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Volume 17, Issue 53 (2024)
JMED 2024, 17(53): 54-62 |
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Ethics code: IR.ZUMS.REC.1398.104
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Tahrekhani M, Dinmohammadi M. Bullying among medical sciences students in clinical placements. JMED 2024; 17 (53) :54-62
URL: http://edujournal.zums.ac.ir/article-1-1934-en.html
URL: http://edujournal.zums.ac.ir/article-1-1934-en.html
1- Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran.
2- Department of Nusing, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran. & Education Development Center (EDC), Zanjan University of Medical Sciences, Zanjan, Iran. ,mdinmohammadi@zums.ac.ir
2- Department of Nusing, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran. & Education Development Center (EDC), Zanjan University of Medical Sciences, Zanjan, Iran. ,
Keywords: workplace bullying, medical sciences students, clinical placement, learning experiences, violence
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Results
In this study, data was collected through individual interviews with 16 students from various medical sciences students (including 3 medical doctorates, 4 anesthesiology technology, 7 nursing, and 1 operating room technology) and 4 FGDs (including 2 groups of anesthesiology technology, and 2 groups of nursing students) (Table 2). Qualitative content analysis was used to analyze the data and generated 138 initial codes. Finally, three main categories and ten subcategories were identified from the participants' experiences and opinions (Table 3).
Table 2. Demographic characteristics of participants in the individual interviews
Table 3. Main and subcategories of study
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Abstract
Background & Objective: Bullying is a growing concern in the workplace. Medical sciences students, in particular, are vulnerable to bullying behaviors during their clinical placements. This study aimed to explore the phenomenon of bullying among medical sciences students in clinical placements.
Materials & Methods: The study utilized a conventional qualitative content analysis method, conducting sixteen semi-structured individual interviews and six focus group discussions (FGDs) with medical sciences students from four fields of medicine. Data were collected for 3 months from November 2020 to February 2021.
Results: The findings revealed that medical sciences students faced various challenges during their clinical education, including failure to meet clinical educational expectations, experiencing violence in clinical placement, and unsafe clinical environments. These challenges negatively impacted the students' learning experiences and overall well-being.
Conclusion: This study provides valuable insights into the phenomenon of workplace bullying among medical sciences students, emphasizing the importance of promoting a positive and supportive learning environment in clinical placements.
Background & Objective: Bullying is a growing concern in the workplace. Medical sciences students, in particular, are vulnerable to bullying behaviors during their clinical placements. This study aimed to explore the phenomenon of bullying among medical sciences students in clinical placements.
Materials & Methods: The study utilized a conventional qualitative content analysis method, conducting sixteen semi-structured individual interviews and six focus group discussions (FGDs) with medical sciences students from four fields of medicine. Data were collected for 3 months from November 2020 to February 2021.
Results: The findings revealed that medical sciences students faced various challenges during their clinical education, including failure to meet clinical educational expectations, experiencing violence in clinical placement, and unsafe clinical environments. These challenges negatively impacted the students' learning experiences and overall well-being.
Conclusion: This study provides valuable insights into the phenomenon of workplace bullying among medical sciences students, emphasizing the importance of promoting a positive and supportive learning environment in clinical placements.
Introduction
Bullying has become a significant concern in the modern era and is prevalent in various settings, including the workplace, schools, and universities. Workplace bullying refers to the persistent, intentional, and negative behaviors directed towards an individual or a group of people in the workplace that create an uncomfortable working environment (1-3). Bullying is a significant problem in the healthcare industry, particularly among medical sciences students, who face numerous challenges and obstacles in their clinical placements (4-8). Clinical placements offer students the opportunity to learn and develop their skills under the guidance of healthcare professionals in a clinical setting. However, bullying behaviors can impact a student's learning and development and may cause significant distress and anxiety (3, 9).
Bullying in the workplace can have negative effects on an individual's health and well-being, leading to psychological distress, anxiety, and depression (10). The healthcare industry is no exception, and bullying behaviors can be particularly harmful to medical sciences students, as they are still in the learning and developmental stages of their careers (11). Rautio et al. have also identified various consequences of bullying behaviors on medical sciences students' learning and development. For example, bullying behaviors can negatively impact students' self-esteem and confidence, leading to reduced motivation and engagement in their work (3).
In response to the prevalence and negative effects of bullying behaviors in clinical placements, several strategies have been suggested to address the issue. These strategies include the implementation of policies and procedures that prohibit bullying behaviors, providing training and education to healthcare professionals on the effects of bullying, and promoting a positive workplace culture that fosters respect, collaboration, and support (12).
Bullying is a recognized issue in the health system, especially in clinical settings where students are placed. The issue of workplace bullying among medical science students in Iran remains understudied despite existing studies on bullying, and as such, this study seeks to provide a complete understanding of bullying by describing the experiences of medical sciences students. Its findings will provide insights into the extent and effects of bullying behaviors and can help inform the development of policies and strategies to prevent and address bullying in the healthcare industry.
Materials & Methods
Design and setting(s)
The study utilized a conventional qualitative content analysis method. The research environment of hospitals affiliated with Zanjan University of Medical Sciences included Ayatollah Mousavi, Hazrat Valiasr, and Shahid Beheshti Hospitals.
Participants and sampling
The study enrolled participants who were pursuing general doctorates in medicine and bachelor's degrees in nursing, midwifery, anesthesiology technology, and operating room technology and had acquired at least one semester of experience in clinical settings. A purposive sampling technique was utilized to select qualified and knowledgeable key informant students who could eloquently articulate their experiences.
