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Background Student bullying in clinical practice persists, and poor outcomes continue: for learning, academic achievement and career goals, for their mental and physical health and potentially affecting all staff and patients in a clinical workplace. We describe an emergent framework for the strategic design of a bullying intervention, presented as a staff development opportunity. Methods CAPLE (Creating A Positive Learning Environment) was a bullying intervention designed around current best evidence about ameliorating student bullying in the clinical environment. CAPLE was also an action research project delivered in two eight- week cycles, one in 2016 & another in 2017. CAPLE’s primary practical foci were to offer clinical staff in two separate hospital wards an opportunity to develop their clinical teaching skills and to guide them in reflection and cultivation of values around students and learning. Research foci were: 1. to gain insight into staff experiences of CAPLE as a development process and 2. to evaluate how CAPLE might best help staff reflect on, discuss and develop values around student learning, to include bullying. Staff undertook five active learning workshops combined with supportive contact with one researcher over the research period. Data include individual interviews, staff and researchers’ reflective journals and a paper survey about staff experiences of the 2017 intervention. Results We confirm the effectiveness of best evidence from the literature and also that a strategic four-part framework of approach, process, content and person can further enhance a bullying intervention by increasing the likelihood of participant engagement, learning and values change. Conclusions This research aggregates and adds weight to the current literature about student bullying and adds important pragmatic detail about best practice for bullying intervention design and delivery. Ultimately, this emergent framework offers insight to help move past some persistent barriers encountered by those wishing to improve workplace behaviour.
R E S E A R C H A R T I C L E Open Access
Itsprobably the teacher!A strategic
framework for clinical staff engagement in
clinical student bullying intervention
Althea Gamble Blakey
, Kelby Smith-Han
, Lynley Anderson
, Emma Collins
, Elizabeth K. Berryman
Tim Wilkinson
Background: Student bullying in clinical practice persists, and poor outcomes continue: for learning, academic
achievement and career goals, for their mental and physical health and potentially affecting all staff and patients in
a clinical workplace. We describe an emergent framework for the strategic design of a bullying intervention,
presented as a staff development opportunity.
Methods: CAPLE (Creating A Positive Learning Environment) was a bullying intervention designed around current best
evidence about ameliorating student bullying in the clinical environment. CAPLE was also an action research project
delivered in two eight- week cycles, one in 2016 & another in 2017. CAPLEs primary practical foci were to offer clinical
staff in two separate hospital wards an opportunity to develop their clinical teaching skills and to guide them in reflection
and cultivation of values around students and learning. Research foci were: 1. to gain insight into staff experiences of
CAPLE as a development process and 2. to evaluate how CAPLE might best help staff reflect on, discuss and develop
values around student learning, to include bullying. Staff undertook five active learning workshops combined
with supportive contact with one researcher over the research period. Data include individual interviews, staff
and researchersreflective journals and a paper survey about staff experiences of the 2017 intervention.
Results: We confirm the effectiveness of best evidence from the literature and also that a strategic four-part framework
of approach, process, content and person can further enhance a bullying intervention by increasing the likelihood of
participant engagement, learning and values change.
Conclusions: This research aggregates and adds weight to the current literature about student bullying and adds
important pragmatic detail about best practice for bullying intervention design and delivery. Ultimately, this emergent
framework offers insight to help move past some persistent barriers encountered by those wishing to improve
workplace behaviour.
Keywords: Bullying, Mistreatment, Intervention, Clinical environment, Engagement, Staff development
thetoolsprovidedtoushave the power to
change an age old culture embedded in blame and
inequality. I have had to examine my own practice
and ensure that I adopt an attitude that reflects
([1], p. 47).
Student bullying in the clinical workplace is a global
problem, largely without a known, effective solution [2
4]. Despite being significantly under-reported [3,4]stu-
dent bullying still has an exceptionally high prevalence,
described in an extensive literature across the healthcare
sector. One indicator of this prevalence is a recent review
of the literature, which indicates that an average of 59% of
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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( applies to the data made available in this article, unless otherwise stated.
* Correspondence:
Otago School of Medicine, University of Otago, Dunedin, NZ, New Zealand
Department, Bioethics Centre, University of Otago, 71 Frederick St, PO Box
56, Dunedin 9054, New Zealand
Full list of author information is available at the end of the article
Gamble Blakey et al. BMC Medical Education (2019) 19:116
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medical students experience bullying during their clinical
training [4].
The nature of clinical student bullying is also well de-
scribed. The commonest reported bullying acts have
been found to be verbal and physical harassment, gender
and racial discrimination and, importantly, several forms
of academic harassment [35]. While any student can
suffer bullying, at the hands of any staff member [68],
students of minority ethnicity, or sexuality, and of the fe-
male gender
are likely to experience it more [4]. A
bullying perpetrator can be any staff member, but have
been found to most likely be senior staff members [3,4].
Because of its potential severity and persistence, stu-
dent bullying can substantially influence the student and
the performance of the health service in which it takes
place. Bullying can negatively affect a students lifelong
learning [9], clinical and academic performance [4],
physical and mental health, and career opportunities
[1012], but also negatively affect the ongoing function-
ing of all staff in a workplace [2,3]. The latter can be to
the extent that avoidable adverse outcomes and rates of
medical error increase [3,4].
Defining bullying
While there is currently no widely accepted definition of
what constitutes clinical student bullying, we define
bullying/mistreatment as explicated by Mavis ([13],
p.706). This definition appropriately acknowledges the
students potentially vulnerable position in the work-
force, and one that sees a percentage prevalence of
bullying almost twice that of senior staff ([13], p. 706):
Mistreatment, either intentional or unintentional
occurs when behaviour shows disrespect for the
dignity of others and unreasonably interferes with the
learning process. Examples of mistreatment include
sexual harassment; discrimination or harassment
based on race, religion, ethnicity, gender, or sexual
orientation; humiliation; psychological or physical
punishment; and the use of grading and other forms
of assessment in a punitive manner.
Detailing the problem
In the academic health sector, bullying interventions
continue to be trialled and in some cases, researched
and reported - see Swiggart [14]. Despite the literature
being generally extensive, such as that about the conse-
quences of bullying, there is sparse and piecemeal prag-
matic detail available with which to plan an intervention
to help students. In other words, it is difficult to know
what exactly to do to effectively engage staff in learning
about student bullying, and moving them on to improve
their behaviour [15].
In some cases, lack of detail in the literature might be
explained by bullying interventions undertaken without a
research component; the information has simply not been
described, evaluated or disseminated. However, because of
the various methods of administration and evaluation
reported in the literature that is available, there still seems
an apparent lack of aggregated, detailed guidance around
which to design an effective intervention.
From the literature, however, these is other evidence
emerging which seems helpful because it indicates why
some interventions might be ineffective. One example is
that an intervention approached in a way that appears to
targeta specific staff group or unwanted behaviour can
be less effective than that which includes all staff and has
a positive focus; participants report these foci to represent
implicit criticism of their behaviour, or themselves as a
person. Specifically, some interventions have been shown
to fail because percieved criticism can engender feelings of
inadequacy, which can ultimately lead to defensiveness,
failure to engage and learn from an intervention, or worse,
active protest or resistance to it [3,15,16].
Defining engagement
Participantsreports about engagement in learning are the
main phenomena by which we judge the effectiveness of
each CAPLE process we report here. While a detailed
discussion of engagement in learning is outside the scope
of this paper, for reference, we indicate that we take a
psychological perspective to understanding engagement in
learning. This perspective, summarised by Kahu [17], allows
several potential influences on engagement to be consid-
ered, and that we draw on as part of this paper. These
include a learners behaviour, the behaviour of others and
psychosocial processes relating to emotions such as fear.
Research aims and questions
As can be usual with action research, research questions
can be proposed at its outset, arise as part of a broader
study question or aim, or develop singularly during the
research process itself [18]. Here, we broadly aimed to put
together and evaluate an anti-bullying intervention devel-
oped from fragmented evidence about ameliorating student
bullying. A related question then emerged as part of this
broader question: what helped staff engagement in CAPLE?
