Nursing is considered one of the most trusted professions according to the Gallup (2022) poll. It is of concern that violations of academic integrity as a nursing student could influence the integrity of one's future nursing practice and the public's view of the profession (McCabe, 2009). According to the International Center for Academic Integrity (ICAI, 2022), academic integrity has six fundamental values: trust, fairness, respect, responsibility, honesty, and courage. Being committed to those values, even in the face of adversity, is what defines academic integrity (ICAI, 2022). Participating in dishonest activities may give one student an academic advantage over another (Waltzer et al., 2021). Krueger (2014) further supports the importance of the six ICAI core values once students transition into clinical practice, explaining that the independence granted to practicing nurses necessitates that nurses possess integrity and promote honesty for the safety of their patients.
Part of promoting a culture of integrity has long been understood to include the responsibility to report peer violations (McCabe et al., 2001b). Historically, Trevino and Victor (1992) defined peer reporting as reporting a group member's action to a person outside the member's peer group. This definition of peer reporting is further supported by the whistleblower definition, that is, providing information to internal or external entities that show a violation of a rule or policy has occurred (Government Accountability Project, 2022). Examples include a nursing student reporting a peer for cheating during an exam to the course faculty, or a practicing nurse reporting a peer to the charge nurse for diverting narcotics. Both examples help foster integrity, whether in the academic program or the hospital unit. The purpose of this article is to examine and describe student perceptions of severity of violations, perceptions of faculty support, and support for program improvement strategies related to their willingness to report peer violations.
BACKGROUND
When discussing what promotes peer reporting, it is important to explore the offenses that violate academic integrity and that often go unreported. As discussed by Kiekkas and colleagues (2020), nursing students cheat for a variety of reasons, for example, feeling that the academic workload is unreasonably high, not believing their behavior would have a negative impact on anyone else, and competition with their peers for higher grades.
Peer reporting is an important component of academic integrity. Often students witness a violation or are aware of dishonest behaviors among their classmates. They then face the moral dilemma of whether to report what they have witnessed (Culiberg & Mihelic, 2020). If students know that their classmates, and future colleagues, will hold them accountable for acting with integrity, perhaps they will be less tempted to cheat. By detailing student responsibilities, which include the reporting of violations, honor codes are one way to promote peer reporting of academic integrity violations (Omarova, 2019).
Peer reporting by students that results in enforcement of academic integrity policies mirrors the impact of peer reporting by nurses that results in disciplinary action or systems-based change to prevent patient harm. To foster a program-wide culture of academic integrity, exploration of the willingness to report peers is needed, as well as further research investigating hurdles that prevent students from reporting violations.
Willingness to Report Peer Violations
McCabe et al. (2001a) explored rationales for the lack of peer reporting. They found that students fear ostracization from their social network and have difficulty identifying violations of academic integrity policies at their universities. Waltzer et al. (2021) identified four potential reasons students may refrain from reporting peers. First, it could be that regardless of what they say, students do not truly care about academic integrity. Second, students may have competing priorities; they feel that a peer's well-being is more important to them, and reporting the peer could jeopardize this. Third, students may be unfamiliar with a college or university's policies. Finally, students may identify other ways of addressing the situation, such as direct confrontation instead of reporting the incident to faculty. Furthermore, students may err on the side of loyalty to the peer group rather than reporting an event if they are not sure it is cheating. Theart and Smit (2012) and Teodorescu and Andrei (2009) found that their participants, despite feeling that cheating was wrong, demonstrated an overwhelming hesitancy to report violations they might witness.
Students should be aware that the importance of peer accountability, or holding peers responsible for their actions, is evident in health care systems as well. For professional nurses, employment within an organization that encourages reporting could lead to an increased rate of peer and self-reporting of ethical violations or medical errors. As explored by Hewitt et al. (2017), working in such facilities allows nurses to learn from their mistakes, depending on the severity of the offense, and frames reporting as a vital part of quality improvement and patient safety. By addressing students' hesitancy to report peer violations before those students enter professional practice, nursing faculty can ensure that graduates understand the importance of integrity and how error reporting can foster that integrity.
