European Journal of Dental Education ISSN 1396-5883

Workplace abuse narratives from dentistry, nursing, pharmacy and physiotherapy students: a multi-school qualitative study C. E. Rees1, L. V. Monrouxe2, E. Ternan3 and R. Endacott4 1 2 3 4

Centre for Medical Education, Medical Education Institute, School of Medicine, University of Dundee, Dundee, UK, Institute of Medical Education, School of Medicine, Cardiff University, Cardiff, UK, South Thames Foundation School, UK, Centre for Health and Social Care Innovation, Faculty of Health, Education and Society, University of Plymouth, Plymouth, UK

keywords student abuse; workplace learning; healthcare students; dental students; narratives. Correspondence Charlotte E. Rees Centre for Medical Education University of Dundee Mackenzie Building Ninewells Hospital and Medical School Kirsty Semple Way Dundee DD2 4BF UK Tel: +44 1382 381971 Fax: +44 1382 645748 e-mail: [email protected] Accepted: 6 May 2014 doi: 10.1111/eje.12109

Abstract Introduction: Previous healthcare student abuse research typically employs quantitative surveys that fail to explore contributory factors for abuse and students’ action in the face of abuse. Following a recent qualitative study of medical students’ abuse narratives, the current study explores dental, nursing, pharmacy and physiotherapy students’ abuse narratives to better understand healthcare workplace abuse. Methods: We conducted three individual and 11 group interviews with 69 healthcare students in three Universities to elicit professionalism dilemma narratives. Of 226 professionalism dilemmas elicited, 79 were coded as student abuse. Secondary-level thematic analysis of the abuse narratives addressed the following questions: What types of abuse experiences do healthcare students narrate? What factors do they cite as contributing to abuse and their responses to abuse? Results: Healthcare students reported mostly covert abuse in their narratives. Although narrators described individual, relational, work and organisational factors contributing to abuse, they mostly cited factors relating to perpetrators. Most participants stated that they acted in the face of their abuse, and they mostly cited factors relating to themselves for acting. Students who did nothing in the face of abuse typically cited the perpetrator-recipient relationship as the main contributory factor. Discussion: There are many similarities across the narratives of the five healthcare student groups, suggesting that complex interactional/organisational factors are all-important when considering how abuse is perpetuated within the healthcare workplace. Although some organisational factors may be difficult to change, we recommend that educational initiatives are a key starting point to tackle healthcare workplace abuse.

Introduction The European Union Council’s 2000 general framework for equal treatment in employment and occupation and the UK Equality Act 2010 emphasise that employees should not experience discrimination on the basis of their gender, race/ethnicity, disability, age, religion or beliefs, or sexual orientation

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(1, 2). Linked with these documents, regulatory bodies for medicine, dentistry, nursing, pharmacy and physiotherapy all espouse their commitment to equality, diversity and inclusion within the healthcare workplace (3–7). However, healthcare students perceive themselves to be confronted with a multiplicity of abuses including gender, age and racial discrimination from clinical teachers and patients within workplace

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learning (8–11). Despite student abuse being well-documented for decades (12), the abusive culture of the healthcare workplace has changed little over the years. Research has typically catalogued the problem rather than offering understandings about how abuse unfolds and continues, and thereby offering solutions (13). In 2011, we published a qualitative study with medical students who shared their workplace abuse experiences through narrative (11). Narratives helped to reveal the context in which abuse occurred and allowed us to explore factors that students felt contributed to abuse and their actions in the face of abuse. In the current article, we report the findings of a follow-up study, which explored the abuse experiences of dental, nursing, pharmacy and physiotherapy students through narrative. Through this qualitative approach, we hope to shed further light onto important ‘why’ questions central to tackling the abusive culture of the healthcare workplace (14).

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types of abuse experienced by 500 medical, dental, nursing, pharmacy and allied health science students were psychological mistreatment, mistreatment related to religion or appearance, sexual harassment and mistreatment related to profession. The only difference found between the five healthcare groups was that perceived mistreatment related to profession was higher for nursing students. To conclude, the experience of abuse appears common among healthcare students and certain types of abuse are more likely to be experienced (verbal) than others (physical). Variations among prevalence figures are likely to reflect differences in methods (e.g. different questionnaires), samples (e.g. different stages of student, different healthcare groups) and settings (e.g. different countries of study).

Common perpetrators of abuse by healthcare student group

Abuse includes unwanted harmful, injurious or offensive acts directed at someone by another (15, 16). Although there is an extensive 30-year literature on medical student abuse (12), there are far fewer studies documenting the abuse experiences of other healthcare students. Most typically, research has explored nursing student abuse, with fewer studies with dental students, and fewer still with pharmacy and physiotherapy students. The existing literature almost exclusively employs questionnaires with small sample sizes, conducted at one site, and with one professional group. Only a handful of papers report studies with large samples, multiple sites and/or multi-professional groups (8–11). Given such methodological challenges, current studies in healthcare student abuse typically focus on the prevalence of abuse, the perpetrators and students’ action in the face of abuse.

The perpetrators of nursing student abuse include patients and their visitors, staff members and classmates (8, 17, 18, 20, 21). The most common perpetrators of nursing student abuse vary across the literature: patients (17, 18), staff members (20) or classmates (8, 21). The perpetrators of dental student abuse include patients and their relatives, classmates and faculty (9, 22, 23). The perpetrators of physiotherapy student abuse include clinical educators, other physiotherapists and patients (25). The perpetrators of abuse of healthcare students in the Al-Hussain et al. (10) study were most commonly teaching staff and fellow students. Different types of perpetrators tend to perpetrate different types of abuse, for example, verbal, academic and physical abuse were most commonly perpetrated by classmates, and sexual abuse by patients (21). The mixed findings across this literature are likely to reflect the different types of abuses reported within these studies, alongside the different types of students.

