synthesis in research about bullying

A Systematic Research Synthesis on Cyberbullying Interventions in the United States

Affiliation.

• 1 Department of Family and Child Sciences, Florida State University , Tallahassee, Florida.
• PMID: 30334647
• DOI: 10.1089/cyber.2018.0307

In a society where it is becoming more common for perpetrators to choose electronic forms of communication (cell phones, social media, etc.) to bully others, it is crucial that we understand how our country is working to intervene in this cyberbullying epidemic. Therefore, this systematic research synthesis sought to examine all intervention efforts addressing cyberbullying that have been implemented within the United States. A systematic search using variations of cyberbullying intervention program search terms was narrowed down to a final sample size of 11 articles fitting the inclusion and exclusion criteria. Results suggested that programs addressing cyberbullying have only been implemented in schools or online, and most have not been evaluated for their effect on actual cyberbullying behaviors, but rather on attitudes and intentions about cyberbullying. Despite the significant concern about cyberbullying and its potential problematic outcomes, there seems to be a glaring lack of effective evidence-based programs that have been implemented in the United States.

Keywords: bullying; cyber abuse; cyber safety; cyberbullying; cyberethics; intervention.

Publication types

• Systematic Review
• Crime Victims / psychology*
• Cyberbullying / prevention & control*
• Cyberbullying / psychology
• Social Media*
• United States

Preventing Bullying Through Science, Policy, and Practice (2016)

Chapter: 1 introduction, 1 introduction.

Bullying, long tolerated by many as a rite of passage into adulthood, is now recognized as a major and preventable public health problem, one that can have long-lasting consequences ( McDougall and Vaillancourt, 2015 ; Wolke and Lereya, 2015 ). Those consequences—for those who are bullied, for the perpetrators of bullying, and for witnesses who are present during a bullying event—include poor school performance, anxiety, depression, and future delinquent and aggressive behavior. Federal, state, and local governments have responded by adopting laws and implementing programs to prevent bullying and deal with its consequences. However, many of these responses have been undertaken with little attention to what is known about bullying and its effects. Even the definition of bullying varies among both researchers and lawmakers, though it generally includes physical and verbal behavior, behavior leading to social isolation, and behavior that uses digital communications technology (cyberbullying). This report adopts the term “bullying behavior,” which is frequently used in the research field, to cover all of these behaviors.

Bullying behavior is evident as early as preschool, although it peaks during the middle school years ( Currie et al., 2012 ; Vaillancourt et al., 2010 ). It can occur in diverse social settings, including classrooms, school gyms and cafeterias, on school buses, and online. Bullying behavior affects not only the children and youth who are bullied, who bully, and who are both bullied and bully others but also bystanders to bullying incidents. Given the myriad situations in which bullying can occur and the many people who may be involved, identifying effective prevention programs and policies is challenging, and it is unlikely that any one approach will be ap-

propriate in all situations. Commonly used bullying prevention approaches include policies regarding acceptable behavior in schools and behavioral interventions to promote positive cultural norms.

STUDY CHARGE

Recognizing that bullying behavior is a major public health problem that demands the concerted and coordinated time and attention of parents, educators and school administrators, health care providers, policy makers, families, and others concerned with the care of children, a group of federal agencies and private foundations asked the National Academies of Sciences, Engineering, and Medicine to undertake a study of what is known and what needs to be known to further the field of preventing bullying behavior. The Committee on the Biological and Psychosocial Effects of Peer Victimization:

Lessons for Bullying Prevention was created to carry out this task under the Academies’ Board on Children, Youth, and Families and the Committee on Law and Justice. The study received financial support from the Centers for Disease Control and Prevention (CDC), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Health Resources and Services Administration, the Highmark Foundation, the National Institute of Justice, the Robert Wood Johnson Foundation, Semi J. and Ruth W. Begun Foundation, and the Substance Abuse and Mental Health Services Administration. The full statement of task for the committee is presented in Box 1-1 .

Although the committee acknowledges the importance of this topic as it pertains to all children in the United States and in U.S. territories, this report focuses on the 50 states and the District of Columbia. Also, while the committee acknowledges that bullying behavior occurs in the school

environment for youth in foster care, in juvenile justice facilities, and in other residential treatment facilities, this report does not address bullying behavior in those environments because it is beyond the study charge.

CONTEXT FOR THE STUDY

This section of the report highlights relevant work in the field and, later in the chapter under “The Committee’s Approach,” presents the conceptual framework and corresponding definitions of terms that the committee has adopted.

Historical Context

Bullying behavior was first characterized in the scientific literature as part of the childhood experience more than 100 years ago in “Teasing and Bullying,” published in the Pedagogical Seminary ( Burk, 1897 ). The author described bullying behavior, attempted to delineate causes and cures for the tormenting of others, and called for additional research ( Koo, 2007 ). Nearly a century later, Dan Olweus, a Swedish research professor of psychology in Norway, conducted an intensive study on bullying ( Olweus, 1978 ). The efforts of Olweus brought awareness to the issue and motivated other professionals to conduct their own research, thereby expanding and contributing to knowledge of bullying behavior. Since Olweus’s early work, research on bullying has steadily increased (see Farrington and Ttofi, 2009 ; Hymel and Swearer, 2015 ).

Over the past few decades, venues where bullying behavior occurs have expanded with the advent of the Internet, chat rooms, instant messaging, social media, and other forms of digital electronic communication. These modes of communication have provided a new communal avenue for bullying. While the media reports linking bullying to suicide suggest a causal relationship, the available research suggests that there are often multiple factors that contribute to a youth’s suicide-related ideology and behavior. Several studies, however, have demonstrated an association between bullying involvement and suicide-related ideology and behavior (see, e.g., Holt et al., 2015 ; Kim and Leventhal, 2008 ; Sourander, 2010 ; van Geel et al., 2014 ).

In 2013, the Health Resources and Services Administration of the U.S. Department of Health and Human Services requested that the Institute of Medicine 1 and the National Research Council convene an ad hoc planning committee to plan and conduct a 2-day public workshop to highlight relevant information and knowledge that could inform a multidisciplinary

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1 Prior to 2015, the National Academy of Medicine was known as the Institute of Medicine.

road map on next steps for the field of bullying prevention. Content areas that were explored during the April 2014 workshop included the identification of conceptual models and interventions that have proven effective in decreasing bullying and the antecedents to bullying while increasing protective factors that mitigate the negative health impact of bullying. The discussions highlighted the need for a better understanding of the effectiveness of program interventions in realistic settings; the importance of understanding what works for whom and under what circumstances, as well as the influence of different mediators (i.e., what accounts for associations between variables) and moderators (i.e., what affects the direction or strength of associations between variables) in bullying prevention efforts; and the need for coordination among agencies to prevent and respond to bullying. The workshop summary ( Institute of Medicine and National Research Council, 2014c ) informs this committee’s work.

Federal Efforts to Address Bullying and Related Topics

Currently, there is no comprehensive federal statute that explicitly prohibits bullying among children and adolescents, including cyberbullying. However, in the wake of the growing concerns surrounding the implications of bullying, several federal initiatives do address bullying among children and adolescents, and although some of them do not primarily focus on bullying, they permit some funds to be used for bullying prevention purposes.

The earliest federal initiative was in 1999, when three agencies collaborated to establish the Safe Schools/Healthy Students initiative in response to a series of deadly school shootings in the late 1990s. The program is administered by the U.S. Departments of Education, Health and Human Services, and Justice to prevent youth violence and promote the healthy development of youth. It is jointly funded by the Department of Education and by the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration. The program has provided grantees with both the opportunity to benefit from collaboration and the tools to sustain it through deliberate planning, more cost-effective service delivery, and a broader funding base ( Substance Abuse and Mental Health Services Administration, 2015 ).

The next major effort was in 2010, when the Department of Education awarded $38.8 million in grants under the Safe and Supportive Schools (S3) Program to 11 states to support statewide measurement of conditions for learning and targeted programmatic interventions to improve conditions for learning, in order to help schools improve safety and reduce substance use. The S3 Program was administered by the Safe and Supportive Schools Group, which also administered the Safe and Drug-Free Schools and Communities Act State and Local Grants Program, authorized by the

1994 Elementary and Secondary Education Act. 2 It was one of several programs related to developing and maintaining safe, disciplined, and drug-free schools. In addition to the S3 grants program, the group administered a number of interagency agreements with a focus on (but not limited to) bullying, school recovery research, data collection, and drug and violence prevention activities ( U.S. Department of Education, 2015 ).

A collaborative effort among the U.S. Departments of Agriculture, Defense, Education, Health and Human Services, Interior, and Justice; the Federal Trade Commission; and the White House Initiative on Asian Americans and Pacific Islanders created the Federal Partners in Bullying Prevention (FPBP) Steering Committee. Led by the U.S. Department of Education, the FPBP works to coordinate policy, research, and communications on bullying topics. The FPBP Website provides extensive resources on bullying behavior, including information on what bullying is, its risk factors, its warning signs, and its effects. 3 The FPBP Steering Committee also plans to provide details on how to get help for those who have been bullied. It also was involved in creating the “Be More than a Bystander” Public Service Announcement campaign with the Ad Council to engage students in bullying prevention. To improve school climate and reduce rates of bullying nationwide, FPBP has sponsored four bullying prevention summits attended by education practitioners, policy makers, researchers, and federal officials.

In 2014, the National Institute of Justice—the scientific research arm of the U.S. Department of Justice—launched the Comprehensive School Safety Initiative with a congressional appropriation of $75 million. The funds are to be used for rigorous research to produce practical knowledge that can improve the safety of schools and students, including bullying prevention. The initiative is carried out through partnerships among researchers, educators, and other stakeholders, including law enforcement, behavioral and mental health professionals, courts, and other justice system professionals ( National Institute of Justice, 2015 ).

In 2015, the Every Student Succeeds Act was signed by President Obama, reauthorizing the 50-year-old Elementary and Secondary Education Act, which is committed to providing equal opportunities for all students. Although bullying is neither defined nor prohibited in this act, it is explicitly mentioned in regard to applicability of safe school funding, which it had not been in previous iterations of the Elementary and Secondary Education Act.

The above are examples of federal initiatives aimed at promoting the

2 The Safe and Drug-Free Schools and Communities Act was included as Title IV, Part A, of the 1994 Elementary and Secondary Education Act. See http://www.ojjdp.gov/pubs/gun_violence/sect08-i.html [October 2015].

3 For details, see http://www.stopbullying.gov/ [October 2015].

healthy development of youth, improving the safety of schools and students, and reducing rates of bullying behavior. There are several other federal initiatives that address student bullying directly or allow funds to be used for bullying prevention activities.

Definitional Context

The terms “bullying,” “harassment,” and “peer victimization” have been used in the scientific literature to refer to behavior that is aggressive, is carried out repeatedly and over time, and occurs in an interpersonal relationship where a power imbalance exists ( Eisenberg and Aalsma, 2005 ). Although some of these terms have been used interchangeably in the literature, peer victimization is targeted aggressive behavior of one child against another that causes physical, emotional, social, or psychological harm. While conflict and bullying among siblings are important in their own right ( Tanrikulu and Campbell, 2015 ), this area falls outside of the scope of the committee’s charge. Sibling conflict and aggression falls under the broader concept of interpersonal aggression, which includes dating violence, sexual assault, and sibling violence, in addition to bullying as defined for this report. Olweus (1993) noted that bullying, unlike other forms of peer victimization where the children involved are equally matched, involves a power imbalance between the perpetrator and the target, where the target has difficulty defending him or herself and feels helpless against the aggressor. This power imbalance is typically considered a defining feature of bullying, which distinguishes this particular form of aggression from other forms, and is typically repeated in multiple bullying incidents involving the same individuals over time ( Olweus, 1993 ).

Bullying and violence are subcategories of aggressive behavior that overlap ( Olweus, 1996 ). There are situations in which violence is used in the context of bullying. However, not all forms of bullying (e.g., rumor spreading) involve violent behavior. The committee also acknowledges that perspective about intentions can matter and that in many situations, there may be at least two plausible perceptions involved in the bullying behavior.

A number of factors may influence one’s perception of the term “bullying” ( Smith and Monks, 2008 ). Children and adolescents’ understanding of the term “bullying” may be subject to cultural interpretations or translations of the term ( Hopkins et al., 2013 ). Studies have also shown that influences on children’s understanding of bullying include the child’s experiences as he or she matures and whether the child witnesses the bullying behavior of others ( Hellström et al., 2015 ; Monks and Smith, 2006 ; Smith and Monks, 2008 ).

