Integrative Review of Qualitative Research on the Emotional Experience of Bullying Victimization in Youth

Abstract

The emotional experience of bullying victimization in youths has been documented primarily using quantitative methods; however, qualitative methods may be better suited to examine the experience. An integrative review of the qualitative method studies addressing the emotional experience of bullying victimization was conducted. From MEDLINE, Cumulative Index of Nursing and Allied Health Literature, PubMed, Education Information Resource Center, and PsycINFO, 14 English-language, peer-reviewed, qualitative studies were reviewed. Applying the Critical Appraisal Skills Programme, the quality of the studies was deemed sufficient. The range of emotional experiences reported included sadness, decreased self-esteem, embarrassment, fear, suicidal thinking, anger, feeling hurt, loneliness, powerlessness, helplessness, and confusion. Overall, these results were similar to those obtained from quantitative method studies, apart from the feeling of embarrassment. This integrative review confirmed and expanded the knowledge of emotional experiences of bullying victimization.

Background

The systematic study of bullying in youths began in Scandinavia in the 1960s and 1970s with Olweus. He proposed that “a student is being bullied or victimized when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more other students” (p. 755). Incorporating the attribute of power imbalance, the definition now includes that “the student who is exposed to negative actions has difficulty defending himself or herself” (Olweus, 2013, p. 755). Cyberbullying, a newer concept, has been defined as “willful and repeated harm inflicted through aggressive actions through the use of computers, cell phones, and other electronic devices” (Hutson, 2016, p. 67). There is disagreement in the scientific community in the defining attributes of cyberbullying, as well as whether cyberbullying is a form of bullying or a different concept altogether.

Nevertheless, bullying in childhood is a public health concern that has many negative consequences. Previous studies, including systematic reviews and meta-analyses, have found higher rates of depression, anxiety, suicidal thinking, psychiatric hospitalization, use of psychiatric medications, low self-esteem, missed school days, academic failure, psychosomatic problems, and aggressive/violent behavior in youths who have been exposed to bullying (Arseneault, 2017; Gini & Pozzoli, 2013; Hinduja & Patchin, 2010; Moore et al., 2017; Sourander, Ronning, & Brunstein-Klomek, 2009; Ttofi, Farrington, & Lösel, 2012). Many of the consequences of bullying relate to the experience of emotional harm on the individual; depression, anxiety, and suicidal ideation are the most cited emotional consequences of bullying (Bottino, Bottino, Regina, Correia, & Ribeiro, 2015; Moore et al., 2017). Suicidal ideation, suicidal behaviors, and completed suicide attempts related to bullying have been given increased exposure in the media (Winburn, Winburn, & Niemeyer, 2014), and a meta-analysis by Holt et al. (2015) found a nearly 3-fold increase in suicidal behavior for victims of bullying. A recent systematic review and meta-analysis by Moore et al. (2017) showed evidence for the relationship between bullying (especially bullying victimization) and mental health consequences such as depression, anxiety, and suicidal ideation. In that review, significant associations were found between bullying victimization and depression, anxiety, poor general health, and suicidal ideation.

An important consideration in reviewing literature on bullying and the experienced emotional harm is that it has mostly been done via quantitative methods with self-reports. There are inherent measurement issues because there is limited research into the accuracy of self-report surveys in the measurement of bullying (Vivolo-Kantor, Martell, Holland, & Westby, 2014). Some of the issues include reporting/responding bias and sensitivity and specificity issues. Importantly, there are limitations in relying on quantitative methods to study bullying, as quantitative methods do not allow for the exploration of youths’ perceptions of the emotional harm that bullying causes. Discovering youths’ perceptions of the experiences of bullying through qualitative methods will allow the research and clinical community to better create and refine bullying assessment and prevention programs, especially at the individual level.

