The purpose of this paper is first to define the concept of bullying in negative workplace relationships in health care contexts, second to use the findings of two empirical studies to illustrate the types and frequencies of bullying that are currently experienced by United Kingdom (UK) nursing students on work (clinical) placements, and third to consider the efficacy of some proposed solutions to the bullying problem.

...if we have evidence [of] bullying...then morally we have an obligation to address the issue.

The issue of negative workplace relationships is a sensitive issue. In highlighting the prevalence of conflict and negative behaviours arising from the behaviour of some qualified (graduate) nurses towards nursing students, we are not suggesting that the UK nursing profession should be characterised only by negative workplace relationships. However, we can suggest that negative workplace relationships definitely exist and seem to flourish in large organisations such as the UK National Health Service (NHS). An example of negative workplace relationships is bullying. Although terms such as workplace relationships and bullying are terms that are hard to define, and we acknowledge that this lack of clarity has hindered efforts to address this topic, we are certain that bullying in health care exists. Adams (1992) offers the following common definition of bullying - a definition which fits with our work on bullying, "Persistent criticism and personal abuse in public or private, which humiliates and demeans the person" (p. 1).

We will argue in this paper that if we have evidence that bullying of the type described above occurs with students on clinical placement, then morally we have an obligation to address the issue. In an environment where many health care providers are facing difficulties with recruitment and retention, it also makes sense that solutions need to be arrived at in order to make working life experiences in health care more positive so that students feel secure and supported in the workplace and wish to continue their education to work as nurses.

Workplace Bullying

...previous literature has identified that bullying in organisations is a worldwide phenomenon.

Hickling (2006), in his analysis of definitional terms of bullying, identified that workplace bullying is increasingly being recognised as a serious problem in society. Field (1996) goes as far to say, "Workplace bullying is ...the second greatest social evil after child abuse, with which it has many parallels" (p.1). Surveys carried out with UK registered nurses by the Royal College of Nursing (RCN) (RCN, 2002) and the trade union for employees in health care called UNISON (UNISON, 2003) suggest that there is increasing evidence that the scale of bullying, harassment, and violence towards qualified health care staff is increasing and that reports of bullying in the workplace are becoming more widespread.

Bullying is not unique to the UK; rather previous literature has identified that bullying in organisations is a worldwide phenomenon (Freire, 1972; Freshwater, 1998; Roberts, 1983). Jackson et al. (2002) state, "Violence in the form of bullying and harassment are...rife in the nursing work environment" (p.15) and a number of studies have reported negative behaviours perpetrated by nurses on nurses (Akerstrom, 1997; Chambers, 1998; Dunn, 2003; Randle, 2003).

Field (1996) has offered a helpful definition of the workplace bully:

• refusal to recognise, face up to, tackle, and overcome one’s own weaknesses, failings, and shortcomings
• denial of responsibility for the consequences of one’s own actions and behaviours on others.

If the bully is in a position of management, control, and/or trust, then also:

• refusal to accept the legal and moral obligation for the safety, care, and well-being of the person(s) in their charge.

Field notes that the workplace bully can be either a peer or someone with authority over the victim.

Many definitions of bullying such as the one above reinforce the ‘bully-blaming’ stance. While in some rare cases an individual bully may be the sole cause of the bullying, in most cases, there are other factors. Scandinavian researchers Einarsen and Skogstad (1996) further our understanding of bullying by suggesting that particular work environments may engender, foster, or sustain workplace bullying. They identify these broader factors affecting workplace bullying as:

• personality traits of victims and bullies
• inherent characteristics of human interaction in organisations
• factors associated with particular work environments and conditions.

Einarsen and Skogstad (1996) therefore move to a broader description of workplace bullying, one which may be more useful to us, in writing, "A person is bullied or harassed when he or she is repeatedly subjected to negative acts in a situation where the victim finds it difficult to defend himself/ herself" (p. 9).

Einarsen’s and Skogstad’s description (1996) clearly shows the difficulty that relatively junior employees, who are linked to the organisation and its procedures, face when attempting to defend themselves. However, although Einarsen’s and Skogstad’s approach is an improvement over earlier definitions in acknowledging the role of the organisation, without specific procedures backed by the organisation’s management to help individuals, it will not actually help the victim. As Randle (2006) points out, in organisations where support for staff to report bullying is absent, those on the receiving end (the victims) are often labeled by management as troublemakers, and coerced to resign, accept enforced redundancy, or take early or ill-health retirement.

