Bullying against nurses is becoming a pervasive problem. Berry et al. studied workplace bullying in a sample of United States’ novice nurses from Ohio, Kentucky, and Indiana finding that 21% (n=43) were exposed to daily bullying.^[1] Dellasega^[2] and Hutchinson, Wilkes, Jackson, and Vickers^[4] both discussed that bullying has become such a norm in nursing settings that the acceptance of bullying now starts in nursing schools. Clarke, Kane, Rajacich, and Lafreniere explained that 89% (n=598) of nursing students experienced at least one bullying behavior.^[5] The primary source of bullying was from their nursing faculty (n=181, 30%). A secondary source was staff nurses (n=152, 25%) at the clinical agency. The bullying behaviors from staff nurses caused the nursing students to work faster than what they believed was safe and led many of them to consider quitting the nursing program.

One explanation for the pervasiveness of bullying in nursing is that persons exhibiting bullying behaviors are often rewarded, receive promotions, and get special treatment because of their clinical expertise and ability to manipulate work situations.^[4] As the targets witness the response to the bullying they receive, they begin to have self-doubt in their competence. Over time, targets begin using self-deprecating language which reinforces the negative comments made by the persons using bullying behaviors.^[2]

Another explanation for the pervasiveness of bullying is reflected in the findings of Lindy and Schaefer’s qualitative study.^[6] In this study, the researchers interviewed 20 nurse leaders from the South Central United States about their experiences with employees who bullied others. The common themes related to bullying were: (1) that was just how the bully is, (2) the targets just take the bullying, (3) there were a lot of competing priorities demanding the leaders’ time, (4) there were other interpersonal reasons for the bullying, (5) there are three sides to every story, and (6) the manager’s own perspective about the bullying. Fundamental to these themes is that the bully is commonly an asset to the department possessing extensive clinical expertise, the persons using bullying behaviors could justify the bullying, and the target didn’t speak up for him or herself. Given that bullying represents a power gradient with the bully in control, targets may not perceive that they have the right to speak up for themselves or notify the department manager that the bullying is occurring.

Recommended strategies to counteract bullying include modeling appropriate behavior; not playing favorites; providing education on bullying, prevention, conflict resolution, and communication skills; adopting a zero tolerance policy; and not allowing bullying behaviors to go unaddressed by promptly addressing the bullying actions.^[4,7–11] Interventions to mitigate nurse bullying are scarce. One study that discussed an intervention with promise used cognitive rehearsal.^[12] In this study, Griffin taught novice nurses how to rehearse their response to persons using bullying behaviors.^[12] The nurses in their sample reported that they were able to confront the aggressor. While the experience was problematic for the novice nurses, the bullying behaviors did stop. Findings from this study reflect the importance of using simulations to prepare nurses on how to effectively handle bullying. The purpose of this paper is to describe the role play simulation and report the evaluation findings from a subsample of students who participated in a role play simulation addressing bullying behaviors.

The role play simulation intervention was delivered to one class of senior nursing students from each college campus during Spring and Summer semesters 2013. Sixty-five full-time pre-licensure baccalaureate of science nursing students participated in the role play simulation intervention. After delivering the intervention, all students who participated in the simulation were invited to participate in a focus group session to discuss their experiences as learners during the simulation. There were no exclusion criteria. Eight students agreed to participate in a focus group session. Exactly one and two weeks after the intervention was delivered, a session was held on each campus for a total of four sessions. Due to low response by students, two sessions were conducted as one-on-one interviews between the researcher and student, one session had two students, and one session had four students. Each session was audio-recorded and transcribed verbatim by a professional transcriptionist. Each transcription was audited for accuracy by simultaneously listening to the audio-recording and reading the transcript. Any errors were corrected before starting data analysis.

The first and second authors, serving as guest lecturers, began the intervention with a discussion of the desired learning outcomes and purpose of the role play simulation during the student’s nursing leadership or community health nursing course. Next, students were clustered into groups of four. Due to class sizes, some groups had three students instead of four. Each group then received an envelope with descriptions of four different roles to play: novice nurse who was the target of the aggression, senior nurse who was the aggressor or bully, a nurse observing the bullying situation, and a patient witnessing the bullying situation. The two observer roles were included to allow an opportunity for targets to solicit support from observers or for observers to intervene during the bullying simulation. Students randomly drew their role from the envelope. Three students between the two classes opted to not participate in the role play simulation and left the classroom just prior to the start of the simulation. All three students returned to participate in the simulation debriefing.

