1. Jennette S. Logan, DNP, RN Morgan state university Baltimore, Maryland
Addressing Incivility: a barrier to Nursing practice and care Maryland action coalition Retreat & Leadership Summit The culture of health May 22, 2017
Jennette S. Logan, DNP, RN
Morgan state university
Baltimore, Maryland

2. The speaker has no financial disclosures or conflicts of interest.

3. Presentation objectives
By the end of this presentation, the participant will be able to:
Define and describe incivility in nursing and the impact on practice and care.
Differentiate between incivility and bullying
Identify the 10 most common types of incivility in nursing .
Describe evidenced based strategies to address incivility in practice and care.

4. Introduction
Incivility in nursing is a global issue. It is defined as “rude, intimidating, dismissive actions or verbal exchanges” which causes physiological and psychological problems for all involved.
(Clark 2013)
Lateral - horizontal
Ascending
Descending
Clark 2013, 2104

6. Impact of Incivility on Practice and Care
Negatively impacts patient satisfaction and outcomes
Contributes to medication errors
Declared a sentinel event in 2008 by Joint Commission
Clark, (2011, 2013), Forni (2003) The Joint Commission (2005)

7. Impact of incivility continued
Creates barriers to learning
Destroys relationships
Hinders collaboration and collegiality
Decreases productivity (Lewis & Malecha 2011)

8. Incivility=Lost Productivity = Lost Dollars
$11,500.00/year/Nurse Lewis & Malecha (2011)

9. Background and Problem
85-96% of nursing students experience incivility – leaving programs
88% of nurses report experiencing incivility- leaving bedside and classroom
The most common response to incivility ( 34%) is to do nothing
Nurse administrators, educators, clinicians and students must have the necessary skills to develop collegiate relationships and to maintain a culture of civility.
Cooper et al. (2009), Robertson (2011)
Lewis & Malecha, (2014)
Robertson, Jason (2010)

10. Back ground and problem Continued
Joint Commission stated that : Health care organizations must address the problem of behaviors that threaten the performance of the health care team.; They must assure quality and promote a culture of safety. American Nursing Association asks that:: RNs and employers jointly create and nurture a healthy, safe, and respectful work environment. Clark , Ahten & Macy (2013) suggested that incivility may occur from the beginning of a nursing student's education, and extend beyond the classroom, into the student clinical setting and to the first nursing position.

11. Description/Prevalence Studies Vs. Evidenced Based Strategies ..??? GAP???
Robertson (2012) concluded that there are many evidenced based studies that identify the problem and its prevalence, however, evidenced based strategies to address incivility are “ conspicuously lacking” Description and Prevalence Studies Strategies to Address Incivility

12. Qualitative Study
Using Cognitive Rehearsal to address Incivility: Student Perceptions

13. Statement of Study Purpose and Research Question
The purpose was: to survey student’s perceptions following an educational intervention which introduced evidenced based strategies to address nurse-to-nurse incivility. The research question is: : (PICO) In senior nursing students (P) how does a workshop using cognitive rehearsal in a role play (I) affect perceptions of how to deal with incivility (O)?
The purpose of this study was to determine the perceptions of students following an educational intervention that utilizes a role play to help nursing students learn about how to address nurse-to-nurse incivility. The intention is to use the workshop as a sustainable part of the curriculum to help students address incivility in the nursing program, during clinical and in their jobs following graduation.

14. Bandura’s Social Learning Theory (1971)
Description
Observational Learning
Imitation
Modeling
The theory that supported this project is Bandura’s Theory of Social Learning (1971), which focuses on how people learn from one another and includes the concepts of observational learning, imitation, and modeling. This learning theory supports the design of an intervention to teach a skill, develop a pattern, or teach using a role play with cognitive rehearsal.

