Strategies for Managing Nursing Students' Incivility as Experienced by Nursing Educators: a Qualitative Study.

INTRODUCTION: Students' incivility is an impolite and disturbing behavior in education and if ignored could lead to behavioral complexities and eventually violence and aggression in classrooms. This study aimed to reveal the experiences of Iranian educators regarding the management of such behaviors.
METHODS: In this qualitative study, qualitative content analysis method was used to evaluate the experiences and perceptions of nursing educators and students. A total of 22 persons (14 educators and 8 students) were selected through purposive sampling and individually interviewed.
RESULTS: Categories of unification of educators regarding behavioral management, teaching-learning strategy, friendship strategy and training through role playing, authority, appropriative decision-making and freedom, stronger relationships between students, reflection, and interactive educational environment were some strategies used by teachers for management of incivility.
CONCLUSION: Educators suggested some strategies which could be used depending on uniqueness of behaviors and given situation. Educators and managers of medical fields can use these approaches in their classrooms to control uncivil behaviors.

Introduction

All university educators encounter students that are disturbing education process at least several times during their service. Lateness, early leave, irrelevant and inappropriate talk, and sleeping during courses are several uncivil behaviors encountered by educators.[1] In nursing education, incivility are those behaviors that are destructive, would lead to physical and mental distress in people who are working in that educational environment, and if not eliminated, could cause a threatening condition.[2]Recently, educators have encountered threatening behaviors which includes stalking, intimidating, verbal or even physical attacks, and changing the course of education.[3,4]

Nursing educators have encountered various incivilities among the students and in most cases do not have enough knowledge to manage them properly. Some educators have left their work as a result of incivility and its effect on their personal and professional life. While there is a shortage of nurses and nursing educators in our country, inability to manage such behaviors will be considered as a big trouble.[5]

Another consequence of incivility in classrooms is that it would interrupt discipline and learning atmosphere, especially in team-based and contributive educations.[6] Today’s student will be tomorrow’s coworker and failing to identify and control his incivility would eventually produce an uncivil employee.[7,8]

If students come up with a weak personality, they can cause many costly and irreversible damages. Problems in interaction with coworkers, patients (customers of nursing services), clients, and organizations are among such damages.[6,9]

If such incivilities treated weakly and inappropriately, they can have long-term negative effects on classroom atmosphere,[10] and even it becomes intolerable and dangerous behaviors. Incivility, at least, can confuse and bewilder educators, employees, and managers.[11] In order to fight such behaviors, a systematic model should be defined.[12]

Educators should use their clinical and educational experiences as well as defining a strategy to repel incivility. Various strategies have been suggested to deal with student incivility. Kuhlenschmidt et al., Clark et al., and Hernandez et al., studies have proposed some strategies.[1,5,12] Kuhlenschmidth has suggested problem-solving strategies as an effective approach to deal with difficult behaviors.[1] Clark recommended social health approach as a violence-preventing model to manage such uncivil behaviors. Using role-playing, active learning strategy, getting help from educational services, holding various conferences between students and educators, and promoting civil behaviors are other approaches suggested by Clark.[5]

In Hernandez’s model for managing students’ incivility, university’s consultants have a leadership role and educators’ unity and bond is required. Each incivility requires a different action from university and consultants. Anarchistic and troublemaking behaviors need legal intervention while emotionally disturbing behaviors require professional counseling.[10,13]

In Iran, there are no studies that examines the management strategies of educators regarding their students’ incivility. Considering the cultural difference between Iranian and western universities, educators, and students, such a qualitative study of managing incivility is a most important subject. Therefore, this research has been done to reflect strategies of Iranian educators in dealing with nursing students’ incivility.

Materials and methods

In this qualitative content analysis study, participants were selected from educators and students of Medical Universities of Razavi Khorasan. Inclusion criteria for educators were: at least one year of teaching skill, dealing with student incivility, and willingness to participate in research. For students the inclusion criteria were as fallow; students were required to be at least in second semester, having the experience of incivility and willingness to participate in research. Research environment was real life (universities and hospitals) and the time and location of interview was selected by mutual agreement. Sampling was done using purposive method with maximum variation until reaching saturation. This study was done in 2014. All participants were individually interviewed using in-depth method. In qualitative studies sample size is not fixed; therefore researcher should continue to interview until no new idea is emerging.[14,15] A total of 22 persons (14 educators and 8 students) were interviewed.

