Student Civility in Nursing Programs

Student Civility in Nursing Programs:A National SurveyF ELISSA R.L ASHLEY,RN,P H D,ACRN,FAAN,*AND M ARY DE M ENESES,RN,E D D†A survey of611nursing programs was performed to determine the extent to which certain problematic student behaviors existed in schools of nursing,and how they were being addressed.Participants were also asked about specific behaviors of current stu-dents compared with those of5years ago.Of the611 surveys sent to program directors,2were undeliver-able and409responded for a response rate of67per cent.The majority of respondents(48.8per cent)were from associate degree programs,followed by bacca-laureate degree(43.9per cent),and diploma pro-grams(7per cent).Three disruptive behaviors were identified by all respondents:inattentiveness in class, attendance problems,and lateness.Objectionable physical contact between students and instructors were identified by24.8per cent,and verbal abuse toward instructors in the clinical setting by42.8per cent.Demographic variables examined in terms of their relationship to the behaviors included type of program,nursing program size,size of the parent institution,geographic region,location of program, and sponsorship of program.Administrators in differ-ent types of educational programs and from various geographic locations reported problematic student behaviors with high frequency.Identifying strategies for handling disruptive behaviors and assistance in implementing them is recommended along with a na-tional forum to discuss the issue.(Index words:Nurs-ing;Behavior;Education;Cheating;Students)J Prof Nurs17:81-86,2001.Copyright©2001by W.B. Saunders CompanyH IGHER EDUCATION HAS begun to identifythe lack of student civility in the classroom as problematic.Such behaviors traditionally were not conceived of at the university or college level and were formerly viewed as confined to elementary and second-ary education settings in North America.This has changed,and various conferences and written material have begun to address these issues(Franklyn-Stokes& Newstead,1995;Richardson,1999).Some undesir-able behaviors,such as cheating,absenteeism,and tar-diness,have been recognized for a longer period of time than those behaviors that are disrespectful and uncivil, such as verbal abuse,threats,and unwanted physical contact between students and instructors(Daniel, Adams,&Smith,1994;Hilbert,1985;Roberts,1997; Schneider,1998),the latter attributed to strong nega-tive emotions(Tiberius&Flak,1999).The purpose of this study was to identify the extent to which certain identified behaviors were occurring in nursing pro-grams,the association with demographic variables(if any),and how problematic behaviors,if occurring were being addressed.Method and ProcedureA questionnaire,based on the investigators’experi-ences and a review of the literature,was developed and then was reviewed byfive expert judges for appropri-ateness of content,clarity,and importance.A small pretest was performed,and further revisions were made based on the input of the judges and the pretest.Re-spondents were asked to indicate the extent to which they had experienced18behaviors in the educational environment that included various types of disruptive behaviors,such as bringing infants/children into the classroom,yelling at or verbal abuse of instructors, making threats to instructors,cheating on tests or as-signments,and student absences,tardiness,or inatten-tion.Respondents also were asked about how they per-ceived certain behaviors today compared with5years ago.Finally,respondents were asked about the disci-plinary actions taken for specified student behaviors. All individual respondents were anonymous and this study was reviewed and approved by the Institutional Review Board of Southern Illinois University Ed-wardsville.Participants for the study were randomly selected from a listing of state-approved schools of*Dean and Professor,School of Nursing,Southern Illinois Uni-versity Edwardsville,Edwardsville,IL.†Associate Dean for Educational Services and Professor,Schoolof Nursing,Southern Illinois University Edwardsville,Edwards-ville,IL.Address correspondence and reprint requests to Felissa shley,RN,PhD,ACRN,FAAN,Dean and Professor,School of Nursing,Southern Illinois University Edwardsville,Alumni Hall,Room2333,Edwardsville,IL62026-1066.E-mail:flashle@Copyright©2001by W.B.Saunders Company8755-7223/01/1702-0007$35.00/0doi:10.1053/jpnu.2001.2227181 Journal of Professional Nursing,Vol17,No2(March–April),2001:pp81-86nursing in the United States.A letter explaining the study and the questionnaire were sent to the dean or director of the eligible nursing unit in January and February1999.There was no follow-up mailing.Of the611questionnaires sent,2were undeliverable,1 was unusable,and409were completed and returned for a response rate of67per cent on one mailing.The response rate was proportional across nursing program types.ResultsDEMOGRAPHIC INFORMATION Demographic characteristics of programs were ob-tained,and included