To guide those wishing to replicate our study and
research, we describe the development and administration
of the CAPLE intervention as well as its associated
research methods.
The CAPLE projects
The CAPLE (Creating a Positive Learning Environment)
projects were strategic anti-bullying interventions developed
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in response to reports of persistent worldwide student bully-
ing and reports of concerning local levels at the hospital in
question [19]. The CAPLE interventions utilised best avail-
able evidence around what works and what doesntwork
to ameliorate student bullying. Each CAPLE was a bullying
intervention offered to staff at a different clinical department
in an Australasian teaching hospital and respectively admin-
istered in 2016 & 2017. Each CAPLE project entailed a
unique approach of workshops about developing staffsclin-
ical teaching skills, and working and supporting them to re-
flect on and develop related values. As indicated, at its
outset, CAPLE was primarily informed by a literature re-
view, and the results from 2016 used to inform the 2017
project. There are 4 more cycles of CAPLE currently being
planned or in progress.
We worked with the following conclusions from the
literature about ameliorating student bullying. In sum-
mary, a more useful approach to ameliorating student
bullying engages staff by:
1. incorporating an understanding of potential
workplace bullying catalysts, such as burnout
[20] and personal values [3] which, when ignored,
can perpetuate bullying [2123];
2. considering staffsunique work context [2427] and
addressing their adult learning needs [15,28,29]
rather than lecturingthem [29];
3. operating over and above policy/reporting about
bullying behaviour which are necessary, but not
sufficient processes for ensuring behaviour change
4. including all staff, without targeting specific groups
5. focusing on cultivating skills (e.g. clinical teaching)
rather than seeking to punitively eliminate negative
behaviour [1,3538];
6. being administered by a skilful interventionist,
understood as credible and engaging, without
taking a top-down approach [1,15].
The CAPLE intervention was then created and imple-
mented. The broader CAPLE team comprised six highly
experienced clinicians, educators and researchers. The
front lineworkshops and contact with staff were ad-
ministered by Althea Gamble Blakey (AGB) and Kelby
Smith-Han (KSH).
In each of the two 2016 & 2017 projects, extensive ne-
gotiation with hospital and clinical service management
enabled a clinical site to be identified and accessed, and
CAPLE introduced to managerial staff at the site via
email. This site was selected on the understanding that
bullying was likely to exist in most departments, rather
than a focus on what was actually happening there. Both
sites were acute intervention, short stay clinical sites,
and staff therefore worked in a highly pressured environ-
ment. Questions and queries from potential participants
were used as opportunities for AGB and KSH to begin
to establish functional and trusting relationships with
each. With the support of senior staff, six doctors and
six nurses of varying levels of experience were recruited
as key participants.
CAPLE workshops were designed around the emergent
conclusions from the literature. Workshops employed ac-
tive learning methods, and each was a 25 min session held
local to the participantsworkplace. Each covered one
topic about clinical teaching and learning per week (total
six), selected broadly around the idea that a positive focus
which aimed to develop skills would be more effective
than some others, as explained by Thomas [37]and
Thompson [38]. We also selected topics, and the level of
delivery, based on what seemed to be current challenges
for, and needs of participants, described in initial individ-
ual interviews. This approach was thus a context-specific
and bottom-up.Topics included teaching under time
pressure,’‘giving effective feedbackand fear in learning.If
a CAPLE key participant was unable to attend an arranged
workshop, they were offered it again, at their convenience.
Thus, each topic was workshopped several times a week,
with varying size groups (125 staff). All staff at each site
were invited to attend the workshops, as well as formal
participants in the broader research.
The researchers who delivered CAPLE, which included
workshop facilitation, were selected for their extensive
expertise in small group teaching, clinical teaching/
learning, developing values, and for being the kind of
personable to help staff engage in learning, determined
by recent evaluations of their teaching. These measures
indicated the researchers to be caring, trustworthy, re-
spectful and approachable, all qualities and values noted
to be helpful for, if not crucial to learner engagement,
especially the adult learner [3840].
Each key participant was assigned a specific researcher
to undertake their entry and exit interviews and stay in
touch throughout the 8- week research period. Contact
was casual, by email or in person, as requested. One ex-
ample of such contact was that AGB sent a brief hows
it going?email once a week, to ask how participants
were finding the application of workshop material in
practice, and chatted further/met with participants as
required, for example, if they described difficulties
with a teaching method, or had strong feelings as a
result of their teaching which they wanted to address
or investigate.
Research methods and data collection
CAPLE was embedded within an action research meth-
odology, considered to be eminently suitable to the de-
velopment and refinement of solutions to problems or
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questions about practice [2024], here, about teaching
clinical staff who are potentially bullying their students.
Specifically, we aimed to iteratively identify issues of
concern and to cultivate, test and evaluate solutions
[25,26]. This paper represents data collected in the
first 2 cycles of CAPLE.
CAPLE began with an interview (2040 min) of each
key participant, about their experiences of clinical teach-
ing and learning, including experiences with bullying, if
raised. Our semi-structured technique allowed scope to
widen conversation to emergent issues specific to each
workplace and person. Workshops were then given, and
participants stayed in contact with the researcher
throughout this time. Interviews were repeated after the
workshop series, with a specific focus on what worked
to help participants engage in learning, and why.
Having undertaken analysis of the 2016 data, small ad-
justments were made to CAPLE processes and methods
for the 2017 study. This kind of adjustment to research
methods is usual in action research and can be one way
to increase research quality and reliability [18]. Import-
antly, the workshops were refined in terms of what was
felt, and said by participants to workfor staff in 2016
(timing, topic focus etc.). A short exitsurvey was also
instigated for 2017 participants. The survey was given in
person and returned by internal mail to the researcher
less well known to the participants (e.g. AGB received
KSHs participant surveys). With this, we sought triangu-
lation between specific findings of each study and
wanted participants to be free from worry that they
might offend the researcher if they wrote negative com-
ments. We also realised the importance of the exit inter-
view in obtaining evaluative comments about the
researchers as workshop facilitators and support per-
sons. Thus, we also added another short post-interview,
done by another researcher. Again, we did this to min-
imise potential participant bias towards the researcher
and ensure we gathered honest and useful feedback
which may have been negative.
Data thus comprise contributions from 24 participants
& two researchers, across two action research projects,
addressing similar issues about teaching and learning,
and, as it arose, student (and staff ) bullying. Specifically,
data include:
individual interview transcripts
emails between participants and researchers
field notes made about interactions between researcher
and participants
reflective journals in which all participants (to
include researchers, as customary with action
research) recorded thoughts and experiences
about their teaching practices and CAPLE
project processes
a short exitsurvey administered to participants
(2017 study), which included general questions,
about participantsjudgements of CAPLE workshop
teaching and three specific questions about teacher
values (respect, integrity, caring) identified from
2016 study data. Questions were mostly evaluated
with a Likert scale of Yes, Possibily, Unsure,
Possibly not, Nowith space open for further
comment. The comments form the basis of what
is reported here about the survey.
Data analysis
We analysed spoken and freehand data with an general
inductive approach [41], creating themes from emerging
ideas to accurately represent our meaning. Our ideas
and themes were thus developed in line with a con-
structivist epistemology [42,43]. In essence, we sought
answers to research questions with an open mind as to
what data might reveal.
AGB, KSH and LA (Lynley Anderson) undertook the
data analysis, creating themes around issues that arose,
and adding/removing themes as discussions continued,
in pursuit of ways to accurately categorise and explain
the findings. Analysis finished when no more themes
emerged and no data remained unclassified [43].
Throughout the process, themes and raw data were
taken to the wider author group to check for accuracy of
meaning and thematic classification.
Data representation
We represent data variously: in our own words to sum-
marise discussion between staff participant groups; ver-
batim quotations from interviews, emails between staff
and researchers and participantsreflective journals.
