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Home , Bullying in nursing, School bullying

Volume 42, No. 2 • Fall 2020

Bullying in ? How Students Describe Their Reactions Renee Buonaguro

ullying is a vicious process that has gained momentum as an area of afflicts students in many settings interest since that time (Karatas et al., B from home and online, to school 2017). Cox (1987) identified verbal and in the community. It is a direct func- within nursing and its negative impact to tion of social or physical power differen- the . tials manifested through toxic relation- could be covert, overt, hori- ships between and among students and zontal , lateral violence, relation others in their social worlds. It can occur , or (Caristo & in any setting but is troubling when it is Clements, 2019). Overt bullying is easy to identified in the related to recognize, the perpetrator is generally nursing professionals and, even more aggressive and others may or may not be troubling, when it occurs insidiously in aware. Covert is more difficult to observe nursing . It is often overlooked Renee Buonaguro, PhD, RN and includes passive-aggressive behav- as a threat to the nursing profession and iors, eyerolling, and withholding informa- reduced to a belief that bullying is a ‘rite tion (Edmonson & Zelonka, 2019). Another of passage’ (Birks et al., 2018). area for bullying to occur is through digital Although definitions vary from source to Bullying within the nursing profes- media including social media, text mes- source, most agree that an act is defined sion occurs in the United States and sages, and online forums. Whatever the as bullying when: internationally (Difazio et al., 2019; platform, the impact could be devastating • the behavior hurts, humiliates, or Vessey et al., 2009; Yokoyama et al., – especially for nursing students and nurs- harms another person physically 2016). In addition, it is well documented es new to the profession. or emotionally, and that bullying occurs in the United States Nurse bullying does not occur in a • those targeted by the behavior and internationally within nursing vacuum and it is well documented new have difficulty stopping the action (Birks et al., 2018; Bowllan, 2015; nursing graduates experience the conse- directed at them, and struggle to Burkley, 2018; Clarke et al., 2012; Karatas quences. It is estimated 43% of newly defend themselves, and et al., 2017). The impact of bullying is licensed nurses leave their first within • there is also a real or perceived linked to patient safety, psychosocial con- 3 years and 17.5% resign within the first “imbalance of power,” which is ditions, physical problems, and con- year of work (Kovner et al., 2014). In addi- described as when the student tributes to a systemic toxic environment tion, this impacts institutions financially as with the bullying behavior has (Houck & Colbert, 2017). It is estimated, well. It is estimated costs are as more “power,” either physically, during , 89% of students high as $2.1 billion (Kovner et al., 2014). socially, or emotionally, such as a reported at least one act of bullying higher social status, or is physical- (Clarke et al., 2012). To promote the con- ly larger or emotionally intimidat- versation within nursing student mem- ing, and bers of the National Student Nurses • repetitive behavior; however, Association (NSNA), the investigators Renee Buonaguro, PhD, RN, ANP-C, has bullying can occur in a single inci- raised the question: What are the experi- been working in nursing for over 20 years in dent if that incident is either very ences of the NSNA student members and major metropolitan hospitals, as well as severe or arises from a pattern of how do they react to these experiences? the pharmaceutical industry, and as an behavior (PACER’s National Adjunct Instructor at Barbara H. Hagan School Background Literature of Nursing at Molloy College for over 10 years. Bullying Pre vention Center, Research studies of She is a past Jonas Nurse Leader Scholar and 2020, para. 6) began with Olweus during the 1980s and Sigma Theta Tau member.

Volume 42, No. 2 • Fall 2020 1 Figure 1. Bullying Incidents Among Nursing Students

If you have been bullied, which of the following best describes your reaction(s) to the bullying (check all that apply). 60%

50%

40%

30%

20%

10%

0% I deal with the effects I try to of bullying I talk with I report I talk face I talk to a I consider work in I talk with my family harmful to face I can’t Other psycholo - them a I can’t I talk to my I ignore regularly in unhealthy I try to my friends or a I talk to the behaviors I do with the control (please gist or to joke and control fellow such a planned ways (e.g. I retaliate. tolerate it. and ask for relative faculty. to the nothing. bully about myself and write your my don’t take myself and students. behavior. manner to smoking, their help. and ask for higher the cry. reason). healthcare them scream. avoid drinking help. authorities. problem. provider. seriously. . alcohol, over - eating). Responses 57% 41.2% 39.5% 37.8% 37.1% 34.6% 32.6% 29.8% 26.7% 21.4% 17.3% 17% 15.9% 15.7% 6.6% 2.1% 0.5%