Therefore, qualitative methods may be better suited to examine youths’ perceptions of the bullying experience. Qualitative methods allow researchers to explore the life of individuals, understand their lived experience, and describe and interpret cultural phenomena (Creswell, 2013). Consequently, studies using qualitative methods have examined the experiences and perceptions of youths who have been involved with bullying including their reactions (Athanasiades & Deliyanni-Kouimtzis, 2010; Side & Johnson, 2014), the coping skills they use when dealing with bullying (Evans, Cotter, & Smokowski, 2017), and the motivations behind bullying (Varjas, Talley, Meyers, Parris, & Cutts, 2010). It is important to note that there are also measurement issues in qualitative methods. Qualitative methods have been critiqued as being small-scale, biased, and lacking rigor; however, when completed according to previously defined methods, qualitative work can be valid, credible, and rigorous (Anderson, 2010; Creswell, 2013).

Although qualitative method study findings about the emotional consequences of bullying have been published in the literature, a summary of these findings has not been published. Therefore, the purpose of this study was to perform an integrative review of the qualitative literature on the emotional experience of bullying victimization in youths. An integrative review method as proposed by Whittemore and Knafl (2005) was selected because it allows for the inclusion of both experimental and nonexperimental studies to understand a phenomenon. Specifically, the steps in an integrative review include (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation (Whittemore & Knafl, 2005).

Method

Problem Identification

The problem identified that guided this project was a lack of a synthesis of the qualitative method studies on the emotional experience of youths who are victims of bullying. Thus, the aims of the review were to describe succinctly the emotional experience of being a victim of bullying as detailed in the qualitative literature and to examine these results within the context of quantitative method study findings in the literature.

Literature Search Method

To complete a thorough review of the literature, the electronic databases searched were MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, Education Information Resource Center (ERIC), and PsycINFO. In the EBSCO databases (CINAHL, ERIC, PsycINFO, and MEDLINE), searches were limited to peer-reviewed articles. No beginning date limit was used, and the search was conducted up to April 2017. The search terms were “bullying” and “qualitative.”

Inclusion criteria for this search are as follows: (1) qualitative or mixed-methods study addressing bullying, (2) pediatric population (<21 years of age), (3) participants described their emotional experience of bullying victimization, and (4) the article was published in a peer-reviewed journal. Articles were excluded if (1) they were published in a language other than English or (2) they were unpublished manuscripts (abstracts or dissertations). Although mixed-method studies were included only the qualitative data were addressed in this integrative review.

Citation titles were first assessed. For titles that indicated qualitative methods to study the experiences/perceptions of youths involved with bullying, abstracts were reviewed for the inclusion and exclusion criteria. For abstracts that met inclusion criteria, the full-text articles were retrieved and fully evaluated for inclusion and exclusion criteria. The study selection process and results can be found in Figure 1. Ultimately, 14 manuscripts were found that met the established inclusion criteria. Data from the 14 studies can be found in Table 1.

Figure 1.

Study selection.

Table 1.

Article Review Table.