the total university or college stu-dent enrollment at the parent institution,number of nursing students,type of program(associate’s degree, diploma,or baccalaureate),type of institution(public or private;religious or nonreligious),location of insti-tution(urban,suburban,rural,small city),and geo-graphic region(west,midwest,south,or northeast). The majority of respondents were from associate’s de-gree(AD)programs(48.8per cent)followed by bac-calaureate(BS)programs(43.9per cent),and diploma (DI)programs(7.1per cent).The demographic data about respondents are presented in Table1.DISRUPTIVE STUDENT BEHAVIORS REPORTED Responses about the occurrence of disruptive nurs-ing student behaviors at the respondents’institutions are reported in descending order of frequency in Table 2.Three behaviors were reported by all of the respon-dents.These were:student inattention in class,student absence from class,and student lateness to class.The least frequently reported behaviors were objectionable physical contact of students with instructors(24.8per cent),and yelling at or verbal abuse of the instructor in the clinical setting(42.8per cent).COMPARISON OF DISRUPTIVE BEHAVIORS WITHDEMOGRAPHIC VARIABLESEach of the reported behaviors was compared with the following demographic variables to learn more about how extensive the problem was in various set-tings and for further insight.These were:1.Type of nursing program(associate’s or bac-calaureate).Because of the small numbers,di-ploma programs were excluded from the anal-yses that used types of nursing programs;2.Nursing program enrollment(fewer than100,100-199,or200or more);3.Parent institution enrollment size(below2,000;2,000-4,999;5,000-10,999;11,000and above);4.Public versus private institution;5.Religious versus nonreligious institution;6.Location of institution,(urban,small/me-dium city,rural,or suburban);and7.Geographic region of the country in whichlocated.Those behaviors that were reported by all or nearly all of the respondents were excluded from the compari-sons,for obvious reasons.Only demographic characteristics that were signifi-cantly associated(PϽ.05)with a specific behavior are discussed.Those behaviors reported by95per cent or more of respondents across the board were not com-pared with demographic characteristics(see Table2) because they were so common to all of the respondents. These included student lateness to class and clinicals, student inattention in class and clinicals,student ab-TABLE1.Demographic Characteristics ofRespondentsProgram type(nϭ408)% AD48.8 DI7.3 BS43.9 Nursing program student enrollment(nϭ407)Fewer than10029.5 100-19933.2 200or more37.3 Geographic location(nϭ408)West15.9 Northeast22.5 South31.9 Midwest29.7 Total student enrollment at parent institution(nϭ377)Fewer than2,00028.1 2,000-4,99930.5 5,000-10,99922.1 11,000and above19.4 Location of nursing unit(nϭ404)Public institution63.6 Private institution36.4 Location of institution(nϭ402)Urban32.1 Suburban15.2 Small/medium city/rural52.7 Type of institution(nϭ403)Religious22.1 Nonreligious77.9 NOTE.Percentages may not add to100%because of rounding error.82LASHLEY AND DE MENESESsence from class and clinicals,rude behavior in class, and cheating on tests and assignments.Yelling or verbal abuse of the instructor in the clin-ical area was significantly associated with type of insti-tution and was reported more often by respondents from public institutions than private ones(␹2(1)ϭ6.863,Pϭ.009).A statistically significant association also was found for the item yelling or verbal abuse of the instructor in the practice laboratory(␹2(1)ϭ11.755,Pϭ.001).In nursing programs of200or more students,these behaviors occurred in the clinical area(␹2(2)ϭ23.772,PϽ.001)and in nursing prac-tice laboratories(␹2(2)ϭ28.224,PϽ.001).Yelling or verbal abuse of instructors in the classroom was sig-nificantly more likely to occur in institutions with a nursing student body size of200or more(␹2(2)ϭ30.67,PϽ.001).Verbal abuse of peers in both class and clinical set-tings was significantly associated with a nursing pro-gram size of200or more(␹2(2)ϭ13.547,Pϭ.001;␹2(2)ϭ8.165,Pϭ.017;respectively).Verbal abuseof peers in the clinical setting was significantly more commonly reported in public institutions(␹2(1)ϭ11.960,Pϭ.001).Verbal abuse of peers in the class-room setting was more commonly reported in nonre-ligious institutions(␹2(1)ϭ7.312,Pϭ.007).Rude behavior to secretaries and staff was reported signifi-cantly more often by public,nonreligious institutions with nursing student bodies of200or more(␹2(1)ϭ7.669,Pϭ.006;␹2(1)ϭ8.348,Pϭ.004;and ␹2(2)ϭ32.655,PϽ.001;respectively).Bringing infants into the classroom was described more often in baccalaureate than associate’s degree programs(␹2(1)ϭ10.708,Pϭ.001)and in nursing programs with an enrollment of200or more(␹2(2)ϭ22.34,PϽ.001).Cheating on tests was said to be more prevalent in nursing programs with200or more nursing students more often than in smaller programs(␹2(2)ϭ21.179, PϽ.001).More serious problems,such as