Do Associate Degree Registered Nurses Fare Differently in the Nurse Labor Market Compared to Baccalaureate-Prepared RNs?

This is an important discussion I couldn't pass on posting!

David I. Auerbach, PhD, Peter I. Buerhaus, PhD, RN, FAAN, Douglas O. Staiger, PhD

Nurs Econ. 2015;33(1):8-12.

Abstract and Introduction

Introduction

Unlike most other countries, there have long been multiple routes toward becoming a registered nurse (RN) in the United States. For decades, RNs have been prepared via three main pathways; a 2-year associate's degree program, a 3-year hospital-based diploma program, and a 4-year baccalaureate program leading to a bachelor's degree in nursing (BSN). Diploma programs have all but disappeared, leaving roughly equal numbers of RNs obtaining their initial preparation toward becoming an RN via the associate's degree programs (ADN) or the BSN. According to the National Sample Survey of Registered Nurses (n.d.), of RNs completing their initial RN education between 2005 and 2008, approximately 3% were prepared via a diploma program, 57% via an ADN, and 40% via a BSN.
Not apparent in those figures, however, is a recent apparent shift in basic entry nursing education away from the ADN and toward the BSN (Buerhaus, Auerbach, & Staiger, 2014). Beginning roughly a decade ago, the American Nurses Credentialing Center (2013) began designating hospitals as Magnet® institutions based on certain quality and other benchmarks, one of which is that by January 2011, 75% of nurse managers must have at least a BSN. Then, building on a series of research studies over the last decade beginning with Aiken, Clarke, Cheung, Sloane, and Silber (2003) who indicated the risk of inpatient mortality is lowered in hospitals employing a greater share of BSNprepared RNs, the Institute of Medicine (2010) recommended 80% of RNs be prepared at the BSN level by 2020. States and institutions appear to have taken up the call; by 2014, 80% of California hospitals require new RN staff to have a BSN (Bates, Chu, Keane, & Spetz, 2014).
These forces may be having important implications for the nursing workforce. Kovner, Brewer, Fatehi, and Katigbak (2014) recently comparing a cohort of roughly 1,000 newly licensed nurse graduates (2010–2011) and found 82% of new BSN graduates were em ployed in hospitals within 18 months of graduation compared to 67% of ADN graduates. In contrast, in an earlier similar cohort graduating in 2004–2005, 83% of new ADN graduates found hospital jobs in the same time frame after graduation. Kovner and colleagues (2014) cited "anecdotal re ports that hospitals are preferentially hiring RNs with a BSN and that if they do hire associate's de gree grad uates, they are requiring those nurses to get a BSN within a specified period" (p. 32). In fact, in 2010, while there were roughly 80,000 ADNs and 50,000 BSN nursing degrees awarded among newly licensed RNs, another 22,000 RNs completed RN-to-BSN programs, converting their ADN preparation to a BSN (Bates & Spetz, 2012).
With the exception of the study by Kovner and associates (2014), however, it is unclear if this apparent preference for BSN-prepared RNs has markedly changed the labor market outlook for a RN who has completed an ADN. These programs have proliferated (along with BSN programs) in the largest expansion of undergraduate nursing education in recent history (Auerbach, Buerhaus, & Staiger, 2013). If this preference for BSN-prepared RNs is truly widespread and universally accepted, one might expect ADNs to be shifting to other employment settings and/or receiving lower wages. In this article, recent employment and earnings data from the American Community Survey is examined to determine whether any of these expected changes are occurring in the nurse labor market.

