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Incivility in the Hospital Environment: Te NurseEducator-Staf Nurse Relationship

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Incivility in the Hospital Environment: The Nurse Educator-Staff Nurse Relationship

by

Cynthia Danque

A thesis submitted to the faculty of

Gardner-Webb University School of Nursing

In partial fulfillment of the requirements for theMaster of Science in Nursing Degree

Boiling Springs

2013

Submitted by: Approved by:

Cynthia Danque, BSN, RN Reimund Serafica, PhD, RN

Date Date


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Abstract

The purpose of this study was to examine the occurrence of incivility in the nurse

educator-staff nurse relationship in hospital environments. Hospital nurse educators’

perceptions of the biggest stressors for nurses during educational experiences, identifying

uncivil traits as seen by nurse educators, and identifying the perceived role of nursing

leadership in addressing incivility in the workplace. A qualitative methodology was used

to determine if incivility affects the nurse educator-staff nurse relationship. A focus

group interview was utilized. The results are the perceptions of the nurse educators who

participated in the study. The nurse educators from this research group have experienced

incivility in nursing education in the hospital environment.

Keywords: Incivility, civility, bullying, nursing education, nursing practice,

continuing education, preceptorship, workplace incivility


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Acknowledgments

I am sincerely thankful for the support of my husband, David, in my pursuit of

higher education. He has been my guiding light for strength of character and

determination to see intentions become reality. When I approached the subject of

continuing my nursing education and the desire to achieve a Master’s he wanted only to

know what he could do to make this goal attainable. He has truly been my partner in this

endeavor from the beginning to the end.

Without the guidance of my Thesis Advisor, I could not have completed this

qualitative research study. Qualitative research is a necessary part of nursing practice

that leads to discovery. I am truly thankful for Dr. Serafica’s fondness of qualitative

research and leadership in sharing the art of qualitative research. Dr. Serafica guided me

through the research process with kindness and patience. I aspire to share these skills

with my future students and am honored to have experienced the teaching/learning

environment with Dr. Serafica. Thank you for exemplifying these methods.

I was very fortunate to have been blessed with a talented and caring preceptor. I

am thankful for the guidance of Jill during my practicum. She is an excellent educator

who cares deeply about nursing education. Thank you for your support during this

research project.

I would like to thank Dr. Cynthia Clark for her research with incivility in nursing

education. Dr. Clark is a leader in fostering civility in nursing education. I am thankful

to Dr. Clark for her encouragement of others to join this large endeavor.


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Cynthia Danque

All Rights Reserved


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TABLE OF CONTENTS

CHAPTER I

INTRODUCTION ...............................................................................................................1

Problem Statement ...................................................................................................3

Significance of the Research ....................................................................................3

Purpose .....................................................................................................................5

Research Question ...................................................................................................5

Theoretical/Conceptual Framework .........................................................................5

Definition of Terms..................................................................................................9

Summary ................................................................................................................10

CHAPTER II

LITERATURE REVIEW .................................................................................................12

Review of Literature .............................................................................................12

Incivility in Academic Nursing Education ................................................13

Incivility in the Nursing Practice Workplace.............................................19

Summary ................................................................................................................23

CHAPTER III

METHODOLOGY ............................................................................................................25

Implementation ......................................................................................................25

Setting ....................................................................................................................26

Sample....................................................................................................................27

Design ....................................................................................................................27


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Protection of Human Subjects ...............................................................................28

Instruments .............................................................................................................29

Data Collection ......................................................................................................30

Data Analysis .........................................................................................................30

Summary ................................................................................................................30

CHAPTER IV:

RESULTS…… .................................................................................................................32

Sample Characteristics ...........................................................................................32

Major Findings .......................................................................................................35

Summary ................................................................................................................46

CHAPTER V

DISCUSSION ....................................................................................................................48

Limitations .............................................................................................................57

Implications for Nursing ........................................................................................57

Recommendations for Practice and Education ......................................................58

Conclusion .............................................................................................................59

REFERENCES ..................................................................................................................61

APPENDICES ...................................................................................................................67


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Appendices

Appendix A: Research Questions ......................................................................................68

Appendix B: Informed Consent Form ...............................................................................69

Appendix C: Study Cover Letter .......................................................................................71

Appendix D: Email Correspondence from Dr. Cynthia Clark ...........................................72


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List of Tables

Table 1: Demographic Characteristics of Nurse Educators ...............................................34


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Laschinger, 2010; Oore et al., 2010; Smith, Andrusyszyn, & Spence Laschinger, 2010;

Thomas, 2010; Spence Laschinger, Finegan, & Wilk, 2009; Spence Laschinger, Leiter,

Day, & Gilin, 2009; Felblinger, 2008; Hutton & Gates, 2008). These articles range from

viewpoints such as generational differences, burnout, and preparing new graduate nurses

to handle uncivil behaviors from supervisors, coworkers, physicians, and patients. The

American Nurses Association’s Code of Ethics (2010) addresses civility in nursing

practice. Provision 1.5 stated that nurses should interact with all persons with

compassion, caring relationships, and fair treatment of all individuals. The principle of

this provision is respect and compassion for all persons.

Although incivility is documented in nursing school education (Gallo, 2012;

Lasiter, Marchiondo, & Marchiondo, 2012; Robertson, 2012; Cooper, Walker, Askew,

Robinson, & McNair, 2011; Clark & Springer, 2010; Heinrich, 2010; Clark, Farnsworth,

& Landrum, 2009; Clark, 2008a, 2008b; Clark & Springer, 2007a, 2007b; Luparell,

2007) and within the nurse practice areas within hospitals (Foley et al., 2012, in press;

Spence Laschinger & Grau, 2012; Guidroz et al., 2010; Leiter et al., 2010; Oore et al.,

2010; Smith et al., 2010; Thomas, 2010; Spence Laschinger et al., 2009; Spence

Laschinger et al., 2009; Felblinger, 2008; Hutton & Gates, 2008), there is no data

available to suggest this problem exists for nurse educators within hospital systems. One

would reason that if uncivil behaviors are traits that affect nursing students and faculty,

that there could also be uncivil behaviors within nursing education in hospital

environments.


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Problem Statement

Incivility in nursing education within the hospital environment is a concern that

needs to be explored in an effort to establish normative and practiced behaviors in the

nurse educator-staff nurse relationship. Uncivil behaviors are disruptive to the teaching-

learning environment. These behaviors may increase stressor responses in the nurse

educator-staff nurse relationship. Stress can lead to job dissatisfaction and loss of nurse

educators. There is a gap in the knowledge base of expected and practiced behaviors of

staff nurses and hospital nursing education.

Identification of the dynamics of the nurse educator-staff nurse relationship in

regards to uncivil behaviors needs to be examined. Once uncivil behaviors are identified,

further studies will create a base of knowledge and lead to change that can increase

civility and job satisfaction for nurse educators. The goal is to create the best possible

teaching-learning environment with civility a positive factor in removing barriers to

education. This may be accomplished with further research bridging the gaps in

knowledge to nursing education within the hospital environment.

