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Running head: COMPREHENSIVE EXAMS 1

Comprehensive Exams: Exploring Student Incivility in Undergraduate Nursing Education

Abby Grammer Horton, MSN, RN

The University of Alabama

Summer, 2018

COMPREHENSIVE EXAMS 2

Comprehensive Exams: Exploring Student Incivility in Undergraduate Nursing Education

Introduction

Academic incivility within higher education is a growing concern and is increasingly

problematic in nursing education (Morrissette, 2001). Student incivility has been described as

faculty-to-student or student-to-faculty. However, few studies have explored student-to-student

incivility, which may be underreported. Though definitions of incivility are highly

individualized, incivility is often defined as micro-aggressions, bullying, or disrespectful

behaviors (Clark & Springer, 2007). Incivility impacts student participation in the classroom

resulting in failure, poor attrition, stress, anxiety, depression, and lack of self-esteem (Ibrahim &

Qalawa, 2015). Ultimately, incivility which begins in the early years of professional education

and development may result in nurses who perpetuate incivility in the workplace leading to nurse

burnout and poor patient outcomes (Ibrahim & Qalawa, 2015). Due to the potential impact and

long-term consequences of incivility, student-to-student incivility within undergraduate nursing

education merits further investigation. The purpose of this study is to explore nurse educator

perceptions of and experiences with student-to-student incivility in undergraduate nursing

education.

Statement of the Problem

Nearly 62% of students and faculty in nursing education have reported incivility in an

academic setting (Clark & Springer, 2007). In a national survey, 24.8% of faculty have been

physically assaulted and 42.8% had experienced verbal abuse while in the clinical setting

(Lashley & de Menese, 2001). Vertical and horizontal incivility may occur across and between

all relationships in nursing education and in the clinical setting. Incivility between faculty-to-

faculty or faculty-to-student has been well-documented in the nursing literature. However, little


has been reported on incivility between students. This gap in the literature is detrimental to the

development of young professional nurses.

Purpose Statement

As stated, the purpose of this proposed Qualitative Descriptive Study is to collect data to

explore nurse educator perceptions of and experiences with student-to-student incivility in

undergraduate nursing education. The goal of this study is to improve our understanding of

incivility between students and to understand how this incivility impacts the teaching-learning

environment in undergraduate nursing education. The findings of this study will inform nurse

educators in the development of teaching strategies and changes to the learning environment that

foster civility and collegiality among students. By learning about how and why academic

incivility occurs in nursing education, a healthy and safe learning and practice environment can

be cultivated for future nursing students.

Significance

Incivility is a phenomenon that is difficult to apply research methodologies to, due to its

quiet and subversive nature (Clark & Springer, 2007). Incivility exists in higher education and

healthcare as demonstrated by recent nursing research and the widespread development of zero

tolerance policies; yet, incivility continues to pervade the culture even with policies against it.

Understanding how and why incivility between students occurs is an important first step in the

prevention of incivility. This proposed study will explore and examine the impact of student-to-

student incivility in undergraduate nursing education; furthermore, data from this study will be

used to show the relationship between stress and incivility, as well as to provide insight into the

issue of creating healthy learning environments in nursing education. In addition, it is hoped that

that this study will serve as the beginning of an ongoing body of research aimed at fostering a

culture of civility within nursing education.


Literature Review

A comprehensive review of the literature was conducted in Medline, Pubmed, CINAHL,

ERIC, and PsycInfo using Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA). Refer to Appendix A for the PRISMA Chart. PRISMA is an evidence-based

minimum set of items that are analyzed and included for systematic reviews of literature. The

primary focus of PRISMA is on the reporting of reviews evaluating randomized trials; however,

it can also be used as a basis for reporting systematic reviews of various types of research,

particularly, evaluations of interventions.

In the review of literature, there were no date restrictions on data collection. The search

was conducted in July 2016 and rechecked for additional works in January 2018. The inclusion

criteria for this literature review included the following: (1) peer-review journals, (2) original

publications, (3) research studies identifying student-to-student incivility, and (4) English

language. Exclusion criteria included other forms of incivility (i.e., faculty-to-faculty incivility,

or online bullying). The terms used in the search included “nursing,” “nursing education,”

“nursing students,” “incivility,” “bullying,” and “micro-aggressions” utilizing Boolean terms.

The terms were selected for the search using the concept analysis on incivility in nursing by

Clark and Carnosso (2008). Additionally, references from articles were examined for possible

inclusion in this research. Refer to Appendix B for the Literature Map.

