The Effects of Group Discussion and Self-Learning on Nursing Students' Civility.

BACKGROUND: Uncivil behavior is a widespread problem among nursing students. Using a proper strategy can help teachers to reduce incivility, and its negative outcomes. The aim of this research was to compare the effects of group discussion, and self-learning on perceived level and rate of incivility in nursing students.
MATERIALS AND METHODS: A two group quasi-experimental design was used to perform the present study. The course was approved by ten members of the nursing faculty for teaching in January 2018. There are about 82 bachelor degree nursing students participated in a course that was designed to teach civility as a course syllabus. Subjects were randomly allocated to discussion group (41 students), and self-learning group (41 students). Incivility in Nursing Education-Revised Questionnaire (INE-R) was used to measure perceived level and occurrence rate of incivility in nursing students. In discussion group, eight sessions were conducted to teach course contents and each session lasted one hour. Self-learning group studied a booklet about civility. Paired and independent t-test was used to compare pretest and posttest mean scores.
RESULTS: Both groups indicated an improvement in perceived level of incivility. The mean score for occurrence rate of incivility in the discussion group was significantly higher than in the self-learning group (t80 = 4.63, p < 0.001). There were significant differences between two groups for perceived level (t80 = 2.81, p = 0.02) and rate of incivility (t80 = 3.01, p = 0.01).
CONCLUSIONS: Using course syllabus to educate nursing students can lead to reducing perceived level of incivility and providing active discussion is an appropriate strategy for promoting academic civility.

Introduction

Academic incivility has been defined as disrespect, indelicacy, irregularity, self-centering, incuriosity, harassment, unaccountability, dishonesty, irresponsibility.[1] It is a widespread problem in the nursing schools.[2] This phenomenon is evidenced by discourteous, disruptive, indelicate behaviors that appears in action, speech or body gestures.[3] Rate of academic incivility has reached a high level in recent years.[4] In one of the studies, 52.8 percent of respondents reported the incivility in nursing education.[5] According to a study, uncivil behaviors have been observed in high percent of students. They found that rude behavior was a moderate to serious concern.[6] The most frequent disruptive behaviors include demanding a passing grade, holding side conversations, using electronic devices,[3] wasting the time, being insulting, dishonesty, irregularity, inappropriate gestures, being unprepared for the scheduled activities, cheating,[7] arriving late, leaving class, using cell phone, sleeping and not paying attention to class.[8] These behaviors may hurt the mutual relationship and blemish interpersonal confidence and trust. Evidence showed that these behaviors interrupted academic integrity, and peaceful relationships.[1] It is assumed that righteous students were unmotivated and passive in conditions where incivility has become the norm. Additionally, incivility can lead to waste institutional resources such as time and cost.[9] It is a noteworthy topic in the field of nursing because nurses have a major role in the care of patients.[10] That's why 61 percent of new graduated nurses leave the nursing profession in the first year of working.[11] It has been attributed to various factors such as unclear expectations and roles, different beliefs, lack of satisfaction, diversity of values and heightened distress.[12]

Students need to understand the concepts of obedience, respect and dignity on the college campus.[10] Civility should be instructed in the academic setting as a priority that is why education is considered as the first approach.[13] The novice nurses can be a factor for change the culture in practical settings. The learning process starts from academia[14] and nursing school has been known as a suitable place for primary prevention.[3] Educators must provide a suitable environment to learn civility before entering students into a clinical setting.[13] Preparing an instructional program would help to prevent the occurrence of incivility and handle its negative long-term consequences such as nursing shortage and unsafe patient care.[3] Instruction may be useful in stimulating students’ motivation for civil behavior.[12] Nursing faculty members have a moral task in nursing school “they are responsible to care for those who care for others”. It is recommended that instructional intervention be performed based on effective strategy for dealing with uncivil behavior.[15] There is poor empirical evidence on suppressing the academic incivility,[1] and the applicable strategy to eliminate incivility remains unknown.[3] Clark indicated that a formal educational course can help students and teachers to handle uncivil behaviors.[16] A study indicated that problem based learning increased the knowledge regarding uncivil behaviors and highlighted the importance of civility.[15] On the basis of another research, article presentation was a useful approach to raising civility.[17] The workshops also were employed to change uncivil behaviors in nursing students.[6]

