The increased numbers of older students undertaking midwifery education (Carolan, 2011) adds an interesting dimension to the issue of bullying on clinical placement. With research on bullying still heavily focussed upon teenagers, this study examines the role of age in altering the bullying experience. Regardless of age, the risk of bullying is thought to be closely related to power differentials (Hodson et al, 2006), with age a potential avenue of power leverage.
The term ‘bullying’ tends to be limited to repeated unwanted behaviour from another that is malicious, abusive and intimidating in nature (Gillen et al, 2004). However, a single incident can be ‘enough’ to trigger lasting adverse consequences with a recent study suggesting this is particularly true in a healthcare student context (Boyle and Wallis, 2016).
Students enrolled in pre-registration midwifery programmes in Australia and the UK are required to undertake clinical placement in order to develop, and evidence the skills and knowledge required to gain professional registration as midwives (Australian Nursing and Midwifery Accreditation Council [ANMAC], 2014; Nursing and Midwifery Council, 2019). Several studies report that this gateway to the profession is tainted with bullying experiences (Gillen et al, 2008; 2009; McKenna and Boyle, 2016). Bullying has been linked to attrition from the profession, short- and long-term physical and mental illness, and even suicide (Hastie, 1996; Ball et al, 2002; Gillen et al, 2008).
A single paper has examined the role that age of the student might play in mediating the bullying experience with Fenwick et al (2016) finding that younger students experienced age-related prejudice from both clinical staff and their older student peers. This study places age at the centre of its focus, exploring whether the age of midwifery students influences the experience of being bullied while on clinical placement.
Method
Participants
Ethical approval was obtained to purposively recruit participants based in the UK and Australia via two closed online groups: one for midwifery students, and the second specifically for registered midwives and midwifery students that had experienced bullying in the clinical setting.
Eligibility criteria included: currently enrolled in an initial entry to midwifery programme in either the UK or Australia, and having experienced at least one episode of bullying or unacceptable behaviour while on clinical placement. Of the 284 respondents, 20 were selected from the youngest and oldest age categories respectively.
Analysis
Due to the first author's role as a midwifery educator and resultant ethical concerns around mandatory reporting requirements, a fully anonymous online approach to data collection was taken. The survey consisted of two sections, demographic variables and open-ended questions developed from a systematic review of the literature, and the framework advanced by Gillen et al (2008) on the nature and manifestation of bullying in midwifery.
Data was analysed using Braun and Clark's (2006) six-phase framework for thematic analysis. This approach enabled the codes to emerge from reading the data and then became further defined during the data analysis process. The analysed themes were then organised in response to four dimensions, perpetrator status, bullying type, bullying context and aftermath.
Findings
Perpetrators: senior players on the ‘team’
The registered midwife-mentor was identified as the main perpetrator of bullying, regardless of the age of the midwifery student reporting the experience. Much of the midwifery student's clinical placement time is spent in the birthing suite and students referred to the ‘stressful’ atmosphere that emerges in this context.
In addition to midwifery-mentors, nursing and midwifery staff outside the birthing areas, obstetricians and even educators (including university staff) significantly removed from the clinical setting were identified by the respondents as perpetrators. Age (or at least experience) of the mentors, rather than the students, did emerge in the data. For example, a student noted that there was a tendency amongst more senior midwives in the birthing suite to focus more rigidly on policy and guidelines, and de-emphasise the context of care.
‘There is a general attitude [in my experience]-more so from older, nursing background midwives who operate to satisfy policy and guideline over the experience and care provided to women.’ -Younger student 5
Respondents also reported that the perpetrators either operated in groups and, at times, actively influenced peers to join them in bullying the student.
