Turkish Nursing Students’ Perceptions and Experiences of

Bullying Behaviors in Nursing Education

Serap Palaz

University of Balikesir

Abstract

Objective: This descriptive study aimed to determine thebullying and harassment experiences of nursing students’ invarious Nursing Schools in Turkey.  The types and frequency ofbullying behaviors, the sources of bullying behaviors, andstudents’ emotions towards these experiences were investigated.

Methods: Study participants were 370 undergraduate nursingstudents from four different Turkish Nursing Schools.  Toestimate bullying at nursing school I used a short version ofthe Negative Acts Questionnaire that adapted according to theearlier studies on bullying against nursing studentsparticularly those conducted by Cooper et al. and Celik andBayraktar.

Results: A total of 222 respondents (60%) reported that theyhad experienced at least one of the thirteen bullying behaviorsat daily and weekly frequencies during the last six months.Work related bullying was the most frequently encountered typeof bullying behaviors which is followed by personal relatedbullying behaviors. Also, an interesting result from this studyis that most students reported clinic nurses as their bully,indicating that the perpetrators were mostly females and olderthan them.

Conclusions: This study supports previous reports of bullyingagainst Turkish student nurses and adds to the scant body ofliterature showing that nursing students often experiencebullying and harassment from clinical nurses (horizontal

bullying), and importantly, this may influence their futureemployment choices.

Introduction

Violence, verbal abuse and bullying at work have been widely

studied by researchers in the field of occupational health and

safety particularly among researchers in the nursing

professions from different parts of the world (Cox, 1987;

Einarsen, Matthiesen, & Skogstad, 1998; Quine, 2001; Stevens,

2002; Inoue, Tsukano, Muraoka, Kaneko, & Okamura, 2006, Lewis,

2006; Celik & Celik, 2007; Cooper, Walker, Askew, Robinson, &

McNair, 2011). Although the study of types, sources and

frequency of bullying/mobbing behaviors encountered by Turkish

nurses in the workplace attracted noticeable attention recently

(Uzun, 2003; Oztunc, 2006; Yildirim & Yildirim, 2007; Kisa,

2008; Ozturk, Sokmen, Yilmaz, & Cilingir 2008; Efe & Ayaz,

2010; Pinar & Ucmak, 2010) according to the best of our

knowledge there has been paid a little attention to the

investigation of bullying and harassment against nursing

students in Turkey (Celik & Bayraktar, 2004; Celebioglu,

Akpinar, Kucukoglu, & Engin, 2010).

National and international literature reveals that the

prevalence of bullying and harassment in the health sector

workplace is well known problem and the risk of being subjected

to psychological violence among nurses are three times higher

than in other professional groups in the service sector (Keely,

2002; Celebioglu, et al, 2010). Also Ferns and Meerabeau

(2007: 437) quote that nursing students have the highest risk

of experiencing aggression because of inexperience, frequent

ward changes and the challenge of meeting new environments.

Although The World Health Organizations, the International

Council of Nurses, and Public Services International recognize

the incidence of violent episodes as a major health priority,

the number of nurses affected by this problem still continues

to rise (Hinchberger, 2009; Kuehn, 2010).

Bullying and harassment are emotional issues for nurses who are

exposed to abusive behaviors and have negative influences on

both their own physical and psychological health and the

quality of service they provide. Especially Celik and

Bayraktar (2004) and Longo (2007) contend that when nursing

students a practice setting encounter bullying behaviors, their

approach to practice, as well as their intent to become a nurse

can be affected. The nursing shortage is considered to be a

world-wide problem and it is suggested that unhealthy work

environments cause the recruitment and retention problem (Gok &

Kocaman, 2011). Yet there is limited research on the

phenomenon of bullying and harassment in the nursing education

and possible impact of this on future employment choices. This

present study attempts to make a contribution to redressing

this gap by determining perceived bullying and harassment

behaviors which experienced by nursing students in four Turkish

Nursing Schools. More specifically, this study intended to

achieve the followings:

1. To describe the types and frequency of bullying and

harassment behaviors that is faced by nursing students in

Nursing Schools, and the association between bullying behaviors

and demographic variables such as gender, year at school,

marital status and participant’s place of living;

2. To describe the sources of bullying and harassment

experienced by nursing students in both their educational and

clinical settings;

3. To determine the effect of bullying behaviors on nursing

students’ academicals and professional achievement and also

physical and psychological health; and

4. To determine the type of behaviors used by students to cope

with bullying and harassment, and to find out whether any

Nursing School has special programs to overcome this problem.

