Workplace Bullying in the NursingProfession

Susan L. Johnson

Contents1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Definitional Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Description of Workplace Bullying Experienced by Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.2 Types of Behaviours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

4 Contributing Factors to Workplace Bullying Among Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Responses to Workplace Bullying in the Nursing Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Cross-References to the Other Volumes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

AbstractNursing is one of the professions with the highest rates of workplace bullying.Since most people access healthcare services at some point in their life, and thereis evidence that workplace bullying negatively affects patient care, workplacebullying among nurses has ramifications for society in general. In order tounderstand the phenomenon of bullying among nurses, this chapter criticallyexamines the international research on workplace bullying among nurses. Thisdiscussion begins with an exploration of the terms workplace bullying, lateraland horizontal violence and mobbing, which have been used in the nursingacademic literature to describe the phenomenon. An overview of the findings ofdescriptive studies of workplace bullying, including the characteristics of targetsand perpetrators, and the most commonly reported behaviours is provided. The

S. L. Johnson (*)University of Washington Tacoma, Tacoma, WA, USAe-mail: slj6@uw.edu

# Springer Nature Singapore Pte Ltd. 2018P. D’Cruz et al. (eds.), Special topics and particular occupations, professions andsectors, Handbooks of Workplace Bullying, Emotional Abuse and Harassment 4,https://doi.org/10.1007/978-981-10-5154-8_14-1

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outcomes of bullying for nurses, patients and healthcare organizations and theimplications for society at large are discussed. In order to understand whyworkplace bullying is so prevalent among nurses, and to develop effectiveinterventions to counter this bullying, the factors which contribute to workplacebullying among nurses are explored. Finally, an examination of current efforts toaddress workplace bullying among nurses indicates that these efforts are insuffi-cient as they are not addressing the antecedents of workplace bullying and areonly targeting behavioural outcomes at an individual level.

1 Introduction

Globally, nurses experience non-physical violence, in the form of incivility, bullyingand verbal abuse, at higher rates than actual physical violence (Spector, Zhou, &Che, 2013). Sources of non-physical violence can be co-workers, patients, familiesand visitors. While non-physical violence perpetrated by patients, families and othervisitors is a concern, it is a phenomenon with different root causes and differentsolutions and is beyond the scope of this chapter to discuss. Incivility, bullying andverbal abuse are all forms of non-physical violence; however, there are sufficientconceptual and operational differences in the definitions of the three that the focus ofthis chapter will be on workplace bullying. The concept of workplace bullyingincludes behaviours also found in the definitions of incivility and verbal abuse;however, to meet the criteria of workplace bullying, these behaviours have to berepeated on a regular basis for an extended period of time. As such, they have thepotential for creating lasting harm and can become more entrenched in anorganization.

Increasingly, research has demonstrated that workplace bullying rates amongnurses are among the highest of any profession. At the same time, the phenomenonhas received attention from nurse leaders, educators and researchers. This chapterwill provide a critical overview of the current state of knowledge of workplacebullying in the nursing profession with the goal of understanding the roots of theproblem and why current efforts to address it are falling short. While great strideshave been made in understanding the phenomenon of workplace bullying amongnurses, there is much that is yet to be learned. As such, recommendations for futureresearch will be interwoven throughout the chapter.

2 Definitional Issues

Within nursing, as within the broader academic community, there has beenmuch debate on how to label and measure bullying-type behaviours in the work-place. Within the nursing literature, workplace bullying, mobbing and horizontal (orlateral) violence are the terms which are most commonly used to describe thesebehaviours. This section will briefly explore each of these terms, how they aredefined and how they are measured in empirical studies.

2 S. L. Johnson

When bullying-type behaviours, such as “overt and covert non-physical hostility. . .criticism, sabotage, undermining, infighting, scapegoating and bickering”(Duffy, 1995, p. 9), were first discussed in the nursing literature (Duffy, 1995;Roberts, 1983), they were given the label of horizontal violence. Horizontal violence(now commonly referred to as lateral violence) was a term which was originally usedby Fanon (1963), and later by Freire (1970), to describe the inter-group violencethey observed among colonized natives, whom they considered to be politicallyoppressed. The premise, which is theoretical rather than empirical, was that insteadof working together to fight oppression, oppressed groups tended to displace theirhostility towards each other (Fanon, 1963; Freire, 1970). Roberts (1983) and Duffy(1995) posit that because nursing practice is historically viewed as subservient tomedical practice, nurses are an oppressed group, and, like the colonized natives thatFanon and Freire wrote about, instead of working to improve their organizationalpositions, they engage in acts of horizontal violence against each other.

While some authors view lateral violence and workplace bullying as essentiallythe same construct (e.g. Sellers, Millenbach, Ward, & Scribani, 2012; Vessey,Demarco, & DiFazio, 2010), others maintain that there are essential differencesbetween the two (e.g. Embree & White, 2010; Nemeth et al., 2017; Oh, Uhm, &Yoon, 2016; Roberts, 2015). These differences will be discussed below. Whileunique instruments to measure lateral violence have been developed (Demarco,Roberts, Norris, & McCurry, 2008; Nemeth et al., 2017; Oh, Uhm, & Yoon, 2016;Stanley, Martin, Michel, Welton, & Nemeth, 2007), some researchers use instru-ments designed to measure workplace bullying (such as the Negative Acts Ques-tionnaire-Revised [NAQ-R; Einarsen, Hoel, & Notelaers, 2009]) in studies of lateralviolence (e.g. Purpora, Blegen, & Stotts, 2012).

Quine (2001) conducted the first study which exclusively examined workplacebullying in the nursing profession, and in the mid- to late 2000s, research on thistopic has expanded rapidly. While the specific definitions of workplace bullying usedin the nursing literature vary slightly, in general “bullying in the nursing workplace isconsidered to be the repeated, cumulative, and patterned form of negative behavioursof a perpetrator abusing his or her power over time toward the victim, resulting in aprofound negative impact on the bully victim and organization” (Lee, Bernstein,Lee, & Nokes, 2014, p. 263).

As in other academic disciplines, workplace bullying in the nursing literature haseither been measured through a single-item question (see Ortega, Christensen, Hogh,Rugulies, & Borg, 2011) or through a validated instrument such as the NAQ-R(Einarsen, Hoel, & Notelaers, 2009). Researchers who have used the NAQ-R havevariously operationalized workplace bullying as one behaviour that occurred at leastonce a week for 6 months (e.g. Sá & Fleming, 2008; Yokoyama et al., 2016), twobehaviours that occurred at least once a week for 6 months (e.g. An & Kang, 2016;Johnson & Rea, 2009; Simons, 2008) or by another scoring method (e.g. Evans,2017; Sauer & McCoy, 2016).

Positing that other instruments did not adequately capture the phenomenon ofbullying among nurses, Hutchinson, Wilkes, Vickers and Jackson (2008) designedan instrument to specifically measure workplace bullying in the nursing profession.Likewise, Simons, Stark and DeMarco (2011) developed a four-item version of the

Workplace Bullying in the Nursing Profession 3

NAQ-R to measure perceived bullying among nurses. To date, neither of theseinstruments has been extensively used in research.

