Dr. Anthony is Associate Professor, and Ms. Yastik is Assistant Professor, University of Detroit Mercy, McAuley School of Nursing, Detroit, Michigan.
This work was supported by the University of Detroit Mercy, College of Health Professions, Dean’s Intramural Research Fund.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank the nursing students who participated in the study.
Address correspondence to Maureen Anthony, PhD, RN, Associate Professor, University of Detroit Mercy, McAuley School of Nursing, 4001 West McNichols Road, Detroit, MI 48221-3038; e-mail: email@example.com.
The process of educating nursing students involves didactic courses, as well as clinical courses where students have the opportunity to apply what they learned in the classroom to a variety of health care settings. It has been well established in the literature that clinical education in nursing is stressful for students (Bond, 2009; Moscaritolo, 2009; Shipton, 2002; Timmins & Kaliszer, 2002). Although a certain amount of stress is thought to facilitate learning, too much stress can result in shame, self-doubt, and insecurity, which can inhibit learning (Bond, 2009). Several studies have identified nursing staff in the clinical areas as contributing to stress and anxiety among nursing students (Atack, Comacu, Kenny, LaBelle, & Miller, 2000; Levett-Jones, Lathlean, Higgins, & McMillan, 2009; Moscaritolo, 2009; Timmins & Kaliszer, 2002). The saying “nurses eat their young” is often heard and discussed in nursing; however, despite potentially serious consequences, this phenomenon has not been well studied in the United States.
A qualitative study conducted in Australia by Levett-Jones et al. (2009) found that student-staff relationships were the most important factors in determining the quality of clinical experiences. Five key areas were identified: receptiveness; inclusion and exclusion; legitimization of the student role; recognition and appreciation; and challenge and support. Timmins and Kaliszer (2002) distributed questionnaires to 110 diploma students in Ireland to investigate factors that caused stress for nursing students. Sixty-eight percent of the students identified poor relationships with the staff as causing stress. Atack et al. (2000) used a phenomenological approach to understand the lived experience of nursing students and staff nurses in Canada. The importance of treating students as colleagues, being welcoming, and sharing knowledge and decision making were characteristics that greatly improved the clinical learning experience.
Shipton (2002) used a grounded theory approach to explore the process of coping with stress among baccalaureate nursing students in the United States. Negative behaviors on the part of nursing staff were identified and described as “demeaning, nasty and not wanting to be bothered” (Shipton, 2002, p. 246). Intimidating and disruptive behaviors in health care settings can interfere with communication, result in medical errors, negatively affect patient satisfaction, and contribute to staff dissatisfaction and high staff turnover rates (The Joint Commission, 2008a). Due to the potential for serious negative outcomes, beginning January 1, 2009, all health care organizations accredited by The Joint Commission must have a code of conduct that makes acceptable and unacceptable behaviors explicit, as well as a plan for managing disruptive behaviors (The Joint Commission, 2008a). Given the seriousness of the problem, further research is needed to better understand what behaviors are perceived by others as unacceptable.
Intimidating and disruptive behaviors are known as workplace incivility, which is defined as “low-intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect” (Andersson & Pearson, 1999, p. 452). Recent literature has identified workplace incivility as a common and distressing problem in nursing (Griffin, 2004; McPhaul & Lipscomb, 2004; Rosenstein & O’Daniel, 2005; Rowe & Sherlock, 2005; Stanley, Martin, Michel, Welton, & Nemeth, 2007). Freshwater (2000) stated that workplace incivility among nurses stems from a long history of oppression and subordination, which in turn has led to nurses directing their frustration toward others, particularly those with less power. Clark (2008a, 2008b) studied and reported extensively on incivility between nursing students and faculty in the classroom setting. The current research extends the phenomenon of incivility in nursing education to the clinical setting.
As a group, nursing students hold little power in health care settings and are particularly susceptible to becoming the targets of incivility. It is essential that nursing faculty foster a clinical environment that is conducive to learning. Although some anxiety among nursing students is understandable and predictable given the serious nature of patient care, stress related to workplace incivility is unnecessary and may discourage students. The purpose of this qualitative study was to explore the experiences of nursing students as targets of workplace incivility in clinical education, to describe their perceptions of specific uncivil and favorable behaviors of nurses, and to examine how they think schools of nursing should address workplace incivility in clinical nursing education. This study is the first in a program of research investigating incivility in clinical nursing education. Results will be used to develop a quantitative tool to measure incivility in clinical nursing education.
