Abstract
Purpose While incivility has been part of higher education for many years, there has been a documented increase as both students and educators have begun to recognize this behavior and its effects on student learning, faculty satisfaction and stress. The purpose of this descriptive study was to investigate the perceptions of incivility among dental hygiene students and faculty/administrators.
Methods This study utilized a convenience sample of five dental hygiene programs in California. The Incivility in Higher Education-Revised survey (IHE-R) was adapted to obtain data regarding perceptions of incivility among dental hygiene students and faculty/administrators. The survey required participants to describe incivil encounters and the perceived reasons for and consequences of the incivil behavior. An online survey was used for faculty and a paper survey was administered for dental hygiene students. Data from the open-ended questions were reviewed, summarized, edited for redundancy, and analyzed using categories.
Results Of the 196 participants, 81.63% were dental hygiene students (n = 160) and 18.37% were dental hygiene faculty and administrators (n = 36). Data analysis of participant responses related to the primary reason for incivil behavior in dental hygiene education revealed five categories including lack of consequences, personality traits, miscommunication, stress, and lack of professionalism. Upon data analysis of participant responses related to the most significant consequence of incivil behavior in dental hygiene education, five categories emerged including hostile environment, decreased student success, emotional distress, relationship damage, and professional damage.
Conclusion Both faculty and students felt there was a lack of consequences for incivil behavior and did not feel adequately equipped to manage these situations when they arose. Dental hygiene institutions and professional organizations need to consider offering advanced training in creating a culture of civility to prevent and address incivil behaviors.
- dental hygiene education
- incivility
- dental hygiene faculty
- dental hygiene administrators
- dental hygiene students
- unprofessional conduct
INTRODUCTION
Incivility has been noted by researchers as an increasing problem in American culture and higher education.1-5 Incivility is defined as “rude or disruptive behavior that often results in psychological or physiological distress for the people involved…and, if left unaddressed, may progress into threatening situations.”6 The perception of incivility has been noted to vary among individuals; some incivil behaviors have included inappropriate use of digital technology, inappropriate or rude comments, or threats or acts of physical or emotional harm.1
Previous research has examined incivility in higher education and more specifically, in nursing education. This research has focused on faculty and student perceptions of incivility, incidence, implications, and interventions.1,4,7-11 Studies demonstrated incivility in nursing education with consequences including student and faculty dissatisfaction, stress, burnout, unsafe patient encounters, and decreased learning.4,7,9,11,12 To avoid these consequences and the escalation of incivil behavior to more aggressive acts, it has been suggested that institutions develop policies related to incivility.7,9 As a result of the increase in documented incivility in the nursing field, associations and boards have begun to take note and release bulletins that address the problem and evaluate their code of ethics.12-14
In the academic environment, incivil behavior has been associated with student and faculty dissatisfaction, stress, burnout, unsafe patient encounters, and decreased learning.4,7,9,11,12 To address this increasing problem, identification of incivility with the appropriate interventions may decrease the incidence of incivility in higher education and reduce the negative effects associated with this behavior.
While there is considerable research examining incivility in various aspects of higher education and in nursing education, there is little research examining the incidence and perceptions of incivility among dental hygiene students compared to dental hygiene faculty and administrators.15 One study examined the existence of student incivility in dental hygiene education and had results comparable to studies of incivility related to nursing education.16-19 A study by McCarthy et al. study identified a positive correlation between the frequency of incivil behaviors by the student and the effect of the behavior on dental hygiene educator’s confidence, career satisfaction, and the desire to remain an educator.16 A culture of civility should be a shared objective in dental hygiene education program settings.16 Future research recommendations included focusing on the relationship between incivility and generational differences between faculty and students as well as examining incivility from the dental hygiene students’ perspective.16 A deeper understanding of faculty perceptions may lead to the development of institutional strategies to manage incivility.
Incivility as a learned behavior, through the example set by faculty or the absence of consequence for the incivil behavior may give the impression to the student that this behavior is acceptable in the workplace.20 The transfer of this behavior to the workplace may have a negative impact on the new professional’s interaction with coworkers, supervisors and subordinates which could ultimately lead to job dismissal and negative recommendations for future employment. Implications for workplace incivilty can include higher turnover rates, decreased job satisfaction, stress, burnout, and emotional distress.