Whilst this outcome for qualified staff is something we deplore, it presumably occurs over a period of time; and we might be forgiven in thinking that workplace bullying is not something that students on clinical placement would encounter. It would be easy to assume that because their placement is not permanent, any discomfort in working relationships can be endured with little or no lasting effects. However, the following two studies suggest that UK students do encounter workplace bullying and it does affect them in some serious ways.

Study 1

A longitudinal empirical study carried out by Randle (2003) showed that over a three year educational period, UK nursing students experienced qualified nurses exercising power over them and bullying them, often with them being ridiculed or humiliated in front of others. Sometimes this behaviour was more subtle in nature, but it still caused students to feel powerless and their self-esteem to be diminished.

Method

This study, which included both quantitative and qualitative components, involved two cohorts of pre-registration nursing students who were studying for their diploma in nursing at one institution of higher education in the UK. A convenience sample of students in all four branches of nursing (adult, child, mental health, and learning disability) participated. Students from all age cohorts were studying the same curriculum and had clinical placements in similar geographical localities. At the start of the course, 43 students were aged between 20 and 24 years, 18 were between 25 and 29 years, 13 were between 30 and 34 years, and four were between 40 and 50 years of age. A minority of the sample were male (eight students). There were 56 studying in the adult branch, 10 in the mental health branch, seven in the child branch, and five in the learning disability branch. At the beginning of the course, 56 of the 78 students in the two cohorts volunteered to participate in interviews, and 30 participated at the end. The reduced numbers were a consequence of theoretical sampling. Theoretical sampling is a key characteristic of grounded theory wherein theories/themes that are derived from the data are 'tested' out on subsequent participants, until these themes are substantiated. In the second phase of interviews it was found that themes such as 'nurse power over patients' were sufficiently substantiated with the first thirty participants used, so further testing of this theme was deemed unnecessary.

At the beginning and the completion of the course, students completed the Tennessee Self-Concept Scale (TSCS) (Roid & Fitts, 1988) and the Professional Self-Concept Nursing Inventory (PSCNI) (Arthur, 1992). The TSCS is a standardised, normative rated, international scale which the respondent uses to portray a concept of him/herself. The PSCNI measures a respondent’s concept of him/herself as a professional nurse.

Grounded theory was used as a framework for collecting and analysing the qualitative data which was collected using unstructured interviews. Interviews were conducted in clinical areas and lasted between 20-90 minutes. Interviews and accompanying field notes were fully transcribed. All transcripts were intensely and repeatedly scrutinised in order to gain theoretical sensitivity, and codes and properties were linked with data as patterns emerged. Two independent researchers coded the same set of data and arrived at consensus via discussion and analysis. These categories were then tested out in subsequent interviews, which in turn informed future interviews.

Permission for the study was granted by the Local Research Ethics Committee. Participation was voluntary and students were told at both phases of data collection (start and end of course) that they could withdraw from the study at any point. Pseudonyms and codes were used in order to ensure confidentiality.

Quantitative Findings

The findings showed that the process of becoming a nurse was a distressing and psychologically damaging one for students.

The findings showed that the process of becoming a nurse was a distressing and psychologically damaging one for students. Their self-esteem as measured by the TSCS dramatically decreased over a three year period with 95% of them having below average self-esteem by the end of their education. This was a shocking result as all of them had an average or high self-esteem when they commenced the course. That the professional self-concept remained healthy throughout might be due to respondents trying to portray a positive image of themselves as ‘would be nurses.’ The TSCS had social desirability scales built in which the PSCNI did not; respondents may have offered a socially desirable picture of themselves.

Qualitative Findings

Student comments provide descriptions of the bullying behaviours they experienced and the consequences of these behaviours. The following extract shows the extent of the bullying problem:

I wouldn’t do it over again, no, not this. If I knew what it was going to be, I don’t know, but I definitely wouldn’t do this again. I never thought nurses could be so bitchy. I’m a grown woman and they’ve made my life hell really. My daughter’s at school and she’s had less bullying than me. They’re just bullies, to other nurses and to the patients as well. They ought to be sacked.

