An Evolutionary Concept Analysis of Bullying Towards Nursing Students in the Clinical Practice Environment

Abstract

The term bullying describes negative behaviour most frequently associated with childhood school conduct. However, bullying frequently occurs among adults across diverse professional working environments. Being bullied is a common experience for nursing students and is seen as an unavoidable feature of the clinical practice environment. The literature reports multiple negative impacts on student learning, health care team functioning, quality of care, and future retention in and satisfaction with the nursing profession. Despite decades of research and interventions, bullying persists. Conceptual clarification of bullying is needed to further understand this phenomenon and develop sustainable interventions to reduce and eliminate bullying in nursing. This evolutionary concept analysis contributes to dialogue on the need for continued clarity and further research on the phenomenon of bullying in the practice environment through reflecting the changes and adaptations that continue in the nursing profession. Ongoing research of the concept of bullying will address the aim of developing and maintaining a concept that is both relevant and useful to the nursing discipline.

The term bullying describes negative behaviour most frequently associated with childhood school conduct. However, bullying frequently occurs among adults across diverse professional working environments (Bartlett & Barlett, 2011). Being bullied is a common experience for nursing students and is seen as an unavoidable feature of the clinical practice environment. The literature reports multiple negative impacts on student learning, health care team functioning, quality of care, and future retention in and satisfaction with the nursing profession (Bowllan, 2015; Budden et al., 2017; Clarke et al., 2012; Small et al., 2019). Despite decades of research and interventions, bullying persists (Adams & Maykut, 2015).

Clarke et al. (2012) reported that more than 80% of nursing students in one Canadian undergraduate nursing program experienced bullying while in the clinical practice environment. Additional studies note that over half of all nursing students experienced bullying at some point during their program of study (Birks et al., 2018; Budden et al., 2017; Mott, 2014; Üzar-Özçetin et al., 2020; Seibel, 2014). The personal harm resulting from bullying is far-reaching, with studies showing a range of psychological and physical impacts (Bartlett & Bartlett, 2011; Bowllan, 2015; Clarke et al., 2012; Minton et al., 2018).

Conceptual clarification of bullying is needed to further understand this phenomenon and develop sustainable interventions to reduce and eliminate bullying in nursing. In this concept analysis, we used Rodgers's (2000) evolutionary approach to clarify the concept of bullying by considering its application in different literature and its changes over time. We used extracted patterns and themes to determine the attributes, antecedents, and consequences of the concept of bullying. We offer a synthesized definition of bullying that reflects current understandings of the concept and provides the basis for continued development and implementation of effective interventions.

Background

Bullying is a persistent phenomenon in nursing. Lack of repercussions for bullying behaviour, low support for targeted individuals, and unclear processes for reporting contribute to this persistence (Nelson, 2012). Decades of corporatization and enduring hierarchical power structures within health systems have contributed to clinical environments in which bullying is perpetuated (Daly et al., 2020). The idiom "nurses eat their young," taken from adaptive theories of evolution, has become a common phrase for students and new graduates (Meissner, 1986). When Meissner wrote about nurses eating their young, bullying behaviour was situated as a metaphor for perpetrators' instinctual survival response. The widespread use and continued acceptance of this idiom reinforces the normalization of bullying in the nursing profession. Anusiewicz et al. (2020) found that bullying in the nursing workplace was viewed as part of the nursing environment and a negative influence on the ability of nurses to provide patient care. Wilson (2016) noted that bullying and incivility were both features of socialization in the nursing profession, creating the notion that bullying behaviour is part of the nursing culture.

The uncertainty of whether an event is considered bullying reflects the lack of a definition of bullying behaviour. For example, nursing students reported being assigned unmanageable workloads, being ignored by staff nurses, being ridiculed, or having information withheld that was required to provide care (Smith et al., 2016). Research shows that faculty may also unknowingly have contributed to the perception of bullying as students may perceive teaching activities, such as providing constructive feedback, as bullying (Seibel & Fehr, 2018).

