Incivility is a problem that exists in nursing education and practice (Aul, 2017; Schaeffer, 2013; Seibel, 2014). Incivility in nursing education and practice threatens the academic environment, impedes student learning and socialization into the professional nursing role, and hinders the opportunity for nursing students to become caring and empathetic nurses (Aul, 2017; Schaeffer, 2013; Wright & Hill, 2015). Nursing students who are exposed to negative socialization in the clinical setting are at risk of continuing the cycle of incivility in their nursing practice (Wright & Hill, 2015). Although Clark (2013) reported that nursing students experience incivility in the classroom setting, nursing students have also reported experiencing incivility in clinical settings (Anthony & Yastik, 2011; Birks, Budden, Park, Simes, & Bagley, 2014; Nixon, 2014; Palaz, 2013).
Like their English-speaking counterparts, English as a second language (ESL, also known as English as an additional language, nontraditional, minority, or culturally and linguistically diverse) nursing students have also encountered similar uncivil clinical experiences (Koch, Everett, Phillips, & Davidson, 2014). However, most of the research about incivility has been phenomenological and does not focus on any particular student category, such as ESL nursing students (Anthony & Yastik, 2011; Hakojärvi, Salminen, & Suhonen, 2014). Because a paucity of literature exists (Anthony & Yastik, 2011; Anthony, Yastik, MacDonald, & Marshall, 2014; Koch et al., 2014), the purpose of this study was to investigate differences between ESL and non-ESL nursing students' perceptions of incivility in the clinical setting and to investigate the elements of collectivism and individualism as possible cultural influences to perceptions of incivility.
Clinical experiences provide students with the opportunity to apply what they have learned in the classroom (Anthony & Yastik, 2011; Rajeswaran, 2016). Clinical experiences are also vital for the continuous growth of students' confidence and competence, as well as the formation of their identity as future nurses (Aul, 2017; Rajeswaran, 2016; Walker et al., 2014). However, nursing students are at risk of experiencing incivility and psychological distress during their clinical experiences (Anthony & Yastik, 2011; Aul, 2017; Birks et al., 2014). Anthony and Yastik (2011) categorized the uncivil behaviors experienced by nursing students in the clinical setting by staff nurses into three primary themes: exclusionary, hostile or rude, and dismissive. Aligning with these themes, nursing students have reported neglect, burnout, and verbal abuse in the clinical setting (Anthony & Yastik, 2011; Babenko-Mould & Laschinger, 2014).
Verbal abuse was the most common uncivil behavior reported, followed by bullying and physical abuse; approximately half of the perpetrators of incivility were identified as staff members (mostly nurses), followed by patients (25%) and visitors (25%) (Hinchberger, 2009; Hopkins, Fetherston, & Morrison, 2014; Magnavita & Heponiemi, 2011; Mateen, 2014; Palaz, 2013). However, Clarke, Kane, Rajacich, and Lafreniere (2012) found that patients and their families were main perpetrators of verbal abuse. Although authors reported that ESL students who perceive themselves as different may endure negative clinical experiences (Sedgwick, Oosterbroek, & Ponomar, 2014), a substantial gap exists regarding ESL nursing students' perceptions of incivility in the clinical setting. ESL nursing students are faced with many struggles during nursing education related to language, culture, communication, and perceived prejudice and discrimination (Alicea-Planas, 2009; Amaro, Abriam-Yago, & Yoder, 2006; Bednarz, Schim, & Doorenbos, 2010; Olson, 2012). Language and communication skill difficulties continue in the clinical setting (Olson, 2012). ESL students report having difficulty understanding medical terminology, abbreviations, patient reports, and directions on how to perform a task (Donnelly, McKiel, & Hwang, 2009; Olson, 2012; Schoofs, 2012). In addition, ESL students tend to be embarrassed to ask questions, fearing that staff nurses may view them as incompetent (Alicea-Planas, 2009; Olson, 2012; Schoofs, 2012). Finally, to complicate matters, cultural influences may place the ESL student at risk of experiencing incivility in the clinical setting (James, 2018; Sedgwick et al., 2014).