Reference	Qualitative Method Used	Aim	Mixed Methods	Data Collection Technique	Sample Size and Characteristics	Setting and Special Population
Athanasiades and Deliyanni-Kouimtzis (2010)	Interpretative phenomenological analysis	To qualitatively investigate secondary students’ interpretations and experiences of bullying with a focus on gender	No	Focus groups	95 participants 15–16 years 45 girls, 50 boys	Schools
Bell, Arnold, Golden, Langdon, Anderson, and Bryant (2014)	Type not given	To determine the role of bullying in the lives of Lumbee youth	Yes	Focus groups	31 participants 12–17 years 15 girls, 16 boys	Community Lumbee Indian youth
Berne, Frisén, and Kling (2014)	Thematic, semantic analysis	To explore adolescents’ experiences of appearance-related cyberbullying	No	Focus groups	27 participants 15 years 13 girls, 14 boys	Schools
Brown-Hajdukova, Hornby, and Cushman (2016)	Transcendental phenomenology	To gain valuable insights into how it is to be a student identified as having SEBD	No	Focus groups and individual interview	29 participants 9–13 years Only male	Residential Boys with social, emotional, and behavioral difficulties
Kentel and McHugh (2015)	Qualitative description	To explore the bullying experiences of young Aboriginal women in team sports	No	Individual interview	8 participants 14–18 years Only females	Sports team through school Aboriginal girls
Kulig, Hall and Kalischuk (2008)	Type not given	To generate information about violence among youth in rural settings	Yes	Focus groups and individual interview	52 participants no ages given but average grade 10 32 girls, 20 boys	Schools Rural youth
Kvarme, Helseth, Sæteren and Natvig (2010)	Phenomenological hermeneutic mode of understanding	To explore how school children experience being bullied	No	Focus groups	17 participants 12–13 years 14 girls, 3 boys	Schools
Lindsay and McPherson (2012)	Type not given	To examine the experiences of bullying and social exclusion of children and youth with cerebral palsy	No	Focus groups and individual interview	15 participants 8–19 years 9 girls, 6 boys	Rehab facility Youth with cerebral palsy
Mishna, Wiener and Pepler (2008)	Basic qualitative methodology	To examine children’s, parents’, and teachers’ perspectives on pervasiveness of bullying in the child’s friendships	Yes	Individual interview	18 participants No ages given but in Grades 4 and 5 9 girls, 9 boys	Schools
Pister (2014)	Phenomenology and grounded theory	To explore the thoughts and attitudes youth hold about bullying	No	Individual interview	15 participants No ages given but in Grades 7 and 8 7 girls, 8 boys	Schools
Shea and Wiener (2003)	Grounded theory	To describe the experience of peer victimization of children with attention deficit hyperactivity disorder (ADHD)	No	Individual interview	4 participants 11–13 years Only male	Unclear Boys with ADHD
Side and Johnson (2014)	Modified thematic analysis	To explore discourses constituting bullying from eight young people who have experienced it	Yes	Focus groups and individual interview	8 participants 13–15 years 3 girls, 5 boys	Schools
Tenenbaum, Varjas, Meyers, and Parris (2011)	Grounded theory	To explore children’s perceptions of how they cope with victimization	No	Focus groups	102 participants 9–15 years 38 females, 64 boys	Schools
Willis and Griffith (2010)	Descriptive phenomenological method	To understand middle school boys’ lived experiences of being bullied, the aftermath, and meanings	No	Individual interview	11 participants 11–14 years Only male	Schools Middle school boys

Data Evaluation

Evaluating and interpreting quality of primary sources in an integrative review can be challenging, as noted by Whittemore and Knafl (2005). Because qualitative methods were used for the studies included, a quality instrument that specifically assesses qualitative methods was used: the Critical Appraisal Skills Programme (CASP; 2014; Lee, 2006). The CASP (2014) qualitative checklist was designed by a group of experts to be used, when reading qualitative literature to think about the quality of qualitative methods in a systematic way. This instrument was used to judge whether the article explicitly identified an aim, method, research design, recruitment strategy, data collection method, ethical issues, data analysis techniques, findings, added value to the literature, and whether the relationship between the researcher and participants was adequately considered. Based on the criteria from the CASP instrument, no articles were excluded due to quality issues. In general, the quality of the studies was determined to be sufficient. All studies had an appropriate methodology, reported their findings, and added value to the literature. The largest area of concern was the relationship between the researcher and participants; five of the studies did not address this issue (Athanasiades & Deliyanni-Kouimtzis, 2010; Bell et al., 2014; Kulig, Hall, & Kalischuk, 2008; Lindsay & McPherson, 2012; Side & Johnson, 2014). This is an important area to address because bias can be introduced if the researcher does not examine her or his role and influence in the qualitative data collection process.

