qualitative research abstract about bullying

Europe PMC requires Javascript to function effectively.

Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page.

Search life-sciences literature (44,131,415 articles, preprints and more)

• Free full text
• Citations & impact
• Similar Articles

Identifying and Addressing Bullying

Author information, affiliations.

• Nickerson AB 2

Study Guide from StatPearls Publishing, Treasure Island (FL) , 20 Jul 2017 PMID: 28722959 

Books & documents Free full text in Europe PMC

Abstract 

Free full text .

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Bulk download.

• Bulk download StatPearls data from FTP

Muhammad Waseem ; Amanda B. Nickerson .

Last Update: December 13, 2023 .

Continuing Education Activity

Bullying is a serious and widespread global problem with detrimental consequences for the physical and mental well-being of children. It is a repeated and deliberate pattern of aggressive or hurtful behavior targeting individuals perceived as less powerful. Bullying manifests in various forms, such as physical, verbal, social/relational, and cyberbullying, each with unique characteristics. Vulnerable youth at greater risk of being bullied are individuals who are perceived as "different,"  including those belonging to racial and ethnic minorities, immigrants, refugees, individuals with notable physical features or disabilities, and younger and defenseless children.

Healthcare professionals are uniquely positioned to identify and prevent bullying and intervene to mitigate its mental and physical health consequences. This activity reviews issues of particular importance to clinicians. It gives them practical tips to increase their awareness of bullying, enabling early recognition and effective management of this complex issue. Bullying is a problem that affects both the victims and the perpetrators, and this course equips learners with the knowledge and skills to positively impact the lives of the youth it affects.

Objectives:

• Identify signs and symptoms of bullying behavior, recognizing overt and subtle indications of victimization.
• Differentiate between various forms of bullying, including physical, verbal, social, and cyberbullying, to tailor appropriate intervention strategies.
• Assess the underlying causes of bullying behavior, including social and psychological factors, to develop prevention and intervention strategies.
• Collaborate with interprofessional team members to select appropriate therapeutic interventions and resources for victims and perpetrators of bullying.

Introduction

Bullying is a significant and pervasive yet preventable public health problem with detrimental consequences for children's physical and mental well-being. Bullying is a repeated and deliberate pattern of aggressive or hurtful behavior targeting individuals perceived as less powerful. [1] The CDC's formal and somewhat unwieldy definition is "any unwanted aggressive behavior by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated."[CDC. Fast Facts: Preventing Bullying ] In Australia, the National Center Against Bullying defines bullying as an "ongoing and deliberate misuse of power in relationships through repeated verbal, physical or social behavior that intends to cause physical, social, or psychological harm." This activity focuses on children and youth younger than 18 and does not address adult or workplace bullying. 

Historically, bullying has been seen as a "rite of passage" in childhood, and even today, there often is a tacit acceptance of bullying behavior. Many healthcare professionals struggle to accept bullying as a public health issue. An increased awareness of the long-term consequences on physical and mental health necessitates a shift in these attitudes.[Campbell, Kristin. Bullying and Victimization . AAP] Populations at greater risk are those perceived as "different," including racial, religious, and ethnic minorities, immigrants, refugees, individuals with notable physical features or disabilities, and younger or more vulnerable children. Bullying episodes are usually unprovoked and deliberate, and bullies often seek visibility and prestige through their actions.

Healthcare professionals play a vital role in preventing and identifying bullying and assisting with mitigating its mental and physical health consequences. This overview provides clinicians with the knowledge and tools to increase their awareness of bullying, enabling early recognition and effective intervention. Bullying is a problem that affects victims, perpetrators, and bystanders, and this overview equips clinicians with the skills to improve the lives of affected youth.

Bullying can happen anywhere, although it is most common in and around schools. Bullying usually occurs in relatively unstructured situations and minimally supervised areas such as playgrounds, cafeterias, hallways, bus stops, and buses. Bullying manifests in various forms, such as physical, verbal, social/relational, and cyberbullying, each having unique characteristics. Verbal bullying, including name-calling and taunting, is the most frequent.

Cyberbullying has received much attention in the past few years, as children and teens now have easy access to digital devices and social media sites. Cyberbullying manifests as text messages, social media posts, emails, online forums, and other platforms, and the risk increases considerably with the duration of a child's online activity. The term was first coined in the 1990s but has only become a significant concern in the 21st century as rates have risen, especially during the COVID-19 pandemic when electronic media use soared during lockdowns. Name-calling occurs most frequently, but 15% of youth bullied online describe being scared. Teens also report receiving unsolicited and explicit images meant to intimidate them.[Vogels, Emily. Teens and Cyberbullying 2022 ]

Artificial intelligence (AI) has complicated this issue. The Wall Street Journal wrote about a group of high school boys who used an online tool powered by AI to create nude photographs of female classmates, which they spread electronically. Although this might have been an isolated event, these fake nude likenesses will persist in cyberspace indefinitely and are likely to cause irreparable adverse effects.[WSJ. Nov 4-5, 2023, p1] Despite these growing concerns, only 11% of teens talk with their parents or caregivers about their cyberbullying experiences.[Security.org. Cyberbullying ] Identifying this form of bullying is challenging because the episodes may be less repetitive than typical verbal or physical bullying. [2]  In many instances, perpetrators remain anonymous, allowing them to engage in behavior they might not display face-to-face with their victims. Because online content is easily preserved and disseminated, cyberbullying results in ongoing suffering, especially when hurtful messages "go viral." Cyberbullying differs from traditional bullying as it does not rely on physical proximity or a specific location and can occur at any time of day or night. Traditional bullying at school usually does not extend to the home setting, but victims of cyberbullying may feel they cannot escape since their electronic devices are turned on 24/7. Like traditional bullying, cyberbullying can cause profound adverse psychological effects.

Relational or social bullying occurs when the aggressor manipulates social relationships to harm or control the victim. Unlike physical and verbal bullying, which involve direct acts of aggression, relational bullying is more subtle. The aggressors often rely on tactics such as spreading rumors, excluding victims from social groups, and manipulating social dynamics to damage reputations or relationships. In social bullying, the bully aims to isolate, hurt, or control the victim emotionally, which can result in psychological and emotional sequelae. Social bullying is no longer restricted to the schoolyard but frequently takes the form of cyberbullying.

Clinicians play a crucial role in identifying bullying and treating the children it impacts. They screen patients for risk factors, educate families about coping skills, and advocate in their communities and local schools. School anti-bullying measures can help prevent bullying and empower youth to intervene when they are bystanders. This overview describes how clinicians can address bullying in an outpatient setting to improve child well-being and reduce its physical, psychological, social, and educational harms.

What creates a bully? Bullying results from a complex combination of individual, social, and environmental factors, and many youths who engage in it have specific backgrounds and qualities. Likewise, victims often share similar traits. 

Exposure to adverse childhood events increases the likelihood of becoming a bully. Associated characteristics include aggression, frustration, lack of empathy, poor impulse control, a tendency to blame others for their problems, an inability to accept responsibility for one's actions, a desire for power, the perception that others are hostile, and having friends who are bullies. Bullies have also been noted to exhibit more antisocial behaviors and use more marijuana and alcohol than their peers. [3]  Bullies do not always need to be physically stronger than their victims. The perceived power imbalance is derived from many factors, including popularity, socioeconomic status, peer group, and cognitive ability. Bullies frequently use their behavior to gain social status within their peer group. [4]  Some perpetrators may not consciously consider themselves bullies, especially those previously victimized. 

Bullying affects all socioeconomic groups, and lower socioeconomic status (SES) has been associated with higher rates of victimization. Still, higher SES does not necessarily prevent an individual from being targeted. [5] [6]  Children from dysfunctional families or those exposed to violence at home are more vulnerable. However, protective factors include being connected with a supportive family or caring adult, strong peer relationships, and having close friends. [7] [Bass, P and Scholar, S. How to Identify and Treat Bullying . Contemporary PEDS Journal] Empowering children with skills to cope with their feelings has been shown to shield them somewhat from bullying's negative effects. [8]  

Children perceived as "different" from their peers are more likely to experience bullying. [9]  This includes youth from racial and ethnic minorities, who may also be disproportionately impacted by other factors associated with bullying, such as adverse community and school environments. A strong ethnic identity and positive cultural and family values, however, may protect these children from the hurtful effects of bullying. [10]  Likewise, youth from religious minorities or immigrant and refugee groups are targeted more often than their peers. Other examples include children with noticeable physical features, such as birthmarks, tall or short stature, disabilities, and chronic medical conditions, including severe acne, seizures, neurofibromatosis, autism spectrum disorder, attention deficit disorder (ADHD), and obesity. [11]  Teens with obesity are twice as likely to be bullied as their normal-weight peers. [12]  Children who are socially isolated, unpopular, lacking in interpersonal skills, or those with few friends are vulnerable as well. 

