The Journal of School Nursing2020, Vol. 36(6) 451-457© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519846649journals.sagepub.com/home/jsn
Bullying has negative consequences for health and quality of life of students. This study is part of a pilot project, “School Health,†which included a web-based questionnaire completed by students before a consultation with the school nurse. The aim of this study was to explore how students experience answering questions about bullying before an individual consultation and how they talk about bullying with the school nurse. This study had qualitative design with individual and focus group interviews and involved 38 students aged 13–14 years, both boys and girls, from three schools. Data were analyzed according to Kvale’s three levels of interpretation within a phenomenological and hermeneutic perspective. The students found it difficult to report being bullied. They expressed confidence in the school nurse and liked talking with her. Some complained about the school environment and reported that having a friend was important.
best practices/practice guidelines, bullying, middle/junior/high school, qualitative research, school nurse knowledge/perceptions/self-efficacy
In recent years, awareness of bullying among adolescents has increased, and bullying is now widely recognized as one of the most significant public health problems in this agegroup (Langford et al., 2015). In Norway, a new act (Lovdata, 2017) includes zero tolerance against bullying in schools and instructs schools to act if a child is bullied. According to a cross-national survey by the World Health Organization, 9–13% of children aged 11–15 years reported having been bullied in the previous couple of months (Langford et al., 2015).
The most common definition of bullying is, “When she or he is exposed to negative actions from one or more persons recurrently over time.†A negative action is when a person intentionally inflicts, or attempts to inflict, discomfort or injury upon another person. Bullying occurs in a relationship in which there is an imbalance of power or strength (Olweus, Danielsen, & Roland, 1983). A newer definition developed by Søndergaard (2012) includes social exclusion and notes that exclusion is possible in all social groups and contexts. The risk of being judged unworthy to belong to a social group includes feelings of being misunderstood, not seen, socially threatened, and deprived of dignity (Søndergaard, 2012, p. 360). Thornberg (2015) noted that bullying involves isolating the victim by labeling him or her as different, odd, or “not like us.â€
National and international studies emphasize the negative consequences of bullying on the health and quality of life of children and youths. The Investigation of the Pupils 2017/2018 revealed that 40% of children and youths do not tell adults about bullying (Wendelborg, 2018).
Bullying has become the focus of increasing attention not at least because of its negative long-term health consequences. Several studies have shown that being bullied is a significant threat to health, as well as social and psychological well-being (Breivik et al., 2017; Folkehelseinstituttet, 2015). Those who were bullied during childhood are more likely to report depression, social anxiety (Boden, van Stockum, Horwood, & Fergusson, 2016), social phobia, low self-esteem, and academic problems in both childhood and adulthood for short- and long-term consequences (Kvarme, Helseth, Sæteren, & Natvig, 2010; Lereya, Copeland, Zammit, & Wolke, 2015; Magklara et al., 2012; Undheim, Wallander, & Sund, 2016). Being bullied can affect health. In addition, bullies themselves can have long-term health challenges (Breivik et al., 2017; Copeland et al., 2014; Folkehelseinstituttet, 2015; Lereya et al., 2015). Being a bully may increase their risk of mental and general health problems as well as they are more likely to display antisocial and criminal behavior (Lereya et al., 2015).
1 Oslo Metropolitan University, Pilestredet, Oslo, Norway
2 Norwegian Centre for Violence and traumatic Stress Studies, Nydalen, Oslo, Norway
3 Regional Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (RBUP), Gullhaugveien, Oslo, Norway
Corresponding Author:Lisbeth Gravdal Kvarme, RN, PHN, PhD, Oslo Metropolitan University, Pilestredet 32, N-0167 Oslo, Norway. Email: liskva@oslomet.no
The Norwegian school health services aim to promote good mental and physical health, facilitate good social and environmental conditions, and prevent disease and injury. School nurses require a 3-year bachelor’s degree and 1 year of further education to receive public health nursing credentials. Currently, a master’s-level degree is required and will be offered throughout Norway in the near future. A new national guideline from 2018 has been launched to improve the overall quality of the service and to reduce unwanted variation. In these guidelines, the school nurse is required to conduct an individual consultation with all eighth graders.
