The incidence and importance of uncivil behaviors of nursing students: Comparing the perception of educators and students

Introduction

   As a serious and growing problem in nursing education (1, 2), incivility occurs at all levels from classrooms to the clinical environment (3). According to Clark (2012), incivility is defined as any action or behavior that disturbs the occupational, social, personal or educational environment (4).

Such behaviors will be a major challenge for educators in academic settings (5). They increasingly face incivility among their students (3,6) and believe that the incidence and severity of incivility has increased (7). These behaviors result in a disturbance in the student-educator communication and the learning environment, especially in team learning (3, 8, 9). They don't only disturb the teaching and learning process, but also they have negative effects on interpersonal interactions (5). The educators’ fear of maintaining personal safety, due to confronting uncivil students, leads to physical and mental tensions, as well as doubting their abilities as an instructor (10)to the extent that in some sources, incivility has been mentioned as one of the most important predictors of  job leaving (11).

   In spite of the importance and the prevalence of incivility among students, there is little published data on the instructor’ experiences of incivility. In the study by Sprunk et al (2014), the Participants' experiences indicated that educators face various kinds of unacceptable student behaviors and, in their opinion, facing such behaviors are time consuming .In addition, they refered to the connection between the civic behaviors of the academic period with those of the professional period (9). Also, Larson (2014) believed that there is a connection between the incivility in the academic environment and the occurrence of these behaviors in the healthcare environment¹², which is a point requiring contemplation by itself. According to Schaeffer (2013), the main goal of nursing education is to train students who will become empathetic nurses in the future. He believed that incivility, due to minor or major effects on the students, prevents students from moving towards this goal (13, 14). Today's students are the future colleagues, and if these uncivil behaviors are not managed, they will turn into uncivil future personnels (7, 15). Therefore, not only incivility is a direct threat to the patient’s safety, but also its continuation at work place results in leaving the job and thus leads to an inefficient care (10, 16), a toxic workplace, and clinical problems such as increasing the likelihood of medical errors and reducing the quality of care (3, 12, 14, 16).

Bjorklund and Rehling (2009) showed that, incivility is a slippery notion (17). What one educator may experience as troublesome and challenging in a classroom may not bother another and may not reflect the experience of the students they teach. Since uncivil behaviors are perceptions based on individual explanations, one behavior may be perceived as uncivil by some but not by others (18).

To date, there is a relative paucity of studies investigating and comparing the students’and educators’ perceptions of incivility. In a study by Nutt (2013), results demonstrated that educators and learners, agreed on the types of uncivil behaviors ,but disagreed on the frequency of incivility(19). In anouther study, there was agreement between students and educators on the majority of behaviors perceived to be troublesome (20).

Nutt (2013) believed that the main precursor to creat favoured strategies to reduce incivility among students would be to assess the perceptions of both educators’ and students’
experiences with incivility. Once it could be determined what behaviors both
groups percieved as uncivil and what occurred most frequently, those behaviors
could be recognized and considered in strategies (19).

     In Iran, few studies have quantified the levels of incivility and they have mostly been conducted in a qualitative method (21).Thus, considering the limited national literature and the need to examine this subject regarding the different perceptions and reactions of the educators and students in dealing with incivility, as well as due to the subject of incivility being based on an individual’s perception and the necessity of identifying the mentioned behaviors before the students’ entering the professional practice (7), the aim of this study  is to explore and compare the nursing educators’ and students’ perceptions and the frequency of their uncivil behaviors in academic environments.

Methods

 In this descriptive comparative study conducted from 2017 to 2018, 63 educators were selected by purposive sampling from 4 nursing faculties of the Lorestan University of Medical Sciences in Iran. Students (178 participants) were selected using stratified sampling, proportional to size of the strata. The students were stratified based on the year of entrance to the university. The entering students of each year were considered as a category and the intra- category included the two sub-categories of men and women. Eventually, a systematic sampling was done in sub-category based on the student number.  The original sample size was estimated based on the following formula: . Considering Z = 1.96, S = 24 and d = 5, the sample size was estimated to be about 89 persons, which was decided to be twice that number, regarding the design effect, which means 178 persons. Criteria for selecting the participants were as follows:  the willingness to enter the study, the second-year students and higher, and being neither a transferred student nor a guest. The inclusion criteria for the educators included the willingness to participate in the study and  having  at least  one  year of teaching experience (class or clinical setting).Those who did not wish to continue participating in the study and completing the instrument were excluded. After preparing a list of sample names and coordinating with the faculty education unit, the researcher provided them with the tool by referring to the classroom or clinical setting and completed it within ten minutes.