Results

The search for nursing literature on student-to-student incivility in nursing education

yielded 146 articles, which discussed nursing incivility in various forms. From those 146 articles,

87 articles were reviewed based on inclusion and exclusion criteria. After reviewing the

abstracts, a total of 29 articles were selected for full examination. Four articles were identified


that met the inclusion criteria. Of the four articles, three were from the United States and one was

from Egypt. Sample sizes ranged from 68-324 students. A consistent instrument was not found to

evaluate incivility in the literature. In addition, there was a lack of evidence-based literature on

student-to-student incivility. Research, particularly nursing research, which explored the

relationship between psychosocial variables, such as emotional intelligence, depression, anxiety,

self-esteem, and fear of failure, and how those can contribute to incivility was also lacking. Refer

to Appendix C for a summary of the literature review findings.

Background

Clark’s Conceptual Model for Fostering Civility in Nursing Education identifies a range

of incivility in which stress levels increase across a continuum (Clark & Kenaley, 2011). Both

students and faculty play a role in this process. In a climate of civility, stress is well managed

with various solutions including opportunities for engagement and participation. Cultures of

incivility exist within organizations and institutions when stress is overlooked, avoided, or poorly

managed and when there are no opportunities for personal engagement (Clark & Kenaley, 2011).

The definition of stress or what is inclusive of stress is not always well defined and thereby

leaves room for interpretation. Clark’s conceptual model identifies stressors as attitudes of

student entitlement and faculty superiority in conjunction with other factors such as: managing

demanding workloads, juggling competing demands, handling technology and information

overload, and lacking knowledge and skills to appropriately manage conflict (Clark & Kenaley,

2011).

Additionally, Clark (2008), identified the factors most often contributing to incivility as

stress and attitudes of entitlement. Students report increased stress due to burnout from their

workloads, determination to outperform other students (e.g., class ranking, scholarships, and


clinical performance evaluations), and competitiveness for clinical placements in nursing

programs (Clark, 2008). Verbal abuse, physical oppression, and psychological oppression are

also included as forms of incivility but are reported to a lesser extent within nursing education.

Incivility includes bullying and micro-aggressions which are major concerns in the classroom

that are frequently overlooked. Bullying in nursing education has been identified as repeated

nasty, rude, belittling, humiliating or hostile behaviors (Gallo, 2012; Kolanko et al., 2005).

Micro-aggressions are statements or actions made by students or faculty which are considered

inappropriate or shocking. Refer to Appendix D for examples of microaggressions.

Discussion

Incivility is a major concern in nursing education and may be defined as any type of

speech or action that is rude, often reciprocal in nature, and nourished by disrespect between two

people (Tiberius & Flak, 1999). Incivility is often identified as the absence of cultural sensitivity

including the unwillingness to be empathetic and listen to other perspectives, a lack of common

ground on daily issues, and the reduced importance of social discourse. Behaviors of incivility

include but are not limited to disrespectful behaviors, condescending statements, negative

attitudes, bullying, and violence. Overt behaviors of student-to-student incivility in the classroom

include: (a) class disruptions, (b) arriving late or leaving early, (c) appearing apathetic or bored,

(d) unwillingness to participate, (e) moaning or excessive talking during class, (f) academic

dishonesty, (g) misuse of phones/or computers, (h) challenging faculty or students, or (i) arguing

with others (faculty or students). While this seems well defined, there is much more to the act of

incivility, adding layers of complexities to the concept of incivility.

In conducting the literature review, several articles described actual and perceived

incivility. Perceived student stressors, lack of coping abilities, and self-concept issues were


reported, which may contribute to or amplify student-to-student incivility. While student

stressors, coping abilities, and self-concept issues were identified in the four studies, there is lack

of research that describes how these issues are related and the interactions that impact how

students treat each other. Perceived student stressors were described as (a) role strain, (b)

financial burdens, (c) time management constraints, (d) lack of faculty support, (e) faculty

incivility, and (f) mental health issues. Students’ lack of coping abilities related to perceived

stressors played a significant role in promoting incivility and included (a) poor communication

skills, (b) lack of faculty or other support, (c) limited problem-solving abilities, and (d)

unrealistic expectations. Students’ self-concept issues included (a) low self-esteem, (b) delayed

nurse identity formation, (c) decreased self-confidence, and (d) a lack of self-efficacy. The

intersectionality of these stressors may strain relationships and lead to increased incivility.

