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Background: Student bullying in the clinical environment continues to have a substantial impact, despite numerous attempts to rectify the situation. However, there are significant gaps in the literature about interventions to help students, particularly a lack of specific guidance around which to formulate an intervention program likely to be effective. With this narrative review about student bullying interventions in the clinical learning environment, we examine and draw together the available, but patchy, information about 'what works' to inform better practice and further research. Methods: We initially followed a PICO approach to obtain and analyse data from 38 articles from seven databases. We then used a general inductive approach to form themes about effective student bullying intervention practice, and potential unintended consequences of some of these, which we further developed into six final themes. Results: The diverse literature presents difficulties in comparison of intervention efficacy and substantive guidance is sparse and inconsistently reported. The final analytical approach we employed was challenging but useful because it enabled us to reveal the more effective elements of bullying interventions, as well as information about what to avoid: an interventionist and institution need to, together, 1. understand bullying catalysts, 2. address staff needs, 3. have, but not rely on policy or reporting process about behaviour, 4. avoid targeting specific staff groups, but aim for saturation, 5. frame the intervention to encourage good behaviour, not target poor behaviour, and 6. possess specific knowledge and specialised teaching and facilitation skills. We present the themed evidence pragmatically to help practitioners and institutions design an effective program and avoid instigating practices which have now been found to be ineffective or deleterious. Conclusions: Despite challenges with the complexity of the literature and in determining a useful approach for analysis and reporting, results are important and ideas about practice useful. These inform a way forward for further, more effective student bullying intervention and research: an active learning approach addressing staff needs, which is non-targeted and positively and skilfully administered. (331w).
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R E V I E W Open Access
Interventions addressing student bullying
in the clinical workplace: a narrative review
Althea Gamble Blakey
, Kelby Smith-Han
, Lynley Anderson
, Emma Collins
, Elizabeth Berryman
Tim J. Wilkinson
Background: Student bullying in the clinical environment continues to have a substantial impact, despite numerous
attempts to rectify the situation. However, there are significant gaps in the literature about interventions to help
students, particularly a lack of specific guidance around which to formulate an intervention program likely to be
effective. With this narrative review about student bullying interventions in the clinical learning environment, we
examine and draw together the available, but patchy, information about what worksto inform better practice and
further research.
Methods: We initially followed a PICO approach to obtain and analyse data from 38 articles from seven databases. We
then used a general inductive approach to form themes about effective student bullying intervention practice, and
potential unintended consequences of some of these, which we further developed into six final themes.
Results: The diverse literature presents difficulties in comparison of intervention efficacy and substantive guidance is
sparse and inconsistently reported. The final analytical approach we employed was challenging but useful because it
enabled us to reveal the more effective elements of bullying interventions, as well as information about what to avoid:
an interventionist and institution need to, together, 1. understand bullying catalysts, 2. address staff needs, 3. have, but
not rely on policy or reporting process about behaviour, 4. avoid targeting specific staff groups, but aim for saturation,
5. frame the intervention to encourage good behaviour, not target poor behaviour, and 6. possess specific knowledge
and specialised teaching and facilitation skills. We present the themed evidence pragmatically to help practitioners and
institutions design an effective program and avoid instigating practices which have now been found to be ineffective
or deleterious.
Conclusions: Despite challenges with the complexity of the literature and in determining a useful approach
for analysis and reporting, results are important and ideas about practice useful. These inform a way forward
for further, more effective student bullying intervention and research: an active learning approach addressing
staff needs, which is non-targeted and positively and skilfully administered. (331w).
Keywords: Bullying, Clinical environment, Intervention, Medical student, Nursing student
A substantial proportion of healthcare students world-
wide experience bullying in clinical practice [14]. Its
prevalence, nature and consequences are well docu-
mented: one survey indicated 59% of medical students
can expect to be bullied by staff (doctors, nurses, allied
health, including management) with whom they work, at
some time during their clinical training [2].
Evidence suggests any student can suffer bullying in
the clinical workplace, and at the hands of any staff
member [57]. However, senior staff are reported to be
the most likely perpetrators, and students of minority
ethnicity, gender or sexuality are likely to fare worse [2].
Verbal harassment, gender and racial discrimination,
and academic harassment (e.g. withholding a grade in
return for favours) are among the commonest recorded
bullying acts [8,9].
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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* Correspondence:
Otago Medical School, University of Otago, Dunedin, NZ, New Zealand
Full list of author information is available at the end of the article
Gamble Blakey et al. BMC Medical Education (2019) 19:220
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Clarification of terms
We use student to represent a learner in the clinical
workplace undertaking supervised clinical work in the
pursuit of a foundational clinical qualification. We ex-
clude postgraduate learners, as they are often posi-
tioneddifferently within a workplace structure.
The potentially complex nature of student bullying
in the clinical workplace results in it having various
definitions, none of which seem widely accepted.
Hence, we use a definition which serves the current
reviews purpose, and has a specific focus on the
undergraduate learner:
Mistreatment, either intentional or unintentional oc-
curs when behaviour shows disrespect for the dignity
of others and unreasonably interferes with the learn-
ing 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 ([10], p. 706).
A significant body of experience and research explicates
the considerable overall harm that healthcare student
bullying can cause. The potential severity of this harm, to-
gether with its prevalence [2], strongly suggests bullying is
an important problem to consider for all concerned. In
summary, bullying can harm a victims learning and the
learning of others in the workplace, influence career
choices [1113], create short and long term mental health
issues and lead to self-harm and suicide [1417]. Student
bullying can also be witnessed by, and be distressing to
others, the consequences of which might also then impact
on the functionality of a clinical service. Together with the
bullying of staff more generally, student bullying is a po-
tentially significant threat to quality (e.g. patient out-
comes, clinical error), efficiency, levels of job satisfaction,
staff retention and turnover [10,16].
A particular feature of bullying behaviour is that it can
become pervasive [18] and dominate workplace culture,
and subsequently be passed downto further genera-
tions of staff and students [9]. Apart from the known
impact of role modelling, suggested explanations for this
phenomenon are that a bullied person develops a sense
of defeatism and learnssuch behaviours themselves [19,
20], and they then fail to develop effective teaching or
communication skills, or insight into how their behav-
iour affects others [21]. Related to this feature is that
bullying can be catalysed by workplace conditions [22]
particularly at times of resource constraints, major
change or other workplace uncertainty [9]. Students are
also at a natural disadvantagein the clinical workplace,
due to potential power differences and misuse of hier-
archy, and some perhaps only beginning to develop their
capacity for resilience. Thus, the healthcare student can
be vulnerable to bullying and less well equipped than
some others to cope with it [23,24].
While several reviews of the healthcare literature specif-
ically acknowledge the potential pervasiveness and ten-
acity of the general bullying problem, many lack detail
relative to student bullying and how to address it. This is
despite bullying being described as a specific and ongoing
concern in recent literature and media [25,26]. For ex-
ample, Stagg & Sheridan [27] comment on the effective-
ness of interventions administered to nurses, with a focus
on identifying best practice, but their report includes re-
views of interventions undertaken in non-clinical work-
places such as schools, an appreciably different context to
the clinical environment. Interventions reviewed therein
also lack reference to the specific context of the adult stu-
dent learner. Similarly, a substantial, commissioned review
of the National Health Service (NHS, UK) includes a di-
verse range of non-medical/nursing clinical workplaces
such as dentistry [28] and again lacks a significant focus
on the student.
Other reviews provide a commentary on nursing bully-
ing research [29] and contain limited descriptions of
non-specific recommendations for future practice, e.g.
the provision of counselling for victims. DAmbra & An-
drews [30] report specifically about the effect of bullying
on the new graduate nurse, and Gallo [31] reports the
nature of behaviours in nurse education generally. Some
aspects of bullying in the clinical workplace, and some
professional groups, receive considerable attention in
these reviews. However, there is still little information to
guide those currently planning to instigate a programme
specifically for staff to improve behaviours around stu-
dents in the clinical workplace. This gap is acknowledged
by others, as are inconsistencies in how any interven-
tions are evaluated and reported [27,32]. While we do
find some useful information in the literature, such as
advice to administer an intervention before bullying be-
haviours escalate [33,34], there is still little detailed
guidance to formulate a specific approach.
Emergent evidence from the literature also raises the
issue of unintended consequences of a bullying interven-
tion, which suggests the need for a new direction in re-
search. This evidence links some bullying intervention
and complaint processes to deleterious adverse effects.
