Abstract
Objective. To determine whether bullying is a significant factor in the clinical training of pharmacy students.
Methods. The literature as well as the Accreditation Council for Pharmacy Education (ACPE) Standards and American Association of Colleges of Pharmacy (AACP) surveys were reviewed for mention and/or measurement of bullying behaviors in the clinical training of pharmacy students. The authors used a Delphi process to define bullying behavior. The consensus definition was used to analyze 2,087 in-house student evaluations of preceptors for evidence of bullying behaviors. The authors mapped strings of text from in-house student comments to different, established categories of bullying behaviors.
Results. The ACPE Standards and AACP surveys contained no mention or measures of bullying. The 2013 AACP survey data reported overwhelmingly positive preceptor ratings. Of the 2,087 student evaluations of preceptors, 119 (5.7%) had at least 1 low rating. Within those 119 survey instruments, 34 comments were found describing bullying behaviors. Students’ responses to the AACP survey were similar to data from the national cohort.
Conclusions. Given the evidence that bullying behaviors occur in pharmacy education and that bullying has long-term and short-term damaging effects, more attention should be focused on this problem. Efforts should include addressing bullying in ACPE Standards and AACP survey tools developing a consensus definition for bullying and conducting more research into bullying in the clinical training of pharmacy students.
INTRODUCTION
The Centers for Disease Control and Prevention (CDC) now recognizes bullying as a major public health problem and provides support for measuring bullying behaviors.1 Stories of bullying in schools and juvenile suicide caused by bullying are common in the news, with the latest focus being on cyber bullying.2,3 Bullying also occurs in the health professions, albeit to an unknown extent. A special concern for those involved in health professions education is bullying as part of clinical training. Behaviors commonly reported by trainees include persistent attempts to belittle, severely criticize, and undermine the work of the trainee or to humiliate the trainee in front of colleagues.4,5 A seminal reference in this area notes, “The abuse of students is ingrained in medical education, and has shown little amelioration despite numerous publications and righteous declarations by the academic community over the past decade.”6
Bullying and similar behaviors can have serious, long-term consequences in the workplace. For example, in 2009, a report from the Governance Institute, an advisory group within The Joint Commission, concluded that “…intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and preventable adverse outcomes, increase the cost of care, and cause qualified clinicians and managers to seek new positions in more professional environments.”7
Patient safety was the focus of a 2003 Institute for Safe Medication Practices (ISMP) survey that investigated whether disrespectful behaviors in the healthcare environment were adversely affecting medication safety.8 The survey, which received more than 2,000 responses from healthcare providers, found high incidences of “…impatience with questions, reluctance or refusal to answer questions, strong verbal abuse” and many other damaging behaviors. A similar ISMP survey in 2013 tracked the frequency of 13 disrespectful behaviors (4,884 responses) and concluded that little improvement or progress had occurred over the previous 10 years. The 2013 ISMP report concluded that “these behaviors are clearly learned, tolerated, and reinforced in both the healthcare culture and the societal culture.”9 This conclusion is reinforced by a report of persistent abusive behaviors in medical training over a 13-year study period despite efforts toward change.10 Beyond deleterious effects in the workplace, victims of bullying scored higher for depression and somatic symptoms, and had lower cortisol levels and higher incidences of posttraumatic stress syndrome (PTSD)-like conditions, recurring nightmares, and other harmful personal consequences.11-13
A search for statutes governing bullying in an educational environment revealed that such behavior was prohibited by state laws only in grades K-12. Expanding the search to bullying in the workplace found no results in any state. Legislation to prohibit workplace bullying has been introduced in at least 20 state legislatures since 2003, although none of these bills was ever enacted.14 The only groups of people protected from workplace bullying and harassment are those those protected by the Civil Rights Act of 1964 (ie, bullying based upon race, ethnicity, national origin, religion, or gender) or the Americans with Disabilities Act of 1990 (based upon a disability, actual or perceived). In court cases, attempts have been made to recover damages in lawsuits for intentional infliction of emotional distress, but these cases are difficult to prove in the first place and the majority of cases are decided for the defendant in the case. Recent articles in the news media may be the impetus for change as the public becomes more aware that these problems exist in the workplace.15,16
We asked whether bullying is a significant factor in the clinical training of pharmacy students. A preliminary PubMed literature search limited to the period 2003 through 2013 and using the combinations of search terms “bullying” and “nurse education,” “bullying” and “physician education,” and “bullying” and “pharmacist education” yielded 80 publications related to nurse education and 18 publications related to physician education. There were no publications related to bullying and pharmacist education.