The overall aim is to “promote life management and contribute to healthy choices, obtain an overview of the challenges of the individual and the student population at the school, evaluate the need for follow-up calls or further referrals and strengthen user participation†(Helsedirektoratet, 2017, p. 55). Based on the recommendation in these guidelines, a dialogue tool called “School Health†has been developed and piloted.
The aim of the current pilot study was to develop a tool to evaluate the feasibility of and user satisfaction with School Health. School Health includes a web-based health questionnaire completed by students that generates individual feedback reports for the nurse to prepare for consultations. Students were asked about their general health and quality of life, including bullying and other stressful life events, first in the questionnaire and later in the consultation. The aim of this study was to explore how students experience answering questions about bullying before an individual consultation and how they talk about bullying with the school nurse.
This qualitative study used an exploratory design with individual and focus group interviews. Data collection and analysis followed phenomenological hermeneutic guidelines. The pilot study was approved by the by Norwegian Centre for Research Data (ID No.: 54731).
Students from five eighth-grade classes and four school nurses from three schools in Norway participated in this pilot study of School Health. The students filled out a web-based questionnaire covering topics recommended in the national guidelines, which the school nurse received prior to the consultation with each individual. After the consultation, some students were interviewed about their experiences. In the current study, we focused on bullying. This article presents the qualitative findings of the students’ experiences and some of the qualitative data from the students’ health questionnaires and the nurses’ evaluation questionnaires. The qualitative part of the study had an exploratory design.
Focus groups interviews were used to collect data from students to get a broad variety of views, and in addition, individual interviews were used to get a deeper information from students. For the 118 invited students, 67% (n = 79) had parental-informed consent for their child’s participation. Seventy-six completed the health questionnaire, and 70 completed the consultation with the school nurse. Of the participants filling out the health questionnaire, 54% were girls and 58% reported that both parents were born in Norway.
A total of 38 students aged 13 years from all three schools participated in qualitative interviews; there was equal participation by boys and girls. Information was collected from six individual interviews and four focus group interviews of eight participants in each group. Students who participated in the interviews received a free movie ticket afterward. The interviews were conducted in December 2017 during the school day and lasted about 1 hr. Three of the authors acted as moderators.
The school nurse selected who should be invited to an individual or focus group interview, and the students agreed to participate. The selections of the students depended on whether they had completed the questionnaire and also wanted to discuss it in a group or individually with the researchers. Both types of interviews opened with a brief orientation and explanation of how the anonymity of the participants would be respected. The specific topics covered in all consultations with students followed a guideline that should promote health and in addition they talked of what was important from the completed questionnaires. There were many other topics covered in the consultation, such as promote health and contribute to healthy choices; screen the challenges for the children at school, sleep, diet, physical activity, sexuality; and use of drugs and violence. The school nurse tried to get a good conversation of their situation according to what they answered at the questionnaire. There were not a specific time to talk of the different subjects. The moderator presented the rules for the group, which stated that one person should talk at a time and that information obtained by questionnaires from the group should be treated confidentially. All group members were encouraged to share their experiences participating in the project.
The interview guide contained open-ended questions about the students’ experiences participating in School Health— including both the health questionnaire, the individual consultation, and aspects of bullying. The interview guide was similar for the students interviewed individually and in focus groups. Examples of questions were: “How difficult did you find it to complete the questionnaire?†“Was there any question you think was uncomfortable to answer (such as questions about violence or bullying)?†“Was there any question you missed?†“How was the health dialogue with the school nurse?†and “How was it to talk about what you answered in the questionnaire (e.g., topics such as violence or bullying)?â€
The questionnaire that was part of School Health also included questions about bullying. The questions were similar to those used in a recurring national student survey called “Elevundersøkelsen†(the student survey) organized by the Ministry of Education in Norway (Wendelborg, 2018). First, the concept of bullying was described as “repeated negative actions from one or more persons targeting a student who may have difficulties defending him or herself. Bullying may take the form of giving others ugly names or teasing, excluding others, slandering, hitting, pushing, or holding†(Wendelborg, 2018, p. 5). The students were asked to answer five questions about their experiences with bullying in the past month, both at school and elsewhere. The answer options ranged from 1 (not at all) to 4 (about once a week or more). The five questions were about whether the student had been bullied, experienced digital bullying, bullied others (also digitally), and been bullied by adults.