Behaviours that constitute bullying continue to evolve over time and in context and inform the contemporary understanding of bullying (Hartin et al., 2020). The concept of bullying is becoming increasingly ambiguous due to the difficulty in identifying the numerous behaviours that demonstrate bullying. These behaviours include yelling, gossiping, criticizing, uttering racial slurs (Petrovic & Scholl, 2018), ignoring, withholding information, and committing physical violence (Anderson & Morgan, 2017; McKenna & Boyle, 2016; Vogel, 2018). In addition, the necessary reporting structures for those witnessing and experiencing bullying are not readily available to safely and effectively call out the behaviour (Edmonson & Zelonka, 2019; Shapiro et al., 2018). Across disciplines, obstacles to students' ability to feel safe to report contribute to underreporting and the perpetuation of bullying behaviour (Colenbrander et al., 2020; Daly et al., 2020; Whiteside et al., 2014). Stubbs and Soundy (2013) found that students typically chose to remain silent about bullying situations because they believed that creating awareness of this behaviour could negatively affect their clinical grades.

Definitions of bullying outlined in the literature emphasize criteria such as intentional, repetitive behaviour resulting in harm for the target. One example of a current definition of bullying and harassment is provided by WorkSafeBC (2013), the provincial agency responsible for occupational safety and insurance compensation in British Columbia:

[Bullying and harassment] (a) includes any inappropriate conduct or comment by a person towards a worker that the person knew or reasonably ought to have known would cause that worker to be humiliated or intimidated, and (b) excludes any reasonable action taken by an employer or supervisor relating to the management and direction of workers or the place of employment. (Policy Item P2-21-2, Section 3)

Similar definitions are integrated in other regulatory and legislative documents, such as the Alberta Occupational Health and Safety Act (2023). Broadening the definition of bullying to include students in the workplace requires the alignment of both workplace and educational institution definitions and policies to avoid role confusion.

Overall, extensive literature is available that explores the historical origins of bullying in nursing, its prevalence and incidence, its varied definitions, and its impacts (Birks et al., 2018; Bowllan, 2015; Daly et al., 2020; Edmonson & Zelonka, 2019; Hartin et al., 2020; Smith et al., 2016; Stanley, 2019). The diverse ways in which bullying manifests and the lack of reporting and repercussions emphasize the need for a clear definition of the concept of bullying.

Methods

Concept analysis methods are widely used in nursing to articulate attributes, determine the appropriate application of the concept, and contribute to knowledge development. We employed Rodgers's (2000) evolutionary method for this analysis as it considers concepts to be constantly evolving over time and within particular contexts. Rodgers's six-step method provides a rigorous process to achieve clarity and understanding of concepts (Rodgers, 1989).

Identifying the Concept and Associated Expressions

The concept in this analysis was bullying in the practice environment as experienced by nursing students. Identifying surrogate terms is a key component of the first step of the analytic process. Surrogate terms are related to the concept and possess commonalities but may have different characteristics (Rodgers, 2000). A concept can be expressed using other words that represent the same idea; for instance, bullying and incivility are used comparatively throughout the

literature and, thus, can create confusion during concept selection. Surrogate terms used to identify bullying behaviours are recognized through the dissection of their meaning and include words such as workplace violence, horizontal or lateral violence, incivility, workplace incivility, harassment, mobbing, and interpersonal conflict (Hartin et al., 2020). Surrogate terms for bullying in the nursing clinical environment embody intricate interactions influenced by work-related stress, culture, power dynamics, hierarchies (Capper et al., 2020), and the management of bullying behaviour, leading to the evolution and contextual changes over time of the terms representing bullying (Hartin et al., 2020).

Selecting a Setting

Practice education remains a cornerstone of prelicensure nursing curricula and provides learning experiences essential for developing and integrating the knowledge, skills, and competencies required for entry to professional practice. This concept analysis included literature focused on settings in which nursing students completed practicums.

Collecting Information: The Search Process

We conducted a literature search over a 30-year time span (1991-2021). Key words and phrases, including bullying, incivility, clinical, nursing students, and eat their young, were used to search four databases: the Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Education Resources Information Center (ERIC), Academic Search Complete, and MEDLINE with Full Text. Inclusion criteria included: a) peer-reviewed articles reviewing the concept of bullying in the clinical environment; b) with the full text available; and c) published in English.

