- Email: [email protected]
For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences
Nurse Education in Practice xxx (2013) 1e4
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences Michelle Seibel* Thompson Rivers University, School of Nursing, 900 McGill Rd., PO Box 3010, Kamloops, BC V2C 0C8, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 29 August 2013
The purpose of this review is to determine what we currently know about faculty bullying of nursing students during undergraduate clinical experiences. The review included 31 peer-reviewed articles and dissertations investigating faculty bullying of nursing students and those factors which can influence the phenomenon. A significant finding of this review is that faculty bullying of students arises out of complex contextual influences involving the practice setting, as well as perceptions and coping strategies of both faculty members and students. This belies the current understanding of bullying within nursing education as intentional, and arising from the personal pathologies of the teacher or student. This has implications for clinical faculty members as well as Schools of Nursing. As well, it highlights future directions for research, including interventions to decrease faculty bullying of students. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Faculty Bullying Nursing Student Clinical education
Bullying by and between nurses in the practice setting is widely acknowledged to be a serious concern in today’s health care system. An extensive body of research has informed anti-bullying strategies that are known to effectively address this concern; however, the extent of workplace bullying in nursing practice continues to escalate (Roche et al., 2009; Woelfle and McCaffrey, 2007). Recently, some authors have suggested that one of the reasons that workplace bullying continues to thrive in nursing practice is that the origins of bullying behaviour exist prior to nurses working in the profession; i.e., bullying begins in undergraduate nursing education (Clark and Olender, 2011; Luparell, 2011; Magnavita and Heponiemi, 2011; Pope, 2010). Recent studies highlight the concerning fact that faculty members are commonly viewed as perpetrators of bullying behaviour towards students (Clarke, 2009; Cooper, 2007; Del Prato, 2010). It is critical that we understand this phenomenon, as it is destructive in terms of student learning and wellness, and also antithetical to our stated intent as instructors. The purpose of this paper is to conduct a critical review of research reports regarding bullying in basic undergraduate nursing clinical education, with a specific focus on faculty roles. Factors that contribute to the perception of faculty members as bullies in the clinical setting will be examined, and strategies to address the issue will be identified. The paper will conclude with a discussion of the implications for nursing education and future research. * Tel.: þ1 250 371 5834; fax: þ1 250 371 5909. E-mail address: [email protected].
Review of the literature Specific types of behaviour are identified as bullying and are highlighted in the literature with startling consistency across professional, educational, and role boundaries. Those who work in specifically in healthcare identify being ignored, humiliated, undervalued, excluded, and receiving negative criticism or evaluation as particularly impactful on their ability to prosper in those environments. Students report the same types of bullying behaviour (Del Prato, 2010; Thomas, 2012). The review of papers and unpublished reports/dissertations is based on the following themes; i.e., systemic factors, faculty-specific and student-specific factors that contribute to the perception of faculty bullying nursing students in clinical settings. First, however, a brief overview of the phenomenon of bullying is needed in order to examine definitions, prevalence, and to understand its significance. Definitions and significance A clear definition of ‘bullying’ is important, as both nurses and student nurses may have difficulty identifying bullying behaviour (Hoel et al., 2007; Seibel, 2007; Sweet, 2005). Bullying is defined herein as both direct and indirect acts of violence that expose the victim to “negative or abusive behaviour, often over a considerable time, where the targets have difficulty in defending themselves” (Hoel et al., 2007, p. 270). This definition highlights both the dimension of time, and the presence of a relational power differential between the victim and the perpetrator.
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.08.013
Please cite this article in press as: Seibel, M., For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.08.013
2
M. Seibel / Nurse Education in Practice xxx (2013) 1e4
The consequences of bullying for nurses and nursing students are decreased job satisfaction and commitment, attrition, as well as overall decreased physical and mental health (Katrinli et al., 2010; Oore et al., 2010). There is no direct correlation between severity of bullying or violent behaviour and its effects on the recipients (Flannery, as cited in Ferns and Meerabeau, 2007; Holmes et al., 2012). In nursing practice, patient safety outcomes are compromised by hostile working conditions (International Council of Nurses [ICN], 2006; Roche et al., 2009). As students are typically on the lower end of hierarchical structures in healthcare and education, they are exceptionally vulnerable to bullying (Clarke, 2009; Hoel et al., 2007).
in which they have competence as novice faculty (Cederbaum and Klusaritz, 2009). Nursing faculty typically rise up through the ranks of nursing, first attaining professional competence and then graduate degrees and then engaging increasingly in academic life, and while they may be experts in a particular field of nursing, they are not necessarily expert instructors (Cangelosi et al., 2009; Clarke, 2009; Cooper, 2007). Benner et al. (2010) concluded that lack of teaching experience and knowledge leads to ambiguity about the role, and not knowing if what they observe in students is to be considered normal, what action to take when concerned about students’ performance, and the appropriate avenues to seek guidance about their role.
