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Undergraduate student nurses experiences of vertical violence Abulaban, Hiam 2013

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   UNDERGRADUATE STUDENT NURSES EXPERIENCES OF VERTICAL VIOLENCE IN PALESTINE     by  Hiam Abulaban  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES AND POSTDOCTORAL STUDIES (Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October, 2013    ? Hiam Abulaban, 2013ii  Abstract  Vertical violence is the term used to describe abusive and bullying behaviours among a group of people with unequal power. Vertical violence is used in this study because the recipients of abusive behaviours are students. The goal of this phenomenological study was to elicit a description of the lived experience of nursing students with vertical violence during their clinical placements in three major hospitals in Palestine. Findings suggest that nursing students are experiencing and witnessing bullying behaviours in different forms, most notably by staff nurses and head nurses. Students reported that their experiences with vertical violence lessen as they advance in their clinical education and gain more skills. The majority of the students told someone about their experiences. Experiencing vertical violence was found to impact the students' learning, socialization and clinical practice. The students reported using different coping strategies to deal with vertical violence. Implications for practice include ensuring that if the issue of vertical violence is not dealt with, it will have a detrimental effect on the student nurses and on their practice. Recommendations include providing policies to address this issue and provide reporting guidelines for student nurses. Also teaching nursing students and nurses about vertical violence is to be a top priority for the schools of nursing and hospital managements.      iii   Preface This thesis is my own original work and currently no part of this thesis has been published, however a paper based on this thesis will be submitted for publication to peer-reviewed journals. This thesis contains research conducted by the candidate, Hiam Abulaban under the supervision of Dr. Bernie Garrett, Fr. Jennifer Baumbusch, and Miss Elsie Tan. The conducted research titled undergraduate student nurses experiences of vertical violence in Palestine was approved by the University of British Columbia Clinical Research Ethics Board (H12-01717), and all study participants provided written informed consent. I conducted this phenomenological study, and I performed data collection and analysis for the project in Chapter Three. I hereby certify that I am the sole author of this thesis and that no part of this thesis has been published or submitted for publication. I certify that, to the best of my knowledge, my thesis does not incorporate, without acknowledgement, any materials previously submitted for a degree or a diploma in any institution of higher education. I certify that my thesis does not contain any material previously published or written by another person except where due reference is made in the text. I declare that this is a true copy of my thesis.      iv   Table of Contents  Abstract .............................................................................................................................. ii Preface ............................................................................................................................... iii Table of Contents ............................................................................................................. iv List of Tables ................................................................................................................... vii Acknowledgements ........................................................................................................ viii Chapter 1 ........................................................................................................................... 1 Introduction ....................................................................................................................... 1 Background ....................................................................................................................... 1 Definition ........................................................................................................................... 3 Problem Statement ............................................................................................................ 4 Purpose and Objectives of the Study .............................................................................. 6 Research Questions ........................................................................................................... 7 Chapter 2 ........................................................................................................................... 8 The Literature Review ...................................................................................................... 8 The Review ........................................................................................................................ 8 VV in the Nursing Clinical Areas and its Forms ........................................................... 8 Canada ............................................................................................................................. 11 United States of America ................................................................................................ 12 United Kingdom .............................................................................................................. 13 Australia and New Zealand ............................................................................................ 13 Palestine ........................................................................................................................... 14 The Perpetrators ............................................................................................................. 14 v   Conceptual Framework .................................................................................................. 15 Under reporting .............................................................................................................. 17 Impacts of VV on nursing students ............................................................................... 18 Chapter 3 ......................................................................................................................... 21 Methodology .................................................................................................................... 21 Research Design .............................................................................................................. 21 Recruitment and Sample Selection ................................................................................ 24 Ethical Considerations .................................................................................................... 25 Data Collection ................................................................................................................ 27 Data Analysis ................................................................................................................... 28 Riguor/Trustworthiness ................................................................................................. 31 Summary .......................................................................................................................... 34 Chapter 4 ......................................................................................................................... 36 Data Collection from Interviews .................................................................................... 36 Ignorance ......................................................................................................................... 36 Lack of Respect ............................................................................................................... 38 Neglect .............................................................................................................................. 40 Lack of Acceptance ......................................................................................................... 42 Coping .............................................................................................................................. 47 Why Does VV Exist ......................................................................................................... 49 Impacts of VV on nursing Students .............................................................................. 51 Summary of Findings ..................................................................................................... 54 Chapter 5 ......................................................................................................................... 56 vi   Discussion ......................................................................................................................... 56 Discussion of the Results Related to the Relevant Literature ..................................... 56 Ignorance ......................................................................................................................... 56 Lack of Respect ............................................................................................................... 57 Neglect .............................................................................................................................. 59 Lack of Acceptance ......................................................................................................... 60 Action to report ............................................................................................................... 60 Coping .............................................................................................................................. 63 Impact of VV on nursing students ................................................................................. 65 Study Limitations ............................................................................................................ 68 Study Strengths ............................................................................................................... 69 Chapter 6 ......................................................................................................................... 70 Conclusion ....................................................................................................................... 70 Implications for Practice ................................................................................................ 71 Recommendations and Suggestions for Future Research ........................................... 71 Conclusion ....................................................................................................................... 74 References ........................................................................................................................ 76 Appendix A ...................................................................................................................... 87 Appendix B ...................................................................................................................... 89 Appendix C ...................................................................................................................... 93    vii   List of Tables Table 1: The most experienced VV behaviours among students......................................43 Table 2: the students' reasons for not reporting.................................................................47 viii   Acknowledgements I would like to acknowledge the following people without whom this thesis would not have been completed: Dr Bernie Garrett for his constant support and for his in-depth knowledge of nursing and the research process. Dr Jennifer Baumbusch for her valued review. Miss Elsie Tan for her assistance and encouragement. To my children Ashraf, Rawan, and Tariq the loves of my life who inspire me to be the best that I can be. I would also like to thank all the student nurses who contributed to the data collection.  Thank you for your trust and support.  1   Chapter 1 Introduction In this chapter, I introduce the issue of vertical violence amongst student nurses. I provide the background and the research questions as well as the significance of violence to the nursing profession. I also include the definition of vertical violence (VV), and I detail the reasons for this current research. Background  According to a recent survey, direct care occupations comprise the largest proportion of healthcare employees in Canada and consist of registered nurses, registered psychiatric nurses and licensed practical nurses (CIHI, 2010). Clark, Cane, Rajacich, and Lafreniere (2012) indicate in their research that nurses enter the profession of nursing because of a desire to care for the sick and to assist patients and their families in attaining or maintaining their well-being. Therefore, it is distressing to hear of the term "eating their young" to describe bullying behaviours in the nursing profession. However, Thomas and Burk (2009) believe that this term has been used to describe workplace violence behaviours that occur between qualified professionals and their students, especially since there is unequal power between individuals, and the recipients of VV are unable to defend themselves.  Workplace violence can be described as nurses directing their displeasure toward each other, toward themselves, and toward those less powerful than themselves (Woelfle, & McCaffrey, 2007). Jackson, Clare, and Mannix (2002) explain that the position of a nurse influences workplace violence when nurses in positions of power inflict violence on nurses with less power. They note, for instance, that managers may  inflict the majority of 2   the ?bullying? on subordinate staff. Randle (2001) points out that nursing students identified negative experiences related to their clinical placements. They described being devalued and felt that nurses used the power associated with their position to undermine the students' self-esteem. The evidence proves that workplace violence is widespread in all areas of nursing and affects all levels of nurses from the nursing student to the most experienced nurse (Thomas & Burk, 2009).  McKenna, Smith, Poole, & Coverdale (2003) indicate that 31% of their study's respondents talked about experiencing bullying (or vertical violence as it is known)  in the nursing clinical areas. Nurses described their experiences by including responses that involved rude, abusive or humiliating comments and said that they were given too much responsibility without appropriate supervision. The study also describes the level of distress caused by the incident as either moderate or severe. Abusive behaviour on the nursing units can take the form of criticism, ridicule, rumour spreading, and unjust roster scheduling (Jackson, Mannix, & Clair, 2002). Unfortunately, workplace violence is not a new problem that faces nurses and causes damages such as stress-related illness, increased absenteeism, sick leave, and deterioration in quality of staff relations and patient care (Johnson, Ohanhtharth, & Jackson, 2009). Clinical practice plays a very important part of nursing education as students are prepared to take active roles as nurses (Sharif, & Masoumi, 2005). However, Sheu, Lin, & Hwang (2002) argue that the initial experience of nursing students doing their clinical practices can be very stressful in itself and affects how they approach their nursing careers. Unfortunately, Clark(2009) points out the existence of VV in the clinical settings where student nurses undertake a significant amount of their nursing education and is adamant 3   that VV behaviours should not be permitted in all nursing areas to allow for better staffing and patient care. Therefore, is not a surprisingly, that (90%) of student nurses in a study have reported their refusal to work in areas where they have experienced or witnessed VV behaviours (Curtis, Bowen & Reid, 2007).  Furthermore, certain factors when present may have a negative impact on nursing students during their clinical rotation. Lofmark & Wikblad (2000) point out that the relationship between qualified nurses and the students can be an obstacle if the students are not treated seriously or if they receive condescending and humiliating comments from the nursing staff on the units. However, according to Papp, Markkanen, and Von Bonsdorff (2003), this behaviour jeopardizes the nurse?s role as a mentor for nursing students and leads to  a negative clinical experience. Furthermore, nursing authors suggest that abusive behaviour begins during nursing education where students are first exposed to different forms of VV. Randle (2003) believes that if the  student is trained in culture that accepts VV, the results can be problematic to the future of nursing practice. Definition Horizontal violence is the term used to describe abusive and bullying behaviours among a group of people of equal rank and status (Duffy, 1995). However, Thomas & Burk (2009) point out that their study was the first of its kind to explore VV in a sample of beginning students and they argue that ?while the terms horizontal or lateral are appropriate to describe the abusive behaviours perpetrated between nurses at the same level in a hierarchical system (eg, staff RN to staff RN), the phenomenon of VV occurs between individuals with unequal power (e.g., instructor to student, staff RN to student)", and 4   they ?propose 'vertical violence' (VV) as an appropriate term ? when the recipients of abusive behaviours are students ? (p.227).  