Data and Methods

Data

The primary data used in the analysis are from the American Community Survey (ACS) (King et al., 2010). The ACS, which began reporting data in 2001, is modeled after the long form of the decennial census (U.S. Department of Labor, 2014) and obtained responses from approximately 12,000 RNs each year from 2001 to 2004 and roughly 30,000 RNs per year thereafter (after the sampling frame was expanded). The ACS identifies RNs by allowing respondents to select their occupation and obtains additional data on respondents' age, educational level, income, industry sector, and other demographic information and has been used extensively by our team to analyze the nursing workforce (Auerbach, Buerhaus, & Staiger, 2011).
Data on RNs between the ages of 21 and 64 were used in this analysis for the years 2003–2013; RNs reporting working fewer than 30 hours in a typical week were recorded as 0.5 full-time equivalents (FTE). RNs reporting a master's level of education or higher were excluded to focus specifically on RNs working as an RN (rather than as a nurse practitioner, for example, which requires a BSN typically followed by an advanced degree). Although the ACS data were first collected in 2001, this analysis begins with 2003 because of a change in the education questions between 2002 and 2003. The final sample included 217,815 RNs across all years.

Identifying Nursing Education

To our knowledge, the ACS has not been used to distinguish ADNs from BSNs in peer-reviewed research. ACS respondents report whether their highest level of education completed is an associate degree, a 4-year college degree, or one of various types of higher degrees such as master's or doctorate. As a simplification, we classified all RNs reporting a bachelor's degree as a BSN-prepared RN and RNs with less-reported education as ADN-prepared RNs (RNs with at least a master's degree were removed from the sample). The reported degrees in the ACS are not nursing-specific, although respondents could indicate a field for baccalaureate degrees starting in 2009. (This information was not used for purposes of consistency with the time period before 2009.) Thus, RNs prepared with diploma degrees (of which there are very few in recent years) would likely be unsure how to classify their education in the ACS. More importantly, RNs with bachelor's degrees in non-nursing fields but no higher than an ADN in nursing would likely select a bachelor's degree as their highest degree and we would be unsure whether they were a BSN or ADN-prepared RN.
To validate the ACS-based assignments, data from the National Sample Survey of Registered Nurses (NSSRN) from 2008 were analyzed and compared to the reported education of RNs to the educational categorization of RNs from the ACS in that same year. The NSSRN, discontinued in 2008, asked RNs directly about their initial and any subsequent nursing degrees as well as other non-nursing degrees. In 2008 NSSRN data, just 5% of respondents had a non-nursing baccalaureate degree but also a highest nursing preparation of an associate's degree. (Another 8% of RNs had baccalaureate degrees both in nursing and in a non-nursing field, but these individuals would be correctly classified in the ACS as BSN-prepared RNs). Overall, after excluding all RNs with a master's degree or higher, our assignments in the ACS yielded 41.3% of RNs with an ADN as their highest nursing degree and 58.7% with a BSN. This is similar to the comparable figures of 43.8% and 56.2%, respectively, in the NSSRN. Other characteristics of ADN-prepared RNs and BSN-prepared RNs were compared between both surveys – patterns were identical. In both surveys, the BSN-prepared RNs were more likely to be male, non-White, unmarried, higher household income and nursing income, foreign educated, and working in hospitals (data available upon request).

Other Labor Force Measures

Labor market outcomes were recorded from direct questions asked in the ACS survey. Unemployed RNs were defined using variables constructed within the ACS based on detailed questions concerning the respondent's employment status (looking for but unable to find employment). Respondents were asked to report their income from wages and salaries in the previous 12 months; this dollar amount was used as an estimate of earnings from nursing employment. Earnings figures were reported only for RNs who work full time, as defined by those reporting working more than 30 hours per week. Finally, all ACS respondents were asked to identify their industry setting from a list that we consolidated into hospitals, offices of physicians and other health professionals, nursing homes and other long-term care settings, other health care settings, and settings unrelated to health care.
To make estimates representative of the U.S. noninstitutionalized population, observations were weighted by sampling weights provided by the ACS. In several instances, statistical significance of differences between ADN and BSN RNs are reported. These tests were conducted using two-tailed tests, with 0.05 as the level governing statistical significance.

Results

Differences Between ADN-prepared RNs and BSN-prepared RNs

Differences in the rate of unemployment among both types of RNs are shown in Figure 1. Though historically quite low, the unemployment rate has diverged between RNs prepared with a BSN and those with an ADN in recent years.