Systemic factors
A balancing act Due to the fact that clinical faculty typically do not work as nurses on the unit, they are often considered outsiders. Inherent in this dynamic are struggles that involve territory, competing priorities, and varying expectations. Faculty are considered ‘guests in the house’ in the clinical arena and as such are limited in their influence and rights within that setting (Glass, 1971). Clinical faculty attempt to mediate these variables, maintain functional working relationships with staff and provide a positive learning experience for their students. At times, this results in faculty behaviour that may be perceived by students as bullying; e.g., a faculty member who tries to keep the clinical staff ‘happy’ by restricting students’ access to patients’ charts risks complaints of bullying by students (Paterson, 1991). Finding a balance between the providing students support and challenge, being directive but allowing students to shape their practice, and leading but allowing the student to exercise leadership can contribute to faculty stress and the perception by students that their needs are being overlooked (Del Prato, 2010). For example, students commonly perceive written clinical assignments as onerous, yet these are also helpful to their learning and developing practice; faculty who are novice may emphasize the necessity of the written work without having the skill and experience to understand that students need support to be able to understand the benefits of such assignments (Benner et al., 2010).
There is a significant body of research that correlates the incidence of bullying in nursing with stressors inherent in the workplace environment and within healthcare (Oore et al., 2010; Roche et al., 2009). Hodgins (2008) proposes that, “individual[s] cannot be treated in isolation from the larger social unit or system in which they operate” (p. 17). Consequently, when nursing students are present within a clinical agency or the academic institution, they may be victims of bullying that is a symptom of organizational stress. Hoel et al. (2007) propose that increased workload in a clinical area negatively impacts the student experience, as increased unit stress results in deteriorating interpersonal interactions. Negative socialization experiences within the profession perpetuate the problem of bullying as these learned behaviours and negative coping mechanisms are repeated post-graduation (KingJones, 2011; Randle, 2003; Thomas, 2010). Other perspectives on bullying include the application of oppressed group theory, which describes nurses as a subjugated group, and postulates that the struggle to achieve status in the profession includes the reinforcement of negative behaviours (Freire, 1972). By extension, nursing faculty members have been socialized into the profession, and some promote the belief that bullying behaviours from coworkers are to be expected. In this context, bullying behaviours actually serve a purpose in that they help to establish such behaviours and their influence as normative within the workplace and the profession (Katrinli et al., 2010). It is this normalizing of bullying that is troubling, and likely influences the passive and resigned manner in which nurses often respond to bullying (Ferns and Chojnacka, 2005; Katrinli et al., 2010; Seibel, 2007). Randle (as cited in Sweet, 2005) states, “traditional approaches to nurse education have helped [to] entrench bullying behaviours, so that each new generation of nurses becomes socialized to regard it as normal” (p. 16). Within schools of nursing, the failure to address bullying can inadvertently lead to a culture of tolerance towards inappropriate conduct (Clark et al., 2009) i.e., it communicates the message that it is a legitimate means to express a point of view or opinion (Clark and Olender, 2011; Sweet, 2005). Faculty factors Numerous factors influence individual faculty members’ approaches to clinical nursing education, as well as how they perceive and address practice issues among students. Among these are a lack of knowledge and understanding of the clinical teaching role, and the requirement to mediate between various parties and expectations within the clinical setting. Lack of knowledge/preparation Faculty must communicate expectations and address disciplinary issues as they arise within clinical nursing education (Kolanko et al., 2006); however, this is not typically something they
Teaching goals, values and ideals Clinical faculty often have ideas about what a nurse should be, look like, and act; their willingness to embrace alternate styles shapes how they respond to students who are different from this perspective (Cederbaum and Klusaritz, 2009; Forbes, 2010; Paterson et al., 2004; Pope, 2010). For example, if faculty highly value caring, and perceive a student to be uncaring, this is likely to cause conflict between them (Forbes, 2010). Faculty ideals of the perfect nurse may include any aspect of the students’ person, including gender, ethnicity, age, and sexual orientation (Cangelosi and Moss, 2010; Paterson et al., 2004). One consequence of faculty preferring a certain type of student to others is favouritism. Faculty may perceive some students as better than others because they are congruent with faculty’s perspectives of the ideal nurse or student. This results in faculty evaluating these students with a less than critical eye (Del Prato, 2010; Pope, 2010). Faculty may single out students who do not comply with either their personal or larger professional norms and identify them as students who need more focused attention (Pope, 2010). Intense scrutiny typically upsets students, increases their chances of making mistakes, and has an overall negative effect on student confidence and development (Del Prato, 2010). Student factors Multiple factors can influence how faculty’s behaviour is perceived or interpreted by a student, including whether or not a
Please cite this article in press as: Seibel, M., For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.08.013
M. Seibel / Nurse Education in Practice xxx (2013) 1e4
