Seeing Students Squirm: Nursing Students’ Experiences of Bullying Behaviors During Clinical Rotations

Abstract

Background

Bullying remains a troubling problem in the nursing profession. Nursing students may encounter bullying behavior in clinical settings. However nursing students may not be adequately prepared to recognize and handle bullying behavior when it occurs. The purpose of this study was to gain greater understanding of nursing students’ experiences of bullying behaviors in the clinical setting.

Method

Using a descriptive qualitative approach, eight focus groups were held with 56 undergraduate baccalaureate nursing students from four college campuses. Focus group data were coded and analyzed for themes.

Results

Four categories of themes were identified: bullying behaviors, rationale for bullying, response to bullying, and recommendations to address bullying. Each category and its corresponding themes are presented.

Conclusion

Interventions for nurse educators to address bullying of nursing students in clinical settings are presented.

Bullying is widely recognized as a persistent problem in the profession of nursing (Ariza-Montes, Muniz, Montero-Simó, & Araque-Padilla, 2013; Berry, Gillespie, Gates, & Schafer, 2012; Chipps, Stelmaschuk, Albert, Bernhard, & Holloman, 2013). Those at particular risk include individuals with limited authority and experience such as nursing students (Clarke, Kane, Rajacich, & Lafreniere, 2012; Hakojarvi, Salminen, & Suhonen, 2014; Kern, Montgomery, Mossey, & Bailey, 2014). Nursing students may encounter bullying behaviors while in the classroom as well as in the clinical area. Considering the increasing demand for professional nurses, it is imperative to move beyond describing bullying behaviors encountered by nursing students to the development of interventions to address bullying in order to mitigate the negative impact it may have on students pursuing careers in nursing.

Background

Bullying behaviors generally encompasses negative and unwanted acts towards others (Clarke et al., 2012). Other terms often cited in the literature to describe bullying behaviors include horizontal violence, relational aggression, and harassment. It is important to note that bullying behaviors differ from incivility in distinct ways: intensity, intent, and frequency. While comparing the two constructs, Hershcovis (2011) noted workplace incivility is “a low intensity behavior with ambiguous intent, while workplace bullying is assumed to have high intensity and intent” (p. 505). Furthermore Hershcovis states incivility occurs with ambigious frequency whereas bullying occurs repeatedly (2011). Consequently, when individuals perceive that a perpetrator is specifically targeting them, the action is of high intensity and intends to harm, and/or is repeated over a period of time, the behavior may be viewed as bullying rather than incivility. In prior studies, nursing students frequently labelled the following verbal and non-verbal behaviors as bullying: undervaluing; negative, sarcastic, or condescending remarks; unreasonable expectations; hostile or degrading treatment; being ignored or socially isolated; and being shouted at or threatened (Clarke et al., 2012; Hakojarvi et al., 2014).

The extent of bullying behaviors experienced by nursing students is unclear as percentages range among studies. For example, a study of 674 undergraduate nursing students in Canada by Clarke et al. (2012) found that 89% (n = 598) had experienced at least one negative behavior classified as bullying. A different study of 313 nursing students in the U.K. found 53% (n = 165) reported experiencing at least one or more negative interactions during their clinical experience (Stevenson, Randle, & Grayling, 2006). Furthermore, a study of 47 senior baccalaureate nursing students in the U.S. revealed 53% (n = 25) had been “put down” by a staff nurse, 40% (n = 19) had been humiliated, 32% (n = 15) had a sarcastic remark made about them, and 26% (n = 12) had been talked about behind their back (Longo, 2007). Despite the variances in the data, it is clear that nursing students experience bullying behaviors.

Yet, there is a dearth known about nursing students’ beliefs about and responses to bullying. Understanding these aspects may provide important information from which interventions can be developed. Beliefs about bullying encountered in the clinical setting include a view that bullying is unavoidable and something to be dealt with (Curtis, Bowen, & Reid, 2007) or occurs because students are “not wanted” or do not belong in the clinical unit (Thomas & Burk, 2009; Kern et al., 2014). Researchers indicated that nursing students respond to bullying by feeling disrespected, not valued, and powerless (Curtis et al., 2007). In addition, students assert the experience impacts their learning (Hakojarvi et al., 2014; Thomas & Burk, 2009) and future employment choices (Curtis et al., 2007; Hakojarvi et al., 2014).