For example, it has been noted that an intervention can
cause staff to disengage from learning, and bullying be-
haviour can become exacerbated if complaints are han-
dled in certain ways [9,34]. That is, some interventions
and complaints processes might actually be harmful, or
create further problems for the student.
Bullying intervention research is thus in need of re-
view regarding the latest thinking and a clearer overall
understanding of what might, and might not, be helpful
for the healthcare student. We offer a narrative review
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of this literature with a pragmatic focus to inform those
wishing to effectively address student bullying in the
clinical environment. This review builds on the work of
Fnais [2] which focuses on the persistence and preva-
lence of bullying in the clinical environment. Now, with
the current review we ask:
What are the features of effective or ineffective
interventions aimed at preventing or reducing the
student bullying in the clinical environment?
We used an approach to narrative review as outlined by
Green [35]. This approach includes searching for journal
articles and also referencing other sources that re-
searchers view as important to the topic in review.
Therefore, we included some authoritative books that in-
cluded information relevant to our review topic [35]. As
many databases exclude such texts, we included Google
Scholar in our database search for this purpose.
Our inclusion criteria for academic papers were
peer-reviewed English language papers from 1991 to
2017 that described research into interventions under-
taken in clinical workplaces to address student bullying,
and administered to populations of nursing, medicine
and allied health professionals. These dates purposefully
include early published/evaluated interventions from a
time when ideas about bullying in the clinical workplace
began to be developed in earnest. Clinical staff, and the
healthcare environment is our specific area of interest
because of a lack of in-depth reviews in the current lit-
erature about this specialised, but important context.
Exclusion criteria were non-English language articles
and those published before 1991, and those not describing
any kind of evidence from research. We excluded articles
about student-to-student bullying and interventions
undertaken in the healthcare student classroom setting.
We excluded interventions undertaken in primary health-
care settings (dentistry, optometry, podiatry and general
practice) as these working contexts have a very different
workplace structure to the hospital, for example, health-
care staff can work in considerable isolation from each
other rather than being part of a more clear team
In summary, we limited our search to students in the
hospital setting because the environment can signifi-
cantly influence bullying manifestation and type [9]; the
student learning environment is unique, as is the posi-
tioning of the student within the staff structure in it.
Literature search in detail
Two researchers searched the literature using specific
keywords (see Table 1) developed from our research
question. In this selection, researchers were supported
by the wider research group members and a research li-
brarian specialist. Keywords were initially developed
using a PICO structure [36] (Population, Intervention,
Comparison, Outcome), which offers a useful, struc-
tured, tailored approach to developing and recording
search terms. We modified the PICO formula by adding
an extra category of I(intervention) so we could ease
the administration of searching for descriptions of bully-
ing acts (e.g. to include other key/common words such
as mistreatment) and substituted environmentfor com-
parison.Our electronic search crossed seven databases:
EMBASE, ERIC, Google Scholar, Medline, Science
Direct, Scopus, Web of Science.
Stage 1 search term definition (PICO method)
As we progressed with our literature search, using the
PICO method (see Table 1outlining the terms we used),
words which were unfamiliar and outside our initial
search terms became apparent. For example, e.g., pimp-
ing,which means deliberately asking a student difficult
questions intended to embarrass [12]. Where these
words were considered important, they were added to
our search criteria and searches re-run.
Stage 2 terms excluded
We avoided gathering articles outside our remit by add-
ing a NOTterm search to the original database
searches, specifically, we excluded the following under
the (P, population) category: dent,* pharmacy, optom-
etry, podiatry, general practice, generalist, parent, youth,
girls, boys, classroom, prison, primary, secondary, high
school, parent/ing.
Stage 3 further eliminating articles from the literature
Independent comparison of Excel spreadsheets allowed
the two researchers to remove duplicate and ineligible
articles. Specifically, by checking each abstract for gen-
eral relevance and removing those containing relevant
keywords, but ultimately did not match our criteria (e.g.
about prevalence only).
Stage 4 extraction of detail
The researchers went on to extract detailed data from
each article, using comparisons of data recorded under
the PICO headings, and then by asking the question:
what was going on in this clinical workplace? What was
done, and how, what were the outcomes, and if mea-
sured, how?
Data extraction and analysis
Because of the diversity of articles identified in the
search, the PICO formula for extracting detailed data
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eventually became less useful, and researchers moved
onto using a general inductive thematic approach, as de-
veloped by Thomas [37], which allowed us to record
additional notes and categories. As analysis of the
reviewed papers progressed, themes/data categorisation
were identified, discussed, changed, and reviewed by all
authors, in an ongoing cycle until consensus and data
saturation were reached. Ultimately, after several consul-
tations with all authors, categories developed into the six
themes and associated sub-themes.
A total of 1427 articles were identified, collected and
reviewed, from which 38 met our inclusion criteria
(Fig. 1); 36 were journal articles and two were authorita-
tive books based on collated research. These two books
represent a substantial amount of peer reviewed work,
some translated into English. Articles and texts from this
search describe quantitative or qualitative data and refer
singularly to student bullying, or to both staff and stu-
dent bullying in the clinical environment.
Despite being peer reviewed, and most containing sub-
stantive data, we found some papers were couched more
as comments/opinion pieces or described ideas for inter-
vention but not research around these. The following
themes and associated sub-themes are derived from all
remaining articles and books (Table 2).
The articles reviewed are summarised in Additional file 1:
Appendix A illustrating how evidence from the articles
and books contributes to our resultant six-theme frame-
work. In summary, our final research question was:
What are the features of effective or ineffective
interventions aimed at preventing or reducing
student bullying in the clinical environment?
Themes were:
Understand bullying catalysts
Establish a relationship between the staff and the
interventionist so that staff needs are understood
Policy, necessary but not sufficient
Aim for saturation rather than targeting specific
Frame the intervention to improve behaviour, not
eradicate bad behaviour
Interventionist teaching and facilitation skill matters
We now describe, and then discuss each theme.
Understand bullying catalysts
Under this theme we describe findings suggesting an
intervention should be designed only after developing
an understanding of potential catalysts for bullying in
a workplace. This suggestion arises from noting bully-
ing can be a consequence of a poor quality work en-
vironment and/or personal factors such as values [20,
34,38,39]. Because some workplace and personal
factors make student bullying more likely, identifying
and understanding these is important before deciding
what an intervention should exactly contain (e.g. ups-
killing in communicating well at busy times).
Relevant papers informing this theme were a retro-
spective analysis of departmental incident reports [22], a
descriptive piece based loosely on several pieces of re-
search [39] and a model for the interpretation of poten-
tially complex workplace behaviours and catalysts,
developed from a review of nursing literature [38]. Over-
all, most articles stress the need for an early workplace
intervention which takes into account what might cause
bullying, rather than one which aims to simply curean
existing problem. Examples of bullying catalysts in the
clinical environment include:
a. environmental - monotonous or heavy workload,
job insecurity, long hours, specialism, high-
technology, high responsibility [40] and lack of job
control [41];
b. personal - lack of social support [41] or training,
say, in teaching or skills of clinical practice [22,41]
and being stressed or burnt-out [16,22].
Table 1 A table which explicates the search terms used for the literature review
P 1 Medical student OR student nurse OR student physiotherapist, student midwife
I 2 AND OR intervention OR strategy OR education OR staff development OR policy OR professional development OR
behaviour modification
Ia 2a OR Verbal OR belittlement OR bully* OR sexual harassment OR abuse OR gender OR emotional OR mistreatment
OR pimping OR incivility
C 3 AND Clinical OR, education OR environment OR hospital OR ward
O 4 AND Prevent OR stop OR reduce OR alleviate OR address OR successful OR unsuccessful OR outcome
NOT dental, pharmacy, optometry, podiatry, general practice, generalist, classroom, prison, primary, secondary, high
school, parent, youth, girls, boys
Search terms using the PICO method. PPopulation, IIntervention (variable of interest) as action (2) or actual intervention (2a) CComparison (we used
Environment as it aligns with our topic more accurately t), OOutcome
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In the light of the variation and significance of pos-
sible bullying catalysts, an across-the-board interven-
tion (silver bullet) is unlikely to effectively address
student bullying in all workplaces. Some further sug-
gest that failure to identify and address catalysts
could itself be understood as a way to facilitateor
perpetuate bullying [40,41].