student feels cared for, respected, and interpersonally connected to the instructor. Also, the students’ self-image affects their subsequent response to feedback as feelings of potential threat such as clinical failure. Caring and respect The perception of connectedness to faculty or lack thereof is described as a major contributor to students’ positive and negative clinical experiences respectively (Del Prato, 2010; McGregor, 2005; Pope, 2010). If clinical instructors do not make time to meet with students and discuss their concerns, students often view this as evidence of incongruence with core educational program values such as caring and respect, which can lead to disillusionment with the profession and educational goals, as well as accusations of faculty bullying (Benner et al., 2010; Del Prato, 2010). Students who feel that faculty expectations are impossibly high will become discouraged and/or disengaged and these faculty members are often perceived as bullies (Del Prato, 2010; Cooper, 2007). Although students may feel that faculty practices or expectations are unreasonable, few “would dare protest or complain, particularly when they rely on good reports for their professional progression” (Hoel et al., 2007, p. 276). Students often feel powerless to challenge faculty practices, and believe that such behaviour will make them targets of the clinical instructor (Del Prato, 2010). Learning, evaluation and formation Faculty’s focus on evaluation, rather than learning, may result in students viewing faculty as bullies (Cooper, 2007; Del Prato, 2010). This is particularly an issue in the execution of psychomotor skills produces where a faculty member closely scrutinizes the student’s performance. If students make errors during the skill performance, faculty tend to increase their surveillance of the student’s performance. This leads to further errors and to heightened anxiety on the part of the student in future skill observation situations (Del Prato, 2010, p. 108). Students are particularly susceptible to experiencing increased anxiety and perceptions of faculty bullying when the faculty member has a reputation of failing students or being excessively harsh in judgements about previous students. They are also susceptible in times when they experience a crisis of confidence or question whether they should really be a nurse; at such times, students are highly vulnerable to negative feedback. Bonnel (as cited in Del Prato, 2010) proposes that all feedback should respect student dignity and self-esteem, and that “angry, belittling, or demeaning words are never justified.” (p. 139). Ego-defense mechanisms Students may respond to negative feedback from a faculty member by incorporating it to positively influence and change their practice, or alternatively withdraw in order to protect themselves from a sense of failure (Cederbaum and Klusaritz, 2009). Various authors describe such behaviours as ego-defense mechanisms, and confirm the connection between motivation, engagement, and affective states (D’Mello and Graesser, 2012; Liem et al., 2007). Those students who see negative feedback as a threat may resort to maladaptive coping strategies in order to preserve their sense of self (Cederbaum and Klusaritz, 2009, p. 427). Such mechanisms may include denial and deflection, where the blame for the unpleasant situation is shifted back to the person who caused the negative emotion (here, the faculty member), which allows the student, at least temporarily, to avoid examining his/her performance. While some educational experts propose that a cognitive and/or emotional disequilibrium is needed for deep learning, it is the presence of internal motivators and locus of control that determines how the student proceeds from this state of confusion and
3
is ultimately successful or defeated in their learning (D’Mello and Graesser, 2012). Van Lehn (as cited in D’Mello and Graesser, 2012, p. 155) proposes that it is the tutor or instructor’s role to manage this confusion in order for it to benefit the learner, or the student could become frustrated and disengage from the situation. Summary The review of the relevant literature has highlighted bullying within nursing education as a highly complex and multifaceted concept. This belies much of the current understanding of bullying within nursing education as entirely intentional, arising from the personal pathology of the teacher and remedied by prohibitions and restrictive policies. Although there are implications for students in this review, the discussion will focus only on faculty implications. As well, I will identify implications for future research in this field of study. Discussion It is apparent in this review of the literature that the solutions to bullying within nursing education must account for the multiple ways in which bullying is a symptom of the stressors associated with being a faculty member. Providing faculty in-service or instruction would help to address some of the current issues in nursing education that perpetuate faculty-student bullying. Schools of Nursing should provide ongoing orientation and mentorship for at least a year to new faculty about topics related to teaching including bullying. Newly hired faculty members need mentoring and support about appropriate levelling of expectations and good teaching practices. Sharing this review with faculty could foster dialogue about their experience and lead to further recommendations for faculty support and development. Opportunities such as this could be provided on a variety of commonly encountered topics and issues, and lead to group problem-solving. Clinical faculty need opportunities to share with each other about the stressors they experience and how to mediate these. This may include specific cases or general issues that arise. Although this kind of informal support is natural and to varying degrees occurs organically within schools of nursing, there exists a need for more formal systems of support. Offering informational and instrumental support to faculty experiencing stressors that perpetuate bullying can be integrated as the norm within the school; for example, faculty dealing with a student’s clinical performance difficulties can be provided information about how to assist the student, as well as emotional support throughout the process. Anti-bullying training should be provided to students and faculty alike (Roche et al., 2009). A zero-tolerance policy towards bullying and other violent behaviours provides a statement of intent towards those involved with incidents of bullying, and also provides a rationale and policy on which both educational interventions are provided, and progressive discipline might be enforced (Sweet, 2005; Hutchinson, 2009). Hutchinson (2009) argues that violence continues to escalate in healthcare institutions despite zero tolerance policies, and questions their effectiveness. However, it is important to publicly acknowledge that a problem exists and that the organization does not condone the behaviour. Students and faculty should also be reminded that, “in a sometimes overlooked portion of the Code of Ethics. [nurses must] in all professional relationship and in all encounters, including those with colleagues, act with respect” (Luparell, 2011, p. 94). Schools of nursing should also implement a fair, consistent, and transparent way to address complaints of bullying. This review highlights the need for research in various aspects of the phenomenon of faculty bullying of students. Some of these