Where wording is changed to preserve confidentiality,
meaning was preserved by checking with the participant
We describe emergent evidence in themes developed
from the analysis of both CAPLE project data. Between
these projects and data collection methods we found
substantial triangulated data about how to engage partic-
ipants in reflecting on, learning about and in developing
clinical teaching skills and related values, as part of ad-
dressing student bullying. We report data from the spe-
cific perspectives of key participants and researchers, in
response to the question: What helped staff engagement
In summary, this research confirmed the current best
evidence to be effective but also revealed further specific
details about how to best engage clinical staff in learning
about clinical teaching and student bullying. We begin
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with a brief illustration of findings that allowed us to
judge CAPLE was successful in engaging participants.
What did we want to see? Evidencing effective
The primary, broad aims of most staff development ac-
tivities are to aid learning and its transfer to the work-
place [44]. In the case of CAPLE, we aimed to help staff:
1. learn/refine clinical teaching skills, 2. learn to reflect
on teaching practice, behaviours to students and under-
lying values and as a result 3. implement enhanced skills
and improved behaviours in the workplace.
We take participantsreports that they had imple-
mented what they had learned on CAPLE into the work-
place as a strong indication that they had effectively
engaged in CAPLE, as well as first-hand reports about
specific features they found engaging. Here, a doctor de-
scribes his developing teaching skills we use such
quotes as representative of several other similar quotes
from data:
I had a great fortnight with a TI [Trainee Intern, 6th
year medical student], which is unprecedented. I felt I
had loads more ways to teach up my sleeve and the
confidence to put it into action.
(Doctor 1 (2016), Reflective Journal)
Here, Doctor 1 reflects on an earlier student interaction:
I ended up talking to [a student] like a father would
to his children. It was not good unfortunately I went
in a bit headstrong. Im not going to do that again.
But, at least, in reflection I know what Ive done and I
will try not to do it again!
(Doctor 1, discussion with AGB)
Here, Doctor 1 reflects on his changing behaviour:
another doctor said to me this [mistake] never
happened to me while I was on [another ward]. I think
its all your fault.I said back to him that is was
inappropriate to say that at the time. I was quite
frankly disgusted I wouldnt have done that [spoken
up] before [before CAPLE].
(Doctor 1, discussion with AGB)
Four major themes emerged from data, here entitled:
approach, process, content and person, which we
present by explaining why we chose to implement these
specific features of CAPLE, and offer evidence from par-
ticipants about how these features helped them engage.
Theme 1 approach: avoiding targeting specific staff, and
any staff
CAPLE was approached as a positive, multidisciplinary
project with a focus on clinical teaching. We developed
this approach on an understanding that failure to engage
participants in learning has been found to result from an
intervention that targetsa staff group or negative be-
haviour [3,15,16]. For example, aiming to recruit only
nursesmight result in resentment and failure to engage
this staff group, or appearing to target communication
could alienate or offend.
Doctor 1 described the elements of CAPLEs approach
which were helpful to his engagement, by comparison
with that of another staff development opportunity, ap-
parently implemented with an approach aimed at Im-
proving Communicationfor the medical staff. He
interpreted the approach to this intervention thus:
I felt like a naughty kid being told off...we were just
send to it [the course] and told to do stuff, no
explanation or reason, and just not very nice. They
clearly didnt give a damn about how it all feels. I
didnt get into it and I certainly dont use the stuff
[what was taught].
Similarly, comments from Nurse 5 (2017):
They [management] just put the [other] program in
the hospital, its like were being told off.
Confirming CAPLE to be more effective in approach,
Nurse 6 (2017):
[CAPLE] empowers you to say noand be in control
it [the CAPLE approach] implies that you think we
are OK [we are good people] and going well...Responding
to our context, but not in a patronising or offensive way.
Having established that our approach was effective for
engaging participants in learning, we discussed other re-
sults that we classified as approach,but were different.
We found that some of CAPLEs results about approach
emanated from necessary pre-research interactions
with senior management, in other words, they were
about engagement of staff outside of our formal par-
ticipant group.
I heard they dont want us to do the project, because
they dont want to be associated with a bullying
project. It [the inference of bullying] means they have
a problem... Even if they are doing something about
the bullying. We are going to have to tread very
carefully .. I think Im going to have to stop making
references to bullying.
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(AGB, written reflection on verbal report to research
group, 2016)
We therefore found that the best approach to CAPLE
needed to address and minimise potential for CAPLE to
lead to any staff feeling targeted, including line manage-
ment in the wider hospital setting. Not only could target-
ingaffect participant engagement in an intervention itself,
but also staffsengagement with our researchersdiscus-
sions, recruitment of potential participants but could also
lead to a refusal to host the intervention at all.
We thus added the following to our no targetingap-
proach to CAPLE, to include further and better ways to
approach all staff for effective engagement. To -
avoid reference to bullyingverbally and in
documentation, unless raised by others
to reassure management that we were coming to
their department to use their knowledge, rather than
because we had been informed of an issue with
student bullying
use circumspectlanguage to discuss bullying, e.g.
euphemisms like tricky behaviour
present CAPLE as research, with an accompanying
emphasis on optional participation and that
participants would be contributing to a specific cause
present CAPLE as an opportunity for the researchers
to learn about staff development from participants, in
particular in specific clinical work contexts that can
be challenging
Theme 2 process: using active learning processes with
participant support
Active learning
CAPLEs aims were to help clinical staff develop teach-
ing skills and reflect on practice and related values. We
understood these aims to require pedagogic processes
congruent with participant engagement in such topics;
we need to teach them as they were best learned. We
looked to the literature on education, as well as bullying,
and instigated proven pedagogic method and process:
workshops as a host to active learning processes
appropriate for adult learners [39,44,45]
small groups, congruent with engagement in
discussion [39] and reflection [44], and about
developing skills of teaching [39] and sensitive topics
such as bullying and personal values [39,40,4648]
teachers with substantial expertise in facilitating
adult small group learning [39,47].
Evidence that participants found these pedagogic
processes helpful for engagement was plentiful. Again,
described in contrast with another staff development
opportunity given at this work site:
we werent talked at or bored, that really turns me
off. (Nurse 6, 2017)
nothing good will come of staff sitting in a lecture
about this stuff and being told stuff. (Doctor 1, 2016)
such a different approach than a PowerPoint. It was
great and really got me thinking. (Doctor 8, 2017)
In contrast, CAPLE participants indicated that experi-
ences of workshops were more positive:
therapeutic they give you chance to think and
then have the skill to bring all your thinking together
good to get things off my chest, especially to talk it
over and reflect with someone who has a different
perspective and come to a new conclusion. (Doctor
8, 2017)
slightly free-form element which can be a little
worrying [at first] but by the end we realised we
had actually covered quite a lot of stuff, so its good.
Youve been taken through stuff without realising that
you have been taken through it! And its a great place
to talk through tricky things, without feeling embarrassed.
I felt relaxed and engaged through the whole thing.
(Doctor 7, 2017)
Participant support for positive values change
We offered participants personal support during CAPLE,
guided by our understanding that some learning would
necessarily concern values or discussion of difficult ex-
periences. As either topic can be eminently sensitive, we
understood some participants might benefit from on-
going support to get throughthe thinking which might
necessarily happen afterwards, in a potentially ongoing
period of values development. We understood that on-
going engagement and achievement of some learning
aims would depend on some staff being provided with
ongoing support [30,48,49].
A specific example of support helping participants to
stay engaged in values change was offered in a discus-
sion with Doctor 2 about offering effective feedback to a
clinical student who they disliked. In summary, Doctor 2
reported that his engagement in discussing, reflecting
and finding ways to deal with this issue was dependant
on the safe spacecreated by the researcher; that his
thinking processes would have otherwise somehow be-
come distracted and waylaidbecause it was too hard
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thinking about why I dont like him [the student], but I
know I need to.
Further examples about support helping partici-
pant engagement in learning about teaching, and in
values change emerged from CAPLE 2017 exit sur-
vey and interviews. We asked participants specific-
ally what it was about CAPLE that helped them
engage and learn:
it legitimises the way I feel and think, being able to
talk to someone about my teaching One-on-one
chats were great, we made a great connection.