Perception of Severity of Offenses
One obstacle that may prevent students from reporting their peers is uncertainty; they may be unsure if what they witnessed is a violation of academic integrity. Benson et al. (2019) studied knowledge of academic integrity, finding that students scored less than 70 percent on a pretest that assessed their understanding of academic integrity. When comparing nursing students to other college students, Arhin and Jones (2009) found that nursing students were able to identify dishonest actions more often than students in other academic areas. However, this was mainly when identifying dishonest behaviors related to exams; nursing students had difficulty identifying other types of academic integrity violations within the classroom and clinical setting.
Arhin (2009) identified that many students believe academic integrity violations occur along a continuum, with some offenses being worse than others. This belief may lead to students engaging in violations of academic integrity based on the false notion that small offenses are not cheating and are of little consequence. In addition, when students believe offenses are insignificant, they may see no reason to report peers known to be engaging in these behaviors.
Perception of Faculty Support
Another deterrent to peer reporting may be the feeling that their faculty do not talk about academic integrity policies or enforce them consistently. Despite these policies being available to students in program handbooks or syllabi, with the expectation that students will review them, the need remains for faculty to communicate policies directly to students (Devine & Chin, 2018; Hart & Morgan, 2010; McCabe & Trevino, 1993; McCabe et al., 1999; McClung & Schneider, 2018; Morgan & Hart, 2013). Faculty can review academic integrity policies at various points throughout the program, including orientation, at the beginning of each course, and as a specific need arises (Azulay Chertok et al., 2014; Lofstrom et al., 2015; McCabe et al., 2001a). Open and clear communication, along with consistent enforcement of policies, supports high ethical standards throughout the nursing program and instills the core value of integrity in students as they become professional nurses. This positive perception may lead to increased peer reporting if students believe their concerns will be addressed fairly and according to policy.
In summary, finding ways to address lack of knowledge related to academic integrity will promote the desired culture of academic integrity within nursing programs and will provide tangible ways to promote this culture of academic integrity and address obstacles that prevent peer reporting of academic integrity violations. Through increasing student knowledge of the severity of offenses, demonstration of clear faculty support of policies, and program-wide strategies that encourage a culture of reporting, nurse educators can begin to address this need. To assess student perceptions surrounding these variables, the research question addressed in this article is: Among prelicensure, baccalaureate nursing students, are student perceptions of severity of violations, perceptions of faculty support, and support for program improvement strategies related to willingness to report peer violations as measured by McCabe's Academic Integrity Survey-Modified for Nursing Students (MAIS-MNS)?
METHOD
Participants were recruited through the National Student Nurses' Association (NSNA). Inclusion criteria included: 1) undergraduate BSN students and 2) over 18 years of age. Exclusion criteria included: 1) being under the age 18 years and 2) enrollment as an associate degree, diploma, or RN-BSN student. Participants represented the following geographic regions within the United States: Midwest (22.9 percent), Northeast (20.6 percent), Southeast (26.9 percent), Southwest (8.6 percent), and West (20.8 percent).
To calculate the needed sample size, the parameters to detect a significant correlation were established as r = .20, [alpha] (two-tailed) = .05, and power of .80. The needed sample size to detect a significant correlation was 194. This sample size was feasible to achieve with the number of NSNA students contacted during recruitment. The convenience sample consisted of 450 participants; surveys from eight participants were removed due to incompleteness.
Instrument
The instrument for this study is a modified version of McCabe's Academic Integrity Survey. This survey has been utilized at the high school, undergraduate, and graduate levels to assess student engagement in cheating and their comprehension of academic integrity policies. Prior studies have utilized selected portions in their research with students (McCabe, 2009; McCabe & Trevino, 1993; McCabe et al., 2001a). In addition, subscales have been used in studies on academic integrity in nursing students (Hart & Morgan, 2010; Krueger, 2014; Morgan & Hart, 2013).
