Incivility experiences of nursing students in South Korea

Abstract

Background:

Incivility behaviors are negative social behaviors that can create conflict and disrespect among the persons involved. In a learning environment, incivility negatively affects learning by reducing academic motivation, lowering satisfaction with the education program, and interrupting the learning process. In addition, incivility causes those involved to feel negative emotions, such as anger, depression, and anxiety.

Research question:

What are the incivility experiences of nursing students during their nursing education? In what context do nursing students experience incivility during their education?

Research design:

This study used an exploratory qualitative methodology.

Participants and research context:

Participants (n = 34) were nursing students at three universities in South Korea. Data were collected during focus group interviews of 34 participants between 20 March and 26 June 2015 and were examined using a qualitative content analysis.

Ethical consideration:

The institutional review board approved this study.

Findings:

The analysis revealed four learning contexts in which participants experienced incivility: (a) in the classroom, (b) outside the classroom, (c) clinical settings, and (d) related to technology use. Five themes were identified: student non-adherence to classroom standards, faculty non-adherence to classroom standards, lack of helping-trusting relationships with peers, lack of dedication to teaching and learning in a clinical setting, and inappropriate use of technology.

Conclusion:

Nursing students experience incivility in a variety of situations and settings and expect a safer, more positive learning environment. The incivility experienced by nursing students during their education affects their goal of becoming professional nurses.

Keywords

Communication technology focus groups incivility experience learning environment nursing student qualitative research

Introduction

Negative social behaviors in nursing and the impact of these behaviors in educational and clinical sectors are garnering much attention in the profession.^1,2 Specifically, incivility is defined as uncivil behavior that creates conflict and disrespect in the learning environment and causes psychological and physiological distress to the targeted person.³ Incivility also encompasses the violation of etiquette or manners and deviance from societal norms. A study of American nursing students showed that 35% had been involved in uncivil or unkind interactions with peers, and 60% had experienced uncivil behavior from a clinical instructor.⁴ In China, incivility in nursing education leads to serious problems, such as a lack of mutual respect between faculty and students, poor communication related to a generational gap, and a perceived lack of quality in students and teachers.³

In South Korea, a strong relationship exists between sunbae (seniors or upperclassmen) and hoobae (juniors) within the same major or same school. Although this relationship has positive aspects, such as promoting bonding and advice regarding a course of study or a school issue, it can translate as “you must do what the sunbae says.” In Moon’s study, 81.8% of nursing college students (N = 280) experienced verbal abuse from their friends (26.2%), leaders (14.0%), but mostly from sunbae (48.6%) on the campus, outside of school, and in cyberspace.⁵

Nursing is a professional program bound by the Code of Ethics for Nurses suggested by the International Council of Nurses (ICN).⁶ Nursing education in South Korea also reflects the Korean Nurses Association code of ethics, which is based on the ICN’s norms of conduct.⁷ Nursing ethics is a required core course in the nursing curriculum of all nursing schools in South Korea. In addition, all junior nursing students in most nursing schools in South Korea sign a pledge at the annual Nightingale Ceremony to uphold the standards and high ethics of the nursing profession. Nursing students expect caring relationships with their teachers.⁸ However, incivility in the learning environment can impede the human caring relationship as well as the learning process by reducing academic motivation among students and lowering satisfaction with the education program.^9,10 Besides, it can reduce the safety of clinical practice by causing disengagement from hospital settings and obstruct professional development by affecting self-esteem and self-efficacy.^8,11 Incivility also causes the targeted person to feel angry, depressed, and anxious, resulting in withdrawal from social experience.^12,13 Students who act unethically in the classroom and clinics are more likely to behave unethically in their practice.¹⁴

Advancements in electronic technologies have dramatically affected the learning environment. Online social media platforms facilitate collaboration and information sharing among students and enhance students’ learning outcomes.¹⁵ However, despite their merits, both students and teachers may experience incivility due to potentially uncivil content found on social media.¹⁶ It is also noteworthy that cyberbullying, a form of incivility in cyberspace, can lead to emotional, physical, and social complications for those affected.³

The education curriculum of South Korean nursing students is more homogeneous than that of students in other majors because nursing students spend most of their time as a cohort listening to lectures and undergoing clinical rotations during the program. Students in class remain together in clinical practice, and good communication among them is particularly important. Therefore, when a nursing student experiences uncivil behavior during their interactions with peers or faculty members, achieving distance from the aggressor or situation can be difficult and it is hard to avoid the negative effects of uncivil behavior. Because incivility influences a student’s behavior toward others and impacts their defined sense of morality, personal integrity, and ethical conduct, incivility in nursing education has important professional consequences.¹⁷

Studies of nursing education have focused on uncivil behavior, the development of instruments to measure and quantify incivility, the factors giving rise to incivility among students and faculty, and incivility of instructors and staff nurses in the clinical setting.^{2
–4,17

–20} Although incivility in nursing education is a serious problem, few studies have explored incivility in this setting, and only one study has examined cyber incivility among South Korean nursing students.