Self-directed learning in education has been recommended as a proper learning tool. One of the main benefits of self-learning is that it provides circumstance for self-regulation. It can help to improve student's knowledge independently.[18] In recent years, electronic self-directed learning has been increasingly developed.[19] It seems that a discussion based approach in the field of incivility will help professors and students to think about a problem, specify its importance, identify supportive resource, clarify the abilities and find strategies to eliminate uncivil behaviors,[20] But the challenge is to find information about the discussion and self-learning.[18] Review of literature indicated that there is a need to investigate the advantages of interventions.[21] If students are informed about different aspects of this phenomena they can distinguish between good and bad behaviors.[13] This research was conducted using an educational course to promote civility. There are no studies comparing the effect of self-learning, and discussion method on academic incivility. The purpose of this article was to compare two learning methods to raise perceived level and rate of incivility among nursing students.

Materials and Methods

The quasi-experimental with pretest- posttest design was employed to evaluate the effect of two learning methods on incivility. This study was conducted at a nursing school in Iran during 4 month between January and May 2018. Students were eligible based on several criteria. Students who had willing to participate in the research and studied for more than two semesters in this nursing school were included. The exclusion criteria were: being a guest student, missing more than a session and unwillingness to read the booklet, being 30 years old and over. Participants included the entire second and third year students. The reason for choosing second and third year students was the experience of uncivil behavior, and familiarity with academic relationships. The final year students were not invited to participate in the study because they were not attending college. Individuals who had at least two missing sessions (in discussion group) were excluded. Through stratified and block randomization, 82 students were randomly allocated to two groups. Firstly, the students of second and third years were divided into female and male groups. Allocation was determined using a randomization with block size of four. The letters were recorded in the possible orders. The two groups were labeled A and B. The names were written and put in a vase. Each student was assigned a code. Students were put in a group based on the number of members in each group. In group one (41 students), intervention consisted of active discussion on civility and how to deal with uncivil behaviors. Students were exposed to the same content. Second group (41 students) received access to the instructional content through an electronic booklet. Content was available on the virtual channel (telegram) for self-learning group. Students had enough time for studying learning issue. Researcher facilitated learning and responded to questions through weekly sessions and virtual channel.

This study consists of three stages: Baseline, intervention and evaluation. Course objectives were sent to students via virtual channel a week prior to running the class. All participants were given instructions regarding course. A session was designed to provide additional information. Students’ responses regarding the perceived level and rate of uncivil behavior were gathered. Pretest evaluation was done to measure views. It included demographic characteristic. Incivility in Nursing Education-Revised questionnaire (INE-R) was used for evaluation of viewpoints based on 4-points Likert-type scale. Items ranged from (1 = not uncivil) to (4 = highly uncivil) regarding level of incivility. Occurrence rate of incivility was rated from (1 = never) to (4 = often). The total score on the scale ranges from 24 to 96. This instrument was designed by Clark,[22] and its reliability confirmed by researchers in similar studies.[23] Questionnaire was reviewed and confirmed by ten nursing scholars. Content validity of tool were evaluated by twenty nursing students and ten members of faculty. They examined the questions for clarity, relevance and simplicity. The mean content validity index was 0.89. The questions were understandable and clear. To evaluate reliability a two week stability was computed on twenty students. Test-retest method was used for confirming reliability of instruments and Cronbach alpha coefficient was calculated for items. This coefficient ranged from 0.82 to 0.87. The INE-R demonstrated high consistency with α=0.86. The Intra class correlation coefficient (ICC) was 0.78.

