students perceptions of incivility

January / February Vol .33 No.1 15

S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C AT I O N R E S E A R C H

Student Perceptions of INCIVILITY in Nursing Education:

Implications for EducatorsGERRY ALTMILLER

ABSTRACT This study explored the phenomenon of incivility in nursing education from the perspective of undergraduate nursing students

and compared it to perspectives of educators as found in the literature. The sample consisted of 24 undergraduate junior and senior nursing stu-

dents from four universities in the mid-Atlantic states. Data from four focus groups were transcribed and content analyzed to reveal themes and

subthemes. Students perceived that incivility in nursing education exists. They shared a common view with findings in the literature regarding inci-

vility from the faculty perspective. Notably, an emerging student view was that faculty may contribute to the escalating incivility in nursing educa-

tion, and that student incivility is justified when faculty are seen as uncivil. The implications for educators, consistent with the literature, are that

students want professors to maintain classroom decorum and set the example for civility.

HE LITERATURE SUGGESTS THAT INCIDENTS OF

AGGRESSION AND VIOLENCE ARE OCCURRING

MORE FREQUENTLY IN THE ACADEMIC ENVIRONMENT

THAN IN THE PAST (HEINEMANN, 1996; LASHLEY & DE

MENESES, 2001; LUPARELL, 2003; MORRISSETTE, 2001;

THOMAS, 2003), INCLUDING IN NURSING EDUCATION.

Faculty in nursing education programs are understandably con-

cerned (Lashley & de Meneses; Luparell, 2003) as inappropriate

behavior is disruptive to the learning process, and students who

exhibit aggressive behavior in the academic setting will eventually

care for vulnerable patients. Such behavior has made it more diffi-

cult to work as a nursing professor and is increasing the anxiety

level of nurse educators (Luparell, 2004).

Incivility in the academic setting is behavior that intentionallydisrupts or interferes with the learning process of others(Morrissette, 2001). The literature identifies unacceptable behav-iors as those that are disrespectful or disruptive. Such behaviorsrange from rude, uncivil actions or words (e.g., lateness to class,verbal disrespect) to physical aggression against other students orinstructors (Amada, 1994; Baron, 2004; Griffin, Ferrin, & Stucki,2001; Lashley & de Meneses, 2001; Luparell 2003; Miller,Hemenway, & Wechsler, 2002; Morrissette; Schneider, 1998;Tiberius & Flak, 1999). Heinemann (1996) identified the corecomponent of incivility as a lack of respect for other human beings. The increasing frequency of incivility in nursing education has

had deleterious effects on faculty (Lashley & de Meneses, 2001;Luparell, 2003; Morrissette, 2001; Tantleff-Dunn, Dunn, & Gokee,2002; Thomas 2003) while infringing on the rights and educationof uninvolved students (Morrissette). More than 50 percent of fac-ulty surveyed by Lashley and de Meneses (2001) reported serious

inappropriate student behaviors; nearly 25 percent reported objec-tionable physical contact between students and instructors. Somefaculty have considered leaving teaching positions because ofencounters with uncivil nursing students (Luparell, 2003). Because of these findings, it is imperative to explore the nature

of incivility in nursing education from the perspective of students.Are students’ views of uncivil behaviors similar to those of faculty?What factors trigger and escalate disputes with faculty? Answers tothese questions support development of strategies to resolve con-flicts between faculty and students before crisis level interventionsare required.

Literature Review Several important studies have targeted the

issue of incivility in nursing education. In a national survey of nurse

educators, Lashley and de Menses (2001) documented the frequen-

cy and extent of uncivil nursing student behaviors against nursing

instructors. Luparell (2003) described how uncivil events provoked

fear and panic for faculty and resulted in long-term as well as short-

term stress-related effects. Clark and Springer (2007) found that

most faculty and students surveyed (61 percent) viewed incivility as

a problem in nursing education.

Little research is available to describe student behaviors per-

ceived as uncivil or to explore the impact of uncivil behavior on fac-

ulty and society in general. Faculty response to conflict may unwit-

tingly exacerbate uncivil classroom behaviors (Boice, 1996). Clark

and Springer (2007) stated that faculty should reflect on how their

own behaviors may escalate incivility in academia. What is clearly

understood is that conflicts between faculty and students can cause

students to disconnect from the learning process (Tantleff-Dunn et

al., 2002). An important first step in de-escalaling conflicts and cur-

R E S E A R C H

T

16 Nurs ing Educat ion Perspect ives

S T U D E N T P E R C E P T I O N S / N U R S I N G E D U C A T I O N R E S E A R C H

tailing incivility is listening to students to understand their percep-

tions, feelings, and fears (Morrissette, 2001; Thomas, 2003).