In 2010, the FPBP Steering Committee convened its first summit, which brought together more than 150 nonprofit and corporate leaders,

researchers, practitioners, parents, and youths to identify challenges in bullying prevention. Discussions at the summit revealed inconsistencies in the definition of bullying behavior and the need to create a uniform definition of bullying. Subsequently, a review of the 2011 CDC publication of assessment tools used to measure bullying among youth ( Hamburger et al., 2011 ) revealed inconsistent definitions of bullying and diverse measurement strategies. Those inconsistencies and diverse measurements make it difficult to compare the prevalence of bullying across studies ( Vivolo et al., 2011 ) and complicate the task of distinguishing bullying from other types of aggression between youths. A uniform definition can support the consistent tracking of bullying behavior over time, facilitate the comparison of bullying prevalence rates and associated risk and protective factors across different data collection systems, and enable the collection of comparable information on the performance of bullying intervention and prevention programs across contexts ( Gladden et al., 2014 ). The CDC and U.S. Department of Education collaborated on the creation of the following uniform definition of bullying (quoted in Gladden et al., 2014, p. 7 ):

Bullying is any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. Bullying may inflict harm or distress on the targeted youth including physical, psychological, social, or educational harm.

This report noted that the definition includes school-age individuals ages 5-18 and explicitly excludes sibling violence and violence that occurs in the context of a dating or intimate relationship ( Gladden et al., 2014 ). This definition also highlighted that there are direct and indirect modes of bullying, as well as different types of bullying. Direct bullying involves “aggressive behavior(s) that occur in the presence of the targeted youth”; indirect bullying includes “aggressive behavior(s) that are not directly communicated to the targeted youth” ( Gladden et al., 2014, p. 7 ). The direct forms of violence (e.g., sibling violence, teen dating violence, intimate partner violence) can include aggression that is physical, sexual, or psychological, but the context and uniquely dynamic nature of the relationship between the target and the perpetrator in which these acts occur is different from that of peer bullying. Examples of direct bullying include pushing, hitting, verbal taunting, or direct written communication. A common form of indirect bullying is spreading rumors. Four different types of bullying are commonly identified—physical, verbal, relational, and damage to property. Some observational studies have shown that the different forms of bullying that youths commonly experience may overlap ( Bradshaw et al., 2015 ;

Godleski et al., 2015 ). The four types of bullying are defined as follows ( Gladden et al., 2014 ):

• Physical bullying involves the use of physical force (e.g., shoving, hitting, spitting, pushing, and tripping).
• Verbal bullying involves oral or written communication that causes harm (e.g., taunting, name calling, offensive notes or hand gestures, verbal threats).
• Relational bullying is behavior “designed to harm the reputation and relationships of the targeted youth (e.g., social isolation, rumor spreading, posting derogatory comments or pictures online).”
• Damage to property is “theft, alteration, or damaging of the target youth’s property by the perpetrator to cause harm.”

In recent years, a new form of aggression or bullying has emerged, labeled “cyberbullying,” in which the aggression occurs through modern technological devices, specifically mobile phones or the Internet ( Slonje and Smith, 2008 ). Cyberbullying may take the form of mean or nasty messages or comments, rumor spreading through posts or creation of groups, and exclusion by groups of peers online.

While the CDC definition identifies bullying that occurs using technology as electronic bullying and views that as a context or location where bullying occurs, one of the major challenges in the field is how to conceptualize and define cyberbullying ( Tokunaga, 2010 ). The extent to which the CDC definition can be applied to cyberbullying is unclear, particularly with respect to several key concepts within the CDC definition. First, whether determination of an interaction as “wanted” or “unwanted” or whether communication was intended to be harmful can be challenging to assess in the absence of important in-person socioemotional cues (e.g., vocal tone, facial expressions). Second, assessing “repetition” is challenging in that a single harmful act on the Internet has the potential to be shared or viewed multiple times ( Sticca and Perren, 2013 ). Third, cyberbullying can involve a less powerful peer using technological tools to bully a peer who is perceived to have more power. In this manner, technology may provide the tools that create a power imbalance, in contrast to traditional bullying, which typically involves an existing power imbalance.

A study that used focus groups with college students to discuss whether the CDC definition applied to cyberbullying found that students were wary of applying the definition due to their perception that cyberbullying often involves less emphasis on aggression, intention, and repetition than other forms of bullying ( Kota et al., 2014 ). Many researchers have responded to this lack of conceptual and definitional clarity by creating their own measures to assess cyberbullying. It is noteworthy that very few of these

definitions and measures include the components of traditional bullying—i.e., repetition, power imbalance, and intent ( Berne et al., 2013 ). A more recent study argues that the term “cyberbullying” should be reserved for incidents that involve key aspects of bullying such as repetition and differential power ( Ybarra et al., 2014 ).

Although the formulation of a uniform definition of bullying appears to be a step in the right direction for the field of bullying prevention, there are some limitations of the CDC definition. For example, some researchers find the focus on school-age youth as well as the repeated nature of bullying to be rather limiting; similarly the exclusion of bullying in the context of sibling relationships or dating relationships may preclude full appreciation of the range of aggressive behaviors that may co-occur with or constitute bullying behavior. As noted above, other researchers have raised concerns about whether cyberbullying should be considered a particular form or mode under the broader heading of bullying as suggested in the CDC definition, or whether a separate defintion is needed. Furthermore, the measurement of bullying prevalence using such a definiton of bullying is rather complex and does not lend itself well to large-scale survey research. The CDC definition was intended to inform public health surveillance efforts, rather than to serve as a definition for policy. However, increased alignment between bullying definitions used by policy makers and researchers would greatly advance the field. Much of the extant research on bullying has not applied a consistent definition or one that aligns with the CDC definition. As a result of these and other challenges to the CDC definition, thus far there has been inconsistent adoption of this particular definition by researchers, practitioners, or policy makers; however, as the definition was created in 2014, less than 2 years is not a sufficient amount of time to assess whether it has been successfully adopted or will be in the future.

THE COMMITTEE’S APPROACH

This report builds on the April 2014 workshop, summarized in Building Capacity to Reduce Bullying: Workshop Summary ( Institute of Medicine and National Research Council, 2014c ). The committee’s work was accomplished over an 18-month period that began in October 2014, after the workshop was held and the formal summary of it had been released. The study committee members represented expertise in communication technology, criminology, developmental and clinical psychology, education, mental health, neurobiological development, pediatrics, public health, school administration, school district policy, and state law and policy. (See Appendix E for biographical sketches of the committee members and staff.) The committee met three times in person and conducted other meetings by teleconferences and electronic communication.

Information Gathering

The committee conducted an extensive review of the literature pertaining to peer victimization and bullying. In some instances, the committee drew upon the broader literature on aggression and violence. The review began with an English-language literature search of online databases, including ERIC, Google Scholar, Lexis Law Reviews Database, Medline, PubMed, Scopus, PsycInfo, and Web of Science, and was expanded as literature and resources from other countries were identified by committee members and project staff as relevant. The committee drew upon the early childhood literature since there is substantial evidence indicating that bullying involvement happens as early as preschool (see Vlachou et al., 2011 ). The committee also drew on the literature on late adolescence and looked at related areas of research such as maltreatment for insights into this emerging field.

The committee used a variety of sources to supplement its review of the literature. The committee held two public information-gathering sessions, one with the study sponsors and the second with experts on the neurobiology of bullying; bullying as a group phenomenon and the role of bystanders; the role of media in bullying prevention; and the intersection of social science, the law, and bullying and peer victimization. See Appendix A for the agendas for these two sessions. To explore different facets of bullying and give perspectives from the field, a subgroup of the committee and study staff also conducted a site visit to a northeastern city, where they convened four stakeholder groups comprised, respectively, of local practitioners, school personnel, private foundation representatives, and young adults. The site visit provided the committee with an opportunity for place-based learning about bullying prevention programs and best practices. Each focus group was transcribed and summarized thematically in accordance with this report’s chapter considerations. Themes related to the chapters are displayed throughout the report in boxes titled “Perspectives from the Field”; these boxes reflect responses synthesized from all four focus groups. See Appendix B for the site visit’s agenda and for summaries of the focus groups.

The committee also benefited from earlier reports by the National Academies of Sciences, Engineering, and Medicine through its Division of Behavioral and Social Sciences and Education and the Institute of Medicine, most notably:

• Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research ( Institute of Medicine, 1994 )
• Community Programs to Promote Youth Development ( National Research Council and Institute of Medicine, 2002 )
• Deadly Lessons: Understanding Lethal School Violence ( National Research Council and Institute of Medicine, 2003 )
• Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities ( National Research Council and Institute of Medicine, 2009 )
• The Science of Adolescent Risk-Taking: Workshop Report ( Institute of Medicine and National Research Council, 2011 )
• Communications and Technology for Violence Prevention: Workshop Summary ( Institute of Medicine and National Research Council, 2012 )
• Building Capacity to Reduce Bullying: Workshop Summary ( Institute of Medicine and National Research Council, 2014c )
• The Evidence for Violence Prevention across the Lifespan and Around the World: Workshop Summary ( Institute of Medicine and National Research Council, 2014a )
• Strategies for Scaling Effective Family-Focused Preventive Interventions to Promote Children’s Cognitive, Affective, and Behavioral Health: Workshop Summary ( Institute of Medicine and National Research Council, 2014b )
• Investing in the Health and Well-Being of Young Adults ( Institute of Medicine and National Research Council, 2015 )

Although these past reports and workshop summaries address various forms of violence and victimization, this report is the first consensus study by the National Academies of Sciences, Engineering, and Medicine on the state of the science on the biological and psychosocial consequences of bullying and the risk and protective factors that either increase or decrease bullying behavior and its consequences.

Terminology

Given the variable use of the terms “bullying” and “peer victimization” in both the research-based and practice-based literature, the committee chose to use the current CDC definition quoted above ( Gladden et al., 2014, p. 7 ). While the committee determined that this was the best definition to use, it acknowledges that this definition is not necessarily the most user-friendly definition for students and has the potential to cause problems for students reporting bullying. Not only does this definition provide detail on the common elements of bullying behavior but it also was developed with input from a panel of researchers and practitioners. The committee also followed the CDC in focusing primarily on individuals between the ages of 5 and 18. The committee recognizes that children’s development occurs on a continuum, and so while it relied primarily on the CDC defini-

tion, its work and this report acknowledge the importance of addressing bullying in both early childhood and emerging adulthood. For purposes of this report, the committee used the terms “early childhood” to refer to ages 1-4, “middle childhood” for ages 5 to 10, “early adolescence” for ages 11-14, “middle adolescence” for ages 15-17, and “late adolescence” for ages 18-21. This terminology and the associated age ranges are consistent with the Bright Futures and American Academy of Pediatrics definition of the stages of development. 4

A given instance of bullying behavior involves at least two unequal roles: one or more individuals who perpetrate the behavior (the perpetrator in this instance) and at least one individual who is bullied (the target in this instance). To avoid labeling and potentially further stigmatizing individuals with the terms “bully” and “victim,” which are sometimes viewed as traits of persons rather than role descriptions in a particular instance of behavior, the committee decided to use “individual who is bullied” to refer to the target of a bullying instance or pattern and “individual who bullies” to refer to the perpetrator of a bullying instance or pattern. Thus, “individual who is bullied and bullies others” can refer to one who is either perpetrating a bullying behavior or a target of bullying behavior, depending on the incident. This terminology is consistent with the approach used by the FPBP (see above). Also, bullying is a dynamic social interaction ( Espelage and Swearer, 2003 ) where individuals can play different roles in bullying interactions based on both individual and contextual factors.

The committee used “cyberbullying” to refer to bullying that takes place using technology or digital electronic means. “Digital electronic forms of contact” comprise a broad category that may include e-mail, blogs, social networking Websites, online games, chat rooms, forums, instant messaging, Skype, text messaging, and mobile phone pictures. The committee uses the term “traditional bullying” to refer to bullying behavior that is not cyberbullying (to aid in comparisons), recognizing that the term has been used at times in slightly different senses in the literature.

Where accurate reporting of study findings requires use of the above terms but with senses different from those specified here, the committee has noted the sense in which the source used the term. Similarly, accurate reporting has at times required use of terms such as “victimization” or “victim” that the committee has chosen to avoid in its own statements.

