Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review.

Background: Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim: To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources: Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results: Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions: Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations. Future work: Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations: This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration: This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a 'realist review', which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature ­ not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour.

JUDO AS AN ALTERNATIVE INTERVENTION MODEL TO PREVENT BULLYING AT SCHOOLS: A PILOT STUDY.

This pilot study investigates the effectiveness of a school judo program as an alternative intervention model for bullying prevention. Conducted with 61 schoolchildren aged 10 to 13, the study employed psychological tests and a structured judo curriculum to assess changes in anxiety levels, bullying roles, and psychological traits. Results revealed a significant reduction in situational anxiety and a trend towards decreased personal anxiety among participants. Additionally, a significant decrease in direct and indirect victimization was observed, although no substantial changes were noted in bullying behaviors themselves. Improvements in self-assessment levels of trust, self-awareness, emotion regulation, confidence, and communication skills were also reported. These findings suggest that integrating judo into school programs may enhance psychological resilience and contribute to a safer school environment. However, further research is needed to explore the long-term effects and additional strategies for addressing bullying behaviors directly.

Preventing Adverse Childhood Experiences in a Sample of Largely Indigenous Children.

OBJECTIVES: The purpose of this study was to develop, pilot, and evaluate a culturally grounded, family-based program to prevent adverse childhood experiences (ACEs) among low-income and Indigenous children aged 10 to 14. The Tiwahe Wicagwicayapi program (TWP) is a 7-session program that teaches skills to prevent ACEs and is rooted in Lakota culture, language, and history. METHODS: A total of 124 families (124 caregivers [96% Indigenous; 90% reported yearly income <$40 000] with 194 children aged 10 to 14 [93% Indigenous]) were randomly assigned to treatment (N = 66 families and 173 individuals) or waitlist (N = 58 families and 145 individuals) control groups. Caregivers and children completed a baseline, immediate posttest, and 6-month follow-up survey. RESULTS: Treatment effects were detected, indicating, compared with control participants, reductions in the incidence of child ACEs (incidence rate ratio [IRR] = 0.64), bullying victimization (odds ratio = 0.53), depression (d = -0.20), and externalizing behaviors (d = -0.23) and increased parent-child communication (g = 0.27) and child help-seeking behaviors (d = 0.28). For caregivers, the effects indicated that the program prevented intimate partner violence victimization (IRR = 0.36) and perpetration (IRR = 0.45), harsh parenting (g = -0.35), and depression (d = -0.24) and increased emotion regulation (d = 0.37), social support (d = 0.33), and cultural connection (d = 0.34). CONCLUSIONS: The TWP holds great promise in preventing ACEs among low-income, Indigenous children, showing potential promise for widespread public health impact. Future rigorous research on the TWP is warranted.

Can classroom seating arrangements help establish a safe environment for victims? A randomized controlled trial.

Students around the globe still experience bullying daily. Teachers play a key role in supporting victimized students and they could do so using their classroom seating arrangement. Common teacher strategies are to separate victims and bullies and to seat victims close to supportive others, but research has not examined whether these strategies support victims' wellbeing. Therefore, the current study tested an intervention in which victims in experimental classrooms were seated far away from their bullies and next to their best friends, whereas a random seating arrangement was implemented in control classrooms. The underlying reasoning was that victims would experience a sense of safety next to their best friend and to limit bullies' opportunities to harass the victim. The outcomes were classroom comfort, internalizing problems, academic engagement, and victimization frequency. We used a sample of 1746 Dutch upper elementary school students (Mage = 10.21) of whom 250 students reported to be chronically and frequently victimized (Mage = 9.96 years). Ethical and practical reasons rendered the conditions similar regarding victims' distances to their bullies. Consequently, the intervention in the end tested the effect of victims sitting next to their best friend. Several mixed-effects models showed that no support was found for the effectiveness of this intervention. Additional exploratory analyses testing the effect of victims' continuous distances to their bullies on their wellbeing also found no effects. These findings suggest that changing victims', bullies', and best friends' seats do not improve victims' classroom wellbeing. Alternative explanations, directions for future research, and practical implications are discussed.

A preliminary randomized controlled study of the PEERS® program for Taiwanese autistic adolescents: The effectiveness on reducing school bullying and enhancing social function.