Components of McCabe's original survey were relevant to the current study; however, there were no nursing-specific questions, and the survey contained questions that were not relevant to the study sample. Therefore, permission was received to modify the instrument to meet the needs of this study. Items were added that were designed specifically for nursing students in the classroom or clinical settings. These included items on topics such as unauthorized collaboration, falsifying clinical data, and sharing confidential information on simulation scenarios with other students.
Items regarding the willingness to report peer violations of academic integrity in the classroom and clinical setting were also modified to fit the study's population. Items retained from McCabe's original survey included those that evaluate student perceptions of the likelihood of success of various program-wide strategies to promote a culture of academic integrity. Of note, there is a lack of evidence for concurrent validity of the modified survey as there is no comparison of results with the original survey. The original survey also has a lack of evidence of validity despite being used for more than 30 years.
The MAIS-MNS consists of 139 items measuring student attitudes toward various aspects of academic integrity. Question types include multiple-choice and modified Likert-type scales. To address the research question posed in this article, four subscales were analyzed: perceptions of severity, perceptions of faculty response, program improvement suggestions, and willingness to report peer violations.
Procedure
This study used a cross-sectional, correlation design. Prelicensure BSN students were surveyed on various aspects of academic integrity. With institutional review board approval, an authorized representative of the NSNA sent a recruitment email with the survey link to approximately 36,000 members enrolled in prelicensure baccalaureate programs. Students who chose to participate in the study by consenting were directed to a Qualtrics survey that included the MAIS-MNS. Upon completion of the survey, participants were prompted to enter their email address if they elected to receive a $10 Amazon gift card to thank them for their participation. Because of budgeting constraints, recruitment was closed after the first 450 participants completed the survey.
Data Analysis
Data were exported from Qualtrics to Excel and reviewed for outliers and missing data. Two participants were removed as they did not consent to the study. The final sample consisted of 442 students. Data were imported into SPSS for analysis. Program improvement items were analyzed individually to assess participant support for each suggested improvement; they were also analyzed together as a subscale. To establish reliability of the subscales discussed in this article, Cronbach's alphas were calculated as follows: perceptions of severity (.929), perceived faculty response (.886), program improvement suggestions (.715), and willingness to report peer violations (.968). Cronbach's alpha for the entire MAIS-MNS, excluding demographic questions, was .922.
RESULTS
Perceptions of Severity
Individual summed scores for this subscale ranged from 31 to 120 (mean score = 89.70, median score = 91, SD = 14.4). Higher subscale scores correlated with more severe identified behaviors, rated along the continuum of "not cheating" to "severe cheating." Forty-one percent of students considered working with peers when individual work was requested "trivial cheating"; 40.5 percent considered it "moderate cheating." Discussing an exam with a peer in a different course section who had not yet taken the exam was perceived as "severe cheating" or "moderate cheating" by 63.3 percent of students. However, 60.6 percent believed that using an unauthorized test bank of previous exam questions maintained by student groups to prepare for an exam was "not cheating."
With respect to clinically based behaviors, 73.1 percent of students identified that documenting vital signs they did not obtain was "severe cheating" or "moderate cheating." Only 49.2 percent identified discussing a simulation laboratory with students who had not yet completed it as "moderate cheating" or "severe cheating." The skewness of perceptions of severity was found to be .64, indicating that distribution was right-skewed.
Perceptions of Faculty Responses
Individual summed scores for the 12-item perceived faculty responses to academic integrity policies subscale ranged from 12 to 60 (median score = 43, SD = 9.888). In the reported results, percentages reflect the student who selected "often" or "very often" on the subscale items. More than 80 percent of students reported that faculty provided information about proper citations or referencing of written or Internet sources. Regarding falsifying data in course laboratories, 45.9 percent reported that faculty discussed this topic with them; 51.1 percent reported faculty discussed falsifying clinical data.