4 For details on these stages of adolescence, see https://brightfutures.aap.org/Bright%20Futures%20Documents/3-Promoting_Child_Development.pdf [October 2015].

ORGANIZATION OF THE REPORT

This report is organized into seven chapters. After this introductory chapter, Chapter 2 provides a broad overview of the scope of the problem.

Chapter 3 focuses on the conceptual frameworks for the study and the developmental trajectory of the child who is bullied, the child who bullies, and the child who is bullied and also bullies. It explores processes that can explain heterogeneity in bullying outcomes by focusing on contextual processes that moderate the effect of individual characteristics on bullying behavior.

Chapter 4 discusses the cyclical nature of bullying and the consequences of bullying behavior. It summarizes what is known about the psychosocial, physical health, neurobiological, academic-performance, and population-level consequences of bullying.

Chapter 5 provides an overview of the landscape in bullying prevention programming. This chapter describes in detail the context for preventive interventions and the specific actions that various stakeholders can take to achieve a coordinated response to bullying behavior. The chapter uses the Institute of Medicine’s multi-tiered framework ( National Research Council and Institute of Medicine, 2009 ) to present the different levels of approaches to preventing bullying behavior.

Chapter 6 reviews what is known about federal, state, and local laws and policies and their impact on bullying.

After a critical review of the relevant research and practice-based literatures, Chapter 7 discusses the committee conclusions and recommendations and provides a path forward for bullying prevention.

The report includes a number of appendixes. Appendix A includes meeting agendas of the committee’s public information-gathering meetings. Appendix B includes the agenda and summaries of the site visit. Appendix C includes summaries of bullying prevalence data from the national surveys discussed in Chapter 2 . Appendix D provides a list of selected federal resources on bullying for parents and teachers. Appendix E provides biographical sketches of the committee members and project staff.

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Bullying has long been tolerated as a rite of passage among children and adolescents. There is an implication that individuals who are bullied must have "asked for" this type of treatment, or deserved it. Sometimes, even the child who is bullied begins to internalize this idea. For many years, there has been a general acceptance and collective shrug when it comes to a child or adolescent with greater social capital or power pushing around a child perceived as subordinate. But bullying is not developmentally appropriate; it should not be considered a normal part of the typical social grouping that occurs throughout a child's life.

Although bullying behavior endures through generations, the milieu is changing. Historically, bulling has occurred at school, the physical setting in which most of childhood is centered and the primary source for peer group formation. In recent years, however, the physical setting is not the only place bullying is occurring. Technology allows for an entirely new type of digital electronic aggression, cyberbullying, which takes place through chat rooms, instant messaging, social media, and other forms of digital electronic communication.

Composition of peer groups, shifting demographics, changing societal norms, and modern technology are contextual factors that must be considered to understand and effectively react to bullying in the United States. Youth are embedded in multiple contexts and each of these contexts interacts with individual characteristics of youth in ways that either exacerbate or attenuate the association between these individual characteristics and bullying perpetration or victimization. Recognizing that bullying behavior is a major public health problem that demands the concerted and coordinated time and attention of parents, educators and school administrators, health care providers, policy makers, families, and others concerned with the care of children, this report evaluates the state of the science on biological and psychosocial consequences of peer victimization and the risk and protective factors that either increase or decrease peer victimization behavior and consequences.

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Understanding Bullying and Cyberbullying Through an Ecological Systems Framework: the Value of Qualitative Interviewing in a Mixed Methods Approach

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• Published: 10 May 2022
• Volume 4 , pages 220–229, ( 2022 )

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• Faye Mishna   ORCID: orcid.org/0000-0003-2538-826X 1 ,
• Arija Birze   ORCID: orcid.org/0000-0002-1988-8383 1 &
• Andrea Greenblatt   ORCID: orcid.org/0000-0002-6964-8193 1  

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Recognized as complex and relational, researchers endorse a systems/social-ecological framework in examining bullying and cyberbullying. According to this framework, bullying and cyberbullying are examined across the nested social contexts in which youth live—encompassing individual features; relationships including family, peers, and educators; and ecological conditions such as digital technology. Qualitative inquiry of bullying and cyberbullying provides a research methodology capable of bringing to the fore salient discourses such as dominant social norms and otherwise invisible nuances such as motivations and dilemmas, which might not be accessed through quantitative studies. Through use of a longitudinal and multi-perspective mixed methods study, the purpose of the current paper is to demonstrate the ways qualitative interviews contextualize quantitative findings and to present novel discussion of how qualitative interviews explain and enrich the quantitative findings. The following thematic areas emerged and are discussed: augmenting quantitative findings through qualitative interviews, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning.

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Introduction

Bullying and cyberbullying are increasingly recognized as complex phenomena that are considered relationship problems (Mishna et al., 2021a ; Pepler et al., 2010 ; Pepler, 2006 ; Spears et al., 2009 ). Appreciating that individuals are embedded in and both shape and are shaped by systems of relationships (Bronfenbrenner & Morris, 2007 ), researchers often endorse an ecological systems framework as paramount and comprehensive in examining bullying and cyberbullying phenomena Footnote 1 (Espelage, 2014 ; Newman et al., 2018 ; Thornberg, 2015 , 2018 ). According to this approach, individuals are embedded in and affected by interconnected and layered systems (Bronfenbrenner, 1979 , 1992 ). Children’s social-emotional development at school is consequently shaped not only by children’s relationships with their teachers and peers, but also by the interconnections between these relationships and the other layers of social ecology, all of which are considered to contribute to social behavioral patterns (O'Moore & Minton, 2005 ). Bullying and cyberbullying are examined across the nested social contexts in which youth live—encompassing individual features, peer relationships, school, family, and ecological climate such as societal norms and conditions as well as online technology (Cross et al., 2015 ; Johnson, 2010 ; Nesi et al., 2018 ). An ecological systems framework is considered an overarching approach that many theories complement and within which they fit (Bauman & Yoon, 2014 ).

The purpose of the current paper is to demonstrate the contributions of qualitative research in understanding the phenomena of bullying and cyberbullying and enriching and complementing the findings of quantitative methodology (Creswell & Creswell, 2018 ). Qualitative inquiry of bullying and cyberbullying provides a research methodology capable of bringing to the fore salient discourses and otherwise invisible nuances that might not be accessed through quantitative studies (Dennehy et al., 2020 ).

There are advantages to utilizing mixed methods in conducting research on various topics including cyberbullying (Creswell & Creswell, 2018 ). When engaging with complex phenomena such as cyberbullying, conceptual and methodological multiplicity offers distinct insights into research questions (McKim, 2017 ; Thornberg, 2011 ). When quantitative and qualitative research are used in combination, it is possible to obtain deeper as well as more comprehensive and accurate understanding of young people’s experiences, which increases the likelihood of informing strategies and responses that can effectively address the needs of children and adolescents (Crivello et al., 2009 ; Darbyshire et al., 2005 ; Fevre et al., 2010 ). The quality of findings may be strengthened when researchers use mixed methods because the data are triangulated (Crivello et al., 2009 ). Data generated through diverse research methods can both complement and contradict each other, which offers an opportunity to better understand the complexities of cyberbullying (Hemming, 2008 ). While quantitative approaches strive for objectivity by examining general concepts, such as cyberbullying, and parceling those concepts into specific, concrete, and understandable behaviors (Fevre et al., 2010 ), qualitative interviews give voice to children and youth, enabling them to express their thoughts and feelings about themselves, their relationships, environments, and the world in which they live (Mishna et al., 2004 ; Chaumba, 2013 ; Dennehy et al., 2020 ; Patton et al., 2017 ).

Through qualitative interviewing, we can step outside the bounds of adult thinking, gaining insights and discovering unanticipated differences in the perceptions of adults and children (Dennehy et al., 2020 ; O’Farrelly, 2021 ). To understand the phenomena of bullying and cyberbullying and inform effective prevention and intervention strategies, it is argued, children’s own views, “are at the heart of these efforts” (O’Farrelly, 2021 , p. 43). Thus, we present findings from the qualitative component of our Canadian federally funded mixed methods longitudinal study on cyberbullying from the perspectives of school-aged youth and their parents and teachers, entitled Motivations for Cyber Bullying: A Longitudinal and Multi-Perspective Inquiry Footnote 2 (Mishna et al., 2016 ).

Background Study Description

The objectives of our longitudinal mixed methods study were to (1) explore youth experiences and perspectives and their parents’ and teachers’ conceptions of cyberbullying; (2) explore how youth and adults view the underlying motivations for cyberbullying; (3) document the prevalence rates of cyberbullying victimization, witnessing, and perpetration; (4) identify risk and protective factors for cyberbullying involvement; and (5) explore social, mental health, and health consequences of cyberbullying among children and youth aged 9 to 18 (grades 4, 7, and 10) over 3 years.

In addressing the objectives, we use an explanatory sequential mixed methods design (Creswell & Creswell, 2018 ). The study comprised a 2-phase data collection approach in which we first collected the quantitative data and then used findings from the first phase to design and plan the qualitative data phase. The quantitative findings informed both our selection of interview participants and the focus of questions we wanted to explore further in the interviews. The overall intent of the qualitative interviews was to enrich and expand upon the quantitative findings and perhaps generate and explore similarities and contradictions (Creswell & Creswell, 2018 ). In the current paper, we briefly review key quantitative findings. We then discuss the qualitative findings and how they provide more depth and insight and demonstrate the complexities of bullying and cyberbullying motivations, behaviors, and attitudes. In so doing, we present novel discussions of how the qualitative interviews augment the quantitative findings.

Participants

Three participant groups were included in the baseline study sample: (1) students in 4th ( n  = 160), 7th ( n  = 243), and 10th ( n  = 267) grades; (2) their teachers ( n  = 103); and (3) their parents ( n  = 246). A stratified random sampling strategy was utilized to select participants. First, a random sample of 19 schools was drawn from one of the largest school boards in North America. Schools were stratified into three categories of need (low, medium, and high) based on an index developed by the school board that ranked schools on external challenges to student achievement (Toronto District School Board, 2014 ). This stratification ensured representation of ethno-cultural and socioeconomic diversity—factors that potentially impact access to Information and Communication Technologies (ICTs), experiences of cyberbullying, and the manifestation of negative outcomes (Lenhart et al., 2015 ; Steeves & Marx, 2014 ). In year 3 of the study, 10 additional schools were recruited for participation to follow those students transitioning from elementary/middle school to middle/secondary school. A total of 29 schools participated in the study. All students in the selected grades at the original participating schools were invited to participate, as were their parents and teachers.

Participating students and their parents provided data in all 3 years of the study, while matching teachers provided data in year 1 only (as student participants’ teachers changed each year). All three participant groups completed quantitative questionnaire packages, and a sub-sample of each group participated in individual interviews. Quantitative data were collected from students and parents in each year of the study, while qualitative data were collected during years 1 and 3, to allow for enough time to elapse for changes in perceptions of cyberbullying to emerge.

Quantitative Measures and Analysis

In year 1, students completed a 45–60-min quantitative questionnaire package in the school setting, while parents completed a questionnaire package by mail. Questionnaires for teachers, which took approximately 45–60 min to complete, were administered in the participating schools. This study utilized several quantitative measures, including standardized measures and measures developed specifically for the study. Student, parent, and teacher surveys obtained information related to experiences with bullying/cyberbullying (Mishna et al., 2012 ; Unpublished Survey), socio-demographics, and Information and Communication Technology (ICT) use. Standardized measures assessing student mental health, health, social, and behavioral issues included Child Behavior Check List (Achenbach, 2001a ), Teacher Report Form (Achenbach, 2001b ), Youth Self Report Form (Achenbach, 2001c ), Self-Perception Profile for Children (Harter, 1985b ), Self-Perception Profile for Adolescents (Harter, 2012 ), Social Support Scale for Children (Harter, 1985a ), and Social Support Behaviors Scale (Vaux et al., 1987 ).

Descriptive analyses were conducted to calculate frequencies for categorical variables and means and standard deviations for continuous variables. We summarized socio-demographic variables among participants in each grade level (4, 7, 10). Items for each outcome scale (e.g., Social Support Scale for Children) were summed to calculate total or subscale scores for each measure.

