Academic Dishonesty in Schools of Nursing:

A Literature Review
Marilyn N. Klocko, MSN, RN, CNE

ABSTRACT
Academic dishonesty in schools of nursing is surprisingly common. The following literature review defines academic dishonesty, describes the scope of the problem, and
sheds light on factors that affect student behaviors that
lead to academic dishonesty in schools of nursing. Finally,
barriers to and best practices for solutions to the problem
will be reviewed as they appear within the literature. [J Nurs
Educ. 2014;53(3):121-125.]

Received: June 26, 2013

Accepted: November 6, 2013
Posted Online: February 5, 2014
Ms. Klocko is Faculty, Brookhaven College School of Nursing, Farmers
Branch, Texas.
The author has disclosed no potential conflicts of interest, financial
or otherwise.
Address correspondence to Marilyn N. Klocko, MSN, RN, CNE, Faculty,
Brookhaven College School of Nursing, 3939 Valley View Lane, X1020,
Farmers Branch, TX 75244; e-mail: mklocko@dcccd.edu.
doi:10.3928/01484834-20140205-01

Journal of Nursing Education Vol. 53, No. 3, 2014

cademic integrity may be defined as the pursuit of

knowledge, understanding and truth in an honest manner (Gaberson, 1997, p. 14). Conversely, academic
dishonesty may be defined as engagement in practices that intentionally represent the work of another as ones own (Gaberson, 1997; Jeffreys & Stier, 1995; Kenny, 2007). Dishonest
classroom behaviors can include copying or giving answers in a
testing situation, divulging a tests contents to another student,
using technology to access test banks, using the Internet to recall or store information that may be on a test, or plagiarism
(Arhin, 2009; Harper, 2006; Kenny, 2007; McCabe, 2009).
Supon (2008) described one students method of recording
answers to an examination on an iPod and simply running an
earpiece through a hooded shirt that fed data to the student in
audio form. Other ingenious modalities used to cheat involve
writing answers on almost anything that can be placed on a
desk, including food wrappers, water bottles, hat brims, tissues,
or pens, or on any body part or appendage such as bandages or
casts (Supon, 2008). Coughing and tapping have also been used
as codes to transmit information between students in a testing
environment (Supon, 2008).
With the increased availability and popularity of online
courses in higher education, novel modalities for cheating are
more difficult to detect than within the traditional classroom.
Young (2013) described one group of students who used
Google Docs, a Web-based word processor, to cheat on an
essay examination. Each student researched and answered a
predetermined section of the test and shared the answer with
the others via Google Docs, accessed by a concealed secondary computer (Young, 2013). The professor did not discover the
group effort. Plagiarism is more tempting and prevalent than
ever before, as the ability to buy a custom-written paper online
or to copy and paste the ideas of another without citation has
been made ultra-accessible in todays high-tech world (Harper,
2006; Kenny, 2007; McCabe, 2009; Tanner, 2004; Young,
2013).
In nursing education, dishonest behaviors can occur in the
classroom, virtual classroom, and clinical arenas. Clinical
cheating behaviors are especially disturbing because they can
translate into harmful patient outcomes (Baxter & Boblin, 2007;
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Gaberson, 1997; Jeffreys & Stier, 1995). Hilbert (1985, 1987)

described a significant correlation between unethical classroom
and clinical behaviors and further demonstrated that a students
belief that a behavior was unethical was not a deterrent to engaging in the behavior. Examples of unethical clinical behaviors
include falsification of patient data, such as vital signs or assessments, alteration of charts, or failure to report a mistake such
as a medication error (Baxter & Boblin, 2007; Hilbert, 1987).
Bailey (1990) and Balik, Sharon, Kelisheck, and Tabak (2010)
reported that among faculty and administrators in schools of
nursing, 86% of respondents perceived academic fraud to be an
indicator of future unethical professional behavior.

trast, Aiken (1991) reported that male students were found to

cheat more than female students. Within all majors, students
with lower grade point averages (GPAs) and students engaged
in collegiate sports were more likely to engage in classroom
cheating behaviors (McCabe et al., 2001). However, Hilbert
(1987) and McCabe and Trevino (1997) found that the occurrence of unethical behaviors was unrelated to age, sex, ethnic
background or GPA. Finally, McCrink (2010) found no significant difference among cultural groups with regard to frequency
of self-reported engagement in behaviors of academic misconduct.
FACTORS AFFECTING BEHAVIORS

