Nurse Education in Practice (2007) 7, 26–35

Nurse Education in Practice www.elsevierhealth.com/journals/nepr Exploring bullying: Implications for nurse educators
Sharon L. Edwards a a,*

, Claire Frances O’Connell

b

Department of Pre-registration, Nursing Faculty of Health Studies, Buckinghamshire Chilterns University College, Chalfont Campus, Newland Park, Gorelands Lane, Chalfont St. Giles, Buckinghamshire HP8 4AD, United Kingdom b Green Lawns, Kilmona Grenagh Co., Cork, Republic of Ireland
Accepted 27 March 2006

KEYWORDS
Bullying; Violence; NHS; Higher education; Nurse education



Summary This article examines briefly the issue of workplace violence and bullying in the hospital environment, but more importantly how the same and different styles of bullying and intra-staff bullying are emerging in nurse education. The content describes the aetiology of violence and bullying and their place in the National Health Service (NHS) including nursing. It explores bullying as the principle form of intimidation in nurse education, the different types and subtle forms of bullying, why individuals become bullies, dealing with and the consequences of bullying. The legislation, guidelines, policies are part of the recommendations for practice. c 2006 Elsevier Ltd. All rights reserved.

Introduction
In modern day society, it could be argued that violence and aggression is a common aspect of daily life. Violence and abuse within the hospital setting occurs throughout the entire health care sector (Zernike and Sharpe, 1998; Wells and Bowers, 2002). Over the years, negative incidents including violence, harassment, and aggression and bullying have been steadily increasing. In the year 2002/
* Corresponding author. Tel.: +44 1494 522141x2123; fax: +44 1494 603182. E-mail address: sedwar02@bcuc.ac.uk.

2003, there were an estimated 116,000 incidents of violence reported in the National Health Service (NHS), 38,000 of which occurred in acute trusts including general hospitals (DoH, 2003), a rise by 13% from the previous year. In the same given year, there were an estimated 7700 incidents of harassment against health care staff (DoH, 2003). Due to this, morale is low, job satisfaction and enthusiasm is diminishing, resulting in one of the main reasons why an increased number of health care staff is reluctant to work, or even opting to leave their profession. Yet the issues of violence remain under-researched, and it is only in the last decade they have received recognition.

1471-5953/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2006.03.004



Exploring bullying: Implications for nurse educators The perpetrators in hospital settings are mainly relatives and patients (Vanderslott, 1998). Bullying can occur between different staff members and between professional groups and from managers. Such acts have infiltrated into the nursing profession (Jackson et al., 2002) and are currently rife within higher education (Cooper, 1999) where the education of nurses is now placed. In addition, there is reason to suspect that the occurrence of bullying practices have transferred via recruitment from the hospital setting to higher education institutes. Nurse educators are now becoming the victims of such horrendous acts, increasing the stresses of working life and few are equipped to deal with bullying (Cameron, 1998). The immense impact that bullying can have on a nurse educator’s physical, psychological and emotional well being is profound. Yet, accepting approaches to such acts are still common (Beech, 2001).

27 results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation.’’ Workplace violence has numerous words used to describe it including aggression, harassment, bullying, assault and intimidation, and the perpetrators of such acts include patients, relatives, nurses and other various health care professionals (Jackson et al., 2002). Budd (2001, p. 1) attempts to define workplace violence: ‘‘All assaults or threat’s which occurred while the victim was working and was perpetrated by members of the public.’’ Bullying is often considered under the heading of violence, but due to its more subtle nature research is emerging whereby it is separated (Ball, 2003; Bray, 2001; Normandale and Davies, 2002) (Table 2). Bullying or workplace bullying has not been officially defined, bullying alone is a new phenomenon, and is open to many interpretations. Randall (1997: p. 1) proposes a variety of terms including: ‘‘. . .verbal unpleasantness, the threat of violence or painful physical contact, being on the receiving end of rumours and vicious gossip or maybe outright rejection by family or colleagues at work.’’ Violence, aggression, harassment and bullying are emotional issues for the victim involved, are detrimental to the victim’s health, especially if physical or psychological trauma is involved. Unfortunately bullying is rife in the health care sector, especially in the nursing profession, and is proposed to occur within higher and nurse education. Yet research studies into its occurrence in nurse education are very limited.