Background

The concept of workplace bullying sometimes referred to as

mobbing (Leymann, 1990), workplace abuse (Keashly, 1998),

victimization (Aquino & Stefan, 2009), workplace harassment

(Brodsky, 1976), and verbal abuse (Ferns & Meerabeau, 2007)

refers to situations where a person repeatedly and over a

period of time feels subjected to negative treatment on the

part of one or more persons, and where the person(s) exposed to

the treatment have difficulty in defending them selves against

this actions (Einarsen, 2000). Also all various constructs

applied in the literature to describe the phenomenon of

systematic and prolonged mistreatment at work share that the

experienced aggression has harmful effects on targets’ health

and well-being.

Although there are numerous words to describe the same

phenomenon including aggression, harassment, mobbing,

intimidation in the literature we use workplace bullying and

harassment in this paper, as suggested by Einarsen, Hoel, Zapf

and Cooper (2011), and the following definition will be applied

to refer to the concept of workplace bullying and harassment;

Bullying at work means harassing, offending, or

socially excluding someone or negatively affecting

someone’s work. In order for the label bullying (or

mobbing) to be applied to a particular activity,

interaction, or process, the bullying behavior has to occur

repeatedly and regularly (e.g., weekly) and over a period

time (e.g., about six months). Bullying in an escalating

process in the course of which the person confronted ends

up in an inferior position and becomes the target of

systematic negative social acts. A conflict cannot be

called bullying if the incident is an isolated event or if

two parties of approximately equal strength are in conflict

(Einarsen, Hoel, Zapf & Cooper, 2003:15).

Considering the present study, the power imbalance between

parties needs to be taken into account particularly.

Typically, targets of bullying find it difficult to defend

themselves against the negative behavior, as their opportunity

for retaliation is more or less ruled out. The imbalance of

power may mirrors the formal power structure of the

organizational context in which the bullying scenario unfolds

(Notelaers, 2011). This would be the case when supervisors to

be more often in the role of the perpetrator as compared to

subordinates. But the source of power may also be informal,

based on knowledge and experiences. The imbalance of power can

be originated in the target’s dependence on the perpetrators,

which may be of a social, physical, economic, or as in our

case, academic dependency. As is indicated by Einarsen (1999)

knowledge about someone’s weak points and deficiencies may also

be exploited and become s a strong source of power in the

development of bullying cases.

Bullying and harassment in the workplace are not new phenomena

however there are growing epidemic of bullying in the health

sector is raising great interest among employers, health care

workers, and governmental agencies across the world

(Hinchberger, 2009). For the reason that explained by Zapf,

Escartin, Einarsen, Hoel & Vartia (2011) health sector jobs

such as nursing profession require a high level of personal

involvement which means that sensing and expressing emotions

and building up personal relationships. The higher the level

of personal involvement, the more personal information is

available and the more possibilities for being attacked exist.

Also in health sector, it is difficult to evaluate or apprise

jobs objectively then this lack of objectivity offers a lot of

opportunity for attacking each other. The studies show that

bullying is rife in the health sector, especially in the

nursing profession and has a negative impact on both nurses own

physical and psychological welfare (Celebioglu et al, 2010;

Lewis, 2006; Pranjic, Males-Bilic, Beganlic, & Mustajbegovic,

2006; Quine, 2001). The previous studies on bullying against

Turkish nurses report wide prevalence rates ranging from 33 %

to 86.5 % (Yildirim & yildirim, 2007; Efe & Ayaz, 2010)

similarly as is found in international studies (Hinchberger,

2009). Workplace bullying and harassment can be both internal

to the workplace, i.e. bullied by nurse, doctor, and manager

and external, i.e. perpetrated by a patient, patient relatives

and visitors. Although nurses often come a cross bullying and

harassment in the healthcare environment, they are reluctant to

complain because they tend to accept it as just “part of the

job”. Therefore workplace abuse in the healthcare sector is

severely underreported (Ferns, 2006; Magnavita & Heponiemi,

2011).

