Background

Nursing curricula are designed to facilitate the acquisition of the profession's knowledge, skills and attitudes1 including the ethical value of maintaining respectful relationships.2 While formal curricula help students develop essential knowledge and skills, much of what students learn about the profession's norms and values comes from social interactions with faculty, sometimes referred to as informal curricula.3 When nursing faculty demonstrate caring and respectful behaviors during student interactions, they act as positive professional role models and encourage such behaviors in their students.3,4 Conversely, unresponsive or demeaning faculty behaviors can invoke reciprocal hostile responses from students, and these negative behaviors may persist into practice.3,5 Bartholomew5 reported that horizontal violence among nurses resulted in 60% of new graduates leaving their first job in nursing within the first six months.

Incivility, defined as rude or disruptive actions or speech, presents in academia in a range of behaviors from insulting remarks to explosive behaviors. Academic incivility may be considered as any speech or behavior that negatively affects the wellbeing of students or faculty members, weakens professional relationships and hinders the teaching-learning process.4 Clark identified that incivility in nursing "often result(s) in psychological or physiological distress for the people involved and, if left unaddressed, may progress into a threatening situation".6^(p.158) The problem is compounded by a lack of consensus on what to call incivility in nursing education. Common words used to describe the phenomenon of incivility include bullying, cyberbullying, lateral violence, violence, disruptive behavior, horizontal violence, misconduct and mobbing.

Incivility in nursing education is a serious global issue, negatively affecting student and faculty relationships and the educational process.4,7 The International Society of Psychiatric-Mental Health Nurses assumes the position that disruptive behaviors, including incivility, in the educational setting poses a threat to nurses' wellbeing and ultimately patient safety.8 Both faculty and students voice concerns about the rise of uncivil behaviors making the issue particularly concerning in light of a national shortage of nurses and nurse faculty. Uncivil behaviors by students may spiral into aggression, which contributes to the reason some faculty choose to leave nursing education,9 while faculty-exhibited uncivil behaviors may leave students feeling demeaned and powerless.8

In face-to-face classes, student incivility visibly manifests as behaviors such as cheating on tests, sleeping in class, holding side conversations, being late, engaging in verbal abuse or using cell phones during lectures.6,7 Students perceive that faculty are being uncivil in traditional face-to-face courses when they cancel classes at the last minute, are unprepared, disinterested or unavailable outside of class, do not allow open discussions or taunt students.6 However, nursing education is increasingly taking place in the online environment, creating a different avenue for incivility where behaviors being perceived as being rude or disruptive may not be as apparent.10,11 Online learning environments (OLEs) are a venue for a unique type of incivility known as cyberbullying and involve the use of the internet, cell phones or other devices to send or post text or images intended to hurt or embarrass another person.12 Examples of behaviors considered as uncivil in the online environment may include intimidation and posting rude comments, rumors, gossip or humiliating materials.13,14 Sending harassing emails where recipients have little opportunity to defend themselves instead of having face-to-face conversation is another common example of cyberbullying.14

Descriptions of the incidence of incivility in online academic learning environments vary. Faculty may describe bullying, or disruptive behavior, cheating on tests, holding side conversations, submitting assignments late, challenging faculty knowledge, engaging in verbal abuse6,7 and inappropriate comments about other faculty, or cultural or sexual slurs.15 Students may identify faculty as uncivil when they provide rude comments, unclear course expectations, untimely or vague replies to students, posting grades late, inadequate feedback or unfair grading, failure to control the classroom and acting superior. Students may also describe peers as exhibiting uncivil behaviors.15 Faculty or students may unknowingly engage in behaviors perceived by others to be uncivil. One possible reason for unintentionally engaging in incivility in the online environment may be that parties lack adequate preparation to understand appropriate online communication.16 Another reason for unintentional incivility may be that students and faculty simply do not understand what constitutes civil interactions and appropriate behavior in an OLE.17 A sense of anonymity in an OLE can encourage rude or aggressive behavior.10