Establish a relationship between the staff and the
interventionist so that staff needs are understood
We use three sub-themes (a, b, c) to describe findings
regarding staff who take part in a bullying intervention.
In contrast to bullying causes or catalysts described
above, texts reviewed here also introduce references to
possible deleterious effects of a bullying intervention
Staff need an interventionist to understand what they do
Clinical work has a unique context, to include specific
tasks and accompanying duties, responsibilities and
stressors. As we describe above, an understanding of this
context has been shown to be important to understand-
ing whether these factors might cause, catalyse or help
bullying to persist in a specific workplace.
However, it has also been found that an interventionist
needs to develop a knowledge and understanding of
what exactly staff do and a departments clinical function
within the health system, again, in order to offer appro-
priate, applicable content, but also to ensure the offering
is accessible [33,39,4244]. An example of such an un-
derstanding might be an intervention should be tailored
in a way that staff can learn skills specifically for use in
an operating theatre, and for it to be offered at times/
places accessible to staff tiedto such a workplace. An
interventionist taking time to acquire such knowledge,
and to develop an intervention around it, can help staff
to engage in learning as it indicates a degree of respect
for those taking part and understanding of their personal
situation [34].
Staff need a relationship with the interventionist
Administering a bullying intervention is not a straight-
forward matter of designing and administering a
programme with particular content. It has also been
found staff need opportunity to develop a functional re-
lationship with the interventionist, in order to achieve
learning outcomes. Such a relationship is needed for the
interventionist to signify respect for staff and to help
Fig. 1 Flowchart of the literature search
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staff view an interventionist as credible - both ultimately
enhancing engagement in learning. A specific suggestion
for developing such a relationship is that an interven-
tionist positions themselves as someone offering help,
rather than one delivering information or imposing a
view; some authors stress overall staff engagement can
depend on the approvalor credibility of an interven-
tionist, obtained by such a relationship [3941,45].
Slightly aside to the above, two texts also discuss rela-
tionshipin terms of a broad requirement to maintain a
functional relationship with both victim and bully, as
would need to be the case where (for example) full, and
truthful information about a bullying incident is being
sought by an interventionist. Authors argue that rela-
tionship can be key in such cases, as ultimately any ef-
fective intervention would need to be based on
obtaining such information [1,34].
Staff need their adult learning needs to be addressed
Clinical staff are adult learners, and as such, have spe-
cific learning needs, and for a variety of reasons. While
couched mostly positively, this sub-theme contains sev-
eral references which also strongly infer what might hap-
pen if an inappropriate teaching method is used.
One important finding in this sub- theme is that adult
learners are unlikely to respond well to being lectured
or toldas would likely be their experience in a lecture
about behaviour. As in adult education more generally,
active learning methods have become widely accepted to
cater specifically to these learners and generally enhance
engagement and learning [4648]. For example, re-
placing a lecture about behaviour with active learning as
a small group discussion can help staff engage in dia-
logue specific to their own context, events and experi-
ences, and can help staff to reflect on their practice in a
saferenvironment - arguably an essential factor in posi-
tive behaviour change. Active learning in small group
discussion has also been shown to help staff generally
explore their own behaviours, and in relation to effects
of bullying [4952] and, especially for older staff, to feel
recognised for their existing skills and knowledge [20].
Thus, the achievement of a bullying interventions
learning outcomes can depend on how it is adminis-
tered, what is inthe programme (and described in other
sections) and at times, on emotional factors such as a
staff member feeling respected and valued. Schoonbeek
& Henderson report a participants positive, transform-
ational experiences of active learning methods used as
part of a bullying intervention:
the tools provided to ushave 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 the behaviours
that I expect from my colleagues ([52], p. 47).
Further claims about the importance of active learning
processes centre around values, attitudes or behaviours,
all of which are potentially complex, challenging and
Table 2 Things to consider for optimal effectiveness when
developing and administering a student bullying intervention
1. Understand bullying catalysts
a) Understand what might cause or catalyse student bullying in a
workplace, e.g. resource constraints
b) Be aware of potential personal issues for staff for whom the
intervention is intended
e.g. lack of specific training in teaching skills
c) Tailor the intervention to take these into account (at least)
2. Staff need: an interventionist to understand what they do, a
relationship with the interventionist, and their adult learning
requirements addressed.
a) Understand what staff do and ensure the intervention is easily
accessible to them
b) Ensure the intervention method allows a functional and supportive
relationship between staff and interventionist to be established
c) Teach staff in ways that adults are more likely to learn (active
learning) especially if values issues need to be addressed
3. Policy: necessary but not sufficient
a) Ensure policy about behaviour is up to date and clearly explicates
the complaints process
b) Ensure policy remit includes staff on adjunct contracts
c) Ensure staff know about policy and understand how to use it
d) Ensure management are skilled in managing policy/complaint
processes and offer support to each employee involved in a
e) Ensure that potential student/staff bullying is addressed in another
way, asides from implementing policy or process, ideally proactively
4. No targeting specific groups, and aim for saturation
a) Include diverse staff groups in the intervention and frame it in
ways to avoid targeting staff groups/specific people/specific
b) Include as many staff as possible (may require several
5. Frame the intervention to improve behaviour, not eradicate bad
a) Ensure the intervention has a positive, relevant topic/content
focused on upskilling
b) Ensure management overtly support the intervention and
c) Ensure staff are offered long term support in enacting new skills
and changing workplace culture
6. Interventionist teaching and facilitation skills matter
a) Ensure the interventionist is skilled in teaching with active learning
b) Ensure the interventionist is knowledgeable of how the clinical
workplace functions
c) Ensure the interventionist is aware of the need to keep information
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delicate to discuss and change. Because of this, some
staff might benefit from the support offered by being in
close contact with a small group of colleagues, a com-
mon pre-requisite for active learning [34,45]. While one
author notes hardened or recidivistbullies might still
be untouched by many such kinds of intervention [53],
others argue that closeness and support, as offered by
most active learning strategies, should indeed be obliga-
tory. This opinion is based on the supposition that de-
veloping staffsreflective thinking and values are central
goals for most interventions [34]. Here, Lucey & Souba
summarise how values change is crucial for most staff to
change their behaviour:
enforcing rules and throwing resources at an
adaptive challenge wont solve the underlying
problem, although those steps might temporarily
mitigate the symptoms. The solution generally
requires changes in the individual ([45], p. 1019).
Some authors also indicate ongoing support might be
required to learn to enact the skills learned from an
intervention, as these might take time to develop, apply
and practise, especially where a negative workplace cul-
ture is engrained [33,54]. While a specific timeframe is
not offered, some recommend further exposure to a pro-
gram of intervention possibly six months after the initial
intervention [54]. The utility of following-up active
learning is supported by others who indicate that wide-
spread change is unlikely in the short term, but would
become more so with support over time [33].
In summary, active learning methods do not guarantee
behaviour change: participant staff might learn well but
fail to action their new learning if they are the only one
doing so [55]. This idea seems to reinforce the notion
raised in sections (a) and (b) about the support active
learning offers for staff group members to enact new
skills or values in the working environment. There may
be no silver bulletto cure bullying, but tailored, multi-
faceted, repeated or ongoing interventions are likely to
do better.
Policy: necessary, but not sufficient
Policy about behaviour is an important feature of a clin-
ical workplace, but on its own has been shown to be
generally ineffective for changing it; policy is of course
necessary, to set out standards and limits of staff behav-
iour [1,22,40,41,5659], legitimise a complaint [9] and
explicate complaints processes, and overall to promul-
gate professional values [18,57]. While in some cases
[59] policy has been shown to be more effective where
used in conjunction with a structured and easy to follow
action plan for management, authors universally stress
that policy alone, or instigated as a bullying
interventionis unlikely to affect staff behaviour [55,57,
58,6066]. Authors justify failure variously: lack of en-
gagement with policy (e.g. its not about me), failure to
know it exists or to understand how to use it [9], or be-
cause bullying can have complex causes and different
manifestations [58]. Johnson [58] illustrates such poten-
tial with the use of an ecological modelof potential
bullying causes. Despite these complexities, developing a
new or revised policy is one of the more common work-
place responses to a bullying complaint.
Policy about behaviour and complaints processes has
been shown to be generally ineffective because bullying
is notoriously under-reported [66]. This means policy is
not enacted as often as the bullying acts are committed.