Aetiology of violence and bullying
The World Health Organization (WHO, 2002a, 2002b) proposes various terminology to apply to and incorporate violence of all forms physical violence, psychological violence, assault/ attack, abuse, bullying/mobbing, harassment, sexual harassment and racial harassment (Table 1). The World Health Organisation (WHO 2002a, p. 3) defines violence as: ‘‘The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either

Table 1

Types of violence and aggression Common types reported Angry tone of voice Yelling and screaming Threats against the institution Derogatory remarks Intimidation Threat of physical violence Actual bodily harm Hitting, hitting across the head Biting Kicking Scratching Pushing against the wall Attempted strangulation

Type of violence and aggression Verbal abuse

Violence and bullying in the NHS
Although violence and aggression has been a recurrent issue in the nursing profession, it is only in the past decade it has received recognition. Therefore, it is difficult to ascertain the true frequency of violence and aggression occurring in the NHS before the last decade, but Vanderslott (1998) suggests that it is an immense problem. The British Crime Survey (BCS) found there were an estimated 849,000 incidents of violence and aggression at work in England and Wales in 2002/2003 (Budd, 2001). ‘High risk’ professions included police, firemen, and health and social care associates including nurses. The BCS found that 3.3% of health and social care associates were

Physical abuse

(Mayer et al., 1999; Cameron, 1998; O’Connell et al., 2000).

28
Table 2 Types of bullying behaviour Descriptions
                       

S.L. Edwards, C.F. O’Connell

Type of abuse Verbal abuse

Written abuse Physical abuse

Intimidation

Displays of offensive material

Using offensive language or innuendo Sexist, racist or patronising remarks Telling racist, sectarian or sexually suggestive jokes Inappropriate or intimate questioning, uninvited, unreciprocated unwelcome behaviour of a sexual nature Derogatory statements of a sexual, racist or sectarian nature Propositions and offensive remarks Name calling, including personal comments about physical looks Language that belittles a person’s abilities Spreading malicious rumours or hurtful gossip Written abuse such as letters, faxes or e-mails (often anonymous) Unwanted physical contact Explicit physical threats or attacks Suggestive gestures (such as mimicking the effects of a disability) Unnecessary touching or assault Stalking which occurs at work or outside of work, but is related to work Slander, music and ‘party tunes’ Conduct that belittles in some way, such as being shouted at Intrusion by pestering, spying, following Unnecessary closeness Apportioning blame wrongly Flags and emblems Badges Graffiti Unnecessary highlighting of differences

NHS Zero Tolerance Zone (NHS, 1999).

assaulted at work, and 2.3% threatened at work in 2002/2003. Nurses are prime targets of violence and aggression as they are principle carers who are in contact with the patient 24 h a day (Vanderslott, 1998). In October 2003 the Commission for Health Improvement (CHI 2004), in conjunction with the National Health Service (NHS) conducted one of the largest workforce surveys ever. The findings suggested that 37% had experienced harassment, bullying or abuse at work in the previous 12 months this is an extremely high and worrying amount of employees in the NHS who are exposed to bullying behaviour. A high percentage of staff witness bullying occurring to other colleagues (Quine, 1999). In 2000, the Royal College of Nursing (RCN, 2000) produced a quantitative questionnaire survey of 6000 RCN members in the UK, excluding student nurses, looking specifically at their well being and working lives in the health sector. The findings reveal that over the previous 12 months of the study, 20% of nurses had been assaulted at least once, 12% of nurses had been assaulted at least once a week, and 3% experienced assault on a daily basis. Just under half of the respondents (49%) had been harassed and assaulted 2–6 times in the previous year.

Statistics produced by Poster and Ryan (1993) show that physical assault is worryingly high. Sofield and Salmond (2003) and O’Connell et al. (2000) suggest the perpetrators of violence and bullying towards nurses are mainly patients, relatives and in some instances doctors, but also includes supervisors and colleagues.

Types of NHS violence and bullying
Experiences that were more common included verbal abuse, intimidation, and the threat of physical assault and actual bodily harm. Verbal abuse is believed to be a frequent problem (Mayer et al., 1999). In Cameron’s (1998) study an angry tone of voice was the most common form of verbal abuse, then yelling/screaming, threats against the institution and derogatory remarks. The most common types of physical assaults reported included biting, kicking, hitting and scratching. Assaults that are more serious included hitting nurses across the head, pushing nurses against a wall, and attempted strangulation (O’Connell et al., 2000). This may not be so shocking if the patient had a known mental or physical condition, but in these instances there is no mention of such occurrences.

