Nursing shortage is a global issue, more serious in China than in many developed counties [1, 2]. Increasing retention of nursing students is essential for shortage in nursing profession, but about a third of new graduate nurses intend to leave their occupation because of experiencing bullying [3]. Due to a high risk of being bullied in clinical placement, nursing students have low level of psychological well-being and do not able to successfully transform from undergraduate students to new graduate nurses [4, 5]. Appropriate conflict management styles and high level of psychological empowerment are effective methods to help nursing students to reduce detrimental effects of bullying experience [6, 7, 8]. While a growing body of knowledge [4, 9, 10] supports the association of bullying experience with poor psychological outcomes and intention to leave, few studies measured the relationships among bullying experience, conflict management styles, psychological empowerment and psychological well-being in the population of nursing students practicing in hospital. Moreover, it is unclear whether the relationship among bullying experience and psychological well-being is mediated by conflict management styles and psychological empowerment. Given this gap in the literature, the purpose of this research was to test a proposed structural equation model in which bullying experience, conflict management styles and psychological empowerment predict psychological well-being among Chinese nursing students in clinical placement.

Bullying referred as horizontal violence, interpersonal conflict, incivility, mobbing, and intimidation [4, 8, 11]. In this study, bullying was defined as act of aggression or hostility perpetrated deliberately or unconsciously by one person on one or more and can repeatedly occur in covert or overt ways over a period of time, which are all unwanted by the victim, but clearly cause humiliation, offence, and distress, and that may threaten the performance of the healthcare team and/or cause an unpleasant working environment. Nursing students have the highest risk of experiencing bullying from experienced nurses [4, 12, 13]. The prevalence of bullying experience varies across countries, culture, the definition and tool used to measure bullying. Approximately four fifths of nursing students experienced at least one bullying behavior in the past six months in clinical settings [4]. Reem [12] reported that 98.8% of students had experienced bullying from staff nurse and 86.7% of nursing students in Korea [13].

Psychological well-being was defined as a complex of cognitive and affective reactions to life experience, and Ren et al.'s study [4] measured psychological well-being as a combination of self-esteem, depression, and academic major satisfaction, with consideration for special attributes of psychological well-being for nursing students. Bullying experience is strongly correlated to a reduced psychological well-being in student nurses [4, 11]. Bullying experience is considered a stressor that can have potentially serious consequences for the psychological well-being, which is essential to improve the abilities of nursing students to successfully perform clinical training and to continue their career as regisregistered nurses [4, 5, 8].

Conflict management styles was defined as an individual's patterns of behavior predisposition that develop an individual's behaviors and reactions, it is divided into five modes: Competing, Collaborating, Compromising, Avoiding and Accommodating [14]. The evidence for the relationship between bullying experience and conflict management styles has been well substantiated by previous studies [6]. Research has suggested that the perceived bullying behaviors received from staff nurses are positively associated with compromising and avoiding [7, 8]. Psychological well-being could be reduced by compromising [6]. According to Ting-Toomey et al. [15], the consequences of bullying experience can be positive or negative depending on bullying management styles. However, compromise and avoidance are two of the most prevalent conflict management styles for nursing students. In contrast, they do not choose collaboration or competition as their preferred approaches, although these approaches are suggested as effective solutions to unravel interpersonal conflicts [7, 8, 16]. Accordingly, it is possible that nursing students might not have high level psychological well-being, possibly due to inability to cope with frequent bullying.

Psychological empowerment is defined as critical to surviving a work environment that experiences continuous change, and requires employee initiative and innovation [17]. Bullying experience has been found to be negatively related to psychological empowerment [1], psychological empowerment positively related to psychological well-being [18]. Pryjmachuk et al. [1] reported that workplace bullying experience can result in feelings of powerlessness and psychological distress, eventually leading to attrition in nursing programs, nursing students with low psychological empowerment don't believe in their own abilities, and they always focus on their deficiencies rather than strengths in the complex practice environment of healthcare systems [18]. Laschinger et al. [18] suggested that when new graduate nurses' work environments provide access to empowering work structures, their exposure to bullying may be less, and that these conditions promote their health and well-being. However, there has been little research into the relationship between bullying experience, psychological empowerment and psychological well-being.

In China, nurses are paid a very low wage but work extremely long hours doing hard work [2]. A hierarchy, with medicine at the top, developed as hospitals became a major care site, and nursing was dominated by medicine, which benefited hospitals and physicians, but created problems for nursing. Nurses feel alienated and removed from autonomy and control over their working condition, leading to a cycle of low self-esteem and feelings of powerlessness [3]. Instead of fighting back and risking retaliation from superiors, nurses tend to alleviate their own suffering associated with their powerlessness through bullying young coworkers or subordinates [19]. Few Chinese students desire to become a nurse, since most believe they would not gain job satisfaction being a nurse.