Method This exploratory study used the focus group method

(Krueger & Casey, 2000) with four male and 20 female nursing stu-

dents. Students ranged in age from 18 years to 45 years and were

juniors and seniors in a traditional pre-licensure baccalaureate

program. They had completed a minimum of two clinical nursing

courses. Students were recruited from a state university and three

private universities located within a major metropolitan area in the

mid-Atlantic states. The researcher visited classes at each school

and invited students to participate in research to discuss student

perceptions of incivility.

Four focus groups were conducted. Each had three to nine par-

ticipants depending on the size of the university program. A list of

questions developed from the literature provided structure for the

focus group sessions. Sessions were audiotaped, transcribed verba-

tim by a professional transcriptionist, and verified for accuracy

against the recordings. Using a word processing program, an audit

trail was developed that allowed for comments to be traced back to

the specific focus group session. A flip chart was used during each

session to record key ideas and facilitate review by the participants

at the completion of the session.

Content analysis, consisting of rigorous examination of the focus

group data for recurrent instances, was used for data analysis (Carey

& Smith, 1994). Immersion in the data involved repeated listening to

all audiotapes. Significant statements were extracted from the tran-

scripts and were reflected upon to formulate meanings. Data were

coded into categories to identify clusters of themes and trends, which

were validated by returning to the original transcripts and checking

whether anything contained in the transcripts was not accounted for

in the clusters. Likewise, the themes were validated by checking

whether any content was not implied in the transcripts. Clusters of

themes and the indicators were scrutinized to create an exhaustive

description of the participants’ perceptions of incivility in nursing

education. Field notes, the written session summaries, and the flip

chart were reviewed in conjunction with the audiotape transcripts as

triangulation strategies to support interpretive validity (Maxwell,

1992). A doctorally prepared nurse educator with qualitative research

expertise confirmed the data analysis and interpretation.

Findings Nine themes were identified and compared to faculty

perspectives found in the literature. Each theme is recognized by its

relevant cluster of subthemes (see Table) and discussed in this arti-

cle. The study showed that nursing students interpret as uncivil

many of the same behaviors identified as uncivil by faculty. Further,

the students in this study expressed concerns similar to those of

faculty regarding the increasing frequency of uncivil behaviors by stu-

dents in the learning environment. They brought a unique perspec-

tive in that they identified faculty behaviors that fueled student inci-

vility, and, in fact, stated that faculty behaviors they perceived as

uncivil justified student incivility.

Table. Focus Group Themes and Subthemes UNPROFESSIONAL BEHAVIOR

Lack of professionalism

Teachers talking negatively about other students

Retaliation

Nurses modeling incivility

POOR COMMUNICATION TECHNIQUES

Belittlement, talking down to students

Feeling disrespected

POWER GRADIENT

Targeting, fear of being next

Fear of being failed

Feeling less than adequate

Embarrassment

INEQUALITY

Favoritism

Different rules for different students; adherence to rules

Different standards for faculty and students

Racial/ethnic bias

Gender bias

LOSS OF CONTROL OVER ONE’S WORLD

Helplessness/hopelessness

Questioning faculty leads to attack

STRESSFUL CLINICAL ENVIRONMENT

Stress

Not getting needed help

School size

AUTHORITY FAILURE

Faculty allow students to give them attitude

Faculty fail to control situation

DIFFICULT PEER BEHAVIORS

Side conversations during class

Inattentiveness in class

Cheating

Lateness

Competition among peers

Intimidation

STUDENTS’ VIEWS OF FACULTY PERCEPTIONS



Unprofessional Behavior In the clinical setting, student behavior that was disrespectful

toward faculty, patients, staff, or peers was equated by students with

incivility as it reflected negatively on the school and, therefore, on

the students themselves. Students avoided seeking help from faculty

who made negative comments about students to other students; such

comments were seen as unprofessional.

Students form an identity as a nurse by observing faculty and

staff nurses. According to findings from the focus groups, students

believed that staff at some clinical sites modeled incivility through

interactions with students and faculty. Staff who denied assistance,

failed to provide direction, or communicated intolerance were viewed

as unprofessional, violating what it means to be a nurse.

Poor Communication TechniquesStudents viewed behavior that was disrespectful to any person as

uncivil. Consistent with Heinemann (l996), they focused on com-

munication as the vehicle for incivility. Supporting findings by

Tantleff-Dunn et al. (2002), students said they felt disrespected

when their questions went unanswered by faculty; this was a fre-

quent source of conflict. Students were particularly sensitive to

what they perceived as “being put down” in the clinical setting.