Exploring bullying: Implications for nurse educators

29 ‘‘. . . a form of harassment which involves persistent, intimidating behaviour, usually by a supervisor toward an employee. It can include repeated unfounded criticism in front of colleagues, constant nit-picking over trivia, the use of offensive language, lying, over-monitoring, isolating an individual, and withholding information to ensure that an individual fails to achieve a given task’’ Other indirect experiences reported by participants included refusing to lend a hand, talking about people behind their backs with other colleagues, excluding one from conversations, withholding information thus detrimentally affecting their career and holding staff on duty when they are officially finished (Farrell (1997). These forms of bullying behaviour are so subtle, the victims might not even be aware of it occurring.

Violence and inter-staff bullying within health care professionals
Workplace bullying can include negative criticism or sarcasm in a direct or subtle way (Normandale and Davies, 2002). However, different bullying styles vary between diverse groups’ newly qualified nurses, experienced nurses and junior doctors (Table 3). The study by McKenna et al. (2003) investigated nurses’ experience of bullying in their first year of practice and bullying therefore may be related to levels of experience. Another study by Brennan (1999) used a questionnaire circulated at a nursing conference to identify the types of bullying occurring. Different types of bullying occurred between these professional groups. Quine (2003) also carried out a quantitative study to investigate the prevalence of inter-professional bullying amongst junior doctors the nature of the bullying again differed from that of McKenna et al. (2003) and Brennan’s (1999) study. It may be suggested that inter-staff bullying in nurse education might be different again from bullying that takes place between practice nurses and junior doctors. However, it is not how the perpetrator delivers the bullying and what form it takes, it is the stress experienced by the individual that constitutes the bullying.

The perpetrators of inter-staff bullying
There is still a small proportion (28%) in these studies that stated peers, and 16% stated that supervisors were common perpetrators of abuse. The Royal College of Nursing (RCN, 2000) reported that the most common sources of bullying were the nurse’s immediate supervisor or manager. Similar findings were identified in McKenna et al.’s study (2003) whereby the most common perpetrators listed were who the nurses were accountable to. It appears that in some instances a common source of intimidation is from nursing peers, clinical nurse specialists and managers. These findings convey the high extent of unseen aggression inflicted upon nurses by their colleagues and managers. These issues need to be exposed and appropriately addressed to stop such distressing events, promoting a safer and harmonious working

Types of inter-staff bullying
Farrell (1997) included innuendo, putdown, threats, intimidation and actual physical violence and identified more subtle forms of bullying, such as one person putting down another person by raised eyebrows, snide remarks and turning away. Bray, 2001, p. 21) included inter-staff bullying in a definition:

Table 3

The different types of intra-staff bullying identified between professional groups Brennan’s (1999) study a questionnaire was handed out at a nursing conference          Humiliation Undermining authority Criticism of work Unreasonable requests Intimidation Exclusion from groups Threat of dismissal Offensive language Denial of work resources Quine (2003) investigated interprofessional bullying amongst junior doctors  Destructive innuendo  Other colleagues attempts to belittle and undermine their work  Unnecessary excess pressure to produce work  Unjust and constant criticism of work  Public humiliation  Goalposts shifted in their work without prior warning

McKenna et al. (2003) investigated nurses’ experience of bullying in their first year of practice  Qualified but treated like students  Undervalued by their colleagues  Having learning opportunities blocked were forms of bullying  Rude, abusive, humiliating or unjust behaviour toward them  Verbal sexual harassment  Racial comments  Inappropriate gestures

30 environment for nurses and other health care professionals.

S.L. Edwards, C.F. O’Connell The differences might include being treated like a student by line managers, undervalued by colleagues, achievements being ignored, having learning opportunities blocked (McKenna et al., 2003), which is detrimental to career progression and promotion. Other suggestions include holding staff at meetings or in the office when they are officially finished, undermining authority, and criticism of work, making unreasonable requests, intimidation, exclusion from groups, threat of dismissal or written or verbal warning (Brennan’s, 1999). In Quine’s (2003) study the type of bullying was unnecessary excess pressure to produce work, shifting of goal posts without prior warning. There are in addition even more underhand forms of bullying, where it can be hidden or bullying becomes subtler (Cooper, 1999). Subtle or smart bullies:  Set their staff up to fail, by withholding or manipulating information.  Calling meetings when staff are not available.  Isolating workers from colleagues.  Criticising them for minor mistakes.  Undermining their self-confidence by ignoring their successes. Bullying styles may evolve and change and vary between different professional or discipline groups. Bullying in HE and within nurse education may well be more wily or conniving than bullying taking place elsewhere and as such particularly more difficult to determine. These forms of bullying behaviour are so subtle, the victims might not even be aware of it occurring. In this instance the fault may lie with others who allow subtle bullying to be maintained against others in their presence without actually doing anything about it.