Data collection methods
Data were collected through semi-structured interviews and FGDs for 3 months from November 2020 to February 2021. The investigation implemented a total of sixteen distinct semi-structured interviews, in conjunction with four FGDs. Two groups of 5-8 anesthesiology technology students participated in FGDs 1 and 3, while two groups of 5-8 nursing students participated in FGDs 2 and 4. Individual interviews were conducted in the clinical environment and at a convenient time and place for the participants to feel comfortable. The interviews were recorded and then immediately transcribed verbatim, and notes were also taken during the interview. FGDs were managed by one of the researchers and lasted about 90-120 minutes. An interview guide was used to extract the facts, mindsets, processes, and views of the participants.
Data analysis
The study data was analyzed based on Graneheim & Lundman's qualitative conventional content analysis method (13). This method involves a systematic approach to analyzing qualitative data by identifying themes and patterns in the data and interpreting the meaning of these themes and patterns.
The analysis process involved converting the sentences into semantic units, making primary codes using words and words close to the participants' statements, and categorizing the codes based on their differences and similarities. The codes were grouped based on similar meanings and their connection and continuity. In this way, the parts were placed next to each other in a meaningful conceptual pattern, and the connections between the data were identified and appeared within the themes (Table 1).
Bullying in the workplace can have negative effects on an individual's health and well-being, leading to psychological distress, anxiety, and depression (10). The healthcare industry is no exception, and bullying behaviors can be particularly harmful to medical sciences students, as they are still in the learning and developmental stages of their careers (11). Rautio et al. have also identified various consequences of bullying behaviors on medical sciences students' learning and development. For example, bullying behaviors can negatively impact students' self-esteem and confidence, leading to reduced motivation and engagement in their work (3).
In response to the prevalence and negative effects of bullying behaviors in clinical placements, several strategies have been suggested to address the issue. These strategies include the implementation of policies and procedures that prohibit bullying behaviors, providing training and education to healthcare professionals on the effects of bullying, and promoting a positive workplace culture that fosters respect, collaboration, and support (12).
Bullying is a recognized issue in the health system, especially in clinical settings where students are placed. The issue of workplace bullying among medical science students in Iran remains understudied despite existing studies on bullying, and as such, this study seeks to provide a complete understanding of bullying by describing the experiences of medical sciences students. Its findings will provide insights into the extent and effects of bullying behaviors and can help inform the development of policies and strategies to prevent and address bullying in the healthcare industry.
Materials & Methods
Design and setting(s)
The study utilized a conventional qualitative content analysis method. The research environment of hospitals affiliated with Zanjan University of Medical Sciences included Ayatollah Mousavi, Hazrat Valiasr, and Shahid Beheshti Hospitals.
Participants and sampling
The study enrolled participants who were pursuing general doctorates in medicine and bachelor's degrees in nursing, midwifery, anesthesiology technology, and operating room technology and had acquired at least one semester of experience in clinical settings. A purposive sampling technique was utilized to select qualified and knowledgeable key informant students who could eloquently articulate their experiences.
Data collection methods
Data were collected through semi-structured interviews and FGDs for 3 months from November 2020 to February 2021. The investigation implemented a total of sixteen distinct semi-structured interviews, in conjunction with four FGDs. Two groups of 5-8 anesthesiology technology students participated in FGDs 1 and 3, while two groups of 5-8 nursing students participated in FGDs 2 and 4. Individual interviews were conducted in the clinical environment and at a convenient time and place for the participants to feel comfortable. The interviews were recorded and then immediately transcribed verbatim, and notes were also taken during the interview. FGDs were managed by one of the researchers and lasted about 90-120 minutes. An interview guide was used to extract the facts, mindsets, processes, and views of the participants.
Data analysis
The study data was analyzed based on Graneheim & Lundman's qualitative conventional content analysis method (13). This method involves a systematic approach to analyzing qualitative data by identifying themes and patterns in the data and interpreting the meaning of these themes and patterns.
The analysis process involved converting the sentences into semantic units, making primary codes using words and words close to the participants' statements, and categorizing the codes based on their differences and similarities. The codes were grouped based on similar meanings and their connection and continuity. In this way, the parts were placed next to each other in a meaningful conceptual pattern, and the connections between the data were identified and appeared within the themes (Table 1).
Study rigor
To confirm the validity and acceptability of the data, the method of long-term engagement with the data and spending enough time to collect and analyze the data, review by the participants, review of the data by the researchers, and peer review was used. The researchers have fully explained all the stages of the research to create the ability to confirm the findings. To check the transferability of the findings, the researcher fully described the context in which the research was conducted.
To confirm the validity and acceptability of the data, the method of long-term engagement with the data and spending enough time to collect and analyze the data, review by the participants, review of the data by the researchers, and peer review was used. The researchers have fully explained all the stages of the research to create the ability to confirm the findings. To check the transferability of the findings, the researcher fully described the context in which the research was conducted.
