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Revista Gaúcha de Enfermagem

Print version ISSN 0102-6933On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.40  Porto Alegre  2019  Epub Nov 04, 2019

http://dx.doi.org/10.1590/1983-1447.2019.20190176 

Integrative Review

Bullying in the nursing work environment: integrative review

Bullying en el medio ambiente de trabajo de la enfermería: revisión integrativa

Roberta Nazario Aokia 
http://orcid.org/0000-0002-7319-6177

Edinêis de Brito Guirardelloa 
http://orcid.org/0000-0003-0457-2850

aUniversidade Estadual de Campinas (UNICAMP), Faculdade de Enfermagem, Programa de Pós- Graduação em Enfermagem. Campinas, São Paulo, Brasil.


Abstract

Objective:

To evaluate the studies that approach bullying in the nursing practice environment.

Method:

Integrative review, conducted between April and December 2018, by combining the descriptors "bullying/bullying" AND "nursing/nursing/nurse" AND "workplace/workplace". We identified 224 studies of which 38 met the inclusion criteria.

Results:

The studies on nursing bullying presented three main approaches related to the prevalence in nursing practice, the repercussions for health and professional development, and the construction of theoretical models for bullying and nursing work environment variables.

Conclusion:

Bullying is a negative behavior present in the nursing practice environment and has a direct impact on professional performance, impairing general health and professional performance. Despite being a behavior with recognized negative potential in the work environment, few studies propose effective actions to prevent or control this phenomenon in health institutions.

Keywords: Bullying; Nursing; Workplace; Review literature as topic

Resumen

Objetivo:

Evaluar los estudios que abordan el bullying en el entorno de la práctica de enfermería.

Método:

Revisión integradora, realizada entre abril y diciembre de 2018, mediante la combinación de los descriptores "bullying / bullying" AND "enfermería / enfermería / enfermera" AND "lugar de trabajo / lugar de trabajo". Se identificaron 224 estudios, de los cuales 38 cumplieron con los criterios de inclusión.

Resultados:

Los estudios sobre el bullying de enfermería presentaron tres enfoques principales relacionados con la prevalencia en la práctica de enfermería, las repercusiones para la salud y el desarrollo profesional, y la construcción de modelos teóricos para las variables de entorno de bullying y trabajo de enfermería.

Conclusión:

El acoso es un comportamiento negativo presente en el entorno de la práctica de enfermería y tiene un impacto directo en el desempeño profesional, lo que afecta la salud general y el desempeño profesional. A pesar de ser un comportamiento con potencial negativo reconocido en el entorno laboral, pocos estudios proponen acciones efectivas para prevenir o controlar este fenómeno en las instituciones de salud.

Palabras clave: Acoso escolar; Enfermería; Lugar de trabajo; Literatura de revisión como asunto

Resumo

Objetivo:

Avaliar os estudos que abordam o bullying no ambiente de prática da enfermagem.

Método:

Revisão integrativa, realizada no período de abril a dezembro de 2018, por meio da combinação entre os descritores "bullying / bullying" AND "enfermagem / nursing / nurse" AND “local de trabalho / workplace. Foram identificados 224 estudos dos quais 38 atenderam aos critérios de inclusão.

Resultados:

Os estudos sobre bullying na enfermagem apresentaram três enfoques principais relacionados à prevalência na prática da enfermagem, às repercussões para a saúde e desenvolvimento profissional e construção de modelos teóricos para o bullying e variáveis do ambiente de trabalho da enfermagem.

Conclusão:

O bullying é um comportamento negativo presente no ambiente da prática da enfermagem e apresenta impacto direto na atuação profissional, ao prejudicar a saúde geral e o desempenho profissional. Apesar de ser um comportamento com reconhecido potencial negativo ao ambiente de trabalho, poucos estudos propõem ações efetivas para prevenção ou controle deste fenômeno nas instituições de saúde.

Palavras-chave: Bullying; Enfermagem; Local de trabalho; Literatura de revisão como assunto

INTRODUCTION

In the last decades of the 20th century, the global economic scenario has undergone profound changes that, in turn, modified the structure of work processes, made the labor environment more competitive and hostile(1) and exposed employees to new work-related risks(2).

It is believed that occupational risks have always existed; since the 1980s(3), however, abuse toward workers has been compared to uncivil acts among schoolchildren and thus received the denomination mobbing(4), consequently leading to more critical analyses on the part of the researchers(3-5). It is noteworthy that expressions such as mobbing, harassment, bullying and horizontal violence are used as synonyms to describe personal, moral and psychological violence in the workplace and the preferred term depends on the region of the studies(6-7).