Common types of abuse by healthcare student group

Common student actions in the face of abuse by healthcare student group

The nursing literature, with sample sizes from 47 to 665, has explored various types of student abuse including verbal abuse, sexual and racial harassment and discrimination, witnessing the abuse of others, and physical abuse (8, 17–21). Several studies found that 100% of their samples reported experiencing or observing abuse within the workplace (8, 20, 21). Common types of abuse included verbal, academic and sexual abuse (17, 18, 21), whereas physical abuse was infrequent (19, 20). The dental literature, with sample sizes from 65 to 471, also explored the verbal, emotional, sexual and physical abuse of dental students (9, 22, 23). The most common types of abuse were verbal and emotional abuse, with sexual and physical abuse being less common (9, 22, 23). The most common abusive incidents experienced by 83 secondyear pharmacy students by patients were verbal abuse and lack of cooperation with instructions (24). The most common types of abuse experienced by 13 physiotherapy students were: belittling remarks, inaccurate or false accusations and being given an unreasonable workload and unrealistic deadlines (25). Al-Hussain et al. (10) found that the most common

Nursing students’ actions include ‘doing nothing’, reporting the incident, discussing the incident with peers and challenging the perpetrator (8, 17–21). While the most common response to abuse in some studies was ‘doing nothing’ (8, 21), in others it was reporting the incident (17, 18), and discussing the incident with peers (20). Infrequent actions included speaking to the perpetrator directly (8). Dental students’ most common actions include discussing the incident with family and friends; less common actions included doing nothing, challenging the perpetrator and informing another teacher (9, 22, 23). Physiotherapy students’ most common action was not reporting the incident to the university (25). Ferns and Meerabeau (17, 18) found that while 62.7% of their nursing sample reported the abusive incident, only 20% of those experiencing abuse from a healthcare colleague reported the incident. Therefore, the mixed findings are likely to reflect the different types of abuse perpetrators. Interestingly, nursing students constructed abusive incidents as an expected occupational hazard and rite of passage, and believed that reporting would yield no benefit (17–19).

Healthcare students’ experiences of abuse

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Factors contributing to abuse To our knowledge, only a couple of studies have recently explored healthcare students’ experiences of abuse using narrative (and therefore factors contributing to abuse) (11, 26). Lash et al. (26) interviewed 66 nursing students across eight focus groups to listen to their verbal abuse experiences during clinical rotations. Using thematic analysis, ten themes were identified, five of which centred on factors contributing to the abuse and many of these related to the abuse recipients (e.g. young age, female gender, and inexperience). Perpetrators of abuse (e.g. practising nurses without university degrees) and the organisational culture (e.g. hierarchical with expectations of compliance in junior staff) were also discussed. Although the authors reported students’ action (they typically coped by sharing their experiences with their classmates), we do not know what factors contributed to these actions. In our previous study, we analysed 86 medical student abuse narratives collected through individual and group interviews (11). Students reported mostly covert abuse, direct verbal abuse and sexual harassment and gender discrimination in their narratives. Although they described individual, relationship, work and organisational factors as contributing to abuse, they mostly blamed the perpetrators. They typically reported inaction, and mostly blamed themselves for their inaction, citing their own lack of ability and confidence, their helpless beliefs, and beliefs that the abuse was their fault. For those students who resisted, they mostly cited factors relating to the perpetrator-recipient relationship including how they feared that the abuse would continue if they failed to act and thus affect their learning negatively. Although research has explored healthcare student abuse previously, only two studies to our knowledge have employed narrative approaches allowing for the exploration of perceived contributory factors (11, 26). Furthermore, few multi-site or multi-professional studies exist, and to our knowledge, no multi-site and multi-professional study has been conducted previously, thereby undermining the transferability of previous studies. Therefore, this study aims to explore the abuse experiences of dental, nursing, pharmacy and physiotherapy students across three different UK institutions through narrative, and to compare these experiences with those of medical students (11). The research questions are: What types of abuse experiences did healthcare students narrate? What factors did healthcare students cite as contributing to abuse and their responses (inaction or resistance) to abuse?

Materials and methods Theoretical perspectives and study design This article is part of a larger study exploring healthcare students’ professionalism dilemmas (27). We draw on complementary theoretical perspectives in this study to understand healthcare students’ experiences of workplace abuse. Our study is underpinned by social constructionist epistemology, and employs interpretivism as its theoretical perspective, which suggests that there are multiple interpretations of reality, ways of knowing, and phenomenon (28). We draw on organisational psychology thinking regarding abuse which focuses on the ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 95–106

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complex interaction between person and environment including the individual (e.g. perpetrator aggression), work (e.g. high workload) and organisation (e.g. hierarchy) (29–32). We aimed to conduct group discussions but also had ethics approval for individual interviews. We employed narrative interviewing techniques in all interviews.

Recruitment and sample We identified three different Universities (England, Wales and Scotland) from which to recruit healthcare students. In University A, we invited students from three courses (Physiotherapy, Dentistry and Pharmacy) and in Universities B and C, we invited students from two courses (B = Dentistry, Nursing; C = Physiotherapy, Nursing). We invited final and penultimate year students in two ways: face-to-face recruitment during teaching sessions and email invitations. Students were required to read the information sheet and sign the consent form before the interviews. Sixty-nine healthcare students participated: Dentistry (n = 29), Physiotherapy (n = 15), Nursing (n = 13) and Pharmacy (n = 12). The sample was mostly 20–24 years (n = 59), female (n = 49) and white (n = 42). The composition of the three individual and 11 group interviews is reported in detail elsewhere (27).

Data collection The interviews were facilitated by a different person at each of the three Universities. Following the welcome, the interviewer asked an introductory question: what is your understanding of professionalism? The interviewers then employed narrative interviewing techniques to elicit students’ personal incident narratives of professionalism dilemmas they had experienced since becoming healthcare students. General open-ended questions were used and the interviewers only asked questions about specific types of dilemmas (based on their previous research with medical students) when participants struggled to recount experiences. When narrating their dilemmas, students frequently volunteered accounts of their own behaviours. If they did not, they were asked to explain their behaviour and why they behaved that way. All interviews were audio-recorded with permission.