Please cite this article in press as: Seibel, M., For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.08.013
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needs include: 1) an examination of the efficacy of specific interventions in reducing faculty bullying of students (e.g., education, mentoring etc); 2) exploration of faculty members’ perceptions and experiences of being charged with bullying and reflecting on experiences that students have interpreted as bullying. Such research would contribute toward a model that could be used to generate interventions to mediate faculty bullying; 3) investigations of interventions to assist students to develop ego-enhancing or sustaining ways when confronted with feedback or situations in which their performance is less than they desire; and 4) studies that examine the attributes of faculty who are most inclined to bully students and to explore the relationship of these attributes to the actual incidence of faculty bullying; e.g., do novice teachers bully more than expert teachers and if so, what contributes to this phenomenon? It is clear that this field of research is in its infancy and much more must be learned about the phenomenon of facultystudent bullying in order to identify strategies to prevent and mediate it. Conclusion Faculty bullying disrupts learning, and perpetuates itself and other forms of violence within the nursing profession. It is also incongruent with stated professional nursing and program values, and can ultimately contribute to attrition of students from nursing programs, and nurses from the profession. This paper has presented a review of relevant literature pertaining to faculty bullying of nursing students. It has raised a number of issues and possible directions for nursing education and nursing research in the future. In addition, it has identified a number of possible solutions to prevent and mediate faculty bullying within nursing education. Ideally, faculty bullying of students will shortly become a phenomenon that is spoken of in history as a thing of the past. As nurse educators, we are obligated to reflect on and explore our individual and collective contributions to this reality. References Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: a Call for Radical Transformation. Jossey-Bass, San Francisco, CA. Cangelosi, P.R., Crocker, S., Sorrell, J.M., 2009. Expert to novice: clinicians learning new roles as clinical nurse instructors. Nurs. Educ. Perspect. 30 (6), 367e371. Cangelosi, P.R., Moss, M.M., 2010. Voices of faculty of second-degree baccalaureate nursing students. J. Nurs. Educ. 49 (3), 137e142. Cederbaum, J., Klusaritz, H.A., 2009. Clinical instruction: using the strengths-based approach with nursing students. J. Nurs. Educ. 48 (8), 422e428. http:// dx.doi.org/10.3928/01484834 20090518e01. Clarke, C., 2009. The Effects of Bullying Behaviours on Student Nurses in the Clinical Setting (Master’s thesis). Available from: ProQuest Dissertations and Theses database, ISBN 978-0-494-73653-1. Clark, C.M., Farnsworth, J., Landrum, R.E., 2009. Development and description of the Incivility in Nursing Education (INE) survey. J. Theor. Constr. Test. 13 (1), 7e15. Clark, C.M., Olender, L., 2011. Fostering civility in nursing education and practice: nurse leader perspectives. J. Nurs. Adm. 41 (7/8), 324e330. Cooper, J.R.M., 2007. A Survey of Students’ Perceptions of Bullying Behaviors in Nursing Education in Mississippi (Doctoral Dissertation). Available from: ProQuest Dissertations and Theses database. (UMI: 3275008). Del Prato, D.M., 2010. The Lived Experience of Associate Degree Nursing Education: Conditions and Barriers in the Learning Environment that Shaped Students’ Learning, Identity Development, and Success (Doctoral Dissertation). Available from: ProQuest Dissertations and Theses database. (UMI: 3429053).
D’Mello, S., Graesser, A., 2012. Dynamics of affective states during complex learning. Learn. Instruct. 22, 145e157. Ferns, T., Chojnacka, I., 2005. Reporting incidents of violence and aggression towards NHS staff. Nurs. Stand. 19 (38), 51e56. Ferns, T., Meerabeau, L., 2007. Verbal abuse experienced by nursing students. J. Adv. Nurs. 61 (4), 436e444. Forbes, H., 2010. Clinical teachers’ approaches to nursing. J. Clin. Nurs. 19, 785e793. Freire, P., 1972. Pedagogy of the Oppressed. Penguin, Harmondsworth, UK. Glass, H.P., 1971. Teaching Behavior in the Nursing Laboratory in Selected Baccalaureate Nursing Programs in Canada (Unpublished doctoral dissertation). Teachers College, Columbia University, New York. Hodgins, M., 2008. Taking a health promotion approach to the problem of bullying. Int. J. Psychol. Psychol. Ther. 8 (1), 13e23. Hoel, H., Giga, S.I., Davidson, M.J., 2007. Expectations and realities of student nurses’ experience of negative behaviour and bullying in the clinical placement and the influences of socialization processes. Health Serv. Manag. Res. 20, 270e278. Holmes, D., Rudge, T., Perron, A.M., St.