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Nursing Theses and Capstone Projects

Hunt School of Nursing

2013

Incivility in the Hospital Environment: The Nurse

Educator-Staff Nurse Relationship
Cynthia Danque
Gardner-Webb University

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Capstone Projects. Paper 58.

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

by
Cynthia Danque

A thesis submitted to the faculty of

Gardner-Webb University School of Nursing
In partial fulfillment of the requirements for the
Master of Science in Nursing Degree
Boiling Springs

2013

Submitted by:

Approved by:

Cynthia Danque, BSN, RN

Reimund Serafica, PhD, RN

Date

Date

UMI Number: 1542574

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Abstract
The purpose of this study was to examine the occurrence of incivility in the nurse
educator-staff nurse relationship in hospital environments. Hospital nurse educators
perceptions of the biggest stressors for nurses during educational experiences, identifying
uncivil traits as seen by nurse educators, and identifying the perceived role of nursing
leadership in addressing incivility in the workplace. A qualitative methodology was used
to determine if incivility affects the nurse educator-staff nurse relationship. A focus
group interview was utilized. The results are the perceptions of the nurse educators who
participated in the study. The nurse educators from this research group have experienced
incivility in nursing education in the hospital environment.

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

continuing education, preceptorship, workplace incivility

ii

Acknowledgments
I am sincerely thankful for the support of my husband, David, in my pursuit of
higher education. He has been my guiding light for strength of character and
determination to see intentions become reality. When I approached the subject of
continuing my nursing education and the desire to achieve a Masters he wanted only to
know what he could do to make this goal attainable. He has truly been my partner in this
endeavor from the beginning to the end.
Without the guidance of my Thesis Advisor, I could not have completed this
qualitative research study. Qualitative research is a necessary part of nursing practice
that leads to discovery. I am truly thankful for Dr. Seraficas fondness of qualitative
research and leadership in sharing the art of qualitative research. Dr. Serafica guided me
through the research process with kindness and patience. I aspire to share these skills
with my future students and am honored to have experienced the teaching/learning
environment with Dr. Serafica. Thank you for exemplifying these methods.
I was very fortunate to have been blessed with a talented and caring preceptor. I
am thankful for the guidance of Jill during my practicum. She is an excellent educator
who cares deeply about nursing education. Thank you for your support during this
research project.
I would like to thank Dr. Cynthia Clark for her research with incivility in nursing
education. Dr. Clark is a leader in fostering civility in nursing education. I am thankful
to Dr. Clark for her encouragement of others to join this large endeavor.

iii

 Cynthia Danque
All Rights Reserved

iv

TABLE OF CONTENTS

CHAPTER I
INTRODUCTION ...............................................................................................................1
Problem Statement ...................................................................................................3
Significance of the Research ....................................................................................3
Purpose .....................................................................................................................5
Research Question ...................................................................................................5
Theoretical/Conceptual Framework.........................................................................5
Definition of Terms..................................................................................................9
Summary ................................................................................................................10
CHAPTER II
LITERATURE REVIEW .................................................................................................12
Review of Literature .............................................................................................12
Incivility in Academic Nursing Education ................................................13
Incivility in the Nursing Practice Workplace.............................................19
Summary ................................................................................................................23
CHAPTER III
METHODOLOGY ............................................................................................................25
Implementation ......................................................................................................25
Setting ....................................................................................................................26
Sample....................................................................................................................27
Design ....................................................................................................................27

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

Instruments .............................................................................................................29
Data Collection ......................................................................................................30
Data Analysis .........................................................................................................30
Summary ................................................................................................................30
CHAPTER IV:
RESULTS .................................................................................................................32
Sample Characteristics ...........................................................................................32
Major Findings .......................................................................................................35
Summary ................................................................................................................46
CHAPTER V
DISCUSSION ....................................................................................................................48
Limitations .............................................................................................................57
Implications for Nursing ........................................................................................57
Recommendations for Practice and Education ......................................................58
Conclusion .............................................................................................................59
REFERENCES ..................................................................................................................61
APPENDICES ...................................................................................................................67

vi

Appendices
Appendix A: Research Questions ......................................................................................68
Appendix B: Informed Consent Form ...............................................................................69
Appendix C: Study Cover Letter .......................................................................................71
Appendix D: Email Correspondence from Dr. Cynthia Clark ...........................................72

vii

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

viii

List of Figures
Figure 1: Conceptual Model for Fostering Civility in Nursing Education ..........................7

ix

1
CHAPTER I
Introduction
Incivility is well documented in academic nursing environments. Student nurses
are reported to exhibit uncivil behaviors in the clinical and classroom settings. Uncivil
and disruptive student behaviors may be as simple as students groaning out loud at
comments made by instructors. Students often arrive late to class and leave early from
class creating interruptions for fellow students and instructors (Clark, 2008a). Many
students use cell phones during class for texting or checking emails. Other uncivil
behaviors can be sleeping in class, rude comments, and talking with fellow students
during lecture. Incivility disrupts the teaching-learning environment (Clark, 2008a).
Incivility can progress to aggressive behaviors and anger over poor grades. National
coverage in the newspapers has shown that uncivil behaviors can progress to violence
(Clark & Springer, 2007b). School shootings and reports of violence have established the
need for interventions and strategies to prevent escalation of uncivil acts (Clark &
Springer, 2007b).
Academic nursing incivility is not limited to students. Many nursing students
have shared stories of experiences of faculty/instructor incivility. These students reported
past experiences of unfair treatment and having professors that use sarcasm, intimidation,
and profanity. These students desired to be treated with respect (Clark, 2008b).
Workplace incivility is also well documented in nursing practice. There are
several journal articles covering workplace incivility in nursing practice from different
angles (Foley, Myrick, & Yonge, 2012, in press; Spence Laschinger & Grau, 2012;
Guidroz, Burnfield-Geimer, Clark, Schweschenau, & Jex, 2010; Leiter, Price, & Spence

2
Laschinger, 2010; Oore et al., 2010; Smith, Andrusyszyn, & Spence Laschinger, 2010;
Thomas, 2010; Spence Laschinger, Finegan, & Wilk, 2009; Spence Laschinger, Leiter,
Day, & Gilin, 2009; Felblinger, 2008; Hutton & Gates, 2008). These articles range from
viewpoints such as generational differences, burnout, and preparing new graduate nurses
to handle uncivil behaviors from supervisors, coworkers, physicians, and patients. The
American Nurses Associations Code of Ethics (2010) addresses civility in nursing
practice. Provision 1.5 stated that nurses should interact with all persons with
compassion, caring relationships, and fair treatment of all individuals. The principle of
this provision is respect and compassion for all persons.
Although incivility is documented in nursing school education (Gallo, 2012;
Lasiter, Marchiondo, & Marchiondo, 2012; Robertson, 2012; Cooper, Walker, Askew,
Robinson, & McNair, 2011; Clark & Springer, 2010; Heinrich, 2010; Clark, Farnsworth,
& Landrum, 2009; Clark, 2008a, 2008b; Clark & Springer, 2007a, 2007b; Luparell,
2007) and within the nurse practice areas within hospitals (Foley et al., 2012, in press;
Spence Laschinger & Grau, 2012; Guidroz et al., 2010; Leiter et al., 2010; Oore et al.,
2010; Smith et al., 2010; Thomas, 2010; Spence Laschinger et al., 2009; Spence
Laschinger et al., 2009; Felblinger, 2008; Hutton & Gates, 2008), there is no data
available to suggest this problem exists for nurse educators within hospital systems. One
would reason that if uncivil behaviors are traits that affect nursing students and faculty,
that there could also be uncivil behaviors within nursing education in hospital
environments.

3
Problem Statement
Incivility in nursing education within the hospital environment is a concern that
needs to be explored in an effort to establish normative and practiced behaviors in the
nurse educator-staff nurse relationship. Uncivil behaviors are disruptive to the teachinglearning environment. These behaviors may increase stressor responses in the nurse
educator-staff nurse relationship. Stress can lead to job dissatisfaction and loss of nurse
educators. There is a gap in the knowledge base of expected and practiced behaviors of
staff nurses and hospital nursing education.
Identification of the dynamics of the nurse educator-staff nurse relationship in
regards to uncivil behaviors needs to be examined. Once uncivil behaviors are identified,
further studies will create a base of knowledge and lead to change that can increase
civility and job satisfaction for nurse educators. The goal is to create the best possible
teaching-learning environment with civility a positive factor in removing barriers to
education. This may be accomplished with further research bridging the gaps in
knowledge to nursing education within the hospital environment.
Significance of the Research
Incivility in academic nursing education has been defined, studied, and the data
has contributed to a growing base of knowledge. These studies have established the need
for policies and strategies to prevent and control uncivil behaviors in the academic
nursing education environment. Workplace incivility has also warranted investigation in
an effort to define and develop plans to decrease job burnout and increase job satisfaction
rates. Due to the growing base of knowledge of documented incivility in these two areas

4
of a nurses career, the effects of incivility in nursing education in the hospital practice
area justify further exploration.
Workplace incivility is known to encompass several different rude behaviors but
is theoretically different from physical aggression and violence as there is no intention to
cause physical harm (Guidroz et al., 2010). Rude acts of incivility in the workplace
include behaviors such as purposefully ignoring a coworker, raising your voice or yelling
at someone, interrupting a coworker who is speaking, spreading rumors, and taking credit
for work that someone else has done (Guidroz et al., 2010). Guidroz et al. (2010) defined
workplace incivility as being different than bullying as bullying involves a power
differential between the aggressor and the victim. However, there is documentation of
bullying in the workplace that affects new nurses and their relationships with preceptors,
experienced nurses, and management (Thomas, 2010; Felblinger, 2008). These studies
combine the intentions of rude behaviors and bullying in their descriptions of uncivil
behaviors as a result of power struggles. Dr. Cynthia Thomas, Assistant Professor at Ball
State University in the School of Nursing, identified incivility in nursing practice by
placing these behaviors in two separate groups which are direct violent behaviors and
indirect violent behaviors (Thomas, 2010). Indirect violence includes behaviors such as
employing coercive techniques, failing to listen to a coworker, gossiping, inflicting the
silent treatment, excluding someone from activities or conversations,
passive/undermining behaviors, refusing to acknowledge someone, rolling the eyes,
sabotaging someone, shrugging the shoulders, sighing or groaning, tapping fingers while
someone is talking, turning away or avoiding a coworker, using someone as a scapegoat,
and withholding important information (Thomas, 2010). Direct violence includes more

5
aggressive behaviors such as belittling statements, confrontational statements, correcting
someone in front of others, creating conflict, cruel acts, disrespectful comments,
controlling acts, hostile behavior, sarcasm, pressuring or coercing a person, roughness or
striking a person, rude statements, sexual harassment, throwing or slamming objects,
uncooperative behavior, arguing, and yelling at someone (Thomas, 2010).
One would assume if these behaviors are prevalent in the academic environment
and practice environment of nursing that they are also present in educational practices
involving the same individuals. These principles need to be investigated to fill the gap
between empirical and normative knowledge, and expectations in nursing education.
Purpose
The purpose of this study was to examine the occurrence of incivility in the nurse
educator-staff nurse relationship in hospital environments. Hospital nurse educators
perceptions of the biggest stressors for nurses during educational experiences, identifying
uncivil traits as seen by nurse educators, and identifying the perceived role of nursing
leadership in addressing incivility in the workplace.
Research Question
How does incivility in the hospital environment affect the nurse educator-staff
nurse relationship? This question was researched from the nurse educators perspective.
Theoretical or Conceptual Framework
Dr. Cynthia Clark, a nursing professor at Boise State University, developed the
Conceptual model for fostering civility in nursing education in 2008. The model
illustrated the stress levels of nursing faculty and students and how the roles of these
individuals contribute to or intensify uncivil behaviors in the faculty-student relationship

