Running head: INCIVILITY AMONG NURSING STUDENTS 1

Incivility Among Nursing Students

Myra Caston

University of St. Mary

Incivility Among Nursing Students

Introduction

Nursing is the dream of many, however to reach the dream, the process begins with

attending nursing school. Imagine upon entering a nursing program, you encounter the following

scenario in the lunchroom. Angie and Denise are two nursing students enjoying lunch together,

after finishing their patient care on the hall they were assigned. A few minutes later, Catherine

enters the room to eat her lunch. Catherine walks over to the two students and states to Denise,

Are you done, other people would like to eat and we are working on the same hall, so you need

to leave now. Denise being visibly upset gets up to leave. Catherine and Angie laugh at Denise

as she leaves crying. As Angie continues to laugh she says to Catherine, thanks Catherine, I

didnt like her anyway. When one is learning to become a nurse, it is not only being committed

to understanding the disease process and application of it, but projecting professionalism. In the

scenario above, professionalism was replaced with incivility.

Incivility is not concurrent with professionalism. Incivility encompasses rude or disruptive

behaviors that often result in psychological and physiological distress for the people, involved

(Clark & Davis Kenaley, 2011, p. 159). In nursing students, this behavior can carry over into the

clinical sites and sometimes into the work place. Incivility comes in lateral stages (nurse to

nurse) and hierarchical stages (nurse administrators or manager to nurse, nurse to student, faculty

member to student, physician to nurse). Incivility can be devastating to the person receiving it

and the staff or peers witnessing, as seen with Angie, Denise, and Catherine. As the nursing field

continues to be in high demand in healthcare, incivility is also on the rise in the form of the

coined phrase nurses eating their young. As the older nurses use to mistreat newer nurses, it has

trickled down through the years and now finds its place in the nursing classroom. This project
INCIVILITY AMONG NURSING STUDENTS 3

will address incivility observed in nursing students. By addressing incivility as a part of the core

curriculum, students will be able to address the causes resulting in civil behaviors that lead to

professionalism. As cited by (Watson, 1994), the profession of nursing is founded on the

principle of caring, and governed by a code of ethical standards (Clark & Carnosso, 2008, p.

11). The code of ethical standards for nursing students is based on the foundation of

professionalism.

Professionalism in nursing behaviors is autonomy, self-regulation, belief in public service, a

sense of vocation, and accountability (Keeling & Templeman, 2013, p. 1). Catherine and

Angies behavior showed a lack of professionalism in the scenario. The core values that are

taught in nursing school consist of honesty, integrity, belief in human dignity, patient equality,

and the desire to prevent and alleviate suffering for all that come within our environment.

Professionalism is a nursing skill that all nursing students are expected to acquire and

demonstrate consistently in the classroom as well as the clinical site (Shepard, 2014, p. 1).

Incivility within the academic arena is becoming mentally and physically damaging for nursing

students when ignored, and even with the nation accepting incivility as the norm, these behaviors

in the classroom and the clinical, must be addressed.

Concept to explore

Classroom incivilities can be a distraction from the learning process and are

undesirable to those interested in achieving an education (Patron & Bisping, 2008). Incivility is

hard to perceive because the person sending the message to the person receiving it, may interpret

it in a different way than intended. We live in a diverse world that includes so many cultures that

have different standards regarding what is incivility and what is considered civil. We must

consider the delivery of how we communicate with others or, whether we use verbal or non-
INCIVILITY AMONG NURSING STUDENTS 4

verbal transmission. In exploring this topic, as Forni so eloquently stated in 2008, in an article by

Stokowski, incivility occurs when people are stressed, unhappy, and rushed (Stokowski, 2011,

p. 2). When a person feels stressed, unhappy, and rushed, whatever message they are trying to

convey to others, may be perceived it in an uncanny way. Incivility erodes self-esteem, damages

relationships, increases stress, contaminates the work environment, and may escalate into

violence (Stokowski, 2011, p. 2). Some behaviors can be perceived as intentional or

unintentional. Joint Commission (2008), offers the following suggestions on how to deal with

incivility by including training in basic business etiquette, particularly people skills and

educating all team members on appropriate professional behavior as defined by the

organizations code of conduct, with an emphasis on respect (Lim & Bernstein, 2014, p. 125).