All parents were informed about the study by the researchers at a meeting with parents at the beginning of the semester; written information was sent by e-mail afterward. Students received oral information from the school nurse along with written information. Before the students could participate, informed consent from their parents was collected. Students not participating in study were offered regular care by the school health service.
The qualitative analyses were performed by reading and rereading the text of the transcribed interviews to obtain an overall understanding of the text and then dividing the text into subthemes and themes. The data analysis was inspired by Kvale and Brinkman’s (2015) qualitative method, which has a phenomenological and hermeneutical framework. The framework has three levels of interpretation: self-understanding, critical understanding based on common sense, and theoretical understanding. The first level of self-understanding is about what the students said and intended to mean. The interpretation was a circular process that moved back-and-forth from parts of the text to the text as a whole and then back again. At the second level of critical understanding, the researchers used common sense and a critical view to interpret and comment on what the students had said in each interview. The interviews were then analyzed as a whole to find common patterns or differences within and between groups. This interpretation has a broader frame for understanding the students (Kvale & Brinkmann, 2015). At the third level, the text was divided into units of meaning, all with content relevant to the purpose of the study by posing the question, “What does this text say about the students’ experiences reporting bullying to the school nurse?â€
These analyses and interpretations were guided by our preunderstanding as researchers and school nurses. Our previous understanding and background also led us to create a safe atmosphere when meeting with the participants and helped us to ask relevant questions. Transferability is one way that qualitative study’s findings are applicable to other contexts. In this case, “other contexts†can mean similar situations, similar populations, and similar phenomena.
To validate the interpretations, three independent researchers read and interpreted the interviews and further discussed the interpretations to reach agreement. The main themes from the analyses were “difficult to talk about bullying,†“the school nurse—a significant partner,†and “the importance of having a friend.â€
In the health questionnaire, 4% reported that they had been bullied 2–3 times or more in the past month at school or other places. After the consultations, the school nurse reported bullying to be a topic in 20 (29%) of the consultations and that bullying was the main focus in one of consultation.
The students participating in this study reported that it was difficult to tell others if they had been bullied. Several students reported that if they told the teacher about the bullying they had witnessed or experienced, little or nothing was done. They expressed greater trust in the school nurse for assisting in this situation. Some talked spontaneously about bullying in the interviews. Several commented that the school environment was not good and that they had no friends. Bullying was mentioned mostly in the focus groups, although a few also mentioned it in individual interview.
Talking about bullying was difficult. One girl said:
I would feel embarrassed, and I do not want anyone to know that I was bullied, that no one likes me. However, if it had been very bad, I might have told the school. I think few students will admit in a way that people would know that they are being bullied.
Another student noted that feeling insecure may make it difficult to tell the school about being bullied.
One student said that the health questionnaire should also include a question about whether the teachers did something to stop the bullying. Another stated, “I feel whatever you tell the teacher about bullying, they do nothing. They just arrange a meeting and nothing changes.†One boy said that he was bullied in elementary school. He had just arrived in Norway from another country, and he said that he was bullied because of the color of his skin and he felt discriminated against. He said: “I was always alone during breaks. I went around in the schoolyard and played ball with myself. I had nothing to do and felt very sad.â€
Another boy said: “If I had been bullied, I would not have informed anyone. Because then I would just be in more trouble. That is not a smart thing to do.†These quotes show the barriers students perceive to telling others about bullying. However, the students commented that they felt it was easier to tell the school nurse about bullying.
The participants found it helpful to talk with the school nurse. One girl said, “I think it is good to talk with someone who is not my family. Then I can tell my point of view.†Another girl said, “It is so nice just to get it out!†These comments show the importance of students having a school nurse to talk with at school.
One participant commented that it was important to know the school nurse before talking about difficult and sensitive issues. “I liked talking to the school nurse because it was in a way good, something I did not need to say, but it was nice to get it out!†They also mentioned that the school nurse might give them some good advice.
Some participants talked of the school nurse as being very understanding and nice. One boy said:
I think it is good that she is so nice and, in a way, I feel I can trust her and I can tell her what is on my mind. And if I am bullied or something, then I can tell her so she can tell the head of the school about it. One girl made this comment: But if the teacher did nothing about it, I would have told the school nurse instead. Maybe she could help in a better way. I would have told the school nurse if the person being bullied thought it was okay.
