The effects of bullying behaviours among nursing students in Sierra Leone: a qualitative exploratory study

Abstract

Background

Bullying can have profound negative effects on nursing students who often contend with psychological trauma because of repeated acts of mistreatment. This study was done to explore the effects of bullying behaviours among nursing students with above average and below average academic performance in two nursing schools in Sierra Leone.

Methods

A qualitative exploratory study involved six rounds of data collection and analysis over a one month period. 48 nursing students recruited from Njala University School of Nursing and Mattru School of Nursing participated in semi structured interviews. Recruitment was done using a purposive sampling method and students with higher than average and lower than average Grade point average (GPA) were selected to participate in the interviews. Interviews were audiotaped recorded and transcribed verbatim for analysis. An inductive approach with line-by-line coding to identify themes and subthemes was done for the first set of interviews, following this the researchers took a deductive approach to analysis to evaluate if subsequent themes were consistent with initial analysis.

Results

Sensitization and apathy were the two broad themes regarding the effects of bullying behaviour demonstrated by students with higher than average and lower than average GPA respectively. Both groups of students had come to accept the inevitability of bullying as nursing students despite the distress it caused them. However, students with lower-than-average GPA also demonstrated resentment and a loss of interest in their studies because of the bullying they had encountered.

Conclusion

The findings of this study demonstrate that bullying negative affects nursing students regardless of their academic performance. There is an urgent need for policy makers to prioritise the deterrence of bullying of nursing students through implementation of strategies that protect students and punish perpetrators of abuse in nursing schools nationwide.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-024-02623-3.

Background

Bullying describes intentional, aggressive behaviours by individuals or groups who often yield significant power and therefore inflict harm on their victims [1]. Several studies have demonstrated the negative impact of bullying in academic settings, and victims often experience psychological distress [2]. Emotions influence learning outcomes, and while positive emotions and an enabling learning environment are associated with improved academic performance, negative emotions such as anger and shame resulting from bullying can derail academic goals [3]. However, acts of mistreatment are seen as a normal rite of passage in the nursing profession, and studies indicate that most nursing students contend with repeated acts of bullying [4]. This is because the nursing profession is characterized by power imbalances, and more experienced nurses are often hostile and treat their subordinates in a condescending manner [5]. Nursing students, who have limited clinical experience and low self-esteem due to a lack confidence in their abilities are therefore frequent targets of bullying [6].

While recent efforts have emphasized the need to dismantle the institutional dynamics that condone bullying in clinical settings, the problem still persists [7] and is perpetuated by a culture where previous victims of bullying become perpetrators when they themselves are in a position of authority [8]. This is counterproductive for a field that aims to produce compassionate and empathetic professionals. Not surprisingly, there are progressively waning levels of empathy among nursing practitioners towards their patients over the course of their nursing education and clinical practice [9].

High-income countries like the United States of America recognize the negative impact of bullying, and health agencies such as the American Nursing Association have increased awareness of this issue [10]. Despite these efforts, high rates of bullying among nursing students continue to be reported in the USA [11], Australia [12] and other developed countries. A study conducted in China [13] revealed that the bullying of nursing students, especially during clinical placement, is a pressing concern, with more than 65% of the students surveyed experiencing some form of bullying from senior nursing staff, nursing teachers, patients and caregivers of patients. High rates of bullying thrive in this setting because inadequate numbers of staff and increased workloads result in frustration among senior staff members and patients. Similar conditions are common in Sierra Leone health facilities, where very few nurses deliver patient care [14]. This could make student nurses in Sierra Leone more vulnerable to bullying. A study conducted among nursing students in Sri Lanka revealed that the country’s patriarchal structure makes nursing students, who are predominantly females, vulnerable to bullying [15]. In such settings, women are trained to be timid; therefore, they rarely confront or report perpetrators of mistreatment. A study conducted in four African countries found that while women dominated the nursing profession, they were relegated to low cadre positions and seldomly held management positions [16].

