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Januar y / Fe br uar y Vol . 33 No.

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S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C AT I O N R E S E A R C H
Student Perceptions
of I NCI VI LI TY in Nursing Education:
Implications for Educators
GERRY ALTMI LLER
ABSTRACT This study explored the phenomenon of incivility in nursing education from the perspective of undergraduate nursing students
and compared it to perspectives of educators as found in the literature. The sample consisted of 24 undergraduate junior and senior nursing stu-
dents from four universities in the mid-Atlantic states. Data from four focus groups were transcribed and content analyzed to reveal themes and
subthemes. Students perceived that incivility in nursing education exists. They shared a common view with findings in the literature regarding inci-
vility from the faculty perspective. Notably, an emerging student view was that faculty may contribute to the escalating incivility in nursing educa-
tion, and that student incivility is justified when faculty are seen as uncivil. The implications for educators, consistent with the literature, are that
students want professors to maintain classroom decorum and set the example for civility.
HE LITERATURE SUGGESTS THAT INCIDENTS OF
AGGRESSION AND VIOLENCE ARE OCCURRING
MORE FREQUENTLY I N THE ACADEMI C ENVI RONMENT
THAN IN THE PAST (HEINEMANN, 1996; LASHLEY & DE
MENESES, 2001; LUPARELL, 2003; MORRISSETTE, 2001;
THOMAS, 2003), INCLUDING IN NURSING EDUCATION.
Faculty in nursing education programs are understandably con-
cerned (Lashley & de Meneses; Luparell, 2003) as inappropriate
behavior is disruptive to the learning process, and students who
exhibit aggressive behavior in the academic setting will eventually
care for vulnerable patients. Such behavior has made it more diffi-
cult to work as a nursing professor and is increasing the anxiety
level of nurse educators (Luparell, 2004).
Incivility in the academic setting is behavior that intentionally
disrupts or interferes with the learning process of others
(Morrissette, 2001). The literature identifies unacceptable behav-
iors as those that are disrespectful or disruptive. Such behaviors
range from rude, uncivil actions or words (e.g., lateness to class,
verbal disrespect) to physical aggression against other students or
instructors (Amada, 1994; Baron, 2004; Griffin, Ferrin, & Stucki,
2001; Lashley & de Meneses, 2001; Luparell 2003; Miller,
Hemenway, & Wechsler, 2002; Morrissette; Schneider, 1998;
Tiberius & Flak, 1999). Heinemann (1996) identified the core
component of incivility as a lack of respect for other human beings.
The increasing frequency of incivility in nursing education has
had deleterious effects on faculty (Lashley & de Meneses, 2001;
Luparell, 2003; Morrissette, 2001; Tantleff-Dunn, Dunn, & Gokee,
2002; Thomas 2003) while infringing on the rights and education
of uninvolved students (Morrissette). More than 50 percent of fac-
ulty surveyed by Lashley and de Meneses (2001) reported serious
inappropriate student behaviors; nearly 25 percent reported objec-
tionable physical contact between students and instructors. Some
faculty have considered leaving teaching positions because of
encounters with uncivil nursing students (Luparell, 2003).
Because of these findings, it is imperative to explore the nature
of incivility in nursing education from the perspective of students.
Are students views of uncivil behaviors similar to those of faculty?
What factors trigger and escalate disputes with faculty? Answers to
these questions support development of strategies to resolve con-
flicts between faculty and students before crisis level interventions
are required.
Literature Review Several important studies have targeted the
issue of incivility in nursing education. In a national survey of nurse
educators, Lashley and de Menses (2001) documented the frequen-
cy and extent of uncivil nursing student behaviors against nursing
instructors. Luparell (2003) described how uncivil events provoked
fear and panic for faculty and resulted in long-term as well as short-
term stress-related effects. Clark and Springer (2007) found that
most faculty and students surveyed (61 percent) viewed incivility as
a problem in nursing education.