Further research is needed to explore how stress and psychosocial influences mitigate or worsen

student-to-student incivility in undergraduate nursing education.

Incivility in Nursing Education

Vertical and horizontal incivility may occur across and between all relationships in

nursing education and in the clinical setting (Clark & Springer, 2007). A variety of interactions

may occur in nursing education that perpetuates incivility. These interactions are reciprocal and

can occur between faculty-to-faculty, faculty-to-student, student-to-faculty, and student-to-

student, among others. Faculty-to-faculty incivility is perhaps the most detrimental to students

and may lead to the adoption of such behaviors by the students who witness the encounters.

Some of the issues that promote faculty incivility include: (a) burdensome workload, (b) lack of

faculty support, (c) insults between faculty, (d) abuse of power, (e) setting others up for failure,

(f) poor performance, (g) marginalization of other faculty, (h) passive-aggressive behaviors, (i)


resistance to change, (j) gossip culture, (k) stress, and (l) unwillingness to negotiate (Clark &

Springer, 2010).

Incivility between faculty and students prohibits learning and can affect academic

performance (Clark & Springer 2007). Faculty-to-student incivility is described as faculty-to-

student, student-to-faculty. Examples of faculty-to-student incivility, as described by students,

are often listed as impatience, incompetence, rudeness, poor teaching style, and poor

communication. Other acts of faculty incivility may include: canceling class without warning,

being unprepared for class, lack of interest in the students or class, and being unavailable to

students (Clark & Springer, 2007; Clark et al., 2009). Faculty incivility towards students are also

reported as condescending remarks, constant criticism, negative feedback, scare tactics, and

threats of failure (Del Prato, 2013). Students report that faculty treat them with bias based on

appearance, behavior, race, gender, and ethnicity; moreover, students report that faculty do target

students who did not meet their expectations (Del Prato, 2013).

Students who experience faculty incivility have higher levels of stress which can result in

poor academic outcomes. Faculty set an example for professional behaviors and may in fact be

unknowingly encouraging incivility within higher education and the nursing profession. Students

who witness or encounter this type of incivility may be more likely to perpetuate incivility in

student-to-student interactions. This is troublesome given our knowledge of incivility’s negative

affect on student and patient outcomes (Ibrahim & Qalawa, 2015). Thus, students who

experience incivility in the classroom may become future professionals who in turn perpetuate

incivility in the workplace.

Faculty report that students practice uncivil behaviors towards the faculty. This includes

arguing in class, being verbally abusive, asking inappropriate questions during class, dominating


class time, causing interruptions (especially with phones and computers), cheating, and academic

dishonesty. Other factors include sleeping in class, displaying a sense of entitlement, blaming

others for shortcomings, and shunning or marginalizing other students (Clark & Springer, 2010).

In a qualitative study from Iran, students’ uncivil behaviors towards faculty were identified and

three themes (i.e., disruptive behavior that affected communication, ethical climate, and learning

climate) emerged around incivility of students-to-faculty (Masoumpoor et al., 2016).

Incivility clearly impacts the culture and climate of the learning environment. The

evidence of incivility between faculty-to-faculty, faculty-to-student, and student-to-

faculty has been well documented. However, there is a dearth of literature on the topic. Student-

to-student incivility in nursing education is important for nurse educators to address and

immediately intervene to help students understand that this behavior is unacceptable. As shown,

this gap in the literature is detrimental to the development of professional nurses.

Implications of the Literature Review

The negative consequences of incivility for students will impact their attitudes towards

the profession after graduation, resulting in a culture of incivility. During the nursing education

experience, students must learn how to be civil to each other to be prepared to work with other

nurses and healthcare providers in their professional careers. There is a lack of knowledge

among faculty on how to address incivility. Faculty need help to identify incivility and stop it

when it occurs. Further research is needed to examine the psychological and social consequences

of incivility in undergraduate nursing students; such consequences may include poor coping, low

self-efficacy, high stress, anxiety, lack of resiliency, and diminished mental, physical, and

spiritual wellbeing.


