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Anthony, Yastik, MacDonald and Marshall (2014) describe the development and validation of a tool to measure American nursing students’ experiences of incivility in the clinical learning environment (CLE). The Uncivil Behaviour in Clinical Nursing Education (UBCNE) is a multi- item tool which represents three themes; hostile/mean, exclusionary and dismissive. Each of the questions has a 5-point Likert-type scale for the response and results are calculated by taking a mean of the respondents’ scores across all items. The themes used emerged from student nurse focus groups facilitated by two of the authors, Anthony & Yastik (2011). Overall, twenty-one students participated in these groups during which they were asked to recall a personal experience during which they had felt that a staff nurse in the CLE had treated them in an uncivil manner. The tool was tested out on a group of nursing students at a private school of nursing in the US. One hundred and eighteen students were invited to participate, and one hundred and six completed surveys were returned. The majority of respondents were female (eighty-nine), sixteen were male and one was unknown. The aim of the survey was to evaluate the extent to which the UBCNE demonstrated reliability and validity with results suggesting the tool had good internal consistency and was easy to administer. Subsequently, a reduction in overlapping items led to a reduction in length making the tool quicker and easier to use.

The UBCNE was developed specifically for use in clinical settings. Whilst some of the items are fairly general others focus specifically on what happens in practice, for example, item 9 ‘did not involve you in a patient care decision you should have been involved in’. This limits the value of

58 the tool for use in academic settings although it has potential to be adapted for use in UK

clinical settings providing the language used is familiar to UK students.

Another instrument developed for use in clinical settings is the Nursing Student Perception of Civil and Uncivil Behaviours in the Clinical Learning Environment (NSPCUB) (Tecza et al., 2015). This tool was designed to gain insight into student nurses experiences of uncivil behaviour from Direct Care Nurses (nurses who provide hands on care as opposed to nurse administrators or leaders). The choice of survey items was informed by a literature review and the views of clinical nursing instructors. It comprises Likert-response questions headed under three constructs; mutual respect, guided participation and student centeredness. Content validity was confirmed by expert review (local faculty) and focus group discussion (four nursing students). After minor revision, the instrument was tested for reliability with the inter-item correlation matrix and Cronbach’s alpha (measures of internal consistency), using data collected from four hundred and ninety nursing students. The authors’ concluded that the instrument was a valid and reliable tool for measuring nursing students’ perceptions of uncivil and civil behaviour.

As with Anthony et al.’s tool, the NSPCUB instrument was designed for use in a clinical setting limiting its usefulness for use in the broader context of nurse education i.e. five of the twelve survey questions refer specifically to situations which would only happen in a clinical setting. The instrument is also designed to elucidate a student nurse perspective and therefore, like Anthony et al.’s instrument, could not be used to elicit other perspectives without amendment. Additionally, there are several issues which throw into question the validity of the instrument. The method for selecting the survey items is only described in vague terms with no detail about how either the literature review or the collection of verbal reports from clinical instructors were conducted. The focus group questions are written in such a way that their meaning may not be readily understood by student nurses. For example, ‘If you had thought about other constructs to civility or incivility what would those be? That only four student nurses were involved in the instrument design is acknowledged by the authors as a limitation as was the fact that the survey sample was a homogenous group of predominantly white (self-identifying) students of between twenty and twenty-five years of age. In terms of usefulness for the researcher’s own setting, this population differs considerably in age and ethnicity a fact which, along with the focus on the clinical environment and questionable validity, renders the instrument of limited use.

Whilst the tools discussed so far were designed specifically to measure the perceptions of nursing students, the Incivility in Nursing Education (INE) survey instrument was designed to

59 measure the presence and frequency of incivility from nurse tutor and student perspectives (Clark et al., 2009). It was based on the ‘Defining Classroom Incivility’ survey tool (University of Indiana Center for Survey Research, 2000), the ‘Student Classroom Incivility Measure’ and ‘Student Classroom Incivility Measure-Faculty’ tools, the latter two being based on some earlier research (Hanson, 2000 cited in Clark et al., 2009). All three tools were designed specifically to measure classroom incivility in higher education. The INE was subjected to a content validation process, then piloted and the inter-item coefficients calculated to ensure validity and reliability (Clark et al., 2009; Clark & Springer, 2007b). It was then further tested for its psychometric properties (Clark, Barbosa-Leiker, Gill, & Nguyen, 2015). The survey is divided into several sections: demographic information; a list of uncivil behaviours and whether any have been encountered in the previous twelve months; perceptions of the extent of the problem; who engages in it; possible causes and preventative measures.