Sample and Setting
This study took place at a private, midwestern university with a large nursing school. After approval was obtained from the university institutional review board, one of the two researchers (M.A.) went to nursing classes to explain the purpose of the study and asked for voluntary participation in one of four scheduled focus groups. Because we were interested in exploring the phenomenon of perceived incivility, purposive sampling was used to recruit students who thought they had been the targets of incivility by staff nurses. Interest sheets requesting names and e-mail addresses were distributed. Those who expressed interest received an e-mail invitation providing the dates and times of the focus groups. Eighteen female and three male nursing students (N = 21) participated. Most of the participants’ ages ranged from 20 to 25 years (n = 11), followed by 26 to 30 years (n = 4), 31 to 35 years (n = 4), and 36 to 40 years (n = 2). The majority of participants were White (n = 17); 2 identified as Middle Eastern and 1 each as Black and Asian. As for educational level, 7 were juniors, 4 were sophomores, 4 were seniors, and 6 were second-degree students.
This qualitative, descriptive study used focus groups to explore student experiences with perceived incivility in the clinical setting. Four focus groups were held on campus immediately following a nursing class that all students at a particular level were required to take. Lunch was served during the focus groups, which lasted approximately 1.5 hours. After the purpose of the study was described and anonymity and confidentiality assured, participants signed consent to participate in the study. They then completed a short demographic questionnaire containing questions about age, gender, race, and educational level in the program. Semi-structured interview questions were then used to explore students’ experiences of perceived uncivil treatment by staff nurses in the clinical setting. The following questions were asked:
- When thinking about your personal experiences with being treated in an uncivil manner in the clinical setting, what particular experiences come to mind?
- What experiences with nurses in the clinical area were positive for you?
- How should this topic be addressed in nursing schools?
All focus groups were audiotaped, and the tapes were transcribed verbatim. Once the transcripts were verified, the tapes were destroyed. Following each session, the two investigators met to discuss the focus group process and findings. Both researchers thought a sufficient number of interviews took place to achieve saturation. The data were contemplated as a whole and in parts on repeated occasions during a 6-month period by both researchers. A line-by-line method of analysis (Miles & Huberman, 1994) was used to code, categorize, and analyze data. Words, phrases, and sentences were labeled with substantive codes and categories and themes were identified from these substantive codes. To ensure trustworthiness of the results, member checking was utilized; three participants were asked to read the results and verify that they accurately represented the experiences of the participants. Two of the members (both female) responded that the results did represent the experiences expressed by the participants. The third member (a male) responded that he agreed for the most part but found the statement “we were always in tears” to be overly dramatic. This may be a result of gender differences in the reaction to uncivil treatment and suggests a need for further research to explore the influence of gender on perceived incivility.
Research Question One
The research question “When thinking about your personal experiences with being treated in an uncivil manner in the clinical setting, what particular experiences come to mind?” guided the discussion on perceived incivility in clinical courses. Three themes emerged in the discussions that followed. Behaviors perceived to be uncivil fell in three themes: exclusionary (“We’re in the way”), hostile or rude (“We were always in tears”), and dismissive (“They just walk away”).
“We’re in the way.” The participants expressed a general sense of feeling like outsiders in the health care arena. Although they recognized their learning needs placed an additional burden on the nursing staff, they expressed surprise that some nurses did not seem to accept that students would be part of their responsibility in a teaching hospital:
- Basically, we were bothersome to the staff. We were there to help and we tried to be helpful.
- I think that they are just annoyed that we are there and in the way.
- They say to ask questions but I feel like when I do ask a question, by the look on their face, they don’t want to be bothered.
- I think nurses are annoyed by their young.
Receiving and giving report on patients was mentioned by most of the students as an event that often resulted in a feeling of exclusion. Some of the students commented:
- I could never get a complete report from the nurses unless it was one of the few [who] were really nice. Most would just shrug it off and say “Oh well, look in the chart.”
- [Nurses were] unhelpful and unavailable, and you can’t get a full report from them.
Many students also related that the nurses appeared disinterested when they (the students) attempted to report off at the end of the shift:
- They’ll take the [report] form we have to fill out and they throw it in the garbage, not even look at it, not even a glance at it. [I felt] like I wasted my time.
