Incivility in nursing has been noted as an ongoing and problematic issue, so much so that the American Nurses Association (ANA) developed a position statement addressing the issue, calling for nurses to “create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect.” (2015). Workplace violence and incivility are escalating, and have become topics of grave concern within the nursing profession. The cultural etiology of lateral violence in nursing is being examined, with considerations that attribution at least in part, is due to precareer educationally based encounters, as well as the influence of varying facets of academe that go well beyond the associated presenting behaviors of violence and incivility (Salladay, 2017 ; Schneider, 2016).
Incivility includes acts such as bullying and horizontal, lateral, or vertical violence (ANA, 2015 ; Anderson, 2002 ; Morrow, 2009) and occurs between peers, interprofessionally, and hierarchically (vertical violence) (ANA; Cantey, 2013 ; Embree & White, 2010). Nursing students practice their skills in clinical settings and, sadly, may be exposed to incivility in this setting.
To date, researchers have focused little on the impact of incivility on nursing students. Anthony and Yastik (2011) found students who experienced incivility described feelings of exclusion, hostility, and reported that they received what they perceived as rude treatment from nursing staff. Studies have primarily consisted of recording nursing students' responses to a variety of emotional and behavioral cues, delivered through controlled methods, such as surveys conducted in nonclinical environments (Armstrong, 2008 ; Arries, 2009 ; Clarke, Kane, Rajacich, & Lafreniere, 2012).
When a behavior is modeled during an educational experience, imitation of the modeled behavior by students has been observed to occur (Luparell, 2011). This imitation, if accepted and internalized, can result in perpetuation of that behavior, whether positive or negative, like incivility (Luparell). Given the continuing issues with incivility in nursing, and the fact that modeled behavior is likely to be perpetuated, it is important to understand encounters with incivility that nursing students may experience in clinical education. Therefore, the overarching purpose of this study was to describe the lived experience of incivility by nursing students in a clinical education setting.
Incivility can be defined as an “action that degrades a person's dignity causing loss of self-respect, ... is injurious, and is occurring in any setting at any time from any person(s)” (Clark, 2013, p. 26). Acts of incivility are forms of aggression. Such acts can occur in any setting, and vary by setting and individuals involved (Cleary, Hunt, Walter, & Robertson, 2009). Workplace incivility in nursing can occur horizontally or hierarchically, and has been well described in the literature (ANA, 2015 ; Bartholomew, 2006; Clark, 2010).
Academic incivility involving faculty-to-student interactions, and vice versa, also has been discussed. Faculty-to-student incivility has been described as: faculty use of condescending tones; embarrassment of students in front of peers; faculty indifference; student shaming by faculty; and faculty unapproachability (Clark, 2008a , 2008b ; Ferns & Meerabeau, 2009). Student-to-faculty incivility has been described as: students being late or leaving class early; unsolicited student peer-to-peer conversations, groaning, or sleeping in class; cheating; and plagiarism (Clark & Springer, 2007a , 2007b). Because exposure to incivility has shown potential as a determining factor toward nurses leaving the profession (King-Jones, 2011), and because behaviors modeled in educational settings tend to be retained (Luparell, 2011), the experience of incivility within a clinical education setting where students are developing as clinicians, has potential to be particularly damaging.
Three theories were used to provide explanatory value and underpin the study of students' experience of incivility: Watson's Philosophy and Science of Caring (1998); the psychological theories of Cognitive Appraisal (Lazarus, 1966 ; Lazarus & Folkman, 1984); and Attribution Theory (Heider, 1958 ; Lyon, 2012). The practice of caring is necessary for effective communication and is the mechanism at the heart of nursing practice.
From a spiritual perspective, the Bible offers knowledge Christian nurses can integrate into our scientifically based nursing theoretical framework to enhance and align practice with faith. We read Jesus' words in the Gospel of John: “A new command I give you: Love one another. As I have loved you, so you must love one another” (13:34, NIV). This command should be incorporated into our day-to-day walk as nurses. The apostle Paul describes this love in detail in verses of 1 Corinthians 13: “Love is patient, love is kind...It is not rude...not self-seeking...not easily angered, ...keeps no record of wrongs” (vv. 4-5, NIV).
