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Discuss strategies in addressing the issue

incivility in the nursing profession

 abstract ; The purpose of this study was to determine if there were differences in the perceptions of uncivil behaviors among nursing students and faculty according to pre-licensure nursing program types, and if there were any relationships in reported uncivil behaviors to the variables of age, gender, ethnic/racial background, and parental level of education. The sample was a convenience sample of 159 pre-licensure senior nursing students and 14 nursing faculty from four schools of nursing in the northeastern United States: two Bachelor of Science in Nursing (BSN) programs, one Associate Degree in Nursing (ADN) program, and one hospital-based diploma nursing program. The nursing students and nursing faculty were administered a mixed method, validated survey instrument, the Incivility in Nursing Education (INE) Survey (Clark et al., 2009). The results of the survey identified similarities and differences between the BSN, ADN, and diploma nursing programs for both the perceptions and experiences of uncivil behaviors, however no significant differences were found between the demographic variables and the occurrence of uncivil behaviors. © 2017 Elsevier Ltd. All rights reserved. 1. Introduction Most nurses choose nursing because they have a strong interest in caring for patients (Lachman, 2014). Incivility is, therefore, a particular problem in nursing because caring is at the heart of the profession (Trossman, 2014). What is incivility? Clark (2008a,b) defines incivility in nursing education as “rude or disruptive behaviors which often result in psychological or physiological distress for the people involved and if left unaddressed, may progress into threatening situations.” Uncivil behavior may be described as a type of behavior that is disruptive to the learning environment. Examples of disruptive behaviors that may be seen in nursing students include the behaviors of making disapproving groans, making sarcastic remarks or gestures, using cell phones during class, and cheating on examinations. Examples of uncivil behaviors that may be exhibited by nursing faculty include canceling class without warning, being unprepared for class, not allowing open discussion, being disinterested or cold, belittling or taunting students, delivering fast-paced lectures, and not being available outside of class (Clark et al., 2009). However, there are varying definitions in the literature used to describe disruptive behavior. One such term is horizontal violence. Baltimore (2006) describes horizontal violence as a wide range of antagonistic behaviors such as gossiping, criticism, innuendo, scapegoating, undermining, intimidation, passive aggression, withholding information, insubordination, bullying, and verbal and physical aggression. Another descriptive term to describe disruptive behavior in nursing is “nurses eating their young.” The American Nurses Association (2013) describes “nurses eating their young” as behaviors reminiscent of bullying, which represents how nurses work against each other instead of working together. In the health care environment, the perpetrators or victims of incivility may be the nurses, graduate nurses (newly licensed nurses), nursing students, or nursing faculty (Ostrofsky, 2012). Despite other definitions, the focus of this study was using the term of incivility. 2. Background 2.1. Incivility in the nursing profession Interpersonal conflict has been reported in the nursing literature for more than twenty years and it is particularly rampant in female dominated professions, therefore is present to a high degree E-mail address: k..l@astate.edu. in nursing (Weinand, 2010). Women have traditionally led the Contents lists available at ScienceDirect Nurse Education in Practice journal homepage: www.elsevier.com/nepr http://dx.doi.org/10.1016/j.nepr.2017.08.016 1471-5953/© 2017 Elsevier Ltd. All rights reserved. Nurse Education in Practice 27 (2017) 36e44 fields of healthcare, education, and psychology. According to the U. S. Department of Education’s National Center for Education Statistics, women dominate healthcare at 78% (Dehne, 2009). Besides nursing, other female dominant disciplines experience disruptive behavior. However, more extant research has been done in the nursing profession (Avillion, 2013). The profession of nursing is mostly female and nurses may come to believe that subjugation in nursing is a natural part of being a nurse (Szutenbach, 2013). The pervasiveness of incivility in nursing can be illustrated from a global perspective. Although there is scant research on how incivility differs among nursing program types, there is research that supports that incivility is a widespread problem in the nursing profession worldwide. Nixon (2014) reports that nurses are one of New Zealand’s most trusted professions as the nurses are expected to follow a code of ethics and demonstrate a high degree of professionalism. However, Nixon found that most undergraduate nursing students experience some form of horizontal violence during their training. International research studies have found that horizontal violence is most prevalent against new graduate nurses during the first year of nursing practice (Flateau-Lux and Gravel, 2013). Iglesias and Vellajo (2012) surveyed 538 Spanish nurses who have been working for at least