threatening instructors or objectionable physical contact with the instructor,were more likely to be described by respon-dents from public institutions(␹2(1)ϭ7.930,Pϭ.005;␹2(1)ϭ9.802,Pϭ.002;respectively),nonreli-gious institutions(␹2(1)ϭ9.184,Pϭ.002;␹2(1)ϭ6.274,Pϭ.012;respectively),and institutions with nursing program enrollments of200or more(␹2(2)ϭ7.318,Pϭ.026;␹2(2)ϭ18.498,PϽ.001;respec-tively).CURRENT BEHAVIORS COMPARED WITH5YEARS AGO Respondents were asked to indicate whether certain behaviors such as the quality of undergraduate nursing work,frequency of student disruptive behaviors,stu-dent preparation for class and clinical experiences,stu-dent performance in class and clinical experiences and the student grievance rate was higher,about the same, or lower for nursing students at their institution cur-rently compared with5years ago.Nearly half of all respondents indicated that the quality of undergradu-ate nursing work at their institution was lower than it was5years ago.Slightly more than half(57.4per cent) indicated that they perceived that student preparationTABLE2.Problematic Behaviors ReportedBehavior Some Degreeof Problem,%Not aProblem,%Student lateness to class(nϭ406)100.00 Student inattention in class(nϭ406)100.00 Student absence from class(nϭ404)100.00 Student absence from clinicals(nϭ408)99.30.7 Student lateness to clinicals(nϭ407)98.8 1.2 Rude behavior such as talking during class(nϭ408)98.5 1.5 Cheating on written assignments(nϭ398)97.2 2.8 Cheating on tests(nϭ402)95.0 5.0 Student inattention in clinicals(nϭ407)94.1 5.9 Rude behavior to staff/secretaries(nϭ404)84.415.6 Bringing infants/children into classroom(nϭ408)80.419.6 Yelling at/verbal abuse of peers in nursing classroom(nϭ407)65.834.2 Yelling at/verbal abuse of instructor in nursing classroom(nϭ407)52.847.2 Threat to instructor(nϭ407)46.453.6 Yelling at/verbal abuse of peers in nursing clinical site(nϭ404)46.353.7 Yelling at/verbal abuse of instructor in nursing laboratory(nϭ407)45.254.8 Yelling at/verbal abuse of instructor in clinical setting(nϭ407)42.857.2 Objectionable physical contact with instructor(nϭ408)24.875.2 NOTE.Percentages may not add to100%because of rounding error.83NURSING STUDENT CIVILITYfor class was poorer today than5years ago,as was student performance in class(50.6per cent).These data are shown in Table3.When the specified behaviors shown in Table3were compared with the demographic variables described earlier,only four items had any statistically significant association with any of the demographic variables.The behaviors of student performance in clinical,disrup-tive behavior,and the student grievance rate did not differ statistically across respondent characteristics.Al-though perceptions of nursing student performance in the clinical setting did not differ significantly accord-ing to respondent characteristics,perceptions of stu-dent performance in class did.Clinical performance was rated as significantly lower today than5years ago by60.6per cent of associate’s degree program respon-dents compared with39.4per cent of baccalaureate program respondents.In regard to preparation for both class and clinical experiences,nursing program sizes of200and more were associated with the belief that current students were less prepared than they were 5years ago(␹2(4)ϭ10.125,Pϭ.038;␹2(4)ϭ11.074,Pϭ.026;respectively).The overall quality of undergraduate student work currently was rated as sig-nificantly lower than5years ago by more associate’s degree than baccalaureate educators(␹2(2)ϭ16.474, PϽ.001)with60.1per cent of AD educators believ-ing this was true compared with39per cent of bacca-laureate educators.CONSEQUENCES OF BEHAVIOR Respondents were asked to indicate what the conse-quences would be at their institution for two situa-tions—verbal abuse of nursing instructors,and objec-tionable physical contact with instructors forfirst, second,and repeated occurrences.The consequences ranged from no action,informal handling by the af-fected instructor through verbal warnings,written warnings,probation,suspension,and separation.The responses to these situations are shown in Tables4 and5.For afirst offense of objectionable verbal behavior, the most common consequence was for the instructor to handle the incident followed by a written warning and a verbal warning.For a second offense,the most common consequence was a written warning followed by the instructor handling the situation in some way, and a hearing in the nursing unit.Consequences were greater for repeated occurrences with about one-fourth indicating that a hearing could take place at the insti-tutional level.One-fourth of respondents indicated the situation of repeated objectionable verbal behavior at their site had not actually occurred to the best of their knowledge.For thefirst episode of objectionable physical con-tact,42.2per cent of respondents said that it would be handled verbally by the instructor followed by a writ-ten warning.For a second offense,a written warning followed by a nursing unit hearing or