15. Stanley/Martin Applied Model of Oppressed Group Behaviors (2008)
Unable to assert self, “silencing of voice
Low self esteem & low group morale
Powerless-ness and frustration
Unable to support one another, dissatisfaction directed towards peers
Tension in work relationshps & conflict charged environment
Unable to trust co-workers, self-reliance,
Unable to effect meaningful change
The framework for this study includes 2 theories and models;
The first is the Stanley Martin Applied model of Oppressed Group Behaviors (2008)) which was developed to explain lateral violence in nursing and to determine when to intervene to improve behaviors and team work. Many nurse researchers and scholars have employed the Oppressed Group Behavior theory in their examination of horizontal or lateral, nurse-to-nurse violence., i.e. Griffin (2004), Longo & Sherman (2007) Purpora,, Blegen & Stotts, (2012), Stanley (2010).
The concept of Stanley/Martin ( Mental Health Nurses)'oppressed group behavior' may be helpful in understanding why nurses will lash out at one another. Nurses as a group display some characteristics of being oppressed including low self-esteem and feelings of powerlessness. When an individual or group feels relatively powerless when compared to another, they can take it out on one another within the oppressed group, especially on someone even less powerful (Friere, 1970; Roberts, 1983). The Joint Commission and CDC describes root causes for worker-on-worker violence: They suggested that "Systemic factors which are unique to the health care cultural environment may contribute. This environment is marked by pressures that include increased productivity demands, cost containment requirements, embedded hierarchies, and fear of or stress from litigation. These pressures can be further exacerbated by changes and differences in the authority, autonomy, empowerment, and roles or values of professionals on the health care team . Other pressures include the continual flux of daily changes in shifts, rotations, and interdepartmental support staff. These dynamics create challenges for inter-professional communication and for the development of trust among team members" (Joint Commission, 2008) .

16. methodology
This study used a qualitative descriptive method to gather perceptions of senior BSN nursing students following a workshop using cognitive rehearsal to address incivility.
A descriptive qualitative design was appropriate for this study as the purpose is to obtain the students’ lived experiences of the educational intervention (Lincoln and Guba,1985)

17. Project Sample Process
Participants were gathered through a purposive sample of senior nursing students from a Northeastern University School of Nursing
Inclusion Criteria:
BSN students
Senior year
Enrolled in Mental Health Class
Exclusion Criteria:
No exclusion criteria
Participants were gathered through a purposive sample of senior nursing students from a Northeastern University School of Nursing
Inclusion Criteria:
BSN students
Senior year
Enrolled in Mental Health Class
Exclusion Criteria:
No exclusion criteria

18. Human Subjects Information
Received Exempt IRB status Information sheet/informed consent Confidentiality/anonymity Voluntary participation/ may withdraw anytime
All participants will receive full explanation of the study at the start of the workshop and will be asked to sign informed consent prior to participate in this study. Participation in the study will not impact students’ grades or standing in the class. Decide to withdraw from the study for any reason at any time. The workshop, role play, and debriefing session will occur in a private place at the school of nursing to provide confidentiality and anonymity. All data from the surveys will be de-identified. Received exempt status IRB status

19. Data Collection
DATA COLLECTION was achieved through written surveys using open ended questions following the workshop.
DEMOGRAPHIC INFORMATION
Gender
Academic year
Experienced Incivility in the nursing program: yes or no
SURVEY QUESTIONS:
What is your definition of nurse to nurse incivility?
 What were your feelings of observing a nurse being treated uncivilly in the role play?
     
What were your personal feelings of being treated uncivilly in the role play?
Describe your experience of using cognitive rehearsal(CR) to respond to being treated uncivilly?
Describe your ability to use CR to address uncivil behavior in the future?
What more do you want to know about how to address nurse-to-nurse incivility?
DATA COLLECTION were achieved through written surveys with open ended completed following the workshop
DEMOGRAPHIC INFORMATION
Gender
Academic year
Experienced Incivility in the nursing program: yes or no
SURVEY QUESTIONS FOR DATA COLLECTION AND ANALYSIS:
What is your understanding of the definition of nurse to nurse incivility?
 What were your feelings of observing a nurse being treated uncivilly in the role play?
     
What were your personal feelings of being treated uncivilly in the role play?
Describe your experience of using cognitive rehearsal to respond to being treated uncivilly?
Describe your confidence about using CR to address uncivil behavior in the future?
What more do you want to know about how to address nurse-to-nurse incivility?