The third term that frequently appears in the nursing literature to describebullying in the workplace is mobbing. Mobbing is used synonymously with work-place bullying and is not seen as a distinct concept. The term most commonlyoccurs in research that utilized the Workplace Violence Questionnaire (WVQ)(International Labour Organization (ILO), Council of Nurses, World Health Orga-nization, & Public Services International, 2003), a survey which was designed tomeasure the scope of workplace violence experienced by healthcare professionalsaround the world. This survey, which has been used in research in countries such asPakistan, Taiwan, Iran and Australia (Pai & Lee, 2011; Somani, Karmaliani,McFarlane, Asad, & Hirani, 2015; Teymourzadeh, Rashidian, Arab, Akbari-Sari,& Hakimzadeh, 2014; Tonso et al., 2016), uses the phrase bullying/mobbing, whichis listed as a type of psychological violence and defined as “repeated and over timeoffensive behaviour through vindictive, cruel, or malicious attempts to humiliate orundermine an individual or groups of employees” (ILO et al., 2003, p. 3). In theWVQ, the following yes/no question is used to measure the prevalence of bullying/mobbing: “In the last 12 months, have you been bullied/mobbed in your work-place?” (ILO et al., 2003, p. 9).

The term mobbing also appears in a Turkish research of workplace bullyingamong nurses (Efe & Ayaz, 2010; Ekici & Beder, 2014; Yildirim & Yildirim,2007; Yildirim, 2009) and is defined as:

attitudes and behaviours that can be psychological abuse, such as, terrorizing, annoying,excluding, being considered parenthetical, belittling, being deprived of some organizationresources, isolating, being treated unjustly in the use of organizational resources, beingprevented from or delayed from claiming rights. (Yildirim & Yildirim, 2007, p. 1445)

While Turkish researchers view mobbing as synonymous with workplace bullying,when studying the phenomenon they typically use instruments specifically designedto capture the experiences of nurses who work in Turkish healthcare settings(Yildirim, 2009; Yildirim & Yildirim, 2008; Efe & Ayaz, 2010).

While there are slight differences in the conceptual and operational definitionsof workplace bullying, mobbing and lateral (or horizontal) violence, these terms areoften used interchangeably within the nursing literature (e.g. Ekici & Beder, 2014; Pai& Lee, 2011; Purpora, 2012; Sellers, Millenbach, Ward, & Scribani, 2012; Tong,Schwendimann, & Zúñiga, 2017). However, by definition, lateral violence can onlyinvolve members of the same profession (i.e. nursing) who are peers, and, unlikeworkplace bullying, even one-time events can be classified as lateral violence (Embree& White, 2010; Griffin, 2004; Nemeth et al., 2017; Roberts, 2015). These differencesmake it difficult to compare research on lateral violence with research on workplacebullying. In order for the research on workplace bullying among nurses to be placed incontext with the greater body of research on workplace bullying, it is recommendedthat future researchers should uniformly adopt the term workplace bullying and useconceptual and operational definitions that are consistent.

4 S. L. Johnson

In this chapter, it is assumed that workplace bullying, mobbing and lateral (orhorizontal) violence are essentially the same concept. Workplace bullying willpredominantly be used, as this is the terminology which is now most commonlyencountered in the nursing literature. However, when reporting results of the givenstudies, the label that is used by the authors of that study will be used.

3 Description of Workplace Bullying Experienced by Nurses

3.1 Prevalence

The estimated global prevalence rate of workplace bullying among the generalpopulation of workers is between 11% and 18% (Nielsen, Matthiesen, & Einarsen,2010). In contrast, a review of the literature on workplace violence in the nursingprofession calculated that 39.7% of nurses worldwide have been victims of work-place bullying (Spector, Zhou, & Che, 2013). Among the articles reviewed for thischapter, the reported prevalence of workplace bullying experienced by nursesranges from 4.6% in Switzerland (Tong, Schwendimann, & Zúñiga, 2017) to44% in the United Kingdom (UK) (Quine, 2001) (see Table 1). While the compar-ison of prevalence rates should be done with caution as sampling and measurementmethods affect results (Nielsen, Matthiesen, & Einarsen, 2010), and while bullyingrates of nurses vary by region (Spector, Zhou, & Che, 2013), it appears thatworkplace bullying is more prevalent in the nursing sector than among the generalpopulation of workers. While studies of workplace bullying among nurses havetended to rely on convenience sampling, and sample sizes have been quite small,these are also limitations to the research on workplace bullying among the generalpopulation of workers (Nielsen & Einarsen, 2012). Future research on workplacebullying of nurses should strive for larger samples with a more robust samplingmethod.

It is important to note that cultural differences undoubtedly affect prevalencerates. For example, when comparing studies that used the same operational definitionof workplace bullying (two behaviours at least weekly on the NAQ-R), prevalencevaried from 15.8% in Korea (An & Kang, 2016) to 22% in Israel (Ganz et al., 2015),21–31% in the United States (USA) (Johnson & Rea, 2009; Purpora, Blegen, &Stotts, 2012; Simons, 2008) and to 29–33% in Canada (Laschinger, Grau, Finegan,& Wilk, 2010; Spence Laschinger, Wong, & Grau, 2012). Similarly, when compar-ing studies that operationalized workplace bullying as one behaviour weekly, usingthe NAQ-R, rates varied from 13% in Portugal (Sá & Fleming, 2008) to 18.5% inJapan (Yokoyama et al., 2015) and to 34% in Italy (Bortoluzzi, Caporale, & Palese,2014). Cultural differences that may explain these variations include the status ofwomen in a given country (since nursing is a predominantly female occupation), thestatus of nursing in the healthcare hierarchy in that country as well as the norms ofcommunication and conflict within a particular culture.

Workplace Bullying in the Nursing Profession 5

Table 1 Summary of studies on the prevalence of workplace bullying and related concepts amongnurses

Country Authors Label used

Measurementtool andoperationaldefinition

Sample andsampling method

Results:Prevalence(sample size)

Australia Demir andRodwell (2012)

Workplacebullying

Single-itemquestion (Hoel& Cooper,2000)

Nurses in onehospitalConveniencesample

34.3%(n = 207)

Rodwell andDemir (2012b)

Workplacebullying

Single-itemquestion (Hoel& Cooper,2000)

Nurses in onehospital and oneaged care facilityConveniencesample

37.3%(hospital)35.6% (agedcare facility)(n = 475)

Rodwell, Demirand Steane(2013)

Workplacebullying

Single-itemquestion (Hoel& Cooper,2000)

Nurses in multiplehospitals in oneorganizationConveniencesample

35%(n = 435)

Tonso et al.(2016)

Workplacebullying/mobbing

WVQ (ILOet al., 2003)Single-itemquestion

Mental healthworkers (76%nurses) who weremembers of aunion in Victoria,AustraliaRandom selection

30%(n = 394)

Brazil Fontes,Santana,Pelloso andCarvalho(2013)

Workplacebullying

LeymannInventory ofPsychologicalTerror (LIPT-45)One behaviourat least weekly� 6 months

Nurses in publicand private sector;employed for>1 yearConveniencesample

11.6%(n = 199)

Canada Laschinger,Grau, Fineganand Wilk(2010)

Workplacebullying

NAQ-RTwobehaviours atleast weekly �6 months

Nurses with<3 years’experience inOntario, CanadaConveniencesample

33%(n = 415)