Across the 14 studies, different types of qualitative methods were used. Phenomenological methods were most commonly used (n = 5), including the subtypes of interpretative phenomenological analysis (Athanasiades & Deliyanni-Kouimtzis, 2010), the phenomenological hermeneutic mode of understanding (Kvarme, Helseth, Sæteren, & Natvig, 2010), transcendental phenomenology (Brown Hajdukova, Hornby, & Cushman, 2016), the descriptive phenomenological method (Willis & Griffith, 2010), and general phenomenology (Pister, 2014). Grounded theory methods were also used in three of the studies (Pister, 2014; Shea & Wiener, 2003; Tenenbaum, Varjas, Meyers, & Parris, 2011). Two studies cited thematic semantic analysis as their method (Berne, Frisén, & Kling, 2014; Side & Johnson, 2014). One study used qualitative description (Kentel & McHugh, 2015), and another cited basic qualitative methodology (Mishna, Wiener, & Pepler, 2008). Three studies did not mention a specific qualitative method that guided their work (Bell et al., 2014; Kulig et al., 2008; Lindsay & McPherson, 2012).

Although the focus of this review was qualitative method studies, it is important to mention that four of the studies also included quantitative components, namely, self-report Likert-type scale surveys; therefore, they are classified as mixed methods (Bell et al., 2014; Kulig et al., 2008; Mishna et al., 2008; Side & Johnson, 2014). Another important consideration is that studies included different types of interview methods: five of the studies used focus groups (Athanasiades & Deliyanni-Kouimtzis, 2010; Bell et al., 2014; Berne et al., 2014; Kvarme et al., 2010; Tenenbaum et al., 2011), five used individual interviews (Kentel & McHugh, 2015; Mishna et al., 2008; Pister, 2014; Shea & Wiener, 2003; Willis & Griffith, 2010), and four used both focus groups and individual interviews (Brown Hajdukova et al., 2016; Kulig et al., 2008; Lindsay & McPherson, 2012; Side & Johnson, 2014).

Data Analysis

Data collected and analyzed for this integrative review were explicitly identified prior to beginning the data collection process, as proposed by Whittemore and Knafl (2005). Data for each article were extracted, including the terms used to describe the emotional experience of bullying victimization, sample size and characteristics, any special populations recruited, the country in which the research took place, the setting of the research, and strengths and limitations. Data regarding the emotional experience were taken from both the write-up in the article and the quotations from participants in the studies. Once extracted, the data from all primary sources were displayed in a chart and were compared iteratively.

Findings

Articles were published between 2003 and 2016. The sample size in the studies ranged from 4 to 102 participants. Participants were between the ages of 8 and 19 years. Studies were conducted in Canada, Greece, New Zealand, Norway, Sweden, the United Kingdom, and the United States. Most of the research was conducted in the school setting (Athanasiades & Deliyanni-Kouimtzis, 2010; Berne et al., 2014; Brown Hajdukova et al., 2016; Kentel & McHugh, 2015; Kulig et al., 2008; Kvarme et al., 2010; Mishna et al., 2008; Pister, 2014; Side & Johnson, 2014; Tenenbaum et al., 2011; Willis & Griffith, 2010), two were performed in the community or home setting (Bell et al., 2014; Shea & Wiener, 2003), and one in a pediatric rehabilitation center (Lindsay & McPherson, 2012).

Some of the studies recruited specialty populations to describe their specific bullying experience. Certain studies selected participants with a specific diagnosis, such as attention deficit hyperactivity disorder (Shea & Wiener, 2003) or cerebral palsy (Lindsay & McPherson, 2012), while one included participants based on the general diagnosis of social, emotional, and behavioral difficulties (Brown Hajdukova et al., 2016). Others recruited based on inclusion in an ethnic or cultural group, such as Lumbee youth (Bell et al., 2014), Canadian Aboriginal youth (Kentel & McHugh, 2015), or rural youth (Kulig et al., 2008). A few of the studies aimed to look at specific gendered experiences related to bullying; thus, they only recruited males (Brown Hajdukova et al., 2016; Shea & Wiener, 2003; Willis & Griffith, 2010) or females (Kentel & McHugh, 2015).

