ARTICLE

‘‘I Didn’t Even Know You

Cared About That Stuff’’:
Youths’ Perceptions of
Health Care Provider
Roles in Addressing
Bullying
Judith A. Vessey, PhD, MBA, RN, FAAN,
Rachel L. DiFazio, PhD, RN, PPCNP-BC, FAAN, &
Tania D. Strout, PhD, RN, MS

ABSTRACT role that advanced practice nurses and physicians play in ad-
Introduction: Youth bullying is a critical public health prob- dressing bullying.
lem, with those exposed to bullying at risk for development Methods: A qualitative descriptive approach was used; focus
of serious sequelae lasting into adulthood. The purpose of groups were used to generate study data. Twenty-four ado-
this study was to explore youths’ perceptions regarding the lescents participated in focus groups centered on exploring
health care providers’ roles in addressing bullying.
Results: Three themes emerged through qualitative analysis:
(a) Not sure that’s part of their job, (b) That’s way too per-
Judith A. Vessey, Lelia Holden Carroll Professor in Nursing,
Boston College, William F. Connell School of Nursing, Chestnut sonal, and (c) They couldn’t help anyway. Participants
Hill, MA; and Nurse Scientist, Boston Children’s Hospital, Boston, described a very limited role for health care providers in ad-
MA. dressing bullying.
Discussion: Youths recognized a narrow role for health care
Rachel L. DiFazio, Nurse Scientist, Boston Children’s Hospital,
providers in addressing bullying, characterizing bullying as a
and Instructor, Harvard Medical School, Boston, MA.
school- or-community-related issue rather than one influ-
Tania D. Strout, Director of Research, Department of Emergency encing health. J Pediatr Health Care. (2017) 31, 536-545.
Medicine, Maine Medical Center, and Associate Professor of
Emergency Medicine, Tufts University School of Medicine,
Portland, ME. KEY WORDS
Conflicts of interest: None to report. Advanced practice nurses, adolescent–provider communica-
tion, focus groups, health screening, nurse practitioners,
Correspondence: Judith A. Vessey, PhD, MBA, RN, FAAN, Boston youth bullying
College, William F. Connell School of Nursing, 140 Commonwealth
Ave, Chestnut Hill, MA 02467; e-mail: [email protected].
Youth bullying is a critical public health problem
0891-5245/$36.00 affecting approximately 20% to 28% of all middle school
Copyright Q 2017 by the National Association of Pediatric youths each year (Centers for Disease Control and
Nurse Practitioners. Published by Elsevier Inc. All rights Prevention & U.S. Department of Education, 2014).
reserved. Youth bullying is defined as ‘‘.any unwanted aggres-
Published online March 6, 2017. sive behavior(s) by another youth or group of youths
http://dx.doi.org/10.1016/j.pedhc.2017.01.004 who are not siblings or current dating partners that

