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How Nurse Educators Cope with Incivility

Michele Pyles

Louisiana State University-LSU School of Nursing New Orleans United States of America

Abstract: Background: Research has clearly defined the issue of nursing student incivility, with evidence that nursing students are engaging in uncivil behaviors on a routine basis [1,2,3,4]. Stress, like that experienced with incivility, impacts an individual’s perception of an uncivil encounter and has been linked to the development of negative coping responses [5]. Methods: A mixed-methods convergent parallel design was used to collect data from 39 nurse educators who were employed at 3 schools of nursing in the southern region of the United States. Creswell [6] described the design as “combining elements of both qualitative and quantitative approaches” (p. 3). The convergent method of the design allowed the researcher to collect both quantitative and qualitative data, conduct separate analyses, and compare the results. A mixed-methods convergent parallel design was appropriate for this study because it supported the Transactional Model of Stress and Coping [7], which formed the foundation for the study. The model purports that individuals conduct a primary appraisal of the significance or threat of a stressful encounter (e.g., challenging, positive, controllable, stressful, or irrelevant). If the encounter is perceived to be threatening, a secondary appraisal will follow, which will activate an individual’s coping mechanisms. The design allowed the researcher to determine the coping responses used by nurse educators when facing uncivil encounters with nursing students. Setting: The setting for the study was 3 separate schools of nursing in the southern region of the United States. Sample: The sample was a purposive convenience sample of nurse educators employed by the selected universities’ schools of nursing in the southern region of the United States. The selection criterion was that a participant had to be a nurse educator who was employed by one of the selected universities’ schools of nursing in the southern Region of the United States. There were no demographic data collected from participants of the study. Procedure for Data Collection: Following receipt of Institutional Review Board Approval from all of the chosen institutions, a letter was drafted and sent to the deans of the selected universities’ schools of nursing to request permission to collect data. Collection of participant data began following receipt of permission from the three study schools. The participants were provided with electronic consent forms and instructed that completion of the surveys denoted voluntary participation. Participants were provided with information about human informed consent and told that there were no anticipated long-term physical effects and minimal (if any) long-term emotionalor psychological effects from participating in the study. Participants were told that they may experience some degree of emotional distress when relating experiences with nursing student incivility. The instrument used to collect data related to perceptions of incivility was the INE-R survey [8] consists of 24 items related to student behaviors using a Likert-type scale and four open-ended questions. No demographic information was collected from the participants. All the responses were collected anonymously. The four open-ended questions of the INE-R [8] were analyzed from the nurse educators’ point of view for the occurrence of themes. The themes were then characterized into categories; the categories were then coded in order to show the relationship between nurse educators’ perceptions of nursing student incivility and coping responses. Participant responses were entered into an Excel spreadsheet, which was housed with the researcher and locked in a secure cabinet. Only the researcher maintained a key to the cabinet. The Excel spreadsheet was secured on a password-protected flash drive maintained only by the researcher. The WCQ [9] was also linked in the body of an email that was sent by the deans of the three selected universities’ schools of nursing to the nursing faculty. The link to the questionnaire was administered using secure Web-based technology (Survey Monkey). The WCQ [9] provided responses to 66 items using a Likert-type scale. All of the responses were collected anonymously and the data collected from the respondents was entered into an Excel spreadsheet for compilation. The data collection process for the WCQ [9] was the same as that of the INE-R [8] and included collecting responses to the 66 items on the questionnaire. All the responses were entered into an Excel spreadsheet, which was ill be housed with the researcher and locked in a secure cabinet. Only the researcher maintained a key to the cabinet. The Excel spreadsheet was secured on a password protected flash drive maintained only by the researcher. Results: Daydreaming, analyzing the issue to better understand it, and jogging or exercising were the top 3 measures for coping with nursing student incivility. Making condescending remarks, discriminatory comments, and cheating on exams were perceived as the most uncivil behaviors. Conclusions: A crucial barrier was identified, in less problem-focused coping among nurse educators facing incivility. Programs designed to combat incivility should be revised to provide additional training and support for faculty and measures should be taken to protect the integrity of the profession of nursing.

Keywords: coping, nurse educator, nursing student, perceptions

Citation: Michele Pyles, How Nurse Educators Cope with Incivility. American Journal of Nursing Research, 4 (3). 56-68. January 2016. doi:10.12691/ajnr-4-3-2

1. Introduction

Nurses, today and throughout history, are known for their kind, caring behaviors [10]. Through association, nursing students are assumed to be as kind and caring as their licensed counterparts. However, nurse educators might not agree with this assumption due to a rise in nursing student incivility [11,12]. The rise in incivility among nursing students is causing great concern for nurse educators and administrators alike [11,13]. For this reason, it is necessary to determine why the issue persists, despite efforts to manage it.

Research has clearly defined the issue of nursing student incivility, with evidence that nursing students are engaging in uncivil behaviors on a routine basis [1,2,3,4]. The classroom behaviors witnessed by nurse educators include talking in class, rudeness, passive aggressiveness, and psychological abuse and the behaviors can lead to violence [2,4]. The threat or perceived threat of violence causes nurse educators to experience powerlessness, and traumatization [4]. The most profound consequence of nursing student incivility is stress [1,3,5,7,14,15,16]. Stress, like that experienced with incivility, impacts an individual’s perception of the encounter and has been linked to the development of negative coping responses [5]. The following research questions were examined in this study:

RQ1: What are the perceptions of nursing student incivility among nurse educators in the Southern Region of the United States?

RQ2: What are the coping responses to nursing student incivility among nurse educators in the southern region of the United States?

