Student's perceptions of using scenario-based education to improve civility: A mixed method study.

INTRODUCTION: Academic incivility is one of the major concerns among nursing student that disrupts the learning process and influences the quality of nursing care. Investigating a useful strategy can be a crucial action in reducing the problem. The purpose of this study was to evaluate the nursing student's perceptions of using scenario-based education to improve civility.
METHODS: An explanatory mixed method approach was employed. Nursing students who were studying in the second and third years participated in research (N=81). Eight sessions were designed for discussion regarding the scenarios that were directed by a faculty leader. Changes in the students' perception were evaluated four weeks after the sessions by a questionnaire. Data were analyzed using paired t-test and calculation of mean scores. Ten focus groups were conducted and content analysis identifed two themes and four subthemes. Both the qualitative and quantitative data were analysed separately and the findings were merged in the discussion.
RESULTS: There was a significant difference between the student's perceptions for the perceived level and occurrence rate of incivility before and after the intervention (p<0.05). The major themes found included awareness of the importance of incivility and capability to change uncivil behavior. The results from the mixed method study showed that the program increased awareness and capability to change uncivil behaviors.
CONCLUSION: This research provided an extended understanding of the outcomes of the scenario- based education on nursing student's perceived behaviors and strengthened their beliefs and capabilities about civil behaviors. It can be applied as an effective strategy to raise the perception of the program value and use. Copyright: © Shiraz University of Medical Sciences.

Introduction

Uncivil behavior has been defined as disrespect, impolite, discourteous or rude behavior that may be intended to upset or harm others. Drastic incivility has been described as severe hostility, strife and violence towards others (1). It has been referred to as threats, insults and abuse (2). Faculty members often complain about the students arriving late, cheating, making indecent remarks toward others, holding inopportune or aberrant dialogues and being uninterested in class (1). Other disruptive behaviors are unrelated conversation, using the laptop and other devices during class, not preparing assignments, having distracting dialogue, and leaving the class early (3). Discourteous actions are on increase among students. Some studies have revealed that uncivil behavior has had an ascending growth in recent years (4). According to a study, more than 50% of the students and faculty members mentioned experiencing rude behavior (5). Nearly all faculty nurses have encountered student incivility while working (6).

Numerous elements like stress are associated to disruptive behaviors. Clark (2011) explained that stress, feeling of inferiority, unclear regulations, and lack of awareness lead to incivility (7). Other effective factors include different individual beliefs, diversity in values, ambiguous expectations, and lack of integration (8). Dissatisfaction, unmet needs and unsolved problems often result in misbehavior by students (9). It is clear that nursing schools are considerably at risk for this problem and its negative outcomes. Most nursing students and faculty members introduced incivility as a concern in academic and clinical settings because of its threatening outcomes (10). Incivility undermines the solidarity, mutual understanding and healthy relationship and leads to hatred, hostility and disrespectful interaction. Disruptive behavior negatively impacts self-esteem and self-confidence (11). Therefore, rude behavior is known as a source of anxiety (7).

It is obvious that some annoying communication such as asking unreasonable questions, indecent speech and distracting dialogue may impede effective education. Students do not learn when they are apathetic or sleepy. These conditions can lead to wasting time and energy (12). Unfavorable meeting in the educational environment disrupts teaching and the learning process. Most academic members have encountered the negative outcomes of incivility (1). These circumstances discourage the academic community and lead to unfit conditions. Uncivil acts can endanger the tranquility and welfare of the academic community on the college campus (2). when uncivil actions remain ignored or unsolved this situation may be associated with critical and dangerous consequences (13). It seems that rude behavior in nurses begins in schools and then is transferred to the workplace (2). Incivility may be normalized secondary to the known culture of the institute and change to permanent habits and traditions. Some researchers believed that misbehavior in formal settings may be an acquired experience that is expressed in a susceptible environment (14). These situations may negatively affect the quality of nursing care and its outcomes.