Crying in clinical was viewed as the result of criticism from a clin-

ical instructor. Criticism of a student’s performance may be inter-

preted as uncaring by the student (Luparell, 2004), creating diffi-

culty in the student-faculty relationship and conflicting with nurs-

ing’s image as a caring profession.

Power Gradient Students viewed clinical evaluation as a less objective process than

classroom evaluation and feared being failed by a subjective clinical

appraisal. They spoke of a power gradient in nursing education and

described a fear of being embarrassed, having their mistakes made

public, and being scolded in the presence of peers, staff nurses, or

patients. Some students choked up or began to cry as they told of their

experiences. Several said they had seen classmates cry and were fear-

ful that they would be next. They spoke of avoiding disagreement for

fear of retaliation, and some admitted to avoiding any interaction at all

with certain instructors.

Students identified targeting as part of the power gradient. They

felt that students who made a negative impression on an instructor

would receive more critical attention, with the ultimate goal to remove

the student from the program.

InequalityGender bias was identified as a trigger for incivility. Male students

perceived they were assigned patients who required the greatest phys-

ical exertion and believed that faculty, mostly female, had greater

expectations for them. Women, on the other hand, thought that some

faculty favored males and were more positive in their communications

with them. Favoritism was seen as unprofessional and a faculty behav-

ior that triggered anger. Behaviors identified as favoritism included

spending more time evaluating work of favored students and testing

favored students in a less rigorous manner.

Consistent with findings in the literature (Tantleff-Dunn et al.,

2002; Thomas, 2003), students saw racial bias and discrimination

as particularly uncivil and a trigger for anger. They described expe-

riences where minority faculty demonstrated racial bias against

white students and visa versa. Students told of experiences serious

enough to elevate to administrators, with some resulting in the

dismissal of a faculty member. Consistently, events of this type

resulted in a loss of respect for faculty, interruption in the learning

process as students were moved to other sections, and the feeling for

students that they had little control.

Loss of Control Over One’s World Students perceived that questioning an instructor regarding grade

assignments could result in a counterattack; they described feeling

they had no recourse for incivility on the part of faculty. Students who

addressed an issue with a course director or administrator said they

were not part of the resolution and received no feedback, but instead

experienced the angry reaction of the offending faculty member.

They told of being yelled at by faculty and fearing further retaliation.

Feeling unprotected, they did not pursue their complaint, which led

to feelings of helplessness and hopelessness. With the learning

process interrupted and afraid to ask for assistance from faculty, stu-

dents created “work-arounds” whereby they learned from other stu-

dents. Even in cases of great duress, students did not see leaving the

nursing program as an option because of the financial burden of

postsecondary education and the difficulty of transferring nursing

credits between universities.

Stressful Clinical Environment Many students identified the stress that accompanies a clinical expe-

rience as a trigger for uncivil behavior. Large clinical groups limit the

availability of the instructor, forcing students into situations that are

unfamiliar and lacking what they interpret as adequate support.

Students identified that frustration can affect communication

between faculty and student, resulting in raised voices, failure to con-

trol what is said, and overreaction to certain situations.

Authority Failure The students acknowledged that they contribute to incivility when

they fail to meet their responsibilities. They expressed disapproval of

some behaviors demonstrated by classmates and concern regarding

the frequency of such behaviors. However, they saw addressing


habitual tardiness and disruptive behavior in the classroom as a fac-

ulty responsibility and were frustrated when faculty failed to act.

They felt they had no control over the behaviors of their peers and

told of experiences that led to fighting after class, when one student

asked another to be quiet so that she could hear the instruction.

When students perceived that faculty had behaved in an uncivil

manner toward a student, they spoke of their satisfaction when that

student responded in kind. Likewise, when they identified their own

behavior as uncivil, they found it justified if done in retaliation for

perceived faculty incivility. Students empathized with faculty when

they believed that student incivility was undeserved.

Students believed that faculty comfort level and class size influ-

enced whether uncivil behaviors were addressed. Consistent with

the literature, faculty in larger classes, where there was greater

anonymity, were less likely to confront uncivil behaviors (Carbone,

1999; Merrow, 2005; Lashley & de Meneses, 2001; Tiberius & Flak,

1999).

Difficult Peer Behavior Students spoke of side conversations in the classroom that interfered

with their ability to hear the instruction. Although disrespectful to

faculty and fellow students, such conversations, they said, were

rarely addressed by faculty. Interestingly, students recognized that

they themselves were uncivil when they had side conversations in

class but felt such behavior was justified when the instructor did not

hold their interest or seemed disinterested in the material.

Peer behaviors identified as disruptive included talking, laugh-

ing, watching a small TV, and talking on the phone during class.