- I had a nurse tell me she didn’t care when I told her I had to report off to her.
Another student recalled feeling excluded from being part of the team when she brought her patient’s husband a glass of hot chocolate:
She [the nurse] was on the other side of the nurses’ station and she said [to the husband] “She’s not your nurse. I’m your nurse. I will help you.”
“We were always in tears.” Many of the students reported behavior on the part of nurses that could only be interpreted as rude and hostile. The participants felt that this type of behavior was a result of a personal problem on the part of the nurses and did not reflect an inadequacy on the part of the student. Despite this insight, being treated this way made them question whether they wanted to be a nurse or whether they could be successful in nursing school:
- She’s either burned out, or she has something going on at home.
- She was just angry and mean all day.
- Not all nurses are nice to their patients and I’ve noticed the nicer they are to their patients, the nicer they are to me. If she’s mean to the patient, she’s going to be mean to me.
- I hate that some nurses are bitter. I think that some feel threatened. You are asking them things they can’t answer.
- She was so mean. We were always in tears.
One student related that because the students were not yet administering narcotics, she asked the nurse to give the patient something for pain. The nurse responded by saying “Thank you, sweetheart. I’m not a moron.” The student then told us:
Honestly, it was like I didn’t want to ask her anything at all from that day on. It just really discouraged me.
Another student related that his instructor told him to ask the nurse to assist him with his first dressing change because she was busy with other students:
So I went back to the nurse, she just said “No. I don’t have time to do this. It’s not my problem.” Then [she] went to every other nurse on the floor and said she didn’t know why we were students there because we didn’t know what we were doing. And she told her boss we shouldn’t be on the floor.
Another student reported the following reply when asking for help obtaining a blood glucose level:
The guy says in front of the patient “you SDO’s [second-degree students], you rush through the program, what do you know? Nothing! Can you even do a glucose?”
“They Just Walk Away.” The final theme that emerged was the dismissive way in which the students perceived some nurses had treated them. Being treated this way made the students feel that not only was their contribution to the care of the patients insignificant, but that they themselves were insignificant. Students said:
- I asked her if it [the student’s charting] was ok. She comes back at me and says, “[I] don’t get paid for this. You need to talk to your instructor.”
- I asked the nurse if she could help me [interpret an electrocardiogram strip] and she said, “No, not my job. Talk to your instructor.”
- Any questions I had for her, she rolled her eyes.… I asked her why there had been no x-ray and she [said], “I don’t know” and walked away.
- She was so flippant and dismissive.… Give me a break, I know you are giving meds and it’s important but why treat another human being like that?
Research Question Two
Although this research study focused on incivility in the clinical setting, we also thought it was important to address positive experiences between student and staff nurses. The question that guided this discussion was: What experiences with nurses in the clinical area were positive for you? The students overwhelmingly reported numerous experiences with staff nurses that they perceived to be positive, and which reaffirmed their desire to be a registered nurse. Students relished their clinical experiences as a time to learn. They reported feeling eager and excited to be on patient care units learning nursing process and procedures. The positive experiences they related involved feeling included by the staff nurses in patient care and when the nurse initiated interaction with them. The degree of inclusion and interaction appeared to be inconsequential. One student said:
There was this one nurse [who] really changed my entire view. The day that I had clinical with her made the difference.… She did everything with me. I did everything that day. I [administered] a heparin shot, we had to pass meds, everything, but she did it with me. It makes such a big difference.
Students related that another positive aspect of their clinical experiences was when they were approached by staff nurses and were included in patient care activities on the unit, even if it was not with their assigned patient. Students are appreciative of being taught by many nurses and obtaining as many learning opportunities as they could while they are in the clinical setting. Comments included:
- I actually had this one nurse last week who wasn’t assigned to me. I just couldn’t find my nurse, so I asked her the question. She came to my patient’s room, explained how something worked for 20 minutes and she wasn’t even my nurse. Later that day, she saw me in the hall and asked if I wanted to see a test done. I wasn’t assigned to her, but if she saw me and I wasn’t doing anything, she asked me if I wanted to learn something.
- I had a nurse that came up and said, “You are going to be my student nurse today so let me tell you what’s going on….” She cared to tell me that she is actually including me in the patient’s care.