536 Volume 31  Number 5 Journal of Pediatric Health Care

involves an observed or perceived power imbalance significant missed opportunity for intervention.
and is repeated multiple times or is highly likely to be Although youths may seek care for psychosocial
repeated’’ (Centers for Disease Control and and physical complaints resulting from bullying,
Prevention & U.S. Department of Education, 2014, p. neither the patient nor provider may be aware that
7). Youths who have been victimized by bullies experi- bullying could be the root cause of the distress the
ence a full range of short- and long-term academic and youth is experiencing.
psychological health problems (Card & Little, 2006; This lack of awareness is more profound for youths
Cook, Williams, Guerra, Kim, & Sadek, 2010; Hawker with chronic conditions. They are often targeted by
& Boulton, 2000; Hepburn, Azael, Molnar, & Miller, bullies while simultaneously interacting with health
2012; Kim & Leventhal, 2008; Nakamoto & Schwartz, care providers who could assist them in handling the
2010; Reijntjes, Kamphuis, Prinzie, & Telch, 2010; bullying issues that they encounter (Faith et al., 2015;
Reijntjes et al., 2011). Bullied youths also experience Sentenac, Arnaud, Gavin, Gabhainn, & Godeau, 2012;
an increased number of common physical health Shiu, 2004). Selected ‘‘provider-side’’ barriers to
ailments and significantly higher levels of screening include a lack of screening mandates and
psychosomatic symptomatology compared with their appropriate screening tools, limited encounter time,
nonbullied counterparts (Due et al., 2005; Fekkes, cultural differences, poor reimbursement for
Pijpers, Fredriks, & Verloove-Vanhorick, 2006; Gini & psychological intervention, and provider discomfort
Pozzoli, 2009). Moreover, being bullied in childhood discussing sensitive topics and identifying treatment
contributes to poorer psychological and physical options (Brown & Wissow, 2009; Cabana et al., 1999;
health outcomes throughout adulthood (Copeland, Kautz, Mach, & Smith, 2008; Sege, Hatmaker-
Wolke, Angold, & Costello, 2013; Copeland et al., Flanigan, De Vos, Levin-Goodman, & Spivak, 2006;
2014; Takizawa, Maughan, & Arseneault, 2014). Van Hook et al., 2007).
Because of the seriousness of bullying sequelae, Little is known, however, regarding the views youths
numerous federal and state legislative remedies and hold regarding health care providers’ roles in address-
public policy initiatives have been introduced, and ing bullying. This study, which assessed youths’ views
HealthyPeople 2020 Objective IVP-35: Reduce bullying of bullying and their views of the role health care pro-
among adolescents has targeted a 10% reduction, from viders play in addressing it, was the first phase of a
19.9% to 17.9%, in the incidence of bullying by 2020 larger National Institutes of Health–funded study,
(HealthyPeople.gov, 2012). To date, the emphasis has Development of the CABS: Child-Adolescent Bullying
been placed on school-based programming designed Screen (R21HD083988). The purpose of the overall
to deter bullying. These programs, however, have re- study is to develop a brief youth bullying screening
sulted in only modest improvements in the school tool for widespread use by health care providers during
climate and student attitudes, with little reduction in primary care and other visits (e.g., emergency depart-
the actual amount of bullying behavior that occurs ment, chronic illness clinics, sports physicals, etc.)
(Lee, Kim, & Kim, 2013; Merrell, Gueldner, Ross, & that provide screening opportunities.
Isava, 2008; Ttofi & Farrington, 2011).
Despite bullying’s omnipresence and its impact on METHODS
health, routine surveillance is rarely initiated. Advanced Study Design
practice nurses and other health care providers are on This study was conducted using a qualitative
the front lines and should be key players in identifying descriptive approach (Sandelowski, 2000). A focus
and assisting victimized youths (Hendershot, Dake, group strategy was used to gain a comprehensive
Price, & Larty, 2006; Lyznicki, McCaffree, & Robinowitz, description of youths’ perceptions of the roles that
2004; Vessey, DiFazio, health care providers should play in addressing
& Strout, 2013). Despite bullying’s youth bullying. Because bullying occurs within a so-
Successful preventive cial context, the focus group methodology was
health care relies in omnipresence and determined to be well aligned with exploring this
part on the relationship its impact on phenomenon and has previously been shown to be
that nurse practitioners, health, routine highly effective for this purpose (Horowitz et al.,
pediatricians, school 2004; Krueger & Casey, 2009). The study was
nurses, and other surveillance is approved by the institutional review boards at
health care providers rarely initiated. Boston College, Boston Children’s Hospital, and
have with youths Maine Medical Center.
(Brown & Wissow,
2009; Jacobson, Richardson, Parry-Langdon, & Study Setting and Recruitment
Donovan, 2001). The failure of health care Purposive sampling was used to select participants who
providers and youths to engage in discussions could provide in-depth information about the phenom-
around bullying is unfortunate and represents a enon of interest. Youths in middle or junior high school