2. Review of Literature

The aim of this study was to examine the relationship between coping responses and perceptions about nursing student incivility among nurse educators in the Southern region of the United States. This review of literature offers justification for examining the relationship between coping responses and perceptions about nursing student incivility among nurse educators. The review of literature provides evidence of stress as an outcome for individuals who experience incivility [1,3,5,7,14,15,16], which is linked to the development of negative coping responses. However, few of the studies included in the review addressed whether or not a relationship existed as a relationship between nurse educators’ coping responses and their perceptions about nursing student incivility.

Coping responses are an individual’s reaction to an internal or external stressor [7]. Nurses have been shown to use coping responses like conflict avoidance when situations are perceived to be stressful [17]. Individuals, who experience uncivil encounters that involve concern over well-being, develop distancing behavior and display a lack of problem-solving abilities [13]. A correlation can be drawn between an individual’s perception of an uncivil encounter and the chosen coping response [5,17]. Folkman et al. [5] and Valentine [17] provide evidence of how the stress of incivility can alter perceptions and impact coping responses.

For the current study, incivility is defined as offensive or impolite behaviors or actions that can cause varying degrees of stress for targeted individuals, affecting an individual’s coping responses. Research has identified a need for nurse educators to address these offensive behaviors or risk an escalation to threatening situations [18]. Coping responses are behavioral responses, which refer to what people do in confronting stress [7]. Research suggests that an individual’s response to a stressful situation includes an appraisal of the power involved in the event [19]. For this reason, targets of incivility employ coping responses based on their perception of the event [20,21]. The review of literature includes detailed information about coping responses, perceptions about incivility, and the effects of incivility.

3. Coping Responses to Incivility

Valentine [17] investigated the ways women, nurses, and nurse managers dealt with conflict. The study proposed that nurses were nurturing, kind, and caring and that this nature hindered their ability to manage conflicts. The author’s review of the literature identified studies that found women predominantly used compromise or conflict avoidance when dealing with conflict. The results of the study suggest that women avoid conflict and often “turn it inwards where it is experienced as stress, low morale, or depression ([17], p. 144)”. Conflict situations involving women were most often dealt with through conflict avoidance or by talking to a friend.

Valentine [17] reviewed literature related to the ways in which staff nurses and nurse managers dealt with conflict. The findings suggest that nurses overwhelmingly choose conflict avoidance. An additional discovery was that nurses would ameliorate the conflict through offerings of home-baked foods or invitations to social events. Often, when a team of nurses would meet to discuss unhealthy group dynamics, the result would be scheduling a luncheon [17].

Although Valentine’s [17] study is not current, it has relevance to the current study because it suggests that among women and nurses, compromising and conflict avoidance were the primary means of dealing with conflict situations. Valentine [17] provides historical evidence of the strategies previously used by women and nurses in the management of conflict.

Lazarus and Folkman [7] conducted a systematic review of the literature, which analyzed the role of personal control in stress and coping processes. The relationships between these variables were examined using Lazarus and Folkman’s Transactional Model of Stress and Coping [7]. The author identified that in recent years, individuals who had personal control over a situation were thought to experience less stress [7]. However, the author suggests that no relationship exists between personal control and stress (p. 840).

Lazarus and Folkman [7] reported that an individual’s level of personal control depends on the meaning of the chosen control response. Further, the meaning of an event is determined through the process of primary appraisal. Primary appraisals are judgments individuals make about the harm/loss, threat, or challenge of an event. The primary appraisal is determined by an individual’s beliefs about the encounter and an individual’s generalized beliefs about control [7]. Secondary appraisals are evaluations of the coping response/resources and options for managing the event [7]. The author suggests that the simple question, “What can I do?” leads to an evaluation of coping responses. Lazarus & Folkman [7] identified how appraisals of control can change as the event unfolds, leading to changes in coping responses.

Lazarus and Folkman [7] described coping as having two functions: the regulation of emotions or distress and the management of the problem that is causing distress. The author suggests that both functions occur during the most stressful encounters. It is important to note that situational appraisals of control affect how much effort a person will expend in the situation (p. 846). For this reason, the more an individual believes that he or she has mastery in managing the event, the more active his or her coping efforts will be (p. 847). An example of this concept is a situation in which an individual believes a situation is controllable. The individual will draw one of two conclusions about the event: it is a threat, or it is a challenge. A challenge appraisal typically produces a more positive outcome, because it makes use of problem-focused coping. A threat appraisal includes distressing emotions, which can impede the individual’s ability to cope and poor problem resolution can result [7].

Lazarus and Folkman’s [7] finding suggests that individuals involved in research about coping and perceptions of control should consider perceptions of control in the context of “specific stressful situations” (p. 850). The author suggests that an individual’s level of personal control has multiple functions in a stressful encounter [7]. The beliefs an individual has about control can alter the appraisal and influence coping responses. Lazarus and Folkman [7] suggests that stress is not alleviated through control of a stressful event. The study has relevance to the current study because it identifies individual beliefs as determinants of the perceptions of a stressful encounter (primary appraisal). Further, individuals are shown to evaluate available coping responses in order to regulate distressing emotions and the distressing event (secondary appraisal). Finally, stress is an outcome for individuals who experience distressing events and is not relieved by simply controlling the situation.

Cortina and Magley [14] examined the patterns of individual responses to work place incivility. The authors used the Transactional Model of Stress and Coping to guide their research [7]. The study was paramount for identifying a correlation between workplace incivility and negative responses of employees. The researchers asked two questions, “How do employees emotionally appraise uncivil behavior at work?” and “How do employees cope with uncivil behaviors at work?” (p. 273).