Research has also indicated that incivility can cause stress-related disorders and physical illness which can contribute to an individual’s ability to present for their designated work hours.13,14 Strain and emotional exhaustion caused by incivility can lead to inefficiency in the workplace which may impact the ability of the institution to reach its goals.20 This inefficiency may result in the faculty member becoming less engaged and approachable, which can ultimately impede student learning and decreased approval of faculty in course evaluations.
In the context of the workplace, incivility directly violates “workplace norms for mutual respect, such that cooperation and motivation may be hindered broadly.”21 These norms consist of moral standards, tradition, and workplace culture.21 The effects of workplace incivility spread beyond the victim of the incivil act to colleagues, the organization, friends and family, and other students when the workplace is an academic environment.21 This can further result in decreased productivity for the organization, whether monetary or intellectual. While incivility may exist in the workplace or educational setting, there is a reluctance of victims to report these behaviors. Clark et al. reported fear of retaliation, lack of support from administration, lack of policies to address incivil behavior, time and effort involved in reporting, poor peer evaluations, and the lack of knowledge and skills often detoured faculty from reporting incidences of incivility.22 Understanding the magnitude of individuals affected by acts of incivility, which is largely underreported, and the inevitable decrease in workplace productivity, increased stress and burnout among its victims and bystanders is the first step in decreasing its prevalence.
The purpose of this descriptive study was to investigate the perceptions of incivility among dental hygiene students and faculty/administrators. Aspects of this survey required participant’s descriptions of incivil encounters and the perceived reasons for and consequences of the incivil behavior. The following research questions were used to guide the study:
What do dental hygiene students and dental hygiene faculty/administrators feel is the primary reason for incivil behavior?
What do dental hygiene students and faculty/administrators feel is the most significant consequence of incivility in dental hygiene education?
METHODS
This descriptive study was approved by the Concordia University Institutional Review Board (#5386) and conducted in the Fall of 2019. A convenience sample of five dental hygiene programs throughout California was used. The sample included junior and senior dental hygiene students as well as full or part-time dental hygiene educators and administrators at these institutions. Dental hygiene alumni, dental hygiene program assistants, and clinic staff members were excluded from this study.
With permission, the Incivility in Higher Education-Revised survey (IHE-R), was modified and adapted to substitute “dental hygiene” for “nursing” in the open-ended items regarding the incivility among dental hygiene students and faculty/administrators.6 Reliability of the IHE-R has been established in previous research. Total item Cronbach alpha was reported as 0.96 for students and 0.98 for faculty.23 Content validity and ease of use was confirmed, but concurrent and predictive validity were not addressed.23
The quantitative portion of the survey consisted of 48 behaviors, using Likert scale responses. Twenty-four items focused on student behaviors and 24 items focused on faculty behaviors. Respondents ranked the level of incivility for each behavior and how often the behavior was observed in the previous 12 months.
Three open-ended questions aimed at collecting perceptions of incivility required the participant to describe an example of an incivil encounter they had experienced or witnessed in the past 12 months, disclose what they felt was the primary reason for incivility in higher education, and describe the most significant consequence of incivility in higher education. Demographic data related to age, gender and ethnicity were also collected.
The survey was pilot tested among a sample of faculty and dental hygiene students from one dental hygiene program. Results of the pilot test were not included in the final data analysis. Other than changing the term “nursing” to “dental hygiene,” no further modifications to the instrument were needed. The pilot test revealed that approximately 20 minutes were needed to complete the survey. This paper will discuss the open-ended items related to perceptions of incivility. The closed-ended, quantitative items of the IHE-R are not reported in this paper.
Students and faculty were provided a letter with informed consent explaining the study. The online survey link and paper surveys were sent to participating dental hygiene program directors via mail and email. Faculty and administrators completed the survey via an online survey tool (Survey Monkey, San Mateo, CA, USA) and students completed paper surveys administered by a designated faculty member from each program who volunteered to distribute the survey. After the paper surveys were completed, they were mailed via a prepaid envelope to the primary investigator. Three reminder emails were sent to faculty and administrators to encourage participation in the electronic version of the survey. Due to the sensitive nature of the information being obtained, complete anonymity and confidentiality was maintained throughout data collection and analysis. No institutional or personal identifiers were collected in the surveys.