6
(Clark & Springer, 2010). The faculty-student relationship is stressed by the power
differences between their roles (Clark & Carnosso, 2008). The diagram demonstrated
when high levels of faculty stress and high levels of student stress interacted that role
stresses may influence and interfere with conflict (Clark & Springer, 2010). Student
entitlement and faculty superiority, demanding workloads, juggling multiple tasks and
competing demands, technology and information overload, and lacking knowledge and
skills to manage conflict are stressors for the faculty-student relationship (Clark &
Springer, 2010). The earlier diagrams showed the dance of civility in comparison to
the dance of incivility. The diagram updated by Dr. Clark in 2010 changed these
captions to the cultures of civility and incivility (Clark & Davis Kenaley, 2011). The
earlier model showed that incivility was interactional and reciprocal in nature and had the
potential to escalate to destructive behaviors (Clark & Carnosso, 2008). Academic
incivility was defined as rude, discourteous speech, or behaviors that disrupt the teachinglearning environment (Clark, 2008a). The 2010 changes in the model, Conceptual model
for fostering civility in nursing education, paved the way for the development of a dual
conceptual model. The dual model, Faculty empowerment of students to foster civility,
compliments the first model and focuses on ways to foster civility in nursing education
(Clark & Davis Kenaley, 2011).
The 2010 Conceptual model for fostering civility in nursing education was
adapted by Dr. Clark in 2011 when working on a research study with a doctoral
candidate, Lynda Olender (Figure 1). This most recent adaption to the model
incorporates nursing practice with nursing education (Clark, Olender, Cardoni, & Kenski,

7
2011). The intention of the modified concept by Dr. Clark and Ms. Olender was to
encourage civility in nursing practice and nursing education for nursing leaders.
The researcher for the current study has adapted the model and framework
developed in 2010 by Dr. Clark and Ms. Olender to the nurse educator-staff nurse
relationship. Permission was granted by Dr. Clark to use the Conceptual model for
fostering civility in nursing education (adapted for nursing practice) in this research
study.

Figure 1. This model shows elevated levels of stress combined with stressors in the educatorstudent relationship contribute to incivility in nursing education. Model by Clark, C. M.,
Olender, L., Cardoni, C., & Kenski, D. (2011). Fostering civility in nursing education and practice:
Nurse leader perspectives. Journal of Nursing Administration, 41(7/8), 324-330.

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

2010)

8
Workplace incivility includes rude behaviors such as ignoring someone, yelling,
interrupting someone who is speaking, spreading rumors, and taking credit for work that
someone else has done (Guidroz et al., 2010). These behaviors are different from
physical aggression and violence as there is no intention for physical harm (Guidroz et
al., 2010). Many of the same stressors affected workplace incivility in the same manner
as academic nursing education incivility. These stressors were demanding workloads,
juggling multiple tasks and competing demands, technology, and information overload
(Clark & Davis Kenaley, 2011). The health care workplace environment may be at
higher risk for incivility due to stressful conditions of constant change, heavy workload,
large number of staff, and diversity of interactions (Hunt & Marini, 2012). Newly
graduated nurses are placed on orientation with a preceptor while learning to function as
a nurse in their new hospital unit. The preceptor-new staff nurse relationship can bring
about many of the same emotional feelings for the new nurse as experienced in the
academic faculty-student relationship (Foley et al., 2012, in press).
The nurse educator-staff nurse relationship may be influenced by preconceived
ideas and experiences from previous and existing roles. Each nurse started out in the
academic nursing education environment, then moved into orientation and preceptorship
in the hospital environment, and then finally discovered that the education of all nurses
must be maintained and kept current with continuing education courses and hospital inservices. In essence, nurses are students throughout their nursing careers whether they
decide to pursue further degrees or maintain their current status. The stressors that affect
workplace nurses are present while the nurse maintains continuing education while
continuing to work in the hospital environment.

9
Definition of Terms
Academic Incivility is disruptive behavior that substantially or repeatedly
interferes with teaching and learning. In-class disruptions include:
Rude comments, put-downs, slurs, and rumors (in person and in cyberspace)
Cell phones, texting, and computer misuse
Interruptions and side conversations
Late arrivals and leaving early
Sleeping in class
Aggressive, intimidating, bullying behavior
Anger or excuses for poor performance
Cheating and other forms of academic dishonesty
Displaying a sense of entitlement
Blaming others for their shortcomings
Shunning or marginalizing other students
(Clark & Springer, 2010).
Civility is characterized by an authentic respect for others when expressing
disagreement, disparity, or controversy. It involves time, presence, a willingness to
engage in serious conversation, and a sincere intention to seek common ground (Clark &
Carnosso, 2008).
Faculty is the term used for academic nurse educators in colleges and universities.
Other interchangeable terms for faculty are nursing instructor or professor.
Nurse Educator is an individual responsible for teaching nurses employed in a
hospital setting courses specific to their patient care population and/or general hospital

10
nursing education. The nurse educator has graduated from a school of nursing and is an
experienced clinical nurse.
Preceptorship is the period of training nurses undergo when starting their first
position as a registered nurse in a hospital environment. The graduate nurse must have
passed state boards before beginning employment and starting the training period on the
nursing unit. The experienced nurse responsible for introducing the new nurse to the
specific nursing unit during the orientation and training period is called the preceptor.
Staff Nurse is the term used to identify a registered nurse who is working in a
clinical setting. The staff nurses in this study are employed in a hospital setting.
Student for the purpose of this paper is a person studying to be a nurse in a school
of nursing.
Workplace is the term used to describe the place where nurses work in clinical
settings. For this study the workplace implies the hospital environment.
Workplace Incivility is rude behaviors such as ignoring someone, yelling,
interrupting someone who is speaking, spreading rumors, and taking credit for work that
someone else has done (Guidroz et al., 2010). These behaviors are different from
physical aggression and violence as there is no intention for physical harm. These
behaviors are considered to be low intensity uncivil acts (Guidroz et al., 2010).
Summary
Incivility exists in academic nursing education for nurse educators and nursing
students. Incivility exists for clinical nurses in the practice areas of the hospital.
Incivility is on the rise as people become more involved with technological advances and
assume heavier workloads due to the current downturn in the national economy. These

11
stressors have a negative impact on civility and increase the intensity of uncivil behaviors
and interactions. The hospital environment may increase the stressors that affect civility
and intensify uncivil behaviors especially in intensive care areas (Clark et al., 2011).
There is a growing descriptive base of knowledge leading to the development of
policies and strategies for the purpose of prevention and control of incivility in academic
nursing education and nursing practice in the workplace. There is a gap in knowledge
related to incivility in nursing education within the hospital environment. This study
evaluated the perceptions of nurse educators within the hospital environment and the
occurrence of incivility in the nurse educator-staff nurse relationship in regard to nursing
education. The nurse educators perceptions of the role of nursing leadership in
addressing the occurrence of incivility were also examined.

12
CHAPTER II
Literature Review
The purpose of this review was to explore the current literature available for
incivility in nursing education. There was a good base of research regarding incivility in
academic nursing education; however, information regarding incivility in nursing
education within the hospital environment was nonexistent. The focus of this study is
incivility in nursing education within the hospital environment and especially the effects
of incivility in regard to the nurse educator-staff nurse relationship. In an attempt to
better understand the environment of the nurse educator in the hospital environment, the
researcher also reviewed literature involving incivility in the nursing workplace. The
review of incivility in the nursing workplace provided a broader understanding of how
incivility affects nurses in the hospital environment.
Incivility is a term that is used in a broad sense throughout the available literature.
This term was applied to rude behaviors and language; however, it was also applied to
bullying and violent behaviors in some of the literature. It is true that bullying and
violent behaviors are uncivil acts and fall under the description of incivility, but these
behaviors should be considered on an elevated level. Some of the literature distinguished
the difference as non-violent and violent uncivil behaviors. Some of the literature
differentiated the levels of uncivil behaviors as low intensity and high intensity incivility.
One theme that carried throughout the literature review in regards to incivility in
academic nursing education and the nursing workplace environment was that low
intensity incivility is reciprocal in nature and had potential to escalate to high intensity
incivility if not appropriately managed.

13
Review of Literature
The literature review was conducted through the online databases of EBSCO and
the Cumulative Index for Medical, Health, and Nursing [CINAHL] through the
Universitys electronic resources. The keywords for the review were incivility, civility,
bullying, nursing education, nursing practice, continuing education, preceptorship, and
workplace incivility. Review of the literature revealed incivility was identified as an area
of concern in academic nursing education and nursing practice in the workplace.
There were ample articles available on incivility in academic nursing education
and nursing workplace incivility. In searching for incivility in nursing education in the
hospital environment the databases were extremely limited. The only applicable articles
in this area pertained to nurses as preceptors and generational differences with newly
graduated nurses in the nurse practice area and experienced nurses in the workplace.
There was one study from the hospital administrator and managements perspective;
however, data from the hospital nurse educators perspective was nonexistent.
There is one common thread in all of the literature reviewed. Heightened levels
of stress intensified the uncivil behaviors for nursing students, faculty, and nurses in the
workplace. Intensive care units were noted to be more affected by incivility in the
workplace environment.
Incivility in Academic Nursing Education
Incivility in academic nursing education is disturbing. Academic incivility is
disruptive to the teaching-learning environment. Uncivil behaviors may harm the
faculty-student relationship (Clark & Springer, 2010). The literature supports defining
uncivil behaviors and development of strategies and policies. The intention of these

14
policies and strategies is prevention of incivility and establishing methods to control
students with uncivil behaviors so that the classroom environment does not suffer
negatively from incidences of incivility. Building a culture of civility requires faculty
and students to work together to promote productive and reciprocal commitment (Clark
& Davis Kenaley, 2011; Clark & Carnosso, 2008).
Incivility on American college campuses is a serious and growing concern
(Robertson, 2012; Clark & Springer, 2007a, 2007b). Incivility can escalate to violence as
has become evident in the violent shootings at the University of Arizona in 2002,
Virginia Tech in 2007, and Northern Illinois University in 2008 (Clark et al., 2009). The
Incivility in Nursing Education (INE) Survey was created by nursing educators in an
effort to define uncivil behaviors in students and faculty. The INE tool can assist schools
of nursing to discover areas of conflict between faculty and students in an effort to
stimulate strategies for interventions and prevention of incivility (Clark et al., 2009).
Nursing student stressors. Student stressors are not limited to the academic
environment. Juggling multiple roles and meeting competing demands of work, school,
and family responsibilities create stress for students. Many students are under large
financial pressures. Some students have issues with time management. Others may
perceive there is a lack of faculty support and faculty incivility. In addition, a small
percentage of the student population may also suffer mental health problems and personal
issues (Clark & Springer, 2010).
The literature supports an increased incidence of incivility in nursing education
and has been linked to a combination of coexisting problems (Robertson, 2012). The
stressors for students may be manageable when occurring individually. Student nurses