Independent sampling was used to collect survey data from three separate groups of people. The first sample came from university employees and included 1,711 participants. Individuals were invited to take part in the survey and were directed to are stricted-access website. In addition, participants were offered gift certificates for their participation. The instrument that was used to measure experiences with incivility was the Workplace Incivility Scale [22]. A change was made to the construct of the Workplace Incivility Scale. New questions were added in which respondents were asked about encounters when an individual may have failed to speak to them, ignored them, yelled at them, or shouted at them. In total, there were 10 items and respondents answered with a “0” (never), “1” (once or twice), or “2”(more than once or twice). Analysis revealed a uni-dimensional structure underlying the items (a = 0.86).

The appraisals of incivility were measured with six items (a = 0.91) that defined the characteristics of uncivil encounters. The Coping with Harassment Questionnaire [23] was used to measure employees’ methods of response to workplace harassment. The average reliability coefficient of the Coping with Harassment Questionnaire [23] was 0.83.

The second sample included 4,605 lawyers in federal practice. Incivility was measured using items from the Interpersonal Mistreatment Scale [22], which measured incivility in federal legal practice (a = 0.88). Participant measurements of appraisal and coping were collected in the same fashion as the participant measurements from the first sample. The third sample included 1,167 employees at a federal judicial court. Data were collected in the same manner by using the same tools as in the second sample.

Cortina and Magley [14] found that employees categorized their uncivil experiences as moderate to very frustrating, annoying, and offensive, but not particularly threatening. Appraisal of the encounters was based on the variety and frequency of the events and the power held by the perpetrator. Participants also responded to questions about coping behaviors. The results were that few employees discussed incivility with organization administrators; only 1% to 6% had filed formal complaints. According to Cortina and Magley [14], the finding suggested that employees rarely bring uncivil encounters to the attention of their supervisors.

Behaviors associated with the instigator, the target, and the situation included support seeking, which led to more offensive and frustrating events. This group reported incidents that lasted weeks to months. Detachers and minimizers shared common characteristics but typically did not address the event at all. Conflict avoiders reported having experienced the most severe types of incivility by powerful instigators. The researchers considered that the uncivil encounters could have come from authority figures. A finding related to conflict avoiders was that they might have avoided the instigator for as long as possible and switched to a different strategy when avoidance failed. According to the authors, this implies a trial-and-error approach to coping [14].

The implications of this study are that individual reactions to incivility can trigger job dissatisfaction, performance decline, psychological illness, and employee turnover [14]. In addition, management of incivility should be proactive since employees do not seek the support of their supervisors; rather they use coping strategies to deal with the problem. Cortina and Magley [14] suggest that the events may be out of control before an organizational leader is aware that a problem exists.

The limitations of the study included the use of three large samples as the basis for the research and the collection of data. This raises the potential for common method bias. In addition, a five-year time frame was used, which could lead to lapses in memory of the encounters, thus resulting in over- or under-reporting. The strength of the study was its ability to lay the foundation for further research.

Cortina and Magley [14] suggest that conflict avoiders experience the most severe types of incivility. The current study seeks to examine the relationship between the coping responses and perceptions about nursing student incivility among nurse educators. The ramification for nurse educators is the risk for increased aggression from nursing students when incivility is ignored. Cortina and Magley [14] has relevance for the current study through its ability to show a relationship between coping responses and perceptions of uncivil encounters.

Almost, Doran, McGillis-Hall, and Spence-Laschinger [24] linked antecedent variables to intra-group conflict among acute care nurses. The purpose was to develop and test theoretical model that linked antecedent variables to intra-group conflict among nurses, followed by conflict management and two outcome variables [24]. The authors used Cox’s [25] critical theory in which conflict is deemed a process with antecedents and outcomes. The method of the study was a predictive nonexperimental survey that tested the theoretical model. The sample for the study included acute care nurses who were chosen from the College of Nurses of Ontario registry. Six hundred nurses were randomly selected from the College of Nurses of Ontarioregistry, but for the purpose of maintaining accuracy in estimates the number was decreased.

Almost et al. [24] used six different tools in the study. The Core Self Evaluation Scale [26] had 12 items, which used a 5-point Likert-typescale. The scale measured self-esteem, generalized self-efficacy, locus of control, and neuroticism. Almost and colleagues [23] reported that the scale had previously demonstrated a Cronbach’s alpha ranging from 0.81 to 0.87. The authors used the Unit Technology Scale[27], which had 21 items and used a 5-point Likert-type scale to measure the complexity of nursing care on the unit. The authors reported that the questionnaire previously had good reliability and validity [28].

The Interactional Justice Scale [29] measured interactional justice with 17 items, using a 5-point Likert-type scale. Roch and Shanock [29] showed the internal consistency of the instrument at 0.96 and had a principle axis factor that accounted for 48% of variability in scores. The Relationship Conflict Subscale from the Intra-Group Conflict Scale [30] measured disagreement, interference and negative emotion associated with conflict. The participants rated their level of agreement by usinga 5-point Likert-type scale. The Tucker-Lewis Index [31] score was 0.95, Comparative Fit Index score was 0.96, and the root mean square error of approximation (RMSEA) score was 0.08.

The conflict management style of the participants was measured by using the Rahim Organizational Conflict Inventory II ([ROCI–II]; [32]). Respondents used a 5-point Likert-type scale. Finally, job stress and job satisfaction were measured through the 6-item Perceived Stress Scale [33] and a4-item global measure of work satisfaction. The Perceived Stress Scale [33] reported a Cronbach’s alpha ranging from 0.83 [34] to 0.90 [35].

The antecedents of intra-group conflict were identified. When a conflict occurred, conflict management styles emerged. The methods for conflict management included agreeable styles and disagreeable styles [24].An agreeable style of conflict management was found to be an integration of one another’s ideas with a collaboration that led to a resolution. A disagreeable style of conflict management was considered to be one that avoided the conflict altogether [24]. The study identified individuals who worked in teams with high levels of conflict more often used conflict avoidance.