www.jpedhc.org September/October 2017 537

from diverse racial, ethnic, socioeconomic, and followed. Participants were told that they did not
geographic backgrounds were recruited from two have to answer any questions with which they
states through fliers posted in the clinic areas, an- were uncomfortable. Members of the research team
nouncements on the hospital Web page, or nomination served as recorders who audiotaped the sessions
by clinic staff. and took field notes.
For youths expressing interest in participating in the During the focus groups, questions were ex-
focus groups via telephone or e-mail, eligibility initially plained, elaborated, redirected, and introduced as
was confirmed through a telephone discussion with necessary to encourage dialogue while addressing
their parent(s). Inclusion criteria required that the the concepts of interest. Open-ended questions for
youths were between 10 and 16 years of age, fluent in each of the major constructs initially were explored,
spoken English, willing to share their expertise and ex- moving from concrete to more abstract constructs.
periences in a focus group, and had participated in Follow-up probes were used to clarify or gain
school or community bullying prevention educational
programs. Youths with significant cognitive or behav-
ioral impairments resulting in disabling language
comprehension or expressive problems as determined
through the parental interview (e.g., use of Individual- BOX. Semistructured interview questions on the
ized Educational Plans, parental report, etc.) were detection and handling of bullying
excluded because they would be unable to participate
in group focus group activities. Data were collected Questions About Bullying
from September through November 2015. Can you tell me what you think bullying is?
Describe a situation you remember when another kid was
Study Measures bullied. What was that like? What happened?
Two measures, a demographic form and moderator What kinds of things do kids get bullied about?
guide, were used during the study. The investigator-  Probe: Kids get bullied about a lot of things. Can
created demographic form collected key information you think of a time recently when it happened?
about the study participants. The moderator guide What kinds of things do kids get bullied about?
was developed based on group process principles How do you know when bullying is taking place?
 Probe: How is it different from teasing or kids just
and the study’s purpose and objectives (Stewart &
‘‘acting stupid’’ with each other?
Shamdasani, 2014). Semistructured interview ques-
Handling Bullying
tions and probes were designed in accordance with
the study’s overall aims and from information culled If you or a friend was being bullied, how would you handle
from published multidisciplinary research findings it?
and were informed by bullying theory and expert clin- Who would you seek help from?
ical opinion. Example questions can be found in the  Probe: Your parents? A school teacher, school
nurse, guidance counselor, resource officer, or
Box.
coach? Someone from your church, synagogue,
or mosque? Another adult?
Data Collection How would you feel if your doctor or nurse asked you
An evidence-based approach for conducting suc- about bullying when you went for care?
cessful youth focus groups on health-related topics  Probes:
was used in the focus group design (Horowitz B Would you bring it up by yourself?
et al., 2003; Morgan, Gibbs, Maxwell, & Britten, B Would you want your doctor or nurse practi-
2002). The groups, 1.5 hours in length, took place tioner to bring it up?
in private conference rooms within regional health What would make you more—or less—comfortable in
care facilities. Before the start of the focus group, talking with your doctor or nurse practitioner about
parental consent and child assent were obtained. bullying?
 Probes:
The participants were then asked to complete the
B How well you know your doctor or nurse
demographic form, were provided with snacks, and
practitioner?
engaged in facilitated informal conversation. The B If you knew what you said was going to be
focus groups were led by experienced moderators private?
and were conducted in a semistructured manner B If you knew something was going to done?
because this approach allowed for the collection of B If your parents were there?
data from both individuals and the individual as Summary Question
part of a larger group. The moderator initially
We want to understand as much about bullying as we can.
began by introducing herself and the recorder and
Are there other things that kids get bullied about that we
by orienting the participants to the group’s purpose have not talked about?
and ground rules. Participant introductions

538 Volume 31  Number 5 Journal of Pediatric Health Care

 TABLE. Youths’ perceptions of health care providers’ role in addressing bullying
Code exemplars Categories Themes
Bullying seen as a school issue
The topic not brought up by youths or
Not a topic for discussion
providers
Not a topic appropriate for acute care or
chronic care visits
Not sure that is part of their job
Seek care for physical health problems
Did not see psychosocial sequelae (anxiety, Health care providers’ roles limited to mental
depression) as mental health issues and physical health concerns
Only would seek provider help for suicide

Only saw the provider annually

Specialty providers only interested in treating
Lack of patient–provider relationship
the illness
Feeling uninformed, many questions

Introduce topic of bullying casually

Complete a form or use an app about bullying
Uncomfortable discussing topic
while waiting That’s way too personal

Many parents viewed as ‘‘best friends’’

Concerned parents would read what they are
Lack of confidentiality
writing
Did not think providers would keep
conversation confidential

Codes Categories Themes

Bullying happens at school
Cyberbullying
Bullying seen as a school or community issue