one year. Almost one in five nurses reported being exposed to workplace bullying with the most frequent negative behavior being given tasks with unreasonable or impossible targets or deadlines. A literature review by Hutchinson et al. (2013) reviewed the existing research on nurses working in Australia, Italy, New Zealand, Sweden, Switzerland, Taiwan, Turkey, and the United Kingdom. The research focused on the country-specific prevalence studies of violence, bullying, and aggression (VBA) in nursing. The findings revealed VBA is a cycle of enculturation; it continues because the unacceptable behaviors are tolerated or passively witnessed. The researchers point out that “many nurses work within environments that feature VBA and situations of disagreement and conflict” (Hutchinson et al., 2013, p. 903). A large survey of 27,000 nurses was given by the National Health Service, which is the largest publicly funded health service in the United Kingdom. This survey found that 42% of nurses had reported some type of workplace violence in 2012 and that the number of nurses who experienced workplace violence has almost doubled in a year (Duffin, 2013). Incivility in the nursing profession is a prevalent concern on a global level (Duffin, 2013; Flateau-Lux and Gravel, 2013; Iglesias and Bengoa Vallejo, 2012; Nixon, 2014; Read and Laschinger, 2013). However, there is a need for large multinational studies as the research thus far has been country-prevalence studies (Hutchinson et al., 2013). 2.2. Incivility in nursing academia Incivility is a pervasive problem in nursing academia and can negatively impact the educational process. Baker (2012) found that negative nursing culture is a learned behavior that sometimes is introduced in nursing school. Uncivil behaviors from nursing school can further transcend into bullying behaviors in professional nursing practice. Nursing students may be socialized in their training programs to expect and perpetuate a continued cycle of horizontal violence in the profession (Croft and Cash, 2012). According to Thompson (2013), incivility and horizontal violence in nursing continue because most nurses believe that this is normal behavior, especially at the beginning of a nursing career. This incivility has been referred to as a rite of passage for nursing students and it will also most likely reoccur when they work as nurses (Nixon, 2014). Clark, Olender, Kenski, and Cardoni (2011) studies of 174 nurse leaders identified incivility and disruptive behaviors in the academic setting and the clinical setting. The researchers report that “both groups identified a noticeable gap between nurses in education and practice” (p. 326). Croft and Cash (2012) recount that nursing students are socialized to understand the hierarchy in nursing and the term “nurses eating nurses.” Incivility may begin in nursing school and continue into the first nursing position when the staff nurse, colleagues or nurse administrators take over as the second offenders (Meissner, 1986). However, the link between disruptive behaviors in nursing school and the clinical setting is questionable. There is no direct study that has made the connection between uncivil nursing students becoming uncivil nurses. Incivility is more of a concern in nursing academia since students are entering a profession that is renowned for caring and professionalism. Ditmer (2010) reports that disruptive behaviors to the classroom environment impede learning in a profession where a strong knowledge base is the single most important tool a nurse can bring to the bedside. Marchiondo, Machiondo, and Lasiter (2010) found that incivility is most likely to occur most often in the classroom environment and almost as often in the clinical setting. The authors point out that, “These environments involve regular interactions between faculty and students and include elements of feedback and criticism” (Marchiondo et al., 2010, p. 613). Therefore, incivility is more likely due to the nature of nursing academia. Faculty incivility. Incivility has been found to occur from nursing faculty as well as nursing students. A major factor of faculty incivility is a high stress environment in nursing education (Clark and Springer, 2007). Another factor identified to cause faculty incivility is the attitude of faculty superiority (Clark, 2008a,b). Nursing faculty incivility can result in a lack of professional, respectful behavior. Beasley (2010) points out that faculty are expected to be a role model for the nursing students by displaying respectful, collegial behaviors. However, many nurse educators thrive on the feeling of superiority that comes from controlling students (Baltimore, 2006; Clark and Springer, 2007). The goal for nursing faculty is to teach acceptable, positive behavior in order for the nursing student to flourish (Kolanko et al., 2006). Another cause faculty incivility is faculty revealing too much personal information regarding aspects of their personal lives to students. Trad et al. (2012) administered a survey to 209 undergraduate students with various majors. The researchers found that instructor selfdisclosure was positively associated with incivility in the classroom; when an instructor revealed personal information to the students, there was an increase in uncivil behaviors of the students. The findings supported the notion that instructors should not selfdisclose their personal lives to students. Student