Individuals with autism spectrum disorder (ASD) often experience lifelong social communication challenges and are more vulnerable to school bullying. Addressing their social difficulties and school bullying requires evidence-based interventions. PEERS® (Program for the Education and Enrichment of Relational Skills) was adapted and translated for Taiwanese adolescents. This randomized controlled study aimed to examine the effectiveness of the Taiwanese version of PEERS® in reducing school bullying and enhancing social function among autistic adolescents. Twenty-one autistic adolescents (mean age 14.29 ± 1.67 years; female n = 733.33%) were randomized to a treatment group (TG, n = 10) or a delayed treatment control group (DTG, n = 11). The outcome measures (school bullying, social challenges, social skills knowledge, and social skills performance) were assessed at baseline, post-treatment, and follow-up. The group and time interaction analyses revealed greater magnitudes of reduction in general school bullying (p < 0.001), victimization (p < 0.001), perpetration (p = 0.012), social challenges (p = 0.001), and peer conflicts (p < 0.001), and improvement in social knowledge (p < 0.001) in the TG group than the DTG group. The findings suggest that the PEERS® program tailored for Taiwanese adolescents is effective in reducing school bullying, decreasing social challenges, and enhancing social skills among autistic adolescents, with very large effect sizes (Cohen's d ranging from 1.19 to 2.88). Consequently, participation in the PEERS® program is recommended for adolescents with social difficulties to improve their social communication and interactions to offset school bullying and other social challenges related to adverse outcomes.

Interventions that address interpersonal violence experienced by adolescents globally: a systematic review of reviews.

Globally, adolescents experience a significant burden of interpersonal violence, impacting their health, well-being and life trajectory. To address this, decision-makers need reliable evidence on effective interventions across various contexts. OBJECTIVES: Synthesise the evidence for interventions addressing interpersonal violence experienced by adolescents aged 10-25 years. METHODS: Six electronic databases were systematically searched. Systematic reviews and meta-analyses published globally between 2010 and 2022 were included if they reported interventions addressing interpersonal violence experienced by adolescents. Results were synthesised narratively. RESULTS: 35 systematic reviews were included, of which 16 were also meta-analyses. Majority of reviews included interventions set in high income countries (71%) and implemented in educational settings (91%). Effectiveness was reported in majority of interventions measuring victimisation and/or perpetration of intimate partner violence, sexual violence, bullying and/or cyberbullying (90%), majority of interventions measuring improvements in knowledge and attitudes towards violence (94%) and all interventions measuring bystander behaviour and improvements in well-being and quality of life. However, the quality of included reviews as per Assessment of Multiple Systematic Reviews 2 and National Health and Medical Research Council was low, and equity as per PROGRESS-PLUS was seldom considered. There was also a paucity of interventions addressing interpersonal violence in low-middle income countries (12%) and none of the included interventions specifically addressed interpersonal violence perpetrated in the home such as family violence. CONCLUSION: There is some evidence of promising interventions to address interpersonal violence experienced by adolescents, however there are gaps in scope and implementation. There is a need for equity-oriented public health approaches to comprehensively address the disproportionate burden of interpersonal violence experienced by adolescents globally, including those at the highest risk of harm. PROSPERO REGISTRATION NUMBER: CRD42020218969.

Positive Youth Development Approach to School Safety: A Comprehensive Conceptual Framework.

BACKGROUND: Youth violence, victimization, and bullying are pervasive in schools across the United States and are detrimental for learning and healthy development. K-12 school safety is an increasingly urgent issue to research and understand from multiple perspectives. Physical and psychological safety in school is linked to better student and school outcomes and is fundamental to fostering well-being and prosocial behavior. METHODS: Despite research demonstrating positive outcomes associated with school safety, there is no comprehensive conceptual model in the literature that considers precursors, strategies, mechanisms, and outcomes of school safety together. The current paper presents an equity-centered comprehensive model of school safety, which is intended as a holistic representation of the multiple factors and pathways that contribute to school safety and positive youth development. RESULTS: This model can guide research and practice through an equity-centered and comprehensive approach. This model can enable practitioners, researchers, and policymakers to make informed decisions and reach consensus regarding planning and decisions related to reducing violence and establishing supportive school environments. CONCLUSION: Our model suggests that a comprehensive approach can ensure the safety and well-being of students and staff. By thinking ecologically, schools, communities, and stakeholders can ensure that all aspects of the school context are included in school safety.

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals.

BACKGROUND: Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program "Ethos" implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for 'reflection' or 'recognition'. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos. METHODS: A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5-3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as 'extreme' (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics. RESULTS: In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P < 0.001) post-Ethos. The odds of experiencing incivility/bullying declined by 24% (adjusted odds ratio [aOR] 0.76; 95% CI 0.66,0.87; P < 0.001) and odds of experiencing extreme behaviours by 32% (aOR 0.68; 95% CI 0.54,0.85; P < 0.001) following Ethos. All four dimensions showed a reduction of 32-41% in prevalence post-Ethos. Non-clinical staff reported the greatest decrease in their experience of unprofessional behaviour (aOR 0.41; 95% CI 0.29, 0.61). Staff attitudes and reported skills to speak-up were significantly more positive at follow-up. Awareness of the program was high (82.1%; 95% CI 80.0, 84.0%); 33% of respondents had sent or received an Ethos message. CONCLUSION: The Ethos program was associated with significant reductions in the prevalence of reported unprofessional behaviours and improved capacity of hospital staff to speak-up. These results add to evidence that staff will actively engage with a system that supports informal feedback to co-workers about their behaviours and is facilitated by trained peer messengers.