Significance of the Research

Incivility in academic nursing education has been defined, studied, and the data

has contributed to a growing base of knowledge. These studies have established the need

for policies and strategies to prevent and control uncivil behaviors in the academic

nursing education environment. Workplace incivility has also warranted investigation in

an effort to define and develop plans to decrease job burnout and increase job satisfaction

rates. Due to the growing base of knowledge of documented incivility in these two areas


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of a nurse’s career, the effects of incivility in nursing education in the hospital practice

area justify further exploration.

Workplace incivility is known to encompass several different rude behaviors but

is theoretically different from physical aggression and violence as there is no intention to

cause physical harm (Guidroz et al., 2010). Rude acts of incivility in the workplace

include behaviors such as purposefully ignoring a coworker, raising your voice or yelling

at someone, interrupting a coworker who is speaking, spreading rumors, and taking credit

for work that someone else has done (Guidroz et al., 2010). Guidroz et al. (2010) defined

workplace incivility as being different than bullying as bullying involves a power

differential between the aggressor and the victim. However, there is documentation of

bullying in the workplace that affects new nurses and their relationships with preceptors,

experienced nurses, and management (Thomas, 2010; Felblinger, 2008). These studies

combine the intentions of rude behaviors and bullying in their descriptions of uncivil

behaviors as a result of power struggles. Dr. Cynthia Thomas, Assistant Professor at Ball

State University in the School of Nursing, identified incivility in nursing practice by

placing these behaviors in two separate groups which are direct violent behaviors and

indirect violent behaviors (Thomas, 2010). Indirect violence includes behaviors such as

employing coercive techniques, failing to listen to a coworker, gossiping, inflicting the

silent treatment, excluding someone from activities or conversations,

passive/undermining behaviors, refusing to acknowledge someone, rolling the eyes,

sabotaging someone, shrugging the shoulders, sighing or groaning, tapping fingers while

someone is talking, turning away or avoiding a coworker, using someone as a scapegoat,

and withholding important information (Thomas, 2010). Direct violence includes more


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aggressive behaviors such as belittling statements, confrontational statements, correcting

someone in front of others, creating conflict, cruel acts, disrespectful comments,

controlling acts, hostile behavior, sarcasm, pressuring or coercing a person, roughness or

striking a person, rude statements, sexual harassment, throwing or slamming objects,

uncooperative behavior, arguing, and yelling at someone (Thomas, 2010).

One would assume if these behaviors are prevalent in the academic environment

and practice environment of nursing that they are also present in educational practices

involving the same individuals. These principles need to be investigated to fill the gap

between empirical and normative knowledge, and expectations in nursing education.

Purpose

The purpose of this study was to examine the occurrence of incivility in the nurse

educator-staff nurse relationship in hospital environments. Hospital nurse educators’

perceptions of the biggest stressors for nurses during educational experiences, identifying

uncivil traits as seen by nurse educators, and identifying the perceived role of nursing

leadership in addressing incivility in the workplace.

Research Question

How does incivility in the hospital environment affect the nurse educator-staff

nurse relationship? This question was researched from the nurse educator’s perspective.

Theoretical or Conceptual Framework

Dr. Cynthia Clark, a nursing professor at Boise State University, developed the

Conceptual model for fostering civility in nursing education in 2008. The model

illustrated the stress levels of nursing faculty and students and how the roles of these

individuals contribute to or intensify uncivil behaviors in the faculty-student relationship


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(Clark & Springer, 2010). The faculty-student relationship is stressed by the power

differences between their roles (Clark & Carnosso, 2008). The diagram demonstrated

when high levels of faculty stress and high levels of student stress interacted that role

stresses may influence and interfere with conflict (Clark & Springer, 2010). Student

entitlement and faculty superiority, demanding workloads, juggling multiple tasks and

competing demands, technology and information overload, and lacking knowledge and

skills to manage conflict are stressors for the faculty-student relationship (Clark &

Springer, 2010). The earlier diagrams showed the “dance of civility” in comparison to

the “dance of incivility.” The diagram updated by Dr. Clark in 2010 changed these

captions to the cultures of civility and incivility (Clark & Davis Kenaley, 2011). The

earlier model showed that incivility was interactional and reciprocal in nature and had the

potential to escalate to destructive behaviors (Clark & Carnosso, 2008). Academic

incivility was defined as rude, discourteous speech, or behaviors that disrupt the teaching-

learning environment (Clark, 2008a). The 2010 changes in the model, Conceptual model

for fostering civility in nursing education, paved the way for the development of a dual

conceptual model. The dual model, Faculty empowerment of students to foster civility,

compliments the first model and focuses on ways to foster civility in nursing education

(Clark & Davis Kenaley, 2011).

The 2010 Conceptual model for fostering civility in nursing education was

adapted by Dr. Clark in 2011 when working on a research study with a doctoral

candidate, Lynda Olender (Figure 1). This most recent adaption to the model

incorporates nursing practice with nursing education (Clark, Olender, Cardoni, & Kenski,


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2011). The intention of the modified concept by Dr. Clark and Ms. Olender was to

encourage civility in nursing practice and nursing education for nursing leaders.

The researcher for the current study has adapted the model and framework

developed in 2010 by Dr. Clark and Ms. Olender to the nurse educator-staff nurse

relationship. Permission was granted by Dr. Clark to use the Conceptual model for

fostering civility in nursing education (adapted for nursing practice) in this research

study.

▀

Figure 1. This model shows elevated levels of stress combined with stressors in the educator-

student relationship contribute to incivility in nursing education. Model by Clark, C. M.,

Olender, L., Cardoni, C., & Kenski, D. (2011). Fostering civility in nursing education and practice:

Nurse leader perspectives. Journal of Nursing Administration, 41(7/8), 324-330.

Figure 1. Conceptual Model For Fostering Civility In Nursing Education (Adapted

2010)


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Workplace incivility includes rude behaviors such as ignoring someone, yelling,

interrupting someone who is speaking, spreading rumors, and taking credit for work that

someone else has done (Guidroz et al., 2010). These behaviors are different from

physical aggression and violence as there is no intention for physical harm (Guidroz et

al., 2010). Many of the same stressors affected workplace incivility in the same manner

as academic nursing education incivility. These stressors were demanding workloads,

juggling multiple tasks and competing demands, technology, and information overload

(Clark & Davis Kenaley, 2011). The health care workplace environment may be at

higher risk for incivility due to stressful conditions of constant change, heavy workload,

large number of staff, and diversity of interactions (Hunt & Marini, 2012). Newly

graduated nurses are placed on orientation with a preceptor while learning to function as

a nurse in their new hospital unit. The preceptor-new staff nurse relationship can bring

about many of the same emotional feelings for the new nurse as experienced in the

academic faculty-student relationship (Foley et al., 2012, in press).

The nurse educator-staff nurse relationship may be influenced by preconceived

ideas and experiences from previous and existing roles. Each nurse started out in the

academic nursing education environment, then moved into orientation and preceptorship

in the hospital environment, and then finally discovered that the education of all nurses

must be maintained and kept current with continuing education courses and hospital in-

services. In essence, nurses are students throughout their nursing careers whether they

decide to pursue further degrees or maintain their current status. The stressors that affect

workplace nurses are present while the nurse maintains continuing education while

continuing to work in the hospital environment.