Kohut [63] estimates that 40% of bullying victims fail to
verbally inform their employer, let alone formally com-
plain. Failure to report bullying can result from a lack of
understanding that bullying is unacceptable, or differing
views of what constitutes bullying [9] or dismissing be-
haviour as idiosyncratic [67], fear of career/academic
suicide[68] or because of a perceived lack of confiden-
tiality during the complaints process (especially for sen-
sitive issues, e.g. sexual harassment) or, sadly, an
understanding that processes will be, or have been, ad-
ministered unfairly or improperly [68].
Policy can also be rendered ineffective in cases where
management fail to take action, such as rejecting
responsibility to address bullying complaints, what some
call ignoring the elephant in the room,([69], p. 1492).
This phenomenon has been shown to be especially pro-
nounced where an accused is on a dual academic/clinical
contract (and a complaint dodged), or where they
possess desirable skills or inhabit a leadership role [9,
6870]. In summary, policy about staff behaviour can be
ineffective as an intervention on its own, or at times
when it is not accessed, understood, followed, or effect-
ively actioned.
Deleterious effects of policy/process
Emerging evidence reveals some behaviour policy/com-
plaints processes, particularly requests to keep a com-
plaint confidential, can have deleterious effects on staff
and resultant behaviour [34]. Such a request can mean
the accused feels, or is seen by others as guiltyprior to
investigation, and precludes that person accessing colle-
gial support. Requests for confidentiality usually aim to
avoid skewing investigation, say, by ensuring an accused
staff member doesnt inappropriately gather supporters
[9,34]. However, it has been found such a request can
be experienced as marginalisation,a practice similar to
that employed by some bullies. Importantly, these expe-
riences have been reported to exacerbate behaviours
because the accused may interpret the request as man-
agements implicit approval of bullying tactics [34]. Such
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a perception can be heightened where management
seem to lack the requisite skill in administering discip-
linary processes [9,23,34].
Instigation of policy processes might infer someone is
guilty,even prior to formal investigation may also be
detrimental to outcomes, because it prevents a bully
from seeking help in the first instance. It immediately
makes the process punitive rather than supportive. For
example, staff who recognize their behaviour as prob-
lematic might fail to seek help because they understand
that a guiltylabel would be then bestowed, and nega-
tively affect their reputation [34]. McGregor [34] stresses
properly enacted bullying policy should actually entail
skilfully nuanced practices that avoid such inference,
but instead withhold judgment and compassionately
and respectfully offer support to both victim and ac-
cused. This author emphasises such practice is espe-
cially important, given the understanding an employer
has a duty of care for the wellbeing of each employee
and accusations can be unfounded, exaggerated or ex-
planations incomplete [34].
Aim for saturation rather than targeting specific groups
Having explained how an intervention might respond to
a workplaces context to assist in engaging staff in learn-
ing, we find indications that a relatively broadapproach,
including all staff, can also optimise engagement [52]
particularly where positive relationships begin to be rein-
forced or forged between professional groups [71]. For
example, an approach which crosses disciplines and
groups of people, and aims to include everyone in devel-
oping a new work culture around students as opposed
to one aimed singularly at troublemakersor the
As part of a non-targeted approach, it has also been
shown it can be helpful for management staff to be seen
toactively participate in any workplace intervention, as
well as to support it via provision of resources and by re-
leasing staff to attend. Management participation is also
important because these staff are not immune to bully-
ing behaviours, and in some cases are central protago-
nists. Either way, what management do(role modelling
and showing they are learning and supporting other
staff) has been shown to vastly influence workplace cul-
ture and any intervention that aims to change it: a stu-
dent bullying intervention needs to be a cohesive effort
that includes everyone [9,57].
Interestingly, management participation in an inter-
vention can enhance overall staff engagement, but also
help with the way student bullying might be understood
and dealt with - some authors suggest bullying incidents
might be better viewed as medical error, thereby avoid-
ing any implication of a personal failure on the part of
the bully [45], and allowing staff to engage better in an
intervention focusing on good practice [41].
While a percentage figure is not offered, the literature
also suggests including as many staff as possible within a
department or section in an intervention, to enhance the
effect on overall workplace culture [72]. As with the sup-
port offered by active learning processes in upskilling
staff or changing behaviour, saturationof new know-
ledge or skill has been said to increase staff confidence
to implement what is learned [48,54].
Deleterious effects of intervention targeting
Under this theme we report further specific evidence to
suggest that staff might suffer negative consequences of
a bullying intervention. These findings add to the work
of McGregor [34] about deleterious effects of policy, re-
ported above. Studies explain how an intervention tar-
geting a single professional group (e.g. the nurses) can
hurt that group, by making the group feel picked on
and at fault [34]. Similarly, interventions specifically tar-
geting the bully,e.g. where mentioned in an interven-
tion description (Lets stop the bullies!) also marginalise
and infer guilt, even in the innocent. Such inferences
have also been shown to result in a staff members fail-
ure to engage because they might respond with a
self-protective counter challenge.Some authors warn
such responses to targeting can also lead to continued
or renewed bullying behaviour [9,34,71,73]. Such ap-
proaches underpin the incorrect assumptions that bully-
ing lies within individuals unrelated to context and that
punitive measures are better than supportive ones.
We also find reference to deleterious effects where the
staff bystanderto student bullying is targeted. While
one paper indicates bystander behaviour is an imperative
part of bullying management [19] another raises a rather
accusatory indication that the bystander who fails to act
is somehow at fault for continued bullying: doing noth-
ing makes you part of the problem([64], p. 299). Some
authors also suggest staff should prevent bullying by
proactively treating each other as potential bullies [66]
which we find a rather unproductive or harmful way to
approach the treatment of ones colleagues.
Frame the intervention to improve behaviour, not
eradicate bad behaviour
Research from the last decade steadily adds weight to
earlier indications that both an interventions content
and its mode of administration are important. A gener-
ally positivefocus aimed to improve behaviours can
better effect behaviour change than one which is nega-
tive or punitive [15,47,50,52,71]. Thomas [16] and
Thomson [71] both suggest such a positive focus is en-
gaging and empowering for participants, and important
to the eventual creation of a blame-free environment,
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again, similar to that described in the field of clinical
error prevention. Similarly, Siassakos [73] and Schoon-
beek & Henderson [51] report a positive focus on en-
hancing skills of teaching and learning can help bullying
by positively influencing overall work culture.
Interventionist teaching and facilitation skills matter
Having described facets of content, topic and interven-
tion framing, we now describe evidence strongly sug-
gesting that the skills of the interventionist can
significantly influence its outcomes. This is echoed by
what we find in the field of adult learning more gener-
ally. As with active learning processes, authors suggest
administering a program or determining its content is
no guarantee that it will be effective but will also depend
on other factors. Jacobs and Bergen [42] offer a specific
example from practice, about how an interventionists
process and content might be appropriate, but their lack
of skill can mean participants side-track discussion away
from a central remit. In this case, the aim was primarily
to aid personal reflection on workplace behaviour. Other
authors [68,74,75] report that as part of skilful teach-
ing, it is those skills relating to interventionists skills of
confidentiality (e.g. how participants hear the teacher
talk about others) that can specifically enhance staff en-
gagement: several studies specifically cite confidentiality
as key to staff participant engagement, especially where
intervention topicsare highly personal. Examples given
in the literature of perceived confidentialityare the
interventionist who offers confidentiality because they
are independent of the participantsemployer [68,69]or
because they have simply formed a trusting, functional
relationship with staff with whom they work (see also
Theme 2).
The information available in the literature presents
challenges in review
The literature about ameliorating student bullying in the
clinical workplace presents several challenges in review.
Literature was both complex and patchy, making it diffi-
cult to develop a clear understanding of best practice.
Details missing from the literature, as noted by others
[27,32], are often substantive, such as a lack of detail
about an intervention or what is meant by a workshop.
Ultimately, such omissions make interpretation and rep-
lication difficult [43,44] and thus limit the total value of
such work.
Many descriptions of interventions also lack detail as
to attendee involvement and teaching methods, research
methods, and results of any evaluation. Likewise, there
can be lack of detail regarding the intervention group.
Some interventions are administered to diverse popula-
tions and, while such diversity is important, the impact
and effect may then vary depending on the staff and stu-
dent roles in each.
We also note a lack of detail about how some out-
comes are ascribed to an intervention [55], e.g. Jacobs &
Bergen [72] report improved workplace atmosphere
after workshops, but without attendant explanation as to
how atmosphere was reported or measured.