-Pierre, I., 2012. Introduction. In: Holmes, D., Rudge, T., Perron, A. (Eds.), (Re)Thinking Violence in Health Care Settings: a Critical Approach. Ashgate, Burlington, VT, pp. 1e17. Hutchinson, M., 2009. Restorative approaches to workplace bullying: educating nurses towards shared responsibility. Contemp. Nurse 32 (1e2), 147e155. International Council of Nurses, 2006. Abuse and Violence against Nursing Personnel. Position Statement. Retrieved March 9, 2012 from: http://www.icn. ch/images/stories/documents/publications/position_statements/C01_Abuse_ olence_Nsg_Personnel.pdf. Katrinli, A., Atabay, G., Gunay, G., Cangarli, B.G., 2010. Nurses’ perceptions of individual and organizational political reasons for horizontal peer bullying. Nurs. Ethics 17 (5), 614e627. King-Jones, M., 2011. Horizontal violence and the socialization of new nurses. Creat. Nurs. 17 (2), 80e86. http://dx.doi.org/10.1891/1078:453517.2.80. Kolanko, K.M., Clark, C., Heinrich, K.T., Olive, D., Serembus, J.F., Sifford, K.S., 2006. Academic dishonesty, bullying, incivility, and violence: difficult challenges facing nurse instructors. Nurs. Educ. Perspect. 27 (1), 34e43. Liem, A.D., Lau, S., Nie, Y., 2007. The role of self-efficacy, task value, and achievement goals in predicting learning strategies, task disengagement, peer relationship, and achievement outcome. Contemp. Educ. Psychol. 33, 486e512. Luparell, S., 2011. Incivility in nursing: the connection between academia and clinical settings. Crit. Care Nurse 31 (2), 92e95. Magnavita, N., Heponiemi, T., 2011. Workplace violence against nursing students and nurses: an Italian experience. J. Nurs. Sch. 43 (2), 203e210. McGregor, A., 2005. Enacting connectedness in nursing education: moving from pockets of rhetoric to reality. Nurs. Educ. Perspect. 26 (2), 90e95. Oore, D.G., Leblanc, D., Day, A., Leiter, M.P., Laschinger, H.K.S., Price, S.L., Latimer, M., 2010. When respect deteriorates: incivility as a moderator of the stressor-strain relationship among hospital workers. J. Nurs. Manag. 18, 878e888. http:// dx.doi.org/10.1111/j.1365-2834.2010.01139.x. Paterson, B.L., 1991. The Juggling Act: an Ethnographic Analysis of Clinical Teaching in Nursing Education (Doctoral Dissertation). University of Manitoba. Paterson, B.L., Osborne, M., Gregory, D., 2004. How different can you be and still survive? Homogeneity and difference in clinical nursing education. Int. J. Nurs. Educ. Sch. 1 (1), 1e13. http://dx.doi.org/10.2202/1548-923X.1005. Pope, M.F., 2010. Faculty Bullying: an Exploration of the Leadership Strategies to Reduce Relational Violence in Nursing Schools (Doctoral Dissertation). Available from: ProQuest Dissertations and Theses database. (UMI: 3480182). Randle, J., 2003. Experiences before and throughout the nursing career: bullying in the nursing profession. J. Adv. Nurs. 43 (4), 395e401. Roche, M., Diers, D., Duffield, C., Catling-Paull, C., 2009. Violence towards nurses, the work environment, and patient outcomes. J. Nurs. Sch. 42 (1), 13e22. http:// dx.doi.org/10.1111/j.1547-5069.2009.01321.x. Seibel, L.M., 2007. An Exploration of the Non-reporting of Violent Incidents in Nursing (Master’s thesis). Royal Roads University, Victoria, BC. Sweet, M., 2005. Beating bullying. Aust. Nurs. J. 12 (9), 16e19. Thomas, C.M., 2010. Teaching nursing students and newly registered nurses strategies to deal with violent behaviors in the professional practice environment. J. Contin. Educ. Nurs. 41 (7), 299e308. http://dx.doi.org/10.3928/0022012420100401-09. Thomas, S.P., 2012. Examining nurse-to-nurse horizontal violence and nurse-tostudent vertical violence through the lens of phenomenology. In: Holmes, D., Rudge, T., Perron, A. (Eds.), (Re)Thinking Violence in Health Care Settings: a Critical Approach. Ashgate Publishing Company, Burlington, VT, pp. 143e161. Woelfle, C.Y., McCaffrey, R.M., 2007. Nurse on nurse. Nurs. Forum 42 (3), 123e131.
Please cite this article in press as: Seibel, M., For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.08.013
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences Michelle Seibel* Thompson Rivers University, School of Nursing, 900 McGill Rd., PO Box 3010, Kamloops, BC V2C 0C8, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 29 August 2013
The purpose of this review is to determine what we currently know about faculty bullying of nursing students during undergraduate clinical experiences. The review included 31 peer-reviewed articles and dissertations investigating faculty bullying of nursing students and those factors which can influence the phenomenon. A significant finding of this review is that faculty bullying of students arises out of complex contextual influences involving the practice setting, as well as perceptions and coping strategies of both faculty members and students. This belies the current understanding of bullying within nursing education as intentional, and arising from the personal pathologies of the teacher or student. This has implications for clinical faculty members as well as Schools of Nursing. As well, it highlights future directions for research, including interventions to decrease faculty bullying of students. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Faculty Bullying Nursing Student Clinical education
Bullying by and between nurses in the practice setting is widely acknowledged to be a serious concern in today’s health care system. An extensive body of research has informed anti-bullying strategies that are known to effectively address this concern; however, the extent of workplace bullying in nursing practice continues to escalate (Roche et al., 2009; Woelfle and McCaffrey, 2007). Recently, some authors have suggested that one of the reasons that workplace bullying continues to thrive in nursing practice is that the origins of bullying behaviour exist prior to nurses working in the profession; i.e., bullying begins in undergraduate nursing education (Clark and Olender, 2011; Luparell, 2011; Magnavita and Heponiemi, 2011; Pope, 2010). Recent studies highlight the concerning fact that faculty members are commonly viewed as perpetrators of bullying behaviour towards students (Clarke, 2009; Cooper, 2007; Del Prato, 2010). It is critical that we understand this phenomenon, as it is destructive in terms of student learning and wellness, and also antithetical to our stated intent as instructors. The purpose of this paper is to conduct a critical review of research reports regarding bullying in basic undergraduate nursing clinical education, with a specific focus on faculty roles. Factors that contribute to the perception of faculty members as bullies in the clinical setting will be examined, and strategies to address the issue will be identified. The paper will conclude with a discussion of the implications for nursing education and future research. * Tel.: þ1 250 371 5834; fax: þ1 250 371 5909. E-mail address: [email protected].