15
suffer the increasing effect of multiple aggravating factors. Meeting the demands of
nursing school while attempting to work full or part time exposes students to increased
levels of stress (Robertson, 2012). These behaviors are undesirable and lead to a
weakened learning environment, poor workforce behaviors, and violence (Gallo, 2012).
Low intensity behaviors of incivility can escalate into violence and undermine the
teaching-learning environment for faculty and students (Clark, 2009).
Uncivil behaviors demonstrated by nursing students. Student uncivil
behaviors often create classroom disruptions. These rude behaviors can be rude
comments, put-downs, slurs, and rumors. The use of cell phones for texting and viewing
emails is disruptive. Students may misuse computers, cause interruptions, and participate
in side conversations. Late arrivals to class and leaving early are interruptions to
classroom lectures. Other behaviors by students that are identified as rude and uncivil are
sleeping in class, being aggressive or intimidating, and displaying bullying behaviors.
Some students become angry or make excuses for poor performances. Cheating and
other forms of academic dishonesty are uncivil behaviors. Students may display a sense
of entitlement or blame others for their shortcomings. Shunning or marginalizing other
students is rude and considered uncivil behavior (Clark & Springer, 2010, 2007a).
Effects of student incivility. The literature suggests academic incivility is a
moderate to severe problem. The level of student incivility has increased in nursing
education to become a significant problem (Clark, 2008a, 2008b). These students are
emotionally and physiologically affected (Clark, 2008b). Uncivil faculty behaviors
contributed to student anger thus intensifying the reciprocal nature of incivility in the
faculty-student relationship (Clark, 2008a). Students in the clinical setting who acted

16
disrespectfully to faculty, patients, staff, or peers were identified as behaving in an
unprofessional manner (Altmiller, 2012). Nursing students defined and perceived uncivil
behaviors almost the same as faculty; however, nursing students felt incivility was
justified when they were the recipient of an uncivil act (Altmiller, 2012).
Another problem associated with incivility in nursing education is the national
nursing shortage. Nursing faculty may suffer physical and emotional effects when
dealing with student incivility. The effects of incivility may lead to the loss of academic
nursing educators at a time when the nation cannot afford to lose faculty (Luparell, 2007).
Uncivil behaviors adversely affect the educational environment. Uncivil acts adversely
affect faculty job satisfaction and morale (Luparell, 2007).
Strategies to offset incivility. It is important for students who have experienced
incivility from a nursing instructor to be associated with a mentor so that the facultystudent relationship may be mended and the student will remain in school (Clark, 2008b).
Students need to be prepared during nursing school to identify and deal with incivility.
Problem-based scenarios presented during nursing school can offer students the
opportunity to develop skills to effectively handle interactions involving uncivil acts
(Clark, Ahten, & Macy, 2013). These skills may be used during academic nursing
education and in the workplace after completion of school. Nursing students reported the
experience of participating in problem-based scenarios increased their knowledge and
awareness in how frequently uncivil acts occur in nursing practice. Students described
participation in the scenarios as an opportunity to learn behaviors and actions that counter
incivility (Clark et al., 2013).

17
Faculty stressors. Instructors experience many demands in academic settings.
There are multiple work demands, heavy workload, and workload inequity. Nursing
instructors must maintain their clinical competence. Advancement issues can increase
faculty stress. Lack of faculty and administrative support are disconcerting stresses for
many nursing instructors. Many academic facilities often undergo changes in faculty
demographics such as educators changing their status to part-time, changes in adjunct
faculty, and faculty turn-over. Personal stressors and poor coping abilities may add to
faculty stress. Problematic students are a serious concern for nursing instructors.
Incivility can harm the faculty-student relationship (Luparell, 2007). Incidence of uncivil
student behaviors to faculty are reported to be advancing in nature in higher education to
the point of students being verbally abusive, yelling at faculty members, and engaging in
physical contact (Clark & Springer, 2007b). These behaviors can negatively impact the
faculty member and affect the nursing instructors job satisfaction and morale. Nursing
educators are also affected by low salaries and financial pressures (Luparell, 2007).
Faculty-to-faculty incivility may also be a stress for many educators (Clark & Springer,
2010).
Uncivil behaviors demonstrated by faculty. Uncivil faculty behaviors toward
students included being rude, belittling someone, demeaning behaviors toward students,
making unreasonable demands on students, and not appreciating student contributions.
Uncivil faculty behaviors toward other faculty and administrators were reported to
include overt rude and disruptive behaviors in person and in cyberspace. These uncivil
behaviors included hazing, bullying and overt acts of intimidation, unwelcome and
unsupportive put-downs, setting others up to fail, exerting superiority and rank over

18
others which were an abuse of power, and not performing ones share of the workload.
Other uncivil faculty behaviors toward faculty and administrators can be avoidant
isolative and exclusionary behaviors. These may include marginalizing and excluding
others, refusing to listen or openly communicate, gossiping, passive-aggressive
behaviors, rude nonverbal behaviors and gestures, being resistant to change, being
unyielding, unwilling to negotiate, and engaging in clandestine meetings behind closed
doors (Clark & Springer, 2010).
Effects of faculty incivility. When nursing students encounter bullying
behaviors from nursing instructors they are left with feelings of powerlessness and
frustration. These feelings create a hostile environment (Cooper et al., 2011). Many of
the uncivil behaviors exhibited by nursing instructors were interpreted by students as
bullying. The literature shows that uncivil behavior by faculty to students is judged as a
higher intensity level of incivility (Lasiter et al., 2012; Cooper et al., 2011).
Strategies to offset incivility. When under stress, nurse educators need to
intentionally prevent the urge to fight or flee. One strategy is to mend and tend to
professional relationships (Heinrich, 2010). Nurse educators should cultivate civil
relationships with colleagues, faculty, and students (Heinrich, 2010). The intentional
method of cultivating relationships serves as a good strategy against stress that may
stimulate uncivil behaviors. Faculty members are in key positions to encourage civility
within the academic setting. Positive faculty-student relationships are a fundamental
component of constructive teaching-learning environments (Clark, 2009). Faculty may
promote positive relations through professional role modeling, purposeful planning, and
application of collaborative learning strategies (Clark, 2009). Nursing instructors should

19
intentionally communicate with students in a manner that is respectful and helpful in the
students professional growth (Suplee, Lachman, Siebert, & Anselmi, 2008).
Incivility in the Nursing Practice Workplace
The literature supports that many workplace environments are affected by
incivility. However, the evidence shows that incivility is more prevalent in the hospital
environment. This is especially true for intensive care units where job stressors are
considered to be higher in intensity (Oore et al., 2010). In the hospital setting, nurses
experience uncivil acts from physicians, supervisors, co-workers, and patients. The
additional stress as a result of uncivil acts may lead to job burnout and job dissatisfaction
(Guidroz et al., 2010).
The Nursing Incivility Scale (NIS) is a tool developed in an effort to define
incivility in the hospital setting. The NIS has assisted hospital administrators in defining
and addressing issues in specific units where concerns have been identified. The goal is
to create a civil and satisfactory workplace environment for nurses (Guidroz et al., 2010).
The assessment of incivility in the health care setting for nurses can provide essential data
for hospital administrators to develop and implement interventions to improve
relationships among hospital employees. Hospital administrators can increase nurse
retentions rates and job satisfaction scores by addressing these issues (Guidroz et al.,
2010).
Nurse leaders in the hospital setting should evaluate the working relationship
between nursing education and nursing practice areas (Clark et al., 2011). Nurse leaders
can be proactive in fostering civility between nursing education and practice (Clark et al.,
2011).

20
Nursing practice. Hospital environments may be predisposed to incivility due to
demanding work conditions and challenges, constant changes, large numbers of staff, and
a variety of interactions with co-workers, supervisors, physicians, patients, and patients
extended families (Hunt & Marini, 2012). Workplace stressors are job characteristics
that create tension and increase stress for employees. The two major stressors in the
nursing practice environment are workload and job control (Oore et al., 2010). Incivility
affects the stressor-strain relationship. Incivility can spread throughout a work unit (Oore
et al., 2010). Stress as a result of uncivil acts may lead to job burnout and job
dissatisfaction (Guidroz et al., 2010). Stressors increased nurses stress levels and
contributed to the occurrence of incivility (Spence Laschinger et al., 2009).
Uncivil behaviors in the hospital workplace are defined as low intensity behaviors
that violate workplace customs of common respect. Uncivil behaviors are rude acts that
demonstrate a lack of respect for others (Spence Laschinger et al., 2009). Workplace
incivility can impact patient care and result in risks to patients (Hutton & Gates, 2008).
Incivility is a precursor to bullying and leads to higher intensity uncivil acts (Felblinger,
2008). Incivility in the nurse practice area when student nurses are on the unit for a
clinical day may have a negative impact on student learning and performance (Hunt &
Marini, 2012).
Evidence has shown hospital administrators that workplace incivility has negative
affects on productivity (Hutton & Gates, 2008). Hospital workplace incivility results in
financial losses and impacts the health of employees (Hutton & Gates, 2008). Promoting
a workplace environment where nurses feel safe from intimidation contributes to
increased productivity (Felblinger, 2008).

21
Newly graduated nurses. The effects of uncivil behaviors on newly graduated
nurses can lead to decreased retention during the first year of professional practice
(Thomas, 2010). New nurses experience many uncivil acts such as: belittling statements,
confrontational statements, being corrected in front of others, becoming part of a conflict,
cruel acts, deflating statements, control or prevention of an act, hostile behavior,
insensitive/sarcastic comments, interruptions to conversations, intolerant behavior, power
play/bulling behavior, pressure to act in a particular manner, pressuring or coercing a
person, roughness like striking a person, rude statements, sexual harassment,
throwing/slamming objects, uncooperative behavior, arguing, yelling, whispering, and/or
whining (Thomas, 2010). Experienced nurses are likely to have high expectations of new
nurses. Veteran nurses assume new nurses are capable of functioning at a much higher
level of practice (Thomas, 2010).
The nurse educator is vital to the implementation of strategies to ensure a culture
of safety for newly graduated nurses (Thomas, 2010). Nurse educators need to be aware
of current research on violent behaviors within hospital environments. New employee
orientation is an ideal time to introduce hospital policies and strategies addressing
hostility. Newly hired nurses in their first professional job need to know strategies to
confront, defuse, and eliminate uncivil and violent acts (Thomas, 2010). Nurse Managers
need to support their newly hired graduate nurses and endorse education measures
presented by the nurse educator. The nurse manager is responsible for the conditions in
the nursing work environment. The nursing environment should be welcoming and
supportive of newly graduated nurses. Supportive workplace environments will ensure
new nurses will want to remain in the profession (Spence Laschinger & Grau, 2012).