In 2015, the American Nurses Association released a position statement on incivility, bullying and workplace violence indicating registered nurses, along with employers, and academia, are legally, morally and ethically responsible to create a healthy environment in the workplace for registered nurses that is free from incivility, bullying and violence.18 The concern for workplace violence in health care spans across the continuum in education and healthcare settings and extends internationally.2,8 World Health Organization, as early as 2006, reported that health workers are at particularly high risk for violence, accidents, illness and death and may lead to workers exiting the workforce, noting that violence against women in the forms of physical violence, assaults and bullying is significant.19 The issue of workplace incivility is global and continues to persist without abating, negatively impacting education and practice. Egyptian nursing students and faculty raised the concern that the rise of uncivil behaviors was leading to a decline in professional ethics.20 Researchers in China studied student perceptions of student incivility in a nursing college and found it was a significant problem needing to be addressed.21 The rise of uncivil behavior in Iranian students was described as multifactorial caused by student, faculty and organizational infuences.22 Canadian studies have shown that female faculty and students are more likely to experience cyberbullying, thus leaving the predominantly female profession of nursing at risk.23,24

The growth of online education continues "even in the face of declining overall higher education enrollments".25^(p.4) No longer considered novel, online learning is an integral part of education. A need to synthesize what is known about faculty and student perceptions of incivility in online nursing education exists to understand uncivil behavior in the online environment, prevent incivility, establish standards for civility in the OLE and recommend directions for future interventional studies to address the behaviors being perceived as most troubling. This qualitative systematic review will synthesize the available evidence to guide faculty as they strive to understand the experiences of incivility and establish expectations for online classroom interactions.

A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, CINAHL and PubMed for existing systematic reviews on the specific topic was conducted and none were located.

Inclusion criteria

Types of participants

The current review will consider studies that investigate faculty who are nurses and are teaching a credit bearing online nursing course or working in an online nursing education environment. The review will also consider nursing students enrolled in an online course or nursing program in an academic institution.

Phenomena of interest

The current review will consider studies that investigate faculty and student perceptions and experiences of incivility in online nursing education occurring in academic environments. The experiences of incivility may involve any interactions that occur between and among staff and students via online.

Context

Academic nursing programs offering online courses in pre-licensure, graduate and post-graduate education which includes the classroom, email, phone and/or text.

Types of studies

The current review will consider studies that focus on qualitative data including but not limited to designs such as phenomenology, grounded theory, qualitative descriptive, ethnography, action research, case study, q methodology and feminist research. Mixed-method studies with a narrative description of faculty or student voices describing the phenomenon under study will also be considered.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of CINAHL Complete, CINAHL with Full Text and PubMed will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article using ("nursing students" OR "nursing faculty") AND (incivility OR bullying OR aggression OR violence OR mobbing) AND (education) AND (online or distance or remote). The results will then be utilized for the additional two steps in the search strategy.

A second search using all identified keywords and index terms will then be undertaken across all included databases.

The third component of the search strategy involves the reference list of all identified reports and articles being searched for additional studies. All primary studies published and unpublished in English will be considered for inclusion in this review. Gray literature such as research reports and dissertations will also be considered for inclusion.

Online-only courses began emerging in the late 1980s, with moderate success. Therefore, the search strategy will include studies published from 1980 through 2016.

The databases and sources to be searched include:

CINAHL

SSCI

PubMed (MEDLINE)

ERIC

ProQuest XML-Dissertations and Theses

ISI Web of Science

Embase

Wiley Interscience

Scopus

NDLTD

EThoS

Google Scholar

National Repository of Digital Theses

Science Direct

British Library

Academic Search Premier

Education Research Complete

PsycARTICLES

PsycINFO

eBook Academic Collection (EBSCOhost)

The search for unpublished studies, including gray literature, will include:

Hand search of references

Open Grey

Conference Proceedings

British Library

National Library of Australia

Deep Blue Library

Assessment of methodological quality

Qualitative papers will be selected for retrieval and be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the populations, study methods and phenomena of significance to the review question and specific objectives.

Data synthesis

Qualitative research findings will be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorize findings on the basis of similarity in meaning (Level 2 findings). The categories will be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Acknowledgements

The current project was made possible through systematic review training received in June 2015 by Dr Lisa Hopp, Dr Leslie Rittenmeyer, BV and Dr Michelle Block from the Indiana Center for Evidence-based Nursing Practice at Purdue Northwest.

Appendix I: Appraisal instruments

QARI appraisal instrument

Appendix II: Data extraction instrument

QARI data extraction instrument

References