Students also relayed that faculty emphasized the importance of not discussing patient information outside postclinical conference (70.3 percent) and not discussing patient information in common areas (71.3 percent). Most students (89.1 percent) reported that faculty discussed policies related to academic integrity at the beginning of a course. The skewness of perceptions of faculty responses was found to be -.47, indicating that the distribution was left-skewed.
Program Improvement Suggestions
Four items describing different program improvement suggestions were analyzed for support. The suggestions were: 1) implementing an honor code, 2) better education regarding academic integrity at the beginning of the program, 3) harsher sanctions for violations of academic integrity, and 4) use of antiplagiarism software including Turnitin or SafeAssign. Better education can be interpreted as providing students with more robust information on what academic integrity means and how it relates to their program of study. Participants selected whether they thought each suggestion would "unlikely," "somewhat," or "likely" improve academic integrity in their nursing programs.
Individual summed scores ranged from 4 to 12 (median score = 10, SD = 2.09). A higher total score indicates stronger support for the program improvement suggestions. Participant support for these suggestions was high. More than 81 percent of participants reported that an honor code would at least somewhat improve academic integrity in their program. Support for more education regarding academic integrity at the beginning of the program was >85 percent. Participants also supported harsher sanctions for violations (83 percent) and the use of antiplagiarism software (93 percent). The skewness of program improvement suggestions was found to be -.62, indicating that the distribution was left-skewed.
Willingness to Report Violations Subscale
The individual summed scores for the 16-item willingness to report subscale ranged from 16 to 64 (median score = 37, SD = 11.96). In the reported results below, the percentages reflect the student who selected "unlikely" or "very unlikely" on the subscale items. Half of the participants (49.5 percent) stated that they would not report a peer they observed cheating on an exam. For online exams, 52.5 percent would not report a peer they observed cheating. Over 55 percent would not report a peer they observed cheating in the simulation or laboratory setting. In the clinical setting, 30.8 percent would not report a peer violation if participants thought the violation could not cause patient harm. Alarmingly, 12.2 percent of participants would not report a violation, even if they thought it could cause patient harm. More than 60 percent felt the typical student in their program would not report a violation they witnessed, and 75 percent believed the typical student in their program would not report a close friend for cheating. The skewness of willingness to report was found to be -.41, indicating that the distribution was left-skewed.
Correlations
To address the research question posed in this article, correlations between the subscales were assessed. As the data were not normally distributed, Spearman's rho was chosen as it is a nonparametric test. The perceptions of faculty response and willingness to report subscales had a weak positive correlation of .298, signifying that the more students felt that faculty supported their universities' academic integrity policies and discussed them in their courses, the more willing students were to report peer violations they witnessed. The willingness to report and perceptions of severity subscales had a moderate positive correlation of .485. The more students understood what was considered a violation, the more likely they were to be willing to report peer violations. The program improvement suggestions and willingness to report subscales had a weak positive correlation of .231. The stronger students believed implementation of program-wide strategies could prevent violations of academic integrity, the higher their scores on the willingness to report subscale.
To assess whether certain improvement suggestions were more significantly correlated with willingness to report peer violations, each item's correlation with the willingness to report subscale was calculated (see Table 1). Although all suggestions were positively correlated with willingness to report, only two were significantly so: implementing an honor code (.293) and better education at the onset of the nursing program (.239).
DISCUSSION
Overall, the results demonstrate that students' perceptions of severity and their perceptions of faculty support positively correlate with the willingness to report peers for violating academic integrity. Understanding what constitutes a violation of academic integrity and feeling as though faculty effectively communicate about and support academic integrity-related policies are correlated with an increased willingness to report violations. In addition, students believe program-wide interventions could create a culture of academic integrity by preventing cheating. At a minimum, implementing an honor code and providing students with more education regarding academic integrity upon matriculation may help increase perceptions of faculty support as well as willingness to report peer violations.