The sparse literature for bullying related to pharmacist education led us to search for documentable evidence of the presence or absence of bullying in the context of pharmacy students’ clinical training. We used available national quality guidelines from the ACPE, national preceptor rating data from the AACP, and in-house practice experience surveys. Completing the latter required us to develop a consensus statement defining bullying as it applies to the clinical training of pharmacy students.
This study had 3 purposes: to investigate available literature and data for evidence regarding bullying in the clinical training of pharmacy students, to use a consensus definition of bullying to search for bullying behaviors during clinical training, and based on the findings, to suggest next steps regarding the issue of bullying in the clinical training of pharmacy students.
METHODS
The study design was reviewed by the Touro University California IRB and determined to have exempt status. Because the ACPE Accreditation Standards and Guidelines for the Professional Program leading to the Doctor of Pharmacy Degree define expectations for the education and training of pharmacy students in the United States, we reviewed the standards for references to bullying or similar behaviors.17 The AACP Online Survey System provides data regarding the educational experience and environment from the perspectives of graduating students, alumni, faculty members, and preceptors, and allows individual programs to compare the results from any of their surveys to national benchmarks and to selected peer programs. Also, the construction of these survey instruments was informed by ACPE Standards. We reviewed the 2013 AACP Online Surveys for graduating students18 and preceptors19 for references to bullying and similar behaviors. We extracted data from in-house items that addressed preceptor behavior as well.
We also analyzed data from in-house APPE student evaluations of preceptors at the Touro University California College of Pharmacy. The College requires students to complete eleven 6-week APPEs, each of which involved a minimum of 40 hours per week. Students were required to submit evaluations of both sites and preceptors after each APPE. Table 1 shows the 6 evaluation items. Students evaluated preceptors on 6 items using a 5-point Likert scale: strongly agree, agree, neutral, disagree, and strongly disagree. Although they were not required to provide feedback, the in-house evaluation also provided space for students’ comments on survey items.
Ratings Distribution from In-House Student Evaluations of Preceptors (N=2,087)
Defining Bullying in the Clinical Education of Pharmacy Students
Bullying is a hard subject to study. Even defining bullying is complex. As reported in the literature, bullying incorporates varying behaviors which, collectively, are not easily applied to a single definition and this presents challenges for validating instances or allegations of bullying behavior. If the bullying is characterized by an accumulation of relatively small incidents over a long period of time, it is sometimes even difficult for the person being bullied to recognize the situation. Often the most commonly reported behaviors among trainees are persistent attempts to belittle, severely criticize, and undermine the work of the trainee, or to humiliate the trainee in front of colleagues.1,2
In order to determine whether student comments related to behaviors that could be defined as bullying, we used the Delphi method to develop a definition of bullying specific to pharmacy student clinical training based on the literature and on consensus among a group of clinical educators.20 Seven clinical educators from 5 California colleges and schools of pharmacy accepted an invitation to participate in a meeting to discuss bullying and pharmacy education. Each panelist was experienced in the clinical training of pharmacy students. Prior to the meeting, each panelist received a list of 11 definitions of bullying and associated citations. The Delphi method for achieving consensus was described to the panel and the panelists agreed to participate in developing a definition for bullying in the context of pharmacy students’ clinical training. By consensus, the panel prioritized the 11 definitions based on their applicability to the pharmacy student in clinical training. From these definitions, the panel extracted the characteristics most important for defining bullying in this context. The resulting statement became a definition of bullying judged to be relevant to the clinical training of pharmacy students. Based on their experience, the panel also developed a list of possible outcomes of bullying during clinical education.