A comprehensive model for the primary prevention of bullying and its negative effect on psychological well-being therefore seems necessary to improve understanding in this field. Schlossberg et al.'s transition theory [5] derived theoretical rationale for understanding variables bullying experience, conflict management styles and psychological empowerment that impact the psychological well-being faced by Asian nursing students while interning at hospitals, this theory emphasized on the transitions that bullying experience throughout life and the means by which they cope and adjust. Schlossberg et al. [5] define a transition as “any event or non-event that results in changed relationships, routines, assumptions, and roles about oneself and the world and thus requires a corresponding change in one's behavior”. Transitions exist only if it is defined as experiencing it by the individual. In this study, being bullied can be considered as a transition, and bullying experience was defined as an event that results in changed nursing students' psychological well-being which requires a corresponding change in their intention to leave nursing profession.

Transition may be negative, positive, or neutral, depending on four major factors: situation, self, support, a nd strategies [5], four factors identifying malleable mediators influence the ability of an individual to cope during a transition. Situation described properties of the transition and reflects an individual's perception and appraisal of the transition. Support referred to the people and assets that help a person during a transition. The third factor of self described the demographic and psychological characteristics of individuals, such as individuals' sense of control over their life, being an optimist or pessimist, self-efficacy, commitment, and values. The last factor, strategies, referred to the actions or tactics that individuals use to cope with transition, including having positive beliefs, problem solving, using social skills or using material resources. In this study, psychological empowerment considered as self factor that was defined as psychological characteristics of an individual; conflict management style was strategies, which was defined as actions which an individual used to coping with a transition. Enhancing appropriate conflict management styles and the level of psychological empowerment have been described as essential to preparing nurses for professional nursing practice [6, 7, 8], and the task of measuring mediators of conflict management styles and psychological empowerment that account that account for variation in psychological well-being of interest is the first step in an intervention research model.

Based on obtained empirical evidence from previous studies [1, 6, 7, 8, 18] and Schlossberg et al.'s transition theory [5] (Figure 1), the hypothesized mediation model in the present study proposed that conflict management styles and psychological empowerment mediate the negative effect of bullying experience on psychological well-being in Chinese nursing students. Verification of the relationships among these variables can provide useful knowledge that can be used to build a conceptual framework of bullying experience in Asian nursing students and help nursing students' instructors to develop effective intervention strategies to attain optimal psychological well-being in nursing students' role transition.

Figure 1
Conceptual framework.

• Download Figure

The aims of this study were to identify the relationships among bullying experience, conflict management styles, psychological empowerment and psychological well-being, and to test a proposed model among Chinese nursing students in clinical placement. In addition, the mediation effects of conflict management styles and psychological empowerment between bullying experience and psychological well-being were examined.

This study aimed to determine the relationships among bullying experience, conflict management styles, psychological empowerment and psychological well-being for nursing students during clinical placement in China. The results indicated that the proposed model provided a good fit to the data based on the values of various model fit indices, and an adequate structural model of bullying was identified and they support previous studies and enhance our understanding of how bullying experience, conflict management styles and psychological empowerment infiuence psychological well-being. As discussed below, these findings have several theoretical and practical implications.

Regarding the relationship between bullying experience and psychological well-being, the dimensions of bullying experience were found to be positively associated with depression, and negatively associated with self-esteem and academic major satisfaction among nursing students during clinical practice in China. These results are consistent with the results of previous studies [4, 11]. Budden et al. [11] found that the majority of nursing students reported that they experience of being bullied made them feel depressed (53.6%). Even after controlling for general characteristics, nursing students' experience of being bullied was a significant predictor of psychological well-being including depression, self-esteem, and academic major satisfaction [4]. During clinical practice, nursing students described themselves as having a poorly defined and unapproved social role, without a salary, a career, and a stable bond with a specific type of nursing work [28]. Based on the transition theory by Schlossberg et al. [5], bullying as an event may interfere with a successful transition, possibly due to lack of resources to manage stressful situations, and thus fail to integrate new relationships, duties, and roles into daily routines. For this reason, bullying experience could easily undermine nursing students' psychological well-being, which may affect how and whether they will perform their job in the future.