Problem Significance

According to Fowler, 2010, the significance of incivility based on provision one of the code

of ethics by American Nurses Association Guide to the Code of Ethics for Nurses Interpretation

and Application, states that, the nurse, in all professional relationships, practices with

compassion and respect for the inherent dignity, worth, and uniqueness of every individual,

unrestricted by considerations of social or economic status, personal attributes, or the nature of

health problems (Fowler, 2010, p. 1). Nursing is caring. In every human encounter, we convey

three messages: (1) Go away, my world would be better without you; (2) You are an object, a

task to be done, you mean nothing to me; or (3) You are a person of worth, I care about you

(Fowler, 2010, p. 6). With an understanding of the definition uniqueness and the three messages,

this project will teach and create a critical thinking environment for nursing students that will

foster a more caring and professional environment in the future. The uncivil behaviors will

populate into the workplace, if they are not addressed in the classroom. The causes and solutions
INCIVILITY AMONG NURSING STUDENTS 5

of incivility must be probed and the results must be evaluated for a positive outcome for future

nurses. There have been various research articles on incivility and civility in the workplace, but

there is still more research needed to address incivility in nursing students.

We live in an age that is much more willing to acknowledge the intrinsic value of all

members of society, regardless of gender, social provenance, sexual orientation, race, or national

origin (Forni, 2002, p. 180). Incivility remains an issue for many people today. The issue of

incivility makes this project significant to nursing students and the future of nursing. In raising

an awareness of incivility, and discussing the students responsibility for promoting civility, in

educational and practice settings are vital endeavors and cannot be underestimated (Clark, 2013).

Conceptual Model, Framework, or Theory

Jean Watsons theory of caring is a key component to professionalism in nursing. One of her

theories is cultivation of sensitivity to ones self and to others that includes:

Explores the need of the nurse to begin to feel an emotion as it presents itself, and the

development of ones own feeling is needed to interact genuinely and sensitively with

others. Striving to become sensitive makes the nurse more authentic, which encourages self-

growth and self-actualization, in both the nurse and those with whom the nurse interacts. The

nurses promote health and higher-level functioning only when they form person to person

relationship ("Nursing theories a companion to nursing theories and models," 2010, p. 1).

Another framework/theory model, the ACE Star Model of Knowledge Transformation

(Stevens, 2004) offers a simple comprehensive approach to translate evidence into practice.

Using PowerPoint presentation and open discussion amongst the nursing student, a summary of

all the information and incorporating the information, into a form of knowledge, will create a

better understanding for the practical nursing students on behaviors of incivility.

A qualitative design will be used for this project. The Clark Civility Index using the Likert

scale will be used to measure the students concept of incivility. This index is evidence-based and

designed to raise awareness, engage the students in discussion, and measure self-perceptions of

civility.

Current Evidence

Literature Review

According to Clark, Farnsworth, and Landrum, 2009 as cited in (Vink & Adejumo, 2015,

p. 2) incivility is defined as rude or disruptive behaviors which can result in psychological or

physiological distress for the people involved. Andersson & Pearson, (1999) as cited in

(Babenko-Mould & Laschinger, 2014, p. 146), incivility includes covert forms of aggression,

and violence, such as rude comments, thoughtless acts, and negative gestures. The effects of

incivility could affect the student nurse, and impede his or her progress along with their ability to

become an empathic nurse, which is a goal of nursing education (Schaeffer, 2013). History

points out that Florence Nightingale was described as an angel with the lamp, but she is also

depicted as someone that was intimidating, domineering, and one that had a caustic manner

(Lim & Bernstein, 2014, p. 124). As mentioned by (Clark, 2008, p. E37), Incivility is like a

dance- one dancer leads and the other follows- and sometimes the dancers do both as seen

between Catherine and Angie. Catherine was the lead dancer in the scenario while Angie chose

to follow. This same perception can be used when envisioning incivility as one person starts the

behavior and the other either accepts it or rejects it. In this case Angie chose to accept

Catherines act of incivility in an academic environment.

Academic incivility is a significant problem and reports of discord on college campuses

underscore the need for addressing uncivil behaviors in a forthright manner (Clark, 2007, p.
INCIVILITY AMONG NURSING STUDENTS 7

458). Uncivil behavior can progress into threatening situations if left unaddressed. What causes

the behaviors? Anxiety during nursing school includes not only the learning environment, but

outside forces as well. As a nursing student, there is so much theory that one must learn, while at

the same time there is the home life to consider. Learning something new is challenging for the

student. A nursing student is being taught that someones life is in his or her hands and they are

responsible. The stress from learning all they need to know and performing patient care can be

very stressful. Can this behavior be changed? Yes, as we explore integrating the understanding of

incivility into the core curriculum. The steps consist of the following:

1. Provide a pretest to be completed prior to lecture to identify students understanding of

civility.

2. Create and introduce lecture material on incivility in a classroom setting with the

practical nursing students at the senior level.

3. Facilitate open discussion as students identify what incivility means to them and how to

handle it when encountered.

4. Facilitate a simulation lab using scenarios that allow students to participate in and

identify key triggers and develop effective communication tools to deescalate the

situation.

5. Introduce the Clark Incivility Index Tool to place emphasis on the perceived behaviors

and how to properly appraise the level of civility competence.