It is therefore very important to study bullying among nursing students in African countries, where the predominantly low socioeconomic status of residents [17] and deeply entrenched patriarchal cultures that encourage gender inequalities and relegate women to positions of submissiveness [18] would allow the bullying of nursing students to thrive. While there is a paucity of research on this topic in African countries, research conducted in Ghana has revealed that student nurses are expected to act submissively towards their superiors while they are treated dismissively and often face acts of aggression and humiliation [8].

Nursing students who encounter bullying suffer severe physical, mental and professional difficulties which ultimately contributes to staffing shortages and derails patient care [19], this would have devastating effects on countries such as Sierra Leone, which is already in dire need of more health professionals. Similar concerns were expressed by a study reporting that exposure to bullying negatively influenced job satisfaction among Zimbabwean nurses which could negatively influence the care of patients in an already under resourced health setting [20].

Despite these concerns, no study assessing the effects of bullying among nursing students, to our knowledge, has been conducted in Sierra Leone. Furthermore, studies have emphasized that bullying negatively affects academic performance of nursing students. This may inadvertently lead to the belief that students who excel academically are less affected by bullying, especially since there is a paucity of research evaluating if the effects of bullying are different for high achieving and low achieving nursing students. This knowledge is important as it could demonstrate that bullying experiences cause harm to all nursing students. Therefore, students regardless of their academic performance may still struggle due to mistreatment.

By separately describing the effects of bullying experiences on nursing students with both high and low GPA scores in Sierra Leone, this research aims to initiate important discussions and provide a clear justification for the need for policies that deter abusive behaviors and compel the reform of nursing education in Sierra Leone.

Methods

Research aims

To describe the effects of bullying behaviours among nursing students with higher than average and lower than average GPA in Sierra Leone.

Epistemological stance

This study utilizes a constructivist approach. Experiences of bullying are subjective, this was demonstrated by a response to a senior medical professional, expressing strong disagreement with his claim that bullying was no longer present in the medical profession [21]. This demonstrates that perceptions regarding the effects of bullying may vary depending on individuals’ experiences, cultures, and specific context.

The constructivist approach acknowledges that reality is subjective and co-constructed based off human experiences [22]. The findings proposed by this research represent the views of the students who participated in this research and may not apply invariably to all students. While the findings may prompt action, further research is needed on the topic, and policy makers must recognize the evolving nature of bullying and offer solutions that reflect unique individual experiences at a given time.

Research design

This research uses an exploratory qualitative study design with data collection done through a series of semi-structured interviews.

Experiences with bullying and are influenced by sociodemographic characteristics [23] which differ across countries, so while research has been conducted in high-income countries on the effects of bullying on nursing students, the findings cannot be assumed to be generalizable to the Sierra Leone context. Exploratory qualitative research design which is useful for phenomena that are not well researched was therefore used to ensure findings were authentic and told from the perspective of nursing students.

Setting

The study was conducted in Njala University School of Nursing and Mattru School of Nursing Sierra Leone. Mattru school of nursing offers a three-year RN program as the highest available qualification while Njala University offers a four-year BSc in Nursing program. In both institutions students undergo clinical placement in different hospital facilities from the second year of study.

Recruitment and sampling

Participants were recruited based on the following inclusion and exclusion criteria:

Inclusion criteria

1. A nursing student who has spent at least one year on a programme of study at one of the institutions under study.

2. Students who consent to having their course grades shared with researchers.

3. Students who consent to participate in the interviews.

Exclusion criteria

1. Nursing students below the age of 18.

2. Students who withheld consent.

The researchers provided an overview of the study to a gathering of students at each of the institutions under study. Students who expressed interest in participating in the research had another face-to-face meeting with the researchers where they received a more detailed explanation of the research aims and processes. They were encouraged to ask questions and seek clarification. At this time written consent was sought allowing the researchers to access the academic records of eligible students. The research utilized a purposive sampling method and participants were selected based on the subsequent assessment of their academic performance. The GPA was used as a measure of academic performance and the average GPA of each class under study was determined. There were six rounds of data collection and for each round of data collection, four students were enrolled from each of the two institutions for a total of eight participants. Two of the selected students from each university had GPA scores that were above the average for their class, and the other two scores fell below the average of the class. Students who were selected to participate in each round of interviews were informed through a telephone call and interview dates were scheduled.

