What student nurses learn and what they experience, either positive or negative, during their formation as a nurse will forever become part of their character. Horizontal violence is common among students for many reasons and perpetuated because they see themselves as powerless. Unfortunately, much research on violence and bullying in nursing usually excludes student nurses in sample populations, and there have been few studies done on the correlation of horizontal violence and nurse bullying and the effect on student nurses. Not only are student nurses victims of bullying, but they themselves become bullies as well. This impact must be addressed as well, because student nurses are our future in the health care system, and the lives of patients depend on the student nurse becoming a just and moral citizen.

Student nurses compete for entrance to nursing school; this pits them against their peers. Then, once in nursing school, they are often met with an instructor who says, “Look on either side of you; that student won’t be with you when you graduate.” This introduces fear of failure and adds to an already stressful environment. The degradation of students continues throughout their clinical rotations and classroom attendance. After graduation, they then must compete for intern placement, academic honors, and job placement. This struggle does not create a colleague, but rather a competitor against whom the student must win or face failure.

Student nurses suffer from lack of sleep, lack of a social outlet, intense worry, stress, and anxiety. Unless they have developed healthy coping mechanisms, this stress is turned outward onto fellow students, faculty, and family, resulting in negative comments and behavior and angry outbursts. Students may also face bullying from several different sources, including staff nurses, clinical and classroom instructors, patients, instructors, visitors, and fellow students.

The most common type of bullying against student nurses is verbal assault, and clinical instructors have been identified as the main source of bullying behavior towards students.

Bullying behavior experienced by student nurses includes: being excluded or alienated; receiving destructive criticism; experiencing resentment; being humiliated in the presence of fellow students, staff, or patients; having their work undervalued; being treated with hostility; being blamed for patient care incidents that were the fault of the staff; being ignored by staff or the preceptor; lack of communication; being threatened with a poor evaluation that may be the result of changing clinical expectations that were not communicated; and faculty who “mentally sabotage” them by not being clear about testing or clinical expectations.

All of bullying forces converge against the student, not allowing him or her to reach full potential. Bullying has a direct effect on the confidence level of the student and causes personal and professional outcomes similar to those of bullied staff nurses. This includes feelings of decreased self-esteem, lack of autonomy, decreased self-worth, anger, fear, low morale, frustration, anxiety, increased errors, stress, apathy, burnout, guilt, worry, sleep disturbances, and symptoms similar to post traumatic stress disorder.

It is the professional and ethical responsibility of faculty within schools of nursing and individual nurse educators to educate their students, beginning early in the process, to recognize signs of bullying from all persons with whom they currently interact or will interact with in the future, including patients, staff, fellow students, instructors/professors, and preceptors and to suggest strategies for a solution.

Nurse educators can help change how bullying is addressed in the following ways:

  • Educate students on what bullying and horizontal and lateral violence are as well as their impact on patient care.
  • Prepare students prior to entering their clinical area for bullying behaviors they may encounter and how to manage their behavior.
  • Teach students prior to their graduation about the behaviors they may encounter at a new job and how to manage those behaviors.
  • Allow students to freely express themselves about negative interactions they have encountered and how they dealt with the behavior.
  • Acknowledge that role playing and conflict resolution should not be considered the “cure” for the bully or the victim. These strategies may actually encourage further bullying behavior if the school of nursing does not utilize other strategies to recognize and end the behavior.
  • Ensure that those who precept students are educated in how to effectively precept.
  • Teach students whom they need to inform if bullying or violence occurs. The school and health care facility policies and procedures regarding bullying reporting must be reviewed with the student. This includes witnesses to bullying.
  • Make sure that students, in turn, feel safe in reporting to their instructor, faculty, preceptor, and later on, to a unit manager. They must feel that their complaints are taken seriously and will be acted upon and are held in confidence.
  • All educators, including preceptors, should be knowledgeable in the methods to resist bullying and horizontal violence as well as to identify it.
  • Educators in every venue, classroom, or clinical area must model behavior that includes effective methods for reducing hostility.
  • Enforce a zero tolerance policy for abuse, bullying, or violence. Nurse educators should model that nothing but respect will be tolerated from any health care professional, student, patient, or visitor.
  • Teach students that violence, bullying, and verbal abuse are not a part of nursing, and enduring them is not a rite of passage!
  • Encourage all nurses to model professional behavior. What is seen by students is imitated by them. If students experience bullying and the bullying is condoned, they will become bullies and the cycle will continue.
  • Clinical instructors should be knowledgeable in not only clinical skills but also in how to effectively communicate and interact with students and staff.
  • All nursing schools and universities have a responsibility to define bullying, and to design and implement anti-bullying policies and procedures.
  • Provide students with information of outside or university support for victims of bullying.
  • Make students aware of the psychological effects of bullying and also coping mechanisms to deal with stress.

Margaret Ciocco

Maggie Ciocco MS, RN, BC, is currently a nursing program advisor for the W. Cary Edwards School of Nursing at Thomas Edison State University in Trenton, New Jersey. She has over 25 years of experience in nursing education, including as a preceptor, mentor, staff development instructor, orientation coordinator, nursing lab instructor, and clinical instructor. Ms. Ciocco received her master of science in nursing from Syracuse University, her bachelor of science in nursing from Seton Hall University, and her associate degree from Ocean County College in Toms River, New Jersey. She has been an American Nurses Credentialing Center board-certified medical-surgical nurse for over 20 years. Throughout her years as an educator, she has established preceptorship programs in acute, subacute, and long-term care settings. She is a member of the National League for Nursing. Ms. Ciocco was awarded the Sigma Theta Tau-Lambda Delta chapter Hannelore Sweetwood Mentor of the Year award in 2012. As a nursing program advisor, she works with Registered Nurses and student nurses as they continue their education, mentoring and advising them as to career and nursing degree choices. She is the author of Fast Facts for the Medical-Surgical Nurse: Clinical Orientation in a Nutshell, Fast Facts for the Nurse Preceptor: Keys to Providing a Successful Preceptorship in a Nutshell, and Fast Facts on Combating Nurse Bullying, Incivility and Workplace Violence: What Nurses Need to Know in a Nutshell, which was awarded second place in the 2017 AJN Book of the Year Awards in the Professional Issues category.

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