Table 1. A sample of the main category, subcategory, initial code, and participant statement
| Main Category | Subcategory | Initial code | Participant statement |
| Failure to meet clinical educational expectations | Inappropriate feedback on student performance | Inappropriate feedback from the instructor in clinical placement | In one of my clinical sections, I had performed a case of a venous catheterization, and she said: "Why are you doing this, sir, [the teacher] questioned. Have I not taught you? Don't enter that procedure when you don't know this kind of thing! |
Results
In this study, data was collected through individual interviews with 16 students from various medical sciences students (including 3 medical doctorates, 4 anesthesiology technology, 7 nursing, and 1 operating room technology) and 4 FGDs (including 2 groups of anesthesiology technology, and 2 groups of nursing students) (Table 2). Qualitative content analysis was used to analyze the data and generated 138 initial codes. Finally, three main categories and ten subcategories were identified from the participants' experiences and opinions (Table 3).
| Participants | Gender | Age | Degree | Major | Semester |
| Participant 1 | Female | 25 | Doctorate | Medicine | 14 |
| Participant 2 | Female | 28 | Doctorate | Medicine | 10 |
| Participant 3 | Female | 21 | Bachelor | Anesthesiology Technology | 7 |
| Participant 4 | Female | 28 | Doctorate | Medicine | 9 |
| Participant 5 | Male | 24 | Bachelor | Nursing | 6 |
| Participant 6 | Male | 22 | Bachelor | Nursing | 6 |
| Participant 7 | Female | 21 | Bachelor | Nursing | 6 |
| Participant 8 | Female | 22 | Bachelor | Nursing | 6 |
| Participant 9 | Female | 23 | Doctorate | Medicine | 12 |
| Participant 10 | Female | 22 | Bachelor | Nursing | 8 |
| Participant 11 | Male | 21 | Bachelor | Nursing | 6 |
| Participant 12 | Female | 23 | Bachelor | Anesthesiology Technology | 8 |
| Participant 13 | Female | 22 | Bachelor | Anesthesiology Technology | 7 |
| Participant 14 | Male | 22 | Bachelor | Nursing | 5 |
| Participant 15 | Female | 23 | Doctorate | Medicine | 12 |
| Participant 16 | Female | 24 | Bachelor | Anesthesiology Technology | 8 |
Table 3. Main and subcategories of study
| Main Categories | Subcategories |
| Failure to meet clinical educational expectations | Inappropriate feedback on student performance |
| lack of clinical teaching load | |
| Experiencing violence in clinical placement | Discrimination among medical students |
| Inappropriate behavior with a student in the clinical environment | |
| Establishing restrictions on clinical placement | |
| Lack of support from the teachers | |
| Humiliating treatment of students | |
| Unsafe clinical environment | Observing inappropriate interprofessional relationships |
| Unwelcoming clinical environment | |
| Exploiting students |
1. Failure to meet clinical educational expectations
This part of the participants' experiences consisted of 2 sub-categories of inappropriate feedback on student performance and lack of clinical teaching load.
1.1. Inappropriate feedback on student performance
Students were dissatisfied with the time and quality of providing educational feedback from teachers and clinical trainers.
In this regard, one of the anesthesiology technology students said: "Some trainers also give up completely, which is not good. Some of them are always present above us, which is also undesirable. For example, they don't worry too much about us and don't get involved too much."
In another section of his interview, the same student claimed that certain teachers occasionally provided critical feedback regardless of the circumstances or the student's aptitude. He mentioned that: " In one of my clinical sections, I had performed a case of a venous catheterization, and she said: "Why are you doing this, sir, [the teacher] questioned. Have I not taught you? Don't enter that procedure when you don't know this kind of thing!" (FGD 3)
One of the medical students describes his experience in this regard as follows: "In the past, we kept notes and health histories. However, we always had the same issue when we went to the teacher. And we were never able to pinpoint the genuine source of our note's issue. He failed to explain this matter to us" (P. 2)
1.2. Lack of clinical teaching load
Participants, particularly medical students, claimed that teachers' dedication to educating their students in clinical settings is insufficient.
One of the interns made the following observation regarding the teachers' little teaching load: "Teachers also visit, depart, and return. It comes to an end when they stamp the patient records. This describes a lot of teachers. You know, there are times when you are unsure if you are his intern or not? What does he anticipate of you?" (P. 1)
Clinical teacher' lack of dedication to education is not just a problem for the medical students; it also seems to be a problem for other students. One of the nursing students said in this regard:
"I questioned a cardiologist if what you are currently witnessing is the tricuspid valve, in other words, the door and the wall made noise, but he was silent. He didn't pay attention to my words at all, as if not!" (FGD 2).
2. Experiencing violence in clinical placement
This part of the experience of the participants was expressed among students of various disciplines.
This part of the participants' experiences consisted of 5 subcategories as follows.
2.1. Discrimination among medical students
This experience was often very evident among nursing, anesthesiology technology, and operating room technology students. These students expressed their displeasure with the fact that the medical students have a series of freedoms in clinical environments and have more facilities and privileges compared to themselves. One of the anesthesiology students said in this regard:
"We all study in the same university. But the way we are treated in clinical settings is completely different. I don't know if you understand this or not! ... This difference has been created and the respect that exists for medical students. … They have freedom in many points." (FGD 3)
In this regard, one of the nursing students said in the FGD session:
"There is discrimination in all sectors. The discrimination that is done in front of a student, a nurse, and a physician is much more visible! If we are a team and no one is above the other and we are all in the same level!" (FGD 2)
2.2. Inappropriate behavior with students in clinical environment
The participants talked about their experiences about the unpleasant behavior of the staff of different clinical departments. These behaviors mainly originated from physicians, senior students, nurses and sometimes from their teachers.
The anesthesiology technology student said:
"I have frequently observed the operating room staff, who have no connection to my field, warning students out loud not to do something! Finally, a teacher is present! Even the operating room technology interfered and sternly admonished, knowing full well that he had no right to interfere with anesthesia fields." (FGD 3)
One of the medical interns commented on the inappropriate behavior of the resident student during the visit of the patient:
"The behavior of some residents is really annoying! For example, they read things from us and reprimand us for things that have no educational burden for us at all and just get on our nerves. For example, why did I stand and you sat down?! Why are you going here and there without my permission?" (P. 15)
The medical student says about his experience in this regard:
"But for example, it has happened a lot that the resident yelled at the students in front of all the surgeons and said why did you do this and so on. … Maybe you gave the wrong size of a [Tracheal] tube and you could have changed it at the same moment, and so on" (P. 1)
2.3. Establishing restrictions on clinical placement
Some participants discussed the absence of learning opportunities in clinical settings, which was often due to the lack of clinical cases and prioritizing the teaching of medical students, or because students were not allowed to meddle with staff members' work processes.