Emotions Experienced

There was a range of emotional experiences related to being a victim of bullying discussed in the articles (Table 2). One of the most commonly mentioned emotions was sadness or depression; this response was found in 10 of the articles (Bell et al., 2014; Berne et al., 2014; Brown Hajdukova et al., 2016; Kentel & McHugh, 2015; Kvarme et al., 2010; Mishna et al., 2008; Shea & Wiener, 2003; Side & Johnson, 2014; Tenenbaum et al., 2011; Willis & Griffith, 2010). The youths reported words such as sad, sadness, or “feel down” (Kentel & McHugh, 2015, p. 370). Self-esteem issues were also often mentioned, reported in seven of the articles (Athanasiades & Deliyanni-Kouimtzis, 2010; Bell et al., 2014; Berne et al., 2014; Kentel & McHugh, 2015; Kulig et al., 2008; Kvarme et al., 2010; Willis & Griffith, 2010). In particular, the youths described feeling “not as good as the others” (Kvarme et al., 2010, p. 795). Another emotional reaction mentioned in seven of the articles was embarrassment or shame (Berne et al., 2014; Kentel & McHugh, 2015; Kulig et al., 2008; Lindsay & McPherson, 2012; Shea & Wiener, 2003; Side & Johnson, 2014; Tenenbaum et al., 2011). In one article, a participant reported that the experience was “humiliating” (Side & Johnson, 2014, p. 225).

Table 2.

Emotions Experienced.

