The rapid uptake of information technology continues to inspire health professions students and faculty to embrace the Internet and its many opportunities for learning and practice. As such, the importance of cybercivility—civil online communication—has been emphasized to health professionals and students in various disciplines (De Gagne, Choi, Ledbetter, Kang, & Clark, 2016). However, existing literature in this area has focused on particular health professions working to improve cybercivility within their disciplines while neglecting to investigate opportunities for interprofessional education (IPE) to introduce the topic to students (De Gagne, Conklin, Yamane, Kang, & Hyun, 2018). Communication that verifies the ethics, roles, and responsibilities of health care team members is at the heart of IPE (Speakman, 2017). In light of the burgeoning demand for health professions students to enhance IPE core competencies, this study aimed to identify needs in regard to educating future health care professionals about cybercivility. The specific goal of this qualitative study was to describe health professions students' cyberincivility experiences and their perspectives toward incorporating the topic into their curricula and continuing education courses.
Cyberincivility, breaches of civility in cyberspace, can be viewed as deviant online behaviors that contradict accepted norms or values held by most members of a group or society (Sternberg, 2012). In health care professions, online communication containing patient information, negative comments about work or coworkers, medical product or proprietary service recommendations, offensive language, or discriminatory statements are considered a breach of professional standards (Chretien & Tuck, 2015; Hajar, Clauson, & Jacobs, 2014; Jones-Berry, 2016; Kung, Eisenberg, & Slanetz, 2012). In addition, the literature identifies cyberincivility as online communication exhibiting unprofessional content, conflicts of interest, and ethical breaches by health professionals, as well as health professions students (De Gagne, Choi, et al., 2016).
Investigating how pharmacists used social networking sites, Hajar et al. (2014) raised some concerns that pharmacists were posting about their frustrations at work, which could damage the reputation of their leaders or organization. Likewise, Bagley, DiGiacinto, Lawyer, and Anderson (2014) found that health professions students who frequently used social media were unaware of the risks for Health Insurance Portability and Accountability Act violations, such as posting medical images or photographs on Facebook® even when not identifying patients. Making the matter more complex, many times it is often difficult to reach a consensus on what defines unprofessional online behavior (Bagley et al., 2014; De Gagne, Choi, et al., 2016; De Gagne, Yamane, & Conklin, 2016; Wankel & Wankel, 2012).
In a systematic review of online professionalism and medical students, Chretien and Tuck (2015) found that students and faculty were unable to find shared definitions of inappropriate or unprofessional behavior. Also questioned is whether the traditional principles of medical professionalism can be applied to the online setting, where boundaries between the personal and professional are blurred (Chretien & Tuck, 2015). The prevailing thought is that health professionals should maintain the capacity for deliberate, ethical, and accountable practice in all their relationships, including online collaborations (Ellaway, Coral, Topps, & Topps, 2015). One way of ensuring best practices in a professional is to start with students. Health professions training could provide students with opportunities to learn about online professionalism and how to protect their reputations (Ellaway et al., 2015).
It is essential for educators to evaluate the ethical awareness of online posting content of health professions students while strategically developing appropriate policies and practices for online behavior. As such, a range of scholars have conducted studies on strategies to improve health care providers' online professionalism and cybercivility (De Gagne, Yamane, et al., 2016). However, existing studies on this topic are limited to intraprofessional endeavors, focusing on the development and evaluation of strategies within a discipline and ignoring the value of knowledge sharing across the professions (De Gagne et al., 2018). Thus, this study seeks to fill this gap in the literature by exploring cybercivility learning needs and providing a conceptual guide for students across the health professions programs.