(Nurse 7, 2017)
The one-on-one discussions give me a chance to think
about things myself rather than in the group, where I
might just sit back. (Doctor 7, 2017)
The one-to-one mentoring to learn I need to talk
rather than listen or write. Its even better to talk to
someone who can help and give me support with that.
(Doctor 8, 2017)
Theme 3 content - relevant, useful and legitimate
CAPLEs initial content focus aimed to help develop par-
ticipantsclinical teaching skills, guided by an under-
standing that such a focus can help improve things for
students and improve general workplace culture. For ex-
ample, learning to give feedback well can help students
learn and staff to communicate [50] and a lack of teach-
ing skill can, for some, catalyse student bullying [50,51]
say, out of frustration.
Our topic selection was initially confirmed as being
relevant and useful by participant entry interview data
and more latterly the 2017 exit survey, in which partici-
pants indicated that this hospitals professional support
for clinical teaching skill development was comparatively
and universally lacking.
Make content wholly relevant and useful to everyone
Participants indicated that they engaged in CAPLE be-
cause it was relevant to their work, both in specific con-
tent and the level at which it was pitched:
going back to the beginning of teaching stuff was SO
useful. I really got into it. (Doctor 5, 2017)
Im genuinely disappointed its over [CAPLE], itsnot
just therapeutic, its more than that, its reminded
me of stuff I have forgotten and to remind me why
I do what I do. I feel better at teaching now and I
hope that I am better too. (Nurse 7, 2017 exit
In her reflective journal, AGB offered further reason-
ing why CAPLE topic helped staff engage: that work-
shops were relevant, but also not superfluous which
might have been the case, say, if a workshop on commu-
nication skills was offered, but staff already had well de-
veloped communication skills.
We found that legitimacy was also important to staff en-
gagement in CAPLE: a participantsgeneral sense that a
topic (here, bullying) was somehow acceptable for dis-
cussion, not off limits.Via workshopsgeneral focus on
clinical teaching, we were able to include bullying as part
of discussion because of the natural relationship between
bullying and teaching, such as academic bullying [5,36]
or how one might behave to a student that you dislike.
References to bullying thus came across to participants
as incidental, part of a wider or related discussion, per-
haps experienced as a softened blowin comparison
with direct references, which can sound accusatory:
its a good way to do it because conversations can be
about mostly something else, and it doesnt sound as
accusatory as having it as the only thing. (AGB,
journal, 2017)
its like its somehow legitimised, isnt it, if you go at
it from the sideas it were. Its not as confrontational,
is it, as the other way which goes at it hammer and
tongs [colloquialism for rather brutal].(AGB
conversation with KSH, reported in reflective journal)
CAPLE participants ultimately seemed happy to
accept references to bullying made within the remit
of clinical teaching, one even remarking about the po-
tential difficulties in framing a bullying intervention
in another way.
I like how you presented it. You have changed the
way I have thought about things which is
important...but you have proven that this is a remit
that allows us to talk about bullying, because as its
about the fears and how you handle yourself and
because some people would struggle doing it
another way. (Doctor 5, 2017)
Theme 4 person being the right person
CAPLE researchers were purposely selected for their ex-
pertise and being the kind of peoplelikely to work well
in potentially challenging situations. Doctor 1, 2016,
confirmed the importance of teacher skill to his own en-
gagement and learning:
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you were very patient, gave me a lot of time for
reflection on my thoughts, pauses, time for me to
explain, open to other ideas, very encouraging and
skilful. (Exit interview)
We also found that being the right person- over and
above skills and knowledge to be confirmed as import-
ant to participant engagement. The right personwas
understood as facets of who the teacher was,revealed
by Doctors 7 and 8 in our 2017 exit interviews with the
second unknowninterviewer:
very comfortable interactions non-threatening,
engaging and empowering the whole atmosphere of
the workshop was mutually respectful, essential if you
are to learn something I felt I had learnt something
about myself, too.
If you didnt want to teach us we would be able to
tell and that would not be good for learning.
We asked participants about the teachersvalues spe-
cifically in the 2017 triangulationexit survey:
What was it specifically about the CAPLE teaching
that worked, or not, for you?
Probably the teacher!
We identified four specific values (the rightper-
son) to be important to participant engagement: re-
spect, integrity, caring and Living that which you
you could not show up, not keep appointments, be
late, all those sorts of things, but instead you gave me
things to read, you were prompt, you went over and
above [what was necessary], I absolutely think you
care about us and that matters. You sold a good
project to me, but in the end I trusted you and thats
what matters. (Doctor 7, 2017)
Respect and engagement
Doctor 7: From the first meeting I could tell that you
had respect for us and what we do, and that it was
mutual. I could tell by the way you spoke and handled
yourself, and how you let us be experts in our field
without it turning into a pissing contest [trying to
AGB: What did it do for you, feeling that I respected
Doctor 7: It helped me engage in the project. And if I
hadnt have felt it, I wouldnt have, even if I do
already like to talk about teaching and learning.
The researchers (AGBs) journal throughout 2016 &
2017 offers further confirmation that the perception of
respect could be helpful to participants engagemet in
I had to work really hard to show them I respected
them, even though some of what came out of their
mouths made me want to not respect them. That man
with the laptop for starters. They have to understand
that I think they are essentially good people,
otherwise it wont work, and they wont think about
what they need to think about. Its bloody hard work!
Integrity and engagement
Integrity was described by a participant in comparison
with different (non-CAPLE) workshop they had attended.
He reported feeling that he ‘…just couldnt believethe
teacher of the workshop; that this person looked like they
didnt know what they were doing or even that they believe
in it [what they were teaching].’‘Integritythus seems to
embrace several ideas, such as being qualified, credible,
keen on teaching and believable. Doctor 6 summarised:
I met with [the researcher] today...shes very
passionate about this project and teaching and clinical
student learning, its invigorating that she shares this
passion. She knows what shes doing, too. I believe
what she is saying, and it makes sense. (Reflective
Nurse 8 and Doctor 7 reported that integrity (in its
various sub-forms) helped them better engage with re-
searchers and was important, and complementary to, re-
spect (theme 1):
that the researcher looks like they want to be here
and know what we do here.Those kinda go together,
dont they?(Nurse 8)
Their experience in teaching and learning is what
makes them great to listen to, and not just some
jumped-up qualification that cant be applied in prac-
tice. They mean it all, too, they are doing it with good
hearts and with our interests at heart too. (Doctor 7)
Caring and engagement
Participants also indicated that caringwas important to
their engagement:
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I think you do care about us to do a program like
this you would struggle if you didnt care, youd feel,
like, 'Ive got to see those wankers today.' (Doctor 5,
2017, exit interview)
One participant went as far as to say that a bullys:
best chance [to learn] is probably how you are
doing it, as you and they can then talk and get them
reflecting on what they do weve [the staff] had
enough of that stuff that targetsbullies.
Living that which you teach
The final value reported as helpful for engagement could
be described as more general than the others, perhaps
encompassing several as yet unidentified individual
values. Colloquially described as the researcher living
outthe methods which they had themselves taught in
the workshops, in their interactions with the participant.
For example, that the researcher avoided making staff
[In discussion about a workshop on Fear & Learning]
I wouldnt have been as impressed or listened to what
you said if you hadnt done exactly what you said we
should do. I hadnt thought about this before, but its
really important. (Nurse 7, 2017).
In illustration, Palmer ([60], p.4):
The question we most commonly ask [in teaching] is
the whatquestion what subjects shall we teach?
When the conversation gets a bit deeper, we ask the
howquestion what methods and techniques are
required to teach well? Occasionally, when it goes
deeper still, we ask the whyquestion for what
purpose and to what ends do we teach? But seldom, if
ever, do we ask the whoquestion- who is the self
that teaches? How does the quality of my selfhood
form-or deform-the way I relate to my students, my
subject, my colleagues, my world?
