Uncivil behavior, a common problem in educational institutions, has been found to have increased in nursing students (Ziefle, 2018), with most students and faculty members reporting a high prevalence of incivility (Natarajan et al., 2017). In a study by Ibrahim and Qalawa (2016), 60.2 percent of students reported uncivil behaviors. Incivility has many negative consequences in educational and clinical settings, reducing productivity among faculty and leading to a reluctance to work in academia (Gallo, 2012). Uncivil behaviors in the clinical setting affect the quality of nursing care and the integrity of nurses. Uncivil behaviors have negative effects on patient satisfaction (Williams & Lauerer, 2013).
Managers and faculty members play an important role in fostering a culture of civility (Abedini & Parvizi, 2019). Organizational culture influenced by values, norms, customs, and relationships has an influence on performance (Milesky et al., 2015). Culture management involves recognizing values and expectations and promoting the civility of members (Ibrahim & Qalawa, 2016). The creation of a civil culture involves prioritizing moral virtues, mutual respect, courtesy, and competence and is achieved through respect for the beliefs of others (Clark, 2011). Students learn civil behaviors through respect for the beliefs of others, the acceptance of differences, and affirming one another (Milesky et al., 2015). Considering the importance of civility in nursing students and the role of faculty members, this study aimed to determine the impact of incivility management on nursing students' behavior.
METHOD
This pilot study was a quasi-experimental study conducted during one semester, from January 2019 to May 2019, at Qom University of Medical Sciences in Iran, with a convenience sample of second- and third-year nursing students and faculty members. Second-year students constituted the control group; third-year nursing students were in the experimental group. Guest students; students who dropped out, changed courses, or transferred from the university; and retired faculty were excluded from the study. Eighty-two students and 15 faculty took part in the study.
The civility management program was conducted during one semester. It included the establishment of a behavior committee, the development of codes of conduct, giving positive scores for civil behaviors, and setting a vision based on Clark's model (Clark et al., 2011). The views of students were used in determining the vision. Group meetings of the Ethics and Civility Committee were held to develop a code of conduct based on relevant texts. The code was approved by faculty members of the Nursing and Ethics Departments. Students in the experimental group were asked to adhere to the code of conduct, and their instructors were encouraged to foster civility and give positive scores to students.
Data were collected using the Persian version of the Incivility in Nursing Education-Revised Questionnaire. Students responded to 24 questions one week before the intervention and four weeks after the intervention. This tool was used for the evaluation of perceived level and occurrence rates of incivility based on a 4-point Likert-type scale. Level of incivility was rated from 1 (not uncivil) to 4 (highly uncivil). Occurrence rate of incivility ranged from 1 (never) to 4 (often). Scores ranged from 24 to 96 (Clark et al., 2015). The questionnaire was administered to 10 faculty and 10 nursing students. Reliability of the questionnaire was assessed by a test-retest method and confirmed by a Cronbach's alpha coefficient of .85. This tool has been used in numerous studies, and its validity and reliability have been investigated (De Gagne et al., 2016). Data were analyzed using descriptive statistics and t-test. The impact of the program was evaluated from the viewpoints of students.
Approval to conduct the study was obtained from the ethical board of Qom University of Medical Sciences (code IR.MUQ.REC.1397.137). Consent to participate was completed by students and faculty members; participants were informed they could leave the study at any time. Data were obtained without participant names, and confidentiality was maintained. Limitations of the study included the low response rate of students, which was reduced by giving gifts. The study tool was a self-report questionnaire and was influenced by the accuracy of the students.
RESULTS
Most students were female (56.10 percent) and indigenous (75.61 percent). Their mean age was 20.76 (SD = 2.02). Most faculty were female (92.3 percent), with a mean age of 39.65 (SD = 4.13). The majority (66.7 percent) were instructors; others were assistant professors. The two groups were homogeneous in terms of demographic characteristics.
Pre-intervention views of students showed that the mean perceived level of incivility in the intervention and control groups was 83.24 (SD = 2.51) and 79.02 (SD = 1.20), and the occurrence rate of incivility in the two groups was 65.32 (SD = 4.17) and 58.13 (SD = 8.30), respectively. The mean posttest perceived levels of incivility in the experimental and control groups were 60.17 (SD = 2.32) and 78.32 (SD = 3.41), respectively, and the mean posttest occurrence rates of incivility were 42.20 (SD = 5.17) and 56.62 (SD = 4.41), for the experimental and control groups, respectively. Changes in mean scores after the intervention showed that perceived level (t80 = 6.59) and occurrence rate of incivility (t80 = 6.80) had a significant decrease (p < .05).
DISCUSSION
The findings of the study indicate that establishing and implementing comprehensive policies was helpful for creating healthy conditions and promoting a culture of civility among nursing students. A similar study found that the role of nursing managers is essential to foster a culture of civility through education and policy development (Clark & Springer, 2010). Other researchers have emphasized the role of educational managers in the implementation of disciplinary regulations (Touzet et al., 2014). Implementing a code of conduct was found to improve student performance (Abedini & Parvizi, 2019). Students' incivility was reduced by clarifying expectations and explaining the rules (Authement, 2016).
According to the findings, creating an open conversation between students and faculty members can help students prepare for appropriate behaviors in real-life situations. In other research, presenting a vision, defining expected behaviors, explaining responsibilities, and creating a commitment to achieve desired behaviors have also been identified (Vermeesch et al., 2018). Other researchers have used similar strategies to define and introduce proper behaviors and to encourage individuals in understanding responsibility (Sanner-Stiehr & Ward-Smith, 2015). Discussing behavioral issues at meetings helped students further understand the subject matter, leading to informed collaboration of participants to improve civility (Yassour-Borochowitz & Desivillia, 2016). The formulation of a shared vision has been recognized as an effective factor in promoting a culture of civility (Clark et al., 2011).
In this study, student evaluation based on specific codes had an impact on achieving civility. In a similar study, using behavioral assessment criteria was effective in encouraging students to adhere to standards (Yassour-Borochowitz & Desivillia, 2016). Applying a code of conduct and specifying how to control uncivil behavior were useful strategies (Aul, 2017). Implementation of a behavioral committee and application of codes of conduct in student evaluation for one semester can be a prelude to creating a civil culture and affect quality of care for the future.
REFERENCES