An example of the instructions for each role was:

Role 1 – Novice Nurse: A patient was admitted during night shift for possible appendicitis. His temperature is quickly rising from 100’F (37.8’C) one hour ago to a current temperature of 102’F (38.9’C). The patient is requesting acetaminophen for his fever and severe headache/abdominal pain. It is now 0800 and the surgeon that admitted the patient does not make rounds until noon. Efforts to contact the surgeon are unsuccessful. An appropriate behavior in this situation is to contact the surgeon for an acetaminophen order. However, in this simulation, your objective is to wait until the surgeon arrives at noon to obtain an acetaminophen order.

Only students playing the roles of novice and experienced nurse were aware of the clinical situation as depicted on their role play cards, although all students made aware that the role play was to simulation a workplace bullying incident. Students then portrayed their respective roles for a five minute period. The two researchers delivering the intervention walked about the classroom assuring that all students were actively involved in the role play simulation and not distracted with personal electronic devices.

The classroom in the urban-based campus was squared-shaped and set up with four rectangular tables that seated 10 students per table. The classroom in the rural-based campus was rectangular-shaped with two columns of tables with seating for four students per table. In both classrooms, students were able to cluster into their groups; however, noise was notable once the students started their role play simulation.

At the close of the role play simulation, all students in the classroom reflected individually on their experiences using a reflection guide designed to accompany the intervention. Next, students were brought back together to reflect on their common experiences during the simulation using a group reflection guide. Finally, a class debriefing took place with students from each respective role coming to the front of the classroom and sharing their experiences. Students were asked to come to the front of the classroom, because this was a norm used with team-based learning activities. This presentation style also gave students additional experience with presenting to an “audience”, a skill necessary locally where nurses will present to physicians and nurses during patient rounds. Students playing the role of the experienced nurses were asked to discuss their experiences as an aggressor and their perceived motivation for the aggression that occurred. Students playing the role of novice nurses were asked to discuss their experiences as the targets of aggression. Students playing the role of the nurse witnessing the event were asked to discuss their experiences as observers of the aggressive events. They also were asked if any of them intervened during the scenario, describe what they did, and what they could have done. Students playing the role of patients were asked to discuss their perceptions of the event and discuss any fears they may have had as a patient during the simulation. Finally, the researchers summarized key points learned during the simulation and verbally assessed students by asking them to describe specific actions they can take for bullying events that they may experience as novice nurses. The researchers provided additional recommendations based on student responses. For example, the researchers encouraged students to relocate aggressors and targets to a private room or different location if already in a private setting with the assumption that the act of relocation would dissipate some of the aggression and tension.

Perceived coercion is a risk for research involving undergraduate students. Students were not required to remain in the room during the role play simulation. The three students who left during the simulation were permitted to do so without reprisal from their course faculty members. Additional efforts to prevent coercion in this study were (1) the researchers recruiting and enrolling students or facilitating data collection did not teach senior level nursing courses, (2) the names of students who participated in the focus group sessions were not shared with the students’ faculty members, and (3) participation or non-participation in the simulation or the research did not affect students’ grades. Focus group participants signed an informed consent document which explained their rights as research participants. Finally, all data were deidentified prior to analysis.

Transcripts were analyzed using Colaizzi’s procedural steps in phenomenological data analysis including reading each transcript multiple times for general essence followed by line-by-line coding, clustering significant statements into themes, and confirming findings with some of the study participants.¹³ During line-by-line coding, each successive interview and focus group was analyzed and compared to previously analyzed and coded data in order to develop a consistent coding schema that by the end of data analysis represented composite themes of the qualitative data. In order to increase the trustworthiness of data analysis, four researchers simultaneously analyzed and coded the qualitative data. The researchers then met to determine consistency in units of information. Disagreements in the coding of a particular unit of information were settled by the researchers reading the content preceding and following the unit of information in situ to the transcript and discussing the rationale for the coding and/or lack of coding. Consensus was achieved in all instances. The data were managed using NVivo 10 (QSR International, Burlington, MA). NVivo outputs of the coded data were then distributed to each researcher. The unit of information in each output was assessed for accuracy and suitability to its subtheme. Each researcher recommended changes. A summary of recommendations was reviewed and discussed by the researchers until agreement on the coding schema, names of themes and subthemes, and units of information were settled.

