Research Article, Int J Ment Health Psychiatry Vol: 5 Issue: 1
Underreporting Bullying and Harassment Perceived by Undergraduate Nursing Students: A Descriptive Correlation Study
Community and Mental Health Department Office, Sultan Qaboos University, Muscat 123, Oman
*Corresponding Author : Mohammad Qutishat
Community and Mental Health Department Office, Sultan Qaboos University, Muscat 123, Oman
Tel: +(968) 98190164
E-mail: [email protected]
Received: March 28, 2019 Accepted: April 29, 2019 Published: May 13, 2019
Citation: Qutishat M (2019) Underreporting Bullying and Harassment Perceived by Undergraduate Nursing Students: A Descriptive Correlation Study. Int J Ment Health Psychiatry 5:1. doi: 10.4172/2471-4372.1000169
Objective: Reporting bullying and harassment among nursing students is crucial in maintaining a healthy learning environment and improving patient’s quality of care as well since the experiencing bullying and harassment in clinical settings is a worldwide phenomenon. We sought to investigate the extent of the bullying and harassment underreporting pattern perceived by nursing students in clinical settings. Method: A descriptive correlational design was used. A sample of 161 undergraduate nursing students was recruited from Sultan Qaboos University in Oman; the questionnaire consisted of Student Experience of Bullying during Clinical Placement (SEBDCP) and student’s socio-demographic background. Results: 161 undergraduate students participated in this study, the majority of the participants were female (82.6%), single (88.2%), lived in campus (68.9%), and studying in their 5th academic year (29.2%). Overall, 61.4% of our students had experienced bullying at least once during their clinical training, however, 27.8% of bullied students have reported the violent behaviors officially, 70.4% of them reported to college faculty. Almost half these issue was solved to student’s satisfaction, the main reason for not reporting among bullied students was considering it as a part of their job (61.11%). The majority of the students are not aware of policies that address bullying and harassment in their clinical settings both in college (60.2%) and clinical settings (65.2%) respectively. Conclusion: bullying and harassment among nursing students are significantly underreported. Addressing such phenomena nursing practice is crucial to raise the awareness of it and to develop processes for valuable reporting and investigating the problem holistically highlightin
Keywords: Bullying; Harassment; Nursing students; Workplace violence; Reporting
Violence in the workplace has been raised many decades ago, with great interest among the employers, health care system, and governmental organization to explore its epidemical growth worldwide . Health care providers are facing more violent behaviors than ever before. Nurses are superior of all health multidisciplinary team to expose the enormous acts of such behaviors .
Bullying and harassment are emotional issues faced by nurses students during their clinical practice and have negative impacts on their psychosocial well-being , it also refers to “situations where a person repeatedly and eventually feels subjected to negative treatment on the part of one or more persons, and where the person(s) exposed to the treatment have difficulty in defending themselves against these actions”  that occur due to the negative interactions that expressed through aggression, criticism, monitoring, and social isolation, and mostly changes over students’ learning years .
It has been estimated that more than half of the health care workers, including nurses had experienced at least one incident of violent behaviors during their life career, either physically or emotionally . In the healthcare system, Nurses experience more such behaviors than any other healthcare provider .
Similar to registered nurse, nursing students are vulnerable to different categories of violence in their clinical training , due to poor educational environment, limited experiences, insufficient knowledge and skills, accelerated academic load and responsibilities, less awareness of culture norms and care, dissatisfaction toward self, poor clinical support, and the vision that nursing, in general, are inferior to other health professions like medicine or pharmacy .
As soon as the students move toward the actual training courses, either in hospital or community, they are now responsible for communicating with a health care multidisciplinary team, patients, families, administrators, and workers, in addition to their instructors and colleagues based on their different perceptions and backgrounds, nursing students might have access to some medications, provide care to people in different health conditions, and take care to terminally ill patients, therefore, being a student nurses means to have the chance to greater exposure to violent behaviors, which are mainly oppressed by, health team workers, colleagues, patients, and visitors in different settings such as medical wards, mental health wards, surgical units, emergency, and others [8,10].