Bullying within higher education
There is no doubt that violence and bullying is a widespread problem within society and in the NHS, mainly towards and between different health care professionals. Yet, violence in higher education (HE) may not be as prevalent as bullying as demonstrated by current literature. Numerous recent surveys have highlighted the problem of bullying, including occurrences in universities and colleges. A survey of 800 members of the lecturer’s union NATFE in Wales reported that 18% of lecturers had been bullied, 25% had been told by colleagues that they had been bullied, 22% had witnessed bullying (Lewis, 1999). In this study workplace experience of bullying was ranked higher than sex discrimination, sexual and racial harassment. In a NATFE sponsored study of more than 300 members in England, it was found that 22% had recently experienced bullying (Cooper, 1999). However, if bullying occurs in HE it cannot automatically be stated that it happens in nurse education as the research articles examined are not specific to nurse education. However, the education of nurses is now part of HE, which may or may not be significant, it is hard to tell with such little evidence to refute or support this, but more importantly lecturing staff are generally recruited from the health care sector. The bullying that takes place within the NHS between colleagues and peers and from senior management, could be transferred into nurse education through recruitment. The investigations and literature into bullying in HE and within the health care sector could be transposed into nurse education. Bullying in nurse education could therefore wear the same mask as that which is present in the NHS and within hospitals. It includes the use of persistent harassment and psychological intimidation and the more subtle forms of bullying identified by Farrell (1997, 1999). The bullies who shout and publicly humiliate their subordinates or colleagues are easy to identify. There are more subtle forms of bullying that takes place such as negative criticism or sarcasm which, demean and humiliate the victims in a devious but ingenious way (Normandale and Davies, 2002). As previously stated bullying between different professional groups varies, bullying in nurse education may differ again from bullying that takes place between practice nurses and junior doctors.

Why individuals become bullies
Paterson et al. (1997) suggests that the perpetrators of bullying have been bullied themselves, yet they still continue to harass others. There are always a small number of individuals who reveal their insecurities when they reach positions of influence. In a managerial system whereby a hierarchical type of organization exists such as in HE, Farmer (1993) states that bullying occurs because the individual has a superior position over others and violates their power and over rates their own importance. Kolanko et al. (2006) reported that certain events separate from the academic

Exploring bullying: Implications for nurse educators setting may lead to bullying behaviours, including failure to achieve a goal, thwarting of ambitions and wishes feeling threatened. This list has relevance for nurse education. These individuals may have low self-esteem and try to enhance their self-worth by demeaning others; or they feel so threatened by a high-flying colleague that they bully them to try and defuse the threat they pose (Cooper, 1999). One theory of why individuals become bullies was proposed by Bray (2001). Bray suggests that workplace gender segregation, which can be found in careers such as nursing, and nurse education increase’s the frequency of same-sex bullying. Bray (2001, p. 23) states ‘. . .people tend to work with colleagues of their own gender, there is a tendency for women to bully women and men to bully men.’ This theory is reflected in Quine’s (1999) study, where in 57% n = 137 of incidents reported the bully was the same sex as the victim, and in Farrell’s (1997) exploration of clinical aggression, the participants stated their prime concern was continual intra-staff woman to woman aggression and bullying. The big issue of bullying today in HE is among the overloaded bullies, those who are unable to cope with their workload, with difficult staff, with their or others’ career problems or with autocratic superiors (Lewis, 1999). HE institutes have taken up the private sector culture. Academics have to deal with high workloads, long and unsociable hours, job insecurity; performance-related demands are being imposed, power imbalance between managers and academics, and a more top down, bottom line management style. Therefore, in all departments within HE some individuals use bullying as a management style. There is no reason to believe that the workload of nurse educators is any less demanding than other HE academic staff. There is a lack of professionally trained managers (Lewis, 1999). This enhances the problems as the majority of managers within nurse education are appointed on the basis of their research competence, volunteer to undertake an academic role to enhance their career opportunities, rather than for their management skills. When these managers find themselves with a work overload, staff conflict or financial crisis, their lack of managerial skills leads some of them to ‘manage by bullying’ (Cooper, 1999). The two most prominent features that are likely to have an impact on workplace bullying within nurse education are the lack of professionally

31 trained middle and senior managers, same sex bullying as the majority of nurse lecturers are women, and a power imbalance between managers and lecturers (Lewis, 1999).