In one of the FGDs, a nursing student described his encounter with ward nurses who refused to provide them access to patients' files as follows:
"Yes. We were compelled to remain silent and observe because they would prevent us from taking action even if we attempted. If we were to examine a case and make a report about it, they would remove the patient files from our possession under a variety of pretexts." (FGD 2)
An anesthesiology technology student commented on providing preference to medical students in another section of the FGD:
"They prefer medical students over us. Here, we must come first. Only one week will be spent there by the stagers, who are junior medical students. We did not intubate once over that one week." (FGD 1)
Another anesthesiology technology students mentioned the distrust of physicians and our clinical teachers as the reason for creating these restrictions in the hospital:
"For instance, throughout the first several semesters, they don't give us any work. When you're trying to work, they are very annoying. But as time went on, we improved. However, there were times when they didn't give us a lot of work." (P. 3)
2.4. Lack of support from the teachers
Participants, especially non-medical students, voiced frustration with their teachers' lack of support for them in clinical settings. This lack of support occasionally hampered how they carried out their teaching responsibilities, and occasionally it influenced how they dealt with difficulties at the bedside.
One of the students stated, "For example, we had a teacher..., she wasn't too far behind the students. Just in case she is my teacher and needs more of my focus. But she would start [blaming] more from one side when she entered the room, for example, rather than supporting me when I made a mistake or forgot something!" (P. 5)
A nursing student said in this regard:
"Some teachers don't arrive on time, or sometimes they come late, and occasionally they come very early. The student then makes a few late arrivals, gets into trouble, and receives poor grades. This is very painful. This is how some teachers are!" (P. 6)
Another nursing student described his experience in the following way: "Additionally, the student is responsible for all mishaps in the ward, including lost property. Everything that happens in the ward is completely the fault of the students! We have no rights at all in the wards!" (P. 8)
2.5. Disrespectful treatment of students
In clinical settings, staff and teachers sometimes humiliate and insult students, among other violent behaviors.
"I went in for an EKG [electrocardiography], but I had no idea what the pedal colors were. I was the target of our teacher's scrutinizing gaze. … You are taking a nursing course for the fourth semester, but you still cannot identify the colors! She behaved in a humiliating way there!" (P. 5)
Alternatively, the anesthesiology technology student in one of his clinical sessions reported her experience as follows:
"In front of the lower-semester students, [the teacher] told me, Yeah, you want to be an illiterate technology! For instance, she asks, with what permission did you do this?" (P. 16)
Of course, not only non-medical students engaged in these negative behaviors; discussions about these incidents also included medical students.
Regarding this, one of the medical interns said: "You will never feel motivated! Any action you take is required of you. You will suffer humiliation and ridicule if you refuse to comply. "(P. 1)
3. Unsafe clinical environment
Three subcategories made up this section of the participants' experiences: observing unwelcoming clinical environments, inappropriate interprofessional relationships, and student exploitation.
3.1. Observing inappropriate interprofessional relationships
Students who see inappropriate interactions between team members, such as physicians and nurses, or with students from various fields in clinical settings are negatively affected. These connections are hidden curriculum that students acquire informally and may become clear once they have finished the course and are working.
One of the nursing students gave his opinion on these communications:
"In the intensive care unit, we were completing our clinical session. One of the doctors took a top-to-bottom look of the nurse. He was looking at the patient's file. He didn't even bother to read the file through, though. Where are the results of the lab tests, he exclaimed [to the nurse]?" (FGD 2)
Or a medical intern commented on how nurses cooperate in bladder catheterization:
"Nurses don't come. They consider that far from their status. … [She says] That is not my duty. Call the crew. " (P. 1)
3.2. Unwelcoming clinical environment
Students get a bad impression about the future of the workplace after witnessing inappropriate actions and unprofessional communication in clinical settings during clinical placement. The motivation and interest of working in these contexts are undermined by improper relationships between various team members and, occasionally, students in clinical settings. Their decision to continue their professional career is uncertain because students aren't treated as potential colleagues.
In his third year of study, a nursing student made the following observation regarding the detrimental impact of clinical personnel and occasionally teachers' behavior: "I had the feeling that I would never go into a hospital setting. that I want to pursue further education or a different career."
This student claims that their presence in the clinical setting and having to deal with staff and instructor interactions are to blame for their lack of desire and interest in working in clinical contexts "It seriously demoralized us. I'm not as motivated as I was throughout the first semester. I truly cherished my work and my academics in the first semester, but not anymore. I don't really care that much." (P. 8)
3.3. Exploiting students
In clinical settings, several participants experienced various forms of maltreatment. These actions took the form of assigning students a lot of work or delegating their own tasks to them. Mostly nursing students and medical interns were affected by this.
Nursing students are treated as nurses' employees during internships, according to one of the nursing students. "We are a tool to make their work easier while they sit at the station telling us to do this and that." (FGD 2)
The intense workload of her shifts and the demands of her education are discussed by one of the medical interns, who adds: "But every hour [nurses] phone you for anything that is not an emergency and they expect you to get up the same minute. But they are unaware that you have been in long shift since the morning! You stayed awake all night! "
In another section of her interview, this participant continues: "You eventually find it difficult to engage in the morning classes because the burden of the night shifts is so great. You're worn out and you don't pay attention. We were in the same section in the morning, for instance, surgery. You stayed awake all night. You must visit 40 patients during the morning shift and check their lab findings. Next, read Morning as well!" (P. 1).