Two theoretical frameworks were incorporated into this study. The first was a theory of media ecology, the study of media as environments (Postman, 1970). Forming the basis of a system of ethics and ethical evaluation of human activity (Strate, 2017), this theory is founded on an inquiry on how online communication affects human perceptions, understanding, feelings, and values by looking into the structure, content, and impact on social media users and their behavior (Postman, 1970). Participants in this study were assumed to experience uncivil behaviors in cyberspace and share their perceptions and feelings toward such situations. The second theoretical framework, principlism (Beauchamp & Childress, 2012), was used to facilitate participants' thoughts and decision-making insights into cybercivility, as well as their perspectives toward IPE cybercivility learning. The four principles of principlism (i.e., autonomy, beneficence, nonmaleficence, and justice) have been used to teach ethical issues across curricula in health professions education, which can serve as a powerful action guide for students' behaviors that may contribute to incivility. Combining these two frameworks to explore participants' cyberincivility experiences and garner their insights into learning needs may assist in the development of educational resources for health professionals and educators.
Participants and Study Design
A descriptive qualitative design with individual interviews was used with a purposive sample of 25 health professions students from a large private university in the southeast region of the United States. Participants were recruited through an invitation e-mailed to all students enrolled in one of the following programs: nursing (accelerated bachelor's, master's, Doctor of Nursing Practice, and PhD), doctor of medicine (MD), physician assistant (PA), and doctor of physical therapy (DPT). The students' mean age was 34.3 6 8.9 (range = 25 to 56 years) and 84% (n = 21) were female. Most students were nursing majors, followed by MD, PA, and DPT programs. Twenty-one students rated cyberincivility as a serious or moderate problem, whereas no one indicated that it was not a problem. Table 1 shows a summary of the characteristics of the participants in the study (n = 25).
Demographic Characteristics of Participants (N = 25)
Following approval from the institutional review board, data were collected through semistructured interviews using a virtual conferencing software, Zoom. The semistructured interview guide was initially developed by three experienced researchers in IPE or cybercivility studies (J.C.D., J.L.C., S.S.Y.). This interview guide was then reviewed for content and relevancy by other IPE experts from nursing, medicine, physician assistant, and physical therapy programs. After multiple revisions of the script, the final guide consisted of 12 open-ended questions covering three main areas of concern: (a) perceptions related to the words cybercivility and cyberincivility; (b) direct or indirect experiences with cyberincivility including triggers and consequences; and (c) perceived benefits of learning cybercivility related to IPE core competencies (see the interview guide, Table 2). The interviews were conducted either by the first author (J.C.D.), who is experienced in qualitative research with a background in nursing education, or by the research assistant (S.S.Y.) in a doctoral nursing program who had been trained in qualitative research. Each interview lasted 30 to 45 minutes and was video recorded with the participant's permission. Member checking was conducted at the end of each interview by summarizing the statements, allowing the participants to correct errors of fact or misinterpretations.
Examples of Interview Guide Questions
Using the thematic analysis approach of Braun and Clarke (2006), the data were transcribed verbatim and qualitatively analyzed to identify both manifest (developing categories) and latent (developing themes) content. A recursive review of the transcriptions was collaboratively conducted by all team members to refine the specifics of each theme and to highlight compelling statements in relation to the three main areas of research inquiry. The team members representing three different health professions (i.e., nursing, physical therapy, and health information science), except the research assistant, had extensive experience in qualitative research. To improve the scientific rigor of the findings, each research member who was involved in the analysis was expected to review all transcripts and maintain a diary and bring it to research team meetings. Through consensus decision making, the team achieved full agreement on all themes, thereby ensuring high reliability and a rigorous approach to analysis (Hays & Singh, 2011).
Perceptions Relating to Cybercivility and Cyberincivility
The three introductory questions in Table 2 formed broad perceptions of the definition, associations to, and ethical components of cyberincivility. The most common definitions of cyberincivility covered a spectrum from seemingly mild to the most offensive infractions of societal behavioral norms. The most common words associated with cyberincivility in the online environment included disrespectful, unprofessional, hurtful, unkind, bullying, and rudeness. Other responses described behaviors that ranged from making derogatory statements about someone or insensitive comments to someone, to intolerance of another person's ideas and a tone of disdain. More serious comments were described as those meant to be demeaning, intimidating, threatening, or racially charged. Almost all commented that infractions were attributed to the idea that virtual communication opened the door to behavior that would probably not happen in face-to-face communication. One person commented, “Cyberincivility is treating people like they are not a person. They don't act like there's actually a human at the other end of the situation.”