Hence, it is required to manipulate academic training to raise the quality of interactions. Teachers have a main role in developing moral virtues. They are responsible for establishing civility in academic settings. They must be prepared to manage the academic environment to prevent further complications and uncompensated effects. Many sources are focused on guiding teachers to support and encourage students (9). Ultimately, students need to recognize the incivility and the way to deal with misbehavior in an academic and clinical setting. However, some authors emphasized involving both students and educators in fostering the civility (15). It seems that civility is neglected in the academic course. In other words, faculty members do not pay attention to this important issue in the curriculum.

There is similar literature on the issue of academic civility, but effective strategy to promote civility remains unknown (16). Although the incidence of incivility has been documented in many studies, the influence of strategies on resolution of conflict and elimination of incivility has received poor attention. Clark reported that problem-based learning scenarios were effective in teaching civility. Students expressed their views on how to deal with scenarios; thus, they were more prepared to perform the right behavior in the nursing work environment. Results showed that didactic presentation and interactive instruction can lead to learning academic norms (17). Scenario is an effective learning tool for working with problems. Scenario-based discussion is a valuable strategy for learners to think and work on realistic situations and try to explore the solutions (18). Scenarios create opportunities for brainstorming and reflection (19). It is a method which enables the learners to practice in a safe condition (20). It is known as a useful tool to improve judgment, communication, competence, self-efficacy and suitable performance. Case-based learning helps the students to analyze the matters and seek proper answers (21). It helps the students to gain a better understanding about complex matters (15). Using a method that includes real issues and challenging matters, a useful solution can be found (9,21).

In another research, educational intervention, article presentation, and active discussion were employed to change uncivil behaviors in nursing students. Their formal course was useful to raise civility (22). According to Clark, workshops may provide a suitable situation for students and faculty members to state their ideas about uncivil acts. The students' perception and frequency of incivility were reduced after the sessions (23). The researcher also provided evidence for integrating civility into nursing education. She believed that a civility-based curriculum could help the faculty members to manage destructive behaviors (24). It seems that there are a few empirical researches with regard to promoting civility. Review of articles showed that the effect of teaching civility on the students’ behaviors in Iran has not been addressed. Rad (2017) conducted a grounded theory research to evaluate the strategies for handling incivility. They found that modifying the culture of the institute was an effective approach to promoting civility. They suggested using democracy for academic management. Instructional strategies are usually applied in order to gain better outcomes (6). We used an active training method to educate. The purpose of this article was to describe nursing student's perceptions of using scenario-based education to promote civility.

Methods

An explanatory mixed method approach using a self-reported questionnaire and ten focus groups was used to describe the students' perceptions regarding the efficacy of scenario-based learning. This design was chosen since t different methods can give a comprehensive understanding of the issue (25). A quantitative study was used to obtain data on the preliminary perspective of the student's views; then, a qualitative study was undertaken to gain better insight into the program and in depth perspective of students. A quasi-experimental study with one group pretest-posttest design was conducted at the nursing department of an Iranian university for a period of 4 months. Second and third year nursing students participated in the research. The inclusion criteria were: being a full time nursing student who had studied at least two semesters and experienced uncivil behaviors during a previous year. The final year students were excluded because they were often working in a hospital and were not attending the nursing school. They were not chosen because numerous factors as environmental and staff members elements affected on their experiences and views. The other exclusion criteria included lack of willingness to participate and being a guest student.