Bullying frequently serves to enforce perceived social norms within adolescent peer groups, such as heterosexual relationships and traditional gender roles. Students who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ)  often find themselves the targets of bias-based bullying, with a reported incidence nearly twice that of other students. They experience higher rates of verbal bullying, physical bullying, and cyberbullying, leading to injuries, emotional distress, and even suicide.[Earnshaw et al. LBGTQ Bullying . AAP] 

Some individuals who engage in bullying behavior may have experienced bullying or victimization themselves. These "bully victims" are at even higher risk of psychosomatic and behavioral problems than their uninvolved peers and report increased rates of suicidal ideation and attempts.[Flannery et al. Bullying and School Violence. Pediatrics Clinics of North America ] 

Epidemiology

According to the National Center for Educational Statistics' School Crime Supplement (2019), 22% of students aged 12 to 18 report being bullied at school. Teachers and academic administrators consider it a frequent disciplinary problem, with 14% saying they deal with it daily or at least weekly. The types of bullying reported include being the subject of rumors (15%), verbal taunting (14%), exclusion from activities (6%), being pushed, shoved, tripped, or spit on (5%), physical threats (4%), and coercion for students to do things they did not want to or the destruction of their possessions. (2%)

The CDC (Preventing Bullying, 2023) reports that about 20% of US high school students report being bullied at school, with 17% overall and as many as 30% of girls reporting cyberbullying. Half say that cyberbullying is a "major problem."[Vogels, Emily.  Teens and Cyberbullying 2022 ]

About 40% of children report witnessing bullying at their school. [13]  This is a global issue, with cited rates internationally ranging from 5% to 45%. [14]  Most studies report a greater prevalence among boys than girls, especially among middle school children. For boys, physical and verbal bullying is typical, but girls experience more verbal and social bullying. [15]  Traditional bullying peaks around age 12 and then gradually declines. Recent research suggests that social and cyberbullying continue to increase during adolescence. [15] [16]  Racial, religious, and ethnic minority youth are disproportionately influenced by bullying, and Black teens experience bullying more than other groups. [17] [18]  They are twice as likely as Hispanic or White teens to report they feel their race made them a target of cyberbullying.[Vogels, Emily.  Teens and Cyberbullying 2022 ]

Approximately 40% of high school students who identify as lesbian, gay, bisexual, or unsure of their sexual identity report being bullied, while 22% of bisexual high school students report being targeted. LGBTQ students are bullied twice as often as their heterosexual and cisgender peers and are less likely to report it. [19] [20]

History and Physical

Bullying may be the chief complaint for an appointment in a clinical setting. However, many children do not disclose they are targets of bullying, and clinicians should be suspicious when the review of systems is positive for somatic complaints and nonspecific symptoms or warning signs appear in the social history. Bullied children can present with insomnia, nightmares, bedwetting, appetite changes, headaches, and stomachaches. When asked, they may endorse mood swings, feelings of helplessness, poor self-esteem, or suicidal thoughts. Children who are bullied may exhibit psychosomatic symptoms or have previously been diagnosed with anxiety or depression. [21] [22]  Social history clues include school absenteeism, declining grades, loss of friends, and lost or damaged belongings such as school books and clothing. 

Recognizing at-risk children early may avert long-term consequences. Identifying risk factors can help prevent bullying, and early detection is the first step in intervention. Clinicians who screen for bullying can support affected families and direct them to appropriate resources. They can utilize validated screening tools such as the HEADDS (Home, Education/employment, Activities, Drugs, Sexuality, Suicide/depression) assessment [23]  or the Bright Futures questionnaires from the American Academy of Pediatrics.[Hagen et al. Bright Futures. AAP] The Bullying, Cyberbullying, and Social Media Use Pediatric Checklist is available online from the Massachusetts Aggression Reduction Center (www.MARCcenter.org) and is free for clinicians. Identifying victims can be tricky since many children do not readily disclose their involvement in bullying. Clinicians should, therefore, foster an inclusive and affirming healthcare environment where youth feel safe discussing their identities and experiences. [24]  This is especially important for LGBTQ patients who may not view their homes or schools as supportive.

About 70% of victims do not want to admit it to an adult, and indirect questioning during the medical history-taking may yield additional information. Inquiring about how school is going or if kids have friends to sit with at lunch may provide insight into how bullying might be a problem. [25]

Physical examination is usually unremarkable, but weight gain or loss alerts clinicians to possible appetite issues, and unexplained bruises or cuts may indicate physical altercations or self-inflicted injuries, necessitating further evaluation. 

Primary care clinicians are often asked to evaluate children for learning or behavior problems, including possible ADHD. An example is a teen boy who previously was a strong student, active in sports, and a musician in the school band who presents with declining grades. The teacher questions attention issues since he no longer completes his homework and says he "forgets to do it."  Further questioning reveals that a classmate has been confronting him daily after school, grabbing his backpack and dumping its contents. Therefore, he leaves his bag in his locker to avoid these unpleasant encounters and no longer finishes or turns in his assignments. He will not require an educational or psychiatric evaluation for ADHD once the clinician identifies that bullying is the underlying cause of his declining grades. 

Another example is a teen immigrant girl with weight loss whose mother is concerned she does not like American school lunches. However, a thorough history and physical examination reveal she has been feeling isolated, and she reports that kids tease her incessantly about her lack of English language skills. No one will sit with her at lunchtime, so she avoids the cafeteria. She admits to mood swings, and the physical examination is notable for self-inflicted cutting scars on her forearms. The clinician must elicit further information to determine if she is at risk of suicidal ideation or behavior before developing a management plan and arranging follow-up.

Bullying belongs to the spectrum of recurrent traumatic experiences of childhood, with similar physiologic, psychologic, social, and cognitive outcomes as child maltreatment or family violence.[Campbell, Kristin.  Bullying and Victimization . AAP] According to the American Academy of Pediatrics (AAP), trauma-informed care is medical care that recognizes the results of traumatic stress on children and their families. Clinicians are often the first professionals who interact with those affected by trauma and have the opportunity and obligation to respond sensitively. They can ensure a patient's safety and confidentiality, use respectful language, and support autonomy. [26]  A trauma-informed physical examination serves to establish trust and reduce feelings of vulnerability or potential triggers of prior traumatic events. [27] [28]  In the case of the teen with cutting scars, this may be the first occasion anyone has seen her skin lesions that are usually covered by her clothing. Performing the examination calmly and privately will foster confidence and encourage the girl to relate further relevant details about her unfortunate experiences.

When bullying is suspected or confirmed, the clinician should first speak with the child directly and privately to assess the severity of the problem. Because this may be the first time sharing such sensitive information, the clinician should create a safe space for the child to feel comfortable, using open-ended questions, active listening, and empathy, and ensuring confidentiality unless a situation mandates reporting to authorities. 

A simple approach is to ask these three questions:

• Are you being bullied?
• How often does this happen?
• How long has this been going on? [29]

Understanding the nature and extent of the episodes is essential for effective intervention. The clinician must differentiate between physical, verbal, social, and cyberbullying, as each requires a unique approach. Assessing the severity of the incidents helps prioritize support and resources and determine if a child's welfare is threatened and if reporting to child protective services is mandated. Clinicians should also inquire about other forms of victimization, such as child maltreatment and domestic violence, during the confidential interview. 

Further evaluation usually co-occurs with treatment and management, as presented in the next section. 

Treatment / Management

How can clinicians manage bullying? When bullying is suspected or confirmed, they should gather additional information about the circumstances and context from the patient, caregivers, and teachers if indicated. Next, they must decide whether to provide anticipatory guidance, direct families to helpful resources, refer them to a mental health specialist, or contact the school or appropriate law enforcement authorities. [8]  In all cases, clinicians should first ensure the child's safety. Most cases of bullying are not emergencies, but at times, a child is in imminent danger, has been the victim of physical or sexual abuse, or has expressed thoughts of suicidal ideation. Clinicians must know when to elevate the level of care and facilitate transporting such children to the nearest emergency facility for evaluation. [8]

When clinicians treat victims of bullying in an outpatient setting, they must first ensure that children feel safe and realize that they are not at fault. Clinicians can teach them skills to use when confronted by bullies. Children should tell the bully to stop, then walk away and notify a trusted adult. They must inform another adult if they have already reported the circumstances and nothing was done. Clinicians can participate in brief role-playing activities with their patients and encourage parents and caregivers to rehearse successful, assertive behaviors at home with their children. Many parents do not know where to start when their child is a target of bullying and appreciate information from trusted clinicians about the signs and effects of bullying and how to convey their concerns to teachers and counselors. Caregivers can be directed to valuable resources such as stopbullying.org  and marccenter.org  and encouraged to promote youth activities that build self-esteem, such as sports and hobbies. Clinicians can advise parents and caregivers not to call the bully's parents or try to retaliate but allow the school to investigate. Parents may also benefit from training to discuss bullying and other issues with their children. [25] They must monitor children's online activity, discuss the possible consequences of their media use, and ask if they have experienced any problems online. Clinicians can recommend never forwarding or responding to hurtful messages and advise keeping evidence of inappropriate digital media, blocking cyberbullies, and always informing a trusted adult about inappropriate content. Clinicians can arrange counseling and mental health services when indicated and work with schools and other agencies as applicable to protect victims from further harm. 

Most structured bullying interventions occur in academic settings, and clinicians should know about local programs when caregivers and schools seek their expertise in addressing bullying. All states in the US require schools to develop anti-bullying policies and procedures, and similar initiatives exist in many other countries. [14]  Clinicians should understand their community's statutes and develop step-by-step strategies to investigate reports when necessary. [30]  School-based initiatives vary, but successful programs promote empathy for victims, strengthen coping and socialization skills, educate staff and families, and foster a schoolwide anti-bullying culture. [31]  Schools can empower bystanders to intervene when they witness bullying. In one study, 57% of episodes ceased within ten seconds when an onlooker spoke up, but they only did so 15-20% of the time. [32] .[Salmivalli, C. Bullying and the Peer Group . Aggression and Violent Behavior.] On the other hand, bystanders who actively support or encourage bullies can empower them to continue their aggressive behavior. Multidisciplinary interventions targeting peer groups rather than individuals involving families, schools, and communities may have the most impact. [33] [34]  Unfortunately, such multifaceted programs are costly, and the effects are difficult to measure. [35]  A meta-analysis of such school initiatives reported a mean decrease of approximately 20% in bullying rates, demonstrating room for improvement. [36]  

Outside their practices, clinicians can advocate locally, in their states, and nationally to support anti-bullying initiatives. They can work to improve community education and services and lobby to strengthen anti-bullying laws and evidence-based policies that prohibit bullying based on racial, ethnic, or sexual stereotypes.

Clinicians are also likely to care for the perpetrators of bullying. It is essential to denounce the behavior but not the child. Bullies themselves may well have been victims and need to tell their stories. Clinicians should listen without interrupting, remain nonconfrontational, and express concern for the victim. They can set boundaries for acceptable behavior, ask the patient to describe their actions, and suggest ways to improve. Effective clinicians communicate that bullying is always inappropriate and will not be tolerated, but also seek to appreciate the underlying causes or circumstances. They can recommend consistent disciplinary consequences, such as removing privileges or making reparations. They can connect with the child's school and advocate for penalties such as mandated community service rather than suspension or expulsion, which should be reserved for youth exhibiting severely disruptive or aggressive behavior. Overly harsh policies often ignore the underlying social and behavioral issues contributing to bullying and may lead students to abandon formal education early. Bullies should be assessed for psychosocial problems and offered mental health counseling if indicated. Some children may even cease bullying when they become aware of the hurt they have caused others and learn alternative coping methods for their feelings. 