institutional hearing was most common.For repeated episodes,the most common outcome was a hearing at the institu-tional level followed by suspension from the program.TABLE3.Current Student Behavior in Comparison to5Years AgoBehavior Lower,%Same,%Higher,%The quality of nursingundergraduate work at myinstitution seems to be(nϭ399)49.637.812.5The frequency of nursing studentdisruptive behaviors at myinstitution(nϭ385)7.848.843.4In general,student preparationfor class(nϭ404)57.436.1 6.4In general,student preparationfor clinical(nϭ402)43.850.2 6.0In general,student performancefor class(nϭ403)50.642.7 6.7In general,student performancein clinical(nϭ404)39.952.77.4The student complaint/grievancerate(nϭ400)13.347.339.5NOTE.Percentages may not add to100%because of roundingerror.TABLE4.Consequences of Objectionable VerbalBehaviorConsequence First,%Second,%Repeated,%Handled verbally by instructor84.333.818.4Written warning/discipline29.254.731.4Verbal warning23.016.710.3Fail entire class/clinical10.5 5.116.2Nothing10.3 4.2 2.5Hearing in nursing unit7.627.028.2Probation 4.49.312.3Fail assignment/class 3.9 6.18.8Suspension(program) 2.78.122.1Hearing/institutional 2.712.727.9Legal services0.7 2.711.3Suspension(university)0.7 1.7 4.9Other0.7 6.9 5.1Separation(university)0.7 1.7 6.1Separation(program)0.5 3.714.7Has not occurred9.115.025.0NOTE.Multiple responses possible;nϭ408.84LASHLEY AND DE MENESESA sizeable number indicated that objectionable physi-cal contact was not reported at their institution for first,second,or even repeated offenses(see last item on Table5).Many of those respondents wrote that they were not sure what actions would actually be taken should this occur.DiscussionAcross various types and locations of programs, nursing administrators reported the occurrence of problematic student behaviors with a high frequency. With the exception of objectionable physical contact with instructors,problematic student behaviors were reported by at least40per cent of responding nursing program administrators.Some behaviors,such as cheating on tests or assignments,have been described for years in both the nursing and nonnursing literature (Carbone,1999;Daniel et al.,1994;Hilbert,1985; Osborn,2000;Roberts,1997)and,thus,such reports were not surprising.Likewise,problems of absentee-ism,tardiness,and inattention in class have been de-scribed previously(Carbone).What was surprising was the high percentage of respondents describing student absence,tardiness,and inattention in the clinical set-ting as well as yelling or verbal abuse of the instructor or peers at these sites.The clinical setting is a place where nursing students and nursing programs are rep-resented to the society served and represents the ulti-mate mission of nursing.Showing such behaviors in health care service settings could be seen as a disregard for professional behavior and may reflect on how stu-dents represent themselves to the recipients of services at a later time.Bringing infants or children into the classroom is,to some degree,a reflection of societal changes such as one-parent families and lack of at-home child care. Some advocates believe that this is an acceptable prac-tice,even on a regular basis.What we heard from re-spondents was that there were many reasons to exclude children from class—distraction to other students in the classroom even when the children were not noisy or crying,exposure to actual,or potentially disturbing, age-inappropriate material being taught as part of the course content,and issues of liability for potential in-jury.Many respondents wrote that they had enacted policies prohibiting children in the classrooms.Parent institutions of higher education often provide low-cost child-care on campus that is usually available during the day or evenings on a regular or drop-in basis.Thus, alternatives are usually available.The program characteristics most often associated with many problematic behaviors included the size of the nursing program,specifically for enrollments of 200students and higher,but not with the large size of the parent institution in which it was located and being a public,nonreligious institution.Some possible rea-sons for suchfindings might include a more anony-mous,less-personal atmosphere in nursing programs with larger student bodies where less faculty-student interaction might occur.Looser social controls and perceived fewer sanctions might occur in a larger envi-ronment shielded from the observation of the student’s significant others who are outside the nursing program in the community.On the other hand,students with certain inherent characteristics that lead to expressing less-desirable behaviors might seek the relative ano-nymity of larger programs.Although larger nursing programs are often located within larger public,non-religious parent institutions,for the most part,the size of the parent institution was not associated with a higher occurrence of problematic behaviors.Addition-ally,complex social,cultural,and generational values and differences play