Abstract

Bullying is widely recognized as a persistent problem in the profession of nursing, especially among individuals at particular risk because of limited authority and experience such as nursing students. Students assert that bullying experience impacts their learning and future employment choices. Aim of the study: was to investigate pediatric nursing students' experience of bullying behaviors in clinical placement and the role of staff faculty. Method: A quantitative descriptive method was adopted. The study was conducted at Faculty of Nursing Damanhour University, Egypt. Purposeful sample, all third year undergraduates nursing students (N = 147), registered at pediatric nursing course and 30 educators of third year from both pediatric and obstetric departments Faculty of Nursing Damanhour University. The study was done during the 1^st term of the academic year (2018-2019). Two tools were used: Tool 1: The self-administered questionnaire to identify nursing students’ experiences with bullying. Tool II: to collect required data from the staff faculty to assess their role towards students' bullying. Results: The study reveals that nursing students experience bullying, the highest bullying behaviors, the nursing students experienced, were shouting in rage and negative remarks about becoming a nurse. Statistically significant differences were found between the bullying behaviors and the effect of bullying behaviors on the students in which bullying behaviors effect lead to academic failure, loss of self-confidence, intolerance to criticism, perceiving that this career is not suitable, concentration impairment, loss of motivation, intolerance to criticism, self-blame and physical impairment. The highest coping mechanism by nursing students was putting up barriers followed by speaking directly to the bully and finally, the use of unhealthy coping behavior. The most coping strategies used by the staff faculty were talking with the bully, and reporting to the responsible authority. Conclusion: Nursing students experienced a problem of bullying, which lead to threatening and frustrated academic environment. Recommendations: Addressing clear written policy for the staff faculty and the nursing students to be educated about bullying forms, strategies for prevention and intervention.

1. Introduction

Provision one of the American Nurses Association's (ANA) Code of Ethics states, "the nurse, in all professional relationships, practices with sympathy and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal characteristics, or the nature of health problems" (ANA, Code of Ethics for Nurses, 2001). ¹ The code also demands that the nurse treats her or his colleagues with the same respect and ethical, professional behavior shown to all patients. Unluckily, despite the increasing interest regarding ethical and professional behavior in nursing, horizontal or lateral violence is growingly being distinguished as a severe issue by some nurses and students in nursing education ².

Bullying is widely identified as a persistent problem in the profession of nursing. The workplace stressors experienced by the nurses and other healthcare workers including stress to deliver care on time, uncontrolled patient workloads, and high pressured work environments are recognized as participating factors in the phenomenon of raised nurse-to-nurse bullying. ³ Horizontal (is interpersonal conflict among nurses who may be colleagues or on the same level of employment) and vertical violence and bullying (abuse is conducted towards a student or new nurse from another person, who is in a superior position in an organization and in nursing, result in individuals with low self-esteem, low morale, depression, hypertension, other physical symptoms, and could also result in impaired relationships, post-traumatic stress and eventually suicide. Student nurses have notified being bullied by nurses, nursing aids, doctors, patients, faculty and classmates with different rates among the offenders ⁴.

The consequences to bullying are increasing in the healthcare setting and include frustration, anger, fear and emotional hurt, feelings of powerlessness, decreased morale and productivity, an increase in errors and symptoms associated with Post Traumatic Stress Disorder. As a result of the distressing nature of bullying, nurses notified having to take days off. ^{2, 5, 6} Furthermore, Minton C, 2018 ⁷ reported that the psychosocial effects of bullying on some students were feelings of inefficiency, anxiousness, embarrassment and humiliation. Some notified that they considered leaving the nursing profession. These emotions lead students to be disabled to attain clinical competency. Furthermore, participant realized that bullying negatively affected the standard of patient care they completed and made them frightened to check orders. ⁷ Moreover, students assert that the experience affects their learning and future employment choices ⁸.