Findings on Prevalence and Reporting

The quantitative findings in the larger study (Mishna et al., 2015 ) show that rates of cyber witnessing were higher than cyberbullying and victimization at each assessment. In year 1, 24.2 percent reported cyber witnessing, 10.7 percent cyber victimization, and 2.9 percent cyberbullying. In year 2, 21.5 percent reported cyber witnessing, 7.6 percent cyber victimization, and 1.6 percent cyberbullying. In year 3, 25.1 percent reported cyber witnessing, 10.8 percent cyber victimization, and 2.5 percent cyberbullying. Similarly, rates of witnessing traditional bullying were higher than perpetration and victimization at each assessment. In year 1, 53.0% reported witnessing traditional bullying, 23.5% victimization, and 7.8% perpetration. In year 2, 42.6% reported witnessing traditional bullying, 17.3% victimization, and 4.3% perpetration. In year 3, 35.7% reported witnessing traditional bullying, 19.2% victimization, and 5.4% perpetration (Mishna et al., 2015 ). Of note, nearly half of all students (48.3%), who reported cyberbullying involvement in our survey, reported that they had not told an adult about what was happening online (Mishna et al., 2015 ). Moreover, 69.5% of students reported that cyberbullying and physical bullying are equally serious, and 64.5% believed that cyberbullying and “real” life verbal bullying are also equally serious (Mishna et al., 2015 ). These quantitative results serve as a springboard for the following discussion of qualitative findings, demonstrating that qualitative interviews reveal nuanced similarities and differences in the views of adults and youth, elucidating important interconnections among the levels of the ecological system (Mishna et al., 2004 , 2009 ; Dennehy et al., 2020 ).

Qualitative Interview Data Collection and Analysis

Student participants in 4th grade ( n  = 20), 7th grade ( n  = 21), and 10th grade ( n  = 16) in the qualitative sub-sample were purposively selected for interviews from the larger quantitative sample, based on gender, grade, school need level, and whether they reported bullying/cyberbullying victimization, perpetration, or witnessing. After selecting student participants, their teachers ( n  = 30) and parents ( n  = 50) were invited to participate in interviews. Interviews lasted approximately 1 h, ranging in length from 30 to 90 min. All year 1 interviews (with students, parents, and teachers) took place in the school setting and utilized a semi-structured interview guide. Following preliminary analysis, this interview guide was refined for use in the year 3 follow-up phone interviews with the students and parents. Areas explored with students comprised understanding of cyberbullying and how it compares with traditional bullying, experiences of online aggression, and others’ attitudes and responses. Questions were informed by existing literature and the research team’s considerable experience. Parent and teacher interviews included questions on their awareness and understanding of cyberbullying, their child or student’s involvement in cyberbullying, links between cyber and traditional bullying, support, and their responses to cyberbullying.

Using a grounded theory inquiry, data were concurrently analyzed and theorized through constant comparison (Birks & Mills, 2015 ; Corbin & Strauss, 2008 ). Through this iterative process, the team used initial interview data and theoretical categories to inform and refine subsequent interview guides and data collection (Charmaz, 2014 ). The team members individually coded a portion of interviews to establish preliminary analytic focuses and inductively identify preliminary themes. Consistent with a grounded theory approach, no hypotheses guided data analysis and coders sought to bracket their biases through reflexive journaling and team discussions of assumptions (Corbin & Strauss, 2008 ). During team meetings, each interview was collectively coded, building upon, revising, and/or removing codes proposed by the initial coder. Emerging categories were developed and expanded. Axial coding promoted connections within and between categories and subcategories and enabled synthesis and explanation (Birks & Mills, 2015 ; Charmaz, 2014 ; Corbin & Strauss, 2008 ). Numerous preliminary codes were identified based on emerging themes that were generated and discussed. A holistic “middle-order” approach to coding resulted in a condensed number of initial codes (Saldaña, 2015 ). Axial coding was then used to identify connections within and between themes and subthemes (Birks & Mills, 2015 ; Charmaz, 2006 , 2014 ; Corbin & Strauss, 2008 ). Through this iterative process of open, holistic, and focused coding, key themes emerged related to the understanding of traditional and cyberbullying according to the perspectives of the students, parents, and teachers. Measures were employed to ensure trustworthiness and authenticity. Prolonged engagement over the 3 years of the study ensured thick descriptions of the youth and adult narratives (Lietz & Zayas, 2010 ). Rigor was established through documentation for auditing purposes (Padgett, 2008 ). Trustworthiness and transferability were further ensured through reflexive journaling, bracketing, and dense descriptions (Corbin & Strauss, 2008 ).

While we use examples from our published manuscripts derived from our study entitled, “Motivations of Cyberbullying,” in the current manuscript, we identify new thematic areas and demonstrate how our qualitative interviews complement our quantitative findings. In analyzing findings across the study publications and datasets, we have not previously drawn the conclusions. The unique contribution of the current manuscript is the use of findings of previous publications to generate broader conclusions about the benefits of a mixed-methods approach (qualitative interviews and quantitative survey data) that makes visible the connections across ecological systems levels.

In discussing how qualitative research contributes to understanding bullying and cyberbullying and complements quantitative findings, the following new thematic areas are discussed: augmenting quantitative findings through qualitative interviews, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning.

Augmenting Quantitative Findings Through Qualitative Interviews

By examining process, context, and meaning for participants, qualitative methodology can augment quantitative findings. Quantitative methodology establishes outcomes and causal relationships and puts forth generalization and predictions (Yilmaz, 2013 ). Our background study which was a longitudinal multi-informant mixed methods study (Tashakkori et al., 1998 ) used grounded theory (Strauss & Corbin, 1998 ) and a longitudinal quantitative design to aid understanding of nuances related to cyberbullying (Mishna et al., 2009 ). In creating opportunities for the voices of young people to be heard (Carroll & Twomey, 2020 ; Gilgun & Abrams, 2002 ), qualitative methodology is especially useful for phenomena that are largely unstudied and/or rapidly evolving, such as cyberbullying, by explicating process and a holistic understanding and directions for future research (Mishna & Van Wert, 2013 ; Gilgun & Abrams, 2002 ).

In our paper, “Benchmarks and bellwethers in cyberbullying: The relational process of telling” Footnote 3 (Mishna et al., 2020 ), the qualitative analysis revealed relational processes among students that occurred when they considered whether to tell adults about their bullying and cyberbullying experiences. As noted above, almost half of the students who reported cyberbullying involvement relayed that they had not told an adult. Qualitative findings, however, exposed complex interactions that informed their decision-making processes. Reticent about speaking with adults, students turned to friends. It emerged that in addition to sharing, telling friends often served as a bellwether to gauge whether to proceed and report the situation to an adult. Often minimizing the severity of their ordeal, many students had decided against informing adults, frequently mentioning their concern about making a “big deal.” Participant interviews further revealed that media reports of high-profile cases involving cyberbullying can serve as benchmarks through which to assess the severity of their own personal experiences. The qualitative findings in our study helped to contextualize the quantitative data by unpacking and making visible the reasoning and contributing factors, thus increasing understanding of what informs youth’s decisions regarding whether and who to tell about cyberbullying involvement. By augmenting the quantitative data detailing the proportion of youth who do not tell adults, particulars attained through qualitative interview data help to inform and direct prevention and intervention strategies that are concrete and actionable for addressing the more challenging aspects of cyberbullying involvement and disclosure. In offering insights on the relational dynamics among peers and between youth and adults with respect to cyberbullying, the qualitative analysis gave voice to these interconnected layers of the youths’ ecological environment.

Contextualizing New or Rapidly Evolving Areas of Research

While cyberbullying is no longer considered a new phenomenon, the rapid development of technology is continually altering the cyber landscape, creating a need for perpetual knowledge generation (Odgers & Jensen, 2020 ; Rosa et al., 2019 ) and for evolving definitions, measurements, and responses (Spears et al., 2009 ). Moreover, rapid and ongoing technological advances create unique challenges for practitioners, policy makers, and researchers, in remaining current and responding to cyberbullying (George & Odgers, 2015 ; Jäger et al., 2010 ). With youth at the forefront of technological advances in many ways, qualitative methodology is well suited to elicit the experiences and perspectives of young people in promoting in-depth understanding of youth cultures, dynamics, and processes (Thornberg & Knutsen, 2011 ).

The data collection for our background study occurred between 2012 and 2014, during the early stages of attention to and research on sexting (sending and receiving sexually explicit images, videos, and text among youth). In the quantitative questionnaires, we included one question related to sexting for students in grades 7 and 10 and their parents and teachers. Our quantitative survey found that 15.6% of students in grades 7 and 10 had seen nude or sexual photos of friends, family, boyfriend, girlfriend, or other romantic partner online or over a cell phone. Furthermore, 27.8% of teachers had witnessed or were aware of their students viewing sexually explicit images, video, or text on cell phones at school. The data indicated that digital sending and receiving of sexually explicit images, video, or text was a new phenomenon among youth participants in grades 7 and 10 in a rapidly changing digital environment.

We did not explicitly inquire about sexting in the interviews with students, parents, and teachers. Rather, we asked participants about the students’ negative experiences with cyber technology. During analysis of the interview data, however, sexting emerged as a new and pertinent phenomenon among youth, which generated knowledge about rapidly evolving cyber dynamics that warranted further attention and inspired a paper entitled, “Gendered and sexualized bullying and cyberbullying: Spotlighting girls and making boys invisible” (Mishna et al., 2021b ). The qualitative interview data in this instance confirmed our quantitative findings on sexting among youth and allowed us to delve into the complex and nuanced ways participants articulated sexting behaviors along gender lines that both reinforced and were reinforced by gendered sociocultural norms and pressures. In student accounts, boys’ presence and participation in cyberbullying were frequently invisible, such as the non-consensual sharing of sexual images. Blamed for their poor choices, girls were spotlighted and their behavior problematized through negative characterizations. The participants’ focus on girls as responsible for the gendered cyberbullying and non-consensual sharing of images corresponds with how youth are typically educated about digital technologies through an “online safety model” with the focus on youth protecting themselves and avoiding “risky” activities (Johnson, 2015 ). As such, our findings provided context for this rapidly evolving environment that then allowed us to draw links between individual cyberbullying behaviors, understanding and articulation of these behaviors, and the broader influence of patriarchal structures (Mishna et al., 2021b ). The qualitative findings underscored the need to consider key factors that go beyond individual characteristics and behaviors and to develop education and prevention and intervention strategies that address sociocultural norms and values. The qualitative findings stimulated new research endeavors and collaborations with community organizations and academics.

Capturing Nuances and Complexity of Perspectives

Bullying and cyberbullying are exceedingly complex and must be studied within the contexts of the involved youth as well as within the larger social context of youth (Cross et al., 2015 ; Dennehy et al., 2020 ; Johnson & Puplampu, 2008 ; Sainju, 2020 ; Thornberg, 2011 ). An ecological systems framework is appropriate as it provides insight into the interconnected relationships among varying aspects and social layers of an individual’s world (Bronfenbrenner, 1979 ). While quantitative research considers and articulates context, qualitative interviews provide an occasion to engage with the richness of students’ perspectives, thoughts, and feelings about themselves and their social worlds (Mishna et al., 2004 ) and allow for a deeper understanding of youth culture and social processes from the vantage point of young people (Chaumba, 2013 ; Dennehy et al., 2020 ; Spears et al., 2009 ; Thornberg & Knutsen, 2011 ). Although qualitative studies are generally bound by a particular timeframe, participants bring their life histories and cumulative experiences to the research engagement (Phoenix et al., 2003 ), which can generate a fulsome and holistic understanding of cyberbullying, taking into consideration individual, family, peer, school, cyber, and sociocultural conditions over time.

Qualitative interview data allow for an interpretive approach that draws upon patterns of understanding, similarity, and contradiction, thereby teasing out underlying assumptions that shape how people define and assess experiences and phenomena such as bullying and cyberbullying (Mishna et al., 2020 , 2021a ). In our paper entitled “Looking Beyond Assumptions to Understand Relationship Dynamics in Bullying” Footnote 4 (Mishna et al., 2021a ), analysis of the qualitative interview data exposed persistent and pervasive assumptions about bullying linked to sociocultural norms and understanding of gender. These assumptions shaped participants’ understanding and conclusions of bullying and cyberbullying experiences, behavior, and motivations. Focusing on the visible hurt and injuries associated with physical bullying, participants tended to make comments such as “you’ll heal in a few days,” whereas they noted that with verbal bullying, the mental anguish “might stay for a long term.” This viewpoint that physical bullying was not a relationship problem appeared to be linked to gender stereotypes and social norms regarding the “natural” behavior of girls and boys. These gendered assumptions led participants to suggest that addressing bullying among girls was “complicated” and ongoing, whereas addressing physical bullying among boys was “simpler” and faster, a finding similar to that of Eriksen and Lyng ( 2018 ) who described participants’ descriptions of bullying among boys as “undramatic.” These assumptions appeared to preclude participants from discussing physical bullying among boys in a manner that acknowledged the physical bullying involvement as entrenched in relationship dynamics.