Purpose SurveyMonkey® for students at all levels. education and several of the meaningful The purpose of the NSNA bullying The items were developed specifically for phrases from the open-ended questions study was to explore the dynamics of bul- this project and included several demo- state the impact it is having on nursing lying – statistically and qualitatively – as graphic questions with open-ended students today in their own words. reported by students. In response to phrases developed to capture the stu- The sample included 87% (1,139) reports of this growing problem and in dents’ self-reported experiences. With females and 12% (149) males. Their ages order to identify how bullying is described over 1,000 student responses from pri- ranged 18-22 (27%), 23-28 (27%), 29-35 by members of NSNA, the marily junior and senior participants (n = (20%), and 36 or over (25%). Type of pro- launched an initiative beginning with this 1,315), the results were examined statisti- gram attended included: Associate survey. The purpose of this study was to cally and coded for the qualitative analy- Degree (34%), Pre- Baccalau - describe the incidence of whether or not sis to highlight in their own words some reate (52%), Diploma (3.7%), Direct Entry students report they are bullied, in what of their bullying experiences and its effect Masters (3%), and RN to BSN (8%). The relationships, and how they describe the on them personally. respondents expected graduation date experiences in their own words. The Bullying is a sensitive subject to ask included: 46% (Year 2020), 31% (Year “Two-Minute Survey” is part of a routine participants to self-disclose and the study 2021-2022), 23% (Year 2023 or other). activity where students of NSNA are sent was IRB approved. SurveyMonkey pro- An overwhelming 71% of nursing (via e-mail) a brief survey with minimal vides protection that all responses are students in the survey were bullied and questions (i.e. under 2 minutes to com- anonymous. Consent was implied in their 29% were not. Of those who were bul- plete). The questions are brief, open- willingness to participate by clicking the lied, 44% were bullied by faculty, 37% by ended, and elicit how participants link. Participants were allowed to stop at fellow students, and 33% by hospital respond to the questions in their own any time; however, they appeared to be staff. Not surprisingly, there were signifi- words: eager to tell their stories as evident in the cant gender differences for males versus amount of lengthy typed-in responses. 1) Have you been bullied? females who answered: “not bullied” 2) If you have been bullied, please (35% males versus 28% females) and for provide a short description of Results “bullied by fellow students” (27% males the situation including who bul- The results yielded a total of 1,315 versus 38% females) (p < 0.05). The lied you. survey responses and 995 qualitative responses to the question about the bul- 3) Please briefly describe how the data entries with lengthy narrative lying incident(s) offer a snapshot into how bullying situation was handled. descriptions that were analyzed using constant comparative content analysis. students reported their reactions (see Methods The quantitative statistics on this large Figure 1). Although most students have a To recruit NSNA members, question- national survey provided several insights minimal type of reaction such as “toler- naires were posted on the website using about the problem of ate, ignore, do nothing, talk with people I