22
Hospital administrators must provide support for newly hired graduate nurses by
providing policies and strategies related to incivility and violence in the workplace.
Newly graduated nurses need increased knowledge about organizational structure and
psychological empowerment to handle workplace incivility. When this knowledge is
shared, new nurses are more committed to their hospital and have increased job loyalty
and decreased job turnover intentions (Smith et al., 2010; Spence Laschinger et al.,
2009). It is important for nursing units to encourage high-quality mutually respectful
working relationships to make certain that new graduates remain engaged in their work
(Spence Laschinger et al., 2009).
Generational differences in the workplace. Models of stress and burnout have
identified social support among coworkers as a buffer against stress. Collegial
relationships are a resource to assist coping with incivility in the workplace (Leiter et al.,
2010). Without these comforting relationships, incivility in the workplace can lead to
distress and burnout (Leiter et al., 2010). Generational differences in the workplace may
influence collegial relationships. Mature nurses in the workplace are referred to in the
literature as Baby Boomers. Baby Boomer nurses were born between 1943 and 1960.
Generation X nurses were born between 1961 and 1981. Millennial nurses were born
after 1981. The largest group in the current workforce is Generation X nurses (Leiter et
al., 2010). The Millennial nurses started entering the workforce in 2002. Generation X
nurses experience more incidence of incivility from coworkers and nursing management
(Leiter et al., 2010). Generational differences require nursing management to be aware of
incivility in the workplace and encourage supportive working relationships (Leiter et al.,
2010). Hospital administrators have an obligation to support initiatives that have the

23
potential to enhance recruitment, socialization, and retention of nurses (Leiter et al.,
2010).
Preceptorship is a nurse/student-preceptor relationship for unit specific training
that often matches nurses together from different generations. Senior nursing students
are placed with an experienced nurse in the role of preceptor prior to graduation in a
hospital unit. Sometimes this arrangement paves the way for the student to be potentially
hired as a nurse/employee after graduation and becoming a registered nurse. Newly hired
graduate nurses are placed in a preceptorship relationship during the orientation process
in hospital nursing units. Different generations have different perceptions of their
workplace environment (Foley et al., 2012, in press). Generational differences may lead
to misunderstandings, conflict, and perceptions of uncivil behaviors. Nurses in the
preceptorship relationship reported many preceptors were rude and uncivil (Foley et al.,
2012, in press). The nurses working with preceptors perceived feelings of being
challenged and encountering conflict. Nurse educators, nurse managers, and hospital
administrators have the potential to develop generational understanding and promote a
more cohesive culture in the nursing workplace (Foley et al., 2012, in press).
Summary
There is incivility in academic nursing education and in nursing practice.
Incivility in academic nursing education is disruptive to the teaching-learning
environment and negatively impacts the faculty-student relationship. Incivility in nursing
practice is harmful to employee relationships and can negatively impact job performance
and job satisfaction. Workplace incivility may negatively impact patient care and unit

24
productivity. Generational differences may affect employee relationships and warrants
further investigation.
Research is not readily available in the literature regarding the nurse educatorstaff nurse relationship. There is a gap in the literature regarding nursing education
within the nurse practice area. In a broad sense, one would expect there is a strong
possibility that incivility in the hospital environment can negatively affect nursing
education and be harmful to the nurse educator-staff nurse relationship.

25
CHAPTER III
Methodology
Previous research data established incivility as a barrier to education in academic
nursing education. Nursing workplace incivility has also been well documented through
research. The purpose of this research study was to identify if incivility affects the
teaching-learning relationship of nurse educators and practicing nurses within hospital
systems. This study reflected the perceptions of research participants from a large
metropolitan hospital in the southeastern United States.
Implementation
A qualitative approach was chosen for this study as there is a gap in the literature
in regards to incivility in nursing education within the hospital environment. Qualitative
research is a pathway to knowledge (Munhall, 2012). There is knowledge that incivility
exists in academic nursing education. There is knowledge that incivility exists in nursing
practice. To better understand incivility and its influence on the hospital nurse educatorstaff nurse relationship this research study utilized a qualitative research method and a
small focus group interview.
The group interview was designed to obtain the participants perceptions in a
focused area in a setting that was nonthreatening (Burns & Grove, 2009). The dynamics
of the group interview assisted the nurse educators to express and clarify their
perceptions (Burns & Grove, 2009). The data was collected through an interview with
six nurse educators (n=6). A survey questionnaire with five open ended questions was
utilized to acquire the perceptions of hospital educators experiences in the nurse
educator-staff nurse relationship.

26
The questionnaire developed for the hospital nurse educators was adapted from
open ended questions developed by Dr. Cynthia Clark for research of incivility in
academic nursing education (Clark & Springer, 2010). These questions asked the nurse
educators to describe their perceptions of stressors and uncivil behaviors in hospital
nursing education. Appendix A is the questionnaire adapted for hospital nurse educators.
The study questions presented to the nurse educators were:
What do you perceive to be the biggest stressors for nurses during hospital
education courses?
What uncivil behaviors do you see nurses displaying during hospital education
courses?
What do you perceive to be the biggest stressors for nurse educators?
What uncivil behaviors do you see nurse educators displaying?
What is the role of nursing leadership in addressing incivility?
Qualitative descriptive studies are a good design for research subjects that are not
previously studied (Thomas & Magilvy, 2011). For the purpose of this research a
qualitative approach was used to acquire knowledge not personally experienced by the
researcher.
Setting
The setting for this study is a large acute care hospital located in the southeastern
United States. The facility offered an educational department that was separate from the
nursing units; however, the educators were assigned to areas in which they had prior
nursing experience.

27
Sample
The participants were acquired through snowball sampling. The target sample of
six nurse educators was recruited by asking early volunteers to refer other study
participants who were nurse educators in the facility. A descriptive survey/interview
design was used to explore the nurse educators perceptions and to determine if incivility
negatively impacts nursing education within the hospital environment and harms the
nurse educator-staff nurse relationship. Qualitative content analysis was used to
breakdown the content of the narrative data to identify prominent themes and patterns
among the themes. The interpretations by the researcher of the answers were the
commonalities of the perceptions of the nurse educators in the hospital setting (Smythe,
2012). This process of analysis substantiates the data collected and reported truly
portrays the perceptions of the participants.
Design
A list of the facilitys nurse educators was provided for study recruitment
purposes. Participants were selected using snowball sampling techniques. Early
volunteers in the study referred other nurse educators until the target focus group of six
participants was reached. A cover letter/debriefing statement was presented to the nurse
educators by the researcher. Questions regarding the study were provided prior to the
audio-taped interview. Informed consent was completed. The cover letter and informed
consent provided directions for participants to notify the researcher for further questions
or clarification and ways to exit the study. Telephone or email cancellation and failure to
show up for the interview time and location were considered the participants way of
quitting the study. Two nurse educators emailed regrets the day before the interview.

28
Two additional educators were recruited. A total of six nurse educators were present for
the focus group interview.
Protection of Human Subjects
Nurse researchers are held accountable for ethical considerations and fair
treatment of research subjects. The nurse researcher must acknowledge therapeutic
obligations to the participants of the study (Munhall, 2012). The researcher must
maintain vigilant observation of these goals in the pursuit of ethical treatment of research
subjects in an effort to prevent harm to study participants while striving to reach the
research objective (Munhall, 2012).
Permission to conduct this study was obtained from the Institutional Review
Board (IRB) of Gardner-Webb University. The members of the IRB placed careful
consideration on the research project in reference to ethical treatment of the participants
and the outcomes of the study (Burns & Grove, 2009). There were no treatments
involved. The participants confidentiality was maintained as names were not disclosed.
The name of the hospital/facility was not reported in the study paper. The facility was
described as a large metropolitan hospital in the southeastern United States. There were
no anticipated effects of the study. There was a slight possibility that mild anxiety might
occur related to incivility and audio-taped interviews; however, the study participants
could decline to continue the interview at any point.
Participants of this study were given opportunities to ask questions. They were
provided telephone and email access to the researcher. The study subjects were given
informed consent (Appendix B) and provided a cover letter with a debriefing statement
(Appendix C). The informed consent and cover letter both provided descriptions of

29
declining to participate and ways to quit the study at any point. These measures were
taken in an effort to protect the study participants.
Instruments
The survey questionnaire used during the interviews for this study was adapted
from an existing 5-item survey. The first survey was developed by Drs. Cynthia Clark
and Pamela Springer while researching the academic nurse leaders role in fostering a
culture of civility in nursing education (Clark & Springer, 2010). These questions were
adapted to work with nurse educators within hospital environments (Appendix A).
Permission was granted by Dr. Clark (Appendix D) for the use of the model and for
adaptation of the survey questions for nurse educators in practice. Dr. Clark has
researched incivility in academic nursing education in several studies over the past
decade. Dr. Clark is a professor at Boise State University in the school of nursing. She is
a leader in fostering civility and establishing study results that may influence
administrators in schools of nursing throughout the United States. Dr. Clark is a
consultant and may be contacted for help with fostering civility in academic institutions.
To ensure validity of the questionnaire/interview, the survey was presented to the
participants in person at the same time as the cover letter and consent form. The
questions were answered during an audio-taped interview with the researcher. The
interviews were held in a neutral location chosen by the participants and limited to one
hour by the researcher. The researcher guided the interviews by the questionnaire.
Two content experts were used in this descriptive interpretive study. The themes
that developed from the narrative responses were evaluated by Expert A and Expert B

30
until the researcher was confident that the analysis was a valid description of the
comments.
Data Collection
The data was collected by the researcher during an audio-taped interview. The
researcher was assisted by a professional transcriptionist who is familiar with qualitative
interviews. Qualitative content analysis was utilized to breakdown the content of the
narrative data to identify prominent themes and patterns among the themes.
Data Analysis
The narrative responses were analyzed by the researcher for recurring responses
and organized into themes. Lincoln and Gubas Framework for developing
trustworthiness of the inquiry was employed to achieve credibility, dependability,
confirmability, and transferability of the study (Munhall, 2012). Experts were used to
verify interpretation of responses. Credibility was established as the resulting themes and
subthemes were representative of the group (Thomas & Magilvy, 2011).
Summary
The researcher provided informed consent, a cover letter with debriefing
statements, and the survey questions for the study participants. Within the contents of the
consent form and cover letter were contact information to reach the researcher for
questions and as a method for quitting the study. The researcher did not use the names of
the participants or the name of the hospital during data collection. The city and state
were also withheld to assist in maintaining confidentiality in the Thesis paper. The
participants were asked not to reveal any identifying information during the interview.

31
A qualitative methodology was used to determine if incivility affects the nurse
educator-staff nurse relationship. The results are the perceptions of the nurse educators
who participated in the study.