Little research is available to describe student behaviors per-
ceived as uncivil or to explore the impact of uncivil behavior on fac-
ulty and society in general. Faculty response to conflict may unwit-
tingly exacerbate uncivil classroom behaviors (Boice, 1996). Clark
and Springer (2007) stated that faculty should reflect on how their
own behaviors may escalate incivility in academia. What is clearly
understood is that conflicts between faculty and students can cause
students to disconnect from the learning process (Tantleff-Dunn et
al., 2002). An important first step in de-escalaling conflicts and cur-
R E S E A R C H
T
16 Nur si ng Educat i on Per spect i ves
S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C AT I O N R E S E A R C H
tailing incivility is listening to students to understand their percep-
tions, feelings, and fears (Morrissette, 2001; Thomas, 2003).
Method This exploratory study used the focus group method
(Krueger & Casey, 2000) with four male and 20 female nursing stu-
dents. Students ranged in age from 18 years to 45 years and were
juniors and seniors in a traditional pre-licensure baccalaureate
program. They had completed a minimum of two clinical nursing
courses. Students were recruited from a state university and three
private universities located within a major metropolitan area in the
mid-Atlantic states. The researcher visited classes at each school
and invited students to participate in research to discuss student
perceptions of incivility.
Four focus groups were conducted. Each had three to nine par-
ticipants depending on the size of the university program. A list of
questions developed from the literature provided structure for the
focus group sessions. Sessions were audiotaped, transcribed verba-
tim by a professional transcriptionist, and verified for accuracy
against the recordings. Using a word processing program, an audit
trail was developed that allowed for comments to be traced back to
the specific focus group session. A flip chart was used during each
session to record key ideas and facilitate review by the participants
at the completion of the session.
Content analysis, consisting of rigorous examination of the focus
group data for recurrent instances, was used for data analysis (Carey
& Smith, 1994). Immersion in the data involved repeated listening to
all audiotapes. Significant statements were extracted from the tran-
scripts and were reflected upon to formulate meanings. Data were
coded into categories to identify clusters of themes and trends, which
were validated by returning to the original transcripts and checking
whether anything contained in the transcripts was not accounted for
in the clusters. Likewise, the themes were validated by checking
whether any content was not implied in the transcripts. Clusters of
themes and the indicators were scrutinized to create an exhaustive
description of the participants perceptions of incivility in nursing
education. Field notes, the written session summaries, and the flip
chart were reviewed in conjunction with the audiotape transcripts as
triangulation strategies to support interpretive validity (Maxwell,
1992). A doctorally prepared nurse educator with qualitative research
expertise confirmed the data analysis and interpretation.
Findings Nine themes were identified and compared to faculty
perspectives found in the literature. Each theme is recognized by its
relevant cluster of subthemes (see Table) and discussed in this arti-
cle. The study showed that nursing students interpret as uncivil
many of the same behaviors identified as uncivil by faculty. Further,
the students in this study expressed concerns similar to those of
faculty regarding the increasing frequency of uncivil behaviors by stu-
dents in the learning environment. They brought a unique perspec-
tive in that they identified faculty behaviors that fueled student inci-
vility, and, in fact, stated that faculty behaviors they perceived as
uncivil justified student incivility.