Data analysis The recordings were transcribed anonymously. Using Atlas-Ti, transcripts were theme analysed using Framework analysis (33). The methods for this primary-level analysis are documented elsewhere (27). This preliminary analysis resulted in the identification of 226 personal incident narratives of professionalism dilemmas, of which 79 were coded as ‘student abuse’ dilemmas. Given that we had previously conducted a secondary analysis of medical students’ abuse narratives (11), we decided to conduct a similar secondary analysis on healthcare student abuse narratives to compare them with medical students’ experiences. The third author, under the supervision of the first, coded each abuse narrative in a similar vein to the coding of the medical students’ narratives. Using the coding framework already developed with medical student data, she coded types of abuse and 97

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TABLE 1. Edited narrative of a fifth-year female dentistry student, coded by abuse type, factors contributing to abuse and reasons for not challenging1 Speaker 2

JANE :

Student’s narrative and interviewer comments

Coding category

I was on clinic. . . ((laughs)) had a patient who needed some treatments and I wasn’t sure entirely how to do the treatment so I asked the supervisor. . . ‘what should be done’ being a teaching hospital her remark was kind of ‘well what do you think should be done’ and kind of left me to decide and I said well ‘I don’t know’ but instead of helping me out she kind of said ‘well you decide what to do’

Contributory factor: recipient

and I went back and what I was doing wasn’t working and I went back to the supervisor to say ‘look this isn’t working can I have some help’ and she just kind of refused to help. . .

and then in the end. . . she just got a bit angry with me sort of in front of the patient. . . and said some things like ((coughs)) I didn’t quite think were acceptable to say in front of the patients. . . rather than helping me she just got angry with me and she stormed off

INT: JANE:

JILLY:

having said these things in front of everyone and then I was left thinking ‘well I still don’t know what to do after all that’. . . so what did you do? I went to the room and I cried ((laughs)) and then. . . the nurses and other colleagues came in and just said ‘look it’s okay. . . just kind of pull yourself together’ and then we went back and the person I was working with helped me out and yeah we kind of discussed what we were going to do together and yeah that was me and I thought that supervisor was ((long pause)) she’s meant to be you know a teaching member of staff and there’s no teaching or help there at all

she just went crazy JANE: JILLY:

JANE:

INT: JANE:

JILLY:

INT: JILLY: JANE:

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yeah and instead of you know some people might say that ‘you should know this but you know I’ll help you but you need to go and read something’ she just can’t understand how or why we didn’t know what we were to do And. . . got angry instead of actually helping us at all so the whole procedure took a ridiculous amount of time. . . that’s unprofessional to a patient because. . . he’s lying there for longer than he needs to for treatment that really isn’t actually maybe correct ((laughs)). . . He actually ended up worse off than when he came in but he could pick up on what was going on as well and I think it made him feel a bit uneasy as well and everybody could see I was a bit upset as well and ((throat clearing)) it was all just a very difficult and awkward situation to be in. . . Did you think about reporting or challenging at some point this tutor? . . . I did go and see someone about it and his words were ‘well I’m not surprised because she’s had loads of other complaints’. . . and he asked what I wanted to do and he said ‘if I go and speak to her she’s going to know that you’ve been to see me’. . . and I said ‘well it’s worth saying something to her not specifically about what happened with me but just in general if loads of people have been to see him and just go and say something to her um just so that she’s aware that her behaviour is wrong’ she wasn’t open to discussion. . . you couldn’t have challenged her because she was literally felt like you were five at school or something she was just like laying the law down and that was it you just like shut up and get on with it ((laughs)) So did you try and challenge or did you just Yeah . . . I asked her to come over and have a look and she said. . . ‘how do you expect that to work with saliva all over the place’ in front of everyone and I said ‘well there wasn’t when I was doing it he’s closed his mouth when I went to get you’

Covert, status-related abuse: supervisor withholding information from student affecting her performance Contributory factor: recipient Covert, status-related abuse: supervisor withholding information from student affecting her performance Covert, status-related abuse: humiliated in front of patients; verbal abuse: being on receiving end of perpetrator’s anger Covert, status-related abuse: supervisor ignores student by leaving scene Covert, status-related abuse: humiliated in front of patient

Covert, status-related abuse: supervisor withholding information from student affecting her performance verbal abuse: being on receiving end of perpetrator’s anger Contributory factor: recipient Contributory factor: perpetrator Verbal abuse: being on receiving end of perpetrator’s anger Contributory factor: perpetrator

Contributory factor: perpetrator Contributory factor: perpetrator

Reason for not challenging: hierarchy

Covert, status-related abuse: Being criticised unfairly by the supervisor; humiliated in front of the patient

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Healthcare student abuse narratives

Table 1. Continued Speaker

Student’s narrative and interviewer comments

Coding category

and she just said ‘don’t argue with me there is no argument’ ((mimics supervisor shouting and group laughs)) so that was that then I was still left not knowing what to do

Verbal abuse: being shouted at by the perpetrator

1

Further exemplar narratives for nursing, pharmacy and physiotherapy can be requested from the corresponding author. Names are pseudonyms to maintain the anonymity of participants.

2

factors cited by students as contributing to abuse and students’ responses (inaction or resistance) to abuse.

Results There were 79 abuse narratives (32 dentistry, 20 pharmacy, 16 physiotherapy and 11 nursing). The abuse recipient was typically the narrator (in at least 67 narratives). The gender of the recipient was mostly female (in at least 61 narratives), and the perpetrator was equally male or female (in at least 30 narratives each). The perpetrators of the abuse included healthcare professionals (50 narratives: 42 by HCP of same profession; 8 by HCP of different profession), patients (24 narratives) or nonHCP colleagues such as pharmacy counter staff (four narratives). The setting for abuse included dental clinics (32 narratives), hospitals (28 narratives), pharmacy shops (16 narratives), nursing home (1) and patient’s home (1). We say ‘in at least X narratives’ because not all narratives included details about perpetrator role/gender or setting.

Perpetrator Students from all healthcare groups cited a range of characteristics including: negative traits (e.g. arrogance, lacking insight, controlling, anal, forgetful, difficult, demanding, disorganised); demographic characteristics (e.g. older, male); mood problems (e.g. angry, bad mood, aggressive, frustrated); interpersonal incompetence (e.g. rude, harsh, poor communication skills, makes you feel subordinate, overstepping personal and professional roles); professional incompetence (e.g. lack of knowledge, lack of understanding) and career issues (e.g. part time, experienced, nearing retirement, dissatisfied by lack of own career progression): ‘I think she was just one of these people that like to feel good about herself and undermine people’ (nursing student). Students from all healthcare groups referred to perpetrators as ‘unprofessional’ (see Table 1). They also described perpetrators as having reputations for abuse (see Table 1), which was emphasised by students’ derogatory names for them such as ‘dirty old man’ (dental student) and ‘big baddie’ (pharmacy student).