‘She (the mentor) is the bully of the unit, other staff join in to avoid being the next victim.’ -Older student 15
Midwifery-mentors are often well-established staff, having developed functional horizontal working relationships in the maternity unit over time, and this set of more-or-less comfortable alliances can become problematic when a bullying complaint emerges against one of the allied group. One student reported how this conflict of interest played out:
‘I contacted a lecturer at the uni. I kept a diary of events … basically I told the [lecturer] what happened. She said she was shocked and disgusted, and knew there was a culture of bullying in maternity and that I should move to another unit. She then asked me who the person was who bullied me (she used those words). I told her, she then told me that the midwife involved was her best friend. I was mortified. She said she would probably not continue the investigation because of a conflict of interest. Next few days were awful for me and I got the impression [from]a few midwives who had previously been normal with me, now ignored me and there were a lot of whispered comments when I walked into a room.’ -Older student 6
Nature of bullying: overt versus covert
When it came to the content or type of bullying experienced, differences by age group did emerge. Younger students were more likely to report overt verbal abuse and ‘open’ use of power and intimidation (‘I've been called names, made to feel and look dumb’), with little attempt to disguise the denigration by the perpetrator, although as younger student 11 notes, just as the attack might take place in public, the attempt to ameliorate the impact also became a public display:
‘She would yell at you, publicly humiliate you in front of the whole ward. When you started crying, she would pull you into hugs and become very emotionally manipulative.’ -Younger student 11
Rarely was age itself deployed as a tool of bullying and only then, explicitly, in the case of younger students:
‘He mocked me in front of the other staff members and was derogatory about my age, making comments such as “I could have delivered you”. I was never taken seriously.’ -Younger student 19
This theme of strategic and covert manipulation of the target emerged to a greater degree in the older cohort. Here, the perpetrators, almost as if they realised their ‘victims’ were not ‘really’ students any more, used more indirect techniques to exert power. The events might take place in plain sight, once again, but they often aimed to intimidate:
‘I respectfully asked the senior midwife, who had a few other midwives with her, if I could be allocated a labouring woman if one came in. She unleashed a barrage of questions at me, including: “Why was I asking now?” She then stared at me for about five seconds and said nothing; I found this very intimidating.’ -Older student 10
This ‘five seconds’ of silence in some cases extended to elaborate ostracisation:
‘I said a polite “hello” to her in passing, and she looked straight through me and didn't reply.’ -Older student 13
‘I was excluded from tea breaks and conversations, and was given so many tasks to do. I was on my feet for 12.5 hours while the midwives sat chatting and laughing together. I was made to feel like an outsider, not part of the team.’ -Older student 8
Five of the older cohorts reported, tellingly, that they had failed or otherwise been removed from the course, while none of the younger cohorts volunteered that experience. The older cohort were much more likely to report being subjected to unrealistic expectations, denied meal or toilet breaks, or grilled/interrogated to expose ‘ignorance’.
However, using elements of the mentoring and education process as a power strategy was not unique to the older students. The following case shows a student trapped in a web of conflicting demands:
‘The midwife was doing paperwork while I was cleaning the room and making the bed post-birth while mum was in the shower. The baby was swaddled in the cot and became fussy. I pulled the cot over to where I was making the bed so I could continue with my task and soothe the baby. The midwife demanded I pick the baby up because you “never leave a baby [to] cry”. I picked the baby up and began swaying gently from side to side, attempting to soothe baby with gentle rocking movements however, the midwife still wasn't happy and yelled at me, “What are you doing?! You never, ever shake a baby, that's how you give them brain damage!” I stopped all movement trying to appease her when she continued berating me, asking me what I thought I was doing:“That bed isn't going to make itself”.’ -Younger student 5
The ‘strategic’ use of power to manipulate the educational progress of students was experienced by both groups of students, but this ‘goal-post shifting’ was more common in the younger groups. Here, typically, students were shifted from the role of ‘student’ to the role of ‘worker’ (and back again), and experienced that shift as harassment:
‘I'd be asked to do mundane tasks like photocopying, printing and stripping beds while I was in the middle of something and actually learning.’ -Younger student 3
The context of bullying: centre stage
There were few striking differences between the two groups of midwifery students when it came to the ‘where’ of bullying. Many incidents, as noted earlier, occurred in the birth suite for both older and younger students, often with mothers present as ‘witnesses’ or even as ‘props’ for bullying:
‘One midwife stood over a labouring woman and asked what I should be looking for visually on her abdomen, turning the woman into a learning experience at the most inappropriate time, when she was alone, in pain, and vulnerable … she [the midwife] used that experience to highlight just how insignificant I was and just how much I had to learn to be approved by her.’ -Younger student 5
The experience of having bullying perpetrated while caring for women in the birthing room was clearly scarring for the students and did not go unnoticed by the women they were caring for:
‘She [the midwife] would criticise me in front of the women to the point the women would tell me, “You shouldn't let her treat you like that”.’ -Younger student 20
Older students were more likely to report that bullying incidents took place outside the at-times intense environment of the birth suite and in the ‘privacy’ of staff areas. The following account, from one member of the younger cohort, is an exception, but demonstrates the ‘use’ of other settings, such as corridors and storerooms to ‘conduct’ abuse:
‘I have worked with one midwife who prefers belittlement and beratement over sharing information and knowledge—she would take you into the equipment room and ask you to find random things for her, hurrying you along if you became flustered.’ -Younger student 5
Students from the younger group also reported isolated episodes of bullying by registered nurses when undertaking placements in the neonatal care areas and general wards. Here, friction between the ‘neighbouring’ professions arose. Some nurses were vocal about their belief that midwifery was an ‘inferior’ or limited profession, and students were belittled for choosing it, particularly those becoming midwives without undertaking nursing education first.