Several nursing workplace researchers have identified destructive adverse reactions to bullying that include hurt, fear, loss of self-esteem, anxiety, sleeplessness, depression, increased blood pressure, panic attacks and feelings of worthlessness. ⁹ In addition, violence against nurses at their workplace leads to their intention to leave the nursing profession. ¹⁰ All areas of nursing must be free of bullying behaviors in an effort to preserve adequate staffing and patient care well in the future. Bullying in nursing has remained for decades and exhibits to be an increasing concern. Since nursing students share the same insecure nursing environment with professional nurses, it is necessary to find out if they too are the victims of bullying. It is our professional and ethical responsibility to participate to raise awareness and support facilitating change to quit the cycle of bullying ².

Nurse educators are integral in the identification and acquisition of clinical sites. So, it is demanding for faculty to recognize clinical positions, where clinical nursing staff will be supportive and greeting students as to offer an enriching environment for learning to take place. Having flexibility in the recognition and choosing of clinical sites may be needed. In the future, leveraging technology to reflect creatively concerning location of clinical sites may be needed. As nurse educators, we require to prepare students to be safe and competent practitioners. Possible intervention ideas include the development and implementation of policies and procedures to treat bullying behaviors directly (Hakojarvi et al., 2014). ⁸ Therefore, any influence on individuals can be minimized; in addition, nurses who teach students need additional education and training on how to interact with students in an ethical way that maintains a safe, learning environment ¹¹.

Strategies for skills training may include role-play, clinical simulation, cognitive rehearsal, and problem-based scenarios. For example, role-play in the classroom and/or clinical location offers students the chance to practice identifying and responding to bullying behaviors in a safe, learning environment ¹¹.

However, nursing students may not be adequately prepared to identify and handle bullying behavior when it happens. The purpose of this study was to acquire greater understanding of nursing students’ experiences of bullying behaviors in the clinical placement and determine the role of the staff faculty.

Considering the growing 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. With a shortage of nurses looming, we cannot afford to lose nurses or nursing students to bullying. The current study demonstrates the existence of bullying in clinical placement, where nursing students undertake a significant amount of their nursing education.

2. Materials and Method

A quantitative descriptive design was used to accomplish this study.

Aim to investigate pediatric nursing students' experience of bullying behaviors in clinical placement and the role of staff faculty

1. What are nursing students' experience of bullying behaviors in clinical placement and their coping behaviors?

2. Who are the sources of bullying behaviors in clinical placement?

3. What are the most coping strategies used by staff faculty to deal with bullying behaviors?

The study was conducted at Faculty of Nursing - Damanhour University, Egypt. The faculty has nine different scientific nursing departments including pediatric nursing department. Pediatric nursing is one of the main courses taught to the students enrolled in the third year in each term in the third scholastic year. Each term consists of 15 weeks. The clinical training (rotation) is given 12 hours /week.

All pediatric nursing students in their third scholastic year during the 1^st term of the academic year 2018 -2019 were included. In total, 163 nursing students and 34 educators of third year (17 members from pediatric department and 17 members from obstetric department) Faculty of Nursing Damanhour University.

Tool 1: The self-administered questionnaire was developed by the researchers after reviewing recent literature ^{12, 13} in order to collect required data from the students. It included the following parts:

Part I:

This part included questions related to demographic characteristics of the nursing students such as: age, gender, residence, and previous academic year grade.

Part II: The Bullying Student Nurse Questionnaire: composed of two sections:

A- It was used to investigate student nurses' experiences of bullying. It comprised of 12 statements associated with the phenomenon of bullying, in which students were asked to indicate behavior frequency. Responses were measured on a 5-point Likert rating scale ranging from always (5) to never (1).

B- It was used to investigate the source of student nurses' experiences of bullying. It comprised of 12 statements associated with the phenomenon of bullying, in which students were asked to indicate the source for each bullying behavior either: nurse, physician, hospital staff, Patient, Classmate or Staff faculty.

Part III:

It included items related to the effects of bullying behaviors on the nursing students which consisted of 13 items concerning:

(1) Physical effects as: migraine, vomiting, lower back or neck pain, becoming forgetful and panic attack.

(2) Psychological effects as: despair and burnout, losing self-confidence, intolerance to criticism and self-blame.

And finally (3), Organizational effects as: academic failure, negative effects on friendship relationships, loss of motivation and concentration impairment. (Responses were measured as Yes=1 or No=zero)

Part IV:

It included behaviors used by the nursing students to cope with bullying experience which consisted of 11 items concerning: did nothing, put up barriers, shouted at the bully, went to a doctor and perceived the behavior as a joke.