The initial search retrieved 1,371 articles. After removing duplicate sources and scanning titles and abstracts, 240 articles were included for full-text review. We conducted a second supplemental review to include articles from three additional selected health disciplines using a hand search approach. Medicine, physiotherapy, and midwifery were included in this analysis due to the similarly close contact between patients and students in these disciplines while learning in the clinical environment. Articles were searched using the same search concepts and inclusion criteria. Nine articles were identified for inclusion from reference list review. The final sample of 62 articles included 48 from nursing, seven from medicine, four from midwifery, and three from physiotherapy. Most of the relevant literature was published between 2010 and 2021.

Analyzing the Findings

The data analysis process began with reviewing each article for initial immersion, followed by organizing the articles based on discipline. We then analyzed the full-text data of the articles for any usage of the concept of bullying, including definitions, surrogate terms, attributes, antecedents, consequences, and exemplars (Rodgers, 2000).

We used a thematic approach to identify, analyze, and synthesize the data found in the articles (Braun & Clarke, 2021). Familiarization with the content was achieved through a process of immersion that involved reading the articles and recording highlights in an Excel database. Information drawn from the articles was organized into columns using the headings of "definitions," "surrogate terms," "attributes," "antecedents," and "consequences" and represented semantic meanings. Each column heading had a question to guide information gathering from the articles. For example, "antecedents" represented information relevant to the question "What has to be present for bullying to occur?" Initial themes were constructed from broader, shared meanings gathered from the literature. We then reviewed and compared the themes to the

information gathered from each article to ensure that the most common meanings were highlighted. Typically, one- or two-word concepts represented surrogate terms, antecedents, and attributes found in the literature that revealed logical themes. Throughout this process, we developed a definition and identified antecedents, attributes, and consequences.

Results

We derived a composite definition from the included articles. Five attributes, four antecedents, and three consequences were identified. Table 1 summarizes the identified attributes, antecedents, and consequences.

Synthesized Definition

The concept of bullying was defined in many ways, often illustrating attributes of the concept. We developed the following synthesized definition of bullying: Bullying is repeated negative behaviour towards a target by a perpetrator, displayed as verbal, physical, or psychological abuse in overt or covert fashion, is intentional, and involves an imbalance of power.

Attributes

Intentionality

Agreement emerged in the literature regarding the attribute of intentionality, specifically that the intent to bully was described as a deliberate goal of the perpetrator (Bowllan, 2015) and expressed as a negative interaction towards the target. Bullying behaviour was commonly portrayed as a purposeful act and considered a defining attribute. In contrast, how the target perceived bullying was infrequently mentioned (Daly et al., 2020; Taylor, 2016).

Bullying was often described as negative interactions that occurred repeatedly and intentionally (Anderson & Morgan, 2017; Anusiewicz et al., 2020). Some researchers purported that a single incident could have lasting and damaging effects on the target (Capper et al., 2021). In contrast, other researchers noted that bullying can be either intentional or unintentional and either repeated or a single incident (Daly et al., 2020).

The attribute of intentionality further contributes to the varying nature of bullying because the intent of bullying is perceived by the target (O'Flynn-Magee et al., 2020). For instance, students might mistake their faculty members' lack of teaching skills for intentional bullying when faculty members appear defensive if questioned about their methods (Capper et al., 2020).

Furthermore, the covert nature of intentionality was impossible to witness, for example, when refusing to help colleagues was not stated explicitly as intentional (Taylor, 2016).

Temporality

The concept of bullying held a temporal attribute in that attributes were illuminated over time as the perception evolved. There was consensus in the literature that bullying was intentional, with most researchers identifying the concept as persistent and recurrent (Hartin et al., 2020; Seibel, 2014). The current use of the concept describes the modern view of how the individual perceives bullying compared to how it has been described in earlier literature (Hartin et al., 2020).

Negative Interactions

Negative interactions were a central attribute of bullying (Edmonson & Zelonka, 2019; Hartin et al., 2020; Ren et al., 2015). There was consensus that the definition of bullying includes negative interactions that consist of verbal or physical harassment, humiliation, or exclusion (Budden et al., 2017; Smith et al., 2016) towards an individual by one or more individuals. The array of negative interactions included both overt and covert behaviour. Covert behaviour was described as not easily observable behaviour, such as "the silent treatment" or rumour spreading, while overt behaviour was described as the occurrence of physically or verbally abusive interactions (Budden et al., 2017; Smith et al., 2016). Additionally, students who experienced bullying perceived receiving bad grades as punishment (Bowllan, 2015; Budden et al., 2017).