All respondents agreed that codes of ethics apply in the virtual world and are directly related to cybercivility. Several students commented on the connection of posted content to their professional roles. Examples of typical students' comments were as follows: “In health care, we are supposed to be seen as helpful and impartial”; I don't think posting inflammatory things on social media is in keeping with that image”; and “people very much look up to us [as a health professional] and value our opinion, and we really need to be careful about the ethics of that.”
Many interviewees also emphasized the duties of being a health professional, which included the concept of “do no harm” and protection of the patient's privacy and rights. One of the students stated, “Ethics should apply also to cyberspace because health care is entering the cyberworld, and it should not change just because the platform where we communicate changes.” In the same vein, another student pointed out that posts on social media could harm a health care provider's reputation: “People think they are not at work and can post anything, but it's a permanent file.” It was also mentioned that cyberincivility is directly opposed to practicing with compassion and respect in that it is a violation of the code of conduct as good cybercitizens. Other students discussed the lifelong and fulltime commitment of being a health care professional and commented, “In medicine, who we are does not end when we clock out of work…. We have to hold ourselves to a higher standard.”
Experiences With Cyberincivility
Six questions (questions 1 through 6 in Table 2) asked about students' direct and indirect experiences with cyberincivility. Responses included reports of uncivil behavior in cyberspace, causes and consequences for cybercivility in the education environment, and the ways in which uncivil behavior could affect interprofessional work. Some interviewees described cases in which they were the targets of uncivil behavior, whereas others commented on incidents they witnessed. Most incidences of cyberincivility took place via e-mail, on social network websites, and in online discussion forums. A few participants mentioned specific instances during group projects and anonymous evaluations.
Interviewees frequently described reading negative comments about patients, peers, and work; culturally insensitive or unprofessional posts; violations of patients' privacy; and misuse of patients' reviews for marketing or business purposes on Facebook, Twitter™, and Snapchat. Comments regarding cyberincivility on social media included, “I am a veteran, and there's some incivility on social media sites where people make fun of non-veterans or the military,” and “I've also experienced it [cyberincivility] professionally where there's an ‘lol’ written after a comment regarding a patient or a hashtag like #cray or #Ineedtofindanotherjob.”
Many students witnessed uncivil behavior via e-mail, such as the use of rude language, terse replies, and passive-aggressive tones. They noted both a lack and a delay of a faculty member's response to queries as instances of cyberincivility. One student described a situation, “I had a problem with an exam, and I tried. Everybody was on vacation, and I tried to get hold of the professor and I couldn't.” Another interviewee described a situation at work with the overuse of the “reply all” function. Within the online learning environment, interviewees reported impolite communication, negative comments, dismissal of others' thoughts and ideas, and sharing of resources that would constitute cheating.
Students articulated many triggers for incivility in cyberspace. Most commonly, they cited the following causes: accumulation of stress, the inability to read cues in the online environment, and an overabundance of work and information preventing time to focus on each online interaction. Some felt that the perception of anonymity made it easier to be uncivil. Others pointed out that when one's values are called out, including one's political opinions, or when a topic of passion is brought up, it becomes a trigger for incivility. Other reasons included misunderstandings, cultural differences, and a lack of accountability.
Students also explained the consequences of cyberincivility. An overarching theme—a breakdown in communication—can lead to isolation, distrust, avoidance, fear, and a lowered self-confidence. In turn, these can lead to missed orders, a decrease in continuity of care, distractions in the workplace, medical errors, and ultimately patient harm. Students reported other consequences, such as loss of job offers, termination from jobs, expulsion from or denied admittance to schools, loss of respect from professors and peers, difficulty getting references, and damaged personal relationships.
Within the workplace, students felt that cyberincivility could strain both intraprofessional and interprofessional relationships and make it difficult to collaborate in what is supposed to be a team environment. One student explained:
Cyberincivility among a professional group doesn't create the type of reputation we want for our profession, and it probably provokes a lack of respect and value, which makes a big difference in health care when our goal is to work as a team, but everyone's being fragmented can ultimately end up harming the patient.