Student bullying in the clinical environment is persistent
and costly in many senses, and we still need to under-
stand how to better engage staff participants in interven-
tions. We offer an emergent framework for the strategic
development of a bullying intervention. We found bully-
ing intervention approach to require careful engagement
with all staff via a concomitant understanding of how to
avoid targeting.A focus on enhancing teaching and
learning skills was palatable to staff; this focus on
promoting desirable behaviours contrasts with what we
suggest would be a less effective approach on removing
undesirable behaviours. Pedagogic process should en-
courage active learning but also offer participants per-
sonal support, for optuimal engagement in long term
thinking and values development. Content should be
relevant and useful, given at an appropriate level and if
possible, determined by participants and be such that
discussion of bullying is legitimised and therefore ac-
ceptable to participants. The person undertaking an
intervention needs to have specific skills and know-
ledge and exhibit positive values congruent with
intended learning outcomes: the right person for the
job.To discuss findings, we reference appropriate lit-
erature and also describe what might eventuate if
each emergent strategy is not employed as part of a
bullying intervention.
Implementing CAPLE required sound ethical principle
and process. Staff working in the service that we wished
to research were also fearful of attracting negative media
attention. This concern may have heightened or exagger-
ated any pre-existing sensitivity about discussions relat-
ing to bullying in the workplace. However, one specific
concern with CAPLEs approach was that potential par-
ticipants might be negatively influenced by other staff
having concerns with it, a phenomenon which has been
acknowledged in the literature [3,45]. Thus, we feel that
our overall positive, teaching and learning approach
without direct reference to bullying was especially neces-
sary. With this approach, we also felt able to engage well
with the wider service staff and potential participants, to
develop discussions about bullying as a related side-is-
sue,and maintain both our effectiveness and ethical
However, this approach to CAPLE was emotionally
and cognitively demanding for the facilitator to main-
tain; avoiding direct reference to bullying was hard, as
was dealing with rather defensive reactions from some
staff (such as people looking at their laptops, rather than
keeping eye contact with the facilitator). To cope with
this, the facilitator took advantage of the considerable
support offered by the wider CAPLE team, to ventand
discuss their reactions to staff, and thus sustain consist-
ently helpful behaviour. We recommend those wishing
to instigate a bullying intervention come to understand
the importance of using such an approach but also to
acknowledge that support should be an important, inte-
gral component to it.
Examining approachfrom the point of view of what
if we dont do it this way,we suggest that more direct
references to bullying or to use an intervention that ap-
pears to target staff may result in:
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Reluctance to host, or attend an intervention (or
Staff negatively influencing participants engagement.
Potential participants feeling targetted and declining
to take part.
Participants attending workshops, but failing to
engage in learning.
There were few surprises about the success of CAPLE
workshop processes, as we understood that effective en-
gagement in small group learning, and about sensitive
topics, could be hard [47,48,52,53] and that active
learning methods can be crucial to engagement and
learning [36]. However, participant support was, for
some, necessary to achieve such goals. This finding
makes sense, given that one ultimate aim of CAPLE
was to change participant behaviour, an inherent chal-
lenge [54].
Reassuringly, the support processes offered as part of
CAPLE were simple and effective, and appropriate for
those working within a busy acute service with serious
time constraints. While researcher availability was casual
(by email, text) this finding is indicative of utility for a
potentially moral issue: if a bullying intervention is likely
to challenge personal values to encourage personal
growth, such support could then be understood as im-
perative to success but also essential for the fulfilment of
the employers duty of care towards its staff. In further il-
lustration, we understand that failure to instigate active
learning or participant support might result in:
Participants feeling talked at/bored and failing to
engage, potentially exascerbating bad behaviour
Participants lacking sufficient guidance to support
the application of skills/behaviour in the workplace
and thus resulting in no positive behaviour change
Participants initially engaging in discussion, but
failing to accomplish the required reflection and
thinking about values development, and resulting in
no values change or positive behaviour change.
We understood a focus on teaching and learning as use-
ful to engage participants in an anti-bullying interven-
tion, on the basis that many aspects of general
workplace culture can be attributed to, and depend on
effective teaching and learning process [1,39] and that
teaching and learning is relevant to a substantial
percentage of the workforce. This topic allowed us
to legitimately raise bullying issues without the
feared targetingand potential resultant disengage-
ment. A focus on teaching and learning also offered
us an opportunity to influence staff behaviour in
other contexts: having discussed some values, we
saw newly cultivated values crossing contexts[40,47]
here, to staff-staff interactions as well as staffstudent. As
such, we add to recent literature about values education
and address a historical lacks of detail about on how
exactly values education might be carried out in the class-
room. Our contribution is that approaching such a diffi-
cult topic carefullyand somewhat laterally can help
We also understand that failure to provide appropriate
content, or containingdirectcontent more directly
about bullying might result in:
Participants feeling targeted and failing to engage.
Participants failing to learn skills appropriate to their
learning, or workplace.
Participants becoming disinterested and failing to
engage or even to provide us with data about why
this was so.
We understood that researchersskill and knowledge
would likely influence participant engagement in
CAPLE. We also had emerging evidence that a teachers
values (who they were) might do so too. The quote you
guys werent arseholes, which was nice,is a favourite ex-
emplar of this phenomenon, which we consider to be
over and above teachersskill or knowledge. While this
comment might be understood as faint praise,we also
understood it as a paradoxical or negative framing of
what workedin the CAPLE project (see later), about
the teacher as a person: participants confirmed this in-
terpretation to indicate that our researchers had requis-
ite values for participant engagement, while others
(arseholes) did not. While this data does not to connect
the presence of a value and participant engagement, but
rather supports a general finding that teacher values are
important to learning, the value-engagement connection
is understood from further exit interview data. In this
data, the value of respectwas described by a participant
as a direct correlate with their engagement.
The specific values reported here to be helpful for par-
ticipant engagement are described in the teaching/staff
development literature [55,56], less so in that about
bullying intervention. All three values (respect, integrity
and caring) have been generally associated with the
engenderment of positive emotion in the learner and, ar-
guably, for some as essential for learning engagement
[48,56]. Respect is reported to positively support change
[15]; integrity to help a learner entrust their learning to a
teacher without fear, or shame [15]. Caring can have a
potentially significant positive effect on engagement
[50,58] specifically via increased confidence [40,46].
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Living out what you teachmight be initially under-
stood as modelling in teaching; the researchers modelled
to CAPLE participants what they wished participants to
learn - see Swennen [59], which can significantly influ-
ence a learner [5557] especially if sceptical or nervous
[59]. However, the phenomenon we observed seemed
deeperthan simply demonstrating a skill: participants
specifically talked about who teachers wereaffecting
their engagement, here; for the teachers to be seen to
value what they wanted the participants to learn to do.
We provisionally interpret this phenomenon as one
which connects teacher values [58] with the idea of con-
gruent teaching [59].
Overall, these findings provide a strategic framework
for bullying intervention that has utility in practice. We
also understand several elements of the framework to
have a moral imperative. There are moves (in NZ, 2015
[60]) to instigate legislation which states that institutions
need to respond to bullying with methods which are ef-
fective, rather than just to respond, as part of their duty
of care for each employee. If values and related behav-
iours are understood to be a focus of an intervention,
and at the same time understood to offer participants
emotional and cognitive challenges, the effectiveness of
factors such as ongoing support could be understood as
obligatory for success and mental health.
This four-part strategic framework offers a sound basis
for the development of a student bullying intervention,
and aggregates and strengthens what we find in the lit-
erature. It offers pragmatic, nuanced ideas about what
an intervention should entail to ensure better participant
engagement, learning and results. As such, we feel our
findings represent a potential turning point for student
bullying research.
Strengths and weaknesses of this research
Data collection methods were generally appropriate for
our aims, but also had drawbacks. Some reports about
staff reactions to CAPLE were by proxy and naturally
subject to interpretation. However, because we used ac-
tion research, we were afforded substantial opportunity
to discuss, test and evaluate our results and thinking
with the wider team, to determine the possible and likely
interpretations we had made.
Another potential drawback was that our participants
might make only favourable, but biased comments about
CAPLE/researchers, or what they wanted to hear.We
proactively and repeatedly reassured participants that we
wished hear about difficultthings, and that this would
not disadvantage them, but offer us valuable insights.