Almost et al.’s [24] model was analyzed by using structural equation modeling(SEM) techniques that are in the Analysis of Moment Structures Program within the Statistical Package of the Social Sciences (SPSS) version 16.0 [24]. The results of the study showed that dispositional, contextual, and interpersonal characteristics impacted intra-group conflict among nurses, which influenced conflict management style. Agreeable styles of conflict management were seen in the presence of these variables: high self-evaluation, low complexity of nursing care, high morale, and high interactional justice. The findings indicated a lower level of intra-group conflict. However, the results of the study were more complex than the authors’ original hypothesis. According to the findings, an agreeable style of conflict management is not enough to influence job stress and job dissatisfaction [24].

Additional findings suggested that a disagreeable style of conflict management, which included conflict avoidance and domination, was indicative of higher levels of conflict. Nurses who reported higher levels of conflict were much more stressed and felt overwhelmed on the job. The nurses who reported high levels of conflict and being overwhelmed at work were also dissatisfied with their jobs.

Almost et al.’s [24] research has relevance to the current study by describing barriers that prevent conflict resolution, with one being conflict avoidance. Research is necessary to determine the extent to which these barriers exist in nurse educators; only then can progress be made in the management of uncivil encounters.

Pearson and Porath [36] conducted a series of studies that examined the effects of workplace incivility on the behavior of targets, witnesses, and stakeholders. Their research included a combination of seven studies, six publications, and 12 academic presentations. Interviews, focus groups, questionnaires, and executive forums were used to investigate workplace incivility over the course of 2 years. In the first study, the authors met with a total of 670 employees, which included physicians, lawyers, judges, and administrators. The interviews focused on the characteristics and roles of the instigator and the behaviors and characteristics of the target.

The second study posed 16 open- and closed-ended questions to collect data from51 managers and 141 attorneys. The questions enabled participants to identify how they defined incivility, aggression, and violence [36]. An additional sample included 233 Fortune 500 employees, who were asked the same 16questions but were asked to include a personal experience with incivility.

The third study examined precursors, consequences, and contexts of incivility. Twenty-four law enforcement officers and 14 inner-city emergency medical personnel were interviewed. Following the third study, a two-day learning forum (the fourth study)was conducted with administrators and managers who dealt with workplace aggression. The forum was important for validating what the authors had learned from their previous efforts [36].

The fifth study collected data from individuals who worked in the pharmaceutical industry, telecommunications firms, and a mid-Atlantic business school. A total of 776 participants were polled about how incivility was experienced. The goal was to gain a better understanding about the emotional toll and the consequences of incivility [36]. In addition to questions about the emotional impact and consequences of incivility, participants were asked about the context of the issue. Thesis questions were framed to elicit responses about culture, norms, and tolerance for incivility (p. 17).

The seventh study collected data from 418 individuals that related to the instigator’s perspective. The authors shifted from an exploratory to an experimental method in order to examine participant responses to staged scenarios of incivility [36]. According to Pearson and Porath [36], uncivil behavior of individuals in the workplace “erodes organizational values and depletes organizational resources” (p. 7). The authors reported that employees who are targets of incivility employ disappearing behavior by missing work to avoid interactions with the instigator. In addition, employees who were targeted contemplated changing jobs to avoid a recurrence.

The research suggested that habitual instigators of incivility are often above reproach because of their position or status. A theme that continued to emerge was inequity, which was reported by participants who had witnessed instigators getting away with uncivil behaviors. The lack of repercussions for instigators spawned an increase in the level of incivility to aggression. Pearson and Porath [36] suggest that men are better equipped to address aggressive behavior while women rely on coping strategies. The authors reported that women tend to disappear in response to conflict and avoid taking any aggressive posture.

Pearson and Porath [36] suggest that female targets of incivility avoid the instigator and prefer to confide in friends outside of the organization. The study finding is significant because it echoes that of Valentine [17]. The authors cited three potential outcomes of incivility including: resolution through reciprocal exchanges, escalation of the intensity of behaviors, and withdrawal of both parties from the exchange, by walking away. Escalation leads to increased aggression, which can lead to physical violence [36].

The research draws parallels between targets of incivility and the development of coping strategies. Pearson and Porath [36] suggest a need for further research to determine whether nurse educators are avoiding conflicts with nursing students who commit acts of incivility.

4. Perceptions about Incivility

Clark and Springer [2] used an interpretive qualitative method to examine student and faculty perceptions about incivility in nursing education. The research was conducted through the use of quantitative and qualitative methodologies from faculty and student perspectives. A sample of 36 faculty members and 467 students from a metropolitan public university was used. The participants were emailed the Incivility in Nursing Education Survey (INE) survey [37], which included four open-ended questions intended to gather perceptions of nurse educators and nursing students.

The reliability of the INE [37] was calculated using Cronbach’s alpha, which yielded a result of0.68 to 0.88 for students and 0.70 to 0.94 for faculty. The respondents included 15 of the 36 faculty (41.6 %) and 168 of 467 nursing students (35.9 %). The authors each independently reviewed the qualitative portions of the survey and identified emerging themes.

The first question of the INE [37] asked nurse educators and nursing students to identify uncivil classroom behaviors among nursing students. Clark and Springer [2] reported that nurse educators identified the following behaviors as uncivil: challenging professors about test scores, dominating class discussions, carrying on side conversations, and sighing to show dissatisfaction were all considered uncivil behaviors. Some out-of-class behaviors identified by faculty were discrediting faculty, turning in assignments late, sending faculty inappropriate emails, and not keeping scheduled appointments.