Data were collected using self-reported INE-R survey that included demographic and uncivil behavior items. This instrument was developed by Clark (2014) and its reliability was confirmed in several studies (26,27). The 4-point Likert-type scale was used to evaluate the students’ point of view. This questionnaire was reviewed by ten nursing faculty members. They confirmed the validity of the instrument. The mean content validity index was computed 0.89. The questions were understandable and clear. A pilot study was done on nursing students and the reliability of the tool was determined with test-retest. Coefficients for the student incivility were 0.78 and 0.89 for the perceived level and occurrence rate, respectively. Cronbach alpha coefficient ranged from 0.82 to 0.87 for the items. Results indicated the high consistency of the questionnaire with α=0.86 and intra-class correlation coefficient= 0.78. The students were asked to respond to the questionnaire based on their own perceptions. Questions were about the students’ perception and occurrence rate of uncivil behaviors. Eighty one students were invited to participate in this research during the second semester in March 2018. The intervention and data gathering took place over 14 weeks.

Pre-test evaluation was conducted to measure the student responses as the baseline assessment. This phase included evaluating the frequency of occurrence and perceived level of incivility. Ultimately, the subjects responded to the questions in the post-intervention phase. They completed questionnaires without identifying the characteristics.

The program was designed to be implemented in clinical course because the target content was parallel to the course objectives. There were appropriate conditions in the clinical course such as sufficient time and appropriate place for sessions. Each group consisted of twenty students.

Scenarios were structured by the researcher and faculty members. The researcher was a doctoral student without experience with participants and declared no conflict of interest. Issues of the scenarios focused on common uncivil actions that were experienced by students, for example being dishonest, unaccountable, irresponsible and disrespectful, and having indelicacy and irregularity. The contents of the scenario were designed to motivate and encourage the students to brainstorm and think about the issues.

Each session lasted 90 minutes. The director led the participants to discuss the issues for cognition and provoking incivility during the session. All the students wanted to listen to the preparatory scenarios and interpret their opinions. They were allowed to think about the issues for 5 minutes. A problem was analyzed and described by the students. They suggested pathways to change the rude behaviors. The faculty had noted comments on the board and ultimately summarized the results.

Overall, the students participated in eight weekly sessions that were implemented in the formal program. The sessions were designed to promote the knowledge of students about civil concepts such as responsibility, accountability, dignity, respect, commitment, privacy, and sympathy. The researcher and leader did not have a role in teaching and giving a grade to students. The learners were informed that withdrawal from the study would not affect their evaluation.

Following the intervention, the post-test was conducted to evaluate the changes of rate and level of disruptive behaviors. Quantitative data were analyzed using SPSS version 18. All effects were calculated at 0.05 level of significance. Paired sample t-test was computed to compare the differences between pre-intervention and post-intervention responses.

Qualitative data were obtained by eight focus groups. The rationale for choosing focus groups was to gain a better insight into the students’ views. It provides forums for the participants and researchers to develop insights and reflecting together (25,28,29). Focus group was used for this study because it encourages the students to interact actively with classmates by exchanging ideas, asking questions and commenting on viewpoints. Groups with a diversity of students in age, gender, marital status, academic year and residential status participated. Students participated in interviews which lasted for 60-80 minutes. All focus groups were conducted by the researcher in a calm classroom. Interviews were continued until data saturation. Two more sessions were carried out, but no new code was extracted. Research questions included: How did the intervention affect you? Could you describe your experiences regarding benefits of intervention? How did the intervention result in changes to the student's uncivil behaviors?

Interviews were audiotaped and transcribed verbatim immediately. Coding was conducted by the authors and another experienced researcher. Content analysis was conducted as introduced by Wildemuth (28) including transcription of data and assigning numbers to students, 2)identifying meaning units, 3) coding the data, 4) matching the codes with the data, 5) assessing the codes and combining them, 6) classifying similar codes, 7) assessing the categories, and 8) assigning the themes (24). Coding and analysis were done several times. The repeated coding and credibility approach were used to increase the rigor and trustworthiness. Other strategies included presenting the themes to the students, having long term relationship with the students, exact recording of the process, and presenting the quotes. The codes were reviewed and compared with previous data. Furthermore, the themes, codes, categories and parts of texts were confirmed by two nursing faculty members familiar with qualitative studies. Two selective scenarios were explained as follows:

One of the students arrives late in class and plays with his personal phone, so that he does not pay attention to the professor's comments. Suddenly, his phone rings and he leaves without permission. The student goes back to the class and interrupts the class. When asked to explain his behaviors, he said that traffic was heavy.