To map the in-house comments from student evaluations of preceptors to the consensus definition of bullying, we compiled definitions for the 9 components of bullying that had been extracted from the definition: harassment, offensive behavior, humiliation, threats, innuendo, excessive criticism, and social exclusion.21 Four faculty members working independently then mapped each of the comments from low evaluations to 1 or more of these 9 components. They then rank ordered the components based on the number of comments mapped to each.
RESULTS
ACPE Standards and AACP Surveys
The term “bullying” does not appear in the ACPE Standards. We searched the Standards for references to expectations regarding the conduct of experiential education by tracking the term “preceptors” throughout the Standards. The ACPE Standards require that preceptors as well as sites be assessed (Guideline, 14.7, Guideline 15.1, Guideline 28.4). The areas for preceptor assessment, as outlined in Appendix C include: “… the ability to facilitate learning, communication skills, quality as a professional role model and effectiveness related to pharmacy education.”15 Overall, all references to preceptor assessment, including student input, focus on the positive qualities to be fostered and recognized and do not invite the discovery of problems like bullying.
The term “bullying” does not appear in the 2013 AACP Online Survey for Pharmacy Preceptors. The 41-item survey addresses assessment procedures for students (3 items) and preceptors (4 items). The 4 preceptor assessment items concern process rather than content. Only 1 item contains terms relating to negative behaviors: “I know how to utilize policies of the college/school that deal with harassment and discrimination.” It is not clear whether the “harassment and discrimination” are directed toward students or preceptors or both. There are no other items that address preceptor behavior.
The term bullying does not appear in the 2013 AACP Online Survey for Graduating Students. The 85-item survey contains 2 items that relate to preceptor assessment. These are item 68, “Overall, preceptors modeled professional attributes and behaviors in the pharmacy practice experiences” and item 69, “Overall, preceptors provided me with individualized instruction, guidance and evaluation that met my needs as a Doctor of Pharmacy student...” Respondents generally showed high levels of agreement with both items (Table 2).
Preceptor-Related Data From the 2013 AACP Online Graduating Student Surveys
Data From In-House Student Evaluations of Preceptors
From 2011-2013, 2,087 in-house evaluations were submitted. Because students were required to complete the survey, the response rate was 100%. Out of 2,087 surveys, 119 had a disagree or strongly disagree response on 1 or more items. For these 119 low evaluations, we recorded the percent of students who agreed or strongly agreed (positive) and the percent who disagreed or strongly disagreed (negative) for each of the 6 items. The ratings distributions for the 6 items are shown in Table 1. We also compiled the comments from these evaluations to determine whether the comments might address behaviors that could be considered bullying. The in-house evaluations included a neutral rating and, therefore, could not be directly compared to AACP survey responses.
Developing a Definition of Bullying
The 7-person Delphi panel selected 4 of 11 definitions as most relevant to the clinical training of pharmacy students. These are presented in Appendix 1. Extracting from these definitions, the Delphi panel constructed the following definition:Bullying in a learning environment means harassing, offending, socially excluding someone or negatively impacting the individual. In order for the label bullying to be applied to a particular activity, interaction, or process, the bullying behavior has to occur repeatedly over a period of time. These behaviors may include threats, intimidation, humiliation, excessive criticism, innuendo, and exclusion or denial of access to opportunity.
The panel also emphasized 2 additional comments: (1) “It is important to note the fundamental distinction between bullying, which is inherently undermining and corrosive, and constructive supervision, which is developmental and supportive…”22 and (2) “these ‘bullying’ behaviors can reasonably be predicted to have the effect of one or more of the following—causing a reasonable learner to fear harm to that learner or learners’ person or property, experience a substantial detrimental effect on his or her physical or mental health, experience substantial interference with his or her academic performance, experience substantial interference with his or her ability to participate in or benefit from services, activities, or privileges provided by the learning environment.”23
Mapping Comments to the Definition
The 119 low evaluations yielded 34 comments. The results of mapping the 34 comments to 9 components from the consensus definition of bullying are presented in Table 3. Examples of comments that were mapped to a particular component were included. Offensive behaviors, humiliation, and intimidation were the most commonly reported bullying behaviors. Many comments were similar to those reported in the 2013 ISMP survey and in the literature about bullying.