They couldn’t help anyway

Just can listen
Not going to do anything about it
No compendium of useful resources

additional information on topic areas that emerged focus groups were held until saturation was reached
from the initial responses to the open-ended ques- and no new categories emerged from the data.
tions. After participants had an opportunity to offer
their personal views, the moderator shifted to a Analytic Procedures
more directive style of questioning by asking partic- Descriptive statistics were used to describe the char-
ipants what they thought about specific topics. acteristics of the study population. For the qualitative
Congruent with focus group methodology, no push analysis, focus group audiotapes were transcribed
toward ensuring conformity or consensus was verbatim at the conclusion of each session by a pro-
made, because the aim was to derive as comprehen- fessional Collaborate Institutional Training Initiative-
sive a picture of the participants’ views as possible certified transcriptionist. The accuracy of the tran-
and to ensure that there was opportunity for contrary scription was ensured by having the moderator and
opinions to arise (Krueger & Casey, 2009). As we will recorder listen to the tape and compare it with the
describe, data analysis began as soon as the first transcript text. The transcripts were entered into Hy-
focus group transcript was available, and additional per-RESEARCH 3.03 (Researchware, Inc., 2011), a

www.jpedhc.org September/October 2017 539

qualitative software computer program, to facilitate make participants feel comfortable to ensure that
the analysis. participants spoke freely about their experiences. The
Field notes about the environment and participant emergence of data was driven by the participants; this
observation, context, and tone were added to facilitate was achieved by allowing participants to express
interpretation. what was important to them rather than leading them
The primary data analytic technique used was con- with notions of what the study investigators assumed
ventional qualitative content analysis (Krippendorff, would be important. To ensure credibility in this
2013). To be consistent with an inductive approach to study, selected focus group participants reviewed the
generate codes, the initial goal was to extract those findings and verified that they represented their
verbatim text statements that could help explain the thoughts, feelings, and statements. They validated that
youths’ views of bullying and their health care providers’ youths who experienced bullying would immediately
role in addressing it. There were no preconceived codes, recognize the information that was been reported.
but the data analysis was guided by the research pur- Purposive sampling, where the participants were
pose. representative of youths at risk for bullying exposure,
Three members of the research team, working inde- helped ensure that the findings would be seen as
pendently, read each of the transcripts in its entirety to meaningful to the audience or readers (fittingness).
obtain a general sense of participants’ perceptions of For example, participants were selected from the
their nurse practitioner’s or physician’s role in assessing middle through high school age groups, when youth
bullying. They then re-read the transcripts, and word- bullying is known to peak. In addition, flyers were
by-word and line-by-line analyses were conducted. placed in settings known to include a diverse range of
In vivo codes, consisting of significant words, phrases, socioeconomic statuses and racial and ethnic
and statements, were identified, and similar codes were backgrounds. Auditability was achieved by having the
clustered together into categories. research team ensure the accuracy of the focus group
After first-level coding, the referential adequacy of transcripts, keep clear notes, and track all of the
the findings was determined. This was done by having decisions regarding data analysis so that others could
the research team members compare their preliminary replicate the study and arrive at the same conclusion
codes against the raw data. In keeping with content based on the original data and decision trail.
analysis processes, the groups and topics were re-
viewed multiple times by the research team to identify RESULTS
key themes existing within and across the focus groups. Three focus groups of middle school students from
Areas of disagreement were resolved through discus- diverse communities across the New England region
sion, further transcript review, and consultation with of the United States provided the initial data. Groups
focus group participants. Lastly, coding redundancies ranged in size from seven to eight participants. A fourth
were removed. A final set of themes was identified group of two hospitalized youths with ongoing chronic
through the process of constant comparison. health conditions was added to reach data saturation.
An iterative, deductive, analytic process then was The study period was September through November
used to aid in data interpretation while fully illumi- 2015. The participants (N = 24) ranged in age from 12
nating the emergent themes (Sandelowski, 2000). First, to 16 years, with a mean of 12.3 years. Participants
categories were developed from codes; broader themes were 22.7% male, 63.6% White, 13.6% African Amer-
then were developed from the categories capturing the ican/Black, 18.2% Asian/Pacific Islander, and 4.5% of
essence of youths’ perceptions of their health care pro- more than one race; ad 22.7% were of Hispanic
viders’ role in addressing bullying (DeSantis & Ugarriza, ethnicity. The median income of participants’ commu-
2000). Care was taken to ensure that the new categories nities ranged from $28,000 to $131,000, with a median
and themes described related, but differing, phenom- of $75,640 (U.S. Census Bureau, 2014).
ena at each level of abstraction (Guba & Lincoln,
1985). At each stage of the process, the team discussed Themes
discrepancies in coding and conducted further tran- Three primary themes emerged from the data that ad-
script review to reach consensus. Data analysis was dressed health care providers’ role in addressing
completed when no further information emerged bullying: (a) Not sure that’s part of their job, (b) That’s
from the transcripts. way too personal, and (c) They couldn’t help anyway.
Exemplar codes, categories, and themes are provided
Maintenance of Rigor in the Table.
Strategies to maintain rigor were be used throughout
the study. Rigor in qualitative research is evaluated by Theme 1: Not sure that’s part of their job
credibility, fittingness, and auditability (Morse, Barrett, When asked, ‘‘[W]ho would you seek help from if
Mayan, Olson, & Spiers, 2002; Sandelowski, 1986). you or a friend were bullied?’’ the participants were
During the focus groups, the moderator attempted to quick to identify friends, school counselors, older