Following the first two rounds of interviews, the researchers purposely selected participants from higher than average and lower than average GPA groups with additional characteristics deemed necessary to contribute to the exploration of initially identified patterns in the data. For example, in the third round of interviews, the researchers purposefully selected only female students to explore a pattern regarding sexual harassment of female students that had emerged from the data collected during the first and second rounds.

Data collection instrument and strategy

A series of individual semi-structured interviews were conducted at both institutions over a one-month period. Pretesting of the data collection instrument involved administering questions to four students: two from each university to gauge the student’s understanding of the questions. These students were not specifically selected or categorized based on their academic performance and their responses are not included in the findings of this research.

Semi structured interviews were conducted via an interview guide (see supplemental file 1 below) with the following three open-ended questions:

1. Describe any instances when you have felt bullied during your time in nursing school.

2. Explain how serious problem bullying is for nursing students in your school.

3. Describe any measures you are aware of to prevent bullying and punish those responsible for the bullying of nursing students.

If participants described instances of bullying, these additional two questions were asked.

• 4.Describe how the bullying you have encountered may have affected your ability to achieve your academic goals.
• 5.Explain how you cope with and overcome bullying as a nursing student.

Following the interview, each participant was required to complete a demographic questionnaire. Following each round of data collection, the interview guide questions were reviewed to ensure a deeper exploration of the emerging concepts.

The interviews were conducted at the university campus premises. The interviews lasted between 30 and 50 min and were conducted in the local Krio language or English to allow the participants to fully express their feelings in the language with which they felt more comfortable. The interviews were audiotape recorded, translated and transcribed verbatim to ensure the completeness of the data. There was consensus among all the researchers that data saturation had been reached after the fourth round of interviews. However, two further rounds of interviews were conducted following this.

Data analysis

Data analysis followed each round of data collection and was performed separately for interviews of students with higher-than-average GPA and those with lower-than-average GPA. The analysis initially followed an inductive approach, and open coding was performed by the first and second researchers following familiarization with the eight transcribed interviews obtained from the first round of data collection. The process was repeated for the transcripts following the second round of data collection. Each transcript was coded independently by the two researchers who then met and reached a consensus with regards categorizing codes and identifying emerging patterns in the data.

Following this, the analysis took a deductive approach, and focused coding guided by initially identified patterns was performed for subsequent transcripts. Following this, the three researchers through an online deliberative meeting, organized and merged the identified codes into the two overarching themes of sensitization and apathy among students with higher than average and lower than average GPA respectively. Subthemes were also created during this process. A consensus was reached by all the researchers regarding the final themes and subthemes reported in this study.

Positionality of researchers

The first and second researchers are medical doctors who studied in Sierra Leone and graduated six years prior to undertaking this research. The third researcher is a senior nursing officer who graduated four years ago. As medical professionals with personal experiences of bullying, the participants may have regarded the researchers as insiders; such insider status would allow for acceptance and trust and guarantee a willingness to share information [24]. However an imbalance of power between the researcher and participants may lead participants to feel compelled to share data, even when they are not comfortable, resulting in inaccurate accounts of their experiences [25]. Student nurses may therefore have viewed the researchers who are experienced clinicians as superiors, which may have affected their interactions with the researchers and, by extension, the validity of findings.

Notably, senior colleagues may be perpetrators of abuse for nursing students; therefore, the researchers may be viewed by students as sharing similarities with the perpetrators of their mistreatment, further emphasizing potential power imbalances and the possibility of generating unreliable information owing to the personal identities of the researchers in this study.

Enhancing rigor

The first step towards addressing biases in this research was self-reflection and transparency among all the researchers regarding how their identities may subconsciously bias the findings of this research. Acknowledging the need for open mindedness, which requires the researcher to actively seek out and consider opposing views and evidence that may challenge their own beliefs [26], An expert who has conducted extensive educational research was also invited to conduct an external review of the entire research process. While this external reviewer did not participate in conducting the research, she was consulted and gave valuable advice towards the conduct of the study.