How do we live in this way? We are told in Scripture that God is love (1 John 4:8); that the Holy Spirit resides with us (1 Corinthians 3:16; Colossians 1:17); and that we can do all things through Christ (Philippians 4:13), which includes loving as God loves. Understanding the command to love as God loves can help us clarify what love of others means, and help us realize our capacity and calling as Christian nurses to embody this command on a daily basis in our work, thus eradicating incivility (Ephesians 3:17-19).
EXPLORING STUDENT INCIVILITY
Following Institutional Review Board approval, 201 traditional baccalaureate degree nursing students attending an urban-based, research-intensive public university in the Midwest in their junior and senior year were invited to participate in the study. Students were emailed a definition of incivility and invited to participate if they had experienced incivility in a clinical education setting. Purposeful sampling was employed to increase chances of enrolling students who had experienced the phenomenon of incivility during clinical experiences with the goal of collecting data that reflected their lived experience. The final sample consisted of students (N = 12) enrolled in educational clinical settings in myriad placement settings, including hospital-based pediatric, obstetric, intensive care, medical surgical units, and community-based settings. Participants were Caucasian (n = 10, 83%), Asian Pacific Islander (n = 1, 8%), and Latino (n = 1, 8%). Most were female (n = 10, 83%) and single (n = 10, 83%), with over 80% of participants between 18 and 24 years (range 18-59 years). Fifty-eight percent (58%) (n = 7) were junior-level students.
A basic qualitative design was employed in the study: students were interviewed regarding their experiences with incivility during their education in clinical settings. An open-ended question set aligned with study aims, and housed in a conversational approach, was utilized. Each interview began with participants being provided descriptions of incivility. After reviewing the descriptions of incivility, audio recording began, and the interview commenced. A nondirective approach by the research interviewer was intentionally incorporated as a form of rigor to elicit salient responses by participants (Merriam, 2009 ; Yin, 2011). Upon interview completion, participants previewed the interview transcription for accuracy. A committee of peer researchers reviewed the data, agreed on the final data analytic approach and on findings. Once interviews were audio-recorded and transcribed, they were hand analyzed for emerging patterns, themes, and thematic clusters.
Common themes emerged from the data, including the theme of covert criticism, along with open shaming. During a clinical experience, students noted the expectation by clinical instructors that students should respond “quickly.” Responses deemed “slow” by clinical instructors were met with criticism. One student noted she was told “how inadequate my intelligence was.” Another student verbalized a similar anecdote: “It was as if I did not know what I was doing [heavy sigh].”
Open shaming was experienced at both student-to-student and staff-to-student levels. Student-to-student shaming was noted by one student accused by another of something that was unproven. The student accused was removed without proof of fact, reflecting: “I felt it unfair that a teacher or student, not the clinical instructor, could judge me.”
Staff-to-student shaming was the most common form of shaming. One student remembered being forewarned “that one physician in particular would pick on nursing students.” Other students felt they were being “talked down to [by the clinical instructor] in front of the entire class and...nursing staff at [a local hospital].” A student who was more than halfway through the nursing program felt belittled, to the point of never wanting to return to a clinical site, stating, “I felt like she [clinical instructor] didn't like me the whole time, but completely [verbally] ripped me apart...stating maybe I should consider changing my career path.”
Although students largely reported they were eager to provide patient care and learn, they frequently found they went unrecognized by staff nurses as a resource or were considered a burden. One student recalled an incident where she was abandoned by the assigned staff nurse, stating, “I was to follow a nurse, but [the nurse] did not want a student and left me with a medical assistant.” Another student, assigned to a nurse approximately the same age, found that instead of camaraderie, the nurse “avoided me and gave me misinformation and ignored me.” Several students reported that they “felt unvalued.”
EMOTIONAL AND COGNITIVE RESPONSES
Uncivil experiences evoked physical responses and had cognitive sequelae, with students reporting that the uncivil incidents “created physical turmoil” and “stifled learning.” Encountering incivility in the clinical setting evoked responses from students, such as anxiety, insecurity, emotional turmoil, and feeling singled out. One student reported that on multiple occasions, a physician “belittled my uniform.” As a result, the student reported, “I was so nervous...so anxious I was going to say something wrong.” Another reported that the experience “created emotional turmoil.”