Promoting a Culture of Academic Integrity
Creating a culture of academic integrity can promote peer reporting by fostering an atmosphere that embraces the responsibility of the student to uphold the integrity of the program and work to maintain the public's trust in the nursing profession. Chunta and colleagues (2019) discussed several recommendations to promote academic integrity including recurrent education, a code of conduct, clear communication regarding expectations, and preventing the temptation to cheat. Benson et al. (2019) supported the need for student education on academic integrity. Using an e-learning program, student knowledge of academic integrity increased 10 percent from pretest to posttest. This increase demonstrates educational programs can be of assistance in increasing academic integrity knowledge and, therefore, can strengthen the culture integrity within a program.
In addition to open communication between students and faculty regarding policy, discussion on how students can prevent violations related to their written work can be useful. One way to deter violations of academic integrity related to plagiarism is the use of plagiarism detection software. This software detects if a student has used material from another source in the current written assignment (Wilkinson, 2009). By encouraging students to use antiplagiarism software, faculty can demonstrate their desire to provide students with opportunities to prevent violating academic integrity. With open communication and use of resources such as antiplagiarism software, a culture of integrity can be fostered among faculty and students.
Another program-wide suggestion to promote a culture that supports peer reporting is implementation of an honor code. Honor codes have been implemented at various institutions for decades. McCabe and Trevino (1993) explored the reasons why honor codes may be successful at creating a culture of integrity that promotes peer reporting. One reason is that honor codes delineate expectations regarding what is considered a violation of academic integrity. Another explanation is that honor codes empower students with the responsibility to uphold integrity, rather than only relying on faculty and university leadership to do so.
Another strategy to promote a culture of integrity in the classroom and online settings is to prevent the temptation to cheat. This may include using various copies of an exam, lockdown browsers for online testing, randomized seating during exams, and removing electronic devices from students while testing. It is more difficult to include preventative strategies in the clinical setting.
A potential strategy to prevent the temptation to violate academic integrity in all settings, including the clinical setting, is to consider harsher sanctions for those who commit violations of academic integrity. Keener et al. (2019) found that both faculty and students believed there should be more significant consequences related to dishonest behaviors that jeopardize the profession or patient safety. Sanctions may include written warnings presented as teachable moments, failure of the assignment, being removed from a clinical agency, failure of a course, documentation of violations on transcripts, documentation in the student file, and removal from the nursing program. Kolb et al. (2015) identified fear of consequences as a reason students may not engage in violations of academic integrity. However, if students feel the benefits of cheating outweigh the risks, they may be willing to engage in dishonest behaviors (Hutton, 2006). In the clinical setting, student awareness that violators will consistently be held responsible for their actions may encourage them to become more familiar with what constitutes academic integrity. Further, students may be deterred from committing violations and encouraged to report peer violations they witness.
Implications and Future Research
Results from this study show that there are discrepancies in student awareness of what constitutes a severe violation of academic integrity and willingness to address these behaviors when they witness a peer violation. The results also provide tangible strategies for nursing faculty to implement to address those discrepancies. Although students stated they would report peers in the clinical setting if they had a concern relating to patient care, this reporting can only happen when students are aware that a particular behavior is a violation of academic integrity. More education can provide students with an awareness of what is considered a violation and the need to report violations they witness.
As evidenced in this study, students are more likely to identify violations as severe and report them if they believe their faculty supports the enforcement of academic integrity policies. Faculty appear to be discussing plagiarism, proper citations, syllabi review, and not discussing patient details in public, but they may be less effective in addressing concepts related to copying and pasting care plan information, using parts of a peer's care plan, or sharing information about an assignment with others. These behaviors are violations of academic integrity, and faculty should address them as such. An honor code would provide faculty with a reliable blueprint for addressing academic integrity with their students. An honor code could also facilitate student buy-in to accept their responsibility in upholding the integrity of their nursing program by reporting peer violations.