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Definition of Terms

Academic Incivility is disruptive behavior that substantially or repeatedly

interferes with teaching and learning. In-class disruptions include:

Rude comments, put-downs, slurs, and rumors (in person and in cyberspace)

Cell phones, texting, and computer misuse

Interruptions and side conversations

Late arrivals and leaving early

Sleeping in class

Aggressive, intimidating, bullying behavior

Anger or excuses for poor performance

Cheating and other forms of academic dishonesty

Displaying a sense of entitlement

Blaming others for their shortcomings

Shunning or marginalizing other students

(Clark & Springer, 2010).

Civility is characterized by an authentic respect for others when expressing

disagreement, disparity, or controversy. It involves time, presence, a willingness to

engage in serious conversation, and a sincere intention to seek common ground (Clark &

Carnosso, 2008).

Faculty is the term used for academic nurse educators in colleges and universities.

Other interchangeable terms for faculty are nursing instructor or professor.

Nurse Educator is an individual responsible for teaching nurses employed in a

hospital setting courses specific to their patient care population and/or general hospital


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nursing education. The nurse educator has graduated from a school of nursing and is an

experienced clinical nurse.

Preceptorship is the period of training nurses undergo when starting their first

position as a registered nurse in a hospital environment. The graduate nurse must have

passed state boards before beginning employment and starting the training period on the

nursing unit. The experienced nurse responsible for introducing the new nurse to the

specific nursing unit during the orientation and training period is called the preceptor.

Staff Nurse is the term used to identify a registered nurse who is working in a

clinical setting. The staff nurses in this study are employed in a hospital setting.

Student for the purpose of this paper is a person studying to be a nurse in a school

of nursing.

Workplace is the term used to describe the place where nurses work in clinical

settings. For this study the workplace implies the hospital environment.

Workplace Incivility is rude behaviors such as ignoring someone, yelling,

interrupting someone who is speaking, spreading rumors, and taking credit for work that

someone else has done (Guidroz et al., 2010). These behaviors are different from

physical aggression and violence as there is no intention for physical harm. These

behaviors are considered to be low intensity uncivil acts (Guidroz et al., 2010).

Summary

Incivility exists in academic nursing education for nurse educators and nursing

students. Incivility exists for clinical nurses in the practice areas of the hospital.

Incivility is on the rise as people become more involved with technological advances and

assume heavier workloads due to the current downturn in the national economy. These


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CHAPTER II

Literature Review

The purpose of this review was to explore the current literature available for

incivility in nursing education. There was a good base of research regarding incivility in

academic nursing education; however, information regarding incivility in nursing

education within the hospital environment was nonexistent. The focus of this study is

incivility in nursing education within the hospital environment and especially the effects

of incivility in regard to the nurse educator-staff nurse relationship. In an attempt to

better understand the environment of the nurse educator in the hospital environment, the

researcher also reviewed literature involving incivility in the nursing workplace. The

review of incivility in the nursing workplace provided a broader understanding of how

incivility affects nurses in the hospital environment.

Incivility is a term that is used in a broad sense throughout the available literature.

This term was applied to rude behaviors and language; however, it was also applied to

bullying and violent behaviors in some of the literature. It is true that bullying and

violent behaviors are uncivil acts and fall under the description of incivility, but these

behaviors should be considered on an elevated level. Some of the literature distinguished

the difference as non-violent and violent uncivil behaviors. Some of the literature

differentiated the levels of uncivil behaviors as low intensity and high intensity incivility.

One theme that carried throughout the literature review in regards to incivility in

academic nursing education and the nursing workplace environment was that low

intensity incivility is reciprocal in nature and had potential to escalate to high intensity

incivility if not appropriately managed.


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Review of Literature

The literature review was conducted through the online databases of EBSCO and

the Cumulative Index for Medical, Health, and Nursing [CINAHL] through the

University’s electronic resources. The keywords for the review were incivility, civility,

bullying, nursing education, nursing practice, continuing education, preceptorship, and

workplace incivility. Review of the literature revealed incivility was identified as an area

of concern in academic nursing education and nursing practice in the workplace.

There were ample articles available on incivility in academic nursing education

and nursing workplace incivility. In searching for incivility in nursing education in the

hospital environment the databases were extremely limited. The only applicable articles

in this area pertained to nurses as preceptors and generational differences with newly

graduated nurses in the nurse practice area and experienced nurses in the workplace.

There was one study f rom the hospital administrator and management’s perspective;

however, data from the hospital nurse educator ’s perspective was nonexistent.

There is one common thread in all of the literature reviewed. Heightened levels

of stress intensified the uncivil behaviors for nursing students, faculty, and nurses in the

workplace. Intensive care units were noted to be more affected by incivility in the

workplace environment.

Incivility in Academic Nursing Education

Incivility in academic nursing education is disturbing. Academic incivility is

disruptive to the teaching-learning environment. Uncivil behaviors may harm the

faculty-student relationship (Clark & Springer, 2010). The literature supports defining

uncivil behaviors and development of strategies and policies. The intention of these


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policies and strategies is prevention of incivility and establishing methods to control

students with uncivil behaviors so that the classroom environment does not suffer

negatively from incidences of incivility. Building a culture of civility requires faculty

and students to work together to promote productive and reciprocal commitment (Clark

& Davis Kenaley, 2011; Clark & Carnosso, 2008).

Incivility on American college campuses is a serious and growing concern

(Robertson, 2012; Clark & Springer, 2007a, 2007b). Incivility can escalate to violence as

has become evident in the violent shootings at the University of Arizona in 2002,

Virginia Tech in 2007, and Northern Illinois University in 2008 (Clark et al., 2009). The

Incivility in Nursing Education (INE) Survey was created by nursing educators in an

effort to define uncivil behaviors in students and faculty. The INE tool can assist schools

of nursing to discover areas of conflict between faculty and students in an effort to

stimulate strategies for interventions and prevention of incivility (Clark et al., 2009).

Nursing student stressors. Student stressors are not limited to the academic

environment. Juggling multiple roles and meeting competing demands of work, school,

and family responsibilities create stress for students. Many students are under large

financial pressures. Some students have issues with time management. Others may

perceive there is a lack of faculty support and faculty incivility. In addition, a small

percentage of the student population may also suffer mental health problems and personal

issues (Clark & Springer, 2010).

The literature supports an increased incidence of incivility in nursing education

and has been linked to a combination of coexisting problems (Robertson, 2012). The

stressors for students may be manageable when occurring individually. Student nurses


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suffer the increasing effect of multiple aggravating factors. Meeting the demands of

nursing school while attempting to work full or part time exposes students to increased

levels of stress (Robertson, 2012). These behaviors are undesirable and lead to a

weakened learning environment, poor workforce behaviors, and violence (Gallo, 2012).

Low intensity behaviors of incivility can escalate into violence and undermine the

teaching-learning environment for faculty and students (Clark, 2009).

Uncivil behaviors demonstrated by nursing students. Student uncivil

behaviors often create classroom disruptions. These rude behaviors can be rude

comments, put-downs, slurs, and rumors. The use of cell phones for texting and viewing

emails is disruptive. Students may misuse computers, cause interruptions, and participate

in side conversations. Late arrivals to class and leaving early are interruptions to

classroom lectures. Other behaviors by students that are identified as rude and uncivil are

sleeping in class, being aggressive or intimidating, and displaying bullying behaviors.

