Share this article on:

Stifled Learning: Nursing Students' Experience of Incivility in Clinical Education

Thomas, Constance, Ann

doi: 10.1097/CNJ.0000000000000477
Feature: education

ABSTRACT: Incivility is of great concern in nursing, yet little is known about nursing students' encounters with incivility during clinical education. The lived experience of nursing students who encountered uncivil acts (n = 12) was explored through narrative interviews. Themes describing incivility emerged, including covert criticism and open shaming. Students experienced emotional and physical turmoil, and mixed messages that created a paradox. Further research is needed to understand components of incivility and the negative remnants left by uncivil encounters on nursing students.

Constance Ann Thomas, PhD, RN, is an assistant professor in the School of Nursing at Indiana State University in Terre Haute, Indiana. She has been teaching nursing since 2004.

The author declares no conflict of interest.

Accepted by peer-review 5/10/2017.





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).

Back to Top | Article Outline


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.

Back to Top | Article Outline


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).

Back to Top | Article Outline


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.

Back to Top | Article Outline


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.”

Back to Top | Article Outline


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 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.”

Back to Top | Article Outline


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).

Back to Top | Article Outline


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.

Back to Top | Article Outline


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.

American Nurses Association. (2015). New ANA position statement: Incivility, bullying, and workplace violence. Retrieved from http://
Anderson C. (2002). Workplace violence: Are some nurses more vulnerable? Issues in Mental Health Nursing, 23(4), 351–366. doi:10.1080/01612840290052569
Anthony M., Yastik J. (2011). Nursing students' experiences with incivility in clinical education. Journal of Nursing Education, 50(3), 140–144. doi:10.3928/01484834-20110131-04
Armstrong N. (2008). Role modelling in the clinical workplace. British Journal of Midwifery, 16(9), 596–603. doi:10.12968/bjom.2008.16.9.30888
Arries E. J. (2009). Interactional justice in student-staff nurse encounters. Nursing Ethics, 16(2), 147–160. doi:10.1177/0969733008100075
Bartholomew K. (2006). Ending nurse to nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc.
Cantey S. W. (2013). Recognizing and stopping the destruction of vertical violence. American Nurse Today, 8(2). Retrieved from
Clark C. (2008a). Student perspectives on faculty incivility in nursing education: An application of the concept of rankism. Nursing Outlook, 56(1), 4–8. doi:10.1016/j.outlook.2007.08.003
Clark C. (2008b). Student voices on faculty incivility in nursing education: A conceptual model. Nursing Education Perspectives, 29(5), 284–289.
Clark C. M. (2008c). Faculty and student assessment of and experience with incivility in nursing education. Journal of Nursing Education, 47(10), 458–465. doi:10.3928/01484834-20081001-03
Clark C. (2010). Why civility matters. Reflections on Nursing Leadership, 36(1). Retrieved from http://
    Clark C. (2013). Reflections on incivility and why civility matters. In C. Hall (Ed.), Creating & sustaining civility in nursing education (pp. 1-15). Indianapolis, IN: Sigma Theta Tau International.
    Clark C. M., Springer P. J. (2007a). Incivility in nursing education: A descriptive study of definitions and prevalence. Journal of Nursing Education, 46(1), 7–14.
    Clark C. M., Springer P. J. (2007b). Thoughts on incivility: Student and faculty perceptions of uncivil behavior in nursing education. Nursing Education Perspectives, 28(2), 93–97.
    Clarke C. M., Kane D. J., Rajacich D. L., Lafreniere K. D. (2012). Bullying in undergraduate clinical nursing education. Journal of Nursing Education, 51(5), 269–276. doi:10.3928/01484834-20120409-01
    Cleary M., Hunt G. E., Walter G., Robertson M. (2009). Dealing with bullying in the workplace: Toward zero tolerance. Journal of Psychosocial Nursing & Mental Health Services, 47(12), 34–41. doi:10.3928/02793695-20091103-03
    Embree J. L., White A. H. (2010). Concept analysis: Nurse-to-nurse lateral violence. Nursing Forum, 45(3), 166–173. doi:10.1111/j.1744-6198.2010.00185.x
    Ferns T., Meerabeau E. (2009). Reporting behaviours of nursing students who have experienced verbal abuse. Journal of Advanced Nursing, 65(12), 2678–2688. doi:10.1111/j.1365-2648.2009.05114.x
    Griffin M., Clark C. M. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. Journal of Continuing Education in Nursing, 45(12), 535–542. doi:10.3928/00220124-20141122-02
    Heider F. (1958). The psychology of interpersonal relations. New York, NY: Wiley.
    Kim S. Y., Park K. O., Kim J. K. (2013). Nurses' experience of incivility in general hospitals. Journal of Korean Academy of Nursing, 43(4), 453–467. doi:10.4040/jkan.2013.43.4.453
    King-Jones M. (2011). Horizontal violence and the socialization of new nurses. Creative Nursing, 17(2), 80–86. doi:10.1891/1078-4535.17.2.80
    Lazarus R. S. (1966). Psychological stress and the coping process. New York, NY: McGraw-Hill.
    Lazarus R. S., Folkman S. (1984). Stress, appraisal, and coping. New York, NY: Springer.
    Luparell S. (2011). Incivility in nursing: The connection between academia and clinical settings. Critical Care Nurse, 31(2), 92–95. doi:10.4037/ccn2011171
    Lyon B. L. (2012). Stress, coping, health, and nursing: A conceptual overview. In V. Rice (Ed.), Handbook of stress, coping, and health: Implications for nursing research, theory, and practice (2nd ed., pp. 2-20). Thousand Oaks, CA: Sage.
    Merriam S. (2009). Qualitative research: A guide to design and implementation. San Francisco, CA: Josey Bass.
    Morrow S. (2009). New graduate transitions: Leaving the nest, joining the flight. Journal of Nursing Management, 17(3), 278–287. doi:10.1111/j.1365-2834.2008.00886
    Salladay S. A. (2017). Toxic teaching. Journal of Christian Nursing, 34(1), 14. doi:10.1097/CNJ.0000000000000343
    Schneider M. A. (2016). Lateral violence: How educators can help break the cycle. Nursing, 46(6), 17–19. doi:10.1097/01.NURSE.0000482881.38607.87
    Ward-Smith P. (2011). Let's leave bullying on the playground! Urologic Nursing, 31(5), 257–263.
    Waters A. (2008). Nursing student attrition is costing taxpayers 99 million pounds a year. Nursing Standard, 22(31), 12–15. doi:10.7748/ns2008.
    Watson J. (1979). Nursing: The philosophy and science of caring. Boston, MA: Little, Brown and Company.
    Watson J. (1998). Philosophy and science of nursing. In A. Marriner-Tomey, & M. Alligood (Eds.), Nursing theorists and their work (pp. 142-156). St. Louis, MO: Mosby.
    Yaman E. (2009). The validity and reliability of the Mobbing Scale (MS). Educational Sciences: Theory and Practice, 9(2), 981–988.
    Yildirim D., Yildirim A., Timucin A. (2007). Mobbing behaviors encountered by nurse teaching staff. Nursing Ethics, 14(4), 447–463. doi:10.1177/0969733007077879
    Yin R. (2011). Qualitative research from start to finish. New York, NY: Guilford Press.

    clinical; incivility; lived experience; nursing education; nursing student; qualitative research; work place violence

    © 2018 by InterVarsity Christian Fellowship