Asian Nursing Research 12 (2018) 245e250

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Asian Nursing Research

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Research Article Development of Instrument of Bullying Behaviors in Nursing based on Structured Equation Modeling

* * Kamuran Cerit,1, , Sultan Türkmen Keskin,2 Dilek Ekici3

1 Nursing Department, Health Faculty, Suleyman Demirel University, Isparta, Turkey 2 Nursing Department, Health Science Faculty, Ankara University, Ankara, Turkey 3 Nursing Department, Health Science Faculty, Gazi University, Ankara, Turkey article info summary

Article history: Purpose: Bullying behaviors experienced during nursing education negatively affect students, educators, Received 14 September 2017 quality of , and patient care. The purpose of this study was to develop a valid, reliable, short, and Received in revised form comprehensive scale to measure the bullying behaviors of nursing students in the education 16 July 2018 environment. Accepted 23 July 2018 Methods: The Bullying Behaviors in Nursing Education (BBNE) tool was developed by adapting the Workplace Psychological Violence Behaviors scale. The data were collected from 442 nursing students Keywords: from April to May 2017. The BBNE was tested using structural equation modeling, and validity and bullying nursing reliability results were obtained. Moreover, complementary statistics were determined, and the violence prevalence behaviors experienced by nursing students were reported. 2 reproducibility of results Results: The full BBNE scale, with 30 items and four factors, was not verified (c /df ¼ 4.31); 12 items 2 students were excluded, and the modified structure with 18 items and four factors was verified (c /df ¼ 2.60; root-mean-square error of approximation ¼ .06). The scale's Cronbach's a coefficient is .88, and the structure reliability is .92. Twenty-five percent of the 442 students scored 1 or higher in the total scale, showing that they were subject to bullying behaviors. Conclusion: The BBNE scale can be used to measure the bullying behaviors of nursing students in the education environment. When such behaviors are identified, students can struggle on the personal and organization level. Providing a safer and comfortable education environment for nursing students who are the guarantee of the future of health care will positively affect the quality of education and patient care in parallel. © 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Studies show nursing students are commonly subject to bullying behaviors both in the classroom and in the clinic envi- Bullying experienced by nurses has been an important problem ronment during their education [5e7]. Widespread bullying can in the health field for many years [1,2]. A similar situation is negatively affect nursing students' educational life and damage applicable for the education environment of nursing students [2,3]. their school and work success [8,9]. This also negatively affects the Bullying is defined as a student constantly and repetitively being quality of their education and of patient care in the clinic envi- subject to negative behaviors such as verbal, physical, relational, ronment [10]. Therefore, it is very important to identify and prevent and social exclusion in an education environment [4]. bullying behaviors among nursing students. This study has been planned to develop a short, comprehensive, valid, and reliable scale compatible with today's conditions to identify bullying behaviors experienced by nursing students. Bullying is an exclusion process in which an individual's ability * Correspondence to: Kamuran Cerit, MSc, RN, Nursing Management Depart- of self-expression is limited, his or her personality is humiliated ment, Nursing Department, Health Science Faculty, Suleyman Demirel University, fi 32200 Çünür, Isparta, Turkey. and rede ned by stigmatizing, and identity is shaped accordingly. E-mail address: [email protected] In this process, individuals are subject to long periods of * ORCID: https://orcid.org/0000-0002-1234-4025 https://doi.org/10.1016/j.anr.2018.07.002 p1976-1317 e2093-7482/© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). 246 K. Cerit et al. / Asian Nursing Research 12 (2018) 245e250 humiliation, scolding, ignoring, isolation, insult to personality and Methods professional status, loss of dignity, and other traumatizing behav- iors [11e13]. Studies report that nursing students are subject to Design and samples mainly verbal violence [4,11,14], despising behaviors, and physical abuse [14]. The study was conducted with nursing students enrolled in the Experiences during nursing education negatively affect stu- nursing department in two state universities that offer a 4-year dents' education lives and preferences after graduation [5]. The nursing education program. The study population comprised bullying behaviors experienced or witnessed by nursing students 1,889 undergraduates enrolled in the nursing department in the during their education can even lead to their dropping out of school Spring semester of the 2016e2017 academic year. The students before completing their education [5,7,15]. Moreover, the existence (N ¼ 442) who volunteered were accepted into the study from April of bullying in the education environment indicates that the envi- 2016 to May 2017. There were 212 (11.2%) students from University ronment is not supportive or healthy. A and 230 (12.1%) from University B. The response rate is 23.3%. The presence of psychological violence behaviors in the class- room and clinic environments negatively affect the students, edu- Ethical considerations cators, and education quality [3,8]. Experiencing bullying can damage a person's sense of self; cause negative professional Ethical approval of the study