SCOPE AND INCIDENCE

Academic dishonesty is historically well documented. In

a 1964 study, Bowers found that 75% of students on college
and university campuses engaged in one or more incidences
of academic dishonesty. In the years since that study, McCabe,
Trevino, and Butterfield (2001) described a continuing trend in
academic dishonesty in higher education within all disciplines.
McCabe (2009) found that there was not a significant difference between the frequency of cheating behaviors in nursing
programs, compared with other disciplines. In fact, cheating in
schools of nursing is prevalent and well documented in the literature. In that study by McCabe (2009), which polled 2,000
nursing students, data revealed that approximately 50% of both
graduate and undergraduate nursing students had engaged in at
least one form of classroom cheating behavior. More than three
quarters of respondents in a study of nursing students by Brown
(2002) stated that they had witnessed cheating behaviors in the
classroom, whereas one quarter had, themselves, admitted to
cheating. A study by McCrink (2010) revealed that 21.5% of
nursing students admitted to engaging in academic misconduct, including cheating on examinations and plagiarism. In a
study of nursing students conducted by Hilbert (1985, 1987),
19% of respondents reported engaging in clinical misconduct
in the form of falsification of patient records, whereas up to
23% of the same sample engaged in some form of classroom
cheating. In a survey study of administrators and faculty, Bailey (1990) found that 38% thought cheating was a significant
problem in the baccalaureate nursing degree program in which
they worked.
DEMOGRAPHIC

The literature is scarce regarding a correlation between

student demographic characteristics and prevalence of cheating behaviors. The available evidence is inconsistent, and few
sources provide data that are exclusive to nursing. McCabe et
al. (2001) found that among students in higher education within
all disciplines, younger students cheated more than those older,
freshman and sophomore students cheated more than juniors
and seniors, and students in larger classes or on larger campuses
had higher occurrences of cheating. Within similar majors, one
study found gender differences to be insignificant with regard
to engagement in cheating behaviors (Hilbert, 1987; McCabe,
2009; McCabe & Trevino, 1997; McCabe et al., 2001). In con122

Many factors may influence a students decision to cheat.

Although McCabe et al. (2001) found individual factors to be
less significant than contextual factors in a students decision to
cheat, both may play a role. Individual factors consist of personality traits, whereas contextual factors encompass environmental influences. Complicating the picture of what factors affect
student behaviors, student and faculty attitudes and perceptions
of what constitutes academic dishonesty are often incongruent
(Arhin, 2009). Ignorance on the part of the student regarding
what exactly constitutes cheating often leads to unknowing engagement in academically dishonest behaviors (Arhin, 2009).
Contextual Factors

Categorized as contextual factors, some of the motives students recognized for engaging in cheating behaviors included
parental pressures to obtain good grades, pressure to get a good
job, unclear definitions of what constituted dishonest behaviors,
quantity and significance of assignments, inadequate proctoring
of examinations, inconsistent enforcement of academic fraud
policy, perceived severity of penalties for cheating, and personal experiences with role models (Balik et al., 2010; Gaberson,
1997; Hilbert, 1987; McCabe et al., 2001). Gaberson (1997)
cited competition with classmates, emphasis on perfection, and
impaired or stalled moral development as other factors that may
influence a students decision to cheat. Baxter and Boblin (2007)
merged the theories of Kohlberg (1981), Gilligan (1982), and
Rest (1986, 1994) to explain that a students interaction with
others has the potential to influence moral development. If a
student is exposed to others with a high level of moral development, student behaviors are positively influenced, whereas
interaction with those who possess unethical behaviors will
impart a negative influence. ORourke et al. (2010) concluded
that cheating is socially driven and chosen over moral values if
it is the accepted behavior within a group. Therefore, academic
dishonesty is often learned from observing peers who provide
a kind of normative support for cheating (Bandura, 1986; McCabe et al., 2001).
Individual Factors

McCabe et al. (2001) described that many college students

use a variety of neutralization techniques (p. 227), such as rationalization, condemnation of accusers, denial, and deflecting
blame to others in explaining cheating behaviors. However, in
a study on attitudes toward behaviors of academic misconduct,
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KLOCKO

McCrink (2010) found that nursing students with negative attitudes toward rationalization behaviors were less likely to engage in them. Certain personality traits add to the individual
factors that can influence the likelihood of cheating behaviors.
Lack of responsibility, laziness, poor self-image, lack of character, lack of personal integrity, lack of moral development, lack
of satisfaction in a job well done, and even a desire to excel are
some of these traits (Harper, 2006; Hilbert, 1987; McCabe et
al., 2001).

Boblin, 2007; Gaberson, 1997; Hilbert, 1987; McCabe, 2009;

McCabe et al., 2001).
A variety of strategies have been proposed and implemented
to deter cheating behaviors in higher education. Evaluation of
outcomes has shown that some strategies were more effective
than others. The methods proven to be effective have been implemented as best practices. Less effective approaches imposed
barriers between the educator and student and did not mitigate
the problem of academic fraud.