In the literature, different labels have been used interchangeably by researchers to describe acts of VV such as bullying, workplace violence, or abuse and regardless of that, they all include negative behaviours toward others (Clarke, Kane, Rajacich, & Lafreniere, 2012). For the purpose of this paper, VV will be the term used to describe any forms of workplace violence that is directed at nursing students). Celik and Bayraktar (2004) describe VV behaviours as those including being yelled at or shouted at or being belittled or humiliated which have been shown to negatively impact the experiences of nursing students in their clinical  rotations. According to Clark's (2009) study, the reported bullying behaviours for nursing students included efforts being undervalued, being held to impossible expectations set for them being frozen out or ignored, being told negative remarks about becoming a nurse, being treated with hostility and experiencing resentment. Furthermore, student nurses identified VV as attempting to belittle or undermine student work, attempting to demoralize and withholding necessary information purposefully. McKenna, Smith, Poole and Coverdale (2003) conclude in their study that the negative behaviours that are experienced in the nursing clinical units encompass making individuals feel isolated, and experience increased responsibility with minimal support. Problem Statement Research on VV worldwide described in literature highlights the potentially harmful consequences for the student nurses as well as the possible implications for patient care and nursing shortages. Further research demonstrates that nursing students and new graduate nursing students have either considered leaving the profession or have left as a 5   result of falling victim to VV behaviours (McKenna, Smith, Poole, & Coverdale, 2003).   Hoel, Giga and Davidson (2007) reveal how some nursing students were disappointed when faced with indifference, hostility, and intimidation by nurses. Others also experienced stress and a decreased self-esteem which has been shown to negatively impact student nurses (Randle, 2001). This brings forth the alarming possibility that student nurses may work in ways that they themselves initially find to be frustrating and intimidating at the start of their nursing practices. Randle (2003) in her study of this phenomenon finds that student nurses vented their frustrations on their subordinates. The consequences for the nursing profession can be horrendous and result in reduced patient care due to nursing shortage (Hewett, 2010). In addition to that, the fact that nurses who are bullied seem to become less compassionate to their colleagues (Randle,2003).  Although international studies have demonstrated that nursing students experience VV during their nursing education, there is little evidence of the incidence of this phenomenon in Palestine. However, there are anecdotal evidence that VV exists, and is imperative that a Palestinian sample be used to determine the extent and nature of  VV in nursing education in Palestine, so we may compare it to other international studies. As researchers, we have an obligation to address the problem by accurately describing the phenomenon of VV within nursing education and helping implement solutions to prevent it from happening in nursing practice. The researcher believes that there is a need to further investigate the prevalence and nature of VV as experienced by the student nurses in the clinical placement areas of the School of Nursing in AQ University in Palestine. The researcher has grave concern that student nurses may be brought into a culture that  accepts the status-quo of VV. 6   Purpose and Objectives of the Study The researcher has become concerned about the nursing students experiencing VV after hearing about the nursing students being exposed to VV behaviours in the clinical areas from one of the clinical educators at AQ University School of Nursing. One example was when a student was reprimanded in front of a patient by the staff nurse for forgetting to introduce herself. Another student left the unit crying after forgetting to ask permission from the staff nurse to talk to her patient. Thus, the purpose of this study is to gain an insight into the phenomenon of VV in nursing education as it relates to student nurses? experiences in the clinical setting and to determine and describe if and to what extent student nurses are exposed to VV in the clinical environment. The specific objectives of this study are: ? To identify the forms of VV as experienced by the nursing students; ? Identify the perpetrators of VV. ? The influences of VV on the nursing students' learning, socialization, and practice. ? Identify the causes of VV.  ? Identify coping strategies that were used by the students. As there is no research in Palestine regarding the phenomenon of VV in nursing education to date, this study will add to a limited body of knowledge for purposes of professional and academic development and understanding. In addition, this study can offer further research ideas such as research into the dynamics of workplace violence (VV), targeting student nurses in the clinical settings, and recommendations on how to interrupt the VV in practice and education.  7   Research Questions The research questions underpinning this study: 1. Have nursing students in AQ University experienced VV their clinical placements?  2. In what ways have these students experienced VV? 3. How does VV affect their behaviours in term of learning, socialization in the clinical areas and nursing practice? 4. If they have experienced VV, how do they adapt and cope with it? Given the scope of this thesis study, I explore the phenomenon of VV from the perspective of student nurses who have experienced violence in the nursing clinical environment. It is my hope that the findings of this study will draw attention to the seriousness of this topic and provide a base for finding strategies to deal with the problem of VV. In this chapter, I have outlined the main rationale for the study, its purpose, the  research question, and my approach. In chapter two I provide a literature review on  VV, in chapter three I include an overview of the methodology chosen and  research methods, and in chapter four I provide the results of the study. Finally, in chapter  five I provide a discussion of the findings, the implications, and recommendations for  further research.             8   Chapter 2 The Literature Review Chapter two is dedicated to a literature review which outlines the broader context of the field of study, and the main contributions of research to knowledge of VV, particularly in relation to nursing students. In this chapter, information from Canada, United States of America, England, Australia & New Zealand, Palestine and other countries where VV in nursing has been identified has been incorporated. A review of published and unpublished literature relating to workplace violence and VV in nursing was conducted using Google Scholar and PubMed. The literature was limited to the English language and included published literature up to and including 2012. The keywords ?workplace violence?, 'bullying?, ?horizontal violence?, ?vertical  violence?, ?violence in nursing?  and ?workplace stress? were typed into the search engines. The search aim was to access articles from international nursing and educational journals, occupational safety bulletins, conferences and theses. Research studies found are discussed in this chapter. The Review VV in the Nursing Clinical Areas and its Forms  Layton-Bennet (2007) highlights a researcher's opinion, which is that"?nursing provides an ideal incubation for fostering interpersonal conflict?either amongst staff themselves or between staff and patients". (p.8). According to Johnson (2009), workplace VV is not just a conflict between individuals, it relates to many factors, some of which are social, individual, and organizational, and adds that VV in the workplace affects work performance and productivity. Workplace aggression can be described using many different terms such as bullying, horizontal and vertical violence, and overt and covert 9   violence. Research has also explored abusive behaviour towards another person, including physical, sexual and non-physical violence. Non-physical violence includes verbal abuse, incivility, and intimidation and can take place at any workplace (Johnson, 2009; Thomas & Burk,2009; Hewett, 2010; Bakker, 2012). In a study, one of three nurses interviewed about VV in 2003 had considered leaving the nursing profession due to humiliation (McKenna, Smith, Poole, & Coverdale, 2003).   Glass (1998) has explored the issue of workplace violence and concludes that nurses encounter many stressors from their co-workers and there exists professional jealousy in the nursing environment. Khalil (2009) reports a study that took place in eight public hospitals in Cape Town  and identifies six types of violence that occur among nurses: Psychological violence (humiliating; isolating), vertical violence (violence from a place of power), covert violence (gossiping; manipulating), horizontal violence (harassing, swearing), overt violence (shouting) and the least is the physical violence (assaulting). Roche, Diers and Catling-Paull (2010) indicate in their study of 21 Australian hospitals that verbal abuse and emotional stress correlate positively with ward instability, poor patient care, and staff restlessness.  The researcher notes that there is a rich body of literature that discusses negative behaviours in the nursing workplace but still little research has been conducted on the experiences of undergraduate nursing students and how they manage and cope with VV behaviours. VV in Nursing Education Nau, Dassen, Needham, & Halfens (2009) in their literature review found only ten articles for a past period of fifteen years that relate to the topic of workplace aggression 10   targeting students. However, recent research has been interested with the issue of abuse in the nursing clinical education worldwide. For example, Ferns and Meerabeau (2008) report that 45.1% of students responded positively when asked about their experiences with verbal abuse. In another study, 90% of nursing students reported experiencing some form of VV while on clinical rotation (Foster, Mackie, & Barnett, 2004) Hinchberger (2009) indicates that nursing students were exposed to violence equally to staff nurses and adds that "many nursing students and new graduates accept horizontal violence as a ?rite of passage? only to mimic and repeat the behaviour later in their careers. Yes, nurses learn to eat their young and each other as part of the profession" (p.43). Negative behaviours encompass all unwanted acts, whether verbal or physical, that are offensive, humiliating, and thus, unacceptable to others (Clarke, Kane, Rajacich, & Lafreniere, 2012). Scholars looked at the types of abuse experienced by nursing students in Turkey and noticed that the most frequently reported types of abuse were swearing, belittling, hostility, and rudeness (Celik  and Bayraktar, 2004)  . In another study, it is revealed that students who were facing VV were unable to comprehend why nurses were uninvolved and neglectful of them (Hoel, Giga, & Davidson, 2007). Hewett (2010) concludes in her thesis that workplace violence targeting nursing students has been widespread. Thomas & Burk (2009) agree and add that VV can be considered a factor in the rapid attrition of many new nurses. Most importantly, positive learning experiences require good clinical areas (Mannix, Faga, Beale, & Jackson, 2006). However, nursing students are vulnerable to unfriendly and negative behaviours which impact their learning and can lead to students suppressing their feelings and developing ?hard fronts?. Such responses may very much contribute to the reproduction of negative 11   behaviours that nurses assimilate (Hoel, Giga, & Davidson, 2007). Hinchberger (2009) indicates that the widespread problem of workplace violence in the healthcare sector is highly worrisome to workers, employers, and governmental agencies across Australia, Canada, the UK, and the US. A specific literature review has been done by the researcher in order to examine bulling in nursing clinical areas in different countries worldwide and determine its prevalence.  Canada "Bullying among nurses in Canada is a problem that drains nurses of both energy and productivity" (Rocker, 2008, p. 1). A recent Canadian study reports that 88.72% of nursing students in four campuses experienced negative behaviours that were recognized as VV in the nursing practice settings, and those students were found to have lower self-esteem and lower self-confidence in their careers (Clarke, Kane, Rajacich, & Lafreniere, 2012). A survey of Canadian nurses reports that the nature of the abuse that occurred on the nursing units was physical (10.6%), psychological (86.4%), or sexual (30.7%) (Lemelin, Bonin, & Duquette, 2009). Similarly a study by Hesketh, et al. (2003) shows that nurses in two provinces in Canada experienced many incidences of violence including abuse committed by hospital co-workers. Respondents reported emotional abuse (38%), physical harassments and threats (19%), and verbal abuse (7.6%). The Canadian Nurses Code of Ethics (2008) highlights the responsibilities of nurses toward nursing students, and it states that nurses must respect each other, their colleagues, students and other healthcare workers and that nurses are mentors to students and they must share their knowledge and guide students in their development.  12   United States of America The first research into workplace violence against nurses was published by Roberts in 1983 and involved details about the problem of bullying in the United States of America as cited by Bekkar (2010). The problem of workplace violence in nursing has been gaining much attention by American researchers. Childers (2004) states that bullying is widespread in hospitals and workplaces across the United States and that 70% of bullied workers leave their jobs. A recent study expands on the current understanding of workplace violence in the US nursing workplace and its effect on nursing turnover. It identifies the presence of abusive behaviour within a population of registered nurses and concludes that it is a significant determinant in predicting nurses? intent to leave the organization (Simons, 2008). In a similar study, 27.3% of the sample had experienced workplace violence in the last 6 months. Nurses accused their managers/directors of bullying or charge nurses with bullying. Also, workplace violence was significantly associated with one?s intent to leave their nursing job (Johnson, & Rea, 2009). In clinical nursing education, Thomas & Burk (2009) report a content analysis of stories written by junior nursing students describing incidents of injustice perpetrated by nurses during their clinical experiences. The detailed stories portray registered nurses as the major cause for junior students? anger and feelings of humiliation. Hinchberger (2009) reveals that one hundred percent of the female nursing students surveyed had experienced some type of workplace violence and the perpetrators were most often other staff members, followed closely by patients.   13   United Kingdom Studies have been done on violence in the workplace in the United Kingdom where it is estimated to have affected up to 50% of workers at some time in their working lives, and is becoming increasingly identified as a major occupational stressor, as cited by McAvoy (2003). Randle (2003), in a three year study conducted in the United Kingdom on nursing students? self-esteem, has identified VV as a common complaint among nursing students. The study concludes that the way a student is treated during hospital training shapes the student?s process of becoming a nurse. Furthermore, a survey exploring the reporting behaviours of nursing students who had experienced verbal abuse while gaining clinical experience states that 44.7% of the participants reported verbal abuse and the most frequent feelings reported by respondents were embarrassment and feeling sorry for the abuser (Ferns & Meerabeau, 2009). Australia and New Zealand Mayhew& Chappell (2002) cited the Australian Public Service Commission definition of workplace harassment in 1994 as: ?? Behaviour that is unwelcome, unsolicited, usually unreciprocated and usually (but not always) repeated. It makes the workplace or association with work unpleasant, humiliating or intimidating for the people or group targeted by this behaviour. It can make it difficult for effective work to be done? (p.1).  Interviews from a New Zealand focus group revealed that 34% of new nursing graduates had experienced abusive, rude, and humiliating behaviours from staff nurses during their clinical practice (McKenna, Smith, Poole, & Coverdale, 2003). 14   Palestine Very limited literature was found regarding negative behaviours and VV in the nursing clinical areas and none related to nursing students. For instance, a recent study by Hassan-Bitar & Narrainen (2011) discusses the reality that Palestinian nurses and midwives experience horizontal violence and humiliation due to their existence in a health system that is dominated by the country?s political and socio-economic instability. The nurses in Palestine are humiliated by the public, the doctors and their supervisors. The midwives and nurses reported that ?shouting? was a daily communication style between them and their managers. Thus, it is suggested that understaffing, job stress, and low job satisfaction are among possible factors that might lead to aggression towards colleagues and co-workers in Palestinian hospitals. This aggression has negative impacts on team cooperation and on the safety of patients (Kitaneh & Hamdan, 2012).  Another study reveals that Palestinian nurses face many challenges, such as decreased chances of job advancement and emotional exhaustion, which may lead to job dissatisfaction. The study points out that there is no regulatory nursing body that advocates for nurses' rights and helps improve their situation. Midwives and nurses do not have the option of leaving their job if they are unsatisfied. Instead, many of them are ?trapped? and obliged to practice in non-enabling work conditions (Abushaikha & Saca-Hazboun, 2009).    