(Responses were measured as Yes=1 or No=zero)

Tool II: The self-administered questionnaire was adapted and developed by researchers after an in-depth review of the recent relevant literature ^{12, 14} in order to collect required data from the staff faculty. It included questions related to the staff faculty such as: age, years of experience, academic position, response for student bullying...etc.

The study was executed according to the following steps:

Official approval from the dean of the Faculty of Nursing Damanhour University, and responsible authorities of pediatric nursing department after explanation of the purpose of the study, was obtained prior to initiation of this research.

Tool I: The student questionnaire was translated into Arabic by the researchers and was tested for content validity by five experts in the field of education and pediatric nursing. The experts were asked to evaluate the questionnaire after translation for readability, appropriateness and ease of understanding.

Tool II: It was sent to five experts in the field of education and pediatric nursing to check content validity. Necessary modifications were carried out accordingly for both tools. The tools were tested for reliability using Cronbach’s Alpha Coefficient test, its value was: Tool I (r= 0.801). Tool II (r= (0.79).

Pilot study was conducted on 16 students (10 %) of the total number of sample size (N = 163) and 4 educators (10%) of the total sample size (N= 34). They were selected randomly in order to test the relevance and applicability of the study tool, and then they excluded from the main study sample. Leading to a total sample size of (N =147 students) and (N=30 educators).

1- The data was collected over a period of approximately two months (beginning of October to mid-November) during first term of the academic year 2018-2019. Data was collected through self-administered questionnaires that were distributed among the students after the theoretical lecture of pediatric nursing department (lecture/week). Each questionnaire took approximately from 10 to 15 minutes/student.

2- Self-administered questionnaire was distributed to educators in Damanhour University. Each questionnaire took approximately from 5 to 10 minutes/educator.

All students and educators were informed about the purpose of the study and given brief explanation; oral informed consent was obtained from each of them.

The right to refuse to participate or withdraw from the study was emphasized after reassuring students that their answer would have no influence on their grades. Data anonymity and confidentiality were appreciated.

Data was fed to the computer and analyzed using IBM SPSS software package version 20.0 (Armonk, NY: IBM Corp). Quantitative data was described using number, percent, mean and standard deviation. The given graph was constructed using Microsoft Excel software. Significance of the obtained results was judged at the 5% level.

The used tests were:

1 - Student t-test

For normally distributed quantitative variables to compare between two studied groups.

2 - F-test (ANOVA)

For normally distributed quantitative variables to compare between more than two groups.

3. Results

Table 1 displays the demographic characteristics of the studied students. The table reflects that most of participants were 22 years old (79.6%) & more (20.4%), with mean age of 20.95 ± 0.81 and most of them were female (80.3%). Nearly three quarters of the participants (72.8%) were from rural (El- Beheira) and 27.2 % of them were from urban. Also, 36.7% of them got excellent grade in 1^st year and 33.3% got very good in second year.

Table 2: Distribution of the studied students according to bullying behaviors that they face, the table reveals that the highest bullying behaviors, that they always face, were shouting in rage (48.3%) and negative remarks about becoming a nurse (36.7%). While the lowest bullying behaviors, that they face, were being ignored or physically isolated (9.5%), with total mean score 29.76 ± 9.88.

Table 3: Descriptive analysis of the studied students according to the sources of bullying behaviors, the table and Figure 1 demonstrate that the highest mean score was to the staff faculty 2.4 ± 2.7 as a source of bullying, the students stated that bullying behaviors were (Assignments or rotation responsibilities made for punishment rather than educational purposes 32.0%, A bad grade given as a punishment 31.3%, Cursing and swearing 29.9%, Unmanageable workloads or unrealistic deadlines 28.6% respectively, followed by hospital staff with mean score 2.3 ± 2.1). They mentioned that bullying behaviors were (shouting in rage 48.3%, and inappropriate, rude or hostile behavior 44.2% respectively), followed by physician with mean score 1.8 ±1.8. They also stated that the bullying behavior was shouting in rage 36.1%.