Emotion	Reference	Example
Sadness/depression	Bell, Arnold, Golden, Langdon, Anderson, and Bryant (2014), Berne, Frisén, and Kling (2014), Brown Hajdukova, Hornby, and Cushman (2016), Kentel and McHugh (2015); Kvarme, Helseth, Sæteren, and Natvig (2010), Mishna, Wiener, and Pepler (2008), Shea and Wiener (2003), Side and Johnson (2014), Tenenbaum, Varjas, Meyers, and Parris (2011), and Willis and Griffith (2010)	“If I get a comment, I feel like really bad, and I can be, you know, I can feel terrible for, like, years, like, over one single comment” (Berne et al., 2014, p. 531) “feel down” (Kentel & McHugh, 2015, p. 370)
Self-esteem issues	Athanasiades and Deliyanni-Kouimtzis (2010), Bell, Arnold, Golden, Langdon, Anderson, and Bryant (2014), Berne, Frisén, and Kling (2014), Kentel and McHugh (2015), Kulig, Hall, and Kalischuk (2008), Kvarme, Helseth, Sasteren, and Natvig (2010), and Willis and Griffith (2010)	“You feel out of place and feel that you are not as good as the other” (Kvarme et al., 2010, p. 795) “It [bullying] makes me feel like a pile of garbage, that people can just throw around!” (Kulig et al., 2008, p. 7)
Embarrassed	Berne, Frisén, and Kling (2014), Kentel and McHugh (2015), Kulig, Hall, and Kalischuk (2008), Lindsay and McPherson (2012), Shea and Wiener (2003), Side and Johnson (2014), and Tenenbaum, Varjas, Meyers, and Parris (2011)	“You feel very small when this is happening to you, you don’t really like to talk about it with anybody because it is kind of embarrassing, when you know somebody is picking on you and you don’t want to tell” (Tenenbaum et al., 2011, p. 276) “humiliating” (Side & Johnson, 2014, p. 225)
Fear/anxiety	Athanasiades and Deliyanni-Kouimtzis (2010), Kvarme, Helseth, Sæteren, and Natvig (2010), Mishna, Wiener, and Pepler (2008), Shea and Wiener (2003), Side and Johnson (2014), and Willis and Griffith (2010)	“I was like scared to go into school” (Side & Johnson, 2014, p. 225)
Suicidal ideation	Bell, Arnold, Golden, Langdon, Anderson, and Bryant (2014), Berne, Frisén, and Kling (2014), Kulig, Hall, and Kalischuk (2008), Kvarme, Helseth, Sæteren, and Natvig (2010), Shea and Wiener (2003), and Side and Johnson (2014)	“bullying is dangerous, because you can think of committing suicide” (Kvarme et al., 2010, p. 795)
Anger	Brown Hajdukova, Hornby, and Cushman (2016), Mishna, Wiener, and Pepler (2008), Shea and Wiener (2003), Side and Johnson (2014), and Willis and Griffith (2010)	“I got very, very angry. I was about to punch somebody” (Brown Hajdukova et al., 2016, p. 214)
Hurt	Kentel and McHugh (2015), Kvarme, Helseth, Sæteren, and Natvig (2010), Mishna, Wiener, and Pepler (2008), Pister (2014), and Tenenbaum, Varjas, Meyers, and Parris (2011)	“Picking on someone, like emotionally hurting them verbally” (Kentel & McHugh, 2015, p. 370)
Excluded/loneliness	Brown Hajdukova, Hornby, and Cushman (2016), Kvarme, Helseth, Sæteren, and Natvig (2010), Lindsay, and McPherson (2012), Mishna, Wiener, and Pepler (2008), and Shea and Wiener (2003)	“I felt like I was alone … I did feel extremely alone” (Side & Johnson, 2014, p. 225)
Helplessness	Kvarme, Helseth, Sæteren, and Natvig (2010) and Side and Johnson (2014)	“I was helpless” (Side & Johnson, 2014, p. 225)
Powerlessness	Kvarme, Helseth, Sæteren, and Natvig (2010) and Side and Johnson (2014)	“It made me feel like some people have massive power over some people… they just have so much power” (Side & Johnson, 2014, p. 225)
Confused	Mishna, Wiener, and Pepler (2008) and Willis and Griffith (2010)	“Sometimes I feel confused, like I don’t know why they are doing it and I don’t really know why they chose me.” (Willis & Griffith, 2010, p. 128)

Other emotional reactions were mentioned in fewer studies, and exemplar quotes are provided in Table 2. Six of the studies mentioned suicidal thinking (Bell et al., 2014; Berne et al., 2014; Kulig et al., 2008; Kvarme et al., 2010; Shea & Wiener, 2003; Side & Johnson, 2014) and anxiety or fear (Athanasiades & Deliyanni-Kouimtzis, 2010; Kvarme et al., 2010; Mishna et al., 2008; Shea & Wiener, 2003; Side & Johnson, 2014; Willis & Griffith, 2010). Five of the studies mentioned feeling hurt (Kentel & McHugh, 2015; Kvarme et al., 2010; Mishna et al., 2008; Pister, 2014; Tenenbaum et al., 2011), anger (Brown Hajdukova et al., 2016; Mishna et al., 2008; Shea & Wiener, 2003; Side & Johnson, 2014; Willis & Griffith, 2010), and feeling excluded or lonely (Brown Hajdukova et al., 2016; Kvarme et al., 2010; Lindsay & McPherson, 2012; Mishna et al., 2008; Shea & Wiener, 2003). Lastly, two of the studies reported feelings of helpless and powerlessness (Kvarme et al., 2010; Side & Johnson, 2014) and confusion (Mishna et al., 2008; Willis & Griffith, 2010).

Discussion

We analyzed the findings from qualitative research about the emotional experience of bullying victimization in youths. This is an important contribution to the literature because much of the previous work on the emotional consequences of bullying comes from quantitative research. This review of the qualitative literature found that youths who were victims of bullying used many emotional adjectives to describe their feelings: (in order of prevalence) sadness, decreased self-esteem, embarrassment, fear, suicidal thinking, anger, feeling hurt, loneliness, powerlessness, helplessness, and confusion.