Nursing students are also exposed to horizontal (negative

behavior directed from colleagues on the same level) and

vertical (negative behavior directed from superiors towards

subordinates) bullying and harassment in nursing school and

workplace. Randle (2003: 395) claims that bullying was found

to be commonplace in the transition to becoming a nurse;

students were bullied and also witnessed patients being bullied

by qualified nurses. The internalization of nursing norms meant

that students then bullied others. This means that if the

student is socialized into a nursing culture that accepts

bullying as a routine practice, then the results can be

destructive (Cooper et al, 2011). In addition, Hodgkinson,

Mclvor, & Phillips (1985) propose that nursing students have

the highest risk of experiencing negative behaviors because of

being younger nurses, less experience, less education, frequent

ward changes and the challenge of meeting new environments and

being vulnerable to patient aggression. Cooper et al (2011:4)

cite that Magnussen and Amundson (2003) in their U.S study

identify some nursing instructors actually impede their

educational experiences, undervalue nursing students, or treat

students in uncaring ways. In Turkey, Celik and Bayraktar

(2004) investigated all types of abuse in the nursing school

and found that students experienced high rates of verbal abuse

as well as academic, physical, and sexual abuse. Nearly all

participants identified their classmates as a source of verbal

abuse and they reported some instances of sexual and physical

violence while in nursing school and clinical placement.

Moreover, Celebioglu et al (2010) investigated the violence

experiences of nursing students’ in clinical settings and they

indicated that similar to nurses, nursing students also

experienced violence in areas of practice. According to their

findings 50.3% of the students were subjected to violence, and

91.6% of these students were subjected to verbal abuse and

anger, fury, and enmity are their most frequent responses after

confronting violence. Consequently, a systematic review of

studies on bullying and harassment in nursing school

demonstrate that in spite of different culture, countries, and

research designs, and settings, high level of workplace

bullying and harassment is a problem for nurses and their

responses to abuse are similar and include anger, anxiety,

guilt, self-blame, and shame (Magnussen & Amundson 2003; Celik

and Bayraktar, 2004; Frens & Meerabeau, 2007; Celebioglu et al,

2010; Cooper et al, 2009; Magnavita & Heponiemi, 2011).

Materials and Methods

Participants and Settings

This descriptive study on bullying and harassment against

nursing students was conducted in four different Nursing

Schools in the wide area of the southern Marmara and Aegean

region of Turkey, namely Balikesir, Bandirma, Canakkale, and

Aydin. In Turkey, the new Nursing Law which passed in 2007

changed the minimum nursing education requirement to a four

year undergraduate baccalaureate degree program and lifted the

barrier to men becoming nurses. Before the new Law introduced,

the Turkish nurses had been educated in a variety of

educational settings. These include diploma from vocational

high school; associate degree from two year college;

baccalaureate degree from four year undergraduate program.

Currently, nursing education is given by 89 undergraduate

nursing programs at the university level.

The data of the study were obtained from four Nursing schools

(NS) of four year undergraduate program which are affiliated to

three different state universities namely, Balikesir University

(Bandirma NS and Balikesir NS), Adnan Menderes University

(Aydin NS), and 18 Mart University (Canakkale NS). The

sampling included only nursing students who were taking courses

in 2nd, 3rd, and 4th grades. First year students were not

included in the scope of the study because they have not

started to gain clinical experience yet. The survey was

anonymous and asked respondents to take part in the study

between March and May in 2011. In total, 400 questionnaires

were delivered and 374 returned. The initial examination of

the returned questionnaires showed that four were incomplete;

these were therefore excluded from the data analysis process.

The number of usable questionnaires was 370 (92 %).

Ethical Considerations

The study was approved by the university ethics committee of

researcher. Also before the research was initiated, legal

permission was obtained from the administrations of each

Nursing Schools. The questionnaires were administrated to the

dropout students by one of the instructor at the nursing

department. The purpose of the research was explained to them

and they were instructed about their right to refuse if they

wished to do so. In addition, respondents were informed that

any information that they shared would be used only for

scientific purposes. No information about the identity of the

volunteers was required.

Instruments

As is well explained by Nielsen, Notelaers, and Einarsen

(2011:150) measuring bullying is not an easy task because it is

a complex phenomenon with many facets. The difficulties in

measuring the phenomenon are reflected through the many

different measurement methods and inventories that have been

applied in research so far. Nonetheless, in most studies

bullying is measured by one of two methods; the operational or

behavioral experience method, and the self-labeling or

subjective method. In the first method, respondents are

usually presented with an inventory that includes various types

of unwanted and negative behaviors that may be called bullying

if occurring repeatedly over time. Then, the respondents are

asked to report how frequently they have been exposed to the

different behaviors listed in the inventory within a given time

period without any reference to the phrase “bullying” (i.e.,

the Negative Acts Questionnaire (NAQ), Einarsen & Raknes,

1997). In the latter method, respondents are provided with a

definition of bullying, and those who judge their experiences

within a particular timescale to fit the definition are

considered bullied. This method connotes the respondents’

overall feeling of being victimized by bullying.