Effectiveness of cognitive rehearsal programs for the prevention of workplace bullying among hospital nurses: a systematic review and meta-analysis.

BACKGROUND: To solve the problem of workplace bullying among nurses, it is necessary to review the effects of interventions and generalize the findings. We conducted a systematic literature review and meta-analysis to evaluate the effects of cognitive rehearsal programs on workplace bullying among hospital nurses. METHODS: Data were collected from March 30 to April 11, 2021, and 11,048 journal articles published in South Korea and internationally were examined across eight databases. Nine articles were selected for inclusion in the systematic literature review; five of the nine studies were included in the meta-analysis. For randomized controlled trials, the risk of bias was evaluated, and for non-randomized controlled trials, the study quality was evaluated using the Risk of Bias for Non-randomized Studies version 2.0. Egger's regression test was performed to determine publication bias. RESULTS: Of the nine articles selected for this study, two were randomized controlled trials and seven were non-randomized controlled trials. The I2 value was 18.9%, indicating non-significant heterogeneity. The overall effect size of the cognitive rehearsal programs was -0.40 (95% confidence interval: -0.604 to -0.196; Z = -3.85; p = .0001) in a random-effects model, indicating a large effect size with statistical significance. CONCLUSIONS: Therefore, cognitive rehearsal programs that address workplace bullying among hospital nurses are effective. Health policymakers must implement cognitive rehearsal programs in a policy manner to address the problems of bullying in the workplace.

Effectiveness of the KiVa anti-bullying program in the Czech Republic: A cluster randomized control trial.

AIMS: One of the most widely used evidence-based anti-bullying programs, KiVa, originates from Finland and aims to change students' peer context, activate teachers, and inform parents with two main components (universal preventive actions and indicated actions when bullying occurs), complemented by monitoring. Because research documented somewhat varied KiVa outcomes in different countries and because there is a lack of research focusing solely on the effectiveness of the universal and indicated actions, this study aimed to evaluate the effectiveness of KiVa main components when implemented in a new country. This two-arm parallel cluster randomized control trial (RCT) evaluated the effectiveness of the KiVa anti-bullying program in elementary schools in the Czech Republic. It examined the effects of the universal and indicated actions on self-reported bullying and victimization as primary outcomes and well-being as a secondary outcome, while keeping monitoring constant across the intervention and control schools. The study also examined the role of implementation fidelity on the proposed outcomes. METHODS: Schools were allocated via stratified randomization into a KiVa intervention group (12 schools, 35 classes, N = 407 students) or a wait-list control group (12 schools, 32 classes, N = 400 students). The study employed data from baseline and post-measurement waves, which were 10 months apart. RESULTS: The data were analyzed using linear mixed effects models, which showed no significant intervention or fidelity effects for bullying, victimization, and well-being. However, promising trends (at α < .10) were revealed, such as lower levels of bullying observed in the intervention group and in schools with high implementation fidelity. Additional analysis using Bayes factors supported these promising trends and provided moderate support for lower levels of victimization in the intervention group compared to the control schools. CONCLUSIONS: Evaluation of effectiveness of anti-bullying programs could benefit from a more targeted fidelity assessment at the classroom or individual level and from distinguishing between the effects of the main components of the programs and the effects of monitoring. The promising yet non-significant intervention and fidelity effects suggest that schools may require enhanced support and longer implementation time frames than a single school year, especially when implementation faces structural obstacles, such as the Covid-19 pandemic.

Antibullying Interventions in Schools: Assessing the Evidence Base.

OBJECTIVE: This systematic review used established rating criteria to describe the level of evidence for interventions aimed at preventing or reducing bullying perpetration and victimization in schools, synthesized the evidence for students from racially and ethnically diverse backgrounds, and reviewed the literature for available information to conduct an economic analysis of the interventions. METHODS: Major databases, gray literature, and evidence-base registries were searched to identify studies published from 2008 through 2022. The authors rated antibullying intervention models as having high, moderate, or low evidence depending on the number and rigor of studies with positive findings. RESULTS: Overall, 80 articles reporting on 71 original research studies describing a total of 48 antibullying interventions met the inclusion criteria for this review. Two schoolwide interventions received a high-evidence rating: the KiVa (Kiusaamista Vastaan) Antibullying Program and the Friendly Schools program. Multilevel interventions with components at the levels of school, classroom, and individual student most consistently showed strong evidence for reducing bullying behavior in elementary and middle school grades. Four interventions yielded positive effects in reducing bullying and victimization among diverse samples of students. CONCLUSIONS: Antibullying interventions can reduce bullying in schools. Some interventions show effectiveness with students from racially and ethnically diverse backgrounds. The gains relative to per-student costs were in the range that is considered cost-effective. Most implementation costs are spent on staff training and support. Research on successful implementation of whole-school interventions and additional synthesis of evidence pertaining to program structures would further advance the antibullying evidence base.

