Midwifery students’ knowledge, understanding and experiences of workplace bullying, and violence: An integrative review

Abstract

Background

Workplace bullying, and violence within the midwifery profession, has been a well-documented concern in health literature since the early 1990′s. However, contemporary research highlights that workplace bullying, and violence is often inflicted upon midwifery students. Workplace bullying, and violence has both short- and long-term effects on the student, including psychological trauma and poor mental health, loss of passion for the midwifery profession and absenteeism. To consider a solution to this phenomenon, current literature regarding midwifery students’ knowledge, understanding and experiences of workplace bullying, and violence has been reviewed.

Objective

To explore and critique current literature on midwifery students’ knowledge, understanding and experiences of workplace bullying, and violence.

Design

An integrative review.

Review methods

Toronto & Remington's six-stage systematic framework was used to conduct the review, with rigour and validity for the research process.

Results

Following critical appraisal, 12 articles met the inclusion criteria. Four themes emerged: (1) Prevalence and types of workplace bullying, and violence towards midwifery students. (2) Impact of workplace bullying, and violence on midwifery students’ experiences during the degree. (3) Impact of negative workplace culture on the midwifery profession. (4) The requirement to develop strategies for midwifery students to address workplace bullying, and violence.

Conclusions

Workplace bullying, and violence is a global health concern within the midwifery profession with evidenced impact on midwifery students’ professional and personal lives. Organisational systems and approaches were identified as causes of a toxic clinical environment and workplace bullying, and violence, which impacted midwifery students’ experiences. Suggestions supported universities incorporating conflict resolution strategies into midwifery degree programs, to prepare midwifery students to manage workplace bullying, and violence.

Tweetable abstract

Workplace bullying, and violence is a global health concern entrenched within the midwifery profession, impacting midwifery students’ professional and personal lives. Incorporating conflict resolution strategies into Bachelor of midwifery degree programs, may help prepare midwifery students to manage workplace bullying, and violence.

Contribution of the paper

What is already known about the topic?

• •Workplace bullying, and violence is a global health concern entrenched within the midwifery profession.
• •Midwifery students are particularly vulnerable to workplace bullying, and violence.
• •Midwifery students perpetuate the cycle of violence to ‘fit in’ and secure jobs on completion of their university degree.

What this paper adds

• •This integrative review identified the important position universities play in preparing and educating midwifery students to manage potential conflict in the workplace.
• •This integrative review highlights the importance of improved reporting pathways for midwifery students who have experienced workplace bullying, and violence.
• •This integrative review emphasises that stronger repercussions for perpetrators of workplace bullying, and violence are required to deconstruct bullying and violence within the midwifery profession.

1. Introduction

Workplace bullying, and violence is an international health concern, with studies in the United Kingdom and Australia exposing a culture of violence in the midwifery profession since the early 1990s (Hastie 1995; Killingley 2016; Pich 2019; Capper et al., 2020a; Capper et al., 2022). More recently, research has highlighted that midwifery students have become targets of workplace bullying, and violence (Hegney et al., 2006; Gillen et al., 2009; Primanzon and Hogan 2015; Capper et al., 2020a, 2020b, 2020c, 2021a). Despite a universal lack of defining workplace bullying, and violence (Van Fleet and Van Fleet 2022), it has been defined by the Oxford University Press (2021) as: “seek to harm, intimidate or coerce someone seen as vulnerable”. The Australian Nursing and Midwifery Federation describes bullying as a repetitive pattern of violence, which brings harm to the victim/s (ANMF, 2018). For the midwifery student, the term ‘workplace’ incorporates venues that the student attends to conduct their clinical placements and continuity of care experiences (UniSA, 2022).

Workplace violence may be the result of individual or group behaviour that is abusive, threatening, intimidating, or disruptive in the workplace (Safework Australia 2020). Midwifery students have reported experiencing workplace violence manifesting as physical, verbal & emotional abuse, and bullying (McKenna and Boyle 2016). As a result of workplace violence, victims report long-term damaging effects on their emotional, psychological and spiritual well-being, including absenteeism, stress, fatigue, psychological trauma, poor mental health, job dissatisfaction and poor job retention (Catling et al., 2017; McKenna and Boyle 2016; Capper et al., 2020a; Hassard et al., 2018; Hegney et al., 2006). Despite these identified negative consequences, minimal improvements have occurred over the last 35 years (Hills et al., 2018), thereby confirming acceptance of this culture within the midwifery profession (Capper et al., 2021a).

Research has reported workplace bullying, and violence is inflicted on junior staff, including midwifery students, both vertically and horizontally (Hegney et al., 2006; Gillen et al., 2009; Capper et al., 2020a; Primanzon and Hogan 2015). Furthermore, the imbalance of power between midwifery students and midwives has been cited as contributory (Lash et al., 2006). Midwifery students’ exposure to workplace bullying, and violence was first reported by Lash et al. (2006), highlighting the vulnerability and risk of workplace bullying, and violence for midwifery students.

Capper and colleagues (2020a) recommended that workplace bullying, and violence of midwifery students be addressed at a policy level, due to the potential for attrition, whilst McKenna and Boyle (2016) proposed the inclusion of formal education on workplace bullying, and violence in the Bachelor of Midwifery degree, to better prepare midwifery students for clinical settings.

To support the consideration of solutions to this issue, current literature regarding midwifery students’ knowledge, understanding, and experiences of workplace bullying, and violence has been reviewed.

2. Background

In common with global Bachelor of Midwifery degrees which enable entry to practice programs, South Australian courses comprise both theoretical and practical components (UniSA, 2022; Flinders University, 2022). Theoretical content is expanded and consolidated through simulation, clinical placements, and continuity of care experiences – where midwifery students follow women throughout their pregnancy, birth, and postnatal period; providing students with an authentic learning experience and a greater understanding of the midwifery profession (UniSA, 2022; Flinders University, 2022; Ackland-Tilbrook and Warland 2015). Midwifery students commence clinical placements in the first year of their midwifery degree, following completion of pre-requisite theory courses (UniSA, 2022; Flinders University, 2022). This structure is followed throughout the midwifery degree (UniSA, 2022a; Flinders University, 2022). Similarly to clinical placements, midwifery students embark on continuity of care experiences in the first year of their midwifery degree, following the completion of pre-requisites, however, midwifery students can continuously achieve these experiences throughout the entirety of their degree (UniSA, 2022; Flinders University, 2022).