Although the self-labeling method is the most frequently used

approach in research on workplace bullying, the method has some

disadvantages such as; it does not offer any insight in the

nature of the behaviors involved. Moreover, because people may

have different personal thresholds for labeling themselves as

bullied, this method is very subjective approach in which

personality, emotional factors, cognitive factors, and

misperception may figure as potential biases (Nielsen et al,

2011). On the other hand, the operational method seems to be

more objective than the self-labeling approach because it does

not require the respondents to label their experiences as

bullying and so the decision about whether or not someone is

bullied rests with the researcher through the use of a

statistical analysis (Notelaers, Einarsen, DE Witte, & Vermunt,

2006). In literature, there are 27 different inventories to

assess bullying or phenomena similar to workplace bullying.

Some of these have been used in only one study, whereas others,

such as the Leymann Inventory of Psychological Terror (Leymann,

1990), and the Negative Acts Questionnaire (NAQ) have been

employed in a range of study (Nielsen et al, 2011). Yet,

except the NAQ, they have not been thoroughly tested and

validated in separate validation studies. It was shown in a

study on the psychometric properties of the NAQ (Einarsen et

al, 2009) that the inventory has high internal stability and

excellent criterion and constructs validity. Therefore, to

estimate bullying at nursing school we used a short version of

the Negative Acts Questionnaire that adapted according to the

earlier studies on bullying against nursing students

particularly those conducted by Cooper et al (2011), Ferns and

Meerabeau (2007), and Celik and Bayraktar (2004). The scale

consists of thirteen items referring to personal related

bullying (e.g., being shouted, spreading gossip, socially

isolated), work related bullying (e.g., unmanageable workloads,

hostility after or failure to acknowledge significant clinical

or academic accomplishment), and physical intimidating forms of

bullying (e.g., threats of violence or physical abuse,

intimidating behavior such as finger pointing). The scale

showed a satisfactory internal consistency, measured by

Cronbach’s alpha (0.80). The questionnaire was discussed and

reviewed with three colleagues of Nursing Schools and their

opinions were sought with regard to face validity. In

addition, the questionnaire was tested for structure and

clarity in a pilot study, and no revisions to the questionnaire

were indicated. Data from the pilot study were not included in

this study. All items are given in behavioral terms with no

reference to the phrase “bullying”, thus measuring perceived

exposure to bullying behaviors without foreign the respondents

to label this situations as bullying. For each item, the

respondents are asked how often they have been exposed to the

specific behavior during the last 6 months. The response

categories are “never”, “now and then”, “about monthly”, “about

weekly”, and “about daily”.

The questionnaire was in three sections. The first part of the

questionnaire aimed to identify the degree of bullying and

harassment using the revised NAQ scale which mentioned above.

The aim of the second part was to find out the reaction to

bullying incidents, effects of bullying on occupational health

and actions taken to escape from the bullying. The third part

consists of students’ demographic information such as gender,

year at school, marital status, age, and student’s

accommodation.

Data Analysis

Data analysis was performed using the Statistical Package

Program for the Social Sciences (SPSS version 11.5). The

frequency and percentage distributions and Pearson chi-square

analysis were used to accomplish our objectives stated in the

first section of the study.

Findings

The findings on demographic characteristics of the study group

are as follows; of 370 nursing students in the sample, the

majority were females (77.8 %), and nearly all of them were

single (97.02%), more than half of the respondents were aged 21

to 23 years (66.7 %). The majority of respondents did not have

any nursing experiences at all (95.4 %). More than half of the

nursing students’ place of birth and place where lived so far

were rural area (village and little town). Most students’

accommodation were dormitory and staying with friends (N=284,

76.6%). The distribution of the nursing schools was as

follows: 21.3 % students from Aydin Nursing School, 20.5 %

students from Canakkale Nursing School, 24.8 % students from

Balikesir Nursing School, and 33.2 % students from Bandirma

Nursing School.

