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Clinical placement serves as a vital bridge between theoretical instruction and professional nursing practice, offering nursing interns the opportunity to translate knowledge into real-world patient care. However, experiences of bullying during clinical placements substantially undermine the quality and effectiveness of nursing education. Such negative behaviours jeopardize the biopsychosocial well-being of nursing interns and affect their career choices, and pose persistent challenges to the long-term stability of the nursing workforce.
Methods
This study employed a descriptive phenomenological approach, conducting semi-structured, in-depth interviews with 14 nursing interns from three educational institutions in Hubei and Guangdong Provinces, China, who reported being subjected to bullying by clinical instructors and nurses. The study adhered to the COREQ guidelines. Data were analyzed using inductive qualitative content analysis, and methodological rigor was maintained through the principles of confirmability, transferability, credibility, and dependability.
Results
Analysis yielded five overarching themes encompassing 25 subthemes:(i) Manifestations of bullying; (ii) Impacts of bullying; (iii) Coping strategies; (iv) Causes of bullying; (v) Recommendations for reducing bullying.
Conclusions
This study presents a comprehensive and multidimensional examination of bullying experienced by nursing interns during their clinical placements. The findings reveal that bullying manifests in diverse forms, resulting in significant physical and psychological distress, undermining professional identity, and revealing the limited coping strategies available to nursing interns. To mitigate these adverse effects, targeted interventions should address contributory factors, cultivate a culture of safety and respect, and enhance institutional support systems to foster empowering learning environments for future nurses.
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Background
Bullying, defined as a form of persistent emotional abuse manifested through repeated negative verbal and nonverbal interactions, such as excessive criticism, intimidation, social exclusion, withholding of information, and insulting gestures, remains a critical concern within healthcare settings [1]. Clinical internships, as an integral component of nursing education, not only strengthen nursing students’ professional competencies but also play a pivotal role in shaping their ethical and professional values. In China, nursing programs require students to complete a minimum of eight months of clinical placement within healthcare institutions, providing a crucial bridge from student to novice nurse. However, this formative stage is often associated with substantial pressure, in terms of both academic requirements and employment uncertainties [2].
Although bullying in healthcare environments is not a new phenomenon, nursing interns are particularly susceptible to such behaviour [3]. Their vulnerability stems from their status as newcomers on the lowest level of the institutional hierarchy [4], young age, limited clinical expertise, and underdeveloped coping strategies [5].
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The repercussions of bullying during clinical placements are profound and multidimensional. Nursing interns subjected to bullying frequently experience physical manifestations such as fatigue and insomnia, alongside psychological distress manifesting as anxiety and depression. These adverse experiences may lead them to question their commitment to the nursing profession, exacerbating workforce shortages within an already strained healthcare system [6‐8]. Despite the serious consequences, many nursing interns choose not to report incidents of bullying. Some perceive such behaviour as an inevitable aspect of nursing culture, perpetuating its normalization. In comparison, others avoid reporting due to apprehension about potential stigmatization as victims, or skepticism regarding institutional responsiveness to reported incidents [9]. Protecting nursing interns from bullying is therefore both an ethical imperative and a strategic priority essential for retaining future nursing professionals and ensuring the delivery of high-quality patient care [10].
Existing research has predominantly examined the overt manifestations and short-term impacts of bullying among nursing interns, with limited exploration of how interns perceive, interpret, and internalize these experiences. Moreover, there remains a lack of understanding regarding how institutional environments influence their coping mechanisms and the formation of professional identity. To address these gaps, the present study employed a phenomenological approach to explore bullying experienced by nursing interns during clinical placements, including manifestations, impacts, coping strategies, cause, and suggested interventions. By capturing the lived experiences of nursing interns, this research provides valuable insights into the realities of nursing education and the complex dynamics of bullying in clinical contexts. The findings provide evidence to inform the development of targeted anti-bullying initiatives and promote safer, more supportive clinical learning environments that enhance nursing education and workforce sustainability.
Methods
Design and participants
A descriptive phenomenological approach was adopted to explore the lived experiences of nursing interns who encountered bullying from clinical instructors and nurses in China. This approach facilitated an in-depth understanding of how participants perceived and interpreted bullying within clinical learning environments. Data were analyzed using inductive qualitative content analysis, which allowed for the condensation and interpretation of textual data to uncover subjective perceptions and contextual meanings [11]. This analytic approach was selected to inductively categorize experiential meanings and contextual factors embedded in participants’ accounts, allowing the analysis to remain descriptive while organizing the data into meaningful thematic categories. To ensure transparency and methodological rigor, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [12].
This qualitative component formed part of a broader sequential explanatory mixed-methods design. The initial quantitative phase assessed the prevalence of bullying and coping strategies among nursing interns through a structured survey that included demographic data, the Negative Acts Questionnaire-Revised (NAQ-R) [13, 14], the Hospital Workplace Violence Questionnaire [15], and the Workplace Violence Coping Resources Scale [16]. Participants were recruited through faculty liaisons at nursing schools in Hubei, Guangdong, and Gansu Provinces. Eligible nursing students completed the online questionnaire via the Questionnaire Star platform (Wenjuanxing, http://www.wjx.cn). The quantitative results of this phase have been reported previously [17].
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At the conclusion of the survey, interns who reported experiencing bullying were invited to provide their contact information if they wished to participate in follow-up qualitative interviews. Participation in these interviews was entirely voluntary, and strict confidentiality was maintained throughout the study.