The consequences of such images may lead the superior group in this society to control and interpret the behavior, values, experience, and achievement of those students and labeling them based on their capacities. As a result, the oppressed students might feel more aggressive toward the oppressor, belittling their feeling inside, and reinforce the belief that they are inferiors [1,11], whereas some students may perpetuate its cycle and repeat these behaviors in their future careers .
Reporting clinical bullying and harassment among nursing students through higher standard nursing learning outcome, confident speaking, and effective communication are essential to reduce the prevalence of such behaviors violence . As a bullying culture, that is, one where such behaviors are known to be norms and accepted by those in power, and the sense that the workplace is unsafe enough, the bullying and harassment will be acknowledged , Students, they may feel unable to handle abusive situations, do nothing, put up barriers, or even may engage in some unhealthy coping behaviors such as smoking, drinking or taking drugs , Yet, there is a little known about nursing students’ beliefs about reporting, and responding to bullying, particularly in Oman. Understanding these aspects may provide important information from which interventions can be developed. The aim of this paper is to determine the extent of underreporting bullying and harassment perceived by nursing students in clinical settings.
This study was conducted at the college of nursing-Sultan Qaboos University. A descriptive, correlational, and cross-sectional research design was utilized. This study utilized all nursing students in the college of nursing at Sultan Qaboos University a convenience sample was used, and the sample size was detected by using power analysis, 220 participants were estimated with an effect size of 0.5 (α=0.05, P=0.80).
Approval was obtained from the Research Ethics Committee of the College of Nursing at the Sultan Qaboos University (SQU). The students who agreed to participate in this study received a consent form explaining all required information, and ethical considerations regarding this study. After ethical approval was obtained, the students E-mail list was provided by the college administration office, a sample of 220 participants were selected randomly, an E-mail was sent to students inviting them to participate in the study in which the study purpose, design, benefits, voluntary participation, and withdrawal were extremely explained, students were also informed also that the questionnaire would not take more than 20 minutes to be completed, and once they finished, they could return it back via E-mail. No students’ identification information was collected. The survey was collected over 3 months, October 2018-December 2018.
Data were collected using a self-administered questionnaire at the college of nursing, SQU. The sample consisted of 161 undergraduate students who met the eligibility criteria, including students who were willing to participate in the study, studying in the bachelor degree, had completed their foundation program (English, computer skills, and mathematics), and had started their clinical training courses as well.
A self-report instrument was used in this study to achieve the research goals and it is divided into two sections: (1) demographical data and (2) the Student Experience of Bullying during Clinical Placement (SEBDCP) questionnaire. In the section for demographic data, the students were asked about their gender, age, level of academic years, and type of education program and others. The second section is the Student Experience of Bullying during Clinical Placement (SEBDCP) questionnaire, this questionnaire was adapted from the effort of Hewett (2010), who developed it by testing bullying experience among 218 undergraduate nursing students in South Africa. Content validity of the original tool was measured via a pilot study. The original survey composed of five sections with 66 individual items based on workplace bullying and harassment including intimidation, bullying or verbal abuse, non-physical violence, and reporting and management of workplace violence. The questionnaire mainly used closed-ended questions that are rated using a 4-point rating scale 1] ‘Never’ (0 times);  ‘Occasionally’ (1-2 times);  ‘Sometimes’ (3-5 times) and  ‘Often’ (>5 times) . Permission was obtained from the author to use the SEBDCP questionnaire via an E-mail.
The Statistical Package for the Social Sciences (SPSS 23) at the 0.05 level of significance was used. The mean and percentage were used to describe the results; chi-square was performed to determine the major statistical differences between the variables.