Effectively engaging adult learners
The overall focus of much of the literature seems to be
on how best to engage adult, qualified staff in learning
new behaviours or skills. We note a focus on the efficacy
of active learning methods and as part of this, creating a
productive relationship with staff as ways to help them
learn and improve the overall environment for students.
All these factors are discussed in the more general litera-
ture about adult learning. Thus, we are offered ideas
about a possible framework for planning a student bully-
ing intervention that contrasts to a reactively imposed
approach such as a lecture about behaviour, which might
save time and money, but which could be seen to per-
petuate negative work atmosphere or culture. We also
note the emergence of the idea that active learning pro-
cesses can offer staff the support they might need (say, if
values change might be required) and the role of on-
going support from every member of the workforce sub-
sequent to such learning.
The review reveals some detail about affecting positive
behaviour change
Specific themes identified here illustrate the importance
of understanding the workplace experiences of staff, the
nature of their work, incumbent stressors and how an
effective intervention might then be framed and admin-
istered. We note the importance of including these fac-
tors in an intervention framed in ways to avoid
targetinga potential bully, or blaminga specific staff
group. The importance of policy for upholding behav-
ioural standards is also noted, alongside a considerable
consensus acknowledging the limits of policy in terms of
actual positive behaviour change. As well as suggesting
more effective ways to pitch an active learning interven-
tion, we gain an understanding of how it should be
staffed, to include indications of potential deleterious
outcomes should the wrongperson administer it. This
last finding is echoed in the higher education literature,
which has now established a focus away from teaching
contentto an understanding of better process,to who
a teacher is [76].
Catalysts, support and policy - issues dealt with
While identifying bullying catalysts has been highlighted
as important for effective behaviour change, there is less
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guidance on what to do once they are identified. Further
guidance about better managing these issues in the
workplace management (perhaps as part of an interven-
tion) would benefit from the addition of a synthesis of
relevant literature about general clinical workplace man-
agement (e.g. workflow control for environmental issues)
or professionalism and values development (for personal
catalysts to bullying). Such a synthesis is outside the re-
mit of our current work but seems important, given
other evidence suggesting apparent lack of support from
management in workplace issues can mean staff subse-
quently interpret, and reject, any intervention as a pen-
alty, e.g. for not coping[55]. There is also a growing
understanding that neglecting to address bullying in the
workplace might render management personally culp-
able [40,41,77].
The literature also contains little guidance about policy
to specifically cater for student needs, for example how
to help a student to report bullying safely.Such a
provision would likely improve reporting rates, as well
as action taken on it. Instead, the present day complain-
ant can still fear exacerbated retribution, to include ser-
ious academic consequences. We watch with interest
about how programmes such as the Vanderbilt [7880]
cater to this unique and vulnerable population.
Concern about bystander research
We are concerned about how the literature portrays the
role of the staff bystander who says nothing as being
complicit in bullying, potentially targetingthese (likely)
innocent staff members. If the environment remains un-
safe and broader issues are not addressed, a staff by-
stander making a standfor the bullied student can be
placed in considerable danger of being bullied them-
selves. Such dangers are described in recent media re-
ports which suggest a bystander who reports bullying to
management risks having their academic or career pro-
gression curtailed by similar means to that suffered by
the student they were trying to help [26]. As we found
with policy and reporting, there are few references to
how a bystander may exactly be supported, or specify an
appropriate process by which student bullying might be
reported, here, by a person who is not the actual target.
We thus find some of the advice offered rather out of
place, e.g. for a bystander to confront a bully [59], given
that the main remit of any bullying intervention should
be to encourage harmony, not discord, in a workplace.
Instead, an approach focused more on the learning
environment, not individuals, seems more likely to be
Limitations of our review methods
Results reported here are limited by the purposeful ex-
clusion of articles about interventions exclusively about
qualified staff (inter-staff bullying) which may have ex-
cluded useful insights into bullying interventions more
generally. There is also a substantial literature from
Norway about staff-staff interventions which might only
be partially reflected in our use of the research-based
book by Einarsen [9]. We also find a relative lack of spe-
cific foci on helping allied health professional students
despite the inclusion of appropriate terms in our search
criteria. Findings are also limited by lack of evaluation of
results of anti-bullying interventions administered by
private enterprises in the clinical environment, e.g. Van-
derbilt programs (see Swiggart [22,80], Yamada [81],
Hickson, et al., [82], Webb et al. [78], Dubree et al. [78]
for partial descriptions). Such enterprises offer interven-
tions which aim to ameliorate inter-staff bullying but we
find little specific reference to student bullying.
Despite these potential limitations, our review
methods seem rigorous, were made explicit, and repre-
sent a novel approach compared with many other re-
views, such as those which follow a levels of evidence
approach (e.g. Green [35]). Such difficulties are relevant
because they are highly likely to be experienced by
others charged with developing a bullying intervention.
Instead, we offer concise, practical guidance with the
aim to help ameliorate bullying for students worldwide.
Summary of recommendations for further research
Despite the concerns and limitations described, we feel
confident the themes identified offer robust areas for fu-
ture interventions and research. As such, we identify the
following as foci for further research, review or synthe-
sis, in the context of student bullying. We suggest:
1. a specific focus on, and evaluation of, what works
for students, in particular, regarding bullying in the
clinical setting;
2. a specific focus on student-student bullying and any
interplay between this literature/interventions with
this in mind, and the current review;
3. a synthesis of ideas about the management of
environmental and personal catalysts with those
about identification and intervention;
4. the development and evaluation of a safesystem
for a student, staff or bystander to raise a bullying
issue or make a complaint;
5. amorein-depthunderstanding of relative effectiveness
of active learning methods in interventions, how these
might best be realised for values change and staff
support, and any specific deleterious effects of
learning methods which are less effective, e.g.
6. how the recidivist bully might be best engaged in an
intervention to include research into how the
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accusedexperiences bullying intervention, to add
further to knowledge about what not to do.
7. the development and evaluation of methods to
address recidivist bullies;
8. a more detailed understanding of the effect of who
an interventionist ison staff engagement and learning;
9. the deliberate avoidance of processes likely to
be deleterious to staff undertaking a bullying
We synthesise findings about interventions designed to
reduce bullying of students in the clinical environment,
into themes to guide the practitioner. We offer substan-
tial synthesised important and useful information about
what exactly might be done to help students in clinical
practice. In doing so, we also bring together some emer-
gent ideas about what we should stop doing,some re-
assurance about aspects which seem to be developing in
alignment with the literature about adult education and
ways to avoid pitfalls and potential deleterious effects of
an intervention. Ultimately, we aim this review to im-
prove the learning and lives of our students, help staff in
clinical practice better enjoy their work and maintain an
increased overall quality of clinical service for patients.
Additional file
Additional file 1: Appendix A Evidence table of literature used in the
review and the corresponding theme(s) they contributed towards.*
(DOCX 37 kb)
EMBASE: Excerpta Medica dataBASE, a biological and pharmacological
database of international published literature; ERIC: Educational Resources
Information Center, a database of international literature with a focus on
education; NHS: National Health Service, a public healthcare provider based
in the United Kingdom; PICO: Population, Intervention, Comparison,
Not applicable.
We would like to acknowledge and thank the Division of Health Sciences,
University of Otago, Dunedin, NZ, for financial support during the writing of
this article.
Availability of data and materials
We confirm that all data generated or analysed during this study are
included in the published article [and its supplementary information files].
AGB is first author of the current text, gathered and analysed all papers for
the review, developed the themes and presentation, drafted the overall
design of the review; wrote and revised multiple drafts of the current article.
KSH gathered and analysed all papers for the review, assisted with thematic
development, presentation and the overall design of the review, helped
develop ideas presented in the discussion section, reviewed multiple drafts
of the current article. LA is the principal investigator and assisted with
thematic development and presentation, the overall design of the review,
helped develop ideas presented in the discussion section, reviewed multiple
drafts of the current article; TW assisted with thematic development and
presentation, the overall design of the review, helped develop ideas
presented in the discussion section, reviewed multiple drafts of the current
article. EC helped develop ideas presented in the discussion section,
reviewed multiple drafts of the current article. EB helped develop ideas
presented in the discussion section, reviewed multiple drafts of the current
article. All authors have approved the submitted version of the article, are
happy for its publication in its current form and agree to be personally
accountable for all aspects of the current work. The authors also acknowledge
responsibility for the investigation of any issue raised about the current works
integrity or accuracy.