incivility. Nursing students from all types of training programs have similar stressors. Clark, Nguyen, and Barbosa-Leiker (2014) found that the three main stressors for nursing students were demanding academic workloads, balancing time, work, and school, and family, and finding time to relax. The academic workload is rigorous and there is an additional pressure to succeed on high stakes testing in nursing school. Once the nursing student graduates, the pressure continues to pass the NCLEX-RN to become licensed as Registered Nurses. The stressors of becoming a nurse may further manifest as uncivil behaviors during school. In addition to the stressors, students may also have generational differences and diverse views on what constitutes appropriate behavior (Alexander and Sysko, 2011). The generational differences may be described as students feeling entitled; this may contribute to uncivil behavior. Incivility has been reported as a moderate to a serious problem in nursing academia. 2.3. Gaps in incivility research Incivility negatively impacts the educational process of both K. Aul / Nurse Education in Practice 27 (2017) 36e44 37 nursing students and nurse educators. There is ample research on the existence of incivility in nursing and nursing education; however, there is minimal research in the targeted area of this study, which is to identify differences in the perceptions of uncivil behaviors among nursing programs. A dissertation by Hoffman (2012) was the first known research to compare incivility among nursing program types (diploma, associate degree, and bachelor’s degree). The study found that students have similar perceptions regarding student incivility among nursing program types. The results also indicated that there was a correlation between the younger ages of the nursing student to an increased perception of faculty incivility. Therefore, there are gaps in the literature regarding the occurrence of incivility in different types of nursing training programs as well as the effect of the nursing student’s demographic variables on uncivil behavior. The variables of sex, age, ethnic/racial background, and parental level of impact were collected to determine if there was an effect on the reported occurrence of uncivil behaviors by program type for nursing students and faculty. This study was significant because the data from the nursing students and faculty were analyzed to determine if there were differences in their perceptions of uncivil behaviors among the three different types of nursing programs. Three different types of nurse training programs were selected because of the author’s experience in observing the differences in nursing student behavior depending on the type of training program. It was expected that there would be differences in the results of the types of uncivil behaviors between nursing training programs. T. 2.4. Research questions There were two research questions posed. Research Question 1 asked: What are the frequencies, types, and differences between the reported uncivil behaviors in clinical and classroom settings among senior level nursing students and nursing faculty in three identified training programs (Diploma, ADN, and BSN nursing programs) as reported by the INE survey? Quantitative data from the INE survey was collected and analyzed to answer this question. Research Question 2 asked: What qualitative differences of uncivil behaviors are reported by nursing students and faculty in the different types of training programs? Qualitative data from the INE survey was collected and analyzed to answer this question. Why is it important to identify the occurrence of incivility in nursing students from different types of training programs? The findings of the study provide information concerning nursing student and faculty perceptions and experiences with incivility in nursing academia. The results from this research confirm that incivility exists in nursing academia, and this varies depending on the type of nurse training program. Strategies to manage uncivil behaviors in nursing academia can be further recommended to help students, faculty, administrators, and healthcare organizations. 3. Methodology 3.1. Design In order to obtain data on the perceptions of uncivil behaviors among nursing students and nursing faculty from the three different types of pre-licensure nursing programs, a cross-sectional analytical study was completed using the validated survey instrument, the Incivility in Nursing Education (INE) Survey. The INE survey was selected because it measures both the nursing student and the nursing faculty perceptions of incivility in nursing education. The types of uncivil behaviors to be measured on the INE survey were adapted by Dr. Cynthia Clark from the following pre-existing surveys: “Defining Classroom Incivility (DCI)” survey designed by the Center for Survey Research at the University of Indiana in 2000 and the “Student Classroom Incivility Measure (SCIM)” and the Student Classroom Incivility Measure-Faculty (SCIM-F)” from the research of Michelle Fryer Hanson in 2000. Content validity of the INE survey was established by an expert panel of content reviewers (Clark et al., 2009). The expert panel consisted of six university professors, both nursing and non-nursing, ten nursing students, and one statistician. “Reviewers found the items highly reflected academic incivility” (Clark et al., 2007, p. 8). With