The 2017 secondexit interview with a researcher un-
known to the participant was also done to specifically
counter this possible drawback. We felt somewhat reas-
sured that participants felt able to offer negative feed-
back because such comments were received from the
outset of CAPLE, such as one participant who reported
feeling briefly badgeredby workshop questions.
We have confidence in our findings for several reasons:
an appropriately small sample size for our aim to
find rich, in-depth qualitative data about staff experi-
ences; a larger group would offer more modest op-
portunities to develop the required participant long
term engagement for this
a rich data set which allowed substantial triangulation
between multiple sources and the ability to confirm
what was effective for what
researchers who offered a consensus of expert
judgment, gained from teaching and participating in
staff development over many decades
researchers with considerable experience in gathering
and interpreting qualitative data, and from staff in
clinical settings
similar results from 2016 and 2017 projects
Another possible drawback of this project was that we
were also unable to quantitatively or comparatively meas-
ure levels of staff engagement, which instead were re-
ported by participants and interpreted by the researchers.
We countered this by employing researchers with exten-
sive experience in gauging cognitive engagement of adult
learners, and by triangulating data between participants
and specific data sources from both studies.
We also need to stress that conclusions from CAPLE
2016 & 2017 are emergent and generated from two
specific departments in one specific hospital with two
researcher/facilitators, each embedded in their own
specific context of practice. Other staff and work-
places might generate different responses and chal-
lenges. One example of this might be that a close-
knit staff group might demand a lesser focus on
teacher respect,perhaps, but require more input in
terms of facilitation skill.
Ideas for further research
1. To clarify how each positive value enhanced
participant engagement, and the effects of other
values on engagement.
2. To explore further ways to avoid targetingstaff
and further develop ideas of legitimatetopics for
workplaces which are different to those described
3. To understand whether CAPLE helped staff engage
because of its nature as an optional research project,
rather than a reactionaryintervention.
Gamble Blakey et al. BMC Medical Education (2019) 19:116 Page 11 of 13
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In some medical schools, the female gender now
constitute significantly more than 50% of the total
student intake
AGB: Althea Gamble Blakey (researcher and primary author); CAPLE: Creating
A Positive Learning Environment the intervention study which was
administered in the hospital in question; KSH: Kelby Smith-Han (researcher and
co-author); LA: Lynley Anderson (Principle Investigator); TI: Trainee Intern final
(6th) year medical student
The authors acknowledge and thank the Division of Health Sciences,
University of Otago for the funding for this project. We also acknowledge and
thank all staff at the teaching hospital with whom we came into contact during
each phase of CAPLE.
Availability of data and materials
We deposit no data in relation to the current article. We choose to retain the
raw qualitative data from the current study from public access. We do this
primarily because this type of sharing was not stipulated in our ethics approval
application, and we thus did not have consent from participants to do so.
Whilst a moot point, we also make this choice on the basis that in Australasia,
medical, clinical and academic communities are exceptionally close-knit. Quali-
tative data contain several comments and/or descriptions (colloquialisms, ac-
counts of a specific staff member) which could be easily identified and put the
confidentiality of a participant or clinical area at risk. The authors have spent a
considerable amount of time interpreting data and representing it accurately in
text at the same time as avoiding risk to our participant confidentiality.
AGB and KSH collected the data. AGB & LA completed the first analysis of
themes. AGB finalised the analysis, in consultation with KSH, EB, LA, TW and
EC. AGB completed the first draft and responded to iterative comments from
the group. All authors contributed to: The overall design of the broader
research project; Ongoing analysis of emergent themes from data; Redrafting
and earlier iterations of the current article; Development of ideas used in the
discussion section of the current article. All authors agree to be accountable
for all aspects of the current work to include work undertaken to ensure
participant confidentiality yet represent data clearly and accurately. We also
acknowledge responsibility for the investigation of any issue raised about
the integrity or accuracy of the current work.
A Gamble Blakey is a Research Fellow (Medical Education) and Professional
Practice Fellow (Early Learning in Medicine) at the Otago School of Medicine,
University of Otago, Dunedin NZ:
K Smith-Han is a Research & Teaching Fellow and Medical Education Research
Academic Lead for Otago School of Medicine, University of Otago, Dunedin NZ:
L Anderson is an Associate Professor and Head of Department, Bioethics
Centre, University of Otago, Dunedin NZ:
E Collins is a Senior Lecturer, Otago Polytechnic and Staff Nurse, Southern
District Health Board, Dunedin NZ:
E Berryman is a Registered Medical Officer, North Shore Hospital, Waitemata
District Health Board, Auckland NZ:
T Wilkinson is a Professor of Medicine and MBChB Programme Director for
Otago Medical School, University of Otago, Dunedin NZ:
Ethics approval and consent to participate
The CAPLE project in its entirety was granted ethical approval by the Otago
University Human Ethics Committee (Health, reference no. H16/091), in
consultation with Māori and appropriate hospital research/locality access
process. Ethical approval included a process of consent to participate
and participant consent to use of data to inform publications.
Competing interests
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
Otago School of Medicine, University of Otago, Dunedin, NZ, New Zealand.
Department, Bioethics Centre, University of Otago, 71 Frederick St, PO Box
56, Dunedin 9054, New Zealand.
Otago Polytechnic and Staff Nurse,
Southern District Health Board, Dunedin, NZ, New Zealand.
North Shore
Hospital, Waitemata District Health Board, Auckland, New Zealand.
Received: 22 October 2018 Accepted: 11 April 2019
1. Schoonbeek S, Henderson A. Shifting workplace behavior to inspire
learning: a journey to building a learning culture. J Cont Educ Nurs.
2. Wilkinson T, Gill D, Fitzjohn J, Palmer C, Mulder R. The impact on students
of adverse experiences during medical school. Med Teach. 2006;28(2):12935.
3. Einarsen S. In: Einarsen S, Hoel H, Zapf D, Cooper C, editors. The concept of
bullying and bullying at work: the European tradition. IN bullying and
bullying in the workplace: developments in theory, research, and practice.
2nd ed. London: CRC Press; 2011.
4. Fnais N, Soobiah C, Chen M, Lillie E, Perrier L, Tashkhandi M, et al. Bullying
and discrimination in medical training: a systematic review and meta-
analysis. Acad Med. 2014;89(5):81727.
5. Major A. To bully and be bullied: harassment and mistreatment in medical
education. Virtual Mentor. 2014;16(3):15560.
6. Berryman E. Bullying culture: valuing the teacher- student relationship. NZ
Med J. 2015;128(1424):137.
7. Watters D. Apology for discrimination, bullying and sexual harassment by
the president of the Royal Australasian College of surgeons. ANZ J Surg.
8. Anthony A, Jones A. Eradicating abusive behavior: time to adjust the
educational paradigm. Med Teach. 2016;38(6):5356.
9. Benbassat J. Role modeling in medical education: the importance of a
reflective imitation. Acad Med. 2014;89(4):5504.
10. Kassebaum D, Cutler E. On the culture of student abuse in medical school.
Acad Med. 1998;3:114958.
11. Ahmer S, Yousafzai A, Bhutto N, Alam S, Sarangzai A, Iqbal A. Bullying of
medical students in Pakistan: a cross-sectional questionnaire survey. PLoS
One. 2008;3(12):e3889.
12. Spence Laschinger H, Nosko A. Exposure to workplace bullying and post-
traumatic stress disorder symptomology: the role of protective psychological
resources. J Nurs Manage. 2015;23(2):25262.
13. Mavis B, Sousa A, Lipscomb W, Rappley MD. Learning about medical
student mistreatment from responses to the medical school graduation
questionnaire. Acad Med. 2014;89(5):70511.
14. Swiggart WH, Dewey CM, Hickson GB, Finlayson AR, Spickard WA Jr. A plan
for identification, treatment, and remediation of disruptive behaviors in
physicians. Front Health Serv Manag. 2009;25(4):311.