Lack of sensitivity to sexual orientation also was reported and resulted in one student feeling insecure and singled out. The student noted, “I guess sometimes with that special kind of thing I feel kind of like, oh, I don't know what to say because I am gay...I was called aside [from other students]; it's like I am held to a different standard...I am singled out sometimes.”
Nursing student participants reported eagerness to learn from their nurse role models, consisting of nursing instructors and staff, noting “I was open to actually learning,” and “My role was to learn from them [nursing staff].” Participants valued harmony, to the point of rationalizing away uncivil behaviors, citing incivility occurred due to staff being “forced” to work with them. They rationalized, “Maybe she was just annoyed students had to follow her,” “She doesn't like us,” “She [the staff member] was inconvenienced,” and “I don't like to make excuses for her; maybe it was just bad timing.” Participants noted that perhaps having the students created a “tipping point” toward overload for the staff, citing, “Maybe they were just overworked and over-stressed.” In addition to rationalizing behavior, students compensated for uncivil behavior to maintain harmony: “I just didn't treat her bad...I let it go,” and “I decided to not worry about it, move on to the next [thing], and get a better experience out of it [clinical].”
Themes also emerged around how students cognitively appraised and then personalized incivility. One student talked about a situation where, as a result, she “felt humiliated, lacked confidence, seemed to sink a little bit [diminished self-approval], felt underappreciated and less prone to speak up.” Another student talked about “being useless,” which resulted in her becoming “angry because of being embarrassed and flustered,” and that she felt a “sense of just being in the way.”
Some students became tearful as they recalled their experiences. All participants were offered the opportunity to stop or postpone their study interview; however, not one accepted. Participants frequently noted that their encounters with incivility were totally unexpected, and that they experienced a “dashing of expectations” when those they perceived as role models acted with incivility toward them. They reported feeling blindsided by the acts of incivility encountered from nurses they expected to be caring professionals. Tearing up, one student remarked, “I was caught off guard and would have liked to have been less emotional.” Feelings of aversion emerged as a thematic cluster comprised of fear, dread, and loathing. Participants noted, “Sometimes the [clinical setting] environment was fear promoting”; “The clinical learning experience was dreadful. I feel like I didn't learn anything. It was like walking on egg shells. I wish I [had been] excited doing what I was doing, but I wasn't”; “As for the hospital, that is forever negative to me, and I don't want to go back.”
Educational experiences are ultimately designed to illuminate and encourage students, to role model caring behaviors, and to reinforce their fit and desire to join the profession of nursing. Students talked about receiving mixed messages, reflecting, “The [clinical instructor] told us it was a privilege to work here, regardless of how they treat you... just buck up and stay strong and deal with it.” Unfortunately, when students feel aversion and privilege toward the same situation, as seen in the mixed messaging reported in the findings, it results in paradox, which can lead to feelings of confusion and distrust. Participants noted, “Well, it always makes me cautious of each nurse...and I know it will impact me one day when I'm a nurse,” and “I felt like I did not want to continue and should change my degree.”
The narrative study findings indicate that student participants experienced signs and feelings of incivility like those reported by Clark (2013). The predominant themes describing student experiences were that incivility from staff and instructors consisted of covert criticism, shaming, and labeling. This incivility resulted in students having emotional responses, personalizing incivility, working to maintain harmony, and experiencing the paradox of aversion in a situation where they were told they should feel privileged.
Ward-Smith (2011) observed similar findings, indicating that acts of aggression and rude conduct between nurses were reported as common in the first 3 years of work as a professional nurse. According to Clark (2008c), faculty and students complained of similar aggression during the educational process of coursework. The terminology used to identify uncivil behaviors is similar to findings in the current study, namely bullying (Clark & Springer, 2007a), mobbing (Yaman, 2009), false accusations, and public shaming (Kim, Park, & Kim, 2013), and any action interpreted by the receiver as one in which the action “degrades a person's dignity causing loss of self-respect, and is injurious, and is occurring in any setting at any time from any person(s)” (Clark, 2013, p. 26). Confidence has been found to be negatively impacted by demeaning acts, which is consistent with current study findings (Waters, 2008).