I think it is good that she is so nice and, in a way, I feel I can trust her and I can tell her what is on my mind. And if I am bullied or something, then I can tell her so she can tell the head of the school about it.
One girl made this comment:
But if the teacher did nothing about it, I would have told the school nurse instead. Maybe she could help in a better way. I would have told the school nurse if the person being bullied thought it was okay.
To have trust in an adult was considered to be important for these students to talk about bullying. However, some students stated that they were afraid to tell the school nurse about being bullied because the nurse may tell others about it, and they were afraid that it could become worse by taking it further.
One student said that she wished more questions in the questionnaire were about having friends. She said, “For instance, not all [students] have friends. I see that some students drop out of school because they have no one to be with during recess.†Another said that he was often alone at recess and had no one to eat with.
Some hoped that the school and class environment could be better. One girl said that she longed for the teacher to react when she was bullied because of the color of her skin. She said, “I was born black, it is not my fault.â€
Another participant reported that the social environment in the classroom was not good. He said, “I have no friends in my class and that is very sad.†He added that he had some friends in another class but still missed having friends in his own.
One girl said that she had to eat alone and play on her cell phone during recess. She wanted to change class, but she was not allowed. She said, “I only want to be friends with someone and I try all the time, but I don’t have any proper friends.†Some said that the number of friends was not important but rather how many friends one can trust.
The aim of this study was to explore how students experienced answering questions about bullying before an individual consultation and how they talk about bullying with the school nurse. The interviews with students showed that they found it difficult to report being bullied and that having friends was important. The students had confidence in the school nurse and liked talking with her.
A previous study on school bullying in Norway found that 6.6% of students reported being bullied at school 2–3 times in the past month (Wendelborg, 2018). We used similar questions in the current study, but our survey was not anonymous. This may be one explanation for the discrepancy in prevalence between the two studies (6.6% vs. 4%). In the current study, the health questionnaire was designed to help the school nurse prepare for a consultation. In the interviews, the students noted that it was difficult to report and talk about bullying. This finding suggests that the prevalence rate in our study might have been influenced by social desirability bias (Szklo, 2007). This form of information bias probably limits the data as a valid prevalence measure of bullying, but it increases the importance of those who report bullying. Knowing the stigma related to reporting bullying emphasizes the need for a thoroughly follow-up by the school nurse of students who do report such experiences. In addition, the participants in our study had just started at a new school and did not know each other well. Because they completed the questionnaire in the classroom with the rest of their class, they may have been afraid that the others may have seen what they had written.
Several of the participants in this study said that they had been bullied when they were younger or knew of someone who had been bullied. Our results correspond with previous research showing adolescents find it difficult to report being bullied (Breivik et al., 2017). Breivik et al. (2017) noted that if students told their teacher about being bullied, little was done to help them. This is consistent with previous research of adolescents from Norway in which 40.5% of students reported that no adults at school knew about the bullying and 16% reported that the school knew about bullying but did not do anything to stop it (Wendelborg, 2018). A recent study of a chat room service about bullying on the Internet found that youths feel there is no point in telling an adult about being bullied (Helgeland & Lund, 2018). Their experience was that they did not trust adults to help when they are subjected to bullying. They believed that the school should take greater responsibility for dealing with bullying (Helgeland & Lund, 2018).
The participants in our study said that they appreciated talking with the school nurse, a finding that is consistent with previous research (Finnpå, Kvarme, & Misvær, 2017; Kvarme et al., 2010). In a cross-sectional study, Finnpå, Kvarme, and Misvær (2017) found that students who visited the school nurse most frequently had psychosocial problems such as being bullied. A review found that when bullying occurs in school, the school nurse is often the first adult the victim goes to for help (Gregory, Clements, & Holt, 2012). The participants in the current study said that the school nurse was very understanding and nice and that they trusted her. They also felt that it was important to answer the health questionnaire honestly, so that they would receive the needed help. This finding is consistent with previous qualitative research from England that found that school nurses have an important role in helping students deal with bullying (Pigozi & Bartoli, 2016). School nurses are in an important position to recognize bullying among students because they seem to have good relationships with students (Borup & Holstein, 2007).
