Please watch the ANA video and read the articles. Research for articles on bullying and incivility in the workplace to help you with your discussion posts this week.

1. Have you experienced or witnessed any bullying or incivility during your previous employment or nursing education? If so, give just a brief outline of the situation. Give example and personalize it.

2. From your readings, present your personal idea of why bullying and incivility or such issues in healthcare.

3. How do you think you would react if you were in different stages of the Benner’s Model (i.e. how do you think you would react being a novice nurse versus an expert nurse?).

4. Why do you think this problem cannot be stopped?

5. If you could develop any plan to stop/decrease bullying and incivility in the workplace, what would it be? Please defend your answer with a scholarly article.

Provide APA FORMATE CITATION 7TH EDITION.

NO PLAGARISM. 

ANSWER ALL QUESTIONS ACCORDINGLY, PROVIDE DETAIL EXPLANATIONS, AND EXAMPLES.

Civility and Workplace Bullying:
Resonance of Nightingale’s Persona and
Current Best Practices
Fidelindo A. Lim, DNP, RN, and Ilya Bernstein, BSN, RN

Fidelindo A. Lim, MA, RN, is Clinical Faculty, College of Nursing, New York University, New York, NY; and Ilya Bernstein,
RN, is Research Assistant, College of Nursing, New York University, New York, NY.

Keywords
Civility, incivility, nightingale and
interprofessional collaboration,
workplace bullying

Correspondence
Fidelindo A. Lim, MA, RN, Clinical
Faculty, College of Nursing, New
York University, New York, NY
E-mail: fl9@nyu.edu

Conflict or aggression occurring between and among healthcare workers
is undermining attempts to create a culture of safety in the workplace.
Healthcare occupations have higher rates of workplace bullying (WPB),
and intimidating behavior across healthcare settings has been shown to
foster medical errors, increase the cost of care, and contribute to poor
patient satisfaction and preventable adverse outcomes. WBP is also par-
tially responsible for the high attrition among nurses, a particular concern
in the current nursing shortage. Through a narrative that explores Flor-
ence Nightingale’s professional persona and experience, this article out-
lines various factors that contribute to incivility and WPB, and provides
suggestions for curriculum design that may help preempt incivility in
tomorrow’s nurses.

In April of 2003, an article in The Washington Post
examined the relevance of Florence Nightingale in
contemporary nursing. The author cited anecdotes
that Nightingale was demanding, manipulative, and
overbearing (Nelson, 2003). These unflattering
traits—not usually associated with the lady with the
lamp—has attracted attention recently in the discus-
sion of workplace bullying (WPB) and incivility.

Biographers have documented Nightingale’s
intimidating, domineering, and caustic manner along-
side her image as an indefatigable ministering angel
(Bostridge, 2008; Strachey, 1918). Some of the
nurses, particularly those of a lower social class, who
worked with Nightingale during the Crimean War,
noted how they were treated with disrespect and
unkindness by Florence Nightingale (Bostridge,
2008). In our time, her “querulous, demanding and
difficult” personality (Bostridge, 2008, p. 331) in
dealing with her peers would be regarded as precursors
to WPB. Rudeness, disrespect, and general
disdain for colleagues are among many examples
of incivility in the workplace (Luparell, 2011). It

appears that Nightingale put down nurses even
as she tried to elevate the stature of the nursing
profession.

Interspersed among practical advice ranging from
room air exchange to noise reduction at the bedside,
Nightingale’s best-selling book Notes on Nursing is
imbued with sharp reproaches for nurses who
neglected to do their best. In her punchy and epigram-
matic style (Bostridge, 2008), one can feel traces of
disdain and sarcasm. For example, she wrote in Notes
in Nursing (Nightingale, 1860):

If a nurse declines to do these kinds of things (emp-
tying a bedside commode) ‘because it is not her
business,’ I should say that nursing was not her
calling. (p. 13)

If you look into reports of trials or accidents, and
especially of suicides . . . it is almost incredible how
often the whole thing turns upon something which
has happened because ‘he,’ or still oftener ‘she,’
‘was not there.’ (p. 23)

bs_bs_banner AN INDEPENDENT VOICE FOR NURSING

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mailto:fl9@nyu.edu

If you wait till your patients tell you, or remind you
of these things (keeping noise level down), where is
the use of their having a nurse? (p. 27)

But if you cannot get the habit of observation one
way or other you had better give up the being a
nurse, for it is not your calling, however kind and
anxious you may be. (p. 63)

. . . if he (patient) has a bed-sore, it is generally the
fault not of the disease, but of the nursing. (p. 6)

To assign blame to Nightingale as the forerunner
of today’s incivility issues is to miss the point on why
this problem should be dealt with proactively. This
article explores the subject of WPB and incivility in
nursing and contextualizes Nightingale’s experience
with contemporary issues and offers best practices
solutions.

Incivility and Its Discontents

It is not uncommon that nurses have to contend
with disruptive behavior of patients. But what if the
perpetrator is a colleague? Civility or its antithesis has
been the subject of discourse in recent years (Luparell,
2011). Overt or covert conflict or aggression, occurring
between and among nurses, is known in the literature
as horizontal or lateral violence (Stanley, Martin,
Michel, Welton, & Nemeth, 2007). Incivility encom-
passes rude or disruptive behaviors that often result in
psychological and physiological distress for people
involved (Clark & Davis Kenaley, 2011). It is not just
hurting nurses, it is undermining the culture of safety
in the workplace (Joint Commission, 2008).

Intimidating and disruptive behaviors of healthcare
workers, such as verbal outbursts and physical
threats, as well as passive activities, such as refusing
to perform assigned tasks or quietly exhibiting unco-
operative attitudes during routine activities, can have
a direct impact on patient’s outcomes and safety
(Johnson & Rea, 2009; Joint Commission, 2008).
The Joint Commission issued a Sentinel Event Alert
(SEA) in 2008 to inform healthcare agencies that
intimidating behavior across the healthcare settings
has been shown to

• Foster medical errors
• Contribute to poor patient satisfaction and to

preventable adverse outcomes
• Increase the cost of care

• Cause qualified clinicians, administrators and man-
agers to seek new positions in more professional
environments.

At a time when nursing shortage is acute, a high
degree of attrition among nurses due to WPB or inci-
vility (Bowles & Candela, 2005; Simons, 2008; Ulrich
et al., 2006) is of particular concern. It is estimated
that 30% of new nurses left their jobs in the first year
and that 57% left by the second year (Bowles &
Candela, 2005). Prevalence rates of WPB in nursing
range from 21% (Berry, Gillespie, Gates, & Schafer,
2012) to as high as 70% (Vessey, Demarco, Gaffney, &
Budin, 2009).

It is interesting to note that of the total of 229
nurses who served during the Crimean War, 40
resigned (17% attrition) and only 17 (including Flor-
ence Nightingale) served for the duration of the war.
While war will always repel many, the considerable nursing
attrition in England during peacetime suggests other factors
are at play. Four years after the establishment of The
Nightingale Training School in 1860, only 25 of the
original 60 were still working (Bostridge, 2008). It is
beyond the scope of this article to list all possible
combinations of reasons to leave the nursing work-
force; however, historical accounts suggest that WPB
already played a role in the high attrition rate of
nurses 150 years ago, and it still resonates with
current trends.

WPB, lateral violence, and incivility are often used
interchangeably. A major distinction between defini-
tions of WPB and lateral violence is that lateral vio-
lence can be used to describe a one-time occurrence,
whereas to qualify as WPB, the conflict needs to occur
repeatedly, at least weekly over at least a 6-month
period (Johnson & Rea, 2009). WPB may be carried
out by one or more employees against a target or
targets perceived as intentional (Zapf, Einarsen, Hoel,
& Vartia, 2003). It is not unheard of to find nurses
working in unhealthy environments, being bullied for
years.

The Context of Incivility: Review of Literature

Although workplace incivility and bullying can
happen in any setting, healthcare occupations have
been noted to exhibit higher rates of bullying (Zapf
et al., 2003). The majority of healthcare professionals
venture into their chosen careers with a strong com-
mitment to care for others and one another, with
elements of altruism (Joint Commission, 2008).

F. A. Lim and I. Bernstein Civility and Workplace Bullying

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Although the number of “difficult” healthcare workers
is relatively small, they can significantly corrode the
system (Clark & Davis Kenaley, 2011). Dealing with
their unprofessional exploits and outbursts require
disproportionally large amount of time and effort, and
they exact a disproportionate toll on the culture of
safety within a group (Luparell, 2011).

Various factors have been identified to contribute
to incivility and WBP. These can be classified into
individual and systemic factors (Joint Commission,
2008).

Individual (Personality) Factors

• Self-centeredness, immaturity, and/or defensive-
ness

• Lack of interpersonal, coping, and/or conflict man-
agement skills

Systemic Factors

• Job pressures that include increased productivity
demands

• Cost containment requirements and embedded
hierarchies

• Fear of or stress from litigation
• Differences in the authority, autonomy, empower-

ment, roles and values of workers
• Continual flux of daily changes in shifts, rotations,

and interdepartmental support staff.

The inherent stresses of dealing with high stakes
situations, particularly in acute care settings, increase
the nurse’s vulnerability for outbursts and disruptive
behaviors—both as the victim and as the perpetrator
(Joint Commission, 2008). High patient ratio might mean
low on patience.

Nightingale’s work during the Crimean War was
fraught with massive breakdown of communication,
lack of government support, severe understaffing, and
nonexistent formal education for nurses. This made
every patient care interface and interprofessional
encounter (between Nightingale the military officials)
ripe for uncivil exchange. One can only imagine the
tremendous emotional stress Nightingale and her
nurses must have experienced laboring in an
“unhealthy” working environment. Combined with
physical fatigue, the chance for exhibiting unprofes-
sional behavior is increased (Joint Commission, 2008).
Interestingly, examples of incivility in the Victorian era
are shrouded under the veneer of overly polite Victo-
rian expressions.

Nightingale’s letters illustrate her introspection of
the many uncivil incidents she experienced from the
press, politicians, and even from her own family in
relation to her career (Bostridge, 2008). Her reflec-
tions solidified her advocacy and health reform efforts.
Instead of quitting, she doubled her efforts to create
lasting reforms in nursing. Debriefing and arbitration
of WPB incidents require purposeful reflection to gain
meaningful lessons from the experience.

Power struggle and empowerment (Clark & Davis
Kenaley, 2011) are two major factors influencing inci-
vility and bullying. Often, one of the parties involved
is higher in rank, and the victim may be someone who
feels less empowered to challenge the perpetrator. Evi-
dence suggests that often the target of bullying is a
novice nurse (Berry et al., 2012). The power imbal-
ance heightens the victim’s difficulty to defend against
the negative acts of bullying (Salin, 2003) due to the
interdependence between the target and the bully.
This creates a quandary because the person expected
to mentor and ease transition of novice nurses to
becoming experts may also be the bully (Vessey et al.,
2009).

In Nightingale’s case, class differences played a role
in accusations of incivility on her part. “It should come
as no surprise then that Florence’s superintendence of
her staff was in large part derived from mistress-
servant relationship to which she had become accus-
tomed, as a ‘lady’ . . . Her manner towards them at
times betrayed its origin in this relationship and was
liable to cause offence” (Bostridge, 2008, p. 232).
Power and status disparity (Lutgen-Sandvik, Tracy, &
Alberts, 2007) resonates in the modern-day’s uncivil
transactions between staff and supervisor, senior and
junior nurses, and between nurses and physicians.

Civility Research Snapshot: It’s More Than
Black and White

While power disparity is difficult to quantify, evidence is
emerging that race and ethnicity influence response to WBP.
Productivity is more significantly reduced by workplace
bullying in White nurses than in non-White nurses
(Berry et al., 2012). Authors of this study contend that
non-White nurses have developed adaption strategies
that White nurses have not as a way of coping with a
largely White, oppressive society that allows them to
respond differently to WPB (Berry et al., 2012). This
study needs to be duplicated given the increasing
number of non-White (immigrants and minorities)
joining the nursing workforce.

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Resilience competence and cultural factors affect
how a nurse responds to WPB. Research is needed to
examine how the variables of race, gender, immigra-
tion status, career history, support system, and per-
ceived social class impact on the dynamics of WPB and
incivility. Academia has an important role in creating a
future workforce steeped in the highest professional standard
of practice and decorum.

Academia and Clinical Setting: A Civil Union

We are often told that a nurse needs only to be
devoted and obedient. This definition would do just
as well for a porter. It might even do for horse. It
would not do for a policeman. (Nightingale, 1860)

Because today’s students are tomorrow’s col-
leagues, efforts to address incivility and bullying
should include specific aspects of nursing academia
and the preparation of new nurses (Luparell, 2011). A
student who responded to the Carnegie National
Student Nurses’ Association survey said the biggest
challenge in nursing education she faced was “being
lectured on caring and building trust by instructors
who don’t practice what they preach” (Benner,
Sutphen, Leonard, & Day, 2010, p. 64). Role-modeling
is a key element in creating a future workforce that is
socialized into a just culture in dealing with patients,
peers, students, and faculty.

One study indicated that students are exposed to a
variety of injustices from staff nurses, including being
made to feel unwelcome or ignored, being belittled,
blamed falsely for events, and being publicly chastised
or humiliated (Thomas & Burk, 2009). These types of
behaviors earned the profession the unsavory allega-
tion that nurses “eat their young.” The American
Association of Colleges of Nursing (AACN) stipulates
interprofessional communication and collaboration
for improving patient outcomes as essential for bacca-
laureate nursing education with emphasis on (AACN,
2008):

• interprofessional and intraprofessional communica-
tion, collaboration and socialization, with consider-
ation of principles related to communication with
diverse cultures

• teamwork and concepts of teambuilding and coop-
erative learning

• relationship building and group dynamics
• conflict management, conflict resolution strategies

and negotiation

These topics are recommended to be incorporated into
lectures, seminars, lab, simulation exercises, and clini-
cal practicum. Curricular activities must incorporate
difficult dialogues dealing with WPB not only between
students and faculty, but between faculties. While no
specific studies were located that deal with incivility
among nursing faculty, anecdotal reports of incivility,
particularly during faculty meetings, is not unheard of.
One potential source of this rancor is rankism and the
hierarchical nature of the academia.