Student Attitudes

Policy Implementation and Code of Conduct

It is evident in the literature that student attitudes toward the

definition of academically dishonest behaviors play a major role
in determining engagement in those behaviors (Bolin, 2004;
McCabe et al., 2001; McCrink, 2010). McCabe (2009) found
that the more serious a student felt a cheating behavior was, the
less likely they were to engage in it. Students who rationalize
cheating are positively correlated with behaviors of academic
misconduct (McCrink, 2010). Certain behaviors of cheating,
such as getting test questions from another student, were not
deemed unethical by 19% of student respondents in a study of
nursing students by McCrink (2010). Seventeen percent of respondents in the same study did not view paraphrasing without citation or appropriate referencing as unethical (McCrink,
2010).
A link has been established between lack of acquired knowledge due to classroom cheating behaviors and clinical misconduct and incompetency (Hilbert, 1987; McCrink, 2010). As
many as 13% of respondents in a study regarding nursing students attitudes towards unethical behaviors did not find falsifying vital signs or breaking sterile technique without replacing
supplies to be unethical (McCrink, 2010). Gaberson (1997) suggested that nursing faculty should be seriously concerned when
a link exists between academic integrity and future professional
practice. Schmidt (2006) found that cheating among nursing
students is a significant ethical concern for nurse educators.
A study by Arhin (2009) found similar results in that todays
Generation Y students have normalized many behaviors considered by faculty to be dishonest. Although a large proportion of
students in this population easily identified dishonest behaviors
in examination situations, only approximately half were able to
identify that making up laboratory data was a dishonest practice (Arhin, 2009). Known for their inventive resourcefulness
and peer-dependent characteristics, the Generation Y age group
felt they demonstrated good use of available resources, creativity, and imagination when falsifying and sharing laboratory
dataa distinct dissimilarity from faculty perceptions (Arhin,
2009; Tanner, 2004). The increased use and availability of technology has only added to the normalization, ease, and incidence
of cheating behaviors in higher education (Arhin, 2009; Harper,
2006; McCabe, 2009; Tanner, 2004).

Many faculty experience an ethical predicament when faced

with implementing policy regarding academic fraud (McCabe
et al., 2001). This, in addition to lack of support by other faculty,
can cause teachers to ignore obvious cheating (Bailey, 1990;
Jeffreys & Stier, 1995; McCabe et al., 2001). Hoyer, Booth,
Spelman, and Richardson (1991) proposed that nurse educators
might be reluctant to admit that students engage in unethical
clinical behaviors, as these behaviors compromise a patients
physical well-being. This may pose a threat to the educators
professional self-image (Hoyer et al., 1991). Harper (2006) explained that the failure of professors to address academically
dishonest student practices contributes to a culture that allows
cheating to be permissible. To curb academic dishonesty, a joint
university and student governmentgenerated policy regarding
academic dishonesty needs to be consistently supported, implemented, and enforced (Arhin, 2009; Bailey, 1990; Balik et al.,
2010; Gaberson, 1997; Jeffreys & Stier, 1995; Kenny, 2007).
The use and enforcement of honor codes has proven to be
efficacious in curbing cheating behaviors (Arhin, 2009; Harper,
2006; Keeci, Bulduk, Oru, & elik, 2011; McCabe, 2009;
McCabe et al., 2001). Students who agree to the honor code are
less likely to cheat and rationalize cheating behaviors (McCabe
et al., 2001). Honor codes need to contain clear definitions of
what constitutes academic fraud, delineate sanctions that will
be imposed for infractions, and deeply embed a contextual
culture of integrity on campus (Gaberson, 1997; Keeci et al.,
2011; McCabe et al., 2001). Student involvement in the development and oversight of an honor code increases the likelihood
of its understanding and acceptance by students (Arhin, 2009;
Balik et al., 2010).

SOLUTIONS: BARRIERS AND BEST PRACTICES

Because a combination of attitudes, contextual factors, and

individual factors contribute to cheating behaviors in students,
best practice solutions consider and incorporate all of these factors when approaching the problem (Arhin, 2009; Baxter &
Journal of Nursing Education Vol. 53, No. 3, 2014