A total of 222 respondents (60%) reported that they had

experienced at least one of the thirteen bullying behaviors at

daily and weekly frequencies during the last six months. As we

mentioned before NAQ scale consists of 5-likert type rating but

in our analysis, the five response categories were subsequently

combined into three categories: never, now and then/monthly,

and weekly/daily. According to the definition of bullying and

harassment which was clarified in Section 2, responses listed

as weekly/daily may best express bullying and harassment, while

now and then/monthly may express isolated incidences of

negative behaviors. Table 1 shows the frequency and the

percentage of bullying behaviors as occurring weekly/daily and

never basis. The most common bullying behaviors were “negative

and disparaging remarks about nursing’s profession” (11.85 %),

“unmanageable workloads or unrealistic deadlines” (8.37%), and

“given a bad grade as a punishment” (5.67 %). “Assignments,

task or rotation responsibilities made for punishment rather

than educational purposes”, “being shouted at or being the

target of anger”, “inappropriate, nasty, rude or hostile

behavior”, “belittling, and spreading of gossip and rumors”

were the following most frequent reported forms of negative

behaviors in our study.

Table 1. Bullying Behaviors Reported by the Study Group (n =370) Frequency categories N (%)Reported Bullying Behaviors Never

Weekly/Daily

Being shouted at or being the targetof spontaneous anger (or rage) 27 (7.29 %)

11 (2.97%)Inappropriate, nasty, rude or hostile behavior

136 (36.75%) 18 (4.86%)

Belittling or humiliating behavior 116 (31.35%) 17 (4.59%)

Spreading of gossip and rumors aboutyou

217 (58.64%) 16 (4.32%)

Cursing and swearing 287 (77.56%) 10 (2.70%)

Negative and disparaging remarks 103(27.83%) 42

about nursing’s profession (11.85%)Assignments, task, work or rotation responsibilities made for punishmentrather than educational purposes

179(48.37%) 21 (5.67%)

Given a bad grade as a punishment 164 (44.32%) 21(5.67%)

Hostility after or failure to acknowledge significant clinical, research or academic accomplishment

222 (60 %) 12 (3.24%)

Threats of violence or physical abuse or actual abuse

308 (83.24%) 4 (1.08%)

Being ignored and excluded or socially isolated

189 (51.08%) 14(3.78%)

Unmanageable workloads or unrealistic deadlines

158 (42.70%) 31(8.37%)

Intimidating behavior such as finger-pointing, invasion of personal space, shoving, blocking/barring the way

323 (87.29%) 5 (1.35%)

A majority of the students reported that clinic nurses were the

most frequently source of bullying behaviors (70.8%). Some of

the students denoted that they had been exposed to bullying

behaviors from the Lecturers (29.5 %), the School (29.2%),

doctors (21.1%), patients (20.8%), and classmates (19.7%). On

the other hand, hospital staffs, patients’ relative, and

visitors seem to be minor source of bullying and harassment

according to the students’ perception. Moreover, most of the

students reported that the perpetrators were older than them

(86.17%) and they were predominantly female (92.4 %).

The results of chi-square analysis showed that there was no

significant relationship between reported bullying behaviors

and age, marital status, place of birth, participant’s place of

living, and participant’s attending nursing school. However,

there were statistically significant differences between gender

and being exposed to the target of spontaneous anger (χ2=

13.14, p=.001), belittling or humiliating behavior (χ2= 9.29,

p=.010), given a bad grade as a punishment (χ2= 17.82, p=.000),

unmanageable workloads (χ2=6.52, p=.038), and threats of

violence (χ2= 10.11 p=.006). Likewise, when the experiencing

of bullying behaviors with regard to the year at school

examined, it is found that second and third grade of students

were exposed to following bullying behaviors more than fourth

grade students; the target of spontaneous anger (χ2= 13.8,

p=.015), belittling or humiliating behavior (χ2= 21.2, p=.002),

and threats of violence and physical abuse (χ2= 13.15 p=.041).

Table 2. Effects of Bullying on Victim

Feeling of extreme fatigue or exhaustion

% n 66.4 246

Getting angry 91.5 339

Thinking about leaving profession 52.97 196

Diminishing school performance 58.37 216

Becoming forgetful Losing self confidenceLoss of concentration InsomniaReducing motivation

46.21 171 56.48 209 71.34 264 47.56 176 70.8 262

Increasing consumption of alcohol and cigarette

26.48 98

Impossible to bear criticismPanic attackDysfunction social lifeDamaging physical health

49.45 183 34.58 128 40.53 150 38.37 142

Feeling guilty 39.45 146

As is seen from the Table 2, bullying and harassment had a

strong effect on students both physical and psychological

health. The most common results of abuse were that students

felt anger (91.4%), lost their concentration (71.34%),

decreased their motivation (70.8%), and felt exhaustion

(66.4%). Also nursing students reported that their school

performance negatively affected as a result of bullying and

harassment (58.37%). Perhaps the most disturbing result is

that 52.97 % of nursing students “thinking about leaving

profession”.