Out of the 220 distributed questionnaires, 183 undergraduate students who were enrolled in a bachelor program at Sultan Qaboos University completed and returned the questionnaire, giving a response rate of 74%. 161 students have met the research criteria, the sample was selected on convenience, and students were assured of their anonymity and confidentiality through the consent form sent by E-mail. The survey took 20 minutes to be completed and was approved by the IBR committee prior to data collection. The age of the respondents ranged from 18 to 25, and the mean age was 21.7 years. The majority of the participants were female (82.6%), single (88.2%), lived on campus (68.9%), and studying in their 5th academic year (29.2%). Overall, 61.4% of our students reported that they had experienced bullying or harassment behaviors at least once during their clinical training, 14.3% indicated that they are not sure about such experiences and 24,2% reported that they didn’t experienced any kind of such behaviors at all, whereas 23.% of the students reported that they occasionally witnessed of violent behaviors among other nursing students compared to 9.3% who reported it sometimes, and 1.2% as often, indeed the study indicated a significant differences between academic year, marital status (p=0.006) and bullying reporting (p=.000), whereas was no significant differences between students age and reporting (p=0.200), as well as gender and reporting (p=0. 835). On the other hand (Table 1).
|Demographic variable||Number||Percentage||Degree of freedom||Chi-square result:
Significant with bullying reports
|18-29 Years||97||60.25||Not significant
|In Campus||111||68.9||Not significant
|Out of Campus||50||31.1||2|
Table 1: Distribution of underreporting bullying experiences among students’ demographical variables.
The majority of students experienced these behaviors in hospital (52,52%) followed by community settings (32.33%), further, the main source of bullying among nursing students in clinical settings were other students (28.28%) followed by patients (18%) and doctors (14.14%), the most common type of bullying perceived by the students were emotional (33.33%) followed by sexual (27.28%), where are leaving the profession became the most common consequences of such behaviors (31.31%), the study indicated no significant differences in reporting bullying and harassment among different training sites (p=0.102), type of bullying (p=0.092), and source of that bullying (p=0.506) (Table 2).
|Demographic variable||Number bullied behaviors||Percentage||Number of unreported case||Percentage of underreporting
|Degree of freedom||Significant with bullying reports|
|Training settings|| Not Significant
|Other health team||12||12.12||9||75||9|
|College faculty /Instructors||6||6.06||6||100|
|Type of bullying|
Table 2: Distribution of underreporting bullying experiences among bullying behaviors characteristics.
Our result also shows that 27.8% of bullied students identified in this study has reported the violent behaviors compared to 72.2% who didn’t, the majority of bullied students reported that behaviors to their college faculty (70.4%), and college administrators 14.8%, 51.86% of them indicated that their issue was solved to their satisfaction, 14.8% the issue was not solved to their satisfaction, and 22.22% the issue wasn’t solved, the main reason for not reporting among bullied students were considering it as a part of their job (61.11%), and afraid of becoming victimized 18.05) (Table 3).
|Reporting bullying and harassment|
|To whom students reported|
|Action after being reported|
|The issue was resolved to my satisfaction||14||51.86|
|The issue was not resolved to my satisfaction||4||14.8|
|No action was taken||6||22.22|
|Unsure if action was taken||3||11.12|
|The reason for being not reported|
|It is part of the job||44||61.11|
|Nothing will be done about||7||9.72|
|Afraid of being victimized||13||18.05|
Table 3: Bullying and harassment reporting pattern
In regard to students awareness about policies available to handle such issues in college as well as clinical settings, the majority of the students reported that they are not aware of such policies that address bullying and harassment in their clinical settings both in college (60.2%) and clinical settings (65.2%) respectively (Figure 1).
Across the study results, which are representative of 161 students, The current study corroborates the findings of previous studies that indicated nursing students is exposed to high rates of bullying that has a tendency to adverse consequences on performance, health conditions, and delivery of care . Although nursing students indicated a high level of bullying experiences, they also reported occasionally witnessed of such behaviors in their last academic year (23%) compared to approximately 40% in previous studies . Indeed, 37.5% of the bullied students reported such behaviors compared to 62.5% who didn’t, which is approximately similar to previous works that examined this phenomenon among the nursing profession . Students in our results claimed these issues mostly to their clinical instructors (70.4%) and college administrators (14.8%), who can play role model of effective conflicts resolutions and effective feedback, that are required to preserve the ego of the students, resulting in open communication flow . Faculty who role-model misuse of power, poor feedback delivery, unable to address bullying, and unable to protect their students may leave the students with negative perceptions that bullying is so far accepted and as a part of the nursing profession . Approximately half of reported cases (51.86%) were solved to the satisfaction of nursing students, whereas, one quarter of the students indicated that no action was done to solve their issue which is slightly lesser than other previous findings , this may due to the absence of special policies regarding workplace violence in clinical training settings , or the unawareness of such policies as shown later in our results.