Course content was designed to stimulate students to think about civility. They were given questions and examples of incivility. The content consisted of concepts such as accountability, responsibility, respect, dignity, privacy, commitment and sympathy. In discussion group, students attended in eight sessions during the formal schedule. Each session lasted 50-60 minutes. A faculty member from the department of nursing led participants in a discussion. He was provided examples of uncivil behaviors. Students were allowed to think about the issues for 5 minutes and state their opinions on them. In self-learning group, students were asked to study the course content and participate in the final exam. The written exam included 20 multiple choice questions. If they answered more half of the questions this resulting in a gift. Students were asked not to talk about the course content with another group. This program was a complementary part of clinical courses because of the same objectives. Nursing department of university confirmed the content to be taught as the course syllabus in the determined semester. Course content had been structured by the researcher and focused on common uncivil behaviors. The original source of content was a text book which included student's behavior protocol. It is known as a reference book for students of Islamic Sciences University and included the behavioral norms in academic setting. It was completed by related articles.[2224] The composition of the course content was the same as questionnaire (INE-R). It consisted of 6000 words. The exam had been evaluated for validity and alignment with instructional content. Course content and exam were approved by a nursing professional panel (ten experts). Students responded to questionnaires 4 weeks after completion of the intervention. The means and standard deviation of behavior scores were calculated at the baseline phase and therefore 4 weeks after intervention. To assess the effects of the intervention, the paired t-test and independent t-test were employed. Independent t-test was conducted to compare the mean scores between discussion and self-learning groups. For evaluation of the demographic variables of the students and the homogeneity test, the independent t-test and the Chi-square test were used. Data were analyzed using SPSS version 22 software (SPSS Inc, Chicago, IL, USA). p values < 0.05 were considered statistically significant.

Ethical considerations

Ethics approval was obtained from the ethics board of Iran University of Medical Sciences by code IR.IUMS.FMD.REC1396.9323199001. Written consents to participate were completed by students. Students were informed that they could leave the study at any time and their information would not be disclosed to others. Data were collected without names and confidentiality was maintained. In the first session, confidentiality, anonymity and volunteering were explained to students. They responded to the questionnaires before and after education without identifying their characteristics.

Results

The total number of subjects was eighty two nursing students: 41 students in the discussion group and 41 students in the self-learning group. General characteristics included the age, gender, marital status, academic year and residence status. The mean (SD) age of students was 20.58 (1.08). Female students were 56.10% of all subjects. The majority of participants were single (70.73%) and indigenous students (75.61%) respectively. Most respondents (48.78%) were in the third academic year. General characteristics of the two groups were summarized in Table 1. There were no differences among students of the two groups in terms of demographic characteristics. They were homogenous in terms of age (t = 0.31, p = 0.72), gender (X2 = 0.52, p = 0.59), marital status (X2 = 0.61, p = 0.63), academic year (X2 = 0.48, p = 0.57) and residence status (X2 = 0.02, p = 0.98) [Table 1].

Table 1

Homogeneity test of the characteristics of nursing students

Characteristics	Category	Group discussionMean (SD)/n (%)	Self-learningMean (SD)/n (%)	TotalMean (SD)/n (%)	X2/t	p
Age	years	21.02 (1.06)	20.14 (1.11)	20.58 (1.08)	0.31	0.72
Gender	Female	22 (53.66)	24 (58.54)	46 (56.10)	0.52	0.59
	Male	19 (46.34)	17 (41.46)	36 (43.90)
Marital status	Single	30 (73.17)	28 (68.30)	58 (70.73)	0.61	0.63
	Married	11 (26.83)	13 (31.70)	24 (29.27)
Academic year	Second	21 (51.22)	19 (46.34)	40 (48.78)	0.48	0.57
	Third	20 (48.78)	22 (53.66)	42 (51.22)
Residence status	Indigenous	30 (73.17)	32 (78.05)	62 (75.61)	0.02	0.98
	Dormitory	11 (26.83)	9 (21.95)	22 (24.39)