The Australian Nursing and Midwifery Accreditation Council mandates the education standards for programs leading to entry to the professional register of midwives (ANMAC, 2021). The The Australian Nursing and Midwifery Accreditation Council standards require midwifery students’ clinical placements and continuity of care experiences occur in environments that facilitate quality learning experiences, including supervision and mentoring by registered midwives. Consequently, the quality of the learning environment has a significant impact on the student's ability to develop knowledge, skills, confidence, and competence to meet the Nursing and Midwifery Board of Australia midwife standards for practice (NMBA, 2018).

Midwives working in clinical practice, are expected to mentor midwifery students, providing them with authentic on-the-job education and real-life experiences, translating theoretical knowledge and skills into the practice environment (NMBA, 2018; Capper et al., 2020b; UniSA, 2022; Flinders University, 2022). Midwives may be required to adopt mentoring responsibilities, without the requisite training in teaching, highlighting a lack of preparation for mentoring midwifery students (Capper et al., 2020b). Two studies by Capper et al. (2020a and 2021a) suggest that the poor behaviour midwifery students are exposed to, may be due to the lack of recognition and formal education for midwives undertaking teaching responsibilities, leading to stress, confusion, and miscommunication.

Midwives engage in respectful partnerships with women, other health professionals, colleagues, and midwifery students (NMBA, 2018). Despite this, the literature demonstrates that respectful working relationships, within clinical settings, do not always occur, resulting in midwifery students’ being exposed to workplace violence (Capper et al., 2020a). Midwifery students are particularly vulnerable and susceptible to workplace bullying, and violence (McKenna and Boyle 2016) and may subsequently emulate the poor behaviour they have witnessed, rather than calling this out. This has been attributed to trying to ‘fit in’, make friends, and secure graduate positions (McKenna and Boyle 2016; Gillen 2009; Arundell et al., 2018; Capper et al., 2020a).

3. Aims and objectives

Workplace bullying, and violence within the midwifery profession has been well documented. This issue is now known to have a negative impact on midwifery students’ affecting both their professional and personal lives. To address this disturbing phenomenon and develop strategies to manage negative workplace behaviour, it is important to gain insight into midwifery students’ knowledge, understanding, and experiences with workplace bullying, and violence. Understanding midwifery students’ experiences with workplace bullying, and violence will help inform the development of a bespoke undergraduate education program on developing conflict resolution strategies and building resilience.

Research Question

• What are midwifery students’ knowledge, understanding, and experiences of workplace bullying, and violence?

4. Methodology

This integrative review utilised a systematic method proposed by Toronto & Remington (2020) (Table 1) to enhance the rigour of the review. Toronto & Remington (2020) built on Cooper's (1982) foundational five-stage framework: (1) Problem identification, (2) Literature search, (3) Data evaluation, (4) Data analysis, and (5) Presentation of findings, to increase precision and validity of the review. Toronto and Remington's (2020) integrative review model was utilised as the framework guides researchers to conduct and critique, current literature in stages, thus enabling a comprehensive search to be completed: promoting a holistic understanding of the phenomenon being investigated.

Table 1.

Deconstruction of research question following Toronto and Remington's (2020) framework.

Steps in Toronto & Remington's Integrated Review framework		Deconstruction of the research question
1	Formulate purpose and/or review question(s)	The integrative review will explore and summarise the body of existing literature on midwifery students’ knowledge, understanding, and experiences of workplace bullying, and violence.
2	Systematically search and select literature	The Participant Concept Context (PCC) research tool was utilised to break down the research question into key search terms. Key search terms and their synonyms were identified to use in searching for literature on the research question. A mix of these terms was entered into search engines of relevant databases, with a combination of Boolean operators, truncations, and wildcards to help limit the search results. A librarian at UniSA was consulted, in developing the most appropriate search strings that would return the most relevant results that addressed the research question. An online search of 4 databases, (Embase, Emcare, Medline, and Scopus) was completed to identify and critically analyse the body of available literature about workplace bullying, and violence for midwifery students. Google Scholar was searched for academic and grey literature. Two reviewers undertook the first and second pass of the retrieved articles (title and abstract, followed by a full-text review of the included studies), with a third reviewer, resolving any conflicts.
3	Quality appraisal	•The JBI Appraisal Checklist for Systematic Review and Research Syntheses (2017) was adapted to appraise the quality of the articles selected for inclusion (Table 3).
4	Analysis and synthesis	•A thematic analysis using Braun & Clarke's (2006; 2019) 6-stage framework was completed, identifying patterns and relationships to uncover underlying themes within the literature. •Four themes emerged during the analysis.
5	Discussion and conclusion	•Reporting and discussion of the emerging themes and key findings found within the literature were undertaken. •Summarising the conclusions was completed.
6	Dissemination of findings	•Journal Article publication •Main researcher's PhD Thesis •Potential for presentation at conferences

5. Literature search

An academic librarian was consulted in the deconstruction of the research question, to identify suitable key words and the subject headings utilised in the Participant Concept Context table (Table 2). The literature search considered all types of studies using Embase, Emcare, Medline, and Scopus online databases. These databases were selected as they combine over five million scholarly and peer-reviewed records from nursing/midwifery and allied health professions, providing high-quality independent evidence. Key terms (Table 2) were utilised in different combinations to generate results. The most productive search string was (midwifery students OR trainee midwi* or student midwi*) AND (workplace conflict OR conflict OR workplace bullying OR bullying OR workplace violence OR violence), which was consistently used across the chosen databases. Only articles published in English were included, due to lack of translation resources. No date limits were applied due to the paucity of literature on midwifery students’ exposure to workplace bullying, and violence in clinical settings. Google Scholar was searched for academic and grey literature.

Table 2.

PCC.

Participants	Concept	Context
Midwifery students Trainee Midwi* Student Midwi*	Workplace conflict Conflict Workplace bullying Bullying Workplace violence Violence	Knowledge Understanding Experiences

5.1. Inclusion and exclusion criteria

5.1.1. Inclusion criteria

• •Midwifery Students
• •Trainee Midwives
• •Student Midwives
• •Students studying for a Bachelor of Midwifery degree
• •Studies that included Midwifery students

5.1.2. Exclusion criteria

• •Registered midwives

6. Search outcome

The steps in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed to conduct a systematic approach to the search, to assist with the rigour and validity of the results (Fig. 1). Endnote 20 (reference management) was utilised in conjunction with Covidence software (screening and data extraction tool) to manage references.