Qualitative interviewing provides an opportunity for participants to express their views and ideas when discussing the topic of interest which can elicit novel conclusions and nuances. As an example, at times, youth who claimed not to have involvement with cyberbullying may go on to describe situations that actually seemed to fit the definition of cyberbullying. In our Spotlighting Girls paper, many participant reports aligned with stereotypes regarding differences in how boys and girls bully others. These stereotypes were shared, however, even when they contradicted participants’ own experiences. For instance, similar to other research findings (Eriksen & Lyng, 2018 ), one participant described a boy as using “guilt trips” as a bullying tactic, yet described boys as only bullying physically. Consequently, relational aggression among boys often goes unnoticed and remains invisible. Similarly, the same behavior displayed by both girls and boys was discounted in boys and highlighted in girls. Boys’ behaviors were often not considered to be bullying because they were positioned as within the bounds of masculine gender norms. For example, one girl reported that “mostly girls, not boys,” bully “because boys would just go over and do some physical things... [Girls would] post embarrassing stuff about the person and do that kind of stuff” (p. 410). It is possible therefore that such actions by boys were not identified as bullying and thus underreported in the quantitative surveys while captured in the interviews. Discrepancies emerged in how cyberbullying had been reported in quantitative measures and how it was described in the interviews. This indicates that qualitative interviews can complement quantitative findings by revealing the complexities and ramifications of social experiences which are not reported in quantitative surveys.

The critical role of witnessing in bullying and cyberbullying is well documented (Salmivalli, 2010 , 2014 ; Spadafora et al., 2020 ; Volk et al., 2014 ). Social experiences related to witnessing are also complex, and bystander decision-making and responses impact both the process and outcomes of bullying incidents (Salmivalli et al., 2011 ). Qualitative research can offer youth the opportunity to explore and explain the motivations and factors they consider in determining whether to intervene, specifically the social costs and benefits of intervening (Spadafora et al., 2020 ). Our qualitative interviews similarly added youth voices concerning the dilemmas they faced in considering whether and how to respond based on emotional and contextual factors (Mishna et al., 2021b ), thus providing nuanced perspectives that serve to augment the quantitative findings related to bystander responses.

Providing Moments for Self-reflection and Opportunities for Learning

Qualitative methodologies are recognized as providing participants opportunities to self-reflect in the context of being listened to empathically (Birch & Miller, 2000 ; Wolgemuth et al., 2015 ). According to a systematic review of quantitative, qualitative, and mixed-methods studies conducted with children and adolescents, participation was mainly considered to be beneficial (Crane & Broome, 2017 ). Negative responses to participating in the research included feeling anxious and upset (Crane & Broome, 2017 ). Research indicates that despite describing negative effects of participating, children and youth reported that overall it was more positive to participate in the research (Crane & Broome, 2017 ) or described the emotional pain they experienced as beneficial in various ways, for example, as “emotionally cleansing” (Wolgemuth et al., 2015 , p. 366). The qualitative research process offers participants the opportunity to come to new understandings and can reveal evolving thoughts within participant narratives (Birch & Miller, 2000 ; Wolgemuth et al., 2015 ). Qualitative processes are iterative and involve probing questions that can prompt dynamic reflection by participants (Wolgemuth et al., 2015 ). Birch and Miller ( 2000 ) explain that they “use the term therapeutic to represent a process by which an individual reflects on, and comes to understand previous experiences in different—sometimes more positive—ways that promote a changed sense of self” (p. 190).

Recognizing the potential risks in research with children and youth (Mishna et al., 2004 ; Crane & Broome, 2017 ), we informed the students in our study of the possible risks should they decide to participate, such as the possibility that they would become upset as we were asking them about hurtful matters, and the limits to confidentiality. Anticipating that some of the questions could lead to a participant becoming distressed or disclosing potentially sensitive or upsetting information, we put in place a protocol (approved by the university and school board research ethics boards) to identify and offer support for students in distress (Mishna et al., 2016 ).

Corresponding with previous research, the reflexivity of sharing their narratives and views seemed to contribute to some participants coming to a different understanding of their experiences. Such reflection was evident in our interviews with students and their parents and teachers. When asked whether he had witnessed cyberbullying, for example, a boy reflected that only in being asked about cyberbullying in the interview did he recognize the behavior as cyberbullying: “When I think about it now, I actually did a few times. I didn’t feel that it’s cyber bullying, I wasn’t thinking that it’s a huge deal. It’s basically a few arguments between people on Facebook, like writing things about each other in public, not in private, chats.”

In another example, a parent reconsidered her views during the interview. This parent first commented that girls and women are “more vindictive” than boys and men, who, she explained, have “your spat, you get over it, and you move on.” After reflecting on her assumptions, she wondered how much of this widely held view of the behavior “is just media driven because I guess the victims that we see on the news, at least in Canada, have been girls, right?… but that doesn’t say that boys aren’t also being bullied.” Similarly, a girl contemplated her assumptions after first casting boys in a favorable light in contrast to girls. In commenting that girls bully each other because of appearance, she praised boys, “because usually they don’t tend to worry about those things...They’re proud of themselves, and they don’t pick on other people. They’re good with what they have.” After pondering these stated differences between boys and girls, this girl surmised, “I think it’s from when we were little because those Barbie dolls are super skinny. We wanted to have blonde hair, blue eyes, and be like Barbie. I think it’s just how maybe we were raised.” Another girl, who asserted that while cyberbullying occurred with equal frequency among boys and girls, added that it was not “a big thing” for boys, in contrast to girls who, “would show it off more, be like oh yah, blah, blah, blah.” Rather than concluding that this difference indicated that cyberbullying was not a big deal for boys, however, this girl attributed the difference between boys and girls to dominant masculinity norms. She asserted that “guys kind of hide it in more” and explained that “they don’t want to show that they’re weak because guys tend to be, they think that they’re very strong, kind of thing.” The evolving perspectives throughout this and the previous exchanges demonstrate the process of deepened understanding that can occur because of qualitative interviewing.

Such new understanding can inspire a desire to act and make change through community engagement. A girl explained that the research was the first time she had spoken with anyone about cyberbullying. This girl’s appraisal of her participation is consistent with findings in which participants may be motivated to take part in research for the opportunity to effect and advocate for change and help others (Cutcliffe & Ramcharan, 2002 ; Wolgemuth et al., 2015 ). She remarked that participating had been a helpful process which led her to,

think of different ways that I could help someone else if I see it happening… Just talking about it makes you think about what could cause it, what could make someone bully someone else. It makes you realize how it could make someone feel. Also, talking about how there isn’t really a support system at school. It makes me want to go and talk to someone to organize it, because it does happen a lot and I know it affects a lot of people

The inclusion of qualitative interviews in mixed methods research brings forth new information about content, process, and meaning that is otherwise not visible. By engaging youth voices as well as adult perspectives through both quantitative measures and qualitative interviews in the mixed methods study discussed in this manuscript, entitled Motivations for Cyberbullying, understanding of bullying and cyberbullying was advanced, thus enriching the quantitative methodology. The findings of the interviews extended knowledge related to bullying and cyberbullying in the following ways, which can inform “bottom-up research and intervention efforts” (Dennehy et al., 2020 , p. 10): augmenting quantitative findings, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning.

Qualitative research constitutes a significant venue through which to amplify the voices of children and youth (Dennehy et al., 2020 ) and ensures that children and youth’s experiences of the world are represented in understanding social phenomena (Mishna et al., 2004 ; Carroll & Twomey, 2020 ; Chaumba, 2013 ; Dennehy et al., 2020 ; Patton et al., 2017 ). According to Dennehy and colleagues ( 2020 ), engaging youth as co-researchers in cyberbullying research may enhance efforts to ethically and earnestly amplify youth voices. A synthesis by Elsaesser et al. ( 2017 ) supports the view that focusing on collaboratively working with youth to understand and safely navigate the cyber world through education and empowerment is more effective than interventions aimed at restricting ICT use without involving youth. Through quantitative measures and qualitative interviews, our mixed methods study examined participant perspectives regarding bullying and cyberbullying on the various ecological systems levels across the students’ lives. The use of mixed methods facilitated a dialogue between the participant responses to both methodologies, thus highlighting the salience of the overlapping influence and interactions among the systems levels. Such complex and nuanced understanding is necessary to inform meaningful prevention and intervention strategies to address bullying and cyberbullying.

According to the United Nations Convention on the Rights of the Child (Assembly UG, 1989 ), children and youth have the right to discuss their views and experiences. The Convention states that all children have the right to protections, provisions, participation, and non-discrimination (Assembly UG, 1989 ). Participation entails the right for children to express themselves and have a voice in situations that have to do with and affect them. The importance of listening to children’s voices underscores the limits of adult proxies in representing children’s emotional and social worlds (O’Farrelly, 2021 ). Bullying and cyberbullying fundamentally violate these protections, silence children’s voices, and compromise their healthy development (Greene, 2006 ). Our mixed methods study through quantitative measures and qualitative interviews facilitated a dialogue between the participant responses in both methodologies. This interaction of data types maximizes the voices of and collaboration with participants as well as knowledge generation.

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Different terms are used to describe the same approach (e.g., social-ecological framework, ecological systems framework, ecological theory, ecological perspectives). For the purposes of this paper, the term ecological systems framework is used.

All additional references to this research study will be shortened to “Motivations for Cyberbullying.”

All additional references to this paper will be shortened to “Benchmarks and Bellwethers paper.”

All additional references to the paper will be shortened to “Relationship Dynamics paper.”

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Acknowledgements

We would like to acknowledge first and foremost the Toronto District School Board for their utmost commitment to participating in the study, as well as each school for their dedication to both data collection and ensuring that the mental health needs of students that were identified through the study were addressed. We would like to thank the students, parents, and teachers for sharing their experiences with us. We would like to thank the research assistants, without whom we could not have completed this study.

This research was supported by a grant from the Social Sciences and Humanities Research Council of Canada: Grant Account Number: 410–2011-1001.

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Mishna, F., Birze, A. & Greenblatt, A. Understanding Bullying and Cyberbullying Through an Ecological Systems Framework: the Value of Qualitative Interviewing in a Mixed Methods Approach. Int Journal of Bullying Prevention 4 , 220–229 (2022). https://doi.org/10.1007/s42380-022-00126-w

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A Qualitative Meta-Synthesis of Studies on Workplace Bullying among Nurses

Haeyoung lee.

1 College of Nursing, Chung-Ang University, Seoul 06974, Korea

Young Mi Ryu

2 Department of Nursing, Baekseok University, Cheonan 31065, Korea

3 College of Nursing, Institute of Health Sciences, Gyeongsang National Universtiy, Jinju 52727, Korea

4 Department of Nursing, Changwon National University, Changwon 51140, Korea

5 College of Nursing, Dankook University, Cheonan 31116, Korea

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This study aimed to further understand and compare the phenomenon of workplace bullying (WPB) among clinical nurses in various sociocultural contexts. The study sought to determine appropriate interventions, examining how said interventions should be delivered at individual, work-unit, and institutional levels. Qualitative meta-synthesis was chosen to achieve the study aims. Individual qualitative research findings were gathered, compared, and summarized using the thematic analysis suggested by Braun and Clark. Based on the predefined analytic points, the findings included the following themes: horizontal yet vertical violence, direct and indirect violence on victims, nurses feed on their own, accepting and condoning WPB embedded in ineffective work systems, and rippling over the entire organization. The results showed that the phenomenon of workplace bullying shares quite a few attributes across cultures in terms of the characteristics, types, perpetrators, subjects, and consequences. The findings suggest that interventions to change and improve organizational work culture must be developed and implemented.