20. Intervention/Protocol
Educational workshop with a role play using cognitive rehearsal based on Griffin (2004)
1. Description and definitions of nurse-to-nurse incivility
Definition, prevalence, behaviors and impact
Role play with actors to demonstrate nurse-to-nurse incivility
2. Description and explanation of cognitive rehearsal
how to use it to address uncivil behavior,
distribution of cue cards,
Watch the actors address uncivil behaviors using cognitive rehearsal
Student role play using cognitive rehearsal
Role play with actors to demonstrate use of cue cards
Play the role of the victim and switch roles play the role of the bully
Survey addressing seven questions for perception of the workshop
Intervention Steps
The intervention for this capstone was developed following a model proposed by Griffin(2004). Griffin conducted a workshop that included a didactic lecture about incivility and interactive instruction on cognitive rehearsal with the appropriate responses. At the conclusion of the educational intervention nurses were given cue cards containing the learned responses to uncivil behavior and accepted behavioral expectations of the profession. The participants agreed to be surveyed at a later date regarding the experience of using cognitive rehearsal in the nursing setting
Many of the aforementioned concepts have been adapted for this capstone intervention. The nurse researcher implemented the following steps. 1) Didactics about the definition, prevalence, behaviors and impact of nurse to nurse incivility 2) Role play about nurse to nurse incivility 3) Didactics about how to use cognitive rehearsal to address the 10 most common uncivil behaviors using cue cards, 4) Interactive role play with students using cognitive rehearsal 5)Debriefing and 6) Survey completion. .

21. Cognitive Rehearsal Cue Card (Griffin, 2004)
Uncivil Actions 
Responses
Nonverbal innuendo (raising eyebrows/face making)
I sense or I see from your facial expression that there may be something you wanted to say to me. It’s okay to speak directly to me
Verbal affront (covert or overt, snide remarks, lack of openness, abrupt responses)
The individuals I learn the most from are clearer in their directions and feedback. Is there some way we can structure this type of situation?
Undermining activities (turning away, not available)
When something happens that is different or contrary to what I thought or understood, it leaves me with questions. Help me understand how this situation may have happened?
Withholding information (practice or patient)
It is my understanding that there was more information available regarding this situation and I believe if I had known that, it would affect how I learn.
Sabotage(deliberately setting up a negative situation)
There is more to this situation than meets the eye. Could you and I meet in private and explore what happened?
Infighting (bickering with peers)
This is not the time or the place. Please stop. (walk away or move to a neutral spot
Scapegoating( attributing all that goes wrong to one individual
Rarely is one individual, one incident or one situation the cause for all that goes wrong. Scapegoating rarely solves the problems.
Backstabbing(complaining to other about an individual and not speaking directly to that individual)
I don’t feel right talking about him/her/situation when I wasn’t there, or don’t know the facts. Have you spoken to him/her.
Failure to respect privacy
It bothers me to talk about that without his/her permission
Broken Confidences
Wasn’t that said in confidence? That sounds like information that should remain confidential
He/she asked me to keep that confidential.
Here is an example of the cognitive rehearsal cue cards created by Griffin (2004) which has been used in several studies that utilized CR as a strategy to address incivility. The same cue card will be used for this capstone. The 10 most common uncivil acts in nursing are listed with an appropriate response. FOR EXAMPLE if the student encounters nonverbal innuendos including raising eyebrows and face making, the response would be I sense from your facial expression that there may be something you wanted to say to me.
Or in the case of a verbal affront, covert or overt snide remarks, lack of openness or abrupt responses, the student would reply, I learn the most from individuals who are clearer in their directions and feedback. Is there someway we can structure this type of situation?

22. Project Findings
SUMMARIZED

23. Final sample and demographics
9 mental health senior nursing students
Gender- 8 females, (89%) 1 male (11%)
Ages range 22 – 30
8 out of 9 (89%) participants reported experiencing uncivil behavior while in the nursing program or clinical setting
The sample consisted of 9 BSN seniors enrolled in a mental health class. The sample was comprised of 8 females and 1 male, with ages ranging from 22 to 30. In a pre-survey administered before the workshop, 8 of the 9 students reported experiencing incivility during the nursing program. This finding is consistent with the literature which suggests 87% of nursing students experience incivility.

24. Data Analysis
Assembled a data analysis team Reviewed the data multiple times Line-by-line coding (Creswell, 1998) Used Word files to organize the data Themes through constant comparative analysis
The process of data analysis for this capstone project included transcribing the interviews and grouping the responses by questions. The data was reviewed multiple times by the researcher and capstone chair with notes made about the content. Common ideas and concepts were identified through line-by-line coding as per Creswell’s (1998) process of open coding. Codes were refined. Themes and subthemes emerged from two broad categories. Major categories with themes were identified through a process of constant comparative analysis to identify similarities and differences (Patton, 2002).