SpenceLaschinger,Wong and Grau(2012)

Workplacebullying

NAQ-RTwobehaviours atleast weekly �6 months

Nurses with<2 years’experience inOntario, CanadaRandom sample

29.2%(n = 342)

(continued)

6 S. L. Johnson

Table 1 (continued)

Country Authors Label used

Measurementtool andoperationaldefinition

Sample andsampling method

Results:Prevalence(sample size)

Rush,Adamack,Gordon andJanke (2014)

Workplacebullying

Single-itemquestion

Nurses with<1 year’sexperience inBritish Columbia,CanadaConveniencesample

39%(n = 242)

China(HongKong)

Cheung, Leeand Yip (2017)

Verbalabuse/bullying

WVQ (ILOet al., 2003)Single-itemquestion

Nurses from sixhealthcareorganizationssupervised by theMacau HealthBureauConveniencesample

14.5%(n = 613)

Denmark Ortega,Christensen,Hogh, Ruguliesand Borg(2011)

Workplacebullying

Single-itemquestion[Frequentlybullied: daily toweeklyOccasionallybullied:monthly orless]

Workersa in theelderly care sectorin 36 DanishmunicipalitiesConveniencesample

9.1%[1.8%frequently7.3%occasionally](n = 9949)

Greece Karatza, Zyga,Tziaferi andPrezerakos(2016)

Workplacebullying

Single-itemquestion[includesrarely,occasionally,daily toweekly]

Nurses in fivemajor GreekhospitalsConveniencesample

30.2%[3.1%frequently9.9%occasionally17.2%rarely](n = 841)

Israel Ganz et al.(2015)

Workplacebullying

NAQ-RTwo negativeacts at leastweekly �6 months

Intensive carenurses in fivemedical centres inIsraelConveniencesample

22%(n = 156)

Iran Teymourzadeh,Rashidian,Arab, Akbari-Sari andHakimzadeh(2014)

Workplacebullying/mobbing

WVQ (ILOet al., 2003)Single-itemquestion

Nurses in a majorteaching hospitalConveniencesample

29%bullying/mobbing(n = 301)

(continued)

Workplace Bullying in the Nursing Profession 7

Table 1 (continued)

Country Authors Label used

Measurementtool andoperationaldefinition

Sample andsampling method

Results:Prevalence(sample size)

Italy Bortoluzzi,Caporale andPalese (2014)

Mobbing NAQ-ROne behaviourat least weekly� 6 months

Nurses in threehospitals inNorthern ItalyConveniencesample

34%(n = 238)

Japan Yokoyama et al.(2016)

Workplacebullying

NAQ-ROne behaviourat least weekly� 6 months

Nurses in TokyoConveniencesample

18.5%(n = 898)

Korea An and Kang(2016)

Workplacebullying

NAQ-RTwobehaviours atleast weekly �6 months

Nurses in eighthospitals in Busan,KoreaConveniencesample

15.8%(n = 297)

Lithuania Malinauskiene,Leisyte,Romualdas andKirtiklyte(2011)

Workplacebullying

Single-itemquestionNever/occasional/severe

Nurses in ninehospitalsRandom sample

23.3%occasional2.7% severebullying(n = 748)

Nigeria Nwaneri,Onoka andOnoka (2017)

Workplacebullying

Single-itemquestionOften: >5events/weekSometimes:3–4 events/weekSeldom: 1–2events/week

Nurses in fourhospitalsProportionatestratified sampling

11.7% often34.6%sometimes44.9%seldom(n = 214)

Pakistan Somani,Karmaliani,McFarlane,Asad and Hirani(2015)

Bullying/mobbing

WVQ (ILOet al., 2003)Single-itemquestion

Nurses in fourhospitals inKarachi, PakistanRandom sample

33.8%(n = 458)

Portugal Sá and Fleming(2008)

Workplacebullying

NAQ-ROne behaviourat least weekly� 6 months

Nurses in thePortuguese publichealth systemConveniencesample

13%(n = 107)

Norton et al.(2017)

Workplacebullying

NAQ-ROne behaviour

Nurses in onehospital

12.5%(n = 264)

(continued)

8 S. L. Johnson

Table 1 (continued)

Country Authors Label used

Measurementtool andoperationaldefinition

Sample andsampling method

Results:Prevalence(sample size)

at least weekly� 6 months

Conveniencesample

Switzerland Tong,Schwendimannand Zúñiga(2017)

Mobbing Simons, Starkand DeMarco’s(2011) four-item version ofNAQ-ROne behaviourat least weekly� 6 months

Nurses in Swissnursing homesRandom sample

4.6%(n = 5311)

Taiwan Pai and Lee(2011)

Bullying/mobbing

WVQ (ILOet al., 2003)Single-itemquestion

Members of theTaiwan NursesAssociationRandom sample

29.8%(n = 545)

Turkey Yildirim (2009) Workplacebullying

Yildirim andYildirim’s(2008)instrument

Nurses in onehospital in Ankara,TurkeyConveniencesample

21%(n = 286)

Efe and Ayaz(2010)

Mobbing Ozturk et al.(2007)mobbing scale

Nurses in onehospital in Ankara,TurkeyConveniencesample

9.7%(n = 206)

Ekici and Beder(2014)

Workplacebullying

Yildirim andYildirim’s(2008)instrument

Nurses in onehospital in TurkeyConveniencesample

12%(n = 309)

Picakciefe,Acar, Colak andKilic (2017)

Mobbing Leymann scaleadapted toTurkey(Yildirim,Yildirim, &Timucin, 2007)

Healthcare workersin primary care inMugla, Turkeya

Conveniencesample

31.1%(n = 119)

USA Simons (2008) Workplacebullying

NAQ-RTwobehaviours atleast weekly �6 months

Nurses in the stateof MassachusettsRandom sample

31%(n = 511)

Johnson andRea (2009)

Workplacebullying

NAQ-RTwobehaviours atleast weekly �6 months

Members ofWashington StateEmergency NursesAssociationConveniencesample

27.3%(n = 249)

(continued)

Workplace Bullying in the Nursing Profession 9

3.1.1 Characteristics of TargetsAs a whole, research on workplace bullying among nurses has found no associationbetween workplace bullying and the demographic characteristics of targets such asgender, age, ethnicity, education level, length of time in the profession or length oftime at a given workplace. While gender minorities in other occupations seem to be

Table 1 (continued)

Country Authors Label used

Measurementtool andoperationaldefinition

Sample andsampling method

Results:Prevalence(sample size)

Berry,Gillespie, Gatesand Schafer(2012)

Workplacebullying

NAQ-RWeighted scoreto determinedaily bullying

Nurses in threestates who hadbeen practising<3 yearsStratified randomsample

21.3%(n = 197)

Purpora, Blegenand Stotts(2012)

Workplacebullying/horizontalviolence

NAQ-RTwobehaviours atleast weekly �6 months

Nurses in the stateof CaliforniaRandom sample

21.1%(n = 175)

Vogelpohl,Rice, Edwardsand Bork(2013)

Workplacebullying

Single-itemquestion

Recent (<3 years)graduates of fivecolleges of nursingin the state of OhioRandom sample