Consequences of bullying
The consequences of intimidation and bullying can have an immense impact on a nurse educator’s mental, physical and emotional well being. The results of such behaviour can be immediate, short term and long term affecting their personal and professional lives. Naab (2000) states that regardless of the severity of the aggression, or if it had been actually experienced or witnessed, the effects of its impact were the same. In O’Connell et al.’s study (2000); the most common feelings experienced were frustration and anger. Fear and emotional hurt closely followed. There were also various reactions by participants in their study some took sick leave and changed their job. Sofield and Salmond (2003) found that following incidents of verbal abuse, there was decreased morale, productivity and increased errors at work. Rippon (2000) highlights the key individual responses including people giving up their jobs to avoid the perpetrators, victims experiencing psychological stress, recurring nightmares, re-experiencing the trauma and moodiness. Normandale

Table 4

The consequences of bullying behaviour Symptom caused Headaches Sweating/shaking Feeling/being sick Irritable bowel Raised blood pressure Inability to sleep Loss of appetite Anxiety Panic attacks Depression A feeling of dread Tearfulness Becoming irritable Becoming withdrawn Becoming aggressive Increased consumption of tobacco/alcohol Obsessive dwelling on the bullying

Area effected Physiological

Psychological

Behavioral

Normandale and Davies (2002).

32 and Davies (2002) listed various physiological, psychological and behavioural effects nurses have experienced due to bullying behaviour, such as feeling/being sick, inability to sleep, anxiety, becoming withdrawn and dwelling on the bully (Table 4).

S.L. Edwards, C.F. O’Connell actually confronting the perpetrator and discussing the problem with them, and more than half of the respondents found this course of action successful. Confronting the perpetrator is one way a nurse educator can deal with bullying. An unexpected unhelpful source for dealing with bullying was line managers. Although just over a quarter of respondents talked with their line manager only a very small proportion (6%) found this action helpful (McMillan, 1995). In relation to nurse educators this may be because the line manager is a source for the bullying. In general support is sought from friends and family, but few report the incident (Cameron’s, 1998). The lack of reporting bullying within universities and nurse education may because these institutions do not have mechanisms to deal with bullies. There are no procedures for staff to disclose bullying experiences safely, no counseling for the bullied or disciplinary or training strategies to deal with the bully. In a study by McMillan (1995) the use of a counselor following bullying was surprisingly low, yet a high proportion found this source most helpful. Many private business and firms have antibullying policies and procedures to allow employees to reveal the problems (Davies, 2002). They employ trained staff to gather evidence and, subsequently discipline or train bullies. Collins (1994) looked at attitudes towards bullying following their

Dealing with bullying
In Sofield and Salmond’s (2003) study the verbal abuse is frequently accepted as part of the job, and many would rather not deal with the situation. Some took precautionary measures by documenting incidents or sought legal advice. Others used avoidance strategies instead of confronting the issue. When discussing their course of action some required time alone to regroup their thoughts or sought support from colleagues. McMillan (1995) highlights that it was probable for individuals to seek practical and emotional support from loved ones talk with a partner or friend or colleague. Nurse educators may not be comfortable using a colleague, who is of the same sex, as they may be the perpetrator of the bullying. A small proportion of respondents did not discuss the matter or seek help from anyone. The course of action taken to deal with the issue of bullying is varied (Table 5). McMillan (1995) found that some respondents were

Table 5

Dealing with bullying What you can do Express your feelings to the individual, tell them to stop what he or she is doing Reassure the person Understand the bullies anger Model calm behaviour Provide cautious reminders One-to-one (not isolated) communication Mirror perpetrators behaviour Talk about it to a colleague Go above the bully’s head (to his or her boss!) Discuss it with human resources (personnel) Talk to the representative from your professional association Keep eye-contact with the perpetrator Move further away from the person Appropriately use touch Use the limitation of the surrounding space to calm the individual Provide a change of topic to refocus the unwanted attention Keep a written record of times, dates and incidents Write to the bully and again request that he or she cease the bullying behaviour Keep copies just in case

Techniques Verbal techniques

Non-verbal techniques

Writing down incidence

Modified from Garnham (2001) and Brennan (1999) (a study which investigated types of bullying that occur in nursing).