Differential Diagnosis

Clinicians can usually elicit a history of bullying if they take the time to ask relevant questions and listen carefully to the patient's responses. However, symptoms frequently associated with bullying may be nonspecific and result from other concerning circumstances, such as peer conflict, dating violence, family dysfunction, harassment, or hazing. [37]  These issues must be addressed and treated accordingly. When bullying is identified as the problem, clinicians should evaluate victims for mental health consequences, including posttraumatic stress disorder, anxiety, depression, and suicidal ideation, understanding that the presence of multiple coexisting issues may worsen the patient's physical and emotional health.  

In the medical model, prognosis predicts disease outcomes, such as recovery, recurrence, and death. Bullying, however, is not a disease, and the focus centers on consequences and complications rather than prognosis. In general use, however, the word prognosis forecasts a likely outcome. The medical and educational literature indicates that unless effective prevention and intervention measures are adopted, the prognosis for bullying is grim, and it will continue to take its toll on children and youth around the globe. 

Complications

Bullying is associated with short and long-term adverse physical and mental health outcomes. [38] [39]  Even when adequately treated, some physical injuries may cause lingering disabilities. Victims often experience academic difficulties, such as worsening grades, absenteeism, and concentration problems. In recent years, unfavorable consequences have been increasingly recognized for both victims and bullies, including social isolation, anxiety, depression, suicidality, and illicit substance use. [40] [41]  These sequelae often continue into adulthood. Stigma-based bullying has been even more strongly associated with health problems than bullying in general. [24]

Victims of severe bullying may feel threatened and depressed and are at risk of developing post-traumatic stress disorder. As adults, they are more likely to carry weapons and have higher rates of suicide attempts and poor psychosocial adjustment. [42] [43]  In one study, victims of bullying in grade 5 used more tobacco, marijuana, and alcohol in grade 10. [44] The self-medication hypothesis suggests these substances are consumed to cope with painful emotions related to psychological trauma. [44]  Depression, anxiety, relationship problems, poor health, failing academic performance, suicidal ideation and attempts, and sleep problems have all been associated with being bullied. [45] [46]  Another study demonstrated homophobic name-calling by nonfriends was linked with increased psychological distress among LGBTQ students, and LGBTQ youth who commit suicide are nearly five times as likely to have been bullied compared with their non-LGBTQ peers who take their own lives. [47] [May 26, 2020. 10.1001/jamapediatrics.2020.0940]   LGBTQ bullying is also associated with increased rates of adolescent substance use, including tobacco, alcohol, marijuana, and illicit drugs [48]  

Teens who have been physically threatened or in a fight are more likely to bring a weapon to school than other bullying victims or nonvictims. They are also more inclined to display violent behaviors at school, contributing to an unsafe academic environment.[Pham et al. Weapon Carrying Among Victims of Bullying . AAP]

Youth who bully often exhibit a negative attitude towards school and may leave before graduating, especially if they are punished by expulsion. Long-term associated consequences include criminal activities and arrests, intimate partner violence, delinquency, and antisocial behavior. [49] ]

Youth who are "bully victims" may experience even worse outcomes than their peers. They have been reported to have higher rates of child mental health issues, more thoughts of self-harm and suicidality, and increased substance use. [50] [51] [52]  Supportive adults at home and school may serve to buffer youth from the effects of bullying on future substance use. Still, controlled studies are lacking because it is difficult to separate bullying from other issues contributing to substance use, such as anxiety or other significant traumatic childhood events. 

Consultations

Several school and community bullying prevention centers provide resources and specialized support to counter bullying. In addition, helplines for bullying and cyberbullying are available in many countries.

The following resources are confidential, free, and available 24/7:

Stop Bullying Now Hotline

• 1-800-273-8255 or www.stopbullying.gov 
• Established by the US Department of Health and Human Services
• Available to adults and children

The Massachusetts Aggression Reduction Center 

www.MARCcenter.org Bullying And Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Children's Hospital Boston: www.childrenshospital.org/BACPAC

Childline 

• 0800 1111 (United Kingdom)
• Available to children under 18 years
• Offers advice and counseling to young people in distress or abusive situations

Kids Helpline

• 1-800-55-1800 (Australia)
• Provides advice to children, parents, and schools

Deterrence and Patient Education

Bullying prevention programs, usually found in school systems, may deter bullying and its effects. Few randomized controlled trials evaluate their efficacy, and it is unlikely that one approach will work in every school or community.[Flnnery et al. Bullying and School Violence.  Pediatrics Clinics of North America ] Successful strategies include an academic culture that does not tolerate bullying, involves bystanders, encourages classroom discussions with role-playing, improves supervision in less-structured areas like playgrounds, and offers educational programs for parents and caregivers. Isolated curriculum interventions are less effective than multidisciplinary programs that allow teachers and all school ancillary staff to participate, including cafeteria workers, administrators, custodians, and bus drivers. [53]  Some schools use focus groups to guide program content and strategize to understand children's perspectives. [54]

Schools with gay-straight alliance clubs demonstrate increased well-being among LGBTQ students. An example of a statewide effort is the Massachusetts Safe Schools Program for LGBTQ Students, a joint initiative between the  Department of Elementary and Secondary Education and the Massachusetts Commission on LGBTQ Youth. It includes classroom instruction, student activities, teacher proficiency workshops, and opportunities for policy development. [24] [55]  Clinicians can recommend that communities and schools use ideas from this and similar programs as models when developing their guidelines.

Pearls and Other Issues

Bullying is not primarily a law enforcement issue, but all 50 states in the US have enacted school anti-bullying legislation or policies. Bullying may also appear in the criminal code related to other crimes, such as aggravated harassment or stalking, and may apply to juveniles, depending upon the locale. Clinicians should be informed about the laws in their communities, report incidents when legally required to do so, and continue to advocate for their young patients.

Enhancing Healthcare Team Outcomes

How can the interprofessional team come together to prevent and intervene with bullying? Pediatricians and other primary care clinicians who care for children are the team leaders for identifying and treating youth affected by bullying. They are experts in advocating for their patients and working with medical specialists, nurses, mental health professionals, teachers, school administrators, parents, and other caregivers. 

The first step is to routinely screen youth for bullying exposure and identify subtle indicators when patients do not readily disclose they are victims. The American Academy of Pediatrics recommends violence prevention counseling for school-age children and screening at well-child visits beginning at age 6. [56]  Clinicians and nurses identify and assess victims and perpetrators of bullying and counsel youth and their caregivers about practical actions. Next, clinicians decide when a referral to a mental health provider or social worker is indicated and arrange appropriate and timely follow-up after the initial consultation. [57]  

Clinicians and mental health specialists teach parents and caregivers communication skills and positive discipline strategies since it is known that children from supportive families are more resistant to bullying and less likely to become perpetrators. Family therapists work on reducing anger and improving interpersonal relationships in dysfunctional families since bullying is often only one symptom of maladjustment in the home.

Clinicians advocate for children at school and assist parents and caregivers in connecting with teachers and administrators. They advise schools on the mental and physical health consequences of bullying and serve as a resource when schools establish and promote policies and academic environments that condemn bullying. These programs teach children who are bystanders to intervene and potentially dissuade bullies, who may feel pressure to conform to the behavior of the majority. [58] [59] [57]  Schools that foster a culture of empathy and encourage students to report bullying may be more successful in reducing its prevalence and consequences. Teachers, administrators, and school nurses often are firsthand witnesses who communicate their concerns to primary care clinicians who assess children for physical and mental health sequelae. The interprofessional team supporting children's welfare includes child protection agencies and law enforcement officials. Clinicians engage with them to coordinate care when necessary to safeguard at-risk children.

In summary, identifying and addressing bullying takes an interprofessional team led by primary care clinicians, including medical, mental health, educational, law enforcement, and community specialists, who work together to achieve optimal health outcomes for youth experiencing this all-too-frequent public health problem.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

Disclosure: Muhammad Waseem declares no relevant financial relationships with ineligible companies.

Disclosure: Amanda Nickerson declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Citations & impact 

This article has not been cited yet.

Impact metrics

Alternative metrics.

Similar Articles 

To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.

Suicidal Ideation

Harmer B , Lee S , Duong TVH , Saadabadi A

StatPearls Publishing, Treasure Island (FL) , 23 Dec 2020

Cited by: 0 articles | PMID: 33351435

Florida Domestic Violence

Houseman B , Semien G

StatPearls Publishing, Treasure Island (FL) , 10 Apr 2018

Cited by: 0 articles | PMID: 29630246

Prescription of Controlled Substances: Benefits and Risks

Preuss CV , Kalava A , King KC

StatPearls Publishing, Treasure Island (FL) , 07 Feb 2019

Cited by: 0 articles | PMID: 30726003

Bullying in children: impact on child health.

BMJ Paediatr Open , 5(1):e000939, 11 Mar 2021

Cited by: 26 articles | PMID: 33782656 | PMCID: PMC7957129

Cyberbullying: Review of an Old Problem Gone Viral.

Aboujaoude E , Savage MW , Starcevic V , Salame WO

J Adolesc Health , 57(1):10-18, 01 Jul 2015

Cited by: 90 articles | PMID: 26095405

Europe PMC is part of the ELIXIR infrastructure

Integrative Review of Qualitative Research on the Emotional Experience of Bullying Victimization in Youth

Affiliations.