The inclusion criteria were as follows: (1) full-time nursing student status during clinical placement; (2) a clinical placement duration of at least six months; (3) self-reported experience of workplace bullying in the preliminary survey; (4) ability to describe bullying incidents in sufficient detail; and (5) intact memory and emotional stability. Exclusion criteria included: (1) being on academic leave during the study period and (2) a recent history of severe psychological trauma or a diagnosed mental health condition.
A total of fourteen nursing interns participated in the interviews. The sample size was determined by data saturation rather than predefined numerical targets, recruitment proceeded iteratively and was concluded when successive interviews failed to yield new or meaningful insights relevant to the research objectives [18].
Data collection
Data were collected through semi-structured, in-depth interviews conducted either face-to-face or via WeChat video, depending on participants’ preferences and geographic accessibility. For participants based in Shenzhen, face-to-face interviews were preferred and held in quiet, private rooms within clinical or educational institutions to ensure comfort and confidentiality. For those located outside Shenzhen, online interviews were conducted via WeChat video due to logistical constraints related to distance and time. Clear instructions were provided beforehand to ensure privacy and minimize potential interruptions during virtual sessions.
The interview guide was developed following an extensive review of the relevant literature and refined after three pilot interviews to enhance clarity, logical flow, and comprehensiveness. The final guide included the following core questions:
1)
How do you understand workplace bullying?
2)
What manifestations of bullying have you experienced or observed during clinical placement?
3)
How did these experiences affect you?
4)
What coping strategies did you use?
5)
What factors do you believe contribute to the occurrence of bullying?
6)
What interventions do you think could effectively reduce bullying?
All interviews were conducted by researcher YFL, who holds a master’s degree in nursing and has previous experience in qualitative research. To establish trust and promote open communication, rapport was built with each participant before the interview began. While following the interview guide, the researcher remained flexible and responsive to the natural flow of conversation, using probing questions to explore emerging themes in greater depth. Active listening was emphasized, clarifications were sought when necessary, and participants were encouraged to express their thoughts and feelings freely. Nonverbal cues, such as tone, facial expressions, and body language, were observed and documented to enrich contextual interpretation. Each interview lasted approximately 30 to 40 minutes.
Data analysis
Data were analyzed using inductive qualitative content analysis, following the methodological framework proposed by Elo and Kyngäs [19]. This approach was selected for its suitability in systematically organizing experiential narratives into data-driven categories while preserving the authenticity of participants’ language and meanings. The analysis emphasized both the explicit content and the experiential significance conveyed in participants’ accounts, ensuring that interpretations remained grounded in their lived experiences without imposing external analytical assumptions [20, 21]. Coding and theme development were carried out manually in Microsoft Word, without the use of specialized qualitative software. The specific contributions of the researchers at each stage of analysis are identified by their initials. The analytical process comprised the following sequential steps:
First, all interview recordings were transcribed verbatim by two researchers (YFL and ML). ML, a second-year student in a three-year nursing program with previous training and experience in qualitative interviewing, contributed to the transcription and data preparation process. To achieve data immersion, transcripts were read multiple times and annotated with reflective notes to capture initial impressions and emerging insights (YFL, XP, RC). XP holds a PhD and serves as a nursing faculty member with expertise in qualitative research. In comparison, RC has a master’s degree and is currently pursuing a PhD in nursing, also with experience in qualitative research.
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Open coding was next conducted through line-by-line examination of the transcripts, with meaning units identified and assigned initial codes (YFL, XP, RC). These preliminary codes were subsequently grouped into subcategories and broader categories based on conceptual similarities and distinctions. Through an iterative process of abstraction, these categories were synthesized into overarching themes that represented recurrent patterns and central ideas emerging from the participants’ narratives.
Theme development and refinement were achieved through researcher triangulation, involving three analysts (YFL, XP, RC). Each researcher independently coded the data, and discrepancies were addressed through regular discussions until consensus was reached. Code matrices and thematic structures were reviewed and refined iteratively to ensure conceptual clarity and coherence.
To enhance the trustworthiness and credibility of the findings, member checking was conducted. Summaries of the emerging themes were shared with participants via telephone, allowing them to verify the accuracy and resonance of the interpretations. Participant feedback was incorporated into the final analysis as appropriate (YFL, ML).
Ensuring rigor
Research rigor was further strengthened through the use of researcher triangulation, reflexive journaling, member checking, and external expert review. Researcher triangulation reduced the potential for individual interpretive bias by ensuring that data coding and thematic interpretation were conducted independently by multiple researchers, followed by consensus-based reconciliation.
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Reflexivity was maintained throughout the study by keeping a reflexive journal, which documented the researchers’ assumptions, methodological decisions, and evolving interpretations during the analytical process.
Member checking was conducted following the initial thematic analysis. The key themes were shared with all 14 participants via telephone. Most participants confirmed that the identified themes accurately represented their experiences, while two participants suggested minor revisions to phrasing for greater precision in conveying their intended meaning, these adjustments were subsequently integrated into the final analysis.
An external expert in qualitative research reviewed the thematic structure and provided constructive feedback, which contributed to refining the analytical framework and enhancing the reliability, credibility, and overall accuracy of the findings.
Ethical considerations and quality assurance
This study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki and received approval from the Ethics Committee of the Health Science Center, Yangtze University (Approval No. 202,102,015). Before participation, all nursing interns were provided with detailed information regarding the study’s purpose, significance, and objectives. Written informed consent was obtained from each participant before data collection.