Denied Opportunities

Similar to the negative interactions of students being alienated from activities, another attribute of bullying was denying students learning and socializing opportunities in the clinical environment (Birks et al., 2018; Budden et al., 2017; Smith et al., 2016). Alienation occurred when students felt unwelcome or unwanted, such as in the break room (Jack et al., 2017). The denial of learning opportunities was also perceived as bullying, such as when students were told they could not observe or participate in a procedure (Birks et al., 2018; Budden, 2017; Smith et al., 2016) or when a skill practice opportunity occurred while the student was off the unit on a break (Jack et al., 2017). The purpose of clinical experiences is for students to gain practice in a live patient environment. The denial of learning opportunities interfered with students' abilities to meet learning objectives and contributed to consequences often associated with bullying.

Inappropriate Workload

In contrast to denied opportunities was the attribute of inappropriate workload situations. Findings across disciplines revealed that assigning students difficult tasks created a situation in which students were set up to fail (Daly et al., 2020; Seibel, 2014). For example, students were asked to complete unnecessary tasks, such as taking vital signs of a confirmed deceased patient (Alavi & Cattoni, 1995, as cited in Daly et al., 2020) or being directed to complete a task outside of their scope (Edmonson & Zelonka, 2019). Additionally, unrealistic work allocation included asking students to complete novel tasks in a defined period while being excessively monitored (Seibel, 2014; Üzar-Özçetin et al., 2020). Inappropriate workload was also identified when students were left alone to address their learning needs (Bowllan, 2015; Thomson et al., 2017).

While the literature provides many examples of attributes of bullying, the attributes of denied opportunities and inappropriate workloads stood out as contemporary representations of how bullying is operationalized in nursing. These overt behaviours represent how perpetrators can evade the intentionality of bullying because it is very difficult to witness in these instances and

there is no explicit statement of intentionality. The lack of an explicit intention coupled with other bullying attributes of the behaviour does not change the impact experienced by the target (Anusiewicz et al., 2020).

Antecedents

Power Imbalance

Understanding bullying requires consideration of the notion of power. Within explanations of bullying behaviour, power imbalance was a key element, wherein power was interpreted as a force to exercise control over another (Hutchinson et al., 2006). Most of the literature identified the presence of power imbalance as an antecedent to bullying.

Commonly, a power imbalance existed between the nursing student, who held little or no power, and the staff nurse or faculty member, who held power (Capper et al., 2020; Seibel & Fehr, 2018). Slemon et al. (2018) studied nursing students' experiences of power and resistance during their clinical experience. Applying Foucault's concept of micropower to inform their analysis, they found that students observed nurses upholding power over patients and nursing students, and observed nursing practice that perpetuated unequal power. For example, when one nurse threatened a patient with an inappropriate punishment, the nursing student felt implicated in the nurses' use of power but knew there were no supports for her to draw on to stop the behaviour.

Power imbalances were described as excessive criticism (Capper et al., 2020), a lack of acknowledgement of accomplishments, or the receipt of assignments as punishment (Seibel & Fehr, 2018). Power is embedded in routines in the clinical environment. Hutchinson et al. (2006) found that bullying behaviour entrenched in routine processes diminished nurses' self-confidence and wore down their capacity to resist the behaviour.

Oppressive group behaviour was associated with bullying (Roberts et al., 2009). Drawing on the work of Paulo Freire, some researchers asserted that nurses were an oppressed group (Hutchinson et al., 2006), where the dominant groups' norms and values were viewed as correct and adopted by the oppressed group, who believed they would gain power and control. For example, nursing faculty members demonstrated oppressed group behaviour as they socialized nursing students to have no voice, perpetuating the cycle of bullying in nursing (Treinen et al., 2022).

Environmental Stressors

Diverse stressors identified in the clinical environment were recognized to be facilitators to bullying. These stressors included a lack of resources, such as sufficient staff or proper tools to do the job (Hartin et al., 2020). The lack of staff resources led nursing students to take on an inappropriate workload beyond their scope. More intangible stressors included entrenched behaviour and social influences, where nursing students perceived bullying as a rite of passage and expected behaviour (Birks et al., 2018). In their 2010 study, Lindy and Schaefer examined nurse managers' insights and perspectives on bullying experienced by nursing staff. They found that stress associated with increased workloads, such as high patient load or critical incidents, contributed to nurses' directing bullying behaviour towards colleagues.