Some students become angry or make excuses for poor performances. Cheating and

other forms of academic dishonesty are uncivil behaviors. Students may display a sense

of entitlement or blame others for their shortcomings. Shunning or marginalizing other

students is rude and considered uncivil behavior (Clark & Springer, 2010, 2007a).

Effects of student incivility. The literature suggests academic incivility is a

moderate to severe problem. The level of student incivility has increased in nursing

education to become a significant problem (Clark, 2008a, 2008b). These students are

emotionally and physiologically affected (Clark, 2008b). Uncivil faculty behaviors

contributed to student anger thus intensifying the reciprocal nature of incivility in the

faculty-student relationship (Clark, 2008a). Students in the clinical setting who acted


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disrespectfully to faculty, patients, staff, or peers were identified as behaving in an

unprofessional manner (Altmiller, 2012). Nursing students defined and perceived uncivil

behaviors almost the same as faculty; however, nursing students felt incivility was

justified when they were the recipient of an uncivil act (Altmiller, 2012).

Another problem associated with incivility in nursing education is the national

nursing shortage. Nursing faculty may suffer physical and emotional effects when

dealing with student incivility. The effects of incivility may lead to the loss of academic

nursing educators at a time when the nation cannot afford to lose faculty (Luparell, 2007).

Uncivil behaviors adversely affect the educational environment. Uncivil acts adversely

affect faculty job satisfaction and morale (Luparell, 2007).

Strategies to offset incivility. It is important for students who have experienced

incivility from a nursing instructor to be associated with a mentor so that the faculty-

student relationship may be mended and the student will remain in school (Clark, 2008b).

Students need to be prepared during nursing school to identify and deal with incivility.

Problem-based scenarios presented during nursing school can offer students the

opportunity to develop skills to effectively handle interactions involving uncivil acts

(Clark, Ahten, & Macy, 2013). These skills may be used during academic nursing

education and in the workplace after completion of school. Nursing students reported the

experience of participating in problem-based scenarios increased their knowledge and

awareness in how frequently uncivil acts occur in nursing practice. Students described

participation in the scenarios as an opportunity to learn behaviors and actions that counter

incivility (Clark et al., 2013).


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Faculty stressors. Instructors experience many demands in academic settings.

There are multiple work demands, heavy workload, and workload inequity. Nursing

instructors must maintain their clinical competence. Advancement issues can increase

faculty stress. Lack of faculty and administrative support are disconcerting stresses for

many nursing instructors. Many academic facilities often undergo changes in faculty

demographics such as educators changing their status to part-time, changes in adjunct

faculty, and faculty turn-over. Personal stressors and poor coping abilities may add to

faculty stress. Problematic students are a serious concern for nursing instructors.

Incivility can harm the faculty-student relationship (Luparell, 2007). Incidence of uncivil

student behaviors to faculty are reported to be advancing in nature in higher education to

the point of students being verbally abusive, yelling at faculty members, and engaging in

physical contact (Clark & Springer, 2007b). These behaviors can negatively impact the

faculty member and affect the nursing instructor’s job satisfaction and morale. Nursing

educators are also affected by low salaries and financial pressures (Luparell, 2007).

Faculty-to-faculty incivility may also be a stress for many educators (Clark & Springer,

2010).

Uncivil behaviors demonstrated by faculty. Uncivil faculty behaviors toward

students included being rude, belittling someone, demeaning behaviors toward students,

making unreasonable demands on students, and not appreciating student contributions.

Uncivil faculty behaviors toward other faculty and administrators were reported to

include overt rude and disruptive behaviors in person and in cyberspace. These uncivil

behaviors included hazing, bullying and overt acts of intimidation, unwelcome and

unsupportive put-downs, setting others up to fail, exerting superiority and rank over


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others which were an abuse of power , and not performing one’s share of the workload.

Other uncivil faculty behaviors toward faculty and administrators can be avoidant

isolative and exclusionary behaviors. These may include marginalizing and excluding

others, refusing to listen or openly communicate, gossiping, passive-aggressive

behaviors, rude nonverbal behaviors and gestures, being resistant to change, being

unyielding, unwilling to negotiate, and engaging in clandestine meetings behind closed

doors (Clark & Springer, 2010).

Effects of faculty incivility. When nursing students encounter bullying

behaviors from nursing instructors they are left with feelings of powerlessness and

frustration. These feelings create a hostile environment (Cooper et al., 2011). Many of

the uncivil behaviors exhibited by nursing instructors were interpreted by students as

bullying. The literature shows that uncivil behavior by faculty to students is judged as a

higher intensity level of incivility (Lasiter et al., 2012; Cooper et al., 2011).

Strategies to offset incivility. When under stress, nurse educators need to

intentionally prevent the urge to fight or flee. One strategy is to mend and tend to

professional relationships (Heinrich, 2010). Nurse educators should cultivate civil

relationships with colleagues, faculty, and students (Heinrich, 2010). The intentional

method of cultivating relationships serves as a good strategy against stress that may

stimulate uncivil behaviors. Faculty members are in key positions to encourage civility

within the academic setting. Positive faculty-student relationships are a fundamental

component of constructive teaching-learning environments (Clark, 2009). Faculty may

promote positive relations through professional role modeling, purposeful planning, and

application of collaborative learning strategies (Clark, 2009). Nursing instructors should


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intentionally communicate with students in a manner that is respectful and helpful in the

students’ professional growth (Suplee, Lachman, Siebert, & Anselmi, 2008).

Incivility in the Nursing Practice Workplace

The literature supports that many workplace environments are affected by

incivility. However, the evidence shows that incivility is more prevalent in the hospital

environment. This is especially true for intensive care units where job stressors are

considered to be higher in intensity (Oore et al., 2010). In the hospital setting, nurses

experience uncivil acts from physicians, supervisors, co-workers, and patients. The

additional stress as a result of uncivil acts may lead to job burnout and job dissatisfaction

(Guidroz et al., 2010).

The Nursing Incivility Scale (NIS) is a tool developed in an effort to define

incivility in the hospital setting. The NIS has assisted hospital administrators in defining

and addressing issues in specific units where concerns have been identified. The goal is

to create a civil and satisfactory workplace environment for nurses (Guidroz et al., 2010).

The assessment of incivility in the health care setting for nurses can provide essential data

for hospital administrators to develop and implement interventions to improve

relationships among hospital employees. Hospital administrators can increase nurse

retentions rates and job satisfaction scores by addressing these issues (Guidroz et al.,

2010).

Nurse leaders in the hospital setting should evaluate the working relationship

between nursing education and nursing practice areas (Clark et al., 2011). Nurse leaders

can be proactive in fostering civility between nursing education and practice (Clark et al.,

2011).


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Nursing practice. Hospital environments may be predisposed to incivility due to

demanding work conditions and challenges, constant changes, large numbers of staff, and

a variety of interactions with co-workers, supervisors, physicians, patients, and patient’s

extended families (Hunt & Marini, 2012). Workplace stressors are job characteristics

that create tension and increase stress for employees. The two major stressors in the

nursing practice environment are workload and job control (Oore et al., 2010). Incivility

affects the stressor-strain relationship. Incivility can spread throughout a work unit (Oore

et al., 2010). Stress as a result of uncivil acts may lead to job burnout and job

dissatisfaction (Guidroz et al., 2010). Stressors increased nurses’ stress levels and

contributed to the occurrence of incivility (Spence Laschinger et al., 2009).