Rank-Ordered Mapping of In-House Comments to Components of the Definition of Bullying
DISCUSSION
We undertook this investigation based on the documented presence of bullying across different age groups, occupations, and environments, coupled with abundant research showing the long- and short-term damaging effects of bullying on individuals, organizations, and systems. Our investigation, designed to be systematic, included reviewing the medical literature, the ACPE Standards, the AACP Online Survey System, and the college’s in-house evaluations. Our literature search yielded: (1) no pharmacy-related articles, (2) no mentions of bullying in the ACPE Standards or the AACP surveys, (3) a small percentage of students, both nationally and in the college, whose responses included low preceptor ratings in AACP surveys, and (4) a small percentage of in-house evaluations that contained low ratings of preceptors. The last step in the process involved strings of text-based comments contributed by a subset of the 119 respondents with low in-house evaluations. A group of faculty members working independently mapped these individual comments to key elements of the definition of bullying derived from the Delphi method. This last step yielded evidence that bullying behaviors had occurred during clinical training.
Because the comments were drawn from students at a single college, we investigated the extent to which the responses of students at our college reflected those from the national pool represented in AACP surveys (Table 2). The very similar distribution of ratings suggested that the 2 student pools were not different with respect to their rating of preceptors.
When we began this study, we wanted to determine why, if bullying behaviors are present as we found, there is little evidence of their presence. We believed it was unlikely that the healthcare delivery environment would include bullying directed at nursing and medical students but not at pharmacy students. We could not exclude the possibility that the paucity of evidence of bullying toward pharmacy students is simply a reflection of there being more nurses and physicians than pharmacists.24 Another explanation is that the assessment tools used in pharmacy education were not intended to identify bullying behaviors. The positively framed ACPE Standards, AACP survey items, and in-house evaluations could be providing subtle cues to respondents about response expectation. This concept, sometimes termed “yea-saying,” refers to “…the tendency of respondents to agree rather than disagree with statements as a whole or with what are perceived to be socially desirable responses to the question.”25 Positively framed assessment tools can also promote social desirability bias; that is, a tendency for respondents to answer questions in a manner that will be viewed favorably by others.26 Finally, professional programs emphasize professionalism and constructive criticism, which would tend to encourage positive responses. In other words, we may not be asking the right questions or we may not be asking the questions the right way.
We also asked, if bullying behaviors are present, why students do not bring them to our attention more often. The answer may be found in the Delphi panel’s statement that a predictable outcome of bullying in students is fear about their grades and other possible adverse consequences. The ACPE Standards also appear to recognize this possibility when advising colleges and schools that preceptor assessment should occur “…in a manner that would not adversely affect the grading process.” To protect students from possible adverse consequences, it is important to provide avenues for students to share negative experiences without fear.
In summary, our investigation suggested that bullying is present in the clinical training of pharmacy students, but available evidence currently provides very little insight into its prevalence or awareness about it. Because of the well-documented negative impacts of bullying on the victims and ultimately on patient care, we suggest the following:
(1) Adopt a consensus definition for bullying in the clinical training of pharmacy students that can be used in education and in constructing evaluation tools;
(2) Consider the addition of language addressing bullying behaviors to ACPE Standards, AACP surveys, and in-house practice experience evaluations;
(3) Establish zero-tolerance policies regarding bullying behaviors. A commitment to zero tolerance will likely require careful follow-up on low student evaluation of preceptors and other measures to determine if bullying may be occurring, even if at low levels;
(4) Create protected environments for students to report bullying behaviors;
(5) Include the topic of bullying in preceptor education. This is especially important because bullying behaviors were for a long time considered a “rite of passage” and were widely regarded as acceptable behavior;
(6) Support additional research to determine the prevalence and awareness of bullying, outcomes from bullying, and effective practices for eliminating bullying behaviors from the clinical training of pharmacy students.