20.5%(n = 135)

Sauer andMcCoy (2016)

Workplacebullying

NAQ-R(Notelaers &Einarsen,2013) scoring

Nurses in one stateRandom sample

22.8%severebullying19.3%moderatebullying(n = 345)

UK Quine (2001) Workplacebullying

Questionnairedesigned forthe studyOne or morebehavioursduring theprevious12 months

Nurses in oneNational HealthService (NHS)trustConveniencesample

44%(n = 396)

Carter et al.(2013)

Workplacebullying

Single-itemquestion

Nurses in sevenNHS organizationsRandom andconveniencesampling

19% daily/weekly(n = 500)

aSample included non-nurses

10 S. L. Johnson

more prone to workplace bullying (Salin & Hoel, 2013), the research in the nursingprofession has not supported this idea. One exception was a study by Eriksen andEinarsen (2004), which found that male assistant nurses in Norway were more likelyto be bullied than female assistant nurses. The fact that an assistant nurse is at a lowerrank than a registered nurse may explain this anomaly. Other exceptions to thefindings on gender are a study in the UK which reported a significantly higherprevalence of workplace bullying among male nurses (Carter et al., 2013) and astudy in Iran which reported a significantly higher prevalence among female nurses(Teymourzadeh, Rashidian, Arab, Akbari-Sari, & Hakimzadeh, 2014). These excep-tions may be due to cultural differences in the relative status of women and menin the overall culture, or they might be statistical anomalies. Future research shouldexplore why male nurses are not experiencing higher rates of workplace bullyingthan female nurses. Since nursing is predominantly female, it is possible that thisfinding reflects the lack of variability in the sample. Therefore, future studies mayconsider oversampling for male nurses.

Despite the often-repeated trope that “nurses eat their young”, a phrase that wascoined by Meissner (1986) to describe the lack of support new nurses received in theworkplace, only a few studies have reported that new nurses were more likely toexperience workplace bullying (Efe & Ayaz, 2010; Fang, Huang, & Fang, 2016;Nwaneri, Onoka, & Onoka, 2017; Yildirim, 2009). As shown in Table 1, studies inthe USAwhich only included new nurses (Berry, Gillespie, Gates, & Schafer, 2012;Vogelpohl, Rice, Edwards, & Bork, 2013) reported similar prevalence rates as thosewhich included nurses with all levels of experience (Johnson & Rea, 2009; Purpora,Blegen, & Stotts, 2012; Simons, 2008).

Among the reviewed studies, the only individual characteristic of targetswhich was consistently associated with workplace bullying was poor physical ormental health. However, most of these studies utilized a cross-sectional design(Carter et al., 2013; Malinauskiene, Leisyte, Romualdas, & Kirtiklyte, 2011;Picakciefe, Acar, Colak, & Kilic, 2017; Sauer & McCoy, 2016), which makes itdifficult to determine if poor health is an antecedent or an outcome. Carter et al.(2013) reported that nurses who had a disability were more likely to report work-place bullying. Since most disabilities are chronic, and take longer than 12 months tomanifest, it is possible that in this study disabilities were an antecedent rather than anoutcome of bullying. In one of the few longitudinal studies on workplace bullyingamong nurses, Reknes et al. (2014) reported that baseline anxiety, depression andfatigue were predictors of subsequent workplace bullying among nurses. Similarly, alarge-scale representative study of workers in all occupational sectors of the UKfound that disability and chronic illness were risk factors for workplace bullying(Fevre, Lewis, Robinson, & Jones, 2013). Nurses with chronic physical and mentalillnesses might be bullied because they are perceived to be less able to perform theirduties. It is also possible that these nurses have higher levels of negative affectivityor lower levels of psychological capital, both of which have been associated withbeing a target of workplace bullying (Demir & Rodwell, 2012; Spence Laschinger &Nosko, 2015). The link between bullying and chronic mental or physical illness is anarea that needs more research, ideally in the form of longitudinal studies.

Workplace Bullying in the Nursing Profession 11

3.1.2 Characteristics of PerpetratorsThe majority of the reviewed studies did not report information regarding perpetra-tors. Among those studies which did report this information, the predominantperpetrator was another nurse who occupied a position of authority over the target(e.g. managers, supervisors or charge nurses) (Johnson & Rea, 2009; Picakciefe,Acar, Colak, & Kilic, 2017; Quine, 2001; Vessey, DeMarco, Gaffney, & Budin,2009; Vogelpohl, Rice, Edwards, & Bork, 2013; Yildirim, 2009). Two studiesreported that peers were primarily responsible for perpetrating acts of workplacebullying (Berry, Gillespie, Gates, & Schafer, 2012; Evans, 2017), and one studyreported that managers and peers were equally responsible for workplace bullying(Pai & Lee, 2011). Vessey, DeMarco, Gaffney and Budin (2009) reported that nurseswho had previously been targets of workplace bullying were more likely to reportthat they had engaged in bullying behaviours themselves. None of the studiesreported that physicians were the primary perpetrators of workplace bullying ofnurses.

3.2 Types of Behaviours

Workplace bullying behaviours are often classified as follows: person-related bul-lying, work-related bullying and physical bullying (Nielsen, Notelaers, & Einarsen,2011; Zapf, Escartin, Einarsen, Hoel, & Vartia, 2011). As a whole, nurses reportmore work-related acts of bullying than person-related bullying (e.g. Berry, Gilles-pie, Gates, & Schafer, 2012; Terzioglu, Temel, & Uslu Sahan, 2016). Examples ofthe predominant forms of work-related bullying reported by nurses include exces-sive monitoring of work (Ekici & Beder, 2014; Quine, 2001; Sá & Fleming, 2008),assigning the target work below their level of competency (Chipps, Stelmaschuk,Albert, & Bernhard, 2013; Johnson & Rea, 2009; Purpora, Blegen, & Stotts, 2012;Sá & Fleming, 2008; Vogelpohl, Rice, Edwards, & Bork, 2013), withholdinginformation (Abe & Henly, 2010; Berry, Gillespie, Gates, & Schafer, 2012; Chipps,Stelmaschuk, Albert, & Bernhard, 2013; Johnson & Rea, 2009) and public humil-iation (Chipps, Stelmaschuk, Albert, & Bernhard, 2013; Nwaneri, Onoka, &Onoka, 2017; Quine, 2001; Vessey, DeMarco, Gaffney, & Budin, 2009). Straddlingthe line between person-related and work-related bullying, nurses also frequentlyreport that they are ignored at work, either via social exclusion (Berry, Gillespie,Gates, & Schafer, 2012; Chipps, Stelmaschuk, Albert, & Bernhard, 2013;Picakciefe, Acar, Colak, & Kilic, 2017; Purpora, Blegen, & Stotts, 2012; Quine,2001; Simons, 2008; Vogelpohl, Rice, Edwards, & Bork, 2013) or by having theirprofessional opinions ignored (Berry, Gillespie, Gates, & Schafer, 2012; Chipps,Stelmaschuk, Albert, & Bernhard, 2013; Johnson & Rea, 2009; Purpora, Blegen, &Stotts, 2012; Simons, 2008; Terzioglu, Temel, & Uslu Sahan, 2016). Gossip isanother form of person-related bullying that is frequently experienced by nurses(Berry, Gillespie, Gates, & Schafer, 2012; Chipps, Stelmaschuk, Albert, &Bernhard, 2013; Nwaneri, Onoka, & Onoka, 2017; Simons, 2008; Vessey,DeMarco, Gaffney, & Budin, 2009; Vogelpohl, Rice, Edwards, & Bork, 2013).