Students and faculty identified the causes of incivility as related to the high-stress environment. Both nurse educators and nursing students perceived incivility as a problem. Contributing factors included stress, disrespect, faculty arrogance, and a sense of entitlement on the part of students [2]. The study was paramount for identifying the perceptions held by nurse educators and nursing students. Further, the study has relevance for the current study through its identification of perceptions about nursing student incivility among nurse educators.

Clark [1] sought to further identify perceptions of nurse educators and nursing students.

In the research study, Faculty and Student Assessment of and Experience with Incivility in Nursing Education [1], a convenience sample was drawn from 504respondents in 41 states. The participants included 194 nurse educators and 306 nursing students. One of the questions included in the study was related to the student behaviors that were considered to be uncivil by nursing faculty and students. In response to the question, the author reported that 75.5% of the faculty identified holding distracting conversations as uncivil, 71.9 % believed that using the computer for activities other than classwork was uncivil, and 74.7 % cited demanding make-up tests and grade changes as uncivil behaviors (p. 461). Further, nursing students identified the same behaviors as uncivil, but in higher numbers: 79.9% of students identified holding side conversations as uncivil,81.5% felt that using the computer for activities other than classwork was uncivil, and78.2% believed that demanding grade changes and make-up examinations was a form of incivility. An interesting finding was that only 58.8% of students considered cheating to be a form of incivility, while 69.9% of nurse educators found the behavior uncivil. Overall, the author suggested that nurse educators are more sensitive to incivility because of the disruption to class.

The relevance for the current study is that both nurse educators and nursing students perceive the same student behaviors as uncivil. Perceptions of nursing student incivility among nurse educators will be examined in the current study as well as the relationship between those perceptions and coping responses.

5. Effects of Incivility

Clark [38] examined the perceptions of incivility between nurse educators and nursing students. The qualitative study, The Dance of Incivility in Nursing Education as Described by Nursing Faculty and Students [38], has relevance for this research and provides evidence of how the incivility of nursing students leads to an environment of disrespect, ineffective communication and stress. A convenience sample was used to ascertain the perceptions of incivility among 125 nurse educators (43.3%) and 164 nursing students (56.7%) who were in attendance at two separate national conventions.

The respondents self-administered the INE [37], which consisted of 48 faculty and student behaviors and four open-ended questions designed to garner perceptions about incivility. The data collected from the INE [37] were analyzed through an interpretive, qualitative method in which narrative responses were transcribed and entered into an Excel data file. The transcripts were read numerous times in order to determine similarities among responses. The similarities were then put into categories and compiled into broader themes. An independent researcher was enlisted to review the themes. Finally, the researcher and the independent researcher came together to ensure the analysis was a good representation of the respondents’ comments. Responses were divided into themes, and the results were presented as aggregate data.

The finding by Clark [38] echoed that of Luparell [4] and included evidence that incivility among nursing students was an antecedent to the physiologicalsymptoms (e.g., stress) experienced by nurse educators. According to Clark [38], uncivil encounters jeopardize the welfare of faculty and ravage the environment of care (p. E37). Further, Clark [38] cited incivility as leading to poor patient care and decreased productivity while taking a significant toll on those affected. The author suggests that incivility has multiple consequences for the target, which has relevance to the current study. The current study uses a model that depicts negative stress as an antecedent to nurse educators’ coping responses.

A groundbreaking study [5] examined the role of stressful encounters on cognitive appraisal, coping, and encounter outcomes. Folkman, Lazarus, Dunkel-Schetter, DeLongis, and Gruen [5] explored how the psychological stress of uncivilen counters influenced encounter outcomes. The authors used an intra-individual method to compare participants with themselves across five uncivil encounters. The goal of this approach was to identify shifts that would differ from the participant’s usual appraisal and coping style in order to recognize relationships between each other and the outcome of the uncivil encounter. The authors examined the relationship between primary and secondary appraisal and coping.

Folkman et al. [5] obtained samples from 85 married couples living in Contra Costa County, in California. The participants were interviewed in their homes on amonthly basis, for six months. The interviews were structured and designed to elicit responses about the most stressful encounter the individual experienced each week. Different interviewers talked with the couples at each meeting, but attempts were made to conduct the interviews at the same time. The data reported in the study were collected from the second through sixth interviews.

An assessment of primary appraisal was conducted through 13-items on a Likert-type scale, that measured the various stakes of stressful encounters. The WCQ [9] examined coping through a range of strategies. Secondary appraisal evaluation was assessed through four coping options, but the researchers identified items on the scale as potentially biased toward unskilled forms of confrontation. Finally, outcomes of the stressful encounters were assessed through self-reporting. The participants identified whether the encounters were resolved, not resolved to their satisfaction, unchanged, or unresolved or worse. The study findings suggest that an individual’s judgment about what was at staked etermined the coping strategy.

Stressful encounters that involved concern over well-beingor a loss of self-esteem led to distancing and a lack of problem solving within encounters. An association between attempts at self-control and delaying action was drawn [5]. In addition, uncivil encounters deemed to have unsatisfactory outcomes were linked to confrontational strategies such as standing one’s ground, while satisfactory outcomes were identified with planned problem solving. Statements such as “I knew what had to be done, so I made a plan and followed it” were associated with resolution and satisfactory outcomes [5]. The authors suggested that a functional relationship exists between cognitive appraisal and coping variables and the outcomes of uncivil encounters. In addition, the authors found stressful encounters to have negative consequences for individuals, based on anindividual’s appraisal of the situation and chosen coping mechanisms.