Person-to-person incivility is, like other human behaviors, a dynamic and reciprocal process, but the nature of incivility among nursing students has been largely unexplored.^17,21 The purpose of our study was thus to explore nursing students’ incivility experience during their education inside and outside the classroom and in clinical practice. The theoretical framework used to guide this study was Watson’s human caring theory and the Code of Ethics for Nurses.^6,22 The human caring theory addresses human-to-human relationships that create meaningful and authentic interactions within the educational learning environment.²² The findings of this study will be useful to improve the overall quality of nursing education and to establish a safe and positive learning environment for students.

Methods

Design

Following Gadamer’s approach,²³ the researchers used an exploratory qualitative design to describe the incivility experiences of nursing students during their education. Our preunderstanding is based on nursing experiences in clinical and classroom teaching.

Participants

Recent graduates (completed degree <2 months prior), juniors, and seniors in nursing school were eligible for the study. Students were recruited via bulletin boards in classrooms and in the e-café for graduates from three universities located in three different provinces in South Korea. Research assistants visited classes and informed students about the research. The 34 participants in the study consisted of five graduates, five juniors, and 24 seniors. All participants were female, and their mean age was 22.24 years (±0.89), ranging from 20 to 24 years.

Data collection

Data were collected during focus group interviews conducted by study researchers with expertise in qualitative research and extensive experience with in-depth interviews and counseling. The researchers recorded field notes regarding participants’ facial expressions and nonverbal responses. The focus group interviews comprised 5–10 participants and were conducted in a quiet room in each school by a researcher who had not participated in assigning grades for academic achievement. Interviews were tape recorded with the permission of the participants. Each session lasted 60–150 min, depending on the group size. To ensure homogeneity of the focus group interviews, the same series of interview questions related to the central question: “What uncivil behaviors have you experienced from peers, faculty members, or clinical practice instructors?” and “In what context do you experience incivility?” were formulated (see the interview guide, Table 1). Participants were informed about the tape recording when given the guidelines before starting the questions.

Table 1.

Examples of interview guide questions.

Introductory: When you hear the word “incivility,” what comes to your mind?

Main (key) questions:

What uncivil behaviors have you experienced from peers, faculty members, or clinical practice instructors?

What do you consider as uncivil behaviors from educators or peers in class or clinical practicum?

What do you think are the common reasons for incivility to occur in the nursing education environment?

What do you think are the consequences of incivility in nursing education?

Probing questions:

Please tell me more about that.

Please give me an example.

Ending: Is there anything that you would like to add?

Data analysis

Qualitative content analysis was used to examine the data obtained during the focus group interviews. The data analysis was conducted immediately after the interviews were transcribed verbatim, according to the content analysis procedures.^24,25 We read each transcript several times to familiarize themselves with the content of the interview, to get a sense of the entire interview, and to make sure that they fully understood the content. All significant units in the interviews related to incivility experiences were identified and coded. After the codes were identified, they were grouped into subthemes based on similarities and differences in meaning. These subthemes then clustered into more abstract themes. Five themes were extracted from 135 codes and 12 subthemes.

The criteria suggested by Lincoln and Guba²⁶ were used to ensure trustworthiness of the study. The credibility of the research findings was established with member checking and peer debriefing. Dependability was achieved by checking the consistency of the findings. Transferability was ensured via thick descriptions of research process. For confirmability, we created an audit trail regarding the raw data and inquiry process.

Ethical consideration

This study was approved by the Institutional Review Board of University Medicine Hospital (ooH 2015-01-013). All participants were informed about confidentiality and anonymity issues and that the interviews would be tape recorded before the start of the focus group. Written consent was obtained from all participants who were assured that they could leave the discussion whenever they wanted and withdraw from the study at any time without penalty. To ensure anonymity and confidentiality, all interview data, related descriptions, and recorded files were stored on the hard drive of a password-protected computer shared only by the authors; backup files were secured in locked file cabinets.