Another student shared her experiences thus:

You were a waste of time as far as the staff were concerned…I didn’t think they could all be that bad, but then I realised what they were like. That’s what worries me about going up to X; it’s the staff that have the problems, not the patients. I’m the kind of person who’d like to say something but I don’t think you can. It depends what ward you’re on. I don’t get upset, I just get annoyed and I can’t ignore it. I can’t go to bed annoyed, ‘cos I can’t sleep and then I wake up even more annoyed. So I think I’d have to go and speak to someone, someone above them without sounding too much that I’m telling tales. There’s something that has to be done to get it sorted out to see why they’re being this way with me.

These extracts, along with others in the study, strengthen the view that student nurses often experience negative physical and psychological reactions to bullying. These reactions include: sleeplessness, anger, anxiety, worrying, stress, self-hatred, powerlessness, decrease in confidence, increase in absence/sickness, and intention to leave the job/profession. By the end of their three-year course, students often described how they exhibited symptoms of burnout, apathy, passive anger, and use of distancing approaches to patients and colleagues (Randle, 2001; Reeve, 2000). Although students had initially been horrified at the bullying practices displayed by some staff at the start of their course, they had come to accept that this was normal as noted in this extract: Oh, but you just have to fit in and get on with the work really. The patients don’t mind, so long as they get treated, that’s all they’re bothered about. Honestly, everything’s fine.

It was not only students who were on the receiving end of bullying. Some students even witnessed patients being bullied. In the following scenario a staff nurse had refused to give a learning disability patient her own money, because she did not approve of what the patient wanted to buy. The student who witnessed this explained how it made her feel:

I felt that it was Heather’s money and that she was a grown woman who came across as knowing what she wanted. I felt she was being treated like a child just because she had a learning disability. If the staff nurse had just given Heather the money she needed and not even asked what Heather intended to buy, this incident wouldn’t have happened.

A more severe example of bullying can be seen in the following extract, where an elderly male patient accidentally spilled his used urinal in his bed. The student had to clean the patient and change his bed:

I thought he was absolutely disgusting. He was horrible. He shouldn’t have done it, and I think he just did it to draw attention to himself. I’ve never seen a man naked other than my husband…I just keep avoiding him now. I’ve asked if I can work with another team and I can’t wait for him to be discharged. I spoke to my mentor about it because I don’t know if I should be feeling like this, but she said he was disgusting as well. He’s still trying to get my attention and keeps trying to say ‘hello’ but I just ignore him.

There may be many different explanations for the above scenario, but the most worrying thing was that the patient received inadequate care, and was placed in a vulnerable and humiliating position. The staff nurse mentor appeared to collude with the student by agreeing that the patient was indeed disgusting. This was not a 'one-off' situation, rather students routinely described events where they had been encouraged to ‘practise’ their skills on patients and participate in inadequate care to the detriment of the patient.

We can see then, that for health care students, bullying can be problematic. Recent prevalence studies, such as the ones carried out by UNISON (2003) and the RCN (2002), have shown the extent to which there is a culture of bullying within the NHS and the detrimental effects this has on staff as well as patient care. The research cited here points to a culture of bullying within health care organisations that can adversely affect students’ self-esteem and consequently their ability to provide patient care.

Study 2

Although these findings of bullying supported previous literature, we desired to carry out a second study to check the generalizability of the findings. The second study was a specially designed survey on work placement experiences of a sample of student nurses in another School of Nursing in another part of the UK. In this survey 400 second and third year nursing students from a large school of nursing at a UK University were asked to identify the frequency and particular types of bullying behaviour they had experienced in their last clinical placement.

Method

The survey was based on a questionnaire, developed by Quine and used in previous studies (Quine, 1999, 2000, 2001), which addressed the extent of bullying experienced by health care professionals. Permission was granted to use Quine’s ’workplace bullying’ questionnaire and adapt the wording where appropriate to fit the experience of nursing students. We decided to select out 25 questions that had relevance to clinical placements for nurses and would provide a question style which would allow respondents to answer in a form that indicated the behaviour frequency based on the following scale:

• never happened,
• happened only occasionally
• happened quite frequently
• happened almost all the time

This format gave students the opportunity to answer each question about bullying behaviour in terms of whether they did or did not experience it and to what degree. The statements used in the questionnaire are listed in Table 1.

Table 1.