The effects of being bullied: voice versus walking away
A desire to ‘leave’ the site of the bullying, and even the profession, emerged in over half of the respondents, regardless of age. For a minority, the exit strategy they contemplated was suicide.
Even though the older students may have been targeted for harassment as ‘fair game’ because they came with a great degree of battle hardness or experience to the position of ‘student’, there was no evidence in the data that the older students were any less traumatised by the experience. An older student explained how her earlier enjoyment of working in the birthing suite has been replaced by fear:
‘I have developed a strong fear of [the] delivery suite—which is sad as during my observational weeks, I was blown away by what I saw happening there and enjoyed the learning that presented itself.’ —Older student 13
One of the younger students similarly noted:
‘I never wanted to go back to [the] birth suite. I changed all of my shifts to [the] postnatal ward just so I did not have to deal with the negativity and hate there.’—Younger student 17
The trauma had spread from being associated with a person to a place:
‘I would be physically sick before entering placement.’ -Older student 4
This general aversion converted, in some students, to a sense of defeat that drove them to contemplate leaving the profession before they had fully entered it. The following quote touches not just on a determination to leave, but extraordinarily mixed feelings about the profession:
‘Definitely am leaving once I do my preceptorship-[I] can't leave now as I'm close to qualifying. Worst decision I made was applying for midwifery – I wish I looked into this more – but I know that it's not the end of the world and I was a part of something beautiful with those families, and will forever treasure that but I can't carry on like this … The disgusting behaviour [witnessed and experienced on placement] makes me embarrassed to be part of this profession.’ —Younger student 12
This resolve (words like ‘determined’ and ‘never’ appear frequently in the discourse of our study participants) reflects the sense of shattered trust, both in the profession and in their own capacity. For the younger cohort, in particular, this damage tended to turn inward into grief (‘I cried all the way home that night’ —younger student 5) and for the emotion to be turned back onto the perpetrators and the profession. For the older students, this confidence shattered a pre-existing sense of self-confidence in their working life:
‘I felt absolutely worthless and disheartened, and made to know that's exactly how I was viewed, regardless of how hard I worked or the impact I've had on the woman's experience.’ —Younger student 5
‘[I] lost my confidence, as before as a nurse I was highly respected.’ —Older student 3
Anxiety and depression were not surprisingly common, with physiological correlates such as digestive disorders and headaches. One element of the student response that did differentiate the two samples was the degree to which passivity was present.
The younger students were less likely to report bullying, take a leave of absence, and other avoidance activities in response to the experience. The older students were more likely to respond by whistleblowing, but also showed a greater sense of emotional resignation to the culture they found themselves in. The younger students felt vulnerable and wondered about an escape route should they complain (‘I didn't report. I was scared it would impact upon my passing the placement’). For those who did complain, this often added to the emotional toll or a sense of powerlessness.
‘I reported it, nothing happened.’ -Older student 5
‘I reported but won't again as I was made to feel like it was my fault, so I deal with things and people in my own way.’ -Younger student 8
A minority of the students expressed outright defiance and two younger students were plotting arguably the best ‘revenge’:
‘I don't want the midwives who treated me terribly to win.’ -Younger student 5
Another said she had ambitions of climbing the ladder in order to ensure better treatment of students in the future:
‘[I want to become] a team leader so I can become in charge and make sure that new students aren't treated the same way.’-Younger student 3
This sense that ‘one day’ they will rectify the situation themselves was also expressed by those who planned to act on the bullying upon graduation.
‘I promised myself that once I qualify, I will escalate these matters to HR and the [national midwifery governing body] because this is not on!’ -Younger student 12
Discussion and conclusion
The aim of this paper was to explore and compare the bullying experiences of two contrasting groups of midwifery students; those aged between 18–21 years and those aged over 43 years of age. To the authors' knowledge, no research to date has specifically explored how age interacts with the bullying experiences of midwifery students.