25. Four major Categories What is Incivility? Observing Incivility
Experiencing Incivility
Using Cognitive Rehearsal
Four major categories with themes resulted from the data
What is Incivility?
Observing Incivility
Experiencing Incivility
Using Cognitive Rehearsal
ories results from the data;

26. Category 1: What is incivility?
Theme #1: Negative Behavior
“ A nurse threatening another nurse in a rude belittling way
“ When a nurse is rude and disrespectful to another nurse”
“ A nurse bullying other nurses’
“ Negative actions or body language,” “verbal or nonverbal”
“ Form of stalking or physical assault”
“ ….can affect patient care”
Theme #2: Directed at New Nurses
“ …bullying fellow nurses because they are new to the career or unit”
“…negative language or behavior towards a new nurse or nurse in general”
participants in the study shared the common theme of nurses acting out Negative Behaviors. They described behaviors between nurses that they considered uncivil. Negative ‘verbal’ behavior was identified by the majority of participants. One student stated “My definition of incivility is a nurse threatening another nurse in a rude, belittling, unfair way.” Another said “From my understanding it is when a nurse is rude, disrespectful or attempts to belittle or sabotage another nurse.” Another said that incivility was “…nurses bullying their fellow nurses.”
Many of the students also described negative ‘nonverbal’ behavior. One participant stated that uncivil ‘nonverbal’ behavior was “Negative actions or body language that impacts nurse-to-nurse relationships.” Other more serious nonverbal behaviors were described as serious forms of aggressions. One student summed this up by saying “Incivility can be verbal or nonverbal or in the form of stalking or physical assault.”
The participants also described their perceptions of the outcomes of negative behavior that resulted in long-term or professional consequences. A student described incivility contributing to “nurses not working together.” Another student implied that incivility could negatively affect the patient by saying “An inappropriate act or act of unprofessionalism f
from one nurse to another … may affect the patient consequently.” One of the participants described incivility as “an expected occurrence in the work place.”
A second theme that emerged under the category of Incivility in Nursing was that uncivil behavior was primarily Directed at New Nurses. Five of the nine students identified new nurses as bearing the brunt of incivility. A student stated “This term [incivility] is used to describe nurses bullying their fellow nurses either because they are new to the career or to the unit.” Another student described uncivil behavior as “the way and manner new nurses are treated” and yet another stated it is “negative language or behavior to new or in general to other nurses.”

27. Category 2: Observing Incivility
Theme #1: Feeling Sympathetic
“ I actually felt sorry for the victim”
“ I felt bad for the nurse; her peers ganging up on her probably affected every aspect of her day including patient care and her psychological well being”
Theme #2: Wanting to intervene
“I feel like it is a helpless situation and I want to intervene”
Theme #3:This is realistic
“Watching the role play made me realize this happens more often than I would like to admit.”
“ I could actually see the roleplay unfolding at a hospital”
Feeling Sympathetic
The category of Observing Incivility included students’ perceptions of watching nurses being treated uncivilly in the role play. Student perceptions revealed the theme of Feeling Sympathetic. Students felt a sense of helplessness in watching the nurses treat each other in an uncivil manner. A participant stated “I actually felt sorry for the victim.” Another said “I felt bad for the nurse; her peers ganging up on her most likely affects every aspect of her day from patient care to her psychological well-being.” The students described feeling “sympathetic,” “apprehensive,” and “disappointed” when watching the actors treat each other uncivilly in the role-play. One student described the uncivil behavior she observed as “detestable.”
Wanting to Intervene
Another theme that emerged as a part of the category of Observing Incivility was Wanting to Intervene. Two of the nine students felt compelled to become involved and defend the person who was being treated uncivilly in the role-play. They acknowledged being unsure of what to do or say to defend the person. A student said “I feel like it is sometimes a helpless situation and I want to intervene.” Another stated “I tried to intervene in a peaceful manner and calm the situation down.” Seven of the participants did not mention wanting to take action on the part of the victim.
This is Realistic
The theme of This is Realistic was revealed by some of the students’ comments about having experienced incivility as student nurses. They acknowledged being involved in similar incidents to what was acted out in the role-play. After observing the role-play a student noted “Even as student nurses, we experience incivility [during] our lecturers, [by] instructors, and at the clinical sites.” Another student said that incivility “happens in everyday life as a student nurse.”
The participants acknowledged that the events in the role-play were realistic and helpful in recognizing incivility. One student said” Watching the role play exercise, made me realize that this happens more often than I would like to admit.” Another student said.” I was able to see [what happened in] the role play [could] actually occur in a hospital. The situations are simple but could easily occur in the workplace.” Another participant stated “It was interesting to see up close; usually you hear about incivility but seeing it up close [in the role-play] was better.” A student noted that in the role-play “you had an opportunity to react and catch uncivil responses before they occur.”
An unexpected response by the participants to observing incivility was that they admitted treating others in an uncivil manner. A student stated “I have also been the person practicing incivility especially to my peers.” Another student said “I would like to admit … to being on both sides of the coin [in regard to incivility], [I] treated others this way.”