The theory of cultural variability was used as the theoretical framework to guide the study and the research questions. The theory of cultural variability has origins that date back to Hofstede (1980) and the theory of cultural dimension as a framework for cross-cultural communication. Hofstede (2011) argued that six dimensions of culture affect peoples' values and behavior. Of interest are the dimensions of individualism and collectivism, defined by “how individuals perceive themselves, how they relate to others, what goals do they follow, and what drives their behavior” (Neuliep, 2015, p. 51). The cultural dimensions of individualism and collectivism, as well as their horizontal and vertical attributes, were studied as possible predictors to the perception of incivility.
Triandis (1995) examined Hofstede's dimension of individualism and collectivism and defined individualism as a social pattern by which individuals view themselves as separate from the group. Individuals are motivated by their individual needs and goals over those of the group. The I overtakes the we identity (Hofstede, 2011). In individualistic cultures such as those of the United States, Northern European countries, and Australia, self-reliance, assertiveness, and creativity are emphasized (Hofstede, 2011; Neuliep, 2015; Welbourne, Gangadharan, & Sariol, 2015).
Individualism is described by its horizontal and vertical attributes. Horizontal individualism is a cultural pattern whereby an individual's uniqueness in the group is noted; however, the individual has equality of status among all members of the group. Singelis, Triandis, Bhawuk, and Gelfand (1995) asserted that “The self is independent and same as the self of others” (p. 245). Horizontal individuals demonstrate self-reliance, prefer to do things on their own, and are not interested in seeking a high status or recognition within the group (Singelis et al., 1995). Vertical individualism is a social pattern in which the individual is independent, highly self-reliant, and achievement oriented. Individuals see each other as different, and inequality is expected (Singelis et al., 1995). The vertical individual will compete with others to acquire high status in the group (Singelis et al., 1995; Triandis & Gelfand, 1998).
Collectivism is a social pattern that consists of individuals who see themselves as part of a group, such as family, coworkers, or community (Neuliep, 2015). Group membership and getting along with others is the focus of collectivism. The self-construct for collectivism is interdependence with others. These individuals are guided by norms and duties imposed by the collective group that determine behavior (Neuliep, 2015). There is shared responsibility, and all members are accountable to each other. The priorities and goals of the group take precedence over those of the individual (Neuliep, 2015; Scheele, Pruitt, Johnson, & Xu, 2011). Sacrificing one's goal for the sake of protecting the objectives of the group and maintaining harmony is a priority (Hofstede, 2011). Collectivists also place importance on belonging (Hofstede, 2011). However, individuals in a group tend to stay in an unpleasant group or relationship rather than leave and lower the status of the group. Latin, Asian, African, Arabic, and southern European cultures embrace collectivism (Neuliep, 2015; Warda, 2008). Other populations, such as people of color (Triandis & Gelfand, 2012) and Hispanic individuals (Neuliep, 2015), incorporate collectivist values.
Collectivism is also is described by its horizontal and vertical attributes. Horizontal collectivism is a social pattern in which equality and cooperation are the primary values (Gouveia, Clemente, & Espinosa, 2003; Singelis et al., 1995; Triandis & Gelfand, 1998). The individual comes together with the group that possesses his or her similar values (Triandis & Gelfand, 1998). Horizontal collectivism individuals “emphasize common goals with others, interdependence, and sociability, but do not submit readily to authority” (Triandis & Gelfand, 1998, p. 119). Vertical collectivism is a social pattern that emphasizes harmony in the context of the hierarchical relationship with others (Gouveia et al., 2003; Singelis et al., 1995; Triandis & Gelfand, 1998). The nursing profession, as a caregiver community as well as a hierarchical discipline (Aul, 2017), could be categorized under the culture dimension of collectivism. Vertical collectivism assesses the extent to which the individual stresses interdependence and competition with other groups and the person's ability to relinquish his or her personal goals for those who belong to the group. Sacrificing for the benefit of the group includes submitting to requests from authority (Singelis et al., 1995; Triandis & Gelfand, 1998).