6. Facilitate open discussion to help students identify where they fall on the Clark Incivility

Index Tool scale and what steps they need to take to manage those behaviors when they

are identified as the person displaying the uncivil behavior.

7. Provide a posttest to identify students understanding of incivility after completing the

tools introduced.

Incivility may arise as students feel a sense of entitlement since they are paying tuition fees.

Their expectation is that the education will be spoon fed to them instead of being required to

study and glean a strong understanding of the care they will be required to administer upon

completion of the nursing program. Students can become uncivil with their instructor when it is

time to receive constructive criticism. As cited by Dulucchi & Korgen, (2002), in (Vink &

Adejumo, 2015, p. 2), Students do not think that higher education includes effort, challenge, or

constructive criticism. Education is significant in maturing a civil society, while higher

education works to develop a sense of civic and social accountable ways to contribute to the

mutual good. The characteristics of the individual nurse and the environment interact in shaping

professionalism (Fetzer, 2003). If the practical nursing student believes that nursing involves

caring, compassion, and competent skills, then a change in behavior should evolve from this

project if incivility is present.

Outcomes of Interest and the Evaluation

The outcomes of interest for the students will be that students will be able to identify certain

signs or behaviors that lead to uncivil behaviors amongst nursing students. The students will be

able to identify key interventions that can create positive behaviors to change the behaviors of

incivility observed in the classroom.

Purpose Statement

The purpose of this study is to introduce behaviors related to incivility into the nursing

curriculum for senior practical nursing students. In addressing these behaviors, we can create

positive ways to address incivility and return to professionalism.

Methods

Setting. A classroom at Penn Valley Community College in the Midwest will be used for the

education portion. The PowerPoint presentations will be done in the classroom. The simulation

lab will be used for scenarios that consist of role-playing. In the PowerPoint and the simulation

lab information will be discussed that relates to behaviors of incivility.

Population and Participants. Practical nursing students from the community college will be

evaluated for this project. There are no inclusions or exclusions. There are no recruitment or

incentives to participate. There are no risks. The benefits will be education that exemplifies a

caring, civil nursing student that will become a beneficial healthcare provider.

Intervention activities

The Clark incivility tool, this will be used to measure outcomes related to incivility.

Interprofessional activities. The PowerPoint on incivility will be presented in the classroom

lecture for one hour and 20 minutes to address questions such as, what are the causes for

behaviors of incivility and how can we change or prevent these behaviors? A PowerPoint

presentation with educational material will be presented in the classroom with the same

questions and discussions that are used in the simulation lab. A thirty-minute open discussion

will follow allowing students to engage in conversation to express their thoughts and

understanding of what incivility means and how it affects their ability to function as a nursing

student. They will attend a two-hour simulation lab activity, which includes a thirty-minute pre-

briefing, one-hour scenario, and a thirty-minute debriefing session. In the simulation labs, the

students will be exposed to a scenario that presents incivility amongst the nursing students doing

role-playing. There will be two groups, a group role- playing and B group observing through a

two-way mirror. Finally, the Clark Incivility Index Tool will be introduced and completed by the
INCIVILITY AMONG NURSING STUDENTS 10

students. Upon completion of the Clark Incivility Index Tool, open discussion will take place to

help students identify the level of civility competence, which teaches the student how to manage

those behaviors when they are the person displaying the behavior.

Methods of Evaluation

Students will be provided a pretest to identify their understanding of incivility and its impact

on them as a nursing student. Upon completion of the project, all students will come together for

debriefing to discuss their experience and what impact it had on them as a nursing student.

Students will then take a posttest to identify if they have a better understanding of incivility and

its impact on them as a nursing student.

Analysis

The data analysis will be completed using the information collected from the open

discussions, simulations, the Clark Incivility Index Tool, and the pre-and post-tests on what

causes incivility and how can incivility be prevented. In doing the analysis, research questions

that will be addressed are what are the causes for incivility in nursing students and how can

incivility in nursing students is prevented?

Proposed Timeline

The proposed timeline to complete the project is twenty-four weeks to include evaluation

outcomes after the following implementation: Creation and introduction of lecture material on

incivility in a classroom setting with the senior level practical nursing students, facilitating open

discussion as students identify what incivility means to them and how to handle it when

encountered. Facilitating simulation activity that allow for scenarios, where the students will

participate to identify key triggers and develop effective communication tools to deescalate the

situation, introducing the Clark Incivility Index Tool to place emphasis on the perceived
INCIVILITY AMONG NURSING STUDENTS 11

behaviors and how to properly appraise the level of civility competence. A final open discussion

will be performed to teach the student how to manage those behaviors when they are identified

as the person displaying the uncivil behavior.

Ethical considerations

Ethical considerations were assessed and no harm or violations of the students right occurred

while completing this project was found.

.
INCIVILITY AMONG NURSING STUDENTS 12

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