Nursing students in the study group were asked that what

behaviors they would do when they encountered bullying

behaviors. Fourteen possible responses were listed according to

the students’ choices which were shown in Table 3. The most

common responses to cope with bullying were “rectify by talking

face to face” (71.74%), “report to superiors” (70.76%), and

“tell to friends” (67.77%). In addition, it was seen that

67.13% of the respondents preferred to “work harder and more

organized to avoid criticism”. Additionally, the majority of

respondents reported (75.4 %, n: 279) that their school of

nursing have no policy or procedure concerning bullying such as

programs or pamphlets on coping with bullying behaviors or

designated person (i.e. counselor) to help with coping with

bullying behaviors.

Table 3. Answers to the Question of Action after Being BulliedAction n %

RankingWork harder and more organized 241 67.13

4 Report to superiors 259 70.76

2Pretend not to see 97 26.94

9Request counseling 72 20.05

10Rectify by talking face to face 259 71.74

1Seek legal charges 153 42.5

6Share with family members 163 45.15

5Demonstrate similar behavior 68 18.68

11Tell to friends 244 67.77

3Do nothing 64 17.29

12Try to put up withShout or snap at the bully Use of Unhealthy coping behavior Do not take it seriously

1171294358

32.23 8 34.86 7 11.97 14 16.20 12

Discussion

This study was carried out in four Nursing School which located

western part of the country and discussed the nature, severity,

frequency and sources of bullying experienced by students

gaining both academic education and clinical experience. More

than half of the respondents were exposed to bullying during

their education (60%). These results are consistent with

previous studies involving nursing students which found that

bullying and harassment at nursing education is an important

problem and that such bullying behaviors have detrimental

effects (Magnussen & Amundson, 2003; Longo, 2007; Ferns &

Meerabeau, 2007; Curtis, Bowen, & Reid, 2007; Hinchberger,

2009; Cooper et al, 2009; 2011; Celebioglu et al, 2010;

Magnavita & Heponiemi, 2011).

The result of present study supports the findings of previous

Turkish study which found that 50.3% of the students were

subjected to violence in the clinical settings. Verbal

violence (91.6%) was the most frequently encountered type of

abuse, followed by physical violence (4.2%), and sexual abuse

(4.2%) (Celebioglu et al, 2010: 689). In addition, another

study which was undertaken by Celik and Bayraktar (2004)

investigated the abuse experiences of nursing students found

that verbal abuse was the most frequently reported type of

abuse with all participants reported being behaved toward in an

inappropriate, nasty, rude, or hostile way, being yelled at,

and being humiliated or belittled.

We found that work related bullying (e.g., negative and

disparaging remarks about nursing’s profession, unmanageable

workloads, assignments, task or rotation responsibilities made

for punishment rather than educational purposes) were the most

frequently encountered type of bullying behaviors, 34.80% in

total, followed by personal related bullying (e.g., being

shouted, spreading gossip, socially isolated), 23.22 % in

total. On the other hand, only very small amount of

respondents, only 2.43 % reported physical intimidating forms

of bullying (e.g., threats of violence or physical abuse,

intimidating behavior such as finger pointing). Nursing

students reported that work related bullying was the most

annoying problem for them but this finding need to be read

carefully because it is possible that students in general do

not understand assignments, workload and deadlines as a part of

the learning environment. Responses were only based on student

perceptions and therefore it is unknown whether the behaviors

are actually occurring or whether grades and workloads which

are fairly given are perceived by students as being punishing.

In any case, student perceptions of being exposed to bullying

and harassment are of concern given the potential negative

impact on student health and academic performance (Cooper et

al, 2011: 12).