For nursing students, managing an academic workload and coping with clinical pressures were frequent challenges in the practice environment (Thomas et al., 2012). Ongoing stressors included pressures associated with clinical competence, challenging work relationships with clinical and academic staff, and exposure to bullying (Timmins et al., 2011; Southwick et al.,

2014). Rowe and Sherlock (2005) examined the relationship between stress and verbal abuse among nurses and found that "burned-out nurses eat their young" (p. 242). The lack of constructive methods and resources available for nurses to deal with stress in their work lives contributed to abusive behaviour (Rowe & Sherlock, 2005).

Organizational Dysfunction

When bullying behaviour is informally adopted into an organization's culture and standards, there is a higher likelihood of occurrence (Trépanier et al., 2016). Hutchinson et al. (2006) found that bullying behaviour was embedded in informal organizational networks or relationships, contributing to the perpetuation of bullying behaviour. For instance, when nurses who engaged in bullying achieved promotions and job rewards, bullying behaviour was seen as acceptable or even part of the job (Hutchinson et al., 2006). Similarly, Pope (2019) identified bullying as an element in organizational silence tactics fuelling the perpetuation and acceptance of the behaviour.

Entrenched Behaviour

Bullying was identified by Johnson (2019) as entrenched behaviour when participants pointed out that the pervasive nature of bullying in nursing stemmed from nursing school- unconsciously adopting behaviour that mirrored the stern and arbitrary assessments they received from faculty members while in clinical practice. Students exposed to bullying during their clinical rotation experience first-hand the entrenched behaviour and may unconsciously adopt bullying behaviour when they move into leadership roles (Johnson, 2019). Some researchers asserted that training on bias recognition and feedback delivery for those in leadership roles may mitigate risks that lead to the perpetuation of bullying (Johnson, 2019; Seibel, 2014) and achieve the overall goal of enhancing student nurse learning in the clinical environment (Raymond & Dahlke, 2022).

Consequences

Individuals/Students

Bullying has individual impacts on nurses and nursing students, as well as organizational impacts on the workplace and nursing program (Daly et al., 2020; Hartin et al., 2019). These impacts manifested as an increased rate of attrition in nursing education programs (Daly et al., 2020). In the clinical environment, patient care was negatively affected (Birks et al., 2017; Clarke et al., 2012).

Bullying had multidimensional consequences for the individual who experienced negative interactions, including psychological and emotional trauma symptoms such as anxiety, fear, burnout, and difficulty concentrating (Samsudin et al., 2020; Tee et al., 2016) and severe medical conditions such as gastric ulcers and cardiovascular disturbances (Karatas et al., 2017). A study by Birks et al. (2018) found that students' bullying experience contributed to diminished learning and studying motivation.

Psychological distress and depression were repeatedly identified as significant adverse impacts (Bowllan, 2015; Hartin et al., 2019; Seibel et al., 2018; Smith et al., 2016). Continual, intense, or overwhelming stress, such as the stress of bullying, had harmful psychological effects (Timmins et al., 2011). Stress from the trauma of bullying destabilized students as it created difficulty in thinking clearly to manage simple tasks to deliver safe patient care (Karatas et al., 2017) and led to more errors in patient care (Üzar-Özçetin et al., 2020). Psychological impacts associated with bullying manifested as increased anxiety, depression, sleep disorders, erosion of

competence, and distress (Bowllan, 2015; Hartin et al., 2020; Karatas et al., 2017), contributing to burnout and withdrawal from the nursing program (Capper et al., 2020; Cooper et al., 2020). The physical and psychological consequences of bullying were numerous (Bartlett & Bartlett, 2011; Bowllan, 2015; Clarke et al., 2012; Minton et al., 2018) and contributed to negative impacts on patient care (Daly et al., 2020).

For nurses and nursing students, higher rates of depression, anxiety, and increased physical illness (Hartin et al., 2020) were connected to bullying. In addition, research on suicide rates and ideation in nurses suggested a relationship with bullying in the profession (Edmonson & Zelonka, 2019).