The limitations of this study included an association between unsatisfactory outcomes and confrontation of the uncivil behaviors. The strength of the study was its ability to show relationships between the appraisal of a stressful encounter and the choice of coping strategy with encounter outcomes. The authors suggest a need for research that examines the way individuals deal with stressful encounters in the short and long-term.

The importance of this study includes evidence that stressful encounters activate coping mechanisms, such as distancing, which impact encounter outcomes. The study has relevance to the current research because of its ability to draw a correlation between uncivil encounters and the activation of coping mechanisms.

6. Human Subject Protection

The participants of the study were provided with the benefits of the study, which included the fact that knowledge would be gained about nurse educators’ coping responses and perceptions about nursing student incivility. The risks of the study were outlined for the participants and included no exposure to any physical, mental, or psychological risk. No invasive procedures, altered states of consciousness, or stressful situations were used in the study. Participants were informed that there would be no anticipated long-term physical and minimal (if any) long-term emotional or psychological effects from participating in the study. Participants were told that they may experience some degree of emotional distress when relating experiences with nursing student incivility.

Confidentiality was maintained throughout the time frame of the study. Neither the participants’ names nor the names of the participating schools were identified. No participant names were known. Numbers were attached to each completed survey and only the researcher had access to the surveys. The collected data were kept in a locked cabinet to which only the researcher had a key. No notes or documents containing identifiers were collected. Records will be destroyed five years after the conclusion of the study.

Participants were informed that involvement in the study would be completely voluntary. If a participant decided not to participate there were no negative consequences. Participants were also told that they could stop participating at any time and may decide not to answer specific questions without any risk to self. Participants were informed that completion of the surveys denoted informed consent.

Prior to collection of any data, an Institutional Review Board form was submitted to William Carey University and the three selected universities’ schools of nursing. The investigator completed the National Institutes of Health’s (Web-based) Human Subject Protection Training and received a certificate.

7. Procedure for Data Collection

Following receipt of Institutional Review Board Approval from all of the chosen institutions, a letter was drafted and sent to the deans of the selected universities’ schools of nursing to request permission to collect data. Collection of participant data began following receipt of permission from the three study schools. The participants were provided with electronic consent forms and instructed that completion of the surveys denoted voluntary participation. Participants were provided with information about human informed consent and told that there were no anticipated long-term physical effects and minimal (if any) long-term emotionalor psychological effects from participating in the study. Participants were told that they may experience some degree of emotional distress when relating experiences with nursing student incivility.

Quantitative data was collected from nurse educators through the self-administration of the INE-R [8] and the WCQ [9]. Nurse educators in the southern region of the United States was surveyed. The surveys were linked in the body of an email that was sent to nurse educators by the deans of the selected universities’ schools of nursing. Qualitative data was derived from the responses that participants provided to the four open-ended questions on the INE-R [8]. The responses were used to clarify questions that arose in the quantitative phase of the study. The qualitative phase of the research design supported Lazarus and Folkman’s [7] Transactional Model of Stress and Coping by allowing nurse educators to expound upon their experiences with incivility, as well as the coping responses employed.

8. Instrumentation

The INE-R survey [8] consists of 24 items related to student behaviors using a Likert-type scale and four open-ended questions. No demographic information was collected from the participants. All the responses were collected anonymously. The four open-ended questions of the INE-R [8] were analyzed from the nurse educators’ point of view for the occurrence of themes. The themes were then characterized into categories; the categories were then coded in order to show the relationship between nurse educators’ perceptions of nursing student incivility and coping responses. Participant responses were entered into an Excel spreadsheet, which was housed with the researcher and locked in a secure cabinet. Only the researcher maintained a key to the cabinet. The Excel spreadsheet was secured on a password-protected flash drive maintained only by the researcher.

The WCQ (Folkman & Lazarus [9]) was also linked in the body of an email that was sent by the deans of the three selected universities’ schools of nursing to the nursing faculty. The link to the questionnaire was administered using secure Web-based technology (Survey Monkey). The WCQ [9] provided responses to 66 items using a Likert-type scale. All of the responses were collected anonymously and the data collected from the respondents was entered into an Excel spreadsheet for compilation. The data collection process for the WCQ [9] was the same as that of the INE-R [8] and included collecting responses to the 66 items on the questionnaire. All the responses were entered into an Excel spreadsheet, which was ill be housed with the researcher and locked in a secure cabinet. Only the researcher maintained a key to the cabinet. The Excel spreadsheet was secured on a password protected flash drive maintained only by the researcher.

Figure 1. Model of Nurse Educators’ Processes for Developing Perceptions of Incivility and the Activation of Coping Responses (Adapted from Glanz, Rimer, & Lewis [39])

9. Results

Descriptive statistical analysis was conducted to address the 2 research questions and hypothesis of the study. Findings included that the coping strategies with the highest mean scores were daydreaming or imagining a better time or place than the one they were in (M = 2.09; SD = 1.04); analyzing the problem to understand it better (M = 2.06; SD = 0.71); jogging or exercising (M = 2.00; SD = 0.83); talking to someone to find out more about the situation (M = 1.47; SD = 0.84); making and following a plan of action (M = 1.89; SD = 0.85) and reminding themselves how much worse things could be (M = 1.69; SD = 0.98). With regard to the participants’ perceptions about incivility, the expressions that were ranked the highest were making condescending remarks towards others (M = 2.59, SD = 0.82); making discriminating comments (racial, ethnic, gender-based, etc.) towards others (M = 2.59, SD = 0.88); cheating on exams or quizzes (M = 2.56, SD = 0.99) and using profanity (swearing or cussing) directed towards others (M = 2.54, SD = 0.91). The results of the correlational analysis did not indicate a statistically significant relationship between the coping responses to and perceptions about incivility. Thus, the null hypothesis for the study was accepted.