content validity established, the INE survey was first used by Clark in a 2004 pilot study of 356 nursing students and faculty. The INE survey was then modified in 2007 after the results from a second study of 504 nursing students and faculty and a qualitative study by Clark revealed the need for some revisions (Clark et al., 2009). This particular survey was also chosen because while the majority of the survey was quantitative (questions 1e15), a qualitative portion of the questionnaire (questions 16e20) provided additional specific data on nursing student and nursing faculty perceptions of incivility. Therefore, objective data was gathered from the questionnaire to determine the presence and types of uncivil behaviors within the pre-licensure nursing programs as well as subjective data from the open-ended questions on the survey. 3.2. Study sample The INE survey obtained data on the perceptions of incivility Table 1 Demographic characteristics of the nursing students (N ¼ 159). Variable Category Diploma n ¼ 23 ADN n ¼ 50 BSN-1 n ¼ 48 BSN-2 n ¼ 38 Gender Female 78.3% 88.0% 89.6% 100.0% Male 21.7% 12.0% 10.4% 0% Age 19e25 34.8% 48.0% 95.8% 89.5% 26e30 26.1% 12.0% 0% 0% 31e35 8.7% 22.0% 4.2% 5.3% 36e40 17.4% 2.0% 0% 0% 41e45 8.7% 4.0% 0% 5.3% 46e50 4.3% 8.0% 0% 0% >50 0% 4.0% 0% 0% Ethnic/Racial Background Caucasian (White) 100% 92.0% 97.9% 89.5% Black/African-American 0% 4.0% 2.1% 10.5% Asian 0% 4.0% 0% 0% Parent/Guardians’ Level of Education Below high school 13.1% 8.0% 0% 2.6% High school/GED 86.9% 92.0% 100.0% 97.4% College degree 43.5% 52.0% 70.8% 63.2% 38 K. Aul / Nurse Education in Practice 27 (2017) 36e44 from a convenience sample of 159 senior level nursing students and 14 nursing faculty from two Bachelor of Science in Nursing (BSN) programs, one Associate Degree in Nursing (ADN) program, and one hospital-based diploma in the northeastern United States. All of the selected pre-licensure nursing programs provide training with a formal curriculum that meets the specific requirements of the National Council of State Board of Nursing. The programs prepare graduate nurses to be eligible to take the National Council of Licensing Examination for Registered Nurse (NCLEX-RN) in order to become licensed as Registered Nurses (National Council of State Board of Nursing, 2016). Since the goal from the Institute of Medicine is to increase BSN prepared nurses to 80% by 2020, two BSN programs were selected for the research sample (Bureau of Health Professions, 2013). Also, the BSN training programs were more convenient to sample due to the geographical area where the study was completed. Due to a lack of research found on how demographic variables effect the behavior of nursing students, the survey collected data on the demographic variables of gender, age, ethnic/racial background, and parental level of education to ascertain if there were any relationships between those variables and findings. The demographic page for this survey was revised from the original INE survey to add the areas of gender and parental level of education. Gender was selected to determine the occurrence and types of behavior between genders. The survey respondents indicated gender by the options of male, female, identify with both, identify with neither, and prefer not to disclose. The parental level of education was selected to determine if a low or high parental level of education level increased or decreased the occurrence and types of uncivil behaviors. The parental level of education included a select all that apply for the options of their parent/ guardians’ level of education: below high school, high school/ GED, associate degree, bachelor degree, graduate degree or higher, and prefer not to disclose. The other variables of age and ethnic/racial background were also collected. Age was obtained by filling in the block of year born. The ethnic/racial background had the selections of Black, African-American, Asian, Caucasian (white), Native American, Pacific Islands, Spanish/Hispanic/ Latino/Mexican, and other. 3.3. Data collection Besides receiving approval from each school of nursing in the study, approval was received from the Institutional Review Board from the University Committee on the Research of Human Subjects. As arranged with each school of nursing, the researcher travelled to the four different schools of nursing to administer the INE survey in a nursing classroom after the senior nursing students were done with class. The data collection took place over a six-week period of time in the spring semester to maintain consistency of the data collected and to capture the data before the senior nursing students graduated. Prior to distributing the surveys, the researcher introduced self and provided informed consent to the survey respondents. The informed consent let the survey respondents make the decision about participation in the research study. The informed consent form described how the participation in the study was voluntary and participation or failure to participate had no impact on their course grade. The informed consent also stressed the fact that the responses were anonymous. Next, the INE survey was distributed in a paper and pencil format to each willing participant and a set of identical directions was read to each group of nursing students and faculty. The researcher read the definition of incivility at the top of the survey and reminded participants not to put their