The Nightingale curriculum in “training” nurses
emphasized the virtue of service. The apprenticeship
system that lasted until 30 years ago is blamed for the
collective subservience of nurses. A good nurse does
not complain and must endure, so the stereotype goes.
But that was then. The education of nurses today must
sufficiently address WPB and incivility. Empowerment
of students during their formative years is known to
promote constructive reciprocal engagement and civil-
ity in their future careers (Clark & Davis Kenaley,
2011). In general, nursing curricula are very effective
in helping students cultivate a deep sense of profes-
sional identity, commitment to the values of the pro-
fession, and to act with ethical comportment (Benner
et al., 2010).

Interprofessional Collaborative Education:
Gateway to Workplace Civility

The Institute of Medicine’s (IOM) Future of Nursing
report admonishes that the nursing curricula must
promote and engage in interprofessional education
and collaboration (IOM, 2010). This is supported by the
American Association of Colleges of Nursing, who write in
their (2008) handbook on necessary curriculum content that,
“Interprofessional communication and collaboration
among health professionals is imperative to providing
patient-centered care.” Early exposure and engage-
ment in interprofessional collaboration and team
building will enable the future workforce to apply the
virtue of civility in their careers.

Civilizing the Workplace: Fundamentals
in Nursing

The principle of respect for persons extends to all
individuals with whom the nurse interacts. (Code
of Ethics for Nurses; American Nurses Association
[ANA], 2008)

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The ANA mandates that nurses exercise civil behav-
ior in all their interactions. The provision further
stipulates that the nurse’s conduct “precludes any and
all prejudicial actions, any forms of harassment or
threatening behavior or disregard for the effect of
one’s actions on others” (ANA, 2008, p. 149). Aligned
with the code of ethics is the American Association of
Critical-Care Nurses’ (AACN, 2005) Standards for
Establishing and Sustaining Healthy Work Environ-
ment consensus report. The AACN standards address
relational issues that can impact patient safety and
remind nurses of their ethical obligation to uphold
workplace civility as one of the core competencies for
health professionals.

Although it is commonly accepted that nurses are
inherently good-natured people, mastering civility is
an acquired skill and therefore must be learned.
Regular and consistent practice of professional
decorum that starts with a system-wide commitment
will enhance staff engagement. The Joint Commission
(2008) offers the following suggestions on how to deal
with WPB and incivility:

• Educate all team members on appropriate profes-
sional behavior as defined by the organization’s
code of conduct, with an emphasis on respect.

• Include training in basic business etiquette, particu-
larly phone skills and people skills.

• Hold all team members accountable for modeling
desirable behaviors, and enforce the code consis-
tently and equitably among all staff regardless of
seniority or clinical discipline in a positive fashion
through reinforcement as well as punishment.

• Develop and implement WPB policies and proce-
dures appropriate for the organization.

There is a paucity of substantive research on what
constitutes best practice for resolving WPB and incivil-
ity (Berry et al., 2012). Based on narratives from
Nightingale’s “notes,” blaming the victim is certainly
counterproductive and can only exacerbate the pro-
blem. She lamented, “Exposed as I am to be misinter-
preted and misunderstood, in a field of action in which
the work is new, complicated, and distant from many
who sit in judgment upon it” (Bostridge, 2008, p. 213).
Since each WPB situation is unique, it requires a more
nuanced analysis, and therefore, solutions must be
individualized. Expert analysis of WPB events must
take into consideration the principles of shared gover-
nance. Staff feedback and recommendations need to be
taken into account if lasting solutions are to be effected.

Conclusion

Reflecting on Nightingale’s fallibility will enable us
to contextualize the challenges nurses face in uphold-
ing quality and safety in the presence of WPB. Reading
Nightingale’s own words strips down the veil of the
mythical woman, who, though brilliant and reform-
driven, was self-righteous, single-minded, and insistent that
tasks be completed to her exact specifications, drawing par-
allel between the Lady of the Lamp and the Iron Lady,
Margaret Thatcher (Bostridge, 2008). Incivility on the
job need not be the social norm. Learning from his-
torical references and literature reviews on WPB will
enable us not only to mine the pathos of this high-
emotion issue, but also increase surveillance and
implementation of best practices in order to eliminate
it from the workplace.

Bullied nurses are more likely to bully others
(Vessey et al., 2009). In seeking remedies to the
problem of WPB, nurse leaders need to focus on root
cause analysis on why bullying occurs and on ways to
halt the vicious cycle (Johnson & Rea, 2009). Practice-
based interprofessional collaboration interventions
can improve healthcare processes and outcomes in
workplace civility (Zwarenstein, Goldman, & Reeves,
2009). With government reimbursement now tied
with patient care satisfaction, the impetus to curtail
WPB is even greater.

References

American Association of Colleges of Nursing. (2008). The
essentials of baccalaureate education for professional nursing
practice. Washington, DC: Author.

American Association of Critical Care Nurses. (2005). AACN
standards for establishing and sustaining healthy work environ-
ments: A journey to excellence. Aliso Viejo, CA: Author.
Retrieved from http://www.aacn.org/WD/HWE/Docs/
HWEStandards

American Nurses Association. (2008). Code of ethics for nurses:
Interpretation and application. Silver Spring, MD: Author.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010).
Educating nurses: A call for radical transformation. San
Francisco: Jossey-Bass.

Berry, P. A., Gillespie, G. L., Gates, D., & Schafer, J. (2012).
Novice nurse productivity following workplace bullying.
Journal of Nursing Scholarship, 44(1), 80–87. doi:10.1111/
j.1547-5069.2011.01436.x

Bostridge, M. (2008). Florence Nightingale: The making of an
icon. New York: Farrar, Straus and Giroux.

Bowles, C., & Candela, L. (2005). First job experiences of
recent RN graduates: Improving the work environment.
Journal of Nursing Administration, 35(3), 130–137.
doi:10.1097/00005110-200503000-00006

Civility and Workplace Bullying F. A. Lim and I. Bernstein

128
© 2014 Wiley Periodicals, Inc.
Nursing Forum Volume 49, No. 2, April-June 2014

http://www.aacn.org/WD/HWE/Docs/HWEStandards

http://www.aacn.org/WD/HWE/Docs/HWEStandards

Clark, C. M., & Davis Kenaley, B. L. (2011). Faculty empow-
erment of students to foster civility in nursing education:
A merging of two conceptual models. Nursing Outlook,
59(3), 158–165. doi:10.1016/j.outlook.2010.12.005

IOM (Institute of Medicine). (2010). The future of nursing:
Leading change, advancing health. Retrieved from http://
www.iom.edu/Reports/2010/The-Future-of-Nursing
-Leading-Change-Advancing-Health.aspx

Johnson, S. L., & Rea, R. E. (2009). Workplace bullying:
Concerns for nurse leaders. Journal of Nursing Administra-
tion, 39(2), 84–90. doi:10.1097/NNA.0b013e318195a5fc

Joint Commission. (2008). Behaviors that undermine a
culture of safety. Sentinel Event Alert, (40). Retrieved from
http://www.jointcommission.org/assets/1/18/SEA
_40.PDF

Luparell, S. (2011). Incivility in nursing: The connection
between academia and clinical settings. Critical Care Nurse,
31(2), 92–95. doi:10.4037/ccn2011171

Lutgen-Sandvik, P., Tracy, S. J., & Alberts, J. K. (2007).
Burned by bullying in the American workplace: Preva-
lence, perception, degree and impact. Journal of Manage-
ment Studies, 44(6), 837–862. doi:10.1111/j.1467-
6486.2007.00715.x

Nelson, R. (2003). Goodnight Florence: With nursing in
crisis, some say it’s time to retire Nightingale as a symbol.
Nursing Leadership, 16(2), 46–50.

Nightingale, F. (1860). Notes on nursing: What it is and what it
is not. London: Harrison.

Salin, D. (2003). Ways of explaining workplace bullying:
A review of enabling, motivating and precipitating
structures and processes in the work environment.
Human Relations, 56(10), 1213–1232. doi:10.1177/
00187267035610003

Simons, S. (2008). Workplace bullying experienced by
Massachusetts registered nurses and the relationship

to intention to leave the organization. Advances in
Nursing Science, 31(2), E48–E59. doi:10.1097/01.ANS.
0000319571.37373.d7

Stanley, K. M., Martin, M. M., Michel, Y., Welton, J. M., &
Nemeth, L. S. (2007). Examining lateral violence in the
nursing workforce. Issues in Mental Health Nursing, 28(11),
1247–1265. doi:10.1080/01612840701651470

Strachey, G. L. (1918). Eminent Victorians: Cardinal Manning,
Florence Nightingale, Dr. Arnold, General Gordon. London:
Chatto & Windus.

Thomas, S. P., & Burk, R. (2009). Junior nursing students’
experiences of vertical violence during clinical rotations.
Nursing Outlook, 57(4), 226–231. doi:10.1016/j.outlook
.2008.08.004

Ulrich, B. T., Lavandero, R., Hart, K. A., Woods, D., Leggett,
J., & Taylor, D. (2006). Critical care nurses’ work envi-
ronments: A baseline status report. Critical Care Nurse,
26(5), 46–57.

Vessey, J., Demarco, R., Gaffney, D., & Budin, W. (2009).
Bullying of staff registered nurses in the workplace: A
preliminary study for developing personal and organiza-
tional strategies for the transformation of hostile to
healthy workplace environments. Journal of Professional
Nursing, 25(5), 299–306. doi:10.1016/j.profnurs.2009
.01.022

Zapf, D., Einarsen, S., Hoel, H., & Vartia, M. (2003). Empirical
findings on bullying in the workplace. In S. Einarsen, H.
Hoel, D. Zapf, & C. L. Cooper (Eds.), Bullying and emotional
abuse in the workplace: International perspectives in research
and practice (pp. 103–126). New York: Taylor & Francis.

Zwarenstein, M., Goldman, J., & Reeves, S. (2009).
Interprofessional collaboration: Effects of practice-based
interventions on professional practice and healthcare
outcomes. Cochrane Database of Systematic Reviews, (3),
CD000072. doi:10.1002/14651858.CD000072.pub2

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http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.jointcommission.org/assets/1/18/SEA_40.PDF

http://www.jointcommission.org/assets/1/18/SEA_40.PDF

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www.sciedu.ca/jnep Journal of Nursing Education and Practice, 2014, Vol. 4, No. 9

Published by Sciedu Press 1

ORIGINAL RESEARCH

Student incivility: Nursing faculty lived experience

Elizabeth Ann Sprunk1, Kathleen B. LaSala2, Vicki L. Wilson3

1. Mercy College of Ohio, Toledo, USA. 2. University of South Carolina, Columbia, USA. 3. University of Northern Colorado,
Greeley, USA.

Correspondence: Elizabeth Ann Sprunk. Address: Mercy College of Ohio, Toledo, USA.
Email: elizabeth.sprunk@mercycollege.edu

Received: March 9, 2014 Accepted: May 20, 2014 Online Published: June 22, 2014
DOI: 10.5430/jnep.v4n9p1 URL: http://dx.doi.org/10.5430/jnep.v4n9p1

Abstract
Student incivility against nursing faculty is recognized as an area of increased concern in nursing education. The negative
experience that this may potentially have on nursing faculty is disturbing. The purpose of this study was to elicit an
understanding of the experiences and impact nursing faculty encountered with nursing student incivility using a
phenomenological research design. Twelve nursing faculty members from seven mid-western universities provided rich
descriptions of their experiences with student incivility. Colaizzi’s analysis method was used to create clusters that
resulted in six identified themes, including: (a) Faculty are subjected to a variety of unacceptable student behaviors;
(b) Dealing with incivility is time consuming; (c) An aftermath of incivility can tarnished one’s reputation; (d) Support
from others is beneficial; (e) Can cause harm to one’s health and well-being; and (f) May result in questioning the future.
Findings support the view that nursing student incivility is becoming more widespread on college campuses and can have
devastating effects on nursing faculty members. This information strongly suggests the importance of identifying
contributing factors of incivility present in nursing students and implementing new and more effective policies and
strategies to address and prevent this increasingly prevalent problem.

Key words
Incivility, Nursing students, Nursing faculty, Experience, Multifaceted tribulations, Policies

1 Introduction
Workplace incivility is a prevalent problem in today’s society, and the nursing academic work environment is not immune
to this phenomenon. Incivility is often described as any type of action or conduct that disrupts the work, social, personal, or
educational environment [1]. Workplace incivility may cause negative physical and psychological effects on an individual,
such as stress, anxiety, illness, job dissatisfaction, and absenteeism. In addition, workplace incivility may negatively
impact retention and recruitment of qualified workers [2-5]. One of the most drastic effects of incivility is violent behavior,
of which nursing education has experienced [6]. Consistent with the broad definition of incivility, academic incivility is
broadly described as any action, or conduct that disrupts the teaching or learning milieu [1], including the classroom,
clinical, and online settings. Incivility against nursing faculty by nursing students is recognized as an area of increased
concern in nursing education and has been reported in all areas of nursing education [7]. The negative potential impacts on
nursing faculty are alarming. A threat to the psychological and physical well-being of nursing faculty is a potential
consequence of nursing student incivility, and may be detrimental to the recruitment and retention of faculty, an academic

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area that is already experiencing a large shortage of qualified nurse educators [8, 9]. Academic incivility may negatively
affect the student–teacher relationship, as well as the teaching–learning process [10, 11]. Clark [12] noted that incivility occurs
on a continuum, ranging from mild, irritating, and annoying behaviors to severe, aggressive, threatening, and potentially
violent behaviors. Stress associated with nursing education has been identified as a major cause of both nursing student
and faculty incivility [10]. When people experience stress, uncivil behaviors become more common, which in turn can
escalate into violent behavior if not constrained [1].

There is a need for nursing research to illuminate the character of the lived experience through the eyes of nursing faculty,
including the potential consequences. There is a lack of empirical studies that describe faculty experiences and reactions to
nursing student incivility. The purpose of this phenomenological study is to describe and understand the experiences and
consequences nursing faculty have had with nursing student incivility at a college or university. Findings may help bring
awareness of the issues and guide the development of policies, procedures, and interventions in the academic setting to
deal with and prevent nursing student incivility. The overarching research question that guided this study was: What is the
lived experience of a nursing faculty member who has experienced nursing student incivility? Sub questions included the
following: What are faculty responses and reactions to nursing student incivility; What are consequences suffered by
faculty related to nursing student incivility experiences; What is it like for nursing faculty to teach nursing students after an
experience of incivility?