Many works of literature declared that bullying and harassment among the nursing profession is underreported , Among those who didn’t report the experiences of bullying and harassment in our study (62.5%), 40.3% indicated that the main reason for not reporting is considering bullying as a part of job, afraid if being victimized (36.11%), and nothing will happen (16.67%). inconsistency with this line , found that nurses who agreed that bullying is expected part of their job reported significantly fewer violence incidents documentations, further, According to Roberts et al. , nurses are more likely to be “good nurses” making themselves silence in order to avoid conflicts with others, this will undervalue their contributing effort in patients’ health care, affect their social life and quality of care, erupt job stress, increase job dissatisfaction and increase missed working days, and create conditions of unfairness and exploitation, call them to leave the profession.
Kassem  found that nursing students are probably not reporting such behaviors due to their insufficient skills to deal with it, and due to the phenomena that they perceived themselves as powerless to change bullying behaviors, thus, students identify these behaviors as a part of their job, less important to be reported, and required to reach its threshold of when such behaviors to be formally reported , students then act as nothing happened and avoid seeking assistance from professional parties  and avoid negative consequences . The findings of this study demonstrate that bullying and harassment among nursing students are such a normalizes and endemic, in which nurses may excuse such behaviors for the continuum of care leads to avoid reporting process .
In regard to students’ socio-demographic variables, neither age, gender, nor living arrangements, pointed towards a relationship with reporting bullying experienced by nursing students which are supported by previous studies , On the other hand, our results highlight significant differences in reporting bullying experiences among students marital status and academic years, single students seem not to report such behaviors more frequently than married (90.2% and 9.8% respectively). Studies in that claim found that the majority of nurse’s experiences bullying and harassment in clinical settings are single in which insufficient social support can contribute negatively to nursing profession commitment and violence declaration [28-30]. Further, student nurses in their 5th academic year were more likely to avoid reporting bullying and harassment than others, the less the students engaged in clinical practice the higher tendency of reporting bullying, 2nd years students are more likely to be overwhelmed by bullying behaviors and its natural process. Later, across the study journey, students may find themselves as an inevitable target, and no longer accept these behaviors as a part of being a profession , a result of such behaviors, violence becomes a fact of nursing career, and students are now unable to obtain trust by those oppressors and may exclude deliberately from patients’ care plan, useful learning discussion, and social interaction .
The result of this study postulated no significant differences in reporting bullying and harassment among different training sites, bullying types and bullying source, despite the results, it seems that the majority of bullying behaviors in hospitals were underreported (80.77%) followed by community settings (71.87%) and college (15.28%), as well as when it comes to emotional and sexual bullying 81.81% and 74.07% respectively. It seems that students don’t define the term of violence unless it cause physical harm, students, as well as staff, are obviously expected these behaviors to have their job completed properly, and to make sure the quality of care is not affected, thus, if these behaviors are not expected and tolerated resulting in perceiving harm, it is then logically reported . Similar to our results, literatures declared that sexual and emotional bullying among the nursing discipline is underreported [15,25], this may due to the phenomena that such behaviors are sensitive issues be openly expressed to others , In the face of emotional or sexual harassment, properly most of the nursing students address these issues passively on their own. For example, they might choose to adjust themselves instead to express their emotion to high authority that can be either embarrassed or inexperienced or unfair to handle it properly . Students in our sample avoid reporting bullying and harassment when the oppressors are either their instructors or college faculty (100%) followed by their colleagues (78.57%). Studies found out that the roots of bullying and harassment in the nursing workplace is in original come from the academic settings , where are some faculty members may critically judge on their students, critique their achievement, deny acknowledgment for good work, given unfair learning allocation, or denied learning opportunities, this may result in student frustration and powerlessness, therefore, of the power imbalance, they believed there were too much to lose if they raise their hands up to argue or confront faculty , thus, the bullied is on, students may lose trust with their teachers and project such experiences ultimately to themselves or colleagues .
