1. Background
Incivility in the workplace is threatening and dangerous to the health of people. Such behaviors also endanger the organizational atmosphere and may cause several unpleasant consequences if ignored (1). Uncivil behavior is socially significant (2). These behaviors have been observed among individuals in different occupational positions in the health system (3).
Psychological issues, low intensity, and lack of consideration in fulfilling tasks are among the definable characteristics of uncivil behaviors with vague intent to harass others (4). Uncivil behavior has been studied from different aspects and in various work environments, such as judicial, health, and academic systems (5, 6).
Medical education is a dynamic, complex, stressful process that pursues educational goals (7). Uncivil behavior in the educational environment is a growing concern that severely disrupts the teaching and learning process (8), which can be either verbal or non-verbal (9).
Nurses are one of the groups that frequently experience uncivil behavior. Students and nursing instructors have reported these behaviors in academic settings (10, 11). In the nursing profession, the role of nurses and nursing staff is well recognized in the world as an influential factor in clinical education. In Australia, the attitudes of nursing staff toward nursing students have been recognized as a vital factor in nursing students' experiences of how the clinical learning environment is (12). In their study in Ireland, Timmins and Kaliszer showed that 68% of nursing students mentioned poor communication between nursing staff and students as a stressor (13). However, the appropriate behavior of nurses toward students and their acceptance as a care team member has been mentioned as a positive factor in clinical education (14). However, uncivil behavior toward students has been identified as a major source of stress (15). A high proportion of students who are affected by uncivil behavior suffer from the consequences of psychological trauma (16).
In clinical education, the environment is a critical aspect of nursing education in which students can apply and practice their theoretical findings. However, despite the importance of this environment, it is known for being stressful for students (17, 18).
Patients, different levels of nursing staff, multiple procedures, and the staff’s behavior toward students are important factors that play a role in creating a stressful environment and, ultimately, anxiety in students. In addition to these stressors, nurses’ disrespect for nursing students has been identified as a negative factor in students' clinical education. Disrespect in nursing education has been recognized as one of the most disruptive behaviors leading to physiological and psychological distress and eventually to dangerous and threatening situations (19).
Considering the destructive effects of uncivil behavior reported in several studies, it is crucial to adopt strategies to create appropriate teaching and learning environments (20). Much of the available evidence suggests that communication between nursing students and staff is crucial to creating a positive learning experience. However, this experience is unfortunately negative in some cases.
2. Objectives
Many studies about nursing incivility in clinical education environments have focused on nurses, and most of these studies have a qualitative approach. Therefore, the present study was conducted to investigate the incidence of uncivil behavior in clinical education environments from the perspective of nursing students in western Iran based on a quantitative approach.
3. Methods
In this cross-sectional study in 2020, all undergraduate nursing students of semesters 3 to 8, taking training and internship courses, were enrolled by the census. The inclusion criteria included nursing students of semesters 3, 4, 6, and 8 who were willing to participate. The exclusion criteria included transfer students and nursing students with a nursing diploma who had experience in working as a nurse.
Participants were 19 to 32 years old, with a mean age of 21.53 years and a standard deviation of 1.60.
In addition to the demographic characteristics of the participants (age, gender, marital status, and semester), the uncivil behavior in clinical nursing education (UBCNE) scale, designed by Maureen Anthony et al., was used in this study. This is a 5-point Likert scale ranging from zero to four (zero [never] and four [often]) for each item and includes 20 questions. The final score is based on the mean score of these 20 questions. The scale questions include three themes: exclusionary, hostile/rude, and dismissive behaviors. Questions 1, 4, 9, 13, 14, 17, and 19 describe hostile/rude behavior; questions 3, 5, 7, 8, 10, 15, and 18 describe exclusionary behavior; and questions 2, 6, 11, 12, 16, 20 describe perceived attitudes towards dismissive behaviors. The reliability and validity of the scale also showed that Cronbach's alpha for the total scale was α = 0.93, for the subscale of hostile/rude was α = 0.86, for the subscale of exclusionary behavior was α = 0.86, and for the subscale of dismissive behavior was α = 0.84 (20).
In this study, after obtaining permission from the designers of the scale, it was translated from English to Persian using the model provided by Wild et al. (21) The face validity and content validity were confirmed by ten experienced clinical nursing professors, and their opinions were estimated using the Lawshe table CVI = 0.75 and CVR = 0.70. The reliability of the scale based on Cronbach's alpha was estimated to be 0.94.
In this study, students were free to answer the questions. The questionnaire was completed anonymously and was kept confidential, and students were assured that the questionnaire data would be used for research purposes only. The research subject was also approved by the Research Ethics Committee of Ilam University of Medical Sciences with the code ir.medilam.iec.1398.034.