name on the survey. The researcher encouraged the nursing students and faculty to fill in all six pages of the survey. The six page survey was administered in paper and pencil version however it also was available as an electronic survey with a link to a secure web-based server. On the electronic survey, there was an added piece to the definition of incivility. Clark (2013) added that incivility, “may progress into threatening situations or result in temporary or permanent illness or injury.” However, this additional definition of incivility was not on the paper and pencil version administered in this research study. The first page of the survey with 9 questions on demographic data was modified to fit the research study. The next four pages of the survey included questions 10e15 and were quantitative in nature. The responses were on a Likert-type scale that rated the item on a continuum that was anchored at either end by opposite responses. Each item was rated according to the frequency in which the behavior occurred, such as always, usually, sometimes, and never. Following the quantitative questions, the last page of the survey was comprised of questions that required a narrative response. These questions were seeking responses to describe the factors contributing to student and faculty incivility, how students and faculty contribute to incivility, and how incivility should be addressed in the academic environment. The qualitative items on the survey were helpful to substantiate the findings from the quantitative questions. Table 2 Student behaviors perceived as disruptive by nursing program type. Type of Behavior Always Perceived as Disruptive Diploma Mean ADN Mean BSN-1 Mean BSN-2 Mean Acting Bored or Apathetic 1.17 1.10 1.11 1.05 Making Disapproving Groans 1.27 2.06 1.75 1.82 Making Sarcastic Remarks 1.35* 1.72 1.98* 1.92* Sleeping in Class 0.77 1.02 1.31 1.26 Not Paying Attention 0.87 1.34 1.38 1.34 Holding Distracting Conversations 2.13 1.92* 2.40* 2.47* Not Answering Questions 1.13 1.06 1.40 1.32 Using Computers During Class 1.04 1.50 1.42 1.11 Using Cell Phones During Class 1.59 1.56 1.63 1.32 Arriving Late 1.48 2.00 1.85 1.82 Leaving Early 1.04 1.42 1.60 1.34 Cutting Class 0.57 0.56 1.31* 0.61* Unprepared for Class 1.04 1.36 1.51 1.39 Dominating ClassDiscussion 1.61 1.84 1.65* 2.16* Cheating on Exams or Quizzes 1.22* 1.80 2.17* 1.87* Demanding Make-up 1.26 1.76 1.81 1.87 *Indicates significant differences among nursing training types, p < 0.05. K. Aul / Nurse Education in Practice 27 (2017) 36e44 39 3.4. Data analysis Data analysis was performed for the quantitative data using SPSS software. A statistical analysis of the demographic variables and the perceptions of uncivil behaviors were completed. The means were determined according to how often the student behavior was considered disruptive according to the Likert scale on the INE survey: never ¼ 0, sometimes ¼ 1, usually ¼ 2, and always ¼ 3. To determine any significant variability between nursing training programs, ANOVA (Analysis of Variance) testing was completed. Further post hoc testing was completed using Scheffe correction to determine which group means were different. For analyzing the demographic variables of gender, ethnic/racial background, and parental level of education, Pearson Chi-Square testing was used to determine whether the frequencies of responses are what would have been expected from the sample. Pearson Correlation was used to determine any relationships between the variable of age. To analyze the qualitative data from the narrative questions, data reduction was first used to organize the information. Rebar et al. (2011) recommends, “breaking down and labeling large amounts of textual data to identify the category in which it belongs” (p. 70). Then the data was analyzed according to Creswell (2013). Preliminary coding helped to sort through the raw data from the responses to questions 16e21 on the INE survey. Open coding helped to separate the data into meaningful categories of labelled information. Finally, axial coding assisted to label the information into groups of key themes. The recurrent themes that occurred throughout the qualitative data were then analyzed. The qualitative results were subsequently compared to the quantitative results and connected to the conclusions. 3.5. Findings 3.5.1. Study variables The demographic characteristics of the nursing students are presented in Table 1. The sample of 159 nursing student participants represented one Diploma nursing program (23 students), one ADN program (50 students), and 2 BSN programs, which are referred to as BSN-1 and BSN-2 in this study (48 students and 38 students). Of the total nursing student participants, 148 students were female and 11 students were male. The nursing students ranged in age from 19 years to over 50 years. The majority of the nursing students (70.4%) were age 19e25 years. Most of the nursing students (94.3%) were Caucasian. Over 95% of students reported having parent/guardians’ level of education at high school/GED. The diploma program reported the most male nursing students, the lowest number of students in the 19e25 age group, the lowest amount of ethnic/racial diversity, and the lowest number of parent/ guardians’ level of education at the high school/GED level. Both BSN programs reported the least amount of male students, the highest number of students in the 19e25 age groups, and the highest