• 1 1 College of Nursing, Ohio State University, Columbus, OH, USA.
• 2 2 Behavioral Health Department, Nationwide Children's Hospital, Columbus, OH, USA.
• PMID: 29092655
• PMCID: PMC8049772
• DOI: 10.1177/1059840517740192

The emotional experience of bullying victimization in youths has been documented primarily using quantitative methods; however, qualitative methods may be better suited to examine the experience. An integrative review of the qualitative method studies addressing the emotional experience of bullying victimization was conducted. From MEDLINE, Cumulative Index of Nursing and Allied Health Literature, PubMed, Education Information Resource Center, and PsycINFO, 14 English-language, peer-reviewed, qualitative studies were reviewed. Applying the Critical Appraisal Skills Programme, the quality of the studies was deemed sufficient. The range of emotional experiences reported included sadness, decreased self-esteem, embarrassment, fear, suicidal thinking, anger, feeling hurt, loneliness, powerlessness, helplessness, and confusion. Overall, these results were similar to those obtained from quantitative method studies, apart from the feeling of embarrassment. This integrative review confirmed and expanded the knowledge of emotional experiences of bullying victimization.

Keywords: bullying; integrative reviews; mental health; pediatrics; qualitative review; school nursing.

Publication types

• Adolescent Behavior / psychology*
• Crime Victims / psychology*
• Qualitative Research*

Grants and funding

• T32 NR014225/NR/NINR NIH HHS/United States

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Environ Res Public Health

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

Haeyoung lee.

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

Young Mi Ryu

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

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

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

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

Associated Data

Not applicable.

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

1. Introduction

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

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

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

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

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

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

2.1. Search Methods

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

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

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

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

2.2. Search Outcomes

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

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

2.3. Quality Appraisal

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

2.4. Data Analysis and Synthesis

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

2.5. Optimization of the Study Validity

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

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

3.1. Horizontal But Vertical Violence: What Characterizes WPB?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.3.1. Victims of WPB

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

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

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

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

3.3.2. Perpetrators of WPB

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

4. Discussion

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

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

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

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

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

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

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

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

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

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

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

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

5. Conclusions

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

Supplementary Materials

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

Funding Statement

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

Author Contributions

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

Institutional Review Board Statement

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

Data Availability Statement

Conflicts of interest.

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

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Q Methodology as an Innovative Addition to Bullying Researchers’ Methodological Repertoire

• Original Article
• Open access
• Published: 11 May 2022
• Volume 4 , pages 209–219, ( 2022 )

Cite this article

You have full access to this open access article

• Adrian Lundberg   ORCID: orcid.org/0000-0001-8555-6398 1 &
• Lisa Hellström   ORCID: orcid.org/0000-0002-9326-1175 1  

6474 Accesses

2 Altmetric

Explore all metrics

A Correction to this article was published on 18 July 2022

This article has been updated

The field of bullying research deals with methodological issues and concerns affecting the comprehension of bullying and how it should be defined. For the purpose of designing relevant and powerful bullying prevention strategies, this article argues that instead of pursuing a universal definition of what constitutes bullying, it may be of greater importance to investigate culturally and contextually bound understandings and definitions of bullying. Inherent to that shift is the transition to a more qualitative research approach in the field and a stronger focus on participants’ subjective views and voices. Challenges in qualitative methods are closely connected to individual barriers of hard-to-reach populations and the lack of a necessary willingness to share on the one hand and the required ability to share subjective viewpoints on the other hand. By reviewing and discussing Q methodology, this paper contributes to bullying researchers’ methodological repertoire of less-intrusive methodologies. Q methodology offers an approach whereby cultural contexts and local definitions of bullying can be put in the front. Furthermore, developmentally appropriate intervention and prevention programs might be created based on exploratory Q research and could later be validated through large-scale investigations. Generally, research results based on Q methodology are expected to be useful for educators and policymakers aiming to create a safe learning environment for all children. With regard to contemporary bullying researchers, Q methodology may open up novel possibilities through its status as an innovative addition to more mainstream approaches.

Similar content being viewed by others

A worked example of Braun and Clarke’s approach to reflexive thematic analysis

Is Empathy the Key to Effective Teaching? A Systematic Review of Its Association with Teacher-Student Interactions and Student Outcomes

Promoting Gender Equality: A Systematic Review of Interventions

Avoid common mistakes on your manuscript.

Introduction

Bullying, internationally recognized as a problematic and aggressive form of behavior, has negative effects, not only for those directly involved but for anybody and in particular children in the surrounding environment (Modin, 2012 ). However, one of the major concerns among researchers in the field of bullying is the type of research methods employed in the studies on bullying behavior in schools. The appropriateness of using quantitative or qualitative research methods rests on the assumption of the researcher and the nature of the phenomena under investigation (Hong & Espelage, 2012 ). There is a need for adults to widen their understanding and maintain a focus on children’s behaviors to be able to provide assistance and support in reducing the amount of stress and anxiety resulting from online and offline victimization (Hellström & Lundberg, 2020 ). A crucial step for widening this understanding is an increased visibility of children’s own viewpoints. When the voices of children, particularly those of victims and perpetrators, but also those of bystanders are heard in these matters, effective support can be designed based specifically on what children want and need rather than what adults interpret and understand to be supporting the child (O’Brien, 2019 ). However, bullying victims and their perpetrators are hard-to-reach populations (Shaghaghi et al., 2011 ; Sydor, 2013 ) for a range of reasons. To name but a few, researchers perennially face difficulties regarding potential participants’ self-identification, the sensitivity of bullying topics, or the power imbalance between them and their young respondents. Furthermore, limited verbal literacy and/or a lack of cognitive ability of some respondents due to age or disability contribute to common methodological issues in the field. Nevertheless, and despite ethical restrictions around the immediate questioning of younger children or children with disabilities that prohibit researchers to perform the assessments with them directly, it would be ethically indefensible to not study a sensitive topic like bullying among vulnerable groups of children. Hence, the research community is responsible for developing valid and reliable methods to explore bullying among different groups of children, where the children’s own voices are heard and taken into account (Hellström, 2019 ). Consequently, this paper aims to contribute to bullying researchers’ methodological repertoire with an additional less-intrusive methodology, particularly suitable for research with hard-to-reach populations.

Historically, the field of bullying and cyberbullying has been dominated by quantitative research approaches, most often with the aim to examine prevalence rates. However, recent research has seen an increase in the use of more qualitative and multiple data collection approaches on how children and youth explain actions and reactions in bullying situations (e.g., Acquadro Maran & Begotti, 2021 ; Eriksen & Lyng, 2018 ; Patton et al., 2017 ). This may be translated into a need to more clearly understand the phenomenon in different contexts. As acknowledged by many researchers, bullying is considerably influenced by the context in which it occurs and the field is benefitting from studying the phenomenon in the setting where all the contextual variables are operating (see, e.g., Acquadro Maran & Begotti, 2021 ; Scheithauer et al., 2016 ; Torrance, 2000 ). Cultural differences in attitudes regarding violence as well as perceptions, attitudes, and values regarding bullying are likely to exist and have an impact when bullying is being studied. For this reason, listening to the voices of children and adolescents when investigating the nature of bullying in different cultures is essential (Hellström & Lundberg, 2020 ; Scheithauer et al., 2016 ).

In addition to studying outcomes or products, bullying research has also emphasized the importance of studying processes (Acquadro Maran & Begotti, 2021 ). Here, the use of qualitative methods allows scholars to not only explore perceptions and understandings of bullying and its characteristics, but also interpret bullying in light of a specific social context, presented from a specific internal point of view. In other words, qualitative approaches may offer methods to understand how people make sense of their experiences of the bullying phenomenon. The processes implemented by a qualitative approach allow researchers to build hypotheses and theories in an inductive way (Atieno, 2009 ). Thus, a qualitative approach can enrich quantitative knowledge of the bullying phenomenon, paying attention to the significance that individuals attribute to situations and their own experiences. It can allow the research and clinical community to better project and implement bullying assessment and prevention programs (Hutson, 2018 ).

Instead of placing qualitative and quantitative approaches in opposition, they can both be useful and complementary, depending on the purpose of the research (Acquadro Maran & Begotti, 2021 ). In their review of mixed methods research on bullying and peer victimization in school, Hong and Espelage ( 2012 ) underlined that instead of using single methods, mixed methods have the advantage of generating a deeper and more complex understanding of the phenomenon. By combining objective data with information about the personal context within which the phenomenon occurs, mixed methods can generate new insights and new perspectives to the research field (Hong & Espelage, 2012 ; Kulig et al., 2008 ; Pellegrini & Long, 2002 ). However, Hong and Espelage ( 2012 ) also argued that mixed methods can lead to divergence and contradictions in findings that may serve as a challenge to researchers. For example, Cowie and Olafsson ( 2000 ) examined the impact of a peer support program to reduce bullying using both quantitative and qualitative data collection methods. While a quantitative approach collecting pre-test and post-test data showed no effects in decreasing bullying, interviews with peer supporters, students, and potential users of the intervention revealed the strength of the program and its positive impact, in light of students and peer supporters. Thus, rather than rejecting the program, the divergence in findings leads to a new rationale for modifying the program and addressing its limits.

Understandably, no single data collection approach is complete but deals with methodological issues and concerns affecting the research field and the comprehension of bullying. To provide a robust foundation for the introduction of an additional methodological perspective in bullying research, common data collection methods and methodological issues are outlined below.

Methodological Issues in Bullying Research

Large-scale cohort studies generating statistical findings often use R-statistics, descriptive analyses, averages, and correlations to estimate and compare prevalence rates of bullying, to explore personality traits of bullies and victims, and the main correlates and predictors of the phenomenon. Nevertheless, large-scale surveys have a harder time examining why bullying happens (O’Brian, 2019 ) and usually do not give voice to study objects’ own unique understanding and experiences (Acquadro Maran & Begotti, 2021 ; Bosacki et al., 2006 ; Woodhead & Faulkner, 2008 ). Other concerns using large-scale surveys include whether a definition is used or the term bullying is operationalized, which components are included in the definition, what cut-off points for determining involvement are being used, the lack of reliability information, and the absence of validity studies (Swearer et al., 2010 ).