Uncivil behaviors in the hospital workplace are defined as low intensity behaviors

that violate workplace customs of common respect. Uncivil behaviors are rude acts that

demonstrate a lack of respect for others (Spence Laschinger et al., 2009). Workplace

incivility can impact patient care and result in risks to patients (Hutton & Gates, 2008).

Incivility is a precursor to bullying and leads to higher intensity uncivil acts (Felblinger,

2008). Incivility in the nurse practice area when student nurses are on the unit for a

clinical day may have a negative impact on student learning and performance (Hunt &

Marini, 2012).

Evidence has shown hospital administrators that workplace incivility has negative

affects on productivity (Hutton & Gates, 2008). Hospital workplace incivility results in

financial losses and impacts the health of employees (Hutton & Gates, 2008). Promoting

a workplace environment where nurses feel safe from intimidation contributes to

increased productivity (Felblinger, 2008).


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Newly graduated nurses. The effects of uncivil behaviors on newly graduated

nurses can lead to decreased retention during the first year of professional practice

(Thomas, 2010). New nurses experience many uncivil acts such as: belittling statements,

confrontational statements, being corrected in front of others, becoming part of a conflict,

cruel acts, deflating statements, control or prevention of an act, hostile behavior,

insensitive/sarcastic comments, interruptions to conversations, intolerant behavior, power

play/bulling behavior, pressure to act in a particular manner, pressuring or coercing a

person, roughness like striking a person, rude statements, sexual harassment,

throwing/slamming objects, uncooperative behavior, arguing, yelling, whispering, and/or

whining (Thomas, 2010). Experienced nurses are likely to have high expectations of new

nurses. Veteran nurses assume new nurses are capable of functioning at a much higher

level of practice (Thomas, 2010).

The nurse educator is vital to the implementation of strategies to ensure a culture

of safety for newly graduated nurses (Thomas, 2010). Nurse educators need to be aware

of current research on violent behaviors within hospital environments. New employee

orientation is an ideal time to introduce hospital policies and strategies addressing

hostility. Newly hired nurses in their first professional job need to know strategies to

confront, defuse, and eliminate uncivil and violent acts (Thomas, 2010). Nurse Managers

need to support their newly hired graduate nurses and endorse education measures

presented by the nurse educator. The nurse manager is responsible for the conditions in

the nursing work environment. The nursing environment should be welcoming and

supportive of newly graduated nurses. Supportive workplace environments will ensure

new nurses will want to remain in the profession (Spence Laschinger & Grau, 2012).


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Hospital administrators must provide support for newly hired graduate nurses by

providing policies and strategies related to incivility and violence in the workplace.

Newly graduated nurses need increased knowledge about organizational structure and

psychological empowerment to handle workplace incivility. When this knowledge is

shared, new nurses are more committed to their hospital and have increased job loyalty

and decreased job turnover intentions (Smith et al., 2010; Spence Laschinger et al.,

2009). It is important for nursing units to encourage high-quality mutually respectful

working relationships to make certain that new graduates remain engaged in their work

(Spence Laschinger et al., 2009).

Generational differences in the workplace. Models of stress and burnout have

identified social support among coworkers as a buffer against stress. Collegial

relationships are a resource to assist coping with incivility in the workplace (Leiter et al.,

2010). Without these comforting relationships, incivility in the workplace can lead to

distress and burnout (Leiter et al., 2010). Generational differences in the workplace may

influence collegial relationships. Mature nurses in the workplace are referred to in the

literature as Baby Boomers. Baby Boomer nurses were born between 1943 and 1960.

Generation X nurses were born between 1961 and 1981. Millennial nurses were born

after 1981. The largest group in the current workforce is Generation X nurses (Leiter et

al., 2010). The Millennial nurses started entering the workforce in 2002. Generation X

nurses experience more incidence of incivility from coworkers and nursing management

(Leiter et al., 2010). Generational differences require nursing management to be aware of

incivility in the workplace and encourage supportive working relationships (Leiter et al.,

2010). Hospital administrators have an obligation to support initiatives that have the


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potential to enhance recruitment, socialization, and retention of nurses (Leiter et al.,

2010).

Preceptorship is a nurse/student-preceptor relationship for unit specific training

that often matches nurses together from different generations. Senior nursing students

are placed with an experienced nurse in the role of preceptor prior to graduation in a

hospital unit. Sometimes this arrangement paves the way for the student to be potentially

hired as a nurse/employee after graduation and becoming a registered nurse. Newly hired

graduate nurses are placed in a preceptorship relationship during the orientation process

in hospital nursing units. Different generations have different perceptions of their

workplace environment (Foley et al., 2012, in press). Generational differences may lead

to misunderstandings, conflict, and perceptions of uncivil behaviors. Nurses in the

preceptorship relationship reported many preceptors were rude and uncivil (Foley et al.,

2012, in press). The nurses working with preceptors perceived feelings of being

challenged and encountering conflict. Nurse educators, nurse managers, and hospital

administrators have the potential to develop generational understanding and promote a

more cohesive culture in the nursing workplace (Foley et al., 2012, in press).

Summary

There is incivility in academic nursing education and in nursing practice.

Incivility in academic nursing education is disruptive to the teaching-learning

environment and negatively impacts the faculty-student relationship. Incivility in nursing

practice is harmful to employee relationships and can negatively impact job performance

and job satisfaction. Workplace incivility may negatively impact patient care and unit


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productivity. Generational differences may affect employee relationships and warrants

further investigation.

Research is not readily available in the literature regarding the nurse educator-

staff nurse relationship. There is a gap in the literature regarding nursing education

within the nurse practice area. In a broad sense, one would expect there is a strong

possibility that incivility in the hospital environment can negatively affect nursing

education and be harmful to the nurse educator-staff nurse relationship.


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CHAPTER III

Methodology

Previous research data established incivility as a barrier to education in academic

nursing education. Nursing workplace incivility has also been well documented through

research. The purpose of this research study was to identify if incivility affects the

teaching-learning relationship of nurse educators and practicing nurses within hospital

systems. This study reflected the perceptions of research participants from a large

metropolitan hospital in the southeastern United States.

Implementation

A qualitative approach was chosen for this study as there is a gap in the literature

in regards to incivility in nursing education within the hospital environment. Qualitative

research is a pathway to knowledge (Munhall, 2012). There is knowledge that incivility

exists in academic nursing education. There is knowledge that incivility exists in nursing

practice. To better understand incivility and its influence on the hospital nurse educator-

staff nurse relationship this research study utilized a qualitative research method and a

small focus group interview.

The group interview was designed to obtain the participants’ perceptions in a

focused area in a setting that was nonthreatening (Burns & Grove, 2009). The dynamics

of the group interview assisted the nurse educators to express and clarify their

perceptions (Burns & Grove, 2009). The data was collected through an interview with

six nurse educators (n=6). A survey questionnaire with five open ended questions was

utilized to acquire the perceptions of hospital educators’ experiences in the nurse

educator-staff nurse relationship.


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The questionnaire developed for the hospital nurse educators was adapted from

open ended questions developed by Dr. Cynthia Clark for research of incivility in

academic nursing education (Clark & Springer, 2010). These questions asked the nurse

educators to describe their perceptions of stressors and uncivil behaviors in hospital

nursing education. Appendix A is the questionnaire adapted for hospital nurse educators.