12 S. L. Johnson

Physical forms of bullying are among the least-reported behaviours in this occupa-tional sector (Berry, Gillespie, Gates, & Schafer, 2012; Nwaneri, Onoka, & Onoka,2017; Purpora & Blegen, 2012; Simons, Stark, & DeMarco, 2011; Wright & Khatri,2015).

The predominance of work-related bullying among nurses is somewhat surpris-ing. In a review of the gendered nature of workplace bullying, Salin and Hoel (2013)concluded that:

when it comes to forms of bullying, women more often appear to rely on social manipula-tion, i.e. strategies affecting communication, social relationships and social reputation,whereas men seem to prefer negative acts which may on the surface appear to be rational,being primarily directed at the work of victims. (Salin & Hoel, 2013, p. 236)

Since nursing is a female-dominated occupation, one might expect person-relatedbullying to predominate. However, among nurses the main perpetrator of bullying issomeone in a supervisory position, and supervisors tend to engage in work-relatedbullying behaviours, whereas peers are more likely to be the source of socialisolation and gossip (Zapf, Escartin, Einarsen, Hoel, & Vartia, 2011).

On the other hand, it is not surprising that nurses tend to report they were ignored(either socially or professionally) at work and tend not to report they have been thevictim of physical forms of bullying. Women predominantly choose more subtle andmanipulative forms of aggression, such as social exclusion, whereas men tend toengage in more overt and physical aggression (Benenson et al., 2013; Salin & Hoel,2013). While social exclusion is an overtly passive act that on the surface appears tobe non-aggressive, it is actually fairly aggressive. When recounting incidents ofsocial exclusion, people say that it was one of the most traumatic experiences theyhave experienced, a finding which has been validated by laboratory studies thatsuggest the pain of social isolation is processed along the same neural circuitry asphysical pain (Eisenberger, 2012). Social exclusion may be a preferred bullyingbehaviour among nurses because women tend to be highly sensitive to the pain ofsocial exclusion (Benenson et al., 2013). Furthermore, it is difficult to prove thatthese behaviours were done with the intent to harm, which means they are an idealway for perpetrators to bully targets without facing repercussions.

3.2.1 Consequences of Workplace BullyingWorkplace bullying among nurses has negative ramifications for healthcareorganizations and their clients, targets of bullying and bystanders. Bullying amongnurses may also be exacerbating global nursing shortages. Workplace bullyingamong nurses has been reported in media such as fashion magazines (Robbins,2015) and newspapers (e.g. Johnson, 2016; Spelitis, 2017), and these storiesmay have a detrimental effect on the ability of the profession to recruit new nurses(Jackson, Clare, & Mannix, 2002; Laschinger, Leiter, Day, & Gilin, 2009).Workplace bullying also exacerbates the nursing shortage through its effects onretention. As with the general population of workers, nurses who have been bulliedare more likely to state that they intend to leave their job in the near future (Evans,

Workplace Bullying in the Nursing Profession 13

2017; Johnson & Rea, 2009; Mackusick & Minick, 2010; Malik, Sattar, Shahzad, &Faiz, 2017; Simons, 2008; Trépanier, Fernet, & Austin, 2013), or nursing as aprofession (Johnson & Rea, 2009). Globally, research indicates that workplacebullying of nurses decreases engagement with work (Trépanier, Fernet, & Austin,2013), commitment to the organization and its clients (Ekici & Beder, 2014;MacIntosh, 2012; MacIntosh, Wuest, Merrit Gray, & Cronkhite, 2010; Trépanier,Fernet, & Austin, 2013; Yildirim, 2009) and job satisfaction (Rodwell, Demir, &Steane, 2013) and increases burnout (Allen & Holland, 2014; Sá & Fleming, 2008;Trépanier, Fernet, & Austin, 2013).

Nurses also report that workplace bullying negatively affects patient safety andcontributes to medication and treatment errors (Oh, Uhm, & Yoon, 2016; SpenceLaschinger, 2014; Wright & Khatri, 2015). Since patient care is generally done bya team of nurses, workplace bullying further affects patient safety by decreasingcollaboration (Ekici & Beder, 2014) and co-worker support (Rush, Adamack,Gordon, & Janke, 2014). Rush, Adamack, Gordon and Janke (2014) report thatnew nurses who have been bullied, even those enrolled in formal training pro-grammes, score lower on overall performance scores and on the subscales oforganization and prioritization. The ability to organize and prioritize care cannegatively affect patient outcomes, while decreased overall performance scoresmay negatively affect targets’ career advancement (Rush, Adamack, Gordon, &Janke, 2014).

Similarly, Berry, Gillespie, Gates and Schafer (2012) reported that when perpe-trators of bullying were supervisors, or when workplace bullying occurred daily,it negatively affected productivity. Productivity effects were greater for white nursesthan non-white nurses, and Berry, Gillespie, Gates and Schafer (2012) speculatedthat in the USA, where the study was conducted, non-white nurses are moreaccustomed to having to prove their worth in the face of hostility, whereaswhite nurses might be more intimidated by hostility and begin to doubt their ownself-worth, leading to a decrease in productivity. It is also possible that white nursesand non-white nurses are targets of different types of bullying behaviours, as hasbeen reported in several studies among the general population of workers (Fox &Stallworth, 2005; Lewis & Gunn, 2007). From a sample in the UK that includednurses, Lewis and Gunn (2007) reported that when the perpetrators of bullyingwere managers, whites were more likely to report work-related bullying, whereasnon-whites were more likely to report person-related bullying. Work-related bully-ing may have more of an effect on productivity than person-related bullying. Inthe future, studies should examine whether demographic characteristics (e.g. race,ethnicity, gender, age) affect the types of behaviours that nurses experience and howthese experiences affect the productivity and quality of patient care.

As with the general population of workers, workplace bullying negatively affectsthe overall physical and psychological health of nurses (Karatza, Zyga, Tziaferi, &Prezerakos, 2016; Sauer & McCoy, 2016; Topa, Guglielmi, & Depolo, 2014).Nurses who have been targets of workplace bullying are more likely to suffer fromwork-related stress (Balducci, Cecchin, & Fraccaroli, 2012; Topa &Moriano, 2013),cognitive stress (Elfering et al., 2017; Yildirim, 2009) or psychological distress (e.g.