In order to generate understanding from the perspective of nursing students as to what types of bullying behaviors they encounter in the clinical setting and how these encounters impacted them, a descriptive qualitative study was conducted. Therefore the purpose of the study was to describe the experiences of bullying encountered by nursing students in the clinical setting.

Method

A descriptive qualitative approach was used for this multi-site study. The study was approved by the Institutional Review Boards of the respective study sites.

Setting and Sample

Respondents were recruited from four college campuses in the Midwest United States. Two campuses were urban-based, one campus was suburban-based, and one campus was rural-based. Respondents were recruited from senior level pre-licensure nursing courses. All respondents signed an informed consent document agreeing to be in the study prior to data collection. The names of students who participated were not shared with the faculty members who taught the senior level students. In addition, these faculty members had no access to the research data.

Procedures

Eight focus groups were held across the four college campuses. Respondents attended the focus group session held at their respective college. The focus group sessions were led by 1 of 2 researchers for consistency. Each researcher used an interview guide to assure the same questions were asked during each focus group session. Questions asked respondents to describe their personal experiences of bullying while a nursing student in the clinical setting, the impact bullying had for achieving their learning objectives while in the clinical setting, and recommendations for future student nurses who may encounter bullying in the clinical setting. The length of focus group sessions ranged from 26 to 58 minutes with a median length of 43 minutes. Focus group sessions were audio-recorded and transcribed verbatim. Names mentioned during the focus groups were replaced with pseudonyms on the transcripts. Data were managed using NVivo 9 (Cambridge, MA) qualitative data management software.

Data Analysis and Trustworthiness

Data were analyzed using Colaizzi’s procedural steps in phenomenological data analysis (Colaizzi, 1978). The data analysis process began with the research team reading the transcripts multiple times to gain a sense for the meaning of the data. Each researcher then conducted line-by-line coding to identify significant statements from each transcript. The research team met to discuss the line-by-line coding and significant statements. Based on this initial analysis, the research team developed a coding schema with four overarching response categories. Next the researchers independently analyzed the transcript data and coded significant statements to their respective category and potential theme. The research team then met and reviewed the coding line-by-line until agreement for all themes was achieved for coded data. Finally a summary of the research findings were presented to a sample of students who participated in a previous focus group session. No changes were made to the research findings.

Trustworthiness of the data was achieved using multiple strategies recommended by Lincoln and Guba (1985). First, the researchers debriefed after each focus group session to discuss their personal thoughts and feelings about the session thereby allowing these thoughts and feelings to be set aside prior to data analysis. Second, investigator triangulation increased the credibility of the research findings by multiple researchers independently analyzing the data and coming to the same conclusions. Third, an audit trail was generated to allow the researchers to document major discussions that led to the categories for thematic coding of the data. This audit trail was used by the researchers during subsequent data analysis/coding meetings to assure consistency in coding. Fourth, confirmability occurred by having a sample of previous respondents critique the research findings for a determination as to their truth-value for their experiences as nursing students experiencing bullying in the clinical setting.

Results

There were 56 nursing students who completed the study. Their ages ranged from 20 to 53 years with mean of 28 years and median of 24 years. Forty-eight (86%) respondents self-reported their race as white, 54 (95%) listed English as their primary language, and 49 (88%) self-identified as female.

Four overarching categories of themes were identified: Bullying Behaviors, Rationale for Bullying, Response to Bullying, and Recommendations. Each theme category is presented below with its corresponding subthemes.