A concerning issue regarding bullying policies is also being addressed in this study, surprisingly, more than 60% of the students in our results are were not aware of bullying and harassment policies either in the college of clinical settings. These results are congruent with other previous studies that showed the majority of nurses are not aware of anti-bullying policies . Procedures and policies for reporting violence among nursing students as well as staff should be clear and consistent, students should have access to medical care and counseling if needed . Bullying and harassment among nursing students are significantly underreported and has been associated with many factors. Addressing bullying and harassment in practice is crucial to raise the awareness of its existence to move beyond describing bullying behaviors encountered by nursing students and develop processes for valuable reporting and investigating the problem and its impact on students pursuing careers in nursing. Policies to formulate should address the following recommendations for both college of nursing and clinical training settings:
Establish workplace committee consist of students, college faculty and admins, clinical sittings stakeholders to create and modify existing strategies that prevent any form of violence and enhance its reporting system.
Establishing a clear procedure for reporting such as incidents reports in a confidential, respectful and supported manner.
Produce a risk assessment sheet to identify potential behaviors contributed to such behaviors and the situation that can lead to it.
Provide nursing students with aggression de-escalating training program as well as healthy coping strategies, communication skills, and positive attitude.
Include standardized violence management practice in the nursing curriculum to facilitate the process of recording these behaviors in clinical settings.
Reassure/remind all nursing students of the Provision the American Nurses Association Code of Ethics which are congruent with local culture and believes with Interpretive Statements.
Nursing students do encounter bullying and harassment through their learning journey, leaving them feeling powerless, frustrated, and rethinking about their future learning opportunities, Overall, 61.4% of our students had experienced bullying at least once during their clinical training, however, 27.8% of bullied students have reported the violent behaviors officially, making half these issue completely solved to student’s satisfaction. The majority of the students are not aware of policies that address this phenomenon, therefore, school of nursing can hold the keys to modifying the learning environment to facilitate respectful and dynamics interactions related clinical learning settings.
First, the questionnaire items related to bullying and harassment experiences were retrospective in nature (past year) this may result in some bias, further research should address this issue and seek to extend the findings of this study, second, the proportion of male students in the sample was small to permit the exact explanation of relationship among some research variables, future research may investigate that properly, third, the definition of bullying and harassment may differ culturally, some of the terms may be misinterpreted though online survey, in which students may or may not have considered a behavior to be bullying or harassment in that given situation.
- Hinchberger PA (2009) Violence against female student nurses in the workplace. Nurs Forum 44: 37-46.
- Tee S, Özçetin YSÜ, Russell-Westhead M (2016) Workplace violence experienced by nursing students: A UK survey. Nurse Educ Today 41: 30-35
- Palaz S (2012) Turkish nursing students’ perceptions and experiences of bullying behavior in nursing education. J Nurs Educ Pract 3: 23
- Einarsen S, Hoel H, Cooper C (2003) Bullying and emotional abuse in the workplace: International perspectives in research and practice. CRC Press, London
- Curtis J, Bowen I, Reid A (2007) You have no credibility: Nursing students’ experiences of horizontal violence. Nurse Educ Pract 7: 156-163
- WHO (2002) Workplace Violence Threatens Service. World Health Organisation. Accessed on: 15 February 2019
- Hahn S, Zeller A, Needham I, Kok G, Dassen T, et al. (2008) Patient and visitor violence in general hospitals: a systematic review of the literature. Aggress Violent Behav 13: 431-441