32
CHAPTER IV
Results
The purpose of this research study was to evaluate the likelihood of incivility in
nursing education within the hospital setting. The research study was performed with a
small focus group in a single hospital setting.
The title chosen for this project was Incivility in the Hospital Environment: The
Nurse Educator-Staff Nurse Relationship. This title was selected in an effort to
differentiate and emphasize the research study group as nurse educators whose students
were practicing nurses in the hospital setting. The literature review for this research
study found numerous research articles supporting the occurrence of incivility in
academic nursing education and nursing practice. Incivility in nursing education within
the hospital environment is a concern that has not been explored and needs to be
researched in an effort to establish normative and practiced behaviors in the nurse
educator-staff nurse relationship. Stressful workplace interactions and relationships can
lead to job dissatisfaction and the loss of nurse educators. The aim of this research study
was to evaluate the occurrence of incivility and establish a beginning baseline of
incivility in nursing education. The primary investigators intention was to discover
information that may be added to the existing knowledge base of expected and practiced
behaviors for staff nurses and hospital nursing education.
Sample Characteristics
A focus group interview was the methodology utilized for this qualitative study.
The data was collected from six nurse educators (n=6) employed in one hospital setting.
Two of the initially recruited nurse educators cancelled the day before the group

33
interview. Two additional educators were recruited prior to the interview. The hospital
for this study was a large acute care facility located in the southeastern United States.
The interview was led by the primary investigator with a predetermined questionnaire.
The questions were adapted from Dr. Cynthia Clarks qualitative questionnaire for
academic nursing education to fit nurse educators in practice (Clark & Springer, 2010).
The interview was audio-taped and a transcript was produced by a professional
transcriptionist who was familiar with qualitative interviews. Qualitative content analysis
was utilized to breakdown the content of the narrative data to identify prominent themes
and patterns among the themes. Lincoln and Gubas Framework for developing
trustworthiness of the inquiry was utilized to achieve credibility, dependability,
conformability and transferability of the study (Thomas & Magilvy, 2011; Shenton,
2004; Whittemore, Chase, & Mandle, 2001). The unit of analysis was the educators
whole response. Qualitative content analyses were focused on the nurse educators
subjective experiences and opinions, and no attempt was made to attribute conceptual or
abstract frameworks to these responses. To maintain rigor and trustworthiness of the
research process, the transcript generated from the focus group was read thoroughly three
times by the primary investigator and the qualitative methodology adviser. An
independent qualitative methodologist who is an expert in qualitative research was also
consulted to peer review the themes and subthemes. Peer review assisted the opportunity
to reveal primary investigator bias and help confirm, disprove, or extend emerging
themes. Findings are described using excerpts from the educators responses; all names
have been replaced with pseudonyms. Transferability was supported by discussion and
sharing findings with content experts and by returning to the literature.

34
The demographics of the study participants were diverse in the demographic areas
of age and years of experience as a registered nurse. The areas of demographic data that
were similar were gender, nursing degree achieved, and years working as an educator.
The six nurse educators ranged in age from 24 to 57 years. All six participants were
female. The educational level or degrees achieved by the participants were five
Bachelors degrees and one Masters degree. The educators years of experience
practicing as a registered nurse ranged from four years of experience and progressed to
34 years. The number of years the nurse educators worked as a nurse educator ranged
from three months to five years.
Table 1
Demographic Characteristics of Nurse Educators
Category

(%)

Gender

Male
Female

0
6

0%
100%

Nursing Degree Preparation

BSN
MSN
Doctoral

5
1
0

83%
17%
0%

Age Group (years)

20-29
30-39
40-49
50-59

1
2
2
1

17%
33%
33%
17%

Nurse Educator (years of practice)

<5 years
>5 years

5
1

83%
17%

RN (years of experience)

1-10
11-20
21-30
31-40

1
4
0
1

17%
66%
0%
17%

35
Major Findings
The experts found five themes and three subthemes that were prominent through
qualitative content analysis of the transcribed narrative produced from the audio-taped
interview. The themes that developed were feeling overwhelmed, sensing rudeness,
fearing failure, valuing support, and meriting responsibility. The subthemes were
feelings of guilt, entitlement, and insecurity.
Theme 1. Feeling overwhelmed. The first question presented to the educators
solicited their opinions for the biggest stressors for nurses during hospital education
courses. The educators perceived the main stressor for nurses to be a sense of being
overwhelmed with the demands of educational courses in addition to working on their
units. Nurses, these are the students of the educators, may be less stressed by courses that
are specifically related to their hospital units specialty area and more stressed by courses
that are required for hospital wide educational purposes.
There was a subtheme of the educators feeling guilty. The feelings of guilt for the
educators were associated to the knowledge that courses added to the nurses workload,
there was unequal time spacing of courses presented throughout the year that required
multiple course completion during short periods of time. There was also guilt over
having to blend students from other units in some courses even though it threatened these
nurses concept of a comfortable learning environment and understanding if the training
was a meaningful experience.
Amanda. I think one of the biggest stressors with hospital education courses, is
probably, they have so much to do on the unit, that we are asking them to do even more

36
in a classroom setting, and taking time out of their already busy schedule, which seems to
cause more stress for them.
Linda. I get a lot of complaints about the time it takes to complete all the
different education. It seems to hit them all at once. They feel pressed for time. There
are times we dont have a lot, and then all of a sudden they are slammed with lots of
education that has to be done now on a timeline, and they get frustrated that they think
they are done, and then they are not done, and there is something else they have to do, so
they dont buy in all the time like I would like them to. They will fuss on how much time
it takes.
Jennifer. I think one of the things too is balance in that people want to do it at
home, and maybe the bosses dont want to pay them for it, because they know it is
important to get done, but they dont want to be here.
Megan. When I was thinking about the question, I was thinking about the actual
classroom setting, and I think one of the stressors I see students that participate go
through is they want to connect it to their individual unit, and it is hospital wide training,
and the instructor may not get to their unit, so we cant connect those dots for them.
Sometimes they need to extract themselves from what they are doing on their unit, but I
think that is one of the stressors I see on hospital wide education.
Michelle. I agree with that, also with what Megan said as far as that buying in
with the value when they cant directly link it to what is going on in their world, their
unit. Even something as simple as the CE processes. There is a little bit more value and
buying in versus just going to a class even though it is still developing them.

37
Theme 2. Sensing rudeness. The second question inquired as to what uncivil or
rude behaviors the educators had observed nurses displaying during hospital education
courses. There was an overall sense of disconnection observed by the educators of the
nurses who displayed rude behaviors during courses. The majority of these behaviors
was nonverbal communications and could have been influenced by generational
differences. These uncivil acts caused the educators to feel unappreciated. Nurses need
to be accountable for their educational needs so that they could possibly appreciate the
educator presenting courses that are necessary to meet their patients and hospitals
needs. At times nurses may only be motivated to participate in courses that are of interest
to them personally and their particular specialty field within the hospital setting. Hospital
leaders are required to arrange for educators to present mandatory courses that meet their
hospitals need to maintain good standing. These leaders are influenced by
reimbursement and Joint Commission accreditation standards.
The subtheme that evolved was the educators feeling entitled. The educators
were meeting the educational requirements of the hospital administrators, nurse
managers, and nursing education department. These courses were necessary to meet the
hospitals needs and should entitle the educators to civility within the classroom setting.
Amanda. I think a big thing is their cell phone use, not really paying attention,
and kind of just being there, not really paying attention, just going through the motions,
and not thinking about what is being covered. I think cell phones and being distracted is
a big issue.
Linda. I have a lot of classes outside of the hospital and at other hospitals, this
was really before the cell phone time, but there was a lot of eyeball rolling, whispering,

38
sighing, just any kinds of indication like that to make you feel like you were
unappreciated while you were there. That they did not value this presentation that
someone may even come, so they do a lot of nonverbal displays of letting you know they
are frustrated and dont want to be here. The biggest one is the eye rolling and huffing
and puffing, and whispering. (The primary investigator inquired if this occurred from
the beginning to the end of the course or more towards the end.) Actually I have seen it
from the beginning to the end. I have seen some attitudes, especially from the more
educated people, lots of times would be the more rude people. Whenever I am in the
unlicensed or less educated people, lots of time they buy in more, but if you got to the
level of a nurse, resident, or physician, you had to work hard to get them to buy in to
what you were teaching; otherwise, they just disconnected and let you know they were
disconnected. It was very frustrating.
Kimberly. I agree. There is one particular classroom that we use to teach our
core curriculum classes that every person has a computer in front of them, and I have
found that the internet becomes a big distraction, along with their phones. I would say
body positioning; you know you hear all of those things about crossing your arms,
closing yourself off. I have witnessed a few incidences of that with different departments
who didnt think they needed to be in our classes.
Megan. I agree with all of that, but I wanted to add that I also see a lot of
intimidation, so if a student wanted to ask a question, but then another group of students
laugh, they chuckle and the whispering, and it really hurts the person, but I agree with all
the other educators that causes complications. (The primary investigator asked if the
person asking the question was a new nurse and if it was a question that only new nurses

39
needed to learn, and if the others were thinking they should already know this.) It might
just be a person who learns at a different pace than you or someone who is not as tech
savvy as the others, so I think it is just a similar situation.
Michelle. I have a couple of examples of classroom settings that I have been in
where I have seen different things, and one of them has been during the orientation
process where, especially and maybe it is a generational thing, with your younger
generational nurses, where they are much more technology advanced. We have had them
to the point where they bring their Nook or their Kindles to class, and they would be
reading, so that is completely disengaged and you have to stop and say, all electronic
devices must be off and it is not a good behavior to display and that type of thing. That
has happened a couple of times. I was in a class not too long ago, where I was attending,
and the person presenting the class started us off by saying; introduce yourself, where
you are coming from, and why you are here. The first couple of people did it okay, then
one person started with I am here because my manager made me and so the next thing
you know that was basically what the entire rest of the class said, I am here because I was
forced to come. I felt like that automatically dropped the mood of the class. Now
everyone kind of used that standard line. So the next time I did a class and I was in
charge, I did not even ask that question, because I did not want it to automatically
dampen the mood of the class.
Theme 3. Fearing failure. Question three surveyed the opinions of the
interview groups perceptions of the biggest stressors for nurse educators. The theme that
evolved was the fear of failure. Educators have demanding jobs. They feel the need to
be many places at one time. Educators have difficulties coaxing nurses in specialty areas

40
to meet their educational requirements within the time restraints set up for their unit.
Educators have responsibilities to the education department for hospital wide courses and
planning committees for future educational needs. Educators plan their schedules to meet
all their responsibilities. Nurses that do not meet the educational requirements in a timely
manner add more stress and work to their educators workload responsibilities. These
nurses may understand how busy their personal workload may be; however, they are
disrespectful of their educator and want individual attention at the educators expense.
Amanda. I think the biggest stressor for nurse educators, in my opinion, is
probably you feel the need to be everywhere every single moment, and you have to
juggle that, whether you have to step off the unit, but then something could come up that
you need to help with or that people have questions about, and also having to track
people down to get stuff done and trying to get their opinions. I think that the biggest
stressor is trying to get people to contact you back and take charge of their own
education. Its kind of hard to initiate that for some people.
Linda. I know you think I am stealing all your answers, but I have done
education for a long time, but have only been an official educator for about a year, and
the difference for me has been, this past year, is holding people accountable for their own
education for their learning, stepping up and wanting to learn because it is the right thing
to do as a nurse. The day you finish nursing school is not your final day of education.
You learn until you retire. I have been at it for 35 years, and its constant, the need is
always there to learn. I have been very frustrated chasing people down for a year, to get
them to do modules, and just even little in-service type things, things that dont take that
much time. Its getting them to step up to the plate and say okay this is only a few

