Educating our future generation-The role of nurse managers in encouraging civility

In the last three decades, the notion of incivility has been receiving increasing attention in the published literature (Viotti, Converso, Hamblin, Guidetti, & Arnetz, 2018). Arising from “subtle forms of mistreatment,” incivility can manifest itself in rudeness and maltreatment of co-workers (Viotti et al., 2018:597). Civility on the other hand “is characterized by an authentic respect for others when expressing disagreement, disparity, or controversy. It involves time, presence, a willingness to engage in genuine discourse, and a sincere intention to seek common ground” (Clark & Carnosso, 2008:13). Incivility in nursing practice is widely reported and the consequences of incivility can be far reaching. Nurses can experience reduced motivation and performance (Skinner, Dijk, Stothard, & Fein, 2018) but also can become overwhelmed by the related negativity and choose to leave their job or move. While much attention has been paid to describing this concept and determining relationships between variables, there has been little concentration on the contribution, if any, of preparatory nurse education programmes. Nursing students are known to experience incivility from nurses (Kang, Jeong, & Kong, 2018) and are encouraged to report these incidents to nurse managers (Kim, 2018). While there have been targeted interventions with students serving to detect and counter incivility (Palumbo, 2018), there is little concentration on teaching civility to nursing students. Role modelling civility is also an issue in the educational environment and there are also reports of faculty incivility towards nursing students and vice versa (Rawlins, 2017). Indeed, incivility among the student body is very common in the classroom situation (Lashley & De Meneses, 2001), ranging from lateness to verbal abuse. In clinical practice, workplace factors appear to have an influence on incivility, including the leadership of the nurse manager (Smith, Morin, & Lake, 2018), although the occurrence of nursing student incivility has received little attention in this domain. However, in terms of nursing students, Rawlins's (2017:713) integrative review identified an important theme of “incivility incites incivility” noting that faculty behaviour (for example condescending comments) could trigger uncivil behaviour in students. The university has thus been identified as a place where civil behaviours ought to be role modelled (Rawlins, 2017). Of interest, is Viotti et al's. (2018) recent analysis that determined a cultural aspect to these behaviours. Interestingly, drawing on the work of Hofstede (1984) and other more recent studies (Lewis & Malecha, 2011; Magnavita & Heponiemi, 2012), Viotti et al. (2018) point out that incivility also has cultural influences. Indeed, studies indicate that the US nursing workforce are more inclined to experience incivility compared with Italy for example. This is explained by the “restrained” Mediterranean culture (Viotti et al., 2018:599). We wondered then whether there were lessons to be learned from the Mediterranean culture, not only in terms of behaviour, but also in terms of our understanding of the term education and its relationship to the development of civility among nurses. In Italy, being educated is synonymous with being civil and mannerly. Etymologically, the term education derives from the Latin word “educere” meaning to bring forth. The word contains two parts, the Latin “e,” which means “out from” and “dùcere,” which means “to guide/lead,” therefore “to lead/guide out”. As such, the term education means to lead and guide. A closer look at the Italian term “educazione” [education] is revealing. It also has the same Latin origins, but in its use and understanding in Italy there is a great emphasis on the behavioural aspect of this word. “Educazione” means “to lead/guide out” in the sense that through discipline it is possible to guide man out of his original primitive nature and develop the positive attitudes of his soul and mind, sowing the seeds of morality and good manners. This promotes a person's instruction, autonomy and liberty, which ensure the individual's integration in the society by learning the behavioural models that enable the preservation and development of man. In Italy, we also use the term Maleducato, literately translated as poorly educated, but is understood to mean ill-mannered, rude and lacking of respect for others. Similarly, the term Ineducato is in regular use to describe a person as savage, primitive and uncivilized, as such a person who has never been taught how to behave. In Italy, there is also clear differentiation with regard to term use. For example, the department responsible for national education is called the Ministry of Instruction thus differentiating instruction from education which is a broader term meaning to instil knowledge but also behaviours. Overall, being educated and being mannerly and civil are synonymous with one another. The term 'nurse education' is widely used to describe the process of preparing people to for their roles as nurses and for advancing the knowledge, skills and competencies of those nurses once qualified. However, while educational programmes for nurses most certainly achieve their goals of ensuring that students attain competence and achieve the programme learning outcomes, little attention has been given to question as to whether or not these programmes lead to education of nurses in the Italian sense insofar as the translation of civil behaviours is not always consistently achieved. In fact, faculty behaviours towards students may have opposite effect insofar as they might inspire incivility (Clark & Springer, 2010; Rawlins, 2017). Historically, nursing students learned about important nursing values and behaviours through a process that has come to be known as professional socialization. In modern education programmes, while clinical practice remains an integral part of nursing curricula, much of the learning takes place in the classroom setting. Indeed, students can be somewhat detached from local professional socialization mechanisms, considering these in some cases to be an outdated method of power and control. While communication skills are extensively covered within international curricula, simple behavioural issues such as good manners, politeness, manners and attentiveness may not be explicitly addressed but rather an expected antecedent of the mature adult, or implicit within the teaching content. Given the extent to which incivility occurs in clinical practice, we believe that we can no longer be complacent about expectations around civility. As such, nursing students need to be explicitly taught about civility in the context of communication skills and professional codes of conduct (Clark, Danh, & Barbosa-Leiker, C., 2014). There are multiple ways to address this such as simulation, role-play, case studies, reflection and problem based learning (Clark et al., 2014). A formal agreement regarding accepted behaviours and code of conduct is also suggested (Woodworth, 2016), with consequences for students if this is broken (Shanta & Eliason, 2014). Overall, faculty staff need to be mindful of the importance of civility and their influence on this (Clark & Springer, 2010; Rawlins, 2017; Woodworth, 2016) and need to do more in terms of role modelling these behaviours. Nurse managers also have a key role in the support and development of nursing students, and their leadership is known to influence staff civility (Smith et al., 2018). This role modelling can be very simplistic: “some of the most valuable tools in our “civility toolbox” are engaging in meaningful conversation, actively listening and showing genuine interest in others (Clark et al., 2014:17). Nursing students for example often report not being addressed by name while on clinical practice. The role modelling of good communication skills such as getting to know students by nurse managers could contribute immensely to role modelling civil behaviours. As such, the education that students receive needs a strong focus on role modelling civil behaviours in the clinical area, with students encouraged to feedback to nurse managers if their experiences are negative (Kim, 2018). This is especially important as civil behaviour is not a static entity but rather it is relationship-based skill that is fluidic and changeable (Clark & Davis Kenaley, 2011; Clark & Carnosso, 2008). Open dialogue about the issues is also an important factor in overcoming incivility (Clark et al., 2014); thus, local meetings with nursing students might serve to address matters as they arise. Close working relationships between nurse managers and educators can also ensure that issues being experienced in the clinical area with regard to civility can be addressed appropriately through curriculum and education. Individual cases of student incivility also need to be managed appropriately. Nurse managers have a key role in “establishing a culture where incivility is not dominant and is not tolerated” (Mikaelian & Stanley, 2016:964). They are strategically and appropriately placed to truly educate the next generation of nurses.