Relevant scholarship/literature
Several definitions of academic incivility in various contexts have been noted in the nursing literature. Overall, the
definitions are similar. These definitions point out that incivility not only disrupts the teaching-learning process, but also
negatively impacts the well-being of an individual and the relationship between individuals.

The outcomes of incivility can include elevated stress levels, headache, inability to sleep, and a weakened immune system,
leading to illness. Common examples of emotional effects are erosion of self-esteem, self-doubt, anxiety, and depression.
In addition, incivility may lead to impairment of cognition, resulting in an inability to concentrate or learn. Incivility may
lead to behavioral changes, such as withdrawal, retaliation, and potential violence [6, 8, 10, 13]. Incivility also weakens
personal relationships. In the academic setting, this could lead to impaired relationships between students and faculty, as
well as between faculty members. In the academic setting, incivility may also impact recruitment and retention of faculty
and students, hinder job satisfaction, increase absenteeism of faculty and students, and interfere with communication and
collaboration [2, 3, 10, 11].

The rigors of nursing education are stressful, often leading to physical and psychological symptoms, behavioral changes
including incivility, as well as impeding the learning process [14-16]. Examples of stress include the clinical experience
expectations, large amount of academic work in the nursing theory classes, time management and financial pressures, and
strain on personal relationships [14, 17]. The need to work full-time or part-time in addition to pursuing the rigors of a
demanding nursing program are frequent and persistent stressors that students are faced with, and often lack the ability to
cope effectively with. The fear of failure, combined with nursing faculty who frequently demonstrate a lack of caring, add
to the already stressful experience nursing students face and leads to a struggle between nursing faculty and students.
Robertson [18] noted that this struggle devalues and diminishes the educational experience for both faculty and students,
and, in turn, may lead to frustration and uncivil behaviors. Individually, each problem is manageable, but it is the
compounding effect of numerous issues and factors that aggravate the situation, leading to incivility [15, 16, 18-21].

The problem of incivility in nursing education as viewed from the perspective of the nursing student and the nursing
faculty member has been perceived to be a moderate problem [6, 8, 22]. Several nurse researchers investigating incivility in
nursing education have indicated that students were more likely to engage in uncivil behavior than were faculty. The most
commonly noted student negative behaviors noted by these researchers were arriving late for class, leaving class early,
cutting class, and not paying attention in class. Other uncivil behaviors of students noted were cell phone usage, sleeping in

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class, and cheating. The most frequent faculty behaviors noted were belittling or humiliating students, being distant or cold,
being inflexible, and being unavailable outside of class [6, 8, 23]. Extreme behaviors of student incivility included vulgarity
and harassing comments, challenging the faculty member’s knowledge, taunting and disrespectful comments, and threats
of physical violence [24].

Academic incivility is not limited to expressions of uncivil behaviors between faculty and students. Faculty-to-faculty
incivility is becoming an increased area of concern in nursing education. Nurse researchers investigating this phenomenon
have found that uncivil behaviors between faculty members are common in the nursing academic environment [4, 25-27].
Clark et al. [26] found faculty-to-faculty incivility in nursing education to be a moderate to serious problem. Heinrich [4, 27]
specifically addressed faculty-to-faculty incivility in a qualitative study. This author refers to faculty-to-faculty i

ncivility

as a joy stealing game that smothers relationships and deters the pursuit of knowledge and scholarship. Similarly, Clark [25],
in a recent national study, found that faculty-to-faculty incivility not only negatively impacts faculty members subjected to
uncivil behaviors physically and psychologically, but also negatively impacts the educational organization. Faculty-
to-faculty incivility may result in increased absenteeism, decreased work performance, and high faculty turnover [25, 26].

After a review of the literature, this researcher found that very few qualitative studies have specifically addressed the lived
experience of nursing faculty members who have experience nursing student incivility. This gap in the nursing literature
identifies the necessity to investigate this phenomenon further. Continued research on this topic is needed to promote the
importance of establishing civility in the nursing education environment. Civility, rooted in caring and mutual respect is
essential for nursing education. Civility and ethical behaviors exhibited by students in nursing school are linked with
civility and ethical behaviors exhibited in the nursing profession [1, 28]. More research is needed on this topic to allow for a
better understanding of this phenomenon. This in turn, may lead to the development of effective prevention strategies and
help direct the development of policies and interventions in the academic setting to handle nursing student incivility in the
nursing educational environment.

2 Method
A phenomenological design was used to examine the lived experience of faculty dealing with incivility from nursing
students and its consequences. Congruent with the purpose of this study, Husserl’s transcendental phenomenology was
used to provide discovery of the understanding and valuing of the lived experience. This method seeks to describe
individuals’ common experiences of a particular phenomenon and provides for a common essence or meaning of the
phenomenon to be described. This method helped the researcher illuminate and understand the lived experiences described
by nursing faculty who participated in this study, and, in turn, helped to answer the research question [29-33].

Approval was obtained from the Institutional Review Board prior to data collection. Participants were recruited from
nursing faculty listings on websites at colleges and universities located in two Midwestern states and by word of mouth
networking. Potential participants were sent an electronic message explaining the purpose of the study, benefits of the
study, pertinent information regarding the study, as well as the researcher’s contact information. The potential participants
were asked to contact the researcher via telephone or e-mail indicating their interest in being a participant in the study.
After making the initial contact with potential participants, the researcher then determined if the interested potential
participants met the criteria for this study and had experienced nursing student incivility. The eligible participants were
invited, verbally by the researcher, to participate in the study and had the option of whether to participate or not. The
procedure of informed consent was followed to provide assurance of the rights of human subjects. Taking into
consideration potential emotional responses of the participants, strategies to be followed in the event anxiety or distress
occurred related to expressing or reliving the experience associated with nursing student incivility were outlined in the
informed consent form. These included: (a) The researcher assessed the participant’s level of comfort during the entire
interview; (b) The researcher reminded the participant that he/she had the option to withdraw from the study at any time;
and (c) A phone number to a local hospital and a local rescue center was provided prior to the interview commencing.

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The final purposive sample for this study consisted of 12 Caucasian women ages 39 to 65 (Χ̄ = 55.8 years), which is
representative of the average age and race of nursing faculty in the two Midwestern states in which the study took place
and in the United States. Ten were married, one divorced, and one single. All 12 were employed full-time at a college or
university in one of two Midwestern states as nursing faculty members. Five taught mainly in the classroom, five taught in
both the classroom and clinical, and two taught in the clinical setting only. Participants’ hours of teaching per week ranged
from 12 to 32 hours (Χ̄ = 18.8 hours/week). Years of teaching experience ranged from 2 to 35 years (Χ̄ = 13.9 years).

Descriptive data was collected via one-on-one interviews, lasting approximately 60 – 90 minutes. The interviews occurred
either face-to-face in a quiet location of the participant’s choice, such as their work office, or a quiet restaurant, or via
telephone. The interview began with an open-ended statement: “Tell me about your experience with nursing student
incivility.” The researcher used open-ended cues and prompts to obtain clarification and depth. An interview guide was
used to provide direction for the discussion and a guide of issues that were covered during the interview, such as asking
participants to describe their experiences with student incivility and how it affected them, and provide accounts of any
physical or psychological consequences of incivility suffered, effects on the student-teacher relationship, and feelings
about their future as a nurse educator. Follow up clarification was obtained as needed. Interviews were audio-taped and
transcribed by the researcher. Audio tapes were erased after transcription was finalized. Transcriptions were stored
electronically in a password protected file. Pseudonyms were used to protect confidentiality of participants. Demographic
forms and participant responses were anonymous with no identifying information in the data summary.

Colaizzi’s [34] phenomenological analysis method was employed to analyze the transcribed qualitative data, including
identifying significant quotes and statements related to the phenomenon of student incivility; creating formulated
meanings by making general restatements of the significant statements; creating theme clusters; developing an exhaustive
description of nursing student incivility experiences expressed by the participants by synthesizing theme clusters and
formulated meanings; identifying the essence of the phenomenon of nursing student incivility by performing a thorough
analysis of the exhaustive description; and validating with the participants the final essence of nursing student incivility.

To ensure validity and trustworthiness of this research study, verbatim accounts were used to make sure that the
descriptions were those of the participants. Personal biases were reflected and examined, using the bracketing technique
throughout the study to set aside any biases or previous knowledge identified. Member checking was used by going back
to the participants and asking them to check the precision and accuracy of their words and thoughts, and the researcher’s
conclusions, helping to avoid bias. An outside, experienced qualitative researcher was employed to verify the steps of this
research process.

3 Results
The analysis provided for rich descriptions of the participants’ encounters with student incivility and the effects on them
personally and professionally. The encounters with incivility described by participants occurred from as recent as 2 weeks
prior to the interview to as long as 14 years prior. Student incivility resulted in multifaceted tribulations for the nursing
faculty members. Two main theme clusters developed related to the main research question: What is the lived experience
of a nursing faculty member who has experienced nursing student incivility? The two theme clusters included: (a)
frequently subjected to inappropriate student behaviors, and (b) consequences of being subjected to inappropriate student
behaviors. The main theme related to theme cluster one was identified as subjected to a variety of unacceptable behaviors,
primarily (a) rude and disrespectful behaviors, and (b) threatening and intimidating behaviors. Theme cluster two focused
on the consequences of inappropriate student behavior, including sub-themes of (a) time consuming, (b) tarnished
reputation, (c) support is beneficial, (d) harmful to health and well-being, and (e) questioning the future. Figure 1
illustrates the multifaceted tribulations of nursing faculty members who have experienced student incivility, illuminating
the lived experience.

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Rita described vividly an inappropriate behavior that she was subjected to 14 years ago from a student who was not
performing in clinical in a satisfactory manner.

“We require each week that the students have a clinical reflective diary. And in that diary he [the student] was
saying how clinical is not a learning experience for him because he couldn’t do anything right to please me. The
line that he wrote in the diary that probably caused me the most stress was, “who do I have to kill to get you off
my back?”

These behaviors were undeserving and clearly violated not only the student code of conduct but also ethical standards for
nurses (and students). Nursing faculty subjected to these behaviors voiced concerns ranging from aggravation to fear.

3.2 Themes related to consequences of being subjected to inappropriate
student behavior

3.2.1 Time consuming
The majority of participants noted that the time to manage or contend with uncivil student behavior was great. This
increased time expenditure often took time away from the faculty member’s time to prepare for teaching or other job
responsibilities, leading to frustration and discontent. Extra time expenditures included activities, such as coordinating
extra meeting times to discuss the situation with administration, writing counseling forms, letters of explanation, and
police reports, as well as arranging for extra meeting times to counsel students. In addition, faculty noted the need to take
the time to develop new policies, procedures, or methods of teaching as a result of uncivil student behavior in an attempt to
prevent similar uncivil behaviors from occurring in the future. Examples follow:

Irene voiced concerns about the time she had to expend to deal with an overly disrespectful and unruly class.

“I spent more time on that class than any class I ever had. Because there were so many of them having issues with
disrespectful behavior, I had to take the time to meet with all of them individually and talk with each of them
about their behavior. I had to make appointments and meet with each of them in my office.”

Celeste described frustrations with having to change her class time test review policy due to an experience with severe
uncivil student behavior during test reviews. This policy change requires much more time expenditure on the part of
Celeste.

“I certainly changed the way I talk about exams now. I don’t do exam reviews unless it is one–on–one, and we sit
down in my office. I have the student e-mail me to make an appointment. The student comes to my office, and we
do the exam review in my office. Of course, this is more time consuming for me, but helps prevent this rude
behavior.”

3.2.2 Tarnished reputation
Damage to the faculty member’s reputation was a major concern and consequence of incidences of student incivility
towards nursing faculty. Both personal and professional attacks were made to most faculty members’ reputations. Social
media, circulation of letters, student comments on faculty evaluations, and word-of-mouth were all avenues for attempting
to damage the faculty members’ reputations. Faculty described this as upsetting and hurtful.

Theresa was distressed that an uncivil student was attempting to harm her professional reputation by making negative
comments about her on Facebook.

“Other students were telling me that there was a Facebook posting like an ongoing site where she [the uncivil
student] was saying things that were uncomplimentary about her experiences with me, and it was not only

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directed towards me but her behavior was directed at other students. She was trying to harm my reputation with
other students. The postings were among student groups, so definitely she was trying to harm my
professionalism.”

Laura was extremely upset by the behavior of a group of uncivil students in her class that were spreading rumors around to
the class to try to discredit her.

“It was that they were sending e-mails around to classmates to report me to the board of nursing. I don’t know
what they thought I was violating, but they were telling the class they should file a complaint against me to the
board of nursing. They were badmouthing me, especially one gal in particular. She began telling other students
that they had gotten me fired, that I was losing my job, that I had been demoted from teaching in the classroom,
and I would be losing my job at the end of my contract, and I had been disciplined. All these things were not true.
It was an attempt to discredit, diminish my role, and ruin my reputation. Basically to undermined me as a
faculty.”

3.2.3 Support is beneficial
The importance of administrative, peer, family, or security support was noted by all participants. Faculty found this to be
very beneficial when dealing with incivility. Others who experienced a lack of support found this troubling and voiced a
strong need. Sample descriptions of participants’ thoughts are below.

Isabelle found support from security and administration comforting after receiving a threatening letter in the mail from a
student. Isabelle recalled:

“The police took it very seriously and actually did check the return address and found out who it came from. The
dean also responded to a letter I wrote her requesting the doors to our office suite remain locked. The dean said
they would be kept locked. The dean reassured me that the suites would be kept locked. This made me feel a bit
safer.”

Laura discussed how the lack of support made her feel.

“I kind of feel like almost defeated. I felt almost victimized that it was allowed to go on without repercussion, and
I felt faculty are almost a sitting target. You know that students can do this [act uncivil], and faculty can file
formal complaints and nothing is going to happen. So I feel here at this college that students are allowed to do it
[act uncivil]. I really felt helpless and that is not a good feeling for me to have.”