A descriptive, cross-sectional, comparative, and correlational research design was used to examine and describe whether differences and relationships existed between ESL and non-ESL nursing students' perceptions of staff nurse incivility during their clinical rotations. The responses were statistically analyzed to describe trends and answer research questions. The software G*Power 3.1 was used to determine how many cases were needed to conduct the statistical analyses to answer the research questions. A two-tailed bivariate normal correlation model at the .05 alpha level and 90% power needed 370 cases to determine if an obtained value of r was significantly different from r = .00.
To obtain the convenience sample of nursing students, the executive director of the National Student Nurses' Association was contacted to request access to members. Members of the National Student Nurses' Association (2016) are nursing students from associate, baccalaureate, and diploma programs. Following institutional review board approval, information about the study was sent by the organization to the approximately 60,000 student members in a mass broadcast e-mail with an embedded video from the researcher explaining the study and asking for volunteer participation. There were no known risks associated with this study; however, participants were instructed to report any unforeseen risks or concerns to the researcher. Completion of the survey was evidence of informed consent. Inclusion criteria included the completion of at least one clinical rotation in an acute care facility, the ability to read and understand English, and access to a computer and the Internet. Participants were excluded from this study if they self-reported that they had been subjected to disciplinary action related to clinical performance.
Responses were received from 1,700 nursing students. Almost 700 (n = 687) incomplete surveys were submitted, thereby reducing the number of valid surveys to 1,013. The data set was screened for multivariate outliers using Mahalanobis distances. Thirty-eight cases were removed. The clean data set contained 975 cases.
The instruments used to obtain data were the Uncivil Clinical Behavior in Nursing Education (UBCNE) tool (Anthony et al., 2014) and the Horizontal and Vertical Individualism/Collectivism Scale (Triandis & Gelfand, 1998). In addition, the respondents were asked to provide information on the following personal and program variables: age; race; ethnicity; whether the participant was born in the United States and if not, how long they had been living in the United States; ESL status; ability to read and understand English; current semester in the nursing program; and type of nursing program.
The UBCNE tool is a self-report 12-item survey that measures perceived incivility by nursing students in the clinical setting (Anthony et al., 2014). The instrument uses a Likert-type scale that ranges from 0 (never) to 4 (very often). A total incivility score was computed as the mean across the 12 items. The two subscales were identified as the hostile-mean behaviors (five items) and exclusionary behaviors (seven items). The mean scores on the total score and the two subscales could range from 0 to 4, with a higher score indicating a perception of higher incivility. Two experts on incivility in nursing education and an expert on incivility in the workplace established content validity for this instrument. Instrument reliability was established by Anthony et al. (2014) for the total incivility scale (α = .88) and for the two subscales of hostile-mean (α = .88) and exclusionary behaviors (α = .83) in a sample of 106. In the current study (n = 975), Cronbach's alpha for the total incivility score was α =.91, for hostile-mean behaviors was α = .85, and for exclusionary behaviors was α = .88.