The study questions presented to the nurse educators were:

What do you perceive to be the biggest stressors for nurses during hospital

education courses?

What uncivil behaviors do you see nurses displaying during hospital education

courses?

What do you perceive to be the biggest stressors for nurse educators?

What uncivil behaviors do you see nurse educators displaying?

What is the role of nursing leadership in addressing incivility?

Qualitative descriptive studies are a good design for research subjects that are not

previously studied (Thomas & Magilvy, 2011). For the purpose of this research a

qualitative approach was used to acquire knowledge not personally experienced by the

researcher.

Setting

The setting for this study is a large acute care hospital located in the southeastern

United States. The facility offered an educational department that was separate from the

nursing units; however, the educators were assigned to areas in which they had prior

nursing experience.


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Sample

The participants were acquired through snowball sampling. The target sample of

six nurse educators was recruited by asking early volunteers to refer other study

participants who were nurse educators in the facility. A descriptive survey/interview

design was used to explor e the nurse educators’ perceptions and to determine if incivility

negatively impacts nursing education within the hospital environment and harms the

nurse educator-staff nurse relationship. Qualitative content analysis was used to

breakdown the content of the narrative data to identify prominent themes and patterns

among the themes. The interpretations by the researcher of the answers were the

commonalities of the perceptions of the nurse educators in the hospital setting (Smythe,

2012). This process of analysis substantiates the data collected and reported truly

portrays the perceptions of the participants.

Design

A list of the facility’s nurse educators was provided for study recruitment

purposes. Participants were selected using snowball sampling techniques. Early

volunteers in the study referred other nurse educators until the target focus group of six

participants was reached. A cover letter/debriefing statement was presented to the nurse

educators by the researcher. Questions regarding the study were provided prior to the

audio-taped interview. Informed consent was completed. The cover letter and informed

consent provided directions for participants to notify the researcher for further questions

or clarification and ways to exit the study. Telephone or email cancellation and failure to

show up for the interview time and location were considered the participants way of

quitting the study. Two nurse educators emailed regrets the day before the interview.


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Two additional educators were recruited. A total of six nurse educators were present for

the focus group interview.

Protection of Human Subjects

Nurse researchers are held accountable for ethical considerations and fair

treatment of research subjects. The nurse researcher must acknowledge therapeutic

obligations to the participants of the study (Munhall, 2012). The researcher must

maintain vigilant observation of these goals in the pursuit of ethical treatment of research

subjects in an effort to prevent harm to study participants while striving to reach the

research objective (Munhall, 2012).

Permission to conduct this study was obtained from the Institutional Review

Board (IRB) of Gardner-Webb University. The members of the IRB placed careful

consideration on the research project in reference to ethical treatment of the participants

and the outcomes of the study (Burns & Grove, 2009). There were no treatments

involved. The participants’ confidentiality was maintained as names were not disclosed.

The name of the hospital/facility was not reported in the study paper. The facility was

described as a large metropolitan hospital in the southeastern United States. There were

no anticipated effects of the study. There was a slight possibility that mild anxiety might

occur related to incivility and audio-taped interviews; however, the study participants

could decline to continue the interview at any point.

Participants of this study were given opportunities to ask questions. They were

provided telephone and email access to the researcher. The study subjects were given

informed consent (Appendix B) and provided a cover letter with a debriefing statement

(Appendix C). The informed consent and cover letter both provided descriptions of


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declining to participate and ways to quit the study at any point. These measures were

taken in an effort to protect the study participants.

Instruments

The survey questionnaire used during the interviews for this study was adapted

from an existing 5-item survey. The first survey was developed by Drs. Cynthia Clark

and Pamela Springer while researching the academic nurse leaders’ role in fostering a

culture of civility in nursing education (Clark & Springer, 2010). These questions were

adapted to work with nurse educators within hospital environments (Appendix A).

Permission was granted by Dr. Clark (Appendix D) for the use of the model and for

adaptation of the survey questions for nurse educators in practice. Dr. Clark has

researched incivility in academic nursing education in several studies over the past

decade. Dr. Clark is a professor at Boise State University in the school of nursing. She is

a leader in fostering civility and establishing study results that may influence

administrators in schools of nursing throughout the United States. Dr. Clark is a

consultant and may be contacted for help with fostering civility in academic institutions.

To ensure validity of the questionnaire/interview, the survey was presented to the

participants in person at the same time as the cover letter and consent form. The

questions were answered during an audio-taped interview with the researcher. The

interviews were held in a neutral location chosen by the participants and limited to one

hour by the researcher. The researcher guided the interviews by the questionnaire.

Two content experts were used in this descriptive interpretive study. The themes

that developed from the narrative responses were evaluated by Expert A and Expert B


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until the researcher was confident that the analysis was a valid description of the

comments.

Data Collection

The data was collected by the researcher during an audio-taped interview. The

researcher was assisted by a professional transcriptionist who is familiar with qualitative

interviews. Qualitative content analysis was utilized to breakdown the content of the

narrative data to identify prominent themes and patterns among the themes.

Data Analysis

The narrative responses were analyzed by the researcher for recurring responses

and organized into themes. Lincoln and Guba’s Framework for developing

trustworthiness of the inquiry was employed to achieve credibility, dependability,

confirmability, and transferability of the study (Munhall, 2012). Experts were used to

verify interpretation of responses. Credibility was established as the resulting themes and

subthemes were representative of the group (Thomas & Magilvy, 2011).

Summary

The researcher provided informed consent, a cover letter with debriefing

statements, and the survey questions for the study participants. Within the contents of the

consent form and cover letter were contact information to reach the researcher for

questions and as a method for quitting the study. The researcher did not use the names of

the participants or the name of the hospital during data collection. The city and state

were also withheld to assist in maintaining confidentiality in the Thesis paper. The

participants were asked not to reveal any identifying information during the interview.


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A qualitative methodology was used to determine if incivility affects the nurse

educator-staff nurse relationship. The results are the perceptions of the nurse educators

who participated in the study.


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CHAPTER IV

Results

The purpose of this research study was to evaluate the likelihood of incivility in

nursing education within the hospital setting. The research study was performed with a

small focus group in a single hospital setting.

The title chosen for this project was “Incivility in the Hospital Environment: The

Nurse Educator-Staff Nurse Relationship.” This title was selected in an effort to

differentiate and emphasize the research study group as nurse educators whose students

were practicing nurses in the hospital setting. The literature review for this research

study found numerous research articles supporting the occurrence of incivility in

academic nursing education and nursing practice. Incivility in nursing education within

the hospital environment is a concern that has not been explored and needs to be

researched in an effort to establish normative and practiced behaviors in the nurse

educator-staff nurse relationship. Stressful workplace interactions and relationships can

lead to job dissatisfaction and the loss of nurse educators. The aim of this research study

was to evaluate the occurrence of incivility and establish a beginning baseline of

incivility in nursing education. The primary investigator’s intention was to discover

information that may be added to the existing knowledge base of expected and practiced

behaviors for staff nurses and hospital nursing education.

Sample Characteristics

A focus group interview was the methodology utilized for this qualitative study.

The data was collected from six nurse educators (n=6) employed in one hospital setting.