All participants valued being supported by their superiors, peers, and other pertinent people. The support led to a feeling of
being defended, validated, and important. In contrast, participants who were not supported felt disappointed, hurt, and
unimportant.

3.2.4 Harmful to health and well-being
All participants described being harmed emotionally and/or physically. Participants voiced being scared, worried,
intimidated, threatened, paranoid, stressed, distressed, upset, defeated, and sad. Some described feelings of anxiety and
dread. Several participants reported feeling upset due to the classroom disruption resulting from incivility and the negative
impact the uncivil behavior had on their relationship with a student or group of students. Participants described negative
physical effects such as migraines, bowel disorders, inability to sleep, and crying.

Rita reported being scared and feeling like her family was in danger after receiving a threatening note directed towards her
and her family in a student diary (even 14 years later).

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“I was concerned about my family. I had small children and a husband. My phone number is in the book. And we
live in a small community. It wouldn’t take much to look through the telephone book and find my name. My
concern was that he [the student] was saying who ‘would he have to kill to get me off his back.’ My first thought
was that he would harm my family—come after my family. I wasn’t as concerned about me as I was my family.
For a long time we [my family] didn’t really answer our phone. We would let the machine take it. And at the
college, I had caller ID [identification] and I would watch to see who was calling before picking up the phone. I
would listen to my messages to see who called. I was very cautious about not having contact with him [the
student].”

Laura, who was subjected to an extremely uncivil group of students, illustrated the magnitude of the physical, emotional,
and psychological consequences she experienced.

“It caused anxiety, tearfulness. I spent days where I was just crying because I did not want to come back to work.
This is not why I am teaching, this is not why I am here. I almost felt helpless. I felt defeated. Just the anxiety of
having to deal with these people in this class and not having anyone else to teach with is kind of like you are
flapping out there in the breeze by yourself to manage all this, so I was pretty spent by the end of the semester. I
was done. I also felt scared, physically threatened. I felt the potential was there. I felt there was a very real
potential that one could be physically violent towards me. I was not sleeping well. I was losing sleep. I was crying.
I started getting migraines and I have not had migraines in years and I started getting migraines again. I had GI
[gastrointestinal] upset almost like irritable bowel syndrome symptoms. So yes, I had many physical
consequences from dealing with this experience.”

3.2.5 Questioning the future
All participants questioned their desire to continue teaching after experiencing uncivil student experiences. Although they
did question the possibly of leaving education, most voiced a desire to continue to teach due to their love of teaching. The
possibility for leaving education was seriously contemplated by some.

Ida noted the uncivil student behavior made her question continuing teaching.

“I love to teach. I was told by many that I should teach. But I did really think, “is this what I want to do or should
I quit?” But I have worked too hard to quit. I have had those thoughts about quitting, but I keep coming back and
something refreshes me. So yes, I keep plugging away.”

Nancy also questioned her desire to continue teaching after an uncivil encounter.

I almost didn’t teach clinical anymore after that [uncivil encounter] because it was so stressful for me. I had a bad
taste in my mouth for a while and I didn’t want anything to do with clinical for a while. But after you have some
time off, you come back and have a different perspective. You have to think of it as having really nice and good
students most of the time. In cases like this, though, it does make you think, is this what I want to do?”

3.2.6 Exhaustive description
The experience of nursing student incivility for nursing faculty members is multifaceted. Resulting tribulations were
described as disrespectful, rude, frustrating, intimidating, threatening, frightful, upsetting, time consuming, and harmful,
both physically and emotionally. All nursing faculty described being subjected to rude, discourteous, and disruptive
student behaviors in the classroom, in clinical, and in their faculty offices. Feelings that resulted from this uncivil behavior
included shock, anger, worry, fright, and distress, often lasting for an extended period of time. Uncivil student treatment
often damaged reputations and hindered the effectiveness of the learning environment as well as the teacher-student
relationship. A support system was perceived by the nursing faculty as necessary and comforting, providing needed

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assistance and encouragement. Although faculty members questioned their desire to remain in teaching, the resounding
consensus from the majority of participants was a continued passion for teaching.

4 Discussion
Incivility is occurring in the academic setting and nurse educators are experiencing this in the nursing educational
environment. This troubling phenomenon is contrary to the essence of nursing. Nursing is based on the concept of caring.
Although the nursing educational environment should be based on mutual respect and civility, this is not always the case.
As evidenced by participants’ stories, nursing faculty members in this study were commonly subjected to uncivil and
unacceptable student behaviors, risking personal emotional and physical harm to the faculty members.

A majority of participants described being very concerned over damage to their professional reputation as a consequence
of student incivility, a theme that has had limited discussion in the nursing literature. This slanderous and discrediting
damage to participants’ reputation was often carried out in a very public arena on social media sites, for example,
Facebook, or on public websites that rate a professor’s job performance, such as Rate My Professors. Clark and
Springer [22] explored issues of academic incivility and found that faculty often were subjected to being publicly criticized
and badmouthed by students in an attempt to discredit the faculty member. Misuse of social media is becoming common
today, with cyberbullying receiving much national attention [35]. The American Nurses Association and the National
Council of State Boards of Nursing have implemented social media policies for nurses and nursing students. Engaging in
unethical and unprofessional conduct aimed at damaging one’s reputation via social media is not acceptable and could be
viewed as lateral violence [36].

The importance of administrative and peer support is noted in the nursing literature sparingly. Nurse scholars who have
examined academic incivility have reported enforcing a strong student code of conduct may offer support for faculty
members with managing student incivility. Many nurse researchers have identified that the rigors of nursing education are
stressful, and often lead to behavioral changes, including incivility [14-16]. These findings demonstrate the need for teaching
students stress management strategies during their educational program to manage and reduce stress. In addition, training
in conflict management skills for both students and faculty can play a critical role in success [7, 10, 22].

Nurse researchers have found that nursing student incivility has resulted in nursing faculty resigning, retiring, or
withdrawing from their teaching positions [8, 9, 37-39]. Although this was not a conclusion in this study, the intensity and
severity of some of the uncivil acts could certainly justify faculty loss. This trend noted in the nursing literature as a result
of student incivility is troubling. There is already a shortage of qualified nurse educators. The nursing profession cannot
afford to lose nurse educators as a result of student incivility.

4.1 Implications for nursing education
Those joining the nursing profession must demonstrate and value the underlying principles of caring and respect that are
essential for nurses to embrace. Accordingly, in the nursing educational environment, the student-teacher relationship
should be based on respect and care. It is very disturbing to contemplate that uncaring and disrespectful behaviors
exhibited by students while in nursing school may very well extend into the workplace once the student graduates.
Therefore, developing and implementing effective policies and procedures to prevent and manage student incivility in the
nursing education setting is suggested. In addition, effective communication, faculty role modeling, and education for
students regarding incivility issues are necessary. Furthermore, faculty members subjected to student incivility should
receive the support and guidance needed to manage incidences of student incivility.

4.2 Development of policies and procedures
This study clearly demonstrates the need for colleges to consider the development or revision of code of conduct policies
for both students and faculty members outlining expectations for civility and consequences of violating the policies.

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Colleges must have no tolerance or lenience for acts of incivility exhibited by students or faculty members. These policies
must be very visible, transparent, and easily accessible for all to view. In addition, it is suggested that faculty members
include these policies in their syllabi and review the policies with students at the beginning of each semester [7, 10, 40].

4.3 Student development
This study demonstrates the need for students to understand and internalize the value and importance of civility, caring and
respect from day one of their college experience. Faculty role modeling civil behavior is a valuable method to promote and
establish a culture of civility in the academic setting. Faculty must lead by example and demonstrate respect and caring
behaviors in all interactions with students and peers. This will, in turn, allow students to identify the expectations for a
culture of civility [10, 40]. Throughout the nursing program, students should be taught about professional and ethical codes of
conduct. Dialogues with students focusing on treating patients, families, peers, and co-workers with respect and care are
important [40]. Student education regarding the importance of establishing a culture of civility in the educational setting
while in nursing school may also help to establish expectations and a demand for a civil work environment.

4.4 Faculty development and support
In the nursing education setting, it is imperative for administration and fellow colleagues to provide support and
encouragement for nursing faculty members who have experienced student incivility. Supportive behaviors such as
listening and mentoring exhibited by administrators may help an individual who has experience student incivility to have a
sense of feeling important, valued, and respected. In addition, administrators should provide information for faculty on
prevention strategies, as well as suggestions on how to intervene and handle an uncivil encounter. Offering faculty
development specifically addressing the topic of student incivility may help faculty feel empowered and better able to
effectively prevent or manage student incivility [10].

4.5 Limitations
Limitations include the fact that only experiences and perceptions of nursing faculty members who experience student
incivility were examined. This presents a narrow and limited understanding of the larger and more encompassing
phenomenon of academic incivility. Additionally, the participants interviewed were all Caucasian, female faculty
members. Interviewing male faculty or ethnic/racial minority faculty members may have yielded different findings.
Furthermore, the accuracy of the information gathered from the participants during the interview process cannot be
absolutely established. In self-report research studies, participants may not always be truthful, may omit information, or
may exaggerate the facts.

4.6 Recommendations for future research
There are numerous opportunities for further research on the topic of academic incivility in nursing education. Examples
of nursing student incivility are increasing. The far-reaching effects this incivility has on nursing faculty has had limited
investigation. Pursuing further research exploring the lived experience of nursing faculty members who have experienced
student incivility may provide a more thorough understanding of this phenomenon. Development of a quantitative study to
investigate this topic, using the emerged themes from this current study, would allow for a large sample size with greater
geographical representation to be reached, helping to provide further understanding of this phenomenon.

Further research might explore the characteristics of the initiator and recipient of the incivility. For example, does age,
gender, or status affect the type or frequency of uncivil encounters? Further studies may examine contributing factors to
student incivility in nursing education, such as the role of stress, generational differences, and attitudes of entitlement. This
information may lead to valuable ideas for management and prevention of student incivility.

Further research is needed to explore the valuable benefit support for nursing faculty members who have experienced
student incivility offers. Exploring if the effectiveness of support is determined by the type of person giving the support

www.sciedu.ca/jnep Journal of Nursing Education and Practice, 2014, Vol. 4, No. 9

Published by Sciedu Press 11

may provide valuable information. For instance, is support more effective if given by an administrator, a peer, or a family
member?

Incivility in nursing education is not limited to student-to-faculty incivility. Exploring faculty-to-student incivility and
incivility between faculty and administrators is also an important avenue to pursue. All of these types of incivility damage
the overall effectiveness of the nursing educational setting. Information obtained through research may prove beneficial
for reducing or eliminating academic incivility.

5 Conclusion
Findings from this current study clearly support findings from studies found in the nursing literature, as well as the larger
body of research on organizational workplace incivility. This information strongly suggests the importance of identifying
contributing factors of incivility present in nursing students and implementing policies to deal with incivility. Themes that
emerged from data analysis provide insights into the variety of uncivil student behaviors that occur along a continuum that
nursing faculty members are subjected to, as well as adverse physical, psychological, and emotional effects that
experiences of nursing student incivility have on nursing faculty members. Additionally, details of how these experiences
affect the teaching-learning process and the academic environment are illuminated. Findings support the view that nursing
student incivility is becoming more prevalent on college campuses and can have devastating effects on nursing faculty
members.

References
[1] Taylor C, Bator S, Hull E, Hill JJ, Spurlock W. Incivility: The antithesis of caring. In J. T. Catalano (Ed.), Nursing Now! Today’s

Issues, Tomorrow’s Trends (6th ed., pp. 297-309). Philadelphia, PA: F. A. Davis, 2012.
[2] Cortina LM, Magley VJ, Williams JH, Langhout RD. Incivility in the workplace: Incidence and impact. Journal of Occupational

Health Psychology. 2001; 6(1): 64-80. http://dx.doi.org/10.1037/1076-8998.6.1.64
[3] Felbinger DM. Bullying, incivility, and disruptive behaviors in the healthcare setting: Identification, impact, and intervention.

Frontiers of Health Services Management. 2009; 25(4): 13-23.
[4] Heinrich KT. Joy stealing 10 mean games faculty play and how to stop the gaming. Nurse Educator. 2007; 32(1): 34-38.

http://dx.doi.org/10.1097/00006223-200701000-00010
[5] Johnson PR, Indvik J. Rudeness at work: Impulse over restraint. Public Personnel Management. 2001; 30(4): 457-465.
[6] Clark C. The dance of incivility in nursing education as described by nursing faculty and students. Advances in Nursing Science.