Incivility in Nursing Education-Revised (INE-R) Survey(Clark 2014) consists of 2 parts. The first part includes demographic information, and the second part includes a 24-item list of uncivil behaviors in nursing students. The participants are asked to rate the level of incivility based on a 4-point Likert scale (from 1 = not uncivil to 4 = very uncivil) and to evaluate the frequency of these behaviors in the last year based on a 4-point Likert scale (1 = never to 4 = often). These are behaviors they may have experienced or seen in the nursing academic environmentover the past 12 months. Finally, the mean and the frequency are calculated separately for each item. Higher mean scores indicated higher levels and therefore higher importance of non-civil behaviors.

 After presenting the list in the form of several open-ended questions, the participants define how much incivility has been identified by them as a problem in the educational  programs. Then they are asked to choose three strategies, among 10, as the most important strategies for promoting civilization. The frequency is calculated separately for each item (5).

 Since the tool was in English, it was translated through forward (to Persian) and back (to English) translation, after sending a written request to the developer and getting permission. In order to evaluate the validity, the scale was provided to 11 experts (5 nursing faculty members, 3 sociologists, and 3 psychologists). The content validity index for the items (I-CVI) was higher than 0.78 and content validity index for the scale was 0.91. For measuring the reliability through test-retest method, the scale was provided to 30 nursing students and teachers, and it was filled out with an interval of 72 hours. The intra-class correlation coefficient (ICC) was 0.94 and the internal consistency of the scale was evaluated using Cronbach's alpha method, which was confirmed with the Cronbach's alpha of 0.94².

For data analysis, SPSS software version 20 and descriptive statistics (mean, standard deviation, frequency and percent), and inferential statistics (Chi-square test and variance analysis) were used and  a p value

 Results

Characteristics of the participants

The age of majority of the students was 19-23, they were single, male, and not dormitory residents. Most of the educators were married females. The age of majority was 40 years and more. Descriptive statistics of the demographic data are given in Table 1.

Frequency of uncivil behaviors

Table 2 provides the frequency of the students' incivility. To evaluate which students behaviors were perceived as most frequently occurring, the percentages listed in the sometimes and often columns were summed. Students’ behaviors identified as most frequently occurring uncivil behaviors were: “expressing disinterest, boredom, or apathy about course content” (78.6% ),“ using a computer, phone, or another media device in class”( 70.2%), and “cheating on exams”(65.8%). From the table 2, 95% of the students hadn’t experienced  never or rarely, “  physical violence ”; 91.5%, “ property damage”, and 86.5%, “ threats of physical harm against others ” over the past 12 months.

 In the case of teachers, the results also showed that during the previous year,73% of them had often or sometimes experienced “ expressing disinterest, boredom,or apathy about course content “; 69.9%, “arriving late for class or other scheduled activities “  and 68.3%, “ using a computer, phone, or other media device during classes and meetings. By contrast, 98.2% had never or rarely experienced “physical violence "; 91.6%, " threats of physical harm against others (implied or actual)”; 90.5%, " using profanity (swearing,cussing) directed toward others " over the past 12 months.

It can be seen from the data in Table 2 that There are no significant differences between educators and students perceptions of uncivil behaviors frequency except on behaviors such as using a computer, phone, or other media device during class, meetings, activities for unrelated purposes; creating tension by dominating class discussion; holding side conversations that distract you or others; cheating on exams or quizzes; and being unresponsive to emails or other communications.

Table2. Compare of  frequency distribution of student s'  incivility from the students and educators' perspective

The mean score of the students’ incivility level

Table 3 presents the mean score of the students’ incivility level for each group. From the perspectives of educators and students, the maximum mean score belonged to the items, “physical violence” (3.9±0.53, 3.84±0.58),“ property damage” ( 3.87±0.49,3.83±0.59) and “physical threats, or harm to others”(3.87±0.58,3.83±0.59), which indicated the high importance of these items. In contrast, the lowest mean score belonged to the items “demanding make-up exams, extensions, or other special favors” (2.19±1.07 , 1.99±1.08), and “ being distant and cold toward others” (2.33±0.91 , 2.41±1.02). Data in table 3 represents there were significant differences between the educators and students  ratings of uncivil behaviors such as using a computer, phone, or other media device during class, meetings, activities for unrelated purposes; leaving class or other scheduled  activities early; being unprepared for class or other scheduled activities; skipping class or other scheduled activities; cheating on exams or quizzes; and demanding a passing grade when a passing grade has not been earned.

Table 3. Comparison of  Mean score of the educators and students’ perception  of students' incivility

Also, there was a significant correlation between the mean score of the students' perceptions of incivility and the college where they studied (0.022). The students of Khoramabad and Boroujerd nursing faculties reported a higher level of incivility, but there was no significant correlation regarding other characteristics (P>0.05). Moreover, there was a significant difference among the frequency of the students' incivility based on their year of entrance at university (0.004), their average score (0.056) and their college, but no significant correlation was found regarding other characteristics (P> 0.05). The frequency of uncivil behaviors was reported to be higher from the perspective of the students of Khoramabad’s nursing college who had entered university in 2013 and whose average score was 18 or more.