a role in what is perceived as prob-lematic behaviors(Osborn,2000). Anecdotally,it was reported that nursing instructors sometimes fear to discipline students for a variety of monly,this had to do with fears of direct reprisal.Instructors reported that they fear they will get poor student evaluations that will result in lower pay raises,unemployment,and/or an adverse effect on ten-ure and/or promotion.Instructors need to be empow-ered with legitimate ways to handle difficult student actions and need to be encouraged to include behav-TABLE5.Consequences of Objectionable Physical ContactConsequence First,%Second,%Repeated,%Handled verbally by instructor42.215.911.3 Written warning/discipline25.728.216.7 Hearing in nursing unit15.420.816.4 Hearing/institutional11.517.420.8 Verbal warning10.0 5.9 5.4 Legal services8.814.217.6 Probation8.39.1 6.1 Suspension(program)8.115.220.1 Suspension(university) 4.27.89.3 Fail entire class/clinical 2.57.49.6 Fail assign/class 2.9 4.2 4.2 Separation(university) 3.4 5.612.5 Separation(program) 3.29.614.7 Other 3.2 3.7 4.4 Not reported34.839.742.6 NOTE.Multiple responses possible;nϭ408.85NURSING STUDENT CIVILITYioral expectations in the course syllabus so that stu-dents are informed about expectations for the class. The administration(with faculty and staff input)needs to have in place,and enforce,program-wide policies such as not allowing children in the classroom.In regard to physical contact,one anecdotal incident described an event in which an instructor in a nursing skills practice laboratory had a chair thrown at her because the nursing student(a man)was told he would have to repeat performing a particular skill on another day.In another anecdote,it was related that two women who were nursing students began physically exchanging blows in the hospital cafeteria during a clinical rotation.What do the display of these and other disruptive and dishonest behaviors bode for the future when these students are practicing nurses?Will they continue to display such behavior?The authors are aware of anec-dotal descriptions of less than professional nursing staff behavior and interchanges among nursing staff that would have been incomprehensible even5years ago. These have included physicalfighting on acute care patient units and an increased prevalence of dishonest patient record keeping.Nursing administrators have also anecdotally reported that newly hired nurses lack a committment to round-the-clock patient care and the need for adequate staffing on holidays and weekends.When we began exploring this topic we were inter-ested in the state of disruptive student behaviors in the nursing classroom based on reports of such occurrences from other disciplines,from the higher education com-munity in general,and from a few anecdotal reports from colleagues.We did not expect tofind the extent to which the problem has become pervasive,not only in the nursing classroom,but also in experiences in the clinical agency as well.The importance of the topic to the nursing education community was indicated by the high response rate on only one mailing of the survey and by the many comments,letters,and phone calls received by the investigators.Our sense is that nursing educators have not yet come to grips with the new types of students entering nursing programs,and still expect to see the dedicated professional behaviors evi-dent in the past.Nursing needs assistance in identify-ing strategies for handling disruptive behaviors within instructional and institutional settings,and in develop-ing expected professional behaviors and demeanor in students.These could include written behavioral ex-pectations delineated on thefirst day of class or clinical or as part of the agency orientation.We also believe that nursing education and nursing service would ben-efit from a national forum or discussion of these issues, sharing strategies for approaching them.ReferencesCarbone,E.(1999,Spring).Students behaving badly in large classes.New Directions for Teaching and Learning,77, 35-43.Daniel,L.G.,Adams,B.N.,&Smith,N.M.(1994).Aca-demic misconduct among nursing students:A multivariate in-vestigation.Journal of Professional Nursing,10,278-288. Franklyn-Stokes,A.,&Newstead,S.E.(1995).Under-graduate cheating:Who does what and why?Studies in Higher Education,20,159-172.Hilbert,G.A.(1985).Involvement of nursing students in unethical classroom and clinical behaviors.Journal of Higher Education,20,159-172.Osborn,E.(2000).Punishment:A story for medical ed-ucators.Academic Medicine,75,241-244. Richardson,S.M.(Ed.).(1999).Promoting civility:A teaching challenge.San Francisco:Jossey-Bass. Roberts,E.F.(1997).Academic misconduct in schools of nursing.Nursing Connections,10,28-36.Schneider,A.(1998,March27).Insubordination and intimidation signal the end of decorum in many classrooms. Chronicle of Higher Education,pp.A12-A14. Tiberius,R.G.,&Flak,E.(1999,Spring).Incivility in dyadic teaching and learning.New Directions for Teaching and Learning,77,3-12.86LASHLEY AND DE MENESES。