2008a; 31(4): E37-E54. http://dx.doi.org/10.1097/01.ANS.0000341419.96338.a3
[7] Suplee PD, Lachman VD, Siebert B, Anselmi KK. Managing nursing student incivility in the classroom, clinical setting, and

on-line. Journal of Nursing Law. 2008; 12(2): 68-77. http://dx.doi.org/10.1891/1073-7472.12.2.68
[8] Clark CM. Faculty and student assessment of experience with incivility in nursing education. Journal of Nursing Education. 2008b;

47(10): 458-465. http://dx.doi.org/10.3928/01484834-20081001-03
[9] Luparell S. The effects of student incivility on nursing faculty. Journal of Nursing Education. 2007; 46(1): 15-19. PMid:17302095
[10] Clark CM, Springer PJ. Academic nurse leaders’ role in fostering a culture of civility in nursing education. Journal of Nursing

Education. 2010; 49(6): 319–325. http://.dx.doi.org/10.3928/01484834-20100224-01
[11] Clark CM, Kenaley BLD. Faculty empowerment of students to foster civility in nursing education: A merging of two conceptual

models. Nursing Outlook. 2011; 59: 158-165. http://dx.doi.org/10.1016/j.outlook.2010.12.005
[12] Clark C. Continuum of incivility. 2009a. Retrieved from http://hs.boisestate.edu /civilitymatters/resources.pubs.htm
[13] Clark CM. Student voices on faculty incivility in nursing education: A conceptual model. Nursing Education Perspectives. 2008c;

29(5): 284-289. PMid:18834058
[14] Gibbons C, Dempster M, Moutray M. Stress and eustress in nursing students. Journal of Advanced Nursing. 2008; 61(3): 282-290.

http://dx.doi.org/10.1111/j.1365-2648.2007.04497.x
[15] Shirey MR. An evidence-based solution for minimizing stress and anger in nursing students. Journal of Nursing Education. 2007;

46(12): 568-571. PMid:18196841

www.sciedu.ca/jnep Journal of Nursing Education and Practice, 2014, Vol. 4, No. 9

ISSN 1925-4040 E-ISSN 1925-4059 12

[16] Tully A. Stress, sources of stress and ways of coping among psychiatric nursing students. Journal of Psychiatric and Mental
Health Nursing. 2004;11: 43-47. http://dx.doi.org/10.1111/j.1365-2850.2004.00682.x

[17] Beck DL, Hackett MB, Srivastava R, McKim E, Rockwell B. Perceived level and sources of stress in university professional
schools. Journal of Nursing Education. 1997; 36(4): 180-186. PMid:9107596

[18] Robertson JE. Can’t we all just get along? A primer on student incivility in nursing education. Nursing Education Perspective.
2012; 33(1): 21-26. http://dx.doi.org/10.5480/1536-5026-33.1.21

[19] Mahat G. Stress and coping: First-year Nepalese nursing students in clinical settings. Journal of Nursing Education. 1996; 35(4):
163-169. PMid:8830130

[20] Pagana K. Stresses and threats reported by baccalaureate students in relation to an initial clinical experience. Journal of Nursing
Education. 1988; 27(9): 418-424. PMid:2852715

[21] Pagana K. The relationship of hardiness and social support to student appraisal of stress in an initial clinical nursing situation.
Journal of Nursing Education. 1990; 29(6): 255-261. PMid:2165145

[22] Clark C, Springer PJ. Thoughts on incivility: Student and faculty perceptions of uncivil behavior in nursing education. Nursing
Education Perspectives. 2007; 28(2): 93-97. PMid:17486799

[23] Lasiter S, Marchiondo L, Marchiondo K. Student narratives of faculty incivility. Nursing Outlook. 2012; 60: 121-126.
http://dx.doi.org/10.1016/j.outlook.2011.06.001

[24] Lashley FR, DeMeneses M. Student civility in nursing programs: A national survey. Journal of Professional Nursing. 2012; 17(2):
81-86. http://dx.doi.org/10.1053/jpnu.2001.22271

[25] Clark CM. National study on faculty-to-faculty incivility: strategies to foster collegiality and civility. Nurse Educator. 2013; 38(3):
98-102. http://dx.doi.org/10.1097/NNE.0b013e31828dc1b2

[26] Clark CM, Olender L, Kenski D, Cardoni C. Exploring and addressing faculty-to-faculty incivility: A national perspective and
literature review. Journal of Nursing Education. 2013; 52(4): 211-218. http://dx.doi.org/10.3928/01484834-20130319-01

[27] Heinrich KT. Joy-stealing games. Reflections on Nursing Leadership. 2006; 32(2): 1-4.
[28] Clark CM, Carnossa J. Civility: A concept analysis. Journal of Theory Construction & Testing. 2008; 12(1): 11-15.
[29] Creswell, JW. Qualitative Inquiry & Research Design: Choosing Among Five Approaches (2nd ed.). Thousand Oaks, CA: Sage,

2007.
[30] Flood A. Understanding phenomenology. Nurse Researcher. 2010; 17(2): 7-15. http://dx.doi.org/10.7748/nr2010.01.17.2.7.c7457
[31] Mapp T. Understanding phenomenology: The lived experience. British Journal of Midwifery. 2008; 16(5): 308-311.
[32] McConnell-Henry T, Chapman Y, Francis K. Husserl and Heidegger: Exploring the disparity. International Journal of Nursing

Practice. 2009; 15: 7-15. http://dx.doi.org/10.1111/j.1440-172X.2008.01724.x
[33] Starks H, Trinidad SB. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory.

Qualitative Health Research. 2007; 17(10): 1372-1380. http://dx.doi.org/10.1177/1049732307307031
[34] Colaizzi P. Psychological research as the phenomenologist views it. In R. S. Valle & M. King (Eds), Existential

Phenomenological Alternatives for Psychology (pp. 48-79). New York, NY: Oxford University Press, 1978.
[35] Weber Shandwick. Civility in America 2012. 2012. Available from: http://www.webershandwick.com/civility/
[36] National Council of State Boards of Nursing. White paper: A nurse’s guide to the use of social media. 2011. Available from:

www.ncsbn.org/Social_media_guidelines.pd
[37] Altmiller G. Student perceptions of incivility in nursing education: Implications for educators. Nursing Education Perspectives.

2012; 33(1): 15-20. http://dx.doi.org/10.5480/1536-5026-33.1.15
[38] DalPezzo NK, Jett, KT. Nursing faculty: A vulnerable population. Journal of Nursing Education. 2010; 49(3): 132-136. http://.dx.

doi.org/10.3928/01484834-20090915-04
[39] Luparell S. Incivility in nursing: The connection between academia and clinical settings. Critical Care Nurse. 2011; 31(2): 92-95.

http://dx.doi.org/10.4037/ccn2011171
[40] Clark CM. Faculty field guide for promoting student civility in the classroom. Nurse Educator. 2009b; 34(5): 194-197.

http://dx.doi.org/10.1097/NNE.0b013e3181b2b589

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M a r c h / A p r i l 2 0 0 7 Vo l . 2 8 N o . 2 9 3

T H O U G H T S o n I N C I V I L I T Y:
S t u d e n t a n d Fa c u l t y Pe r c e p t i o n s

of U N C I V I L B E H AV I O R in Nursing Education
C Y N T H I A M . C L A R K A N D PA M E L A J . S P R I N G E R

CONNIE SEEMS TO CHALLENGE EVERYTHING HER NURSING PROFESSOR SAYS.

During small-group work, Connie text messages her friends and rarely pays
attention. The professor is impatient and uses harsh language with Connie in
front of other students.

T H I S S C E N A R I O, a common one in many of today’s nursing programs, is typical of sit-
uations that are at best disparaging and, under the worst circumstance, potentially violent.
Evidence suggests that incivility on American college campuses is a serious and growing
concern (1-8).

Fostering an atmosphere of civility on college campuses presents a challenge. To be “civil” is to be polite,

respectful, and decent. Conversely, “incivility ” is defined as speech or action that is disrespectful or rude and

ranges from insulting remarks and verbal abuse to explosive, violent behavior (9). Academic incivility is any

speech or action that disrupts the harmony of the teaching-learning environment. Some uncivil behaviors

can be quite disruptive and affect the academic environment so radically that learning is effectively termi-

nated (10). T H I S A R T I C L E reports on a study of perceptions of nurse faculty and nursing students in one school of

nursing regarding incivility in nursing education, its possible causes, and potential remedies.

ABSTRACT Faculty members complain about the rise of uncivil behavior in their students, and students voice similar complaints about faculty. Using

an interpretive qualitative method for research, this study examined student and faculty perceptions of incivility in nursing education, possible causes

of incivility, and potential remedies. Narrative analysis yielded the following categories: in-class disruption by students, out-of-class disruption by stu-

dents, uncivil faculty behaviors, and possible causes of incivility in nursing education. The authors argue that further research is needed to increase

awareness and understanding about academic incivility, its impact, and its psychological and social consequences.

9 4 N u r s i n g E d u c a t i o n P e r s p e c t i v e s

Review of the Literature I N C I V I L I T Y I N H I G H E R E D U C AT I O N

To create a more civil society, Eberly urges Americans to elevate
common good over self-interest, to encourage wider civic partici-
pation, and to renew social values (11). Carter believes that rude-
ness and disrespect are “the merest scratch of the surface of [our
societal] crisis” (12, p. 16) and evidence of our nation’s growing
incivility. According to Carter, selfishness and getting one’s own
needs met are crowding into the social life of America, including
our nation’s classrooms.

While academic incivility is not a new phenomenon, Braxton
and Bayer (2,3) suggest that it is on the rise, and that courtesy and
civility among faculty and students are fracturing and dissolving on
college campuses across the country. Faculty members complain
about the rise of uncivil behavior in their students (5,8,13,14), and
students voice similar complaints about faculty (1,2,15-17).

Education plays an important role in developing a civil soci-
ety, and higher education plays a special role in helping students
develop a sense of civic and social responsibility and learn ways
to contribute to the common good (18). In the United States,
where public education is integral to preparing citizens for
employment and socioeconomic mobility, education also accepts
social responsibility for well-being in civil society (19).

Many explanations for academic incivility have been suggested,
including exposure to violence, poor secondary school preparation,
changing student demographics, and inadequate parenting (2).
Levine and Cureton describe contemporary college students as dis-
trustful of leadership, lacking confidence in social institutions, and
being ill prepared for the rigors of academe (20). Braxton and
Bayer indicate that it is important to consider the changing demo-
graphics of students as well as the impact of faculty behaviors (2,3).

Clearly, a safe teaching and learning environment is needed
and deserved. Incivility within the academic community is too
damaging to ignore, and even though acts of disrespect and
harassment may be reflective of a changing nation, such behav-
iors must be immediately and effectively addressed (1,7,21).

I N C I V I L I T Y I N N U R S I N G E D U C AT I O N Further research in
the area of incivility in nursing education is needed. A qualita-
tive study by Luparell used a critical incident technique to con-
duct extensive interviews with 21 nursing professors representing
nine different nursing programs in six states (5). Faculty
described aggressive and severe incidents of student incivility
and reported being verbally abused by students. As a conse-
quence of significant and sustained negative effects of these
encounters, faculty reported losing sleep, having interrupted
sleep patterns, and experiencing a number of other negative reac-
tions to these encounters. Some faculty changed their pedagogy
and modified grading criteria to avoid further conflict with stu-

dents, and many harbored self-doubt about their teaching abili-
ties and assumed much of the blame for what occurred.

Thomas conducted extensive interviews with nursing students
from a variety of nursing programs across the country (14). These
students offered the opinion that faculty play a significant role in
academic incivility and provided examples of uncivil faculty
behaviors. They described themselves as being angry about unex-
pected changes in clinical schedules, changes to the syllabus, and
nurse faculty who “seem to make up the rules as they go” (14, p.
19). Several common triggers of their anger were identified, includ-

ing perceptions of faculty unfairness, rigidity, being overly critical
of students, insistence on conformity, and discrimination against
nursing students based on gender, race, and ethnicity.

Lashley and deMeneses surveyed 409 nursing programs in the
United States regarding the frequency of uncivil student behaviors
(22). Inattentiveness, absence from class, and tardiness were the
most frequently reported uncivil behaviors. Fewer than 50 percent
of respondents reported verbal abuse of faculty and student peers
as a problem. Forty-three percent indicated that disruptive behav-
iors had increased over the last five years.

A plenary session panel at the National League for Nursing
Education Summit 2005 focused its attention on incivility in nurs-
ing education, and a report on the panel discussion was published
in Nursing Education Perspectives (23). Clark, a panelist, reported
on the use of the Incivility in Nursing Education (INE) survey,
which includes both quantifiable and open-ended items (24). Clark
and Springer used the INE survey to investigate incivility in nurs-
ing education from both faculty and student perspectives in a nurs-
ing program in the northwest United States (17).

Findings from the pilot study revealed that both nursing faculty
and students viewed academic incivility as a moderate to serious
problem. Both groups reported similar behaviors as uncivil, and both
indicated a desire to learn more about the problem. The qualitative
comments were illuminating and form the basis for this article.

The Qualitative Study This study was conducted using quan-
titative and qualitative methodologies to investigate the problem

U N C I V I L B E H A V I O R

Clearly, a safe teaching and learning
Incivility within the

and even though acts of disrespect and
a changing nation,

immediately

U N C I V I L B E H A V I O R

M a r c h / A p r i l 2 0 0 7 Vo l . 2 8 N o . 2 9 5

U N C I V I L B E H A V I O R

of incivility in nursing education in a university environment
from both student and faculty perspectives. Its purpose was to con-
sider possible causes of incivility and to recommend potential
remedies. The qualitative portion of this study was developed to
examine three research questions:
• How do nursing students and nurse faculty contribute to inci-
vility in nursing education?
• What are some of the causes of incivility in nursing education?
• What remedies might be effective in preventing or reducing
incivility in nursing education?

All faculty (n = 36) and students (n = 467) in the associate and
baccalaureate degree nursing programs of a metropolitan public
university received information about the study and were asked to
participate (17). Approval to conduct the study was obtained by
the university Institutional Review Board.

S U RV E Y I N S T R U M E N T All participants completed the Inci-
vility in Nursing Education survey, which included demographic
questions, quantitative items designed to measure faculty and
student perceptions of incivility in nursing education, and four
open-ended questions used to gather perceptions of faculty and
students. This survey was developed by modifying items from two
instruments designed to measure faculty and student incivility in
higher education: 1) the Defining Classroom Incivility survey
designed by the Center for Survey Research at the University of
Indiana (25), and 2) the Student Classroom Incivility Measure
(known as the SCIM-Part C), where students are asked to rate
uncivil faculty behaviors in the classroom (4). After obtaining
permission, Clark developed the INE by modifying items from
these instruments to be more applicable to nursing education.

To establish initial content validity, faculty with experience in
student and faculty incivility reviewed the newly developed sur-
vey and compared the content to themes found in the literature.
Faculty and students pilot tested the survey for readability, and
revisions were then made to the wording of questions.

P R O C E D U R E The researchers emailed faculty in the depart-
ment of nursing to invite them to participate in the study and
request permission to distribute surveys to their nursing students.

Faculty response was favorable; all agreed to assist in the distri-
bution of the survey to nursing students.

Clearly written instructions were provided with the surveys.
During a two-week period in October 2004, faculty self-adminis-
tered their own surveys and provided time during classes and
clinicals for students to complete their surveys. All participation
was voluntary. All responses were collected and placed in a large
envelope, which was then given to a research assistant to compile.

Fifteen of 36 nurse faculty (41.6 percent) and 168 of 467 nurs-
ing students (35.9 percent) completed the qualitative parts of the
survey. An interpretive qualitative method was used to analyze
the data from narrative responses (26). Each researcher indepen-
dently reviewed the student and faculty comments to identify
recurring responses and organize them into themes. Areas of
agreement and disagreement were discussed and verbatim com-
ments reviewed until both researchers were comfortable that the
analysis was a valid representation of the comments.

