Effectiveness of educational intervention and cognitive rehearsal on perceived incivility among emergency nurses: a randomized controlled trial

Incivility is a dysfunctional interaction that is a recognized problem in the nursing workplace [1]. Nationally, 50.10% of Iranian nurse’s experience incivility [2]. Incivility is verbal and nonverbal behaviors that demean, reject, or exclude the person [3]. Witnessing or experiencing incivility affects nurses’ perceptions of the ethical climate and the quality of their work life [4].

There is a high level of incivility in the emergency department (ED) [5]. 62.6% of ED nurses reported that they had experienced uncivil behavior in the workplace. The most commonly perceived rude behaviors among ED nurses are blaming others for their mistakes or misdemeanors, displaying offensive body language, badmouthing others in the workplace, and gossiping about each other [6]. The consequences of these behaviors are low self-esteem, anxiety, sleep disturbances, recurrent nightmares, and depression in nurses [5]. Another consequence is also that of turnover intention [7, 8]. The prevalence of incivility in the emergency department is significantly related to nurse stress and burnout [9].

Nowadays, it is obvious that any kind of disrespect and incivility can change the organizational climate and increase the severity of burnout among nurses, lead to negative consequences such as clinical errors, and thus threaten patients' lives. Therefore, it is necessary to study how to deal with these behaviors [10].

One hypothesis for the continued prevalence of incivility in nursing is that nurses are socialized to maintain uncivil behaviors when a culture of incivility exists in nursing practice or academia [11]. This assumption is congruent with the underlying premise of Bandura's social learning theory. Bandura's social learning theory is a cognitive-behavioral approach that leads to behavior change [12]. The underlying premise of this model of nursing incivility is that nurses use social information from their environment as determinants of their behavior [13].

Some studies have hypothesized that the use of a series of interventions based on Bandura's social learning theory may help nurses cope with experienced incivility [14, 15]. Rehearsals based on this theory have been suggested in many studies to prepare nurses to recognize, deal with, and reduce incivility in education and the workplace [11, 16, 17], and to provide opportunities for appropriate behavior-based communication for future interactions [18].

In some studies, all participating nurses reported feeling able to recognize, cope with, and manage these behaviors after the cognitive rehearsal program [11, 19]. Some other studies believed that the cognitive rehearsal has impacts on the nurses' behavior over a long time. For example, in one study, 70% of participating nurses reported that they changed their behavior in bullying situations and that the occurrence of incivility decreased in the six months following training [20].

Although it appears that training and use of cognitive programs improves nurses' awareness of incivility and increases their ability to manage these behaviors and reduce the incidence of incivility, these changes vary across studies. The findings of a non-statistically significant decrease in the occurrence of incivility and a slight increase in nurses' awareness of incivility following the cognitive training programs are examples of these findings [21]. A culture-based study assumed that raising nurses' awareness of violence would lead to better recognition of these situations and that they would have to deal with more complex situations [7].

Given the commonality of the lived experience of incivility among Iranian nurses [22] and the need to reduce and prevent the consequences of these growing phenomena, especially in emergency departments as frontline services, this study hypothesizes that training and cognitive rehearsal will improve nurses’ ability to manage incivility in emergency departments. The aim of this study was to determine the effectiveness of educational intervention and cognitive rehearsal on perceived incivility among emergency nurses.

There were 40 samples from each hospital whose statistical data were analyzed. The mean age of nurses in the intervention and control groups was 31.6 ± 5.5 and 29.1 ± 4.4 years, respectively. The majority of nurses in both groups were female. It was found that there was no significant statistical difference between the intervention and control groups in terms of mean age, emergency department work experience, and work hours (Table 3).

ANOVA and repeated-measures ANOVA showed that overall incivility and supervisor incivility increased in the intervention group but decreased in the control group. However, there were differences in overall incivility between the two groups, but these changes showed only an insignificant decrease in the control group (Table 4).

Figure 2 shows the changes in the scores in the subscales of incivility and total incivility in the two groups of intervention and control. Although the figure shows that the scores of incivility in the control group generally decreased, the changes in both groups are almost the same, ranging from -1 to + 1 (2 scores).

The purpose of the current study was to determine the effectiveness of training and cognitive rehearsal on improving nurses’ ability to deal with incivility in emergency departments. One of the most effective methods to assist nurses in effectively responding to workplace incivility is the use of cognitive rehearsal [11]. Cognitive rehearsal involves mentally rehearsing responses to scenarios involving behaviors commonly associated with workplace incivility, such as nonverbal allusion, humiliation, gossiping, subversion, verbal disrespect, and physical violence. Cognitive rehearsal allows nurses to translate the training they received on effective communication techniques into acquired behaviors they can used in the workplace.

Results showed that the education and cognitive rehearsal had effects on general incivility, supervisor incivility, and overall incivility. After the intervention, overall incivility and supervisor incivility increased in the intervention group, while they decreased in the control group. Overall incivility showed significant differences between the two groups, with a significant decrease only in the control group, which received only written education. Patient or visitor incivility, physician incivility, and nurse’s incivility toward other nurses did not change significantly with the intervention. It may also be due to a paradoxical effect of workplace violence interventions. Some studies assumed that after an intervention, by increasing participants' awareness of workplace violence characteristics, a higher prevalence of workplace violence was recorded [28]. Another reason for this change in the present study could be the change in emergency management in the control group that occurred during the study, and it seems that the new leadership model has played an effective role in reducing incivility.