28. Category # 3 Experiencing Incivility
Theme # 1: Vulnerability
“I felt disrespected and looked down upon. “
“I felt bad and disgusted.”
“I was not sure how to react to find the best solution.”
Theme #2: Anger
“ I wish had great power or authority to strike back”
“ There are times when I can’t control my behavior and I respond to incivility with more incivility”
Vulnerability
The initial responses of participants when they Experienced Incivility in the role play was to share personal feelings of Vulnerability. A participant stated “I felt disrespected and looked down upon. “ Another student stated “I felt bad and disgusted.” A participant shared that she had been in a similar ‘real life’ situation in the hospital where a nurse made her feel “...less that useful.”
A part of feeling vulnerable according to the participants was that they did not know how to respond to uncivil treatment. One student stated “It was not as easy to come up with an appropriate and effective response right away. This is probably one of the reasons incivility between nurses is so large.” Another stated “I was not sure how to react to find the best solution.”
Anger
Several students acknowledged feelings of anger when being treated uncivilly in the role play. Theses feeling were revealed by comments such as “there are times when I am not able to control my behavior and I respond to incivility with more incivility.” Another student admitted to feelings of frustration and anger during the roll-play and said “I wished I had real power or authority to strike back...”

29. Category 4: Using Cognitive Rehearsal
Theme #1: A Way to Respond
“Cognitive rehearsal aided me to form an automatic response that was professional and helped me to [give] a leading statement and or question to elicit a helpful response.”
Theme # 2:CR was helpful
“ I feel more confident about using CR to address uncivil behavior. This will make the working environment a happier place to be and patient focused.”
Theme #3: Further Needs
“What would be the next course of action if the behavior does not stop and [incivility] continues?”
A Way to Respond
The theme of A Way to Respond was revealed by the participants as part of the category of Using CR in the Role-Play. Students spoke of wanting to be professional in giving responses to other nurses and that CR gave the opportunity to respond appropriately. A student said “We need to learn how to address someone professionally [when treated uncivilly].” Students also spoke of wanting to be prepared to respond in difficult situations. They described how CR gave them something to say and do when faced with uncivil treatment. A student addressed this by saying “I found that responding appropriately with cues relies on [knowing] what to say and how to say it.” Another student said “Cognitive rehearsal aided me to form an automatic response that was professional and helped me to [give] a leading statement and or question to elicit a helpful response.” Yet another student shared that “Having something to say [using CR] to address the issue without [causing] further escalation is good.”
One student gave a specific example of the way they used CR in the role-play. The student said “I walked into someone gossiping about me and I approached [her]. She slowed her speaking and stopped talking when I stood by her. So I told her that I was right here and she could speak to me directly and [she] should never talk behind my back.”
Role-Play was Helpful
A theme that emerged from the students’ experiences of Using CR was that the Role-Play was Helpful. Students shared ways that the role-play helped them gain experience dealing with uncivil situations. A student shared “It was good to experience using cognitive rehearsal to respond because it gives us a chance to be in the situation and lets us practice using the cue card.” Another student shared “The cognitive rehearsal was very appropriate and [it] is recommended for everyday situations and other incidences.” Another said “I felt that this exercise was very helpful.”
Participants also explained how the role-play helped them gain confidence in their ability to deal with difficult situations. A student said “I feel confident that [by] being mindful and aware of incivility in the workplace that I will have an advantage when dealing with an issue.” Another said “I feel more confident about using CR to address uncivil behavior. This will make the working environment a happier place to be and patient focused.”
Further Needs
Students described the theme of Further Needs in the category of Using CR in the Role-Play. They described wanting the opportunity to practice skills they learned in the role-play to gain confidence. A student said “I would like to continue to work on these skills and [my] responses [in order] to use them if this occurs again.” Another student said “I believe if I practice CR, I will be very confident in my implementation in the future. By conditioning myself to a better more efficient way for responding, many situations can be resolved.” Another said “I believe if I continue to practice the responses, I will be well prepared.”
Participants also requested more information about CR. Many students wanted to know what to do if uncivil behavior continued after CR was used. A common question asked was “What would be the next course of action if the behavior does not stop and [incivility] continues?” There were also requests to have information about “techniques to help control or eliminate negative responses” and “…to watch some video that addressed real life situations.” Other students wanted to know what resources were available to them in the event that they experienced incivility. A student asked “Do institutions have committees or teams that help nurses deal with incivility or inappropriate behaviors of nurses?”