Table 1. Descriptive Statistics Analysis Results Central Tendency – Coping Strategies

Table 2. Descriptive Statistical Analysis Results Central Tendency – Level of Incivility

Table 3. Correlational Analysis Results - Incivility vs. Coping

Table 4. Most Significant Consequences of Incivility

Correlational analysis findings included that the top three perceived solutions for combating uncivil behavior were role-modeling professionalism and civility; establishing codes of conduct that define acceptable and unacceptable behaviors; and the developing and implementing comprehensive policies and procedures to address incivility. Similar to the uncivil behaviors experienced in the quantitative method, the top three issues to emerge among the qualitative results were disrespectful remarks and actions; disruptive behaviors inside the classroom such as talking loudly and use of gadget; poor attendance; and cheating on exams. As a consequence of these behaviors, nurse educators observed a poor learning environment, which was seen as having a larger effect of producing unprepared and unprofessional nurses after graduation. Participants believed that to stop the negative impacts of incivility, nurse educators and academic institutions should promote increased awareness of civility standards and expectations.

10. Triangulation of the Quantitative and Qualitative Findings

Study findings revealed that in both the quantitative and qualitative portions of the study the following results emerged: (a) making condescending remarks toward others (quantitative) and using disrespectful remarks and actions (qualitative); (b) Talking loudly and using a computer, phone, or other media device for activities unrelated to class (quantitative) and engaging in disruptive behaviors inside the classroom (qualitative); (c) arriving late for class or other scheduled activities (quantitative) and having attendance issues (qualitative); (d) cheating on exams or quizzes (quantitative) and cheating (qualitative). Unfortunately, the most commonly occurring themes for combatting these issues of nursing student incivility were: (a) daydreaming or imagining a better time or place than the one they were in; (b) analyzing the problem to understand it better; (c) jogging or exercising; and (d) making and following a plan of action.

The researcher found that nurse educators believed that there were three effective solutions for addressing issues of incivility: (a) role-modeling professionalism and civility, (b) establishing codes of conduct that define acceptable and unacceptable behaviors, and (c) developing and implementing comprehensive policies and procedures to address incivility. However, these strategies were not reported in the quantitative section of the study. Nurse educators strongly agreed that if issues of incivility were not addressed, the result would be a poor environment of learning. In addition, participants believed that a poor learning environment would lead to unprepared and unprofessional nurses, following graduation. Finally, most of the nurse educators who participated in the study believed that incivility could be minimized, by increasing nursing students’ awareness of institutional expectations for civil behaviors. Based on the two methods of study, differences were found in the results of the first research question. Research question one asked about the strategies study participants used to cope with uncivil situations. In the qualitative findings, nurse educators did not define the coping strategies used, but rather identified the most effective methods to make the situation better.

Upon analysis, the quantitative and qualitative methods had corresponding results for the top three incivility actions observed or encountered. Both quantitative and qualitative analysis findings revealed that students frequently display unruly and disrespectful behaviors while inside the classroom including poor attendance habits, talking loudly in class, not paying attention, using cell phones or other gadgets, and cheating on exams. Through analysis, it was reinforced that the three most frequently encountered uncivil behaviors, as identified by nurse educators, appeared as the top three concerns of the nurse educators in both methods of the study. These triangulated findings prove the need for strategies to combat issues of nursing student incivility, with assistance for nurse educators.

A major difference in the study findings was that nurse educators included concrete plans for managing incivility in the qualitative section whereas only the coping strategies nurse educators used to manage their emotions were reported in the quantitative section. In the qualitative section, the researcher found that nurse educators experienced a poor learning environment and agreed that the promotion of awareness of academic incivility should be promoted, with clear conveyance of the nurse educators’ and institution’s behavioral standards. A comparison of quantitative and qualitative findings can be found in Table 5.

Table 5. Triangulation of Quantitative and Qualitative Findings

11. Conclusions

Nurse educators in the southern region of the United States reported their perceptions of nursing student incivility, the coping responses employed when faced with incivility, and the measures they believed were necessary to combat the issue. Based on the results of the study, nursing student incivility is a problem that persists and causes stress for nurse educators; affecting their coping responses and ability to combat the issue. For this reason, it is necessary to consider the problem from the nurse educators’ vantage point, with provisions of additional support for nursing faculty.

12. Discussion

Lazarus &Folkman [7] described coping as having two functions: the regulation of emotions or distress and the management of the problem that is causing the emotions or distress. Stress, like that experienced with incivility, impacts an individual’s perception of the encounter and has been linked to the development of negative coping responses [5]. Lazarus and Folkman’s [7] Transactional Model of Stress and Coping postulates that through primary appraisal of a stressful situation, an individual determines the threat level of an uncivil encounter. If the individual determines that there is no threat, no action is taken. A secondary appraisal takes the place of the available coping mechanisms, when a threat is perceived. Available coping mechanisms are considered and are either employed to combat the issue, or negative stress results. These concepts are the foundation of this study and add credence to the study finding. If Lazarus and Folkman’s [7] model was correct, nurse educators who participated in this study conducted a primary evaluation of the uncivil behavior encountered and determined that either the threat level of uncivil encounters were minimal, or they determined that they were not equipped to manage the issue. Certainly, making disrespectful comments, using gadgets while in class, and disrupting lectures by talking does not pose an imminent threat of physical harm, but these behaviors do disrupt the environment of learning.

Nurse educators in the study identified a poor environment of learning as a consequence of incivility. In addition, participants of the study reported that this poor environment of learning would ultimately lead to unprepared graduate nurses and poor care of clients in the future. These findings indicate that participants of the study recognize the monumental impact of incivility for not only the environment of learning, but the care of clients. Why then would nurse educators employ coping strategies that does not focus on maintaining a civil environment?