Research Question Three
Research question three focused on how faculty of the school of nursing should address the topic of incivility. Responses to this question varied. Some students seemed resigned to the occurrence of incivility and did not think faculty could do anything to change the situation. Others thought it would have been better to be warned that this was something they may encounter. The students agreed they would bring about the change when they graduate by including and valuing nursing students. They commented:
- I think students could benefit from getting a heads up about what they are going to face.
- I think it’s just to prepare us—don’t fool yourself, not all nurses are going to love having you there. That’s not real life.
- Letting them know—it’s not going to be you, don’t take this personally.… These are some of the things you are going to face, so just be ready to deal with it.
- We need to remember how it was to be a student nurse and be willing to help other student nurses in the future.
Students felt more could be done to communicate with the nursing unit about the level of student and their clinical objectives:
- Clinical instructors need to relate to staff what students are there to do and what level we are.
- Meet with [the] floor [staff] to determine if students are wanted.
Of note, students related that the way they were treated sometimes depended on how well respected their clinical instructor was. One student commented:
Last semester, my clinical instructor had worked at the hospital we were at. My clinical instructor this semester does not work at the hospital and it is night and day because last semester…I feel like they respected her.… The nurse wouldn’t have acted like that because she works with [the instructor].
The aims of this study were to explore nursing students’ experiences with incivility in clinical education, to gain an understanding of what nurse behaviors are perceived by students to be positive, and to identify how students think this topic should be addressed in schools of nursing. Results suggest that incivility toward nursing students does occur and has a significant effect on student experiences in the clinical areas. It was reported by study participants that positive experiences outweighed negative ones in frequency but not in impact on student self-confidence and attitude toward nursing as a career.
Of particular concern is the difficulty the participants described receiving and giving report on their assigned patients. The Joint Commission (2008b) identified a standardized approach to patient hand-off communication as National Patient Safety Goal. Nursing students assigned to a particular patient should be made aware of the current condition of patients they are to care for, recent changes in condition or treatments, anticipated changes in the patient’s condition, and what to watch for during the next interval of care, and they should have opportunities to ask and answer questions (The Joint Commission, 2008b). This process needs to be repeated at the end of the student’s shift, with the nurse as the recipient of report on the patient’s current condition and again with an opportunity to ask and answer questions. Gaps in communication can potentially lead to missed or extra doses of medications, as well as missed diagnostic tests and therapeutic procedures, and can prevent students from recognizing signs and symptoms that should be acted upon or reported.
It is essential that nurse administrators and managers educate all team members about the organization’s code of conduct and expected professional behavior. In addition to disciplinary action for disruptive behaviors, it is also important to develop a system for recognizing and rewarding the many positive interactions that students described. The expectation of providing role modeling and support for students on units where students are assigned should be clarified with nursing staff. Dedicated education units (DEUs) are a creative approach being used increasingly in nursing education. DEUs provide a learning environment in which the staff nurses, with support from school of nursing faculty, serve as clinical instructors. Moscato, Miller, Logsdon, Weinberg, and Chorpennig (2007) described DEUs as an opportunity for positive role modeling for students, as well an opportunity for professional growth for staff nurses.
There are several implications for schools of nursing. It would be disingenuous to assume that nursing students do not also demonstrate disruptive behavior in the clinical setting; thus, they too need to be made aware of the expected code of conduct in health care settings and the effect of disruptive behavior on staff morale and patient outcomes. It is important that the instructor clarify with the nurses and manager on the unit the level of students and what they are permitted and expected to do. Finally, the issue of incivility should be a topic of discussion with students in the classroom or in clinical conferences. Griffin (2004) found that newly licensed nurses who were made aware of workplace incivility were better able to depersonalize it and confront the offender. Simulation to prepare students for various clinical experiences has gained popularity recently in schools of nursing. Conflict resolution and addressing workplace incivility should become part of the simulation experience.
Although the sample size was small and limited to a single university, we feel the findings enhance understanding of the often repeated saying “nurses eat their young.” Further research on a larger scale with both associate degree and baccalaureate degree nurses is needed to provide quantifiable and generalizable findings. It is also important to gain an understanding of staff nurses’ perceptions of nurse–student interactions and having nursing students on their unit. Research is also needed to determine the influence of student gender and age, type of unit, and the level of the student in the nursing program. Finally, interventions to help students develop skills to effectively cope with incivility should be implemented and studied.
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