After passing necessary paperwork, Medical Universities of Razavi Khorasan were visited and qualified educators and students were selected with the help of university deans. The purpose of research as well as interview method and participants rights regarding their willingness to contribute were described by interviewer and their informed consent was received. Open and semi-structured interviews were used for data collection. The interview started with questions such as “what is the first thing that comes to your mind when you hear the term ‘academic incivility’?”, “describe your personal experiences of academic incivility.”, and “how do you deal with incivility?” and continued with probing questions such as “please explain this further.” Other questions were emerged based on information provided by participants. Questions for other interviews were designed based on extracted categories.

Interviews length was between 30 to 90 minutes. Qualitative content analysis was used for data analysis. This method is defined as a mental interpretation method which is more than objective content extraction of textual data. With this method, contents and hidden patterns can be revealed through contents of data provided by participants.[16]

Interviews were digitally recorded and were transcribed on paper word by word and resulted data were reviewed several times so they can be understood thoroughly. Then, using continuous comparison and inductive content analyzing methods as well as using MAXQDA 10 Software of data analysis was used. Data were categorized to semantic units, summary of semantic units codes, subcategories, categorizes, and theme. Summarization of semantic units were done to shorten the text of semantic units while maintaining their core and were also coded based on them. After coding process, categories and resulted meanings were interpreted as main themes.[17]

After several listening, transcribing, reading, and investigating data, a general picture were achieved and meanings were extracted. Key ideas of contents were emphasized and different codes were sorted and categorized based on their relationships.

External audits use for credibility. Thus, we wanted a researcher that not involved in the research process examine both the process and product of the research study to evaluate the accuracy and assess whether or not the findings are supported by the data. Moreover, for assess of neutrality, taken the opinions of experts and consulting educators regarding codes and categories, returning initial codes to participants for reviewing and confirming.

In order to transferability was used maximum variety in participant selection. Maximum variety in selecting participants in terms of age, educations, job history, people with different teaching methods, being a member of students' disciplinary committee, have a post in university, and the type of teaching fields was considered.[18]

In this research, confidentiality of data, informed consent for interview, and the right to withdraw anywhere during the study were among the moral considerations respected in this research. This study was based on PhD thesis no. 921903/1/114 and is approved by Ethical Committee of Medical University of Mashhad.

Results

In this research 14 educators (8 male and 6 female), and 8 students (4 male and 4 female) were interviewed (a total of 22 persons). Age range was between 18 to 28 for students and 30 to 55 for educators. Main categories are shown in table 1, as followings: freedom, appropriative decision-making, authority, training through role-playing and friendship strategy and teaching-learning strategy, unification of educators regarding behavior management, interactive educational environment, and self- reflection.

Table 1

Categories and subcategories of incivility managing strategies of educators

Category

Freedom

Overlooking

Non-strictness

Appropriative decision-making

Mixing approaches

Quick decision-making

Sensible decision-making

Authority

Showing the seriousness of education

Indirect warning

Direct warning or threatening

Setting strict rules

Severity in behavioral adjustment

Training through role-playing

Role-playing

Providing a role-model for students

Friendship strategy

Providing motivation

Providing attraction

Devoting enough time for students

Friendly relationships

Respectable interaction with students

Using humor

Teaching-learning strategy

Engaging students to education

Just evaluation

Using appropriate apprenticeship methods

Unification of educators regarding behavior management

Defining standards and norms

Evaluating educators’ behaviors in sessions

Defining standards and norms

Self- Reflection

Reflection

Self-control

Personal experience

Finding the root of an student’s behavior

Interactive educational environment

Interactive educational experience

Other students’ control over incivility

Mentor

Supportive educational environment

1. Freedom in classroom

One of categories designed for managing incivility was “freedom in classroom strategy” which was included subcategory of Overlooking and non-strictness.

1.1. Overlooking and Non-strictness

Due to several reasons such as simplistic and non-severe nature of incivility, lack of incivility management strategy, and inability of the master to manage incivility, master may decide to overlook an instance of incivility. Self-comfort in overlooking, childhood or family experiences, and previous history of such encounters are among reasons behind a master’s silence toward an instance of incivility. In Iran, most educators who are teaching general courses have more tendencies to overlook students’ incivility. According to students:

“General educators are pitiful! (Laughter) they cannot do anything!” (Students no. 5 and 6).