Review of the literature Specific types of behaviour are identified as bullying and are highlighted in the literature with startling consistency across professional, educational, and role boundaries. Those who work in specifically in healthcare identify being ignored, humiliated, undervalued, excluded, and receiving negative criticism or evaluation as particularly impactful on their ability to prosper in those environments. Students report the same types of bullying behaviour (Del Prato, 2010; Thomas, 2012). The review of papers and unpublished reports/dissertations is based on the following themes; i.e., systemic factors, faculty-specific and student-specific factors that contribute to the perception of faculty bullying nursing students in clinical settings. First, however, a brief overview of the phenomenon of bullying is needed in order to examine definitions, prevalence, and to understand its significance. Definitions and significance A clear definition of ‘bullying’ is important, as both nurses and student nurses may have difficulty identifying bullying behaviour (Hoel et al., 2007; Seibel, 2007; Sweet, 2005). Bullying is defined herein as both direct and indirect acts of violence that expose the victim to “negative or abusive behaviour, often over a considerable time, where the targets have difficulty in defending themselves” (Hoel et al., 2007, p. 270). This definition highlights both the dimension of time, and the presence of a relational power differential between the victim and the perpetrator.
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.08.013
Please cite this article in press as: Seibel, M., For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.08.013
2
M. Seibel / Nurse Education in Practice xxx (2013) 1e4
The consequences of bullying for nurses and nursing students are decreased job satisfaction and commitment, attrition, as well as overall decreased physical and mental health (Katrinli et al., 2010; Oore et al., 2010). There is no direct correlation between severity of bullying or violent behaviour and its effects on the recipients (Flannery, as cited in Ferns and Meerabeau, 2007; Holmes et al., 2012). In nursing practice, patient safety outcomes are compromised by hostile working conditions (International Council of Nurses [ICN], 2006; Roche et al., 2009). As students are typically on the lower end of hierarchical structures in healthcare and education, they are exceptionally vulnerable to bullying (Clarke, 2009; Hoel et al., 2007).
in which they have competence as novice faculty (Cederbaum and Klusaritz, 2009). Nursing faculty typically rise up through the ranks of nursing, first attaining professional competence and then graduate degrees and then engaging increasingly in academic life, and while they may be experts in a particular field of nursing, they are not necessarily expert instructors (Cangelosi et al., 2009; Clarke, 2009; Cooper, 2007). Benner et al. (2010) concluded that lack of teaching experience and knowledge leads to ambiguity about the role, and not knowing if what they observe in students is to be considered normal, what action to take when concerned about students’ performance, and the appropriate avenues to seek guidance about their role.
Systemic factors
A balancing act Due to the fact that clinical faculty typically do not work as nurses on the unit, they are often considered outsiders. Inherent in this dynamic are struggles that involve territory, competing priorities, and varying expectations. Faculty are considered ‘guests in the house’ in the clinical arena and as such are limited in their influence and rights within that setting (Glass, 1971). Clinical faculty attempt to mediate these variables, maintain functional working relationships with staff and provide a positive learning experience for their students. At times, this results in faculty behaviour that may be perceived by students as bullying; e.g., a faculty member who tries to keep the clinical staff ‘happy’ by restricting students’ access to patients’ charts risks complaints of bullying by students (Paterson, 1991). Finding a balance between the providing students support and challenge, being directive but allowing students to shape their practice, and leading but allowing the student to exercise leadership can contribute to faculty stress and the perception by students that their needs are being overlooked (Del Prato, 2010). For example, students commonly perceive written clinical assignments as onerous, yet these are also helpful to their learning and developing practice; faculty who are novice may emphasize the necessity of the written work without having the skill and experience to understand that students need support to be able to understand the benefits of such assignments (Benner et al., 2010).
There is a significant body of research that correlates the incidence of bullying in nursing with stressors inherent in the workplace environment and within healthcare (Oore et al., 2010; Roche et al., 2009). Hodgins (2008) proposes that, “individual[s] cannot be treated in isolation from the larger social unit or system in which they operate” (p. 17). Consequently, when nursing students are present within a clinical agency or the academic institution, they may be victims of bullying that is a symptom of organizational stress. Hoel et al. (2007) propose that increased workload in a clinical area negatively impacts the student experience, as increased unit stress results in deteriorating interpersonal interactions. Negative socialization experiences within the profession perpetuate the problem of bullying as these learned behaviours and negative coping mechanisms are repeated post-graduation (KingJones, 2011; Randle, 2003; Thomas, 2010). Other perspectives on bullying include the application of oppressed group theory, which describes nurses as a subjugated group, and postulates that the struggle to achieve status in the profession includes the reinforcement of negative behaviours (Freire, 1972). By extension, nursing faculty members have been socialized into the profession, and some promote the belief that bullying behaviours from coworkers are to be expected. In this context, bullying behaviours actually serve a purpose in that they help to establish such behaviours and their influence as normative within the workplace and the profession (Katrinli et al., 2010). It is this normalizing of bullying that is troubling, and likely influences the passive and resigned manner in which nurses often respond to bullying (Ferns and Chojnacka, 2005; Katrinli et al., 2010; Seibel, 2007). Randle (as cited in Sweet, 2005) states, “traditional approaches to nurse education have helped [to] entrench bullying behaviours, so that each new generation of nurses becomes socialized to regard it as normal” (p. 16). Within schools of nursing, the failure to address bullying can inadvertently lead to a culture of tolerance towards inappropriate conduct (Clark et al., 2009) i.e., it communicates the message that it is a legitimate means to express a point of view or opinion (Clark and Olender, 2011; Sweet, 2005). Faculty factors Numerous factors influence individual faculty members’ approaches to clinical nursing education, as well as how they perceive and address practice issues among students. Among these are a lack of knowledge and understanding of the clinical teaching role, and the requirement to mediate between various parties and expectations within the clinical setting. Lack of knowledge/preparation Faculty must communicate expectations and address disciplinary issues as they arise within clinical nursing education (Kolanko et al., 2006); however, this is not typically something they