Types of abuse Narratives often included multiple different types of abuse (see Table 1). In decreasing order of frequency, 58 narratives were coded as covert abuse, 16 as verbal, 12 as witnessing the abuse of others, 8 as sexual harassment and gender discrimination, 3 as ‘other’ discrimination such as racial and age discrimination and 2 as physical abuse. Participants from all four healthcare groups reported experiencing various covert abuses and witnessing the abuse of others. Participants from dental, pharmacy and physiotherapy student groups reported experiencing sexual harassment and/or gender discrimination and dental, nursing and pharmacy student groups reported being verbally abused: I heard her [clinical teacher] say ‘oh that student’s starting to get on my nerves now’ (nursing student). Only three participants from pharmacy and physiotherapy reported experiencing other forms of discrimination, and only two participants from dental and physiotherapy reported experiencing physical abuse (see Table 2 for a summary of the types of abuse cited in the narratives by healthcare student group and illustrative quotes).

Recipient Students across all healthcare groups cited numerous factors such as their junior status and associated lack of experience, and lack of professionalism within the healthcare workplace: ‘I wasn’t sure entirely how to do the treatment’ (dental student: see Table 1). They also cited their demographics (e.g. young, female), perceived shortcomings (e.g. weak, unconfident) and their negative emotions about learning in the healthcare workplace (e.g. fear, discomfort). Ultimately, many students blamed themselves for the abuse: ‘I felt that that was my fault’ (nursing student).

Work Work factors tended to be specific to the abuse narratives recounted. However, there were several work-related factors cited across students’ abuse narratives such as time pressures, understaffing, financial constraints, disorganised workplace, small and ‘closed’ workplace and hostile environment: ‘there was lots of bitching if you like going on’ (nursing student).

Factors contributing to abuse Students cited various factors contributing to their abuse (see Table 1). In decreasing order of frequency, they cited characteristics of the perpetrator (110 citations), recipient (72), work (66), perpetrator-recipient relationships (8) and the organisation (7). ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 95–106

Perpetrator-recipient relationships Students across all healthcare groups cited numerous factors such as the hierarchical recipient-perpetrator relationship; relationships imbued with conflict (e.g. poor communication, blaming students for the mistakes of the team) and the 99

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challenging nature of these recipient-perpetrator relationships (e.g. coming from different backgrounds, having newly established relationships: ‘it was sort of the end of my first week so I hadn’t really got to know them’, physiotherapy student).

Organisation Dental, pharmacy and physiotherapy students cited several factors including the organisational hierarchy: ‘that you are a meagre lowly student’ (physiotherapy student). Students also talked about an organisational climate of unprofessionalism: ‘it was a bad care home’ (nursing student) and an ethos of having to do things outside of their comfort zone, having to get everything checked and a lack of support. One pharmacy student also described pharmacies as ‘female’ environments.

Student action in the face of abuse Forty-four students (55.7%) reported acting in the face of their abuse dilemma, while 35 (44.3%) reported doing nothing (i.e. inaction). For those saying they did something, 15 reported debriefing after the incident, 12 challenged the perpetrator directly and 10 reported the perpetrator. Participants gave a myriad of reasons for their inaction and resistance (see Table 1).

Factors contributing to student action Students cited numerous factors for their action. In decreasing order of frequency, students cited factors related to the recipient (16), perpetrator (11), perpetrator-recipient relationships (5) and work (4). Students across dentistry and nursing cited recipient factors: these students stated that they challenged the perpetrator because they believed the abuse was unfair, they feared that the abuse would impact negatively on their own learning and they did not want other students to experience the same problems with perpetrators. One student also stated that they challenged because they did not think about the possible negative consequences of acting at the time of the abuse. Students across all healthcare groups also cited perpetrator factors, specifically weaknesses in perpetrators’ knowledge: ‘he didn’t even work on the ward he came there for a day as a bank person’ (physiotherapy student). Students across dentistry and nursing cited perpetrator-recipient factors, specifically students challenging perpetrators because they felt pushed to their limits by them. Finally, nursing students cited work-related factors, namely that they received encouragement from universitybased teachers to challenge their abuse perpetrators.

Factors contributing to student inaction Students cited numerous factors for their inaction. In decreasing order of frequency, students cited factors related to the perpetrator-recipient relationship (29), recipient (20), organisation (12), work (9) and perpetrator (9). Students across all healthcare student groups cited perpetrator-recipient factors: students stated that they did not challenge because they feared the challenge would affect their relationship with the perpetrator adversely and thus they would receive poor assessments from 100

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their tutors: ‘I wanted to make sure they gave me a really good reference so I could get my pre-reg. ‘cause I wanted it with this company’ (pharmacy student). They also did nothing because they would not see that specific perpetrator again. Students across all healthcare student groups also cited recipient factors: students stated that they did not challenge because they were stressed, lacked confidence and felt that challenging would be socially rude. They also held beliefs that challenging would not lead to any positive outcomes (‘it was just not worth raising waves’, dental student) and that as a student within the healthcare workplace they had to put up with abuse (‘sometimes you’re put in the situation where you have to just shut up and just say ‘no I’m wrong’ even if you think you’re right’, dental student). Students from all healthcare student groups cited organisational factors, namely the institutional hierarchy (see Table 1). One pharmacy and one nursing student cited one work-related factor each, specifically that the learning environment was small (pharmacy) and there was no opportunity to challenge (nursing). Finally, students from dental, nursing and physiotherapy cited perpetrator factors: they stated that they failed to challenge the perpetrator because they were ‘scary’ or because the perpetrator had some positive qualities like usually being ‘nice’.

Discussion Students from all healthcare groups and across three institutions in different countries reported abusive workplace learning experiences through narrative. By far the most common type of abuse across the 79 narratives was covert abuse such as being ignored, being given menial tasks and being humiliated in front of patients. These qualitative results extend previous questionnaire findings exploring the prevalence of types of abuse in dentistry, nursing, pharmacy and physiotherapy students by illustrating a broader array of abuses (e.g. covert abuse) than previously documented (8–10, 25). However, the types and amounts of abuse revealed by dentistry, nursing, pharmacy and physiotherapy students’ narratives are similar to those of medical students (11). Our findings also extend current abuse literature by revealing the context in which abuse unfolds for dental, nursing, pharmacy and physiotherapy students. Like the nursing study by Lash et al. (26) and our previous medical student study (11), the healthcare students in the current study cited multiple factors (individual, relational, work and organisational) as contributing to abuse. However, participants most commonly cited contributory factors relating to perpetrators such as their negative traits and interpersonal and professional incompetence; findings similar to our previous medical student study (11). Over half of the healthcare students in the current study reported doing something in the face of their abuse, as has been found in nursing questionnaire studies (17, 18, 20). This finding, however, differs from our previous study with medical students, which illustrated that medical students typically did nothing in the face of abuse (11). We know from the nursing literature that student action seems to be influenced by the type of perpetrator (17, 18). Therefore, the higher numbers of healthcare students ‘doing something’ in the current study may ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 95–106