Table. Focus Group Themes and Subthemes
UNPROFESSI ONAL BEHAVI OR
Lack of professionalism
Teachers talking negatively about other students
Retaliation
Nurses modeling incivility
POOR COMMUNICATION TECHNIQUES
Belittlement, talking down to students
Feeling disrespected
POWER GRADIENT
Targeting, fear of being next
Fear of being failed
Feeling less than adequate
Embarrassment
INEQUALITY
Favoritism
Different rules for different students; adherence to rules
Different standards for faculty and students
Racial/ethnic bias
Gender bias
LOSS OF CONTROL OVER ONES WORLD
Helplessness/hopelessness
Questioning faculty leads to attack
STRESSFUL CLINICAL ENVIRONMENT
Stress
Not getting needed help
School size
AUTHORITY FAILURE
Faculty allow students to give them attitude
Faculty fail to control situation
DIFFICULT PEER BEHAVIORS
Side conversations during class
Inattentiveness in class
Cheating
Lateness
Competition among peers
Intimidation
STUDENTS VIEWS OF FACULTY PERCEPTIONS
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S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C AT I O N R E S E A R C H
Unprofessional Behavior
In the clinical setting, student behavior that was disrespectful
toward faculty, patients, staff, or peers was equated by students with
incivility as it reflected negatively on the school and, therefore, on
the students themselves. Students avoided seeking help from faculty
who made negative comments about students to other students; such
comments were seen as unprofessional.
Students form an identity as a nurse by observing faculty and
staff nurses. According to findings from the focus groups, students
believed that staff at some clinical sites modeled incivility through
interactions with students and faculty. Staff who denied assistance,
failed to provide direction, or communicated intolerance were viewed
as unprofessional, violating what it means to be a nurse.
Poor Communication Techniques
Students viewed behavior that was disrespectful to any person as
uncivil. Consistent with Heinemann (l996), they focused on com-
munication as the vehicle for incivility. Supporting findings by
Tantleff-Dunn et al. (2002), students said they felt disrespected
when their questions went unanswered by faculty; this was a fre-
quent source of conflict. Students were particularly sensitive to
what they perceived as being put down in the clinical setting.
Crying in clinical was viewed as the result of criticism from a clin-
ical instructor. Criticism of a students performance may be inter-
preted as uncaring by the student (Luparell, 2004), creating diffi-
culty in the student-faculty relationship and conflicting with nurs-
ings image as a caring profession.
Power Gradient
Students viewed clinical evaluation as a less objective process than
classroom evaluation and feared being failed by a subjective clinical
appraisal. They spoke of a power gradient in nursing education and
described a fear of being embarrassed, having their mistakes made
public, and being scolded in the presence of peers, staff nurses, or
patients. Some students choked up or began to cry as they told of their
experiences. Several said they had seen classmates cry and were fear-
ful that they would be next. They spoke of avoiding disagreement for
fear of retaliation, and some admitted to avoiding any interaction at all
with certain instructors.
Students identified targeting as part of the power gradient. They
felt that students who made a negative impression on an instructor
would receive more critical attention, with the ultimate goal to remove
the student from the program.
Inequality
Gender bias was identified as a trigger for incivility. Male students
perceived they were assigned patients who required the greatest phys-
ical exertion and believed that faculty, mostly female, had greater
expectations for them. Women, on the other hand, thought that some
faculty favored males and were more positive in their communications
with them. Favoritism was seen as unprofessional and a faculty behav-
ior that triggered anger. Behaviors identified as favoritism included
spending more time evaluating work of favored students and testing
favored students in a less rigorous manner.
Consistent with findings in the literature (Tantleff-Dunn et al.,
2002; Thomas, 2003), students saw racial bias and discrimination
as particularly uncivil and a trigger for anger. They described expe-
riences where minority faculty demonstrated racial bias against
white students and visa versa. Students told of experiences serious
enough to elevate to administrators, with some resulting in the
dismissal of a faculty member. Consistently, events of this type
resulted in a loss of respect for faculty, interruption in the learning
process as students were moved to other sections, and the feeling for
students that they had little control.
Loss of Control Over Ones World
Students perceived that questioning an instructor regarding grade
assignments could result in a counterattack; they described feeling
they had no recourse for incivility on the part of faculty. Students who
addressed an issue with a course director or administrator said they
were not part of the resolution and received no feedback, but instead
experienced the angry reaction of the offending faculty member.
They told of being yelled at by faculty and fearing further retaliation.