was obtained from the ethical board integrity and perceptions; and reduce motivation, performance, of Ankara University (Approval no. 85434274-050.04.04/11957). ability to concentrate, self-confidence, and school and work success During collection of data, students were informed about the pur- [8,9]. pose of the study and information confidentiality, and data were A nursing student who is isolated from the education envi- collected with their consent. ronment, is not supported, does not question what is being done, and who has a damaged self-confidence cannot develop the sense Measurements of belonging to nursing education and the . Such stu- dents have challenges in learning important theories, skills, atti- A two-part form was used to collect data. The first part included tudes, and behaviors [16]. This also negatively affects the quality of questions about the demographic characteristics of students (e.g., the nursing education in the clinic environment where patient grade, age, gender). The second part was composed of the Bullying care is delivered [10]. Behaviors in Nursing Education (BBNE) scale adapted from the Identification of bullying experienced by nursing students in WPVB scale developed by Dilek and Aytolan [20] to identify the education environment is very important for coping bullying behaviors experienced by nursing students in the educa- with these behaviors on the individual and organizational level tion environment. The WPVB scale uses 33 items and four factors to [17]. Various scales in the literature identify bullying behaviors identify bullying behaviors experienced at the workplace. experienced by nursing students [4,6,12]. In some studies, scales The first factor in the WPVB is isolation of individuals from work without validity and reliability results were used to measure and includes behaviors such as ‘not being informed about social bullying against nursing students [4,18]. In other studies, the meetings’. Some of the behaviors under this factor were included scales used to determine mobbing behaviors exposed on nurses without change in the BBNE scale, and some items (e.g., ‘having were used with nursing students without ensuring validity and duties that you are responsible for taken from you and given to reliability [12]. The Bullying, Harassment, and Horizontal others in lower positions’) not suitable for the factor were removed. Violence scale developed by Geller [6] only measures the hori- Moreover, behavior statements that can be encountered by stu- zontal bullying behaviors exhibited by nursing students to each dents such as ‘not being accepted to the group of friends’ were used, other in the clinic environment. However, nursing students are and Factor 1 was called isolation of students from the education subject not only to horizontal bullying behaviors but also to environment (ISO). bullying behaviors from sources including physicians and nurses The second factor of the original scale is “attack on professional in the clinic environment and educators in the education envi- status” and includes behaviors such as “being forced to do a that ronment [15]. will negatively affect your self-confidence”. Some of the items of Therefore, there is a need for a scale that enables the identifi- this factor were unchanged and included in the BBNE scale, and cation of possible bullying behaviors from all kinds of sources in the suitable items such as ‘not being trusted in the competence related classroom and clinic environment, not only from colleagues in the to lectures’ also were included, and some items (e.g., ‘having you education environment. In conclusion, there is a need for a short, feel like you and your work are being controlled’) not suitable for comprehensive, valid, and reliable scale compatible with today's the factor were removed. The new Factor 2 was called attack on conditions to identify bullying behaviors specifically experienced academic achievement (AA). by nursing students in the education environment. The third factor of the original scale is attack on personality For this purpose, items from the Workplace Psychological (PER) and includes items such as ‘talking in a humiliating and Violence Behaviors (WPVB) scale were used. This scale was devel- degrading style’. In the BBNE scale, some items from this factor oped for nurses by Yıldırım and Yıldırım [19]; validity and reli- were kept the same, and some items (e.g., ‘having unfair reports ability of the scale was established by Dilek and Aytolan [20]. The written about you’) not suitable for the factor were removed, and WPVB scale was identified as a valid and reliable scale that could be new items suitable for the factor (e.g., ‘being scolded loudly in adapted and used to identify bullying behaviors experienced by public’) were added; the name of the factor was not changed. nursing students in the education environment having been used The fourth factor of the original scale is direct negative behav- with nurses and physicians in different hospitals [21e23], with iors (NEG) and includes items such as ‘applying physical violence’. different employee groups [24,25], and in academic environments In the BBNE scale, again some items were kept the same, and some [26]. items (e.g., ‘preventing or forbidding coworkers from talking with This study has been planned to develop a short, comprehensive, you’) not suitable for the factor were removed, and other items valid, and reliable scale compatible with today's conditions to suitable for the factor (e.g., ‘mild violence such as pushing with identify bullying behaviors experienced by nursing students in the hands and slamming the folder to intimidate’) were added; the education environment. name of the factor was not changed. K. Cerit et al. / Asian Nursing Research 12 (2018) 245e250 247