Ignored by supervisors of own profession

Covert

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Felt used by supervisors of same profession for own gains

Supervisors of same profession withholding information affecting performance adversely

Being criticised unfairly by patients

Feeling humiliated in front of patients by supervisors outside of their profession

Verbally forced to observe, examine or conduct procedures on patients by supervisors of same profession Given menial tasks below their level of competence by supervisors outside of their profession Feeling humiliated in front of patients by supervisors of same profession

Ignored by supervisors of different professions

Given unsatisfactory assessments unfairly by supervisors of own profession

Theme type

Abuse theme

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

‘they [pharmacy staff] sort of said a few things to me like ‘don’t worry about that, the child will do it, the child will do it, the little kid, you can come and do it, come on back you can do it’ and then I would go off to do whatever menial task they’d like let me do’ (pharmacy student) ‘it makes you look bad in front of the patient because. . . we can say to the patient ‘we’re going to repair all your crowns’ and then the next visit I’m saying ‘actually we’re going to take all your teeth out’ you know so it makes you look bad in front of the patient’ (dental student) ‘there was a prescription and it was for an antibiotic and Paracetamol. . . I said [to the patient] ‘you have to take these four times a day and you have to take them an hour before food and then the pain killers you can take four times a day as well’ and he said ‘well can I take them at the same time or do I have to leave some time in between them’, [I said] ‘no you can. . . take them. . . at the same time’. . . and a lady who was working on the counter and she’d sort of been there for like 40 years. . . she said ‘no no no you can’t. . . take those two together’, and I said. . . ‘these two are absolutely fine to take together, it’s not a problem, there’s no interaction at all’. . . she said ‘no no no don’t do that, you’re going to kill him, you’re going to kill him’ (pharmacy student) ‘so he [patient] was annoyed at me. . . because nothing was moving on with the treatment. . . so he was really annoyed with me, I was dreading him coming in, I didn’t want to see him anymore’ (dental student) ‘I wasn’t really getting the help I needed and then I went over [to dental supervisor] again and I said ‘I am really struggling here’ and then she said ’I’ve already told you what to do, go away and do it’ so it kind of leaves me in a position where I’m still not really sure because I haven’t got any clarification’ (dental student) ‘he’d [dentist] made out like it was you [student] that had done it [made clinical error] [narrator: yeah]’ (dental students)

U

U

U

U

U

U

U

U

U

U

Phys

U

Pharm

‘it’s like you’re invisible. . . my third week there [placement] it was ‘oh. . . you’re going to have a student today with you’ and it was like ‘well for one thing I’ve been here 3 weeks, student has been here 3 weeks, student has a name and student is sitting right in front of you’’ (physiotherapy student) ‘he came to give me a mark um on my sheet, I can’t remember what it was but it was something crap anyway. . . I said nothing. . . and the thing is I should have because you know I knew 100 per cent myself that [the procedure] that’s what he told me to do, the girl who was nursing for me said ‘no that’s definitely what he told you to do’’ (dental student) ‘I was about 5 min into my assessment [of the patient]. . . and the surgeon, maybe registrar and the surgical team. . . came in and just completely butted in and started doing his assessment on the patient and then just walked away again so I just stood there for like 5 min’ (physiotherapy student) ‘we’re just that dog’s body basically, aren’t we? They [dentists] tell the treatment and. . . you do it’ (dental student)

Nurs

Dent

Illustrative quote

TABLE 2. Summary of types of abuse cited in the narratives by healthcare student group

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Abuse theme

102

Being given unpleasant tasks as a joke by supervisors of different profession

Being given punishment by supervisors of own profession

Being verbally forced to observe, examine or conduct procedures on patients by supervisors of different profession Being given menial tasks below their level of competency by supervisors of own profession Being pushed by supervisors of own profession beyond students’ level of training

Being asked intimidatory questions by supervisors of same profession

Patients withholding information affecting performance adversely

Felt excluded from learning opportunities by patients

‘there was one patient that I got on really well with but she’d had a stroke. . . so every morning I would get her ready, every night I would get her ready, like they [nurses] were just sending me in all the time because I think they just didn’t want to deal with her’ (nursing student) ‘I’ve been sent out by local pharmacists saying ‘go on it’ll be good experience for you. . . you can go and see how to deal with patients’ and they throw you in situations like that. . . it’s unfair. . .I’m thinking ‘I don’t know what I’m meant to be doing, I don’t know what the protocol is. . . ‘ (pharmacy student) ‘I come on time [to work] every day, like my train was late, I have to catch a very early train and I have to wait 1 h for the pharmacy to open and still when I came one day late it was quarter past nine she [pharmacist] told me ‘when you’ve come 15 min late make sure your lunch is 45 min’ (pharmacy student) ‘they were like deliberately picking horrible jobs for me to do. . . I was coming back into the dispensary I heard them all talking about it saying ‘oh yeah we’ve got this little kid now, I don’t do all that, she does all that sort of stuff’ and they [pharmacy staff] were all laughing and like the pharmacist was there laughing as well’ (pharmacy student)

U

‘I wasn’t treated as part of the team at all. . . they’d have staff meetings. . . ‘it’s not suitable for you to come in’ and send me off to do something else’ (physiotherapy student) ‘I had a patient that I offered him a few treatment options and I documented it in the notes. . . when the member of the staff came in and said ‘oh I hear you’ve had these explained to you and you’d opted for this one’ he refused to acknowledge the fact that I had given him this option’ (dental student) ‘he [patient] came in a day before the appointment [with student]. . . to have a review and then on the day of the actual review [with student] he just did not bother turning up and he did not bother calling to tell anybody that he’d been seen. . . I felt like obviously if he wasn’t willing to have treatment by me’ (dental student) ‘I had some money in a Christmas card [from a patient] and I just thought it was a plain Christmas card and I opened it at home, there was twenty pounds in it but apparently if they hand over money to you you are meant to hand it in to the hospital’ (dental student) ‘I had a patient that required molar endo. and I wanted to do it, our supervisor challenged me on it and said ‘do you think you’re competent to do it?’ and I said ‘well I’m not competent now but I do need to learn and we completed the endodontic teaching so I can’t see what’s stopping me from learning to do it’. . . the supervisor was. . . quite antagonistic about it’ (dental student) ‘I was doing a drug round with my mentor and the HCA came up to us and said ‘can you just sign the drug chart, I’ve just given so and so two Paracetamol’’ (nursing student)