Teacher assigned a schoolwork to the tree students. Two students decided to go ahead and complete the assignment without the third member of the group. After the third member realizes the matter, he has an aggressive behavior toward his classmates and teacher. He leaves the professor's office and slams the door.

Ethical consideration

Institutional approval for this study was obtained from the ethical board of Iran University of Medical Sciences. Nursing students completed the formal consent to enter the study. Students who had been invited to the study became well-informed about the quality of the intervention. We randomly assigned numbers for the students. These numbers were recorded in a notebook. Students were informed that no one else was aware of these numbers. The principles of anonymity and confidentiality and voluntary participation were considered in the focus groups.

Results

Eighty one nursing students participated in the present research. Their mean age was 22.11±3.58 years. Female subjects constituted 55.6% of the students. Most of the participants (71.6%) were unmarried. The majority of them (76.3%) were indigenous students. Table 1 displays the general characteristics of nursing students.

Table 1

Characteristics of nursing students.

Variable	Category	N (%)
Age (year)	19-24	72 (88.2)
	25-30	7 (8.6)
	31-36	2 (2.6)
Gender	Female	45 (55.6)
	Male	36 (44.4)
Marital status	Single	58 (71.6)
	Married	23 (28.4)
Academic year	Second	40 (40.9)
	Third	41 (50.6)
Residence status	Indigenous	58 (76.3)
	Dormitory	18 (23.7)

Student responses before the intervention revealed serious perceived level and rate of incivility. Perceived level and occurrence mean scores were 74.81±11.55 and 45.93±13.31 respectively at baseline. After instruction, the mean score of the perceived level of incivility was 68.87±13.31. There was a significant difference between the pre-test and post-test scores (p<0.05).

All of the item means decreased between pre- and post-intervention, but only six items were statistically significant (p<0.05). These behaviors included 1) using a computer, phone, or other media device during the class, 2) holding side conversations that distract others, 3) skipping class or other scheduled activities, 4) ignoring, failing to address, or encouraging disruptive behaviors, 5) making discriminating comments toward others, and 6) leaving class or other scheduled activities early. The mean scores of post-test responses indicated that the occurrence rate of incivility was 41.84±10.87. The comparison of the mean scores before and after the instruction revealed significant improvements in the occurrence rate of incivility (p<0.05).

Results are summarized in Table 2. According to INE-R scale, the findings showed that mean scores of perceived level and rate of incivility were on a moderate level. This intervention had a positive effect on incivility.

Table 2

Effect of scenario based education on perceive and occurrence rate of incivility among nursing students

Students incivility (n=81)	Pre-test Mean±SD	Post-test Mean± SD	Change Mean± SD	t-test	P
Perceived level	74.81 ±11.55	68.87 ±13.31	5.93±16.50	3.22	0.01*
Occurrence rate	45.93 ±13.31	41.84 ±10.87	4.09 ±14.81	2.39	0.03*

M: mean, SD: standard deviation

P<0.05.

Qualitative analysis

The analysis produced 184 codes which were reduced to 53. These data generated two themes and four subthemes. Selected quotations are mentioned. The content analysis of data from the ten focus groups indicated the following themes: "awareness of the importance of civility" and "capability to change uncivil behavior" (Table 3). Selected quotations for the extracted themes are exhibited.

Table 3

Student’s perceptions by category

Themes	Category	Sub Category
awareness of the importance of civility	Behavioral consciousness	Perception of wrong behavior
		Giving priority to uncivil behavior
		Familiarization into consequences
	Accountability for correct behavior	Seeing behavioral modification as a task
		Being able to self-regulative
		Having moral sensitivity
		Affecting honesty
Capability to change uncivil behavior	Trying to solve the problem	Acting on reflective thinking
		Seeking a solution
		Properly dealing with incivility
	Deciding to create a respectful relationships	Development of communion
		Training communication skills
		Pay attention to others
		Building friendly conversations
	Tendency to contributing with others	Espouse helping others
		Trying to strengthen team work
		Tendency to avoid self-centeredness

Theme one: awareness of the importance of civility

The subthemes of this theme included behavioral consciousness and accountability for correct behavior.