In this study, nursing students preferred avoiding and compromising behaviors to manage conflict, and the conflict management styles had a negative impact on psychological well-being. Previous studies support this finding [7, 8, 16], nursing students scored above the 60th percentile for avoiding [8], and the average score on Compromising was 7.33±2.10 [7]. The choice of inappropriate conflict management styles depends on many variables, such as a mixture of nursing virtue and cultural value toward self-sacrifice [19]. Ni et al. [16] found the mental health of Chinese nursing students was related to the ways of coping, they suggested that avoiding passive coping is very necessary for them to improve the mental health of nursing students. Besides the direct effect of conflict management styles, we also found that bullying experience exerted an indirect effect on psychological well-being through conflict management styles, which was supported by previous studies [6, 29]. Lin et al. [6] reported that although compromising was considered a useful strategy to solving conflict with others for undergraduates, it may also lead to anxiety and depression. Individuals who have inappropriate conflict management styles may be more likely to suffer bullying, compromising interacts with bullying experience at work to predict psychosocial strain [29]. Lack of bullying management skills was not a cause of bullying but a consequence of nursing culture that emphasized self-silencing about bullying as an acceptable way [19]. Preparation in bullying management should start from nursing student education, negative coping styles, such as collaboration or competition [7, 8, 16], were provided through professional guidance can be significant indicators of clinical performance in nursing students and affect the process of role transition from nursing students to staff nurses.

In relation to psychological empowerment and psychological well-being, psychological empowerment had a significant positive impact on psychological well-being, this is consistent with previous studies [10], psychological empowerment increased the academic success among nursing students. In addition, the result showed that bullying experience affect psychological empowerment, which serves as a mitigating factor to reduce effects of bullying experience on psychological well-being [7]. As mentioned before [3, 4], bullying experience and hierarchical structures are pervasive in nursing culture, nursing staff with higher hierarchy feeling superior to unskilled nursing students and engaging in bullying behavior. In China, doctor-patient relationships have been deteriorating for the past 10 years. Medical staffs are involved in tense and confrontational doctor-patient relationships and most patients do not believe medical staff, with even physical attacks on these professionals [28]. In this context, nursing students are not allowed to join fully in clinical practice and may be treated as 'a pair of hands', removed from situations of potentially rich learning. Bradbury-Jones et al. [30] categorized three words for empowerment, which included: 1) leaning in practice (i.e., being understood, encouraged to learn and having responsibility), 2) team membership (i.e., being part of the team), and 3) power (i.e., justice, respect and having a voice). In this study, 43.4% of students did not receive any help from teachers whereas 68.0% of students did not receive any help from nurses when dealing with bullying experiences, and about 71.0% of students reported that their relationship with nurses was not good. Based on these comparisons and the above explanation, it is possible to say that nursing students may frequently encounter absence of continuity of placement, the presence of a mentor and time underpinned empowering experiences, raising problems of low self-esteem, motivation for quitting learning and negative regard for placement [30].

Bullying experience carries with it both short-term and longterm effects on psychological well-being in nursing students. There are psychological responses to the stress from bullying experience dependent on the victims' coping skills and their psychological empowerment level. Bullying experience is harmful to individuals who are bullied constantly and the work environment, unless bullying is monitored and managed. Mediator variables were examined simultaneously, conflict management styles and psychological empowerment received adequate empirical attention, and identifying distinct pathways of influence offer implications for prevention and treatment. These results suggest that more antecedent and mediating variables should be found to explain variance of psychological well-being among nursing students during clinical practice. Using of Schlossberg's Transition Theory may help evaluate relationships of bullying with a wide range of its known correlates in the literature in a more precise way in future research and develop educational intervention to prevent bullying in clinical practice.

This study adds significant empirical evidence to the literature on bullying and it will facilitate our understanding of the role of conflict management styles and psychological empowerment in mediating the relationship between bullying experience and psychological well-being in nursing students during clinical placement. The findings of this study suggest that bullying experience is a critical problem among nursing students' psychological well-being including depression, self-esteem and academic major satisfaction. Interventions for increasing nurse psychological well-being should include efforts for reducing bullying experience, improving conflict management styles and providing psychological empowerment. The findings of this study suggest that further research is needed to learn about more mediators between bullying experience and psychological well-being. There is also a need for nursing educators to teach nursing students how to recognize the bullying behaviors. Nursing curriculum is important for nursing students to learn conflict management styles of how to handle bullying behaviors, and practical guidelines are required to promote psychological empowerment in nursing students during clinical training. Furthermore, nurse administrators can utilize these findings to establish policies that create a bully-free culture with supportive and communicative environment in clinical workplace.