Teaching goals, values and ideals Clinical faculty often have ideas about what a nurse should be, look like, and act; their willingness to embrace alternate styles shapes how they respond to students who are different from this perspective (Cederbaum and Klusaritz, 2009; Forbes, 2010; Paterson et al., 2004; Pope, 2010). For example, if faculty highly value caring, and perceive a student to be uncaring, this is likely to cause conflict between them (Forbes, 2010). Faculty ideals of the perfect nurse may include any aspect of the students’ person, including gender, ethnicity, age, and sexual orientation (Cangelosi and Moss, 2010; Paterson et al., 2004). One consequence of faculty preferring a certain type of student to others is favouritism. Faculty may perceive some students as better than others because they are congruent with faculty’s perspectives of the ideal nurse or student. This results in faculty evaluating these students with a less than critical eye (Del Prato, 2010; Pope, 2010). Faculty may single out students who do not comply with either their personal or larger professional norms and identify them as students who need more focused attention (Pope, 2010). Intense scrutiny typically upsets students, increases their chances of making mistakes, and has an overall negative effect on student confidence and development (Del Prato, 2010). Student factors Multiple factors can influence how faculty’s behaviour is perceived or interpreted by a student, including whether or not a
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student feels cared for, respected, and interpersonally connected to the instructor. Also, the students’ self-image affects their subsequent response to feedback as feelings of potential threat such as clinical failure. Caring and respect The perception of connectedness to faculty or lack thereof is described as a major contributor to students’ positive and negative clinical experiences respectively (Del Prato, 2010; McGregor, 2005; Pope, 2010). If clinical instructors do not make time to meet with students and discuss their concerns, students often view this as evidence of incongruence with core educational program values such as caring and respect, which can lead to disillusionment with the profession and educational goals, as well as accusations of faculty bullying (Benner et al., 2010; Del Prato, 2010). Students who feel that faculty expectations are impossibly high will become discouraged and/or disengaged and these faculty members are often perceived as bullies (Del Prato, 2010; Cooper, 2007). Although students may feel that faculty practices or expectations are unreasonable, few “would dare protest or complain, particularly when they rely on good reports for their professional progression” (Hoel et al., 2007, p. 276). Students often feel powerless to challenge faculty practices, and believe that such behaviour will make them targets of the clinical instructor (Del Prato, 2010). Learning, evaluation and formation Faculty’s focus on evaluation, rather than learning, may result in students viewing faculty as bullies (Cooper, 2007; Del Prato, 2010). This is particularly an issue in the execution of psychomotor skills produces where a faculty member closely scrutinizes the student’s performance. If students make errors during the skill performance, faculty tend to increase their surveillance of the student’s performance. This leads to further errors and to heightened anxiety on the part of the student in future skill observation situations (Del Prato, 2010, p. 108). Students are particularly susceptible to experiencing increased anxiety and perceptions of faculty bullying when the faculty member has a reputation of failing students or being excessively harsh in judgements about previous students. They are also susceptible in times when they experience a crisis of confidence or question whether they should really be a nurse; at such times, students are highly vulnerable to negative feedback. Bonnel (as cited in Del Prato, 2010) proposes that all feedback should respect student dignity and self-esteem, and that “angry, belittling, or demeaning words are never justified.” (p. 139). Ego-defense mechanisms Students may respond to negative feedback from a faculty member by incorporating it to positively influence and change their practice, or alternatively withdraw in order to protect themselves from a sense of failure (Cederbaum and Klusaritz, 2009). Various authors describe such behaviours as ego-defense mechanisms, and confirm the connection between motivation, engagement, and affective states (D’Mello and Graesser, 2012; Liem et al., 2007). Those students who see negative feedback as a threat may resort to maladaptive coping strategies in order to preserve their sense of self (Cederbaum and Klusaritz, 2009, p. 427). Such mechanisms may include denial and deflection, where the blame for the unpleasant situation is shifted back to the person who caused the negative emotion (here, the faculty member), which allows the student, at least temporarily, to avoid examining his/her performance. While some educational experts propose that a cognitive and/or emotional disequilibrium is needed for deep learning, it is the presence of internal motivators and locus of control that determines how the student proceeds from this state of confusion and