An interesting result from this study that most students

reported clinic nurses as their bully, indicating that the

perpetrators were mostly females and older than them. In

previous Turkish studies of nursing students’ abuse, the

abusive behaviors considered were mainly those committed by

patients and their relatives, and classmates (Celebioglu et al,

2010; Celik & Bayraktar ; 2004). In present study, nursing

students rarely reported bullying and harassment on the part of

patients and their relatives and classmates. The reasons might

account for using different sample from different part of the

country, with different characteristics of participants. For

instance, the study of Celebioglu et al (2010) was carried out

in a nursing school where located in the eastern part of the

country, and the sample in the study of Celik and Bayraktar

(2004) included nursing students from Ankara where is in the

middle of the country. Turkey is a large country and there are

huge cultural differences between western and eastern side of

the country, therefore, a nationwide survey of the students of

different nursing schools will be needed for investigating the

nature and sources of bullying phenomenon to be further

developed.

On the other hand, in consistent with the present study that

nurse-on-nurse bullying is a significant workplace problem that

depends on the flow of power within workplace. Bullying within

nursing is primarily intra-professional (i.e. between nurse and

nurse) and horizontal violence is common in nursing and the

victims are especially the younger and student nurses (Stevens,

2002; Lewis, 2006; Curtis et al, 2007; Longo, 2007;

Hinchberger, 2009; Efe & Ayaz, 2010). It is proposed that

external pressures are often held responsible, such as health

care workers’ need to find a scapegoat for errors as a reason

for the existence of bullying behavior towards nursing students

(Stevens, 2002). Recent change in health sector in Turkey

which involves adaptation requirements for the issue of

accreditation and patient rights and the financing of hospitals

on output-based formula which leads to greater levels of

alertness in the hospital patient population increased

workloads for nurses. Therefore, increased stress and pressure

on clinical nurses might cause increased tendency of bullying

student nurses in the clinical settings.

Additionally, as is well explained in the study of Curtis et al

(2007: 157) nursing as a profession is considered to be

oppressed; in this context, a hierarchical system has arisen in

which nurses, in order to succeed, must accept that their roles

is defined by those with power and authority. Such a system

supports the occurrence of horizontal violence, and in many

case, perpetrators are usually themselves past or current

victims and most are convinced that their experiences have

strengthen them for their nursing role. It is suggested that

the cycle of horizontal violence actually begins during nursing

education. The findings of this study support this suggestion

as lecturer and the faculty was reported being responsible for

bullying followed by clinical nurses.

Longo (2007:177) states that when nursing students in a

practice setting encounter horizontal bullying and harassment,

their approach to practice, as well as their intent to become a

nurse, can be influenced. In same manner, Bartholomew (2006)

claims that in a study of nurse-to-nurse hostility that 60 per

cent of new graduates leave their first position within the

first 6 months because of horizontal hostility. Moreover,

Curtis et al (2006) indicate that over half of the students in

their study had experienced or witnessed horizontal violence

during their education and all of those students revealed that

those experiences of violence from clinical nurse would

influence their future employment choices. Likewise, the

findings of the present study shows that nursing students who

experienced bullying behaviors felt anger, lost their

concentration, their social life affected badly, and they even

thought of leaving profession as a consequences. The nursing

shortage is considered to be world-wide problem and in many

countries, including Turkey, facing a shortage of nurses.

According to the OECD report, Turkey takes the last place among

51 countries in European region in terms of the number of

nurses per 1000 individuals. In other words, Turkey had the

fewest nurses having fewer than five nurses per 1000 in the

Europe (OECD, 2010). This alarming fact suggests that further

research is needed to clarify the extent of nursing students’

experiences of bullying and the practical effects on their

choices.

In contrast to previous studies on bullying in nursing

education, this study shows that students preferred active

responses to cope with bullying instead of using unhealthy and

passive coping behaviors which were found in other studies

(Celik & Bayraktar , 2004; Celebioglu et al, 2010; Cooper et

al; 2009; 2011 ). When coping responses of nursing students

considered in four categories; the most frequently reported

responses to bullying were active responses, such as rectify

by talking face to face (71.74%), report to superiors (70.76%),

tell to friends (67.77%), seek legal charges (42.5%), and share

with family members (45.15 %). Additionally, passive responses

were used by some of students such as work harder and more

organized to avoid criticism (67.13%), pretend not to see it

(26.94 %), do not take it seriously (16.20%), and did nothing

(17.29 %). Some of the respondent preferred aggressive

responses; shout or snap at the bully (34.86 %), and

demonstrated similar behaviors (18.68%). However, unhealthy

responses were reported rarely such as use of unhealthy coping

behavior such as drinking or taking medications (11.97%). As

is noticed from the Table 4, the respondents reported

discussing the bullying incidents more frequently with friends

and family members rather than with their nursing instructors

or counselors. This result shows that instructors or lecturers

at nursing school need to create open atmosphere in which

students are willing to share their stories and seek guidance

in dealing with the situation as suggested by Longo (2007:

178).