2 Volume 42, No. 2 • Fall 2020 about the incident,” there was a • “I stood up for myself and • “I went home and cried, told large number of reactions that were informed them to stop.” myself I won’t be in nursing school directed inward including “talk with psy- • “I went to the student advocate at forever, got over it and got back to chologist, lose control and cry or scream,” the school and used them as an work.” and unhealthy behaviors that are con- intermediary to solve the issue • “I cried.” cerning. Only 21% stated they talked with with me.” • “I was afraid of retribution. I didn’t the bullies about the problem. • “I finally went to the dean of nurs- know who to go to. I didn’t even There was a large number of re- ing and explained about a faculty feel safe giving her a review sponses to the open-ended question. In member and their actions and because I found out she was talk- fact, many students gave lengthy descrip- words. She was very distraught. I ing about me to other staff mem- tions of bullying incidents suggesting have asked other students about bers.” their enthusiasm to discuss it. Several this person and they said yes to statements addressed these areas of con- them too. More people need to Discussion cern and the effects the bullying had on report. No matter how you feel or We found bullying occurs at alarm- the student being bullied. These included: if you’re scared.” ing rates, yet it is poorly understood how 1) Minimal reaction: Tolerate it, • “It has been discussed in our members of the most trusted profession – ignore it, do nothing, speak to school chapter Student Nurse nursing – can be so hostile towards one someone they trust. Association meetings while our another. Is it a case arrested develop- 2) Personally taking action: Planned supervising faculty was present. ment? Are our chronological ages not avoidance, reporting to others, The only response we have matching our behaviors? retaliate. received was ‘yes, the culture This study, as in the study by Birks 3) Internalizing serious feelings of needs to change’ without any and colleagues (2018), of nursing stu- despair: Cry, lose control, scream, details in how they plan to handle dents’ in Australia, found bullying behav- mental breakdown, talk to a this.” iors included verbal, racial, and physical therapist. • “[A] clinical RN on unit – I kept abuse. Many statements concurred with silent until a week later when my the researchers’ findings that the victims “I simply ignored their laughs kind clinical professor seemed to had lasting consequences including emo- and comments.” know something had happened, I tional instability, physical illness, and The first and most common cluster cried and told her, she said it hap- seeking professional help. Nursing stu- of statements were coded in the ‘minimal pened to her when she was a stu- dents are vulnerable and exposure to bul- reaction’ group to the question, “How dent too, I learned I needed to be lying can leave students feeling incompe- was the bullying handled?” Statements confident and believe in myself, tent and powerless (Bowllan, 2015). It is included: and ask for help right away.” essential to understand the contributing • “I did not do anything to resolve factors in order to develop effective the situation; I tried to talk to the “I cried and doubted myself strategies to intervene (Hartin et al., 2018). nurse about my viewpoints and that affected me personally.” Bullying needs to be addressed, rec- what I learned in school.” The third cluster of statements were ognized, and mitigated until it is eradicat- • “I just kept moving and let it go. coded in the “internalizing serious feelings ed. The moment we see bullying, it must Was told it’s a part of the profes- of despair” group to the question, “How be corrected and recognized as unaccept- sion.” was the bullying handled?” State ments able behavior. Bullying cannot continue to • “It wasn’t [handled]. It made me included: be accepted as a rite of passage. Bullying very bitter for a while. Honestly, • “I took that semester off.” is unacceptable behavior and, as with any the whole situation made me lose • “I was supposed to be grateful for behavior, it can be modified. DN

complete faith in the administra- the ‘help’ as they were trying to References tion of the school. I suppose, in a ‘make me a better nurse.’ Crying Birks, M., Budden, L.M., Biedermann, N., Park, T., & twisted way, it is a very good les- every day and doubting yourself Chapman, Y. (2018). A ‘rite of passage?’: Bullying son in what to expect from hospi- does not make a better nurse.” experiences of nursing students in Australia. tal administration.” • “I went to talk therapy for support, Collegian, 25(1), 45-50. https://doi.org/10.1016/ j.colegn.2017.03.005 my classmates and I supported Bowllan, N.M. (2015). Nursing students’ experience of “I decided to take action or enlist each other.” bullying: Prevalence, impact, and interventions. others to resolve the problem.” • “It never was handled. I felt like the , 40(4), 194-198. https://doi.org/ The second most common cluster black sheep constantly and never 10.1097/NNE.0000000000000146 of statements were coded in the fit in. It brought me into a very Burkley, J., (2018). Adopt a for hospital staff bullying nursing students. American Journal ‘personally taking action’ group to the deep . I still to this day of Nursing, 118(5), 11. question, “How was the bullying get bullied by those in my old Caristo, J.M., & Clements, P.T., (2019). Let’s stop “eating handled?” Statements included: cohort but I choose to ignore our young”: Zero-tolerance policies for bullying in • “Basically, I decided that I wasn’t them. That faculty is still working nursing. Nursing2019 Critical Care, 14(4), 45-48. Clarke, C.M., Kane, D.J., Rajacich, D.L., & Lafreniere, going to lay down and take it but my second time around I got a K.D. (2012). Bullying in undergraduate clinical from her. So, I read over the con- different lab instructor.” nursing education. Journal of Nursing Education, tract and nursing school hand- • “Not very well. The professor failed 51(5), 269-276. https://doi.org/10.3928/01484 book. Then I met with her and me, and I had a mental - 834-20120409-01 showed her where she was down, thus impacting the rest of Cox, H.C. (1987). in nursing: Report of a study. , 18(11), 47- 50. wrong. She just said: ‘oh my bad.’ my classes, which I performed No apology, nothing.” poorly in during that time period.”