Category 1: Bullying Behaviors

Six themes encompassed the various types of bullying behaviors nursing students described feeling and experiencing in the clinical setting (see Table 1). In the first theme, Being ignored, avoided, or isolated, participants described feeling as if nurses ignoring students’ attempt to engage them in conversation, isolating students by not assisting with patient care, intentionally withholding clinical information, or “trying to avoid having to work with a student.” The second theme, Witnessing non-verbal behavior, involved students witnessing bullying behaviors like “rolled eyes” or negative body language by the perpetrator. Experiencing negative interactions was the third theme of bullying behavior identified. Participants described receiving critical, negative, or rude verbal comments from perpetrators such as “we’re gonna dumb it down a little bit so that you can keep up” as well as overhearing spreading of rumors or gossip deemed unprofessional. In the fourth theme, Being denied an opportunity to learn, students reported feeling like preceptors appeared impatient with them, not explaining what was going on with the patient, or not giving students opportunities to perform patient care. The fifth bullying behavior experienced by students resembled Being hazed where students reported feeling taken advantage of, being shamed, or experiencing mind games at the hands of perpetrators. Being intimidated was the final subtheme identified. In this theme, participants described experiencing overt and covert threats from perpetrators. One participant recalled feeling intimidated when their clinical instructor said, “I can fail you for that right now in front of the patient.”

Table 1.

Themes and exemplars for Category 1: Bullying Behavior

Themes	Exemplars
Being ignored, avoided or isolated	“One nurse I had, and I’ve heard other stories, other people have had similar experience and seen it happen, but personally just this one who was just abrupt, she didn’t want to talk to me, she didn’t want – I had her patient, she wanted me to leave her alone and do my thing and just not like [bother] her. She wasn’t gonna answer any more than she had to.”
Witnessing non-verbal behaviors	“It’s a non-verbal thing. It’s a – it’s not a go away, it’s a ‘you again’ kind of look. It’s a – it’s an extra breath that you can hear. It’s a – it’s a way the movements suddenly turn a bit harsher and jerkier. It’s whipping the badge out, scanning it through the thing real fast as if you’re irritating. You know, it’s all those things that – the non-verbal signals that people use to communicate.”
Experiencing negative interactions	“As soon as the nurse that I was working with found out that I was a nursing student, um, it was like a night and day switch. Like one minute, ‘Oh hey, here’s – welcome to the job. Here’s how we do things around here.’ And then like night and day switch, just – I don’t – I don’t know how to describe it other than, ‘Well, you should know better.’ It’s like, ‘Well, I’m new. It’s like I got this job yesterday. And it’s like I’m new, I know – I shouldn’t know better.’ And, uh, just this attitude switch and then – and then when I didn’t meet that expectation there was back biting. There was talking about me just loud enough so that I could hear to the other nurses about how horrible I was. How – how – what a terrible nurse that I would be.”
Being denied an opportunity to learn	“Yeah, it was just, you know, simple things like putting in a Foley or something that a nursing student could do, [the clinical nurse] would do it really quick so that you wouldn’t get the opportunity, or you know, keep putting it off until you were at lunch, and they do it while you were gone.”
Being hazed	“She said she liked to see student nurses squirm. She wanted to see your reaction that way. She purposely did things a certain way so that student would feel uncomfortable.”
Being intimidated	“My nurse didn’t, like, ask me. She basically, like, told me you’re going to help me with this other patient that I wasn’t assigned to, which wouldn’t have been a problem, but I was in the middle with my patient. She was, like, a total pain, so I couldn’t just, like, leave her, you know? So I told the nurse, I was, like, okay, I’ll help you bathe your patient — or, she wanted me to bathe her patient or something. I was like I’ll help you with that in just a minute. And she made some comment, like, well, I’m gonna have to tell your instructor that you’re not helping in patient care, or, like, something like that.”