In the pre-test evaluation the mean scores and standard deviations for perceived level of incivility in the discussion group and self-learning group were 77.00 (2.88) and 76.83 (4.01) respectively, which were not significantly different (t80 = 1.43, p = 0.81). The mean score and standard deviation for occurrence rate of incivility in the discussion group and self-learning group was 48.31 (3.72) and 46.34 (4.30) respectively, which were not significantly different (t80 = 1.52, p = 0.16). For the perceived level of incivility, the mean scores and standard deviations in the discussion group and self-learning group were 70.12 (3.12) and 68.32 (4.05) respectively in the post-test evaluation, which were significantly different (t80 = 2.81, p = 0.02). The mean scores and standard deviations for rate of incivility in the discussion group and self-learning group were 42.33 (5.17) and 45.12 (2.13) respectively in the post-test evaluation, which were significantly different (t80 = 3.01, p = 0.01). In both groups the differences between mean scores and standard deviations for perceived level of incivility before and after intervention were significant (t80 = 7.83, p < 0.001) (t80 = 6.23, p < 0.001). In the discussion group, the difference between mean scores for rate of incivility before and after intervention were significant (t80 = 4.63, p < 0.001). In the self-learning group, this difference was not significant (t80 = 1.20, p = 0.06). Results were summarized in the Table 2. All students have participated in the final exam. Most of them (90.2 percent) passed the exam and only (9.7 percent) of students failed.

Table 2

Comparison of effects between the discussion and self-learning groups on perceived level and occurrence rate of incivility among nursing students

Students incivility		Pre-test Mean (SD)	t80	p	Post-test Mean (SD)	t80	p	differences Mean (SD)	t80	p
Perceive level	Discussionn=41	77.00 (2.88)	1.43	0.81	70.12 (3.12)	2.81	0.02	6.91 (2.33)	7.83	<0.001
	Self-learningn=41	76.83 (4.01)			68.32 (4.05)			7.36 (5.21)	6.23	<0.001
Occurrence rate	Discussionn=41	48.31 (3.72)	1.52	0.16	42.33 (5.17)	3.01	0.01	5.35 (4. 07)	4.63	<0.001
	Self-learningn=41	46.34 (4.30)			45.12 (2.13)			4.02 (6.03)	1.20	0.06

Note: M: Mean, SD: Standard deviation

Discussion

On the basis of these results, nursing students who had acquired the training, reported lower perceived level and rate of incivility. Therefore both educational approaches were associated with significant effects. The finding generated from our research is supported by past researches. Jenkins (2013) and Kerber (2012) showed that instructional plans were effective ways to raise civility.[1725] The perceived level and rate of incivility improved to lower level. Most scholars described it as a severe or moderate problem and proper intervention is necessary to diminish uncivil behaviors.[46] According to Clark, perceived level and rate of incivility in the educational intervention had been changed from serious level at the baseline to mild level in the posttest.[26] Another researcher showed that educational strategy was vital to informing students about incivility.[24] Most students were unaware of desirable social behaviors and instructional courses were useful for informing them.[13] In a similar study, students mentioned that teachers were not attentive to behaviors and they were only focused on teaching.[9] In fact, faculty members did not pay attention to academic civility and norms. Through creating the right circumstances, the faculty are expected to enhance virtues and ideal practice among nursing students.[16] Authors frequently stated that education and consciousness are imperative for promoting civility.[5]

Our findings confirmed the effectiveness of discussion. There are various reasons why the discussion could result in optimal behavior. Choe et al. indicated that student-centered discussions were effective in moral practice.[27] Researchers demonstrated that both individual and interactive instructional approaches were useful, but discussion based learning was more effective.[28] Our results were in accordance with the other study that workshop using the directed discussion was improved student's behaviors. Researchers recommended the use of questioning approach in teaching virtual issues in nursing. Students obtained knowledge by listening to other student's views and used these experience to improve their judgment.[29] Although an essential factor in effective discussion is to provide a safe climate.[30] In the current study, sessions were provided in such a way that students would listen to content and corrective suggestions. Our sessions were performed without any concern and fear. If the students are informed about civility in a calm and safe atmosphere they behave better.[31] This approach causes a just objective insight to incivility.