Another student expressed the importance of interprofessional team work by stating:
There's already somewhat of a divide between medicine, nursing, physical therapy, etcetera, and we don't interact with each other that much.… We don't need any more reasons to distrust each other or for things to go wrong…. We're taught that patient-centered care means working as a team with other professionals, so if you foster more of the distrust by having cyberincivility, it can lead to huge gaps in patient care and would be a horrible consequence.
Strategies for Fostering Cybercivility
Three questions (questions 7 through 9 in Table 2) invited students to share potential strategies that could prevent cyberincivility both intraprofessionally and interprofessionally. Such strategies ranged from attending annual training or in-service to discuss the current state of cyberincivility in the health care setting to sharing specific examples of uncivil online behavior, descriptions of how to avoid violations, and explicit rules and regulations regarding virtual communication. One respondent suggested the use of positive reinforcement when cybercivility was exercised. Modeling appropriate behavior was also mentioned as a means of educating others about proper online communication. Students also valued using guidelines on how to make virtual communication more neutral and therapeutic, less emotional, and nonconfrontational.
Maintaining professional distance from patients and individuals they work with, as well as finding good role models, were suggested as helpful strategies. Specifically, students spoke about the need to set boundaries and to be professional, careful, and deliberate. The consensus was that individuals are responsible for what they post online and accountable in how they represent themselves, their institution, and their profession. Many stated they had posted either little or nothing online due to the fear that they might offend others or violated a standard. Some respondents chose to ignore incidents of uncivil behavior so as not to give them any weight, whereas others chose to discuss the incidents directly with the person who initiated the behavior. In addition, respondents spoke of the need to be mindful and to reread messages before posting or e-mailing them. Other approaches mentioned included signing contracts to uphold certain online standards for behavior, being willing to report uncivil communication to supervisors, asking others to proofread messages before sending them, changing privacy settings, smoothing things over by clarifying posts, and being open to others' opinions, rather than instantly critical or easily offended.
When students were asked about the benefits of learning about cybercivility in terms of ethics, roles, interprofessional communication, and teamwork, many agreed that there would be great value in it. They cited the increasing use of cyber environments by health professionals. One student also articulated its benefit as “making oneself a professional while prompting a very healthy learning environment where one can increase his or her potential.” Finally, students shared a wide range of preferred learning approaches, such as online, in class, hybrid (online and in class), self-paced individual work, or group projects, that could maximize the benefits of cybercivility learning. They suggested setting the stage in the beginning at orientation and then reinforcing lessons learned every year. One student shared her thoughts by stating:
It [cybercivility learning] could be part of a normal classroom teaching or come in as you're learning ethics…or it could also come in as part of the terms and conditions for an online class…. It could also be a one-credit course that you take as a student before you participate in online classes.
Another student emphasized that the learning would be more meaningful if taught in the online learning environment. Regardless of what methods are used to teach cybercivility, students felt a personalized, yet not complex, method would help make the learning stick. Other suggestions for incorporating cybercivility into a curriculum included: making it a part of existing courses, such as role development or cultural health; making it a mandatory annual competency requirement; watching emotional cases on short video clips and reflecting upon them; and engaging in activities such as mobile gaming or just-in-time learning. Motivational interviewing, in conjunction with media that can facilitate appropriate cyber behaviors, was also suggested.