Findings The first research question asked students and faculty
how each group contributes to incivility. Findings were grouped
into two themes: in-class disruption and out-of-class disruption.
Table 1 lists uncivil in-class student behaviors as identified by
faculty; response frequencies are provided in descending order.

With regard to in-class student disruption, respondents wrote
about disruptions in class, negative remarks, and other forms of
student incivility. Cited behaviors included challenging profes-
sors regarding test scores in class, dominating class discussion,
carrying on side conversations that disturb other students, and
sighing to express displeasure with assignments. Students com-
mented as follows:
• “Students are disruptive when they do not listen to faculty and
other students, text message their friends, and use cell phones
during class.”
• “It is most frustrating when students challenge professors,
especially during class.”

With regard to out-of-class disruption, respondents wrote
about discrediting faculty, complaining about faculty, and failing
to use appropriate communication channels. (See Table 2.) Uncivil
behavior in this category included students discrediting faculty
knowledge, publicly bad-mouthing professors, and turning in
assignments late, without making prior arrangements. Students
commented as follows:
• “I hear students bad-mouthing professors between classes. I
don’t think it’s helpful to prejudice another student against a pro-
fessor in that way.”
• “Students send inappropriate emails, are negative toward fac-
ulty and other students, and sigh because they think that an

environment is needed and deserved.
academic community is too damaging to ignore,
harassment may be reflective of
such behaviors must be
and effectively addressed.

9 6 N u r s i n g E d u c a t i o n P e r s p e c t i v e s

assignment is stupid.”
The students identified six themes of uncivil faculty behaviors

as shown in Table 3. Comments referred to faculty condescension,
poor communication skills, and superior attitudes toward stu-
dents. Uncivil behavior included challenging students’ knowledge
or credibility in front of others, demeaning the profession of nurs-
ing, and failure to provide a respectful forum for discussing con-
cerns. Students commented as follows:
• “Some faculty make belittling comments and try to weed out
students. They are arrogant and show superiority over students.”
• “Some faculty treat students like they are stupid and make
condescending, rude remarks.”

The second research question asked students and faculty to
suggest possible causes for uncivil behavior in nursing education.
Their responses are presented in descending order in Table 4.
Themes included the high-stress environment of nursing educa-
tion, faculty arrogance, and a lack of immediacy in addressing
incivility when it occurs. Students commented as follows:
• “Faculty lose their patience and take out their personal stress
on students. They either do not deal with uncivil behaviors or are
overly harsh and demeaning.”
• “Incompetent, rude professors encourage the same rude behav-
ior from students. If you can’t teach, don’t! Students are frustrated
by the lack of resources to report a rude, incompetent professor,
and fear retaliation if they go to the top to report it. We’ve been
told that it can cost us our degrees and that we’ll be flunked out if
we speak up. This simply encourages incompetence and incivility
to continue.”
• “Many students believe they can be as rude as they want
because they are paying customers.”

The third research question asked students and faculty to sug-
gest possible remedies for incivility in nursing education. In many
cases, the respondents called for a swift, immediate response to
incivility, and some suggested a “zero tolerance” approach to the
problem.

Several possible remedies were offered, including setting forth
standards and norms, strengthening university policies and sup-
port for faculty, and enforcing campus codes of conduct. It was
recommended that incivility be addressed immediately and that
open forums and mediation panels be developed to resolve con-
flicts related to incivility. It was also recommended that faculty
and students learn conflict negotiation/mediation skills.

Implications for Nursing Education and Research Nurse fac-
ulty and students perceive incivility as a problem both in and out
of the classroom. Stress, disrespect, faculty arrogance, and a

Table 1. In-Class Disruption by Students as Identified by Faculty

UNCIVIL STUDENT BEHAVIOR FREQUENCY OF RESPONSE

Disrupting others by talking in class 20

Making negative remarks/disrespectful

comments toward faculty 11

Leaving early or arriving late 9

Using cell phones 7

Sleeping/not paying attention 3

Bringing children to class 1

Wearing immodest attire 1

Coming to class unprepared 1

Table 2.

Out-of-Class Disruption by Students as Identified by Faculty

UNCIVIL STUDENT BEHAVIOR FREQUENCY OF RESPONSE

Verbally discrediting faculty 4

Turning in late assignments without proper notification 2

Sending inappropriate emails to faculty 2

Not keeping scheduled appointments 1

Complaining about constructive feedback from faculty 1

Stealing/driving too fast on campus 1

Making veiled threats toward faculty 1

Table 3. Uncivil Faculty Behaviors as Identified by Students

UNCIVIL FACULTY BEHAVIOR FREQUENCY OF RESPONSE

Making condescending remarks 26

Using poor teaching style or method 23

Using poor communication skills 19

Acting superior and arrogant 15

Criticizing students in front of peers 7

Threatening to fail students 7

Table 4. Possible Causes of Incivility in Nursing Education

as Identified by Students and Faculty

POSSIBLE CAUSE FREQUENCY OF RESPONSE

High-stress environment 10

Lack of professional, respectful environment 9

Lack of faculty credibility and responsiveness 8

Faculty arrogance 6

Sense of entitlement among students 3

Students not really interested in nursing 3

Not being clear about expectations 2

Competitiveness 2

Lack of immediacy to address incivility 2

Distance learning (virtual) environment 2

Lack of student preparation 1

U N C I V I L B E H A V I O R

sense of student entitlement contribute to incivility in nursing
education. To deal effectively deal with these issues, faculty and
students must work together with administrators to develop and
implement comprehensive codes of conduct and effective strate-
gies to prevent incivility. Further, they must craft remedies for
effective intervention when incivility occurs.

Standards and ethical principles that define the profession
exist to ensure that qualified, ethical nurses are graduated from
nursing programs. Nurse faculty and students must be account-
able to these standards and bear a shared responsibility to con-
duct themselves in an ethical, professional manner. They must
engage as partners in lively dialogue to address these problems.

This study of incivility in nursing education is timely. Most
earlier studies on this topic have focused on the problem of stu-
dent incivility. These findings shed light on possible causes of
incivility, potential remedies, and how faculty, as well as stu-
dents, contribute to the problem. From the classroom to the prac-
tice setting, further research is needed to address several topics:
• The nature of incivility and its impact on the educational
process and on the profession as a whole

• The relationships between student and faculty perceptions of
incivility and ways to effectively address the problem
• Whether there are gender differences in ways that faculty
and students experience incivility
• How civility experienced by students — or perpetrated by
students — affects patients

It is clear that uncivil encounters have a negative effect on
the academic environment and have the potential to disrupt the
teaching-learning environment. Greater awareness and under-
standing about academic incivility, its impact, and its psycho-
logical and societal consequences are needed.

About the Authors Cynthia M. Clark, PhD, RN, is associate
professor, Department of Nursing, Boise State University, Boise,
Idaho. Pamela J. Springer, PhD, RN, is professor and department
chair, College of Nursing. Boise State University. For more infor-
mation, contact Dr. Clark at cclark@boisestate.edu.

Keywords Codes of Conduct – Incivility – Student Behavior – Student-

Faculty Relations

References

1. Boice, B. (1996). Classroom incivilities. Research in

Higher Education, 37, 453-486.

2. Braxton, J. M., & Bayer, A. E. (1999). Faculty miscon-

duct in collegiate teaching, Baltimore, MD: Johns Hop-

kins University Press.

3. Braxton, J. M., & Bayer, A. E., Eds. (2004). Addressing

faculty and student classroom improprieties. New

Directions for Teaching and Learning, 99, 89-95.

4. Hanson, M. F. (2000). Classroom incivility: Manage-

ment practices in large lecture course (Doctoral dis-

sertation, South Dakota State University, 2000). Dis-

sertation Abstracts International (UMI No. AAT

9978835).

5. Luparell, S. (2003). Critical incidents of incivility by

nursing students: How uncivil encounters with stu-

dents affect nursing faculty (Doctoral dissertation,

University of Nebraska, 2003). Dissertation Abstracts

International (UMI No. AAT 3092571)

6. Luparell, S. (2004) Faculty encounters with uncivil

nursing students: An overview. Journal of Professional

Nursing, 20(1), 59-67.

7. Luparell, S. (2005). Why and how we should

address student incivility in nursing programs. In M.

H. Oermann & K. T. Heinrich (Eds.), Annual review of

nursing education: Strategies for teaching, assessment,

and program planning (pp. 23-36). New York: Springer

Publishing.

8. Schneider, A. (1998, March 27). Insubordination and

intimidation signal the end of decorum in many class-

rooms. Chronicle of Higher Education, 44(29), A12-A14.

9. Tiberius, R. G., & Flak, E. (1999, Spring). Incivility in

dyadic teaching and learning. New Directions for Teach-

ing and Learning, 77, 3-12.

10. Feldman, L. J. (2001). Classroom civility is another

of our instructor responsibilities. College Teaching,

49(4), 137-140.

11. Eberly, D. E. (1998). America’s promise: Civil society

and the renewal of American culture. New York: Row-

man & Littlefield.

12. Carter, S. L. (1998). Civility: Manners, morals, and the

etiquette of democracy. New York: Basic Books.

13. Gonzales,V., & Lopez, E. (April, 2001). The age of

incivility: Countering disruptive behavior in the class-

room. AAHE Bulletin, 55(8), 3-6.

14. Thomas, S. P. (2003). Handling anger in the

teacher-student relationship. Nursing Education Per-

spectives, 24(1), 17-24.

15. Amada, G. (1994). Coping with the disruptive college

student: A practical model. Asheville, NC: College

Administration Publishers.

16. Hall, J. M. (2004). Dispelling desperation in nursing

education. Nursing Outlook, 52, 147-154.

17. Clark, C. M., & Springer, P. J. (2007). Incivility in

nursing education: A descriptive study on definitions

and prevalence. Journal of Nursing Education, 47(1), 7-

14.

18. Boyer, E. (1990). Campus life: In search of community.

Princeton, NJ: Carnegie Foundation for the Advance-

ment of Teaching.

19. Mourad, R. (2001). Education after Foucault: The

question of civility. Teachers College Record, 103(5),

739-759.

20. Levine, A., & Cureton, J. S. (1998). What we know

about today’s college students. About Campus, 3(1),

4-9.

21. Baldwin, R. G. (1997-1998). Academic civility

begins in the classroom, Teaching Excellence, 9(8).

[Online]. Available: http://iteso.mx/~ruth/05_

reflexiones/02_ambiente/civility.html.

22. Lashley, F. R., & deMeneses, M. (2000). Student

civility in nursing programs: A national study. Journal

of Professional Nursing, 17(2), 81-86.

23. Kolanko, K. M., Clark, C., Heinrich, K. T., Olive, D.,

Serembus, J. F., & Sifford, K. S. (2006). Academic dis-

honesty, bullying, incivility, and violence: Difficult chal-

lenges facing nurse educators, Nursing Education Per-

spectives, 27(1), 34-42.

24. Clark, C. M. (2004). Incivility in nursing education: A

pilot study on faculty and student perspectives. Unpub-

lished manuscript.

25. Center for Survey Research, University of Indiana,

Bloomington,. (2000, June 14). A survey on academic

incivility. Preliminary report. [Online]: Available:

www.indiana.edu/~csr/Civility%20PreReport .

26. Merriam, S. B. (2002). Qualitative research in prac-

tice: Examples for discussion and analysis. San Francisco:

Jossey-Bass.

U N C I V I L B E H A V I O R

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R E S E A R C H P A P E R

Bullying among nurses and its relationship with
burnout and organizational climate

Gabriele Giorgi PhD
Full Researcher, Department of Psychology, European University of Rome, Rome, Italy

Serena Mancuso Psychologist
PhD Student, Department of Psychology, European University of Rome, Rome, Italy

Francisco Fiz Perez PhD
Full Professor, Department of Psychology, European University of Rome, Rome, Italy

Andrea Castiello D’Antonio Psychologist Psychotherapist
Full Professor, Department of Psychology, European University of Rome, Rome, Italy

Nicola Mucci MD Postgraduate specialization in Occupational Medicine
Research Fellow, Institute of Occupational Medicine, Catholic University of Sacred Heart, Rome, Italy

Vincenzo Cupelli MD Postgraduate specialization in Occupational Medicine
Full Professor, Health Services Research Unit, Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy

Giulio Arcangeli MD Postgraduate specialization in Occupational Medicine
Associate Professor, Health Services Research Unit, Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy

Accepted for publication November 2014

Giorgi G, Mancuso S, Fiz Perez F, Castiello D’Antonio A, Mucci N, Cupelli V, Arcangeli G. International Journal of
Nursing Practice 2014; ••: ••–••

Bullying among nurses and its relationship with burnout and organizational climate

Workplace bullying is one of the most common work-related psychological problems. Bullying costs seem higher for
organizations composed of health-care workers who perform direct-contact patients-complex tasks. Only a few studies have
been carried out among nurses in Italy and integrated models of bullying antecedents and consequences are particularly
missing. The aim of this study was to develop a bullying model focused on the interaction between bullying and burnout in
the setting of a climate–health relationship. Research involved 658 nurses who completed a survey on health, burnout,
bullying and organizational climate. Structural equation modeling was used to test the hypothesis. Results suggest that
workplace bullying partially mediates the relationship between organizational climate and burnout and that bullying does not
affect health directly, but only indirectly, via the mediation of burnout. Our study demonstrates the key-role of workplace
bullying and burnout in the climate–health relationship in order to understand and to improve nurses’ health.

Key words: health care, nursing, occupational health, professional burnout, workplace bullying.