Findings

The participants reported having experienced incivility in the classroom, outside the classroom, and in clinical settings, as well as incivility related to technology use. Five themes and 12 subthemes were extracted (Table 2). The themes were (a) student non-adherence to classroom standards, (b) faculty non-adherence to classroom standards, (c) lack of helping-trusting relationships with peers, (d) lack of dedication to teaching and learning in the clinical setting, and (e) inappropriate use of technology.

Table 2.

The themes and subthemes of the incivility experiences of nursing students.

Themes	Subthemes
Student non-adherence to classroom standards	Lack of commitment to academic performance Lack of self-reflection on one’s own misbehavior
Faculty non-adherence to classroom standards	Lack of commitment to faculty roles and responsibilities Neglect of students’ self-worth
Lack of helping-trusting relationship with peers	Taking advantage of peers’ work Mistreatment of hoobae by sunbae or upperclassmen
Lack of dedication to teaching and learning in clinical setting	Poor role models Lack of respect for student nurses Lack of engagement to clinical learning
Inappropriate use of technology	Privacy breaches through social media Lack of netiquette or e-manners Technology-facilitated academic misconduct

Incivility in the classroom

Student non-adherence to classroom standards

Lack of commitment to academic performance

Participants reported that incivility was a problem in the classroom. The most common uncivil behaviors included sleeping during class, putting on make-up during class time, tardiness, and disrupting class by conversing with friends. Other examples were a lack of sincerity in the classroom or in academic achievement, as exemplified by doing class work for other subjects while in the classroom and submitting homework late. Participants perceived uncivil behavior among students in the classroom as a lack of commitment to academic performance:

Sincerity and punctuality are very important for a professional nurse. For example, being late to class, even for an examination, is a problem. If students graduate from college and work in a hospital without addressing their uncivil behavior, it might lead to more serious problems.

Lack of self-reflection on one’s own misbehavior

Participants noted other students’ uncivil behavior and lack of self-reflection but were unaware of their own uncivil behavior. Participants also reported incivility related to exams or grades, such as emailing professors to request higher grades, and dishonest behaviors, such as making memos on the desk before the exam, or cheating during the exam. Participants complained that the students perpetrating these behaviors did not care about their negative impacts on others. Examples of typical students’ comments were as follows: “During class, [students are] using cell phones (smartphones) or texting”; “another problem is that some students disrupt the learning atmosphere in the classroom by using computers for non-class activities (not doing so secretly)”; “more freedom is permitted to college students because they are adults. However, they act immaturely. Maybe their ego is not well developed. Many students do not act responsibly and fail to take responsibility for their own learning.”

Faculty non-adherence to classroom standards

Lack of commitment to faculty roles and responsibilities

Common faculty-related incivility experienced by participants included a lack of professional responsibility and accountability, tardiness for class, not being well prepared for class (overreliance on the textbook or preparing only a PowerPoint presentation that copied the textbook), talking too much about personal matters, and dismissing the class too early or too late. Participants also felt that several uncivil behaviors of faculty members reduced credibility and trust in them. For instance, a faculty member announced that a grade of A, B, C, or D would be assigned for the course. Instead, they submitted “pass/fail” final grades. The professor believed that this deception was a harmless way of making students study harder, but when students discovered the real intention, they were disappointed and it lessened the credibility of the professor and the students’ overall trust in the faculty:

A trusting relationship with the professor is very important. My professor informed me that she would check the assignment. So, I worked hard during the holiday to finish. However, the professor never checked the assignment. She lied to make the students work harder. I understood the professor’s intention. However, I felt fooled and was very discouraged.

Neglect of students’ self-worth

Participants felt that some faculty behaviors contributed to fostering a negative culture that diminished students’ sense of self-worth. Those behaviors included talking sarcastically to students in front of others, belittling them, and treating students with good grades with respect while picking on lower performing students. Uncivil behaviors that disregard students’ personalities or uniqueness included ignoring or scolding students in front of others during class. Some faculty members treated students as if they were stupid and made condescending, rude remarks. Typical student comments were “The professor accused a student by looking at their test paper and saying: ‘Why did you have so many incorrect answers? Did you study?’”; “professors believe that a low score means that the student did not study at all”; “the way professors talk about my score, comparing me with a person who achieved a good score, and look down on me because of a poor score makes me feel guilty (horrible).”