Felt excluded from learning opportunities by supervisors of same profession Ignored by patients

U

U

U

U

Dent

Illustrative quote

Theme type

Table 2. Continued

U

U

Nurs

U

U

U

Pharm U

Phys

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Sexual harassment and gender discrimination

Witnessing other abuse

Receiving verbal abuse from supervisors of own profession for lack of competence

Verbal

Witnessing supervisors of their own profession verbally abusing other healthcare professionals Witnessing staff outside the profession be verbally abusive about other healthcare professionals Being subjected to unwanted sexual talk from patients Being subjected to unwanted sexual attention from patients Being subjected to sexism by supervisors of the same profession Being subjected to unwanted sexual talk from supervisors of same profession

Receiving verbal abuse from patients in response to history taking or examination skills Being shouted at by supervisors of their own profession Being shouted at by supervisors of different profession Being called derogatory names by supervisors of own profession Being called derogatory names by supervisors of different profession Being verbally abused by supervisors of different profession for lack of competence Being subjected to supervisors in their own profession criticising other clinical colleagues Being subjected to staff outside profession criticising other colleagues

Being shouted at by patients

Theme type

Abuse theme

Table 2. Continued

‘I had placement at [names place] back at home and that. . . had a male pharmacist. . . and all the other staff were female. . . whenever he wasn’t there all they would talk about was how awful he was and just really be quite like catty about it all’ (pharmacy student) ‘I had um um an older man patient and he was so inappropriate you know he was saying things like ‘oh it’s lovely to have two young ladies mucking about in my mouth’’ (dental student) ‘seriously she doesn’t stop touching me to a point she’s always rubbing my arm and stroking my leg, she kisses me at the end of every appointment’ (dental student) ‘we were talking about how I’d been treated as though ‘you’re just a young silly female, what do you know?’’ (physiotherapy student) ‘and like he’d [pharmacist] do things like telling inappropriate jokes but like quite crude jokes. . . I’d never worked with him before, he didn’t know me but obviously I don’t have a [names place] accent. . . and he was like ‘where are you from?’, ‘[names hometown]’ so then I got like all those kind of really crude [names hometown] girl jokes’ (pharmacy student)

‘I moved up into the main dispensary. If you were like on your own she’d [pharmacy staff] come in and like moan about somebody else. . . it could be a pharmacist or somebody like below her. . . she’d come in and go ‘what an idiot’’ (pharmacy student) ‘But it was just the way they [older nurses] spoke to her [junior nurse]. . . I felt really bad’ (nursing student).

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

‘the way she [mentor] would like speak to you. . . there was no please or thank you it was ‘go do this go do that’ and she wouldn’t call me by my name like she’d actually shout at me’ (nursing student) ‘And he [doctor] just shouted all these instructions and just walked off and I was like ‘ah help’’ (nursing student) ‘she would not call me by my name so if I was in with a patient she’d shout ‘student nurse’’ (nursing student) ‘she’d [healthcare worker] been really rude and really derogatory to me since I’d started the placement. . . she spoke to me like a complete idiot’ (nursing student) ‘And then you get the consultant who tries to chastise you in the ward in the middle of people, in front of people’ (nursing student) ‘And the older nurse turned round and said ‘well you are just newly qualified and we have been in this profession 35 years how dare you come into my ward and tell me what to do’’ (nursing student).

U

U

Pharm

‘I was about to sell him [patient] two boxes [medication]. . . then the pharmacist noticed and. . . said ‘no you can only sell one sell one packet’. . . I said ‘okay I’m sorry I didn’t know’ and then when the customer left she [pharmacist] said ‘don’t they teach you at the school?’ (pharmacy student) ‘she [patient] was shouting all the odds at me and saying that ‘oh you’re so unprofessional how can you not make the veneers’’ (dental student) ‘she was really really in a bad mood because she just [said] ‘well my dentist gave me a check-up, why are you giving me another check-up?’’ (dental student)

Nurs

Dent

Illustrative quote

U

U

U

U

Phys

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103

‘you’re quite often the only man in the shop with a whole team of women around you. . . the shop when I went into it there was a male pharmacist who was the manager there. . . all the females [pharmacy staff] sort of united against him’ (pharmacy student) ‘I heard. . .there’s a sort of racial problem there so that really affected me and I was like ‘oh I definitely don’t want to work with this company’. . .it was a general thing really ‘cause I thought I was the only one experiencing that. . . there was a time I even got shouted at and the pharmacist was there and he didn’t say anything and it was just so upsetting’ (pharmacy student) ‘the other guy who’s the mature male student said he’d had a young female educator and. . . she even mentioned that she felt threatened by him. . . she didn’t know how to cope with him being that much older. . . so I think the age and sex thing does come into it’ (physiotherapy student) ‘I’ve had a patient hit my hand when I was in the mouth’ (dental student) ‘she [clinical teacher] just flipped her lid and she literally grabbed the walking frame and chucked it across the ward. . . I just like stepping out of the road because. . . thought she might hit me with the walking frame’ (physiotherapy student)

U

U

‘I’ve worked with a male pharmacist who was a bit like you know. . . you sometimes get a feeling that you don’t really want someone like him you know they get a bit too close to you’ (pharmacy student)

Being subjected to unwanted sexual attention from supervisors of same profession Being subjected to sexism by supervisors outside of profession

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U Being physically hit by patient Being nearly hit by walking frame thrown by supervisor Physical abuse

Receiving ageist remarks by supervisors of the same profession

Receiving racist remarks from other healthcare professionals Other discrimination

Abuse theme

Table 2. Continued

Dent

Nurs

U

U

Illustrative quote

U

Rees et al.