Fig. 1.

PRISMA 2020 flow diagram.

The initial search was conducted by the primary researcher (NS), generating 725 articles (Fig. 1). One hundred and forty-five (145) duplicates were removed in Covidence. The first screening of title and abstract was completed by two researchers (NS, DW), independently, using the inclusion criteria: midwifery students AND workplace conflict, workplace bullying OR workplace violence. A third researcher (RV) was used to resolve conflicts arising in the first screening process. A total of 554 articles were removed in the first screening process. The second full-text screening of the remaining 26 articles was completed by two researchers (NS, DW). A third researcher (RV) was consulted to discuss any conflicts and reach a consensus. A further 14 articles were excluded due to incorrect indications (n = 5), outcomes (n = 4), population (n = 4), and the inability to access full-text publications (n = 1). No external input outside of the research team was required. Final consensus was reached (NS, DW, RV, MS), with a total of 12 articles found to meet the inclusion criteria for the study.

7. Quality appraisal

An appraisal was conducted to assess the quality and internal validity of the selected articles, to improve the strength of the research, and mitigate any perceived or actual bias (Toronto and Remington 2020). The primary researcher created a table (Table 3) based on the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Review and Research Syntheses (JBI 2017) (Appendix 1). The table was then adapted to accommodate differences in literature review styles and to facilitate a quality appraisal of the studies selected for inclusion in the research. Due to the small number of studies returned as a result of the research strategy, further removal of studies based on methodological quality would have caused further loss of data (Hong et al. 2018).

Table 3.

Quality appraisal (adapted version of JBI (2017) critical appraisal checklist for systematic reviews and research syntheses).

	Capper 2020a	Capper et al., 2020b	Arundel 2017	Shapiro 2018	McKenna 2018	Capper et al., 2020c	Gillen 2009	Capper et al., 2021a	Boyle 2016	Capper et al., 2021b	Hogan 2017	Steen 2011
Clear aims	X	X	X	X	X	X	X	X	X	X	X	X
Methodology	X	X	X	X	X	X	X	X	X	X	X	#
Research design	X	#	X	#	X	0	0	X	#	X	X	X
Recruitment	N/A	X	N/A	#	X	X	#	X	X	X	#	#
Data collection	X	X	X	X	X	#	#	X	X	X	X	#
Reflexivity	N/A	0	N/A	N/A	N/A	0	N/A	0	N/A	X	N/A	N/A
Ethics	0	X	0	X	X	X	X	X	X	X	X	0
Data analysis & rigour	X	X	X	X	#	X	#	X	X	X	X	#
Findings	X	X	X	X	X	X	X	X	X	X	X	X
Value of research	X	X	X	X	X	X	X	X	X	X	X	X
Overall quality rating	A	A	A	B	A	B	C	A	A	A	A	C

Key: Overall Quality Rating:

X = Yes A = High study credibility, transferability, dependability, and confirmability (CTDC)

# = Can't Tell B = Some flaws, however, are unlikely to affect CTDC

0 = No C = Some flaws which may affect CTDC

N/A = Not applicable D = Significant flaws which are very likely to affect CTDC

8. Data extraction

Data were extracted from the 12 sources deemed appropriate for inclusion and summarised in a template (Table 4). Summaries include author, year and country of publication, title, aim, sample size, methods/tools, results, and conclusions.

Table 4.

Summary of included studies.