15. Hodgins M, MacCurtain S, Mannix-McNamara P. Workplace bullying and
incivility: a systematic review of interventions. Int J Workplace Heal Manag.
16. McGregor FL. Bullying: the perspective of the accused. In: The handbook of
dealing with workplace bullying. Surrey: Gower Publishing Limited; 2015.
17. Kahu ER. Framing student engagement in higher education. Stud High
Educ. 2013;38(5):75873.
18. Herr K, Anderson GL. The action research dissertation: a guide for students
and faculty. New York: Sage Publications; 2014.
19. NZMSA, Press Release for TV1, 10 Sep 2015: Final results for NZMSA medical
student bullying survey. Downloaded from:
results.pdf. Sept 24, 2018.
20. Longo J. Bullying and the older nurse. J Nurs Manage. 2013;21(7):9505.
21. Felblinger D. Bullying, incivility, and disruptive behaviors in the healthcare
setting: identification, impact, and intervention. Front Health Serv Manag.
22. Rosenstein A. Addressing the causes and consequences of disruptive
behaviors in the healthcare setting. J Psych Clin Psychiatry. 2015;3:00136.
Gamble Blakey et al. BMC Medical Education (2019) 19:116 Page 12 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
23. Trépanier S, Fernet C, Austin S, Boudrias V. Work environment antecedents
of bullying: a review and integrative model applied to registered nurses. Int
J Nurs Stud. 2016;55:8597.
24. Jacobs C, Bergen M. A sexual bullying workshop for medical students. Acad
Med. 1995;70:4345.
25. Robinson G, Stewart D. A curriculum on physician-patient sexual misconduct and
teacher-learner bullying part 1: content. Can Med Assoc J. 1996;154(5):643.
26. Cohen D, Rollnick S, Smail S, Kinnersley P, Houston H, Edwards K.
Communication, stress and distress: evolution of an individual support
programme for medical students and doctors. Med Ed. 2005;39(5):47681.
27. Zweibel E, Goldstein R. Conflict resolution at the University of Ottawa
Faculty of medicine: the pelican and the sign of the triangle. Acad
Med. 2001;76(4):33744.
28. McDonnell P, McNiff J. Action research for nurses. London: Sage Publications;
29. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an
intervention for newly licensed nurses. J. Contin. Educ. Nurs. 2004;35(6):25763.
30. Johnson S. An ecological model of workplace bullying: a guide for intervention
and research. Nurs Forum. 2011;46(2):5563.
31. Hollands M. Short Report: Bullying and bullying can we solve the problem?
Med J Aust. 2015;203(4):192.
32. Lachman V. Practical use of the nursing code of ethics: part I. Med Surg
Nurs. 2009;18(1):5557.
33. Lachman V. Practical use of the nursing code of ethics: part II. Med Surg
Nurs. 2009;18(3):191194.
34. Walton MM. Sexual equality, discrimination and harassment in medicine: it's
time to act. Med J Aust. 2015;203(4):1679.
35. Siassakos D, Timmons C, Hogg F, Epee M, Marshall L, Draycott T. Evaluation
of a strategy to improve undergraduate experience in obstetrics and
gynaecology. Med Ed. 2009;43(7):66973.
36. Lucey C, Souba W. Perspective: the problem with the problem of professionalism.
Acad Med. 2010;85(6):101824.
37. Thomas CM. Teaching nursing students and newly registered nurses
strategies to deal with violent behaviors in the professional practice
environment. J Cont Educ Nurs. 2010;41(7):299308.
38. Thomson D, Patterson D, Chapman H, Murray L, Toner M, Hassenkamp A-M.
Exploring the experiences and implementing strategies for physiotherapy
students who perceive they have been bullied or harassed on clinical
placements: participatory action research. Physiotherapy. 2015;103(1):7380.
39. Biggs J, Tang C. Teaching for quality learning at university (2nd Ed.).
Buckingham: SRHE & OUP; 2013.
40. Blakey A. Cultivating student thinking and values in medical education:
what teachers do, how they do it and who they are. [PhD thesis]. University
of Otago, NZ.2016.
41. Carter S, Little M. Justifying knowledge, justifying method, taking action:
epistemologies, methodologies and methods in qualitative research.
Qualitative Heal Res. 2007;17(10):131628.
42. Conrad C. Grounded theory: an alternative approach to research in higher
education. Rev Higher Educ. 1982;5(4):23949.
43. Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative research.
Qual Rep. 2015;20(9):140816.
44. Boud D, Walker D. Experience and Learning: Reflection at work, In: Adults
learning in the workplace: part a. adult and workplace education, Faculty of
Education, Deakin University, Geelong, Victoria, Australia.1991.
45. De Rijdt C, Stes A, van der Vleuten C, Dochy F. Influencing variables and
moderators of transfer of learning to the workplace within the area of staff
development in higher education: research review. Educ Res Rev. 2013;8:4874.
46. Gamble Blakey AJ, Golding C. Of course theyre bloody scared!Managing
medical student fear to better cultivate thinking. Med Sci Educ. 2018;28(1):
47. Harland T, Pickering N. Values in higher education teaching. Buckingham:
Routledge; 2010.
48. Gamble Blakey A, Pickering N. Putting it on the table: towards better
cultivating medical student values. Med Sci Educator. 2018;28(3):53342.
49. Bandura A. Selective moral disengagement in the exercise of moral agency.
J Moral Educ. 2002;31(2):10119.
50. Hamblin LE, Essenmacher L, Upfal M, Russell J, Ager J, Arnetz JE. Catalysts of
worker-to-worker violence and incivility in hospitals. J Clin Nurse. 2015;24:
51. McCarthy CP, McEvoy JW. Pimping in medical education: lacking evidence
and under threat. JAMA. 2015;314(22):23478.
52. Kitchen M. Facilitating small groups: how to encourage student learning.
Clin Teach. 2012;9:38.
53. Garet MS, Porter AC, Desimone L, Birman BF, Yoon KS. What makes
professional development effective? Results from a national sample of
teachers. Am Educ Res J. 2001;38(4):91545.
54. Cooper L. Partnering to facilitate teacher professional learning. Antistasis.
55. Connell J, Wellborn J. Engagement versus disaffection: Motivated patterns of
action in the academic domain. Rochester, NY: University of Rochester.1994.
56. Klem A, Connell J. Relationships matter: linking teacher support to student
engagement and achievement. J Sch Health. 2004;74(7):26273.
57. Reyes M, Brackett M, Rivers S, White M, Salovey P. Classroom emotional
climate, student engagement, and academic achievement. J Educ Psych.
58. Patton K, Parker M, Tannehill D. Helping teachers help themselves: professional
development that makes a difference. NASSP Bull. 2015;99(1):2642.
59. Swennen A, Lunenberg M, Korthagen F. Preach what you teach! Teacher
educators and congruent teaching. Teach Teach. 2008;14(5-6):53142.
60. NZ. Introduction to the health and safety at work act 2015. Special Guide:
Wellington, New Zealand. 2015. Downloaded from:
guide/ January 2018.
Gamble Blakey et al. BMC Medical Education (2019) 19:116 Page 13 of 13
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... Evaluations in the schoolyard show how promising interventions aimed at increasing constructive roles in these groups are for reducing NWB (Escartin, 2016;Raveel and Schoenmakers, 2019). Also in work situations, interventions that not only suppress negative behavior but encourage positive behavior at the same time are positively evaluated (Gamble Blakey et al., 2019). Since constructive bystander roles create a PWB balance in a group, we cannot exclude this meaningful element from an integrated operationalization (Juvonen and Galván, 2008;Brechwald and Prinstein, 2011). ...