In addition, the findings following each round of data collection and analysis were shared with randomly selected students from both institutions who had participated in the interviews to determine if the results obtained were representative of their views.

Results

Participant characteristics

Eight participants were interviewed in each of the six rounds of data collection (four from each institution). Therefore, 48 participants were interviewed. The sociodemographic characteristics of the participants are summarized in Table 1 below.

Table 1.

Socio-demographic Characteristics of Respondents

Individual Characteristics	Frequency	Percentage
Age	N	%
Under 20 years	5	10.4
20–30 years	28	58.3
Above 30 years	15	30.6
Gender
Female	38	79.2
Male	10	20.8
Year of study
2nd Year	18	37.5
3rd Year	16	33.3
4th Year	14	29.2
Previously Repeated a year of study
Yes	12	25
No	36	75
Previous Professional Nursing Experience
Yes	20	41.7
No	28	58.3
Current Employment
Yes	17	35.4
No	31	64.6
If Yes, Current Monthly Income		% of total employed
Below NLe 1,000 (<$45)	9	52.9
Between NLe 1,000 and 5,000($45-$220)	6	35.3
Above NLe 5,000 (>$220)	2	11.8

Due to rounding percentages may not add up to 100

Qualitative findings

Data analysis on the effects of bullying revealed two broad themes: The theme of Sensitization for students with higher-than-average GPA was informed by five subthemes and is demonstrated in table 2 below and the theme of Apathy for students with lower-than-average GPA was informed by six subthemes and is demonstrated in table 3 below.

Table 2.

Illustrated findings among students with higher-than- average GPA

Theme	Subthemes
Sensitization	1. Preparation and Inevitability 2. Routine and Norm 3. Optimism and Expectation 4. Shame 5. Diminished Confidence

Table 3.

Illustrates findings among students with lower- than- average GPA

Theme	Subthemes
Apathy	1. Preparation and Inevitability 2. Routine and Norm 3. Self-blame 4. Shame 5. Diminished Confidence 6. Resentment

These themes were informed by seven subthemes. Four of these subthemes were demonstrated by all students regardless of their GPA scores: (1) preparation and inevitability, (2) routine and norm, (3) Shame, (4) diminished confidence.

One Subtheme: 5. optimism and expectation were demonstrated by only the students with higher-than-average GPA, while two subthemes 6. Self-blame, 7. Resentment were only demonstrated by students with lower-than-average GPA scores.

Themes

Sensitization in students with higher-than-average GPA

Most but not all the students with higher-than-average GPA scores reported having experiences of bullying during their time in nursing school. While lecturers were the main perpetrators of bullying, students reported bullying from other sources, including colleague students, senior nurses and medical doctors, while on clinical rotation. Acts of mistreatment that included name calling, sexual harassment and public acts of humiliation were so commonplace that for almost the students in this group, there was a general sense of acceptance and a belief that bullying was a normal part of being a nursing student.

However, despite their expressed indifference toward acts of mistreatment, several students described instances when they felt severe distress, lost confidence and humiliation due to these acts. This indicates that while students with higher-than-average GPA were largely sensitized towards acts of bullying, it still had negative psychological effects on them.

Apathy in students with lower-than-average GPA

All the students with lower-than-average GPA scores described having experiences of bullying during their time in medical school. While instances of bullying were from different sources, most bullying was in the form of public humiliation from lecturers because of poor performance. They described instances of name calling and open mockery, which left them open to bullying from their peers even outside the classroom setting. These instances of mistreatment were accepted as the norm, and students in this group blamed themselves for being victims while feeling powerless to change the situation.

While there was an acceptance of bullying behaviours in this group that was similarly demonstrated by students with higher-than-average GPA, there was additionally a strong feeling of resentment in this group of students for the poor treatment they had received. The vast majority therefore expressed intense apathy towards their nursing education. While all the students in this group reaffirmed their desire to complete their course and graduate as registered nurses; they did not express much optimism or enthusiasm regarding this desire demonstrating that this group also contended with negative psychological effects because of bullying.