I had threats of physical violence made against me I was intimidated by disciplinary procedures Unfounded threats were made about my placement evaluation I was set impossible deadlines I experienced forms of sexual harassment Inappropriate jokes were made about me Malicious rumours/allegations were spread about me I was unreasonably refused applications for leave or study days I was unjustly criticised Necessary information was withheld from me purposefully Attempts were made to belittle or undermine my work I was discriminated against on grounds of race/gender/disability Areas of responsibility were removed from me without warning Expectations of my work were changed without me being told about them I was placed under undue pressure to produce work Health care staff were abusive towards me Health care staff were openly hostile towards me I felt attempts were made to demoralise me I felt attempts were made to undermine my personal values and beliefs I was teased by staff I felt my efforts were undervalued I was humiliated in front of others I experienced resentment towards me I experienced destructive innuendo or criticism I was frozen out/ignored/excluded

 

It was also felt that students should be given the opportunity to describe and explain their answers. Therefore, questions exploring what the student nurses felt about the negative experiences and what they had done about reporting them were provided for this purpose. To establish if students in particular branches (specialty areas) of education experienced more bullying than others, or whether age or previous experience influenced responses, information concerning these matters was requested. The questionnaires were distributed to 400 second and third year nursing students from a large UK University School of Nursing which had agreed to take part in the survey. The questionnaire study was approved by the University Medical School Ethics Committee.

Quantitative Findings

The sample (N=313) included 78.3% of those who were given a questionnaire and invited to participate. Demographic data was used to compare participants’ specialty areas with the national specialty area statistics (see Table 2). The national figures (the most recent figures available) were taken from the Nursing & Midwifery Council (NMC) report (2005). The comparison shows that distribution of this sample was similar to the national distribution in various specialty areas with the exception of the study sample having fewer mental health nurse trainees than the national sample and more child branch trainees. Demographic information was also collected to provide a description of the sample (see Table 3).

Table 2. Comparison of participants in various specialty area with the number of nurses in these areas nationally.

Specialty Area	Student Survey Returns (%)	National Figures (%)
Adult Branch	76.7	78
Child Branch	15.7	5
Mental Health Branch	5.8	14
Learning Disability	1.9	3

Table 3. Description of Participant Respondents

Fifty three percent of student nurses in this study had experienced one or more of Quine's 25 possible negative interactions during the course of their placement. This figure can be compared with existing research on bullying among UK qualified nurse professionals. Quine (1999), using the original Workplace Bullying Survey found that 38% of staff in a community health trust had experienced one or more of the specified bullying behaviours in the last month. In a later study she found that 44% of qualified nurses had experienced at least one or more of the bullying behaviours (Quine, 2001).

The most frequently reported negative behaviours from our study are listed below in Table 4 along with the percentage of students who indicated the behaviour 'happened frequently' or 'happened a lot', i.e., that the behaviour was common.

Table 4. Most frequently reported negative behaviors.

Question	Percentage indicating common behaviour
1. I was frozen out/ignored/excluded 2. I experienced destructive innuendo and criticism 3. experienced resentment towards me 4. I was humiliated in front of others 5. My efforts were undervalued 6. I was teased by health care staff	34.0% 29.7% 29.1% 28.8% 28.0% 26.6%

The least frequent negative behaviour selected by the students was the threat of actual physical violence which was reported by 2.5% of the sample. However, 2.5% is still a significant number in this context. This translates to 7 students reporting that they experienced threats of physical violence from health care staff. The fact that any student should report that they were threatened with physical violence by employed staff whilst on placement is surely an unacceptable position for any organization to defend.

Qualitative Findings

The perpetrators of bullying were often reported to be doctors or non-nurse trained Health Care Assistants.

The sections below report the qualitative findings based on the students' comments. A comparison of these findings to those reported in the literature is also described.

Who was doing the bullying? The perpetrators of bullying were often reported to be doctors or non-nurse trained Health Care Assistants (HCAs). Doctors have long been a dominant group in health care and studies have previously reported how they often use their power negatively against young, newly qualified nurses (Daiski, 2004). Interactions with doctors have been shown to cause newly qualified nurses to feel intimidated (Jackson, et al., 2002). Thus it is not surprising that this student sample reported their encounters with doctors in this fashion. Studies have also shown that students also experience negative attitudes from non-nurse trained HCAs (Hart & Rotem, 1994; Jackson & Mannix, 2001). These staff can use a more passive approach to destabilising students’ confidence by ignoring them, not allowing them opportunities to learn, and generally excluding them from the team. In the survey reported here it was exactly this type of passive behaviour from HCAs that the nursing students identified. These behaviours included lack of appreciation, lack of communication, and not being given opportunities to learn.