Theoretical Framework

As evidenced in this paper, incivility is a dynamic concept that is difficult to define and

identify. Incivility is highly individualized and experienced differently across individuals and

groups. Since few studies have addressed how and why student-to-student incivility occurs in

undergraduate nursing, it is critical that nurse educators examine this phenomena through a

phenomenological approach to gain insight and understanding. Phenomenology studies lived

experiences, which are the experiences a person has at any given moment in time and they

encompass the entirety of one’s being and life (Van Manen, 1997). The lived experience is

always within our collective consciousness and is part of our awareness. The lived experience is

central to phenomenology and without the lived experience, there would be no phenomena to

explore and evaluate. With its emphasis on the lived experience, phenomenological inquiry

welcomes an empirical exploration into the constructs of incivility, bullying, and

microaggressions.

Conceptual Model

Clark, a nurse educator and researcher, is the leading expert on incivility in nursing

education and her body of work spans more than a decade, laying the foundation for all other

incivility research. Clark (2008b) created and developed the Conceptual Model for Fostering

Civility in Nursing Education (p. E37). In this model, she illustrates how the stress and attitudes

of faculty and students intersect to create an environment of incivility. Clark maintains that

stress is a significant source of uncivil behavior among those in nursing education. Clark uses the

dancing metaphor “it takes two to tango” to describe and discuss the dynamic relationship

between nursing faculty and nursing students in their encounters with one another (Clark, 2008b,

p. E37). However, student-to-student incivility is often not highlighted in these discussions.


Clark’s conceptual model is used to describe a continuum of civility and incivility, which is

denoted with a double-sided arrow that references the fluidity of civility versus incivility (Clark,

2008b, p. E49). See Figure 1 (below). For this proposed study, Clark’s Conceptual Model for

Fostering Civility in Nursing Education will be used to inform the study and to serve as a

framework for studying student-to-student incivility in relationship to stress and other

psychosocial factors.

Figure 1

Conceptual model for fostering civility in nursing education. From “The Dance of Incivility in Nursing Education

as Described by Nursing Faculty and Students” by C. Clark, 2008b, Advances in Nursing Science, 31, p. E49.

Methodology and Method Selection

Given this clear and established need for further research, the proposed study is a

Qualitative Descriptive design with an interpretive phenomenological approach, which will be

used to gather individual nurse educator experiences with student-to-student incivility.

Phenomenology is the best framework for this study because it will provide a foundation for the

exploration and interpretation of found meaning identified by those impacted individuals. In

exploring the lived experiences of nurse educators familiar with student incivility, it is important

to assess the thoughts, perceptions, and biases of the educators. Thus, nurse educators will be

asked to define student incivility, provide examples of student-to-student incivility and will be


asked to share their approaches to both manage and ultimately prevent incivility. There are three

overarching research questions that will guide the study.

Research Questions

This study will be guided by the following research questions addressing student-to-

student incivility:

1. What types of student-to-student incivility occur in undergraduate nursing programs?

2. If incivility does occur, what factors may contribute or influence incivility among

undergraduate nursing students?

3. How do nurse educators address student incivility?

Research Design

To answer the research questions outlined above, a phenomenological approach in which

the lived experiences of multiple individuals (i.e., nursing educators) will be explored to study

their common experience with student-to-student incivility within undergraduate nursing

education. According to Van Manen (1997), a phenomenological approach allows for the

acquisition of knowledge about the lived experience, while achieving understanding through the

collective meaning and representation. The researcher will interview nurse educators at a four-

year institution with a baccalaureate of nursing program, who have personal experiences with

student-to-student incivility to gain understanding about the phenomenon of incivility. Nurse

educators are the target population for this study because the researcher is seeking to understand

how and why incivility exists within the context of a classroom setting or learning environment.

It is unlikely that students will accurately or reliably report student-to-student incivility in in-

person interviews for fear of retaliation or repercussions from faculty or other students. Nurse

educators are a richer source of information as they often witness and encounter student-to-

student incivility and they may have more perspective or insight about how and why those


behaviors are occurring. Exploring student perceptions of student-to-student incivility may be a

viable future study.

To seek the essence of a phenomena, Seidman (2013) created a three-interview series for

conducting phenomenological interviews, known as Seidman’s Model of Inquiry. The initial

interview is designed to allow the participant to describe the context of their experience while the

second session encourages participants to reconstruct their experience within the context in

which it occurs. Finally, the last interview promotes the individual’s reflection on the personal

meaning of the experience, referred to as meaning making. Seidman maintains that the

interviews do not have to occur independently, particularly if there are time constraints or

inquiry could influence future interviews (Seidman, 2013). Thus, this study will include three

interviews with each participant with consideration of the tenants of Seidman’s Model of

Inquiry.