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Figure 1. Unemployment Rate of RNs, by Ultimate Degree Type, 2003–2012

While fluctuating between 1% and 1.5% from 2003 to 2009 for both ADNs and BSNs, the unemployment rate for two groups then began to differ significantly, growing to 1.9% among ADNs in 2013 compared to 1.2% among BSNs in that year (p<0.01). With roughly one million RNs in each group in recent years (excluding RNs with master's degrees or higher), an unemployment rate of 2% represents roughly 20,000 RNs.
The trends in FTE employment suggest a fairly dramatic divergence in hospital employment by type of basic nursing education (see Figure 2 and Table 1). In 2003, a similar percentage of RNs with each degree type worked in hospitals. A few years later, a gap in hospital employment had started to materialize, and, by 2013, more than 10 percentage points separated the two groups, with 72% of BSN graduates employed in hospitals compared to 61% of RNs whose highest degree was an ADN. These data are consistent with a growing preference for BSN-prepared RNs on the part of hospitals.

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Figure 2. Percent of Full-Time Equivalent RNs Employed in Hospitals By Ultimate Degree Type, 2003–2013

A further breakdown of trends in work settings of ADN and BSN-prepared RNs outside of the hospital is shown in Table 1. The data provide insights into alternative settings that appear to have drawn the ADNs who might have otherwise been employed in hospitals. It appears roughly 10% of ADN-prepared RNs have shifted from hospitals to long-term care settings over this period. For example, in 2003, 13% of ADNs were employed in long-term care settings – a percentage that grew to 18% by 2013. In contrast, the proportion of BSN-prepared RNs working in long-term care settings remained at roughly 10% throughout the period. The percentage of ADN-prepared RNs employed in offices of physicians and other professionals hovered around 10% throughout the period where as the percentage of BSN-prepared RNs employed these settings decreased from 9.1% in 2003 to 7.7% in 2013.
Finally, trends in overall earnings and earnings among hospital-employed RNs over the same time period are shown in Figure 3. In contrast to the trends shown in Figures 1 and 2, the data shown in Figure 3 do not indicate a divergence over the 10-year time period. If anything, the wage gap between ADNs and BSNs, which has been relatively constant over the last decade at roughly $10,000 for RNs in hospital and other settings, has shrunk slightly in the last 2 years.

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Figure 3. Overall and Hospital-Employed Earnings of Full-Time Equivalent RNs by Ultimate Degree Type, 2003–2013

NOTE: Earnings figures exclude those of RNs working fewer than 30 hours per week.

Labor market outcomes can be expected to differ for newly graduating RNs who are seeking their first jobs compared to more experienced RNs. The sample of RNs was limited to those under 35 years of age to test for possible differences from the trends noted previously. Among younger ADN RNs, the rate of hospital employment dropped from 70% to 63% between 2010 and 2013. Unemployment rates for ADN-prepared RNs were double those of their BSN counterparts in 2013 (1.9% vs. 0.9%), but figures were more jumpy in earlier years. Similarly, as with all RNs, the earnings gap did not change significantly over time.