According to the non-native teachers’ opinions, the importance of uncivil behaviors was reported to be at a higher level (P=0.001). In addition, the frequency of incivility showed a significant difference based on the employment status (0.005) and age group (0.017). The teachers who were more than 40 years old and were employed by the government reported a higher frequency of incivility.

 Both groups reported incivility as a serious problem in nursing education. From the students' perspective, the probability of the occurrence of incivility was higher among students than educators, while the educators reported it to be equal in both groups. From the educators’ perspective, three strategies for promoting the civility in nursing education were respectively “increasing awareness of civility” (2.4 ± 1.24), “being a role model in terms of professional behavior and civility” (2.52±1.44), and “training in effective communications and discussions on conflicts” (3.34 ± 0.90). From the perspective of the students, the most important strategies included “increasing awareness of civility” (2.7 ± 1.24), “being a role model in terms of professional behavior” (3.08 ± 1.32), and “defining behavioral codes” (3.42 ± 1.18).

Discussion

 The primary question in this study sought to determine the frequency and the importance of uncivil behaviors from the perspectives of nursing educators and students.One interesting finding are the offensive behaviors such as threats of physical harm against others, and property damage possess the highest mean scores. This result indicates the importance of these behaviors from the both group perspective. This finding is consistent with that of De Gagne et al. (2015) who also found that the items of the threat of physical harm to others and  physical violence have been identified as highly uncivil (22). Similarly, Karimi Moonaghi et al. (2015) and Foreman (2017) reported that physical threats and harm have the highest level of incivility (23,24). In this study, therefore, physical violence was considered as a threat. Nevertheless, fortunately, their frequency was negligible and from the perspectives of both groups nobody had experienced such things during the previous year. Similarly, in the study of Vardanjani et al (2016), the frequency of these behaviors has been reported to be negligible and near zero (25), since a threatening behavior does not necessarily mean that it is committed by the person (22). This outcome is contrary to that of Natarajan et al. (2017) who found the item" property damage " was one of  the most common uncivil behaviors experienced by educators (20).

 Another possible explanationis that other researchers as well as the present researchers have used  the scales of the western countries in Asia, which despite their acceptable validity and reliability, they do not cover the socio-cultural conditions of the incivility of the working environment. Also, as a result of cultural and social unevenness, the threshold of people tolerance towards incivility may vary(26). Hence, these items were most significant, but their frequency was reported to be low and sometimes insignificant.

    In contrast, “ demanding make-up exams, extensions, or other special favors ”, and “ being distant and cold toward others” had the lowest mean score from both groups’ perspectives, which could be due to the lack of awareness of these issues and ignoring them, on the part of the students and even the teachers, since in the current study most of the participants have experienced the mentioned items in the previous 12 months. Also,in China “demanding make up exams” was one of the common uncivil students’ behaviors reported by instructors.

According to the students and teachers, the mostly experienced uncivil behaviors  were: expressing disinterest, boredom, or apathy to course content, using a media device during class, and cheating on exams. There are similarities between the findings expressed by common uncivil behaviours in this study and those described by Clark (2009). Also, these results are in line with those of previous studies. In a study by Foreman (2007), most of the participants believed that using a computer, phone, or other media devices during class were experienced (24, 27). Also, cheating on exam as one of the highly-occurring forms of academic dishonesty (28) was reported in the study. In the study by Luparell et al. (2007), offensive behaviors from the teacher’ perspective included items such as delaying in entering the class, using mobile phones, and cheating on exams (29). However, the incidence of behaviors such as cheating on the exam was reported to be among the most frequent behaviors on the part of students, which was consistent with the students' viewpoints in this study. In Clark et al. (2007), the most important offensive behaviors from the educators’ perspective included having rude gestures, being ill prepared for class, distracting discussions, using mobile phones, and cheating on the exam (30), which were all consistent with our results.

Also,there were significant differences between the teachers’ and students’  rating of  some uncivil behaviors such as using a computer or phone in class; leaving class early; being unprepared for class; skipping class; cheating on exams or quizzes; and demanding a passing grade when a passing grade has not been earned. These behaviors were more important from the instructors’ perspectives. According to knepp et al. (2012), technology is widely available to students; however, the form of uncivil behaviors has varied in the past two decades (31). In accordance with the present results, Natarajan et al.(2017) demonstrated that since the teachers are older, they are more sensitive to behaviors such as using cell phones in the classroom (20). Also, cheating on exam was more important to the instructors.There are some similarities between the attitudes expressed by instructors in this study and those described by Nutt (2013) and Krecara et al.(2016)(19, 32). Krecara et al.(2016)examined the prevalence and disturbance of 30 destructive behaviors from the viewpoint of instructors and students. Similarly, instructors estimated the disturbance of behaviors such as cheating on exams more than the students (32).