Feeling unprotected, they did not pursue their complaint, which led
to feelings of helplessness and hopelessness. With the learning
process interrupted and afraid to ask for assistance from faculty, stu-
dents created work-arounds whereby they learned from other stu-
dents. Even in cases of great duress, students did not see leaving the
nursing program as an option because of the financial burden of
postsecondary education and the difficulty of transferring nursing
credits between universities.
Stressful Clinical Environment
Many students identified the stress that accompanies a clinical expe-
rience as a trigger for uncivil behavior. Large clinical groups limit the
availability of the instructor, forcing students into situations that are
unfamiliar and lacking what they interpret as adequate support.
Students identified that frustration can affect communication
between faculty and student, resulting in raised voices, failure to con-
trol what is said, and overreaction to certain situations.
Authority Failure
The students acknowledged that they contribute to incivility when
they fail to meet their responsibilities. They expressed disapproval of
some behaviors demonstrated by classmates and concern regarding
the frequency of such behaviors. However, they saw addressing
18 Nur si ng Educat i on Per spect i ves
habitual tardiness and disruptive behavior in the classroom as a fac-
ulty responsibility and were frustrated when faculty failed to act.
They felt they had no control over the behaviors of their peers and
told of experiences that led to fighting after class, when one student
asked another to be quiet so that she could hear the instruction.
When students perceived that faculty had behaved in an uncivil
manner toward a student, they spoke of their satisfaction when that
student responded in kind. Likewise, when they identified their own
behavior as uncivil, they found it justified if done in retaliation for
perceived faculty incivility. Students empathized with faculty when
they believed that student incivility was undeserved.
Students believed that faculty comfort level and class size influ-
enced whether uncivil behaviors were addressed. Consistent with
the literature, faculty in larger classes, where there was greater
anonymity, were less likely to confront uncivil behaviors (Carbone,
1999; Merrow, 2005; Lashley & de Meneses, 2001; Tiberius & Flak,
1999).
Difficult Peer Behavior
Students spoke of side conversations in the classroom that interfered
with their ability to hear the instruction. Although disrespectful to
faculty and fellow students, such conversations, they said, were
rarely addressed by faculty. Interestingly, students recognized that
they themselves were uncivil when they had side conversations in
class but felt such behavior was justified when the instructor did not
hold their interest or seemed disinterested in the material.
Peer behaviors identified as disruptive included talking, laugh-
ing, watching a small TV, and talking on the phone during class.
Reading a magazine or putting ones head down on the desk to sleep
were considered inappropriate but more acceptable because they
were done quietly. Habitual lateness to class was considered a disre-
spectful behavior.
Students had no sympathy for peers regarding the consequences
of rule infractions and were angry when faculty did not enforce the
rules. Most students stated that cheating was pervasive but was
often not addressed, even though it violated the universitys academ-
ic code of conduct and was witnessed by faculty.
As identified by Amada (1994), students perceived that compe-
tition provokes uncivil behavior. Incivility could lead to an atmos-
phere of intimidation, where one student, fearing interaction with
another, would go to great lengths to avoid contact. Concern over
being ridiculed caused students to avoid asking questions in class.
Students Views of Faculty Perceptions
Students interpreted faculty failure to maintain control of the class
as lack of concern or resulting from fear of certain students. They
were also concerned that faculty may be influenced by bias, and
that the authority they wield discourages them from reining in their
biases. This finding is consistent with Luparells (2003) observation
that students hold a negative perception about faculty motivations.
The focus group sessions evidenced the magnitude of this perception
as students comments were reaffirmed by others.
Discussion Findings from this study provide insight into how stu-
dents interpret events common to many nursing education programs.
They show key areas of agreement between faculty perceptions of
incivility as found in the literature and student perceptions, as well
as some unique student perspectives. Students are concerned about
the increasing frequency of uncivil behaviors they see in the class-
room. There is recognition that communication is the most frequent-
ly used vehicle for incivility, and there is concern that societal influ-
ences may be a catalyst for increasing competition.