14 S. L. Johnson

Berry, Gillespie, Fisher, Gormley, & Haynes, 2016; Rodwell & Demir, 2012b;Rodwell, Demir, & Steane, 2013). They also report higher rates of anxiety (Berry,Gillespie, Fisher, Gormley, & Haynes, 2016; Quine, 2001; Reknes et al., 2014; Sá &Fleming, 2008) and depression (Ekici & Beder, 2014; Quine, 2001; Sá & Fleming,2008; Yildirim, 2009). Similar to the general population of bullied workers, nurseswho have been bullied score higher on post-traumatic stress disorder (PTSD) scoresthan nurses who have not been bullied (Berry, Gillespie, Fisher, Gormley, & Haynes,2016; Spence Laschinger & Nosko, 2015), or than those who have been victims ofphysical workplace violence (Pai & Lee, 2011). Spence Lachinger and Nosko (2015)found that among experienced nurses, self-efficacy buffered the effects of workplacebullying on PTSD, a finding that suggests bullying may be more traumatic and hasgreater negative effects on new nurses. To further explore whether new nurses havedifferent, or more severe, outcomes from workplace bullying than experiencednurses, studies should quantify and compare the health outcomes of these twogroups.

While negative impacts on the health of individual nurses is concerning in andof itself, the health of nurses also affects healthcare organizations and their clients.Nurses who have been targets of bullying report higher levels of fatigue (Ekici &Beder, 2014; Reknes et al., 2014), which in turn can negatively affect their abilityto safely take care of patients (Rogers, 2008). Workplace bullying among nursesalso leads to absenteeism (Asfaw, Chang, & Ray, 2013; Kivimäki, Elovainio, &Vahtera, 2000; Ortega, Christensen, Hogh, Rugulies, & Borg, 2011; Quine, 2001).Absenteeism is costly to organizations, and costs associated with sick leave areeither passed on to consumers or taxpayers. Absenteeism also affects patient safetywhen sick nurses are replaced with less-experienced temporary staff, or when theyare not replaced, leaving the unit short-handed (Belita, Mbindyo, & English, 2013).

4 Contributing Factors to Workplace Bullying Among Nurses

Building on empirical findings, various authors have proposed theoretical modelsto explain the factors which contribute to workplace bullying among nurses(Hutchinson, Wilkes, Jackson, & Vickers, 2010b; Johnson, 2011; Trépanier, Fernet,& Austin, 2013). These models highlight that organizational factors, rather thancharacteristics of individual employees, are the predominant antecedents of work-place bullying in the nursing profession. Indeed, the high rate of bullying amongnurses may be a result of the presence of a variety of organizational and occupationalrisk factors, which will be explored in this section.

Globally, healthcare organizations have been characterized by almost constantchange and reorganization, leading to chaotic working conditions for nurses(Hutchinson, Vickers, Jackson, & Wilkes, 2005; Malinauskiene, Leisyte,Romualdas, & Kirtiklyte, 2011; Pearson, 2006). Role stress, role ambiguity andwork stress—elements which are often evident in organizations that are undergo-ing change—have all been associated with workplace bullying among nurses(Balducci, Cecchin, & Fraccaroli, 2012; Bortoluzzi, Caporale, & Palese, 2014;

Workplace Bullying in the Nursing Profession 15

Quine, 2001). Other work-related stressors which have been associated withworkplace bullying among nurses are role overload (Yildirim, 2009), excessiveworkloads (Ekici & Beder, 2014; Hamblin et al., 2015; Quine, 2001; Tong,Schwendimann, & Zúñiga, 2017) and working on units with limited resources(Hamblin et al., 2015). Nurses often work on units that are understaffed (either due tocost containment efforts at an organizational level or because of chronic vacanciescreated by recurrent nursing shortages) (Chan, Tam, Lung, Wong, & Chau, 2013),another factor which has been associated with workplace bullying among nurses(Bortoluzzi, Caporale, & Palese, 2014; Tong, Schwendimann, & Zúñiga, 2017;Yokoyama et al., 2016). Nurses who have been bullied are more likely to quit,increasing the workload of the unit (and the overall level of stress), which couldfurther increase the risk that bullying will occur on a given nursing unit.

Fatigue is another factor which might contribute to the high rate of workplacebullying in the nursing profession. Stressful, fast-paced workplaces, shift work,shifts that often extend beyond 12 h and a lack of regular breaks contribute tochronic fatigue in the nursing profession (Chen, Davis, Daraiseh, Pan, & Davis,2014; Rogers, 2008). While fatigue has not been directly associated with workplacebullying, studies have shown that fatigued individuals are more prone to exhibitanger and aggression and to engage in uncivil behaviours (Kamphuis, Meerlo,Koolhaas, & Lancel, 2012; Meier & Gross, 2015). These behaviours, if displayedregularly, would constitute workplace bullying. The connection between fatigue andworkplace bullying is an area that warrants further research.

The presence of physical violence at work is also a risk factor for workplacebullying (Fevre, Lewis, Robinson, & Jones, 2013). Worldwide, 36.4% of nurseshave been exposed to workplace physical violence and 66.9% to workplace non-physical violence (excluding workplace bullying), and 32.7% have reported havingbeen physically injured in an assault at the workplace (Spector, Zhou, & Che, 2013).Exposure to violence may increase workplace bullying by contributing to a stressfulwork environment. Furthermore, nurses are expected to respond to violence andaggression from patients and visitors without displaying negative emotions, aprocess which involves emotional labour. Since emotional labour has been linkedwith incivility (Branch, Ramsay, & Barker, 2013), it might lead to subsequentbullying. This is an area which also warrants further research.

Leadership styles have been identified as one of the key determinants ofworkplace bullying in the studies of general populations of workers (Salin & Hoel,2011). Likewise, in studies of nurses, authentic leadership (a leadership style whichis characterized by honesty and emotional intelligence) is negatively associated withworkplace bullying (Spence Laschinger, Wong, & Grau, 2012). Alternatively, lowlevels of supervisor support have been associated with higher levels of workplacebullying (Demir & Rodwell, 2012; Rodwell & Demir, 2012a; Yokoyama et al.,2016). Not surprisingly, nurses who stated their managers were capable of handlingworkplace bullying also had lower levels of self-reported bullying (Lewis &Malecha, 2011; Tong, Schwendimann, & Zúñiga, 2017).

16 S. L. Johnson

Several factors impede nursing managers’ ability to effectively manageworkplace bullying. Managers are often promoted from the ranks of staff nurseswith no managerial training (Cadmus & Johansen, 2012), and managers report thatlack of training impedes their ability to resolve workplace bullying (Johnson et al.,2015c; Lindy & Schaefer, 2010). Additionally, the recruitment and retention ofnursing managers is a challenge for many healthcare organizations (Brown, Fraser,Wong, Muise, & Cummings, 2013). Chronic vacancies in managerial positions,coupled with recurrent turnover of managers, can result in units which are essentiallyself-governed, creating a laissez-faire type of leadership situation. Laissez-faireleadership is one of the styles which has been associated with workplace bullyingin the general population of workers (Hoel, Glasø, Hetland, Cooper, & Einarsen,2010). Additionally, managers report that eliminating bullying on units which haveoperated without a manager, or which have operated with a series of short-termmanagers, is especially problematic, as the perpetrators of bullying on these unitshave become accustomed to the ability to exert their power without being challenged(Johnson et al., 2015c). Finally, nursing managers typically have a large span ofcontrol (Brown, Fraser, Wong, Muise, & Cummings, 2013). It is not unusual forhospital nursing managers to supervise large numbers of direct reports who workthree different shifts, 7 days a week, on multiple units which are geographicallydistinct (Wong et al., 2014). These conditions make it nearly impossible for man-agers to learn about or directly intervene in incidents of workplace bullying (Johnsonet al., 2015c; St-Pierre, 2012).