Profession

Consequences for the nursing profession included erosion of competence, increased absences, and students leaving the nursing program (Mott, 2014). These consequences negatively affected the profession when attrition rates increased due to bullying and the individual developed a negative perception of nursing or health care (Hartin et al., 2020). McKenna & Boyle (2016) found that bullying in midwifery led students to pursue employment outside of the clinical environment or leave midwifery completely. Capper et al. (2021) conducted a study examining midwifery students' perception of bullying and, through secondary data, found that mothers, babies, and other family members were affected by witnessing students being bullied as it damaged the patient's confidence in the students' ability to provide care and fractured relationships between care provider and patient.

Workplace

The consequences of bullying in the workplace were identified as issues of financial costs associated with the turnover of employees, such as the lack of resources dedicated to the orientation of new employees (Hartin et al., 2019). The unprofessionalism communicated to patients who witnessed bullying events and the instability that staff turnover portrayed to remaining staff and the public were negative impacts of bullying (Bowllan, 2015; Capper, 2020; Hartin et al., 2019; Jack et al., 2018). Research examining medical students' experience of bullying showed that increased absences and turnover of employees significantly affected health care environments by decreasing the quality of patient care and safety (Vogel, 2016).

Examining an Exemplar

Using an everyday example to illustrate attributes assists in describing and underlining the concept. Presenting a model case of a concept enriches the clarification of the analysis (Rodgers, 1989). The exemplar case below was derived from the included research studies to illustrate attributes, antecedents, and consequences associated with bullying experienced by a nursing student in the clinical environment.

Exemplar Case

A second-year nursing student, Anaya was excited to begin her clinical rotation on a medical unit. She was interested in pulmonary conditions because she had lived with asthma her whole life and felt she had a unique view of the patient's perspective. The instructor was confident in Anaya's abilities as a student nurse and looked forward to working with her. On the first day of clinical practice on the unit, Anaya was assigned to work with one patient. Jackie, the nurse assigned to the patient, refused to acknowledge Anaya and consistently responded to her questions with, "Were you in class when they taught that at school?" or "It's common sense for you to know

that!" In addition, Anaya was encouraged to leave the unit early or sit in the break room to research patient conditions and missed learning experiences. Anaya spoke to her instructor about the situation. Her instructor responded, "That is just how Jackie is. I will talk to her." For the remainder of her 4-week rotation on the unit, Jackie blatantly ignored Anaya except for one situation in which Jackie asked Anaya in front of others in the lunchroom if she was going to be able to "get all her charting done this time on the shift." Anaya felt embarrassed and worried that she had missed charting from a previous shift. Anaya began to second-guess herself and her abilities, and her confidence eroded. Anaya wondered if nursing was the career she wanted to pursue.

As described in the exemplar, Anaya experienced attributes of bullying. The negative verbal and physical interactions she experienced were intentional, and temporality was present as the perpetrator was persistent. Anaya was denied learning opportunities when directed to remove herself from the immediate patient areas to complete research. The existing antecedents in this exemplar were the power imbalance between the student and the nurse and organizational dysfunction, as Anaya received no support when the negative interactions persisted. The consequences of this experience included a negative psychological impact on Anaya, erosion in her confidence as she second-guessed herself and her abilities, and a growing desire to leave the profession.

Discussion

This evolutionary concept analysis has provided further clarity on and understanding of the context and concept of bullying. Moreover, this analysis has drawn out the antecedents that contribute to the phenomenon of bullying and the consequences that ensue. The findings in this concept analysis suggest that the way in which bullying behaviour is identified and perceived by a target contributes further to the need for an expanded definition of the concept. The experiences of student nurses who are bullied influences how the concept is understood and ultimately defined. One of the tensions associated with defining bullying lies in its subjective nature. Perception plays a role in how an individual assesses bullying, which can result in a disparity between what was intended and the consequences. Defining a concept with a wide reach to include professions, workplaces, and professional learning environments requires acknowledging attributes that are not easily recognizable or explicit in intent, such as those nursing students experience (namely, workload challenges or denied opportunities).

This analysis corroborates the absence of a universal definition of bullying in the health professional education literature. The complexity of the concept and its relation to the context in which bullying occurs creates difficulty in understanding what it is, identifying the behaviour, and, ultimately, naming it. With the myriad of surrogate terms that have developed over time, defining precisely what bullying is has become muddied. The concept of bullying appeared to be more easily described rather than specifically defined.