These findings are similar to Einarsen’s study (2000) which was

found that bullying victims actively use a problem-solving

process and when they cannot solve the problem they leave the

institution. The result indicates that latest studies and some

court case have a good effect on people comprehension of

bullying as a work life problem. The respondents in this study

seem to be aware of bullying, but as is mentioned in previous

section, the nursing schools have no policy or procedure about

the bullying phenomenon therefore, nursing students try to cope

with bullying and harassment paddling theirs own canoe. This

study suggests that nursing schools should provide anti-

bullying policies and procedures to allow students to cope with

bullying properly.

Study limitations

Some methodological limitations of the present study need to be

mentioned. Firstly, the data reported are based on self-

reports which suggest problems with both common method variance

and issues of validity in the classification of victims as is

presented by Einarsen (1996). This type of research enables

measuring only perceptions, not the actual behaviors and this

study is subject to single-rater bias as only the students’

responses have been considered. The present study does not

include any information from the nursing school’s staff and the

hospital’s staff or independent observers confirming the

victimization reported. Therefore, it would be beneficial if

multiple data collection methods and multiple raters are used

in the future study.

Secondly, the number of people participated into the study

located in one certain part of the country and although they

were representative of the total population of nursing students

in this area the obtained results could not be generalized.

Future research could focus on larger samples from different

nursing schools in all over the country. In addition, students

in the western part of the country where the present research

took place may not be more likely to experience aggressive

incidents than those in some parts of the Turkey which are more

rural and have less educated population. In the future, a

cross cultural study can be more instrumental in investigating

bullying and harassment at nursing school.

Finally, as is mentioned in the study of Ferns and Meerabeau

(2007) questionnaire approaches may be accused of bias due to

an unrepresentative sample because people who do not return

questionnaires frequently differ from those who do. But, in

this study the response rate is quite high (92 %) this may

offer confidence in the findings.

Conclusion

The findings of the study have found that nursing students

experience high levels of bullying and harassment during their

education. Work related bullying were the most frequently

encountered type of bullying behaviors followed by personal

related bullying behaviors. It is seen that bullying in

nursing education is detrimental to the health and well-being

of students, and to the provision of quality nursing care.

Moreover, our analyses have shown that there was no significant

relationship between reported bullying behaviors and age,

marital status, place of birth, participant’s place of living,

and participant’s attending nursing school. This may suggest

that bullying can happen to anyone, regardless of their age,

gender or education etc.

This study supports previous reports of bullying against

Turkish student nurses (Celebioglu et al, 2010; Celik &

Bayraktar ; 2004) and adds to the scant body of literature

showing that nursing students often experience bullying and

harassment from clinical nurses (Horizontal bullying), and

importantly, this may influence their future employment

choices. Moreover, although educators need to be sensitive to

its occurrence and assist students to deal with it, but our

findings show that the school and lecturer also considerable

source of the bullying behaviors. Nursing students were exposed

to bullying and harassment in both the practice settings and

the educational settings, as suggested by Randle (2003) there

is concern that students may begin to assimilate this conduct

into their practice, perpetuating the behavior. For this

reason, the aspect of bullying in nursing education need to be

crucially taken into consideration in order to stop this

vicious cycle of bullying in nursing profession.

As is recommended by the American Association of Colleges of

Nursing Position Statement, all faculties (schools of nursing)

prepare nurses to recognize and prevent all form of violence in

the workplace. Nursing students also should be treated fairly

and consistently, and with respect and dignity, wherever they

study or undertake practice placements (AACN, 2011). Therefore

strategies to increase students’ awareness of this problem and

its potential consequences are indicated. Reliable procedures,

education, follow up and organizational policies and clear

statement of a “Zero Tolerance” approach are needed to diminish

workplace bullying and to prevent its negative consequences.

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Serap Palaz PhD MA is an associate professor in the Departmentof Labor Economics and Industrial Relations at University ofBalikesir, Turkey. She received her doctorate degree from DeMontfort University in England in 1999. She was served as thedirector of Bandirma Health School at University of Balikesirduring the period of January, 2007 to January 2011. Herresearch priorities are labor market discrimination andbullying at workplace. Her main duties at University ofBalikesir include teaching social policy, labor economics andconducting research on various subjects relating to bullying atworkplace recently.

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