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The research team clearly communicated that the study sought to explore participants’ experiences and perceptions rather than assess their professional performance. This clarification fostered a sense of trust and openness, encouraging participants to share their experiences candidly during the interviews. Participants were explicitly informed of their rights, including the right to decline participation or withdraw from the study at any stage without penalty, remarkably, no participants chose to withdraw.
All participants were informed of the audio recording procedures and provided explicit consent for their interviews to be recorded. To ensure anonymity, participants were identified using alphanumeric codes, and all agreed to the anonymous use of their data. Access to the raw interview materials was strictly limited to members of the research team, maintaining confidentiality and data security throughout the research process.
Results
Characteristics of participants
As summarized in Table 1, participants were recruited from three educational institutions located in Guangdong and Hubei Provinces. Their ages ranged from 20 to 22 years. The sample consisted of 13 females and 1 male, all of whom were enrolled in associate degree programs (three-year nursing programs within the Chinese educational system). Each participant had completed an eight-month clinical internship at the time of the study. Of the fourteen participants, twelve expressed their intention to pursue a career in nursing, while two planned to continue their academic studies after graduation.
Table 1
Characteristics of participants
Coding
Age
(years)
Gender
Education
Duration of internship (months)
Intention of career choice
S1
21
Female
Associate degree
8
Nursing
S2
21
Female
Associate degree
8
Nursing
S3
21
Female
Associate degree
8
Continuing academic studies
S4
21
Female
Associate degree
8
Nursing
S5
21
Female
Associate degree
8
Nursing
S6
20
Female
Associate degree
8
Nursing
S7
21
Female
Associate degree
8
Nursing
S8
21
Female
Associate degree
8
Nursing
S9
20
Female
Associate degree
8
Nursing
S10
20
Female
Associate degree
8
Nursing
S11
21
Male
Associate degree
8
Nursing
S12
22
Female
Associate degree
8
Nursing
S13
22
Female
Associate degree
8
Nursing
S14
20
Female
Associate degree
8
Continuing academic studies
Types of bullying
Five overarching thematic categories were identified from participants’ accounts of bullying by clinical instructors and nurses: (1) manifestations of bullying, (2) impacts of bullying, (3) coping strategies, (4) causes of bullying, and (5) recommendations for reducing bullying. These themes collectively informed the development of a conceptual framework that encapsulates nursing interns’ experiences of bullying during clinical placements, as illustrated in Fig. 1.
Fig. 1
Nursing interns’ experiences of bullying from instructors and nurses
All fourteen participants reported having experienced some form of bullying from clinical instructors or nurses during their clinical placements. The manifestations of bullying were classified into eight distinct subthemes: “inappropriate criticism”, “verbal intimidation and gossip”, “lack of concern”, “insufficient guidance”, “unfair treatment”, “exclusion from the team”, and “systemic management deficiencies”.
Participants frequently described being publicly reprimanded, or subjected to sarcastic remarks. Several interns recounted instances of physical mistreatment, such as being pushed or struck on the back. In comparison, others recalled situations in which instructors demonstrated disproportionate emotional outbursts in response to minor errors or misunderstandings.
When I first started, my instructor frequently reprimanded me in front of others, often overreacting to minor mistakes. She even remarked that I might not be suited for nursing, her tone was disdainful and sarcastic. (S6)
I made a mistake while writing a nursing note, and my instructor pushed my head. On another occasion, she struck me on the back. (S14)
Verbal intimidation and gossip directed toward or made about interns contributed to the creation of a hostile and unsupportive learning environment. Two participants reported experiencing direct verbal intimidation from their instructors, while others recounted overhearing derogatory comments made by nurses about nursing interns.
I had a fever and needed to take time off. My instructor advised me that individuals with poor health are unlikely to be retained and should consider other employment options. (S9)
The nurses often talked behind our backs, passing judgment on the interns. (S13)
The participants also reported neglect by instructors, amid demanding workloads and high-stress environments, which led to feelings of isolation and a lack of support.
After a needlestick injury, my instructor did not provide any assistance or guidance. I had to treat the wound, review the patient’s records, and complete the necessary testing myself. (S6)
During an X-ray procedure involving radiation risks, my instructor told the others to leave the room but failed to inform me, leaving me alone in the ward. (S7)
Owing to limited instructor availability, unstructured teaching approaches, and poorly planned schedules, interns frequently received insufficient supervision and guidance. As a result, they were often confined to performing routine or basic tasks, which impeded their clinical development.
When the call bell rang, I was sent alone to respond. My instructor became impatient when I was unsure what to do, despite never having been taught how to handle such situations. (S10)
Some instructors assumed that interns would be unable to learn much in a short period and assigned us only routine tasks, such as measuring vital signs, which precluded opportunities for more in-depth learning related to the department. (S5)
All participants reported experiencing unfair treatment during their clinical placements. Such treatment manifested in various forms, including unwarranted blame, dismissive attitudes, assignment to non-instructional or menial tasks, biased comparisons with peers, and denial of access to basic resources or amenities.