A few of the participants reported that they had no friends in their class and that they had no one to be with during school breaks. Previous research (Helseth & Misvær, 2010) shows that having a friend is essential for students’ perceived quality of life and well-being. Research also shows that having a friend may provide a buffer against bullying (Davidson & Demaray, 2007; Kvarme, Aabø, & Sæteren, 2015). Peer support (Wolke, Woods, & Samara, 2009) and friendship can protect children from bullying (Kendrick, Jutengren, & Stattin, 2012). Encouraging schoolchildren to practice safe strategies to support and defend their victimized peers may help to protect them from bullying (Poyhonen, Juvonen, & Salmivalli, 2012). Friends and peer support i important on both prevention and recovering from bullying. Bullied children have difficulty making friends because of fear of rejection (Fox & Boulton, 2006; Salmivalli & Isaacs, 2005). Peer support (Wolke et al., 2009) and friendship can protect children from bullying (Kvarme et al., 2015, Kendrick et al., 2012). To prevent and stop bullying is perceived important for all children at schools.
Some participants felt that the school environment could be better. The students reported that they did not feel that the social environment was safe enough at school. A recent study based on Norwegian schools focused on psychosocial factors in the school environment (Eriksen & Lyng, 2018). The researchers interviewed school leaders and teachers by 20 schools that worked well on bullying. In addition, they have done fieldwork by four schools and interviewed students in six classes. The authors explored the school characteristics in schools with less bullying. They found that having an inclusive environment and good relationships between students, teachers, and parents and making the effort to promote inclusion, fellowship, and unity were important factors for building a collective “we.†In addition, they found less bullying if teachers managed in a caring way and were present during the breaks and if the school had rules against bullying with consequences for breaking these rules (Eriksen & Lyng, 2018).
Since the new guideline was launched, the school nurse is required to have a health talk individually with every student in the eighth grade. This is implemented in all schools in Norway; however, evaluation is planned by the research project School Health.
It is important that school staff, including the school nurse, acknowledge that students seldom report being bullied. When students report being bullied to a teacher or the school nurse, it is important to follow up thoroughly. School nurses and teachers should be aware it they see any student being bullied. To ensure this, all schools should have guidelines about which procedures to follow to help students exposed to bullying. Further make certain that a health-promoting environment and close follow-up of bullied children by the school nurse and teachers, in collaboration with parents, is important to preventing further bullying (Johannesen & Skotheim, 2018). Further research should emphasize how the school nurse may promote a good school environment and in addition to investigate how school nurse in collaboration with the teachers may prevent bullying on the three different levels such as primary, secondary, and tertiary prevention.
There was a discrepancy between the few reports of being bullied in the health questionnaire and the experiences the students talked about in the interview. The students felt it difficult to report when they had been bullied, and some felt that they did not receive adequate help from the school. However, they felt positively about talking to the school nurse. Students thought that the health dialogue could be a useful tool for revealing bullying. It is essential to promote an inclusive and tolerant environment and to create good relationships and friendship between students, parents, teachers, and school nurses.
The authors are grateful to the school nurses and schoolchildren for their participation and their help in making this study possible and in addition to financial help from partnership against bullying (PMM).
All authors contributed to the overall conception of the manuscript, approved the final draft as well as agree to be accountable for all aspects of work ensuring integrity and accuracy. LGK, SH, MCH, NM, Ã…S, and LV contributed to the analysis of the data. LGK and Ã…S drafted the manuscript while SH, MCM, NM, Ã…S, and LV were involved in the revision of the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Nina Misvær, RN, PHN https://orcid.org/0000-0002-8779-7512
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Lisbeth Gravdal Kvarme, RN, PHN, PhD, is a professor at Oslo Metropolitan University, Oslo, Norway.
Nina Misvær, RN, PHN, is an associate professor at Oslo Metropolitan University, Oslo, Norway.
Lisbeth Valla, PhD, RN, PHN, is at Oslo Metropolitan University, Oslo, Norway, and Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway.
Mia Cathrine Myhre, MD, PhD, is a researcher at Norwegian Centre for Violence and traumatic Stress Studies, Oslo, Norway.
Solveig Holen, PhD, is at Regional Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway.
Ã…se Sagatun, RN, PHN, PhD, is at Regional Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway.