number of parent/guardians’ level of education at the high school/ GED level. The BSN-2 program had the most Black/AfricanAmerican students, and neither BSN program reported any students who identified with other ethnic/racial backgrounds other than Black/African-American. Therefore, the majority of the nursing students among all programs were female, Caucasian, ages 19e25 years, and having parent/guardians’ level of education at high school/GED. Of the 14 nursing faculty, 3 faculty members were from an ADN program, 6 faculty members were from a BSN program, and 5 faculty members were from a diploma program. Of the nursing faculty participants, 13 were female and 1 was male. The nursing faculty ranged in age from 39 to 64 years, with 78.5% of the faculty being in the age group of 41e60 years. Correlations of study variables. The demographic variables of sex, age, ethnic/racial background, and parental level of education were examined for correlations. The results from Pearson ChiSquare testing found only one uncivil behavior to be significant in male students; harassing comments directed at faculty. However, it was influenced by the means of the sample having more females than males. For the variable of ethnic/racial background, there were only two uncivil behaviors found to be significant; harassing comments directed at students and inappropriate e-mails to faculty. More Black/African-American and Asian students perceived harassing comments directed at students (p ¼ 0.041) and inappropriate e-mails to faculty (p ¼ 0.032) to be uncivil as compared to Caucasian/White students. However, this finding may have been skewed because of the low sample size of students other than Caucasian. For parent/guardians’ level of education, the nursing students who had parent/guardians with a high school education or higher perceived harassing comments as an issue, but those students who had parents with a below high school education did not perceive harassing comments to be an issue. It could be that the more uneducated parents had a greater exposure of harassing comments as acceptable behavior. The variable of age had a significant correlation (p ¼ 0.011) which identified a positive correlation between the age and frequency of reporting harassing comments directed at students. Therefore, as the age of the nursing student increases, so did the frequency with which the student reported seeing harassing comments directed at students. Table 3 Student behaviors experienced or seen in past 12 months by nursing program type. Type of Behavior Often Experienced or Seen Diploma Mean ADN Mean BSN-1 Mean BSN-2 Mean Acting Bored or Apathetic 1.48* 2.19* 2.00* 2.39* Making Disapproving Groans 1.27* 2.06* 1.46* 2.21* Making Sarcastic Remarks 1.52* 2.19* 1.42* 2.11* Sleeping in Class 0.50* 0.73* 1.10* 1.24* Not Paying Attention 0.91* 1.81* 2.23* 2.24* Holding Distracting Conversations 1.61* 1.94 2.31* 2.21* Using Computers During Class 0.36* 1.86* 2.42* 2.22* Using Cell Phones During Class 1.50* 1.98* 2.70* 2.38* Arriving Late 1.30* 2.25* 1.88* 1.58* Leaving Early 0.96* 1.65* 1.69* 1.37* Cutting Class 0.27* 0.94* 1.62* 1.29* Unprepared for Class 1.09* 1.69* 1.44 1.47 Dominating Class Discussion 1.17* 1.83* 1.54* 2.13* Cheating on Exams or Quizzes 0.09* 0.21* 0.75* 0.92* Demanding Make-up Exams or Grade Changes 0.48* 1.29* 1.42* 1.55* *Indicates significant differences among nursing training types, p < .05. 40 K. Aul / Nurse Education in Practice 27 (2017) 36e44 3.5.2. Quantitative survey results Student behaviors. The quantitative results from the 159 nursing student surveys found that there was variability between nursing programs. Student behaviors perceived as disruptive by nursing program type are in Table 2. The means were determined according to how often the student behavior was considered disruptive according to the Likert scale on the INE survey: never ¼ 0, sometimes ¼ 1, usually ¼ 2, and always ¼ 3. Table 2 displays the five student behaviors that were perceived significantly different between the training programs: making sarcastic remarks, holding distracting conversations, cutting class, dominating class discussion, and cheating on exams or quizzes. There was a statistically significant difference between the groups (p < 0.05) for these behaviors. Making sarcastic remarks was perceived to be more disruptive for BSN students than diploma students; holding distracting conversations was perceived to be more disruptive for BSN students than ADN students; cutting class was perceived to be more disruptive for BSN-1 students than BSN-2 students; dominating class discussion was perceived to be more disruptive for BSN-2 students than BSN-1 students; and cheating on exams or quizzes was perceived to be more disruptive for BSN-1 students than BSN-2 students and diploma students. Besides behaviors perceived as disruptive, the survey obtained data from nursing students that were often experienced or seen in the past 12 months (refer to Table 3). The student behaviors that were significantly different between the training programs include: acting apathetic or bored, making disapproving groans, making sarcastic remarks, sleeping in class, not paying attention, holding distracting conversations, using computers during class, using cell phones during class, arriving late, leaving early, cutting class, unprepared for class, dominating class di

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