Data from the open-ended questions were reviewed, summarized, edited for redundancy, and analyzed using categories. Excel spreadsheets were used to organize the respondent comments and identify categories. Respondent comments were grouped based on similarities. The researchers evaluated the summary statements for patterns based on frequency of responses.
RESULTS
A total of 268 dental hygiene students (n=200), faculty (n=60) and administrators (n=8) agreed to participate in this study. Of the 268 surveys returned, 48 were excluded, due to lack of completion of key data points, yielding a 73.13% response rate. Of the 196 participants, 81.63% (n=160) were classified as dental hygiene students and 18.37% (n=36) were dental hygiene faculty and administrators. Nearly all the participants were female (90.8%, n = 178), however 7.14% (n=14) were male, and 2.04% (n=4) did not disclose their gender. Dental hygiene student participants ranged from 20 – 50 years of age with a mean age of 26 years. Faculty/administrator respondents ranged in age from 28 – 70 years with a mean age of 50 years. Participant characteristics for are further summarized in Table I and additional faculty demographic data is shown in Table II.
Demographics (n=196)
Faculty and administrator demographics (n=36)
Incivil encounters in dental hygiene education
Open-ended responses were provided by the participants as examples of incivil behavior witnessed and/or personally experienced in dental hygiene education by students and faculty/administrators. Frequencies of encounters were recorded, but not in a percentage format, because responses included multiple categories. Encounters included the use of personal digital technology in class by both students and faculty (n=14), rude comments by both students and faculty (n=44), disruptive behavior in class by students (n=39), faculty being unprepared for class and having vague expectations (n=29), faculty and students being unresponsive to emails (n=9), and speaking about others poorly by both students and faculty (n=30). Additional incivil encounters cited by participants are shown in Table III.
Examples of Incivil Encounters (students and faculty/administrators)
Primary reason for incivil behavior
Participant responses related to the primary reason for incivil behavior in dental hygiene education were analyzed; 959 words were evaluated and five categories emerged including lack of consequences (n=153), personality traits (n=415), miscommunication (n=24), stress (n=19), and lack of professionalism (n=148).
One example provided by a student participant related to a lack of consequences was “some students specifically continue to disrupt and disrespect professors, but nothing is done.” In terms of personality traits, one participant stated they had experiences with an individual who was “mean and catty” while another student reported “yesterday I was given condescending remarks by a male professor in clinic. I think that is his personality, but it was extremely rude and discouraging.” Another student participant reported a “teacher telling some students one thing and other students’ other things” which can contribute to the perception of miscommunication. One faculty participant discussed a stressful situation and reported:
“When certain faculty members don’t follow protocol with the patients, therefore leading to confusion on the part of the patients. This usually turns into the patient blaming the next faculty member that comes along for actually maintaining our policies, which can lead to unnecessary conflict. This leads to stress for both the patient and the faculty member.”
Lastly, a student participant reported “a professor talked bad about students to a representative during class” which displayed a lack of professionalism. Additional examples related to the primary reason for incivil behavior in dental hygiene education are provided in Table IV.
Primary Reason for Incivil Behavior (n=196)
Consequences of Incivility
Participant responses related to the most significant consequence of incivil behavior in dental hygiene education were analyzed; 804 words were classified and five categories were identified. These categories included hostile environment (n=11), decreased student success (n=116), emotional distress (n=89), relationship damage (n=39), and professional damage (n=106). One student described a hostile environment and stated:
“A student verbally attacked me when I was having a private conversation with another classmate. They overheard our conversation. We tried to talk it out with an instructor, and it didn’t go their way so they decided it would be best involving the dean of students. We both ended up with critical errors and it scared me. I walk on eggshells around this person to make sure I don’t say something that may offend them.“
An example illustrating decreased student success was “a teacher has told me I was dumb and not as good as her in front of my patient; the patient doesn’t want to come back because of her.” Another participant displayed emotional distress in their comment “I feel like a burden to this program.” Relationship damage was reported as “friend groups excluding others.” Lastly, an incident that might lead to professional damage was discussed and the participant stated, “a black student accused an instructor of racism when the instructor expressed concern about attitude. The instructor was not racist. The student was taking advantage of her position.” Additional examples related to consequences of incivility in dental hygiene education are presented in Table V.
