Workplace Bullying Among Nursing Students: Prevalence, Consequences, and the Bullying-to-Attrition Cascade Framework

Technical Summary: Workplace Bullying Among Nursing Students in Kenya

Problem Statement
Clinical placements are the cornerstone of nursing education, yet they frequently expose students to workplace bullying, a pervasive threat to wellbeing, skill acquisition, professional identity, and patient safety. While global systematic reviews estimate bullying prevalence among nursing students between 50% and 73%, evidence from Low- and Middle-Income Countries (LMICs), particularly sub-Saharan Africa, remains scarce. Existing literature suggests that resource constraints, chronic understaffing, and hierarchical cultures in African health systems may exacerbate these risks. However, no comprehensive study had previously examined the prevalence, perpetrators, and multidimensional consequences of workplace bullying among nursing students in Kenya, a country facing persistent nursing workforce challenges. This study addresses this evidence gap to inform clinical education policies and health-system strengthening aligned with Sustainable Development Goal 3 (SDG 3).

Methodology
The study employed a descriptive cross-sectional survey design conducted between December 2025 and January 2026.

• Participants: The sample consisted of 102 Bachelor of Science in Nursing (BScN) students from a public Kenyan university who had completed a mandatory four-month clinical placement. Participants were recruited via stratified proportionate random sampling across Years 2, 3, and 4.
• Setting: Clinical placements occurred across eight teaching and referral hospitals in the Rift Valley region and Nairobi, characterized by high patient volumes and workforce shortages.
• Instrument: Data were collected using a validated, adapted version of the Negative Acts Questionnaire-Revised (NAQ-R), contextualized for nursing students. The instrument assessed exposure frequency, perpetrators, location of incidents, and consequences (psychological, educational, professional, and physical).
• Analysis: Data were analyzed using R (v4.3.1). Descriptive statistics summarized prevalence and characteristics. Chi-square tests and independent t-tests examined associations between bullying exposure and demographic variables. Multivariable logistic regression models identified independent predictors of bullying exposure and mental health outcomes, adjusting for age, gender, year of study, prior education, and ward rotations.

Key Results

• Prevalence: Workplace bullying was highly prevalent, with 79.4% of students reporting direct experience of bullying during their four-month placement. Additionally, 78.4% reported witnessing another student being bullied.
• Frequency: Among those bullied, 22.2% experienced five or more incidents (chronic bullying), while 38.3% experienced three to four incidents.
• Perpetrators: Qualified nurses and midwives were the dominant perpetrators (72.8%), followed by patients or their relatives (43.2%). Other perpetrators included student mentors, doctors, allied health staff, and fellow students.
• Consequences: The most reported consequence was emotional/mental health impact (75.3%), including stress, depression, and anxiety. Other significant impacts included impaired learning (53.1%), reduced teamwork (48.1%), negative effects on patient care (39.5%), and 40.7% of bullied students considering leaving the nursing profession.
• Predictors of Harm:
  • Chronic Bullying: Students experiencing chronic bullying (≥5 incidents) reported significantly more consequences and had 4.08 times higher odds of adverse mental health outcomes compared to those with low-frequency exposure.
  • Gender: Female students reported significantly more consequences than males and had 3.21 times higher odds of reporting mental health impacts.
  • Prior Education: Interestingly, students who had received prior education on bullying were more likely to report exposure (aOR = 3.12), suggesting that training enhances the ability to recognize and label bullying behaviors rather than increasing victimization.

Key Contributions

1. First Empirical Evidence from Kenya: This study provides the first comprehensive data on workplace bullying among nursing students in Kenya, revealing a prevalence rate (79.4%) that exceeds global pooled estimates.
2. Identification of Perpetrators: It confirms that qualified nurses and midwives are the primary perpetrators, reinforcing the role of power imbalances within clinical hierarchies.
3. The Bullying-to-Attrition Cascade Framework (BACF): The paper proposes a new theoretical model integrating Meleis's Transitions Theory, Conservation of Resources Theory, and hierarchical workplace violence theory. The BACF explains how structural antecedents (e.g., workforce shortages, hierarchical culture) lead to bullying, which initiates a sequential cascade of psychological distress, impaired learning, compromised patient safety, and ultimately, workforce attrition.
4. Dose-Response Relationship: The study establishes a clear link between the frequency of bullying incidents and the severity of harm, particularly regarding mental health outcomes.

Significance and Claims
The authors claim that workplace bullying in Kenyan clinical training environments is not merely an educational or occupational health issue but a critical determinant of patient safety and health-system sustainability. The findings suggest that bullying drives a "cascade" of negative outcomes that threatens the retention of the nursing workforce, directly undermining SDG 3 Target 3.c (recruitment, training, and retention of health workers).

The study posits that addressing bullying requires multilevel interventions:

• Educational: Structured pre-placement training and psychological safety mechanisms.
• Practice: Mentor accountability systems and zero-tolerance policies within healthcare institutions.
• Policy: Regulatory bodies must embed anti-bullying governance into clinical placement accreditation standards.

By linking individual-level harm to systems-level attrition, the paper argues that eradicating workplace bullying is a prerequisite for building a resilient nursing workforce capable of achieving Universal Health Coverage in Kenya and similar LMIC contexts. The proposed BACF offers a replicable, theoretically grounded scaffold for future longitudinal research and intervention design.