Ethics approval and consent to participate
Ethical approval and participant consent is not applicable to this review.
Consent for publication
Not applicable.
Competing interests
Author Tim Wilkinson is a member of the BMC Medical Education Editorial
Board. The authors declare no further competing interests between the
article and other individual or workplace interests. This article has not been
published or presented elsewhere.
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Author details
Otago Medical School, University of Otago, Dunedin, NZ, New Zealand.
Bioethics Centre, University of Otago, Dunedin, NZ, New Zealand.
Polytechnic & Staff Nurse, Southern District Health Board, Dunedin, NZ, New
North Shore Hospital, Waitemata District Health Board, Auckland,
NZ, New Zealand.
Received: 31 May 2018 Accepted: 25 April 2019
1. Martin W. Is your hospital safe? Disruptive behavior and workplace bullying.
Hosp Top. 2008;86(3):218.
2. Fnais N, Soobiah C, Chen M, et al. Bullying and discrimination in medical
training: a systematic review and meta-analysis. Acad Med. 2014;89(5):81727.
3. Jamieson J, Mitchell R, LeFevre J, Perry A. Bullying and harassment of
trainees: an unspoken emergency? Emerg Med Australas. 2015;27(5):4647.
4. Mikkelsen E, Einarsen S. Bullying in Danish work-life: prevalence and health
correlates. Eur J Work Organ Psychol. 2001;10(4):393413.
5. Berryman E. Bullying culture: valuing the teacher-student relationship. NZ
Med J. 2015;128(1424):137.
6. Watters D, Hillis D. Discrimination, bullying and sexual harassment: where
next for medical leadership? Med J Aust. 2015;203(4):175e.
7. Anthony A, Jones A. Eradicating abusive behavior: time to adjust the
educational paradigm. Med Teach. 2016;38(6):5356.
8. Major A. To bully and be bullied: harassment and mistreatment in medical
education. Virtual Mentor. 2014;16(3):15560.
9. Einarsen S, Hoel H, Zapf D, Cooper C. Bullying and bullying in the
workplace: developments in theory, research, and practice. 2nd ed. London:
CRC Press; 2011.
10. Mavis B, Sousa A, Lipscomb W, Rappley M. Learning about medical student
mistreatment from responses to the medical school graduation
questionnaire. Acad Med. 2014;89(5):70511.
11. 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.
12. Orum H, Semalulu T, Underwood W. The social and learning environments
experienced by underrepresented minority medical students: a narrative
review. Acad Med. 2013;88(11):176577.
13. McCarthy C, McEvoy J. Pimping in medical education: lacking evidence and
under threat. JAMA. 2015;314(22):23478.
14. Kassebaum D, Cutler E. On the culture of student abuse in medical school.
Acad Med. 1998;73(11):114958.
Gamble Blakey et al. BMC Medical Education (2019) 19:220 Page 11 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
15. 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):3889e.
16. Thomas C. Teaching nursing students and newly registered nurses
strategies to deal with violent behaviors in the professional practice
environment. J Contin Educ Nurs. 2010;41(7):299308.
17. Spence Laschinger H, Nosko A. Exposure to workplace bullying and post-
traumatic stress disorder symptomology: the role of protective
psychological resources. J Nurs Manag. 2015;23(2):25262.
18. Skehan J. Nursing leaders: strategies for eradicating Bullying in the
workforce. Nurs Lead. 2015;13(2):602.
19. Vessey J, Demarco R, Gaffney D, Budin W. Bullying of staff registered nurses
in the workplace: a preliminary study for developing personal and
organizational strategies for the transformation of hostile to healthy
workplace environments. J Prof Nurs. 2009;25(5):299306.
20. Longo J. Bullying and the older nurse. J Nurs Manag. 2013;21(7):9505.
21. Swiggart W, Dewey C, Hickson G, Finlayson A, Spickard W Jr. A plan for
identification, treatment, and remediation of disruptive behaviors in
physicians. Front Health Serv Manag. 2009;25(4):311.
22. Hamblin L, Essenmacher L, Ager J, Upfal M, Luborsky M, Russell J, Arnetz J.
Worker-to-worker violence in hospitals: perpetrator characteristics and
common dyads. Workplace Health Saf. 2015;64(2):516.
23. Curtis J, Bowen I, Reid A. You have no credibility: nursing students
experiences of horizontal violence. Nurse Educ Pract. 2007;7(3):15663.
24. Crampton P, Wilkinson T, Anderson L, Walthert S, Wilson H. Bullying in
health care settings: time for a whole-of-system response. NZ Med J. 2015;
25. Wood D. Bullying and harassment in medical schools: still rife and must be
tackled. BMJ. 2006;333(7570):664.
26. RACS. Royal Australasian College of Surgeons: Surgeons stories: https://'-stories.
Downloaded March 17, 2016.
27. Stagg S, Sheridan D. Effectiveness of bullying and violence prevention
programs: a systematic review. AAOHN J. 2010;58(10):41924.
28. Illing J, Carter M, Thompson N, et al. Evidence synthesis on the occurrence,
causes, consequences, prevention and management of bullying and
harassing behaviours to inform decision-making in the NHS. Project Report.
London: HMSO; 2013.
29. Mitchell A, Ahmed A, Szabo C. Workplace violence among nurses, why are
we still discussing this? Literature review. JNEP. 2014;4(4):147.
30. D'Ambra A, Andrews D. Incivility, retention and new graduate nurses: an
integrated review of the literature. J Nurs Manag. 2014;22(6):73542.
31. Gallo V. Incivility in nursing education: a review of the literature. Teach
Learn Nurs. 2012;7(2):626.
32. Volk A, Veenstra R, Espelage D. So you want to study bullying?
Recommendations to enhance the validity, transparency, and compatibility
of bullying research. Aggress Violent Behav. 2017;36:3443.
33. Vartia M, Lecka S. Interventions for the prevention and management of
bullying at work. In: Einarsen S, Hoel H, Zapf D, Cooper C, editors. The
concept of bullying and bullying at work: the European tradition. Bullying
and bullying in the workplace: developments in theory, research, and
practice. 2nd ed. London: CRC Press; 2011.
34. McGr egor F-L. Bullying: the perspective of the accused. In: The
handbook of dealing with workplace Bullying. Surrey: Gower Publishing
Limited; 2015.
35. Green B, Johnson C, Adams A. Writing narrative literature reviews for peer-
reviewed journals: secrets of the trade. J Chiropr Med. 2006;5(3):10117.
36. PICO (2015) The PICO method of systematic review. https://www.femtomedicine.
com/the-pico-method-university-of-warwick/ Downloaded 21 March 2016.
37. Thomas D. General inductive approach for analyzing qualitative evaluation
data. Am J Eval. 2006;27(2):23746.
38. 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.
39. Rosenstein A. Early intervention can help prevent disruptive behavior.
Physician Exec. 2009;35(6):14.
40. Felblinger D. Bullying, incivility, and disruptive behaviors in the healthcare setting:
identification, impact, and intervention. Front Health Serv Manag. 2009;25(4):23442.
41. Rosenstein A. Ad dressing the causes and consequences of disruptive
behaviors in the healthcare setting. J Psychol Clin Psychiatry.
42. Jacobs C, Bergen M. A sexual bullying workshop for medical students. Acad
Med. 1995;70:4345.
43. Robinson G, Stewart D. A curriculum on physician-patient sexual
misconduct and teacher-learner bullying part 1: content. Can Med Assoc J.
44. Robinson G, Stewart D. A curriculum on physician-patient sexual
misconduct and teacher-learner bullying part 2: teaching method. Can Med
Assoc J. 1996;154(7):10215.
45. Lucey C, Souba W. Perspective: the problem with the problem of
professionalism. Acad Med. 2010;85(6):101824.
46. Zweibel EB, Goldstein R, Manwaring JA, Marks MB. What sticks: how
medical residents and academic health care faculty transfer conflict
resolution training from the workshop to the workplace. Confl Resolut
Q. 2008;25(3):32150.
47. Biggs J, Tang C. Teaching for quality learning at university: what the student
does. Berkshire: McGraw-Hill Education; 2011.
48. Lasater K, Mood L, Buchwach D, Dieckmann N. Reducing incivility in the
workplace: results of a three-part educational intervention. J Contin Educ
Nurs. 2015;46(1):1524.