When the medication was misplaced, my instructor immediately blamed me without inquiring about the details. The assumption that students are inherently suspect or incompetent is deeply distressing. (S10)
The instructor would say, ‘Use my student, I don’t need her,’ in front of others. I felt this was dismissive, as though I was merely a tool being passed around. The staff didn’t even know my name. They ordered me around. (S10)
I was frequently assigned menial tasks unrelated to my knowledge, such as taking out trash or fetching meals. (S7)
The head nurse openly said that she preferred undergraduates over specialist students. (S12)
We were not allowed to eat in the staff cafeteria and had to order takeaways. (S1)
Many interns also reported feeling excluded from the team culture and social activities, which hindered their sense of belonging.
On holidays such as Nurses’ Day and International Women’s Day, we received no gifts and weren’t invited to departmental dinners or outings. (S13)
Participants underscored several systemic deficiencies in nursing management, including irregular scheduling, cumbersome leave approval processes, and poorly coordinated rotation arrangements.
I once worked 10 consecutive days, including multiple night shifts, followed immediately by a day shift. The instructors didn’t have such packed schedules. I also didn’t have a consistent mentor, resulting in disjointed and fragmented learning. (S10)
When I was sick, I had to go through leave procedures despite having a fever. Taking sick leave required multiple signatures. If staff were absent, the sick leave could not be processed. (S13)
In other hospitals, rotations are prearranged. Here, we’re moved around constantly according to staffing needs. Sometimes, students stayed in one department for a long time, missing valuable exposure to others. (S10)
Theme 2: Impacts of bullying
The analysis revealed that bullying during clinical placements produced multifaceted consequences, influencing interns’ physical well-being, psychological health, professional identity, and overall professional development. Four major subthemes emerged: “impaired physical and psychological health”, “self-doubt and diminished self-efficacy”, “weakened professional identity and sense of belonging”, and “an essential process for professional growth”.
Participants reported a range of adverse physical symptoms, including fatigue and sleep disturbances, accompanied by negative psychological reactions such as anxiety, frustration, depression, anger, helplessness, humiliation, and fear. These effects frequently extended beyond the clinical environment, disrupting interns’ social interactions and emotional stability in their daily lives.
Anxiety and insomnia became routine …. My hands would tremble, and I would break out in a cold sweat …. The situation led to frustration, distraction, and a decline in mood and work efficiency. (S10)
The stress lingered even after work. There was no sense of happiness, and I had no desire to socialize, as a result, I became increasingly withdrawn. The fear of making mistakes during procedures remained the next day. (S7)
Experiencing bullying often caused interns to doubt their professional competence and self-worth, leading to self-doubt and diminished self-efficacy. The presence of supportive instructors was identified as a crucial protective factor that helped mitigate these negative effects and restore interns’ sense of capability.
Sometimes this led to self-denial, but then you look back and see that we weren’t actually that bad. (S7)
The bullying made me feel worthless. I dreaded going to work and cried after shift, not because of the workload but because I couldn’t trust the people around me. However, if I had received support and protection from my instructor, I would have felt safer, making it easier to tolerate bullying from others. (S5)
Bullying diminished interns’ sense of professional identity and belonging, negatively influencing the development of their professional identity and future career planning. Several participants reported questioning their decision to remain in the nursing profession, while others began to consider pursuing alternative career paths.
Negative feedback or criticism severely erodes confidence, fostering a persistent fear of underperformance and potential reprimand. This leads to hesitation, hypervigilance, and emotional sensitivity, impairing decision-making and reducing enthusiasm for the nursing profession. (S11)
Initially, I lost interest in nursing altogether. I even questioned whether to continue studying … However, I later met encouraging instructors who helped me regain my sense of identification with and passion for the nursing career. (S2)
Despite these challenges, several participants reframed bullying as an opportunity for personal development and the cultivation of resilience.
The environment will not change, and we must learn to adapt, regardless of how difficult that may be. Confronting challenges is an unavoidable part of any nursing role. (S13)
Theme 3: Coping strategies
Participants identified five primary coping strategies employed in response to bullying: “toleration”, “self-reflection”, “positive communication”, “seeking support”, and “self-regulation”.
Five participants reported choosing to endure or avoid the bullying, primarily due to fear of confrontation, perceived power imbalances, or concerns about possible retaliation from instructors or nurses.
As students, we didn’t know how to respond and could only endure the situation silently. Later, I learned about coping strategies from research. (S5)
Although my clinical instructor bullied me, I didn’t dare request a change. I was unsure if there would be any difference or improvement in the replacement, and my peers advised me to endure the situation. (S11)
Eight participants reported engaging in self-reflective analysis following bullying incidents. This reflective process served a dual function, it helped improve their professional competence and communication skills and strengthened their ability to recognize and anticipate potential bullying behaviours in future clinical interactions.
I reflect on what happened. If I were wrong, I would work on improving to demonstrate my abilities. If not, I would encourage myself to move on. (S6)
Rather than searching for endless explanations, I focus on improving my skills. Once I perform well, I won’t face criticism. (S8)
Several participants moved beyond passive endurance, adopting more assertive approaches through direct communication or formal reporting.
Addressing the issue directly with the person involved is often the best approach. Open conversation can clarify misunderstandings and enable constructive resolution. (S5)
If communication didn’t work, I followed the hierarchy, reporting first to the teaching secretary and then to the head nurse or nursing department. (S2)
The majority of participants sought emotional support from peers, roommates, or instructors, and, when necessary, from family or faculty members.
I shared my experience with friends or roommates and asked for their perspective. My family also provides emotional support. If they could not relate, I reached out to my school faculty for targeted support. (S5)
Several participants demonstrated self-regulation through active psychological reframing and engagement in stress-alleviation activities.