Moral and Character Development and Role Modeling

Another barrier to academic integrity is impaired or stalled

moral development. This character trait leads to student unawareness of or indifference to unethical behaviors in the academic or clinical setting (Gaberson, 1997). Nursing faculty
must contribute to the development of moral character in nursing students to ensure that honesty and integrity are practiced,
not only in school but after graduation as well (Gaberson, 1997;
Keeci et al., 2011; Schmidt, 2006). Keeci et al. (2011) and
Tippitt et al. (2009) found that nurse educators play a major
role in establishing a culture of integrity in the academic setting
and are responsible for facilitation of student achievement of
ethical professional behaviors. Lewenson, Truglio-Londrigan,
& Singleton (2005) challenged nurse educators to examine their
own values and to engage in behaviors that provide positive role
modeling for nursing students to follow. Tippitt et al. (2009)
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found that bringing about an environment that fostered academic integrity often required a cultural change on campus, but
it is a goal that must be pursued by nurse educators to achieve
long-term changes.
Socialization into the profession of nursing that emphasizes ethical and caring practices is an essential component in
the education of the nursing student (Baxter & Boblin, 2007;
Gaberson, 1997; McCrink, 2010). Nursing students are socialized in clinical areas regarding ethically sound behaviors by
adopting behaviors to which they have been exposed (Baxter
& Boblin, 2007). However, the reverse is true when improper
role modeling provides examples of unprofessional, ethically
deviant behaviors or when students have had poor or absent role
models in their lives (Baxter & Boblin, 2007; Gaberson, 1997).
Nursing faculty have a responsibility to provide students with
opportunities to work alongside ethically sound practitioners in
a professionally positive learning environment (Baxter & Boblin, 2007). Finally, it is imperative that nursing faculty personally act as shining examples of professionalism and character
by role modeling the ethical practices and behaviors they expect
to instill in students (Baxter & Boblin, 2007; Gaberson, 1997;
Tippitt et al., 2009).
Allowing Mistakes

Academic dishonesty can and will proliferate in an environment of high stress, where students feel the need to perform perfectly at all times (Gaberson, 1997). Perfection is a particularly
unrealistic goal for nursing students, who naturally will make
mistakes in the course of their education (Gaberson, 1997).
When faculty offer an atmosphere that allows a safe place to
make mistakes, they create an environment that promotes academic integrity by acknowledging that errors can and do occur
(Baxter & Boblin, 2007; Gaberson, 1997).
Student-Suggested Solutions

Students surveyed regarding methods that would discourage cheating suggested closer student observation, additional
proctor presence, keeping belongings at the front of class during testing, and not allowing students to leave the room during
examinations (Brown, 2002). Regarding examinations, students
felt less cheating would occur if examinations were changed
often and kept under lock and key, if seating was assigned during examinations, and if different versions of the same test were
administered simultaneously (Arhin, 2009; Brown, 2002; Tippitt et al., 2009).
McCabe (2009) suggested that many of these safeguards address individual factors and are ineffective in deterring cheating
behaviors. Rather, it is suggested that honor codes and academic
environments of integrity have been proven to be the keys to
successful solutions to academic fraud (Chiesl, 2007; McCabe,
2009).
Harper (2006) recommended that a combination of high-tech
and low-tech methodologies might be effective in diminishing
the incidence of cheating. High-tech methods that detect plagiarism include Internet plagiarism search sites, such as Turnitin,
that scan submitted papers for similarity to other papers within
a large database (Chiesl, 2007; Harper, 2006). New software is
being developed that identifies a students literary fingerprint in
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a writing assignment known to be original. Most students use

the same vocabulary within writing assignments, so comparing
the known writing to subsequent writings identifies suspicious
differences (Young, 2013).
Online course designers are devising new ways to prevent
and detect cheating. Testing systems are available that select
questions at random from a computerized test bank while an examination is being administered. Tests could still be taken from
anywhere, but students should have a very narrow time window
in which to test (one minute or less per question), disallowing
the opportunity look up answers (Chiesl, 2007; Young, 2013).
Chiesl (2007) suggested computerized testing that does not allow a student to go back to a question when an answer has been
selected, minimizing the ability to look up and change answers.
A method under consideration at the Massachusetts Institute
of Technology uses electronic fingerprinting to analyze each
users typing style and face recognition to help verify student
identity in testing situations (Young, 2013). Some online universities are using products that allow a 360 view around students, with human proctors who remotely watch students on
Web cameras and monitor keystrokes during testing (Young,
2013). Fingerprint scanning has also been used to determine a
students identity in a testing environment (Young, 2013).
Low-tech methods suggested to deter cheating incorporate
contextual solutions, such as honor codes, communication of
academic integrity expectations, maintenance of a community
of trust and integrity on campus, and support for university
standards regarding academic integrity (Harper, 2006; McCabe,
2009). Chiesl (2007) suggested that classroom cheating can be
almost eliminated by using multiple versions of the same paper
test, verbally warning students regarding the consequences of
cheating, and by increasing proctor presence within the testing
environment. Chiesl (2007) further hypothesized that allowing
a student multiple attempts to take an examination and averaging the results reduces the pressure to cheat and allows for additional learning as new questions are introduced on subsequent
tests.
CONCLUSIONS AND RECOMMENDATIONS

Academic dishonesty among nursing students is particularly disturbing because it has been linked to unethical clinical
behaviors that may endanger human lives. It is essential that
schools of nursing graduate technically and ethically competent
practitioners. Monitoring for dishonest behaviors is an essential precursor for achieving this goal. A good understanding of
the reasons for academic dishonesty provides a solid basis for
enlightened action plans that avoid barriers to solutions and incorporates best practices into the academic arena.
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