Category 2: Rationale for Bullying Behavior

This category of themes focused on participant explanations for why bullying behavior occurs in the clinical setting. Five unique themes of rationales were described (see Table 2). In the first theme, Rite of Passage, participants explained experiences of bullying behaviors as a normal part of life that one must go through. In particular, participants viewed bullying as an accepted rite of passage in nursing culture that assists new nurses with developing a “tough skin.” Another explanation for bullying behavior experienced by student nurses was found in the subtheme of Unpreventable. Participants reported feeling resigned to the fact that bullying behaviors would likely occur because “there’s nothing you’re going to be able to do about [it].” Bullying behavior was not seen as preventable, rather an inevitable experience for which one must be prepared to handle. The third theme detected, Students are not welcome, captured students’ views that experiences of bullying behaviors may be caused by nurses unwilling to be preceptors, feeling territorial, or having negative attitudes towards students working on the unit. Participants reported nurses varying in their demeanor from “being excited about teaching” to seeing students as “more of a nuisance.” In the fourth theme, Other stressors, participants thought bullying behaviors may be explained or caused by external factors. Students thought individuals feeling overwhelmed or frustrated, everyday stresses of the work environment, or competing unit- or organizational-level demands may explain why some individual nurses engage in bullying behaviors. For example, one student reported that her clinical instructor explained that other stressors were likely to blame for the bullying behaviors she had experienced and explained it as “frustrations get taken out on you.” The final theme, Not a nice person, attributed the reason for bullying behaviors to the characteristics of individual perpetrators. Examples included viewing the perpetrators as being jealous, needing control/power, or just not being a nice person.

Table 2.

Themes and exemplars for Category 2: Rationale for Bullying Behavior

Themes	Exemplars
Rite of passage	This is what your teacher … this is what your new grads or your new students are seeing. “I can’t wait until it’s my turn and I get to pass it down.” You create that kind of [bullying] culture. Now, what they see as hostility, or they see you talking about somebody, whatever it may be, if that’s how it’s practiced, you’re either made or broken. So, you’re broken and you stop and you find another job, that may not be the field that you wanted, but at least you’re working with people that treat you well. But if you stay, you’re probably going to take on the personalities and the traits and the characteristics of those on the floor, which, like I said, is just going to perpetuate that cycle. So, I think that’s one of the worst things, is not being able to break the cycle. This is people just waiting for their turn to be on top.”
Unpreventable	“[Bullying] is going to happen no matter – I kind of feel like it’s going to happen no matter what hospital or whatever you’re at. Um, so you just kind of have to be prepared for it.”
Students not welcome	“Some nurses are very nice to students and very helpful and others you get the vibe you know they don’t want you there.”
Other stressors	“It is like a lot of the time the nurses are overwhelmed. They have six or seven patients instead of the four that they should have and they’re – they convey their stress onto people. They put it onto others – and it turns into bullying, but it’s really you know ‘I feel overworked or I’m too told to be in this position or I’m – you know, I – I can’t lift like I use to. My back is killing me because I threw it out.’ And just like all these things that build up… And that’s just like – you know, I can tell that their – their frustration with their situation I think that that’s what is has to do with. Um, because it’s just – they’re just upset about their – I don’t know. They’re just angry.”
Not a nice person	“I honestly feel like a lot of what has to do with it is jealousy. Like people are genuinely jealous of like how smart and intelligent you might be as an individual and like how, you know, you – you’re a nursing student, you’re in nursing school, you’re going to be successful. Maybe she never had that opportunity or like path to do that. And she’s kind of expressing her anger and jealousy like indirectly to you and her patients and stuff like that. But I feel like that’s like a big like defining [characteristic of] bullies is that they’re generally jealous of other people’s situations.”

Category 3: Responses to Bullying Behavior

The third category of themes describes participants’ responses to and the impact of bullying behaviors and consisted of seven distinct themes (see Table 3). Theme one, Physical, encompassed participants reports of responding to the episode of bullying by crying or feeling physically sick. These responses occurred during as well as after events of bullying behavior. Similarly, the second theme, Emotional, incorporated participants reports of feeling scared, nervous, irritated, angry, “pissed off”, and uncomfortable during and after bullying events. One participant remembered how it took her crying in front of the perpetrator for the bullying behavior to stop. In addition to physical and emotional, the third theme, Psychological, involved participants’ reports of experiencing dread, disbelief, worry, feeling self-conscious, loss of confidence, and decreased self-esteem in response to bullying events. In the fourth theme, Avoidance, participants described using avoidance as a behavioral response immediately after bullying behaviors occurred as well as a strategy to protect themselves from additional encounters with a perpetrator. In theme five, Productivity and Performance, participants described how the bullying behavior events impacted their ability to engage in patient care activities and be productive during the clinical rotation. In theme six, Learning, participants explained how events of bullying behavior impacted the ability to learn while at the clinical site. One student reported that due to the event of bullying behavior, “I didn’t learn anything. I had a terrible experience.” The final theme was View of Nursing and Healthcare. In this theme, participants describe how the bullying behaviors made them question their thoughts about becoming a nurse, their opinion of the specific organization, and their view of the overall healthcare system. One participant stated, “All I could think about was how I hoped none of my loved ones are ever cared for by anybody in this agency.”