Our study suggests that health professions students have various conceptions of cybercivility but aptly describe situations in which learning to become a health professional is influenced by interactions in various virtual communities. They articulated a broad range of definitions for cyberincivility and indicated that it was something they had experienced in formal and informal educational settings. Although this concept has been formally defined in the literature (Sternberg, 2012) and various authors have advocated for stronger recognition of the importance of cybercivility in health professions training disciplines (De Gagne, Choi, et al., 2016), requirements for training are not regulated by any of the accrediting bodies for nursing, medicine, physician assistant, or physical therapy. The variety of definitions provided by respondents in this study may be an indication that health professions students have created their own definitions and norms for operating in a civil and professional environment online and received no formal guidance. Given that communication is seen as a hallmark of effective interprofessional practice in health care (Speakman, 2017), students learning to be health professionals in a rapidly developing cyber environment have the additional challenge of learning communication strategies that facilitate effective interprofessional relationships in person and online. Health professions educators should strive to create a civil learning environment and model civil behavior (De Gagne, Yamane, et al., 2016). Moreover, it would be prudent to bring students' perspectives into the shaping of educational programs.
The negative experiences shared by participants in this study add to the body of literature suggesting that health professions students are frequently engaged in and/or affected by unprofessional communication. Many researchers have indicated that potential reasons for such experiences may be the changes in communication platforms, anonymity provided by online communication, and negative perceptions of participants in online learning experiences (Berg, 2016; Hopkins et al., 2017; Kleinke & Bös, 2015). Students in this study also offered suggestions as to how cybercivility could be promoted in the context of IPE. Students called for more formal education around the importance of cybercivility, discussions about how best to apply these concepts interprofessionally, and the need for instruction on how best to react to uncivil behaviors. Such a call for transformation implies a need to encourage students to communicate with civility and to respond with professionalism in instances where they witness interprofessional incivility (De Gagne et al., 2018).
This study has two notable limitations. First, although qualitative studies often have a limited number of participants, this was a sample of convenience from a single institution. Second, data analysis was completed by a limited set of professionals. Although the researchers took the utmost care to analyze the data objectively, it is possible that their own concepts of cybercivility and professional biases could have influenced the analysis.
This study was the first of its kind that examined the role of cybercivility in interprofessional education. Although cyberincivility is a well-documented phenomenon, concepts of cybercivility within the IPE context remain an emerging topic in the literature and in health professions education. The results in our study suggest a need to develop curricula across professions to promote civil behavior in online communications and collaborations. Future research should also explore professional differences and similarities in how learners experience cyberincivility and its influence on their roles as students and, later, as health care providers.
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Demographic Characteristics of Participants (N = 25)
|Characteristic||N||% or SD|
|Mean age (years)||34.28||8.86|
| Accelerated Bachelor of Science||1||4|
| Doctor of Nursing Practice||1||4|
| Doctor of Philosophy||2||8|
| Doctor of Medicine||6||24|
| Physician Assistant||3||12|
| Doctor of Physical Therapy||2||8|
|Number of social networking sites|
| 1 to 5||21||84|
| 6 to 10||4||16|
|Number of texts per day|
| 0 to 10||3||12|
| 11 to 20||7||28|
| 21 to 50||9||36|
| 51 to 100||4||16|
| > 100||2||8|
|Mean earned credits from online courses (range = 0 to 50)||16.63||16.31|
|Perception level of cyberincivility problems|
Examples of Interview Guide Questions
What comes to your mind when you hear the word cyberincivility?
How would you define cyberincivility and/or cybercivility?
How do you think the codes of ethics for health professionals are related to cybercivility?
Main (key) questions:
Q1. What uncivil behaviors have you experienced from peers, faculty, or other health professionals in cyberspace?
Q2. What are common reasons or triggers for cyberincivility in the health professions education environment?
Q3. What are the consequences of cyberincivility in health professions education?
Q4. What approaches have you taken or witnessed in an effort to prevent cyberincivility during your education?
Q5. What problems do you think cyberincivility might cause for individuals working intraprofessionally and/or interprofessionally?
Q6. As a health professions student, what is your responsibility with regards to the content you post or distribute online?
Q7. What strategies do you think would be helpful in dealing with cyberincivility when working intraprofessionally and interprofessionally?
Q8. What is your perceived benefit of learning about cybercivility in terms of interprofessional core competencies?
Q9. What types of educational formats do you think would be effective in learning or teaching cybercivility?
Please tell me more about that.
Please give me an example.
Ending: Is there anything that you would like to add?