1. Introduction

Workplace bullying (WPB), or horizontal violence among healthcare workers, is a global and cross-cultural phenomenon. Victims of such violence suffer from long-term physical and psychological aftereffects, and they transfer from their departments, resign, or may even commit suicide in extreme cases. In addition, these long-term stressful situations reduce nursing competencies for patients, negatively affecting patient outcomes and significantly impacting hospital organizations’ productivity [ 1 ]. The seriousness of the consequences, including problems of individual employees being bullied, those of the organization as a whole, and harm to patients receiving care, mean that WPB must be resolved in healthcare organizations [ 2 ].

In Korea, harassment among nurses is a particularly well-known societal issue. The suicide incident of a nurse at a university hospital in 2018 [ 3 ], and a recent case of a nurse’s suicide when the workload of clinical nurses increased due to the COVID-19 pandemic [ 4 ], have highlighted the issue of harassment between nurses, which has again attracted social attention. Harassment among nurses in Korea is not new, and it has long been given special terms, such as “military culture” or “tae-um [Korean language].” In particular, “tae-um” is a representative term for harassment between nurses, which means “burning the soul until it turns to ash” and refers to the harassment that senior nurses inflict on new nurses in the name of education [ 5 ].

These incidents offer the following questions: Why does workplace harassment among nurses attract particular attention in Korean society? Is the degree of harassment in Korea particularly severe? What social and cultural factors in Korea increase WPB? What are the similarities and differences between WPB in Korea and WPB in other countries or cultures? To answer these questions, we analyzed and synthesized previous qualitative studies on the WPB phenomenon in Korea and other countries. Notably, this paper presents what we found regarding the last question of cross-national comparison. We synthesized qualitative studies so that we could grasp the contexts in which the research phenomena occurred within such studies and potentially understand their plausible explanations. The comparative analysis of qualitative studies on WPB occurring under various sociocultural backgrounds aimed to reveal the necessary interventions at the individual, unit, and institution levels required to provide and maintain safe environments for nurses and nursing recipients, and to obtain requisite information for the effective development and application of the interventions.

This is a qualitative meta-synthesis study, which uses the results of primary qualitative studies as raw data. Primarily, qualitative meta-synthesis (QMS) is based on literature review. However, QMS pursues new or greater understanding of a phenomenon of interest, than what can be found in individual qualitative research, by analyzing and synthesizing the raw data from individual qualitative research [ 6 , 7 ]. Since our study aimed to determine potential underlying mechanisms, or conditions, under which WPB may be expressed differently, and any commonalities or differences in WPB across countries, we chose to employ QMS to achieve our goals.

QMS methods undertake five common steps: formulating research questions, retrieving relevant qualitative research studies, appraising the quality of selected studies, analyzing and synthesizing the results, and securing the validity of the process and synthesized findings. The QMS approach requires analytic or synthetic methods to integrate the findings from primary qualitative studies. The terminology, QMS, itself does not refer to a specific method or technique [ 8 ] and the purpose of a study, the type of desired output, and the characteristics of individual research results to be included in the QMS should be the foundation for method selection [ 9 ] (pp. xv–xix, 1–10).

This study used the analytic points pre-defined by the researchers to compare and contrast WPB among nurses, occurring under various social and cultural influences, to further understand the phenomenon. Therefore, Braun and Clarke’s thematic analysis [ 10 ], an analytic and synthetic method that allows this approach, was selected as the analysis and integration approach to obtain the results.

2.1. Search Methods

This study included qualitative studies on the WPB experiences of nurses for comparative analysis to deeply understand WPB among nurses working in medical institutions, and to compare the situation in Korea with those of other countries. Therefore, studies on conflicts or difficulties among mixed healthcare professionals, such as midwives, doctors, and nursing assistants were excluded as it was difficult to separate out nurses’ experiences. Non-research papers or review papers were excluded because they contained no raw data that could be used in this study. Studies not written in either Korean or English were also excluded as those are the only languages in which this study’s authors are fluent. In addition, to enable the collection of rich and comprehensive raw data on the research phenomena, we placed no restrictions on the period or research methods. For mixed-method studies, the main texts were reviewed to determine the applicability of the qualitative data, and inclusion was decided based on discussion within the research team.

The process of literature retrieval was as follows. For literature in Korea, the electronic databases of the Research Information Sharing Service (RISS), the Korean studies Information Service System (KISS), the DataBase Periodical Information Academic (DBPia), the National Digital Science Library (NDSL), and the National Assembly Library were searched. The RISS contains academic references produced and owned by Korean universities, whereas the KISS offers bibliographic information published by academic societies and research institutes in Korea. The DBPia and NDSL are academic information portals that contain research studies published in Korea. All of the databases we used are the most searched databases and academic resource portals and have slightly different ranges of academic disciplines, types of resources, and systems of organizing resources. Literature published until June 2020, the final search period in Korea, was included. The search criteria phrase for the databases was “nurse” AND “qualitative” AND “(burning OR harassment OR violence OR hospital culture OR organizational culture OR burnout OR turnover OR resignation)”.

For foreign literature, EBSCO, PubMed, CINAHL, Web of Science, EMBASE, and PsycINFO were searched. Foreign literature published until June 2020, the final search period of the literature search in Korea, was included and the search query for the databases was “nurs* AND (incivilit* OR bully* OR workplace violence OR uncivil OR aggression* OR harass*) AND (hospital* OR clinic* OR workplace*) AND (qualitative* OR phenomenological* OR grounded* OR grounded* OR (ethnographic*)”.

First, duplicate literature was removed, and then the title and abstract of each study was reviewed to confirm whether the paper met the inclusion criteria. If it was difficult to judge whether a study fit the criteria only by the title or abstract, the contents and results of the papers were read to determine whether the literature met the inclusion criteria. Then, the main texts of the selected studies were reviewed, and the literature to be included in this study was finally selected. The literature search and selection were performed independently among the researchers, but the selected literature was cross-checked in several research meetings. If there were disagreements during this process, the main texts were reviewed together to determine inclusion. After each of the authors reviewed the papers individually, we examined each paper together, based on our study aims, to decide whether the study under review contained “raw data” for our synthesis study.

2.2. Search Outcomes

The literature search and selection were performed in four stages for Korea and other countries. In the Korean literature, 506 research papers were obtained from five electronic databases, of which 52 duplicate papers were excluded ( Figure S1 ). Of the remaining 454 studies, 74 that were either not research papers or written in languages other than English or Korean were excluded. Of the 380 remaining papers, 314 studies that did not meet the inclusion criteria were excluded after reviews of their titles and abstracts. The excluded literature included studies unrelated to bullying among nurses, such as those about patient assault, those with subjects other than nurses, and surveys or intervention studies that did not use qualitative methods. Then, after reviews of the full texts of the remaining 66 papers, 31 studies were chosen for inclusion in the qualitative synthesis after 35 papers that did not meet the inclusion criteria, or for which the full text could not be retrieved, were excluded. After that, two related articles from the reference lists of other articles and four articles searched using the terms “rudeness” and “silence”, which were suggested as keywords from relevant literature, were added, resulting in 35 papers being included in the qualitative synthesis.

For the literature from other countries, a total of 1995 research papers were obtained from six electronic databases, of which 1210 duplicate papers were excluded ( Figure S2 ). Of the remaining 785 studies, 41 non-academic papers were excluded. After that, 664 of the 744 papers that did not meet the inclusion criteria were excluded, after reviews of their titles and abstracts. The excluded literature was made up of studies unrelated to bullying, those involving subjects other than nurses, surveys or intervention studies that did not use qualitative methods, and two studies that were not peer-reviewed. After the remaining 80 papers were reviewed, 52 studies that did not meet the research selection criteria, or whose original texts could not be found, were excluded from the analysis. Finally, 28 papers were included in the qualitative synthesis. Of these 28 included studies, the majority (13 studies) were conducted in the United States, followed by Australia (seven studies), and then one each for Iran, Chile, Turkey, New Zealand, Singapore, and South Africa.

2.3. Quality Appraisal

All 68 qualitative studies included in the synthesis were evaluated for their quality using the Critical Appraisal Skills Program (CASP) [ 11 ]. Among the 14 qualitative research quality evaluation tools used in the previous qualitative meta-synthesis studies, CASP was used here because it is the most commonly employed, it includes an evaluation category common to the 14 tools, it is relatively simple to apply, and enables the gathering of opinions. As the similarity of topics is more important than the quality of individual studies in qualitative synthesis, it was not appropriate to exclude studies due to quality issues [ 9 ]. Therefore, the quality evaluation results were used to improve the researchers’ understanding of individual studies and determine the reliability of the research results as raw data in this synthesis. No studies were excluded on account of their CASP score. Although there were slight differences in the quality of included studies, there was no study with such poor reliability that it could not be used for synthesis.

2.4. Data Analysis and Synthesis

The process of qualitative synthesis began with researchers familiarizing themselves with the contents of the included studies by reading them individually several times. Based on this, basic information about each study, including the purpose, characteristics of the research participants, data collection methods, and research methodology, were collected and summarized ( Table S1 ). Next, the results of the individual studies, comprising the raw data to be included in this study, were analyzed, while carefully reading and contrasting the topics or names of categories, the explanations or interpretations presented by the original authors and the research participants’ statements regarding each topic. After that, the results were recorded alongside the researchers’ interpretations. Based on these summarized results, we re-analyzed the studies by comparing and contrasting common findings from researchers, similarities and differences in results, and diversity among studies. Specifically, the comparison and analysis were repeated depending on the experiences of WPB revealed by individual studies, how the properties and forms of WPB appeared, the causes of WPB occurrence, factors that promoted or mitigated WPB, methods or situations that overcame WPB, and the results caused by WPB ( Table S2 ). After being repeatedly analyzed, data were classified, based on their similarity to other data, and the results with differences between studies were classified separately and re-reviewed to discern patterns or similarities. The content classified as similar was named using a concept that suitably expressed its nature. In addition, when the relationship between topics was analyzed, the findings were included in the synthesis results and described. As a final step, meta-synthesized topics, focusing on common results, were presented.

2.5. Optimization of the Study Validity

The validity of the process and results of this qualitative synthesis study was ensured using the method proposed by Sandelowski and Barroso [ 9 ]. The first step was to record the activities conducted at each research stage, the decision-making process and the results as specifically as possible. While conducting this study, we collected and recorded various materials to ensure the reliability of the research process and results, such as synthesis results, the decision-making process and its results, reflective notes, tables, and figures derived through individual analysis and discussions between researchers. The second step was to secure negotiated consensual validity as a key procedure for securing validity in the qualitative synthesis. All decisions made throughout this study were considered for a sufficient amount of time, and the researchers tried to reach consensus through in-depth discussions. As several researchers participated, there were slightly varying opinions. By examining these differences through discussions, we could identify areas where the results were unclear or where there was a logical leap that warranted re-review. The differences of opinion were finally resolved by reviewing the original materials, including findings presented in individual papers and memos related to the findings.

Thirty-five Korean and 28 international studies on nurses’ WPB experiences were analyzed and summarized by means of the following: The definition, attributes, causes, types, and perpetrators and victims of WPB; factors related to the occurrence of WPB; reactions to WPB; Consequences of WPB. In accordance with this study’s purpose, the comparison results were described in the corresponding areas if there was a difference between the Korean and non-Korean literature.

3.1. Horizontal But Vertical Violence: What Characterizes WPB?

WPB can be defined as verbal, physical, and emotional violence between nurses based on their work relationships within a nursing organization. Many studies have shown that this harassment has “deliberate”, “repetitive”, and “continuous” characteristics (K6, K8, K11, K31, K32, INT8, INT11, INT18, INT19, INT20, INT23, INT26), creates unfavorable or hostile working environments for victims of WPB, and is connived, passed down, and circulated within the organization (K28, K32, INT13, INT16, INT18, INT19, INT20). Based on these characteristics, WPB can be distinguished from simple one-off quarrels or interpersonal conflicts, and those involved in it easily expand to form groups (INT13).

Internationally, this violence has also been described as “lateral”, or “horizontal”, to characterize the context of violence committed between colleagues in the workplace. However, particularly in the Korean context, even if there is no difference in formal rank, it can be seen as vertical violence by hierarchy, rather than horizontal, because of the implicit, informal and authoritarian power hierarchy formed by differences in terms of years of experience in the ward. In a non-Korean context, being in the majority in terms of race, ethnicity, or age was a determining factor in the power hierarchy, and this characteristic sometimes overrode official rank.