It is important to note that peer accountability is not limited to the academic setting. Reporting peer violations of integrity in the hospital setting is critical for a culture of safety, and in some states, nurses can face disciplinary action for failing to report a peer who is diverting medication or otherwise jeopardizing patient safety. Cementing this concept with nursing students through early and continuous education throughout the nursing programs is essential to promote the culture of safety, both as students and professional nurses.
The findings of this study support the need for further research on the topic of academic integrity in schools of nursing and how to best promote a culture that empowers students to report peer violations. Reporting alone is not the only way to promote a culture of integrity, and further research could expand on other factors that cultivate honesty. Technological advances both in and out of the classroom can impact cheating and are worth investigating. For example, it is possible for students to pay someone to attend online courses in their place, pay a fee for a paper, or access written assignments online (Mortati & Carmel, 2021).
Beyond the methodology of cheating, the impact of loyalty to one's peer group and how that influences the willingness to report peer violations should be also explored. As noted by Hollman and colleagues (2021), sharing of test questions, files, or other documents can now be done anonymously, "weaken[ing] social processes that stood as a barrier to academic dishonesty in the past" (p. 36).
Possessing academic integrity not only encourages taking ownership of one's knowledge in order to be successful as a nurse, but it also promotes the moral and ethical development needed to care for individuals during their times of need. Studies on the individual's responsibility to possess the moral fortitude needed to uphold academic integrity are warranted. The demands of nursing school are well known, and targeted interventions that increase knowledge early in the nursing program, such as utilizing online learning modules during orientation, could be a way to promote academic integrity in students as they begin a rigorous field of study.
LIMITATIONS
One of the major limitations of this study was the time in which it was conducted. The online learning demands created by the COVID-19 pandemic may have led to Internet fatigue. Many students were overwhelmed with school and outside responsibilities and may not have clearly read the survey questions or decided not to participate. There is also the potential that students simply went through the survey, marking answers to receive the gift card incentive. To mitigate that threat, data from four participants who completed the survey in less than five minutes were excluded from analysis.
Another limitation is that the MAIS-MNS is a new instrument that underwent significant modifications from its predecessor. There is a lack of evidence for concurrent validity as there is no comparison of results from the modified survey to McCabe's original survey. There is also a lack of evidence for the instrument's construct validity. Future studies could be done using this instrument to aid in establishing validity.
Generalizability could be limited as well by using only the NSNA listserv for recruitment; not all nursing students in the United States are members. In addition, the sampling design was a nonprobability cross-sectional design, which can impact the ability to make causal inferences and is not always representative of the target population. Other limitations include budget constraints that limited the number of participants, participant concerns regarding their anonymity, and the possibility of response bias, with participants wanting to give answers they felt was correct. Although students were told there were no identifying data with the survey, there may have been concern with remaining anonymous and potential ramifications for disclosing information regarding academic integrity violations.
CONCLUSION
The need to further educate nursing students on academic integrity is apparent. As identified by other researchers, this study supports that students have varied opinions on how supported they feel by faculty and what constitutes violations of academic integrity. In addition, students vary greatly in their likelihood of reporting dishonest behaviors. It is necessary to educate students on the importance of peer reporting while acknowledging that peer reporting alone is not the sole way to create a culture of integrity within nursing programs. By providing better education on academic integrity that includes why peer reporting is important, students may feel their reports will be taken seriously to uphold the integrity of the program and safeguard the public from dishonest nurses. The hope is that values related to integrity will remain with students well past graduation and into their practice. Without interventions aimed at defining and promoting academic integrity, including the responsibility to report peer violations, the potential exists that violations of this nature could impact patient care.
REFERENCES