Following the interviews, the researcher will employ general inductive analysis and

thematic representation, to establish a collective understanding and meaning of common themes

that may be interwoven throughout the individual experiences represented in this study. Using a

Qualitative Descriptive Study, data will be collected over the course of one semester to explore

nurse educator perceptions of student incivility in nursing education. Previous studies focus on

tracking the incidence of incivility with traditional quantitative designs and typically do not

address student-to-student incivility; whereas, this study seeks to understand how and why

student-to-student incivility occurs.

Timeline of The Study

Exploring Student-to-student Incivility In Undergraduate Nursing Education is expected

to be a year-long study that will involve one main data collection. In-person interviews with


nurse educators will be conducted in Spring 2019. Nurse Educators will be invited to participate

in this study on student-to-student incivility in undergraduate nursing education. Nurse educators

will be asked demographic and open-ended questions involving their perceptions, encounters and

experiences with student-to-student incivility in individual interviews. Data analysis will be

conducted in the Summer of 2019 immediately following data collection. Refer to Appendix E

for the Proposed Study Timeline.

Site Selection

The setting proposed for this study uses a purposive sample of nurse educators teaching

in a traditional baccalaureate nursing program at a public, four-year university in the

Southeastern United States. According to Marshall and Rossman (2010), for a site to be

considered for a study it should embody the following four characteristics: (a) access and entry

must be possible, (b) high probability of an information-rich environment, (c) rapport is likely

attainable and (d) the credibility and quality of the data are reasonably assured. Additionally, the

researcher sought to use a purposive sampling strategy in seeking an “information-rich”

institution for study (Patton, 2001). Due to these reasons, the researcher selected a large, public

institution of higher education in the Southern United States, within proximity of the researcher,

as the preferred research site. Most of the individual interviews will be conducted in-person on

the main campus in a private, neutral location of the participant’s choosing. For the study, the

researcher plans to conduct interviews with 8-10 nurse educators who teach in the undergraduate

nursing program.

After obtaining approval from the Institutional Review Board (IRB) and administrative

consent from the College of Nursing, recruitment of participants will begin. Recruitment

activities will include advertisements posted within the college, announcements at faculty


meetings, an email with an attached research invitation, and, if necessary, a private meeting with

a potential participant to explain the purpose of the study, participation requirements, and a

review of the potential risks and benefits of participation. After all questions have been

answered, the researcher will obtain informed consent via a signed consent form for each

participant. It is important to note that purposive or convenience sampling from a single site does

limit generalizability of the research findings; however, this study seeks to explore this area of

research interest through meaning making and generalizability is not a goal of the study

(Creswell, 2012). Data will be collected through individual interviews, researcher field notes and

memos. More information will be provided about the methods of data collection, below.

Participant Selection

Participants for the study will be nurse educators at a tier 1, four-year public institution of

higher learning with a baccalaureate of nursing program, student population of approximately

38,000, located in the Southeastern United States. In exploring the lived experiences of nurse

educators familiar with student incivility, it is important to assess the thoughts, perceptions, and

biases of the educators. Thus, nurse educators will be asked to define student incivility, provide

examples of student-to-student incivility and will be asked for ways to both manage and

ultimately prevent incivility.

From within the context of this environment, I will conduct a convenience sample. I will

recruit nurse educators based on purposive sampling strategies which were adapted for this

phenomenological inquiry. The strategy is a combination of two sampling techniques

which are characteristic of qualitative research: criterion sampling and maximum variation

sampling, which involves intentionally selecting nurse educators whose experiences, when

analyzed from an aggregate standpoint, provide the fullest description of the experienced


phenomenon (Creswell, 2012). As stated, nurse educators will be recruited to participate in this

study through a variety of techniques detailed above.

Data Collection Method Procedure

In this section, data collection methods are reviewed. A series of individual interviews

are the primary method the researcher will use to collect data. Each interview will last

approximately one hour. The researcher will audio record all interviews to ensure accurate

transcripts. Audio recording is preferred over video recording due to the emotional responses that

may be elicited by the questioning and it also helps to ensure anonymity (versus video

recording). Thus, it is more likely that the researcher will receive authentic responses to the

questions asked. The researcher will conduct the interviews and make field notes to document

non-verbal reactions or responses observed during each interview session. Anecdotal memos will

also be noted by the researcher at the end of each interview.