Primary Consequence of Incivil Behavior (n=196)
DISCUSSION
In this study, a lack of consequences emerged as one of the categories related to the primary reason for incivility. Faculty have a responsibility to try to retain students in their classrooms and respective programs; therefore, they might be more inclined to be protective over their students and less inclined to be aggressive in addressing incivil behaviors. The fear of being challenged by a student exhibiting incivil behavior who is confronted with consequences may be a deterrent in faculty addressing incivil behaviors as well. This student could report the faculty to leadership creating an investigation in which the faculty might fear consequences including loss of their position. A lack of training in managing incivility can contribute to the failure of faculty to address incivil behaviors when encountered. Training in this area might increase the confidence of the faculty in addressing these behaviors. Additionally, support from institutional leadership in addressing incivility might increase the likelihood of the faculty managing the negative behavior as it occurs.
It is common for institutional policies to exist for plagiarism and other forms of academic dishonesty, but there are no policies directly related to incivility. Due to increases in incivility in academic institutions and the workplace, professional organizations have begun to recognize the seriousness of incivility and have made efforts to address this issue. The Joint Commission of Nursing issued a “Sentinel Even Alert 40” in 2008 in which behaviors were discussed that constituted incivility. Organizations were urged to adopt zero tolerance policies to address these behaviors.14 In 2015, the American Nurses Association (ANA) released a position statement that emphasized “individual and shared roles and responsibilities of registered nurses and employers to create and sustain a culture of respect, free of incivility, bullying and workplace violence.”24 Additional reference was made to incivility in the ANA code of ethics which states nurses are obligated to “create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect.”25 The code goes on to state disregard for the effects of an individual’s actions linked to behaviors identified in the above studies as incivil is “always morally unacceptable.”25
Results from this study confirmed the existence of incivility in dental hygiene education; therefore, it might be timely for dental hygiene institutions and professional associations to add verbiage related to incivility in their professional codes of ethics. The code of ethics created by the American Dental Hygienists’ Association (ADHA) focuses on individual autonomy and respect for human beings, confidentiality, non-maleficence, beneficence, justice, fairness, and veracity.26 Included in the standards of professional responsibility are aspects stating all people, including colleagues, have the right to be treated with respect and conflicts should be managed in a constructive manner.26 However, civility is not specifically addressed.
In 2005, the American Dental Education Association (ADEA) adopted a dental faculty code of conduct and stated the essential characteristics of a dental faculty included honesty, integrity, openness in communication, and trustworthiness.27 A few years later in 2009, ADEA defined professionalism using six value-based statements.28 These statements were created with the following themes: service-mindedness, respect, responsibility, integrity, fairness, and competence.28 No statements specifically related to civility were made in this definition.
The National Education Association Code of Ethics for Educators has principles reflecting commitments to the student and the profession that specifically address incivil behaviors.29 For example the code states that the educator:
“Shall not unreasonably deny the student’s access to varying points of view.
Shall not intentionally expose the student to embarrassment or disparagement.
Shall not on the basis of race, color, creed, sex, national origin, marital status, political or religious beliefs, family, social or cultural background, or sexual orientation, unfairly.
Shall not knowingly make false or malicious statements about a colleague.”29
Faculty members often receive training related to institutional policies such as academic dishonesty. Similar training related to classroom management along with institution and professional code of ethics for incivil encounters might assist faculty to be better prepared to deal with these situations. It might be beneficial for institutions to create or modify faculty and student codes of conduct to address concerns about retaliation, loss of employment, professional damage, bullying, and workplace violence.
Stress was identified as one of the primary reasons for incivil behavior in this study. In a study conducted to measure nursing faculty perceptions of faculty to faculty incivility Clark et al. identified stress (72%); demanding workloads (70%); unclear role and expectations and imbalance of power (66%); volatile and stress environments (62%); attitudes of superiority (52%), and the possession of multiple roles (52%) as factors that contribute directly to incivil behaviors.22 Dental hygiene curriculum is a highly complex curriculum condensed into two years. This curriculum schedule can cause increased stress for students and faculty/administrators alike. Increased levels of stress can predispose individuals to not always act as their best self which can lead to an increased likelihood of a person exhibiting incivil behavior.