Horizontal and Vertical Individualism/Collectivism Survey
The Horizontal and Vertical Individualism/Collectivism Survey was used to estimate levels of attributes of the cultural dimensions of individualism and collectivism (Triandis & Gelfand, 1998). Participants respond by indicating their level of agreement with 16 statements using a 9-point Likert scale that ranges from 1 (never or definitely no) to 9 (always or definitely yes). Four subscales (four questions each) indicate the cultural dimensions of horizontal individualism, vertical individualism, horizontal collectivism, and vertical collectivism. Each dimension's items were averaged separately to create horizontal individualism, vertical individualism, horizontal collectivism, and vertical collectivism scores. Scores for each subscale range between 1 and 9; a high score for each subscale indicates an agreement with each corresponding description of horizontal individualism, horizontal collectivism, vertical individualism, and vertical collectivism (Triandis & Gelfand, 1998). However, most individuals will score predominantly in one dimension while having strengths in more than one. Construct validity was established by means of factor analysis (Triandis & Gelfand, 1998), with good convergent and divergent validity reported (Cozma, 2011; Singelis et al., 1996; Triandis & Gelfand, 1998). Cronbach alpha coefficients were used to examine instrument reliability and ranged from .67 to .81 for horizontal individualism, .74 to .82 for vertical individualism, .74 to .80 for horizontal collectivism, and .68 to .73 for vertical collectivism (Cozma, 2011; Singelis et al., 1995; Triandis & Gelfand, 1998). In the current study (n = 975), Cronbach alpha coefficients were as follows: horizontal individualism = .77, vertical individualism = .73, horizontal collectivism = .67, and vertical collectivism = .71.
The data were screened for assumptions of the statistical analyses used to answer three research questions. Multivariate outliers were removed. The data met the assumptions for linearity, homogeneity of variance, and normality of the variables. The following research questions and statistics tests were used in the study:
What is the difference in perception of incivility between ESL and non-ESL students? A t test was used to determine differences between the two groups of students' perceptions of incivility.
What is the difference between ESL and non-ESL students' perceptions of hostile and mean and exclusionary behaviors among staff nurses? A multivariate analysis of variance (MANOVA) was used to determine differences between the two groups of students' perceptions of hostile-mean and exclusionary behaviors among staff nurses.
How do horizontal and vertical individualism scores and horizontal and vertical collectivism scores differ between ESL and non-ESL students? A MANOVA was used to determine differences between the two groups of students' scores on horizontal and vertical individualism and on horizontal and vertical collectivism.
Which demographic and program variables best predict perceptions of incivility? A multiple regression procedure was used to determine predictors for incivility. Several of the characteristics (type of student, ethnicity, and gender) were categorical and coded dichotomously.
Demographic Characteristics of the Sample
Almost all the respondents were female (92%) and enrolled in a Bachelor of Science in Nursing program (68%). Nearly 19% self-identified as ESL students. The average age of the students was 28 years and the average length of time participants had been in a nursing program was 2 years.
Means and Standard Deviations of Scales
The means and standard deviations of the scales from the two measurement instruments are provided in Table 1. The majority of nursing students reported that they encountered uncivil behaviors either rarely or occasionally. The students were more likely to disagree with statements of vertical individualism and slightly more likely to agree with statements of horizontal individualism and both horizontal and vertical collectivism.
Ranges, Means, and Standard Deviations of the Scales (Uncivil Clinical Behavior in Nursing Education, and Individualism/Collectivism) Used in Data Analysis (n = 975)
Correlations of Variables in the Study
Positive and negative Pearson r and point-biserial correlations were obtained. As expected, the hostile-mean and exclusionary behaviors were highly correlated with the incivility total score (each correlated at r = .92, p < .05). The vertical and horizontal individualism scores were significantly correlated with each other (r = .33, p < .05), whereas the vertical and horizontal collectivism scales were significantly correlated with each other (r = .38, p < .05). The large sample size allowed for statistically significantly correlations as low as r = .07, and many times were of little value in determining substantial relationships. Aside from obvious correlations between ESL and ethnicity, other significant relationships were found between time in the program and hostile-mean behaviors (r = .22), exclusionary behaviors (r = .24), and incivility (r = .25), indicating that the longer students have been in the nursing program, the more often they have observed incivility.
Research Question 1: What Is the Difference in Perceptions of Incivility Between ESL Nursing Students and Non-ESL Nursing Students?
ESL (M = 1.68, SD = 0.73) and non-ESL (M = 1.91, SD = 0.86) students were significantly different in their perceptions of staff nurses' exclusionary behaviors (t = 3.67, p < .01, η2 = .010). ESL (M = 1.65, SD = 0.60) and non-ESL (M = 1.77, SD = 0.65) students also differed in their perceptions of staff nurses' incivility (t = 2.24, p < .03, η2 = .005). In both cases, non-ESL students reported higher perceptions of exclusion behavior and incivility from staff nurses than did ESL students. However, the effect sizes of the differences were small.