I try to think more positively instead of fixating on the negative. (S5)
During that difficult time, I often listened to music or went for a walk or run by myself, which helped me feel better. (S7)
Theme 4: Causes of bullying
Participants identified several interrelated factors contributing to bullying during clinical placements, which were categorized into five subthemes: “individual characteristics of interns”, “quality of instructors”, “organizational climate”, “institutional deficiencies”, and “clinical environment”.
The personal attributes of nursing interns, such as their personality traits, learning attitudes, and clinical competencies, were found to influence their susceptibility to bullying. Interns who were introverted, less communicative, less engaged, or perceived as inadequately prepared were reportedly more likely to become targets of bullying behaviour.
My clinical instructor communicated smoothly with others but rarely interacted with me. This may have been due to my personality. I’m sensitive and tend to keep to myself, which may have made me seem distant or difficult to approach. (S7)
Some interns lacked basic clinical competence and often felt overwhelmed. Others were frequently late, left early, or displayed a lack of initiative, resulting in negative feedback. (S11)
The quality of instruction was perceived to depend mainly on the instructor’s teaching competence, communication approach, and emotional regulation. Some instructors were reported to prioritize clinical duties over educational responsibilities, while others projected their stress or frustration onto students, creating a negative learning atmosphere.
Some instructors have not been trained to teach and just let students follow them aimlessly without a structured learning plan. (S8)
As interns, we’re seen as temporary. Some instructors vent their negative emotions on us, knowing that they cannot do the same with long-term colleagues. (S12)
The organizational climate played a crucial role in shaping how interns were treated. Supportive and collaborative environments fostered positive learning experiences, whereas punitive and hierarchical cultures tended to normalize behaviours such as criticism, exclusion, and intimidation.
We feel supported in friendly departments. In comparison, some departments are tense and oppressive, characterized by criticism and a lack of encouragement. (S3)
Some staff members view bullying as part of their organizational culture. Bullying becomes normalized because everyone is accustomed to it. (S10)
Institutional deficiencies, particularly the absence of effective reporting mechanisms, were identified as systemic factors contributing to bullying. Many interns reported limited awareness of available reporting channels, coupled with fear of retaliation and doubt regarding institutional responsiveness, which collectively discouraged them from reporting bullying incidents.
I don’t even know where or how to report issues. (S2)
Our feedback seems ineffective. If it is not anonymous, it might affect our future opportunities. (S6)
The clinical environment was found to play a critical role in influencing interactions between interns and instructors. High-pressure and fast-paced settings often amplify interpersonal tensions, contributing to misunderstandings and conflicts between teaching responsibilities and clinical service demands.
When instructors are less busy, they are more approachable and allow more opportunities for learning. However, with high workloads and when you are not yet proficient, instructors often perform tasks themselves instead of teaching, which makes learning more challenging. The department is bustling, and many teachers are unwilling to mentor interns. (S5)
Nursing work is highly hierarchical, and as an intern, I often feel at the very bottom. (S13)
Theme 5: Recommendations for reducing bullying
Participants proposed a comprehensive framework of interventions designed to reduce bullying behaviours during clinical placements. This framework encompassed four major subthemes: “nursing intern-focused strategies”, “clinical instructor-oriented approaches”, “educational institution initiatives”, and “healthcare organization reforms”.
Nursing intern-focused strategies centered on three key domains: emotional self-regulation, enhancement of clinical competence, and development of effective coping strategies. Participants emphasized that emotional regulation was crucial for managing challenging clinical interactions and mitigating the psychological impact of potential bullying. As one intern remarked:
Avoid bringing personal emotions into work; try to stay calm and understand the perspectives of others. Focus on providing positive feedback and encouragement, rather than negativity. (S3)
Strong clinical skills were also considered protective, as they fostered confidence and reduced the likelihood of criticism, with one participant reflecting:
Confidence derived from solid knowledge and techniques helps protect against bullying. (S5)
Finally, the interns underscored the importance of developing practical strategies for responding to bullying, including seeking support from others, assertively communicating their needs, making appropriate refusals, and utilizing available educational and institutional resources. As one participant explained:
I recognize the importance of respectfully refusing tasks that I am unwilling to perform and strive to express my thoughts more openly … … If the situation becomes intolerable, a request for a change of instructor should be considered. (S7)
Clinical instructor-oriented approaches encompassed several key strategies, including enhancing teaching effectiveness, providing protection, demonstrating empathy and understanding, addressing interns’ legitimate needs, and offering career guidance. Instructors who possessed strong pedagogical abilities, facilitated hands-on learning opportunities, and delivered constructive feedback were particularly valued by participants. As illustrated by the accounts of two interns:
Some patients were reluctant to allow interns to perform procedures on them. However, my instructor reassured them by saying, ‘She is very skilled.’ If I failed, she guided me gently instead of criticizing, which gave me a great sense of security. (S3)
Instructors who protected students during interpersonal conflicts played a key role in minimizing harm, as one participant noted:
When conflicts arose, my instructor supported me and helped resolve the issue without blame rather than siding with the patient and indiscriminately criticizing me. (S1)
Empathy and understanding also emerged as essential for fostering an environment of psychological safety:
She never shamed me for not knowing something and encouraged me to ask questions … … She was patient and considerate, recognizing our challenges and providing support. (S3)
The ability to remain flexible and responsive to interns’ legitimate needs and requests was emphasized as a key element of respectful and supportive educational practice:
When an important personal matter arose, my instructor adjusted the schedule on my behalf. That meant a lot to me. (S1)
Finally, mentorship beyond clinical teaching, particularly career guidance, was also appreciated:
My instructor provided practical tips on job searches and career development, which were extremely valuable. (S14)
