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Creating Healthy Work Environments 2019

Check out these articles written by presenters at the 2019 Creating Healthy Work Environments conference.

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Starting the conversation: Gender and incivility in nursing education

Brett T. Morgan, Benjamin A. Smallheer, Helen A. Gordon, and Margory A. Molloy |

Efforts to mitigate uncivil behavior must be ongoing.

Starting the conversation: Gender and incivility in nursing education

In the classroom, online, in the clinical setting, or the simulation lab, there’s no place for incivility, including microaggressive behavior directed toward male students.

Benjamin Smallheer, Helen Gordon, Brett Morgan, and Margie MolloyIt is safe to say that the majority of nursing faculty members desire classrooms that are civil and respectful and where professional behavior is the norm. Nursing education is unique in that learning environments extend into multiple and diverse settings, including traditional classrooms, online environments, simulated experiences, and clinical training sites. Strategies for fostering civility in these settings require deliberate effort by faculty as well as students, and they begin with identifying situations where incivility can negatively impact nursing education.

Our work has focused specifically on civility as it relates to male students in prelicensure nursing programs. In the process, we became aware of issues relating to student-to-student incivility. In particular, we learned that female nursing students exhibit concerning patterns of microaggression and uncivil behavior toward male colleagues. These behaviors have been found in all nurse education settings.

In the classroom
The literature provides evidence that male nursing students are frequently the targets of uncivil encounters in nursing education. Using an identified theme of gender-associated bias and aggression in the classroom, our qualitative research agreed with these findings. The majority of these interactions occurred between students or student groups. For example, female students referred to male students as “the penis group.” Male students felt excluded from study groups, and male-initiated social activities were regarded as less important than those initiated by female students.

As educational technology has advanced, learning management systems, student response forums, and discussion boards have become the norm. These technologies have enabled connectedness amongst students, allowing for project collaboration and opportunities to reflect and grow through shared experiences. Unfortunately, they also create an environment that can foster incivility and cyberbullying.

We’ve heard reports of male graduate students being excluded from online work groups, being targeted because their opinions differ from those of female classmates, or having a difficult time completing assignments that require engagement with others. Comments such as “You will bring a little testosterone to the group” or “You will do great because you’re a man” discredit the potential intellectual contributions and unique perspectives male students bring to their groups.

In clinical settings
The clinical environment facilitates numerous teaching objectives, including development of nursing skills, professional behavior, teamwork, and student integration of the nursing profession’s core values. While this setting is regarded as a natural extension of the classroom, faculty members are challenged to view this part of the nursing curriculum with more sensitivity.

As the men in our study described, they experienced different uncivil behaviors in the clinical environment than they did in the classroom.

For example, when a nurse manager revealed to a student that he was being considered for a position after graduation and would be a perfect addition to the unit, female students ridiculed him and expressed the belief that he would get a job over them simply because he was male. One female student suggested the male student was being selected because men are helpful for moving heavy patients. These examples of incivility disregarded the male student’s aptitude and skills, minimizing the contributions he would make to the nursing workforce.

Objective: Decrease gender-associated incivility
The time has come to shed light on the uncivil behaviors male nursing students experience. In nursing education, we focus on how nursing students should behave toward their patients but don’t often discuss how they should treat each other. With regard to social media, the National Student Nurses’ Association places significant emphasis on appropriate and inappropriate interaction between nurses and patients but makes no mention of the need for respect among nursing students when connecting online or in clinical environments. Faculty members, both in classroom and clinical settings, need strategies for identifying and intervening when uncivil behavior surfaces in those domains.           

At our institution, we have made a conscious effort to address challenges related to gender-driven incivility in our student population. One strategy that has been successfully implemented is role-playing that focuses on disruptions in the classroom. Faculty members lead the role-play, and the goal is to offer students a vicarious way to experience the negative impact of incivility. When the scenarios are completed, the group has an opportunity to discuss what it means to demonstrate civility and professionalism, thus laying the groundwork for students to commit to fostering a civil academic environment. One scenario involves a male student who is singled out for his “male perspective.” This hypothetical enactment of what can be a very real situation helps start conversation about the value that uniquely individual perspectives—not limited by gender or sex—bring to education.

Norming in the learning environment
Another tactic we have begun to institute is creating classroom norms. This occurs after students have had several days of getting to know each other and faculty members. Creating classroom norms provides an opportunity for students to engage actively in discussion with course faculty on how to create a respectful atmosphere. This exercise has been successfully implemented in both traditional and online classroom environments. Students enjoy the interactive discussion and feel a sense of ownership in creating something that benefits the cohort. Some cohorts even come up with a motto that follows them through their prelicensure program—for example, “Caring for ourselves while caring for others.”

Similar norms are also created in the simulation lab. During orientation, students sign a confidentiality agreement that spells out expected laboratory behaviors. These behaviors, which include not discussing how other students perform in a simulation, help protect the psychological safety of students. During the norming discussion process, students are guided through experiences that expose them to uncivil behavior that could involve other nursing students. One such example exposes students to rejection by their patients because of their gender. The debriefing that follows this simulation gives female and male students an opportunity to discuss how such rejection might create a challenge to learning and student confidence.

Empowering nursing faculty
Evidence suggests that one factor that contributes to incivility in nursing education is inability of nursing faculty to recognize and manage conflict among students. Discussion with male students in our study supported this finding. They specifically stated that they felt faculty members did not recognize uncivil behavior of female students as uncivil. If they did recognize it, said the students, they were not equipped to manage these disruptions. Although the male students felt faculty members were inherently supportive of them, they also felt that if the educators had been better equipped, they would have intervened effectively. This finding led to development of a training program to provide nursing faculty and clinical instructors interventions to use when needed.

Our first step was to bring the issue before the faculty. Our research team felt it important for them to learn the results of our study in a nonthreatening manner that emphasized the potential for improving an already supportive environment. The results of the study were shared with leadership and faculty groups across the school. In addition, our team brought the issue of gender-associated incivility to our monthly “Diversity Conversation,” hosted by our dean.

Faculty members have been overwhelmingly appreciative of the information shared with them, and several have instituted course changes to reflect what they learned. Soon we will host a workshop focusing on gender-associated incivility in nursing education. The goal will be to empower nursing faculty with skills to identify and intervene when uncivil behavior occurs.           

Efforts to mitigate incivility must be ongoing. Thinking of civility as a living entity helps emphasize the importance of keeping it in the forefront of our minds. This is especially important in the nursing profession, where students enter challenging situations as novice practitioners. Our hope is that the time will come when gender is no longer ignored as a contributing factor to disruptions in quality nursing education; instead, gender will be recognized as an area that deserves the same degree of attention as other factors associated with creating a safe environment. 

Brett T. Morgan, DNP, CRNA; Benjamin A. Smallheer, PhD, RN, ACNP-BC, FNP-BC, CCRN, CNE; Helen A. Gordon, DNP, CNM, CNE, CHSE; and Margory “Margie” A. Molloy, DNP, RN, CNE, CHSE, are assistant professors at Duke University School of Nursing in Durham, North Carolina, USA. Morgan directs the school’s Nurse Anesthesia Program and Molloy the school’s Center for Nursing Discovery.

Editor’s note: Brett Morgan presented Leading an Initiative to Addressing Gender Associated Incivility in Nursing Education on Saturday, 23 February 2019, at Sigma’s Creating Healthy Work Environments conference in New Orleans, Louisiana, USA. See the Virginia Henderson Global Nursing e-Repository for additional information.

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