The Perpetrators Randle (2001) states that nurses are the most influential group with respect to student nurses? self-esteem, and describes them as the main perpetrators of negative behaviours against students. The Canadian Nurses Association Code of Ethics (2008) states that registered nurses are obligated to support initiatives and provide effective mentoring to 15   students in their clinical nursing education. This obligation is moral, ethical and legal. Unfortunately, current research shows that nursing students have reported being bullied while doing their clinical placements by staff. A Canadian survey shows that workplace abuse is inflicted by a colleague (65.9%), a superior (59.6%), or a physician (59.1%) (Lemelin, Bonin, & Duquette, 2009). Moreover, results from a recent study suggest that Canadian nursing students experience and witness VV behaviours quiet often, mostly by clinical instructors and nursing staff (Clarke, Kane, Rajacich, & Lafreniere, 2012). Celik and Bayraktar (2004) point out that nurses perpetuated 68.4% of students? abuse in the clinical practices, as reported by nursing students. Interviews from a New Zealand focus group reveal that 34% of new nursing graduates experienced abusive, rude, and humiliating behaviours from staff nurses during their clinical practices (McKenna, Smith, Poole, & Coverdale, 2003).  A Turkish study?s findings shows that harassments of students were worse when nurses held high and superior positions and suggests that verbal abuse is more harmful to the students than sexual or physical abuse (katrinili, Ataby, Gunay, & Cangarli, 2010).  Conceptual Framework Begley (2002) suggests that a hierarchy exists in the nursing profession and the nursing students are at the bottom of it. This hierarchy sustains bullying and allows it to exist. Farrell (2001) points out that in nursing culture, nurses having been bullied by those in higher positions and may perceive that students should be bullied too. Jackson, Clare & Mannix (2002) indicate in their study that workplace violence happens when it is inflicted by nurses in positions of power on nurses with less power. The study also notes that managers are the main culprits in bullying subordinate staff. In another study on nurse 16   experiences with workplace bullying, 50% of the participants identified their managers as bullies and 25% indicated that their charge nurses bullied them (Johnson and Rea, 2009). Furthermore, in a study of twenty four managers in both private and public settings, managers reported that they, too, had been victims of upwards bullying (Branch, Ramsay, & Barker, 2007).  Farrell (2001) states that when nurses are bullied, they lack control and autonomy over their work and the ability to make decisions, which prevent them from feeling empowered. Furthermore, Hutchinson, Vickers, Jackson, & Wilkes (2006) indicate that nurses who feel that they have limited control and power may in turn display oppressive behaviours, leading to bullying and workplace violence. This disempowerment is also described by Woelfle and McCaffrey (2007) as oppressive and may lead to oppressive behaviour as defined by the oppression theory. This theory indicates that ?oppression exists when a powerful and a dominant group controls and exploits a less influential group? (p.124). And if workplace bullying is continued to be conceptualised as an inherent feature of nursing, there is the risk of accepting that bullying as a feature of nursing. However, there are a few weaknesses to this theory as noted by researchers. For instance, Johnson and Rea (2009) indicate that workplace violence is a far more complex phenomenon; they indicate that the oppression theory may be limited in that it does not take into account the fact that workplace violence also occurs in other professions. Of a similar opinion, Hutchinson, Vickers, Jackson, and Wilkes (2006) point out that there is a flaw in the oppression theory because it puts the blame solely on nurses and conceals the role of power relations within the organization. They also reveal that oppression is found among other workers as well. 17   Under reporting Hesketh, et al. (2003) conducted their research on VV  in two Canadian provinces and were surprised to note that up to 70% of incidences of workplace violence among nurses were not reported for fear of retaliation. Ferns & Meerabeau (2009) point out that thirty-two students (62.7%) who experienced verbal abuse stated that they reported the incident and 19 (37.3%) stated that they had not. Although of great importance, VV remains underreported. Clark's (2012) reports that not even a quarter of those who were identified as having experienced bullying behaviours reported their experiences to someone. Given all the negative cosnequences of VV behaviours that nursing students experience, why does VV continue to be underreported?  A study shows that 32.8% of nurses who reported abuse were met with disbelief, and blame (Fisher et al, 1995). Interestingly, Wilkie (1996) provides two explanations to the problem of underreporting. First: The perpetrator is often in a more senior position and any complaining may be considered simply ?jealousy?, and may result in retribution. Second: The individuals misunderstanding of their rights and responsibilities limits the reporting of incidences of negative behaviour. McKenna, Smith, Poole, & Cloverdale (2003) argue that very little is known about the reasons for the non-reporting of VV. They also note that VV behaviour is reported in less than 50% of cases, mostly for fear of retaliation. Also, only a small percentage of those reported (12%) had "received formal debriefing and very few respondents had had training to deal with any abusive behaviour in their workplace" (p. 96).  In a Palestinian study, it was found that 'low violence reporting level' (56.3%) is due to a lack of clear procedures for reporting and a failure of hospital management 18   encouragement to report. Moreover, it has been suggested that nurses believe that reporting is useless because no action will be taken by the management and they also fear the consequences and repercussion if they do report (Kitaneh & Hamdan, 2012).  McKenna, Smith, Poole, & Coverdale (2003) point out that to be able to report incidence of abuse, people must feel safe. Moreover, nurses may feel ashamed if they report negative behaviours because they are seen as professionals and believe that, as professionals, they should be able to cope with aggression or verbal abuse (Bakker, 2012).  Impacts of VV on nursing students Nursing students feel that their identities are oppressed, show signs of being ?burnt-out?, and have internalized their feelings of inferiority (Randle, 2001). Other student victims of VV have reported feeling angry towards the abusers, or guilty and depressed (Celic & Bayraktar, 2004). Randle (2001) states that the students in her study included the intention to leave the profession in their reactions to VV.  Furthermore, workplace violence has caused distress to nurses leading to work absenteeism (McKenna, Smith, Poole, & Coverdale, 2003). Celik & Bayraktar (2004) agree as they also found that more than half of the Turkish nursing students in their research who experienced VV thought about leaving the profession. Simons (2008) found that there was a great deal of co-workers? abuse causing a lack of supportive teamwork and creating a negative attitude in the nursing clinical units, leading to job dissatisfaction and staff turnover, which in turn affect patient care and safety.  Workplace violence has been raised by the Canadian Nursing Advisory Committee (2002). It notes that workplace violence relates to staff shortages, long working hours, staffing dynamics and politics. The committee added that there is little support from within 19   the organization when abuse happens. Hutchinson, Vickers, Jackson, & Wilkes (2006) conclude that organisational characteristics were responsible for the development of a culture of VV among nurses where many cases were not investigated and dealt with. Nursing students coping strategies Across different studies, it is clear that students experiencing VV coped with the situations differently. For instance, Randle (2003) concludes that many nursing students adapted to their work culture by adopting VV behaviours as their own personal ones. McKenna, Smith, Poole, & Coverdale (2003) believe that while many students  became overwhelmed and disillusioned by the nursing profession, some students struggled to find a way through abusive situations by learning to 'stand up' for themselves and to 'feel stronger'. The most common coping method among participants of a Turkish study was ?doing nothing? and only 11% reported the abuse to a superior person (Celik, & Bayrakar, 2004). Fortunately, other students gained awareness of ways to deal with VV and made the decision to be different and to stop VV behaviours by not repeating any of the negative behaviours that they had previously experienced during their clinical placements (Curtis, Bowen, & Reid, 2007). Clarke, Kane, Rajacich, & Lafreniere (2012) point out that students who have experienced more VV behaviours were more likely to have considered leaving the nursing profession.   In summary, there is some enlightening literature that focuses on VV, or intimidating behaviours in the nursing workplace, both nationally as well as internationally, and suggests that nursing students have been on the receiving end of VV and negative behaviours. However, VV has not been studied in nursing education in Palestine and it is 20   unknown to what degree it exists. For the purpose of my study, VV is investigated as it is experienced in the school of nursing at the AQ University to find out how prevalent it is. In addition, the forms of VV experienced by the students and their reactions toward it are examined in an attempt to reveal the effects of VV on the students (if experienced) and their coping and adaptation methods.                                21   Chapter 3 Methodology The main ideas behind a phenomenological method are the description and the clarification of a specific phenomenon. According to Giorgi (2005), a phenomenological study does not explain nor discover causes but rather clarifies the meanings of phenomena. Taking into account the absence of studies assessing the experiences of nursing students with vertical violence (VV) in the clinical setting in Palestine, phenomenological inquiry can provide a base for understanding the experiences of these students. The goal of this study is to describe the experiences of nursing students with VV during their clinical rotations in Palestinian hospitals. Research Design The body of literature on the experiences of nursing students with VV is clearly worth studying as it is a phenomenon that has been discussed in multiple studies (Randle, 2003; Thomas, & Burk, 2009). As such, a qualitative methodology is appropriate, with emphasis on the emic perspective and with data collected within a naturalistic context (Morse, & Field, 1995). The emic approach investigates how people think from their own perspective and how they perceive and categorize the world, and their rules for behaviour. The rationale for the use of this methodological approach is the need for an in-depth study of the students' lived experiences of VV during their clinical rotations in their undergraduate nursing education. Phenomenology is an inductive qualitative approach that has roots in philosophy and psychology and focuses on the lived experiences of humans (Polit, & Beck, 2008). The main ideas behind a phenomenological approach are the description and the clarification of specific phenomena. According to Giorgi (2005), a 22   phenomenological study does not explain nor discovers causes, but rather, it clarifies the meanings of phenomena. Phenomenological inquiry can provide a useful basis to develop an understanding of the lived experiences of Palestinian nursing students with VV.  The goal of this study is to explore and describe the experiences of nursing students with VV during their clinical rotations in Palestinian hospitals.   This methodology represents a ?study of consciousness? and as Giorgi (2005) points out, anything that has to be dealt with in the world has to come through consciousness. Furthermore, he explains that phenomenology has the ability to focus on presences and phenomena which can all be understood in terms of their personal meanings. Holloway, & Wheeler (2010) agree and indicate that phenomenology is a very useful approach that brings together the mind and the body.  However, the differences in individuals? perceptions of the phenomenon are based on various influences such as "thoughts, images, memories, fantasies, and the flowing of experience with it's vague interconnecting bonds" (Giorgi, 2005, p.76). Thus, researchers applying phenomenological methods in their studies aim at investigating the realities in people's lived experiences which gives meaning to a person's perception of a certain phenomenon (Polit, & Beck, 2008). Van Manen (1990) indicates that phenomenological research has to 1) study lived experience, 2) explain the phenomenon as it is perceived by the consciousness, 3) study the essence of the meanings, and 4) study the essential structure of a phenomenon and what it means to be human.  In addition, Giorgi's (1995) methods for doing research provide guidelines for researchers to use, while also allowing for the use of one's judgement on how to adapt the methods as needed to conform to the phenomenon being studied. Holloway & Wheeler (2010) point out that Giorgi reminds the researchers to stay close to the phenomenon 23   during their inquiries. However, the researchers must begin their studies by having an area of interest and using scientific and systematic ways of gaining information through the process of inquiry. For instance, phenomenologists are encouraged to ask about people's everyday experiences of the phenomenon under study in an attempt to clarify it and understand it. This inquiry aims at describing the essence of a particular phenomenon as it is experienced by people and what it means to them. To clarify, Giorgi (1994) indicates that the phenomenological method involves three steps:  1) Description: The researcher provides a precise description of the phenomenon as it presents itself without adding or eliminating anything.  2) Reduction: The researcher attempts to avoid interjecting any personal prejudices. This can be done by identifying or bracketing all preconceived ideas that may influence the data's description. This will allow for better representation of the concrete situation in which one is encountering. Giorgi (1984) indicates that bracketing does not mean that one empties oneself of all possible past knowledge. He explains that an individual "puts aside" or renders "non-influential" previous knowledge that may relate to the presently given object, in order to allow it to present itself in its fullness in the current situation. It seems that for a researcher to achieve the most rigorous standards possible, they should be aware that past interpretations can predetermine present experiences. 3) Search for the essence: The researcher identifies  the "invariant and unchangeable characteristics" of the phenomena and describes them in relation to each other. Thus, phenomenology represents a useful and appropriate method of inquiry to explore students perceptions of VV in their clinical experiences. 24   Recruitment and Sample Selection The setting for the study was at the school of nursing at a university in Palestine. The school has a four year baccalaureate nursing program and the students are required to undergo most of their clinical training in three Palestinian government hospitals. Their clinical rotations vary from a 1-week to a 12-week block, depending on the clinical focus of the particular placement. The sampling plan was designed to obtain a minimum of twelve students to take part in interviews. The participants were nursing students who were on their clinical rotations in hospitals. A non-probability purposeful sampling technique was used to recruit twelve nursing students. Recruitment of students was made possible through the distribution of letters inviting students to participate via the school secretary (Appendix A). The other form of recruitment was through word of mouth. For example, the students who participated told others about the study and encouraged them to participate. The inclusion criterion was simply any male or female student doing his/her clinical training on the different units of three Palestinian government hospitals. The students excluded were those who were in their first and second year as these students do not have much practical hospital experience. Students were recruited for this study from January to April 2013. The sample size was based on the needs of the study, which depended on the ability of the participants to provide the required data. The sample was a purposeful one, in that the sample targeted students who could provide in-depth information of their experiences of VV during their undergraduate nursing education.  