Incivility outside the classroom

Lack of helping-trusting relationships with peers

Taking advantage of peers’ work

Participants reported that the following behaviors showed taking advantage of peers’ work: freeloading (i.e. not doing one’s share), lowering team scores by not sufficiently preparing for group activities in team projects, not putting sufficient effort into group activities, and avoiding responsibility for group projects. Participants perceived communication among team members as very important, particularly in group work. Behaviors that cut off communication channels necessary for group projects were also considered uncivil. These behaviors included cutting off contact intentionally, not responding to messages (or not answering the phone), and intentionally not checking KakaoTalk (i.e. instant messaging application similar to Facebook Messenger or WeChat) text messages (despite knowing that group members were using the app for communication). Students commented as follows:

KakaoTalk is a convenient channel for group chatting and communication during a group project. However, some team members intentionally or unintentionally do not read the messages, so we had trouble with group work.

It was an important day for us because we had to decide on the topic for our group project. One of our group members, who did not participate in the discussion for several hours, responded later that she fell asleep after dinner [rather than participate in the group meeting]. Some people do not work well with others and show no interest in achieving group goals.

Mistreatment of hoobae by sunbae or upperclassmen

Participants reported that sunbae, particularly male senior students, made unreasonable demands by forcing juniors to drink alcohol during college group (club) meetings, perform in talent shows, be excessively polite and courteous to them, and participate in membership training without respecting personal circumstances. Participants commented that sunbae should respect individual boundaries, including those of younger students. Among the comments of the students were

A sunbae I saw for the first time said: “Do you want to be in trouble with me?” I had heard about the severe discipline in nursing schools before and was wondering whether I could adjust to school life or not. Interacting with sunbae in school is the hardest part of school life for me.

Hoobae should respect sunbae, I got that! But, seniors should not nag juniors or demand that they drink unconditionally. Our drinking culture is a big part of life, but there are some students who do not drink or cannot drink because of their religion, health, or some other reasons. Sunbae should accept such differences among hoobae.

Incivility experiences in clinical settings

Lack of dedication to teaching and learning in the clinical setting

Poor role models

Among the uncivil behaviors exhibited by clinical instructors or teachers, poor role model behaviors were associated with the lack of clinical instructors’ responsibility for clinical education. Other uncivil behaviors were criticizing students’ appearance behind their backs, bad-mouthing fellow nurses to students, drawing comparisons with other students from different nursing schools who were doing their clinical rotations in the same setting, acting as if they were unaware of students’ existence, showing annoyance or complaining about teaching students in addition to their busy workload, and not answering students’ questions. Students commented as follows:

During my clinical rotations, I witnessed my clinical instructor taunting a student. I would have understood if the student had done something wrong or made a mistake, but the teacher was making fun of the student’s face in front of other students, “Don’t you think she looks old and ugly?” I was so shocked!

While I was shadowing a head nurse in the nursing management practicum course, I experienced continuous bad-mouthing and complaining about other nurses and co-workers about everything. I just could not believe her behavior, particularly as I was there to learn and use this manager as a role model.

Lack of respect for student nurses

Participants responded that they had experienced disrespectful treatment from clinical instructors and preceptors, such as talking down to students, showing annoyance, or getting angry. Instructors’ uncivil behaviors in the clinical practicum included shouting at students and commenting disrespectfully while giving feedback (e.g. “you guys cannot do better than this, uh?”). One participant summarized, “We go to the clinical setting to learn. Honestly, I understand how busy they [the clinical instructors] are, but it seems that nurses who dislike and don’t want to teach this situation [practicum teaching] are being assigned to students.” Another student added about clinical instructors that are selected:

Management should reconsider assigning nurses to supervise students if they have the attitude: “Why do I have to teach students on top of my own busy schedule?” Many nurses showed uncivil behaviors. Only nurses with a good [positive] attitude toward teaching should be assigned to students.

Lack of engagement in clinical learning

Participants responded that some students showed a lack of sincerity in the clinical practicum, such as being late, working passively, lingering in the nursing station or resting lounge, and using a cell phone instead of doing their clinical tasks. Students perceived these uncivil behaviors by their peers as indicating a lack of engagement in clinical learning.