A focus group interview was conducted with six nursing stu- of the nursing students was 21.18 (±1.61), grade point average was dents who were experiencing or had experienced bullying at 2.91 (±0.35) of 4, and 380 (86.0%) were women while 62 (14.0%) nursing school for preparing of the items of the BBNE scale. The were men (Table 1). interview of the students was analyzed descriptively and system- atically. According to the interview analysis, new 17 items were Confirmatory factor structure of the scale added to the factors. After then, a plot study was conducted among 20 nursing students for determination of the items and under- A CFA was used to analyze if the structure with 30 items and four standing of the statements. By recommendations of the students, factors (Model I) was not verified for nursing students. Considering two items were removed from the item pool, and three items were the fit indexes used to determine construct validity, the Model I c2/ rewritten as statements. df value was ¼ 1720.13/399 (4.31) and RMSEA ¼ .09 (Table 2). Ac- Fifteen items of the WPVB scale were included without change cording to these results, it was determined that Model I did not in the BBNE scale. The BBNE scale adapted for nursing students have good fitness. comprised 30 items in total, seven items in Factor 1 (ISO), seven The items for which error variances were related to each other items in Factor 2 (AA), nine items in Factor 3 (PER), and seven items according to CFA correction indexes were excluded from the mea- in Factor 4 (NEG). A six-point Likert scale was used to define the surement tool. When the errors of the items are correlated, the frequency of behaviors (0 ¼ never experienced, 1 ¼ experience for a model's theoretical structure is impaired because the assumption few times a year, 2 ¼ experience for a few times a month, that the variables of structural equation modeling are independent 3 ¼ experience for a few times a week, 4 ¼ experience once a day, from each other is violated. and 5 ¼ experience a few times a day). The Cronbach's a coefficient In conclusion, 12 items were excluded from the measurement of the original scale is .93. model, and a measurement model with 18 items and four factors was obtained. Three items were excluded from each factor. More- Data analysis over, the error variances of two items in Factor 1 were adjusted according to modification recommendations. In the end, Model I fi LISREL 8.80 (Scientific Software International Inc., Lincolnwood, was modi ed and the new structure (Model II) was created. fi IL, USA) and SPSS 20.0 (IBM Inc., Armonk, NY, USA). software were The t indexes of Model II were examined and showed that this fi used for data analysis. The number, percentage, means, and stan- model demonstrated good tness (Table 2). Table 3 provides dard deviations were calculated to determine the grade, gender, average points for items and factors as well as standardized loads, t 2 and ages of the participants. A confirmatory factor analysis (CFA) values, R values, and average points for the items in Model II. fi c2 was run with LISREL to provide proof of the scale's construct val- The t indexes of Model II were calculated. /df [330.62/127] fi ¼ fi ¼ idity. The parameter estimations of the measurement tool were with a value of 2.60 (good t), RMSEA .06 (good t), SRMR .05 ¼ ¼ fi ¼ obtained with CFA, and the statistically suitable measurement (GFI .92, and AGFI .90) as was perfect tness (NFI .95, ¼ ¼ model was determined. At this point, items which were not NNFI .96, and CFI .97). The critical N value calculated for the considered statistically significant were excluded from the model, model is 222.92. The entire scale's extracted variance is 51.61%, and recommended corrections were made, and goodness of fit indexes the average variance extracted of all the factors in the scale is (GFIs) of the measurement tool were obtained. provided in Table 4. In assessment of model fit, researchers considered Chi-square (c2)/degree of freedom (df), adjusted GFI (AGFI), GFI, normed fit Findings about reliability of the scale index (NFI), non-NFI (NNFI), comparative fit index (CFI), root- mean-square error of approximation (RMSEA), and standardized The Cronbach's a internal consistency coefficient for the BBNE root mean square residual (SRMR) values. For reliability of the scale was calculated to be .88. The Cronbach's a for Factors 1e4 measurement tool, Cronbach's a coefficients were obtained using were .73, .77, .77, and .70, respectively. The CR of the scale is .92, and SPSS 20.0 software, and the construct reliability (CR) and the the CR of factors varies between .70 and .78 (see Table 4). average variance extracted values were calculated. Independent Bullying behaviors experienced by nursing students samples t-test, analysis of variance, and Pearson correlation ana- (prevalence). lyses were conducted for analysis of demographic data. Table 3 presents the average scores of the students on the BBNE scale. The average score of the students on the total scale was 0.70 ± 0.61. Results Distribution of the students who experience bullying a few times (1 point) and more violent behaviors a year is provided in Figure 1. The study population was divided almost exactly in half be- Twenty-five percent of the students scored 1 or more points on the tween University A (48.0%) and University B (52.0%). The mean age total scale, and it was determined that they were subject to bullying behaviors in the education environment. Evaluating the students Table 1 Characteristics of Nursing Students (N ¼ 442). who scored 1 or more points on the factors, it was determined that