Consistent with the findings of Tantleff-Dunn et al. (2002),
this study shows that faculty responses to students can escalate
or ease tension. The disturbing negative student perceptions
regarding faculty contributions to incivility are consistent with
findings from previous studies (Clark & Springer, 2007;
Luparell, 2003; Tantleff-Dunn et al.) and are particularly con-
cerning in view of the enormous responsibility that nurse educa-
tors have as positive role models for the profession. The perception
that student incivility is justified in the face of perceived faculty
incivility warrants attention as such a perception can only esca-
late current levels of incivility and aggression, creating a danger-
ous work environment for faculty. Just as civility is learned
behavior that is incorporated through repetition, incivility is a
learned behavior that, left unchecked, can become the framework
for ones professional relationships.
Limitations of the Study Participants in this study were a
convenience sample of students who met specific criteria and
were willing to discuss the subject matter. Not all participants
spoke of firsthand, direct experience with incivility, but all
spoke of witnessing what they perceived as incivility on the
part of students or faculty. It is difficult to know how far-reach-
ing the negative perceptions that students expressed regarding
faculty contributions to incivility are. It is not known if stu-
dents in the focus groups were more likely than others to per-
ceive events from a negative perspective or if these students
were simply more open than others to talking about the topic.
Although all four focus groups provided examples of what
the students interpreted as incivility in nursing education, the
most extreme instances, particularly those involving faculty
termination, happened at larger programs where enrollment
exceeded more than 100 students per class. The impact of the
nurse educator shortage on such large programs may be a fac-
tor, but the full implications are not known.
S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C AT I O N R E S E A R C H
Januar y / Fe br uar y Vol . 33 No. 1 19
Implications for Educators Findings from this study pro-
vide indicators of how faculty-student relationships can be
improved through the implementation of strategies that deter
incivility and de-escalate conflict. A good beginning is to
introduce nursing students to the American Nurses
Association Code of Ethics for Nurses with Interpretive
Statements (2001). As outlined in the code, respect and com-
passion in all relationships are expectations for nurses.
Incivility toward others is a direct violation of this concept, and
it is the moral responsibility of nurse educators to deter such
behavior (Luparell, 2005).
Lewenson, Truglio-Londrigan, and Singleton (2005) recom-
mend placing a greater emphasis on appropriate student behav-
iors in class and clinical settings by demonstrating applications
of the code so that students can see how they should conduct
themselves. Just as students recognize how uncivil nurse behav-
ior violates the profession, so is it important that nurse educa-
tors help students understand that uncivil student behavior also vio-
lates it. If students are to learn civility, faculty must demonstrate
discretion, attentiveness, respectful communication, and profes-
sional behavior overall. It is important that faculty help students
understand that uncivil behavior on their part is a violation of
professional standards. In keeping with the code of ethics, facul-
ty should condemn any behavior that demonstrates bias against
or disrespect for any individual.
Clear communication of course-related information at the first
class meeting, and an open dialogue about expectations, will
decrease ambiguity about what constitutes uncivil behavior.
New faculty should seek guidance from experienced faculty about
proactively managing the classroom environment. They should
also seek advice regarding reasonable expectations for various
student levels, methods to establish clear boundaries in the stu-
dent-faculty relationship, and how to develop a syllabus that
clearly outlines course requirements. Acknowledging the incred-
ible responsibility nurse educators have to protect the public, it
is vital to maintain high standards and expectations yet create a
positive learning environment that will allow students to admit
mistakes without fear of public humiliation, a dictate that sup-
ports the obligation for educators prescribed by the National
Education Association (n.d.).
The blurring of boundaries between faculty and students can
promote inappropriate behavior. Faculty need to practice de-
escalation behaviors, particularly that of maintaining civility in
the face of incivility. Other de-escalation techniques include
attentiveness, listening, and reflection. It was shown in this
study and elsewhere (Tantleff-Dunn et al., 2002) that students
frequently identify not having their questions answered as a
source of conflict. Therefore, faculty need to be open to stu-
dents questions and suppress defensive reactions when being
challenged by students. In addition, it is important to promote
strong peer relationships among students by modeling such
behavior, appreciating diversity, and demonstrating the princi-
ples of teamwork, respect, and camaraderie with other faculty.