Discussion

In two of three labor market outcomes analyzed using data from the ACS, there was a divergence of the experience of AND-prepared RNs compared to BSN-prepared RNs. ADNs are more likely to be unemployed (though unemployment rates are still extremely low) and increasingly less likely to work in hospitals than their BSN counterparts. These findings are consistent with hospitals' expressing a preference for BSN graduates in recent years. On the other hand, although BSN earnings are greater than ADN earnings in every year of the sample, there does not appear to be a widening divergence in the earnings between BSN and ADN-prepared nurses.
As with any labor market evaluation, it is difficult to discern whether the observed differences in unemployment rates and hospital employment by level of nursing education reflect the RN's education itself, or whether other characteristics of the RN who may obtain different degrees could also be related to these labor market outcomes. With regard to the latter possibility, it is unlikely in the short time frame of these observations (2003–2012) that characteristics of RNs who obtained an ADN or a BSN have changed substantially. Rather, the timing of the divergence in unemployment rates between ADN and BSN-prepared RNs, and to some extent, the increased employment of BSNs in hospitals found in this analysis, appears to have occurred several years before the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health was released. In the middle part of the decade, hospitals were becoming aware of a growing body of evidence indicating the association of lower mortality and higher BSN-educated RNs. Moreover, in 2008 the Centers for Medicare & Medicaid Services and several states began to link hospital payment to performance on avoidable inpatient outcomes, some of which were sensitive to nurse staffing (Kurtzman & Buerhaus, 2008) Later, the IOM (2010) report was released. The IOM emphasized the need for a more highly educated nursing workforce, and its wide dissemination more than likely provided "tipping point" information that influenced employers' decisions to prefer the more highly educated BSN.
Finally, it should be noted our estimates of RNs by level of educational preparation are imperfect. As noted previously, the educational categories in the American Community Survey are not designed specifically to identify nursing education. Also, individuals in the ACS are identified as nurses by their answers to the occupation questions. Yet, in both cases, findings from the ACS have been validated against data from the NSSRN and workforce and educational estimates are very similar.

Policy Implications

The IOM set a goal of 80% of newly graduating RNs having a BSN by 2020. This call has been echoed by others who have suggested a BSN-level preparation is needed for the increasing complexity of care (American Association of Colleges of Nursing, 2014). Supported by the Affordable Care Act, health care delivery organizations are placing increasing emphasis on quality metrics, care coordination, population health management, and prevention and education. Accountable Care Organizations, expanding rapidly in the last several years, have strong financial incentives to manage care of their enrollees. These organizations seek to reduce total costs and improve quality by requiring health care professions to eliminate care duplication, coordinate and manage care received at home and among fragmented providers, and reduce hospitalization.
Our results indicate, as did Kovner and colleagues (2014), ADN-prepared RNs appear to be experiencing diverging labor market outcomes from BSN-prepared RNs. Yet, at the same time, there has been a rapid increase in ADN educational programs over the last 10 years (Buerhaus et al., 2014). This growth may be helping to fill what would otherwise be a potential new nursing shortage as the baby boomer RNs begin to exit the workforce? Even if ADN-prepared RNs are not always finding the hospital positions some of them expect upon entering nursing school, the widespread availability of RN-to-BSN programs provides a relatively easy step for conversion to a BSN. Ultimately, it is unclear whether ADNs are shifting away from hospital settings out of necessity because hospital jobs are unavailable, or if their skill set is better suited for less-acute nonhospital patients.
Thus, the increasing percentage of ADN-prepared RNs employed in nonhospital settings, just as demand for RNs in these settings appears to be increasing, is a finding that requires close monitoring (Spetz, 2014). Most studies of care outcomes differences between ADNs and BSNs have focused on hospital care; there is no evidence to suggest any quality differences in nonhospital settings. ADN programs may find it in their interest to specialize in, and focus on, the kinds of skills increasingly critical to enhanced ambulatory settings such as care coordination, communication, teamwork, population health, and education and prevention (Pittman, 2014). Ultimately, a robust, integrated, complex and efficient health care system requires a diverse nursing workforce and the schools that prepare nurses for this new world ought to anticipate these needs and graduate nurses with the skills and competencies required.

Cindy’s ‘Five RITES’ for fostering student-driven civility Part Two

Cindy’s ‘Five RITES’ for fostering student-driven civility ​Second of a three-part series.