Table 4: Descriptive analysis of the studied students according to behaviors used to cope with bullying experience, the table illustrates that the highest coping mechanism they used was putting up barriers 57.8%, spoke directly to the bully 43.5%, warned the bully not to do it again 38.8%, and increased the use of unhealthy coping behavior 36.7% respectively.

Table 5: Descriptive analysis of the studied students according to the effects of bullying behaviors, the table shows that the highest effects of bullying behaviors were as following: loss of motivation 53.1%, sleep disorder 44. 9%, panic attacks and constant anxiety 43.5%, and 42.2% perceiving that this career is not right for them.

Table 6: Regarding the relation between the bullying behaviors and the effects of bullying, it was found that there are statistically significant differences between the bullying behaviors and the effect of bullying behaviors on the students; in which bullying behaviors effects were: Academic failure P=0.001, Loss of self-confidence P=0.001, Intolerance to criticism P= 0.008, Perceiving that this career is not right for me P= 0.043 , Concentration impairment P= 0.026 , Loss of motivation P= 0.020, Intolerance to criticism P= 0.008, Self-blame P= 0.041, Physical impairment(e.g. migraine, vomiting, lower back or neck pain) P= 0.022 and Negative effects on friendship relationships P= 0.005.

Table 7: Concerning the relation between sources of bullying behaviors with behaviors used by the students to cope with bullying experience, statistically significant differences were found between classmate and staff faculty and did nothing (P=0.021, 0.019) respectively. Between staff faculty and put up barriers (P=0.006) and Spoke directly to the bully (P=0.028). Among hospital staff, Reported the behavior to a superior / authority (P= 0.036) and Warned the bully not to do it again (P=0.036). Among patients (P=0.028) and classmate (P=0.032) with Shouted at the bully. Between classmate and demonstrated similar behavior (P= 0.027). Finally, between hospital staff and Perceived the behavior as a joke (P= 0.032).

Table 8: Distribution of the studied staff faculty according to their criteria and the responses to students' bullying, the table explains that, 43.3% of the studied sample was demonstrators, more than half of them were less than ten years’ experience and all of them were responsible for the clinical setting area. They mentioned that the faculty did not have clear written policy for staff to be educated about bullying forms, strategies for prevention and intervention. Furthermore, the faculty did not have clear, written policy for students about bullying victimization forms, strategies for prevention and intervention throughout their careers. Also 83.3% of them mentioned that students reported about bullying experience during clinical experience. 100% mentioned that nurses were the most common bully (more than one answer). 100% (more than one answer) mentioned that talking with bully, 76% mentioned report to pediatric department authority, and 12% withdrawal the student from the situation as responses toward bullying. 100% Stated that they assure and support bullying students, 96% stated that they discuss the situation and suitable take action. 16% stated they train students to deal with the situation wisely.

4. Discussion

The phenomenon of bullying in workplaces and schools has become widely growing recently. There is an increasing rate of research on this issue. ¹⁵ Bullying can include verbally, physically or psychologically aggressive behavior which is intentionally harmful to another person. Bullying take place repeatedly over a period of time to an individual, who is perceived to be less physically or psychologically influential. ^{16, 17} Students bullying is surely not a new concept. As a result of high prevalence rates and the short and long term consequences of bullying, it is demanding more attention. ¹⁸

Knowledge of bullying among university students, and the way in which it has been experienced, is rather unclear. ¹⁵ So, the current study was conducted to investigate nursing students' experience of bullying behaviors in clinical placement and role of the staff faculty.

In the present study, the most of participants were 22 years old and more, with mean age of 20.95 ± 0.81 and most of them were females. Nearly three quarters of the participants were from rural (El-Beheira) and approximately one quarter of them were from urban. Also, approximately one third of them got excellent grades in 1^st academic year and got very good in the second academic year.