Even with the absence of a clear definition, the awareness of the persistence of bullying in the practice environment continues to grow. This may be due to the increase in and overlap of constructs associated with bullying, coupled with the effort to fine-tune or be more explicit about what constitutes bullying (Daly et al., 2020). For example, as nursing students increasingly engage in online learning and virtual nursing practice, there will be a need to draw attention to cyberbullying (Kim & Choi, 2021).

The literature showed that many instruments are used to measure the incidence and prevalence of bullying (Anusiewicz et al., 2019). The use of a standardized instrument, such as the

Negative Acts Questionnaire-Revised (NAQ-R), could contribute to the development of a consistent definition. Specifically, the covert characteristics of bullying associated with the targets' objective experience could be captured more readily.

The entrenched behaviour of bullying has been linked to unacknowledged needs that surface in institutions (Johnson, 2019). Students who are exposed to bullying during their clinical rotation experience first-hand the entrenched behaviour and may unconsciously adopt bullying behaviour when they move into roles of leadership (Johnson, 2019). While not examined in this analysis, education for those in leadership roles, such as faculty members or clinical educators, on such issues as bias recognition and feedback delivery may mitigate risks that lead to the perpetuation of bullying (Johnson, 2019; Seibel, 2014). Moreover, it is critical to support nurses' moral courage to question and address ethical challenges such as discrimination and racism in health care (LaSala & Bjarnason, 2010; Raymond & Dahlke, 2022). Allan et al. (2009) examined bullying aggravated by racism, which they termed racist bullying, in the health care environment. In this context, a nurse may be excluded and their status undermined because they are different from others. For example, employing different cultural expressions in nursing care was viewed as delivering inadequate care.

Implications for Nursing Education and Research

The absence of a universal definition of bullying in the clinical environment supports the need for further development of the concept. Different health care professions refer to bullying behaviour using similar terminology and a range of descriptors involving verbal, physical, or psychological abuse. Adopting a unified definition minimizes the risk of failing to realize the true scope of the phenomenon. A shared interdisciplinary definition of bullying would enable comparison across health professions to develop comparable research results and contribute to developing interventions and programs to prevent and eliminate bullying (Gillespie et al., 2018; Petrovic & Scholl, 2018). Indeed, naming the phenomenon of bullying is the first step towards finding a resolution (Daly et al., 2020), because how it is presented in the nursing discourse has implications for both practice and education.

Rodgers et al. (2018), in their review of the state of the science of concept analyses, contend that there is a pressing need to move conceptual work beyond analysis to include correlation to problem resolution in the discipline, especially for concepts that have been repeatedly analyzed. Bullying in the clinical environment could be framed as a wicked problem, one that has endured despite repeated efforts at conceptual analysis and intervention development. The current health human workforce crisis creates an even stronger argument to address sustainable strategies for resolution.

Using interview research methods to enhance nursing knowledge on the appropriate interventions for bullying involving students is necessary in this area. Studies that illuminate the influence of intersectional norms on how bullying is perceived could expand knowledge in this area. The nursing profession and students constitute a population in health care that faces power imbalances related to gender, race, and ethnicity. Addressing these multiple intersecting forms of discrimination requires work towards reform (Daly et al., 2020; Hartin et al., 2020; Mott, 2014). Research focused on discovering factors contributing to individual perceptions of bullying is also needed. For example, understanding how students differentiate between constructive criticism and bullying or between conflict resolution and bullying could be examined.

Limitations

Several limitations exist within this analysis. Since the search included only English- language articles, some relevant literature may not have been included. The search terms and databases may not have captured all relevant sources. Including additional disciplines, such as engineering or education, may have created greater complexity for this analysis, so the number of disciplines was limited to four within health services.

Conclusion

This evolutionary concept analysis contributes to dialogue on the need for continued clarity and further research on the phenomenon of bullying in the practice environment through reflecting the changes and adaptations that continue in the nursing profession. Ongoing research of the concept of bullying will address the aim of developing and maintaining a concept that is both relevant and useful to the nursing discipline. With increased attention to clarifying the antecedents and attributes of bullying, creating interventions to reduce and eliminate bullying can be made possible.

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