Behavioral consciousness

Perception of wrong behavior

"When we talk about disrespectful works and classroom disturbance, we realize the effects of our behaviors. We had numerous mistakes; I felt that the disrespect had a significant influence on others, and we were accustomed to some behaviors".

Giving priority to uncivil behavior

"I believe that incivility cannot be ignored. This is a serious matter in nursing schools; these activities would clarify the importance of rudeness and violence. Unfortunately, this problem is common".

Familiarization into consequences

"We were able to share our previous experiences and think about the consequences of incivility".

"I found that the rude actions have a negative effect on others. It is difficult to study in an aggressive environment; it disrupted the classroom".

Accountability for correct behavior

Seeing behavioral modification as a task

"We became distressed by the discussion about ugly behaviors. I think that disruptive behaviors must be followed and all of the students and teachers should help to root out this problem".

Being able to be self-regulative

"Talking about the positive behaviors caused the students to assess their own actions; then, they were able to stop negative acts."

Having moral sensitivity

"By implementing this program, we became sensitive to harassment and violence, I don't like to make trouble".

Affecting honesty

"We were willing to participate in the dialogue; we were more likely to guide others. When I hear a gossip, I try not to support it; I try to minimize blame".

"I feel that the course had a significant influence on students; the behavior of many students has been changed. These classes influenced how they deal with others".

Theme two: capability to change uncivil behavior

The subthemes of this theme included trying to solve problem, deciding to create respectful relationship, and having the tendency to contribute to others’ issues.

Trying to solve the problem

Acting on reflective thinking

"We became aware of the other's thoughts and views; it led us to ask questions. The faculty members asked the students to state how these behaviors affect the environment. It helped me to think more deeply".

Seeking a solution

"There was an opportunity to identify how we were able to avoid irritations and troubles; we attempted to find a way together".

Properly dealing with incivility

"My poor experience can distract me from how to deal with impolite classmates. I learned how I should respond to certain behaviors".

Deciding to create respectful relationship

Development of communion

It helped me in my relationships.

"Fighting and harassment could harm our relationships. I think that kindness is one of the key factors for building a positive environment. We should respect each other. Such conversations facilitate this".

"My opinion that the respectful relationships are significant has become stronger".

Training communication skills

"The most important benefit of participating in sessions was working together; we learned to respect others, to listen and to be patient".

"The best work in academia is dialogue; we should be prepared to build good relationships."

Paying attention to others

"We learn to be sensitive versus each other and listening to other's beliefs. I should notice other people's needs".

Building friendly conversations

"I stated my emotions in a comfortable atmosphere. I verbalized them without fear and without any problem".

Tendency to contribute to others’ issues

Espouse helping others

"I judged students based on my view, but I am more likely to help others in different situations. Some students have problems and it is necessary to help them".

Trying to strengthen team work

"I felt the sessions were like the council; relationships were supportive and friendly. We worked together and I found that tensions should be solved in relationship with students in a peaceful and calm environment".

Tendency to avoid self-centeredness

"It is not easy to verbalize virtual issues. Each person wants to get what he needs".

"Before I was thinking about myself, this caused me to neglect the other peoples' needs".