By Cynthia Clark

Some readers may know I am a professor in the School of Nursing at Boise State University. In June 2010, an article I co-authored with one of my nursing students, titled “What students can do to promote civility,” was published in Reflections on Nursing Leadership (RNL) as part of a five-part series on civility. As I mentioned in the first installment of this present series, nursing students are our promise and our hope. They are the Jedi Knights who will lead our noble profession to a bright future where personal and organizational civility reign. To frame this article, I have developed the Five RITES of Civility: Raise awareness and expose effects of incivility. Inspire action and catalyze change. Take responsibility for creating civility. Engage and commit to personal and organizational change. Sustain results and generate more change. Raise awareness and expose effects of civility Raising awareness with students about the power of civility and the negative consequences of incivility in academic and practice settings is an important and vital endeavor. Students at the very beginning of their nursing education need to know what is expected of them regarding professional behavior and what they can expect from others. Schools of nursing can raise awareness in a variety of important ways. As a result, students will better understand what civil, respectful, and professional behavior is; how to promote it; and how to integrate civility into their daily lives. Consider raising civility awareness for incoming students during general student orientation. This is an excellent venue to introduce a number of ways for students to thrive in their academic pursuits. In our institution, our Statement of Shared Values (SSV), which includes academic excellence, caring, citizenship, fairness, respect, responsibility, and trustworthiness, is woven into the fabric of student orientation. Students learn from the very beginning of their college experience what being a member of the campus university means, why civility matters, and how the SSV provides a touchstone for all members of the university. One of my favorite activities is to have students participate in slicing the “civility pie.” In the school of nursing, we also conduct a formal student orientation. Before classes officially begin, newly admitted nursing students participate in a full-day program where we specifically address what it means to be a nurse, professionalism, ethical conduct, and the importance of civility. I am responsible for conducting the civility portion of the orientation process, though all faculty members and administrators in the school of nursing reinforce and extend the message in a variety of interesting and creative ways. I also facilitate a second civility workshop during Week 6 of the students’ first semester, where we reintroduce the concepts of civility, professionalism, and how students can promote a safe and civil teaching-learning environment. In the initial orientation class, I present an overview of the state of the science on civility and incivility in nursing and engage students in activities focused on what they can do to promote civility throughout their nursing program. One of my favorite activities is to have students participate in slicing the “civility pie.”                                                                                         I provide students with a large index card that is blank on both sides. With the students working independently, I ask them to draw a large circle on one side of their index cards. This is the civility pie. Next, I ask each student to slice his or her pie into three pieces—representing students, faculty, and school administrators—according to what he or she believes is the approximate amount of responsibility each group has for promoting civility. After the students divide their pies, I ask them to turn their cards over and provide a rationale for why they sliced their pies the way they did. Most of them divide the pie into three equal parts. I love it when students draw three circles around the perimeter of the pie and comment that all three groups—students, faculty, and administrators—are 100 percent responsible for fostering civility. Awesome! One of the most enjoyable aspects of this exercise is discussing the students’ rationales for why they sliced—or didn’t slice—their civility pie the way they did. My favorites include: “Civility is a shared responsibility; we are equal partners.” “Civility helps grow and strengthen relationships.” “Leaders are the drivers of civility—and we’re all leaders.” And “Civility starts from the inside out.” In other words, “It starts with me.” Inspire action and catalyze change Raising awareness and actively discussing civility and incivility are crucial, but insufficient. We must also inspire action and engage students in making a commitment to create a civil academic environment. In addition to having students share how they slice their civility pie and their rationale for doing so, I ask them specifically what students can do to promote civility. This often results in a spirited and enlightening discussion where students identify specific actions, such as respecting others, being inclusive and collaborative, using open communication, being honest and nonjudgmental, and making a positive difference. We also identify additional ways students can promote civility, which include engaging in stress-reducing behaviors, assuming personal responsibility for co-creating classroom and clinical norms, and conforming and abiding by those norms. We discuss the importance of modeling civility; engaging in respectful social discourse; and participating on teams, committees, and governance councils. We also reinforce the importance of attending class, being on time, being prepared, avoiding side conversations, and not using media devices in disruptive ways. One of the new activities I will be using with students is the Clark Academic Civility Index for Students (below). This tool encourages students to think deeply about civil and respectful interactions with others and to engage in thoughtful self-reflection to improve their civility awareness and to identify strengths as well as areas that need improvement. It is important that educators who adopt the Clark Academic Civility Index instruct students to dedicate sufficient time and space to complete it.  