Discussion
Bullying is a prevalent phenomenon in various fields of society, including education, and healthcare. Medical students are no exception and are vulnerable to being victimized by bullying. The results of this study revealed the various forms of bullying experienced by medical students in clinical settings. This discussion will provide a detailed analysis of these findings and their implications for clinical education.
One of the main challenges identified in this study was the failure to meet clinical educational expectations. Students reported inadequate feedback from teachers and clinical trainers regarding their performance, which left them dissatisfied with the quality and timing of feedback. This finding is consistent with previous studies that have identified feedback as an essential component of effective clinical teaching (14, 15). Also, this result is consistent with previous research that suggests that inappropriate feedback can have a significant impact on students' emotional and academic well-being (16, 17). The lack of clinical teaching load was also reported by participants, especially medical students, who highlighted the weak educational commitment of teachers in clinical settings. This finding is concerning, as clinical exposure is essential for developing students' clinical skills and competencies (18, 19). Teachers who do not provide adequate teaching can lead to students feeling unsupported and lost. Students may feel like they are wasting their time and not learning the necessary skills required to become a competent clinician. Steinert et al. (2015) highlighted the importance of having supportive and effective clinical teachers (20).
Furthermore, the study found that medical sciences students experience violence in clinical placements. Violence can take the form of verbal abuse, discrimination, inappropriate behavior, establishing restrictions on clinical placement, lack of support from the teachers, and humiliating treatment of students. This finding aligns with previous research which has found that medical students are at a high risk of experiencing violence in the workplace (3, 21-23). The occurrence of violence in the clinical environment is a significant concern as it can have negative impacts on the students' mental health, academic performance, and job satisfaction (4, 24).
Students from various disciplines reported experiencing discrimination, inappropriate behavior from staff, and limited learning opportunities. These findings are consistent with previous studies that have reported high rates of bullying, harassment, and discrimination in clinical education (5, 19, 25-27). Such experiences can have long-lasting effects on students' mental health and well-being (24, 26).
The study also highlighted the issue of discrimination among medical students, as they were found to have more freedoms and privileges in clinical environments than students from other fields. This finding is consistent with previous studies that have identified medical student privilege and bias in clinical settings (28, 29). Addressing this issue is essential for creating a more inclusive and equitable learning environment for all students. Discrimination can also negatively affect the quality of care provided to patients, as it can impact the development of effective team dynamics. This finding is consistent with previous studies, which have highlighted the prevalence of bullying in clinical settings (9, 23, 25, 28, 30, 31).
Furthermore, the lack of support from the teachers and supervisors was also highlighted as a contributing factor to the students' negative experiences in the clinical environment. Students reported feeling unsupported and isolated, which negatively impacted their learning experience and their ability to cope with the demands of the clinical setting. This finding is consistent with previous studies that have identified the importance of supportive relationships between students and clinical staff in promoting positive learning experiences and reducing the incidence of bullying (9, 19, 32).
The third major finding of the study was that medical sciences students reported an unsafe clinical environment. This w:as char:acterized by observing inappropriate interprofessional relationships, an unwelcoming clinical environment, and exploiting students. Previous studies have also identified the impact of unwelcoming clinical environments on students, including feeling unwelcome and unsupported, which can result in the students feeling disengaged from the learning process (33).
Also, this finding is in line with previous studies which have identified that clinical learning environments can be unsafe for students, potentially leading to harm (25-27). The unwelcoming clinical environment is often characterized by a lack of trust, support, and communication, which creates an atmosphere of hostility and aggression toward students (12, 29). It is also essential to promote interprofessional collaboration and teamwork, as this has been found to contribute positively to students' learning experiences and provide support in the clinical environment (9, 31). Some students reported feeling exploited and forced to perform tasks that were beyond their competence level, which put them and their patients at risk. This finding is consistent with previous research that has identified the importance of creating a safe and supportive learning environment in healthcare settings (30).
The study's findings have important implications for medical sciences education, particularly in the development of policies and practices that support the provision of a safe and supportive learning environment for medical sciences students where students feel supported and valued, and where their contributions are recognized and appreciated. Specifically, policies need to address the issues of bullying, violence, and an unsafe clinical environment. The policies should provide guidelines for the behavior of all stakeholders, including teachers, students, and supervisors, in clinical settings. The guidelines should promote respectful behavior, encourage the reporting of inappropriate behavior, and outline the consequences of such behavior.
Limitations of the study should also be considered. The study was conducted in a specific geographic region, which may limit the generalizability of the findings to other contexts. Future research could explore the experiences of medical science students in different settings and contexts, including different cultural contexts, to gain a more comprehensive understanding of the phenomenon of bullying in healthcare education. Additionally, future research could explore the role of individual and organizational factors in contributing to bullying in healthcare settings and identify potential interventions to address this issue.
Conclusion
This study investigated the phenomenon of bullying among medical sciences students in the workplace. It found that medical sciences students face various forms of bullying, including failure to meet clinical educational expectations, experiencing violence in clinical placements, and an unsafe clinical environment. To prevent bullying, policies should provide guidelines for behavior and clinical teachers should be trained to recognize and manage instances of bullying. It is essential to create a supportive learning environment for medical sciences students to prevent bullying and promote their academic and personal success. By addressing the issue of bullying in healthcare education, we can create a more positive and productive learning environment and improve the quality of care provided to patients.