Incivility experiences related to technology use

Inappropriate use of technology

Privacy breaches through social media

Participants reported breaches of patient and peer privacy through social media. Participants described behaviors showing a lack of awareness of the importance of privacy/confidentiality protection for patients, such as capturing electronic medical records on cell phones (smartphones), so they could use the data for case studies. Behaviors that did not protect patients’ privacy (confidentiality) in cyberspace were also considered uncivil. These behaviors included posting incidents from the clinical setting on a social networking service and discussions on Facebook about activities during a clinical practicum (e.g. describing personal grievances with a patient’s behavior). In addition, participants also reported privacy breaches in cyberspace and on social media that included behaviors ranging from uploading negative comments, posting personal material on the official notice café (e.g. conducting private conversations with friends), being rude during group chats, and uploading photographs or private conversation content onto Facebook without permission. Students commented as follows:

After a clinical practicum in the hospital, someone posted information about a patient who was upset at a student and her negative feelings in cyberspace. Moreover, some students captured EMR screens for case studies by cell phone. I think the fact students do not recognize this as unacceptable behavior is more problematic.

We have a notice room in cyberspace (e.g., e-café) for nursing students. After something was posted, someone who was against it [disagreed] responded with an aggressive and critical tone. People often make hurtful remarks in cyberspace that cannot be made face-to-face.

One of my friends told me to check the group chat room about what was going on, and I was very surprised to find that my private conversation with someone yesterday had been captured as it unfolded and was posted in KakaoTalk’s group chat room without any (kind of) revisions having been made.

Lack of netiquette or e-manners

Common uncivil behaviors related to technology use were allowing a cell phone to ring in class, answering the phone during lectures, and allowing the “clicking” of a smartphone camera instead of using the silent mode in class. Participants also identified behaviors that exceeded the boundary between a professor and student were uncivil. Examples were sending a text message to a professor at night and sending a too frank message to the professor, as if they were a close friend:

Some friends were taking pictures of slides during class. It bothered me when their phones made an electronic camera shutter sound. I am amazed at their boldness and what they take for granted without permission. There may be confidentiality or copyright issues.

Technology-facilitated academic misconduct

Participants reported technology-facilitated academic misconduct as incivility. For example, some students were perceived as not being fully engaged in class due to technology use. The most common uncivil behaviors were using a cell phone to surf the Internet for non-curriculum subjects during class, watching videos on the Internet, and doing homework for other classes in the classroom during lectures. In addition, students photographed lecture notes or recorded the class lecture without the professor’s permission or photocopied the entire textbook instead of buying it because photocopying is cheaper:

I noticed that some students surfed the Internet or browsed images unrelated to the lecture or topic during class. I tried to ignore these behaviors, but it was difficult because images on a computer screen are large. It is hard for me to concentrate on the class, which bothers me a lot.

Discussion

This study explored the uncivil behaviors experienced by nursing students during their nursing education in South Korea. Nursing students experienced different levels of incivility from being late or sleeping in class to more serious uncivil behaviors such as breaching the privacy of patients or peers. These findings were consistent with that of Clark’s continuum of incivility and the conceptual model that incivility exists from low risk behaviors on one end, to higher risk ones, such as threatening behaviors on the other end.²⁷ According to Clark’s continuum of incivility, sleeping during a lesson is less serious (low risk) than bullying fellow students or teacher which is considered more serious (high risk). In addition, technology played a role in the incivility in the classroom, during clinical practice, and in social interactions.

Participants reported uncivil behaviors in the classroom not only from peers but also from faculty members. Uncivil behaviors, such as disrupting the class, were common in the classroom according to the student participants. Similar uncivil behaviors were reported in previous studies.^17,18,28 Altmiller²¹ noted that students expected the faculty to manage student incivility and were indignant when the rules were not enforced. According to Sun,²⁹ a deficient educational system leads to uncivil behavior among students. Consequently, faculty should be concerned with student incivility and emphasize the importance of civility in their teaching environments. Participants reported that their peers were unaware of their own uncivil behaviors. Culture among college students emphasizes individualism, personal happiness, and independence, with disregard for others.³⁰ Zhang¹⁰ reported that college students do not develop sufficiently, either psychologically or morally, and have no capacity for self-reflection. Therefore, the tools that encourage self-reflection and personal evaluation by students need to be taught in school. Altmiller²¹ also reported that cheating is regarded as a pervasive uncivil behavior with a broad negative impact. All participants in this study also considered cheating a severe form of uncivil behavior. Nurses will implement activities related to patients’ health and lives during their careers and will play a role caring for vulnerable patients.²¹ Cheating behaviors by nursing students should not be tolerated; instead, nursing education should help foster the highest standard of ethical behavior and personal integrity in their students.