Students need to find a quiet place, void of distractions, to carefully consider the behaviors listed in the index and respond truthfully and candidly by answering yes or no regarding each behavior. Once students have completed the index and their civility score has been determined, I ask them to consider their score and identify areas of satisfaction as well as areas for improvement. I also urge students to share their index responses with a classmate, colleague, or mentor and to ask that person to compare the student’s response to the index with his or her assessment of the student. Are there similarities between how the student sees himself or herself with how he or she is viewed by others? Are there differences or gaps? Discuss with your students ways to maintain the positive aspects of their “civility index” and identify strategies to address those areas they wish to improve.    The Clark Academic Civility Index for Students  Ask yourself the following questions, responding either “Yes” or “No”:  Do I, the majority of time (80 percent or more) … Role-model civility, professionalism, and respectful discourse? Yes/No Add value and meaning to the educational experience? Yes/No Communicate respectfully (by email, telephone, face-to-face) and really listen? Yes/No Avoid gossip and spreading rumors? Yes/No Avoid making sarcastic remarks or gestures (staged yawning, eye-rolling)? Yes/No Pay attention and participate in class discussion and activities? Yes/No Use respectful language (avoid racial, ethnic, sexual, gender, and religiously biased terms)? Yes/No Avoid distracting others (misusing media devices, side-conversations) during class? Yes/No Avoid taking credit for someone else’s work or contributions? Yes/No Co-create and abide by classroom and clinical norms? Yes/No Address disruptive student behaviors and promote a safe, civil learning environment? Yes/No Take personal responsibility and stand accountable for my actions? Yes/No Speak directly to the person with whom I have an issue? Yes/No Complete my assignments on time and do my share of the work? Yes/No Arrive to class on time and stay for the duration? Yes/No Avoid demanding make-up exams, extensions, grade changes, or other special favors? Yes/No Uphold the vision, mission, and values of my school? Yes/No Listen to and seek constructive feedback from others? Yes/No Demonstrate openness to other points of view? Yes/No Apologize and mean it when the situation calls for it? Yes/No Scoring: Add up your “yes” responses to determine your Civility Index score: 18-20 (90 percent or more “yes” responses)—Very civil 16-17 (80 percent)—Moderately civil 14-15 (70 percent)—Mildly civil 12-13 (60 percent)—Barely civil 10-11 (50 percent)—Uncivil Less than 10—Very uncivil Take responsibility for creating civility The activities described above are just a few of the initiatives that can be implemented to encourage students to take responsibility for creating civility. There are a number of other ways to reinforce the positive focus achieved during orientation. However, I highly recommend collaborating with students to co-create classroom and clinical norms to foster a safe teaching-learning environment and to consistently and intentionally discuss with students the imperative of fostering civility. One of the most effective ways to foster civility is to co-create behavioral norms. I contend that any organization devoid of norms (including the classroom) is a rudderless ship. Thus, co-creating classroom and clinical norms is essential to successful teaching and learning. In classes I teach, we begin co-creating classroom norms by describing the institution’s vision and mission, defining civility, and discussing the university’s Statement of Shared Values (SSV). With regard to the latter, we discuss how each provides a foundation upon which the vision of our college and school of nursing is based. We also co-create classroom norms by asking the following questions: “What behaviors do we want to see in class? What behaviors do we not want to see in class? And, once we determine and agree upon expected behaviors, how will we monitor their effectiveness?” We also co-create norms in our clinical groups and involve our community partners (preceptors) in the process, so they have a voice in how we behave together in our clinical groups. It is everyone’s responsibility to reinforce and monitor adherence to the norms. At midterm, we conduct a formal evaluation of how the norms are working. Classroom and clinical norms must be reviewed periodically, revised as needed, and reaffirmed throughout the course of the semester. Norms are living documents that provide a civility touchstone for students, faculty, and clinical partners. They provide a framework for working, collaborating, and learning with and from one another. Engage and commit to personal and organizational change To engage students in civility initiatives and encourage their commitment to