Full-text available
The objective of this systematic review was to identify the overlapping and unique aspects of the operationalizations of negative work behaviors (NWBs) to specify a new integrative definition of NWB. More specifically, we examined (1) how many operationalizations and conceptualizations of NWB can be identified, (2) whether these operationalizations can be categorized into facets, i. e., the nature of NWB, harm, actor types, and roles, with subcategories, (3) what the meaningful overlap in these operationalizations was, (4) whether the operationalizations tapped unique and meaningful elements, i.e., positive labels and dynamic processes, and (5) how the overlapping and unique elements of the operationalizations could be integrated into a new theory-based research model for NWB for future research. In the literature search based on the Prisma framework, Pubmed, PsycINFO, and Google Scholar, we identified k = 489 studies that met the inclusion criteria of our review. The results of these studies revealed 16 frequently studied NWB labels, e.g., bullying and aggression. Many of these could be categorized in the same way, namely, in terms of the type of behavior, type of harm, and type of actor involved in the NWB. In our new definition of NWB, we integrated the content of the overlapping and meaningful unique elements of the 16 labels.
... Answering these questions is key to informing the development of a response to bullying and harassment of health professional students. Furthermore, as effective interventions are developed, for example the Creating a Positive Learning Environment (CAPLE) initiative (Gamble Blakey et al. 2019aBlakey et al. , 2019bBlakey et al. , 2019c), we need reliable and valid measures to determine impact. ...
Full-text available
Background: Instruments that measure exposure to bullying and harassment of students learning in a clinical workplace environment (CWE) that contain validity evidence are scarce. The aim of this study was to develop such a measure and provide some validity evidence for its use. Method: We took an instrument for detecting bullying of employees in the workplace, called the Negative Acts Questionnaire – Revised (NAQ-R). Items on the NAQ-R were adapted to align with our context of health professional students learning in a CWE and added two new factors of sexual and ethnic harassment. This new instrument, named the Clinical Workplace Learning NAQ-R, was distributed to 540 medical and nursing undergraduate students and we undertook a Confirmatory Factor Analysis (CFA) to investigate its construct validity and factorial structure. Results: The results provided support for the construct validity and factorial structure of the new scale comprising five factors: workplace learning-related bullying (WLRB), person-related bullying (PRB), physically intimidating bullying (PIB), sexual harassment (SH), and ethnic harassment (EH). The reliability estimates for all factors ranged from 0.79 to 0.94. Conclusion: This study provides a tool to measure the exposure to bullying and harassment in health professional students learning in a CWE.
Full-text available
Earlier chapters have considered the costs and impact of workplace bullying on targets and their organizations; there is no doubt that these are significant and that ongoing research and practical support to all parties involved is necessary. In this chapter Frances-Louise McGregor prompts those who have a bullying experience in the workplace to consider an alternative perspective to the rather simplistic assumption that the bully is always in the wrong and the target or victim is always in the right. Based on her personal and professional experiences in the UK, and notably her conversations with alleged bullies, Frances-Louise reveals the effects an accusation can have on the person accused, how their organization may act towards them and the restrictions placed upon them. She reveals an imbalance in how the person accused and the person making a complaint of bullying may be treated, and unlike some of the other case studies in this book, this is not often in favour of the people who were accused of bullying that she has interviewed.
Full-text available
Background One aim of medical education is to cultivate student thinking, and specific methods have been developed, implemented, and evaluated for doing this. However, doing so is not as straightforward as simply employing these methods. Methods In a wider year-long participatory action research study about developing student thinking, we interviewed, observed, and video-recorded six medical teacher-participants. Participants also filled out reflective journals and regularly discussed practices as a group. ResultsWe found that teaching methods customarily used to develop student thinking (e.g. reflective thinking, clinical reasoning) sometimes failed. This failure was because students experienced fear as a result of such methods, such as fear of looking stupid in a discussion. Our teacher-participants went on to develop very specific methods for identifying and mitigating fears and better cultivating students’ thinking. They (1) got to know students and understand what they were afraid of, (2) mitigated student fear by talking regularly and ‘normalising’ fear in learning for them, (3) modified teaching methods to make students feel less scared and (4) demonstrated ‘care’ for their students, a value which could increase students’ confidence and help them mitigate fears for themselves. Recommendations and SummaryWe suggest teachers to (1) create opportunities to learn about their students, (2) regularly discuss with their students how fear can be normal in learning, (3) adjust teaching methods to mitigate fear and (4) care and show their care for their students. We also suggest that medical teachers could benefit from staff development about the phenomenon of potential student fear and recommend the pursuit of a better understanding of how ‘caring’ might be identified, nurtured in teachers and usefully expressed in practice.
Problem Medical teachers, like many others in higher education, need to help some students cultivate values essential to good practice. However, there is a paucity of evidence-based practical advice about how to exactly do this. While several educational methods are widely accepted as generally useful for such a purpose, specific pedagogical guidance is lacking. Teachers still need to know how to effectively develop values in the classroom. Research Aim As part of an existing curricula with teaching methods already understood to be useful, we pursued the development of specific classroom strategies to more effectively cultivate medical students’ values. Methods We undertook a year-long action research project with six experienced medical teachers. Data included group discussion meetings, semi-structured interviews, observations and interpersonal process recall of each teacher’s classroom practice. Results Participant teachers developed an understanding of values as highly sensitive, in the sense of their relation to an individual’s sense of self. This understanding explained, in part, the challenges teacher participants had experienced in teaching values. From this understanding, participants developed a specific discourse to help one another understand and describe effective values teaching; one of cultivation, placing in sight and of moving a student from where they started to another place. A specific two-part pedagogy was then developed from this discourse: to avoid engendering negative emotion in the student and to implicitly value or ‘believe in’ the student as a person. Conclusions Results have implications for teacher pedagogy and development, and in nominating who might best teach values. Further research should focus on the finer points of language and developing a more specific understanding of how teacher ‘caring’ might help cultivate values.
Objectives: To explore and empower physiotherapy students who reported being bullied or harassed on clinical placements by co-developing, implementing and evaluating strategies that could be adopted by the university. Design: A participatory action research design was employed. Participants: Two focus groups were carried out involving 5 final year physiotherapy students. In the first focus group negative experiences were discussed and coping strategies suggested for their penultimate placement. A second focus group was held following the students' final placement when these strategies were evaluated and further ones proposed. Analysis: A thematic analysis of the data was carried out. Results: Four themes and sub-themes emerged from the analysis. The four themes were negative experiences on placement, coping strategies, the role of the visiting tutor and the assessment. The students' highlighted various degrees of threat to their efficacy and in most cases could draw upon a suggested 'tool box' of coping strategies. They all agreed that serious cases of harassment require wider support from the University senior management team which should be clearly documented. The role of the visiting tutor was deemed to be critical in these situations and recommendations were made regarding this role and the assessment of placements. Conclusion: Students understand that they are going to be assessed before achieving their professional qualification and in essence they will always find themselves in a hierarchical position but equally fairness must prevail and it is important and that there are clear avenues for them to seek support.
This Viewpoint discusses “pimping” as a medical teaching tool in clinical rounds and its future use in relation to increasing awareness of student mistreatment.Medical student harassment and mistreatment have become topics of increasing concern to a wide range of stakeholders in US medical education.1,2 In this context, traditional methods of bedside teaching, particularly the time-honored “pimping” of medical students and house staff,3 have recently come under scrutiny.4 In this Viewpoint, we define pimping, briefly summarize the evidence base for and against pimping, discuss pimping in the context of medical student mistreatment, and outline future directions.
Objectives and design: This review paper provides an overview of the current state of knowledge on work environment antecedents of workplace bullying and proposes an integrative model of bullying applied to registered nurses. Data sources and review methods: A literature search was conducted on the databases PsycInfo, ProQuest, and CINAHL. Included in this review were empirical studies pertaining to work-related antecedents of workplace bullying in nurses. Results: A total of 12 articles were maintained in the review. An examination of these articles highlights four main categories of work-related antecedents of workplace bullying: job characteristics, quality of interpersonal relationships, leadership styles, and organizational culture. A conceptual model depicting the interplay between these factors in relation to bullying is also presented. Suggestions regarding other factors to incorporate within the model (e.g., individual factors, outcomes of bullying) are provided to increase our understanding of bullying in registered nurses. Conclusions: This paper hopes to guide future efforts in order to effectively prevent and/or address this problem and ultimately ensure patient safety and quality of care provided by health care organizations.