Moreover, it seems that an essential challenge facing the academic community is the lack of readiness for proper communication. Sessions can be used as effective tool help students to improve their relationships. Thus academic sessions are appropriated sites to state expectations and build honest communication.[32] Peer group has been known as effective factor to correct relationships. Nursing students mentioned that they have been affected by peers. Classmates have a key role in improvement of social behavior.[1] When students discussed issues they became informed about other attitudes.[25] Students should be assembled in a friendly situation.[25] Face to face relationships are needed to state viewpoints and enhance social skills.[26]

In addition, in the current study participating in sessions facilitated learning through reflection. Educational course helps student to review and think about their behaviors. They prepare for this situation through dynamic methods. The authors suggested that students need to become familiar with this phenomena through lecture or reflection.[15] Talking about the experiences and emotions cause the students to reflect on their uncivil behaviors and evaluate discrepancies and inconsistencies between behaviors and thoughts. They were able to think and notice how they acted in a special site. Students are directed to ask more questions.[33] Feedback also could clarify the effectiveness of discussion method. In the present study faculty members regularly held meetings. Students attended all sessions and discussions. The main differences between self-directed learning and discussion are the feedback. Students who received immediately clear feedback from the faculty would have better learning.[34] It is imperative that educators describe expectation and emphasize on acceptable behaviors.[35] They must review the course syllabus and clarify training needs and expectations.[10]

Although, researchers emphasized that the discussion and critical thinking were considered to be the effective strategies to build healthy relationship, and reduce troubling interactions among the academic community,[13] raising information and awareness about challenging matters through self-directed education assists in the recognition of civility.[5] In our study, self-directed learning is known to be associated with positive outcomes in perceived level of incivility. Researchers comparing instructor-led course versus self-instruction indicated lower effectiveness of courses without educator.[18] It is clear that learning is a process to gain the attitude and knowledge via cognitive and affective learning but self- learning is not sufficiently focused on affective domain of learning.[20] Additionally, consciousness is an introduction for correcting function. This process may last in the self-learning method. Successful results take time and require effort and tolerance.[6] Incorporation of self-directed learning activities into discussion appeared to be a useful strategy for guiding students to handle incivility.[18]

In present intervention, the faculty developed opportunities for teaching norms through the course syllabus. We held an exam session and student's knowledge was tested through questions. Authors showed that taking the time, spending energy and planning accurately for implementing the program can lead to a substantial effect on improving student behaviors.[36] It has been revealed that incivility that occurs in nursing school is a prevalent issue. Most faculty members agreed to teach the above issues in the course syllabus.[15] Milesky et al. (2015) indicated that with approved protocol, academic behaviors had been changed to a positive condition.[3] Course syllabus was focused on guiding students to gain professional goals and standards. According to Clark, adding norms to the curriculum helps students to learn civility.[15] A suitable education can be made through a clear and simple syllabus which contains a comprehensive educational approach.[5]

In our study the expected outcomes were achieved by eight biweekly sessions. According to Kim (2018) using six educational meetings results in positive consequences.[37] Another study also showed that the same number of sessions raised civility in nursing students.[29] Kerber et al. (2012) stated that six to eight sessions were enough to teach civility.[25] On the basis of findings it is recommended that civility be taught to students during a period of eight hours. In this study, problem was assessed based on students’ viewpoints. Most scholars believed that peer evaluation is a valuable tool. In some studies, teacher responses have been evaluated.[9] Teachers’ perception might be one-sided and biased. Therefore objective viewpoints of students were gathered in this study.

Although the results of this research may be applicable in other nursing schools, generalization of findings should be done with caution. The limitations are due to the following reasons. Firstly, data was collected by self-reported questionnaire. Secondly, this study was conducted on second and third year nursing students and more studies need to be performed on first and last year students. In this study students’ viewpoints were employed to evaluate incivility and no information was obtained from the educators. Recommendation for future research is to evaluate perceptions among educators and students to compare results. Using the qualitative research design would provide complete information through rich data. It is recommended that similar studies should be conducted on nursing students in nursing colleges over several places.

Conclusion

Uncivil behavior changed to a lower level by discussion method. We offered a formal strategy to prepare students for challenging conditions. The title of incivility can be entered into the nursing course because nurture is prior to education. Discussion can be used as suitable method in developing civility. Self-learning appears to be less effective for promotion of civility. This method is recommended as a complementary approach with minimal control or interference over the learning. The value of this method as an inexpensive tool should be compared with other educational strategies in future studies.

Financial support and sponsorship

Iran Universityof Medical Sciences, Tehran, Iran

Conflicts of interest

Nothing to declare.