Author. Year, Country	Title	Aim	Sample size	Method / Tools	Findings and conclusions
Capper, T, Muurlink, O & Williamson M. 2020a Australia	Midwifery students’ experiences of bullying and workplace violence: A systematic review.	To systematically review the literature to identify what is known about workplace violence and bullying experienced by midwifery students’ whilst on clinical placement	9	Systematic Review	The studies suggest that bullying is commonplace in Midwifery and that it has a significant impact on a personal and professional level. Four themes emerged from the data: the role of power in bullying, prevalence and impacts, culture of compliance, and the victim's response. Stronger organisation response & greater policy is required in a clinical education context, to break the cycle of bullying and maintain a sustainable workforce for midwives.
Capper, T, Muurlink, O & Williamson, M. 2020b Australia	Midwifery students’ perceptions of the modifiable organisational factors that foster bullying behaviours whilst on clinical placement. A qualitative descriptive study.	To explore and describe midwifery students’ perceptions of what modifiable organisational factors foster bullying behaviours and to map the identified factors against the students’ perceptions of a solution.	120 midwifery students – 53 from the UK and 67 from Australia.	A qualitative descriptive study	The study describes three factors that foster bullying of midwifery students when on clinical placements, including ineffective midwifery mentorship, a high-stress environment, and challenges with transparency and whistleblowing. Both universities and health services have a key role in addressing bullying of midwifery students. Recommendations including better preparation of midwifery students concerning workplace culture and bullying issues by universities, recognition of mentors by health services, and providing them with formal education around teaching midwifery students in a clinical setting, continuity of mentorship, improved workplace culture (removal of cliques) and teamwork.
Arundell, F, Mannix, J, Sheehan, A & Peters, K. 2018 Australia	Workplace culture and the practice experience of midwifery students: A meta-synthesis.	To describe midwifery students’ practice experience and to explore facilitators and barriers to positive clinical learning experiences	12 studies met eligibility criteria.	A meta-synthesis	Two main themes were seen in the literature – “workplace culture and relationships”, so they were broken into two follow-up papers. This paper focuses on workplace culture, in which there were five subthemes – feeling unwelcomed, knowing your place, being flexible or inflexible, deciding on my future, fitting in, and commitment to student learning. Barriers to a positive clinical placement experience included: lack of support, negative workplace culture, feeling excluded, and not being respected, not supporting the development of critical thinking.
Shapiro, J, Boyle, M & McKenna, L. 2018 Australia	Midwifery student reactions to workplace violence.	Explore Australian midwifery students’ responses to workplace violence as well as to gauge the impact of workplace violence on them.	52, 2nd and 3rd - year midwifery students from a Victorian University	Cross-sectional study	Most midwifery students were found to report workplace violence (WPV) immediately after the event. WPV caused preclinical post-traumatic stress with participants displaying intrusive behaviours. Minimal students completed an incident report form. Minimal (11%) underwent professional debriefing of the incident – due to a lack of trust in the hospital staff and concerns regarding employment following their studies. The researchers suggest that students must complete an incident report so that the workplace can implement strategies to prevent violence. Further, longitudinal studies are required.
McKenna, L & Boyle, M. 2016 Australia	Midwifery student exposure to workplace violence in clinical settings: An exploratory study.	Examine undergraduate midwifery students’ experiences of workplace violence during clinical placements.	52, 2nd and 3rd - year midwifery students from a Victorian University	Cross-sectional study	Midwifery students’ were exposed to workplace violence (WPV) during clinical placement, experiencing intimidation, verbal abuse, physical abuse, and sexual harassment. Midwifery students are more vulnerable than midwives and this increases their risk of experiencing WPV. WPV results in a lack of trust, confidence, and attrition from studies. There is a need to provide midwifery students with education and the development of strategies around managing WPV at a University level. There needs to be a transparent hospital reporting system that is anonymous, therefore no retribution for the student.
Capper et al., 2020c. Australia.	Being bullied as a midwifery student: does age matter?	To explore whether the age of midwifery students influences the experience of being bullied while on clinical placement.	40 midwifery students from UK and Australia, which included. 20 midwifery students aged between 18 and 21 years old and 20 midwifery students aged 43 years old or above.	Qualitative	The pattern of bullying was similar between the two groups, suggesting that age is not a factor for midwifery students experiencing bullying. Both groups experienced bullying from the same set of perpetrators, primarily within birthing areas. The nature of bullying was different in the two groups. Younger midwives experienced a power disadvantage when compared with their older counterparts. Younger midwifery students experience more verbal and overt forms of bullying.
Gillen, P, Sinclair, M, Kernohan, G & Begley, C. 2009. United Kingdom	Student midwives’ experience of bullying	To define and examine the nature and manifestations of bullying in midwifery as experienced by a cohort of student midwives in the UK.	164 midwifery students in the UK.	Quantitative	There is a strong prevalence of bullying in the midwifery profession with midwifery students experiencing being treated badly, suffering intimidation, excessive criticism, belittling of their work, undervaluing of their skills, questioning of their competency, and undervaluing their effort. Midwifery students’ were commonly bullied by another midwife or mentor, highlighting power imbalances in midwifery. The impacts of bullying on midwifery students’ included loss of confidence, loss of self-esteem, anxiety, and thoughts of leaving the course. The majority of midwifery students’ enjoyed their clinical placements, but those that did not cite reasons that were linked to poor treatment by midwifery colleagues. Future research into the bullying culture of midwifery is required in Australia. A proactive approach to bullying is required, moving toward a culture change. This includes including education around bullying phenomena in curricula.
Capper et al., 2021a. Australia	Social culture and the bullying of midwifery students whilst on clinical placement: A qualitative descriptive exploration	Explore how the social culture of the maternity setting influences midwifery students’ experiences of being bullied whilst on clinical placement.	120 midwifery students, comprising 53 from the UK and 67 from Australia.	Qualitative descriptive study	There is an acceptance of bullying culture in the midwifery profession, which therefore leads to replication of the problem. Bullying is quite brazen, occurring in public, with midwives who bully students, not fearful of repercussions. Bullying impacts midwifery students’ education – clinical experiences are intrinsically linked to theory, the experience and quality of care for women and their partners, and the reputation of the midwifery profession. Midwifery students turn to each other for support when bullied. The study supports the body of literature on midwifery students’ attrition after experiencing bullying. Change is urgently needed.
Boyle, M & McKenna, L. 2016 Australia.	Paramedic and midwifery student exposure to workplace violence during clinical placements in Australia – A pilot study.	To identify the type of workplace violence experienced by undergraduate paramedic and midwifery students.	393 students, which included 132 BEH students, 158 BN/BEH students, and 103 BMid students	Cross-sectional study	69% of midwifery students had experienced either verbal abuse, intimidation, or sexual assault. The most common form of abuse to midwifery students’ was verbal abuse (83.3%). Only female students in the study experienced sexual assault. Midwifery students experience more acts of violence against them during clinical practice, when compared with paramedic students. A need for education on managing workplace bullying and violence is needed for undergraduate students. There is currently no formalised education in midwifery curricula at Monash University where the study was completed. Students need awareness of and access to reporting systems for violence, so this can be followed up with the student.
Capper, T, Muurlink, O & Williamson, M. 2021b Australia	The parents are watching: Midwifery students’ perceptions of how workplace bullying impacts mothers and babies.	To examine how midwifery students, who self-identify as having been bullied, perceive the repercussion on women and their families.	120 midwifery students, comprising 53 from the UK and 67 from Australia.	Qualitative descriptive study	Bullying of midwifery students impacts women and their families in several ways, including putting women's safety at risk, fracturing relationships between the woman and midwifery student, damaging rapport, damaging woman-centred care, and impairing women's confidence in the midwifery student and the midwifery profession. Women and their families feel compelled to step in and defend midwifery students, which impacts their overall birth experience and care.
Hogan, R, Orr, F & Fox, D, Cummins, A & Foureur, M. 2018 Australia	Develop nursing & midwifery students’ capacity for coping with bullying and aggression in clinical settings: Students’ evaluation of a learning resource.	To develop nursing and midwifery students’ capacity for coping with bullying and aggression that they may encounter in clinical settings.	210 nursing & midwifery students from an urban university in Australia. Due to the anonymity of the survey, it was impossible to discern between the two clinical professions.	Qualitative descriptive study	Developing a blended learning resource that builds capacity for nursing and midwifery students to effectively respond to aggression and bullying, provides a solution to managing some of the demands of the clinical setting. The realistic resources enriched students learning, with the online learning environment providing a convenient platform for students’ to learn at their own pace. The strategies improved students’ confidence to approach colleagues for support and assistance.
Steen, M. 2011 United Kingdom	Conflict resolution for student midwives.	Provide insight into the Start Treating Others Positively (STOP) model and how it has been adapted to develop an educational workshop for student midwives.	32 Midwifery students at the University of Chester, UK.	Educational workshop evaluation Student self-report	The STOP model was successfully adapted to meet the needs of midwifery students at the University of Chester. Students identified that skills learned regarding how to recognise anger signals, de-escalate anger, identify how you wind yourself up or down, how to have a balanced argument, and how positive self-talk can change anger behaviour, enabled them to manage conflict with their colleagues and peers. Students were able to identify past examples that they could have dealt with differently following the STOP workshop. The STOP model has the potential to be developed further, increasing transferability.