Educational institutions initiatives focused on improving education and training while strengthening faculty-student communication. Interns emphasized the need for structured programs that address emotional regulation, interpersonal communication, and practical strategies for responding to bullying. They recommended interactive approaches, such as group counseling, role-playing, and peer-sharing sessions, to foster resilience and improve coping skills in real-world clinical contexts. Participants further emphasized that the timing of these interventions is critical, noting that such programs have a greater impact when implemented after initial clinical exposure. As one participant remarked:
We need to understand how to recognize bullying, how to respond to it, our rights, and how to handle these situations effectively. (S1)
Proactive communication from faculty members was regarded as vital for fostering openness and trust between educators and students. Participants recommended that faculty maintain regular contact with interns through both formal mechanisms, such as scheduled meetings, and informal interactions, to ensure ongoing support and early identification of potential issues:
Faculty may solicit input not only through formal meetings but also by engaging in informal conversations, reducing pressure, building trust, and contributing to a more open and supportive atmosphere. (S4)
Healthcare organization reforms were described as encompassing the selection and training of clinical instructors, active managerial engagement, the establishment of robust institutional systems, and enhancements to the clinical environment. Interns advocated for a more rigorous and merit-based selection process for clinical instructors, one that prioritizes teaching competence, communication skills, emotional intelligence, and willingness to teach, rather than relying solely on seniority. They further recommended implementing systematic pedagogical training programs to raise clinical instructors’ awareness of bullying behaviours and foster inclusive, supportive teaching practices.
Clinical instructors should not be appointed solely based on seniority. Their teaching ability, professional qualifications, emotional regulation, and communication skills should also be taken into account. (S11)
Instructors may not recognize that their words or behaviours, although seemingly harmless to them, can be experienced as distressing or intimidating by students. Without sufficient awareness of what constitutes bullying, inappropriate conduct may go unrecognized and unaddressed. (S5)
The participants also identified hospital managers as key to the shaping of clinical culture and argued that managers must be more actively involved in preventing and addressing bullying. They emphasized the need for targeted managerial training as an essential component of any anti-bullying strategy.
Managers should be able to address bullying immediately and send a clear message that bullying behaviour is unacceptable. (S10)
Participants underscored the importance of establishing robust institutional systems to prevent and address bullying during clinical placements. A central recommendation was the implementation of secure, anonymous reporting mechanisms that would allow students to disclose bullying incidents without fear of retaliation or adverse effects on their academic evaluations. Incorporating time-delayed feedback was also suggested as a means of further safeguarding student confidentiality.
To improve accountability and transparency, participants proposed that anonymized student feedback be regularly reviewed by an independent evaluation committee separate from clinical instructors. Furthermore, they recommended appointing a designated staff member to monitor and follow up on reported bullying cases. Regular performance assessments of clinical instructors were also advised, incorporating structured reward and sanction systems based on student evaluations to promote fair and responsible teaching practices.
A secure and impartial reporting platform should be established so that students can safely report bullying incidents without fear of negative consequences. (S4)
Finally, participants emphasized the need to improve the clinical environment by reducing staff workload and promoting a more supportive and collegial atmosphere. Several interns expressed a desire for stronger emotional connections within clinical teams, suggesting that communal activities and team-building initiatives could help foster a sense of belonging, strengthen interpersonal relationships, and diminish hierarchical barriers within the healthcare setting.
When nurses are overwhelmed, they are more likely to make mistakes or become irritable. Reducing the workload could significantly improve the clinical learning environment. (S8)
Discussion
This study presents a comprehensive phenomenological analysis of nursing interns’ experiences of bullying during clinical placements, identifying five major themes: manifestations of bullying, impacts of bullying, coping strategies, causes of bullying, and recommendations for reducing bullying. The findings offer valuable insights into the nature and consequences of bullying, providing evidence-based guidance for nursing educators and administrators seeking to strengthen occupational protection and supportive learning environments for nursing interns.
Participants described a broad spectrum of bullying behaviours, encompassing inappropriate criticism, verbal intimidation and gossip, lack of concern, insufficient guidance, unfair treatment, exclusion from the team, and systemic management deficiencies. These findings are consistent with previous research documenting verbal abuse, inadequate guidance, biased task allocation, and unjust treatment as common forms of mistreatment encountered by nursing interns [22‐24].
Previous studies have emphasized that the presence of competent and supportive clinical instructors serves as a crucial protective factor, significantly shaping interns’ clinical experiences, professional confidence, evidence-based practice competence, and attitudes toward nursing practice [25, 26]. However, the current findings indicate that such positive mentorship was not consistently available to all participants. Given the pivotal influence of clinical instructors on the professional growth and psychological well-being of nursing interns, all staff engaged in student supervision must adhere to professional and ethical standards that foster respectful, constructive, and empowering mentorship within the clinical learning environment.
Consistent with previous research, this study underscores the profound physical and psychological impacts of bullying on nursing interns [27‐29]. Participants reported a range of physical symptoms, including fatigue and insomnia, alongside psychological distress characterized by anxiety, frustration, depression, anger, helplessness, humiliation, and fear. Prolonged exposure to these stressors was found to erode self-esteem and self-efficacy, while also undermining the development of professional identity and sense of belonging, factors that, in some cases, led interns to reconsider their commitment to a nursing career. These findings are consistent with earlier studies that have documented similar outcomes [8, 30].