540 Volume 31  Number 5 Journal of Pediatric Health Care

siblings, and parents as individuals that they believed like casual.you didn’t go there just to talk about
would be empathetic and knowledgeable. When bullying and stuff like that.’’ Another added, ‘‘I think
specifically probed to whether they would seek maybe if it was on paper or not physically just talk-
help from their nurse practitioner or pediatrician, ing to them. I think it makes it uncomfortable
the participants were visibly flummoxed. They noted because you might not know what to say.’’
that their health care providers often made general The use of technology, such as an electronic tablet,
conversation about school but did not specifically also was endorsed by participants. They supported
ask about bullying, as noted in this quotation: the idea that an electronic screening tool could be
‘‘Like my doctor goes, ÔHow’s school?Õ and I’m like, completed at a health visit and that this modality might
ÔGood,Õ and she doesn’t get that personal like are afford more privacy than a paper version or direct ques-
you getting bullied.’’ They clearly had not considered tioning by a provider.
the possibility that health care providers had a sub- The role parents play in mediating health care en-
stantive role in addressing bullying. More commonly, counters between youths and providers was viewed
youths viewed bullying as a school and community both positively and negatively. Although many
issue rather than a health care concern. After giving youths stated that they were comfortable talking
the idea some thought, the following response about sensitive topics with their parents in atten-
captured the participants’ shared views: dance, others expressed significant reluctance and
I don’t even think it’s like a question that people think to had concerns about provider–patient confidenti-
bring up to their doctors because people think doctors ality, as noted by these quotations: ‘‘I don’t know
are for more like mental illness and physical illnesses. how many kids are actually going to answer those
They don’t think of it as a help for that type of thing. questions [about bullying].because doctors can
tell your parents.if something is happening like
The participants did endorse health care providers’
bullying, they’re probably going to tell your par-
role as helping with ‘‘mental illness’’ and were quick
ents,’’ and ‘‘I’d rather talk to the doctor first (without
to identify bullying’s psychosocial sequelae—including
parents present).’’
fear, sadness, depres-
sion, self-harm, and Youths viewed Theme 3: They couldn’t help anyway
school avoidance—
but they did not classify bullying as a school Lastly, youths were concerned that even if they dis-
cussed bullying with their health care provider, that
these outcomes as and community the provider would not be in a position to help. They
mental health con- issue rather than a perceived health care providers’ roles as primarily
cerns. The participants
saw the health care health care limited to assisting in the case of physical injury, as
noted in this quotation: ‘‘.if they are getting physically
provider as having a concern. bullied they may help you.’’ Second, youths viewed
primary role only if
bullying as a school- or community-related issue, as
bullying sequelae rose to the level of suicide ideation,
noted in this quotation: ‘‘.but I don’t know how
as noted by this quotation: ‘‘I think that if you’re getting
much say they would have, if it’s connected to school
to the point in bullying that you’re trying to hurt yourself
or wherever else you may go.’’
or commit suicide.’’
Lastly, they doubted that providers had the necessary
compendium of resources to offer meaningful help, as
Theme 2: That’s way too personal noted in this quotation:
Youths were queried about what would make them I think that you know that if something’s going to be
more or less comfortable in talking about bullying done, it makes you feel more comfortable that you
with their nurse practitioners or physicians. The know that what you’re doing is going to be successful.
lack of a patient–provider relationship was the first Like if you just talk to someone and they’re not going to
identified barrier, as noted by this quotation: ‘‘Some do anything about it, it doesn’t really matter.
kids don’t feel okay talking to their doctors because
they don’t know them personally because it DISCUSSION
[bullying] is like outside of the doctor’s office you The three themes that emerged from this study: (a) Not
don’t see them.’’ The second concern was that sure that’s part of their job, (b) That’s way too personal,
they would be made to feel uncomfortable, as noted and (c) They couldn’t help anyway provide a deeper
by this quotation: ‘‘.like maybe if your stress was insight into the understanding of youths’ perceptions
up or something. I don’t think that a lot of kids of their health care providers’ roles in addressing
feel comfortable talking to their doctor about that.’’ bullying.
Study participants clearly endorsed the notion that The idea that youths have a limited view of their health
an indirect approach for initiating the conversation care providers’ role in preventive health care is concern-
should be used. One participant stated, ‘‘If it was ing. The first focus groups were composed of essentially