Data were reported based on descriptive statistics such as frequency, mean, standard deviation, and median and on analytical tests such as Kolmogorov–Smirnov test to investigate the distribution of exclusionary, hostile/rude variables and dismissive behaviors. Kruskal-Wallis test was used to compare the scores of behaviors under the scales. Mann-Whitney test was used to compare the mean score of exclusionary, hostile/rude, and dismissive behaviors and the total score based on gender using SPSS version 21. The significance level was 0.05.
4. Results
Of 135 students who participated in this study, 103 (76.3%) were trainees, 21 (15.6%) were in the third semester, 32 (23.7%) were in the fourth semester, 50 (37%) were in the sixth semester, and 32 (23.7%) were interns (eighth semester). 64 (47.4%) were female, and 71 (52.6%) were male. The results showed that none of the variables followed a normal distribution (P < 0.001).
In terms of the semester, the highest incidence of exclusionary behaviors was 10.32 ± 6.5 for semester 6 and the lowest for semester 8 with a mean of 3.34 ± 2.2. Regarding hostile/rude behaviors, the highest mean was reported for students of semester 6 with a mean of 9.8 ± 6.48, and the lowest was reported for students of semester 8 with a mean of 3.3 ± 1.9. Regarding dismissive behaviors, the highest mean was reported for students of semester 6 with a mean of 9.24 ± 5.6, and the lowest was for students of semester 8 with a mean of 2.62 ± 1.75.
Descriptive results of dismissive behaviors are reported in total and by components in Table 1.
Table 1.Description of UBCNE Questionnaire Based on the Total Score and Based on Each Variable
| Item | Mean ± Std. Deviation | Minimum | Maximum | Median | Interquartile Range |
|---|---|---|---|---|---|
| Total instrument score | 22.92 ± 1.35 | 0 | 71 | 20.5 | 22.25 |
| Exclusionary | 7.25 ± 0.48 | 0 | 25 | 6 | 7 |
| Hostile/rude | 8.33 ± 0.51 | 0 | 26 | 7 | 10 |
| Dismissive | 7.34 ± 0.44 | 0 | 23 | 6.5 | 8 |
Abbreviations: UBCNE, uncivil behavior in clinical nursing education.
Table 1 shows the mean, standard deviation, median, and interquartile range for the variables of exclusionary, hostile/rude, and dismissive behaviors, with the highest median being related to exclusionary behaviors with a median and interquartile range of 7 (10).
The Kruskal-Wallis test was used to compare the mean score of exclusionary, hostile/rude, and dismissive behaviors and the total score in different semesters (Table 2). The results show that the mean score of exclusionary, hostile/rude, and dismissive behaviors and the total score were significantly different in different semesters (P < 0.001).
Table 2.Comparison of the Mean Score of Exclusionary, Hostile/Rude, and Dismissive Behaviors and Total Score Based on Semester
| Behaviors, Educational Term | No. | Median (IQR) | P-Value a |
|---|---|---|---|
| Exclusionary | ≤ 0.001 | ||
| 3 | 21 | 6 (6) | |
| 4 | 32 | 7 (6) | |
| 6 | 50 | 9 (11) | |
| 8 | 32 | 3 (2) | |
| Hostile/rude | ≤ 0.001 | ||
| 3 | 21 | 8 (7) | |
| 4 | 32 | 9 (6.75) | |
| 6 | 49 | 11 (9.5) | |
| 8 | 32 | 3 (2) | |
| Dismissive | ≤ 0.001 | ||
| 3 | 21 | 7 (7) | |
| 4 | 32 | 8 (6) | |
| 6 | 50 | 9 (8) | |
| 8 | 32 | 3 (3) | |
| Total | ≤ 0.001 | ||
| 3 | 21 | 25 (13) | |
| 4 | 32 | 25 (19) | |
| 6 | 49 | 28 (16) | |
| 8 | 32 | 8 (7) |
Abbreviation: IQR, Inter-quartile range.
a Based on Kruskal Wallis Test
The results also show that the mean score of hostile/rude behavior (P = 0.327), exclusionary behavior (P = 0.657), and dismissive behavior (P = 0.966), and the total score (P = 0.659) were not significantly different between men and women.
5. Discussion
Uncivil behavior is one of the main concerns of the nursing profession. Several studies have focused on the uncivil behavior between professors and students (11) and between nurses and other staff (22). This study, conducted for the first time in Iran based on the UBCNE standard questionnaire, describes the incidence of uncivil behavior from the perspective of nursing students in western Iran.
According to the results, the total score of uncivil behaviors toward nursing students was 22.92. The mean scores of behaviors from highest to lowest were related to exclusionary, dismissive, and hostile/rude behaviors, respectively. Uncivil behavior among nursing students is increasing and is one of the problems affecting nursing education in different countries (1, 23). Uncivil behaviors in nursing education are defined as inappropriate or disruptive behaviors that often lead to psychological or physiological distress in the person involved and may lead to ominous situations (24). The results of studies by Dinmohammadi et al. indicate that there is vertical violence in clinical settings based on the experience of nursing students. Humiliation, reproach, abandonment, exploitation, discrimination, bullying, lack of support, and limitations in learning are evidence of vertical violence. Such behaviors are often observed in nursing staff and clinical instructors (25).