There are significant differences between teachers and students perceptions of uncivil behaviors such as using a computer or a phone during the class; creating tension by dominating class discussion; holding side conversations; cheating on exams; and being unresponsive to emails. For all of the mentioned behaviors, students reported more frequency. While in the study  by Natarajan et al. (2017), instructors described the side conversations more than students (20).

    Moreover, the mean score of the perception of uncivil behaviors was reported to be higher in non-native lecturers, the reason behind which can be traced back in cultural differences. In addition, regarding the year of entrance to the university, the highest amount of incivility was reported by the students entering the university in 2013, while the lowest one was reported by the students entering the university in 2015. This confirms that these results are likely to correlate directly with the students’ age. The frequency of uncivil behaviors has been reported to be lower by the elder students while the younger ones seem to be more sensitive.

    Also, from the perspective of the teachers, the frequency of uncivil behaviors was significantly different depending on the employment status and the group age. Most reports on the high frequency of these behaviors were made by the official and contractual staffs. It seems that the occurrence of such behaviors has been of more importance from the viewpoint of the official and contractual staffs due to a stronger employment commitment and having a better job prospect. Regarding the age variable, it seems that due to less age differences and having a closer relationship with students, as well as less work experiences, a lower incivility frequency has been reported by younger educators.

   Both groups reported incivility as a serious problem in nursing education. Regarding the occurrence of incivility in the two groups, it seemed that the educators have a more moderate attitude in comparison with the students and they generally ignored many of the students’ uncivil behaviors or considered them to their age as well as their rawness. In the study of Vardanjani et al. (2016), according to 58% of students, the degree of uncivil behavior was moderate and 48% of them believed that uncivil behaviors had been seen equally among both the teachers and the students. From the perspective of the teachers, too, the occurrence of such behaviors in educational environments was moderate and it was reported to be a bit higher among the students (25). Contrary to the present study, in the study of Joibari et al. (2011), the frequency and the severity of offensive behaviors have not been reported to be significant. The reason behind this difference may be the time of doing the research, the previous decade, and the upward trend of uncivil behaviors in the recent years (33), as pointed out in the study of Ibrahim et al. (2016) (34).

   Regarding the major strategies of promoting civility, the educators and the students had a mutual perception of offering common solutions. Both groups emphasized the need to raise awareness of uncivil behaviors. Focusing on teaching civil ethics and informing students are requied in higher educaion. If the necessary training is provided for educators and students, their perception of civility will be enhanced and, as a result, the possibility of the occurrence of uncivil behaviors will decrease (33). Role modeling is also a method based on patterning and the presentation of objective and practical examples. Regarding their experiences and their social integrity, educators are at a higher level in comparison to students. Therefore, they are considered as objective models for students. The third strategy offered by educators was training through effective communication. Effective communication is considered as a vital element in the civility of the medical education.Therefore, it is necessary to include the techniques of effective communication and enhance the interpersonal skills as much as possible as credits in curriculum.

  From the perspective of students, defining the codes of conduct can identify norms and abnormalities and place them within the framework of ethics. Generally, holding meetings to discuss challenging behaviors and their causes, as well as the establishment of a specific framework and discovering the procedures to make the necessary changes are among the useful strategies to prevent uncivility and deal with challenging behaviors (35). Clark et al. (2011), have highlighted the importance of making students and educators familiar with the topic of incivility (36).

Given the findings of this study, the high frequency of some behaviors such as students' reluctance to contents, delayed entry, and the use of media tools in the classroom from the perspective of both educators and students, identifying the reason for these behaviors is of a high importance. On the other hand, the different views of these two groups on some uncivil behaviors and the seriousness of the uncivil behaviors in nursing education, the necessity of designing interventions such as holding workshops with the aim of raising their awareness of uncivil behaviors or considering the subject in the undergraduate nursing curriculum are necessary.

Ethical considerations 

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

Acknowledgement

The authors express their gratitude to the Research and Technology Deputy of Lorestan University of Medical Sciences for the financial support, and to the teachers and the students participating in the study.

Financial Support:

This article is a part of the Master Thesis of Nursing approved by Lorestan University of Medical Sciences. It was approved by the Research and Technology Deputy of Lorestan University of Medical Sciences with the project code: A-10-1496 and ethical approval code: lums.REC.1395.197 .

Conflict of interest

The authors declare no conflict of interest in this study.