Students on adult wards experienced more negative interactions than those in children's wards.

Less bullying in paediatrics. Students on adult nursing wards experienced more negative interactions than those in childrens’ wards. In particular behaviours that lead to destabilization were more commonly reported by adult branch students. Drawing upon Einarsen and Skogstad (1996), it is possible to conclude the structure of children’s nursing in clinical areas provides a more supportive environment for staff and students. This may account for less reported negative interactions in these areas. Paediatric areas traditionally have been thought to offer better staffing levels and better team working relationships, which would be instrumental in providing a less oppressive environment and less bullying. However, there is only anecdotal evidence to support these claims. Research into differences in ward culture and its effect on bullying would need to be carried out to substantiate these reports.

Students over 35 years old experienced negative interactions significantly more than those under 35.

Age and bullying. Students over 35 years old experienced negative interactions significantly more than those under 35. The older students (35 years plus) experienced discrimination, hostility, and teasing significantly more than their younger colleagues. Studies have shown that older students often feel that trained staff treat them as if they were just out of school and fail to acknowledge the value of older students’ life experiences (Glackin & Glackin, 1998; Kevern & Webb, 2004).

Gender and bullying. Male nurses indicated experiencing significantly more sexual harassment than their female colleagues. Although the number of male students was small in this sample, they experienced significantly more inappropriate jokes being made about them. Research suggests that though male nurses often experience advantages being a minority, they also struggle to cope with being accepted in a female-dominated profession (Cunningham, 1999; Stott, 2004). Patients are often less accepting of male nurses; and this lack of acceptance, combined with negative experiences with clinical staff, probably contribute towards the general attrition of male student nurses (Stott, 2004).

Taking no action against the bully. A total of 34% of students in the survey (over 100 students) experienced bullying on placement but took no action. These figures can be compared to studies on UK qualified nurses. The Royal College of Nursing reported (2002) that 23% of qualified nurses experiencing bullying had not taken action. Students not taking action against bullying may well be slightly higher compared with qualified staff.

Male nurses indicated experiencing significantly more sexual harassment than their female colleagues.

Reasons for this lack of action could lie in the relatively short time period of a student’s placement, with no more than 10 weeks being the average placement length. Students explained their inaction using comments, such as ‘not worth the hassle’ and ‘you just put up with it.' Students also reported that they recognised they are acknowledged in organisational terms as a group with very little power, so they find it difficult to challenge negative behaviour directed towards them from more experienced staff.

Students were asked to explain why they had not taken action over the incidents of bullying they had experienced. Reasons for not taking action varied, but included:

• The experiences were not significant enough to complain about
• It was felt that staff were ‘just having a bad day’
• It was part of the normal student experience
• As the placement was short they could cope with behaviours within that limited time
• Mentors would have to complete an assessment and therefore they did not wish to jeopardise the report of their ability to fit in while on placement

Coping strategies. Students indicated that talking to someone about the event was the easiest form of action to try to resolve their situation. Mentors were considered an important source of support for students in the clinical placement. Studies addressing the value of mentoring have reported that students who experience good supervision and mentorship settle into the clinical environment and team quicker (Nolan, 1998; Spouse, 2003). Good supervision enables students to develop confidence, increase their knowledge, and move towards their potential (Griffith & Bakanuaskas, 1983; Hanson & Smith, 1996). Good supervision is also vital in situations where conflict needs to be resolved (Hart & Rotem, 1994). For some, but not all of the students in our survey, mentors were providing them with the support and help they needed, especially when they experienced bullying. This suggests that the creation of a good mentor-student relationship is a key component in supporting students who experience bullying.

Students who had witnessed good nursing care were able to offer their own solutions to bullying in health care. Most of these solutions suggested have already been identified in the literature.

Mentors were considered an important source of support for students in the clinical placement.

Nolan (1998) noted that working alongside friendly, helpful, and supportive staff is important to students and has a positive effect on their clinical learning and confidence. When students feel cared for and supported they feel they are able to provide better patient care (Dillon & Stines, 1996). Gillespie (2002) reported that feeling supported enhances self-esteem, increase motivation to learn, and can affirm students in their choice of nursing as a career. Being included in the team gives students the opportunity to learn and practise nursing skills within the safety of the team (Wilson-Barnett, et al., 1995).