Bullying is characterized as systematic and persistent behavior occurring for more than six months in the form of repeated negative acts such as insulting observations, exposure of the victim, verbal abuse, offensive provocation, isolation and social exclusion or the constant degradation of working conditions and worker effort(8).

Negative attitudes caused by bullying can trigger high levels of stress, mental and psychological disorders, including anxiety and depression among workers(9). Other physical manifestations include gastrointestinal disorders, hypertension, headache and eating and sleep disorders, which eventually affect the sufferer´s overall health(10). In addition, it may result in dissatisfaction with work and social isolation(11-13). For the institution, bullying can cause an increase in absenteeism, a reduction in productivity and efficiency and job abandonment(13-14).

Studies in health care show that bullying accounts for up to a quarter of all work-related cases of violence(3,15) and that nursing professionals are more exposed to bullying by their peers, by other professionals and even by patients(10,16-17).

Nursing is a predominantly female professional category and, as such, still subjected to gender-related workplace inequalities, which have already be related to higher rates of workplace bullying1. Moreover, nursing is the largest and one of the most stressful professional categories in the field of health since nurses must cope with the demands of patients, other professionals and their own coworkers(2). Nursing professionals must endure situations of anguish and pain, work overload and extensive work shifts on a daily basis(15), all of which expose them to workplace bullying.

Considering the negative repercussions of bullying on the performance and physical and emotional health of workers, especially nurses, it is important to understand its dimensions in the workplace in order to implement preventive and control actions and favor a positive safety culture in health care institutions. Consequently, the aim of this paper was to assess studies on bullying in the nursing work environment.

METHOD

This is an integrative review conducted according to the stages recommended by Whittemore and Knafl(18), namely a) problem identification and creation of research question; b) establishment of inclusion and exclusion criteria and literature search; c) definition of information to be collected in the studies obtained in the search; d) categorization of selected studies and analysis of this information; e) interpretation of results and f) review presentation.

In the first stage, the following question was formulated: What is the focus of studies on bullying in the nursing work environment? After defining the guiding question, the study selection stage was initiated.

Prior to selection, the following inclusion criteria were adopted: publications with all the descriptors cited in the title of the study and full-text publications in Portuguese, English or Spanish published between January 2010 and December 2018. Studies of integrative or systematic reviews, editorials, letters, theses and dissertations and duplicate papers were excluded.

In the third stage, the online search for studies was carried out. We consulted the primary source databases Web of Science (WOS), MEDLINE/PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Literature on Health Sciences (LILACS). The search strategy comprised the operators "bullying/bullying" AND "enfermagem/nursing/nurses" AND "local de trabalho/workplace". The descriptors used are standardized in the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH).

The database searches resulted in 224 studies, which went through further selection stages. The flow of study selection is shown in Figure 1, based on PRISMA recommendations for preparing a flow diagram of the stages of this integrative review(19).

Source: Research data, 2018.

Figure 1 Flowchart prepared and adapted from the PRISMA recommendations for mapping the articles that are identified, selected and included. 

In the following stage, the studies listed in an Excel spreadsheet were characterized in descending order according to year and country of publication, authors, title, study objectives, methodology and main results. In the fifth stage, the main findings were interpreted and synthesized and, finally, the review was presented.

RESULTS

Based on the descriptors of DeCS and MeSH, we identified 224 articles in the databases, three of which were in LILACS, 18 in CINAHL, 29 in MEDLINE/PubMed, 118 in Embase and 50 in the Web of Science. Of these studies, 186 articles were excluded because they were duplicates, they did not refer to the subject matter or they did not meet the criteria, resulting in 38 articles. The main characteristics of the studies - such as first author, year of publication, country, objectives and main results - are presented in Chart 1.

To analyze the results, the findings were categorized according to the key focal points attributed to bullying in nursing: 1) perception of bullying 2) impact of bullying on health care and professional performance and 3) construction of theoretical models on bullying in nursing.