2. Appropriative decision-making

Educators use different methods to deal with incivility depending on time, location, and conditions. Even in case of previous record of such incivility, it may not be helpful and a new decision should be taken based on current situation. Mixing various approaches, quick decision-making, and sensible decision-making were subcategories of appropriative decision-making.

“In other words, we use various methods. A single one is not working on everyone. You should know that in each term, you have a new version of students.” (Faculty no. 3)

3. Authority

Subcategories of showing the seriousness of education, severity in behavioral adjustment, direct warning and threatening, indirect warning, and setting strict rules were led to the main category of authority in incivility management.

3.1. Showing the seriousness of education and severity in behavioral adjustment

Sometimes the relationships goes further from normal friendship and would turn to a much more intimate relationship for student which may lead to incivility. In these cases, educators’ reaction was such that students understand their behavior as well as the seriousness of education and the necessity to respect master-student boundaries

“At 11:30 of near midnight I received a happy birthday SMS from a student and again another one several minutes later. Such ridiculous messages are normally exchanges between young girls and boys and I couldn’t believe that he would have sent it for me. I texted him that do you know what time it is? Maybe you have mistaken me for your friends...” (Faculty no. 9)

3.2. Indirect warning

Many educators preferred warnings, and more specifically indirect ones to manage incivility with authority. These warnings are directed toward the whole class. Thus, not only offenders would understand the inappropriateness of their behavior, but also other students would understand it too and will avoid to do such behaviors. The educator generally does this warning in a way that it doesn’t point a finger to a specific person

“Many of my verbal warnings are completely indirect and in many cases it’s not even emphasize the behavior” (Faculty no. 10).

3.3. Direct warning and threatening

Direct warnings are generally come after indirect warnings in case of repeated incivility and could be either in front of the whole class or individually

“Immediately after that incident I didn’t say anything, but after the end of session, I called him and requested him to stay alone. After everyone left, I talked to him…” (Faculty no. 3)

Threatening to expel student from class, threatening to give lower marks, canceling one’s courses altogether, and sending the case to disciplinary committee are among the last resort management actions from educator’s perspective. Since such strategies are more common in novice educators who don’t have enough management skills, they may adopt too early.

“The master heavily confronted one of students who was using his laptop and dumped him out of class” (student no. 2)

3.4. Setting strict rules

Outlining the goals of the course and clear expectations regarding the behaviors and norms of the students as well as setting clear and strict rules during the first session is another way of managing incivility for many educators

“In the first session, we explain everything for students. If one is absent in that session, it can make our life harder…” (Faculty no. 11)

4. Training through role-modeling

It consisted of 2 subcategories of providing a role-model for students, and role-playing method. Appreciating proper behaviors of students is a good way to provide a role-model for other students. Role-modeling was another approach that most educators used this strategy. Many educators believed that behaviors such as truthfulness, responsibility, commitment, endeavor and drive, desire, and respect toward self and others are all can be learned from educators’ actions and behaviors.

“I generally arrive earlier than my students and I also try to arrive earlier on my appointments.” (Faculty no. 7)

5. Friendship strategy

Devoting enough time for each student, friendly relationships, respectful encounters, and using humor were among subcategories of friendship strategy. This strategy can be implemented to reduce instances of incivility as well as dealing with current cases. Friendly relationships would lead to more interactions between educator and student and can improve the learning ability of the students. They can talk about their problems and conflicts and working with each other to resolve them. Although, there should be a sensible boundary and their relationship should not reach the point of intimacy.

Friendly relationships can improve students’ engagement and interest toward their lesson as well as reducing their related tiredness.

“After the end of the session, I talk to them out of class to be able to find their problems…” (Faculty no. 12)

6. Teaching-learning strategy

Improving students’ engagement toward education, fairness in evaluation, proper apprenticeship methods, providing motivation, and providing attraction are the subcategories of this strategy. Since many incivility instances are rooted in teaching methods and learning abilities, using proper teaching approaches and providing attraction and motivation can help prevent incivility between educators and students. Engaging all students in teaching process as well as using different apprenticeship method for different students, especially those who tend to express incivility, can help managing such behaviors. Fairness in evaluation of students’ performance can prompt a good feeling in them since they know that those who express more endeavor and respecting the rules are treated differently comparing to those who does not regard such matters; and this can eventually help reducing incivility.