Table 3.

Themes and exemplars for Category 3: Response to Bullying Behavior

Themes	Exemplars
Physical	“I made myself physically sick one morning because I didn’t want to be there.”
Emotional	“It like pissed me off, like I’m a freaking adult you know. I don’t know, it like really made me mad more than hurt and upset.”
Psychological	“I had a really difficult time in clinical at one point. Um, like to the point where I just didn’t want to go to clinical anymore because that person is there and you would just get like so stressed out and have so much anxiety about it and like apprehension that you’re going to have to interact with this person.”
Avoidance	“Every time I had to call the doctor [bully], I was really hesitant. And like I normally was like always on top of like calling the doctor and be like, “Hey, this is going on, this. I need an order for this.” But when that doctor – I saw her name, and I had a pager, I wouldn’t do it. Like, I told my nurse to do it. So like, I tried to just avoid it.”
Productivity and performance	“You get anxiety and that completely shuts a lot of people down. And you - you can’t get your work done. You can’t, um, critically think. You can’t do all these things that are necessary to provide optimal - adequate, optimal patient care and then ultimately a safe healthcare environment, um, because your brain is just clouded with am I going to have to see this person? What am I going to do? They’re going to say this and then I’m going to say this. And, you know, we kind of flood our brains with all these other scenarios, but that’s anxiety and that’s - that’s so real to the - to a lot of students. And they’re put in certain situations or made to interact with certain people that they may not get along well with or otherwise mistreat them. Um, so yeah. That’s - it definitely affects your clinical work.”
Learning	“I had a problem with one of the staff nurses and she came in after ignoring me for a long time and refusing to give me a report and stuff, making me behind. You were talking about meeting objectives, I didn’t meet any of them that day because um I couldn’t get the patient – I couldn’t establish trust with the patient.”
View of Healthcare	“It personally made me not want to be a nurse for a little bit because I was like am I, am I that dumb, am I – am I not supposed to be doing this. Am I going to kill someone because if that’s what this is about then I need to stop now cause that’s how she made me feel every day was that I was just the worst possible nurse in the world and I shouldn’t even be continuing.”

Category 4: Recommendations

This category contains themes which reflect participants’ recommendations to address bullying behaviors experienced by nursing students and identified eight specific areas of focus, or themes (see Table 4). Educate and prepare students was the first specific recommendation identified. Participants stated students need to receive bullying education as well as training on how to prevent and handle bullying behaviors throughout the nursing program. Recommendations included educating students on how to recognize and mitigate bullying behaviors, learning how to handle bullying behaviors though simulation training, and establishing a zero tolerance policy. In the second theme, Student responses to bullying, participants recommended strategies for how future students respond to bullying behavior. Recommended responses varied and included ideas like being polite and respectful as a way to avoid being bullied as well as seeking guidance from clinical faculty, sticking up for oneself, and not worrying or taking things personally if bullying occurs. The third recommended strategy is Support. In this theme, participants suggested students seek out and receive support from others (e.g., fellow students, faculty instructor) in order to handle and recover from bullying behavior. The fourth theme, Faculty member response, reports participants’ recommendations for how faculty members should respond to bullying behaviors reported by nursing students. Desired responses included increased awareness about potential bullying behaviors taking place at the clinical site, advocating for respectful treatment of students, working with clinical managers to prevent and/or address bullying behaviors, and supporting students when bullying behaviors occur. Similar to faculty responses, recommendations for how hospitals could prevent and respond to bullying behaviors toward nursing students were identified in the theme, Facility/organization response. Participants discussed how the management or the hospital facility/organization could prevent bullying behaviors by having a dedicated floor on which nursing students would conduct their clinical as well as fostering open communication between nurse managers, the charge nurse, and the clinical faculty regarding the unit as an appropriate site for clinical instruction. In Qualifications of preceptor, participants suggested the use of high quality preceptors through routine evaluation of preceptors’ qualifications as well as providing incentives for positive student evaluations. The theme, Making student assignments, reports students’ recommendations for how the process of making student assignments at the clinical site could be improved to prevent future bullying. Improvements included making assignments by determining nurses’ willingness to have nursing students or evaluating both a clinical nurse assigned to a patient and the patient’s diagnosis rather than patient diagnosis only. Finally, the theme, Clarification of student role, focuses on participants’ recommendation that the role of the nursing student should be made clear to the student, preceptor, and unit staff on which the student is working. Students believe that bullying could be prevented through open and clear communication of the skills nursing students may engage on the unit.