Discussion

The findings from both the quantitative and qualitative approaches showed that scenario was perceived as a useful strategy to improve civility. The analysis of data indicated that scenario-based training is a beneficial way for promoting academic civility and handling the rate of uncivil actions among nursing students. The decrease in some uncivil behaviors between pre- and post-tests was significant including: using a computer, phone, or other media device during the class, holding side conversations that distract others, skipping class or other scheduled activities, ignoring, failing to address, or encouraging disruptive behaviors, making discriminating comments toward others, and leaving class or other scheduled activities early. Researchers indicated that having no discipline, using electronic devices, being disrespectful, demanding a passing grade, wasting the class time, holding side conversations being insulting, inappropriate gestures, being unprepared for the scheduled activities, leaving class, using cell phone, and not paying attention to class activities were the most frequent uncivil behaviors (12,30,31), Ibrahim and Qalawa (2015) reported a high level of irresponsible behaviors and a lower level of aggressive behaviors; they suggested that there was a need to train the students to behave in a respectful and accountable manner. According to Clark (2013), scenarios can be used for promoting respectful relationships (15) and improving the ability to build a regular learning environment (20). It seems that aggressive behaviors were not common and the related changes were not significant. In this research, selected issues were according to common uncivil actions that were frequently reported in nursing literature. This approach helped the students to understand incivility and improve their performance.

As a result of the focus groups, many students stated that changing their behaviors affected honesty. Therefore, they were able to apply learning experiences in the actual setting. Kerber (2012) also noted that problem-based discussion improved the students’ awareness and their tendency to be civil (1). These results were in accordance with similar research in which active training raised awareness and led to reduction in incivility (15). According to the students’ perceptions, awareness was the main core category in this study. Some authors reported that most students do not have enough information about academic norms (3). Ability to educate and raise consciousness is necessary to foster civility (9). Consciousness was also one of the subthemes in similar studies, orientation of students by educators has been proposed to exemplify and distribute desirable behavior (17). These qualities include moral values and acceptable acts such as truth telling, honesty, positive communication, and social support (16). These results were in accordance with the quantitative findings.

Giving priority to behavior was another subtheme. According to Clark et al. (2014), students who participated in the program became informed of the significance of civility. They believe that learning of norms and moral virtues is an imperative priority and students must be informed about how to modify their ideas and emotions.

Our intervention helped the students to realize their mistakes and develop their sensitivity to moral issues. Shanta and Eliason (2014) pointed out that expectations and rules should be clearly explained. Of course, some students had different perspectives regarding cheating (32,33). They believed that cheating is a friendly behavior which is performed for helping a classmate to pass a course (1). Students usually want to succeed in any way. In this situation, civility and moral values may be ignored (3). However, they are expected to behave in an honest way even in unpleasant situations. According to Russell (2014), the scenarios that demonstrated real relationships between students and educators were useful starting points to promote moral sensitivity (16).

The current study showed that critical conversations could help the students to understand their defects and improve self-regulation. This reality has been confirmed by other authors (20). We arranged sessions as a means to promote social interaction, and creating respectful relationships was cited by the participants as an important issue. In a similar study, during the sessions, the students were asked to learn and speak about career and its social matters because the nursing profession is progressing consistently (3). It is clear that the college campus, as a social environment, exposes the learners to varied situations such as tasks and roles (16). Promoting socialization towards disseminating culture of civility is an important priority in nursing education (18). Proper interaction generates social behaviors (34). Students ought to experience interpersonal communication and evaluate their own abilities and faults to extend the social relationship

Building friendly conversation was extracted as a significant topic. Students can learn from peers via social interactions. In the study of Jenkin’, students mentioned that they required discussion with peers to improve the academic relationship (2). Kerber also showed that students discussed with peers to be aware of other opposite and similar attitudes (1). Peer group is a substantial factor in consciousness and preparation for the new social situation. The main matter in this condition is the poor knowledge about the norms and safe behavior, especially when entering the academic environment. Students who participated in our study were young. The majority of them belonged to the 19-27 year old age group and were unmarried. They had different cultures and values. Therefore, a proper strategy can promote civility through social approaches (2). Empathetic perception and active listening can result in safe relationship (33,35).

