Bullying Behaviors in Clinical Settings: Potentially Harmful Distractions

Abstract

Student nurses exposed to bullying behaviors are at risk for making medication errors. A quasi-experimental design was used with 15 prelicensure nursing students at a Midwestern U.S. university. Participants were exposed to simulated bullying behaviors or common distractions while administering medication in laboratory setting. Data were analyzed using Kruskal-Wallis tests. There was no significant difference in medication administration rubric score (H [2] = 1.489, p = 0.475) or time spent in room (H [2] = 1.778, p = 0.411) between groups. Bullying behaviors and other interruptions distract student nurses from successfully completing medication administration simulation.

Introduction

Distractions are simple, seemingly innocent actions; however, when they occur during patient care, errors or detrimental consequences can occur (Danesh et al., 2022). Distractions inhibit individuals from focusing their full attention on safe patient care and can adversely impact patient safety (Danesh et al., 2022). One distinct group of distractions, bullying behaviors, also has potential to impact care. The Joint Commission (2021) acknowledges bullying behaviors as distractions and condemns these behaviors. The purpose of this study was to examine if bullying behaviors as a distraction impacted patient care could be mitigated during a simulation with student nurses.

Background

The Joint Commission (2021) defines bullying as repetitive abusive behavior that interferes with work. Due to the limited length of time student nurses have in particular clinical settings, they may experience bullying intermittently but not repetitively from the same person(s). These behaviors, although not necessarily repetitive are still abusive and can adversely affect them. There has been limited but growing number of research endeavors examining the impact of bullying behaviors on student nurses (Gillespie et al., 2024; Mohamed et al., 2024). Student nurses report neglect and disrespect, lack of confidence, symptoms of anxiety, and other physical ailments as a result of experiencing bullying behaviors (Dafny et al., 2023).

As individuals new to healthcare, student nurses are more susceptible to the effects of various influences. When the environment including distractions are combined with an individual’s cognitive processes, errors in care such as medication administration are apt to occur (Kellogg et al., 2021). There is a need to understand how bullying behaviors impact nursing students. The impact of bullying behaviors combined with the environment and an individual’s cognitive processes warrant additional study. To continue this work, research on how bullying distractions affect a student nurse’s interactions with patients and ability to perform a routine nursing task seemed necessary.

Methods and Study Design

This study used a quasi-experimental design to determine whether an educational intervention can mitigate the distractions that bullying behaviors have on one’s ability to administer medications. Study procedures commenced after Institutional Review Board (IRB) approval. The study was guided by Bronfenbrenner’s (1979) Social Ecological Model. The study was performed at a Midwestern U.S. university. A convenience sample of 15 prelicensure nursing students who had completed their fundamentals course and passed their medication administration simulation were recruited. Participants were randomly assigned to 1 of 3 study groups: five to routine distraction group, in which a routine clinical distraction was introduced; four were assigned to bullying behaviors group, in which a bullying distraction was introduced; and six to intervention group.

Intervention

Intervention group participants received structured one-hour instruction on bullying behaviors management, including a rehearsal of skills. The program was based on Thompson’s (2012) strategies for addressing bullying behaviors. Participants received Thompson’s (2012) book to reference after the training.

Procedures

A common task performed by student nurses is medication administration. For high-alert medications like insulin and heparin, higher cognitive processing is needed (Chippewa Valley Technical College, 2023). To analyze participants’ ability to perform medication administration, the study site’s medication administration rubric was used. The tool included items to measure asepsis, physical safety, patient well-being, communication, and documentation. Subjects participated in the simulation without overlapping with other participants. Upon arrival, each participant was provided a clinical scenario to administer a subcutaneous medication into human patient simulator. Participants were informed they could end the simulation at any point without repercussions. Simulation staff were immediately available should a participant become upset and need psychosocial support during or after the simulation.

Concurrent with the simulation, subjects were introduced to either non-bullying behavior or bullying behavior distraction. Routine distraction group was exposed to routine (non-bullying) distractions such as constant chatter from a colleague. Both the bullying behaviors group and intervention group were exposed to verbal bullying behavior distractions such as criticism of nursing skills. Each simulation was video recorded.

Data Analysis

Two researchers watched the simulation video recordings and scored participants performance using the medication administration rubric. Each correctly performed step on the rubric was given a value of 1. Items were summed to yield a rubric score ranging from 0 to 33. Student nurses are expected to score minimum of 30 to successfully pass the simulation. Data were analyzed using IBM SPSS Statistics (Armonk, NY) version 25 software. A Kruskal-Wallis test was performed to compare medication administration scores and time needed to complete the simulation between groups. Alpha was set at 0.05.

Findings

Participants were predominantly female (93.3%) and white (86.7%). Their mean age was 22.5 years old (range: 20-24).