Table 4.

Themes and exemplars for Category 4: Recommendations

Themes	Exemplars
Educate and prepare students	“Maybe like every like nursing student needs to like go through some kind of like simulation or have some kind of like lecture on [bullying] because it does happen…I think I mean a good idea to just like have simulations maybe at the beginning of each clinical and to like agree about just go over [bullying] again… this all could happen again maybe just to refresh everybody every time you go [to clinical].”
Student responses to bullying	“If you go into all of your clinical experiences knowing that you’re there as a guest, and that they are going out of their way to let you have experiences, and to be appreciative of that, and polite and respectful to everybody that you’re working with, that sometimes that can go a long way. It’s harder to bully somebody who is thanking you and being genuinely kind to you, and not – you know, if they ask you to dump a bed pan, not to be feeling like that’s the PCA’s job. No, that’s your job as a student. I think sometimes if you’re more in a servant role, that it’s harder to be bullied.”
Support	“Well, I think we’re all in the same situation, so when we’re vulnerable and kind of slightly self- conscious, especially in our first clinical studies, our peer relationships and kind of discussing what happened and getting feedback from someone else who understands is a big positive because you don’t feel as alone, because when that’s happening to you, whether it’s from a nurse or an instructor, you start feeling very inadequate. If you have an opportunity to discuss with someone that may have gone through the same thing, or has the vulnerability of going through the same thing, you don’t feel that you’re the only one.”
Faculty responses	“Maybe follow up and monitor closely. Like you know, follow up with the situation immediately, and then kind of continue to monitor so that subsequent encounters, you know, to kind of keep an eye on things. Get a feel from the student as far as, has any more bullying occurred? Is it – is it just isolated to a bad day and a bad situation? Or is this a consistent theme with the, with the nurse or the – physician or whatever? … Look for trends, and um, and just continue to follow up on both ends with the student, you know? And uh, and the nurse or whoever’s involved.”
Facility/Organization responses	“And there really should just be a teaching floor where that’s all they do, that’s where everybody goes, they know they’re getting students and the hospital can budget for it and maybe make a premium to the people but also be able to use less people because they’ve got students.”
Qualifications of preceptors	“Those nurses are acting as teachers and some people weren’t meant to be teachers. They may be good nurses but they’re not good teachers and they need to think about that more in terms of who they’re assigning and make the compensation for it so they want to do it, the ones who are good at it want to do it. It should be a regular thing where they’re evaluated on it. They’re not even evaluated based on anything they did with us. Nobody is checking in and saying you did a good job or a bad job. If it doesn’t matter, if it’s not important enough that they’re not going to get checked on it, why should they care? It should be one of those things where it’s the same cadre of people, they’re evaluated on it and the good ones get to keep doing it and the bad ones get shifted out and you keep going to find another one.”
Making student assignments	“My adult clinical right now, we get assigned based on the patient diagnosis. So the – the – the clinical instructor is saying this patient has a bunch of problems, I want a student to see what this looks like instead of I want a student to go with the good nurse… They’re picking based on the patient, not picking based on the nurse who you’re partnered with. I think picking based on the nurse would be a smarter move.”
Clarifying the role of student nurses	“They [nurses in clinical setting] don’t understand, like, what we’re allowed to do as far as students, like our limitations.” “I wish they just, like, asked people, or just tell them that they, like, train them as to what we can do because I can’t give meds by myself.”