Exploring bullying: Implications for nurse educators attendance at ‘The Prevention and Management of Aggressive Behavior Programme’ (PMAB). The study provides evidence that training and education plays a key role in successful management of aggressive and bullying behaviour, and that it does contribute to staff confidence when bullying occurs. Universities too must train senior staff in people management and develop ways of tackling the growing problem of subtle and cunning bullying.

33 Upson, 2003). A directive called ‘Zero Tolerance’ from the Health Minister John Denham in 1999, in conjunction with the NHS (NHS, 1999) set about preventing violence and bullying incidents. This directive not only addressed the physical and verbal abuse that staff were subjected to by patients, visitors and members of the public, but aimed at staff attitudes towards each other. Yet, in this report nurse education was not referred to, and may not have relevance as it is dealing with clearer areas relating to violence and bullying. In order for a change in the working environment to occur, various actions must occur. Primarily, nurse educators’ must accept that there is a need to alter practice, and have a shared vision of a healthier working climate. Nurse educators need to identify the problems that exist and work together diligently to eliminate them (Kolanko et al., 2006). Although some nurse educators may

Recommendations for practice
All employees including nurse educators should not have to experience any form of violence, aggression or bullying behaviour. There are various national and governmental policies, guidelines and legislation from 1974 to current day to protect them from such ordeals (HMSO, 1974, 1977, 1996;

Table 6

The recommendations for practice Outcome  Violence and bullying causes emotional and psychological distress  An infliction of immense harm upon an individual  Bullying contradicts the principle of respect, as such actions disregard the recognition for an individual’s autonomy  Acts of bullying oppose clause 4.2 of the Nursing and Midwifery Council’s Code of Professional Conduct (NMC 2002:6)  The perpetrators of bullying, who are registered nurses, should accused of professional misconduct for breaching this clause  Formal preparation to deal and cope with bullying  Education and training should be provided on policies and protocols of inter-staff bullying, as well as management and interpersonal techniques.  Attendance at study days, inclusion in continual professional development programs and induction training  Awareness of bullying, HEI have an obligation to provide information through relevant means  A complaints procedure against bullies  Employees need to be appropriately informed that intra-staff bullying will not be tolerated and is unacceptable  Confidential counselling services, hotlines provided for staff to seek guidance without fear of retribution  Booklets, leaflets and internal memos should be made readily available for staff  Bullying is not a ‘fad’ and HEIs need to work towards a general university wide and local discipline specific policy  A formalised policy including what actions constitute bullying and those which do not, common ground  The specific policies may differ significantly between disciplines  Further research is needed in intra-staff bullying within HE and specifically within nurse education  In order for national and local organisational bodies to effectively tackle the issues of workplace bullying, further research is required in order to establish what specific areas needs to be focused upon

Recommendation The acts of violence and bullying from one individual to another opposes the Principle of Beneficence and NonMaleficence (Hendrick, 2001)

Education and training – One of the greatest methods for overcoming change is through education (Ewles and Simnett, 1999) The provision of information (Naab, 2000)

The provision of policies and guidelines (NHS, 1999; Ball, 2003; Quine, 1999) Further research (Cormack, 2000; Upson, 2003)

34 resist change, as they may believe the change is not in their interests (e.g. the perpetrators of aggression may believe they should not have to change their practice). The recommendation for the practice base of nurse education is to consider the ethic of caring between each other, education and training, the provision of information, new directives, policies and guidelines and the need for further research (Table 6).

S.L. Edwards, C.F. O’Connell governing, professional bodies, as well as university policy organisers and local departmental managers. Abusive behaviour, albeit emotional or physical is not acceptable in any career and nurse educators are not an exception.