A senior nurse made me take an exam in front of doctors and medical students because she thought I knew nothing. I was so embarrassed because she treated me ferociously with her eyes down and with scolding tone while I took the test in front of them. Once I made a mistake by misreading a pill label. I double-checked it with a nurse who has 5-year experiences and she told me I did great on finding out the pharmacy’s mistake. But after a while, she called me out loud and said “Can’t you read the label? This is exactly the right one!” I looked at the label closely and found that I was the one who made the mistake. I told her I was so sorry, but she grabbed my collar around my neck. She poured her anger out to me because she heard a blame from a pharmacist. I felt so bad that I had a resignation interview. (K32)

I was fearful of them. Because I thought that I was going to be in their firing line. I think there was, I think in my mind it looked like it had been happening for a long time and that, you know, the talk around the traps was, ‘Yes, I tried to do something about this and that, and this and that, and nothing ever happened or came of it’…You know you are in the firing line at that stage. (INT16)

This bully would always try to see if she could take me down to another level and embarrass me in front of the entire group. It was always me at every single meeting, putting me down; criticizing anything I came up with. (INT23)

3.2. Direct and Indirect Violence toward the Victim: Types of WPB

Our critical analysis and comparison revealed that there are two different types of WPB, based on how it is carried out: direct and indirect. Direct violence includes behaviors that stand out in the face-to-face interactions between perpetrators and victims. While some verbal and physical violence is intentionally carried out in front of others, violence carried out in private or closed spaces remains invisible to others. Specifically, it includes verbal violence (K8, K11, K13, K20, K28, K31, K32, K33, K34, K35, INT4, INT6, INT13, INT14, INT17, INT18, INT21, INT28), physical violence (K8, K11, K13, K20, K28, INT6, INT14, INT17, INT18,), expressions of doubt or devaluation of work ability, surveillance (K3, K6, K7, K8, K20, INT15, INT19, INT21), intentional ignorance, ostracism or isolation (K6, K8, K10, K13, K20, INT8, INT13, INT14, INT18, INT21, INT28), intentional insult, embarrassment, hurting one’s pride (K7, K8, K10, K11, K20, K28), invasions of privacy, spreading rumors or gossip (INT14, INT4, INT5, INT17), and inappropriate comments unrelated to work (K8, K10, K28). As these actions are performed to control the victim, such as by breaking their spirit through actions or taming (K6, K11, K20), they are unilateral, lack consideration or respect for the victim, and are repeated until the perpetrator is satisfied.

… I was in public and then taken to a warehouse and scolded. Of course, I was dragged out because I could not be scolded in front of the patient, but it was really tough for me… I think I really wanted to quit when I heard if my mom and dad know about how you are working, and what did you learn at school… (K8)

The staff was threatening me that day, and all her friends ganged up against me when I reported it. Even though the person was transferred to another shift, her friends continued to give me a silent treatment causing me to be unhappy to come to work. (INT8)

Indirect violence is not limited to the relationship between perpetrators and victims; it negatively impacts the victim’s relationships with other ward members. Victims become marginalized, and the perpetrators exert their influence in the ward atmosphere. Examples of this include manipulating the working atmosphere, interfering with work (providing information, work assistance, creating a hostile and difficult working environment without providing medical equipment, K6, K8, K10, INT8, INT14, INT17, INT28, INT4, INT10, INT12), disadvantages at work (unfair assignment of shifts, patients, duties, responsibilities, working authority, K8, K10, K11, K12, K20, K30), hindering professional career development (promotion, salary, unfair evaluation, INT4, INT14, INT15, INT22), and interfering with legal responses to bullying (INT13, INT14). These individual and group actions injure the identity and self-esteem of the victimized nurses.

And I do not know that it is necessarily [that nurses] ‘eat their young’. I think it is ‘eat somebody that’s not part of the group’. (INT15)

I have a friend in another ward, and every time I ask them, they say they work in the evening. Quoting what my friend said, it was really difficult because the work wasn’t fair… It’s about giving favorable shifts and assigning easy patients to only some nurses… It was really hard when I was scolded for not being able quickly to do my job while I had a lot of work to do… They didn’t mention important things to learn, asked to do things like chores, and didn’t teach important things just because they did not like them. (K8)

In Korean studies, forms of WPB that criticize “work competency” and “interpersonal relationships at work” were prominent, whereas non-Korean studies relatively more frequently reported experiences of personal and emotional harassment and being alienated or being forced to be a loner, in addition to the violence of attacking victims’ work ability, as in Korea.

It was group behavior, with a nurse provoking other nurses. For example, when I enter the room in the morning and say ‘Good morning’, all of them suddenly leave the room. (INT26)

I was totally alone…one patient in what I thought was SVT, one pulling out all of his lines because he was disoriented, and one who really seemed to have a hard time breathing. The RNs in the break room said they would be there “in a minute.” I called the supervisor [for help], and she told me to find my mentor. I was…all alone, all the time. Yet I was responsible. (INT18)

Sometimes I used to feel that I wasn’t present there, and I wasn’t acknowledged when I was there for handovers and for any opinions regarding my patients. (INT19)

3.3. Nurses Feed on Their Own: Perpetrators and Victims of WPB

The WPB reported in the qualitative studies was repeated occurrence of violence by one or more individuals or groups within an organization, and had various causes, from individual tendencies to organizational characteristics. Although personal tendencies may play a role in becoming a victim or perpetrator of WPB, it is characterized by the abuse of unilateral power between the weak and strong, which is formally, or implicitly, created within the organization, due to the hierarchical order or imbalance of power.

3.3.1. Victims of WPB

In both domestic and international studies, most of the victims of WPB were new nurses (K8, K11, K12, K13, K20, K17, K21, K22, K23, K24, K25, K26, K28, K30, K32, K33, K35, INT12, INT16, INT17, INT18, INT19, INT20, INT21, INT22, INT25). However, nurses with little hospital experience (K19, K20, K25), those with intermediate careers, preceptors (K30), or nursing managers (K13, INT26) were also targets of harassment. In other cases, ethnic minorities (INT15), a nurse (INT3) who was part of a minority group in the organization, and a young nurse (INT3) were also the targets of harassment.

Heterogeneity between groups was also a factor that led to WPB: age (INT3, K16), place of education (K1), and race (INT3) were the criteria that divided groups. As nurse groups in Korea are mostly homogeneous (i.e., native Korean), no case of becoming a victim of WPB due to race or culture was seen.

Hey, what does this abbreviation mean? What school did you go to? Did your school teach you that way? (K29)

And then race got into play. I am Hispanic, but many people on the floor think I look Muslim. And then …. a co-worker approached me and asked me if I can take less assignments because they thought I was Muslim and they didn’t feel comfortable with me working with them, with other—with their patients as well. (INT15)

3.3.2. Perpetrators of WPB

The most common perpetrators of WPB were fellow nurses who had longer careers (K11, K12, K13, K15, K20, K22, K23, K24, K26, K30, K31, K32, K33, K35. INT1, INT2, INT4, INT5, INT6, INT10, INT11, INT16, INT17, INT19, INT20, INT21, INT22, INT23, INT24, INT26, INT27, INT28). They included preceptors (K21, K25, K30, K33, INT25), charge nurses, nursing managers (K11, K12, K33, INT2, INT4, INT18, INT19, INT20, INT22, INT25, INT26, INT27, INT28), or nursing department heads (K11), and, in some cases, even White and non-immigrant nurses (INT3). In other words, various types of perpetrators can exist, depending on the relationship with the victim within the organization, but perpetrators were people who had an advantage within the hierarchy of the organization. Bullies need to dominate, create conflict to exert power over violence, and have no fear of repercussions for continuing their harassment of victims (INT1). In addition to these personal characteristics, they form a bullying hierarchy as an informal network promoting WPB (INT13). In addition to organizational culture and work characteristics, individual issues of the perpetrators were also causes of WPB. Examples include professional jealousy of others, fatigue, anger, insecurity, and being hateful (INT2), dissatisfaction, jealousy, and prejudice (INT26); and personal situations of nurses (lack of self-care, imbalance between home and work, etc.) (INT17).

There seems to be an aspect of relieving one’s own personal stress and a backlash to the subordinates who did not respect properly…… It seems like ‘I retaliate because you ignored me’. (K12)

I think we’ve got some very incestuous relationships here in senior executive. I think it’s very hard for people, particularly if they’re outsiders that haven’t grown up here, gone to school here, trained with everybody, worked with everybody for the last twenty, thirty years, all those people have moved up into higher positions. They’ve got a vested interest in keeping people where they are. (INT13)

3.4. Accepting and Condoning WPB Embedded in Ineffective Work Systems: What Makes WPB Long-Lasting?

Several studies in Korea and in other countries reported the power structures caused by inefficient organizational culture (K1, K2, K8, K11, K33, K34, K35, INT1, INT21, INT27) and power imbalance (K11, K31, K35, INT1, INT8, INT9) as being triggering factors for WPB. In an inefficient organizational culture, WPB occurs due to power imbalance. WPB was also explained as occurring in an “unfavorable environment” (INT18), which refers to systematic characteristics such as lack of various resources (lack of workforce, or lack of systematic education programs) (K13, INT26), lack of attention and competence (leadership) of a senior colleague (K30, INT1, INT22), and an improper organizational system (K33, K34, INT17)). These work environments amplify the situation and position of each class in the ward (head nurse, senior nurse, and new nurse) and cause conflict (K13).

The major conditions that could sustain WPB within nursing organizations, in Korea and other countries, were the conformity of the victims and the connivance or apathy of colleagues and managers. The compliant attitude of victims of WPB (K6, K12, K13, K30) encouraged the perpetrators to continue their WPB. The perception of fellow nurses who viewed WPB as a part of adapting to work or the organization contributed to connivance with the perpetrators (K8, K28, INT8, INT18, INT20) and the organization members (manager or nursing department head) that knew about the victims or the ward’s atmosphere but just stood by and watched (K12, K13, K30, INT10, INT16, INT8, INT11, INT18, INT26), allowed the WPB to continue without obstacles.

“Move on when it is about a person you know. Time will solve the problem. I have been through that much too. I have been through worse than you. Saying I cannot help, it is just okay. I was responding like this. They do not think seriously about this culture of bullying. No one thinks that bullying should be eradicated.” (K13)

“When the director of the department didn’t respond, I went to senior leadership. However, they were friends with one another so no one would support me.” (INT20)

3.5. Personal Endeavor for Survival vs. Publicizing WPB: How to Deal with WPB

There were many similarities in how to respond to WPB in the studies analyzed. In the early stages, victims were embarrassed by the situation, greatly shocked emotionally, and intimidated, so they tended to withdraw into themselves, rather than confronting the perpetrators (K3, K6, K20, K17, K18, K29, K30, K31, K32, K33, INT4, INT11, INT12, INT15, INT16, INT26, INT27). Moreover, the tendency of WPB to be resolved through efforts to improve competencies to escape the ongoing WPB, or due to the improvement of practical skills as victims continue their careers, have been discussed in many studies worldwide (K13, K14, K27, K28, K29, K32, INT3, INT16, INT19). Cases of WPB reduction through the improvement of peer relations (K4, K5, K6, K13, K19, K27, K35, INT16, INT19) have also been commonly reported.

In studies of Korean nurses, victims had a clear tendency of considering themselves the cause of the problem because of nursing work requiring “continuity of work” through shifts and WPB frequently starting with accusations or conflicts related to “competency” (K6, K8, K12, K14, K27). Therefore, victims had a tendency to consider it as an unavoidable problem in patient care, or to recognize that individual survival efforts play a central role in changing the situation.

First of all, I think it is a process of making people suitable for the environment in order to adapt them to the organization. At that time, I was just annoyed and felt like ‘I can’t stand it anymore!’, but to a certain extent, I think that Tae-um [WPB] made me a good nurse. (K12)

If we do not pay attention to our work, medical accidents happen and people die… I think this was the reason that it was connived even if it was a little excessive. (K28)

In contrast, confrontation with the perpetrator, or an attempt to formally resolve it, resulted in two different consequences in Korea and internationally. When the problem was reported to the manager or publicized, the problem was ignored (INT8), or victims were rather attacked, resulting in the situation getting worse (INT16, INT27); or they were further harmed by the organizational actions of bullies (INT12, INT15). Eventually, no further action could be taken, and they became silent (K6, K30, INT12, INT15, INT16, INT27).