Two of the initially recruited nurse educators cancelled the day before the group


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interview. Two additional educators were recruited prior to the interview. The hospital

for this study was a large acute care facility located in the southeastern United States.

The interview was led by the primary investigator with a predetermined questionnaire.

The questions were adapted from Dr. Cynthia Clark’s qualitative questionnaire for

academic nursing education to fit nurse educators in practice (Clark & Springer, 2010).

The interview was audio-taped and a transcript was produced by a professional

transcriptionist who was familiar with qualitative interviews. Qualitative content analysis

was utilized to breakdown the content of the narrative data to identify prominent themes

and patterns among the themes. Lincoln and Guba’s Framework for developing

trustworthiness of the inquiry was utilized to achieve credibility, dependability,

conformability and transferability of the study (Thomas & Magilvy, 2011; Shenton,

2004; Whittemore, Chase, & Mandle, 2001). The unit of analysis was the educator’s

whole response. Qualitative content analyses were focused on the nurse educators’

subjective experiences and opinions, and no attempt was made to attribute conceptual or

abstract frameworks to these responses. To maintain rigor and trustworthiness of the

research process, the transcript generated from the focus group was read thoroughly three

times by the primary investigator and the qualitative methodology adviser. An

independent qualitative methodologist who is an expert in qualitative research was also

consulted to peer review the themes and subthemes. Peer review assisted the opportunity

to reveal primary investigator bias and help confirm, disprove, or extend emerging

themes. Findings are described using excerpts from the educators’ responses; all names

have been replaced with pseudonyms. Transferability was supported by discussion and

sharing findings with content experts and by returning to the literature.


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The demographics of the study participants were diverse in the demographic areas

of age and years of experience as a registered nurse. The areas of demographic data that

were similar were gender, nursing degree achieved, and years working as an educator.

The six nurse educators ranged in age from 24 to 57 years. All six participants were

female. The educational level or degrees achieved by the participants were five

Bachelor’s degrees and one Master’s degree. The educators’ years of experience

practicing as a registered nurse ranged from four years of experience and progressed to

34 years. The number of years the nurse educators worked as a nurse educator ranged

from three months to five years.

Table 1

Demographic Characteristics of Nurse Educators

Category N (%)

Gender Male 0 0%

Female 6 100%

Nursing Degree Preparation BSN 5 83%MSN 1 17%

Doctoral 0 0%

Age Group (years) 20-29 1 17%30-39 2 33%

40-49 2 33%

50-59 1 17%

Nurse Educator (years of practice) 5 years 1 17%

RN (years of experience) 1-10 1 17%

11-20 4 66%

21-30 0 0%31-40 1 17%


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Major Findings

The experts found five themes and three subthemes that were prominent through

qualitative content analysis of the transcribed narrative produced from the audio-taped

interview. The themes that developed were feeling overwhelmed, sensing rudeness,

fearing failure, valuing support, and meriting responsibility. The subthemes were

feelings of guilt, entitlement, and insecurity.

Theme 1. Feeling overwhelmed. The first question presented to the educators

solicited their opinions for the biggest stressors for nurses during hospital education

courses. The educators perceived the main stressor for nurses to be a sense of being

overwhelmed with the demands of educational courses in addition to working on their

units. Nurses, these are the students of the educators, may be less stressed by courses that

are specifically related to their hospital units’ specialty area and more stressed by courses

that are required for hospital wide educational purposes.

There was a subtheme of the educators feeling guilty. The feelings of guilt for the

educators were associated to the knowledge that courses added to the nurses’ workload,

there was unequal time spacing of courses presented throughout the year that required

multiple course completion during short periods of time. There was also guilt over

having to blend students from other units in some courses even though it threatened these

nurses’ concept of a comfortable learning environment and understanding if the training

was a meaningful experience.

Amanda. “I think one of the biggest stressors with hospital education courses, is

probably, they have so much to do on the unit, that we are asking them to do even more


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in a classroom setting, and taking time out of their already busy schedule, which seems to

cause more stress for them.”

Linda. “I get a lot of complaints about the time it takes to complete all the

different education. It seems to hit them all at once. They feel pressed for time. There

are times we don’t have a lot, and then all of a sudden they are slammed with lots of

education that has to be done now on a timeline, and they get frustrated that they think

they are done, and then they are not done, and there is something else they have to do, so

they don’t buy in all the time like I would like them to. They will fuss on how much time

it takes.”

Jennifer. “I think one of the things too is balance in that people want to do it at

home, and maybe the bosses don’t want to pay them for it, because they know it is

important to get done, but they don’t want to be here.”

Megan. “When I was thinking about the question, I was thinking a bout the actual

classroom setting, and I think one of the stressors I see students that participate go

through is they want to connect it to their individual unit, and it is hospital wide training,

and the instructor may not get to their unit, so we can’t connect those dots for them.

Sometimes they need to extract themselves from what they are doing on their unit, but I

think that is one of the stressors I see on hospital wide education.”

Michelle. “I agree with that, also with what Megan said as far as that buying in

with the value when they can’t directly link it to what is going on in their world, their

unit. Even something as simple as the CE processes. There is a little bit more value and

buying in versus just going to a class even though it is still developing them.”


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sighing, just any kinds of indication like that to make you feel like you were

unappreciated while you were there. That they did not value this presentation that

someone may even come, so they do a lot of nonverbal displays of letting you know they

are frustrated and don’t want to be here. The biggest one is the eye rolling and huffing

and puffing, and whispering.” (The primary investigator inquired if this occurred from

the beginning to the end of the course or more towards the end.) “Actually I have seen it

from the beginning to the end. I have seen some attitudes, especially from the more

educated people, lots of times would be the more rude people. Whenever I am in the

unlicensed or less educated people, lots of time they buy in more, but if you got to the

level of a nurse, resident, or physician, you had to work hard to get them to buy in to

what you were teaching; otherwise, they just disconnected and let you know they were

disconnected. It was very frustrating.”

Kimberly. “I agree. There is one particular classroom that we use to teach our

core curriculum classes that every person has a computer in front of them, and I have

found that the internet becomes a big distraction, along with their phones. I would say

body positioning; you know you hear all of those things about crossing your arms,

closing yourself off. I have witnessed a few incidences of that with different departments

who didn’t think they needed to be in our classes.”

Megan. “I agree with all of that, but I wanted to add that I also see a lot of

intimidation, so if a student wanted to ask a question, but then another group of students

laugh, they chuckle and the whispering, and it really hurts the person, but I agree with all

the other educators that causes complications.” (The primary investigator asked if the

person asking the question was a new nurse and if it was a question that only new nurses


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needed to learn, and if the others were thinking they should already know this.) “It might

just be a person who learns at a different pace than you or someone who is not as tech

savvy as the others, so I think it is just a similar situation.”

Michelle. “I have a cou ple of examples of classroom settings that I have been in

where I have seen different things, and one of them has been during the orientation

process where, especially and maybe it is a generational thing, with your younger

generational nurses, where they are much more technology advanced. We have had them

to the point where they bring their Nook or their Kindles to class, and they would be

reading, so that is completely disengaged and you have to stop and say, all electronic

devices must be off and it is not a good behavior to display and that type of thing. That

has happened a couple of times. I was in a class not too long ago, where I was attending,

and the person presenting the class started us off by saying; introduce yourself, where

you are coming from, and why you are here. The first couple of people did it okay, then

one person started with I am here because my manager made me and so the next thing

you know that was basically what the entire rest of the class said, I am here because I was

forced to come. I felt like that automatically dropped the mood of the class. Now

everyone kind of used that standard line. So the next time I did a class and I was in

charge, I did not even ask that question, because I did not want it to automatically

dampen the mood of the class.”