References
Ball, C., 2003. Bullying and dignity at work. Community Practitioner 76 (7), 250. Beech, B., 2001. Zero tolerance of violence against healthcare staff. Nursing Standard 15 (16), 39–41. Bray, C., 2001. Bullying nurses at work: theorising a gendered experience. Contemporary Nurse 10 (1–2), 21–29. Brennan, W., 1999. I’m talking to you. Emergency Nurse 7 (2), 16–20. Budd, T., 2001. Violence at Work: New Findings From the British Crime Survey, Home Office, Occasional Paper. Home Office, London. Cameron, L., 1998. Verbal abuse: A proactive approach. Nursing Management 29 (8), 34–36. Collins, J., 1994. Nurses’ attitudes towards aggressive behaviour, following attendance at ‘The Prevention and Management of Aggressive Behaviour Programme’. Journal of Advanced Nursing (20), 117–131. Commission for Health Improvement, 2004. NHS National Staff Survey 2003. Available from: http://www.chi.nhs.uk/eng/ survey/nss2003/index.shtml, Department of Health. Cooper, G., 1999. We must deny bullies a pulpit. Times Higher Education 23 (April). Cormack, D., 2000. The Research Process In Nursing, fourth ed. Blackwell Science, Oxford. Davies, D., 2002. People management – combating the greatest business risk of the 21st century: corporate bullying. Computer Law and Security Report 18 (4), 269–271. Department of Health, 2003. 2002/2003 Survey of Violence, Accidents and Harassment in the NHS, HMSO, London. Ewles, L., Simnett, I., 1999. Promoting Health: A Practical Guide, fourth ed. Bailliere Tindall, London. Farmer, B., 1993. The use and abuse of power in nursing. Nursing Standard 7 (23), 33–36. Farrell, G.A., 1997. Aggression in clinical settings: nurses views. Journal of Advanced Nursing (25), 501–508. Farrell, G.A., 1999. Aggression in clinical settings: nurses views – a follow-up study. Journal of Advanced Nursing 29 (3), 532–541. Garnham, P., 2001. Understanding and Dealing with Anger, Aggression and Violence. Nursing Standard 16 (6), 37–42. Health and Safety at Work Act, 1974. Crown Court and Home Office. HMSO, London. Health and Safety Commission, 1977. Safety Representatives and Safety Committees, HSE. HMSO, London. Health and Safety Executive, 1996. Everyone’s Guide to RIDDOR 1995: Reporting of Injuries, Diseases and Dangerous Occurrences, HMSO, London. Hendrick, J., 2001. Law and Ethics in Nursing and Healthcare. Nelson Thornes, Cheltenham. Jackson, D., Clare, J., Mannix, J., 2002. Who would want to be a nurse? Violence in the workplace – a factor in recruitment and retention. Journal of Nursing Management (10), 13–20. Kolanko, K.M., Clarke, C., Heinrich, K.T., Olive, D., Serembus, J.F., Sifford, K.S., 2006. Academic dishonesty, bullying, incivility, and violence: difficult challenges facing nurse educators. Nurse Education Perspectives 27 (1), 34–43.

Conclusion
The frequency of both violence and bullying in the NHS and against nurses is of concern. The types of aggression include verbal and physical abuse, all of which are found to be common actions by patients, visitors, members of the public, and even work colleagues. Many of the nurses state they accepted abuse as part of the job, and do not seek support or know where or how they could access the relevant resources in their area of employment. The issue of workplace bullying is significantly under-researched, and yet it exists. Studies that have investigated this issue have found that the frequency of bullying behaviour within universities is a common occurrence, ranging from implicit actions such as refusing support at work to explicit actions such as direct humiliation or offensive threatening language. The education of nurses is now part of HE and lecturing staff are generally recruited from practice areas within the NHS sector. Bullying in nurse education is similar to that present in the health service, but proposed to be different in that it can be more subtle and wily. The consequences of bullying have a detrimental impact on nurse educator’s psychological and physical well being. There is evidence of numerous physiological responses to bullying such as being sick, anxiety, and insomnia, as well as various behavioural and psychological responses manifesting as depression, moodiness, nightmares and being withdrawn from friends and family. These are not healthy coping mechanisms, and no individual should have to endure such horrific experiences, especially in their daily working lives. The issue of bullying in nurse education and the differences in styles of bullying desperately needs further investigation. This is in order for the problem to be effectively tackled, but due to the astute, guile and sly manner in which this type of bullying manifests itself this may be difficult. Bullying in nurse education is an on-going problem that has yet to be appropriately acknowledged by

Exploring bullying: Implications for nurse educators
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