The results of the present study showed that the incidence of uncivil behavior varies between students based on their semesters. The UBCNE questionnaire examines behaviors based on three variables of exclusionary, dismissive, and hostile/rude behaviors. Based on the results, exclusionary behavior was the most common behavior experienced by students. However, its rate differed according to semester and had the highest mean in students of semesters 3, 4, 6, and 8, respectively. Regarding hostile/rude behaviors, the highest mean was reported for students of semester 6 and the lowest for students of semester 8. Regarding dismissive behavior, the highest mean was reported for students of semester 6, and the lowest was for students of semester 8. There may be different reasons for the difference in the results in terms of the semester. Students who are in this environment for the first time may find issues they can’t realize whether they are right or wrong. These differences are also found in the results of other studies. The results of a qualitative research by Darvishpour and Khoshnazar focused on the first experience of nursing students, clinical confusion, captivity in clinical prison, and the decline of human dignity as challenges to professional ethics (26). The results of a qualitative content analysis by Naseri‐Salahshour and Sajadi showed that nursing students are in a stressful situation in their final year of study in the workplace. This is a threatening situation for students and leads to adverse physical and mental reactions such as anxiety, fatigue, leaving the profession, ignoring professional values , and job dissatisfaction (27).
In a study by Rafiee Vardanjani et al., who examined uncivil behavior among students and instructors, maltreatment or disrespect towards students were the most threatening behaviors in 57.3% of cases during the past year. In addition, these behaviors were more common in students of lower semesters (28).
Perhaps these behaviors have become normal or less important as students go to higher semesters, or maybe the students have adapted to such behaviors and viewed these behaviors as a challenge and adopted an optimistic approach towards such behaviors.
Each of the examined components includes different types of behaviors, including communication. Communication between students and nursing staff is a very important factor in determining the quality of clinical experience (12). Poor communication between nursing staff and students causes stress. According to Clark, civility and deep learning will likely increase if stress levels are minimized and supportive strategies are in place (29). One of the themes of a qualitative study by Hyun et al. in South Korea was a lack of dedication to teaching and learning in the clinical setting. In this regard, they pointed to the lack of respect for nursing students by instructors, classmates, and nursing staff, as well as the lack of involvement in clinical learning (30). In their qualitative study, Anthony and Yastik achieved three themes of exclusionary, hostile/rude, and dismissive behaviors. Students noted in their experiences that nurses disregarded them in taking care of patients, ignored their reports, and did not answer their questions. A positive experience was felt when they participated in patient care with the nursing staff (31).
In general, many nurses are reluctant to educate students and do not meet or support their educational needs (26).
In addition to the importance of the communication factor, the results of the study by Dehghani et al. reported other factors, such as staffing shortages and uncoordinated job shifts, as barriers to professional ethics from the perspective of nursing students (32). In addition to clinical nurses, students' experiences about uncivil behavior also include the behaviors of other students and clinical instructors. In a study in the US, the prevalence of uncivil behavior in peers was 35%, and uncivil behavior in clinical instructors was 60% (33). A study in China reported a lack of mutual respect between instructors and students and poor communication between them (34).
According to the results of the present study, there was no significant relationship between gender and different components of uncivil behavior. However, the total score of these behaviors was higher among male students. Maybe male students are not sensitive to these behaviors and are comfortable with issues, or maybe they do not care about their profession and its issues. There was no statistically significant relationship between the most common uncivil behaviors and gender in the study of Rafiee Vardanjani et al. However, female students were more involved in uncivil behaviors (28).
Uncivil behavior in educational environments can severely impair teaching and learning and lead to inconsistency and anxiety in the student. Anthony and Yastik examined the uncivil behaviors between students and nursing staff and how these behaviors affect students' willingness to complete their curriculum (31), which may lead to quitting. From the perspective of students, such behaviors are critical since they influence their knowledge for success in the future.
The clinical setting plays a vital role in shaping and developing students' professional values, norms, and attitudes (26). Experiencing uncivil behaviors is not limited to nursing students. This issue has also been reported after entering the clinical setting and providing services as a nurse. The results of a qualitative study by Sanagoo et al. indicate that humiliation, verbal and nonverbal aggression, being threatened, disregard for abilities, excluding one from participation, and being blamed were the themes of uncivil behavior based on nurses' experiences (22).
5.1. Strengths and Limitations of the Study
Using the standard tool and examining students' views in different semesters of internships and dissertations about uncivil behaviors are the strengths of the study. However, the use of the tool for the first time and the small number of students can be a limitation of the study and can be further explored in future studies.
5.2. Conclusions
The results show the experience of students regarding uncivil behaviors in different clinical settings. Since these experiences can affect students' learning process and their professional future, further studies are required to understand these behaviors in clinical settings and to provide strategies to minimize them.