Interviews will consist of open-ended questions to elicit more thoughtful and engaging

responses, which may result in the capturing of more authentic reflections. Sample questions

may include, “Can you tell me about your experience with student-to-student incivility?” The

researcher may define the term “incivility” and provide examples to the participant. Another

sample question may be, “Can you tell me about a time you witnessed incivility while teaching?”

Member checking will be used to validate the accuracy of the recording and interpretation of the

participant’s responses (Creswell, 2012). In the individual interviews, open-ended questions will

be used to provide faculty an opportunity to freely express their opinions and perceptions on

student-to-student incivility. Follow-up interviews will take place in order to provide participants

with an opportunity to member check their responses and to add to their initial interview.


Validity and Trustworthiness

Validity with this research may be hindered by using a convenience sample, which may

limit the generalizability of the research findings. This will be addressed in the findings and

limitations of the study. The lack of generalizability is a threat to the study’s validity. This may

be accounted for by asking for previous experiences with incivility beyond their current

experience at this institution. More threats to the validity of this study may include bias and

reactivity. Researcher bias may be the greatest validity threat to the study given that the

researcher will interpret the nurse educator experiences and associate meaning with their

responses (Maxwell, 2013). To minimize researcher bias, a positionality statement will be

provided that outlines the researchers’ background, knowledge, goals, and explicit biases. It is

important that the researcher maintain an open-mindedness when analyzing the data collected. In

addition, the researcher will also use member checking to help improve the accuracy, credibility,

validity, and transferability of the study.

Another threat may be researcher reactivity which can unduly influence the study or

participant (Maxwell, 2013). This may be seen in the researcher reacting during interviews with

participants or by the researcher changing the questions asked based on such reactions.

Collecting additional data via an online survey tool or reflective journaling, along with

researcher field notes and memos, may help to reduce the impact of reactivity through the

approach of triangulation. Triangulation is a research method used in a study to check the results

by using more than one approach to verify the accuracy of the findings (Creswell, 2012). Other

factors may pose a threat to the study’s findings, such as emotional responses or the use of

gendered or inflammatory language. Awareness of these potential issues is paramount to

controlling for them in the study.


Data Analysis

In this section, the data analytic plan for the study is provided. Demographics Descriptive

statistics will be used to analyze demographic data. The qualitative data from the personal

interviews will be analyzed for major themes regarding student-to-student incivility as perceived

by the nurse educator participants. The qualitative data will be transcribed verbatim into a word

file and line-by-line coding will be completed to identify emerging themes and categories. Data

analysis will involve the researcher manually coding interview transcripts, as well as any

researcher field notes and memos for themes surrounding observations of incivility between

students and nurse educator perceptions.

The first phase of coding will begin following each interview and will employ holistic, in

vivo, and emotional coding to identify overarching themes associated with characteristics,

academic behaviors, and attitudes surrounding incivility. Research field notes and memos will

undergo a similar analysis as these may include initial impressions noted at the time of each

interview. The goal of coding the interview transcripts, journals, researcher field notes and

memos is to explore the themes reported by nurse educators who observe or witness incivility in

nursing education. After the data is categorized and themes are identified, a debriefing will be

held to validate the agreement of data assignment to both the category and theme.

Assumptions

As a nurse educator, it is imperative to address and discuss assumptions associated with

this study. My explicit bias with relation to this study is outlined as follows: nursing students and

faculty may be perpetrators of incivility or targets of incivility, or they may be both perpetrators

and targets. One’s perception of incivility or acts of uncivil behavior are highly subjective and

difficult to define, identify, or discuss. As a nurse educator, I have a responsibility to report any


known acts of incivility and to protect the public from any harm. Thus, it is essential to hold any

perpetrators of incivility accountable to the ethical principles and moral codes that govern the

profession of nursing. Finally, as a person of faith it is my belief that all people should be treated

with dignity and respect, which I maintain as a personal value.

Limitations

This study will use self-report data that may be influenced by the nurse educator’s ability

to accurately self-assess perceptions and credibly respond to the interview questions. In addition,

fatigue, external obligations, concerns unrelated to this study, or distracting environmental

circumstances may impact participants’ responses. This study will be used as an assessment to

determine the state of nurse educator perceptions as a first step to determine the types and

frequency of incivility in an undergraduate nursing program at the baccalaureate level.

Therefore, the findings of this study cannot be generalized to all nursing students or nursing

education programs. Additionally, operational definitions will need to be listed and defined.