Subthemes

Preparation & inevitability

The students described being informed about bullying, having firsthand experiences of bullying or watching their peers being victims of bullying very early in their nursing education. This resulted in them accepting bullying behaviours as an inevitable part of their education, and they tried, sometimes unsuccessfully, to prepare themselves mentally for this experience.

Quote 1: The first day I set foot on this campus, I met some final year students, and they told me which lecturer I should be afraid of. I already knew what to expect, I have never been late for that lecturer’s class, and I always read ahead so I can answer his questions. There is this student who was late on the very first day. He has not forgotten her in the three years we have been here. He never misses a chance to embarrass her.3rd year Female student, aged 24, Higher-than-average GPA.

Quote 2: After one week of class, you understand that some of these lecturers find it amusing when they make you uncomfortable. They will ask you questions they know that you will not answer and then ask if you want to be a nurse to kill patients. It’s just their own way of releasing stress. After that, they will still laugh with you and encourage you. You know its going to happen in every class, so just prepare your mind and you will be fine.2nd year Male student, aged 30, Lower-than-average GPA.

Routine & norm

The students’ view of bullying behaviours as routine and normal within their institutions impacted their ability to discuss or report perpetrators of bullying to the school’s authority. Tellingly, none of the interviewed students had ever made an official report. Viewing bullying as a normal experience was also key to students’ coping strategies as many students did not believe that they were being singled out for mistreatment but rather recognized a broader culture of bullying that allowed the normalization of student victimization.

Quote 1: When you are on clinical rotations, the male doctors speak about you like you are not there.

They will be like ‘a new bail of clothes has landed, have you found your size?’

I had no idea what they were talking about, but the matron told us that we were the new clothes, and they were distributing us among themselves. She was laughing when she told us. My colleague thought they were rude, but the matron told her not to be uptight.Final year female student, aged 26, Lower-than-average GPA

It’s how things are done here, its normal. So many nurses found their husbands in this way.

Quote 2: When they call you stupid, you immediately think; it is not just me, it is my friend, it is almost everyone in the class. We can’t all be stupid. It’s just the way they talk; it doesn’t mean anyone is stupid. It is normal.2nd Year Male Student, aged 35, Higher-than-average GPA.

Shame

Most students who had experienced bullying described feeling embarrassed because of it. Shame mostly came after they were humiliated in front of their peers; however, some students described feelings of shame when they were belittled in front of patients while on clinical rotation. For most students, these feelings were deeply personal, and while they caused them significant distress, they found it difficult to share their emotions with anyone else because they were afraid that their feelings would be trivialized and misunderstood.

Quote 1: There are times you just want to disappear or die. During an exam when I was already struggling, the invigilator stood over my shoulders and started laughing loudly. Then, he said, ‘If you see the rubbish this one is writing, you will wonder if she finished secondary school. How can you call yourself a second-year student, and you don’t spell venous.’ The whole class could hear him, and they were all looking at me. I almost cried.3rd year Female Student, aged 25, Lower-than-average GPA.

Quote 2: I failed my paediatric rotation because of poor attendance. The nursing officers in the ward were always teasing me because I have broad hips. They would tell the junior doctors coming into the ward that they have kept me especially for them. Some doctors would ignore them, others would say things such as ‘I can’t handle heavy duty machinery’, and they would all laugh. After some time, I just stopped coming.Final year Female student, aged 23, Higher-than-average GPA.

Loss of confidence

Over half of the students who had experienced bullying reported that they had doubted their abilities at least once because of this. For some of the students, loss of confidence was a transient feeling, but for a few, it had a more lasting impact. Students who reported frequent instances of bullying from a particular lecturer and feeling singled out for mistreatment, reported that they often neglected that module, as they were not confident, they would pass regardless of the effort they put into their studies. Some students expressed that this loss of confidence was particularly evident when they approached patients on clinical rotation, as they avoided tasks involving patient care out of fear and self-doubt in their capabilities.