25   As an incentive to participate, refreshments and snacks were provided at each interview and participants entered into a draw for a $25 gift card which could be used at the university diner. A few students initially contacted me via email whilst others chose to phone me for further clarification on the nature of the study. I then made appointments to meet the students at times and locations of their choice. Three of the students were male and nine were female, with ages ranging between twenty one and twenty four years. Five students were in their third year and seven were in their fourth. The clinical areas where they had received clinical experience included medical, surgical, psychiatric and maternity. The total number of participants in this study (N) was 12. Ethical Considerations An application was made to the University of British Columbia (UBC) Research Ethics Board (REB). Applications were also made to the selected school of nursing and the director of the participating hospitals to conduct the research study and permissions were granted. All efforts were taken to ensure that the participants understood the research study. The purpose, benefits and risks of this study were explained, and participants were told about the interview process. Any questions about the study were answered prior to commencing the interviews. Each participant was given a consent form (a copy of the consent form is available in Appendix B), which includes the assurance of confidentiality and anonymity of all data collected as well as the right of participants to withdraw from the study at any time. Furthermore, all questions and clarifications of the consent were answered prior to the interview. All of data has been stored in a secure place in my office and the signed consent forms have been stored separately. The data are also stored in my personal laptop which is kept safe and requires a password to unlock. Furthermore, I 26   continued to use extreme caution to maintain the participants' confidentiality and privacy and no individual identifiable quotes or experiences were written up. Much of the questions asked were to address concerns about the staff members who were reported as being involved in those experiences. However, they were not identifiable in the study as 1) students who participated remained anonymous, 2) the name of the university was not used in the write up, 3) names, places and times were not given, and 4) during analysis and write up, care was taken not to use quotes or events that would lead to the identification of the actual student or staff. Also, participation and disclosure were completely voluntary. I was aware that the students may experience increased emotional stress as a result of the interviews as they recall their experiences on VV and abusive encounters. I have contacted the School of Nursing regarding counselling and was told by the head of the nursing school that there is a professional counsellor available for any student needing assistance. An information sheet for contact with the counsellor was attached to the consent form and given to the students at the time of the interview. Although it has been noted that recalling events through qualitative interviewing may cause some emotional distress to participants, there is no evidence that this distress is greater than that which they face in their day-to-day life or that they need follow up counselling. The researcher's interviewing skills and a code of ethics are crucial in preventing participant distress (Corbin , & Morse, 2003). For instance, when two participants showed some emotional distress as they recalled their experiences, I contacted them the next day following the interview to determine if their distress persisted.   27   Data Collection Individual interviews were used as the approach of choice using semi-structured questionnaires. The aim of the interviews was to provide a comfortable atmosphere that would allow the students to tell their stories and share their experiences, as is the purpose behind phenomenological research (Polit, & Beck , 2008). A formal Letter of entry (Appendix A)  preceded the interview and included an introduction to the research, the purpose of the study, the risks and benefits to the student, the contact information for the researcher, and a request to respond within one week of receiving the invitation. The place and time of the interview were determined based on each student's convenience and school schedule. Every effort was made to provide a comfortable environment during the interview that was accessible and easy to locate.  Semi-structured individual interviews were designed to collect data, and incorporate McNamara's (2009) suggestions to achieve the best outcomes with subjects. These include: Picking a quiet area with minimal distractions and giving clear explanations of the interview purposes and conditions of confidentiality. Also the researcher must provide instructions about the interview structure, length, and the researcher's contact information. Also, there should be time for questions to be answered prior to starting the interview.   The interview was aimed at obtaining the necessary information regarding the prevalence of VV, the forms in which it exists, and the ways in which the students have experienced and coped with it. The interview questions that were used (Appendix C ) were designed to allow the students to answer from their own framework of meaning and promoted ongoing dialogue with the participants by encouraging them to fully share their experiences (Corbin, & Straus, 1998).  28    I was the primary mediator and the interviews were conducted in Arabic (as the language of choice for the participants). Audio recording as well as note taking were used to record the interviews. Preliminary questions covered some demographic information (i.e. age, and years in college), asked about the students? understanding of VV, their experiences with any behaviors indicative of VV, and the students' observations and responses to it. However, during the interview, more questions were added as appropriate to stimulate further dialogue. Reporting of the students? experiences involved a large group of people across multiple venues, and was not focused on specific individuals who could be identified. Furthermore, the students were advised to use fictitious names and venues so that no individuals or units could be identified. Each interview recording was transcribed then translated to English. I limited the number of interviews conducted to two per day but due to unforeseen practical issues, there was some delay in conducting all the interviews consecutively as proposed. However, this delay allowed me time to transcribe and translate the audio recordings from the interviews. Each interview ranged from thirty minutes to forty-five minutes. Data Analysis Giorgi (1999) indicates that phenomenological analysis is ?a method for accessing and describing the essential features and relationships of the objects or events (i.e. the phenomena) that are present to the consciousness? (p. 8). He suggests that the function of the consciousness is to bestow meanings on these objects which are constituted by it and can be expressed in pictures or articulated linguistically. Furthermore, these meanings refer to the specific individuals? hopes, ambitions, values and fears. 29   Researchers need to be able to organize, sort, and report data which makes qualitative data analysis somewhat more challenging than quantitative analysis (Polit, & Beck, 2008). As mentioned earlier, bracketing has been employed in this study, and as I am aware that my past interpretations could predetermine present experiences, I put aside my own personal perceptions about VV and focused on data in order to present the issue in its fullness. Holloway and Wheeler (2010) have highlighted the four steps of Giorgi's method of data analysis, which has been adopted for this study. These steps are described as follows: Step One:  The first step in the analysis of interview data is to get a holistic sense of the issue from the description through reading the information presented in the interviews, and by verbatim transcription of the initial data. Step Two: In this step of data analysis, the researcher continues to read and re-read the transcriptions, marking individual meaning units as they present themselves to the reader. Then, the researcher works at differentiating between these 'meaning units' using everyday language (or coding them with terms that describe their general thematic content or characteristics). Step Three: Here the researcher uses the participant's words and quotes to highlight common themes. This is done by writing down the meaning units that are relevant to the phenomenon (using more detailed descriptive terms or codes) and then transforming them to express the insight within. Step Four: The final step in the analysis of individual interview data is to describe the experience according to the meaning units discovered in the third step of the analysis. Each meaning unit is part of the whole of the phenomenon being studied, and at this level, they 30   are synthesized to generate a structure of the phenomenon that arrives at the essence of the experience (exploring and describing how the coded units are inter-related). Giorgi (2005) concludes that upon doing these steps, the researcher will reflect on all the data and combine all the themes. Any individual variations pertinent to the structure will be identified and used in the final description of the phenomenon. This reflection on the data described will enable the researcher to refine the data's description to focus only on the aspects that are common to all participants resulting in a general structure. This structure provides a final description of the phenomenon, which is called the ?essential structure?.  I listened carefully to the students? interviews to familiarize myself with the information presented and probe for understanding. I transcribed each interview within the same week. I did that by listening to the recording while writing down the student's words. The interviews were conducted in Arabic as it was the students? language of choice and it was transcribed and translated by me. While I am fluent in both Arabic and English language, I still used an internet program to help with word by word translations from Arabic to English. It was time consuming and required great effort to get it as accurate as possible. I read through each transcribed interview and I re-read it to get a holistic sense of the issue. This reading was aimed at identifying ?meaning units?, or commonalities, within the descriptive data. Immediately after, I coded each individual wording to describe its general thematic content and to determine the relevance of each of these meaning units.  Line by line coding (Charmaz, 2006) was used to code data and to help in identifying common themes that arise from the data. I then used individual quotes to identify common themes across all the interviews by using more detailed descriptive codes 31   that highlighted the core insight. Through extensive exploration of these descriptive codes, I was able to find how they inter-relate with each other by looking at patterns and relationships. Finding out this inter-relation between codes allowed me to understand the phenomenon of VV and to bring together the experiences of the participants in descriptions that were consistent with the interview material. I also noted the similarities and differences between the students' experiences. All data collection materials that were used in the interviews, such as field notes and tapes, were labelled and filed. My analysis included descriptions of the situations between the nurses and the nursing students during their clinical rotations, which were based on what the students told me. These descriptions provided vivid images of what forms of VV were experienced by the students.  Riguor/Trustworthiness Trustworthiness (rigour) in this study was maintained using Holloway and Wheeler (2010) framework. Rigour indicates the soundness and adequacy of the research. There are five criteria for evaluating trustworthiness of a qualitative study, these are: reliability (dependability), validity (credibility), generalizability (transferability), objectivity (confirmability), and authenticity. Reliability (dependability): This term refers to the stability of data over time in terms of accuracy and consistency (Holloway, & Wheeler, 2010). This study was described in detail and an audit trail was maintained to achieve dependability such as recordings, notes and transcriptions. In this study, dependability was optimized by following the methods of Giorgi (2005) in the analysis of the study data. This analysis was clearly documented, in a step-by-step process, to allow for better understanding. The use of 32   additional interview questions and member checking were two techniques that I used to address dependability. However, In this study, triangulation was limited to collecting data from many different participants with different experiences and perspectives. Validity (credibility): in order for this study to be credible, there has to be confidence in the truth of the data presented. In this study, the techniques of prolonged engagement, persistent observation, peer debriefing, negative case and member checking were used to establish credibility (Holloway, & Wheeler, 2010). Prolonged engagement consisted of travelling to the participants? chosen locations for the interviews and conversations prior to and after the scheduled interview times to listen to and clarify any questions. Persistent observation was done using an in-depth interview and by focusing and immersing myself in the interviews to allow for better understanding of the issue of VV in the hospital clinical settings. Peer debriefing consisted of conversations with the thesis advisor to discuss drafts for this study as it progressed. Identifying any negative cases was done by searching for any data that did not fit with the overall idea. Finding a few students that consider experiencing VV to have advantages does not fit with the literature review performed which indicated that VV is not a good experience to live through. However, according to Holloway and Wheeler (2010), one needs to address and consider alternative explanations or interpretations of the data to come to a better understanding. I used member checking during the interviews as I summarized and paraphrased the participants' words to be able to interpret their meanings accurately. I also had the students confirm with me their stories by referring back to what they said earlier and asked them for more clarification. Generalizability (transferability): To make this study transferable means that the findings would be expected in similar situations and the knowledge acquired would be 33   relevant (Holloway, & Wheeler, 2010). In my study I provided descriptive data from a variety of students who did their clinical rotations on different hospital units. Also, the depth of the interview questioning and the rigorous analysis provided rich rather than superficial analysis. This allowed for a better description of the issue of VV and would aid the readers in determining transferability. Objectivity (confirmability): To achieve objectivity, there should be the assurance that the study findings stem from the original data (Holloway, & Wheeler, 2010). When this is achieved, the readers can trace the data to its origin by following the route that the researcher took to arrive at the final description. In this study, field notes were made and analysed, and individual interviews were transcribed with personal notes added, reflecting the emotion of the data. Furthermore, memos were written to record any emergent understandings as they evolved throughout the coding process (Miles, & Huberman, 1994). Both the code notes and the memos will form a detailed audit trail that provides a chronological record of the analysis as it unfolds (Holloway, &Wheeler, 2010).   The study has a descriptive design that calls for researchers to constantly bracket prior knowledge in order to ensure that bias in data descriptions is minimized (Streubert- Speziale, & Carpenter , 2010 ; Connelly, 2010), and for researchers to have a deep involvement in the data collected (Armour, Rivaux, & Bell, 2009). However, to ensure the objectivity of the study, attention was given to reflexivity. Polit and Beck (2008) define reflexivity as self-assessment of ones own biases; it is a process of self scrutiny  that the researchers go through throughout their interactions with the study participants. However, through regular debriefing, reflection, and solicitation of input from committee members, it is expected that these efforts to foster rigor will also aid in reflexivity (Holloway, & 34   Wheeler, 2010).  Prior to the interviews, I was aware that I needed to reflect on any prior assumptions that I might have had that could influence the collection of data. I have maintained this approach during the interviews to capture the participants' experiences and to allow the participants to speak freely and without judgement.  Triangulation is another strategy that is used in order to improve the trustworthiness of a research study. Triangulation, as described by Polit and Beck (2008), happens when the researcher uses different methods to collect and interpret data about a phenomenon. Holloway and Wheeler (2010) point out that there are several types of triangulation, which include a) time triangulation, which happens when data collection is done on the same phenomenon or on the same participants at different points in time, b) space triangulation, which involves collecting information about the phenomenon from different areas, c) person triangulation, which is done by interviewing a variety of participants, and d) investigator triangulation, which is described as "two or more researchers to analyze and interpret data coding and analytic decision" (p. 546). I have incorporated these types of triangulation in my analysis, and I have achieved an element of the researcher triangulation through having my research supervisors review my thesis as it was developed. Summary This phenomenological study of the experiences of nursing students' with VV was undertaken using Giorgi's method of data collection and data analysis. The participants involved were interviewed in a way that allowed them to share their experiences without a defined agenda. The study participants were allowed to share the experiences they felt relevant. The standards for trustworthiness were based on criteria appropriate to a 35   phenomenological study. The procedures for this evaluation are based on the criteria presented in Holloway and Wheeler (2010). Providing a description of the phenomenon identified in this study may provide guidance that allow for further study. The results from the study interviews are presented in Chapter four                    36   Chapter 4 Data Collection from Interviews This study was guided by these research questions: 1. Have nursing students in AQ University experienced VV in their clinical placements? 2. In what ways have these students experienced VV?  3. How has VV affected their behaviours in terms of learning, socialization in the clinical area, and nursing practice? 