Delimitations

For this study, the researcher will explore the issue of student-to-student incivility in the

classroom within undergraduate nursing education at a public four-year institution of higher

learning with a baccalaureate nursing program. Educators at other programs of nursing will not

be included in this study as a matter of convenience. Incivility may occur across many

relationships within nursing and higher education but for the purposes of this study only

incivility between students in the classroom will be explored. This will limit the transferability of

the study’s findings.

Relationships and Ethical Considerations

The study will follow the guidelines governed by the Institutional Review Board (IRB) at


my institution and will submit to the standards set forth by the Family Educational Rights and

Privacy Act (FERPA) that oversees protection of student educational records and ensures that

privacy will be maintained. The main ethical consideration of this study is to protect the identify

of its participants and to approach the topic of incivility with sensitivity. Unique identifiers or

pseudonyms will be assigned to each participant to further ensure anonymity. All data will be

stored on secure and protected devices according to what is specified by the IRB.

Another consideration involves conveying the true purpose of the study without

deception and without influencing the answers of the respondents. In this study, an important

ethical consideration is ensuring that participants feel comfortable with answering questions

related to the civility within their work and teaching environment with a colleague as the primary

investigator of this study. One solution to this potential problem is to have a research assistant to

ask the interview questions and to help code the information for the transcriber. This may add a

degree of privacy and collegiality that builds trustworthiness with potential participants. Ethical

considerations are of utmost importance when conducting research studies of this nature.

Future Research Recommendations

Incivility exists between students in undergraduate nursing programs. Incivility in

undergraduate programs is reported as a problem both in the classroom and in clinical settings.

Incivility can result in poor performance in the classroom and higher attrition rates in nursing

education. In addition, incivility experienced by nursing students may impact professional

behaviors in those that are both the perpetrators and the victims of incivility. Although this study

will inform theory and practice by providing insight on how and why student-to-student

incivility occurs, there is more to be learned regarding student-to-student incivility and its impact

on undergraduate nursing education. More research is needed to explore the effects of incivility


on academic performance, student life, self-efficacy, stress, anxiety, resiliency, and mental,

physical, and spiritual wellbeing.

Summary

The review of the literature uncovers a pressing need for more research on student-to-

student incivility. It is important for nurse educators to understand the complex nature of

incivility to better foster collegiality and mutual respect among students and thereby create a

healthy, safe, effective learning environment for students. Currently, there is a lack of knowledge

and consensus among nurse educators on how to manage student incivility. What can be learned

from this study is how nurse educators identify, address, and respond to student-to-student

incivility. The value of this inquiry lies in the exploration and examination of how and why

student-to-student incivility occurs from the perspective of nurse educators, while seeking to

identify potential solutions to deter student incivility within undergraduate nursing education.

If incivility is not addressed in nursing education, educators are contributing to the

growing problem of incivility in higher education and healthcare, today. The attitudes and

behaviors nursing students learn in their nursing education programs will continue into the

students’ professional development and nursing practice. Thus, nurse educators must understand

how to combat incivility when it occurs. The purpose of this study is to explore nurse educator

perceptions of and experiences with student-to-student incivility in undergraduate nursing

education. From this research, implications of the study and future recommendations will be

disseminated to advance the science of nursing related to academic incivility within nursing

education. Future research is recommended to examine the psychological and social

consequences of incivility in undergraduate nursing students from the student perspective.


Appendix A: PRISMA 2009 Flow Diagram

*Inclusion Criteria: Student-to-student Incivility in Nursing Education, English Language, Peer Reviewed Journals, Published in the last 5-10 years.

Records identified through database searching

(n = 146)

Scr

ee nin g

Inc

lud ed

Elig

i

bilit y

Ide

nti fica

tio

Duplicates removed

(n = 54)

Records screened (n =112)

Records excluded, did not meet the inclusion

criteria.*

(n = 25)Full-text articles assessed

for eligibility(n =87)

Studies included in the synthesis

(n = 4)

Records excluded, did not meet the inclusion

criteria.*

(n = 83)


Appendix B: Literature Map


Appendix C: Literature ReviewWhat is the evidence that reports data on incivility between nursing students in undergraduate programs?”

Title/Author/Year

Objectives/ Purpose ofStudy

Research Questions

Methodology Instrument used

Sample/Setting

Findings Conclusions

Incivility in Nursing Education: A Descriptive Study of Definitions and Prevalence (Clark & Springer, 2007a).