Research Question 2: How Do Horizontal Individualism, Vertical Individualism, Horizontal Collectivism, and Vertical Collectivism Scores Differ by ESL and Non-ESL Students?
The four scales of the Horizontal and Vertical Individualism/Collectivism Scale were used in a MANOVA to determine whether horizontal individualism, vertical individualism, horizontal collectivism, and vertical collectivism scores differed by ESL and non-ESL students. A significant multivariate result was found (F = 2.87, p = .02, ηp2 = .012). Univariate analysis found a significant difference on vertical collectivism (F = 5.33, p = .02, η2 = .005). ESL students identified more with a vertical collectivism orientation than did non-ESL students. However, the effect size of the significant finding was small.
Research Question 3: Which Demographic and Program Variables (Age, Gender, Ethnicity, Type of Student, and Time in the Program) Best Predict Perceptions of Incivility?
Multiple regression using forward selection was used to determine which demographic and program variables best predicted perceptions of incivility (Table 2). A significant regression equation was created (F = 28.56, p < .01, adjusted R2 = .078). Three demographics (time in the program, age, and gender) were significant predictors of incivility. The three predictors accounted for 7.8% of the variance of incivility. All predictors were positive, indicating that as nursing students' time in the program and age increased so did their perceptions of incivility. Female nursing students were more likely to score higher in perceptions of incivility than were male nursing students.
Multiple Regression of Demographic and Program Characteristics of Nursing Students as Statistically Significant Predictors of Incivility (n = 975)
Results suggested that non-ESL nursing students perceived exclusionary behaviors and total incivility behaviors by staff nurses more frequently than did ESL nursing students. However, the effect sizes of those differences were minimal and did not provide enough evidence that ESL and non-ESL nursing students perceived staff nurses' incivility differently. On average, nursing students either reported rarely or occasionally observed uncivil behaviors. These results are similar to those of Budden, Birks, Cant, Bagley, and Park (2017), who reported that participants experienced being ignored, were treated as though they were not part of the team, and were shown negative nonverbal behaviors either never (34%) or occasionally (32%). Ferns and Meerabeau (2009) postulated that students are not consistent in reporting verbal abuse. Some nursing students did not report verbal abuse because of the lack of follow up after the incident, negative feelings after the incident, and their reluctance to report verbal abuse involving staff for fear of retaliation by the perpetrator (Ferns & Meerabeau, 2009). Students' lack of reporting of incivility by staff nurses in the clinical setting may be also influenced by the perception that incivility is a normal part of nurses' clinical education or an important ritual in the transition from nursing student to professional nurse (Decker & Shellenbarger, 2012; Magnavita & Hepomiemi, 2011). Yet another possible reason for not reporting incivility was that “behavior that may be perceived uncivil by one person may be acceptable behavior to another person” (Clark, 2008, p. 458).
Difference in perception of incivility between ESL and non-ESL students in this study may relate to influences of individualism/collectivism and their orientation on perceptions of incivility. Results suggested no differences between the two student groups in three of four subscales (horizontal individualism, vertical individualism, and horizontal collectivism). However, ESL nursing students scored higher in vertical collectivism scale than did non-ESL students, indicating it is possible that ESL students' values help them manage encounters with in-civility in the clinical setting. Triandis and Gelfand (1998) reported that those who identify themselves within the vertical collectivism dimension see themselves as part of a collective. Nursing students are part of a collective group and are “socialized to understand the hierarchy in nursing” (Croft & Cash, 2012, as cited by Budden et al., 2015). Furthermore, they may also accept inequality within that collective, which might influence their willingness to accept incivility as normal behavior in clinical nursing education (Decker & Shellenbarger, 2012; Magnavita & Hepomiemi, 2011). In addition, vertical collectivists' values also stress close relationships (e.g., family or familism) within the group, which helps them develop resilience against stressors and makes it possible for many to tolerate or accept incivility from others (Welbourne et al., 2015).