First author, year and country Objectives Main results
Logan(20)2018 USA Exploring nurses' perceptions of teamwork and workplace harassment. Two-thirds of nurses reported the presence of important variables such as leadership, trust and communication in their teams. One-third of the nurses reported being bullied and half observed others being intimidated.
Yun(21)2018 Korea Build and test a model outlining factors related to moral harassment A relationship-oriented organizational culture had a direct effect on harassment, and harassment had a direct effect on the experience mediated by positive psychological capital. Harassment also had an indirect effect on the intention to leave the workplace.
Savaşan(22)2018 Turkey Examining the relationship between personality characteristics and bullying Significant negative, albeit weak correlations were found between Hacettepe Personality Inventory scores (general, personal and social adjustment points) and bullying scores.
Olender(23)2017 USA Examining the relationship between team members' perceptions of moral harassment A significant inverse relationship was found between nursing managers and exposure to bullying in the workplace. Sex, work environment and high workload influenced these findings.
Olsen(24)2017 Norway Further understand workplace harassment and relate it to the work climate. Most of the characteristics of the work climate influenced moral harassment in the workplace. Bullying played a mediating role in most dimensions of the work climate, such as performance, satisfaction and the ability to work.
Kang(25)2017 Korea Investigate the effects of a cognitive testing program on moral harassment After the intervention, significant differences were found in interpersonal relationships and turnover intention for the experimental groups and the waiting list. However, no significant difference was found for moral harassment between the two groups.
An(26)2017 Korea Identify the relationship between organizational culture and the bullying experience The prevalence was 15.8%. Multivariate analysis revealed that the chances of being bullied were 2.58 times higher among nurses in a hierarchy-oriented culture than among nurses in a relationship-oriented culture.
Blackwood(27)2017 New Zealand Investigate the role of workplace factors in bullying behavior A number of work environment factors affect the efficacy of bullying intervention in the nursing workplace.
Karatza(14)2017 Greece Identify the impact of bullying on nursing professionals One-third of the nurses reported bullying in the last six months. The impact of bullying on nurses varied depending on the family support or the friendly environment provided to cope with moral harassment in the workplace.
Nwaneri(28)2017 Nigeria Assess the occurrence and effects of bullying among nurses. The prevalence among nurses who worked in tertiary hospitals was reported as high. The effects of bullying on nurses include anger, the desire to travel abroad because of the feeling that the prevalence is lower, frustraton and tense social relations among coworkers.
Ma(29)2017 Taiwan Explore the relationships between negative perceptions and negative acts on bullying 80% of nurses experience bullying at some point in their professional lives. The consequences of bullying are severe psychological trauma; low self-esteem; depression and anxiety; post-traumatic stress; physical disease; financial loss and eventual inability to work.
Bardakci(30)2016 Turkey To determine the effects of bullying on the psychological distress of nurses. Nurses with master’s degrees were more exposed to bullying. The nurses exposed to bullying had higher levels of psychological distress and preferred to keep quiet about it. The nursing managers were the main bullies.
Tee(31)2016 England Explore and describe the incidence and experiences of bullying in nursing. Around 42.18% of respondents reported they had suffered intimidation/harassment in the current year. One-third (30.4%) witnessed others being harassed and 19.6% of the incidents involved more experienced nurses.
Fang(32)2016 China Investigate bullying among nurses. The general mean of bullying was 1.47, showing that the frequency was between never and not at the time. Nurses from emergency rooms were more exposed to bullying. Harassment at work has been associated with years of experience.
Giorgi(33)2016 Italy Develop a bullying model focused on the interaction between bullying and burnout Bullying was a partial mediator of the relationship between organizational climate and burnout. Bullying affected health only when mediated by burnout.
Karatza(11)2016 Greece Investigate the relationship between bullying and the general health status of nursing 30.2% reported having been psychologically harassed in their workplaces in the previous six months and their general health status had worsened.
Oh(34)2016 Korea Identify individual and institutional characteristics for moral harassment Negative affection, individualism and work in hospital specialty units predict bullying. Individualism, negative affection, type of hospital and working hours predicted verbal abuse, while the workplace was significantly associated with lateral violence.
Oh(35)2016 Korea Test a model that relates bullying with stress, intent to quit employment and adverse events. Bullying and stress at work and the intention to leave were associated with adverse outcomes of patients from the perspective of the interviewed nurses.
Berry(36)2016 USA Determine the differences in perceived stress, state of anxiety, post-traumatic stress and bullying. Significant differences regarding perceived stress, anxiety and post-traumatic syndrome were reported by people with frequent exposure to bullying at work.