Quote 1: Lecturers would say, ‘you are a student, so do not be afraid to answer my questions. Even if you are wrong, I would correct you. However, when you give a wrong answer, they humiliate you. Sometimes I think I know the answer, but I am afraid to say anything. I am always doubting myself.Final year Female Student, aged 30, Lower-than-average GPA.

Quote 2: Some patients refuse to allow you to touch them except it is to empty their bedpan or bed bathe them. The older nurses on the ward are always telling us about the rigorous demands of nursing education in their days and that we are not learning anything of significance right now. The patients hear them talking about how incompetent we are, so they do not want us near them, and we find it hard to approach them.3rd Year Female student, aged, 23, Higher-than-average GPA.

Optimism & expectation (subtheme identified for students with higher-than-average GPA)

There was a strong feeling of optimism among students with higher-than-average GPA scores, who believed that experiences with bullying were only temporary. Their expectations were that as they progressed in their nursing education and careers, they would come to respect their superiors and peers. They emphasized the importance of focusing on the bigger picture and considered bullying acts as trivial and necessary inconvenience in achieving their goals. However, some students made statements regarding their intention to also engage in the intimidation and bullying of nursing students when they were eventually placed in a position of authority.

Quote 1: I know what I came here for, I am the first person in my family to ever enter university, and I have never failed any module. I am going to be a matron by God’s grace. If someone wants to insult me, that’s their business. For me, its part of the process, the people insulting me now, I am very sure that someone insulted them when they were students.2nd Year Female Nursing student, aged 20, Higher-than-average-GPA.

Quote 2 (3rd Year female nursing student, aged 38, Higher-than-average GPA): If I continue to do well, maybe I will also start lecturing in nursing school. When that happens, I will also make sure the students know that becoming a nurse is not a child’s play. You must go through fire in the hands of your seniors. It is just how things are meant to be.

Self-blame (subtheme identified among students with lower-than-average GPA)

Most students with lower-than-average GPA expressed self-disappointment and blame when describing their experiences of bullying, often directing anger for their experiences at themselves rather than towards the perpetrators of their mistreatment. For some students, there was a feeling of gratitude towards their abusers, as they believed that instances of mistreatment and belittlement were meant to motivate them and help them improve their academic performance.

Quote 1: There are things they expect you to know before coming to the wards. I was posted to a preeclamptic ward with more than 20 critical patients. One night shift when there were only two nurses in the unit, they asked me to take the patient’s vitals, but I did not understand how to do it. I don’t blame the nurses for getting angry with me; it was a difficult night, and I could not help them. It was all my fault.3rd Year Female student, aged 22, Lower-than-average GPA.

Quote 2: The truth is for some of us to be here; our families have sacrificed a lot. Therefore, if a man is going to help me pass and he wants sex. I am not going to be difficult. Most times, they see that we are ready before they approach us, so you can’t blame them.2nd Year Female Student, aged 29, Lower-than-average GPA.

Resentment (subtheme identified in students with lower-than-average GPA)

Students with lower-than-average GPA often expressed anger and resentment for the instances of mistreatment they had encountered while in nursing school. This resentment was mostly self-directed but was also directed at the perpetrators of abuse, with some students expressing hatred for some tutors who they felt had humiliated and belittled them over their time in nursing school. A few students directly attributed their poor academic performance to this treatment. Notably, ten students in this group reported that they regretted their decision to enter the nursing profession at least once during their studies.

Quote 1: You enter nursing school and are humiliated for four years and then become a nurse and wait another four years before you are verified and start earning a salary. In that time, the people you went to school with are far ahead of you in life, while your patients are rude and have no gratitude no matter what you do for them. I see it on the wards and ask myself why I ever wanted to be a nurse.Final year Female student aged 25, Lower-than-average GPA.

Quote 2: When a lecturer makes your life miserable, you sometimes do not even bother studying their module. There are some lecturers that just hate you; no matter what you do, you will still fail.2nd Year female student, aged 19, Lower-than-average GPA.