Correspondence: Gabriele Giorgi, Department of Psychology, European University of Rome, Via degli Aldobrandeschi, Roma 190 00163, Italy. Email:
gabriele.giorgi@unier.it; dott.gabriele.giorgi@virgilio.it

International Journal of Nursing Practice 2014; ••: ••–••

doi:10.1111/ijn.12376

© 2014 Wiley Publishing Asia Pty Ltd

INTRODUCTION
Its growth now a worldwide phenomenon, workplace
bullying is considered one of the most common work-
related psychological problems.1 Bullying means ‘harass-
ing, offending, socially excluding someone or negatively
affecting someone’s work tasks. In order for the label
bullying (or mobbing) to be applied to a particular activ-
ity, interaction or process it has to occur repeatedly and
regularly (e.g. weekly) and over a period of time (e.g.
about six months)’.2 In addition, there is strong evidence
that bullying has detrimental effects on both individuals
and organizations. These include reduced well-being and
reduced job satisfaction, helplessness, sleep problems,
concentration difficulties and negative emotions (anger,
frustration, depression, anxiety), which might lead to
corrective actions in terms of wrongdoing, self-harm,
suicide, etc.3–6 Furthermore, bullying is extremely expen-
sive in terms of manpower, increased absenteeism, higher
intent to leave the organization and staff turnover.7–11

Workplace bullying among nurses
The cost of bullying appears to be higher for organizations
composed of health-care workers performing complex
tasks in direct contact with patients. Indeed, health-care
employees have a high risk of exposure to bullying at
work.11–14 Such studies show that people working in
health care (primarily nurses and doctors) have a 16-fold
higher risk of being exposed to negative behaviours than
other service sectors workers and that the risk to nurses
is three times higher than that of other health service
employees.15 Despite increasing international attention on
workplace bullying, few studies have been performed
among nurses in Italy. In addition, as underlined in recent
studies, the effects of bullying on health might be limited
among Italian employees due to the fact they have a higher
acceptance and tolerance of negative workplace acts.
Victims might attribute bullying behaviours to different
aspects of the environment, such as the work group
culture, especially nurses, who might be more resigned to
the lack of autonomy and power.16

Indeed, considering that bullying in Italy is mainly a
top-down process, in which the target is usually in a lower
position than the perpetrator,17,18 and the fact that, in
some professions, especially among nurses,16 bullying
might be considered as part of the job,19,20 it seems clear
that nurses tolerate negative acts and do not complain
about bullying. Thus, an illustration of bullying among
Italian nurses will be given in the present study with the

aim of developing a model focused on the interaction
between bullying and burnout in a climate–health
relationship.

Organizational factors as antecedents of
bullying in nurses

Although it is clear that workplace bullying is prevalent
among nurses and there are serious implications to the
problem,21,22 there is little awareness of this phenomenon
and why workplace bullying continues in health-care
environments.

International literature suggests that low autonomy
and high workloads are some of the characteristics that
encourage bullying, contributing to a climate wherein it
can flourish.23–25

According to a recent Canadian study conducted
among health-care-workers,26 it seems that the main
causes of between-nurses bullying are organizational
dimensions such as work overload, lack of control, insuf-
ficient reward and lack of managerial communication.
Several studies of nurses from the UK,25 Australia,27 New
Zealand13 and the USA28 have reported that leadership is
often the source of bullying behaviours. Nurses often
work in hierarchical organizational structures that encour-
age bullying.23,29–31 Bullying behaviours can be used to
reinforce rules and norms and to neutralize nurses who
seek to challenge the status quo.24,30

Bullying and burnout
Several studies have investigated the occurrence of bully-
ing and its potential consequences, particularly the rela-
tionship between workplace bullying and symptoms of
burnout. Bullying is largely associated with psychological
distress and psychosomatic complaints, including experi-
ences of burnout.12,32 In a Finnish study of more than 5000
hospital staff members, it was found that bullying victims
had 26% more certified absences than those who had not
suffered this phenomenon. Bullying, in hospitals and other
organizations, has been associated with self-reported
burnout and the propensity to leave.33 A study of 745
Norwegian nurses12 showed how bullied nurses presented
a significantly higher level of burnout compared with their
non-bullied colleagues.

A recent study among 1179 nurses in Quebec34 inves-
tigated how exposure to workplace bullying undermines
psychological health at work. The results showed that
workplace bullying negatively predicted work engage-
ment and positively predicted burnout, due to the lack of

2 G Giorgi et al.

© 2014 Wiley Publishing Asia Pty Ltd

employee autonomy. Another study investigated the
potential associations between bullying and burnout
symptoms in 107 Portuguese nurses. Results indicated
that bullied nurses presented significantly higher levels of
burnout. Symptoms of burnout (emotional exhaustion
and depersonalization) were higher and more frequent
among nurses who reported to have been bullied.35

In a Norwegian research, the occurrence and potential
consequences of bullying and harassment in the restaurant
sector were explored.5 Results showed a positive associa-
tion between exposure to bullying behaviour and individ-
ual burnout. Employees exposed to bullying felt more
exhausted, were more cynical towards their job and felt to
be less efficient as a worker. Although weaker, similar
relationships were found for observed bullying and for
being subjected to bullying. Studies carried out among
teachers36 evaluated stress (workload and workplace bul-
lying), strain (physical symptoms and burnout) and mod-
erating variables (self-efficacy, social support and coping
strategies). These studies support the assumptions that
exposure to workload or mobbing can lead to increased
strain (physical symptoms and burnout) among school
teachers. Furthermore, the negative impact of stress on
strain can be buffered through factors such as perceptions
of support and the use of appropriate coping strategies.37

Development of a model
As previously underlined, there are several studies in
international literature on nurses being bullied that
revealed organizational antecedents and personal conse-
quences for the victims. However, integrated models
of bullying antecedents and consequences are missing
in Italian literature. Here, we wish to explore the
assumption that workplace bullying is associated with
organizational climate. In addition, according to the lit-
erature, organizational climate is recognized to be associ-
ated with burnout.2 Consequently, the role of workplace
bullying on the climate–burnout relationship is assumed
in our hypothesis. Indeed, people who perceive a negative
organizational climate and feel to be victimized might
report burnout.38 Negative acts might be considered more
harmful by victims because they occur in a hostile and
negative organizational climate. Some negative acts, com-
monly stressful, but normally tolerated, might be per-
ceived as intentional and harmful when the climate is
negative.37 Indeed, when the target feels intentionality on
the part of the harasser, he or she starts to feel bullied and
to develop health and burnout problems.20 Furthermore,

a negative organizational environment could be related
to burnout; if people suffer negative acts, the climate
might be perceived not only as negative, but also as
deconstructive and could be associated with burnout,
leading to mental and physical health problems. Thus, in
our view, bullying and organizational climate could be
related with burnout in nurses. Burnout, then, will have
an impact on psychological and physical health. To evalu-
ate this problem, we propose a theoretical model of the
antecedents and the outcomes of workplace bullying
among Italian nurses. A complete description of the devel-
opment of this model is shown in Figure 1.

First, we primarily want to test the association of
organizational climate with workplace bullying, in which
the team, leadership, job involvement and description,
autonomy and communication could contribute to work-
place bullying, as well as to two of its components: work-
related bullying and personal bullying. Second, we
hypothesize that harassment could be negatively related to
burnout. Third, we hypothesize that burnout could be
associated with psychological and physical health. We also
propose that a negative organizational climate might result
in a direct contribution to health. The degree to which
health is affected in the climate–health association could
be considered an important baseline against which the
potential effects of workplace bullying and burnout on
health could be evaluated. In short, we have three main
hypotheses:

Hypothesis 1: Workplace bullying partially mediates the
climate–burnout relationship.

Hypothesis 2: Workplace bullying influences health through
the mediation of burnout.

Hypothesis 3: Organizational climate influences health, both
directly and indirectly, through the mediation of burnout.

METHOD
Sample and procedures

This study involved 658 nurses working for the Local
Health Authorities (LHA) in Lecce (Italy). Forty-eight
per cent of the nurses were male and the remaining 52%
female. They were chosen conveniently and represented
78% of the nursing population in LHA/Lecce. Psycholo-
gists administered the questionnaire during professional
courses. In this context, the compilation of the survey was
very thorough and nearly all of the questionnaires were

Testing a new theoretical model 3

© 2014 Wiley Publishing Asia Pty Ltd

collected with complete data or only a few missing
elements that were replaced with the scales’ means. Con-
sequently, the response rate was very high: 90%. Data
were collected preserving the nurses’ anonymity, and par-
ticipation was voluntary. No payment was provided to
participants. The average time to fill in the questionnaire
was 40 min. Informed consent was obtained from each
subject of the research. An Italian University ethics com-
mittee approved the study. As far as the participants are
concerned, 31% of the nurses had less than 15 years
seniority, 47% between 15 and 25 years and 22% over
25 years. Eighty per cent of them had been working
under open-ended contracts and 20% under fixed-term
contracts.

Instruments
Health Scale

This scale assesses the level of perceived psychological and
physical health. It uses 20 factors, divided into psychologi-
cal factors (10 factors, e.g. ‘I felt exhausted’) and physical

(10 factors, e.g. ‘I had sleep problems’). The health scale
measures both physical (energy and fatigue, pain and dis-
comfort, sleep and rest) and mental health (negative feel-
ings, concentration, anxiety and depression) by asking
whether the respondent had recently experienced a
symptom or behaviour of psychological or physical dis-
turbance. It was successfully validated in Italy among a
population of more than 8000 employees.39 In addition,
the instrument was shown to have adequate convergent
validity with theoretically related constructs, such as
work-related stress. Subjects were asked to answer to
each item using a five-point Likert scale. Higher scores
indicate perceptions of negative health status (1 = never,
5 = almost every day). The reliability of the health scale
in this study was very high: Alpha = 0.93.

Burnout
Burnout was assessed by the 8-item scale Burnout Indica-
tor Tool (BIT), developed in Italy.40 Four factors measure
cynicism and the other four factors measure emotional

Figure 1. (The) proposed theoretical model. Note: Organizational climate was assessed using five psychological aspects of climate: communication,

leadership, job involvement, team and autonomy; workplace bullying was divided into personal bullying and work-related bullying; health was

assessed by perceived psychological and physical health; burnout was assessed by two indicators, measuring cynicism and emotional exhaustion.

4 G Giorgi et al.

© 2014 Wiley Publishing Asia Pty Ltd

exhaustion. The scale was validated in a sample of 814
health-care service employees. An exploratory factor
analysis and a confirmatory factor analysis rendered
support for the construct validity of the scale. In this
study, BIT presented a good reliability as Alpha was 0.75.

Negative Acts Questionnaire Revised (NAQ-R)
Workplace bullying was assessed by a reduced version of
the NAQ-R; this was validated in Italy,17 although the
original version was developed in English.4 The factors are
divided into personal bullying (12 factors) and work-
related bullying (5 factors). In the present sample, the
NAQ-R (Italian version) had an Alpha of 0.88.

Majer-D’Amato Organizational
Questionnaire (MDOQ10)

Organizational climate was assessed by 5 out of 10 factors
of the MDOQ10.41 D’Amato and Majer distinguished
organizational from psychological aspects of climate. The
psychological climate factors were assessed in this study:
(i) communication—the free sharing of information
throughout the organization; (ii) autonomy—designing
jobs in ways which give employees wide scope to enact
their work; (iii) team—group cohesion, collaboration and
support among employees; (iv) job involvement—the
extent to which employees experience commitment and
dedication in the organization; (v) leadership—the extent
to which employees experience support and understand-
ing from their supervisors or leaders.

In this study, MDOQ10 factors internal consistency
estimates were: communication (0.80), autonomy
(0.78), team (0.83), job involvement (0.70) and leader-
ship (0.73).

Data analysis
The coefficients of correlation were calculated, and a
structural equation modeling (SEM) was used to examine
structural models. To examine the hypothesis, a series of
analyses and comparisons of competitive models were
conducted. Chi-square difference test for nested models
were conducted.42 In order to evaluate (the fit of) the
models, multiple indices (of fit) were examined.43 One of
the most used (fit) indices is (the) chi-square (χ2); a small
χ2 indicated that the observed data was not significantly
different from the hypothesized model. However, many
authors have suggested that the chi-square test presents
limitations, especially in large sample studies.44 There-
fore, to support the appropriateness of the model,

alternative indices, which seem preferable in large
samples, were used: (i) the goodness of fit index (GFI)45;
(ii) the comparative fit index (CFI)46; (iii) the root mean
square error of approximation (RMSEA)47 and the root
mean square residual (RMR)45; and (iv) the incremental fit
index (IFI).43 The following criteria were established
to assess the model fit: GFI ≥ 0.90, AGFI ≥ 0.90,
CFI ≥ 0.90, RMSEA < 0.08, IFI ≥ 0.90.48

RESULTS
Table 1 presents correlations among the research vari-
ables. All dimensions presented in the model were
correlated.

The results from the structural equation modeling par-
tially support the theoretical model (Fig. 1). As can be
seen in Figure 2, organizational climate is associated with
negative acts (β = −0.56). Negative acts (β = 0.47) and
organizational climate (β = −0.15) are then associated
with burnout. Finally, burnout is associated with health
(β = 0.75).

Hypotheses 1 and 2 were confirmed: workplace bully-
ing partially mediated the climate–burnout relationship
and influenced health only indirectly, through the media-
tion of burnout. The third hypothesis was only partially
confirmed, because a direct effect of climate of health was
not found. Indeed, the direct association of organizational
climate with health is not significant. However, the
effects of bullying and burnout were found in the climate–
health relationship; consequently, organizational climate
affected health only indirectly. An evaluation of the
considered indices showed that this model met
the recommended criteria better than competitive
models: GFI = 0.959, AGFI = 0.933, CFI = 0.953,
RMSEA = 0.066, IFI = 0.953. In combination, these
indices suggest a satisfactory fit to the data. Examination
of the path coefficients for the model (Fig. 2) indicated the
proposed paths were significant, with standardized esti-
mates ranging from 0.84 to 0.15.