49. Heru A. Role play in medical education to address student mistreatment.
Virtual Ment. 2014;16(3):358.
50. Johnston M. A model program to address insensitive behaviours toward
medical students. Acad Med. 1992;67(4):2367.
51. Clark C, Ahten S, Macy R. Using problem-based learning scenarios to prepare
nursing students to address incivility. Clin Simul Nurs. 2013;9(3):7583e.
52. Schoonbeek S, Henderson A. Shifting workplace behavior to inspire
learning: a journey to building a learning culture. J Contin Ed Nurs. 2011;
53. Moscarello R, Margittai K, Rossi M. Impact of faculty education on the
incidence of sexual bullying experienced by Canadian medical students. J
Womens Health. 1996;5(3):2317.
54. Heru A. Using role playing to increase residentsawareness of medical
student bullying. Acad Med. 2003;78(1):358.
55. Fried J, Vermillion M, Parker N, Uijtdehaage S. Eradicating medical student
mistreatment: a longitudinal study of one institutions efforts. Acad Med.
56. Lachman V. Practical use of the nursing code of ethics: part I. Medsurg Nurs.
57. Barnsteiner J, Madigan C, Spray T. Instituting a disruptive conduct policy for
medical staff. AACN Adv Crit Care. 2001;12(3):37882.
58. Johnson S. An ecological model of workplace bullying: a guide for
intervention and research. Nurs Forum. 2011;46(2):5563.
59. Leiper J. Nurse against nurse: how to stop horizontal violence. Nursing.
60. Hollins-Martin C, Martin C. Bully for you: bullying and bullying in the
workplace. Br J Midwifery. 2010;18(1):2531.
61. Hollands M. Short report: Bullying and Bullying can we solve the problem.
Med J Aust. 2015;203(4):192.
62. Lachman V. Practical use of the nursing code of ethics: part II. Medsurg
Nurs. 2009;18(3):1914.
63. Walton M. Sexual equality, discrimination and harassment in medicine: its
time to act. Addiction. 2015;165(24):1679e.
64. Kohut M. The complete guide to understanding, controlling, and stopping
bullies & bullying at work: a complete guide for managers, supervisors, and
co-workers. Ocala: Atlantic Publishing Group; 2007.
65. Clarke C, Kane D, Rajacich D, Lafreniere K. Bullying in undergraduate clinical
nursing education. J Nurs Educ. 2012;51(5):26976.
66. Hills L. What the medical practice employee needs to know about
workplace bullying. J Med Prac Manage. 2012;27(5):295300.
67. Hakojärvi H, Salminen L, Suhonen R. Health care studentspersonal
experiences and coping with bullying in clinical training. Nurs Educ Today.
68. Best C, Smith D, Raymond J Sr, Greenberg R, Crouch R. Preventing and
responding to complaints of sexual bullying in an academic health center: a
10-year review from the Medical University of South Carolina. Acad Med.
69. Souba W, Way D, Lucey C, Sedmak D, Notestine M. Elephants in academic
medicine. Acad Med. 2011;86(12):14929.
70. Hodgins M, MacCurtain S, Mannix-McNamara P. Workplace bullying and
incivility: a systematic review of interventions. Int J Workplace Health
Manag. 2014;7(1):5472.
Gamble Blakey et al. BMC Medical Education (2019) 19:220 Page 12 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
71. Siassakos D, Timmons C, Hogg F, Epee M, Marshal L, Draycott T. Evaluation
of a strategy to improve undergraduate experience in obstetrics and
gynaecology. Med Educ. 2009;43(7):66973.
72. Jacobs C, Bergen M. Impact of a program to diminish gender insensitivity
and sexual bullying at a medical school. Acad Med. 2000;75(5):324.
73. Houghton A. Bullying in medicine. British Med J (Clinical Research Ed). 2003;
74. 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.
75. 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 Educ. 2005;39(5):47681.
76. Palmer P. The courage to teach: exploring the inner landscape of a
teachers life. San Francisco: Wiley; 2017.
77. NZ. Introduction to the health and safety at work act 2015. Wellington: Special
Guide; 2015. Downloaded from:
and-safety/getting-started/introduction-hswa-special-guide/ January 2018
78. Webb L, Dmochowski R, Moore I, Pichert J, Catron T, Troyer M, et al. Using
coworker observations to promote accountability for disrespectful and
unsafe behaviors by physicians and advanced practice professionals. Jt
Comm J Qual Pat Saf. 2016;42(4):14961.
79. Dubree M, Kapu A, Terrell M, Pichert J, Cooper W, Hickson G. Nursesessential
role in supporting professionalism. Am Nurse Today. 2017;12(4):68.
80. Swiggart W, Pichert J, Brown M, Callahan T, Catron T, Webb L, et al.
Promoting professionalism and professional accountability. In: Viera A,
Kramer R, editors. Management and leadership skills for medical faculty.
Champagne: Springer; 2016. p. 11527.
81. Yamada D. Understanding and responding to bullying and related behaviors
in healthcare workplaces. Front Health Serv Manag. 2009;25(4):336.
82. Hickson G, Pichert J, Webb L, Gabbe S. A complementary approach to
promoting professionalism: identifying, measuring, and addressing
unprofessional behaviors. Acad Med. 2007;82(11):10408.
Gamble Blakey et al. BMC Medical Education (2019) 19:220 Page 13 of 13
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... Uno de los primeros pasos para la prevención es la educación de los estudiantes y los adultos de la detección de situaciones indeseables en el ambiente académico y clínico 10 . En el estudio se realizaron preguntas a los estudiantes (1 y 2 de la tabla 1) en donde cerca del 40% refiere haber sido víctimas de violencia. ...
... Es necesario contar con canales de denuncia confidenciales que protejan el anonimato de la víctima 10 . Estos canales de denuncia deben de derivar en evaluaciones profesionales con opiniones expertas a imparciales a la investigación de los hechos donde se tenga el análisis de todos los involucrados, incluyendo la perspectiva de género 15 . ...
Full-text available
El maltrato y acoso en estudiantes de medicina es un tema que requiere atención y prevención. Diversos estudios demuestran la necesidad de crear un ambiente de formación seguro dentro y fuera de las instituciones educativas a lo largo del programa, incluyendo escenarios clínicos y el servicio social. El presente trabajo conjunto entre la AMFEM y la AMMEF muestran un diagnóstico sobre la situación actual y una propuesta para prevenirla. No hay pretexto para seguir postergando acciones contundentes desde las Escuelas y Facultades de Medicina.
... Students have expressed that the appointment of pastoral tutors has made it more feasible to approach members of faculty regarding sensitive issues. 5 These initiatives not only facilitate a medium for Correspondence: Anushka Sharma Imperial College School of Medicine, Imperial College London, London, UK Tel +44 7427404135 Email complaints, but communicate to the student body that their mental wellbeing is a priority. ...
... At early stages of training, medical students collectively consider the initiatives described above to be crucial in reducing bullying. 5 The provision of different channels through which students can express concerns about mistreatment is more meaningful than a mere "tick box" exercise. Moreover, the consequences of mistreatment have been outlined, with schools emphasising a zerotolerance policy for any such behaviour. ...
... 3,4 We note and welcome the safeguarding changes made to the undergraduate experience in many countries highlighted by Sharma and her co-authors, in the creation of both personal and pastoral tutors to provide pathways to channel concerns and difficulties on all aspects of medical student welfare, including bullying. 5 We maintain that bullying of whatever form should have no place in the Medical Profession and agree with Sharma and her co-authors that this must also involve medical student education. There can be no room for teaching by humiliation. ...
... Literature on how students might be protected from bullying as part of the teacherstudent relationship in small groups is emergent (Palmer, 2007;Plaut & Baker, 2011). Some literature broadly acknowledges the possibility that a student might be mistreated in small groups (Recupero et al., 2004), but most focus on how to administer a formal bullying "intervention", for instance, aimed at changing a teacher's potentially sexist behaviour (Einarsen et al., 2011; see also Gamble Blakey et al., 2019). ...
... 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. ...
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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.