Other issues include the validity in cross-cultural comparisons using large-scale surveys. For example, prevalence rates across Europe are often established using standard questionnaires that have been translated into appropriate languages. Comparing four large-scale surveys, Smith et al. ( 2016 ) found that when prevalence rates by country are compared across surveys, there are some obvious discrepancies, which suggest a need to examine systematically how these surveys compare in measuring cross-national differences. Low external validity rates between these studies raise concerns about using these cross-national data sets to make judgments about which countries are higher or lower in victim rates. The varying definitions and words used in bullying research may make it difficult to compare findings from studies conducted in different countries and cultures (Griffin & Gross, 2004 ). However, some argue that the problem seems to be more about inconsistency in the type of assessments (e.g., self-report, nominations) used to measure bullying rather than the varying definition of bullying (Jia & Mikami, 2018 ). When using a single-item approach (e.g., “How often have you been bullied?”) it is not possible to investigate the equivalency of the constructs between countries, which is a crucial precondition for any statistically valid comparison between them (Scheithauer et al., 2016 ). Smith et al. ( 2016 ) conclude that revising definitions and how bullying is translated and expressed in different languages and contexts would help examine comparability between countries.

Interviews, focus groups and the use of vignettes (usually with younger children) can all be regarded as suitable when examining youths’ perceptions of the bullying phenomenon (Creswell, 2013 ; Hellström et al., 2015 ; Hutson, 2018 ). They all allow an exploration of the bullying phenomenon within a social context taking into consideration the voices of children and might solve some of the methodological concerns linked to large-scale surveys. However, these data collection methods are also challenged by individual barriers of hard-to-reach populations (Ellard-Gray et al., 2015 ) and may include the lack of a necessary willingness to share on the one hand and the required ability to share subjective viewpoints on the other hand.

Willingness to Share

In contrast to large-scale surveys requiring large samples of respondents with reasonable literacy skills, interviews, which may rely even heavier on students’ verbal skills, are less plentiful in bullying research. This might at least partially be based on a noteworthy expectation of respondents to be willing to share something. It must be remembered that asking students to express their own or others’ experiences of emotionally charged situations, for example concerning bullying, is particularly challenging (Khanolainen & Semenova, 2020 ) and can be perceived as intrusive by respondents who have not had the opportunity to build a rapport with the researchers. This constitutes a reason why research in this important area is difficult and complex to design and perform. Ethnographic studies may be considered less intrusive, as observations offer a data collection technique where respondents are not asked to share any verbal information or personal experiences. However, ethnographical studies are often challenging due to the amount of time, resources, and competence that are required by the researchers involved (Queirós et al., 2017 ). In addition, ethnographical studies are often used for other purposes than asking participants to share their views on certain topics.

Vulnerable populations often try to avoid participating in research about a sensitive topic that is related to their vulnerable status, as recalling and retelling painful experiences might be distressing. The stigma surrounding bullying may affect children’s willingness to share their personal experiences in direct approaches using the word bullying (Greif & Furlong, 2006 ). For this reason, a single-item approach, in which no definition of bullying is provided, allows researchers to ask follow-up questions about perceptions and contexts and enables participants to enrich the discussion by adjusting their answers based on the suggestions and opinions of others (Jacobs et al., 2015 ). Generally, data collection methods with depersonalization and distancing effects have proven effective in research studying sensitive issues such as abuse, trauma, stigma and so on (e.g., Cromer & Freyd, 2009 ; Hughes & Huby, 2002 ). An interesting point raised by Jacobs and colleagues ( 2015 ) is that a direct approach that asks adolescents if they have ever experienced cyberbullying may lead to a poorer discussion and an underestimation of the phenomenon. This is because perceptions and contexts often differ between persons and because adolescents do not perceive all behaviors as cyberbullying. The same can be true for bullying taking place offline (Hellström et al., 2015 ).

When planning research with children, it is important to consider the immediate research context as it might affect what children will talk about (Barker & Weller, 2003 ; Hill, 2006 ; Punch, 2002 ). In addition to more material aspects, such as the room or medium for a dialog, the potential power imbalance created in an interview situation between an adult researcher and the child under study adds to a potentially limited willingness to share. Sitting in front of an adult interviewer may create situations where children may find it difficult to express their feelings and responses may be given based on perceived expectations (Punch, 2002 ). This effect is expected to be even stronger when studying a sensitive topic like bullying. Therefore, respondents may provide more honest responses when they are unaware that the construct of bullying is being assessed (Swearer et al., 2010 ). Moreover, in research about sensitive topics, building a strong connection with participants (Lyon & Carabelli, 2016 ), characterized by mutual trust, is vital and might overcome the initial hesitation to participate and share personal accounts. Graphic vignettes have successfully been used as such unique communication bridges to collect detailed accounts of bullying experiences (Khanolainen & Semenova, 2020 ). However, some reluctance to engage has been reported even in art-based methods, usually known to be effective in research with verbally limited participants (Bagnoli, 2009 ; Vacchelli, 2018 ) or otherwise hard-to-reach populations (Goopy & Kassan, 2019 ). Most commonly, participants might not see themselves as creative or artistic enough (Scherer, 2016 ). In sum, the overarching challenging aspect of art-based methods related to a limited willingness to share personal information is an often-required production of some kind.

Ability to Share

Interviews as a data collection method demand adequate verbal literacy skills for participants to take part and to make their voices heard. This may be challenging especially for younger children or children with different types of disabilities. There is a wide research gap in exploring the voices of younger children (de Leeuw et al., 2020 ) and children with disabilities (Hellström, 2019 ) in bullying research. Students’ conceptualization of bullying behavior changes with age, as there are suggestions that younger students tend to focus more on physical forms of bullying (such as fighting), while older students include a wider variety of behaviors in their view of bullying, such as verbal aggression and social exclusion (Hellström & Lundberg, 2020 ; Monks & Smith, 2006 ; Smith et al., 2002 ; Hellström et al., 2015 ). This suggests that cognitive development may allow older students to conceptualize bullying along a number of dimensions (Monks & Smith, 2006 ). Furthermore, the exclusion of the voices of children with disabilities in bullying research is debated. It is discussed that the symptoms and characteristics of disabilities such as Attention Deficit Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD), i.e., difficulties understanding the thoughts, emotions, reactions, and behaviors of others, which makes them the ideal target for bullying may also make it hard for them to perceive, verbalize and report bullying and victimization in a reliable and valid manner (Slaughter et al., 2002 ). It may also be difficult for children with ASD to differentiate between playful teasing among friends and hurtful teasing. While many argue that children with ASD are unreliable respondents of victimization, under-reporting using parental and teacher reports has been shown in research on bullying (Waters et al., 2003 ; Bradshaw et al., 2007 ) and child maltreatment (Compier-de Block et al., 2017 ).

This Paper’s Contribution

The present paper contributes to this special issue about qualitative school bullying and cyberbullying research by reviewing and discussing Q methodology as an innovative addition to more mainstream approaches in the field. Despite the fact that Q methodology had been proclaimed as “especially valuable […] in educational psychology” (Stephenson, 1935 , p. 297) nearly 90 years ago, the approach has only relatively recently been described as an up-and-coming methodological choice of educational researchers interested in participants’ subjective views (Lundberg et al., 2020 ). Even though, Q enables researchers to investigate and uncover first-person accounts, characterized by a high level of qualitative detail in its narrative description, only few educational studies have applied Q methodology to investigate the subject of bullying (see Camodeca & Coppola, 2016 ; Ey & Spears, 2020 ; Hellström & Lundberg, 2020 ; Wester & Trepal, 2004 ). Within the wider field of bullying, Q methodology has also been used to investigate workplace bullying in hospitals (Benmore et al., 2018 ) and nursing units (Choi & Lee, 2019 ). By responding to common methodological issues outlined earlier, the potential Q methodology might have for bullying research is exemplified. A particular focus is thereby put on capturing respondents’ subjective viewpoints through its less-intrusive data collection technique. The present paper closes by discussing implications for practice and suggesting future directions for Q methodological bullying and cyberbullying research, in particular with hard-to-reach populations.

An Introduction to Q Methodology

Q as a methodology represents a larger conceptual and philosophical framework, which is by no means novel. However, the methodology has largely been marginalized since its invention in the 1930s by William Stephenson (Brown, 2006 ). As a research technique, it broadly consists of three stages that each can be split into a set of steps (see Fig.  1 ); (1) carefully constructing a data collection instrument, (2) collecting data, and (3) analyzing and interpreting data. The central, and therefore also best-known feature of Q methodology is Q sorting to collect data in the form of individual Q sorts. Participants thereby rank order a sample of self-referent stimuli along a continuum and in accordance with a central condition of instruction; for example, children might be asked to what extent particular scenarios describe bullying situations (Hellström & Lundberg, 2020 ) or they might be instructed to sort illustrated ways to resolve social exclusion according to the single face-valid dimension of “least preferred to most preferred” (de Leeuw et al., 2019 ). As soon as all items are placed on a most often bell-shaped distribution grid (see Fig.  2 ), participants might be asked to elaborate on their item placement to add a further layer of qualitative data. Such so-called post-sorting activities might include written annotations of items placed at the ends of the continuum or form the structure for interviews (Shemmings & Ellingsen, 2012 ).

Three stages and six steps of a Q methodological research process (adapted from Lundberg et al., 2020 )

A vertical distribution grid with two examples of face-valid dimensions. This rather small distribution is designed for a 16-item Q sample and therefore contains 16 slots to be filled

For participants to provide their subjective viewpoint toward a specific topic in the form of a Q sort, researchers need to construct the data collection instrument, called Q sample. Such a set of stimulus items is a representative sample from all possible items concerning the topic, which in the technical language in Q methodology is called concourse (Brown, 1980 ). The development of such a concourse about the topic at hand might stem from a wide range of sources, including academic literature, policy documents, informal discussions, or media (Watts & Stenner, 2012 ). Moreover, in a participatory research fashion, participants’ statements can be used verbatim to populate the concourse. This way, children’s own words and voices are part of the data collection instrument. A sophisticated structuring process then guides the researchers in selecting a Q sample from all initial statements in the concourse (Brown et al., 2019 ). In Hellström & Lundberg ( 2020 ), a literature review on findings and definitions of bullying, stemming from qualitative and quantitative research, provided the initial concourse. A matrix consisting of different modes, types, and contexts of bullying supported the construction of the final Q sample.