Finally, it has been argued that in their profession, nurses have become inured tobullying behaviours and no longer view them as abnormal (Dellasega, Volpe,Edmonson, & Hopkins, 2014; Hutchinson, Vickers, Wilkes, & Jackson, 2010a;Tong, Schwendimann, & Zúñiga, 2017). In one study, a significant number of nurseswho reported that they had witnessed workplace bullying during the previous 6months also said that they did not think bullying was an issue in their workplace,suggesting that these nurses accept bullying as a normal way of interacting in theworkplace (MacCurtain, Murphy, O’Sullivan, MacMahon, & Turner, 2017). Fur-thermore, it has been argued that workplace bullying has deep roots in the nursingprofession as Florence Nightingale, one of the founders of modern nursing, usedbullying-type behaviours to train and discipline nurses (Lim & Bernstein, 2014). Tothis day, nursing students report being exposed to bullying in clinical and classroomsettings (Birks et al., 2017; Smith, 2016; Tee, Üzar Özçetin, & Russell-Westhead,2016). A study which followed nurses throughout their 3-year programme found thatstudents who experienced bullying were less shocked when they subsequentlywitnessed or experienced bullying and that students were more likely to bully fellowstudents, and patients, as the programme progressed (Randle, 2003). Further perpet-uating the cycle of bullying, preceptors of new nurses also engage in bullying as atraining strategy, and new nurses report being told to “toughen up” and get accus-tomed to these behaviours (Hutchinson, Jackson, Wilkes, & Vickers, 2006; Leong &Crossman, 2016).

Workplace Bullying in the Nursing Profession 17

5 Responses to Workplace Bullying in the NursingProfession

While it is beyond the scope of this chapter to explore all of the efforts that havebeen undertaken to address workplace bullying in the nursing profession, a briefoverview of the responses of professional associations and unions, regulatoryagencies, healthcare organizations and researchers will be offered. As workplacebullying has garnered increased attention among nurses, trade magazines for staffnurses and student nurses have also published articles on the topic of workplacebullying among nurses. These articles tend to discuss the issue as an individual-levelproblem that targets should address by confronting perpetrators (Johnson, 2016).International, national and regional nurses’ associations and nursing unions havebeen at the forefront of addressing workplace bullying. Some of their efforts includesupporting or conducting research on workplace bullying and offering education tomembers in the form of workshops and publications. In addition, nursing unions andassociations have issued position statements on workplace bullying that call forsystemic efforts to address the issue (e.g. American Nurses Association, 2015;Canadian Nurses Association, 2014; Australian Nursing and Midwifery Federation,2015; Royal College of Nursing [UK], n.d.).

Agencies which oversee healthcare organizations have also weighed in onworkplace bullying. In the USA, the Joint Commission, a non-governmental bodyresponsible for the accreditation of hospitals, has issued guidelines to help hospitalsaddress bullying-type behaviours (The Joint Commission, 2016). However, sincethere are no laws in the USA that specifically address workplace bullying, it isunclear how effective these guidelines actually are (Johnson, Boutain, Tsai, & deCastro, 2015a). Similarly, in the UK, the NHS has identified workplace bullying asan issue of concern and has information and resources in place for trusts to use toaddress the issue (NHS, 2016). In countries that have legal codes that addressworkplace bullying, healthcare organizations are responsible for meeting the samestandards as other workplaces.

In general, healthcare organizations have tackled workplace bullying through acombination of policies and education. Rigorous research on the effectiveness oforganizational responses is lacking. However, workplace bullying among nurses isnot abating. One of the problems is that staff (Sellers, Millenbach, Kovach,& Yingling, 2009; Simons & Sauer, 2013) and managers (Johnson, Boutain, Tsai,& de Castro, 2015b) are often unaware of their organization’s policies on workplacebullying, and policies can be inconsistently enforced (Sellers, Millenbach, Ward, &Scribani, 2012). Indeed, the majority of nurses who said that they reported work-place bullying to their managers or to human resource personnel report that they didnot get appropriate assistance, and the problem was not resolved (Gaffney, DeMarco,Hofmeyer, Vessey, & Budin, 2012; Pai & Lee, 2011; Rutherford & Rissel, 2004;Simons & Sauer, 2013; Somani, Karmaliani, McFarlane, Asad, & Hirani, 2015;Vogelpohl, Rice, Edwards, & Bork, 2013). Other nurses report that they did not seekorganizational assistance to resolve bullying as they felt it would not be forthcomingor effective (Efe & Ayaz, 2010; Picakciefe, Acar, Colak, & Kilic, 2017; Somani,

18 S. L. Johnson

Karmaliani, McFarlane, Asad, & Hirani, 2015). Nurse managers also report strugglingto address workplace bullying, and while some state they have been supported by theirorganizations in these efforts (St-Pierre, 2012), others report that they have receivedlittle or no organizational support (Johnson et al., 2015c; Lindy & Schaefer, 2010).

Policies and procedures addressing workplace bullying are only effective if theyare well written, if they contain clear procedures for handling incidents of bullyingand if they become part of the organizational discourse (see Johnson (2015a) foran in-depth discussion of how to draft an anti-bullying policy and a prototypicalpolicy). Since some incidents of workplace bullying are amenable to informalmanagement, workplace bullying policies should give managers the latitude toaddress incidents via either informal or formal disciplinary procedures (Johnson,2015a; Rayner & Lewis, 2011). Policies which are not discussed or widely dissem-inated are not likely to change organizational culture. To create lasting change,ongoing education reminding managers and staff of the existence of these policiesis needed. Educational efforts should also include discussions of behavioural norms,effective communication and conflict resolution.

Overall, research indicates that workplace bullying is viewed as an individualissue rather than a systemic issue by healthcare organizations and nurse managers.The expectation is that targets need to attempt to resolve the issue on theirown, and management will only intervene if they are unsuccessful (Gaffney,DeMarco, Hofmeyer, Vessey, & Budin, 2012; Johnson et al., 2015c; St-Pierre,2012). Unfortunately, research indicates that targets are rarely able to bring an endto workplace bullying without outside assistance (Keashly & Nowell, 2011). Alsoin contrast to what research has shown about the environmental factors whichcontribute to workplace bullying, prevention of workplace bullying in healthcaretends to be framed as an individual-level initiative that can be accomplished throughdiscipline, either by retroactively disciplining perpetrators or by proactively settingbehavioural standards for employees (Johnson, 2015b).

Research on interventions to address workplace bullying among nurses has alsopredominantly focused on individual-level solutions. Strategies that have been testedinclude assertiveness training (Karakaş & Okanli, 2015), team-building exercises(Barrett, Korber, Padula, & Piatek, 2009), educating nurses about their responsibil-ities in addressing workplace bullying (Hutchinson, 2009), strengthening nurses’communication skills (Ceravolo, Schwartz, Foltz-Ramos, & Castner, 2012), increas-ing awareness of workplace bullying (Keller, Budin, & Allie, 2016), offering formalmentoring and support for new nurses (Rush, Adamack, Gordon, & Janke, 2014) anddevelopment of a “Be Nice” programme (Chipps & McRury, 2012). These interven-tions have reported various levels of success. However, none of the studies have beenrobust as they had limited sample sizes, utilized convenience sampling, were descrip-tive rather than experimental and did not include data on long-term outcomes.