A review of the literature establishes that nurses in the clinical setting experience bullying. ¹⁹ The present study revealed that the studied students face many types of bullying behaviors. Concerning the highest bullying behaviors they face, they were shouting in rage, followed by negative remarks about becoming a nurse. This may be related to that all students are young, so they lack the experience to deal with bullying. In addition, although nursing role is crucial, they still suffer from professional stigmatization. This finding is in accordance with Kassem A (2015), who found that yelling or shouting in rage was the most frequently bullying behavior as reported by student nurses followed by unmanageable workloads or unrealistic deadlines then, negative or disapproving remarks about becoming a nurse. ¹⁴ The same result was found in a study performed among undergraduate clinical nursing 2014. ²⁰ On the other hand, the lowest bullying behaviors the student face in the present study, were being unnoticed or physically isolated. This could be attributed to that nursing students' training depends on their involvement in the hospital work.

In the current study, the studied students suffer from bullying behaviors from many sources. The highest source of bullying was the staff faculty with mean score was 2.4 ± 2.7, the students reported that bullying behaviors were assignments or rotation responsibilities made for punishment rather than educational purposes followed by a bad grade given as a punishment then cursing or swearing and unmanageable workloads or unrealistic deadlines respectively. This could be explained by the frequent contact between the staff faculty and their students during clinical training. In addition, the staff faculty has the upper hand on their clinical evaluation. This finding in accordance with what was found in 2015 at North-eastern University among college students who reported that high rate of bulling was by professors in college ²¹.

Regarding to the second source for bullying behaviors in the present study, it was hospital staff with mean score 2.3 ± 2.1, the students mentioned that they were exposed to shouting in rage, and inappropriate, rude or hostile behavior. This may be related to the hospital staff being overworked and lack of enough time to answer student's questions in addition to busy environment of the ward. The students reported that they were exposed to bullying by physician with mean score 1.8 ± 1.8. They also stated that a bullying behavior was shouting in rage. This could be attributed to crowdedness of students around certain patients, sometimes may hinder his work. This finding in congruent with the findings of Cooper et al., 2011. ¹³ While incongruent with another Egyptian study, which revealed that physicians and other hospital staff are the most frequent sources of bullying behaviors as perceived by nursing students ¹⁴.

As regards, the student's behaviors used to cope with bullying experience. The results of the current study revealed that the highest coping mechanism was putting up barriers followed by, speaking directly to the bully, warning the bully not to do it again, and finally the use of unhealthy coping behavior. This could be explained by; due to their limited experience and young age they try to protect themselves as much as possible in healthy and safety manner. On the contrary, Budden et al. (2017) explained that almost three-quarters of the studied students had never reported an episode of bullying ²².

Bullying is a wide spread problem among our children that leads to contrary consequences. It can cause short and long term adverse effects to both mental and physical health. ¹⁸ Results of the present study showed that, the highest effects of bullying behaviors were: loss of motivation, sleep disorder, panic attacks and constant anxiety, and perceiving that this career is not right for them respectively. This could be explained by being exposed to bullying lead to feeling of anger. In addition, if the students did not have the power to defend themselves against the bully that may lead to frustration feeling of helplessness which may cause certain psychological disorders. This is consistent with a study at University of Eastern Finland (2012) which identified that the passive coping strategies for the students exposed to bullying were decreasing motivation, capacity, self-esteem and even depression_. ¹⁵ Another study by Clarke C (2012) found that students, who experienced more bullying behaviors, were more motivated to consider leaving the nursing program ²⁰.

The present study revealed that there were statistically significant differences between the bullying behaviors and the effect of bullying behaviors on the students (Table 5) in which these behaviors resulted in academic failure, loss of self-confidence, intolerance to criticism, perceiving that this career is not right for them, concentration impairment, loss of motivation, intolerance to criticism, self-blame, physical impairment (e.g. migraine, vomiting, lower back or neck pain) and negative effects on friendship relationships. This may be due to the bullying which behaviors may affect the emotions of the students and make them feel powerless leading to alteration in their performance within the academic setting. Additionally, all students are young so they lack the suitable way to deal with bullying. Their victimization experience causes many negative behaviors. This is supported by Karatas et al. (2016) who reported the difficulties that participants face because of exposure to bullying. Most participants (85.1%) reported feeling anger, 70.8% thought they had not chosen the right career, 70.8% said their levels of motivation decreased, 70.3% reported experiencing sleep disorders, 62.4% felt helpless and experienced burnout, and 60.9% became intolerant to criticism. ¹² Similarly, with another study at Istanbul University (2014), which revealed that the basic emotional responses experienced by students after a violent incident were anger, anxiety, lack of confidence, fear, shame, and unwillingness to continue in clinical practice and becoming discouraged to the profession respectively ²³.