As a student and assistant of Charles Spearman, Q’s inventor Stephenson was well-informed about R-methodological factor analysis based on correlating traits. The British physicist-psychologist however inverted the procedure and thereby suggested correlating persons to study human behavior (Stephenson, 1935 , 1953 ). A detailed description of the statistical procedure of Q factor analysis is outside the scope of this article, especially as the focus of this special issue is put on qualitative research methods. In addition, with its focus on producing quantifiable data from highly subjective viewpoints (Duncan & Owens, 2011 ), it is safe to say that Q methodology is more often treated as a qualitative methodology with quantitative features than the other way around. Nevertheless, it is important to note that through factor analysis, individual viewpoints are clustered into so-called factors, representing shared viewpoints if they sufficiently correlate (see Fig.  3 ). In that sense, no outside criterion is applied to respondents’ subjective views and groups of similar sorts (factors/viewpoints) are not logically constructed by researchers. Instead, they inductively emerge through quantitative analysis, which helps “in learning how the subject, not the observer, understands and reacts to items” (Brown, 1980 , p. 191). This procedure allowed Hellström & Lundberg ( 2020 ) to describe two age-related definitions of bullying. Older students in particular perceived offline bullying as more severe than online bullying and their younger peers were mostly concerned about bullying situations taking place in a private setting.

A simplified illustration of Q factor analysis (step 5). Arrow A represents the statistical correlation of all collected individual viewpoints. Arrow B represents inverted factor analysis as the data condensation technique resulting in a manageable number of shared viewpoints

Despite its quantitative analysis, participant selection in Q methodology is largely in line with purposive sampling with small numbers. It, therefore, represents a major difference to R methodological research, where larger opportunity samples are desired. In Q methodology, participants are selected strategically in line with those who might likely “express a particularly interesting or pivotal point of view” (Watts & Stenner, 2012 , p. 71). Investigating a large number of similar respondents might therefore simply lead to more participants correlating with the same shared viewpoint and not necessarily add new viewpoints. In recent educational Q research, the average number of participants is 37 (Lundberg et al., 2020 ). Many studies have however been successfully conducted with considerably fewer, as for example illustrated by Benmore et al. ( 2018 ), who described three distinctive groups within their sample of 12 participants.

To illustrate Q methodology in bullying research, our small scale and exploratory study published in Educational Research (Hellström & Lundberg, 2020 ) serves as a practical example. The purpose of that study was to investigate definitions of bullying from young people’s perspectives and was guided by the following research question: What are students’ subjective viewpoints on bullying behavior? . In Table 1 , we describe the methodological steps introduced in Fig.  1 .

Q Methodology’s Response to the Methodological Issues Outlined Above

Above, methodological issues have been structured according to participants’ willingness and ability to share their subjective viewpoints and lived experiences. In order to respond to those, the present section focuses on Q methodology’s built-in features. A particularly important component is Q sorting as the central data collection technique that facilitates participants’ communicability of their subjectivity.

Engaging participants in a card sorting activity encourages students to express their viewpoints and thereby making their voices heard in a less-intrusive way, despite being cognitively engaging. Because they are asked to rank-order a predetermined sample of items, ideally in accordance with a carefully selected condition of instruction, they do not need to report or disclose their own personal experiences and are not obliged to actively create anything, as criticized in arts-based research. In that sense, Q methodology can be seen as a method to collect sensitive data in a more depersonalized way. This provides the basis to find a vital “balance between protecting the child and at the same time allowing access to important information” (Thorsen & Størksen, 2010 , p. 9), which is of particular importance for research about emotionally charged situations or sensitive topics as it is often the case with bullying (Ellingsen et al., 2014 ). Sharing their view through a fixed collection of items certainly makes participation in research for young children or otherwise hard-to-reach respondents less intimidating and results can be expected to be more truthful.

In comparison to researchers applying ethnographical approaches, who immerse themselves into the studied context to understand and document patterns of social behavior and interaction in a less intrusive way, Q methodologists are not expected to observe their participants. Even though the purpose of these approaches is different, being part of the culture under investigation or at least involving community partners in Q methodological research can still be useful for at least two reasons. As mentioned in Table 1 featuring the study by Hellström & Lundberg ( 2020 ), the pupils’ physical education and health teacher guided an exploratory and informal discussion and thereby provided valuable insights into the participants’ lifeworld that informed the Q sample. In addition to better tailoring the sample to the participants and making them feel seen and heard, the community partner could help build a positive rapport between participants and researchers, which otherwise requires much work. During the actual data collection exercise, participants were already familiar with the topic, well-informed about the research project, and perceived the sorting activity as an integral part of their lesson.

The play-like character of Q sorting has as well been reported as a positive influence on respondents’ motivation to participate (de Leeuw et al., 2019 ) and Wright ( 2013 ) mentions the engaging atmosphere created between the sorter and the researcher. The combination of these features allows assuming that obtaining participants’ viewpoint through Q methodology is less threatening than for example sitting in front of an interviewer and providing on-spot oral responses about a sensitive topic.

Q sorting as a data collection instrument represents a major advantage for Q methodological research with participants that do not (yet) possess sufficient verbal literacy and/or cognitive ability to process receptive or expressive language. To illustrate, two features are outlined here: first the flexibility of the Q sample, say the set of stimuli and second the fact that primary data collection in Q methodology is based on a silent activity.

Written statements are undoubtedly the most common type of items used in Q methodology and the number of such in a Q sample greatly varies. In recent research reporting from compulsory education settings, the average Q sample consists of about 40 items (Lundberg et al., 2020 ). In addition to applying a smaller set of items, their complexity can easily be adapted in line with participants’ receptive literacy skills and their developmental stage to facilitate understanding. Statements can for example be shortened or they can start identically to make the activity less taxing (Watts & Stenner, 2012 ). A different approach to cater to limited verbal literacy is the use of images instead of written statements. Constructing a visual Q sample might be more challenging for the researcher, in particular, if images are carefully selected and culturally tailored, meaning that they are clear, appealing and without too many details (Thorsen & Størksen, 2010 ). It might nevertheless be worth it, as such items provide a powerful tool to elicit viewpoints from otherwise marginalized or hard-to-reach research participants. Combes and colleagues ( 2004 ) for example, created a 37-item-Q sample with intellectually disabled participants’ own pictures to evaluate the planning of activities and de Leeuw et al. ( 2019 ) have used 15 images of hypothetical scenarios of social exclusion in a study with primary school pupils. Furthermore, as illustrated by Allgood and Svennungsen ( 2008 ) who photographed their participant’s own sculptures, Q samples consisting of objects (e.g., toys) or symbols (emojis) might be other options to investigate issues about bullying and cyberbullying without using text.

In addition to adaptations to the data collection instrument, the sorting process is usually carefully introduced and illustrated. Researchers might want to go through the entire Q sample to ensure the participants are able to discriminate each item (Combes et al., 2004 ). Even with adult participants without any cognitive impairments, it is suggested to pre-sort items into three provisional categories (Watts & Stenner, 2012 ). Two categories represent the respective ends of the continuum in the distribution grid and might be labeled and. Any items the sorter feels insecure or neutral about, are moved to the third category, which receives a question mark (?) for the sake of this exercise. During the actual rank-ordering process, the participants start to allocate items to one of the ends of the continuum (the top of the distribution grid in Fig.  2 ) with cards from the ☺ category and work themselves toward the center of the distribution grid. The process continues with items in the ☹ category, which are placed from the opposite end of the continuum toward the center. Any free spots are then filled with the remaining items in the (?) category. The graphic display of their viewpoint has been experienced as enabling for self-reflection (Combes et al., 2004 ) and might be utilized for a further discussion about the topic, for example as part of teacher workshops (Ey & Spears, 2020 ).

Meeting children at an appropriate cognitive level through adaptations of the data collection instrument and procedure, is not only a promising and important ethical decision in order to show young participants the respect they deserve (Thorsen & Størsken, 2010 ), but makes the sorting procedure a pleasant experience for the participants (John et al., 2014 ). Unsurprisingly, Q methodology has been described as a respectful, person-centered, and therefore child-friendly approach (Hughes, 2016 ).

Limitations

Despite its potential for bullying research, Q methodology has its limitations. The approach is still relatively unknown in the field of bullying research and academic editors’ and reviewers’ limited familiarity with it can make publishing Q methodological research challenging. Notwithstanding the limitation of not being based on a worked example, the contribution of the present paper hopefully fulfills some of the needed spadework toward greater acceptability within and beyond a field, which has only seen a limited number of Q methodological research studies. Because the careful construction of a well-balanced Q sample is time-consuming and prevents spontaneous research activities, a core set of items could be created to shorten the research process and support the investigation of what bullying means to particular groups of people. Such a Q sample would then have to be culturally tailored to fit local characteristics. Finally, the present paper is limited in our non-comprehensive selection of data collection methods as points of comparison when arguing for a more intensive focus on Q methodology for bullying research.

Future Research Directions

The results of Q methodological studies based on culturally tailored core Q samples would allow the emergence of local definitions connected to the needs of the immediate society or school context. As illustrated by Hellström & Lundberg ( 2020 ), even within the same school context, and with the same data collection instrument (Q sample), Q methodology yielded different, age-related definitions of bullying. Or in Wester and Trepal ( 2004 ), Q methodological analysis revealed more perceptions and opinions about bullying than researchers usually mention. Hence, Q methodology offers a robust and strategic approach that can foreground cultural contexts and local definitions of bullying. If desired, exploratory small-scale Q research might later be validated through large-scale investigations. A further direction for future research in the field of bullying research is connected to the great potential of visual Q samples to further minimize research participation restrictions for respondents with limited verbal or cognitive abilities.