The effect of self-esteem development programme applied to secondary school students on self-esteem and peer bullying victimization: A randomized controlled trial.

BACKGROUND: Self-esteem and peer bullying, which affect the academic success and psychological development of secondary school students, are increasingly becoming a serious problem. AIM: This study was conducted to examine the effect of the Self-Esteem Development Programme applied to secondary school students on self-esteem and peer bullying victimization. METHODS: This randomized controlled trial was conducted with 66 students (intervention = 33, control = 33) studying in the 6th grade at a secondary school. Personal Information Form, Rosenberg Self-Esteem Scale and Peer Bullying Identification Scale Adolescent Form were used to collect the data. The intervention group received 8 sessions of Self-Esteem Development Programme in the form of one session per week of 45-60 min; the control group continued their routine education programme. RESULTS: In the study, after the Self-Esteem Development Programme, the mean self-esteem score of the intervention group increased and the mean peer bullying score decreased, and the difference between the groups was found to be statistically significant (p < 0.05). CONCLUSION: In conclusion, it can be stated that the Self-Esteem Programme is an effective psychiatric nursing intervention in increasing self-esteem and reducing peer bullying. IMPLICATIONS FOR PRACTICES: Students with low self-esteem are at risk of exposure to peer bullying. This study provides significant evidence for improving the self-esteem and reducing peer bullying among students who are at risk due to low self-esteem and peer bullying. The results of this study demonstrate that the Self-Esteem Development Programme can be utilized to enhance self-esteem and reduce exposure to peer bullying among students. CLINICALTRIALS ID: NCT04737374.

Why step in? Shifting justifications for bystander behaviors through interventions with youth in the Middle East.

Research shows positive bystander intervention effectively mitigates bullying experiences. Yet, more evidence regarding bystander responses to bias-based social exclusion (BSE) is needed in intergroup contexts, especially in the majority world and in areas of intractable conflict. This study assessed the effectiveness of skills and skills + contact-based interventions for BSE among 148 Palestinian Citizens of Israel (Mage = 10.55) and 154 Jewish-Israeli (Mage = 10.54) early adolescents (Girls = 52.32%) in Tel Aviv-Yafo. Bystander responses were assessed by participants' reactions to hypothetical BSE scenarios over three time points. Repeated measures ANOVAs revealed both interventions significantly increased positive and decreased negative bystander responses, with changes maintained at the follow-up. The opposite result pattern emerged for the control group. Findings suggest that both interventions can effectively encourage youth to publicly challenge BSE, even amidst intractable conflict.

Examining Teacher Concerns and Anxiety on the Implementation of a Universal Body Image Program.

In the past 30 years, there have been numerous positive body image and eating disorder prevention programs targeting youth developed for school-based settings. Frequently, teachers are used as interventionists to increase dissemination, decrease costs relative to researchers, and increase scalability. However, little is known about teacher concerns and barriers that may hinder successful uptake and implementation. The current study recruited a total of 269 teachers who consented to implement a universal body image and appearance-related bullying and teasing prevention program in their classrooms as part of a randomized controlled trial. Teachers expressed some worry that they may say the wrong thing, and concern about feeling uncomfortable teaching the program due to their own body dissatisfaction. Teacher's ethnicity, gender, years teaching, dieting behaviors and other weight control behaviors, and self-efficacy were not associated with concerns related to teaching the curriculum. Teachers with lower body esteem reported higher concerns and anxiety related to teaching a body image curriculum. In free response items, teachers worried about handling student comments that were beyond the scope of the curriculum. Teacher self-efficacy was the only variable associated with the number of program sessions implemented. Findings suggest avenues to increase implementation.

Sex and Racial/Ethnic Differences in School Security Measures, Bullying Victimization, and Perceived School Safety: Implications for Pediatric Health Care.

INTRODUCTION: Using the 2017 National Crime Victimization Survey dataset, this study examined the association between the types of school security measures and students' bullying victimization and perceived school safety. METHOD: Using logistic regression and ordinary least square regression analyses, the study addressed whether these associations vary by sex and race/ethnicity, as most research has treated sex and race/ethnicity as covariates. RESULTS: The study found that none of the security measures were associated with bullying victimization among the total sample. However, there were sex and racial differences in the association between security measures and bullying victimization. There were also sex and racial/ethnic variations in the association between security measures and perceived school safety. DISCUSSION: Scholars, health care practitioners, and policymakers must reflect and reconsider whether increasing school security and control would contribute to the safety and well-being of racial/ethnic minority students in school.