Discussion

For students with higher-than-average GPA, the theme of sensitization demonstrated that they had accepted the inevitability of bullying, however it was still a significant source of distress to them. For students with lower-than-average GPA, there was a sense of apathy towards their education because of bullying behaviours. Therefore, bullying had negative effects on all students regardless of their academic performance.

Almost all the students who were interviewed had experienced bullying during their time in nursing school. Nursing students are among the most vulnerable groups in clinical practice, as they often lack knowledge and skills and are thus at the bottom of the historically hierarchical healthcare profession [27]. Predictably, bullying rates among nursing students are high, with research conducted in Canada finding that up to 80% of surveyed students were victims of bullying during their nursing education [28]. According to another study conducted in China stated that, 96% of nursing students had encountered at least one instance of bullying in the last six months [29].

Owing to the perceived low status of nursing students, they are vulnerable to mistreatment from various sources, including their colleagues and other clinicians, whom they rely on for guidance and teaching [30]. This is corroborated by this study, as the students faced bullying from different sources, including their peers and patients, but the most frequent perpetrators of bullying were the lecturers within the institution. However, while a study conducted among nursing students in Egypt revealed that bullying increased as students progressed in their education and started clinical placement, this research revealed comparable rates of bullying regardless of the year of study [31]. This may be explained by the fact that while bullying experiences intensified for students on clinical rotations, students in the earlier years of study also had to deal with bullying from older colleagues, who were frequently listed as perpetrators of abuse.

This study shows that bullying of nursing students can result in negative psychological effects and all students regardless of their academic performance contended with feelings of shame, and diminished confidence due to bullying experiences. Other studies have similarly emphasized the severe negative consequences bullying can have, with bullying behaviours contributing to high rates of depression, poor self-image and a lack of academic satisfaction [32]. For students with low academic performance, there were additional feelings of resentment and self-blame for ill treatment which also contributed to the distress victims of bullying faced. These feeling resulted in the intense apathy demonstrated by students in this group who reported missing classes and ignoring studies because of the mistreatment they received from their lecturers. This further derailed their academic goals. Similar findings among nursing students in Saudi Arabia demonstrate the physical and emotional toll bullying can have on nursing students, ultimately results in negative consequences for their academic performance [33].

Both groups of students demonstrated widespread acceptance of bullying behaviours, as they asserted that they always had to be prepared to receive routine acts of mistreatment over the course of their education. Acceptance of bullying was also a major reason why, for all the interviewed students in this research, bullying had gone unreported. These findings are consistent with those in a study conducted among Canadian nursing students that found nursing students often normalize and minimize the severity of bullying and thus fail to take any action against it [34]. For students with lower-than-average GPA, there was even a feeling that bullying was justified, with these students blaming themselves rather than the perpetrators for these actions. Another study reported similar findings, stating that students experiencing bullying as a coping strategy make excuses for the perpetrators of their mistreatment [35]. This self-blame contributed towards the feelings of apathy demonstrated by this group of students.

Students with higher-than-average GPA coped with the impact of bullying by resolving to work hard to attain a position within the nursing profession where they would not be subjected to demeaning treatments. While this was an important coping strategy for this group and may have helped mitigate the devastating effects that bullying may otherwise have had. It reinforced their belief that, in attaining a higher position within the nursing profession, they would be justified in exhibiting the same unpleasant behaviors they are victims of. This concern has been raised in a study that described the dangers of toxic cycle in which victims of bullying within the nursing profession end up inflicting abuse when they are in a position of power. The study stated that the notion that bullying is a rite of passage for nurses, helps perpetuate the negative culture of bullying within the field [36].