9. Results

A total of 12 articles were critically analysed and synthesised to address the research question on midwifery students’ knowledge, understanding, and experiences of workplace bullying, and violence. The included studies were primarily conducted within Australia (n = 10), with two additional studies undertaken in the United Kingdom (UK) (n = 2). A thematic analysis using Braun and Clarke's (2006; 2019) 6-stage framework was undertaken as the ideal method of data analysis for integrative reviews (Whittemore and Knafl 2005). Patterns and relationships were identified within the text and were continuously reviewed until no new emerging themes were apparent in the literature (Braun and Clarke 2006; 2019). Four main themes were evident in the research: (1) Prevalence and types of workplace bullying, and violence towards midwifery students, (2) Impact of workplace bullying, and violence on midwifery students’ experience whilst undertaking a midwifery degree program, (3) Impact of negative workplace culture on the midwifery profession, and (4) Need to develop strategies for midwifery students to address workplace bullying, and violence.

9.1. Prevalence and types of workplace bullying, and violence towards midwifery students

Of the twelve studies included in this integrative review, all discussed the prevalence of bullying and violence towards midwifery students in clinical settings, whilst undertaking their Bachelor of Midwifery degree (Gillen et al., 2009; Steen 2011; Boyle and McKenna 2016; McKenna and Boyle 2016; Arundell et al., 2018; Hogan et al., 2018; Shapiro et al., 2018; Capper et al., 2020a; Capper et al., 2020b; Capper et al., 2020c; Capper et al., 2021a; Capper et al., 2021b). Gillen et al. (2009), also reported on midwifery students experiencing bullying and violence in the University environment.

In Gillen et al.’s (2009) study, 55% (n = 90) of midwifery students personally experienced bullying in clinical settings and 36% (n = 59) witnessed colleagues being bullied. Gillen et al.’s (2009) findings of workplace bullying, and violence were corroborated by McKenna and Boyle's (2016) study. This Australian study reported three-quarters (n = 52) of midwifery students enroled in the Bachelor of Midwifery degree, experienced nervousness and were frightened because of workplace bullying, and violence when attending clinical placements and continuity of care experiences. In both these studies, abuse was variably experienced, including intimidation, verbal and physical abuse, and sexual harassment amongst others as reported in Table 4 (Gillen et al., 2009; McKenna and Boyle 2016). Additionally, Gillen et al. (2009) reported that 15% (n = 9) of midwifery students indicated abuse occurred 2–3 times per week.

Despite these findings highlighting the prevalence of bullying within the midwifery profession, 94% (n = 154) of the midwifery students included in Gillen et al.’s (2009) study expressed enjoyment of their clinical placement, which they attributed to the special relationship they developed with women and the satisfaction gained from working with them.

9.2. Impact of workplace bullying, and violence on midwifery students’ experience while undertaking the bachelor of midwifery degree

9.2.1. Professional

Six of the included studies described the impact that workplace bullying, and violence had on midwifery students’ professional life (Gillen et al., 2009; McKenna and Boyle 2016; Hogan et al., 2018; Capper et al., 2020a; Capper et al., 2020c; Capper et al., 2021b), including attrition, a lack of trust and loss of passion for the profession, inhibited woman-centred care and damaging the relationship the student had built with the woman (McKenna and Boyle 2016; Hogan et al., 2018; Capper et al., 2020c; Capper et al., 2021b). This resulted in midwifery students leaving the program/course to study elsewhere or seek alternative career pathways (McKenna and Boyle 2016; Capper et al., 2020c).

Two studies by Capper et al. (2020a) and Hogan et al. (2018) investigated whether age and gender were indicators for workplace bullying, and violence experienced by midwifery students. Whilst Capper and colleagues (Capper et al., 2020a) found no evidence of this, Hogan et al. (2018) suggested that young women experienced a greater threat of aggression in the workplace. This led to a loss of confidence in knowledge and skills for young midwifery students (Hogan et al., 2018).

McKenna & Boyle (2016) and Capper et al. (2021b) described midwifery students as having an increased risk of workplace bullying, and violence if they were studying the direct-entry pathway to the Bachelor of Midwifery degree, rather than previously completing a nursing degree. Suggesting that students lack the skills and abilities to become a midwife if they have not previously worked within the biomedical model, inherent in the nursing degree. This contributed to poor working relationships between staff within the maternity unit.

One study described midwifery students’ being allocated menial tasks and having to “keep their head down” when undertaking clinical placements, to ‘fit-in’ and avoid workplace bullying, and violence. This behaviour resulted in being rewarded with better clinical experiences (Arundell et al. 2017, p.305). The same study reported midwifery students felt pressure to conform to workplace practices to avoid experiencing bullying, and violence (Arundell et al. 2017). This led to students learning individual techniques, rather than working from an evidence base, which impacted progression through the degree and ultimately future career opportunities as their clinical experiences may have been deficient, when compared to students who were compliant with the clinical workplace culture (Capper et al., 2020a)

In the three studies completed by Gillen et al. (2009), Arundell et al. (2017), and Shapiro et al. (2017), belittling and harassment were common forms of workplace bullying, and violence in the clinical setting. This increased stress for midwifery students undertaking placements, leading to cancelled shifts to avoid associating with the perpetrator of the violence, and ultimately adversely impacting their clinical placement (Gillen et al., 2009; Arundell et al. 2017; Shapiro et al. 2017).

Three studies reported that midwifery students were unlikely to report workplace bullying, and violence, particularly early on in their degree, due to a lack of confidence, fear of retribution, and concerns regarding the potential impact of this on securing employment after completion of their studies (Shapiro et al., 2018; McKenna and Boyle 2016; Capper et al., 2020c). In the study by Gillen et al. (2009), 24% (n = 14) of midwifery students had attempted to address their bully. However, the majority (90%, n = 53) opted to debrief with other midwifery students, family, or friends, due to fear of repercussions. These authors also stated that whilst some midwifery students reported workplace bullying, and violence, no action or change to the workplace resulted from this process, increasing the students’ lack of confidence in the midwifery system (Gillen et al., 2009), and perpetuating the cycle of violence (Capper et al., 2020a and 2021b).