4. If they have experienced VV, how have they adapted and coped with it? In this chapter I present the findings of the interviews. Through the process of analysis described in Chapter Three, I identified the following themes: Ignorance, lack of respect, neglect, lack of acceptance, action to report, and coping. The first theme deals with the students' lack of preparations and knowledge regarding VV prior to starting their clinical practice. The second two themes describe the forms in which students have experienced VV, the third focuses on the impacts of VV on the students in terms of their learning, socialization in the clinical area and nursing practice, and the last two themes focus on how students reported and coped. However, through much reflection, students disclosed that their experiences had affected them and had deep impacts on their learning and nursing practices but surprisingly, none of the students interviewed in this study had any intentions of leaving nursing. Ignorance In regards to their experiences with VV, every student interviewed lacked knowledge of this term despite the use of different labels such as bullying, abuse, or horizontal violence. The term bullying was recognized by only one student who said that 37   she had heard of it among school children. It seems that workplace violence has  not been recognized as an issue in the culture of  Palestinian hospitals, or maybe, it is regarded as culturally acceptable. In the course of the interviews, I had to explain what VV meant by giving examples of negative behaviors in order for it be easier to recognize. After this explanation, all the students in this study indicated that they had encountered behaviours that may be indicative of VV during their clinical rotations. What was common to all students was that they should have been aware of the issue of VV. Student (2) and (3) said: "In the beginning, I did not know what is being a nurse is all about...I did not recognize what it entitles...I was not prepared. And, "....Because of our lack of preparation, we felt incompetent and we were ignored and disrespected." When VV  was explained to the students using examples, most of the students were able to connect events that they encountered with it. Here student (1) recalled his first hospital placement and indicated that at the time he was so new to the nursing unit but still felt that a certain behaviour was not right. He said: ....My experience with  workplace violence goes back to when I first started my clinical rotation. I was still new to nursing. I did not know how things are... and one thing I did not expect is to be told  by a nurse to go and buy her a sandwich from the cafeteria...  It is of utmost importance to examine the orientation and preparation of student nurses prior to placing them in a position of subordinates.   38   Lack of Respect What bothered several students was the general lack of respect itself, which appeared to be a recurring theme, and most students felt that it was unnecessary and demeaning. Student (12) talked about being humiliated by the nursing staff. She said: I asked one nurse to let me insert an IV line with her supervision. While I was in the process of doing just that, another nurse came and talked over me to this nurse and told her not let me do it. She did not even look at me....as if I didn't exist... why did she do that? Some nurses did not hesitate to shout and make their displeasure with the students public. Being yelled at by the nurse was a lived experience for student (8) and was especially upsetting to her when it occurred in front of a patient and his family. She stated: The nurse asked me to give IV meds to a patient and left. I let the IV run and went to get his Ventolin... I was away for a few minutes... the nurse came back and started screaming and telling me that I  made a big mistake and that she would  report me I cried and was ashamed. I felt that I was not good and not trustworthy.... It was horrible.... the patient's family did not allow me  to go near him again...I did not respond... I could not... I was so choked...I wished that she had taken me aside instead of embarrassing me in front of the patient and his family...I know that I made a mistake but I was still learning. Student (2) recalled witnessing another student treated badly by a nurse saying: ....The head nurse on one of the unit was yelling at a student for screwing up an IV line insertion...he did not care that patients were around. This student felt so humiliated that he left the unit and never came back. 39   Many students recalled being left alone to do the ward chores with minimal support and they see that the nurses sit back instead of helping them. Student (2)  Felt used and belittled, he laughed humourlessly when he talked about his experience with VV and said: ....You know, the nurses sit back and wait for us to do their chores. It was belittling, we felt like servants... they were rude...the only time they talked nicely  to us was when they asked us to go get them something to eat. Here is an example of student (6) expressed her frustrations over a perceived lack of support by the nurses at times when the instructor was not available to offer immediate guidance. She said: Our instructor used to give us our assignment at the beginning of the shift and he would leave to go to the other units. In the meanwhile, we were left alone and   when we asked the nurses for help, only few helped us, and most did not...there was little support... Several students said similar things to the researcher and they all wondered why nurses act with hostility. Many students felt devalued as learners and some felt they had been used as an extra pair of hands. All the students agreed that the nurses took advantage of them by making them do the washing, dressing, bed making and other menial chores. The following is an interesting quote by student (9). I was talking with my classmates about our assignments for that day and what  we needed to do. We all agreed that we needed to focus on getting more  practice working with women in labour. To our surprise, we were verbally  attacked by one nurse who heard our talk. She said that if we wanted to be   40   part of a team, we have to do as we are told even if it was dusting or bed  making. We were shocked...our clinical time was limited and we needed to   learn more important things than that. However, for those students who refused to do the nurses errands, they were treated like an outcasts and were ignored as depicted by student (2): When I refused to go buy the nurse something to eat, my behaviour was frowned   upon by the other nurses. I was excluded from their inner circle and was made to   feel like an outcast. Student nurses' experiences with VV seem to primarily be of being rudely treated and taken advantage of. According to several students, public criticism and humiliation composed the most offensive form of injustice Many students recalled their frustration with the nurses' lack of support and guidance as well as the nurses' failure to display basic courtesies toward them. Neglect Many students in this study repeatedly moved from one placement to another, and they encountered nurses with different temperaments and personalities. Their encounters with many nurses were significantly lacking and unsatisfying. VV behaviours were manifested in making the students feel neglected and ignored. Student (7) introduced this theme perfectly when she said: ....Staff stayed on to cover day shift. It was a bad shift from the start, they were so miserable and moody that I did not have any inclination to ask them any   questions... How could I?... I dealt with nurses' lack of communication, and their withholding information on the excuse that they had no time for me or they were   41   not in the mood to talk. Refusal to answer a simple question was a common occurrence on the nursing units, as was experienced by student (9) when the nurse told her that she should know the answer to her own question and left. Several students voiced their disappointments upon entering the units. They were ignored and made to feel that they would not be helped and would be treated with indifference if they approached the nurses. Nurses withholding information was considered the worst form of VV by several students. On the same theme, Student (9) recalled her experience saying: If the nurse was free and in a good mood, I could approach her with my   questions. I found that I was always looking for the right time... the nurses would   often tell me to go ask somebody else because they were busy...it made me   hesitate to ask for information The experiences of being neglected and feeling unsubstantial were considered other forms of VV by Student (7) who told of her friend's experience during her internship. She said: My friend had almost finished her internship on one of the units. She had done   over  fifty shifts on that unit, and one morning, she was approached by a regular   nurse who asked her if it was her first day. She  was speechless...can you    imagine?... How invisible was she?    The students' narratives clearly highlight a few important points such as finding out that many nurses were not actively involved in the learning process and that they took part in the problem of VV by withholding information and treating the students with 42   indifference. Excerpts provided so far reflect the students' need to be valued as a learner and to be supported throughout their learning process.  Lack of Acceptance All the students in this study indicated that they felt unwelcomed and unwanted by most of the staff nurses, more so on some units than others, but the general feelings were that hospital staff nurses were annoyed by their presence and resented them. According to students' narrative comments, their experiences with VV were observed by the way the staff resented having student nurses occupy their workplace. This was supported through Student's (11) reflection, ....The worst  feeling that I had during my clinical rotation was of being   unwanted. Nurses don't want to give you anything, they don't want your presence   on their units, they don't want any students around... Similarly student (7) narrated:  It felt as though we were a burden to them and they didn't want us there...many of   my classmates expressed their feelings of disappointment when faced with nurses'  negative attitudes toward them. For me, I used to come to the hospital hoping that  I would  have a good and interesting day, but unfortunately, I ended up feeling discouraged...the nurses seemed to be frustrated and annoyed with us...I truly felt   like a burden... I was told to my face that they had enough stress and did not need  any more. This student recognized the fact that the addition of students to a stressful environment may create greater stress, but that did not make her experience any easier. She told the 43   researcher that no matter the circumstances she promised that she would be supportive to any student that would need her in the future.  Table 1. displays the most experienced VV forms among students. Table1. The Most Experienced Forms of VV Most Recalled  Forms of vertical violence experienced 1 Yelled and shouted at 2 Humiliated and criticized in public 3 Used and taken advantage off to carry out personal and menial tasks 4 Left to do nursing care unsupported 5 Neglected and dismissed 6  Ignored and resented 7 Vital information withheld 8  Unwelcomed and made to feel redundant 9 General rudeness and hostility  Several students used the word hate to attribute that to the nurses' behaviours. Student (6) said: "She hated the students...she told me herself."  And student (1) also said: Don't they remember how it was for them? I think they forgot what it's like to be student. Don't they know that what comes around goes around? Don't they think that one of these days I might be the nurse on the unit where their own child trains? 44   The students' narratives imply a sense of anger directed at the staff nurses. They also drew a bleak picture about the clinical culture that has been predominant in the nursing units. The researcher believes that living through VV is probably the only way to understand it and suggests that research is crucial in determining the reasons behind the existence of VV in the Palestinian hospitals and among Palestinian nurses. All the students wondered about what they could have done to make their hospital placements more satisfying and rewarding. The students expressed the significance of being accepted as part of the team. They also reflected about experiencing VV in a profession that should be warm and inviting. They expressed disillusionment at the fact that some nurses do not model the care and respect for human values in a profession  such as nursing.  Nursing students exposed to VV said that the experience was bad but they did not have the luxury of switching to other schools. Cost of living is high schools are not funded loans are scarce. However, while a number of students in this study mostly had negative placements, their competences and confidences were affected. Few others had positive placements where their learning experiences were optimised. One student (1) remarked:  You just need to get to a certain understanding to know how to deal with the nurses. There should be a balance...we need to help each others...not all nurses   are bullies. On further prompting, this student elaborated saying :       It depends on the hospital and how things are being carried on...I think it has a  lot to do with the head nurses and their behaviour as it may be a reflection to the  norm. 45   Student (12) told of an incident where she was told by a nurse that she did great and they should celebrate. This student was jubilant and wished that all nurses can be this encouraging. Student (5) remarked that nurses were mentors to the students only during their clinical placements that took place in a private hospital but leastwise in the government hospital. The students unanimously agreed that "the nurses hate it when we ask question and it gets better as we get better." Overall, nurses were not considered to be good mentors to the students, nurses resented having them around, they did not hesitate to make their disdain obvious, and they lacked proper communication skills. Students considered their hospital placements to be negative ones.  Action to Report Nursing students in this study made frequent references to their desire to report VV but felt that there was no point. To compound this issue, many of the students in this study found out that individuals in positions of authority were ineffective in dealing with the problem of VV. This was illustrated by student (1) when he said: We told our instructor and our school dean but nothing was ever done...the  hospital management did not seem to care...we started doing double shifts to   finish our clinical hours and get out". Student (2) and (3) both said that they did not report VV; they said that they put it all behind them. Student (12) pointed out that she talked directly to the nurse but nothing came out of it so she talked to her instructor, who talked to the head nurse but no disciplinary measures where taken. Most of the students who reported their experiences to their instructors were told to 'tough it up and ignore it' or not to talk to the nurses until the 46   instructors arrived. Student (10) and (11) were upset when they were told by the nurses that they do not get paid to teach. To make matters worse, despite the nurses' rudeness, they were told to not make a big deal out of it. These examples exemplify where  a VV issue that was not dealt with and that this was established as the norm. The result was the negative impact on the student nurses and, more importantly, the potential for poor learning experience. The majority of the students reported that they shared their experiences of bullying behaviors with their friends and talked about their feelings. Student (6) said that talking to her friends helped a lot and made her realize that she was not alone in her experience. Whereas, student (7) said that her instructor stood up for them when they were bullied and like other students in this study, she looked to her instructors for support as was narrated here:  I liked the clinical rotation because of my instructor...the instructor is the most  important person...more important than the nurses...he is the one that puts you in   the right place and gives you the support you need. Although there were some attempts to address VV, the students lacked the  ability to make a difference. It was unfortunate that nothing was done about what had taken place on the nursing clinical units or what the students experienced. Several students indicated that they remained in the nursing program through sheer will and the help of others. In Table 2. the Students' reasons for not reporting VV are displayed and rated according to most recalled ones.   47   Table 2. Students' reasons for not reporting VV Rating per student Reasons 1 No point in reporting; nothing would be done anyway 2 Leaders are ineffective in dealing with VV; no disciplinary measures were taken 3 Not worth the effort; they were told to ignore it 4 It?s something that I just have to put up with and have to tough it up 5 feeling powerless Coping Student nurses reported using coping strategies in dealing with VV. The most frequent ones were emotional support, talking to someone, doing nothing or working on themselves and improving their skills. Student (3) said:   I got through it by praying and getting my strength from God...I also got my    satisfaction by helping others...no point in reporting it...they just cover it all    up...this is a big problem here in Palestine...no one takes action. Student (9) said that her way of dealing with VV was to vent through crying she said: When I felt low, I cried...it made me feel better...sometimes I read the Holy  Quran... the best thing that worked for me was crying...talking to my mother   helped too. However, several students revealed that their instructors were their main source of support as narrated by student (10): I was lucky to have the support of my instructors... I had an amazing one during   my rotation in labour and delivery. She always told me that I have the knowledge   48   and should not be afraid to use it. Several students remarked that their belief in God was their salvation, and they derived their strength from knowing that He alone can help them. When the students were asked whether they took any drugs, they answered negatively, and only the male students said that they smoked, and it helped.  Surprisingly, few students did not take any action and talked about VV as something that was the norm and not a big deal. They carried on with their clinical rotations, and when they finished and looked back, they said that all was forgiven. Student (2)'s way of dealing with VV was to ignore it and have 'a thank you party for the staff nurses.  