Apprenticeship sessions should be held properly and should not be a theoretical class in hospital.

“In apprenticeship session a student asked me do you try to take a written quiz. Are you trying to interpret books and tapes here? Is this a theoretical class?” (Faculty no 4)

7. Unification of educators regarding incivility management

Setting standards and norms and co-evaluating the behaviors of students can lead to unification of educators regarding management of incivility. Most educators believed that one crucial element which can help controlling difficult behaviors as well as preventing them is an almost equal and standard approach toward students’ problems. Holding regular meetings to evaluate students' behaviors and designing a protocol that should be respected by all students is an approach recommended by educators as they believed a pre-defined and standardized trend can prevent them from disturbing educational regulations as well as improving their learning ability and allegiance.

“It should not be in a way that I have a personal mechanism; another master has his or her own mechanism and so on. In this way, student would not tell me that this doctor is very kind and would not expel me from her class, but that master is very cruel and impolite and would expel you at first chance?” (Faculty no. 5)

8. Self-reflection

According to educators and students experiences, reflection and interactive education are approaches that can be used to manage incivility.

Educators can review their teaching methods as well as their previous experiences regarding incivility to find the reasons behind such behaviors. They can evaluate their performance and improve themselves behaviorally and morally so they can have a better feeling in managing difficult behaviors.

“I should think that what I have done despite my entire endeavor that the student would express such a behavior…” (Faculty no. 8)

Master’s self-belief in his actions and behaviors was also proved to be helpful in managing incivility.

“One does not have a good feeling at that moment, I personally may become very angry, but I try to control myself because I somehow know that it would not lead to good anything and this is achieved with experience. I know that in that situation I may say something that may has many worst consequences.” (Faculty no. 1)

9. Interactive educational environment

Interactive educational environment is consisted of control and contribution of other students over managing incivility, mentor, supportive educational atmosphere, and good relationships. The behavior and reaction of other students toward incivility instances can greatly affect managing strategies of an educator. Since educators are constantly under the careful attention of their students, they try to express proper behaviors and respect moral principles. On the other hand, if educators do not react to their students’ incivility, other students would undermine his authority and they may even feel cheated due to the double-standards expressed by their educator.

“If you don’t warn this guy or girl regarding the way he or she sits or behaves, others get this negative feeling that you don’t have the necessary authority and have willing to make exceptions.” (Faculty no 8)

Educators who are relatively new to their field do not have enough experiences and may need help in dealing with their problems. These helps can be of different forms: help in holding class sessions, apprenticeship, interacting with students, and reaction to their incivility. Novice teachers can get help from their more experienced counterparts in dealing with such issues and can even look to them as their role-model.

“It’s very good and beneficial that regular meeting sessions would be held between novice and experienced teachers so they can share their knowledge and experiences.” (Faculty no. 13)

Discussion

Iranian educators suggested some approaches regarding the management. One approach suggested by nearly all educators was the unification of educators regarding their management of incivility which is similar to approaches recommended by Hernandez who argued that the unity between educators, providing a rulebook for educators and employees, and planning an educational program for educators and employees are some measures that are very effective in managing difficult behaviors.[12]

One of the main responsibilities of educators is efficient teaching and those who have good skills in presenting their lessons and engaging students, can have a considerable success in dealing with incivility. Therefore, teaching-learning strategies along with friendship strategy are among approaches recommended by several participants. Clark is also argues that interactive teaching methods which can boost students’ learning abilities can improve the relationship between educators and students and such approaches have a main role in students’ success, closer relationships and better social skills, improved learning abilities, and general efficiency and eventually can prevent incivility.[5,19] Interactive relationship between educators and students can greatly improve educational environment comparing to authoritative environments.

Therefore constant review of teaching methods, behaviors, and communication models can have an unconscious effect on incivility.