9.2.2. Personal

The impact of workplace bullying, and violence on midwifery students’ mental health was discussed in three of the articles included in this integrative review (Gillen et al., 2009; McKenna &^ Boyle 2016; Capper et al., 2020b). The negative mental health outcomes included loss of confidence, low self-esteem, anxiety, depression, self-blame, self-doubt, grief, post-traumatic stress disorder, and the most significant, suicidal ideation (Gillen et al., 2009; McKenna and Boyle 2016; Capper et al., 2020b).

Approximately 50% of midwifery students in Shapiro et al.’s study (2018) reported higher stress levels than average on their Impact of Event Scale, indicating the daily lives of midwifery students were negatively affected by workplace bullying, and violence (Shapiro et al., 2018). Midwifery students seemed incapable of separating their professional and personal lives, which escalated emotional dysregulation and increased stress (Hogan et al., 2018). Capper et al. (2020b) also noted that the economic repercussions of midwifery students’ leaving the profession following exposure to workplace bullying, and violence created financial burdens which may have further increased their stress (Capper et al., 2020c).

In four of the included studies, midwifery students reported physical symptoms including digestive disorders, headaches, insomnia, and general feelings of being unwell as a negative side-effect of workplace bullying, and violence (Gillen et al., 2009; Shapiro et al., 2018; Capper et al., 2020a and 2020c).

9.3. Impact of negative workplace culture on the midwifery profession

The impact of bullying and violence on workplace culture was described in six papers included in this integrative review (Gillen et al., 2009; McKenna and Boyle 2016; Arundell 2017; Hogan et al., 2018; Capper et al., 2020a; Capper et al., 2021b). Workplace bullying, and violence were frequently witnessed by other staff members, with no repercussions, therefore fostering a culture of violence and acceptance (Gillen et al., 2008; Capper et al., 2020a and 2021b). Interestingly, it was reported that often, offenders of workplace bullying, and violence were promoted into positions of power (Arundell 2017; Capper et al., 2021b). Thereby, perpetuating a culture of fear of reporting workplace bullying, whilst promoting attrition resulting in workplace shortages (Gillen et al., 2008; McKenna and Boyle 2016; Hogan et al., 2018; Capper et al., 2021b). The impact of negative workplace culture creates a loss of confidence in the midwifery profession and damages its reputation (Capper et al., 2021b).

This integrative review identified four studies (Arundell et al. 2017; Gillen et al., 2009; Capper et al., 2020a; Capper et al., 2021a) that described the impact that poor workplace culture on midwifery students attending clinical experiences, as a means of “hardening the troops” and a “rite of passage” (Capper et al., 2020a, p.7). Examples of negative workplace culture, included low morale, job dissatisfaction, attrition, staff shortages, ineffective teamwork, and poor standards of care for mothers and babies (Gillen et al., 2009). Organisational strain comprising of time constraints, heavy workloads, poor skill mix, budgetary constraints, and pressure to transfer women to other midwifery services or homes, were highlighted as common justifications for poor workplace culture (Capper et al., 2020b). Birthing suites were reportedly the main offenders of workplace bullying, and violence due to cliquey cultures and the increased stress and pressure of working within the birth environment (Capper et al., 2020b and 2020c).

The impact of organisational strain triggers poor learning experiences for midwifery students, who describe being given menial tasks as midwives were “too busy to teach them” (Capper et al., 2020b, p.611). Inadequate learning experiences may result in midwifery students lacking role preparedness when transitioning to professional practice.

9.4. The need to develop strategies for midwifery students to address workplace bullying, and violence

Two studies included in the review recommended a proactive approach to workplace bullying, and violence, including a culture change that encourages repercussions for poor behaviour (Gillen et al., 2009; Capper et al., 2021b). Further to this proactive approach, several studies identified the need to incorporate conflict resolution strategies into university education to better prepare midwifery students to manage workplace bullying, and violence (Gillen et al., 2009; McKenna and Boyle 2016; Capper et al., 2020b; Hogan et al., 2018). Suggestions for curricula included defining bullying and its manifestations, strategies to manage bullying and violence, identifying supports, as well as building individual coping capacity (Gillen et al., 2009; Hogan et al., 2018).

In the included study by Steen (2011), a conflict resolution workshop was developed for midwifery students, based on the Start Treating Others Positively (STOP) model. This included the following four principles: (1) Stop - Stop and observe what is happening. Don't just react! (2) Think - What is important here? What could be the threat? (3) Observe - Calmly work out the problem, and (4) Proceed – Take time out? Be assertive (Steen 2011). Following facilitated workshops, student feedback demonstrated insight, skills, and abilities to manage workplace bullying, and violence (Steen 2011).

In two studies by Capper and colleagues (2020a; 2021a) midwifery students suggested improved pathways to escalate workplace bullying, and violence complaints in the clinical setting were needed. In one study, following an incident of workplace bullying, and violence, the majority (88.8%, n = 8) of midwifery students ‘never’ completed an incident report or accepted professional debriefing (Shapiro et al., 2018). Only 11.1% (n = 1) ‘always’ completed an incident report and accepted professional debriefing (Shapiro et al., 2018). This study highlighted the lack of incident reporting and adequate avenues for whistleblowing perpetuates deeply ingrained workplace bullying, and violence within the midwifery profession to continue (Shapiro et al., 2018).

One study identified that much of the responsibility for managing workplace bullying, and violence lies with midwifery students, through undertaking conflict resolution education and building resilience. Nevertheless, improvements within the midwifery workforce to address this problem are paramount to improving workplace culture (Capper et al., 2021a). Results from the literature unanimously identify that workplace bullying, and violence need urgent addressing within the midwifery profession. Strategies to address the serious issue of workplace bullying, and violence have included funding for anti-bullying measures, anonymous feedback channels, improved hierarchical support, and a team approach to facing staff workloads, staff shortages, and skill mix (Capper et al., 2021a). It was further recommended that education around workplace bullying, and violence and its impact on midwifery students, be provided to midwives working in clinical settings, in association with regular audits by universities to ensure that placement venues are providing safe places for students to learn and develop clinical skills (Capper et al., 2021a).