DISCUSSION AND CONCLUSION
The present study supports the importance of poor
organizational climate, workplace bullying and burnout as
predictors of negative psychological health. However,
climate impacts on health only directly, highlighting the
significant and important roles played by bullying and
burnout. Negative organizational climate might have a
limited impact on health. As advanced earlier, nurses
learn to cope with or to tolerate job and organizational

Testing a new theoretical model 5

© 2014 Wiley Publishing Asia Pty Ltd

difficulties typical of the profession. However, where they
are victims of workplace bullying and develop burnout
symptoms, their health is seriously affected. In addition,
our results suggest that workplace bullying partially medi-
ates the relationship between organizational climate and
burnout. Thus, increased perceptions of bullying are asso-
ciated with burnout and seem to play a significant role in
health. Indeed, when bullying occurs, people working in
hostile and negative organizational climates are generally
inclined to consider it as intentional and harmful, to per-
ceive the seriousness of the event and to feel a victim and
at risk of burnout.20 Consequently, people perceiving a
bullying and negative organizational climate are more
prompt to report burnout. Indeed, burnout is more likely
to appear in those organizations where a ‘climate for bul-
lying’ exists (e.g. negative communication, poor leader-
ship, lack of support). The association of bullying with
burnout agreed with current literature that reported a
significant association between bullying behaviours and
burnout.35 Accordingly, employees often did not experi-
ence isolated stressors and the effects of multiple stressors
seem particularly hazardous.49 In addition, our study
shows that workplace bullying does not affect health
directly, but indirectly, via the total mediation of
burnout. Indeed, bullying is associated with nurses’
psychological and physical health through the mediation of
burnout only. According to recent studies, organizations
could have greater responsibility50,51 for diffusing negative
acts, and employees could tolerate and accept these nega-
tive acts, unless they report burnout. Indeed, our results
suggest that organizational climate does not affect health
directly, but only via the mediation of bullying and
burnout. These findings demonstrate the importance of
workplace bullying and workplace burnout in the
climate–health relationship and suggest that, in order to
understand and to study nurses’ health, attention must be
paid to this pattern.16,31,52,53 This particular finding leads us
to reflect on the importance that workplace climate per-
ception has on mental and physical health. Negative
climate perceptions could be considered tolerable and
endurable, whereas when employees suffer burnout and
bullying simultaneously they could be perceived as
harmful and intolerable, causing negative consequences
on workers’ health. Consequently, bullying and burnout
can intensify the effect of a negative workplace climate on
health, creating a toxic work environment. Once a work-
place has an entrenched pattern of negative interaction, it
can be difficult to disrupt.38Ta

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6 G Giorgi et al.

© 2014 Wiley Publishing Asia Pty Ltd

Limitations exist in this study. Caution is necessary with
cross-sectional data because causality cannot be inferred.
Additionally, our study used only one source of informa-
tion for data collection (self-reported questionnaire),
which might introduce common bias and might inflate
correlations between variables.54 Furthermore, the
samples are limited and are not representative of the Italian
population. Thus, further research should overcome these
limitations and conduct studies using different information
sources and samples. However, implications for this study
do exist. Due to the limited role played by organizational
climate on health, the policies, orientation, training pro-
grammes and interventions that aim to improve health
would benefit from a focus on workplace bullying and
burnout. Such interventions should be performed by
supervisors or co-workers to increase their knowledge of
these organizational occurrences. In particular, our results
suggest that organizational programmes that take into con-
sideration the prevention of workplace bullying and
burnout can better create protective factors for mental

health and physical problems than by focusing solely on the
organizational climate. In addition, providing supervisors
with skills and information on bullying and burnout could
have a positive effect on both individuals and teams. In
addition, our results underline the importance of mea-
suring organizational climate, workplace bullying and
burnout concurrently, in order to prevent health prob-
lems in nurses. The present findings show that focusing on
organizational climate alone is not sufficient, because the
occurrences of harassment and burnout problems might
have additional negative effects on health. In our opinion,
an integrated evaluation on the effects of burnout, bullying
and organizational climate is necessary to better under-
stand how to promote health and prevent psychological
and physical problems. Finally, this study underlines
the phenomenon of bullying tolerance and negative
organizational climate acceptability that appear novel in
the research field; different interventions appear to be
needed in professions where bullying is more acceptable
and invisible than in professions where bullying appears

Figure 2. (The) proposed structural equation model. Note: Organizational climate was assessed by five psychological aspects of climate: commu-

nication, leadership, job involvement, team and autonomy; workplace bullying was divided into personal bullying and work-related bullying; health

was assessed by perceived psychological and physical health; burnout was assessed by two indicators, measuring cynicism and emotional exhaustion.

Testing a new theoretical model 7

© 2014 Wiley Publishing Asia Pty Ltd

socially sanctioned and visible. In conclusion, programmes
aimed to reduce nurse resignations because of a lack of
power and autonomy are recommended in order to
prevent the development of burnout as well as improve
well-being at work.

REFERENCES
1 Chappell D, Di Martino V. Violence at Work. Geneva: Inter-

national Labour Office, 2006.
2 Einarsen S, Hoel H, Zapf D, Cooper CL. The concept of

bullying at work: the European tradition. In: Einarsen S,
Hoel H, Zapf D, Cooper CL (eds). Bullying and Emotional
Abuse in the Workplace: International Perspectives in Research
and Practice, 1st edn. London: Taylor & Francis, 2003;
3–30.

3 Leymann H. Mobbing and psychological terror at work-
places. Violence and Victims 1990; 5: 119–126.

4 Einarsen S, Mikkelsen EG. Individual effects of exposure to
bullying at work. In: Einarsen S, Hoel H (eds). The Negative
Acts Questionnaire: Development, Validation and Revision of a
Measure of Bullying at Work. Paper presented at the 10th
European Congress on Work and Organizational Psychol-
ogy, Prague, 2001.

5 Mathisen GE, Einarsen S, Mykletun R. The occurrences and
correlates of bullying and harassment in the restaurant
sector. Scandinavian Journal of Psychology 2008; 49: 59–68.

6 Ouellet-Morin I, Danese A, Bowes L et al. A discordant
monozygotic twin design shows blunted cortisol reactivity
among bullied children. Journal of the American Academy of
Child and Adolescent Psychiatry 2011; 50: 574–582.

7 Einarsen S, Skogstad A. Prevalence and risk groups of bul-
lying and harassment at work. European Journal of Work and
Organizational Psychology 1996; 5: 185–202.

8 Aquino K. Structural and individual determinants of work-
place victimization: The effects of hierarchical status and
conflict management style. Journal of Management 2000; 26:
171–193.

9 Raynor C. Bullying and Harassment at Work: Summary of Find-
ings. Research Update Conference on Bullying at Work’,
University of Staffordshire Business School, 2000.

10 Salin D. Prevalence and forms of bullying among business
professionals: A comparison of two different strategies
for measuring bullying. European Journal of Work and
Organizational Psychology 2001; 10: 425–441.

11 Johnson SL. International perspectives on workplace bully-
ing among nurses: A review. International Nursing Review
2009; 56: 34–40.

12 Einarsen S, Matthiesen SG, Skogstad A. Bullying, burnout
and well-being among assistant nurses. Journal of Health
Safety 1998; 14: 563–568.

13 McKenna BG, Smith NA, Poole SJ, Coverdale JH. Experi-
ence before and throughout the nursing career. Horizontal

violence: Experiences of Registered Nurses in their first
year of practice. Journal of Advanced Nursing 2003; 42:
90–96.

14 Hogh A, Carneiro IG, Giver H, Rugulies R. Are immigrants
in the nursing industry at incresead risk of bullying at work?
A one-year follow-up study. Scandinavian Journal of Psychol-
ogy 2011; 52: 49–56.

15 Kingma M. Workplace violence in the health sector: A
problem of epidemic proportion. International Nursing
Review 2001; 48: 129–130.

16 Arcangeli G, Giorgi G, Ferrero C, Cupelli V, Mucci N.
Prevalence of workplace bullying in a population of nurses
of three Italian hospitals. Giornale Italiano Di Medicina Del
Lavoro Ed Ergonomia 2014; 36(3): 181–185.

17 Giorgi G, Arenas A, Leon-Perez JM. An operative measure
of workplace bullying: The negative acts questionnaire
across italian companies. Industrial Health 2011; 49: 686–
695.

18 Moreno Jimenez B, Rodriguez Muñoz A, Salin D,
Morante ME. Workplace bullying in Southern Europe:
Prevalence, forms and risk groups in a Spanish sample.
International Journal of Organisational Behaviour 2008; 13:
95–109.

19 Escartin J, Zapf D, Arrieta C, Rodriguez-Carballeira A.
Workers’ perception of workplace bullying: A cross-
cultural study. European Journal of Work and Organizational
Psychology 2011; 20: 178–205.

20 Hoel H, Faragher B, Cooper CL. Bullying is detrimental to
health, but all bullying behaviours are not necessarily
equally damaging. British Journal of Guidance and Counselling
2004; 33: 367–387.

21 Einarsen S. Harassment and bullying at work: A review of
the scandinavian approach. Aggression and Violent Behavior
2000; 5: 379–401.

22 Beech B, Leather P. Workplace violence in the health care
sector: A review of staff training and integration of training
evaluation models. Aggression and Violent Behaviour 2006; 11:
27–43.

23 Farrell G. From tall poppies to squashed weeds: Why don‘
t nurses pull togheter more? Journal of Advanced Nursing
2001; 36: 26–33.

24 Hutchinson M, Vickers M, Jackson D, Wilkes L. Work-
place bullying in nursing: Towards a more critical
organizational perspective. Nursing Inquiry 2006; 13: 118–
126.

25 Lewis MA. Nurse bullying: Organizational considerations
in the maintenance and perpetration of health care bullying
cultures. Journal of Nursing Management 2006; 14: 52–58.

26 Duffy M, Sperry L (eds). Mobbing, Causes, Consequences and
Solutions, New York, Oxford University Press Inc., 2012;
106–115.

27 Hutchinson M, Vickers M, Jackson D, Wilkes L. I‘m gonna
do what i wanna do: Organizational change as a legitimized

8 G Giorgi et al.

© 2014 Wiley Publishing Asia Pty Ltd

vehicle for bullies. Health Care Management Review 2005; 30:
331–336.

28 Rowe MM, Sherlock H. Stress and verbal abuse in nursing:
Do burned out nurses eat their young? Journal of Nursing
Management 2005; 13: 242–250.

29 Curtis J, Bowen I, Reid A. You have no credibility: Nursing
student’s experiences of horizontal violence. Nurse Educa-
tion in Practice 2007; 7: 156–163.

30 Daiski I. Changing nurses‘ dis-empowering relationship pat-
terns. Journal of Advanced Nursing 2004; 48: 43–50.

31 Arcangeli G, Mucci N. Health problems in the working
occupation of young people in handicraft factories. Giornale
Italiano Di Medicina Del Lavoro Ed Ergonomia 2014; 31: 303–
306.

32 Savicki V, Cooley E, Gjesvold J. Harassment as a predictor
of job burnout in correctional officers. Criminal Justice and
Behavior 2003; 30: 602–619.

33 Kivimäki M, Elovainio M, Vahtera J. Workplace bullying
and sickness absence in hospital staff. Occupational and Envi-
ronmental Medicine 2000; 57: 656–660.

34 Trépanier S, Fernet C, Austin S. Workplace bullying and
psychological health at work: The mediating role of satis-
faction of needs for autonomy, competence and related-
ness. Work and Stress 2013; 27: 123–140.

35 Sà L, Fleming M. Bullying, burnout, and mental health
amongst portuguese nurses. Issues in Mental Health Nursing
2008; 29: 411–426.

36 Van Dick R, Wagner U. Stress and strain in teaching: A
structural equation approach. British Journal of Educational
Psychology 2001; 71: 243–259.

37 Giorgi G, Leon-Perez JM, Cupelli V, Mucci N, Arcangeli
G, Do I. Just look stressed or am I stressed? Work-related
stress in a sample of italian employees. Industrial Health
2014; 52: 43–53.

38 Giorgi G, Majer V. Mobbing virus organizzativo (Mobbing
Organizational Virus). Firenze: Giunti Os Organizzazioni
Speciali, 2009.

39 Magnani M, Mancini G, Majer V. Opra (Organizational Psy-
chosocial risk assessment). Firenze: Giunti Os Organizzazioni
Speciali, 2009.

40 Mancini G, Magnani M. La misura del burnout: Sviluppo di
un indicatore per la valutazione del benessere organizzativo.
Risorsa uomo: Rivista di psicologia del lavoro e dell’organizzazione
2008; 14: 221–234.

41 D’Amato A, Majer V. M_DOQ10 Majer_D’Amato
Organizational Questionnaire 10. Firenze: Giunti Os
Organizzazioni Speciali, 2005.

42 Satorra A, Bentler PM. A scaled difference chi-square test
statistic for moment structure analysis. Psychometrika 2001;
66: 507–514.

43 Bollen KA. Structural Equations with Latent Variables. New
York: Wiley, 1989.

44 Tabachnick BG, Fidell LS. Using Multivariate Statistics. New
York: HarperCollins College Publishers, 1996.

45 Jöreskog K, Sörbom D. LISREL 8: Structural Equation Mod-
eling with the SIMPLIS Command Language. Chicago, IL, USA:
Scientific Software International Inc, 1993.

46 Bentler PM. Comparative fit indexes in structural models.
Psychological Bulletin 1990; 107: 238–246.

47 Steiger JH. Structural model evaluation and modification.
Multivariate Behavioral Research 1990; 25(2): 173–180.

48 Schumacher RE, Lomax RG. A Beginner’s Guide to Structural
Equation Modeling. Mahwah, NJ, USA: Lawrence Erlbaum
Association, 1996.

49 Schneider KT, Hitlan RT, Radhakrishnan P. An examina-
tion of the nature and correlates of ethnic harassment
experiences in multiple contexts. Journal of Applied Psychol-
ogy 2000; 85: 3–12.

50 Giorgi G. Workplace bullying in academia creates a
negative work environment. An italian study. Employee
Responsibilities and Rights Journal 2012; 24: 261–275.

51 Lansisalmi H, Peiro JM, Kivimaki M. Collective stress and
coping in the context of organizational culture. European
Journal of Work and Organizational Psychology 2000; 9: 527–
559.

52 Mucci N, Giorgi G, Gonnelli IM, Garbarino S, Cupelli V,
Arcangeli G. The operational role of the occupational health
physician in the assessment and management of health risks
related to night work. Giornale Italiano Di Medicina Del Lavoro
Ed Ergonomia 2014. in press.

53 Mucci N, Montalti M, Cupelli V, Arcangeli G. Evaluation
of the impact of night-work on health in a population of
workers in Tuscany. Giornale Italiano Di Medicina Del Lavoro
Ed Ergonomia 2012; 34: 381–384.

54 Podsakoff PM, MacKenzie SB, Lee J, Podsakoff NP.
Common method biases in behavioral research: A critical
review of the literature and recommended remedies.
Journal of Applied Psychology 2003; 88: 879–903.

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