Discussion

Results from this study confirm that nursing students experience various types of bullying behaviors in the clinical setting. These findings share similarities to those reported in prior studies of undergraduate nursing students (e.g., Curtis et al., 2007; Stevenson et al., 2006). A unique finding in this study includes participants describing being denied the opportunity to learn as a bullying behavior. The main objective of a clinical practicum is for students to gain real world experiences with patients. When bullying behaviors occur, it interferes with students meeting these objectives. Though simulation experiences provide students with opportunities to practice and learn (Vincent, Sheriff, & Mellott, 2015), simulations do not supersede real-world clinical experiences. Thus, students should to be instructed to inform clinical instructors immediately if the nurse preceptor will not let them take care of their assigned patient.

Results also demonstrated a variety of reasons why nursing students believe they were targets of bullying behavior in the clinical setting. Though we acknowledge that the perception of bullying behaviors as a “rite of passage” and “unpreventable” in the nursing profession needs to be addressed, one area that can readily be addressed is the finding that bullying behaviors occur because students are not welcome. Similar findings were reported in a recent study of nursing students getting ready for their first clinical placement (Levett-Jones, Pitt, Courtney-Pratt, Harbrow, & Rossiter, 2015). Of the 144 student responses, nearly 20% were primarily concerned about “not being welcome” on the unit and perhaps being the target of bullying (Levett-Jones et al., 2015). Similarly, Kern et al. (2014) found in their qualitative research that nursing students felt unwanted by unit nurses which in turn prevented them from achieving a sense of belonging in the clinical setting. In another study of 2^nd and 3^rd year nursing students in Australia, researchers found students perceived a hierarchical environment where nursing students were treated poorly by the clinical nurse staff created a hostile learning environment (Curtis et al., 2007). In contrast, it is possible that preceptors are managing multiple patients with complex medical conditions as well as multiple other responsibilities. Given these competing priorities, some nurses may not be cognizant that they are being perceived as demonstrating bullying behaviors.

Nurse educators are integral in the identification and acquisition of clinical sites. Therefore it is imperative for faculty to identify clinical sites where clinical nursing staff will be supportive and welcoming of students as to provide an enriching environment for learning to occur. Having flexibility in the identification and selection of clinical sites may be needed. In the future, leveraging technology to think creatively regarding location of clinical sites may be required. For example, nursing faculty could have students on different units within one healthcare organization with clinical instructors monitoring student work using remote technology such as videoconferencing or robotic devices (see Figure). Findings from previous research using a remote telepresence robotic system reflect robotic systems can be an effective mechanism to achieve learning outcomes with nursing students (Sampsel, Vermeersch, & Doarn, 2014). Through integration of technology, instructors may not need to be physically present on the unit when supervising students. This strategy would allow nursing students to spread throughout a single healthcare site with supportive preceptors instead of being relegated to a single unit of the healthcare site and subjected to various degrees of bullying behaviors.

Figure.

Example of remote clinical instruction via robot.

Photo courtesy of XXXX.

Responses to bullying behaviors reported by participants are similar to those found elsewhere (Stevenson et al., 2006). In addition to the emotional, physical, and psychological toll bullying can have on students, participants state the experiences of bullying influenced their productivity and performance when providing clinical care. As nurse educators, we need to prepare students to be safe and competent practitioners. If they experience bullying behaviors and this impacts their performance, the bullying needs to be addressed immediately. Researchers have shown experiencing aggression impacts work productivity among professional nurses (e.g., Berry et al., 2012; Gates, Gillespie, & Succop, 2011). When students are still in the process of learning, bullying can impede getting to a safe and competent level of performance. Potential intervention ideas include the development and implementation of policies and procedures to address bullying behaviors immediately (Hakojarvi et al., 2014) so that any impact on individuals can be lessened. In addition, nurses who precept students need additional education and training on how to interact with students in an ethical manner that promotes a safe, learning environment.