Ethical considerations
This study started to collect data after obtaining the approval of the Research Ethics Committee (IR.ZUMS.REC.1398.104) of Zanjan University of Medical Sciences. A written consent was prepared for the informed participation of the students. The students were assured that their statements would be kept confidential and would not be shared with anyone other than those participating in the study. The names of the participants were known only to the researcher and those who introduced the participants. Students were allowed to withdraw from the study at any stage of the research.
Acknowledgments
This study was supported financially by the Zanjan University of Medical Sciences' Educational Development Center in Zanjan, Iran. We would like to show our thanks to those students who volunteered to take part in this study.
Disclosure
There are no relevant conflicts of interest to disclose.
Author contributions
Tahrkhani M. was involved in writing the proposal, and data collection. Dinmohammadi M. was responsible for the design the research, data analysis, and writing the article. All authors were involved in a critical review of the article.
Data availability statement
Access is permitted upon request.
This part of the participants' experiences consisted of 2 sub-categories of inappropriate feedback on student performance and lack of clinical teaching load.
1.1. Inappropriate feedback on student performance
Students were dissatisfied with the time and quality of providing educational feedback from teachers and clinical trainers.
In this regard, one of the anesthesiology technology students said: "Some trainers also give up completely, which is not good. Some of them are always present above us, which is also undesirable. For example, they don't worry too much about us and don't get involved too much."
In another section of his interview, the same student claimed that certain teachers occasionally provided critical feedback regardless of the circumstances or the student's aptitude. He mentioned that: " In one of my clinical sections, I had performed a case of a venous catheterization, and she said: "Why are you doing this, sir, [the teacher] questioned. Have I not taught you? Don't enter that procedure when you don't know this kind of thing!" (FGD 3)
One of the medical students describes his experience in this regard as follows: "In the past, we kept notes and health histories. However, we always had the same issue when we went to the teacher. And we were never able to pinpoint the genuine source of our note's issue. He failed to explain this matter to us" (P. 2)
1.2. Lack of clinical teaching load
Participants, particularly medical students, claimed that teachers' dedication to educating their students in clinical settings is insufficient.
One of the interns made the following observation regarding the teachers' little teaching load: "Teachers also visit, depart, and return. It comes to an end when they stamp the patient records. This describes a lot of teachers. You know, there are times when you are unsure if you are his intern or not? What does he anticipate of you?" (P. 1)
Clinical teacher' lack of dedication to education is not just a problem for the medical students; it also seems to be a problem for other students. One of the nursing students said in this regard:
"I questioned a cardiologist if what you are currently witnessing is the tricuspid valve, in other words, the door and the wall made noise, but he was silent. He didn't pay attention to my words at all, as if not!" (FGD 2).
2. Experiencing violence in clinical placement
This part of the experience of the participants was expressed among students of various disciplines.
This part of the participants' experiences consisted of 5 subcategories as follows.
2.1. Discrimination among medical students
This experience was often very evident among nursing, anesthesiology technology, and operating room technology students. These students expressed their displeasure with the fact that the medical students have a series of freedoms in clinical environments and have more facilities and privileges compared to themselves. One of the anesthesiology students said in this regard:
"We all study in the same university. But the way we are treated in clinical settings is completely different. I don't know if you understand this or not! ... This difference has been created and the respect that exists for medical students. … They have freedom in many points." (FGD 3)
In this regard, one of the nursing students said in the FGD session:
"There is discrimination in all sectors. The discrimination that is done in front of a student, a nurse, and a physician is much more visible! If we are a team and no one is above the other and we are all in the same level!" (FGD 2)
2.2. Inappropriate behavior with students in clinical environment
The participants talked about their experiences about the unpleasant behavior of the staff of different clinical departments. These behaviors mainly originated from physicians, senior students, nurses and sometimes from their teachers.
The anesthesiology technology student said:
"I have frequently observed the operating room staff, who have no connection to my field, warning students out loud not to do something! Finally, a teacher is present! Even the operating room technology interfered and sternly admonished, knowing full well that he had no right to interfere with anesthesia fields." (FGD 3)
One of the medical interns commented on the inappropriate behavior of the resident student during the visit of the patient:
"The behavior of some residents is really annoying! For example, they read things from us and reprimand us for things that have no educational burden for us at all and just get on our nerves. For example, why did I stand and you sat down?! Why are you going here and there without my permission?" (P. 15)
The medical student says about his experience in this regard:
"But for example, it has happened a lot that the resident yelled at the students in front of all the surgeons and said why did you do this and so on. … Maybe you gave the wrong size of a [Tracheal] tube and you could have changed it at the same moment, and so on" (P. 1)
2.3. Establishing restrictions on clinical placement
Some participants discussed the absence of learning opportunities in clinical settings, which was often due to the lack of clinical cases and prioritizing the teaching of medical students, or because students were not allowed to meddle with staff members' work processes.
In one of the FGDs, a nursing student described his encounter with ward nurses who refused to provide them access to patients' files as follows:
"Yes. We were compelled to remain silent and observe because they would prevent us from taking action even if we attempted. If we were to examine a case and make a report about it, they would remove the patient files from our possession under a variety of pretexts." (FGD 2)
An anesthesiology technology student commented on providing preference to medical students in another section of the FGD:
"They prefer medical students over us. Here, we must come first. Only one week will be spent there by the stagers, who are junior medical students. We did not intubate once over that one week." (FGD 1)
Another anesthesiology technology students mentioned the distrust of physicians and our clinical teachers as the reason for creating these restrictions in the hospital:
"For instance, throughout the first several semesters, they don't give us any work. When you're trying to work, they are very annoying. But as time went on, we improved. However, there were times when they didn't give us a lot of work." (P. 3)
2.4. Lack of support from the teachers
Participants, especially non-medical students, voiced frustration with their teachers' lack of support for them in clinical settings. This lack of support occasionally hampered how they carried out their teaching responsibilities, and occasionally it influenced how they dealt with difficulties at the bedside.