Lemos (2007) stated that civil behavior is learned behavior
and as society becomes more complex, so do the codes by which
civil society lives. Therefore, faculty need to continually update
their skills to meet the challenges of such complexity. Students
clearly want faculty to address uncivil behaviors in the class-
room. Faculty have an obligation to the nursing program, the uni-
versity, and individual students to control the learning environ-
ment and address uncivil, disruptive behaviors as they are
encountered. Administrators must support faculty by providing
a thorough orientation for new educators and offering ongoing fac-
ulty development workshops in managing classroom behavior.
Administrators need to be clear that faculty have a right and a
responsibility to provide a classroom that is conducive to learn-
ing and free of incivility and intimidation.
Maladaptive behaviors must be addressed promptly but done
in a civil manner. For behaviors where there is a zero-tolerance
level, such as talking on the phone or putting ones head on the
desk to sleep, the consequence should be communicated ahead of
time, before the behavior occurs, preferably on the first day of
class and then enforced if necessary. Cheating must be addressed
directly. Failure to do so conveys the message that clearly wrong
behavior is accepted in the classroom.
Nurse educators must develop curricula that help students
learn strategies to shield themselves from incivility on the part
of peers, patients, and other health care professionals.
Strategies could include role playing and using cognitive
rehearsal techniques that pointedly address offenses, such as,
I learn best when people are direct with me. You can be direct
with me if there is something that you want to say. As part of
their professional development, students need to learn how to
maintain civility, even when confronted by incivility. Clinical
evaluations, particularly those with grade assignments, need to
be informed by clear, measurable, objective criteria to decrease
the perception of subjectivity. A transparent grievance policy
must be in place so that students are informed of the process
and confident that an option is available for serious concerns.
Finally, the role of caring in the faculty-student relationship
cannot be overstated. This study, like Luparells (2004), recog-
nized that incivility is frequently triggered by the conundrum
that is created when poor performance on the part of the student
necessitates constructive criticism from the instructor. Many
students identify this with uncaring behavior from a person that
is serving as a role model in a caring profession. Strategies need
S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C AT I O N R E S E A R C H
to be developed to communicate unsatisfactory performance by
helping students appraise their performance realistically. One
such strategy may be to develop a process by which the instruc-
tor takes the student through a questioning route that views the
student performance from the patients perspective in accor-
dance with safe levels of practice. Such processes of reflection
may help the student arrive at the conclusions that are now com-
municated directly by the faculty member but so frequently
serve as the triggering event for incivility in the teacher-student
relationship.
Conclusions The findings of this study indicate that stu-
dents and faculty have similar perceptions regarding unciv-
il behavior, particularly in defining it, acknowledging its exis-
tence, and noting its increasing frequency in the academic
setting. The unique perspective students expressed regard-
ing the contributions of faculty behaviors to incivility is concern-
ing. That students believe incivility is justified when they
perceive incivility demonstrated toward them validates the
urgency with which nurse educators need to address this
issue. An important first step includes implementing effec-
tive strategies that de-escalate incivility and foster appropri-
ate professional behavior. Faculty reflection, the sharing of
experiences, and adequate preparation for classroom manage-
ment will support an environment where incivility can be
deterred.
About the Author Gerry Altmiller, EdD, APRN, ACNS-BC, is
an assistant professor at La Salle University School of Nursing and
Health Sciences, Philadelphia, Pennsylvania. For more informa-
tion, contact her at altmiller@lasalle.edu.
Key Words Academic Incivility Nursing Students Nurse
Faculty Nursing Education
20 Nur si ng Educat i on Per spect i ves
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