Yokoyama(37)2016 Japan Explore the association between bullying and work environment factors 18.5% of the nurses reported bullying. A logistic regression analysis indicated that bullying was associated with low scores in two domains of the work environment: capacity of the nursing manager, leadership and support of nurses and adequacy of personnel and resources.
Blackstock(38)2015 Canada Examine the impact of organizational factors on bullying and its effect on the intention to quit the job. Informal organizational alliances and improper use of organizational processes/procedures favored the increase in horizontal bullying, which, in turn, predicted the intention to quit the job.
Ganz(10)2015 Israel Describe the prevalence of bullying and its preventive measures. 29% reported that they were victims of bullying. Bullying levels were low to moderate. The level of prevention was weak or moderate. The higher the level of bullying, the lower the level of prevention.
Laschinger(39)2015 Canada Examine the relationship between harassment and post-traumatic stress disorder and psychological capital. Regression analysis revealed that the most frequent exposure to harassment at work was significantly related to the symptomatology of post-traumatic stress disorder, regardless of the level of the disorder.
Allen(40)2015 Australia Examine the relationship between bullying and burnout and the effect of psychological distancing Bullying was associated with burnout. Psychological distancing did not significantly moderate the relationship between bullying and burnout.
Wright(41)2015 USA Examine the relationship between three types of bullying with psychological/behavioral responses Person-related bullying showed significant positive relationships with psychological/behavioral responses and medical errors. When related to work, bullying showed a significant positive relationship with psychological/behavioral responses, but not with medical errors. Feeling physically intimidated was not significant for any outcome.
Ekici(42)2014 Turkey Evaluate bullying and its effects on the performance and depression of physicians and nurses No significant differences were found between physicians and nurses in terms of bullying, however, an association was found between performance, depression and the violent behaviors experienced.
Esfahani(43)2014 Iran Examine bullying in the workplace among a group of Iranian nurses. Only 9% of the nurses had been frequently exposed to bullying, 22% reported having been victims of bullying occasionally and 69% had never been exposed to bullying in the last year.
Etienne(44)2014 Alaska Assess the perception of nurses regarding exposure to harassment 48% of the nurses admitted they had been victims of bullying in the previous six months. Being ignored or excluded were the most common negative experiences in the workplace.
Ovayolu(45)2014 Turkey Determine whether nurses are intimidated by other team members. 44% of the nurses reported experiencing one or more types of bullying in the last 12 months.
Schlitzkus(46)2014 USA Determine whether nurses bully surgery residents. The nurses bullied the surgery residents and 30.2% reported intimidation in the workplace.
Yun(47)2014 Korea Examine the relationship between perception of the work environment and moral harassment 94.0% reported at least one negative act in the last six months. The prevalence of harassment was 17.2%, according to criteria for assessing bullying. Significant negative correlations were found between the work environment and harassment.
Fontes(16)2013 Brazil Identify nurses who are subject to bullying and associated factors. 11.56% were victims of bullying in the last 12 months. The nurse's profile was characterized by having children, practicing in public health, working at the institution for one to three years and perceiving oneself as bullied.
Vogelpohl(48)2013 USA Investigate bullying among new graduates. Nurses, physicians or relatives of patients were the main sources of bullying, and 29.5% of the nurses considered leaving the nursing profession.
Berry(49)2012 USA Determine the prevalence and effects of moral harassment in the work of new graduates. 44.7% reported bullying and 55.3% reporting no bullying. The individuals who bullied were primarily more experienced nursing coworkers (63%). The productivity of the nurse was negatively affected
Gaffney(50)2012 USA Report the experiences of nurses regarding workplace harassment. When nurses were confronted with harassment in the workplace, they became involved in a process of doing things right, they put bullying in context and they evaluated the situation, acted and judged the results of their actions.
Farrel(51)2012 Australia Report the nature and extent of aggression and bullying. 52% reported some form of aggression. 36% suffered violence mainly from patients or their visitors/relatives and 32% from coworkers or their managers/supervisors.
Laschinger(52)2012 Canada Test a model that relates leadership to the experiences of new graduates regarding moral harassment Authentic leadership had a negative direct effect on workplace harassment that had a direct positive effect on emotional exhaustion. Authentic leadership, moral harassment and emotional exhaustion had significant direct effects on job satisfaction and a lesser desire to quit work.
Hutchinson(17)2010 Australia Test a multidimensional model of workplace bullying. The study emphasizes a strong relationship between organizational characteristics, bullying and the resulting consequences. An incremental relationship was found between the latent factors in the model and indicate the direction of the relationship between the three organizational factors, bullying and the resulting consequences.