Implications for Practice

When designing future bullying prevention strategies, Q methodology presents a range of benefits to take into consideration. The approach offers a robust way to collect viewpoints about bullying without asking participants to report their own experiences. The highly flexible sorting activity further represents a method to investigate bullying among groups that are underrepresented in bullying research, such as preschool children (Camodeca & Coppola, 2016 ). This is of great importance, as tackling bullying at an early age can prevent its escalation (Alsaker & Valkanover, 2001 ; Storey & Slaby, 2013 ). Making the voices of the hard-to-reach heard in an unrestricted way and doing research with them instead of about them (de Leeuw et al., 2019 ; Goopy & Kassan, 2019 ) is expected to enable them to be part of discussions about their own well-being. By incorporating social media platforms, computer games, or other contextually important activities when designing a Q sample, the sorting of statements in Hellström & Lundberg, ( 2020 ) turned into a highly relevant activity, clearly connected to the reality of the students. As a consequence, resulting policy creation processes based on such exploratory studies should lead to more effective interventions and bullying prevention programs confirming the conclusion by Ey and Spears ( 2020 ) that Q methodology served as a great model to develop and implement context-specific programs. Due to the enhanced accountability and involvement of children’s own voices, we foresee a considerable increase in implementation and success rates of such programs. Moreover, Q methodology has been suggested as an effective technique to evaluate expensive anti-bullying interventions (Benmore et al., 2018 ). Generally, research results based on exploratory Q methodology that quantitatively condensates rich data and makes commonalities and diversities among participants emerge through inverted factor analysis are expected to be useful for educators and policymakers aiming to create a safe learning environment for all children. At the same time, Q methodology does not only provide an excellent ground for participatory research, but is also highly cost-efficient due to its status as a small-sample approach. This might be particularly attractive, when neither time nor resources for other less-intrusive methodological approaches, such as for example ethnography, are available. Due to its highly engaging aspect and great potential for critical personal reflection, Q sorting might be applied in classes regardless of representing a part of a research study or simply as a learning tool (Duncan & Owens, 2011 ). Emerging discussions are expected to facilitate and mediate crucial dialogs and lead toward collective problem-solving among children.

The use of many different terminologies and different cultural understandings, including meaning, comprehension, and operationalization, indicates that bullying is a concept that is difficult to define and subject to cultural influences. For the purpose of designing relevant and powerful bullying prevention strategies, this paper argues that instead of pursuing a universal definition of what constitutes bullying, it may be of greater importance to investigate culturally and contextually bound understandings and definitions of bullying. Although the quest for cultural and contextual bound definitions is not new in bullying research, this paper offers an additional method, Q methodology, to capture participants’ subjective views and voices. Since particularly the marginalized and vulnerable participants, for example, bullying victims, are usually hard to reach, bullying researchers might benefit from a methodological repertoire enriched with a robust approach that is consistent with changes in methodological and epistemological thinking in the field. In this paper, we have argued that built-in features of Q methodology respond to perennial challenges in bullying research connected to a lack of willingness and limited ability to share among participants as well as studying bullying as a culturally sensitive topic. In summary, we showcased how Q methodology allows a thorough and less-intrusive investigation of what children perceive to be bullying and believe that Q methodology may open up novel possibilities for contemporary bullying researchers through its status as an innovative addition to more mainstream approaches.

Availability of Data and Material

Not applicable.

Code Availability

Change history, 18 july 2022.

A Correction to this paper has been published: https://doi.org/10.1007/s42380-022-00135-9

Acquadro Maran, D., & Begotti, T. (2021). Measurement ideas relevant to qualitative studies. In P. K. Smith & J. O’Higgins Norman (Editors). Handbook of bullying (no pages assigned yet). John Wiley & Sons Limited.

Allgood, E., & Svennungsen, H. O. (2008). Toward an articulation of trauma using the creative arts and Q-methodology: A single-case study. Journal of Human Subjectivity, 6 (1), 5–24.

Google Scholar  

Alsaker, F. D., & Valkanover, S. (2001). Early diagnosis and prevention of victimization in kindergarten. In J. Juvonen & S. Graham (Eds.), Peer harassment in school (pp. 175–195). Guilford Press.

Atieno, O. P. (2009). An analysis of the strengths and limitation of qualitative and quantitative research paradigms.  Problems of Education in the 21st Century ,  13 (1), 13–38.

Bagnoli, A. (2009). Beyond the standard interview: The use of graphic elicitation and arts-based methods. Qualitative Research, 9 (5), 547–570. https://doi.org/10.1177/1468794109343625

Article   Google Scholar  

Barker, J., & Weller, S. (2003). “Is it fun?” Developing children centred research methods. International Journal of Sociology and Social Policy, 23 (1/2), 33–58. https://doi.org/10.1108/01443330310790435

Benmore, G., Henderson, S., Mountfield, J., & Wink, B. (2018). The Stopit! programme to reduce bullying and undermining behaviour in hospitals: Contexts, mechanisms and outcomes. Journal of Health Organization and Management, 32 (3), 428–443. https://doi.org/10.1108/JHOM-02-2018-0047

Article   PubMed   Google Scholar  

Bosacki, S. L., Marini, Z. A., & Dane, A. V. (2006). Voices from the classroom: Pictorial and narrative representations of children’s bullying experiences. Journal of Moral Education, 35 , 231–245. https://doi.org/10.1080/03057240600681769

Bradshaw, C. P., Sawyer, A. L., & O’Brennan, L. M. (2007). Bullying and peer victimization at school: Perceptual differences between students and school staff. School Psychology Review, 36 , 361–382. https://doi.org/10.1080/02796015.2007.12087929

Brown, S. (1980). Political subjectivity: Applications of Q methodology in political science . Yale University Press.

Brown, S. (2006). A match made in heaven: A marginalized methodology for studying the marginalized. Quality and Quantity, 40 (3), 361–382. https://doi.org/10.1007/s11135-005-8828-2

Brown, S., Baltrinic, E., & Jencius, M. (2019) From concourse to Q sample to testing theory. Operant Subjectivity, 41 , 1–17. https://doi.org/10.15133/j.os.2019.002

Camodeca, M., & Coppola, G. (2016). Bullying, empathic concern, and internalization of rules among preschool children: The role of emotion understanding. International Journal of Behavioral Development, 40 , 459–465.

Choi, J. K., & Lee, B. S. (2019). Response patterns of nursing unit managers regarding workplace bullying: A Q methodology approach. Journal of Korean Academy of Nursing, 49 , 562–574.

Combes, H., Hardy, G., & Buchan, L. (2004). Using Q-methodology to involve people with intellectual disability in evaluating person-centred planning. Journal of Applied Research in Intellectual Disabilities, 17 , 149–159. https://doi.org/10.1111/j.1468-3148.2004.00191.x

Compier-de Block, L. H., Alink, L. R., Linting, M., van den Berg, L. J., Elzinga, B. M., Voorthuis, A., Tollenaar, M. S., & Bakermans-Kranenburg, M. J. (2017). Parent-child agreement on parent-to-child maltreatment. Journal of Family Violence, 32 , 207–217. https://doi.org/10.1007/s10896-016-9902-3

Cowie, H., & Olafsson, R. (2000). The role of peer support in helping the victims of bullying in a school with high levels of aggression. School Psychology International, 21 , 79–95.

Creswell, J. (2013). Qualitative inquiry and research design: Choosing among five approaches (3 rd ed.). Sage.

Cromer, L. D., & Freyd, J. J. (2009). Hear no evil, see no evil? Associations of gender, trauma history, and values with believing trauma vignettes. Analyses of Social Issues and Public Policy, 9 (1), 85–96. https://doi.org/10.1111/j.1530-2415.2009.01185.x

De Leeuw, R. R., de Boer, A. A., Beckmann, E. J., van Exel, J., & Minnaert, A. E. M. G. (2019). Young children’s perspectives on resolving social exclusion within inclusive classrooms. International Journal of Educational Research, 98 , 324–335. https://doi.org/10.1016/j.ijer.2019.09.009

De Leeuw, R. R., Little, C., & Rix, J. (2020). Something needs to be said – Some thoughts on the possibilities and limitations of ‘voice.’ International Journal of Educational Research, 104 , 101694. https://doi.org/10.1016/j.ijer.2020.101694

Duncan, N., & Owens, L. (2011). Bullying, social power and heteronormativity: Girls’ constructions of popularity. Children & Society, 25 , 306–316. https://doi.org/10.1111/j.1099-0860.2011.00378.x

Ellard-Gray, A., Jeffrey, N. K., Choubak, M., Crann, S. E. (2015). Finding the hidden participant: Solutions for recruiting hidden, hard-to-reach, and vulnerable populations.  International Journal of Qualitative Methods, 1–10.  https://doi.org/10.1177/1609406915621420

Ellingsen, I. T., Thorsen, A. A., Størksen, I. (2014). Revealing children’s experiences and emotions through.  Q Methodology Child Development Research, 1–9. https://doi.org/10.1155/2014/910529

Eriksen, M. I., & Lyng, S. T. (2018). Relational aggression among boys: Blind spots and hidden dramas. Gender and Education, 30 (3), 396–409. https://doi.org/10.1080/09540253.2016.1214691

Ey, L., & Spears, B. (2020). Engaging early childhood teachers in participatory co-design workshops to educate young children about bullying. Pastoral Care in Education, 38 , 230–253. https://doi.org/10.1080/02643944.2020.1788129

Greif, J. L., & Furlong, M. J. (2006). The assessment of school bullying. Journal of School Violence, 5 , 33–50. https://doi.org/10.1300/J202v05n03_04

Griffin, R. S., & Gross, A. M. (2004). Childhood bullying: Current empirical findings and future directions for research. Aggression and Violent Behavior, 9 , 379–400. https://doi.org/10.1016/S1359-1789(03)00033-8

Goopy, S., & Kassan, A. (2019). Arts-based engagement ethnography: An approach for making research engaging and knowledge transferable when working with harder-to-reach communities. International Journal of Qualitative Methods, 18 , 1–10. https://doi.org/10.1177/1609406918820424

Hellström, L. (2019). A systematic review of polyvictimization among children with Attention Deficit Hyperactivity or Autism Spectrum Disorder. International Journal of Environmental Research and Public Health, 16 (13), 2280. https://doi.org/10.3390/ijerph16132280

Hellström, L. & Lundberg, A. (2020). Understanding bullying from young people’s perspectives: An exploratory study. Educational Research, 62 (4), 414-433. https://doi.org/10.1080/00131881.2020.1821388

Hellström, L., Persson, L. & Hagquist, C. (2015). Understanding and defining bullying– adolescents’ own views. Archives of Public Health 73 (4), 1-9. https://doi.org/10.1186/2049-3258-73-4

Hill, M. (2006). Children’s voices on ways of having a voice: Children’s and young people’s perspectives on methods used in research and consultation. Childhood, 13 (1), 69–89. https://doi.org/10.1177/0907568206059972

Hong, J. S., & Espelage, D. L. (2012). A review of mixed methods research on bullying and peer victimization in school. Educational Review, 64 (1), 115–126. https://doi.org/10.1080/00131911.2011.598917

Hughes, M. (2016). Critical, respectful, person-centred: Q methodology for educational psychologists. Educational and Child Psychology, 33 (1), 63–75.