Faculty behaviors perceived by participants as unacceptable incivilities were tardiness, poor class preparation, and talking too much about private matters during class time. Li et al.³¹ noted that students were stressed by being poorly taught or improperly educated. Clark and Springer¹⁸ also included poor teaching style or method as an uncivil faculty behavior. Faculty members should consider that sincerity and commitment to teaching are important to satisfy the learning needs of students. In addition, faculty neglect of students’ self-worth was uncivil, according to participants. Other uncivil behaviors by faculty members included verbal exchanges or identifying students purely based on their academic grade. Romanowski³² also noted that faculty members are more concerned with academic achievement of their students on tests or exams than with the morality, personal development, or coping skills of students. Negative treatment and feedback from teachers affect the ability of students to form a sense of self as a nurse by hindering self-esteem, self-efficacy, and confidence.¹⁸ Teachers need to be careful not to damage students’ self-esteem and sense of self-worth and to make sure they are acting as good role models regarding professional commitment and positive communication in the classroom.

Participants also reported experiencing incivility outside the classroom, in their interactions with peers and particularly during group projects. Uncivil behaviors included avoidance, lack of effort, and refusing to communicate with team members. In some cases, students would become intentionally unresponsive to project-related messages to avoid work, thus causing anxiety for the other team members. These findings are consistent with those of Clark et al.³ who reported that students tend to be sensitive to completion of an assignment by peers because the grades assigned for group work depend on the work of all group members. Jenkins et al.²⁸ noted that students emphasize the importance of respect, equality, and working together in team settings. Participants in our study also described the social incivility of upperclassmen (sunbae). The interactions between sunbae and hoobae showed a lack of respect for boundaries toward junior students. Uncivil behaviors by sunbae included severe pressure encouraging alcohol consumption or forcing student participation in talent shows. Students complained that sunbae have too much power, are disrespectful, and give little thought to students’ personal situations. Uncivil behaviors among peers outside the classroom might hinder sustaining helping-trusting authentic caring relationships in human caring.³³ Therefore, more efforts should be made to create a culture of helping, trusting, and caring relationships among peers.

Participants reported incivility in the clinical setting on the part of teachers (clinical instructors and professors) and peers. Tardiness and loafing around at the nurses’ station or lounge, rather than focusing on clinical learning, were perceived as uncivil. A student can be a positive or negative role model for others and their attitude can influence that of their peers. Students must exemplify the best work and learning standards every day.⁸ In addition, clinical instructors behaved unprofessionally with personal negative comments about student appearance or abilities, general complaints about co-workers, and showed indifference and little effort to teach in the clinical setting. It is important to realize that students develop a professional identity by observing the actions and responses of nurses and that clinical instructors serve as role models for students.²¹ Disrespectful behaviors by clinical instructors and professors, such as negative verbal exchanges with students in front of others, were also described as uncivil. Del Prato⁸ showed that negative feedback from a professor or a clinical instructor can lower a student’s confidence and influence their professional development. Nursing educators’ perception of students as valued learners is important to increase students’ self-esteem in clinical practice.³⁴ Educators should be aware of the importance of providing feedback in a civil manner and particularly providing a supportive and protective environment to enhance student learning.

Participants experienced privacy breaches in cyberspace and social media. The use of social media has become common among nursing students. The benefits of social media include rapid communication, but it can also be a source of incivility. Misuse of social media negatively affects nursing students and their patients by violating privacy. Therefore, the importance of protecting private information should be emphasized through education and related policies that detail the consequences of violating a school’s policy on breaches of patient privacy. Consistent with the findings of De Gagne et al.¹⁶ that students share unprofessional content on social media and in different learning environments and both faculty and students experience uncivil behavior in cyberspace, this study also cited inappropriate use of technology inside and outside the classroom. This category included a lack of etiquette or e-manners, such as allowing a cell phone to ring during class and taking photos of lecture notes without the professor’s permission. De Gagne et al.¹⁶ pointed out the negative effect of technology misuse on health professionals’ education. In Sun’s²⁹ opinion, college students misunderstand the true meaning of freedom, have poor self-control, and lack social responsibility, which should be addressed by fostering a learning culture in which there is “no use of electronic or mobile devices unrelated to class.” Students should be instructed on etiquette and e-manners in the classroom and the professional clinical world. According to Altmiller,²¹ the blurring of boundaries between faculty and students promotes inappropriate behavior. Thus, the boundaries between professor and student must be recognized when using technology. Although what constitutes uncivil or unprofessional online behavior is debatable, common understanding as to which behaviors are considered “uncivil” in cyberspace is of importance. Compliance to the Code of Ethics for nurses can also be negatively affected by cyber incivility. Therefore, students should be provided with guidelines and instructed on professional behavior when using social networking environments.