Although the INE is a valid instrument for measuring perceptions and frequency of uncivil behaviours (as defined by an American audience), it does not address personal impact despite it being raised as an issue of importance by many authors (Anthony & Yastik, 2011;Del Prato, 2010; Luparell, 2004; Thomas, 2003). Personal impact is also omitted in the Nursing Education Environment Survey (NEES) (Marchiondo et al., 2010). This tool was designed to measure students’ experiences of incivility from nurse tutors and considers the type of behaviours encountered, the frequency and whereabouts of occurrence and the type of coping response adopted. The NEES design utilised elements of the INE (Clark et al., 2015) and the Workplace Incivility Scale (WIS) (Cortina et al., 2001), both established instruments. All three have been tested for content validity and internal consistency. However, the NEES does not allow the respondent to provide much information beyond the options given and it focusses only on faculty to student behaviour and not student to student. This latter, along with the failure to address impact, is an important omission because student to student incivility is an issue cited regularly in the literature (Clark et al., 2015; J. Cooper et al., 2009; Gallo, 2012).

Another survey tool focussed on students’ perceptions is the Nurses’ Intervention for Civility Education Questionnaire (NICE-Q). Developed by Kerber, Jenkins, Woith and Kim (2012) the NICE-Q was designed to measure students’ pre-test and post-test perceptions of incivility in the context of a journal club intervention to foster student to student civility. Specifically, the

instrument was developed to test whether the intervention changed students’ behaviour or not with the findings showing that students were generally more aware of civility, more likely to be helpful to their peers and better equipped to cope with episodes of incivility, post-intervention.

60 A slightly different perspective is offered by Hunt and Marini’s study (2012) which explored incivility in the practice environment from the perspective of clinical nursing tutors (CNTs) in a Canadian healthcare institution. They used a survey instrument called the ‘Perceptions on Incivility Survey (PICS) to assess participants’ experiences of incivility in practice. The survey was an adaption of a previously designed instrument for measuring indirect and direct incivility, which was amended to meet the needs of the CNTs in practice environments specifically. It comprised quantitative and qualitative measures and was therefore analysed in two ways: SPSS and narrative analysis. The narrative analysis was conducted using a simple conceptual model called the Multidimensional In/Civility Identification Model (MIIM). The model enabled the researchers to analyse the responses in terms of their form and function as conceptualised by two intersecting axes. Proactive versus reactive forms of incivility were plotted on the horizontal axis and direct versus non-direct functional aspects of incivility were plotted on the vertical axis. Thirty-seven CNTs completed the survey (two male and thirty-five female) the majority of whom were working in acute care areas. All the CTs reported experiencing some form of incivility with those working in acute settings reporting the highest frequency of occurrence. Narrative

analysis against the model showed indirect incivility (such as spreading unpleasant gossip) and reactive incivility (such as responding angrily to a perceived insult) to be the more common forms and functions respectively. Whilst the survey instrument (which was not included in the publication) would not be directly applicable to this research the MIIM could be a useful way of categorising interview data.

Of the five instruments reviewed the INE is by far the most comprehensive facilitating measurement of frequency, perceptions, perpetrators, possible causes, and preventative measures from both student and nurse tutor perspectives. However, none were developed with the UK nurse educational context in mind. Four of the five tools were developed in the US, the other in Canada. Given the socio-cultural, educational, and healthcare differences between these countries and the UK, there is significant potential for there to be differences in peoples’ experiences and expectations and therefore their perceptions of incivility. Tools developed in other countries do not therefore transfer readily to a UK context.