Hughes, R., & Huby, M. (2002). The application of vignettes in social and nursing research. Journal of Advanced Nursing, 37 (4), 382–386. https://doi.org/10.1046/j.1365-2648.2002.02100.x

Hutson, E. (2018). Integrative review of qualitative research on the emotional experience of bullying victimization in youth. Journal of School Nursing, 34 (1), 51–59. https://doi.org/10.1177/1059840517740192

Jacobs, N., Goossens, L., Dehue, F., Völlink, T., & Lechner, L. (2015). Dutch cyberbullying victims’ experiences, perceptions, attitudes and motivations related to (coping with) cyberbullying: Focus group interviews. Societies, 5 (1), 43–64. https://doi.org/10.3390/soc5010043

Jia, M., & Mikami, A. (2018). Issues in the assessment of bullying: Implications for conceptualizations and future directions. Aggression and Violent Behavior, 41 , 108–118. https://doi.org/10.1016/j.avb.2018.05.004

John, A., Montgomery, D., & Halliburton Tate, A. (2014). Using Q methodology in conducting research with young children. In O. Saracho (Editor): Handbook of Research Methods in Early Childhood Education , Volume 1, (pp. 147–173), University of Maryland.

Khanolainen, D., & Semenova, E. (2020). School bullying through graphic vignettes: Developing a new arts-based method to study a sensitive topic. International Journal of Qualitative Methods, 19 , 1–15. https://doi.org/10.1177/1609406920922765

Kulig, J. C., Hall, B., & Grant Kalischuk, R. (2008). Bullying perspectives among rural youth: A mixed methods approach. Rural and Remote Health, 8 , 1–11.

Lyon, D., & Carabelli, G. (2016). Researching young people’s orientations to the future: The methodological challenges of using arts practice. Qualitative Research, 16 (4), 430–445. https://doi.org/10.1177/1468794115587393

Lundberg, A., de Leeuw, R., & Aliani R. (2020). Using Q methodology: sorting out subjectivity in educational research. Educational Research Review, 31 , 100361. https://doi.org/10.1016/j.edurev.2020.100361

Modin, B. (2012). Beteendeproblem bidrar till utsatthet för mobbning och psykisk ohälsa. I: Skolans betydelse för barns och ungas psykiska hälsa - en studie baserad på den nationella totalundersökningen i årskurs 6 och 9 hösten 2009 behavior problems contribute to victimization from bullying and poor self-related mental health. in: The role of the school for young people’s mental health. A study based on the national Swedish survey of students in grades 6 and 9 in 2009. ( No. 2012–5–15). National Board of Health and Welfare and Centre for Health Equity Studies.

Monks, C. P., & Smith, P. K. (2006). Definitions of bullying: Age differences in understanding of the term, and the role of experience. British Journal of Developmental Psychology, 24 (4), 801–821. https://doi.org/10.1348/026151005X82352

O’Brien, N. (2019). Understanding alternative bullying perspectives through research engagement with young people. Frontiers in Psychology, 10 , 1984. https://doi.org/10.3389/fpsyg.2019.01984

Article   PubMed   PubMed Central   Google Scholar  

Patton, D. U., Hong, J. S., Patel, S., & Kral, M. J. (2017). A systematic review of research strategies used in qualitative studies on school bullying and victimization. Trauma, Violence & Abuse, 18 (1), 3–16. https://doi.org/10.1177/1524838015588502

Pellegrini, A. D., & Long, J. D. (2002). A longitudinal study of bullying, dominance, and victimization during the transition from primary school through secondary school. British Journal of Developmental Psychology, 20 , 259–280. https://doi.org/10.1348/026151002166442

Punch, S. (2002). Research with children: The same or different from research with adults? Childhood, 9 (3), 321–341. https://doi.org/10.1177/0907568202009003005

Queirós, A., Faria, D., & Almeida, R. (2017). Strengths and limitations of qualitative and quantitative research methods. European Journal of Education Studies, 3 (9), 369–387. https://doi.org/10.46827/ejes.v0i0.1017

Scheithauer, H., Smith, P. K., & Samara, M. (2016). Cultural issues in bullying and cyberbullying among children and adolescents: Methodological approaches for comparative research. International Journal of Developmental Science 10 , 3–8.  https://doi.org/10.3233/DEV-16000085

Scherer, L. (2016). Children’s engagements with visual methods through qualitative research in the primary school as “Art that didn’t work.” Sociological Research Online, 21 (1), 1–16. https://doi.org/10.5153/sro.3805

Shaghaghi, A., Bhopal, R. S., & Sheikh, A. (2011). Approaches to recruiting ‘hard to reach’ populations into research: A review of the literature. Health Promotion Perspectives, 1 , 86–94. https://doi.org/10.5681/hpp.2011.009

Shemmings, D., & Ellingsen, I. T. (2012). Using Q methodology in qualitative interviews. In J.F. Gubrium, J.A. Holstein, A.B. Marvasti, & K.D. McKinney (Eds.), The SAGE handbook of interview research: The complexity of the craft (2 nd ed), (pp. 415–426). Sage.

Slaughter, V., Dennis, M. J., & Pritchard, M. (2002). Theory of mind and peer acceptance in preschool children. British Journal of Developmental Psychology, 20 , 545–564.

Smith, P. K., Cowie, H., Olafsson, R. F., & Liefooghe, A. P. D. (2002). Definitions of bullying: A comparison of terms used, and age and gender differences, in a fourteen–country international comparison. Child Development 73 (4): 1119–1133.  https://doi.org/10.1111/1467-8624.00461

Smith, P. K., Robinson, S., & Marchi, B. (2016). Cross-national data on victims of bullying: What is really being measured? International Journal of Developmental Science, 10 (1–2), 9–19. https://doi.org/10.3233/DEV-150174

Stephenson, W. (1935). Technique of factor analysis. Nature, 136 , 297.

Stephenson, W. (1953). The study of behavior: Q technique and its methodology. Chicago University Press.

Storey, K., & Slaby, R. (2013). Eyes on bullying in early childhood. Education Development Center. Retrieved from www.eyesonbullying.org

Swearer, S. M., Siebecker, A. B., Johnsen-Frerichs, L. A., & Wang, C. (2010). Assessment of bullying/victimization. The problem of comparability across studies and across methodologies. In S.R. Jimerson, S.M. Swearer, & D.L. Espelage (Eds.), Handbook of bullying in schools: An international perspective (pp 305- 328). Routledge

Sydor, A. (2013). Conducting research into hidden or hard-to-reach populations. Nurse Researcher, 20 , 33–37.

Thorsen, A. A., & Størksen, I. (2010). Ethical, methodological, and practical reflections when using Q methodology in research with young children. Operant Subjectivity, 33 (1–2), 3–25.

Torrance, D. A. (2000). Qualitative studies into bullying within special schools. British Journal of Special Education, 27 , 16–21.

Vacchelli, E. (2018). Embodiment in qualitative research: Collage making with migrant, refugee and asylum seeking women. Qualitative Research, 18 (2), 171–190. https://doi.org/10.1332/policypress/9781447339069.003.0004

Waters, E., Stewart-Brown, S., & Fitzpatrick, R. (2003). Agreement between adolescent self-report and parent reports of health and well-being: Results of an epidemiological study. Child Care Health Development, 29 , 501–509. https://doi.org/10.1046/j.1365-2214.2003.00370.x

Watts, S., & Stenner, P. (2012). Doing Q methodological research: Theory, method and interpretation . Sage.

Book   Google Scholar  

Wester, K. L., & Trepal, H. C. (2004). Youth perceptions of bullying: Thinking outside the box. Operant Subjectivity, 27 , 68–83.

Woodhead, M., & Faulkner, D. (2008). Subjects, objects or participants? Dilemmas of psychological research. In P. Christensen & A. James (Eds.), Research with children (2nd ed., pp. 10–39). Routledge.

Wright, P. N. (2013). Is Q for you?: Using Q methodology within geographical and pedagogical research. Journal of Geography in Higher Education, 37 (2), 152–163. https://doi.org/10.1080/03098265.2012.729814

Download references

Open access funding provided by Malmö University.

Author information

Authors and affiliations.

Malmö University, Malmö, Sweden

Adrian Lundberg & Lisa Hellström

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Adrian Lundberg .

Ethics declarations

Ethics approval, consent to participate, consent for publication, conflict of interest.

The authors declare no competing interests.

Additional information

The original online version of this article was revised: References are not in alphabetical order.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Lundberg, A., Hellström, L. Q Methodology as an Innovative Addition to Bullying Researchers’ Methodological Repertoire. Int Journal of Bullying Prevention 4 , 209–219 (2022). https://doi.org/10.1007/s42380-022-00127-9

Download citation

Accepted : 26 April 2022

Published : 11 May 2022

Issue Date : September 2022

DOI : https://doi.org/10.1007/s42380-022-00127-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Bullying prevention
• Children’s voice
• Hard-to-reach
• Methodological issues
• Q methodology
• Find a journal
• Publish with us
• Track your research