Characteristic Category n (%) M ± SD Table 2 Model Fit Indexes for Bullying Behaviors in the Nursing Education Scale. University A 212 48.0 B 230 52.0 Model c2/df RMSEA RMR/SRMR NFI/NNFI CFI GFI/AGFI Grade First 51 11.5 Second 79 17.9 I (30 items and 4.31 .09 .09/.08 .90/.92 .92 .79/.76 Third 123 27.8 four factors) Fourth 189 42.8 II (18 items and 2.60 .06 .06/.05 .95/.96 .97 .92/.90 Gender Women 380 86.0 four factors) Men 62 14.0 Note. AGFI ¼ adjusted goodness of fit index; CFI ¼ comparative fit index; GFI ¼ Age (yrs) 442 21.18 ± 1.61 goodness of fit index; NFI ¼ normed fit index; NNFI ¼ non-normed fit index; RMR ¼ Grade point average of 4 442 2.91 ± 0.35 root mean square residual; RMSEA ¼ root-mean-square error of approximation; Note.M¼ mean; SD ¼ standard deviation; yrs ¼ years. SRMR ¼ standardized root mean square residual. 248 K. Cerit et al. / Asian Nursing Research 12 (2018) 245e250

Table 3 Items, Standardized Loads, t Values and R2 of Bullying Behaviors in the Nursing Education Scale.

Items M ± SD Standardized loads Standard errors t R2

Factor 1. Isolation of students from the education environment 0.43 ± 0.68 ISO1. Not being wanted in the study group related to the school or internship 0.37 ± 0.84 .55 .70 10.81 .30 ISO2. Not being accepted to the group of friends 0.37 ± 0.90 .67 .55 13.19 .45 ISO3. Being left alone during breaks 0.60 ± 1.11 .54 .71 10.19 .29 ISO4. Intentionally leaving the environment when you enter an environment 0.39 ± 0.78 .67 .55 13.34 .45 Factor 2. Attack on academic achievement 0.98 ± 0.97 AA1. Limiting self-expression 1.34 ± 1.37 .74 .45 16.94 .55 AA2. Not being trusted in the competence related to lectures 1.15 ± 1.27 .65 .58 14.14 .42 AA3. Being forced to do a job that will negatively affect your self-confidence 0.68 ± 1.12 .70 .51 15.74 .49 AA4. Constantly assigning tasks over the capacity 0.76 ± 1.23 .64 .59 13.92 .41 Factor 3. Attack on personality 0.96 ± 0.81 PER1. Not making eye contact while talking 1.67 ± 1.29 .41 .83 8.51 .17 PER2. Talking in a humiliating and degrading style. 0.88 ± 1.27 .70 .51 16.03 .49 PER3. Questioning your honesty and reliability 0.81 ± 1.16 .59 .65 12.88 .35 PER4. Being scolded loudly in public 0.73 ± 1.09 .65 .58 14.42 .42 PER5. Using degrading mimics or body language 0.89 ± 1.18 .67 .55 15.10 .45 PER6. Talking bad or unfounded behind you 0.79 ± 1.19 .60 .64 13.17 .36 Factor 4. Direct negative behaviors 0.32 ± 0.58 NEG1. Making practical jokes 0.65 ± 1.11 .50 .75 10.00 .25 NEG2. Being exposed to verbal or behavioral sexual implications 0.28 ± 0.83 .72 .49 15.11 .51 NEG3. Mild violence to intimidate (slamming a file, pushing with hands, and so forth) 0.27 ± 0.76 .65 .57 13.60 .43 NEG4. Being exposed to physical violence 0.09 ± 0.46 .61 .62 12.71 .38 Total scale score 0.70 ± 0.61