The environment and culture of nursing education are the basis through which students develop professional identities as nurses.⁸ Clark et al.³ suggested several policies and procedures needed to create a culture of civility by encouraging personal responsibility, improving teaching methodologies, and improving the quality of faculty and students. In addition, faculty members, clinical instructors, and students should be held accountable and assume responsibility for conducting themselves in a professional, respectful, and civil manner. Given the current growing concern regarding incivility in the clinical setting, nursing students who practice civil behavior will contribute to civility in nursing.^20,35,36 In addition, tools for faculty and students to evaluate civil behavior and create an environment in which civil behavior is the norm are needed.

Academic incivility interferes with teaching and learning and negatively impacts the formation of caring relationships.³⁷ It is anticipated that civil behaviors acquired or developed during nursing education may carry into nursing practice and affect patient outcomes.³⁸ One study reported that students involved in a civility journal club were more aware of civility and incivility.³⁹ Therefore, it is important to provide students with opportunities to reflect on their own and others’ behaviors to be more aware and to adhere to the professional values as part of human growth. Creating a positive learning environment would help students’ professional quality of caring relationships and ethical behaviors. As there are potential legal and ethical risks related to the misuse of electronic/online teaching and learning methods, more efforts, including providing guidelines, must be made to prevent incivility.

A limitation of this study was that all participants were female. Clark¹⁷ found that male nursing students experience incivility related to gender bias and feel that they are treated differently than female students. However, Altmiller²¹ reported that female students perceive that some faculty members favor male students. Further research is needed to explore the incivility experiences of male students and to examine gender differences in incivility. Another limitation was that researchers’ preconceptions about how students should behave may have affected the results. In addition, no information regarding the frequency and severity of incivility was explored. Selection bias may have been present because some participants may have felt more vulnerable and/or motivated to participate in the study than others. Future studies that explore incivility experiences with more diverse students are needed. Finally, we did not examine how the experience of incivility affected the participants in terms of learning and the process of becoming a professional nurse. Future studies are needed to explore how incivility in the learning environment affects students and what its consequences might be.

Conclusion

Participants in this study described experiencing incivility in different learning environments. Incivility in the education field is reciprocal and takes place during interactions with peers, sunbae, faculty members, and clinical instructors. The nursing education curriculum forms the basis of the journey from student to nurse. A healthy educational environment helps nursing students develop a confident and professional identity. Therefore, faculty and clinical instructors should strive to be role models who can help students complete their educational journey. In addition, students need to take responsibility for civility inside and outside the classroom and must be particularly aware of the importance of patient privacy. Qualitative research focusing on faculty experience, as well as the issues confronting male nursing students, is also needed. Additional studies should seek to identify factors that allow incivility in education and develop programs to decrease incivility in nursing education.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Clark

. Faculty field guide for promoting student civility. Nurse Educ 2009; 34(5): 194–197.

Guidroz

Burnfield-Geimer

Clark

. The nursing incivility scale: development and validation of an occupation-specific measure. J Nurs Meas 2010; 18(3): 176–200.

Clark

Werth

Ahten

. Cyber-bullying and incivility in the online learning environment, Part 1: addressing faculty and student perceptions. Nurse Educ 2012; 37(4): 150–156.

Rieck

Crouch

. Connectiveness and civility in online learning. Nurse Educ Pract 2007; 7: 425–432.

Moon

. A study on nursing students experience in verbal abuse. Master’s Thesis, Catholic University of Korea, Seoul, South Korea, 2013.

International Council of Nurses (ICN). The ICN code of ethics for nurses. Geneva: ICN, 2012, http://www.icn.ch/images/stories/documents/about/icncode_english.pdf

Korean Nurses Association. The KNA code of ethics for Korean nurses. Seoul: KNA, 2013, http://www.koreanurse.or.kr/about_KNA/ethics.php

Del Prato

. Students’ voices: the lived experience of faculty incivility as a barrier to professional formation in associate degree nursing education. Nurse Educ Today 2013; 33: 286–290.

Marchiondo

Lasiter

. Faculty incivility: effects on program satisfaction of BSN students. J Nurs Educ 2010; 49: 608–614.

10.