10. Discussion

All 12 studies evaluated, recognised a high prevalence of workplace bullying, and violence within the midwifery profession directed at midwifery students (Australia and the United Kingdom). This concurs with findings from research investigating workplace aggression within a cohort of nurses, midwives, and care personnel in Victoria (Hills et al., 2018). This study identified workplace aggression as a major problem within health care services, with minimal improvements over the past 35 years, despite initiatives such as the Australian Government's introduction of anti-violence policies and programs (Hills et al., 2018).

This integrative review indicates that workplace bullying, and violence are particularly prominent within clinical settings where midwifery students undertake their placements and continuity of care experiences (Gillen et al., 2009; McKenna & Boyle 2Co016). This finding was further confirmed by some studies suggesting that the worst offenders of workplace bullying, and violence are potentially those employed in birthing areas, due to the increased stressors and responsibilities required of midwives working in these environments (Astrup 2015; Hills et al., 2018; Capper et al., 2020b). Reported forms of workplace bullying, and violence included verbal abuse, physical abuse, sexual harassment, intimidation, belittling, undervaluing, withholding information, and lying to students (Gillen et al., 2009; McKenna and Boyle 2016). In a report commissioned by the UK Royal College of Midwives (RCM), workplace bullying, and violence was expanded to include gossiping, name-calling, excessive criticism, excluding, and undermining (Astrup 2015). Workplace bullying, and violence incidents are not isolated events, with some experiencing occurrences as frequently as three times per week (Gillen et al.2009). McKenna and Boyle and Capper et al. (2021a) concurred, reporting senior staff as the biggest perpetrators of bullying. This claim was further substantiated by Hills and colleagues (2018), with 72.3% (n = 693) of participants reporting workplace bullying, and violence from senior, internal sources. Astrup (2015) concurred, reporting 43% (n = 462) of midwives who participated in the UK National Health Service survey experienced bullying, and more than half of these reports occurred through vertical violence.

This literature review emphasises the significant impact workplace bullying, and violence has on midwifery students’ undergraduate experiences, both professionally and personally (Gillen et al., 2009; Steen 2011; Mckenna and Boyle 2016; Hogan et al., 2018; Shapiro et al., 2018; Capper et al., 2020a, 2020b, 2021a; McKenna and Boyle 2016a; Capper et al., 2021b). Midwifery students reported feeling frightened and nervous about attending clinical placements, reporting they were not taken seriously and commonly experienced a lack of support, which triggered attrition (McKenna and Boyle 2016; Arundell et al. 2017; Capper et al., 2020c). This was also documented by McCarthy et al. (2018) who identified that students described a lack of support, feeling ignored or unwanted in the clinical space, being exploited to undertake menial tasks, and experiencing intimidation as key factors that led to difficult relationships between students and clinical colleagues.

Safety issues were raised as a concern by some midwifery students, who felt they were asked to work outside of their scope of practice, which negatively impacted woman-centred care. Despite their reservations, midwifery students proceeded to undertake these tasks to avoid being in the ‘firing range’ from midwives and to be rewarded with improved clinical experiences (Gillen et al., 2009; Barker and Linsley 2016; Goshomi 2019).

Midwifery students reported that women witnessing them suffering workplace bullying, and violence adversely impacted their relationships with the woman and her family, which undermined the holistic nature of midwifery (Capper et al., 2020c and 2021b). Woman-centred care is a focal point of midwifery care, which is achieved by working in partnership with the woman (COAG 2019). When this partnership is disrupted, and trust between the midwife and woman is damaged, the relationship between the two becomes vulnerable, resulting in unsustainability and safety issues (MacGregor and Smythe 2014). Midwifery students experienced a resultant loss of passion for the midwifery profession and ultimately withdrew from the Bachelor of Midwifery degree (McKenna and Boyle 2016; Capper et al., 2020c).

On a personal level, midwifery students experienced loss of confidence and low self-esteem which contributed to poor mental health (Gillen et al., 2009; McKenna and Boyle 2016; Shapiro et al., 2018; Capper et al., 2020a and 2020c). Anxiety and depression were commonly experienced by many students, caused by self-doubt, post-traumatic stress disorder (PTSD), and burnout (Shapiro et al., 2018; Capper et al., 2020c). In addition to the impact on the victim, Astrup (2015) highlighted that those who witnessed bullying, were also impacted, experiencing psychological trauma and sickness, which led to decreased job satisfaction, attrition, and high levels of staff turnover (Astrup 2015). The impact on relationships, inability to separate work from home life, and financial implications were reported as contributing to midwifery students choosing to withdraw from the program (Hogan et al., 2018; Australian Government, 2022).

10.1. Implications

Changing a culture of workplace bullying, and violence is multifactorial and complex. Compounded by victims of this negative phenomenon, adopting learned behaviours, and potentially, progressing to bully their colleagues as this is seen as acceptable behaviour (Gillen et al., 2009). Therefore, the cycle of violence is repeated, becoming entrenched within the midwifery workforce (Gillen et al., 2009), leading to low morale in the workplace, job discontentment, poor teamwork, and absenteeism, due to sick leave (Capper et al., 2021a).

10.2. Recommendations

Changes within the workplace to improve the midwifery culture must include anti-bullying measures, healthier relationships with management, and effective teamwork to reduce workplace bullying, and violence and protect the integrity of the midwifery profession (Capper et al., 2021a). Arundell et al. (2017) suggest that a positive workplace culture, where midwifery students are included and experience feelings of belonging, will reduce the incidence of workplace bullying, and violence and support retaining the midwifery workforce. Astrup (2015), also reported that the medical dominance within the midwifery profession and the oppression of midwives contribute to high levels of workplace bullying, and violence. Midwives working within a medical model, whilst attempting to maintain a holistic woman-centred approach to midwifery care, is not sustainable, as reported by Astrup (2015), and impacts workplace bullying, and violence. The holistic model of midwifery care is reported to increase access to birthing centres, and caseload midwifery programs, and may assist in reducing the incidence of workplace bullying, and violence in clinical settings (Astrup 2015).

Universities play an integral role in preparing midwifery students for clinical experiences, and therefore, education must include responding to, and managing, workplace bullying, and violence (Gillen et al., 2009; McKenna and Boyle 2016; Hogan et al., 2018; Capper et al., 2020b). Currently, in Australia, there is no formal education regarding managing conflict resolution and management of workplace bullying, and violence in midwifery programs. This situation appears to be similar to undergraduate midwifery degrees overseas, given the paucity of data within the literature (Gillen et al., 2009; McKenna and Boyle 2016; Capper et al., 2020b; Hogan et al., 2018).