This study focused on bullying behaviors in the clinical training of pharmacy students. Bullying may also occur in the classroom; however, that was not investigated in this study. We may have underreported bullying behaviors that occurred during clinical training because we only compiled and examined comments from low in-house student evaluations of preceptors. Direct reporting of bullying behaviors to experiential staff members or student services personnel would not have been captured in our study, and this also may have resulted in under reporting. Over reporting also may have occurred because follow-up interviews with preceptors to learn “the other side of the story” were not conducted. The definition of bullying developed for this study is subject to review and revision as more information becomes available. The evidence of bullying came from a single college, which raises the possibility that similar events do not happen elsewhere. We attempted to overcome this limitation by comparing our school response patterns to national survey data.
CONCLUSION
Given the abundant evidence that bullying during the training of health professionals has long-term and short-term damaging effects, more attention needs to be paid to bullying in pharmacy education. The ACPE quality standards and national survey tools from AACP do not directly address bullying. Further, there is no agreed upon definition of bullying in the clinical training of pharmacy students. We used a Delphi method to develop a consensus definition of bullying in this context. Comments from in-house student evaluations of preceptors, when mapped to components of the definition, documented behaviors that are consistent with bullying. Efforts to address bullying should include developing a consensus definition, bringing attention to bullying in ACPE Standards and AACP survey tools, and conducting more research to determine the prevalence of bullying, awareness about bullying, outcomes, and effective practices for eliminating bullying behaviors from the clinical training of pharmacy students.
ACKNOWLEDGEMENTS
The authors acknowledge the assistance of Rebecca Miller, Touro University California librarian, for helping us research the extensive medical literature about bullying. We also acknowledge colleagues from the Institute for Safe Medication Practices for collaboration regarding their research that helped us frame the study. The authors also acknowledge members of the Delphi group: Dr. Kathleen Hill-Besinque, Dr. James Colbert, Dr. Robert Ignoffo, Dr. Melissa Mitchell, Dr. Daniel C. Robinson, Dr. James Scott, and Dr. Keith Yoshizuka.
Appendix 1.
Definitions Selected by the Delphi Panel as Most Appropriate for Clinical Education of Pharmacy Students
Definition A. Verbal aggression, abuse, or bullying: Incorporates a wide range of behaviors, including threats, intimidation, humiliation, excessive criticism, covert innuendo, exclusion or denial of access to opportunity, undue additions to work requirements, and shifting responsibilities without appropriate notice.1
Definition B. Bullying at work means harassing, offending, socially excluding someone or negatively affecting someone’s work tasks. In order for the label bullying to be applied to a particular activity, interaction or process, the bullying behavior has to occur repeatedly and regularly and over a period of time. Bullying is an escalating process in the course of which the person confronted ends up in an inferior position and becomes the target of systematic negative social acts.2
Definition C. Bullying is any severe or pervasive physical or verbal act or conduct, including communications, made in writing or by means of an electronic act, and including one or more acts committed by an individual or group of individuals … directed toward one or more individuals that has or can be reasonably predicted to have the effect of one or more of the following:
• Placing a reasonable [student or students] in fear of harm to that pupil’s or those pupils’ person or property.
• Causing a reasonable [student] to experience a substantially detrimental effect on his or her physical or mental health.
• Causing a reasonable [student] to experience substantial interference with his or her academic performance.
• Causing a reasonable [student] to experience substantial interference with his or her ability to participate in or benefit from the services, activities, or privileges provided by a school.3
Definition D. Given its shifting nature, the categories of behavior that might be considered bullying cannot be listed exhaustively. However types of behavior which might be considered bullying include: threats to professional status; threats to personal standing; isolation; overwork; and destabilization. It is, however, important to note the fundamental distinction between bullying, which is inherently undermining and corrosive, and constructive supervision, which is developmental and supportive. This distinction is of particular importance in the medical profession in light of its hierarchical nature.4
- Received December 13, 2013.
- Accepted January 31, 2014.
- © 2014 American Association of Colleges of Pharmacy
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