personal and organizational change, I believe that we, as members of nursing faculties, must “begin at the beginning” with faculty members intentionally preparing students to identify and effectively address incivility in academic and practice settings. In a policy statement on lateral violence and bullying, the Center for American Nurses (2008) addressed the “reality shock” that new graduates experience and made several recommendations for eliminating disruptive behavior, including 1) disseminating information to nurses and students that addresses conflict and provides information about how to change disruptive behavior in the workplace, 2) developing educational programs on how to recognize and address disruptive behavior, and 3) implementing curricula to educate nursing students on ways to address and eradicate such behavior. In response to these recommendations, I began to integrate, several years ago, civility content into my senior-level leadership course. We use a Problem-Based Learning (PBL) scenario with live actors (standardized patients, or SPs) to portray incivility among nurses in the workplace. Students prepare by reading specific articles on the topic before coming to class. In class, before we observe a “live” scenario, we engage in an interactive didactic presentation and large-group discussion. In the past, students from our university theater department portrayed the scenario, but last semester, I asked three student volunteers to enact it. It was a rousing success! Two of the students acted out a situation in which a staff nurse was extremely uncivil to her co-worker, and a third student played the part of the nurse manager who used an evidence-based framework to address the conflict. After observing the enactment, students analyzed the scenario, developed and practiced specific ways to address the situation, and debriefed the encounter in a whole-class discussion. I asked students about what they had observed, including how the scenario helped them learn about dealing with incivility in nursing practice. The majority of students viewed the enactment as realistic, believed the role of the nurse manager was crucial in addressing incivility, and identified the importance of teamwork, effective communication, and directed education—readings and group discussion, to name two. Students also commented that the scenario raised their civility awareness, provided them with specific ways to prevent and address incivility, and helped them to be more cognizant of their own behavior and how they treat others. In small-group sessions, I asked students to consider specific ways they could foster civility in nursing education. They came up with some excellent suggestions, including 1) taking an active role in integrating civility into the nursing curriculum, 2) participating in candid discussions and open forums on the topic of incivility, 3) holding themselves and others accountable for uncivil actions, 4) rewarding civility, and 5) identifying helpful phrases to use when incivility occurs. The latter, an excellent suggestion based on the work of Martha Griffin (2004), is discussed briefly below. Sustain results and generate more change To counter uncivil behaviors and empower new nurses to address and confront uncivil co-workers, Griffin (2004), drawing upon cognitive rehearsal strategies, suggests identifying phrases to use when incivility occurs. Accordingly, after students observe a live PBL scenario, I have them generate and practice specific responses they can use to address uncivil co-workers in the workplace. The following are two examples of student-generated responses: 1) “It takes teamwork and support to care for our patients, and your behavior toward me is getting in the way. What can we do to resolve our differences?” 2) “I have noticed a conflict between us, and it is affecting our working relationship and caring for our patients. I would like to discuss the situation and resolve our differences.” Once students have identified potential responses, we practice them and discuss their impact. Students write their responses on an index card, which they keep with them for use when and if a situation calls for it. This helps sustain results and generate more change. Time after time, student feedback reveals a vital need for integrating civility content into courses. More importantly, by adopting civility training into the nursing school curriculum, students are better prepared to foster civility in the academy, in the practice setting, and in life. RNL Part One: Students, Jedi Knights and the promise of civility Part Three: Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES’ (article by Cindy Clark's daughter) For another article by Cindy Clark on civility and nursing students, see What students can do to promote civility. Cynthia “Cindy” Clark, PhD, RN, ANEF, FAAN, professor at Boise State University School of Nursing and founder of Civility Matters, is a psychiatric nurse/therapist with advanced certification in addiction counseling. She is the author of “Musing of the great blue,” a blog written for Reflections on Nursing Leadership. References: Center for American Nurses. (2008). Lateral violence and bullying in the workplace (Policy Brief). Retrieved from http://www.mc.vanderbilt.edu/root/pdfs/nursing/center_lateral_violence_and_ bullying_position_statement_from_center_for_american_nurses.pdf Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35, 257-263. Nurse educators: For more ideas on ways to promote civility in the classroom and in clinical environments, see Clark’s newly released book, Creating & Sustaining Civility in Nursing Education, from Sigma Theta Tau International