Reading a magazine or putting one’s head down on the desk to sleep

were considered inappropriate but more acceptable because they

were done quietly. Habitual lateness to class was considered a disre-

spectful behavior.

Students had no sympathy for peers regarding the consequences

of rule infractions and were angry when faculty did not enforce the

rules. Most students stated that cheating was pervasive but was

often not addressed, even though it violated the university’s academ-

ic code of conduct and was witnessed by faculty.

As identified by Amada (1994), students perceived that compe-

tition provokes uncivil behavior. Incivility could lead to an atmos-

phere of intimidation, where one student, fearing interaction with

another, would go to great lengths to avoid contact. Concern over

being ridiculed caused students to avoid asking questions in class.

Students’ Views of Faculty PerceptionsStudents interpreted faculty failure to maintain control of the class

as lack of concern or resulting from fear of certain students. They

were also concerned that faculty may be influenced by bias, and

that the authority they wield discourages them from reining in their

biases. This finding is consistent with Luparell’s (2003) observation

that students hold a negative perception about faculty motivations.

The focus group sessions evidenced the magnitude of this perception

as students’ comments were reaffirmed by others.

Discussion Findings from this study provide insight into how stu-

dents interpret events common to many nursing education programs.

They show key areas of agreement between faculty perceptions of

incivility as found in the literature and student perceptions, as well

as some unique student perspectives. Students are concerned about

the increasing frequency of uncivil behaviors they see in the class-

room. There is recognition that communication is the most frequent-

ly used vehicle for incivility, and there is concern that societal influ-

ences may be a catalyst for increasing competition.

Consistent with the findings of Tantleff-Dunn et al. (2002),

this study shows that faculty responses to students can escalate

or ease tension. The disturbing negative student perceptions

regarding faculty contributions to incivility are consistent with

findings from previous studies (Clark & Springer, 2007;

Luparell, 2003; Tantleff-Dunn et al.) and are particularly con-

cerning in view of the enormous responsibility that nurse educa-

tors have as positive role models for the profession. The perception

that student incivility is justified in the face of perceived faculty

incivility warrants attention as such a perception can only esca-

late current levels of incivility and aggression, creating a danger-

ous work environment for faculty. Just as civility is learned

behavior that is incorporated through repetition, incivility is a

learned behavior that, left unchecked, can become the framework

for one’s professional relationships.

Limitations of the Study Participants in this study were a

convenience sample of students who met specific criteria and

were willing to discuss the subject matter. Not all participants

spoke of firsthand, direct experience with incivility, but all

spoke of witnessing what they perceived as incivility on the

part of students or faculty. It is difficult to know how far-reach-

ing the negative perceptions that students expressed regarding

faculty contributions to incivility are. It is not known if stu-

dents in the focus groups were more likely than others to per-

ceive events from a negative perspective or if these students

were simply more open than others to talking about the topic.

Although all four focus groups provided examples of what

the students interpreted as incivility in nursing education, the

most extreme instances, particularly those involving faculty

termination, happened at larger programs where enrollment

exceeded more than 100 students per class. The impact of the

nurse educator shortage on such large programs may be a fac-

tor, but the full implications are not known.



Implications for Educators Findings from this study pro-

vide indicators of how faculty-student relationships can be

improved through the implementation of strategies that deter

incivility and de-escalate conflict. A good beginning is to

introduce nursing students to the American Nurses’

Association Code of Ethics for Nurses with Interpretive

Statements (2001). As outlined in the code, respect and com-

passion in all relationships are expectations for nurses.

Incivility toward others is a direct violation of this concept, and

it is the moral responsibility of nurse educators to deter such

behavior (Luparell, 2005).

Lewenson, Truglio-Londrigan, and Singleton (2005) recom-

mend placing a greater emphasis on appropriate student behav-

iors in class and clinical settings by demonstrating applications

of the code so that students can see how they should conduct

themselves. Just as students recognize how uncivil nurse behav-

ior violates the profession, so is it important that nurse educa-

tors help students understand that uncivil student behavior also vio-

lates it. If students are to learn civility, faculty must demonstrate

discretion, attentiveness, respectful communication, and profes-

sional behavior overall. It is important that faculty help students

understand that uncivil behavior on their part is a violation of

professional standards. In keeping with the code of ethics, facul-

ty should condemn any behavior that demonstrates bias against

or disrespect for any individual.

Clear communication of course-related information at the first

class meeting, and an open dialogue about expectations, will

decrease ambiguity about what constitutes uncivil behavior.