Theme type

Pharm

Phys

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reflect differences in the types of abuse perpetrators across the two studies. For example, the perpetrators of medical student abuse were almost exclusively clinical teachers (11). However, we identified more examples of healthcare student abuse by patients in the current study. Healthcare students cited multiple factors contributing to their action, with the most commonly cited factors relating to recipients such as their motivation to challenge for fear the abuse would affect their learning negatively. For students stating that they did nothing, the most commonly cited contributory factors related to the perpetrator-recipient relationship such as fears about receiving poor assessments from their perpetrators if they challenged. These findings are also similar to those found in our earlier medical student narratives (11). This study is not without its methodological challenges and these must be taken into account when interpreting our results. First, narratives are rhetorical in the sense that narrators are motivated to persuade their audience and portray themselves in a positive light (34). It is therefore unsurprising that healthcare students typically blame the perpetrators for their abuse. In this study, we have presented a thematic rather than narrative analysis of student narratives, so that we can illustrate patterns across a large number of narratives to help us understand the complexities about how abuse unfolds and can therefore be perpetuated. However, elsewhere we have conducted narrative analysis of abuse narratives which do foreground things like how narrators construct their own and others’ identities through the narration of their abuse experiences (e.g. abuse recipient as victim, perpetrator as villain) (35, 36). Second, although we present some frequencies to illustrate patterns in our qualitative data (37), our figures do not equate with prevalence figures like those presented in questionnaire studies (8– 10). We typically did not ask students specific questions about types of abuse. It is likely, for example, that our healthcare student participants witnessed the abuse of others more than they directly experienced abuse, despite ‘witnessing the abuse of others’ being a less common theme in our data. Rather than reflecting the prevalence of abuse, these numbers simply reflect the numbers of narrators who constructed certain experiences as professionalism dilemmas. Finally, we had different sample sizes across the four healthcare student groups (from 29 dental students to 12 pharmacy students). That we did not find examples of certain types of dilemmas for certain types of healthcare students is not necessarily because those groups did not experience those types of dilemmas (e.g. none of the nursing students’ narratives described sexual harassment even though sexual harassment of nursing students is relatively common) (21). A lack of findings is therefore more likely to be indicative of the small samples for some groups. However, despite these challenges, we believe that our study makes an important contribution to the abuse literature because it is the first study to explore the abuse experiences (and multiple contributory factors) of four healthcare student groups qualitatively. We conducted a large number of narrative interviews for a qualitative study and analysed a large number of contributory factors across the 79 narratives. That abuse was experienced across the four student groups and across three institutions suggests that our findings are transferable to other UK, and possibly other westernised contexts. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 95–106

Rees et al.

As with our earlier medical student study, healthcare students cite predominantly individual factors contributing to abuse and their responses to it, rather than more complex interactional/organisational factors typically discussed in the organisational psychology literature (29–32). That there are lots of similarities in abuse narratives across the five healthcare student groups implies that those more complex interactional and organisational factors are all-important when considering how abuse is perpetuated within the healthcare workplace. As suggested previously, the dynamic interplay between the individual and organisation is central to a culture of abuse and to combating abuse (11). Organisational structures and cultures of the healthcare workplace could actually encourage abuse: enabling factors such as the lack of sanctions for abuse; motivating factors like high internal competition and precipitating factors like organisational change (11, 14). While some of these organisational factors may be difficult to alter (e.g. constant organisational change), others could be more easily addressed (e.g. lack of sanctions for abuse) and this is where educational initiatives are a starting point. The culture of abuse should be tackled using top-down and bottom-up educational approaches (11). The findings outlined here in this follow-up study also suggest that this bi-directional approach is warranted. All the different healthcare regulatory bodies advocate the importance of staff understanding equality legislation made explicit in policies and staff handbooks (3–7). They also typically discuss the importance of training (e.g. workshops and online educational packages) to help staff understand E&D legislation. However, it is only the GMC (4) that advocates staff being able to apply the E&D knowledge to their own roles and responsibilities. Therefore, we think that current training efforts could better help healthcare professionals to apply E&D legislation into their own everyday working practices. This could be possible through educational opportunities to discuss their own and others’ experiences of abuse (perhaps using those highlighted in this article to trigger discussion), factors that contribute to abuse and recipients’ action, to discuss how abuse is perpetuated and can therefore be tackled. We would argue for such educational opportunities being interprofessional given that abuse is similarly experienced across different professions, and are often interprofessional (35). It is essential that organisational leaders participate in such training, not only because they may be perpetrators of abuse but because they can also inadvertently sanction abuse by turning a blind eye to it (14). As for bottom-up approaches, healthcare students should also be able to understand and apply E&D legislation to their own workplace learning experiences. They should also be provided with educational opportunities to discuss their own and others’ abuse experiences. Furthermore, they should be helped to resist in the face of abuse by providing them with a safe forum to consider different possibilities for resistance, in addition to practising actual resistance strategies such as direct challenges of abuse perpetrators through simulated role-play activities (11). In terms of further research, we have recently conducted a UK-wide online survey of 1399 nursing, dental, pharmacy and physiotherapy students across 40 healthcare schools to determine the prevalence of common types of abuse, and the levels ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 95–106

Healthcare student abuse narratives

of moral distress experienced by healthcare students as a result of abuse. We have sent anonymised study results to each school that participated, but we told each school which results were theirs to enable them to compare their findings with other healthcare schools. Those healthcare schools with higher than average prevalence rates might be more motivated to change educational policies and practices regarding E&D if they know that they compare disfavourably with other healthcare schools. Repeated use of this survey could help demonstrate whether E&D initiatives can make a difference to the abusive culture of the healthcare workplace.

Acknowledgements We would like to thank all participants for giving their time to participate and sharing their stories with us so candidly. We thank Ria Poole for coding the data as part of the preliminary Framework analysis.

Contributors C.E. Rees and L.V. Monrouxe had the idea for the original study, wrote the grant application for funding, and were responsible for the preliminary Framework analysis of the data. C.E. Rees, L.V. Monrouxe and R. Endacott secured ethics approval and collected data. E. Ternan was responsible for further coding of the abuse narratives under the supervision of C.E. Rees. C.E. Rees conducted the literature review and wrote the first draft of the article. L.V. Monrouxe, R. Endacott and E. Ternan commented on manuscript revisions. C.E. Rees is responsible for the overall content as guarantor.

Funding This research was supported by a grant from the Higher Education Academy. Edwina Ternan was supported by an Education Vacation Scholarship funded by the Centre for Medical Education, University of Dundee.

Ethical approval This study was approved by all three University Research Ethics Committees. They are not named here to protect their anonymity.

Other disclosures None.