41
minutes out of my life, it is not my life. I can take 20 minutes to do this module and be
okay. So that has been my biggest stressor in the past year, to just getting people to buy
in. It was much easier when I had one little unit that I did. Now that I have more units, it
is a much harder job to get people to buy in. It has frustrated the life out of me. (The
primary investigator asked if it was more difficult now that her area was larger because
while she was situated with one unit it was more like her community.) The one unit that
I came from I had more buy in. With the other units its been harder. I had to work very
hard to get them to respect my position and the need for me in their units and to keep
them all up to date. They are all out patient, so they think everything is in-patient driven,
but it is not and there are lots of things they need to learn. The big stressor for me is to
keep that going and keep up my momentum and keep a positive attitude, and not to get
frustrated with them, and that there is a better day coming.
Jennifer. I agree with the whole accountability issue. I think one of the biggest
stressors is if I dont agree with something, it is trying to get someone else to buy into it.
I have to make sure that I convince myself before I go out there and try to sell it.
Sometimes that is very difficult. But yes the accountability is ever lasting. I think if you
can get people to be accountable, it can make all the difference in the world.
Kimberly. I have always described our role as the cheer leader, and you have to
be on when you come into the unit, so sometimes, kind of like what Jennifer, Linda, and
Amanda said, to be the accountability for getting the education done, but also
cheerleading to make sure that they understand why they need to do it, why it is
important, what it really means. Sometimes when you come in and you have had your

42
own bad day, you are stuck in traffic, sometimes you have to focus yourself and be ready
to go out and say alright, here I am.
Megan. I agree with Amanda, Linda, Jennifer, and Kimberly with
accountability, and I was thinking about the comfort level with the material we have to
teach sometimes. I think as a department here at our facility, we have done a much better
job recently with our leaders making sure that we have the information we need to be
successful, so I think that is a huge step in the right direction for us. But one of the
stressors that I have sometimes faced is teaching something and having to be the expert in
something that I am not particularly comfortable with. Most of the time it is not clinical
based but sometimes it is.
Michelle. I agree with Amanda, Linda, Jennifer, Kimberly, and Megan. They
hit all the major points. Specifically back to Megan with not feeling that you are the
expert. It is true; it is not always about the clinical. A lot of us have been teaching some
lateral violence classes, and sometimes some of the situations that come up. I even
question, wonder sometimes what can I say to this person and what would be the correct
answer, not just my opinion, but what would be the correct answer, so that stresses me,
wanting to make sure that I dont give someone else incorrect information
professionally.
Theme 4. Valuing support. Question four inquired as to what uncivil behaviors
the educators observed in other educators. These educators acknowledged that they were
human and occasionally observed or participated in uncivil behaviors. Prior to and
during the time of this research interview the hospital where the group of educators was
employed was presenting hospital wide Lateral Violence courses. These classes were

43
inspired by the Joint Commission. The purpose of these courses was to inform all
employees, licensed and unlicensed, about disruptive behaviors in an effort to create a
healthier work environment. Due to exposure to these classes, the educators were aware
of uncivil behaviors and eager to identify the behaviors they had personally experienced.
There was a subtheme of feeling insecure. The educators suggested there was a
lack of collaboration and fear of retribution within their peer group. Nonverbal
communications among peers during collaboration were perceived as rude and brought
about feelings of insecurity and fear of retribution. The educators perceived females as
instigators and commented that the majority of educators were female. The educators
valued the support of their peers and were reluctant to address the nonverbal
communications among peers during collaborations.
Amanda. I cant really say that I see too much. I think everyone is there for our
department, because we kind of feel like the outsiders, but the insiders with your
department, but you are not, but you are, but then sometimes youre not. I think we
group together well. I always have questions, so it is nice to have other people to ask
questions, so I dont really see much uncivil stuff.
Linda. I have been here for a year, and I can honestly say I have never been
mistreated one day. If anything occurred, it occurred behind my back. Because I have
not had questions go unanswered. Someone has cheerleaded me up when I felt
overwhelmed. Someone has always been in there to help me. I think we have a very
good group of educators. They have all walked the walk, so they are helping me to walk
that walk. Sometimes I feel a little self conscious because I feel like I am the old one,
and that I should be able to catch on to the electronic stuff a little quicker than what I feel

44
I have, but someone is always there to help me. I havent seen any educator be uncivil to
another.
Jennifer. I would like to think we dont partake in it, but we do because we are
nurses and we are women. I know that there are certain groups that if you have done
something to not necessarily fit into their group you have been oust. Its really sad
because what happens is, our group, we are pretty intelligent, and so it really makes them
look bad and not the person you are ousting. The funny thing is a lot of us are talking
and teaching about lateral violence, and we are supposed to be the leaders. But we are
still having that behavior. But I do know that our leadership does not permit that
behavior once it has been brought to their attention, and that is the hard thing. Thats the
hard thing because we are afraid to bring it, we dont want to bring it to the leaders
attention because we are afraid we have already been ousted once, are we going to be
ousted again. I have my bad days, but I really like to think of myself and that I am
somebody that anybody can get along with. I should just believe that if we continue to
hold each other accountable, then those of us who continue to act in that uncivil behavior
will find their way out the door or change.
Kimberly. We had a book that came out last spring that had the bad words of
being a nurse, like frequent flyers, things like that. And we as an education group sat
down and came up with our words. I would say that I did wrong. There was a particular
class that I hated to teach, and I always made the joke that I drew the short straw to teach
that class. So I would say that, that would be me acting uncivil, so yes I have done it. I
would hope that I havent out casted any of my friends or anything like that, but I have
said that I drew the short straw when teaching that class.

45
Michelle. Unfortunately I am in a relatively new role. In my previous role of an
educator, I was more of a participant with everyone in our group [educator staff
meetings]. Our leader stood up in front and talked about new processes and whats going
on and that kind of stuff, and now in this role I have to present things, and it is terrible
when I look out there and see people rolling their eyes at me and these are my coworkers
and we are all on the same team. But I see people texting or crossing their arms. All of
the things we talk about in our Lateral Violence classes, I see it almost every time I stand
up. It is not the question. It is all of the behaviors that I see that go along with the
questions or beside the question, because it is not necessarily the one who had the
question, it is other people. I would like to say that none of us do it and it will be better.
That is when I feel I am a victim of it, I hate to say that but if you are talking about
putting it into a box thats when I have to say yes I am a victim of it.
Theme 5. Meriting responsibility. Question five dealt with the role of nursing
leadership in addressing incivility. The educators perceived themselves to be in a
leadership role. They accepted accountability and the challenge to help create a healthier
environment in the workplace and classroom. The educators were aware of incivility and
interested in ways to resolve disruptive behaviors within their classrooms.
Amanda. It is their responsibility and our responsibility because we are in
somewhat of a leadership role, even though we are not the managers. It is always better
to stay positive and not participate in the bad talking, but kind of stop it. I try to stop a lot
of it and not have that kind of stuff going on in the workplace, but I think it is important
that people be held accountable for what they are saying. I think it is kind of hard if
management or other leaders are having a rough day and they dont feel like managing up

46
per say, they should take it off the unit for their personal health and not let other people
get involved.
Linda. I feel that we are just really strong role models, and it is hard to stay in
that role model mindset every day, all day, but in the end we are supposed to reflect what
we expect to see back from them, so if we can control our uncivil behavior then hopefully
we can set an example for them to control theirs.
Jennifer. The nurse educator is in a leadership role. Educators need to have
courage to handle incivility and stand up to it.
Megan. I looked at this question differently and felt the nurse manager was the
leadership for the nurses in her core classes. I feel little is done to address uncivil
behaviors. You have to trust that nurse managers follow up with behaviors that they are
told about.
Michelle. I am the leadership as my students are hospital wide and not part of a
specific department. I address offenders by a general comment first, second I make eye
contact and walk over to the person and ask them to put away the cell phone or Nook.
The most important part of leadership is letting people know. If you dont, it can dampen
the mood and productivity of the class.
Summary
The nurse educators from this research group have experienced incivility in
nursing education in the hospital environment. There was a sense of disconnection
observed by the educators of the nurses who displayed rude behaviors during courses.
The behaviors of nurses in courses that led to these perceptions were nonverbal
communications such as rolling the eyes, crossing the arms, sighing, whispering, texting,

47
and reading a Nook. These behaviors made the educators feel unappreciated. The
educators conveyed that nurses have not accepted responsibility for their educational
development. The educators were searching for ways to help nurses accept responsibility
for their education requirements.
The educators identified stressors for practicing nurses that they felt could
possibly contribute to rude behaviors. They perceived the main stressor for nurses to be a
sense of being overwhelmed with the demands of educational courses in addition to
working on their units. They also felt the nurses in courses did not appreciate or
understand that many of the educational demands were necessary to meet their hospital
leaders needs for reimbursement and maintaining Joint Commission accreditations.

48
CHAPTER V
Discussion
The purpose of this research study was to discover if incivility occurs in nursing
education within the hospital setting. This study specifically evaluated the relationship of
hospital nurse educators and staff nurses within the hospital environment. The
relationship was evaluated from the nurse educators perspective. A small focus group
interview was performed and consisted of six nurse educators from a single hospital
setting. A qualitative analysis of the narrative transcript produced from the audio-taped
interview was evaluated. The themes that emerged were feeling overwhelmed, sensing
rudeness, fearing failure, valuing support, and meriting responsibility. The subthemes
were feelings of guilt, entitlement, and insecurity.
The biggest stressor for nurses during hospital educational courses was a sense of
being overwhelmed with responsibilities to the hospital. A review of nursing literature
shows the major stressors in nursing practice that contribute to incivility were workload
and job control (Oore et al., 2010). Practicing nurses must staff and cover their units and
yet meet education requirements by deadlines that may affect their good standing on their
unit. Course deadlines and multiple course demands in short time frames may have
added to the practicing nurses sense of a loss of job control. Some courses may have
required additional days at work which required the nurses to be unable to meet demands
from home. Also, courses that could be worked into the staffing day added stresses to
demanding work conditions. These stressors increased nurses stress levels and
contributed to the occurrence of incivility by the nurses who clearly exhibited rude
behaviors implying that they resented being at work for a course they may or may not

49
feel was a necessary part of their professional development. The acuity of nursing
practice may be a factor in the high demands of additional educational courses. Complex
care of critical care patients, trauma patients, and surgical patients is continuously
changing and improving in an effort to provide safe quality care. Specialty units within
hospitals must improve and change the way nursing care is provided for patients to keep
up with evidence-based care. Patient acuity has increased along with advances in
medical care. There are higher educational requirements or demands for nurses working
in intensive care units and other highly specialized areas of nursing. Nurses are
performing a substantial amount of procedures that increase the need for continuing
education and competency in these skills (McCarthy, Cornally, OMahoney, White, &
Weathers, 2012). The educational needs of high acuity patient care can add to the
stressors for nurses by the volume of competencies and increased educational demands.
The subtheme that developed as the nurse educators evaluated the stressors for
nurses in education courses was one of feeling guilty. The feelings of guilt were
associated to the knowledge that courses added to the nurses workload. There was some
discussion of courses having unequal spacing in time throughout the year and this added
to the demands of the nurses. This study did not explore the factors contributing to this
stressor. Did the nurses have multiple opportunities throughout the year to sign up for
classes and failed to meet these requirements in a timely manner? Or did this situation
occur as a result of poor planning by the educators? It was also difficult to determine
from this study how often the nurse educators experienced feelings of guilt. The
subtheme of feeling guilty could be a true compassionate response to the nurses feeling
overwhelmed. If the occurrence of too many courses in too short of a time period was in

50
part due to the nurses failure to sign up for educational offerings until the deadline for
completion occurred, the educators may have felt empathy sometimes instead of guilt.
Sensing rudeness was the second theme. The nurse educators for this study
supported the assumption that incivility does indeed occur in nursing education within the
hospital practice area. They have witnessed rude behaviors from their class participants
that were similar to the uncivil behaviors exhibited by academic nursing students in
previous studies (Clark & Springer, 2010). These behaviors included cell phone use
during class, a lack of attention to class material, eye rolling, whispering, sighing, using
computers for personal use during class, reading personal electronic devices, and
intimidation of classmates with nonverbal expressions and laughter. The nurse educators
desired civility in their classrooms for two reasons. First, they were responsible for the
teaching/learning environment of the class and did not want rude and disruptive
behaviors to negatively impact the classroom group. Further, they worked hard to plan,
prepare, and present educational courses for their hospital and felt they deserved to be
treated with respect.
The effects of incivility in the classrooms of hospital nurse educators damaged the
teaching/learning environments for both educators and class participants. This in turn
impeded staff development as disruptive behaviors affected the overall mood of classes
and negatively impacted course outcomes. Class participants rude behaviors were
interpreted as a lack of respect for educators. The lack of respect for educators
sometimes led to role ambiguity as some of the educators struggled with their role as a
nurse educator within their unit and for the hospital wide education department.