In the study by Kang et al. (2017), the cognitive rehearsal program did not reduce the bullying behaviors among nurses. They attributed this to the fact that the program focused only on nurses and did not address organizational issues, as well as the very early measurement of outcome variables [29].

It is hypothesized that the non-significant subscales of incivility, particularly patient or visitor incivility, and physician incivility are dependent on other structural causes inherent in nursing workplaces. Hosseinpour-Dalenjan et al. (2019) showed that there is a high correlation between nurses' work engagement and patient or visitor incivility [26]. Charrier et al. (2021) showed that nurses in the emergency department face lack of civility and deviant behaviors with patients and their accompanying family members, which requires strategies to manage the interpersonal difficulties [30]. An Iranian study showed that the incivility of physicians in the nursing workplace was the highest and the incivility of supervisors was the lowest [27]. Some studies assumed that incivility among emergency room physicians is high and is especially perceived in critical situations [31].

Clark et al. (2013) study showed that nurses experienced incivility before and after the intervention and also indicated that they tried to control their body language, tried to reduce or stop arguments with a colleague, and were aware of their behavior and reactions [32]. Warner et al. (2016) hypothesized that cognitive rehearsal has a greater effect in atmospheres with a higher prevalence of incivility [21].

It appears that the structural factors such as organizational culture are important in preventing and eliminating incivility in the nursing workplace [33]. The phrase “nurses eat their young” refers to the intentional mistreatment of nurses, by nurses. It is reported that more than one-third of nurses leave their jobs due to incivility [34].

The authors recommended that given the importance of incivility to patient, organizational, and caregiver outcomes, incivility in medical centers needs to be assessed regularly as a measure of organizational performance; and that necessary management actions should be taken based on the outcomes achieved. In this regard, it may be helpful to hold team meetings, address group dynamics, teach management skills, determine organizational values, recognize the organizational culture and history of organizational incivility as well as existing leadership techniques, and recognize the risks of incivility [33, 35]. Training on teamwork, appropriate communication, and managing incivility could be considered as complementary interventions for managing incivility among all health care healthcare professionals [35]. Also, modern innovative education approaches such as flipped classroom are crucial for nursing education, which leads to improving evidence-based teaching strategies and preparing nursing students for their future workplaces and proved to have positive effects in knowledge, risk assessment, and prophylaxis among nursing students [36]. This method can be recommended as an innovative and student-centered method in the teaching of evidence-based nursing practices for managing incivility in the workplace.

Education and cognitive rehearsal were effective in increasing nurses’ recognition of incivility and ability to confront it. Educational intervention improves civility in nursing practice and promotes a positive work environment in which patients are cared for safely and efficiently [11]. The use of workplace incivility education, training about effective responses to uncivil workplace behaviors, and active learning activities to practice newly learned communication skills will help nurses improve their ability to manage workplace incivility [37]. Workplace incivility has a negative impact on the health and well-being of health care team specially nurses. Long-term implementation of the cognitive rehearsal, training about effective responses to uncivil workplace behaviors, and the new leadership model can improve manage of incivility. Therefore, the need for the present study to help nurses to improve their ability to manage these types of behaviors seems necessary.

Our hypothesis about the effect of the training and cognitive rehearsal on improving nurses’ ability to deal with incivility in emergency departments is not confirmed by the findings of this study. Workplace incivility seems to be a multifaceted phenomenon that is affected by various variables such as time, gender, leadership model, organizational culture, etc. The study also has an important secondary finding, which is the mediated role of managers on perceived incivility among employees. In future studies, it is necessary to consider the mediated variables in the effectiveness of interventions affecting incivility.

The current study has some limitations, including the lack of blinding, which may cause the Hawthorne effect. The small sample size and focus on only nurses rather than all emergency professionals limit the generalizability of the results. Also, the changes in hospitals due to the pandemic COVID-19 could affect the results and led to a limitation in the long-term follow-up of participants. Another limitation of this study was the change in emergency department leadership in the control group during the study. Most of the participants in this study were women. The incidence and determinant of workplace incivility can differ by gender [38]. Future studies should ensure the recruitment of male participants to future investigate gender differences in the incidence of workplace incivility. This will provide data for the development of gender specific strategies to address incivility in the workplace.

The study contains some promising insights for the existing body of knowledge. It appears that the transformation of awareness of a relational problem into a behavioral reduction of that problem is more complex than it appears and may have a reverse effect. It is recommended that future studies be conducted to track the effects of the intervention over a three and six months’ period. Considering that only nurses participated in this study, it is recommended that training and sampling with nurses, physicians, and supervisors be conducted in future studies. Therefore, Future studies with longer interventions and higher frequent measurements are required to draw greater empirical conclusions regarding the outcome variables.

The results of the study suggest that incivility in nursing is a widespread phenomenon in which several latent confounding variables that should be considered. Continuing education and cognitive rehearsal, greater emphasis on teamwork among nurses, physicians, nurse managers, and emergency department managers could prove effective if incorporated into continuing education, which warrants further study. However, the cognitive rehearsal program did not decrease incivility among emergency department nurses in the short time of our study. One reason for this could be the focus on individual levels and nurses, the other reason seems to be the limited time to measurement outcomes.