Students who had experienced positive placements often commented on the presence of a supportive and enthusiastic mentor. This reinforced previous findings indicating that effective support increases a student’s ability to fit into clinical settings and to make the most of the learning experience (Gillespie,2002; Spouse, 2003). Sharing knowledge and involving the student in decision making have also been shown to be important, allowing students to deliver care in partnership with their mentor (Cahill, 1996; Griffith & Bakanuaskas, 1983). Good supervision from a mentor ensures that students learn sound care delivery practices and skills in relating to patients in a safe environment ( Spouse, 2003). A good mentor is essential. Yet one needs to ask whether a good mentor is all that is needed for eliminating bullying, or whether a good mentor is just a way of reducing the impact of bullying.

Discussion of Research Findings

Bullying is clearly still part of nursing culture in UK, and can be a part of a student nurse’s work placement experience. As student nurses are a relatively powerless group, it is not surprising that so many experience bullying behaviours. The existence of a hierarchy in nursing has been shown to perpetuate bullying, and students are seen as being the bottom rung of this hierarchy (Begley, 2002; Cahill, 1996). This suggests that they are more than likely to experience bullying behaviours from senior members of staff. It also suggests that in many specialty areas there is a generational culture of nurse-to-nurse abuse, with registered nurses perceiving that nursing students should be treated as badly as they were during their education (Farrell, 2001). It appears that this socialization into a culture of abuse begins in work placements, with students nearing the end of their education already using bullying tactics against junior colleagues (Randle, 2003; Reeve, 2000).

It is reasonable to expect student nurses to use a number of strategies to smooth the process of professional socialization. An important one is that of ‘playing the game’ and ‘fitting in’ (Gray & Smith, 2000). In the ‘fitting in’ period students will put up with things and try to make sure they don’t ‘rock the boat’. However, by ‘fitting in’ and ‘playing the game’ student nurses run the risk of letting bullying behaviours continue. As we have seen, the fear of ‘more hassle’ or ‘bad evaluation’ stops student nurses from taking action; and as has previously been suggested, fear of retaliation is a significant factor in under-reporting of negative experiences (McKenna, et al., 2003).

Individual Strategies to Overcome Bullying

Assertiveness training, with specially designed scenarios that mimic situations nursing students are likely to experience...should be included as part of the nursing curriculum.

Students need to be aware that bullying exists, know how to identify if they are being bullied, and be prepared to report any bullying they have experienced or observed. Assertiveness training has been suggested as one way to increase students’ ability to address bullying by giving them the power they need to change the situation (Begley & Glackin, 2004). Assertiveness training, with specially designed scenarios that mimic situations nursing students are likely to experience on placement, should be included as part of the nursing curriculum.

Additionally, the RCN has produced a document specifically for nursing students who feel they have experienced bullying and harassment (RCN, 2005). It provides students with information on various options for action against the bullying and suggests that if students decide to take action, it is helpful to first use informal approaches such as:

• Talking to friends, mentors, and personal tutors
• Talking to the bully and requesting that he/she stop the bulling behaviour
• Keeping a record of incidents and interactions with the bully

When an informal approach has not been effective, the student may choose to take formal action in line with the placement hospital’s harassment and bullying policy. The student is advised that before taking formal action they will likely need the following:

• written evidence of the date/time of incident(s), location, nature of evidence, and names and status of any witnesses
• written evidence of previous attempts to informally resolve the situation
• a representative at any meetings
• a written complaint that should be registered formally with the organisation’s representative – if studying at a university this may be the Course Director, Head of School, or Human Resources Administrator
• patience to wait whilst the investigation proceeds

Such a process is quite daunting and time-consuming for a newcomer. Given the relative power differentials that operate in health care, it is asking a lot of a student to embark on this process in an organisation that is not necessarily supportive of such actions. Support from the student's educational institution during this process is strongly encouraged.

Organisational Solutions for Overcoming Bullying

Workplace environments can both produce and sustain acts of bullying.

One of the key points made in the introduction in this article is that bullying of and by nurses needs to be understood in context before it can be addressed. Workplace environments can both produce and sustain acts of bullying. The study of bullying in organisations has been fraught with difficulties and false trails which have concentrated on investigating attributes of the bully or attributes of the victim. Hickling (2006) has urged that if we wish to pursue an understanding of bullying, we use the research-based conclusions by Einharsen and Skogstad (1996) which place the study of bullying within the organisational context. In this framework, bullying is understood to be the outcome of at least four interrelated factors, namely, interpersonal, intrapersonal, organisational, and social dimensions.