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is ultimately successful or defeated in their learning (D’Mello and Graesser, 2012). Van Lehn (as cited in D’Mello and Graesser, 2012, p. 155) proposes that it is the tutor or instructor’s role to manage this confusion in order for it to benefit the learner, or the student could become frustrated and disengage from the situation. Summary The review of the relevant literature has highlighted bullying within nursing education as a highly complex and multifaceted concept. This belies much of the current understanding of bullying within nursing education as entirely intentional, arising from the personal pathology of the teacher and remedied by prohibitions and restrictive policies. Although there are implications for students in this review, the discussion will focus only on faculty implications. As well, I will identify implications for future research in this field of study. Discussion It is apparent in this review of the literature that the solutions to bullying within nursing education must account for the multiple ways in which bullying is a symptom of the stressors associated with being a faculty member. Providing faculty in-service or instruction would help to address some of the current issues in nursing education that perpetuate faculty-student bullying. Schools of Nursing should provide ongoing orientation and mentorship for at least a year to new faculty about topics related to teaching including bullying. Newly hired faculty members need mentoring and support about appropriate levelling of expectations and good teaching practices. Sharing this review with faculty could foster dialogue about their experience and lead to further recommendations for faculty support and development. Opportunities such as this could be provided on a variety of commonly encountered topics and issues, and lead to group problem-solving. Clinical faculty need opportunities to share with each other about the stressors they experience and how to mediate these. This may include specific cases or general issues that arise. Although this kind of informal support is natural and to varying degrees occurs organically within schools of nursing, there exists a need for more formal systems of support. Offering informational and instrumental support to faculty experiencing stressors that perpetuate bullying can be integrated as the norm within the school; for example, faculty dealing with a student’s clinical performance difficulties can be provided information about how to assist the student, as well as emotional support throughout the process. Anti-bullying training should be provided to students and faculty alike (Roche et al., 2009). A zero-tolerance policy towards bullying and other violent behaviours provides a statement of intent towards those involved with incidents of bullying, and also provides a rationale and policy on which both educational interventions are provided, and progressive discipline might be enforced (Sweet, 2005; Hutchinson, 2009). Hutchinson (2009) argues that violence continues to escalate in healthcare institutions despite zero tolerance policies, and questions their effectiveness. However, it is important to publicly acknowledge that a problem exists and that the organization does not condone the behaviour. Students and faculty should also be reminded that, “in a sometimes overlooked portion of the Code of Ethics. [nurses must] in all professional relationship and in all encounters, including those with colleagues, act with respect” (Luparell, 2011, p. 94). Schools of nursing should also implement a fair, consistent, and transparent way to address complaints of bullying. This review highlights the need for research in various aspects of the phenomenon of faculty bullying of students. Some of these
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needs include: 1) an examination of the efficacy of specific interventions in reducing faculty bullying of students (e.g., education, mentoring etc); 2) exploration of faculty members’ perceptions and experiences of being charged with bullying and reflecting on experiences that students have interpreted as bullying. Such research would contribute toward a model that could be used to generate interventions to mediate faculty bullying; 3) investigations of interventions to assist students to develop ego-enhancing or sustaining ways when confronted with feedback or situations in which their performance is less than they desire; and 4) studies that examine the attributes of faculty who are most inclined to bully students and to explore the relationship of these attributes to the actual incidence of faculty bullying; e.g., do novice teachers bully more than expert teachers and if so, what contributes to this phenomenon? It is clear that this field of research is in its infancy and much more must be learned about the phenomenon of facultystudent bullying in order to identify strategies to prevent and mediate it. Conclusion Faculty bullying disrupts learning, and perpetuates itself and other forms of violence within the nursing profession. It is also incongruent with stated professional nursing and program values, and can ultimately contribute to attrition of students from nursing programs, and nurses from the profession. This paper has presented a review of relevant literature pertaining to faculty bullying of nursing students. It has raised a number of issues and possible directions for nursing education and nursing research in the future. In addition, it has identified a number of possible solutions to prevent and mediate faculty bullying within nursing education. Ideally, faculty bullying of students will shortly become a phenomenon that is spoken of in history as a thing of the past. As nurse educators, we are obligated to reflect on and explore our individual and collective contributions to this reality. References Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: a Call for Radical Transformation. Jossey-Bass, San Francisco, CA. Cangelosi, P.R., Crocker, S., Sorrell, J.M., 2009. Expert to novice: clinicians learning new roles as clinical nurse instructors. Nurs. Educ. Perspect. 30 (6), 367e371. Cangelosi, P.R., Moss, M.M., 2010. Voices of faculty of second-degree baccalaureate nursing students. J. Nurs. Educ. 49 (3), 137e142. Cederbaum, J., Klusaritz, H.A., 2009. Clinical instruction: using the strengths-based approach with nursing students. J. Nurs. Educ. 48 (8), 422e428. http:// dx.doi.org/10.3928/01484834 20090518e01. Clarke, C., 2009. The Effects of Bullying Behaviours on Student Nurses in the Clinical Setting (Master’s thesis). Available from: ProQuest Dissertations and Theses database, ISBN 978-0-494-73653-1. Clark, C.M., Farnsworth, J., Landrum, R.E., 2009. Development and description of the Incivility in Nursing Education (INE) survey. J. Theor. Constr. Test. 13 (1), 7e15. Clark, C.M., Olender, L., 2011. Fostering civility in nursing education and practice: nurse leader perspectives. J. Nurs. Adm. 41 (7/8), 324e330. Cooper, J.R.M., 2007. A Survey of Students’ Perceptions of Bullying Behaviors in Nursing Education in Mississippi (Doctoral Dissertation). Available from: ProQuest Dissertations and Theses database. (UMI: 3275008). Del Prato, D.M., 2010. The Lived Experience of Associate Degree Nursing Education: Conditions and Barriers in the Learning Environment that Shaped Students’ Learning, Identity Development, and Success (Doctoral Dissertation). Available from: ProQuest Dissertations and Theses database. (UMI: 3429053).
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Please cite this article in press as: Seibel, M., For us or against us? Perceptions of faculty bullying of students during undergraduate nursing education clinical experiences, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.08.013