When a nursing student encounters incivility from individuals in professional roles or from peers, the natural tendency is to appraise the experience to create understanding about why the uncivil act may have occurred, and try to react in an appropriate fashion (Lazarus, 1966). Watson's (1979) Theory of Human Caring suggests that the premise of nursing is caring, and that the professional nurse projects caring and kindness for the promotion of health for every individual. Early in nursing education, students are introduced to the history of nursing and its theoretical underpinnings in caring science. The participants in this study were approximately 1 year from graduation and moving into the role of novice nurses, a vulnerable period in the nurse's student-to-novice career. According to Laschinger (2010), novice nurses are less inclined to ask for help or present questions for fear of reprisal, especially during the initial stages of employment. Consistent with Laschinger's work, in the current study, students rationalized and compensated for behaviors to maintain harmony. Student nurses who are beginning to develop skills and confidence may be less apt to question situations that could put a student and/or patient at risk. Incivility that occurs within the clinical educational setting has great potential to damage the development and socialization of nursing students, and impede relationships with nurses and other healthcare professionals in the facilities where students practice (Yildirim, Yildirim, & Timucin, 2007).
The study has several limitations. The sample was small but met the requirements for qualitative research. The fact that the sample was largely young, single females, may limit generalizability of findings. The interview method may not have elicited the full breadth of sequelae resulting from the uncivil encounters. However, the verbal cues, body language, and passion with which the participants conveyed the experiences of incivility during the interviews added legitimacy and credibility to the data reported. The use of a nondirective approach added rigor, in terms of validity through participants self-prioritizing events to report.
IMPLICATIONS FOR EDUCATION
Hospitals and patient-care facilities act as venues where students are offered the opportunity to become proficient in practice and increase their skills. It is important for students to be prepared to resolve any issues about uncivil behaviors. Nursing curricula can best serve students by providing an education on what constitutes incivility and incorporate a skill set of assertive training and respectful behaviors. Nursing graduates entering the workforce often are viewed as change agents for the profession. If properly educated about incivility, new graduates may be able to begin turning the tide of incivility by modeling professional behaviors and properly managing occurrences of incivility they may encounter.
Further research is needed to explore the origins of academic incivility, to uncover and find ways to effectively root it out. In an article on Christian ethics in nursing, Salladay (2017, p. 14) importantly notes that “considerations should be given to look more closely at factors which may impact academic violence, such as financial greed, fraud, dumbing down course content and admission requirements, and nursing programmatic oversight by decision makers who are not nurses.”
Additional research also is needed regarding nursing students' understanding of incivility, their responses to uncivil acts, the components of incivility, and the physical and emotional remnants left by uncivil encounters. Assessing and identifying incivility is an important foundational skill, along with understanding how to properly respond to it. Clark (2013) provided a self-assessment for incivility in the workplace that could be considered for adaptation within the educational setting. Griffin and Clark (2014) suggest cognitive rehearsal as an intervention that allows one to practice strategies that prevent or diffuse incivility when confronted with uncivil acts.
From a Christian perspective, nurses can begin addressing incivility by embracing the command to love as God loves and understanding from Scripture that God will help us in difficult situations (1 Corinthians 10:13; 2 Corinthians 9:8). As we study Scripture and are filled with the Holy Spirit, God's power can be at work in us (Ephesians 3:20), helping us daily run the race set before us (Hebrews 12:1-2). We realize this is a supernatural gift from God, and that “We love because he first loved us” (1 John 4:19, NIV).
The power to change incivility remains a needed community effort among healthcare professionals, educators, and students. Temperaments, attitudes, and actions can change for the better with proper understanding and effort. Implementing Christian principles can facilitate change. As Scripture notes, “Therefore, if anyone is in Christ, the new creation has come: The old has gone, the new is here!” (2 Corinthians 5:17, NIV). Let us embrace this good news and work together each day to effect change and model God's love to the world as caring professional nurses.
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Keywords:© 2018 by InterVarsity Christian Fellowship
clinical; incivility; lived experience; nursing education; nursing student; qualitative research; work place violence