Note.M¼ mean; SD ¼ standard deviation. the nursing students experienced attack on academic achievement students from the education environment” factor was excluded the most (43.4%), then attack on personality (42.1%), isolation of from the model owing to a low R2 value (.017) and a high error students from the education Environment (16.5%), and direct variance (.90). In addition to that, two item from “isolation of stu- negative behaviors (10.9%). dents from the education environment”, three items from “attack Considering the behaviors most experienced by students, it was on academic achievement”, two items from “attack on personality”, determined that 79.4% experienced ‘not making eye contact while and three items from “direct negative behaviors” were excluded talking’, 62.4% experienced ‘limiting self-expression’, and 58.3% without making any correction because error variances of these experienced ‘not being trusted in the competence related to lec- were found to be related to other items' error variances. One item tures’. Students reported that they were exposed to these behaviors from “attack on personality” factor was excluded from the model by classmates, instructors, clinical nurses, patient's relatives, and owing to a high error variance (.84). As a result, after 12 items were doctors. excluded, the four-factor model composed of 18 items was No statistically significant difference was obtained between the validated. exposure of the nursing students in the study to bullying behaviors Model fit was evaluated using fit indices as recommended by by the school (t ¼ 0.13; p ¼ .895), grade (F ¼ 1.39; p ¼ .244), and Schreiber et al [27]. To measure GFI for the recommended theo- gender (t ¼1.82; p ¼ .073) (p > .05). No statistically significant retical model, c2 (with associated degrees of freedom and p value), difference was obtained with the correlation analysis between relative c2 (c2/df < 5.00), RMSEA < .05, GFI > .90, AGFI > .90, mean age (r ¼.02; p ¼ .738), grade point average (r ¼.05; CFI > .90, NFI > .95, and SRMR < .08 are used [28]. Study results p ¼ .338), and being exposed to bullying (p > .05). show that the BBNE scale c2/df value is 2.60; RMSEA value is .06, and the data exhibit good fitness with the new model. Considering other fitness indexes related to the model, it was determined that Discussion the model has good fitness. It can be concluded that with a higher Cronbach's a coefficient in of validity and reliability of the scale a new model, the items in this scale are consistent with each other