Theme 3. Fearing failure. Question three surveyed the opinions of the

interview groups’ perceptions of the biggest stressors for nurse educators. The theme that

evolved was the fear of failure. Educators have demanding jobs. They feel the need to

be many places at one time. Educators have difficulties coaxing nurses in specialty areas


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to meet their educational requirements within the time restraints set up for their unit.

Educators have responsibilities to the education department for hospital wide courses and

planning committees for future educational needs. Educators plan their schedules to meet

all their responsibilities. Nurses that do not meet the educational requirements in a timely

manner add more stress and work to their educator’s workload responsibilities. These

nurses may understand how busy their personal workload may be; however, they are

disrespectful of their educator and want individual attention at the educator’s expense.

Amanda. “I think the biggest stressor for nurse educators, in my opinion, is

probably you feel the need to be everywhere every single moment, and you have to

juggle that, whether you have to step off the unit, but then something could come up that

you need to help with or that people have questions about, and also having to track

people down to get stuff done and trying to get their opinions. I think that the biggest

stressor is trying to get people to contact you back and take charge of their own

education. It’s kind of hard to initiate that for some people.”

Linda. “I know you think I am stealing all your answers, but I have done

education for a long time, but have only been an official educator for about a year, and

the difference for me has been, this past year, is holding people accountable for their own

education for their learning, stepping up and wanting to learn because it is the right thing

to do as a nurse. The day you finish nursing school is not your final day of education.

You learn until you retire. I have been at it for 35 years, and its constant, the need is

always there to learn. I have been very frustrated chasing people down for a year, to get

them to do modules, and just even little in-service type things, things that don’t take that

much time. It’s getting them to step up to the plate and say okay this is only a few


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minutes out of my life, it is not my life. I can take 20 minutes to do this module and be

okay. So that has been my biggest stressor in the past year, to just getting people to buy

in. It was much easier when I had one little unit that I did. Now that I have more units, it

is a much harder job to get people to buy in. It has frustrated the life out of me.” (The

primary investigator asked if it was more difficult now that her area was larger because

while she was situated with one unit it was more like her community.) “The one unit that

I came from I had more buy in. With the other units it’s been harder. I had to work very

hard to get them to respect my position and the need for me in their units and to keep

them all up to date. They are all out patient, so they think everything is in-patient driven,

but it is not and there are lots of things they need to learn. The big stressor for me is to

keep that going and keep up my momentum and keep a positive attitude, and not to get

frustrated with them, and that there is a better day coming.”

Jennifer. “I agree with the whole accountability issue. I think one of the biggest

stressors is if I don’t agree with something, it is trying to get someone else to buy into it.

I have to make sure that I convince myself before I go out there and try to sell it.

Sometimes that is very difficult. But yes the accountability is ever lasting. I think if you

can get people to be accountable, it can make all the difference in the world.”

Kimberly. “I have always described our role as the cheer leader, and you have to

be on when you come into the unit, so sometimes, kind of like what Jennifer, Linda, and

Amanda said, to be the accountability for getting the education done, but also

cheerleading to make sure that they understand why they need to do it, why it is

important, what it really means. Sometimes when you come in and you have had your


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own bad day, you are stuck in traffic, sometimes you have to focus yourself and be ready

to go out and say alright, here I am.”

Megan. “I agree with Amanda, Linda, Jennifer, and Kimberly with

accountability, and I was thinking about the comfort level with the material we have to

teach sometimes. I think as a department here at our facility, we have done a much better

job recently with our leaders making sure that we have the information we need to be

successful, so I think that is a huge step in the right direction for us. But one of the

stressors that I have sometimes faced is teaching something and having to be the expert in

something that I am not particularly comfortable with. Most of the time it is not clinical

based but sometimes it is.”

Michelle. “I agree with Amanda, Linda, Jennifer, Kimberly, and Megan. They

hit all the major points. Specifically back to Megan with not feeling that you are the

expert. It is true; it is not always about the clinical. A lot of us have been teaching some

lateral violence classes, and sometimes some of the situations that come up. I even

question, wonder sometimes what can I say to this person and what would be the correct

answer, not just my opinion, but what would be the correct answer, so that stresses me,

wanting to make sure that I don’t give someone else incorrect information

professionally.”

Theme 4. Valuing support. Question four inquired as to what uncivil behaviors

the educators observed in other educators. These educators acknowledged that they were

human and occasionally observed or participated in uncivil behaviors. Prior to and

during the time of this research interview the hospital where the group of educators was

employed was presenting hospital wide “Lateral Violence” courses. These classes were


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inspired by the Joint Commission. The purpose of these courses was to inform all

employees, licensed and unlicensed, about disruptive behaviors in an effort to create a

healthier work environment. Due to exposure to these classes, the educators were aware

of uncivil behaviors and eager to identify the behaviors they had personally experienced.

There was a subtheme of feeling insecure. The educators suggested there was a

lack of collaboration and fear of retribution within their peer group. Nonverbal

communications among peers during collaboration were perceived as rude and brought

about feelings of insecurity and fear of retribution. The educators perceived females as

instigators and commented that the majority of educators were female. The educators

valued the support of their peers and were reluctant to address the nonverbal

communications among peers during collaborations.

Amanda. “I can’t really say that I see too much. I think everyone is there for our

department, because we kind of feel like the outsiders, but the insiders with your

department, but you are not, but you are, but then sometimes you’re not. I think we

group together well. I always have questions, so it is nice to have other people to ask

questions, so I don’t really see much uncivil stuff.”

Linda. “I have been here for a year, and I can honestly say I have never been

mistreated one day. If anything occurred, it occurred behind my back. Because I have

not had questions go unanswered. Someone has cheerleaded me up when I felt

overwhelmed. Someone has always been in there to help me. I think we have a very

good group of educators. They have all walked the walk, so they are helping me to walk

that walk. Sometimes I feel a little self conscious because I feel like I am the old one,

and that I should be able to catch on to the electronic stuff a little quicker than what I feel


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I have, but someone is always there to help me. I haven’t seen any educator be uncivil to

another.”

Jennifer. “I would like to think we don’t partake in it, but we do because we are

nurses and we are women. I know that there are certain groups that if you have done

something to not necessarily fit into their group you have been oust. It’s really sad

because what happens is, our group, we are pretty intelligent, and so it really makes them

look bad and not the person you are ousting. The funny thing is a lot of us are talking

and teaching about lateral violence, and we are supposed to be the leaders. But we are

still having that behavior. But I do know that our leadership does not permit that

behavior once it has been brought to their attention, and that is the hard thing. That’s the

hard thing because we are afraid to bring it, we don’t want to bring it to the leader’s

attention because we are afraid we have already been ousted once, are we going to be

ousted again. I have my bad days, but I really like to think of myself and that I am

somebody that anybody can get along with. I should just believe that if we continue to

hold each other accountable, then those of us who co

incivility in the hospital environment- the nurse educator-staff.pdf

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