While male and female students in this study had similar experiences of bullying, female students had to contend with sexual harassment. Sexual harassment was reported by several female students regardless of their academic performance. While sexual harassment was reported by females in every year of study, it reportedly intensified for students on clinical placement. This resulted in some students avoiding the wards and refusing to contribute during ward teachings to avoid lewd and inappropriate comments, which they stated were very common during rotations. Other studies have reported that sexual harassment is a common occurrence for nursing students on clinical rotation, with verbal sexual harassment being the most common form of harassment inflicted on nursing students [37]. The main perpetrators of harassment during clinical rotations in this study were young medical doctors, who the students stated often sexualized them and spoke of them in a demeaning way. Generally, nurses are regarded as subservient to doctors in most clinical settings [38] this power imbalance may have allowed the sexual harassment and other forms of mistreatment reported in this study to be unchecked.

Apathy towards learning is as a major barrier that derails academic success. It describes a lack of motivation or interest, which can affect students, resulting in absenteeism and other negative behaviors [39] and can cause academic frustration among students [40]. Therefore, the apathy described by students with lower-than-average GPA because of bullying experiences may further contribute to and worsen their below-average academic performance. This emphasizes far reaching negative effects that bullying can have on nursing students. Consistent with findings of another study, this research also demonstrated that apathy and disillusionment resulted in students regretting their choice of nursing as a profession, this further demonstrates the deep-seated negative effects bullying experiences have on nursing students [41].

Limitations

This study is subject to limitations. This study explored students’ experiences of bullying while they were in nursing school, which depends on their recollection of past experiences. This creates the potential for recall biases, as students may have been unable to correctly remember or narrate their experiences. We acknowledge this study was conducted among two nursing schools in the same region of the country and may therefore not be indicative of the experiences of nursing students nationwide. Wider studies covering nursing students in different regions of the country would therefore be beneficial and add to the discourse regarding bullying of nursing students in Sierra Leone.

Owing to predicted time challenges, only one data collection strategy in the form of individual in-depth interviews was used. Utilizing more than one method would have been beneficial. For example, the group dynamics in focus group discussions would have helped encourage responses from participants who are reluctant to share their experiences, and the responses of peers may have helped improve the recall of otherwise forgotten instances of abuse.

Conclusion

Nursing as a profession has deeply entrenched hierarchal structures that allow a bullying culture to thrive, and nursing students are frequently victims of mistreatment from more senior colleagues.

This qualitative exploratory research utilized semi-structured interviews to explore the effects of bullying experiences among students with higher-than-average GPA and those with below average GPA in two Sierra Leonean nursing schools. Following six rounds of data collection and analysis the study determined that, various forms of bullying were common in both nursing schools and constitute a source of distress for students regardless of their academic performance. While bullying was widely accepted by all the students, it still resulted in feelings of apathy in students with lower-than-average GPA scores, while students with higher-than-average GPA had become sensitized to its effects.

Sierra Leone struggles with poor health outcomes due to several factors, including a shortage of healthcare workers. Despite the dire consequences bullying may have on the wellbeing of nursing students and by extension the country’s health system, there is a paucity of research examining this topic and its implications for students. This study was done to determine the effects of bullying experiences on nursing students and determine if these effects affected all students regardless of their academic performance. This research aims to prompt action by policy makers and stakeholders to ensure steps are taken for the protection of Sierra Leone nursing students.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Author contributions

J.J conceptualized the study, wrote the original main manuscript text and contributed to data acquisition and analysis, S.A and F.K contributed to data acquisition and analysis. Both S.A and F.K reviewed and edited the original draft. All authors approved the final version for submission.

Funding

This research was entirely self-funded by the authors.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval

The study was carried out in accordance with the declaration of Helsinki. Ethical approval to conduct this study was granted by the institutional review board of Njala University. Institutional and departmental approval was sought from both institutions under study to permit the researchers access available student academic records. All eligible students gave written consent for their departments to share their accumulated GPA scores with the researchers prior to the interviews. Students who withheld consent did not have their grades assessed and were thus excluded from the study. Students who provided consent were assured that the data would be handled confidentially and would not be used for any purpose other than this research. Participants who were recruited for the interviews provided informed written consent and were assured of confidentiality and their rights to withdraw consent at any time. All the data in this study were fully anonymized, and all identifying information was removed.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.