References 1 Council of the European Union. Council directive 2000/78/EC of 27 November 2000 establishing a general framework for equal treatment in employment and occupation. Retrieved from: http:// eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32000L0078: en:HTML 2 The Stationary Office. Equality act. London: The Stationary Office, 2010. Retrieved from: http://www.legislation.gov.uk/ukpga/2010/15/ pdfs/ukpga_20100015_en.pdf

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3 General Dental Council. Equality and diversity. London: General Dental Council, 2010. Retrieved from: http://www.gdc-uk.org/ aboutus/equalityanddiversity/Pages/default.aspx 4 General Medical Council. Equality and diversity strategy 2010–2013. London: General Medical Council, 2010. Retrieved from: http:// www.gmc-uk.org/ED_Strategy_2010_2013_36700815.pdf 5 General Pharmaceutical Council. Equality, diversity and inclusion scheme. London: General Pharmaceutical Council, 2011. Retrieved from: http://www.pharmacyregulation.org/sites/default/files/Equality %20diversity%20and%20inclusion%20scheme.pdf 6 Nursing and Midwifery Council. Nursing and midwifery council equality and diversity strategy. London: Nursing and Midwifery Council, 2011. Retrieved from: http://www.nmc-uk.org/Documents/ Consultations/Equality-and-Diversity/NMC_Equality-and-diversitystrategy-2012.pdf 7 Health Professions Council. Equality and diversity scheme. London: Health Professions Council, 2007. Retrieved from: http://www.hpcuk.org/assets/documents/100021B1HPCEqualityandDiversityScheme. pdf 8 Cooper JRM, Walker JT, Winters K, Williams PR, Askew R, Robinson JC. Nursing students’ perceptions of bullying behaviours by classmates. Iss Educ Res 2009: 19: 212–226. 9 Rowland ML, Naidoo S, AbdulKadir R, Moraru R, Huang B, Paul A. Perceptions of intimidation and bullying in dental schools: a multi-national study. Int Dent J 2010: 60: 106–112. 10 Al-Hussain SM, Al-Haidari MS, Kouri NA, El-Migdadi F, Al-Safar RS, Mohammad MA. Prevalence of mistreatment and justice of grading system in five health related faculties in Jordan University of Science and Technology. Med Teach 2008: 30: e82–e86. 11 Rees CE, Monrouxe LV. ‘A morning since eight of just pure grill’: a multischool qualitative study of student abuse. Acad Med 2011: 86: 1374–1382. 12 Silver HK. Medical students and medical school. JAMA 1982: 247: 309–310. 13 Hinze SW. ‘Am I being over-sensitive?’ Women’s experience of sexual harassment during medical training. Health 2004: 8: 101–127. 14 Salin D. Ways of explaining workplace bullying: a review of enabling, motivating and precipitating structures and processes in the work environment. Hum Relat 2003: 56: 1213–1232. 15 Silver HK, Glicken AD. Medical student abuse. Incidence, severity and significance. JAMA 1990: 263: 527–532. 16 Wilkinson TJ, Gill DJ, Fitzjohn J, Palmer CL, Mulder RT. The impact on students of adverse experiences during medical school. Med Teach 2006: 28: 129–135. 17 Ferns T, Meerabeau L. Verbal abuse experienced by nursing students. J Adv Nurs 2007: 61: 436–444. 18 Ferns T, Meerabeau E. Reporting behaviours of nursing students who have experienced verbal abuse. J Adv Nurs 2009: 65: 2678– 2688. 19 Longo J. Horizontal violence among nursing students. Arch Psych Nurs 2007: 21: 177–178.

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20 Hinchberger PA. Violence against female student nurses in the workplace. Nurs Forum 2009: 44: 37–46. 21 Celik SS, Bayraktar N. A study of nursing student abuse in Turkey. J Nurs Educ 2004: 43: 330–336. 22 Garbin CAS, Zina LG, Garbin AJI, Moimaz SAS. Sexual harassment in dentistry: prevalence in dental school. J Appl Oral Sci 2010: 18: 447–452. 23 Premadasa IG, Wanigasooriya NC, Thalib L, Ellepola NB. Harassment of newly admitted undergraduates by senior students in a Faculty of Dentistry in Sri Lanka. Med Teach 2011: 33: e556– e563. 24 Rahim H, Shah B. Pharmacy students’ perceptions and emotional responses to aggressive incidents in pharmacy practice. Am J Pharm Educ 2010: 74: 1–7. 25 Stubbs B, Soundy A. Physiotherapy students’ experiences of bullying on clinical internships: an exploratory study. Physiotherapy 2013: 99: 178–180. 26 Lash AA, Kulakac O, Buldukoglu K, Kukulu K. Verbal abuse of nursing and midwifery students in clinical settings in Turkey. J Nurs Educ 2006: 45: 396–403. 27 Monrouxe LV, Rees CE, Endacott R, Ternan E. ‘Even now it makes me angry’: healthcare students’ narratives of professionalism dilemmas. Med Educ 2014; 48: 502–517. 28 Crotty M. The foundations of social research. Meaning and perspective in the research process. London: Sage, 2003. 29 Lutgen-Sandvik P. Take this job and. . .: quitting and other forms of resistance to workplace bullying. Commun Monogr 2006: 73: 406– 433. 30 Liefooghe APD, Davey KM. Accounts of workplace bullying: the role of the organisation. Eur J Work Organ Psychol 2001: 10: 375– 392. 31 Monks CP, Smith PK, Naylor P, Barter C, Ireland JL, Coyne I. Bullying in different contexts: commonalities, differences and the role of theory. Aggress Violent Behav 2009: 14: 146–156. 32 Baillien E, Neyens I, De Witte H, De Cuyper N. A qualitative study on the development of workplace bullying: towards a three way model. J Community Appl Soc Psychol 2009: 19: 1–16. 33 Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, eds. Analysing qualitative data. London: Routledge, 1994: 173–194. 34 Riessman CK. Narrative methods for the human sciences. Thousand Oaks, CA: Sage Publications, 2008. 35 Rees CE, Monrouxe LV, Ajjawi R. Professionalism in workplace learning: understanding interprofessional dilemmas through healthcare student narratives. In Jindal-Snape D, Hannah EFS, eds. Exploring the dynamics of personal, professional and interprofessional ethics. Bristol: Policy Press, pp, 295–310. 36 Rees CE, Monrouxe LV, McDonald LA. Narrative, emotion and action: analysing ‘most memorable’ professionalism dilemmas. Med Educ 2013: 47: 80–96. 37 Maxwell J. Using numbers in qualitative research. Qual Inq 2010: 16: 475–482.

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Workplace abuse narratives from dentistry, nursing, pharmacy and physiotherapy students: a multi-school qualitative study.

Previous healthcare student abuse research typically employs quantitative surveys that fail to explore contributory factors for abuse and students' ac...
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