51
The subtheme that evolved as the educators evaluated incivility in the classroom
was feeling entitled. They expected civility in the classroom environment. There should
be a reciprocal relationship that is respectful between the educator and the nurse. The
courses were a requirement for both the educator and the nurse and were met within their
roles. Nurse executives and managers set the expectations for both educators and nurses.
This is a part of the hierarchy that exists within the hospital system. The Joint
Commission has addressed disruptive behaviors in the workplace with hospital
administrators (Clark et al., 2011). Disruptive behaviors include incivility and bullying.
Disruptive behaviors can lead to sentinel events and deaths related to medical errors
(Clark et al., 2011). Hospital nurse executives and managers have been placed in the
position to demand civility and expect civility to become a normative behavior.
Management must maintain a safe workplace environment that is conducive to safe
patient outcomes. Nurse executives and managers as leaders recognized workload as a
stressor and acknowledged the contributing effects of heavy workloads to incivility
(Clark et al., 2011). Policies to prevent and manage incivility are being put in place in
many hospitals throughout the United States. Courses identifying disruptive behaviors of
incivility, bullying, and lateral violence are being introduced in hospital workplaces
(Clark et al., 2011).
This study did not explore the rationale for the educators feelings of entitlement
or differentiate the expectations for civility in the classroom. The results of this study
cannot address the subtheme of entitlement. The educators could have felt civility was a
normative behavioral expectation. The educators could have felt they deserved civility in
the classroom due to their being in a leadership position. These educators were aware of

52
new policies and courses they were presenting in an effort to promote civility in the
workplace. Nurse educators are experts in their specialty area and have been given the
opportunity to train inexperienced and experienced nurses. The title of educator may be
considered a promotion for a staff nurse; however, the nurse educator position is not a
management position.
In academic schools of nursing an obvious hierarchy exists. Classroom dynamics
are similar to other workplace environments (Cooper et al., 2011). Instructors and faculty
are proposed to symbolize supervisory positions in companies and students personify the
status of submissive workers (Cooper et al., 2011). Teacher-learner relationships must be
positive or the students need for support and respect cannot be met (Cooper et al., 2011).
Uncivil student behaviors occur in academic nursing education and were well
documented by Dr. Cynthia Clark (Clark & Springer, 2007b). These behaviors were
cutting class, arriving late for class, talking during class, not paying attention in class,
being unprepared for class, dominating class discussions, using cell phones, acting bored
or apathetic, making sarcastic remarks or gestures, making disapproving groans, sleeping
in class, demanding make-up examinations or extensions, using a computer during class,
cheating on examinations or quizzes, and refusing to answer direct questions (Clark &
Springer, 2007b). Strategies to increase nursing faculty and nursing student awareness
and accountability for professional behaviors have been presented in many Schools of
Nursing (Clark & Spring, 2010). Dr. Clark has studied incivility in nursing from the
educator and the student points of view. The teacher-student relationship is reciprocal in
regards to incivility. Dr. Clark is a strong proponent for fostering civility in nursing
education for both faculty and students (2010 & 2011).

53
Fearing failure was the third theme extracted from the narrative interview.
Educators have demanding jobs with responsibilities to their specialty unit and in many
hospitals to their education department. The heavy workload and split allegiances are
stressors that can affect workplace relationships. They feel the need to be in multiple
places at the same time. Educators are responsible for prompting nurses to enroll in
courses that are unit specific in addition to hospital wide requirements. Failure to attend
courses is attributed to both the nurse and the educator; however, the educator should not
have to stoop to incivility or bullying to induce nurses to attend courses that are a part of
their professional development and requirements to maintain good standing with their
manager. The nurse educator must plan courses, meet managements needs for courses
and timelines, and also meet their managers expectations if their manager is in the
education department. Hospitals would benefit greatly by utilizing preceptors and
mentors for new educators. Providing these leadership roles would benefit the hospital in
the long run as new educators would make their role transitions more quickly and
smoothly with support. This could improve job satisfaction for educators and increase
intentions to stay.
Valuing support was the educators fourth theme. The educators in this study
have observed or been the recipient of uncivil behaviors from other educators. The
hospital where the educators were employed during this study was presenting hospital
wide Lateral Violence courses. These classes were inspired by the Joint Commission.
Due to exposure to these classes, the educators were aware of uncivil behaviors. In the
past many of these behaviors were endured or ignored. The courses were alerting
employees to the awareness that incivility could lead to lateral violence and should be

54
addressed before escalation could occur. Even though they were aware incivility could
lead to lateral violence, some of the educators were reluctant to address fellow educators
due to fear of retribution.
The emerging subtheme was feeling insecure. The educators proposed that
sometimes there was a lack of collaboration and fear of retribution within their peer
group of educators. The educators implied females were instigators and were aware the
majority of nurse educators were female. The educators valued the support of their peers
and were reluctant to address nonverbal communications that were uncivil among peers
during collaborations.
Meriting responsibility was the final theme. The educators from this study
perceived themselves to be in a leadership role. They accepted accountability and the
challenge to help create a civil environment in the workplace and the classroom.
Incivility could lead to job dissatisfaction for educators and the loss of educators in the
hospital setting. The educators in this group were strong advocates of assuming
leadership roles and leading by example. They felt the first step to encouraging civility
was to make nurses aware of uncivil behaviors in the workplace.
Nurse educators are in leadership roles. They coach and develop leadership skills
in nursing staff. Nurse educators are responsible for staff development for nurses and
allied health employees in the hospital setting. Nurse educators and nurse managers both
recruit staff with the purpose to develop staff to reach their highest ability for nursing
practice (Narayanasamy & Narayanasamy, 2007). Staff development should be as
important to each individual nurse as it is to educators. Nurse educators are responsible
for sharing knowledge, developing skills, and changing attitudes (Narayanasamy &

55
Narayanasamy, 2007). Nurse educators are important change agents for hospital
facilities. Being the change agent and assisting staff to accept different approaches to
skills has placed nurse educators in a leadership role (Narayanasamy & Narayanasamy,
2007). Nurse educators are responsible for recruiting staff into leadership roles such as
mentors and preceptors. They provide educational courses for staff orientation, inservices for new equipment and procedures, clinical practice updates, conferences,
learning resources, development of new policies and competences, help staff to solve
problems related to changes in practice, and promote evidence-based practice
(Narayanasamy & Narayanasamy, 2007). Hospital administrators and nurse managers
must prioritize staff development of nurses to increase patient safety, quality of care,
personal development and lifelong learning for nurses (Sykes, Durham, & Kingston,
2013). To promote safe and effective patient care, nurses must commit to lifelong
learning in an effort to keep up with changing health care practices (Sykes et al., 2013).
Workplace incivility in the hospital setting affects practicing nurses in the work
environment and in the classroom setting. Nurse educators can increase nurses
awareness of behaviors that are considered rude and disruptive. Rude behaviors have a
negative impact in classroom environments and thus hinder staff development. This can
negatively affect the promotion of safe and effective patient care. Incivility can lead to
bullying (Houshmand, OReilly, Robinson, & Wolf, 2012). Workplace bullying is a
common occurrence in the healthcare environment and nurses tend to have a greater
likelihood of experiencing these behaviors than other healthcare professionals
(Houshmand et al., 2012). Incivility can lead to job dissatisfaction and affects intentions
to stay in the same position or unit in the hospital environment (Houshmand et al., 2012).

56
Uncivil behavior must be identified for staff nurses and policies to address incivility
should be developed in an effort to increase employee retention rates for staff nurses and
educators.
Generational differences need to be evaluated for teaching/learning purposes.
Generational disparity should also be evaluated for possible effects in identifying and
addressing incivility in the workplace. Belonging to different generations may affect
perceptions of incivility. It is essential that health care organizations have the ability to
attract, retain, and motivate nurses of all generations (Stanley, 2010). One study found
that Generation X nurses encountered more incivility from coworkers and from
supervisors than any other generation (Leiter et al., 2010). Conceivably these Generation
X nurses found their hospital workplace unwelcoming. Perhaps incivility was a factor in
the poor socialization of these nurses during their role transition.
Health care organizations need to invest in their education department and
cultivate nurse educators as leaders. They too need to have lead educators who are
developed as preceptors and mentors for nurse educators. Developing leadership skills as
educators could help nurse educators develop self-confidence. Many times a nurse is
placed in a position as nurse educator for a specific unit because he or she is an expert
practice nurse in a specific specialty unit. Often these nurse educators do not have
degrees or training in education. Their expertise is purely clinical practice. They know
how to care for these patients, but may lack self-confidence in teaching these methods in
the classroom which is a different skill set than being a preceptor for new nurses at the
patients bedside. Lead educators mentoring new educators could assist new educators in
the development of confidence and competency (Perry, 2011).

57
Limitations
The study sample size was a small focus group interview. For the purposes of this
study the sample size was adequate for the intention of discovery as to whether incivility
occurs in hospital nursing education. The location of the nurse educators was a single
acute care hospital. As to diversity of the group, there was a good representation of age
groups and years of practice as a nurse. However, there was no diversity in gender as all
of the participants were female. Also, there was a lack of diversity in years of experience
as an educator as all had worked in this capacity for five years or less. This study was
also limited in qualifying the volume of uncivil behaviors in practicing nursing education
in comparison to academic nursing education.
This is one study and is limited as it has not been replicated in regards to the nurse
practice education area. There are, however, large amounts of data supporting the
occurrence of incivility in academic nursing education and workplace nursing practice.
Implications for Nursing
Incivility is a low intensity act of rudeness that can lead to bullying, harassment,
or violence (Githens, 2011). Further, incivility is insidious and often ignored. Human
resource departments in large companies that deal with all types of professions
throughout the United States are recognizing the effects of incivility in the workplace and
addressing these issues with education and policies to guide and strengthen accountability
of acceptable behaviors (Githens, 2011). It is with dismay to discover, even though
incivility affects all types of professions that nurses are more likely to be affected by acts
of incivility than employees in any other profession (Houshmand et al., 2012).