30. Summary/Discussion
Students described incivility as negative verbal and nonverbal behaviors.; supported in the literature by Clark (2013) and Dellasega (2009)
Students’ description of the professional consequences of uncivil behavior were astute.
Participants identified new nurses as the focus of incivility which was supported by Griffin (2004) and other researchers.
The incidences in the role-play were described as “realistic” by the study participants.
Role play was described by participants as helpful in identifying behaviors and attitudes that were uncivil.
Using CR in the role–play was viewed by participants as an effective and appropriate way to address incivility.
Students were able to accurately describe incivility following the role play about incivility. Perceptions about using CR as a professional way to respond to incivility was an astute observation. Students were able to accurately identify the most frequent recipient of incivility as a new graduate or a new nurse to a unit. Students actualized the role play and described it as realistic. Students shared their perspectives about cognitive rehearsal which suggested that it is a professional response to incivility.

31. Limitations and Implications
This study had a small sample size limited to senior students in one class at a single school of nursing.
Implications
The workshop is a valuable part of an overall approach to creating a civil environment that supports student learning and success after graduation. Civil environments provide opportunities for collaboration and productivity.
One limitation of this study was a small sample size at a single school of nursing.
However, data saturation was obtained. The research revealed that a role play about incivility can be used as an approach to create a civil environment which can support student learning and improve patient outcomes. Based on the results of this student, this researcher would recommend that this school of nursing’s administrators should develop comprehensive policies addressing incivility, and should strive to create and sustain a civil, healthy nursing environment. This researcher would also recommend that the research should be expanded on a larger scale inclusive of BSN and Associate degree nursing students in the junior and senior years.

32. Recommendations
Begin the discussion about incivility in the work place and in academia
Clear comprehensive policies based on best practices need to be crafted and disseminated.
Educators, administrators, clinicians and nursing students should strive to create and sustain civil, healthy work environments
Further research on a larger scale with BSN and Associate degree students, nurse educators, clinicians and administrators.

33. References
Clark, C., Ahten, S. & Macy, R. (2013). Using problem-based learning scenarios to prepare nursing students to address incivility. Clinical simulation in nursing 9, Clark, C., Ahten, S. & Macy, R. (2014). Nursing graduates’ ability to address incivility: kirkpatrick’s level-3 evaluation. Clinical simulation in nursing, 10, Clark, C. & Kenaley, B. (2011) Faculty empowerment of students to foster civility in nursing education: a merging of two conceptual models. Nursing outlook. 59,

34. References Continued
Cooper, J., Walker, J., Winters, K., Williams, R., Askew, R. & Robinson, J. (2009). Nursing students’ perceptions of bullying behaviours by classmates. Issues in educational research, 19(3). Retrieved from: Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of continuing education in nursing, 35, Griffin, M. & Clark, C. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. The journal of continuing education in nursing, 45 (12),

35. References Continued
Lewis, P. S. & Malecha, A. (2011). The impact of workplace incivility on the work environment, manager skill, and productivity. Journal of nursing administration, 41, Lincoln, YS. & Guba, EG. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage Publications. Robertson, J. (2012). Can’t we all just get along? Nursing Education Perspectives, 31, 2. Stokowski, L. (2011). The Downward Spiral: Incivility in Nursing, Medscape Nurses WebMD LLC retrieved at

36. Thank you for your Attention Questions?
Thank you for your attention and time. I will entertain any questions at this time.