One of the students stated, "For example, we had a teacher..., she wasn't too far behind the students. Just in case she is my teacher and needs more of my focus. But she would start [blaming] more from one side when she entered the room, for example, rather than supporting me when I made a mistake or forgot something!" (P. 5)
A nursing student said in this regard:
"Some teachers don't arrive on time, or sometimes they come late, and occasionally they come very early. The student then makes a few late arrivals, gets into trouble, and receives poor grades. This is very painful. This is how some teachers are!" (P. 6)
Another nursing student described his experience in the following way: "Additionally, the student is responsible for all mishaps in the ward, including lost property. Everything that happens in the ward is completely the fault of the students! We have no rights at all in the wards!" (P. 8)
2.5. Disrespectful treatment of students
In clinical settings, staff and teachers sometimes humiliate and insult students, among other violent behaviors.
"I went in for an EKG [electrocardiography], but I had no idea what the pedal colors were. I was the target of our teacher's scrutinizing gaze. … You are taking a nursing course for the fourth semester, but you still cannot identify the colors! She behaved in a humiliating way there!" (P. 5)
Alternatively, the anesthesiology technology student in one of his clinical sessions reported her experience as follows:
"In front of the lower-semester students, [the teacher] told me, Yeah, you want to be an illiterate technology! For instance, she asks, with what permission did you do this?" (P. 16)
Of course, not only non-medical students engaged in these negative behaviors; discussions about these incidents also included medical students.
Regarding this, one of the medical interns said: "You will never feel motivated! Any action you take is required of you. You will suffer humiliation and ridicule if you refuse to comply. "(P. 1)
3. Unsafe clinical environment
Three subcategories made up this section of the participants' experiences: observing unwelcoming clinical environments, inappropriate interprofessional relationships, and student exploitation.
3.1. Observing inappropriate interprofessional relationships
Students who see inappropriate interactions between team members, such as physicians and nurses, or with students from various fields in clinical settings are negatively affected. These connections are hidden curriculum that students acquire informally and may become clear once they have finished the course and are working.
One of the nursing students gave his opinion on these communications:
"In the intensive care unit, we were completing our clinical session. One of the doctors took a top-to-bottom look of the nurse. He was looking at the patient's file. He didn't even bother to read the file through, though. Where are the results of the lab tests, he exclaimed [to the nurse]?" (FGD 2)
Or a medical intern commented on how nurses cooperate in bladder catheterization:
"Nurses don't come. They consider that far from their status. … [She says] That is not my duty. Call the crew. " (P. 1)
3.2. Unwelcoming clinical environment
Students get a bad impression about the future of the workplace after witnessing inappropriate actions and unprofessional communication in clinical settings during clinical placement. The motivation and interest of working in these contexts are undermined by improper relationships between various team members and, occasionally, students in clinical settings. Their decision to continue their professional career is uncertain because students aren't treated as potential colleagues.
In his third year of study, a nursing student made the following observation regarding the detrimental impact of clinical personnel and occasionally teachers' behavior: "I had the feeling that I would never go into a hospital setting. that I want to pursue further education or a different career."
This student claims that their presence in the clinical setting and having to deal with staff and instructor interactions are to blame for their lack of desire and interest in working in clinical contexts "It seriously demoralized us. I'm not as motivated as I was throughout the first semester. I truly cherished my work and my academics in the first semester, but not anymore. I don't really care that much." (P. 8)
3.3. Exploiting students
In clinical settings, several participants experienced various forms of maltreatment. These actions took the form of assigning students a lot of work or delegating their own tasks to them. Mostly nursing students and medical interns were affected by this.
Nursing students are treated as nurses' employees during internships, according to one of the nursing students. "We are a tool to make their work easier while they sit at the station telling us to do this and that." (FGD 2)
The intense workload of her shifts and the demands of her education are discussed by one of the medical interns, who adds: "But every hour [nurses] phone you for anything that is not an emergency and they expect you to get up the same minute. But they are unaware that you have been in long shift since the morning! You stayed awake all night! "
In another section of her interview, this participant continues: "You eventually find it difficult to engage in the morning classes because the burden of the night shifts is so great. You're worn out and you don't pay attention. We were in the same section in the morning, for instance, surgery. You stayed awake all night. You must visit 40 patients during the morning shift and check their lab findings. Next, read Morning as well!" (P. 1).
Discussion
Bullying is a prevalent phenomenon in various fields of society, including education, and healthcare. Medical students are no exception and are vulnerable to being victimized by bullying. The results of this study revealed the various forms of bullying experienced by medical students in clinical settings. This discussion will provide a detailed analysis of these findings and their implications for clinical education.
One of the main challenges identified in this study was the failure to meet clinical educational expectations. Students reported inadequate feedback from teachers and clinical trainers regarding their performance, which left them dissatisfied with the quality and timing of feedback. This finding is consistent with previous studies that have identified feedback as an essential component of effective clinical teaching (14, 15). Also, this result is consistent with previous research that suggests that inappropriate feedback can have a significant impact on students' emotional and academic well-being (16, 17). The lack of clinical teaching load was also reported by participants, especially medical students, who highlighted the weak educational commitment of teachers in clinical settings. This finding is concerning, as clinical exposure is essential for developing students' clinical skills and competencies (18, 19). Teachers who do not provide adequate teaching can lead to students feeling unsupported and lost. Students may feel like they are wasting their time and not learning the necessary skills required to become a competent clinician. Steinert et al. (2015) highlighted the importance of having supportive and effective clinical teachers (20).