Examining the findings from this review and placing them within the context of prior findings resulting from quantitative method studies may provide additional insight into the effect of bullying victimization. As bullying research has grown, multiple systematic reviews and meta-analyses have been published documenting the quantitative method study findings, which is the strongest level of evidence (Melnyk & Morrison-Beedy, 2012). A recent systematic review and meta-analysis were done examining bullying victimization and found statistically significant relationships between bullying victimization and depression, anxiety, nonsuicidal self-injury, and suicidal ideation. Odds ratios were calculated for the abovementioned emotional consequences. Highest odds ratios were found between frequent bullying victimization and (a) depression and (b) suicide attempts. A nearly fourfold increase in suicide attempts was found for youths who experience frequent (as opposed to “sometimes”) bullying victimization (Moore et al., 2017). Similar results were found in a systematic review of cyberbullying and adolescent mental health. Findings from that study indicated that adolescents who were victims of cyberbullying were more likely to report symptoms of depression and suicidal ideation and behaviors (Bottino et al., 2015). Another meta-analysis found moderate effect sizes for bullying victimization and suicidal ideation and suicidal behavior (Holt et al., 2015). A meta-analysis was also performed looking at bullying victimization and self-esteem and found a significant negative correlation, meaning that as youths were more frequently bullied their self-esteem decreased (Tsaousis, 2016).

The above mentioned systematic reviews and meta-analyses found results similar to this integrative review, in that the emotional reactions often mentioned included depression or sadness, anxiety or fear, suicidal ideation, and self-esteem issues. The current review reported herein additionally found that youths often report embarrassment as an emotional reaction to bullying, which has not previously been documented in quantitative research. Therefore, the new results found in this review point to a need to include measures on embarrassment or shame in future studies on bullying victimization. Importantly, many youths who are victims of bullying do not tell adults about the situation; therefore, feelings of embarrassment or shame should be explored in future studies as a potential reason for the lack of reporting.

Strengths and Limitation of the Research Designs

Results of this review contribute to the growing field of literature on the consequences of bullying, in particular the emotional consequences. This review provides the first integrated review of the literature using qualitative methods to describe the emotional experience of bullying victimization of youths. Rigorous methodology as proposed by Whittemore and Knafl (2005) guided this review.

In the 14 qualitative studies included in this review, one strength was that most of the studies (n = 11) explicitly stated the qualitative method used. It is important to be transparent in stating the qualitative methods used so that studies can be assessed for rigor, which has been a criticism of qualitative methods (Anderson, 2010). Another strength of the research designs was that some of the studies used validation techniques recommended by Creswell (2013). For example, Mishna, Wiener, and Pepler (2008) used triangulation with parents, teachers, vice principals, and principals to validate their findings. Shea and Wiener (2003) also used triangulation with teachers and parents. Kentel and McHugh (2015) used member checking to verify the results of their analysis with their participants. They also used prolonged engagement or spending extended time with the participants in their everyday world (Creswell, 2013). Other researchers used constant comparison (Berne et al., 2014; Kulig et al., 2008; Mishna et al., 2008; Shea & Wiener, 2003), as defined by Strauss and Corbin (1990). The use of these validation methods is a strength of these particular studies; however, many authors did not explicitly discuss their validation methods, a major limitation of their research designs. Therefore, future qualitative work should consistently describe validation techniques to ensure the rigor of the research design.

Limitations among the studies included lack of design description in three of the studies (Bell et al., 2014; Kulig et al., 2008; Lindsay & McPherson, 2012) and variance among the data collection techniques (focus groups, individual interviews, or both).