- Özcan NK, Bilgin H, Tülek Z, Boyacioglu NE (2014) Nursing Students' Experiences of Violence: A Questionnaire Survey. J Psychiatr Nurs/Psikiyatri Hemsireleri Dernegi 5: 49-56
- Ferns T, Meerabeau L (2008) Verbal abuse experienced by nursing students. J Adv Nurs 61: 436-444
- Clarke CM, Kane DJ, Rajacich DL, Lafreniere KD (2012) Bullying in undergraduate clinical nursing education. J Nurs Educ 51: 269-276
- Dong D, Temple B (2011) Oppression: A concept analysis and implications for nurses and nursing. Nurs Forum: 43: 169-176
- Barber C, Dague R, McLaughlin T, Mullen E, Scott J (2017) Horizontal violence among nursing students in the clinical setting. The National Conference On Undergraduate Research, Tennessee
- Jones AL (2017) Experience of protagonists in workplace bullying: An integrated literature review. Int J Nurs Clin Pract 4: 246-252
- Cooper JR, Walker J, Askew R, Robinson JC, McNair M (2011) Students' perceptions of bullying behaviors by nursing faculty. Issues Educ Res 21: 1-21
- Budden LM, Birks M, Cant R, Bagley T, Park T (2017) Australian nursing students’ experience of bullying and/or harassment during clinical placement. Collegian 24: 125-133
- Higazee M, Rayan A (2017) Consequences and control measures of workplace violence among nurses. J Nurs Health Stud 2: 22
- Samir N, Mohamed R, Moustafa E, Abou Saif H (2012) Nurses' attitudes and reactions to workplace violence in obstetrics and gynecology departments in Cairo hospitals. East Mediterr Health J 18: 198-204
- Hattie J, Timperley H (2007) The power of feedback. Rev Educ Res 77: 81-112
- Seibel LM, Fehr F (2018) "They can crash you": Nursing student experiences of bullying and the role of facultyJ Nurs Educ Practice 8: 66-76
- Rayan A, Qurneh A, Elayyan R, Baker O (2016) Developing a policy for workplace violence against nurses and health care professionals in Jordan: A plan of action. Am J Public Health Res 4: 47-55
- Abdellah RF, Salama KM (2017) Prevalence and risk factors of workplace violence against health care workers in the emergency department in Ismailia, Egypt. Pan Afr Med J 26: 1-8
- Copeland D, Henry M (2017) Workplace violence and perceptions of safety among emergency department staff members: experiences, expectations, tolerance, reporting, and recommendations. J Trauma Nurs 24: 65-77
- Roberts SJ, Demarco R, Griffin M (2009) The effect of the oppressed group behaviors on the culture of the nursing workplace: A review of the evidence and interventions for change. J Nurs Manag 17: 288-293
- Kassem AH (2015) Bullying behaviors and self efficacy among nursing students at clinical settings: Comparative study. J Educ Practice 6: 25-36
- Gaihre S, Regmi S, Shrestha P (2018) Experience of sexual harassment among nursing students in clinical settings in private nursing colleges in Kathmandu Valley. Glob J Med Public Health 7: 1-9
- Hogarth KM, Beattie J, Morphet J (2016) Nurses’ attitudes towards the reporting of violence in the emergency department. Australas Emerg Nurs J 19: 75-81
- Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, et al. (2015) Underreporting of workplace violence: Comparison of self-report and actual documentation of hospital incidents. Workplace Health Saf 63 200-210
- Azim MT, Islam MM (2018) Social support, religious endorsement, and career commitment: A study on Saudi nurses. Behav Sci 8: 8
- Pandey M, Bhandari TR, Dangal G (2017) Workplace violence and its associated factors among nurses. J Nepal Health Res Counc 15: 235-241
- Zhao S, Liu H, Ma H, Jiao M, Li Y, et al. (2015) Coping with workplace violence in healthcare settings: Social support and strategies. Int J Environ Res Public Health 12: 14429-14444
- Madison J, Minichiello V (2004) The contextual issues associated with sexual harassment experiences reported by registered nurses. Aust J Adv Nurs 22: 8-13
- Sang RKA, Kemboi JK, Omenge RO (2016) Sexual harassment among university students within the University of Eldoret, Uasin Gishu county, Kenya. J Dent Med Sci 15: 142-151
- Misawa M (2015) Cuts and bruises caused by arrows, sticks, and stones in academia: Theorizing three types of racist and homophobic bullying in adult and higher education. Adult Learn 26: 6-13.
- Albashtawy M (2013) Workplace violence against nurses in emergency departments in Jordan. Int Nurs Rev 60: 550-555
- Teymourzadeh E, Rashidian A, Arab M, Akbari-Sari A, Hakimzadeh SM (2014) Nurses exposure to workplace violence in a large teaching hospital in Iran. Int J Health Policy Manag 3: 301-305.