The study was conducted to develop a valid and reliable mea- surement tool to be used to identify bullying behaviors experienced by nursing students. Therefore, the WPVB scale developed by Dilek Bullying Behaviours in Nursing Education 100 and Aytolan [20] was adapted, and a structure with 30 items and 90 four factors (Model I) was created, and validity and reliability an- 80 alyses were conducted. According to the adjustment indexes, 12 70 items were excluded, and a new structure (Model II) was created 60 with 18 items and four factors. One item in the “isolation of 50 43 42 40 30 Table 4 Reliability of Bullying Behaviors in Nursing Education. 16 20 10 Factor Construct reliability Average variance extracted Cronbach's a 10 0 Factor 1 .70 .37 .73 ISO AA PER NEG Factor 2 .78 .47 .77 ISO AA PER NEG Poly. (ISO) Factor 3 .78 .37 .77 Factor 4 .72 .39 .70 Figure 1. Prevalence of bullying behaviors in nursing education (%). K. Cerit et al. / Asian Nursing Research 12 (2018) 245e250 249 to the same extent and question the components of the same achievement are more preferred by the attacker as demonstrated property. The Cronbach's a coefficient of the BBNE scale is .88 and of by the results of this study shown in Figure 1 [8,12,15,17]. the factors is .70e.77. Accordingly, it was determined that the scale Moreover, passive-aggressive behaviors are manipulative be- was reliable. haviors in which the attacker is not at the forefront but exhibits these behaviors under his or her control. Therefore, they are not Evaluation of the items and factors in the scale easily distinguished, and the attacker frequently displays kind be- haviors to cover up the bad behaviors [31]. Thus, it becomes harder University years are the years of transition from youth to for the victims to understand that they are victims of bullying, to adulthood. In this period, some students leave their families, enter immediately distinguish the attacker, and to take timely measures. a new environment, try to make friends, are left alone, and cope In conclusion, aggressive behaviors are exhibited to isolate the with many challenges, including financial problems. The education victim from the education environment and against his or her environment is an arena in which the student tries to survive. The personality and student status, and thus, the victim's public dignity, image of a student in the education environment depends on how self-respect, self-value, and self-confidence are damaged. In this educators (academics, assistants, nurses, and so on) and friends study, the behaviors most experienced by the students were attack treat them in public. In the literature although more than half of on academic achievement student status and manipulative be- the students are reported to be exposed to violent behavior haviors against their personality. These behaviors are very hard to [5,12,15], this ratio appears to be lower in this study. That may be prove as they do not leave concrete marks such as physical violence. explained by the fact that nursing students cannot accurately describe behaviors due to the lack of sufficient information about Study limitations bullying and as a result of the institution's normalization of the bullying, students may regard these behaviors as part of their A vast majority of the nursing students enrolled in the univer- education. It is also reported that bullying behaviors in organiza- sities where the study was conducted were not willing to be tions are related to the mentality and culture of the institutional involved in the study for various reasons. The study reached a total management [1,22]. With the differences in the literature, it is of 23% of the students in both universities. Low participation is a seen that the students reported the source of bullying behaviors as limitation of the study. The purpose of this study, however, is not to their classmates [4,15], instructors [4,8,12,15], clinical nurses measure the amount of the bullying experienced by the students. [2,8,11,12], patient relatives [2,8,11,12], and doctors [2,11,15]. The But low or high reporting of behaviors by the students is not sig- results of the study on source of the bullying may be due to dif- nificant for the analysis of the validity, reliability, and conceptual ferences in the definition of bullying behaviors and in the sampled construct of the scale [17,30]. In this study, the critical N value is groups. calculated as 222. The fact that 442 students took part in the study Bullying behaviors experienced by students in a university ed- demonstrates that a sufficient sample was obtained for data anal- ucation environment prevent them from developing healthy re- ysis in the study. lations and is a continuous and persistent attack on their self- Data were collected from nursing students enrolled in two state confidence and self-respect. In this process, the students' ability universities in the capital city of Turkey, Ankara. Therefore, results of self-expression is limited; they are continuously interrupted, are limited only to nursing students. Moreover, the study results ignored, and excluded, and their identity is redefined accordingly. have country-specific cultural characteristics, and it is recom- In the literature, the reason for these behaviors is to rule, exclude mended to test the results in different cultures. from the environment, or destroy [29]. Attackers who exhibit bullying behaviors use various strategies. Some of these strategies Conclusion are passive, and some of them are direct negative, aggressive be- haviors [17,30]. Direct negative behaviors can range from practical It is very important to ensure a peaceful and safe education jokes and mild violence to physical violence. As direct negative environment to train nurses to whom we will entrust the health behaviors are easy to distinguish and enable the victim to imme- service in the future. Bullying, however, negatively affects the diately take measures for self-defense, it is hard for the attacker to learning process of the individual. Bullying behaviors in the edu- reach his or her target. Therefore, these behaviors are less preferred cation environment are not desirable as they negatively affect by the attacker as demonstrated by the results of this study shown students, educators, and education quality. Faculty, instructors, in Figure 1 [8,15,17]. On the other hand, exposure of the victim to nurse managers, and clinical nurses must implement strategies that direct negative behaviors indicates that the victim also is experi- will end the bullying behaviors and promote a healthy work envi- encing intensive bullying behaviors [31]. ronment. The most efficient way to reduce the impact of bullying is When passive-aggressive behaviors are considered separately, to prevent it. For this reason, it is necessary to identify bullying they can be accepted as ordinary interactions of daily life. However, behaviors experienced by nursing students in the education envi- the meaning and content of these behaviors continuously and ronment. There may also be strategies that could be implemented frequently repeated in the education environment change in time to reduce the effect of bullying, including a supportive university and turn into consciously organized dangerous social relations. environment and teaching assertiveness. By doing these, it might Limiting the ability of self-expression; not being trusted in be possible to protect nursing students from bullying behaviors and competence related to lectures; being left alone during breaks; not to prevent damages experienced in the education process. In the making eye contact while talking; not being included in the school, study, the 18-item BBNE scale was considered sufficient, compre- internship, and friend group; and continuously being assigned hensive, valid, and reliable in identifying the bullying behaviors tasks over their capacity are examples of passive-aggressive be- experienced by nursing students in the education environment. haviors. According to the findings of the study, students who were exposed to bullying behavior were mostly subjected to the forms of Conflicts of interest passive aggressive behavior such as, “not making eye contact while talking” [8,12], “limiting self-expression”, and “not being trusted in The author(s) declared no potential conflicts of interest with the competence related to lectures” [12,15], which are consistent respect to the research, authorship and/or publication of this with literature. These attacks on personality and academic article. 250 K. Cerit et al. / Asian Nursing Research 12 (2018) 245e250

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