The intervention which has been tested the most among nurses is cognitiverehearsal, which consists of training nurses to respond to lateral violence usingphrases that they have rehearsed beforehand (Griffin, 2004; Stagg, Sheridan,Jones, & Speroni, 2011; Warrner, Sommers, Zappa, & Thornlow, 2016). Despiteclaims that this is an effective, evidence-based strategy to reduce or eliminate

Workplace Bullying in the Nursing Profession 19

incivility and lateral violence (Griffin & Clark, 2014), robust evidence of the efficacyof this method is lacking (Stagg, Sheridan, Jones, & Speroni, 2013). Since it isunrealistic to expect targets who invariably have less power than perpetrators toresolve workplace bullying without outside assistance (Keashly & Nowell, 2011),cognitive rehearsal and the other individual-level interventions which have beentested by researchers are not realistic long-term solutions to the problem of work-place bullying among nurses.

Future research needs to focus on organizational-level initiatives which addresssome of the underlying antecedents to workplace bullying such as fatigue, workstress, role overload and poor leadership. While randomized controlled trials areprobably not realistic, organizational research should strive to incorporate robustnon-experimental designs, including baseline data collection and post-interventiondata collection at meaningful intervals (e.g. immediately after the intervention,6 months and 1 year). Research should also focus on how interventions work indifferent settings and cultures. Healthcare organizations do not have the samehierarchical structure in every country. Cultural differences may affect what isperceived as bullying and how it should be addressed. Therefore, interventionsthat have worked in one country should not be assumed to work in another.Additionally, acute care facilities (e.g. hospitals), long-term care facilities andoutpatient clinics can have vastly different organizational structures. To date, mostof the research on workplace bullying in healthcare has focused on the hospitalsetting. To advance an understanding of what works in the prevention and mitigationof workplace bullying, interventions should be adapted to the requirements of agiven organization. These adaptations should be rigorously tested, and the resultsshould be widely disseminated.

6 Conclusion

While workplace bullying is a problem for the nursing profession, it is also an issuethat has received a fair amount of attention from researchers, healthcare organiza-tions and nursing associations. Increasingly, evidence suggests that systemic factors,many of which are unique to nursing, may contribute to high levels of bullying inthis profession. However, current efforts to manage and prevent bullying amongnurses remain focused on individual-level initiatives. Going forward, initiatives toaddress this issue should focus on a combination of systemic-level interventions andindividual-level efforts. Finally, since the structure of healthcare organizations canvary based on their function and on the cultural setting in which they are located,these initiatives need to be rigorously tested globally in a variety of settings.

7 Cross-References

▶Bullying in Precarious Work▶Customer Abuse

20 S. L. Johnson

▶Media Portrayals of Workplace Bullying▶Workplace Bullying, Emotional Abuse and Harassment in Academe▶Workplace Violence

8 Cross-References to Other Volumes

▶Dignity, Vol. 1▶Ethical Challenges and Workplace Bullying and Harassment: Creating Ethical

Awareness and Sensitivity, Vol. 1▶The Hallmarks of Workplace Bullying, Emotional Abuse and Harassment, Vol. 1▶The Presence of Workplace Bullying and Harassment Worldwide, Vol. 1▶Theoretical Frameworks That Explain Workplace Bullying, Vol. 1▶Workplace Bullying and the Polemic of Subjectivity and Intent, Vol. 1▶Health Consequences of Workplace Bullying: Physiological Response and Sleep,

Vol. 2▶Long-Term Consequences (Costs) of Workplace Bullying, Emotional Abuse and

Harassment for the Workplace, Organization and Society, Vol. 2▶ “Me? A Bully?”: The Different Faces of the Perpetrator in Workplace Bullying,

Emotional Abuse and Harassment, Vol. 2▶New Directions in Reciprocal Influences: The Cases of Role Stressor–Workplace

Bullying and Interpersonal Conflict–Workplace Bullying Linkages, Vol. 2▶Targets of Workplace Bullying and Mistreatment: Helpless Victims or Active

Provocateurs?, Vol. 2▶The Contested Terrain of Power in Workplace Bullying, Emotional Abuse and

Harassment, Vol. 2▶The Contribution of Organizational Factors to Workplace Bullying, Emotional

Abuse and Harassment, Vol. 2▶The Moderating Effects of Coping Mechanisms and Resources in the Context of

Workplace Bullying, Emotional Abuse and Harassment, Vol. 2▶The Role and Impact of Leaders on Workplace Bullying, Emotional Abuse and

Harassment, Vol. 2▶The Role of Personality in Workplace Bullying Research, Vol. 2▶Workplace Bullying and Mental Health, Vol. 2▶Addressing Workplace Bullying: The Role of Training, Education and Develop-

ment, Vol. 3▶Age, Vol. 3▶Alternate Dispute Resolution in Workplace Bullying and Harassment Complaints,

Vol. 3▶Complaint Investigation in Cases of Workplace Bullying, Emotional Abuse and

Harassment, Vol. 3▶Diagnosis and Treatment: Repairing Injuries Caused by Workplace Bullying,

Vol. 3▶Ethnicity and Workplace Bullying, Vol. 3▶Gender and Workplace Bullying, Vol. 3

Workplace Bullying in the Nursing Profession 21

▶Managing Workplace Bullying Complaints: Conceptual Influences and Effects ofConceptual Factors, Vol. 3

▶Regulation as Intervention: How Regulatory Design Can Affect Behaviours in theWorkplace, Vol. 3

▶Religious Harassment and Bullying in the Workplace, Vol. 3▶Risk Management and Bullying as a Workplace Health and Safety (WHS) Hazard,

Vol. 3▶ Sexual Orientation and Workplace Bullying, Vol. 3▶ Strengthening the Evidence-Case of Workplace Bullying Interventions Through

Implementation Research: Taking Interventions to Scale, Vol. 3▶Work and Organizational Design: Influence on Workplace Bullying, Vol. 3▶Worker Representation and Advocacy in the Context of Workplace Bullying,

Emotional Abuse and Harassment, Vol. 3▶Workplace Bullying Policies: A Review of Best Practices and Research on

Effectiveness, Vol. 3▶Workplace Bullying, Disability and Chronic Ill Health, Vol. 3

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Allen, B. C., & Holland, P. (2014). The effect of bullying on burnout in nurses: The moderating roleof psychological detachment. Journal of Advanced Nursing, 71(2), 381–390. https://doi.org/10.1111/jan.12489.

American Nurses Association. (2015). Incivility, bullying and workplace violence. Retrieved fromhttp://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/Incivility-Bullying-and-Workplace-Violence.html.

An, Y., & Kang, J. (2016). Relationship between organizational culture and workplace bullyingamong Korean nurses. Asian Nursing Research, 10(3), 234–239. https://doi.org/10.1016/j.anr.2016.06.004.

Asfaw, A. G., Chang, C. C., & Ray, T. K. (2013). Workplace mistreatment and sickness absenteeismfrom work: Results from the 2010 National Health Interview survey. American Journal ofIndustrial Medicine, 57(2), 202–213. https://doi.org/10.1002/ajim.22273.

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