Several participants also described experiences of personal growth through adversity, interpreting bullying as a developmental challenge that fostered resilience, optimism, and professional maturity, a perspective aligned with the findings of Zheng et al. [1].
The study further revealed that many nursing interns tended to endure bullying passively, often refraining from reporting incidents due to fear of retaliation, perceived institutional inaction, or the belief that bullying was an inevitable aspect of clinical placements. Although participants did not condone such behaviour, they frequently expressed a sense of powerlessness in addressing it, echoing the findings of Dafny and Beccaria [31].
Some interns reported that their experiences with bullying prompted critical self-reflection, motivating them to strengthen theoretical knowledge and enhance practical skills to improve their professional competence, as similarly observed by Liu et al. [32]. Others eventually overcame their initial fear and demonstrated assertive coping behaviours, including reporting incidents or confronting perpetrators directly. Moreover, several participants sought emotional and social support from social networks, consistent with the observations of Cao et al. [8]. Participants also described employing self-regulation techniques, such as cognitive reframing and physical exercise, to manage emotional stress. While these proactive strategies contributed to restoring self-worth and reducing vulnerability, they did not completely alleviate the lasting psychological effects of bullying. Therefore, addressing the systemic and cultural foundations that perpetuate bullying within clinical education remains crucial for fostering healthy learning environments and supporting the well-being of future nurses.
The causes of bullying in clinical placements is multifactorial, encompassing individual, interpersonal, organizational, and environmental dimensions. This study identified several contributing factors, including nursing interns, clinical instructors, the organizational climate, institutional deficiencies, and the broader clinical environment.
Participants perceived that individual vulnerability to bullying was influenced by interns’ personality traits, learning dispositions, and clinical competencies. This observation aligns with previous findings that link low self-confidence and inherent psychological vulnerability to an increased likelihood of bullying among nursing interns [33].
Furthermore, participants emphasized that inadequate pedagogical preparation and limited emotional regulation among clinical instructors, often stemming from excessive workloads or occupational burnout, were major contributing factors. Instructors lacking formal training in supervision were also seen as unintentionally perpetuating bullying through ineffective teaching and poor communication, consistent with the conclusions of Capper et al. [34].
At the organizational level, participants highlighted the influence of a pervasive “bullying climate” within certain departments. This finding is in agreement with earlier research demonstrating that hostile organizational cultures and insufficient managerial support hinder the implementation of effective anti-bullying measures [35]. The lack of explicit anti-bullying policies, ineffective reporting mechanisms, and unresponsive leadership contributed to underreporting and fostered a sense of helplessness among interns, were perceived as perpetuating tolerance for bullying, corroborating the results of Cao et al. [8].
The broader clinical environment was also identified as a critical contextual factor. Time constraints, staff shortages, and rigid hierarchical structures created conditions conducive to bullying behaviours. The inherent power imbalance in instructor-student relationships, coupled with the temporary and unfamiliar nature of clinical placements, further heightened interns’ vulnerability. These findings are consistent with previous research [33], which suggests that high-pressure clinical settings and unrealistic expectations of students significantly contribute to the persistence of bullying within nursing education.
The findings of this study underscore the need for multidimensional interventions to mitigate bullying during clinical placements, necessitating a coordinated approach across four key levels: nursing interns, clinical instructors, educational institutions, and healthcare organizations.
At the nursing intern level, participants emphasized the importance of developing emotional self-regulation, enhancing clinical competence, and adopting effective coping strategies were outlined by Dafny et al. [36], who identified a range of practical responses, including confrontation, seeking support from social networks, consulting instructors, utilizing counseling services, employing self-protective behaviours, reporting incidents to senior staff, and alerting hospital security when necessary. Previous research has also emphasized the importance of enabling students to distinguish between constructive criticism and bullying, analyze feedback objectively, and engage in reflective practice to identify areas for improvement [17]. Moreover, the formation of peer support networks, especially those encouraging experience-sharing and mutual encouragement, is highly effective in reducing the impact of bullying and fostering a more resilient student community [37].
At the clinical instructor level, participants advocated that instructors should enhance teaching effectiveness, provide protection, demonstrate empathy and understanding, address interns’ legitimate needs, offer career guidance. These findings align with earlier studies that identify exemplary nurse role models as those who excel as instructors, instill confidence, cultivate supportive learning environments, and demonstrate a genuine interest to interns’ growth and professional development [38].
At the educational institution level, participants emphasized the importance of comprehensive preparation for clinical placements, encompassing targeted educational initiatives and enhanced faculty-student communication. These findings support previous recommendations for integrating multicomponent, longitudinal curricula that address the typologies, consequences, prevention, and coping strategies related to bullying throughout the nursing education program [39]. Moreover, practical training in recognizing, managing, and de-escalating bullying incidents was considered essential for empowering students to respond effectively in real-world clinical contexts [40].
At the healthcare organization level, participants identified four key areas of reform necessary to reduce bullying in clinical settings: the selection and training of clinical instructors, active managerial involvement, and the establishment of robust institutional systems, and enhancements to the clinical environment.