Furthermore, the study found that medical sciences students experience violence in clinical placements. Violence can take the form of verbal abuse, discrimination, inappropriate behavior, establishing restrictions on clinical placement, lack of support from the teachers, and humiliating treatment of students. This finding aligns with previous research which has found that medical students are at a high risk of experiencing violence in the workplace (3, 21-23). The occurrence of violence in the clinical environment is a significant concern as it can have negative impacts on the students' mental health, academic performance, and job satisfaction (4, 24).
Students from various disciplines reported experiencing discrimination, inappropriate behavior from staff, and limited learning opportunities. These findings are consistent with previous studies that have reported high rates of bullying, harassment, and discrimination in clinical education (5, 19, 25-27). Such experiences can have long-lasting effects on students' mental health and well-being (24, 26).
The study also highlighted the issue of discrimination among medical students, as they were found to have more freedoms and privileges in clinical environments than students from other fields. This finding is consistent with previous studies that have identified medical student privilege and bias in clinical settings (28, 29). Addressing this issue is essential for creating a more inclusive and equitable learning environment for all students. Discrimination can also negatively affect the quality of care provided to patients, as it can impact the development of effective team dynamics. This finding is consistent with previous studies, which have highlighted the prevalence of bullying in clinical settings (9, 23, 25, 28, 30, 31).
Furthermore, the lack of support from the teachers and supervisors was also highlighted as a contributing factor to the students' negative experiences in the clinical environment. Students reported feeling unsupported and isolated, which negatively impacted their learning experience and their ability to cope with the demands of the clinical setting. This finding is consistent with previous studies that have identified the importance of supportive relationships between students and clinical staff in promoting positive learning experiences and reducing the incidence of bullying (9, 19, 32).
The third major finding of the study was that medical sciences students reported an unsafe clinical environment. This w:as char:acterized by observing inappropriate interprofessional relationships, an unwelcoming clinical environment, and exploiting students. Previous studies have also identified the impact of unwelcoming clinical environments on students, including feeling unwelcome and unsupported, which can result in the students feeling disengaged from the learning process (33).
Also, this finding is in line with previous studies which have identified that clinical learning environments can be unsafe for students, potentially leading to harm (25-27). The unwelcoming clinical environment is often characterized by a lack of trust, support, and communication, which creates an atmosphere of hostility and aggression toward students (12, 29). It is also essential to promote interprofessional collaboration and teamwork, as this has been found to contribute positively to students' learning experiences and provide support in the clinical environment (9, 31). Some students reported feeling exploited and forced to perform tasks that were beyond their competence level, which put them and their patients at risk. This finding is consistent with previous research that has identified the importance of creating a safe and supportive learning environment in healthcare settings (30).
The study's findings have important implications for medical sciences education, particularly in the development of policies and practices that support the provision of a safe and supportive learning environment for medical sciences students where students feel supported and valued, and where their contributions are recognized and appreciated. Specifically, policies need to address the issues of bullying, violence, and an unsafe clinical environment. The policies should provide guidelines for the behavior of all stakeholders, including teachers, students, and supervisors, in clinical settings. The guidelines should promote respectful behavior, encourage the reporting of inappropriate behavior, and outline the consequences of such behavior.
Limitations of the study should also be considered. The study was conducted in a specific geographic region, which may limit the generalizability of the findings to other contexts. Future research could explore the experiences of medical science students in different settings and contexts, including different cultural contexts, to gain a more comprehensive understanding of the phenomenon of bullying in healthcare education. Additionally, future research could explore the role of individual and organizational factors in contributing to bullying in healthcare settings and identify potential interventions to address this issue.
Conclusion
This study investigated the phenomenon of bullying among medical sciences students in the workplace. It found that medical sciences students face various forms of bullying, including failure to meet clinical educational expectations, experiencing violence in clinical placements, and an unsafe clinical environment. To prevent bullying, policies should provide guidelines for behavior and clinical teachers should be trained to recognize and manage instances of bullying. It is essential to create a supportive learning environment for medical sciences students to prevent bullying and promote their academic and personal success. By addressing the issue of bullying in healthcare education, we can create a more positive and productive learning environment and improve the quality of care provided to patients.
Ethical considerations
This study started to collect data after obtaining the approval of the Research Ethics Committee (IR.ZUMS.REC.1398.104) of Zanjan University of Medical Sciences. A written consent was prepared for the informed participation of the students. The students were assured that their statements would be kept confidential and would not be shared with anyone other than those participating in the study. The names of the participants were known only to the researcher and those who introduced the participants. Students were allowed to withdraw from the study at any stage of the research.
Acknowledgments
This study was supported financially by the Zanjan University of Medical Sciences' Educational Development Center in Zanjan, Iran. We would like to show our thanks to those students who volunteered to take part in this study.
Disclosure
There are no relevant conflicts of interest to disclose.
Author contributions
Tahrkhani M. was involved in writing the proposal, and data collection. Dinmohammadi M. was responsible for the design the research, data analysis, and writing the article. All authors were involved in a critical review of the article.
Data availability statement
Access is permitted upon request.
Article Type : Orginal Research |
Subject:
Medical Sciences
Received: 2023/05/3 | Accepted: 2023/09/5 | Published: 2024/04/16
Received: 2023/05/3 | Accepted: 2023/09/5 | Published: 2024/04/16
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