Qualitative rigor or the determination of trustworthiness (comparable to validity and reliability in quantitative studies) was performed as described by Lincoln and Guba.^[14] The components of trustworthiness are credibility, dependability, confirmability, and transferability. Credibility of the findings was enhanced by cross analyzing the transcripts for consistent themes and subthemes as well as the researchers coming to consensus on the coding schema. Dependability was achieved through the generation of an audit trail to explain coding decisions. Confirmability occurred through the audit trail, investigator triangulation, and several participants agreeing to the “validity” of the study findings. Transferability happened by providing a rich description of the findings with supporting exemplar statements.

There were two subthemes to this theme reflecting the bullying the participants experienced during their lives (see Table 1). The first subtheme, Previous experience with bullying, represented the personal reflections and responses of being bullied or observing bullying as a child, adult, or nursing student. Personal accounts included having flashbacks, memories, and negative emotions about the previous bullying events. The second subtheme, “Why am I so stupid?”, included self-blaming and rationalizing for why they were targeted for bullying by others. At times participants asked themselves “Why me?” and justified the reason for being a target for bullying because they were “stupid”.

There were seven subthemes to this theme reflecting the effectiveness or recommendations for improvement of role play simulation (see Table 2). The first subtheme, Role play instructions, denoted participants’ desire for the role play scenarios and process to be concrete. All participants suggested that additional instructions and briefing at the start of the exercise as well as additional scripting on the role play cards so that the process would be easier to initiate. The second subtheme, Can’t act like a bully, signified that acting like a bully was unnatural, awkward, strange, terrifying, silly, or weird for the participants. While most participants reported difficulty acting like a bully, a few participants reported that some students in the groups easily adopted the role of bully particularly referring to the male nursing students. The third subtheme, Role of the observer, represented the participants’ interpreting their roles as watching only and not intervening during the role play simulation. This subtheme reflected the need for further clarity in the simulation roles. The fourth subtheme, Realism vs. fake, represented the scenarios and role play experience being very realistic and true to life. Other comments referred to the simulation scenarios being fake or not rational for what would occur in real student practicums or nursing practice. The fifth subtheme, Debriefing and discussion, represented the value of and recommendations for improving the discussion and debriefing at the end of the role play simulation. The sixth subtheme, The learning space, analyzed specific aspects of the learning environment (e.g., room design, furniture, acoustics) where the role play simulations took place. Some specific recommendations to improve upon the simulation environment were performing the simulation in the hallway or adjacent classrooms and having the students who assume the role of target and bully stand during the simulation. The seventh subtheme, Courses for program adoption, provided the recommendations for specific nursing courses and similar class simulation exercises where the bullying program content could be incorporated for future intervention delivery.

There were three subthemes to this theme reflecting the knowledge attained from the intervention (see Table 3). The first subtheme, Now aware of bullying in nursing, illuminated participants’ shock that bullying occurred in nursing practice while now being aware of the impact of bullying, its presence in nursing, and that “there’s more than one way to bully.” The second subtheme, Teach the tools to help with bullying, embodied the need for students and nurses to be prepared to deal with workplace bullying by having an arsenal of tools. Some recommendations to prepare for bullying were conflict resolution and the ability to compromise and negotiate. The third subtheme offered by participants, Stand in support, symbolized a memorable recommendation of the role play simulation where students were encouraged to show support by standing next to or just behind someone being targeted for bullying.

There were three subthemes to this theme reflecting the dichotomy of being victimized vs. advocating for their future patients as practicing nurses (see Table 4). The first subtheme, Submissive role, represented the submissive, powerless positions and at times, perceptions of weakness experienced or witnessed by the participants. The second subtheme, Don’t rock the boat vs. confronting the problem, indicated that participants avoided conflict and aggressive situations and just “took it”, especially when the situation involved a peer as opposed to a physician. Four participants stated the need to stand up for themselves and not avoid, accept, or tolerate the negative behaviors. The third subtheme, Do the right thing, exemplified participants’ beliefs that as long as they did the right thing, their license would be protected, they would be serving as a patient advocate, and would be altruistic. The ability to do the right thing would be complemented by having clinical competence and the confidence that their actions were the best thing for their patients despite the presence of bullying.

The findings from this study are limited due to the small sample size (n=8), predominantly female sample, and participants being drawn from a single university; although participants were recruited from two geographically dissimilar campuses. While the homogeneity of the sample limits generalizability, the sample being predominantly female is representative of the overall Unites States’ nursing population. While the sample size and single institution are additional limitations to generalizability, the rich, descriptive exemplars may allow transferability of the study findings to similar nursing school populations.