Volume 42, No. 2 • Fall 2020 3 PRSRT STD Anthony J. Jannetti, Inc. US Postage East Holly Avenue, Box 56 CHANGE SERVICE PAID Volume 42, No. 2 • Fall 2020 REQUESTED Pitman, NJ 08071-0056 Deptford, NJ Editor Permit #142 Diane J. Mancino, EdD, RN, CAE, FAAN President, NSNA Brandi Borden Executive Director Diane J. Mancino, EdD, RN, CAE, FAAN Art Director Jack Bryant Managing Editor Kaytlyn Mroz, MA Layout and Design Specialist Darin Peters Publisher Anthony J. Jannetti, Inc. Advisory Board G. Rumay Alexander, EdD, RN, FAAN Michael L. Evans, PhD, RN, NEA-BC, FAAN Florence L. Huey, MS, FNP Mary P. Tarbox, EdD, RN Rebecca M. Wheeler, PhD, RN Dean’s Notes is indexed in Cum ulative Index to Nursing & Allied Health Literature. Dean’s Notes is published four times a year (winter, spring, summer, and fall) by Anthony J. Jannetti Inc., East Holly Avenue, Box 56, Pitman, New Jersey 08071-0056. Telephone 856.256.2300. FAX 856.589.7463. All rights reserved. No part of this publication may be reproduced without the express written permission of the publisher. Address changes should include mailing label and be forwarded to the publisher. www.facebook.com/NSNAinc www.twitter.com/NSNAinc © Anthony J. Jannetti, Inc., 2020

Difazio, R.L., Vessey, J.A., Buchko, O.A., Chetverikov, of Nursing Care Quality, 32(2), 164-171. https:// Vessey, J.A., Demarco, R.F., Gaffney, D.A., & Budin, W.C. D.V., Sarkisova, V.A, & Serebrennikova, N.V. doi.org/10.1097/NCQ.0000000000000209 (2009). Bullying of staff registered nurses in the (2019). The incidence and outcomes of nurse bul- Karatas, H., Ozturk, C., & Bektas, M., (2017). A study of : A preliminary study for developing per- lying in the Russian federation. International bullying against nursing students. The Journal of sonal and organizational strategies for the transfor- Nursing Review, 66(1), 94-103. https://doi.org/ Nursing Research, 25(3), 198-202. https://doi.org/ mation of hostile to healthy workplace environ- 10.1111/inr.12479 10.1097/JNR.0000000000000144 ments. Journal of Professional Nursing, 25(5), Edmonson, C., & Zelonka, C. (2019). Our own worst ene- Kovner, C.T., Brewer, C.S., Fatehi, F., & Jun, J., (2014). 299-306. https://doi.org/10.1016/j.profnurs.2009. mies: The nurse bullying epidemic. Nursing What does nurse turnover rate mean and what is 01.022 Administration Quarterly, 43(3), 274-279. https:// the rate? Policy, Politics & Nursing Practice, 15(3- Yokoyama, M., Suzuki, M., Takai, Y., Igarashi, A., doi.org/10.1097/NAQ.0000000000000353 4), 64-71. https://doi.org/10.1177/15271544145 Noguchi-Watanabe, M., & Yamamoto-Mitani, N. Hartin, P., Birks, M., & Lindsay, D. (2018). Bullying and 47953 (2016). among nurses and the nursing profession in Australia: An integrative PACER’s National Bullying Prevention Center. (2020). their related factors in Japan: A cross-sectional review of the literature. Collegian, 25(6), 613-619. How is bullying defined? https://www.pacer.org/ survey. Journal of Clinical Nursing, 25(17-18), https://doi.org/10.1016/j.colegn.2018.06.004 bullying/resources/questions-answered/how-is- 2,478-2,488. https://doi.org/10.1111/jocn.13270 Houck, N.M., & Colbert, A.M. (2017). Patient safety and bullying-defined.asp workplace bullying: An integrative review. Journal

Please Join NSNA for a Monthly Online Faculty Forum Timely topics and lively discussion moderated by Dr. Diane Mancino, NSNA Executive Director

The next Online Faculty Forum takes place on Monday, November 30, 2020 at 5:00 - 6:30 p.m. EST

Featured Topics: Forming Professional Identity with Dr. Nelda Godfrey NSNA Bullying Survey Part II Faculty with Dr. Renee Buonaguro & Dr. Veronica (Ronnie) Feeg

This event will be followed by an Open Mic.

Please visit www.nsna.org/faculty for more information.

4 Volume 42, No. 2 • Fall 2020