The findings highlighted that the careful selection of qualified clinical instructors represents a crucial strategy in bullying prevention. Appointments to supervisory roles should be restricted to individuals who demonstrate strong teaching competence, effective communication skills, and a genuine commitment to mentorship. Beyond selection, participants emphasized the need for formalized training programs designed to enhance clinical instructors’ teaching effectiveness and emotional intelligence. As Burkley [41] observed, empathy and genuine concern for students are essential to establishing positive, supportive mentoring relationships. Similarly, Capper et al. [34] advocated for greater institutional support and professional development opportunities to better equip clinical instructors for the demands of their supervisory roles.
These findings are consistent with previous research that emphasizes the importance of managerial training and leadership in bullying prevention. Nurse managers should receive specialized education in recognizing, preventing, and addressing bullying behaviours, along with leadership development to promote an environment of psychological safety and reinforcing a zero-tolerance culture toward bullying in clinical placements [34].
Participants further emphasized the urgent need for robust institutional systems to prevent and address bullying during clinical placements. This finding aligns with previous research advocating for the establishment of comprehensive support structures for nursing interns, active improvements in monitoring systems and reporting mechanisms, and the integration of bullying experiences into the evaluation of instructors’ teaching effectiveness of instructors, and timely psychological assessments and mental health support for affected interns. Additionally, previous research also stressed the importance of collaboration between hospitals and educational institutions, recommending regular feedback exchanges regarding clinical placement experiences to ensure a coordinated and responsive approach to student welfare [8].
Enhancing the broader clinical environment, particularly through reducing instructor workloads and promoting team cohesion, mutual respect, and inclusivity, was regarded as vital in preventing the normalization of bullying behaviours. These findings are consistent with those of Mamaghani et al. [42], who emphasized the importance of a positive clinical learning environment in mitigating workplace bullying.
Although further research is warranted to evaluate the effectiveness of these student-proposed interventions, the insights provided are noteworthy. The nursing interns in this study acknowledged both their own limitations in preparedness and the institutional challenges faced by overburdened and undertrained instructors. While these recommendations require empirical validation, existing literature supports their practical relevance, indicating that resource-constrained environments and organizational stressors contribute to a higher prevalence of bullying behaviours [43].
Limitations
This study has several methodological limitations that should be acknowledged. First, as participants were recruited based on their self-reported experiences of bullying, the findings primarily reflect the perspectives of nursing interns who were willing to discuss such incidents. While this purposive sampling strategy was appropriate for the study’s aims, the results did not encompass the full diversity of clinical learning experiences among nursing interns in China. Consequently, the generalizability of the findings may be constrained.
Second, the retrospective design relied on participants’ recollections, which may have been influenced by recall bias arising from the passage of time, emotional processing, or subsequent professional development.
Third, although both face-to-face and online (WeChat) interviews were conducted, the online format may have restricted the researcher’s ability to observe nonverbal cues, potentially affecting the depth and richness of contextual data. These methodological differences should be considered when interpreting the results.
Fourth, while member checking was employed to enhance data accuracy, it was conducted only after the initial thematic analysis had been completed. As such, participant feedback may not have been sufficiently comprehensive to capture all subtle interpretive nuances.
Fifth, although triangulation was used to strengthen the trustworthiness of the findings, it primarily involved investigator and data triangulation. Other forms, such as methodological triangulation (integrating multiple data collection approaches, including focus groups discussions or field observations) and theoretical triangulation (examining findings through multiple conceptual frameworks), were not employed. The absence of these additional triangulation strategies may have limited the analytical breadth and depth of the study.
Finally, cultural context represents an important consideration. Within the Chinese sociocultural framework, hierarchical relationships and deep-rooted respect for authority may shape both the manifestation of bullying behaviours and the coping strategies available to nursing interns. These cultural dynamics may differ significantly across other settings, therefore, caution should be exercised when generalizing these findings to international contexts.
Despite these limitations, this study offers valuable qualitative insights into the manifestations and impacts of bullying, the coping strategies employed by nursing interns, and the underlying factors that contribute to such behaviours. Furthermore, it offers practical recommendations for fostering safer and more supportive clinical learning environments for nursing interns.
Conclusion
This qualitative study examined the lived experiences of nursing interns who encountered bullying from clinical instructors and nurses during clinical placements. The findings revealed that bullying manifested in both overt and subtle forms, each exerting substantial effects on interns’ well-being, self-efficacy, and professional identity formation. In response, interns employed various coping strategies, including toleration, self-reflection, positive communication, seeking support, and self-regulation.
The causes of bullying were found to involve a complex interplay of individual, interpersonal, organizational, and environmental factors. Participants proposed a series of multilevel interventions targeting nursing interns, clinical instructors, educational institutions, and healthcare organizations, emphasizing the need for systemic change.
Creating and sustaining safe, respectful, and empowering clinical learning environments requires coordinated efforts from all stakeholders to address the conditions that perpetuate bullying. The adoption of comprehensive, evidence-based strategies to prevent and manage bullying within nursing education has the potential to not only protect the well-being and professional growth of nursing interns but also to cultivate a supportive organizational culture, ultimately contributing to the long-term sustainability and resilience of the nursing workforce.
Acknowledgements
We would like to thank the nursing interns who participated in the study.
Declarations
Ethics approval and consent to participate
The study was conducted in accordance with the ethical principles of the World Medical Association Declaration of Helsinki. Ethical approval was granted by the Ethics Committee of Health Science Center, Yangtze University (No. 202102015), and all participants provided written informed consent before enrolment.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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