Zhang

. Teacher misbehaviors as learning demotivators in college classrooms: a cross-cultural investigation in China, Germany, Japan, and the United States. Commun Educ 2007; 56: 209–227.

11.

Lasiter

Marchiondo

. Student narratives of faculty incivility. Nurs Outlook 2012; 60(3): 121–126.

12.

Al-Zayyat

Al-Gamal

. A review of the literature regarding stress among nursing students during their clinical education. Int Nurs Rev 2014; 61: 406–415.

13.

Lei

Jin

Shen

. Influence of clinical practice on nursing students’ mental and immune-endocrine functions. Int J Nurs Pract 2015; 21: 392–400.

14.

Klainberg

McCrink

Eckardt

. Perspectives on academic misconduct: implications for education and practice. J N Y State Nurses Assoc 2014; 44(1): 11–21.

15.

De Gagne

Yamane

Conklin

. Evidence-based strategies to create a culture of cybercivility in health professions education. Nurse Educ Today 2016; 45: 138–141.

16.

De Gagne

Choi

Ledbetter

. An integrative review of cybercivility in health professions education. Nurse Educ 2016; 4(5): 239–245.

17.

Clark

. Student voices on faculty incivility in nursing education: a conceptual model. Nurs Educ Perspect 2008; 29(5): 284–289.

18.

Clark

Springer

. Incivility in nursing education: a descriptive study of definitions and prevalence. J Nurs Educ 2007; 46: 7–14.

19.

Anthony

Yastik

MacDonald

. Development and validation of a tool to measure incivility in clinical nursing education. J Prof Nurs 2014; 30: 48–55.

20.

Kim

Park

. Path analysis for workplace incivility, empowerment, burnout, and organizational commitment of hospital nurses. J Korean Acad Nurs Adm 2013; 19: 555–564.

21.

Altmiller

. Student perceptions of incivility in nursing education: implication for educators. Nurs Educ Perspect 2012; 33: 15–20.

22.

Watson

. Caring science and human caring theory: transforming personal and professional practices of nursing and health care. J Health Hum Serv Adm 2009; 31(4): 466–482.

23.

Gadamer

. Truth and method. New York: Continuum International Publishing Group, 2006.

24.

Downe-Wamdoldt

. Content analysis: method, application, and issues. Health Care Women Int 1992; 13: 313–321.

25.

Granehein

Lundman

. Qualitative content analysis in nursing analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105–112.

26.

Lincoln

Guba

. Naturalistic inquiry. Newbury Park, CA: Sage, 1985, pp. 281–331.

27.

Clark

. Creating and sustaining incivility in nursing education. Indianapolis, IN: Sigma Theta Tau International.

28.

Jenkins

Kerber

Woith

. An intervention to promote civility among nursing students. Nurs Educ Perspect 2013; 34: 95–100.

29.

Sun

. Explore the influential factors of incivility behaviors in contemporary university students. J Jiangxi Youth Vocation Coll 2009; 19: 12–14.

30.

Wang

. Value changes in an era of social transformations: college-educated Chinese youth. Educ Stud 2006; 32(2): 233–240.

31.

Lin

Bray

. The measurement of stressful events in Chinese college students. Psychol Sch 2005; 42(3): 315–323.

32.

Romanowski

. A changing nation: issues facing Chinese teachers. Kappa Delta Pi Record 2006, http://findarticle.com/p/articles/mi%20qa4009/is%20200601/ai%20n17170578/

33.

Watson

. Social justice and human caring: a model of caring science as a hopeful paradigm for moral justice for humanity. Creat Nurs 2008; 14(2): 54–61.

34.

Ahn

Choi

. Factors affecting Korean nursing student empowerment in clinical practice. Nurse Educ Today 2015; 35: 1301–1306.

35.

Abolfazl Vagharseyyedin

. Workplace incivility: a concept analysis. Contemp Nurse 2015; 50(1): 115–125.

36.

Kerber

Woith

Jenkins

. Perceptions of new nurses concerning incivility in the workplace. J Contin Educ Nurs 2015; 46: 522–527.

37.

Luparell

. The effects of student incivility on nursing faculty. J Nurs Educ 2007; 46(1): 15–19.

38.

Woodworth

. Promotion of nursing student civility in nursing education: a concept analysis. Nurs Forum 2016; 51(3): 196–203.

39.

Kerber

Jenkins

Woith

. Journal clubs: a strategy to teach civility to nursing students. J Nurs Educ 2012; 51(5): 277–282.