Hogan et al. (2018) proposed incorporating education into the Bachelor of Midwifery degree that focuses on workplace bullying, and violence, along with strategies and resources to de-escalate conflict and prevent incidences of violence, may prepare midwifery students to strategically manage difficult situations with confidence. Hogan and colleagues (2018) further suggested education approaches to improve conflict resolution including discussion and debriefing with colleagues, participating in social events and interactions, undertaking personal self-reflection, and maintaining a good work/home life balance. In addition, research, outside the remit of this integrative review conducted by McCarthy et al. (2018), suggested further education strategies to reduce workplace bullying, and violence and lessen the impact on the victim, including problem-solving, being optimistic, having a good support network, and practicing self-care, including exercise and listening to music (McCarthy et al., 2018).

In Shapiro et al.’s study, midwifery students were identified as being reluctant to complete incident reports following experiences of workplace bullying, and violence (Shapiro et al., 2018). This is not uncommon within healthcare professions. Kvas and Seljak (2014) investigated a cohort of nurses who experienced physical abuse (9.5%, n = 21), psychological abuse (12.4%, n = 97), economic abuse (13.1%, n = 53), and sexual assault (17.9%, n = 31), but did not report workplace bullying, and violence, due to lack of previous action and perceived repercussions, including losing their jobs. Improved pathways for reporting workplace bullying, and violence, with repercussions for offenders – not victims, may help to deconstruct workplace bullying, and violence ingrained within the midwifery profession (Shapiro et al., 2018).

Whilst there was little discussion concerning resilience in the included studies, the concept of personal resilience was deemed to be an important characteristic for midwives, due to the emotionally demanding nature of the profession (Clohessy et al., 2019; McDonald et al., 2012; Killingley 2016). Killingley (2016) suggested that whilst students may not have the same stressors as registered midwives, they are pre-disposed to stress relating to completing their degree and gaining professional skills, whilst concurrently trying to assimilate the workplace culture.

In the study by Capper et al. (2020), midwifery students reported taking a resilient approach and reaching out for support from university professionals, counsellors, and family and friends to cope with the fallout of bullying and violence within the workplace. However, as midwifery students have variable capacities for resilience and coping, this highlights the need for education within the Bachelor of Midwifery degree to develop, or build upon existing, resilience levels, as a measure to reduce attrition and departure from the midwifery profession (McDonald et al. 2013; Clohessy et al., 2019).

Hogan et al. (2018) describe resilience as a learned skill. Studies have suggested strategies to develop or build upon resilience include, self-reflection, debriefing with colleagues, positive work-social life, and the ability to separate work from home life (Earvolino-Ramirez 2007; McDonald et al. 2013; Garcia-Dia et al., 2013). McDonald et al. (2012) suggested that midwives are time-poor, with minimal opportunities to undertake work-based interventions to improve their resilience in the face of challenging workplace environments. Therefore, incorporating resilience education into the conflict resolution workshops within the undergraduate curricula, is important in supporting midwifery students’ development of resilience and coping capacity, before graduating with their degree (Clohessy et al., 2019).

11. Limitations

Two of the studies that met inclusion criteria, combined midwifery students’ experiences with other professions’ experience of workplace bullying, and violence. Results in the study were unable to be separated between the different professions, and therefore over- or under-representation of midwifery students’ experiences of workplace bullying, and violence may be apparent. The original search was conducted across four separate databases and google scholar using the same search string, however, only papers from the United Kingdom and Australia met the inclusion/exclusion criteria. As a result, the findings from this integrative review, are not indicative of the experiences of midwifery students outside of these areas.

12. Conclusion

Workplace bullying, and violence is a universal health concern within the midwifery profession. It impacts the midwifery students’ journey and is particularly prevalent in birthing areas and is generally perpetrated by more senior staff. Workplace bullying, and violence have a significant impact on both the professional and personal life of the midwifery student, as well as those who witness workplace bullying, and violence, resulting in a lack of trust in the midwifery profession, therefore promoting midwifery students’ attrition; ultimately leading to pursuing alternative career paths. Negative workplace culture due to organisational strain and hierarchical structures was emphasised as an underlying cause of workplace bullying, and violence, and was perceived as being responsible for damaging the reputation of the midwifery profession for midwifery students and the public. The results of this integrative review have highlighted the responsibility of the midwifery profession to address inherent workplace bullying, and violence that has been evidenced in the review, to reduce midwifery students’ attrition and loss of passion for the midwifery profession. Universities are encouraged to include formal conflict resolution education and resilience training into their midwifery programs, to enable midwifery students to manage workplace bullying, and violence whilst in the clinical environment, whilst also educating midwifery students to promote better behaviours in the workplace.

Author contributions

NS: Conceptualisation, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualisation, Writing - original draft, Writing - review & editing.

DW: screening, manuscript review, supervision.

RV: screening conflicts, manuscript review, supervision.

AB: manuscript review, supervision.

MS: Study conceptualisation and design, screening conflicts, manuscript review, supervision.

All authors approved the final version of the manuscript.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix 1

JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (2017)

Reviewer_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Date_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Author_ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ Year_ _ _ _ _ _ _ _ _ _ _ Record Number_ _ _ _
	Yes	No	Unclear	Not applicable
1Is the review question clearly and explicitly stated?	□	□	□	□
1Were the inclusion criteria appropriate for the review question?	□	□	□	□
1Was the search strategy appropriate?	□	□	□	□
1Were the sources and resources used to search for studies adequate?	□	□	□	□
1Were the criteria for appraising studies appropriate?	□	□	□	□
1Was critical appraisal conducted by two or more reviewers independently?	□	□	□	□
1Were there methods to minimize errors in data extraction?	□	□	□	□
1Were the methods used to combine studies appropriate?	□	□	□	□
1Was the likelihood of publication bias assessed?	□	□	□	□
1Were recommendations for policy and/or practice supported by the reported data?	□	□	□	□
1Were the specific directives for new research appropriate?	□	□	□	□
Overall appraisal: Include □ Exclude □ Seek further info □
Comments (Including reason for exclusion)