Many students got their persistence from their will to remain strong and to keep going. Student (6) said:  The more they push, the harder I worked at improving myself...I have my goals   and it did not matter how rude they were... Student (8) told the researcher her similar views saying that a person must never give up and must fight for his/her rights because he/she has ambitions and these must be achieved.  What is particular to this study is that none of the students indicated that they thought about leaving nursing as it was never an easy option for them. Student (9) remarked saying: I don't have the option of leaving nursing... I am more than halfway done...it costs   a lot to start over and I love nursing...I just needed to tough it up and to ignore   the issue. 49   This student and several others made a few recommendations that they thought might lessen the problem of VV and make their clinical placements more inviting.  For example, one of the recommendations was to include a course in the nursing curriculum on how to deal with VV in order to prepare the students prior to starting their clinical rotations  Another recommendation was to have clear communication between the school of nursing and the hospitals regarding students roles and their rights. A third recommendation was to provide nursing staff with hospital training in communication skills and how to be good mentors to students.  Regardless of the coping strategy chosen, the majority of the students remarked that they pulled through their clinical rotation with a few unpleasant memories. However, the main and lasting message that was delivered by all the students was that if the occurrence of VV is not acknowledged and dealt with, then the situation with the students' learning and their nursing experiences cannot be improved. Why Does VV Exist Nursing students' experiences with VV were mainly from staff nurses, but to compound this issue, many of them found that those in positions of authority, such as the head nurses, displayed VV behaviours toward the student nurses. Student (8) told  the researcher her opinion about the head nurses: ....I have never seen any head nurse do anything except give orders to the staff  nurses...they always came to the units and walked around without a smile...we,   the students, were completely ignored and it seemed that when they saw us, they   looked through us... they did  not acknowledge us at all. 50   Several students indicated that it seems as though the problem of VV starts at the top with those holding higher positions. Students suggested that nurses have more than likely experienced bullying behaviours from those who are above them. This was explained by student (6)   The nurse is pressured by the head nurse who is pressured by the manager who is  pressured by the administrator who is pressured by the minister and so on, no   wonder the nurses take their frustrations on the students.  Furthermore, the students were acutely aware of the power differential between those holding higher position (staff nurses and the head nurses) and the students and how it relates to the cycle of VV. This issue was revealed by the students as they told of feeling  powerless to deal with certain behaviours such as being yelled at and disrespected, which occurred far too often. Student (3) also indicate his perspective saying: It is all about who is in control and who has more muscles...it comes down to who   can make people do his biddings without questions asked...I believe that for    anyone wanting to bully others, it has to do with his own personal issues and  problems.  Student (11) told the researcher her personal understanding saying: I believe that the political and financial problems in Palestine do have negative   effects on the staff nurses, they are stressed out, Israeli check points at every   corner, not enough staffing, very low pay and they lack management support. You  know, I have the feeling that hospital management does not like to educate their   nurses so the nurses wouldn't ask for changes...there is no nurses union...no    51   nurses association...nothing Student (1) added  her reason for the nurses behaviour: There is no job satisfaction...nurses haven't the will to help us ...I was told to get  lost...that the nurse has it up to her neck. I don't understand why they were mean   to us...we should be a team and work together Impacts of VV on nursing Students Experiencing VV had negative impacts on the students. Several students described their experiences throughout their clinical as unpleasant and unhappy. For instance, student (7) said: In general, staff nurses had no respect for nursing students, which made it really   hard in the clinical experience. They were extremely rude which at times, made   me not want to do my clinical rotation and hate being there. I just tried to pass the   time there as fast as possible. Nursing students indicated that being on the receiving end of VV has negatively impacted their feelings of self worth. Student (1) said: When I refused to go buy the nurse something to eat, my behaviour was frowned   upon by the other nurses and  I was excluded from their inner circle and was   made to feel like an outcast....worthless. Or when student (6) said that she felt like a bug. Unexpectedly, the researcher found that experiencing VV had actually positively impacted the students' learning. Some students said that being subjected to negative behaviours made them want to improve their nursing skills and not give the staff nurses an excuse to treat them badly. Student (6) said: 52   The incident with the nurse made me realize that I needed to work on myself and  improve my skills, so I did a lot of work on my own and figured out what areas I   needed to improve. I read more and I came to my clinical placement much more  prepared. Student (7) took extra training at a private clinic to improve her skills. Throughout her training, she utilized critical thinking to organize her shifts and her skills in patient care. She remarked: Prior to starting my shifts, I used to go to a private clinic that provides IV   treatment to patients requiring IV antibiotics. The staff helped me improve my  skills.... I inserted many IV lines and gave  patient's their medications....I felt   much more confident. It seems that many students felt that they had to improve their sense of self-worth by improving their nursing skills and working on their knowledge. Student (3) said: ....And that is why I considered my first and second year of nursing as my worst....nurses started treating me much better in my third and fourth year....they  now give me more responsibilities and trust me more... An interesting finding that was revealed throughout the interviews is that as the students moved up in their years of practice, their experiences on the units improved. The students were treated better during their third and fourth years in nursing and were given more responsibilities. A similar story was told by student (6) who became confident in herself as she became more skilled as she neared the end of her clinical placement. She explained:  ....It was during my internship that I felt truly accepted. The head nurse and the   53   nurses were very happy with me and I was treated as part of the team... I had   worked on improving my skills to prove to everyone that I could  handle  anything...finally I felt that I belonged... I felt great. The students shared their beliefs that they all needed to get more practice and gain more experience in order to be recognized and respected. They all agreed that nurses would only accept them and respect them only if they could depend on them to carry more responsibilities. One wonders whether this trend of VV progression reflects some sort of ritualistic rite of passage especially when one of the students asked the researcher about why nurses bully students and how can they forget what it feels to be a student. When the students were asked whether they or one of their classmates had adopted any of the staff nurses abusive behaviours as part of the student's socialization into the existing culture. This was narrated by student (10) as: ....I saw one student yell at a patient for asking him for analgesia and complained   that he had a lot on his plate...prior to this outburst, the student was yelled at by a   nurse in front of others. Here the adopted bullying behaviour had a direct indication on how it influenced patient care. Student (3) confirmed this by saying that he observed other students talk to the patients in the same rude ways the nurses talked to them.. As mentioned earlier, VV had impacted the students learning and socializing on the nursing units in several ways. Overall, the general census was that the nursing students can minimize this problem by working harder and  becoming more skilled. None of the students remarked that, at any time, they intended on leaving nursing. However, all the students wondered about what they could have done to make their hospital placement more 54   satisfying and rewarding. The students expressed the significance of being accepted as part of the team. They also reflected about experiencing VV in a profession that should be warm and inviting. They expressed disillusionment at the fact that some nurses do not model the care and respect for human values in a profession such as nursing.  Summary of Findings Student nurses? experiences with VV and its negative behaviours were explored. It was noted that overall the following frequently reported behaviours were identified as: being treated with disrespect, humiliated, feeling unsupported, undervalued, used and ignored. This coupled with feeling unwanted, resented, and having information withheld from them throughout their clinical placements. Student nurses' unhappiness and disillusionment in their rotations and their exposure to episodes of VV were most often suppressed. The students' lack of preparation and awareness about VV were noted by all the students. They disclosed their ignorance regarding their ability to deal with VV and prevent it. Several students did not perceive that they could successfully confront the staff nurses about their behaviours. Their narratives demonstrated acute feelings of being cheated out of learning experiences and their inability to let go of their disappointments. It was clear that there were consequences for students who had experienced VV and that had direct effects on how students regarded themselves and their learning experiences. VV was an issue that was being ignored by nurses, head nurses, and the nursing school. What have been noted was that policies on respectful workplace were not in place at the study site coupled with the absence of nursing union and nursing association. There was a lack of internal and external support that could attempt to address VV on the nursing units and these issues 55   need to be addressed. Furthermore, the study results provide researchers with an opportunity to focus on understanding the relationship between staff nurses and nursing students in an effort to improve the rapport between them and ultimately improve the learning of student nurses.                    56   Chapter 5 Discussion This phenomenological study describes the lived experiences of nursing students with VV while doing their clinical rotations on different nursing units with the goal of using the information obtained to improve the work environment during their placements. In chapter five I provide a summary and discussion of the study findings. The results of this study are consistent with previous literature, wherein all nursing students reported experiencing negative behaviours. The findings are also consistent with other international studies, in which most of the nursing students reported experiencing VV in the clinical setting (Foster, Mackie, & Barnett, 2004; Celik & Bayraktar, 2004). Discussion of the Results Related to the Relevant Literature The findings were categorized into six overarching themes. These themes are as follows: Ignorance, lack of respect, neglect, lack of acceptance, action to report, and coping. These themes were reflected in the data gathered in this research study. Ignorance The students recalled experiencing bullying behaviours during their clinical rotations. However, prior to this study, the students did not consider themselves to be bullied and many of them did not recognize these behaviours as VV. Clark (2009) indicates that the fact that students are not recognizing negative experiences as bullying is related to the underreporting of such behaviours, and this results in unacceptable behaviour.  However,  in another study, Curtis, Bowen, & Reid (2007) revealed that many participants indicated the presence of a culture of workplace violence and tolerance of incivility towards students. International studies have been unanimous in their findings of workplace 57   bullying being an underreported issue. As Barber (2012) states, ?bullying is always present somewhere, but many people, including those who have the power and authority to prevent it, recognize or acknowledge it, are choosing not to see it? (p.301).  When the students were first asked about VV, only one student recognized the  term when the word ?bullying? was used to describe it. However, bullying was not associated with nursing practice but recognized only as being related to young school students. In this study, all the students indicated their disappointment in their insufficient preparation for the culture of practice and their lack of awareness regarding  the issue of VV. Griffin (2004) suggests that teaching about hostility helps the oppressed individuals recognize that they are capable of stopping the dominant group/individual from oppressing them. These individuals will then feel liberated and the cycle of workplace violence will be stopped allowing them to proceed with their learning process. This researcher explains that workplace violence oppresses people and prevents them from asking questions, thereby negatively impacting their learning. Lack of Respect Students being publicly criticised and humiliated made up the most vicious forms of injustice (Thomas, 2009). Disrespect to students has been widely reported in the literature (McKenna, Smith, Poole, & Coverdale, 2003; Curtis, Bowen, & Reid , 2007; Clark, 2009). Disrespect takes several forms and a number of students reported that they were belittled and yelled at as in the example shared by the student nurse. Levett-Jones,  Lathlean, Higgins, & McMillan (2009) found that some nurses disregarded students' feelings and they did not hesitate to show their impatience and frustration during clinical practice. 58   The students in this study reported being treated with humiliation, used, and unsupported. These findings are consistent with several anecdotal comments made by the nursing students in the interviews during this study. Several students commented on the general rudeness of the nursing staff which appeared to be a recurring theme. Others reported being yelled at and humiliated by the nurses. These reports are similar to another study's findings where participants? reports describe VV behaviours as those including being yelled at or shouted at or being belittled or humiliated. (Celik & Bayraktar, 2004). A large study of nursing students in the U.K. (Stevenson, Randle, & Grayling, 2006) revealed similar behaviours when compared with those most frequently reported in the current study. Being ignored, resented and humiliated were reported as the most frequently experienced behaviours between the two studies. Another study (Clark, 2009) was found to have many bullying behaviours in common with the current study, including being treated with hostility, ignored, belittled, having information withheld, being resented and being humiliated in front of others. On the matter of mentoring, the students in this study indicated their disappointments in not receiving the proper clinical learning they so much needed. Many students felt devalued as learners, their learning opportunities were limited, and some felt they had been used as an extra pair of hands and were taken advantage of by the staff nurses. This aligns with the findings in a study (Stevenson, Randle, & Grayling, 2006) in which students felt undervalued by the nursing staff. In a study by Gray and Smith (2000), students described nurses as poor mentors when they invariably used the students by delegating their unwanted jobs to them, which often resulted in resentment. The students may have had a misconception of their role and value in the system and may not have 59   recognized that some mundane tasks that comprise nursing care were important to the team. It was mentioned to the students by the staff that in order to be part of the team, they should do what they were told. However, Dick and Rayner's (2004) findings indicate that attack through work tasks may be a central feature of bullying. Neglect A New Zealand study (Vallent, & Neville, 2006) revealed that students felt disempowered, insulted, and marginalized by negative staff nurse behaviour. Negative clinical experiences were distressful and adversely influenced the students? feelings about themselves and their chosen profession. Moreover, being dismissed and discouraged were the outcomes of being ignored in a study by Thomas and Burk (2009). Students exposed to negative behaviours considered the staff nurses to be poor mentors and often found them to dislike their job and/or students. Also, students noted that poor mentors are often distant, unfriendly, unapproachable and intimidating to the students (Gray & Smith, 2000). Students who shared their narratives with us were ignored by the nurses in the hospitals to which they were assigned for their clinical experiences. Several students voiced their disappointments upon entering the units, where they were ignored and made to feel that they would not be helped and would be treated with indifference when approaching the nurses. Several students also commented that nurses ignored them by withholding vital information from them. A study by Dick and Rayner (2004) suggests that withholding information is of primary importance in bullying. 