Research addressing the issue of bullying of midwifery students is sparse and tends to focus on the types of bullying experienced, the status of the perpetrators and the consequences of bullying (Gillen et al, 2009; Boyle and McKenna, 2016; Shapiro et al, 2017). The literature confirms that students experience a range of physical and mental health issues, and are impacted sufficiently to question their decision to continue their education programmes and/or practice upon registration (Shapiro et al, 2017; Gillen et al, 2008).
This paper adds depth to this body of work but, in addition, shows that at least as far as the nature of the perpetrators, the location in which the bullying primarily occurred, and the degree of impact on victims, there was no pattern of difference between the older and younger groups of midwifery students. Both groups of students face the same set of perpetrators, primarily those mentoring students in the birthing areas. When it came to the nature of bullying, however, age does emerge as a factor.
Perpetrators appear more willing to be direct and overt in the use of power and intimidation when faced with a younger midwifery student. With the older students, there appears to be a more covert attempt to undermine. Similarly, in terms of impact, while there was no difference between the two cohorts as far as magnitude of impact, the ‘next steps’ for the two cohorts differed. For the younger students, the impact was often internalised, with self-blame and self-doubt frequently appearing. For the older cohort, their experience in the world of midwifery did not occur on a blank slate of employment experience however, confidence built up in their previous working lives was often shattered.
Younger students were more passive in their response to the bullying experience, with older students showing greater grasp of workplace practice by being likelier to whistleblow. For both cohorts, occasionally their response escalated to outright defiance, with students resolving to push on in the profession despite the obstacles placed in their path. These students were plotting revenge of sorts: an intent to reform the profession. The descriptions that the participants give of their bullying experience makes grim reading, particularly in those cases where the students speak of suicidal ideation or intent. This is the most severe expression of the students' desire to leave the profession without even having fully entered it.
Hirschman's (1970) influential work on how consumers respond in the face of deteriorating quality of service or goods has been expanded to a broader understanding of how employees respond to workplace stressors. He proposed three options for an employee under pressure: express voice, double down in their loyalty to the organisation, or depart (exit). The cost to an organisation of students choosing to exit as a response to stress is extraordinary, particularly in a profession where the cost of training is high and can be measured in the welfare of mothers and babies.
The fact that this study confirmed the findings of early work by Begley (2001), suggesting students feel most vulnerable to bullying when working in the birth suite, is particularly concerning. The birth suite is an area known to intensify staff stress levels (Geraghty et al, 2019) but it's also the area where both midwifery students and many women feel vulnerable and in need of additional care and support (Brunstad and Hjälmhult, 2014; Chang et al, 2018). This study is not the first to arrange responses to bullying on an active to passive spectrum, with Jóhannsdóttir and Ólafsson (2004) looking at age as a predictor of response to bullying in store and office workers. They explored assertiveness and avoidance as two possible responses in their sample and did not find age as predictor of either. Age did show a significant relationship with the likelihood of ‘doing nothing’ increasing with age, in contrast to our current study.
Leap (1997) describes oppressed groups, such as midwives, often direct their frustrations and dissatisfactions towards each other in response to a network or system that has excluded them from power. In the context of this study, it was frequently observed that students experienced this internecine rivalry, particularly with the nursing profession. It is notable that students rarely referred to bullying instances by mothers or their support persons. It is important to be mindful that the mothers midwives care for are also experiencing acute stress and the wellbeing of the healthcare workforce affects the wellbeing of those in their care (Boorman et al, 2009; Keogh, 2013).
The issue of age and bullying of midwifery students is interesting due to the unusual profile of students who choose to study midwifery. Our broader sample shows that they can be split into two groups: school leavers entering the workforce for the first time and mature age students with previous work experience choosing midwifery from a position of relative strength. In choosing to become midwives, this latter group opt in a sense to ‘infantilise’ themselves by taking a subordinate role in an existing strict and fixed hierarchy, a transition that has been rarely explored in the literature (Best, 2002).
Put in terms of power relations, the mature age student enters a midwifery education programme, bringing a wealth of previous experience to the role. It appears that in becoming a victim of bullying, they are being asked or forced to leave that experience at the door. Bullying is cast in the healthcare literature as a function of power relations (Hutchinson et al, 2010), including in midwifery where there is a strong hierarchy (Catling et al, 2017). This stands at odds with a view of the profession as being one that works in partnership with women and their families to provide holistic care and support at a potentially vulnerable time in their lives. The shock that our participants experienced in encountering bullying in the early stages of their career is a mark of the degree to which regardless of age of the student, the reality of midwifery education is not matching the expectation.