58
Incivility in hospital environments can lead to unsafe working conditions, poor
patient care, and increased medical costs (Clark et al., 2011). Incivility in the hospital
nurse educators classrooms can have a negative impact on classroom environments and
impede staff development.
Recommendations for Practice and Education
It is important in the medical arena for nurses to identify uncivil behaviors, and
understand how to address these behaviors prior to escalations that may lead to violence.
Nurse leaders must promote civility in order to create a healthy work environment.
Nurse leaders function in many roles such as administrators, nurse managers, educators,
charge nurses, mentors, and preceptors. Nurse educators have the opportunity to develop
these leadership skills for themselves, nurses, and allied health employees.
Nurse executives, nurse managers, and nurse educators need to participate in
interdisciplinary meetings to develop a cohesive vision and culture of civility, develop
codes of conduct and policies of acceptable and civil behaviors, establish healthy practice
environments that highlight workplace civility, be positive role models, hold self and
others responsible for acceptable behaviors, and reinforce positive behavior (Clark et al.,
2011). Promoting civility may be a learned process that is a necessary part of the
promotion of a work environment conducive to caring (Clark et al., 2011).
Nurse executives and nurse managers need to develop a mentorship program
designed specifically for nurse educators as part of their staff development. Educators
are often responsible for mentorship programs for nurses on their specialty unit. This
program works well in assisting newly graduated nurses to adapt to their new role. New
nurses need support in the beginning of their nursing career. Preceptors and mentors are

59
roles designed to facilitate the new nurses support during the novice period (Smith et al.,
2010). Academic nurse educators have been aware of the positive impact of collegial
mentoring for nurse educators (Thorpe & Kalischuk, 2003). New faculty members were
inundated with responsibilities for teaching research, and community service. Support
from mentors was found to be essential to professional achievements (Thorpe &
Kalischuk, 2003). New academic educators may lack confidence, experience, and
problem-solving skills that are necessary to meeting these expectations (Jacobson &
Sherrod, 2012). Colleges and universities discovered that mentor relationships with new
faculty promoted faculty retention, career development, and quality education (Jacobson
& Sherrod, 2012). The expert nurse who is a novice educator could also benefit from the
support of preceptors and mentors. A uniquely designed program for mentors of new
nurse educators in the hospital could become the best support during the nurse educators
role transition and promote educator retention, career development, and quality education
for hospital nurse educators.
Conclusion
Incivility occurs in academic nursing education and nursing practice (Clark et al.,
2011). According to the findings of this study, incivility also occurs in the continuing
education classrooms of hospital nurse educators. Uncivil acts are disruptive behaviors
that negatively impact the teaching/learning environment. Stress is a major contributor to
incivility (Clark et al., 2011). Nurses are often overwhelmed with obligations for staffing
and covering their units, meeting educational demands, and meeting responsibilities at
home.

60
Educators are in a unique leadership position to be advocates for civility.
Generational diversity can be a part of uncivil acts as the majority generation in a group
such as a classroom may be biased against younger and/or older generations (Githens,
2011). Hospital educators could also put emphasis on spreading out courses over the
year and avoid adding to staff stress levels with heavy concentrations of courses.
Educators could support nurse managers as leaders by including new policies related to
civility/incivility in modules or courses about incivility (Ostrofsky, 2012). This would be
one way hospital organizations could support leaders responsible for enforcing policies
related to uncivil and unacceptable behaviors. For hospital administrators, managers, and
educators to be effective leaders and promote civil and safe workplaces, they need to
bond together and strengthen communication and education for promoting civility
(Ceravolo, Schwartz, Foltz-Ramos, & Castner, 2012). The first step may be identifying
incivility, but much more will be needed to promote civility. In the early stages,
workshops or courses for continuing education can strengthen the communication
regarding uncivil behaviors (Ceravolo et al., 2012). Story telling is a great way to
emphasize unacceptable behaviors and point out the stressors that contributed to rude
behaviors (Ceravolo et al., 2012). However, it is also important for these courses to
advise employees in the proper way to handle uncivil situations when these situations
occur. There must be policies that support the promotion of a safe and civil workplace in
place and accessible for employees. Promoting civility can have a positive impact on
intentions to stay for nurses in leadership roles and all healthcare employees.

61
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APPENDICES

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Appendix A
RESEARCH QUESTIONS
Incivility in the Hospital Environment: The Nurse Educator-Staff Nurse
Relationship
Demographics
Age:
Gender:

Male

Nursing Degree: ADN

Female
BSN

MSN

PhD

Number of years worked as a Nursing Educator:

Number of years of total practice as a registered nurse:
Questions
1. What do you perceive to be the biggest stressors for nurses during hospital education
courses?
2. What uncivil behaviors do you see nurses displaying during hospital education
courses?
3. What do you perceive to be the biggest stressors for nurse educators?
4. What uncivil behaviors do you see nurse educators displaying?
5. What is the role of nursing leadership in addressing incivility?

* I appreciate the job you do and I am interested in your perceptions on the nurse educator-staff nurse
relationship. Thank you for your participation in this research study. Cynthia T. Danque

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Appendix B

INFORMED CONSENT FORM

GARDNER-WEBB UNIVERSITY
CONSENT TO BE A RESEARCH SUBJECT
Purpose and Background
Cynthia T. Danque, RN, MSN student, Gardner-Webb University is conducting a
study to investigate the effects of incivility and the nurse educator-staff nurse
relationship. Current data supports the fact that incivility is a major concern in academic
nursing education. Uncivil behaviors are disruptive to the teaching-learning
environment. Current data also supports the fact that incivility is an important concern in
regards to the health care environment and nurses in the workplace. Incivility in the
nurse practice workplace area can negatively impact hospital unit productivity, employee
job satisfaction, and employee retention rates. Academic nursing education incivility and
nursing practice workplace incivility are serious concerns for university and hospital
administrators.
The purpose of this study is to explore if incivility negatively impacts nursing
education within the hospital environment and harms the nurse educator-staff nurse
relationship. You are being asked to participate in this study because you are a nurse
educator in a large metropolitan teaching hospital in the southeastern United States.
Procedures
If you decide to participate in this study, you will be involved in an audio-taped
interview of five questions regarding incivility in nursing education within the hospital
environment. The following procedures apply to the subjects of this study:
1. My participation is voluntary, and I understand that I may choose to respond to
any, all or none of the questions written in the survey.
2. I was informed that I may withdraw my consent to participate in the study at
any time without penalty by advising the researcher.
3. I have been assured that my responses will remain strictly confidential with
regard to my identity.
4. I am aware that excerpts from the survey may be included in the thesis and/or
publications to come from this research, with the understanding that the quotations will
be anonymous. No identifying information will be associated with individuals in the
study.
5. I understand that I will not receive any direct personal rewards from
participating in this study, and my participation will not affect my professional position.

70
Risks and/or Discomforts
Little or no risks are anticipated in this study. There is a small possibility that
answering questions about incivility may cause slight discomfort. The interview should
take approximately 45 minutes to one hour to complete. I may drop out of the study
without penalty at any point during the study.
I understand that the hospital location will not be identified in the thesis paper and
that results of the survey will not disclose the identity of the participants.
Benefits
There will be no direct benefit to me for participation in this study. It is possible
that I may become more aware of incivility and pursue ways to promote civility in
regards to nurse educator-staff nurse relationships and nursing education.
Costs/Financial Considerations
There will be no financial costs to me for taking part in this study.
Payment/Reimbursement
There will be no payment for my participation in this study.
Questions
I have talked to Cynthia T. Danque about this study and have had my questions
answered. If I have further questions about the study, I may call her at 803-240-3474 or
e-mail her at cdanque@gardnerwebb.edu.
If I have any questions or comments about my participation in this study, I should
first talk with the researcher. If for some reason I do not wish to do this, I may contact
Dr. Rei Serafica at 704-406-2298 or email rserafica@gardner-webb.edu.
Consent
I have read this Consent and Authorization form. I have had the opportunity to
ask and I have received answers to any questions I had regarding the study. I understand
that PARTICIPATION IN RESEARCH IS VOLUNTARY. I am free to decline to be in
this study, or to withdraw from this study at any point. My decision as to whether or not
to participate in this study will have no influence on my current employment or future
status as a nurse educator.
My signature below indicates that I agree to participate in this study. I
acknowledge that I have received a copy of this Consent and Authorization Form.

Print Participants Name

Participants Signature

Date

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Appendix C
Study Cover Letter
Dear

My name is Cynthia T. Danque and I am a registered nurse working on my Masters

degree in nursing education at Gardner-Webb University. I am writing today to invite
you to participate in a qualitative research study. This research will be conducted for my
Thesis.
Participation will be met through an audio-taped interview of five questions for
nurse educators in the hospital environment. Your involvement in the study is voluntary,
so you may choose to participate or you may choose not to participate. I am interested in
discovering if incivility affects nursing education within the hospital environment.
Current literature reports incivility as a barrier to education in academic nursing
education. Uncivil behaviors or acts may be a student talking during class or texting on a
cell phone, or checking emails on a cell phone instead of paying attention to the nursing
instructor. Uncivil acts are behaviors like being late or leaving class early. Interruptions
like these are rude and disruptive. They are barriers to the teaching-learning
environment. Research shows incivility is evident in the hospital workplace for nurses.
Heavy workloads, constant changes, large numbers of staff and interactions with coworkers, supervisors, physicians, patients, and patients families can create stressful work
environments that may be a catalyst for uncivil behaviors for one or more of these
individuals.
Do you feel incivility is present in the nurse educator-staff nurse relationship? If
you would like to participate in this study, please sign the consent and answer the
questionnaire. You may choose to skip any questions that are uncomfortable for you.
You may decide to quit the study at any time without penalty. If you decide not to
participate or have any questions, please call me at 803-240-3474 or email
cdanque@gardner-webb.edu. Your identity and the location of the hospital will remain
anonymous in the paper. The information collected for the study will be kept
confidential for ten years and then destroyed. Your participation in this study will be
greatly appreciated. Thank you for your consent and assistance with this study.
Sincerely,

Cynthia T. Danque, RN
Masters Nursing Student
Gardner-Webb University

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Appendix D
Email Correspondence
Re: Permission to use Conceptual Model & Questions
Cindy Clark [cclark@boisestate.edu]
Sent:
Thursday, October 18, 2012 9:42 AM
To:
Ms Cynthia Tucker Danque
Attachments:
Conceptual Model to Foster 1.pdf (21 KB)
Dear Cynthia--thank you for your interest in my work and in your interest in civility. Yes,
you have my permission to use the Conceptual Model to Foster Civility in Nursing
Education [Adapted for Practice, 2010]. I have attached the model for your use.
Similarly, you have my permission to adapt my research questions--with proper
citation/reference of course.
I wish you well with your studies. I would enjoy hearing about your results.
Dr. Cindy Clark