Generational factors also have influence on perceptions of incivility. Leiter, Price, and Laschinger (2010) noted that Generation X nurses reported more negative experiences at work than did Baby Boomer nurses. However, Clark and Springer (2007) reported no differences among the ages of students regarding how they viewed examples of uncivil behaviors. Gallo (2012) and Clarke et al. (2012) reported no relationship between demographic information, such as age and gender, and perceptions of incivility. In this study, female nursing students scored higher in incivility than male nursing students, a fact that coincides with Babenko-Mould and Laschinger (2014); yet, this is contrary to what Gallo (2012) reported. Regarding time in the program, Clarke et al. (2012) reported that third- and fourth-year nursing students reported experiencing more bullying. Furthermore, Curtis, Bowen, and Reid (2007) found that students learn how to cope and accommodate, on both a personal and an organizational level, with horizontal violence as they progress through their education.
A convenience sampling of nursing students was recruited to participate in the study; therefore, the transferability of the results may be limited (Polit & Beck, 2017). In addition, surveys can yield incomplete data and lead to self-reporting bias as participants may not feel encouraged to provide accurate answers (Dillman, Smyth, & Christian, 2014). Finally, 687 participants chose to omit responses to demographic questions and/or survey instrument questions and were omitted from the data analysis. The length of the questionnaire may have fatigued these participants. Because these participants were omitted from the data analysis, those partial responses, if analyzed, could have influenced the study results.
Recommendations for Future Study
This study contained the largest sample, to date, for a quantitative study in incivility. However, a recommendation for future research is to replicate the study and target nursing schools with known populations of ESL students. Recruiting more ESL nurses would allow researchers to study in more detail the collectivism values of ESL nursing students and how they manage incivility in the clinical setting. Possible findings may assist nursing faculty in the development of best practices to assist ESL nursing students with the incivility they may encounter in the clinical setting.
The researcher attempted to explore ESL and non-ESL nursing students' perceptions of staff nurse incivility. No practical difference was observed between ESL and non-ESL students' perceptions of staff nurse incivility. However, time in the program, age, and gender predicted which students might be more likely to encounter and/or perceive staff nurse incivility. As nursing students' time in the program and age increased, so did their perceptions of incivility. Female nursing students were more likely to score higher in perceptions of incivility than were male nursing students.
Although nursing students in this sample reported incivility in the clinical setting, they did not perceive staff nurse incivility to the extent as previously reported in the literature. It is possible that schools of nursing have been diligent in including content related to incivility in nursing education, and nursing students are more knowledgeable and aware of coping strategies. Additionally, it is also possible that health care agencies have been proactive in addressing workplace hostility. If nursing is in fact seeing a trend toward more civil workplace relationships, the core value of caring as the essence of nursing will be strengthened not only for nursing students, but also for patients, families, and the entire health care team.
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Ranges, Means, and Standard Deviations of the Scales (Uncivil Clinical Behavior in Nursing Education, and Individualism/Collectivism) Used in Data Analysis (n = 975)
|Hostile-mean behaviors||1.00 to 4.14||1.67||0.60|
|Exclusionary behaviors||1.00 to 5.00||1.87||0.84|
|Total incivility||1.00 to 4.25||1.75||0.65|
|Horizontal individualism||1.00 to 9.00||6.32||1.55|
|Vertical individualism||1.00 to 9.00||4.42||1.56|
|Horizontal collectivism||3.00 to 9.00||7.72||1.01|
|Vertical collectivism||3.00 to 9.00||7.00||1.29|
Multiple Regression of Demographic and Program Characteristics of Nursing Students as Statistically Significant Predictors of Incivility (n = 975)
|Time in program||.184||0.256||8.23||< .01||.062|