse leader perspectives. J Nurs Adm 2011;41(7-8):324-30. DOI: 10.1097/NNA.0b013e31822509c4
5. Stievano A, Tschudin V. The ICN code of ethics for nurses: a time for revision. Int Nurs Rev 2019;66(2):154-6. DOI: 10.1111/inr.12525
6. Sanjari M, Zahedi F, Aalaa M, Peimani M, Parsapoor A, Cheraghi MA, et al. Code of ethics for Iranian nurses. Iran J Med Ethics Hist Med 2011;5(1):17-28. Link
7. The 20-year national vision of the Islamic Republic of Iran for the dawn of the solar calendar year 1404. National Vision of Iran. Available at: URL: https://rc.majlis.ir/fa/law/
   show/132295; 2003. Link
8. Rafiee Vardanjani L, Parvin N, Shafiee Z, Safdari Dehcheshmeh F. Assessment of uncivil behaviors of teachers and students in nursing and midwifery faculties of Shahrekord. Dev Strateg Med Educ 2016;3(2):25-37. Link
9. Joibari L, Mohammadi Z, Sanagoo A. A glance at students and faculty members perceptions of incivil behavior in educational settings. Strid Dev Med Educ 2011;7(2):127-33. Link
10. Ibrahim SA, Qalawa SA. Factors affecting nursing students' incivility: as perceived by students and faculty staff. Nurse Educ Today 2016;36:118-23. DOI: 10.1016/j.nedt.2015.08.014
11. Burke LA, Karl K, Peluchette J, Evans WR. Student incivility: a domain review. J Manag Educ 2014;38(2):160-91. DOI: 10.1177/1052562913488112
12. Clark CM. Faculty field guide for promoting student civility in the classroom. Nurse Educ 2009;34(5):194-7. DOI: 10.1097/NNE.0b013e3181b2b589
13. Elmblad R, Kodjebacheva G, Lebeck L. Workplace incivility affecting CRNAs: a study of prevalence, severity, and consequences with proposed interventions. AANA J 2014;82(6):437-45. Link
14. Regulations of forming free-thinking seats. Supreme Council for Cultural Revolution. Available at: URL: https://sccr.ir; 2014. Link
15. Rad M, Ildarabadi EH, Moharreri F, Moonaghi HK. A study of incivility in the Iranian nursing training system based on educators and students’ experiences: a quantitative content analysis. Global J Health Sci 2015;7(2):203-9. DOI: 10.5539/gjhs.v7n2p203
16. Abedinipoor A, Samadi F, Momeniyan S. Prevalence and factors associated with cheating among students of Qom University of Medical Sciences. J Med Educ Dev 2015;8(19):73-80. Link
17. Clark CM, Barbosa-Leiker C, Gill LM, Nguyen D. Revision and psychometric testing of the incivility in nursing education (INE) survey: introducing the INE-R. J Nurs Educ 2015;54(6):306-15. DOI: 10.3928/01484834-20150515-01
18. De Gagne JC, Kang HS, Hyun MS. Psychometric properties of the Korean version of the incivility in nursing education-revised (INE-R) survey. Nurs Health Sci 2016;18(4):425-34. DOI: 10.1111/nhs.12285
19. Arab N, Sheykhshabani E, Beshlideh K. Antecedents of workplace incivility: investigating some personal and organizational variables. J Psychol 2013;17(3):294-309. Link
20. Touzet S, Cornut PL, Fassier JB, Le Pogam MA, Burillon C, Duclos A. Impact of a program to prevent incivility towards and assault of healthcare staff in an ophtalmological emergency unit: study protocol for the PREVURGO On/Off trial. BMC Health Serv Res 2014;14(1):221-8. DOI: 10.1186/1472-6963-14-221
21. Russell MJ. Teaching civility to undergraduate nursing students using a virtue ethics-based curriculum. J Nurs Educ 2014;53(6):313-9. DOI: 10.3928/01484834-20140512-03
22. Clark CM. Pursuing a culture of civility: an intervention study in one program of nursing. J Nurse Educ 2011;36(3):98-102. DOI: 10.1097/NNE.0b013e3182161238
23. Sun RC, Shek DT. Classroom misbehavior in the eyes of students: a qualitative study. Sci World J 2012;2012:398482. DOI: 10.1100/2012/398482
24. Rad M, Moonaghi HK. Strategies for managing nursing students’ incivility as experienced by nursing educators: a qualitative study. J Caring Sci 2016;5(1):23-32. DOI: 10.15171/jcs.2016.003
25. Abedini Z, Parvizi S. Student's perceptions of using scenario-based education to improve civility: a mixed method study. J Adv Med Educ Prof 2019;7(4):165-74. DOI: 10.30476/jamp.2019.74933
26. Abedini Z, Parvizy S. The effects of group discussion and self-learning on nursing students’ civility. Iran J Nurs Midwifery Res 2019;24(4):268-73. DOI: 10.4103/ijnmr.
    IJNMR_212_18
27. Kerber C, Jenkins S, Woith W, Kim M. Journal clubs: a strategy to teach civility to nursing students. J Nurs Educ 2012;51(5):277-82. DOI: 10.3928/01484834-20120323-02
28. Tsuruwaka M, Asahara K. Narrative writing as a strategy for nursing ethics education in Japan. Int J Med Educ 2018;9:198-205. DOI: 10.5116/ijme.5b39.d5d2
29. Lee HL, Huang SH, Huang CM. Evaluating the effect of three teaching strategies on student nurses’ moral sensitivity. Nurs Ethics 2017;24(6):732-43. DOI: 10.1177/0969733015623095
30. Vermeesch A, Cox PH, Baca S, Simmons D. Strategies for strengthening ethics education in a DNP program.Nurs Educ Perspect 2018;39(5):309-11. DOI: 10.1097/01.NEP.00000000
    00000383
31. Clark CM, Springer PJ. Academic nurse leaders’ role in fostering a culture of civility in nursing education. J Nurs Educ 2010;49(6):319-25. DOI: 10.3928/01484834-20100224-01
32. Knepp KA. Understanding student and faculty incivility in higher education. J Effective Teach 2012;12(1):33-46. Link
33. Williams SC, Lauerer J. Implementing a nursing civility code: implications for education. J Nurs Educ 2013;52(3):165-70. DOI: 10.3928/01484834-20130218-01
34. Palumbo R. Incivility in nursing education: an intervention. Nurse Educ Today 2018;66:143-8. DOI: 10.1016/j.nedt.
    2018.03.024
35. Kim JS. Relationship between incivility experiences and nursing professional values among nursing students: Moderating effects of coping strategies. Nurse Educ Today 2018;65:187-91. DOI: 10.1016/j.nedt.2018.03.007
36. Jenkins SH, Woith WM, Stenger DA, Kerber CS. Using an innovative journal club strategy to teach civility to nursing students: Lessons learned. J Nurs Educ Pract 2014;4(3):161-6. Link