The overall mean medication administration score was 16.7 (median = 17.5), indicating participants failed the medication administration simulation. The mean scores by group were: 17.8 for routine distraction group (median = 18.0), 16.00 for bullying behaviors group (median = 15.0), and 16.3 for intervention group (median = 16.5). There was no statistically significant difference between groups, H (2) = 1.489, p = 0.475.

The overall mean time spent in the room to complete the simulation was 6 minutes 20 seconds. The mean time spent in room by group was: 6 minutes 43 seconds for routine distraction group (median = 7 minutes 29 seconds), 5 minutes 21 seconds for bullying behaviors group (median = 5 minutes 36.5 seconds), and 6 minutes 40 seconds for intervention group (median = 6 minutes 30 seconds). There was no statistically significant difference between groups, H (2) = 1.778, p = 0.411.

Discussion

Despite the use of an educational intervention, medication administration performance scores and time in room were not statistically better for the intervention group. The findings also failed to indicate that bullying behaviors were more problematic for participants compared to routine distractions. These findings reflect Thomas et al.’s (2014) findings: distractions, even commonplace distractions, decrease the performance of the novice healthcare provider. Based upon the clinical aptitude of student nurses, it appears they lack the skills to manage any form of distraction and therefore may benefit from training to mitigate distractions in general.

Bullying behaviors are known negative distractions in the nursing profession and can impact students with them becoming emotionally and physically ill (Dafny et al., 2023). The participants’ perception of the bullying distraction presented was solely that of a distraction and negatively impacted their ability to pass the medication administration simulation. Based on the observed performance of the participants, the distraction regardless of the type, may have affected their performance (Thomas et al., 2014). Thomas et al. (2014) noted distractions while attempting to perform a simulated medication administration caused participants to make medication errors. It should be noted the subjects’ self-perception of having the ability to accurately perform multiple tasks simultaneously was overestimated.

Although the data were not statistically significant, they were clinically relevant. The length of time the students spent administering the medication varied between groups to administer the medication, particularly for the bullying behaviors group. The mean time spent administering medications by the routine distraction group was 6 minutes 59 seconds and by the intervention group was 6 minutes 40 seconds. However, the bullying behaviors group, which was exposed to bullying behaviors without any form of intervention, spent the least time performing the medication administration; mean time was 5 minutes 21 seconds. In a single instance, the least amount of time spent with one patient may not inflict harm upon a patient; however, in multiple instances several patients may have inadvertently been subjected to missed or inadequate care as a means to avoid bullying behaviors. For example, while participants may have used an alcohol swab to prepare an injection site, they may not have waited a sufficient amount of time to let the site dry before injection, a time measure not noted on the medication administration rubric.

Limitations

By design, the intervention group received bullying behaviors education. However, the researchers did not investigate whether the other participants (routine distraction group and bullying behaviors group) received any prior training or instruction on how to mitigate bullying behaviors in the clinical setting. These participants, if having received applicable information, could have drawn upon their previous knowledge in order to manage the simulation. However, this limitation is minimized as all three groups came from the same institution and would have had the same educational exposure. In addition, the one-hour class may have been too brief for the participants to grasp key constructs and integrate them into practice. Even though time was allotted for rehearsal, the brevity of the course and two-week period after the intervention may not have been adequate. In future research efforts, a longer training period can be offered where there would be ample time for participants to have repetitive sessions of cognitive rehearsal to better process and integrate behavior. In addition, the verbal bullying behaviors used in the simulation were not as extreme as commonly seen in actual clinical practice; therefore, the participants may not have been impacted by the bullying behaviors—only that a distraction was occurring.

Implications

It is possible bullying behaviors group participants experienced a form of acute stress that impacted time they spent performing the task requested. In conjunction with the reaction to a negative event, such as bullying behaviors, targeted individuals may resort to avoidance behaviors (Gillespie et al., 2024). The possibility exists that exposure to bullying behaviors would lead student nurses to rush care and exit the room more quickly. In the simulated setting, no harm could be inflicted upon a patient, yet in an actual clinical setting the potential for harm exists. Interventions are needed at the organizational level to help prevent these medication errors. Of note, no participants indicated psychological harm with the simulation.

Conclusion

Bullying behaviors and distractions impact the nursing profession and the effects also are experienced in the pre-licensure population. As novices in healthcare, student nurses may benefit from meaningful interventions to counteract any distraction. Although the bullying intervention in this study did not lead to better performance for medication administration, participants experiencing bullying behaviors without the intervention left the simulation room sooner than their counterparts. These findings reflect the importance of providing mental health care to targets of bullying behaviors. Further research is warranted to test educational interventions to assist in lessening the impact of bullying behaviors and distractions with student nurses prior to their entry into practice where suboptimal performance could have a clinically significant impact on patient care, and it could have a deleterious impact on the novice nurse’s emerging professional identity.