This research study provides evidence that nurse educators facing nursing student incivility employ coping mechanisms that regulate only the emotions or distress experienced with an uncivil encounter. Problem-focused coping responses, which are necessary for the management of academic incivility, were not the first choice of participants. Instead, the types of responses reported were characteristic of negative coping responses like conflict avoidance. Therefore, based on Folkman et. al. [5] nursing student incivility = stress for nurse educators = perceptions of incivility that are impacted by stress = negative coping responses, like conflict avoidance. Negative coping responses are a major barrier in combatting academic incivility.

Luparell [4] found that nurse educators physically and emotionally disengaged when facing uncivil behaviors. The author suggested that nurse educators work through any cynicism, look for the good in others, and when faced with incivility, avoid responding in a way that would escalate the issue. The very nature of nursing is grounded in caring, as a hallmark of the profession; Therefore, nurse educators may find confronting issues of incivility as aggressive in nature. This could explain why the majority of participants in the study chose daydreaming about a better time and place than the one they were in, as the best coping response to incivility. It enabled the individual to disappear in their mind. Pearson and Porath [36] suggest that women do tend to disappear in response to conflict and avoid taking an aggressive posture.

Perhaps academic incivility has grown so commonplace that nurse educators’ cognitive appraisals of uncivil events include normalizing inappropriate behaviors. A study finding that speaks to this is that 59.8% of nurse educators report that nursing students use computers, cell phones, or other devices in the classroom, for activities other than class activities. In a world where many people are anchored to computerized devices, nurse educators may find that addressing the problem would be a battle not worth fighting. Therefore, an appraisal is made to ignore the issue and coping mechanisms would be activated that aid in managing the emotions felt by the nurse educator, rather than the event. This type of appraisal would only propagate the issue and the outcome would be reinforcement of the inappropriate behavior, not combatting the issues. This calls attention to the vital need for civility programs that offer ongoing training for nurse educators.

The American Nurses Association (ANA; [40]) addresses the need for ongoing training and support to assist employees dealing with incivility. The ANA [40] Position Statement on Violence in Healthcare includes the following recommendations: (a) provide a mechanism for nurses to seek support when feeling threatened, (b) inform employees about available strategies for conflict resolution and respectful communications, and (c) offer educational sessions on incivility and bullying, including prevention strategies. The addition of these recommendations to current programs that target issues of incivility could improve the coping strategies employed by nurse educators.

The findings of this study included evidence that the top three expressions of incivility, as perceived by study participants, were disrespectful remarks and actions, disruptive behaviors inside the classroom such as talking loudly and use of gadgets, and attendance issues. Other studies have identified similar issues. In a study by Clark and Springer [2], participants reported holding distracting conversations, using the computer for activities other than classwork, and demanding make-up tests and grade changes as uncivil behaviors (p. 461). Clark and Springer [2] reported that nurse educators identified the following behaviors as uncivil: challenging professors about test scores, dominating class discussions, carrying on side conversations, and sighing to show dissatisfaction were all considered uncivil behaviors.

The behaviors identified by participants in the current study are similar to, and in some cases identical to, the issues identified in past studies. In example, holding side conversations, talking loudly, or holding distracting conversations are common among Clark & Springer [2], and the current study. The use of gadgets in the classroom, for a purpose other than classroom activities, is another common occurrence found in the literature. Participants in the current study reported this problem as well. Important nursing knowledge never reaches the student when they are engaged in the use of gadgets, or holding side conversations. This is troubling in light of the setting, which is intended to prepare future nurses to deliver safe, quality care to the community.

Participants in the research study identified the consequences of uncivil behavior among nursing students as an antecedent to a poor learning environment. This was seen as having an even bigger effect of producing unprepared and unprofessional nurses after graduation. In a study by Clark [1] participants identified incivility as leading to poor patient care as well as decreased productivity. An additional effect could be the loss of public trust and the loss of caring as a hallmark of the profession of nursing. The effects for society could be catastrophic as poor outcomes are experienced by clients. These consequences underscore the need for programs that promote civility and protect the environment of learning. 

The top three strategies chosen by study participants for combating uncivil behaviors were role-modeling professionalism and civility; establishing codes of conduct that define acceptable and unacceptable behaviors; and developing and implementing comprehensive policies and procedures to address incivility. Cortina & Magley [14] suggested that employees do not typically draw support from supervisors, but rather use coping strategies to manage problems. The current study finding provides evidence that the coping strategies most likely used by nurse educators are ineffective and not problem-focused. Today, most institutions of learning have civility programs in place, but are they being employed by nurse educators in the management of uncivil behaviors? Additional research is needed to determine whether nurse educators make use of civility programs, and if not, why? The best efforts at academic civility can be futile if nurse educators’ strategies for managing the problem are not effective. Positive coping responses that address academic incivility are necessary in order to maintain a civil, effective learning environment.

This study proved a need to modify existing programs to combat nursing student incivility with additional support for nurse educator’s. In addition, the need to protect the integrity of the profession of nursing, from a culture of incivility was identified. Finally, and most importantly, a crucial barrier in the management of incivility was identified, in less problem-focused coping among nurse educators. The future of nursing education requires purposeful dialogue and continued research to address this ongoing issue.

13. Recommendations

The implications for nursing practice include the potential to greatly improve programs designed to combat incivility, through additional training and support for faculty. The use of negative coping responses among nurse educators should be a considered an integral part of program development. Based on this study, schools of nursing, clinical practice environments, and professional organizations should take measures to protect the integrity of the profession of nursing, from uncivil behaviors.

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