60   Lack of Acceptance Students in Thomas and Burk's (2009) study narrated that their presence in the hospital was not welcomed and unaccepted, and they felt that they were resented by the staff nurses. The students in the current study were hoping for a warm learning environment but instead felt that they were not welcomed and that they were seen as redundant. This is consistent with a study about nursing students, in which reports of passive and unhelpful behaviour from staff included making students feel unwelcome and intrusive (Jackson & Mannix, 2001). It has been indicated that an unreceptive and unwelcoming clinical environment is found to alienate nursing students causing distress, detachment, and disengagement and negatively impacting the students' capacities and motivations for learning (Levet-Jones, Lathan, McMillan, & Higgins, 2007).  Action to report Stevenson, Randle, and grayling (2006) report that nearly 35% of the students who experienced VV did not do anything about their experiences, and Clarke, Kane, Rajacich, & Lafreniere (2012) indicate that most of their study's responders did not tell anyone about their experiences. Another New Zealand study reported that the action to report incidents of VV was taken in only 3.8% of the cases (Foster, Mackie, & Barnett, 2004). In keeping up with these studies, the nursing students in this study felt that there was no point in reporting VV and that they lacked the ability to make a difference. Similarly, Clark's (2009) students indicated that their reasons for not reporting VV were that they believed there was nothing that could be done and they were afraid of a poor evaluation. 61   In the current study, most of the students talked about their experiences with VV either to their friends, their classmates or to their instructors. Where as in Clark's (2009) study, not even a quarter of the students who were identified as having experienced bullying behaviours reported their experiences to someone. Longo (2007) found that 49% of students did not report their experiences of bullying behaviours and those who reported their experiences with bullying only did so to their classmates. On the other hand, in this study, several students narrated that they were told to "not make a big deal out of it" or told that ?it's  nothing ...forget it until we finish...we don't need any trouble". The problem with 'not making a big deal out of it', according to Gray and Smith (1999), is that students will  learn to conform to the  staffs' behaviours as a way for them to fit in with the culture, and thus, feel like they are ?part of the team' which would ease their socialization process into the clinical culture. Through the students? narratives, it was evident there was no process to reporting VV that included any sort of written documentation or communication. All of the students remarked that they verbally communicated their experiences with VV verbally. This has been discussed in a Palestinian study, where it indicates that the level of reporting violence is low due to the lack of clear procedures for reporting and the lack of encouragement from the hospital management to report (Kitaneh & Hamdan, 2012). On the other reasons why VV was not addressed, scholars explain that bullying behaviours often occurs over time and may continue for a period before the recipient recognises it. Furthermore, bullying behaviour when ?normalised? makes it tough for the bullied individual to challenge and change it (Stevenson, Randle, & Grayling, 2006). This has been evident in the current study where most of the students were ignorant about the 62   fact that VV exists in the nursing clinical practice and unaware of how to deal with negative behaviours. Another matter that the students referred to was that the individuals holding higher positions were ineffective in dealing with VV and in taking any disciplinary actions toward the perpetrators. The students revealed that no action was taken upon reporting VV to their instructors even when it was communicated to the head nurses. The students also talked about how the head nurses themselves used their positions to feel superior. Rayner, et al. (2002) points out that those in positions of authority may lack the preparation in assuming certain duties and may unintentionally abuse power. Farell (2001) states that nurse managers are to blame when they fail to take action to prevent the occurrence of bullying. However, according to Thomas (2009),  angry and unprofessional managers add to the stress in the work setting and set a bad example for those individuals subservient to them. She states that not taking action will ensure the persistence of VV on the nursing units.  The students in this study also talked about the issue of fitting in. They revealed that the nurses used their position to make the students do their biddings and those students who did not do so were treated like outcasts. Farrell (2001) suggests that in the nursing profession, subgroups may form among staff as a way of gaining power and control, which may contribute to acts of bullying.   In this study, a few of the nursing students believed that hospital management does not like to educate their nurses so the nurses wouldn't ask for changes and thus keep the status quo. On a similar note, Hutchinson, Vickers, Jackson, & Wilkes (2006) have the opinion that workplace bullying is a function of the character of the workplace and a way to regulate the nurses. Unanimously, the nursing students agreed there was a scarcity of 63   educational opportunities and a lack of ongoing training in the hospitals that help nurses keep up to date with the current issues such as VV.  Unfortunately, in Palestine, there is no nursing governing body or nurses' union to provide guidance and support to the nurses and the nursing students, as well as, assess for competency. Therefore, it is the author's opinion that for any change to happen, individuals must work together to bring awareness and educate on the issue of VV and the hospital management must take action to deal with VV and put policies to protect the rights of nurses and nursing students. It is important that the issue of VV be dealt with and as Brunt (2011) states, ?not dealing with cases speedily will give rise to worsening of the situation, and may increase the psychological damage involved? (p.7). This researcher calls for conflict management training, education, and clear guidelines on how to deal with workplace violence. This study may be used as an educational tool to provide knowledge on VV. Coping Lazarus and Folkman (1984) define coping as the "constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" (p. 14). They divide coping strategies into two forms of coping. One form is emotion-focused, by which strategies are internally directed and involve actions to deal with emotional distress and the other is problem-focused, by which strategies are directed externally and involve actions to manage or change the problem,. Lambert and Lambert (2008) provide examples of these coping strategies. Examples of emotion-focused coping include wishful thinking, avoiding confrontations, and disengagement from the situation. An example of problem-focused 64   coping is doing problem-solving activities as individuals need to know their own roles in solving a problem in light of the risks. According to Lazarus and Folkman (1984), individuals use both emotion-focused and problem-focused coping when dealing with stressful situations.  Overall, in the current study, nursing students reported using both coping strategies in dealing with VV. The most used emotion-coping strategies reported were: Talking to someone (their classmates, family, or their instructors), seeking emotional and spiritual support by praying or crying, avoiding confrontation, and doing nothing. On the other hand, several students used problem-solving strategies by working on themselves and improving their skills. Problem solving strategies had the greatest effect as several students chose to take actions by working hard at improving their nursing skills. Gray (1999) suggests that for students to cope successfully and elevate their self esteem, they need to think holistically, measure their progress by the accomplishment of tasks and recognize their roles as nursing students. By comparison, in a study by Celik and Bayraktar (2004), nursing students coped by either doing nothing, putting up barriers or pretending not to see the bullying. Consistent with the previous study, McAdam Cooper et al. (2011) revealed that students often did nothing or put up barriers, and in some cases, spoke directly to the bully. However, in Stevenson, Randle, and Grayling?s (2006) study, the students frequently chose to talk to someone about the event in an effort to resolve the issue. Clark (2009) maintained the importance of nursing schools and educators in knowing which behaviours are being experienced by nursing students and the types of coping strategies they are using to deal with VV. She believes that this may assist in the identification of distressed students and may provide guidance for implementing a 65   curriculum for teaching coping strategies in the nursing education. Brunt (2011) suggests that the best strategy to deal with workplace violence is to alert the individuals about the problem through  "education, development and communication of policies" (p. 7). Impact of VV on nursing students Nursing students in this study indicated that their experiences with VV while on hospital placements have had negative and positive impacts on their learning. In a study investigating the effects of a nursing program on self-esteem, Randle's (2003) did a qualitative three year longitudinal study in United Kingdom with a convenience sample  of 39 participants. This study revealed that the self worth of nursing students was associated with how they were treated in the clinical environment. The study reported that the self-esteem of nursing students who experienced VV dramatically decreased over the three year period of their nursing program. Consistent with Randle's (2003) results, Clark (2009) found that a negative relationship exists between experiences of bullying behaviours in the clinical setting and the self-esteem of nursing students. The students in the current study narrated that they "felt worthless" and "felt like a bug" which clearly demonstrates that their self-esteem has been affected by their experiences with VV.  On the other hand, there have been indications throughout the students' narrations that experiencing VV motivated them to work hard at improving their clinical skills and becoming proficient in performing nursing tasks in order to fit in with the hospital culture and avoid being on the receiving end of bullying behaviours.  Many students felt that they had to improve their sense of self-worth and self-esteem by improving their nursing skills and knowledge. They noted that as they improved their skills throughout their clinical rotations, their experiences on the nursing units became more pleasant. On the contrary, 66   Clark's (2009) study reported that third and fourth year students experienced higher levels of VV than first and second year students. On the matter of VV affecting students' socialization into the nursing profession, Eggertson (2011) states that ?nurses who have been bullied themselves tend to view bullying as a kind of initiation that others, particularly new graduates or new members of a unit, must endure? (p.18). This is consistent with Farrell's (2001) study, where it is suggested that there is a generational culture of nurse-to-nurse abuse in many specialty areas and registered nurses perceive that nursing students should be treated as badly as they were treated during their education. Similarly, Woelfle and McCaffrey (2007) states that "bullying was found to be a common experience in the transition to becoming a nurse"(p. 127). In this study, nursing students? socialization into the nursing profession may have been influenced by their experiences with VV. The students remarked that their passage throughout their clinical placements improved as they became more experienced in their nursing skills, which aligns with Gray's (1999) findings. These findings suggest that students' experiences in their final placement were more positive and they felt valued, more respected and that their opinions were acknowledged. Furthermore, Begley and white (2003) draw a positive picture as they report that most of their students, as they progressed into their nursing education, showed an increase in self-esteem and a significant decrease in fear of negative evaluation. Thus, in this case, the improved self-esteem was considered ?intrinsically linked with identifying with the nursing profession and its socialization process? (p. 398). In contrast, the students in two studies remarked that their experiences with VV were worse in their third and fourth years (Clark, 2009; Celik & Bayraktar, 2004). 67   Another matter that was found alarming by Randle (2003) is that socialization into a culture of violence often begins in work placements, with students nearing the end of their education already using bullying behaviours against more junior coworkers. According to Hinchberger (2009), clinical experiences, especially those involving VV, may trigger strong emotional responses for nursing students. The impact of stressful situations may lead to long-term, suppressed feelings for students which may cause many students to change their desire to continue within the nursing profession or to adopt violent behaviors directed toward others. Furthermore, Luparell (2011) suggests that it would be worrisome if students are exposed regularly to VV in the clinical and academic settings where the potential problem may arise that they will view the behaviour as the norm within nursing. It was indicated in the current study through students' narratives that some of the students may have adopted VV behaviours in dealing with patients.   A serious impact that VV had on the students is that they were unable to get many answers to their questions or assistance in their professional development in order to reach their full potential due to staff nurses withholding information from them. Withholding information is recognized by scholars to have damaging results on the learning process and on the delivery of patient care, and it may be a less obvious aspect of VV. Withholding information is a more indirect form of oppressive and negative behaviour, as it involves the purposeful exclusion of action. Becher and Visovsky (2012) revealed that patient and patient safety is compromised when the bullied nurse is unable to provide proper patient care due to withheld information. Furthermore, the costs to the patient, the patient?s family, and the institution can be staggering.   68   Study Limitations An important limitation of this study was the concern of some of the students in actually speaking out about the issue of VV. For instance, in the beginning, prior to consenting to the interview one of the students refused to have her interview recorded and required much reassurance about confidentiality. All students needed to be reassured that any information given to the researcher would be securely stored, have no identifying information as to the school or to the hospitals on either the audio tapes or the written transcripts. They were made aware that they and their data could withdraw from the study at any time. This type of data collection may attract some bias with recall issues which would affect reliability. Moreover, there is no way of checking the accuracy of the responses, as they may relate to the subjective views of the students which may include over- or underreporting of the seriousness of the events.  Another limitation is that the nursing students lacked the knowledge and awareness of VV. The students needed explanation and further clarification regarding which behaviours were considered VV. This may have affected their recounting of events when asked about their clinical practice experiences involving VV.  Another limitation is that the interviews were done in Arabic and were transcribed and then translated to English. This process, even when done correctly and accurately, may not capture all the intended emotions and the exact expressions of the participants, as it may cause different word usage.  The nature of this research is that it is a single small case study which may limit the information gathered and may not have the data that is transferable/confirmable outside of 69   the environment that the work was carried out. Also the study was done in three major government hospitals where private hospitals were excluded.  An additional limitation of this proposed study is that there is no available study of this nature in Palestine or in the Arab speaking world to help inform the work, compare findings and draw conclusions. The gap in the literature further highlights the challenges of this study but also reinforces the importance to examine the issue.  Study Strengths This study provides valuable insights on VV in nursing education in Palestine. It is a pilot study and the only one that calls attention to the VV issue in Palestine. The sample was a representation of the population of nursing students within a school of nursing doing their clinical placements in the three major hospitals in Palestine. The variety of work areas that the students represented were strengths of this study.       70   Chapter 6 Conclusion In this final concluding chapter, I revisit my original objectives and summarize the key findings. I then discuss implications for practice, recommendations for future practice, and suggestions for further research. This study addressed students' experiences with VV by fulfilling the objectives presented at the beginning. These objectives were aimed at answering a few research questions that allowed the researcher to understand the phenomenon of VV as was told by the nursing students. The research questions were:  1. Have nursing students in AQ University experienced VV during their clinical placements?  2. In what ways have these students experienced VV? 3. How has VV affected their behaviours in terms of learning and socialization in the clinical areas and nursing practice? 4. If students have experienced VV, how have they adapted and coped with it? All the students appeared to have encountered behaviours of VV. The forms of VV experienced were being humiliated, shouted at, used, not supported, undervalued, neglected, resented, not welcomed and having information withheld. Six key themes emerged in this study, which are: Ignorance, lack of respect, neglect, lack of acceptance, action to report and coping. The main perpetrators of VV were the staff nurses and the head nurses. VV had negative and positive impacts on the nursing students? learning, socialization and nursing practice. Furthermore, nursing students used different strategies of coping and adapting. 