Hickling (2006) applied an organizational framework in interviewing managerial staff and staff who had experienced bullying. Hickling identified the phenomenon of a ‘situated serial bully’ which conceptualized the bully not as a psychotic temper tantrum waiting to happen but rather a calculating problem solver who uses bullying tactics to ensure activities occur in the way he or she wants them to. In this framework bullies are seen as intentional actors manipulating their world to keep it they way they want it.

The fact that bullying behaviour has been operational and 'normalised' for some time makes it quite difficult for the victim to suddenly challenge and change it...

Since this intentional manipulation often occurs over time, it may continue for a period before the recipient recognises it. The fact that bullying behaviour has been operational and ‘normalised’ for some time makes it quite difficult for the victim to suddenly challenge and change it; and this difficulty explains in part, the insidious, long-term effect of bullying.

In health care the organisational structure supports bullies because power is exerted downward in health care organisations. The culture of nursing may provide the almost perfect habitat for the manipulative bully. Powerlessness infects the lower status health care workers, such as nursing students on placement or new entrants, who are made to feel they have failed if they seek help in dealing with quite unrealistic demands. 

Bullivent and White (2006) recommend the introduction of tangible, managerial structures and procedures to help identify persistent bullies within an organisation. They recommended, for example, ‘exit’ interviews as well as ‘returning to work after illness’ interviews as means of identifying the effect of an individual staff member on employee sustainability. 

We applaud health care organisations which set up a culture that will not tolerate management by bullying. A culture that supports victims through the creation and implementation of an agreed-upon, workable, anti-bullying charter would in effect strip away the cover that bullies need in order to operate. Our recommendation for health care managers who wish to remove bullying from their organisation is to create a culture where management supports the workforce against bullying and is prepared to develop and actually implement anti-bullying procedures.

Conclusion

Our recommendation...is to create a culture where management supports the workforce against bullying and is prepared to develop and actually implement anti-bullying procedures.

This paper has addressed the specific issue of UK student nurses’ experiences of bullying while on placement, thus providing an example of inter-group difficulties within health care. From our research on student nurses’ experience of bullying whilst on work placement, we have identified common issues that future student nurses may face during their education. In doing this we have shown that bullying clearly exists in UK nurse education and is likely to continue unless nurse educators and health care organisations that offer placement opportunities recognise the problem and agree to do something about it. Creating an organisational culture that actively encourages reporting of bullying is a first step in addressing this problem. We hope this article will empower employers, clinical colleagues, and educators to support an organisational response to bullying for the benefit of nursing students who need a positive environment in which to learn to give nursing care.

Authors

Keith Stevenson PhD, MA (Psych), MA (Ed), Cert Ed.
E-mail: keith.stevenson@nottingham.ac.uk

Keith Stevenson is a newly appointed Associate Professor in the Postgraduate Division of the School of Nursing and Academic Division of Midwifery in the University of Nottingham, UK. He heads up the MPhil/PhD programme and teaches research methods and quantitative techniques in the masters’ and doctoral programs. His doctorate is from the University of Leicester, UK, where he developed a psychometric measure of primary care organisational culture and used it to examine the relationship between organisational culture and resistance to quality improvement in primary health care teams. Keith helped to adapt and analyse the data from the questionnaire used in the second study reported in this paper.

Jacqueline Randle, PhD, MSc, BA, PGDip, ILTM
E-mail: Jacqueline.randle@nottingham.ac.uk

Jacqueline Randle is also newly appointed Associate Professor in the Postgraduate Division of the School of Nursing and Academic Division of Midwifery in the University of Nottingham, UK. She has extensive experience in nurse education and research. Her doctoral work explored nursing students’ self concept as they progressed through their three year university and work placement training, and she has presented some of this work in this article. Jacqueline has published in the area of bullying behaviours and is editor of Workplace Bullying in the NHS commissioned by Radcliffe Publishing currently in press.

Ian Grayling, BA (Hons) PGDip (Training Management)
E-mail: idg1@le.ac.uk

Ian Grayling is Director of Short Course Development in the Institute of Lifelong Learning at the University of Leicester, UK. Ian has considerable experience in the educational environment and is involved in setting up high quality, nationally recognised courses for the certification of teachers in further and higher education. He has written a chapter in Workplace Bullying in the NHS (in press) that looks at the role of the trainer/mentor in supporting nursing students who are subject to bullying in the workplace

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