Another concern was how bullying impacted the students’ view of healthcare. Nursing students who experience bullying behaviors may question whether they should continue nursing studies and may be at risk for leaving the profession prematurely. A study of 674 Canadian nursing students found similar results with students who experienced bullying being more likely to consider leaving the program (Clarke et al., 2012). With the growing anticipation of a shortage of nurses in the United States, there is a need to not only retain but also increase the number of students who stay in nursing.

One recommendation proposed by participants that may address the issues of preparing and retaining students in the nursing profession is education. Academic nurse leaders and faculty need to integrate bullying education throughout the curriculum. Education should focus on the recognition of bullying behaviors, what is not bullying, how to manage these encounters, and how to interact professionally with persons of diverse backgrounds. Students can be taught professional management techniques to address safety concerns including bullying behaviors (e.g. crucial conversations) and advocacy for others when bullying behavior is witnessed. Strategies for skills training may include role-play, clinical simulation, cognitive rehearsal, and problem-based scenarios (Levett-Jones et al., 2015). For example, role-play in the classroom and/or clinical setting provides students with the opportunity to practice recognizing and responding to bullying behaviors in a safe learning environment (Decker & Shellenbarger, 2012; Gillespie, Brown, Grubb, Shay, & Montoya, 2015). A potential role-play scenario may include a unit-based nurse educator bullying the clinical instructor and then holding a debriefing session with students to ask how this situation should be addressed.

Another educational strategy to address bullying is for nursing students to discuss how bullying behaviors are a direct violation of the American Nurses Association’s (2015) Code of Ethics. Students can explore how ethical nursing practices such as demonstrating respect for all persons; fostering an ethical, moral, and civil work environment; and promoting one’s personal integrity can provide a solid foundation for calling out and quashing bullying behaviors. Furthermore, students can discuss how the adoption and promotion of ethical behaviors early on as nursing students can assist with developing collaborative relationships with clinical nursing staff (Decker & Shellenbarger, 2012). Considering U.S. Americans have consistently ranked nurses as having the highest honesty and ethics standards among 21 professions in the annual Gallup Poll of Honesty and Ethics in Professions (Saad, 2015), isn’t it about time that nurses live up to the public perception by treating each other with respect and dignity and eradicating bullying behaviors for good?

There were several major limitations in this study. First, the study focused on exploring bullying behaviors experienced by nursing students in the clinical setting. While it is possible that students may experience bullying behaviors from other potential perpetrators (e.g., classmates, academic faculty (Mott, 2014; Seibel, 2014)] and in other settings (e.g., classroom, on-campus), or may engage in bullying behaviors themselves (Kolanko et al., 2006), participants were not asked to explore these aspects. Therefore, results reported may only represent one aspect of nursing students’ experiences with bullying behaviors their academic program. Second, the veracity of students’ experiences could not be validated. It is possible that there were extenuating circumstances not explained to the students which could account for some actions exhibited by nursing preceptors and clinical staff nurses. Third, convenience sampling was used thus limiting the generalizability of the study findings. Given the qualitative design of this research, achieving generalizability would not be a suitable goal. However, the rich description of the study findings and the study sites do promote the transferability of the study findings to similar colleges of nursing. Third, the study was conducted in the Midwest United States. Students completing clinical rotations in other parts of the United States or other countries may experience different types or outcomes of bullying behaviors.

Conclusion

Bullying behaviors experienced by current and future nurses must be addressed. The ANA’s Code of Ethics for Nurses with Interpretive Statements states that nurses are obligated to “create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” (ANA, 2015, p. 4). Failure to adequately prepare future nursing professionals to recognize, manage, and root out bullying behaviors of other healthcare workers indirectly perpetuates the dysfunctional behavior that threatens the safety of patients and the nursing profession itself. Findings from the study indicate that nursing students do experience bullying behaviors in the clinical setting and may experience negative responses. Interventions based on these findings and implemented by nurse educators could assist nursing students with recognizing, mitigating, and responding to bullying behaviors in ways that promote a positive and ethical work culture. Considering the increasing demand for nursing professionals, nurse educators must work collaboratively with clinical staff and leaders in health care organizations where clinical experiences are held to support a culture of safety and zero tolerance for bullying and other types of workplace aggression. Future research is needed to directly evaluate the learning outcomes impacted when bullying behaviors occur against nursing students.