Limitations of This Review

First, though bullying is the most common term used to describe this phenomenon in the English language, other terms are used, such as “cyber mobbing” or “peer victimization” (Nocentini et al., 2010). Importantly, Nocentini and colleagues (2010) found that the term bullying arose consistently among youths when describing these behaviors, which is why only this term was included in the literature search. The broad term “qualitative” was also exclusively selected for the literature search because this would capture all research using qualitative methods, as opposed to limiting it to specific types of qualitative methods (i.e., grounded theory).

An important limitation of qualitative research is that authors may group content into themes, thus leaving out other terms the participants may have used to describe their emotional experience. Because this is the standard way to organize qualitative method studies, this is an inherent problem that could not be controlled for in this review. Many of the reviewed studies commented on this limitation and mentioned their use of constant comparison in grounded theory designs (Strauss & Corbin, 1990) or open coding (Kentel & McHugh, 2015; Pister, 2014; Shea & Wiener, 2003) to mitigate this limitation.

Implications for School Nurses

As one in five youths report being the victim of bullying on school property, bullying can be seen as a public health concern for youths in the school setting (Kann et al., 2016). Consequently, school staff, especially school nurses, frequently encounter students who have been victims of bullying and suffer from adverse physical and emotional outcomes. The school setting is frequently where these students first present with concerns related to bullying; therefore, school nurses are often the first health-care provider to encounter, assess, and help treat these students. It is important for school nurses to be aware of the emotional experiences that were found in this review that may result from bullying victimization.

Based on this review, there are two main recommendations for school nurses when working with children who have been victims of bullying. First, it is important to note that youths often do not feel comfortable talking to an adult, including school staff, when they are experiencing bullying because they are worried about the adults overreacting to the situation or they are worried about being blamed for the situation (Fenaughty & Harré, 2013). As was found by this review, feelings of embarrassment may also contribute to students’ reluctance to tell an adult when they are victims of bullying. Therefore, when school nurses encounter youths with the emotional symptoms found from this review (sadness, decreased self-esteem, embarrassment, fear, suicidal thinking, anger, feeling hurt, loneliness, powerlessness, helpless, and confusion), they should be suspect of bullying victimization and screen the student appropriately. This is in line with the position statement from the National Association of School Nurses (NASN) on Bullying Prevention in Schools, in that school nurses should be key players in identifying and responding to bullying in schools (DeSisto & Smith, 2014). This recommendation from this review goes further to recommend that students with emotional symptoms frequently associated with bullying be screened for bullying rather than just unexplained somatic symptoms as recommended by the position statement (DeSisto & Smith, 2014).

The second recommendation is that, when a student does present to the school nurse or other school staff with concerns related to bullying victimization, they should be screened for depression, anxiety, suicidal thinking, and decreased self-esteem (some of the most cited emotional consequences found from this review) and referred to the appropriate treatment services. This is an important recommendation because some students may not openly admit to the cause of adverse emotional experience unless directly asked. Again, this goes beyond the NASN position statement that school nurses should recognize and be knowledgeable about long-term consequences of bullying, but also that school nurses should screen students affected by bullying for emotional symptoms and refer to the appropriate treatment (DeSisto & Smith, 2014).

Conclusion

Results generated from qualitative studies can provide valuable information documenting the emotional experience of youths who have been victims of bullying. Because most previous studies examining the negative consequences of bullying victimization have used quantitative methods, this review of qualitative method studies is an important addition to the literature. The results of this integrated review found that documented emotional experiences in youths who are victims of bullying include sadness, decreased self-esteem, embarrassment, fear, suicidal thinking, anger, feeling hurt, loneliness, powerlessness, helplessness, and confusion. An important distinction between previous quantitative studies documenting the consequences of bullying victimization and this review is that this review found embarrassment was the second most commonly mentioned emotional experience (along with decreased self-esteem). This finding points to a need to include measures on embarrassment in studies addressing bullying.

Author Biography

Elizabeth Hutson, MS, RN, PMHNP-BC, is a doctoral student at Ohio State University.