Concerning the relation between sources of bullying behaviors with behaviors used by the students to cope with bullying experience, statistically significant differences were found between classmate and staff faculty and did nothing. Between staff faculty and put up barriers and spoke directly to the bully. Among hospital staff, reported the behavior to a superior authority and warned the bully not to do it again. Among patients and classmate with shouted at the bully. Between classmate and demonstration similar behavior. Finally, between hospital staff and perceived the behavior as a joke. This could be attributed to the students used appropriate response to them according to the nature of bully and in accordance to the situation. They tried to gain as much as possible from the situation, decide to use the most optimum response from their point of view. So, the study revealed their response sometimes may be doing nothing and on the other hand, may be shouting at the bully.

According to the staff faculty criteria and their responses to students' bullying, the results of the present study revealed that, approximately half of the studied sample was demonstrators, more than half were less than ten years’ experience and all of them were responsible for the clinical setting area. Unfortunately, they mentioned that the faculty did not have clear, written policy for staff to be educated about bullying forms, strategies for prevention and intervention. Furthermore, the faculty did not have clear written policy for students about bullying victimization forms, strategies for prevention and intervention throughout their careers. Additionally, they declared that nurses at hospital are the most common bully for the student nurse. This could be attributed to shortage in staff in relation to student's number in clinical setting make burden on hospital nurse and consequently allow for more resistance between students and hospital nurse during their clinical training.

Regarding the staff response after students' bullying experience during clinical setting, all staff faculty reported that they talk with the bully, more than two thirds of them mentioned reporting to pediatric department authority. This could be explained by nursing education mainly is based on clinical training. So, it is important to maintain cooperative and successful relationship with hospital nurse, explain the role of student nurse at clinical setting. On the other hand, reporting to pediatric department authority is essential to protect under graduate students’ dignity and identity. On the contrary with this finding, several participants in a pilot study conducted by Fehr and Seibel (2016) reported that faculty members were often unaware to situations of bullying, did not respond effectively or supportively, and left students feeling hopeless ²⁴.

In the present study, all staff reported that they assure and support bullying students, the majority stated that they discuss the situation and the suitable taken action. This is due to the importance for the students to feel supported from their faculty that will help for development of professional self-esteem and competence. Additionally, knowledge about quick intervention increases students' confidence in their university. On the contrary, Seibel and Fehr (2018) found that the participants recognized gaps in faculty action, knowledge and understanding about bullying. ²⁵

5. Conclusion

The current study has highlighted a specific issue of Egyptian nursing students’ experiences of bullying while being in clinical placements. Results revealed that nursing students experience bullying. The highest bullying behaviors the nursing students experienced were shouting in rage, and negative remarks about becoming a nurse. Statistically significant differences between the bullying behaviors and the effect of bullying behaviors on the students in which these behaviors result in academic failure, loss of self-confidence, intolerance to criticism, perceiving that this career is not suitable for them, concentration impairment, loss of motivation, intolerance to criticism, self-blame, and physical impairment. The highest coping mechanisms by nursing students were putting up barriers followed by, speaking directly to the bully, warning the bully not to do it again, and finally using unhealthy coping behavior. The most coping strategies used by staff faculty to deal with bullying behaviors were talking with the bully, and reporting to the responsible authority. There is no written policy for the staff to be educated about bullying behaviors.

6. Recommendations

Based on findings, the study recommended:

1. Addressing clear, written policy for the staff and the nursing students to be educated about bullying forms, strategies for prevention and intervention.

2. Maintain cooperative and successful relationship with hospital nurse and physician.

3. Explain the role of the student nurse at clinical placement.

4. The urgent need for educating nursing students and providing training for coping with bullying in nursing education.

5. Consultation clinic in the faculty should be present, mange by psychiatric professor to help student nurse to cope with any stressful situation as bulling.

Acknowledgments

We are grateful to all the students and staff faculty who participated in this study.

References