71   Implications for Practice As discussed previously, VV was experienced by all the nursing students in this study, and to various degrees, they were influenced by it in many different ways. Hutchinson (2008) indicates that workplace bullying is considered a critical global issue for healthcare organizations. The effect of VV has been widely documented in the literature, but unfortunately, it has not been talked about in Palestinian nursing schools or in the hospitals. The worry is that the lack of awareness about this problem may lead to disastrous results and detrimental effects on nursing students' learning, nursing practices and patient care. Randle (2003) has revealed that at the start of their nursing rotations, students find bullying behaviours disturbing, but as they move further along in their education, they come to recognize these behaviours as part of becoming a nurse, and thus, the cycle for bullying continues. The students experiencing VV felt powerless, and their ways of dealing with the problem included working hard to fit in order to make other nurses more positively responsive to them. There has been much said about workplace bullying and the evidence shows that it starts when students are at the beginning of their nursing education. Baltimore (2006) said: "the initial breeding ground for dysfunctional nurse-to-nurse behaviour is nursing academia" (p.31). Lewis & Orford (2005) suggest that VV in the nursing clinical areas is a learned behaviour. This behaviour is learned from student days and if it is not dealt with early on, it will continue to go unchecked and unreported throughout nursing. Recommendations and Suggestions for Future Research It is apparent that VV has to be addressed and dealt with when it first occurs, and Clark (2009) states that institutions of higher learning have a responsibility for defining 72   bullying and implementing policies and procedures that address this issue. There should be clear procedures about the reporting process as well as the provision of support for any student who has experienced VV. Johnson and Rea (2009) indicate that there are some bullying behaviours that are not as obvious as being shouted at and getting dismissed by the hospital leaders. Less obvious behaviours are manifested when students are assigned work below their ability, ignored or have information withheld from them. Therefore, leaders need to be sensitized to the subtleties of bullying behaviours and they need to set the tone for establishing a civil workplace. Furthermore, leaders need to reflect on their own behaviours and modify those that might be construed as bullying. Students in this study recommended that the nursing school introduce a curriculum into the nursing education on how to recognize offensive behaviour and the signs of VV and how to report it. Scholars maintain that a nursing faculty could promote civility by discussing expectations, developing activities that include case studies, and using activities to teach practice relationship skills. Offering social events to allow students to become better acquainted and talk about civility may also be a good way of educating nursing students (Jenkins, Woith, Kerber, and Stenger, 2011). Another suggestion is to permit the nursing staff to have input into the students' assignments which will help to improve the learning environment and show them that they are recognized for the important role that they have in the education of the students (Decker, & Shellenbarger, 2012). Griffin (2004) concludes that teaching students about bullying will help prevent negative workplace experiences from occurring and will allow their educational process to proceed. Gray (1999) describes how a positive learning environment positively affects nursing students and allows for a growing sense of maturity in their roles. The students were found 73   to experience greater self-esteem and self-confidence related to succeeding in taking on the responsibility of determining and delivering appropriate patient care. Furthermore, it was indicated that much of the responsibility falls upon the staff nurses to have good communication skills and to be good mentors to students. In a study by Bradbury-Jones, Sambrook, and Irvine (2010), students describe good mentors as approachable, confident in their own abilities, good communicators, professional, organized, enthusiastic, friendly, possessing a sense of humour, caring, patient and understanding. If nurses fail to be good mentors, the students in this study recommended that hospital managements needs to take an active role in providing the much needed hospital training on multiple levels that will produce better trained nurses.  In Canada, the Canadian Nurse Association?s Code of Ethics for Registered Nurses (2008) states that ?nurses share their knowledge and provide feedback, mentorship and guidance for the professional development of nursing students, novice nurses and other health care team members? (p.49). In Palestine, there are no nurses association or nurses union to regulate nurses' code of ethics. So it is recommended by the students that there be hospital policies to safeguard the rights and wellbeing of nurses and nursing students. Stevenson, Randle, and Grayling (2006) suggest creating a culture where management supports the workers against bullying and is ready to develop and seriously implement anti-bullying procedures. And if managements fail to address and no attempts are made to change the status quo, then it will seem as if ?bullying arises from organizational cultures that tolerate violence?and subconsciously support the behaviour? (Johnston, Phanhtharath, and Jackson, 2010, p.38). It is of the utmost importance that VV is recognized as a dangerous challenge to the nursing profession. The consequences that ignoring the effects of VV have on students 74   learning, socialization and practice may lead to unhealthy working situations and ultimately the wellbeing of nursing students and patient safety. The students in this study have endured different forms of VV during their nursing program, which have lead to stressful learning environments and had negative impacts on their education. Therefore, the author suggests that more research studying the levels of stress in Palestinian hospitals and the impacts on student learning, practice, and socialization into the nursing practice should be done. Conclusion It was not the aim of this study to debate the reasons for the staff nurses? behaviours or to validate reported episodes of VV but rather to give nursing students the opportunity to describe their experiences from their own personal perspective. Credibility of the student narratives is enhanced by the lack of cueing in the study instructions to describe the staff nurses' behaviours. Furthermore, nursing students had no incentive to give wrong accounts, since participating in this study had no personal benefits. This study has addressed the specific issue of Palestinian nursing students? experiences of VV while on clinical rotations, thus providing an example of their experiences within the nursing culture. The nursing students reported being humiliated, yelled at, and feeling undervalued and not welcomed by the nurses. Several students had little learning opportunities; students often felt neglected and that they were not supported. The students received comments that were rude, abusive, and humiliating by staff nurses. VV during clinical placements is an important issue and several studies have highlighted the fact that the well-being of nursing is in jeopardy. 75    Several common issues have been identified that future nursing students may face during their education. This study has shown that VV clearly exists in Palestinian nursing education and is likely to continue unless immediate measures are taken. Nurse educators, schools of nursing, and health care organisations must recognise the problem and take action to resolve it. Creating an organisational culture that actively encourages reporting of bullying is a first step in addressing this problem. It is hoped that this study will educate those who are concerned and want to take actions to respond to the problem of VV in order to ensure that nursing students have healthy clinical environments in which they can learn and develop professionally.  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Nursing Forum, 42(3), 123.                                             87   Appendix A INVITATION TO PARTICIPATE IN A RESEARCH STUDY  My name is Hiam Abulaban and I am a Master's of Science in Nursing student in the nurse education track at the University of British Columbia, School of Nursing. Currently I am researching my thesis on vertical violence (bullying, gossiping, and demoralizing behaviors in the nursing practice). I am interested in learning about student experiences with vertical violence (VV) on the hands of the nursing staff and I would like to invite you to participate in an individual interview on this subject and talk about events and issues that you have been exposed to during your nursing practice on the hospital units. This interview will be held at XXX in XXX room on [DATE] at [TIME}. I would like to explore whether VV is present and if yes, how you deal with it. The purpose of this research is to determine the extent to which students enrolled in the BSN program perceive their experiences with vertical violence. You are being asked to participate because you have been identified as a student enrolled in the BSN program at the AlQuds University and are at least eighteen years old.  What is Involved? Interviews will be done on an individual bases, and you will be invited to communicate your viewpoints on VV. These will be conducted at a place and time that is convenient to you to elicit information about your experiences with vertical violence in a short 45 minute to 1-hour focus group session. Your responses will assist in advancing research aimed at understanding and preventing vertical violence in nursing. I invite you to be as open as you wish. Your instructors and the nursing staff will not have access to the data nor will any identifying information be obtained during the interview. The interview 88   will be audio-taped and, while no personal identifying information will be required, your voice and contributions to the focus group conversation will be audio-taped, and then transcribed for the use of research. Your participation is completely voluntary and refreshments and cookies will be provided at each focus group session and the first 16 respondents that reply back and participate will be entered into a draw for a $25 coffee gift card from the University diner. This draw will take place at the end of each interview. A consent form for this study is attached to this email. Please review it if you are interested in participating in the study. If you would then like to participate please contact me directly by email at xxx@xxx by XXX date, so I can contact you and set a time and date for the focus group meetings. I will need you to bring a signed copy of the consent form prior to starting the interview.    Thank you very much for considering this request.  PLEASE CONTACT ME VIA EMAIL TO CONFIRM YOUR PARTICIPATION Yours sincerely  Hiam Abulaban Student Researcher:  Hiam Abulaban , School of Nursing, University of British Columbia,              Master of Science in Nursing Student Researcher Supervisory Committee: Dr. Bernie Garrett, School of Nursing, University of British Columbia: Chair       Dr. Jennifer Baumbusch, School of Nursing, University of British Columbia Ms.  Elsie Tan, School of Nursing, University of British Columbia. 89   Appendix B  Consent form Undergraduate Nursing students experience of vertical violence in Palestine Principal Investigator/ Supervisory Committee Chair:  Dr. Bernie Garrett, School of Nursing, University of British Columbia,          Co- Primary Investigator: Hiam Abulaban , School of Nursing, University of British Columbia, Master of Science in Nursing Student Researcher Supervisory Committee: Dr. Jennifer Baumbusch, School of Nursing, University of British Columbia Ms. Elsie Tan, School of Nursing, University of British Columbia Purpose:  This study is aimed at exploring the effects of vertical violence (VV) as experienced by the nursing students from the nursing staff on the hospital units during their clinical rotations. In order to explore this, I intend to interview about 12 students in the Aquds Bachelor of Science in Nursing program. Each interview aims at exploring and discussing personal experiences, perceptions about how participants  feel about VV as it relates to their practice and any coping strategies they may use if they have experienced it. Study Procedures:  The participants are being asked to participate in this project for one session over 30- 45 minutes, followed by an email verification of the summary that will be sent to them to see if the researcher grasped all the perceptions correctly. By participating in this study the students are required to do the following: Participate in one interview session in which each participant will be invited to comment on particular aspects to this study in further detail.  It is anticipated that the total time commitment for the project will be approximately 3 hours or less, including the reading the intent of the study, interview session and replying 90   back to the researcher in feedback to her generation of summary of themes. The specific dates for these tasks will be confirmed once the project is underway.  Research use and Confidentiality: By agreeing to participate in this project, the participants will be allowing the research team to use and analyze the materials you produce in order to be written up for research thesis. The focus group will be audio-recorded. Participants'  personal identities will be kept strictly confidential in all written materials. Furthermore, no identifying information apart from their first names will be required in the interview. All physical documents and files pertaining to this study will be identified only by code number and kept in a locked filing cabinet in a locked office in the UBC School of Nursing and can be accessed only by the supervisory committee and Hiam Abulaban. Any data kept on electronic media (computers) at UBC's School of Nursing and personal lap-tops, will not include the name or personal details of the individual subject and will be password protected, kept solely on the computers of the principal researchers, Dr. B.Garrett and Hiam Abulaban .  By participating in the interview, the participants will consent to have the responses used in any form for this research or for any future publications. The results obtained from the study may be presented at seminars, conferences or published in scholarly papers. As a research participant, names will not be identified in any reports of the completed study, although quotations from the interview may be used without personal identifiers. There are no known risks to participating in any aspect of this educational study. Potential risk may be due to the emotional distress that students may experience due to the sensitive topic.  Confidentiality will be maintained throughout the interviews and the risk of   breaking confidentiality can be minimized through scrupulous attention to record   91   handling and the concealing of identifying information.   Compensation: Refreshments and cookies will be provided at each session and the first 12 respondents that reply back and participate will be entered into a draw for a $25 coffee gift card from the university diner. This draw will take place at the end of each interview. Contact for information about the study:  If the participants have any questions related to this project or wish to have further information with respect to the study, they may contact Hiam Abulaban or Dr. Bernie Garrett the Primary Investigator/Supervisory Committee Chair. Contact for concerns about the rights of research subjects:  If the participants have any concerns about their treatment or rights as a research subject, they may contact the Research Subject information Line in the UBC Office of Research Services at (+1) 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598.  Contact for counseling: Please note that there are counseling services available at the school of nursing and the students can contact Miss Nadia Sbeih at the students' counseling office located in the administration building Mondays and Thursdays from 0800hrs until 1600hrs and on Saturdays from o900hrs until 1400hrs. Concerns: Participation in this project is entirely voluntary and the participants may refuse to participate or withdraw from the project at any time without jeopardy to their employment or class standing. The signature below indicates that the participants have received a copy of this consent form for their records. The signature bellow also indicates that the participant consent to participate in this project.     92   Name of Participant ____________________________________  Signature_______________________________________________ Date: _________________                                      93   Appendix C Interview Questions   Interview about harassment and aggression by staff nurse against undergraduate nursing students in AlQuds University. The questions: 1. What is your current term of the nursing program? 2. What do you know about vertical violence (bullying, harrassement)? 3. Have you ever experienced vertical violence (in any form) during your clinical practice? 4. If yes,  a. Can you describe in what form? Who was/were the perpetrator(s) without using any personal identifiers? b. How have your experiences as an undergraduate nursing student influenced or not influenced you in your clinical practices?        c. How did you feel as a result (explain in as much as possible)?       d. Please describe how you coped with it, or any strategies that helped you. 5. Have you noticed that other students have adopted bullying behaviors? 6. If yes, can you explain in what forms? 7. What do you think are the causes of VV during nursing practice?      

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