www.jpedhc.org September/October 2017 541

healthy youths who likely had limited interaction with Jacobson, Richardson, Parry-Langdon, & Donovan,
their providers; however, a fourth group was convened 2001). Youths who frequently seek health care at
of youths with significant health care needs who had had school or specialty clinics often benefit from a
extensive contact with their primary care and specialty long-term trusting relationship with the staff; such
providers. Regardless of group, participants indicated visits provide an excellent opportunity for health
that during primary care visits, neither they nor their care providers to initiate discussions around
nurse practitioners nor physicians routinely brought up bullying.
bullying, with conversation limited to the general quality Youths’ willingness or reluctance to be open about
of their school life. Nor did the youths indicate that other sensitive topics with their health care providers is
health care providers, highly influenced by their degree of trust and
such as school nurses, The idea that knowing, a priori, what pieces of information, and
emergency department youths have a how selected information, would be disclosed to par-
personnel, or specialty ents. This is a realistic concern, because parents unan-
care providers, initiate limited view of their imously wish to be informed about any health issue
conversations about health care their adolescent may have (Carlisle et al.,
bullying. None of the providers’ role in 2006).Youths will often forego care or avoid discus-
youths saw this as a sing sensitive topics if they include illegal behavior
deficit in care; they just preventive health (e.g., drug and alcohol use; texting while driving),
did not view bullying care is concerning. are in conflict with familial cultural norms (sexual ac-
as a topic that was within tivity, gender identity), or are associated with societal
their providers’ scope of practice but rather something stigma (e.g., serious mental health disorders;
that was the school’s purview. Akinbami, Gandhi, & Cheng, 2003; Carlisle et al.,
It is interesting to note that the study participants did 2006; Lehrer, Pantell, Tebb, & Shafer, 2007). Bullying
see a role for health care providers if bullying reached fits none of these categories, especially because the
the level of suicide ideation. One participant had expe- youths in this study did not view the consequences
rienced a bullied peer who attempted suicide. For of bullying as rising to the level of a significant
others, suicide ideation likely arose to the level of a mental health problem worthy of their providers’
mental health problem that their nurse practitioners attention. This is congruent with teens’ general
or physicians could address. Another, although uncon- views on common adolescent mental health issues
firmed, explanation is that youth views on suicide/sui- (Coles & Coleman, 2010). For some youths, a breach
cide ideation have been shaped by health care of confidentiality would require them to contend with
providers implementing screening for depression and their parents’ responses to bullying. This is a legiti-
suicidal ideation secondary to the 2007 American Acad- mate concern, because parents’ responses are often
emy of Pediatrics recommendations (Shain, 2007) and uniformed and ineffective and can potentially can
the 2016 Joint Commission’s Sentinel alert (Joint aggravate the situation (Sawyer, Mishna, Pepler, &
Commission, 2016). Wiener, 2011).
There is little research on the quality of adoles- Recent Pew estimates suggest that at least 93% of
cent–health care provider relationships. The results youths 12 to 17 years of age are regularly online
of one landmark study reported by Brown and (Lenhart, Ling, Campbell, & Purcell, 2010), and
Wissow (2009), however, show that when sensitive although adolescent Internet use can present dangers,
topics are explored in primary care visits, adoles- it also provides an opportunity for screening and
cents had a more positive and robust view of the health-related education activities (Kachur et al., 2013;
visit. These findings were independent of the charac- Lord & Marsch, 2011; Olson, Gaffney, Hedberg, &
teristics of the participant population. Youths can be Gladstone, 2009). Across demographic and
helped to gain a fuller appreciation of the role their socioeconomic profiles, youths participating in this
nurse practitioners and other health care providers study were comfortable with the notion of completing
can play in helping them address situations that an online bullying screen and even believed that this
lead to stress, psychological, and physical problems. would afford additional confidentiality over other
Prior research indicates that adolescents are more forms of screening. This is consistent with prior
comfortable talking about sensitive topics during pri- research indicating that adolescents are comfortable
mary care visits when they are primed to do so in with electronic screening, even when used for
advance, when providers facilitate an active dialogue sensitive topics such as sexually transmitted infection
designed to elicit adolescent disclosure of personal screening (Goyal, Teach, Badolato, Trent, &
concerns, when there is adequate time during the Chamberlain, 2016) and assessment of risky behaviors
visit for this to occur, and when an appropriate level (Chisolm, Gardner, Julian, & Kelleher, 2008). Given
of confidentiality is ensured (Boekeloo et al., 2003; the widespread use of both general technology and
Carlisle, Shickle, Cork, & McDonagh, 2006; electronic health records, future screening tools would