The presence of educator as a role-model has a great effect on expressing incivility or lack of it and nearly all participants were agreed on this matter. Obviously, when a master expresses any instance of incivility, his students would follow and think of it as a desirable and acceptable behavior. This finding was also in line with Clark’s view who believes a professional role-modeling has a pivotal role in nursing students’ progress and sociality. The role of educator is consisted from a model for professional behavior, suitable clothes, and good communication and linguistic skills.

Efficient communication can be achieved by using a respectable vocabulary, maintaining general view, proper teaching manners, and listening to students. An educator should be self-conscious regarding his own actions to be a good role-model. Some educators consider themselves on a higher level than their students and constantly try to humiliate them using a taunting and sarcastic language which would lead to an inefficient educational atmosphere. The result of such approaches will be students’ incivility in reaction to unjust and insensible behaviors of their educator.[1,5]

Overlooking and lack of strictness are among subcategories of freedom in classroom which if implemented could have many consequences. Hernandez & Fister has similar views and believes that silence is one of the approaches which educators chose in regard to incivility. They even do not talk with their counterparts regarding their emotions and feelings towards such behaviors. The reason behind this feeling could be the feeling of incompetence, lack of responsibility, or shame. Moreover, some educators may feel severe inability which may have its roots in lack of support from managers regarding students’ incivility.[12]

Another researcher believes that overlooking uncivil behaviors is a questionable behavior and silence in front of problems means agreement toward that matter. When encountering incivility, in case required immediate actions, an educator should request his student to remain in class after the end of sessions.[1]

Participants emphasizes on the fact that students should understand the seriousness of educational environment and educators should take efforts against any actions undermining this fact by direct or indirect warnings, setting classroom rules, and strictness in behavior adjustment. In setting classroom rules, Kuhlenschmidt and Clark have similar opinions.[1,5] They believe that at the start of a course, educators should clearly explain their agenda and rules as well as the qualities that should be achieved by students. Inappropriate behaviors should also be outlined and explained as well as expected behaviors. A good planning of first session could prevent many issues that could happen during academic semester. First session should begin earlier than regular sessions and the master should welcome his students while supporting them, and conduct professionally. When the session starts, students should stand one by one and fully introduce themselves and demonstrate their interests in their fields. Depending on the size of the class and the number of students this introduction could be more informative. It’s even possible to design a card in which the students write their desired names and from then moment the educator and his classmates call him by that name. Therefore, creating classroom norms in the first session and building a proper atmosphere by expressing respectable manners is seems necessary. In this way, the students would have an ownership feeling and would express a commitment to behave in a respectable academic manner.[1,5]

Building a stronger relationship between students and interactive educational environment is other approaches suggested by educators for managing of incivility. Kuhlenschmidt believes that relationship with students can help educators to understand their problems and inconveniences and eventually discover the reasons behind their incivilities. Moreover, discussions with an experienced mentor can also greatly improve incivility management skills. Interpersonal problem-solving approach is a skill that should be achieved and nurtured.[1]

Reflection and self-evaluation is another approach suggested by participants. Kuhlenschmidt argues that knowing one’s own limitations is a skill which is needed for better managing of incivility. Characteristics such as femaleness, shortness, having a low tone, and shyness can increase the challenge presented by incivility. Some these characteristics are unchangeable but there are conditions in which educators can successfully manage incivility despite his or her limitations.[1]

Although this study revealed several strategies that can help dealing with students’ incivility, but depending on location, individual, and time, any single strategy may be ineffective and a combined strategy may be required. This research was qualitative and the opinions of a limited number of participants were collected and categorized and thus could not provide a general instruction for managing incivility and only provides a big picture of various approaches implemented by educators to manage such behaviors.

Conclusion

There are many strategies and approaches for managing students’ incivility in Iran which can be implemented depending on the given situation. Some of them are strict and some of them are more democratic. In some cases no specific approach is needed and educators’ manners and behaviors can manage students’ behaviors by being a role-model. Teaching-learning strategies and educators’ control over his class should not be ignored as an effective way of dealing with incivility. Educators and managers working in nursing fields can use the results of this study to deal with such behaviors.

Acknowledgments

This research has been done with the financial support of Mashhad’s University of Medical Sciences and Mashhad’s Nursing Faculty in Razavi Khorasan Province as a program to “evaluate nursing students’ incivility management processes by educators”. It was approved in university’s research council by the code number of 921903. We sincerely thank all educators and students who helped us with their contribution and participation.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.