Personality traits, miscommunication, and a lack of professionalism were also identified as reasons for incivility in dental hygiene education. Being able to uphold professionalism and high standards is essential to the professional growth of individuals and institutions. Failure to adequately educate students in professionalism and provide them with tools to increase their communication skills might attribute to the likelihood of partaking in incivil behavior which can impede their professional growth. A deficiency in faculty/administrator skill set in handling incivility might also lead to the perception of a lack of professionalism.
Decreased student success, emotional distress, and a hostile environment were identified as three categories related to the most significant consequence of incivility in dental hygiene education. Previous research indicated incivility caused stress-related disorders and physical illness which contributed to an individual’s ability to present for their designated work hours.13,14 In dental hygiene education, the intensive workload both students and faculty/administrators carry prohibits them from missing work and school hours as this can put them extremely behind schedule, contributing to increased levels of stress and incivil behavior. Oyeleye et al. found correlations between stress and incivility (p=0.001), stress and burnout (p=0.005), and turnover intentions and burnout (p=0.005) among acute care nurses.30 Strain and emotional exhaustion can lead to inefficiency at the workplace, which may then impact the ability of the institution to reach its goals.20 Inefficiency due to stress and exhaustion can result in the faculty member becoming less engaged and less approachable, which can impede student learning and decreased approval of faculty in course evaluations.
Two additional categories that emerged as the most significant consequences of incivility were relationship and professional damage. Both relationship damage and professional damage can result in a loss of credibility for the individual or institution. Damage in these areas can lower trust, contribute to the feeling of an unsupportive environment, lower confidence in the ability of the individual, increase stress leading to lower student outcomes, and a decrease in job or school satisfaction. Additionally, the affected individual may need to re-earn their reputation because incidents that have caused relationship or professional damage would most likely be shared with others.
Incivility research in nursing has demonstrated negative effects on patient care and safety and ineffective communication.12,31 It has been estimated that incivil behavior can lead to over 3,500 sentinel events over a 10-year period of time.13 These events are categorized as unforeseen events in the health care setting that resulted in death or serious injury to a patient that were unrelated to their illness of concern. Furthermore, nursing staff turnover results in a decrease in experienced nurses and general staffing shortages leading to a higher patient to nurse ratio that can negatively affect patient care and outcomes.13,14 High turnover leads to increased costs in attaining and hiring new staff, lower productivity, risks of lawsuits, compensation for disability, and a negative reputation for the institution.12,14 It has also been reported that medication safety has been compromised in instances where nurses were afraid to admit errors due to fear of gossip and retaliation.13 All these factors can have adverse effects on the coordination of patient care which can ultimately lead to poor patient outcomes.13
If incivility exists in the dental hygiene profession and is left unaddressed, similar negative outcomes may be seen in dentistry. The promotion of professional, civil behavior is essential to upholding the reputation of the dental hygiene profession as viewed by the public and other professionals. Failure of the dental hygienist to work harmoniously with colleagues can lead to turnover in the workplace, causing strain on other employees and the population they serve, whether in a clinical practice setting or educational institution. Increased costs can be incurred by the employer if the incivil behavior leads to employee turnover, lawsuits, and/or a negative reputation.
Limitations
This study is not without limitations. A convenience sample was used which limits the generalizability of the study and external validity. Future research inclusive of a larger sample size should be considered to explore the extent of incivility within dental hygiene education on a national level.
CONCLUSION
Both faculty and students perceive there is a lack of consequences for incivil behavior and do not feel adequately equipped to manage these situations. Faculty have an obligation to be models of civility in their interactions with students, other faculty and administrators, patients, and other professionals through collaboration. Educational institutions and professional organizations should consider offering advanced training in creating a culture of civility to prevent and address incivil behaviors. Further development of this skillset for dental hygiene students and faculty/administrators will increase awareness and may decrease the incidence of these behaviors.
Footnotes
NDHRA priority area, Professional development: Education (evaluation)
- Received August 23, 2023.
- Accepted October 30, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