542 Volume 31  Number 5 Journal of Pediatric Health Care

likely be more readily adopted by both patients and Boekeloo, B. O., Bobbin, M. P., Lee, W. I., Worrell, K. D., Hamburger,
providers in an electronic form. E. K., & Russek- Cohen, E. (2003). Effect of patient priming and
primary care provider prompting on adolescent-provider
Unfortunately, it was not surprising that youths do communication about alcohol. Archives of Pediatrics & Adoles-
not immediately view bullying as a critical issue for cent Medicine, 157, 433-439.
health care providers to address. Despite calls in the Brown, J. D., & Wissow, L. S. (2009). Discussion of sensitive health
professional literature declaring youth bullying a pro- topics with youth during primary care visits: Relationship to
fessional responsibility for over a decade (Lyznicki youth perceptions of care. Journal of Adolescent Health, 44,
48-54.
et al., 2004; Spector & Kelly, 2006; Storch & Ledley, Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H.,
2005), there are currently no explicit preventive Abboud, P. A. C., & Rubin, H. R. (1999). Why don’t physicians
health care recommendations specific to bullying follow clinical practice guidelines?: A framework for improve-
screening and intervention by pediatric health care ment. JAMA, 282, 1458-1465.
organizations (Committee on Injury, Violence, and Card, N. A., & Little, T. D. (2006). Proactive and reactive aggression in
childhood and adolescence: A meta-analysis of differential rela-
Poison Prevention, 2009; Committee on Practice and tions with psychosocial adjustment. International Journal of
Ambulatory Medicine & Bright Futures Periodicity Behavioral Development, 30, 466-480.
Schedule Workgroup, 2016; NAPNAP, 2013; Vessey Carlisle, J., Shickle, D., Cork, M., & McDonagh, A. (2006). Concerns
et al., 2013). The incorporation of explicit information over confidentiality may deter adolescents from consulting their
pertaining to bullying into professional position doctors. A qualitative exploration. Journal of Medical Ethics, 32,
133-137.
statements and practice standards is needed. Centers for Disease Control and Prevention & U.S. Department of
Although adolescents are well aware that bullying is Education. (2014). Bullying surveillance among youths: Uniform
harmful, those participating in this study believed the definitions for public health and recommended data elements.
role of their nurse practitioners and physicians in Atlanta, GA: Author. Retrieved from: http://www.cdc.gov/
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