To investigate the problem of incivility in nursing education in a university setting from both student and faculty perspective

What behaviors are perceived as uncivil?

Do both groups perceive incivility the same?

Does age make a difference?

Do they believe incivility is a problem?

Descriptive Cross Sectional

INE (Incivility in Nursing Education)

Student behavior interitem coefficients ranged from 0.68to 0.88.

Faculty interim coefficients ranged from .070to 0.94.

University setting in NW part of country

BSN

n=32 faculty

n=324nursingstudents

16 student incivilities were identified

Students identified behaviors they thought were uncivil but did not discuss student-to-student incivility per se.

The INE has been used to measure incivility in nursing education but may not be sensitive to other variables that contribute to incivility. It is a self-report – students may not perceive their own behaviors asuncivil.

Faculty and Student Assessment of and Experience with Incivility in NursingEducation (Clark, 2008).

To investigate the problem of incivility in nursing education from both faculty and student perspectives

What student behaviors are considered to be uncivil by nursing faculty and students?

What is the perceived frequency of uncivil

Descriptive Mixed Methods

INECronbach alpha 0.85-0.96

Convenience sample from two national meetings.

n=194faculty

Students reported the following student behavior as uncivil (top third):

Students report incivility in the classroom.


student behaviors in nursing education?

n= 306students

80% holdingdistracting conversation


What faculty behaviors are considered to be uncivil by nursing faculty and students?

82% using the computer unrelated to class

What is the perceived frequency of uncivil faculty behaviors in nursing education?

78%demanding grade changes, etc.

83% being unprepared for class

71% Sarcasm

69% cutting class

Student Perceptions of Stress, Coping, Relationships, and Academic Civility: A Longitudinal Study (Clark, Nguyen, Barbosa-Leiker, 2014).

To examine nursing students’ perceptions of stress, coping, faculty:student and student-to-student relation, and ways to promote civility in nursing education

Are there significant changes in overall civility, quality of faculty:student and student-to-student relationships, and hours spent per week in stress reducing activities?

What are the top stressors for nursing students, most effective ways to cope with stress, top strategies to improve

Descriptive Repeated Measures Survey Longitudinal Study 3 years

Survey completed in 6th week of sophomore, junior, and senior years in nursing school

Survey developed by author and has not been tested for reliability and validity

Survey included questions on

Students (n=68)

BS Program in NW USA

There was a significant difference in level of incivility across time (p<0.01).Incivility decreased over time.

Students identified stressors in the program including

The perception of incivility was measured across time in nursing school, however, there was not a good description of what uncivil behaviors occurred and what variables impact incivility.


Appendix D:

Example of

Micro-

aggressions

Examples of Micro-aggressions* To an older nursing student: “Why are you in nursing school? You are so old.”

To a male nursing student: “You must be gay if you are in nursing school.”

To a homosexual nursing student: “I don’t know why you are asking questions about labor

the quality of student:faculty relationships, stop strategies to improve the quality of student-to-student relationship, and most effective waysto improve civility in the nursing program?

student-to-student incivility

faculty incivility.

Factors affecting To determine None Descriptive Self-developed Portsaid 60% of This is the onlynursing students’ students’ uncivil Comparative questionnaire that University, students study thatincivility: as behavior levels as focused on 1) Egypt reported identifies theperceived by perceived by perceptions of irresponsible level ofstudents, faculty, and staff.

nursing studentsand faculty/staff.

student incivility, Faculty/Staff student student-to-student

(Ibrahim & and 2) factors (n=66) behaviors and incivility.Qalawa, 2015). affecting inappropriate

To investigate student’s civility Students student It is not afactors that affects (n=186) behaviors perception orstudent nurses’ Reliability of description ofincivility as instrument 48% of incivility butperceived by measured @0.961 students an accountablenursing students reported report ofand faculty staff aggressive behaviors

student identified asTo identify the behaviors incivility.relationshipbetween students’ 55% reporteduncivil behavior total incivilityand factor in the on theoccurrence of incivility scaleuncivil behavior

>50% reportedtheir ownuncivilbehavior


and delivery, you are never going to get pregnant.”

To a student using a wheelchair: “How can you be a nurse? How are you going to work in

the hospital or run down the hall in case of an emergency?”

To a minority student: “You just got in to the nursing program because you are Latino.”

*Author Generated Examples

Appendix E: Proposed Study Timeline


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