“Why do you keep making excuses when it is unimportant who did it? I am just telling you not to do it. This was how I was scolded. So after that, I do not make excuses and say, ‘ah, I see, I am sorry’.” (K6)

“I might be retaliated if I say this and that is a problem, and they say, “Look at her/him, she/he has such poor social skills”, and I could not say anything because I could get a worse disadvantage”. (K30)

“I would say that I kept silent and tried to go through avoidance, that is, almost annulling myself and getting out of the way…”. (INT4)

Conversely, there were cases where WPB was mitigated or resolved when there was an active intervention at the administrator or organizational level (K13, K27, K32, INT2, INT3, INT4, INT8, INT12, INT15, INT17, INT20, INT24, INT25). In literature outside of Korea, solidarity among nurses, active response to WPB by managers or the entire nursing department, and active action or response by victims were recognized as important.

“We need to bring people together and find out what the root cause is and help one another to change”, “Maybe have early reporting of behaviors and commitment between nursing peers to address and stop this behavior”. (INT20)

It is essential to make it clear to their staff that nurse managers are ‘‘not going to tolerate this behavior.’’ Institution-wide ‘‘mandatory programs’’ were not deemed effective. Instead, nurse manager-initiated interventions on a unit level, in collaboration with institutional and administrative support, were perceived to be effective for addressing WPB among RNs (INT24).

3.6. Rippling over the Entire Organization: WPB’s Consequences

WPB negatively impacts nurses’ physical and mental health by causing depression, anxiety, posttraumatic stress disorder, insomnia, headaches, and indigestion (K3, K4, K6, K7, K8, K11, K20, K25, K27, K29, K30, K32, K35, INT1, INT4, INT6, INT9, INT11, INT19, INT26, INT27). If victims did not have a support system while experiencing WPB, they became more vulnerable to complete coercion and domination (INT10) and experienced self-contempt and frustration (INT11).

“Whatever they tell me, I got dazed. I just kept losing motivation.” (K4)

“I think it causes depression…And a lot of nurses are caregivers and they’re very emotional about their work and about taking care of people and they internalize that. And depression is anger turned inward. So you’re angry at the bully but instead of funneling back at them, you are turning it into yourself and that’s not healthy. (INT1)

The influence of WPB could extend beyond individual victims and spread to patients and organizations as a whole. In some cases, nurses in similar situations supported each other (K8) or tried to break the vicious cycle of the WPB situation (K6, K13, K19). However, WPB had negative effects on patient care, such as leading to burnout and eventually causing medical accidents such as medication errors or malpractice (K28, INT1, INT3, INT4, INT6, INT8, INT19, INT24). Eventually, the victims lost confidence in their nursing ability, lost their passion for their career, and burned out (K4, K31, K32, K33, K35, INT1, INT3, INT4, INT8, INT10, INT18, INT19, INT24, INT27). This negatively affected the quality of nursing care and the maintenance of nursing staff, resulting in long-term leave (INT10, INT13), absenteeism (INT3, INT20, INT21), resignation, or turnover (K5, K6, K14, K27, K32, INT1, INT3, INT7, INT9, INT13, INT15, INT16, INT19, INT20, INT21, A420, INT26).

“I pointed out the danger of assigning one nurse to monitor nine infants, two months and younger with RSV, without monitors and on tank oxygen. They expected the same nurse to cover additional patient orders. My nurse manager told me if I did not like it, I could leave.” (INT8)

“… It is not just a matter of one department, but the whole hospital. As a result, experienced nurses also quit, and new nurses continue to come in… then there are more mistakes in practice… and the quality of nursing is getting worse and worse. In addition, when a new nurse quit, the reason for the resignation was driven by the problem of the remaining nurses while we were barely holding on to it. They tried to find out who the contributor was… and we became distrustful and blamed each other. It led to a complete loss of motivation.” (K28)

4. Discussion

In this study, we sought to determine the similarities and differences in WPB and the reasons behind them among nurses in Korea and those in other countries. Interestingly, we found more similarities than differences between Korea and other countries.

Characteristics and types of WPB were common across countries. Our findings showed that in both Korea and other countries, WPB has vertical as well as horizontal characteristics, due to unofficial power imbalance. Differences in these power imbalances seem to arise from social characteristics, (i.e., multicultural vs. monocultural society). Within multicultural societies, such as the U.S. or Australia, race, ethnicity, or characteristics of the majority in the nursing staff could provide covert power, whereas in Korea, the length of nursing career was the strongest factor for such invisible power.

In Korean studies, the length of one’s nursing career plays a significant role in the hierarchy. A plausible explanation for this can be found in the Korean national cultural character, which is highly hierarchical, resulting in the work environment in hospital settings also emphasizing hierarchy, which is based on the length of one’s nursing career. According to Hofstede’s model, Korea is highly hierarchical, so Korean people accept power imbalances by hierarchy with less resistance [ 12 ]. This tendency is also a possible explanation of Korean nurses’ acceptance of WPB as an unavoidable part of one’s adaptation to the job or job training. This underlying cultural influence seems to have allowed WPB in hospitals to be naturally contextualized as one of the ways to enhance work competency and reduce or prevent significant errors that might threaten the patients’ lives.

Considering the overt power hierarchy in the work unit or organization, the subjects of WPB were primarily the weakest in the hierarchy, young nurses. This was universal across all the countries where WPB studies were conducted. Additionally, a weaker position in the hierarchy could make anyone a victim of WPB, even experienced nurses or nurse managers, depending on the cultural circumstances. Perpetrators were those who had powers in any way and showed authoritative, pursuing, and wielding characteristics. Psychological characteristics of WPB victims and perpetrators were related to bullying behaviors. Homayuni et al. [ 13 ] reported that a high degree of core self-evaluations, such as self-esteem and self-efficacy, could have a preventive effect on WPB or be closely related to bullying behaviors.

The study results also illustrated close connections among inefficient organizational cultures, unfavorable work environments, and the amplification of work conflicts. Ineffective organizational culture creates and reinforces power imbalance, which, in turn, creates unfavorable work environments that are susceptible to WPB. Such environments encourage perpetrators’ continuation of WPB and make those who have less or no power more vulnerable to WPB. Under this context, responses to the WPB were also similar across various cultures. Psychological withdrawal and taking individual-level strategies to address WPB were common across countries. These tendencies are consistent with what Karatuna and colleagues [ 14 ] defined as “emotion-centered approaches” to resolve the issues, such as avoidance or seeking emotional support. Problem-centered approaches, such as speaking out and communicating directly with the bully or manager, were more prominent in studies conducted outside Korea. Although more attempts at confrontation were reported in international studies, even the pursuit of legal actions was often disrupted by WPB perpetrators.

Long-term consequences of WPB included negative impacts on individual victims’ physical and mental health, organizational productivity, and patient care outcomes. These results are consistent with those of many previous studies. For example, Shorey and Wong [ 15 ] reported that WPB negatively affects nurses’ physical and mental health; in addition, when a nurse becomes a target of WPB, their productivity and creativity decrease [ 15 , 16 ]. WPB’s adverse effect extended over patient safety [ 17 ] by decreasing the nurses’ competencies and quality of care, ultimately hindering the organization’s development [ 1 , 18 , 19 , 20 ]. Patients thus become the ultimate victims of WPB [ 18 , 21 ]. It has been reported that witnesses of harassment also experience stress, depression, and anxiety [ 15 ], which may cause them to experience similar consequences to direct victims [ 22 ].

Therefore, creating and maintaining safe, efficient work environments for nurses is one of the most urgent necessities for reducing, and ultimately eradicating, WPB in the field. Johnson [ 23 ], in his ecological model, emphasized the importance of a multi-layered and systematic approach to prevent bullying, claiming that orchestrated efforts should be implemented for successful prevention of WPB and the building of a collaborative, sound colleagueship and work atmosphere.

First, interventional approaches for individual nursing staff need to be considered. Institutional and unit-based supporting programs for new members’ adaptation and transitions are needed [ 24 ]. Such programs should contain training regarding work relationships and how to deal with conflicts with colleagues and WPB. In addition, it is also necessary to educate senior nurses, who can be WPB perpetrators, to distinguish between work rigor and harassment. Additionally, interventions to support senior nurses in managing work stress that they may experience, while educating or working with new nurses, need to be provided. As such, work environments that effectively reduce work conflicts will help prevent WPB as well [ 14 ].

As previous findings have shown, managerial or institutional intervention can be one of the most effective measures to deal with WPB [ 25 ]. Strategies that target nurse managers are needed to impart to them leadership skills that enable them to properly handle WPB. Improper leadership of nursing managers is highlighted as an aggravating factor causing WPB [ 14 , 16 ]. Therefore, there is a need for continuous education to ensure nursing managers recognize the negative effects of WPB on individuals and organizations and actively respond to it. Any measures that allow nurses to communicate with nurse managers or report bullying at any time, without feeling threatened or insecure, would enable immediate action in response to WPB [ 26 ].

At the institutional level, regular, systemic surveillance of WPB within organizations needs to be implemented. Not every situation under which WPB occurs and worsens can be handled by individual nurses or nurse managers. Accordingly, higher-level measures to monitor and effectively intervene WPB are necessary. Fortunately, due to the implementation of the Workplace Harassment Prohibition Act in 2019, all organizations in Korea are legally required to renew existing ethics committees, or launch such units, to formally report, manage, and prevent WPB. It was reported that organizations with a rigid, very vertical structure, job insecurity, and an adversarial and competitive work culture were more likely to report WPB [ 27 ]. On the contrary, organizations with guaranteed job security, clear expectations, and consistent rules had lower levels of WPB [ 16 ]. Political and relational conflicts amplify WPB in nursing organizations [ 28 ]. Active efforts should, thus, be made to secure an adequate nursing workforce, improve the work environment and solve the problems of nursing workforce allocation, supply and demand, and turnover, caused by the shortage of nurses and poor working conditions, which are important causes of WPB.

On a social level, effective regulation systems for WPB need to be operated so that such systems can have actual impacts on medical institutions. In the revised Labor Standards Act from July 2019 in Korea, a clause on the prohibition of WPB that stipulates the concept of WPB, prohibits it, and punishes offenders has recently been added (Article 76 Paragraph 2). However, implementing legal actions cannot resolve the issue; continuous social awareness and spontaneous controls over WPB are critical to eradicate WPB.

This study has the following limitations. First, it included only studies written in Korean and English, so it was not possible to compare WPB studies in non-English speaking countries. Second, although we tried to understand and compare WPB in Korea and other countries, the number of studies included from each country was very small, except for the United States and Australia. Therefore, it was impossible to analyze the WPB phenomenon in detail by culture. Third, the results are raw data of the results of the original articles, interpreted from the perspective of nurses who were the targets of WPB. Therefore, it is necessary to understand the research phenomenon from the perspective of nurses or nurse managers who act as active agents of WPB.

5. Conclusions

This study was conducted to reveal what, how, and why different types of WPB occur in Korea and in other national or cultural contexts in clinical nursing organizations. The findings showed more universality of the phenomenon across countries, in terms of characteristics, forms of the violence, targets and agents, conditions that triggered and sustained WPB, and responses to WPB. However, a distinctive feature of WPB in Korea was that it was strongly inculcated in nurses as an unavoidable part of job training and adaptation to the job. Improper power imbalances, reinforced by ineffective organizational work environments and systems, were common conditions that triggered and sustained WPB. Characteristics held by the majority (e.g., White and non-immigrants) could be the measure of unofficial power in other countries, whereas the length of one’s nursing career was the prominent measure of unofficial power in Korea. Eradicating WPB in nursing fields is mandatory to secure high-quality nursing care and, thereby, improve patient outcomes and safety. To achieve this goal, multi-level efforts should be implemented, including individual training on how to deal with WPB, unit level and organizational regulations, and national board-level regulations. Building collaborative colleagueship needs to be taught and encouraged in college-level education as well.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph192114120/s1 , Figure S1: Flowchart of the search process for Korean studies; Figure S2: Flowchart of the search process for international studies; Table S1: List of studies analyzed and synthesized in this study; Table S2: Examples of analysis of qualitative studies on workplace bullying among clinical nurses.

Funding Statement

The present research was supported by the research fund of Dankook University in 2019.

Author Contributions

Conceptualization, S.O.; methodology, S.O.; analysis and integration, S.O., M.Y., Y.M.R., H.K. and H.L.; writing—original draft preparation, S.O., Y.M.R. and H.L.; writing—review and editing, S.O.; visualization, H.K.; funding acquisition, S.O. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to review of published studies.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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