New faculty should seek guidance from experienced faculty about

proactively managing the classroom environment. They should

also seek advice regarding reasonable expectations for various

student levels, methods to establish clear boundaries in the stu-

dent-faculty relationship, and how to develop a syllabus that

clearly outlines course requirements. Acknowledging the incred-

ible responsibility nurse educators have to protect the public, it

is vital to maintain high standards and expectations yet create a

positive learning environment that will allow students to admit

mistakes without fear of public humiliation, a dictate that sup-

ports the obligation for educators prescribed by the National

Education Association (n.d.).

The blurring of boundaries between faculty and students can

promote inappropriate behavior. Faculty need to practice de-

escalation behaviors, particularly that of maintaining civility in

the face of incivility. Other de-escalation techniques include

attentiveness, listening, and reflection. It was shown in this

study and elsewhere (Tantleff-Dunn et al., 2002) that students

frequently identify not having their questions answered as a

source of conflict. Therefore, faculty need to be open to stu-

dents’ questions and suppress defensive reactions when being

challenged by students. In addition, it is important to promote

strong peer relationships among students by modeling such

behavior, appreciating diversity, and demonstrating the princi-

ples of teamwork, respect, and camaraderie with other faculty.

Lemos (2007) stated that civil behavior is learned behavior

and as society becomes more complex, so do the codes by which

civil society lives. Therefore, faculty need to continually update

their skills to meet the challenges of such complexity. Students

clearly want faculty to address uncivil behaviors in the class-

room. Faculty have an obligation to the nursing program, the uni-

versity, and individual students to control the learning environ-

ment and address uncivil, disruptive behaviors as they are

encountered. Administrators must support faculty by providing

a thorough orientation for new educators and offering ongoing fac-

ulty development workshops in managing classroom behavior.

Administrators need to be clear that faculty have a right and a

responsibility to provide a classroom that is conducive to learn-

ing and free of incivility and intimidation.

Maladaptive behaviors must be addressed promptly but done

in a civil manner. For behaviors where there is a zero-tolerance

level, such as talking on the phone or putting one’s head on the

desk to sleep, the consequence should be communicated ahead of

time, before the behavior occurs, preferably on the first day of

class and then enforced if necessary. Cheating must be addressed

directly. Failure to do so conveys the message that clearly wrong

behavior is accepted in the classroom.

Nurse educators must develop curricula that help students

learn strategies to shield themselves from incivility on the part

of peers, patients, and other health care professionals.

Strategies could include role playing and using cognitive

rehearsal techniques that pointedly address offenses, such as,

“I learn best when people are direct with me. You can be direct

with me if there is something that you want to say.” As part of

their professional development, students need to learn how to

maintain civility, even when confronted by incivility. Clinical

evaluations, particularly those with grade assignments, need to

be informed by clear, measurable, objective criteria to decrease

the perception of subjectivity. A transparent grievance policy

must be in place so that students are informed of the process

and confident that an option is available for serious concerns.

Finally, the role of caring in the faculty-student relationship

cannot be overstated. This study, like Luparell’s (2004), recog-

nized that incivility is frequently triggered by the conundrum

that is created when poor performance on the part of the student

necessitates constructive criticism from the instructor. Many

students identify this with uncaring behavior from a person that

is serving as a role model in a caring profession. Strategies need


to be developed to communicate unsatisfactory performance by

helping students appraise their performance realistically. One

such strategy may be to develop a process by which the instruc-

tor takes the student through a questioning route that views the

student performance from the patient’s perspective in accor-

dance with safe levels of practice. Such processes of reflection

may help the student arrive at the conclusions that are now com-

municated directly by the faculty member but so frequently

serve as the triggering event for incivility in the teacher-student

relationship.

Conclusions The findings of this study indicate that stu-

dents and faculty have similar perceptions regarding unciv-

il behavior, particularly in defining it, acknowledging its exis-

tence, and noting its increasing frequency in the academic

setting. The unique perspective students expressed regard-

ing the contributions of faculty behaviors to incivility is concern-

ing. That students believe incivility is justified when they

perceive incivility demonstrated toward them validates the

urgency with which nurse educators need to address this

issue. An important first step includes implementing effec-

tive strategies that de-escalate incivility and foster appropri-

ate professional behavior. Faculty reflection, the sharing of

experiences, and adequate preparation for classroom manage-

ment will support an environment where incivility can be

deterred.

About the Author Gerry Altmiller, EdD, APRN, ACNS-BC, is

an assistant professor at La Salle University School of Nursing and

Health Sciences, Philadelphia, Pennsylvania. For more informa-

tion, contact her at [email protected].

Key Words Academic Incivility – Nursing Students – Nurse

Faculty – Nursing Education



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