This research emphasized the active participation of students during discussions. Their chairs were arranged in a semi-circle position (U-shaped). This situation encourages closer interaction. Teachers also play a major role in attaining effective instruction (23). This method can be based on group activity. Strengthening team work was found to be another finding of the present study. Team approach has been suggested for use in class (2). Clark also stated that students’ chairs should be arranged face-to-face or in a semi-circle manner that allows mutual interaction, so that the participants can see each other (5). In a similar study, the students were placed in a half-circle manner in the sessions. According to their findings, the friendly interaction helped them to express ethical information (36).

Reflection was a key element in learning civility. We used a strategy which combined questioning and ethical dialogue to raise the students' knowledge and change behavior. Students stated the scenario-based discussion was a useful tool for reflective thinking. The facilitator primarily asked the students to explain opinions regarding a specific matter. Self-reflection, as an educational major skill, was recommended to teach civility (37). In the current study, the students listened to a scenario and participated in an analyzing debate. Scenario prompted them to think about incivility and its impacts on the academic community.

Participants also believed that seeking a solution and properly dealing with incivility were valuable outcomes of the intervention. In the present study, the students were allowed to criticize and conclude the dialogues. It was beneficial for preparing them for a positive performance in real life situation. Learning through a case includes useful skills such as critical thinking, communication, and problem solving. This intervention was conducted to teach the students about how they think and make decisions on specific situations. They answered the questions. Problem solving and critical thinking enhance the students’ ability to eliminate errors and increase knowledge regarding their own behaviors and highlight the importance of a respectful relationship (1).

Additionally, this program helped the students to recognize the outcomes of their own behaviors. During the sessions, the students pointed to the outcomes and negative effects of incivility. They stimulated the dialogue by reflective questions. The authors showed that a similar instructional intervention developed the abilities such as critical appraisal, responsibility, accountability, commitment to rules and regulations, social support and offence avoidance (1), the use of respectful speech and friendly language, accountability and responsibility, professional action and ethical values are examples of behaviors that should be demonstrated by the faculty members (14). Individual accountability is required to make effective decisions (7). Students should be responsible for respecting academic rules and regulations (6).

In the current study, the leader of the sessions was a professor at the Center of Research Ethics and member of the Ethics Department at the University. Students were familiar with him as an ethics-centered teacher. Faculty members can help to promote the moral development using reflective thinking, case presentation, and role modeling.

Ultimately, in our study eight training sessions were implemented. A similar study showed that positive outcomes were achieved by six to eight weekly sessions (20). Another author reported that six biweekly sessions were associated with significant changes (1). Torabizadeh et al. (2018) showed that six educational sessions had positive effects. In their study, each meeting lasted 45 minutes (36). Using six to eight sessions to reduce perceived level and rate of incivility has been suggested. On the basis of findings, a minimum one hour discussion can be useful.

Limitation

The results of this research may be applicable in other nursing schools, but generalization should be done doubtfully. Firstly, it was implemented among nursing students at a single school. It is suggested that more evaluations should be done and compared in several colleges. Secondly, this intervention did not have a control group. It is recommended that the future researches should include a control group without the training. Thirdly, findings were collected by self-reported questionnaire. Therefore, responses may be biased by students. Additionally, this study was conducted on the second and third year students and more studies are required to be performed on different academic levels of students.

Conclusion

Our mixed method approach provided convergent findings of the changes in the nursing student's perceptions regarding civility after the intervention. It results in a better insight and understanding of the outcomes of the scenario-based education. This research indicated that the program provided extended knowledge of students and strengthened their beliefs about civil behaviors. Uncivil behavior reached a desirable level through educational intervention. On the basis of the findings, case-based learning as a cooperative and reflective method that includes a real issue can help the students to acquire useful resolutions for the challenging matters. Students participated in sessions, disclosed their opinions and shared information in a friendly manner. Awareness of the importance of incivility and capability to change uncivil behavior have effective roles on improving incivility.