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Aim To explore how an ecological approach be used to explore relationships among workplace empowerment, authentic leadership, trust in management, areas of work life and co‐worker incivility experiences of new graduate nurses. Design Key concepts related to new graduate nurses' incivility experience informed the research question building on the findings of our first author's integrative review. Second, relevant theories and concepts were identified by conducting a literature review. Third, the themes build on prior theories and factors to propose a hypothetical model. Data Sources (2016–2019) CINAHL, OVID, PSYCINFO, PUBMED, EBSCO, ERIC, SCOPUS, Cochrane Library; PROQUEST and Google Scholar. Review Methods (a) Constructs identified in an IR (Blackstock et al., 2018) guided a literature review on predictive variables linked to new graduate nurse's co‐worker incivility experiences; (b) an ecological approach was explored; and (c) we demonstrate how multidimensional organizational factors related to incivility experiences of new graduate nurses can be situated in an ecological model. Results Structural and organizational factors, and nurse leaders influencing new graduate nurses' experiences are situated in an ecological model. Placing new graduate nurses' co‐worker incivility experiences in the microsystem and close to the mesosystem (nurse supervisor) and exosystem (workplace empowerment) of our ecological model provides new insights into their incivility experiences and informs future research. Conclusion The ecological approach and operational definition of incivility help to clarify incivility behaviours as not merely individual behaviours observed by others needing corrective cognitive behaviours, nor support in a graduate transition program, but rather a symptom of work environment factors contributing to multidimensional work environments of new graduate nurses' and influence incivility behaviours. Impact New graduate nurse co‐worker incivility research could measure change across time and across system domains informed by this ecological approach and can shape new ways of thinking about how to prevent and mitigate incivility.
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Introduction Nursing students are confronted with bullies in the classroom and during clinical placement. Acquisition of the necessary psychomotor skills intended during clinical placements may be impeded when workplace bullies intimidate students. This study aimed to describe the various bullying behaviours experienced by nursing students and their effects during clinical placement in the Central Region of Ghana. Methods A qualitative phenomenological descriptive approach using a semi-structured interview guide was employed to collect data from nursing students in focus groups. Overall, six (6) focus groups were used, with five (5) students in each group comprising males and females. The sample size was based on data saturation and was saturated on the six focus group discussions giving a sample size of 30. Purposive sampling was used to select students who had been on the ward at least three clinical placements and had experienced bullying in the clinical setting. In-depth interviews were conducted, recorded, transcribed verbatim and analysed using content analysis. Results The study revealed that nursing students had experienced bullying practices such as shouting, isolation, humiliation and being assigned tasks below their competency level. In addition, findings showed that bullying led to a loss of confidence and caused stress and anxiety in nursing students. Conclusion Therefore, it is recommended that nursing students are mentored holistically in a caring and accepting environment where they will be supported to achieve their learning goals, build their confidence, and develop their personal and professional identity.
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Purpose To characterise the dynamics and consequences of bullying in academic medical settings, report factors that promote academic bullying and describe potential interventions. Design Systematic review. Data sources We searched EMBASE and PsycINFO for articles published between 1 January 1999 and 7 February 2021. Study selection We included studies conducted in academic medical settings in which victims were consultants or trainees. Studies had to describe bullying behaviours; the perpetrators or victims; barriers or facilitators; impact or interventions. Data were assessed independently by two reviewers. Results We included 68 studies representing 82 349 respondents. Studies described academic bullying as the abuse of authority that impeded the education or career of the victim through punishing behaviours that included overwork, destabilisation and isolation in academic settings. Among 35 779 individuals who responded about bullying patterns in 28 studies, the most commonly described (38.2% respondents) was overwork. Among 24 894 individuals in 33 studies who reported the impact, the most common was psychological distress (39.1% respondents). Consultants were the most common bullies identified (53.6% of 15 868 respondents in 31 studies). Among demographic groups, men were identified as the most common perpetrators (67.2% of 4722 respondents in 5 studies) and women the most common victims (56.2% of 15 246 respondents in 27 studies). Only a minority of victims (28.9% of 9410 victims in 25 studies) reported the bullying, and most (57.5%) did not perceive a positive outcome. Facilitators of bullying included lack of enforcement of institutional policies (reported in 13 studies), hierarchical power structures (7 studies) and normalisation of bullying (10 studies). Studies testing the effectiveness of anti-bullying interventions had a high risk of bias. Conclusions Academic bullying commonly involved overwork, had a negative impact on well-being and was not typically reported. Perpetrators were most commonly consultants and men across career stages, and victims were commonly women. Methodologically robust trials of anti-bullying interventions are needed. Limitations Most studies (40 of 68) had at least a moderate risk of bias. All interventions were tested in uncontrolled before–after studies.
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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.
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Bullying and harassment is a significant predicament that midwives face on a regular basis. Bullying and harassment may be characterized by unpleasant, threatening, malevolent or offensive behaviour. It involves abuse or misuse of power intended to undermine, humiliate, denigrate or harm the recipient. Deliberate bullying and/or harassment can have a major impact upon physical and mental health, as well as function within role. There are consequences for the persecutor, victim and institution in terms of health, cost and reputation. The objective of this paper is to provide managers with solutions to diminish levels of bullying and harassment within maternity units. To this effect, a bullying and harassment protocol has been written to guide managers to use appropriate strategies to diminish the intensity of bullying and harassment within their unit. To audit success, a Bullying and Harassment Scale (BAHS) has been devised to measure effectiveness of interventions targeted at reducing the problem.
Dedicated leadership, effective planning and teamwork, and reliable implementation are essential elements of successful healthcare initiatives, clinical outcomes and research endeavors. Lapses in professional conduct at any level may undermine the teamwork necessary to achieve goals in safety and outcomes. Therefore, Academic Medical Center (AMC) leaders need means for identifying lapses and addressing unnecessary variation in professional performance. This chapter discusses application of self- and group-regulation—hallmarks of professionalism—to a hypothetical AMC faculty member, “Dr. A,” recruited to create a Coordinated Clinical Care Center, an important programmatic need for the department. Despite his department Chair’s expectations that Dr. A will implement a multidisciplinary approach to patient care, evidence accumulates that Dr. A’s performance is undermining attainment of the Center’s goals. The chapter describes an evidence-based plan and process by which AMCs may promote professionalism and restore full and effective functioning (“redeem”) physicians—both leaders like Dr. A and non-leader colleagues—who model conduct inconsistent with AMC values and a culture of safety.
Bullying is a serious problem that affects millions of individuals worldwide each year. In response to this, thousands of research articles have been published on bullying. Unfortunately, much of bullying research remains largely atheoretical in its approach to defining bullying as a unique form of aggression. Another key problem in bullying research is the proliferation of heterogeneity of bullying measures whose validity is sometimes questionable. Combined, these two problems have made progress difficult as comparisons between studies and results are impeded by a lack of commonality. As a solution to these problems a discussion of the issues surrounding defining and measuring bullying is offered. This paper aims to promote thoughts and insights about the critical issues and concepts facing those who seek to define and measure bullying for research, intervention, or policy work. Although suggestions for best practices are offered, the overriding goal is to promote all practices that enhance the validity, transparency, and compatibility of bullying research. The time seems right for a general call to action for researchers to individually produce data that are both theoretically and empirically more communicable to the broader bullying community.
Background: Health care team members are well positioned to observe disrespectful and unsafe conduct-behaviors known to undermine team function. Based on experience in sharing patient complaints with physicians who subsequently achieved decreased complaints and malpractice risk, Vanderbilt University Medical Center developed and assessed the feasibility of the Co-Worker Observation Reporting System(SM) (CORS (SM)) for addressing coworkers' reported concerns. Methods: VUMC leaders used a "Project Bundle" readiness assessment, which entailed identification and development of key people, organizational supports, and systems. Methods involved gaining leadership buy-in, recruiting and training key individuals, aligning the project with organizational values and policies, promoting reporting, monitoring reports, and employing a tiered intervention process to address reported coworker concerns. Results: Peer messengers shared coworker reports with the physicians and advanced practice professionals associated with at least one report 84% of the time. Since CORS inception, 3% of the medical staff was associated with a pattern of CORS reports, and 71% of recipients of pattern-related interventions were not named in any subsequent reports in a one-year follow-up period. Conclusions: Systematic monitoring of documented co-worker observations about unprofessional conduct and sharing that information with involved professionals are feasible. Feasibility requires organizationwide implementation; co-workers willing and able to share respectful, nonjudgmental, timely feedback designed initially to encourage self-reflection; and leadership committed to be more directive if needed. Follow-up surveillance indicates that the majority of professionals "self-regulate" after receiving CORS data.
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.