Source: Research data, 2018.

DISCUSSION

The evaluation of studies addressing bullying in the nursing environment made it possible to systemize some results. It should be noted that most of the studies were published in Asia (39.5%), followed by North America (31.5%). Few publications on the subject were found for South America and Africa, indicating the need for further studies in these localities(16,28).

Regarding the year of publication, 97.3% of the studies were published from 2014, demonstrating a growing interest of researchers on the subject of bullying in nursing practice environment.

Most articles sought to identify the existence of bullying among nursing professionals using specific data collection instruments in the fields of psychology and health care. In this review, we observed a predominance of the Negative Acts Questionnaire Revised (NAQ-R), used in 21 studies(2,10,11,14,22-26,28,33-37,39,41,44,46-49,52). The original version of this instrument contains 22 items that report negative acts in the work environment and it is widely used in research on bullying(53).

The analysis of the objectives of the studies that addressed bullying in nursing allowed us to identify three approaches to this behavior, namely: the perception of the teams regarding the presence of this behavior in the workplace, the influence of bullying on the physical health and professional performance of the victims and the construction of theoretical models to formulate postulates that relate bullying to the determinant factors of this act of violence at work. These approaches are presented in three categories: 1- perception of bullying by professionals, 2- impact of bullying on health and professional performance and 3- construction of theoretical models on bullying behavior in nursing.

Category 1. Perception of bullying by professionals

In the evaluation of the perception of bullying, the studies presented and applied different instruments to identify the indices of this behavior, which were perceived by the nursing professionals. The percentage of bullying among nursing professionals ranged from 9% to 94%(43-49), and some studies related characteristics of the professional(14,29,31,49) and the environment(21,24,26,33,52) as factors associated with bullying. It is noteworthy that the lowest percentage of bullying identified in this review corresponds to research based solely on the self-reports of nurses from a province of Azerbaijan, a region marked by strong cultural peculiarities(43).

The differences between the prevalence found in studies on bullying may reflect the reality of the working conditions of many nursing professionals, considering particular aspects of their region and culture, although it is possible to find variations due to difficulties in establishing standardized definitions on bullying and appropriate data collection methodologies for bullying in health institutions(54).

Regarding the characteristics of the workers who influence the perception of bullying, the variable age was related to bullying in a study conducted in southern Taiwan(29), in which older nurses, with more professional experience, showed negative behavior in relation to younger nurses and often questioned their skills and ability to resolve conflicts(14). Furthermore, the variable years of experience influenced the behavior of bullying since newly graduated workers were more exposed to violent behavior at work(49), exemplified by a study in which 19.5% of the acts of bullying were practiced by more experienced nurses(31). These findings indicate that some nurses use their professional experience as a form of power, while it is expected that the knowledge acquired in the nursing practice environment be passed on to the novice professionals.

In relation to the work environment, studies pointed out that the organizational climate(24,33) of the institutions and hierarchy-oriented work structures(21,26) - to the detriment of personal work-based relationships - were related to acts of bullying. The absence of leadership figures(52) was also related to the higher probability of acts of violence in the workplace.

Category 2. Impact of bullying on health and professional performance

Bullying mostly affects the overall health status of workers(14,29,39). The victims of bullying exhibited several physical and emotional manifestations, mainly symptoms of stress, anxiety and depression(21,36,37,40) and a strong relationship with cases of burnout(40) was observed in environments where negative acts against workers were reported. These manifestations reveal the high degree of psychological impairment nursing professionals experience in relation to bullying and work.

With regard to nursing, studies show that the effects of this type of violence on workers go beyond the physical and emotional manifestations, often demonstrated by high levels of stress, anxiety and depression(29). Professional development is also affected by bullying, which can be perceived by an increase in absenteeism that reduces productivity and efficiency and causes social isolation, dissatisfaction with work and coworkers, often resulting in job abandonment(21-22,24,28,38,52).

Therefore, it is important to perceive and address the nursing workplace in order to create standards of quality of life and professional performance. The low level of work satisfaction, especially in health care, causes other negative outcomes related to bullying, such as job abandonment(20) and even abandonment of the profession(14) since workers believe they are not capable of continuing their activities or of adequately performing their duties.

Category 3. Construction of theoretical models on bullying behavior in nursing

In this category, studies on bullying in nursing sought to construct theoretical models(17,21,33,35) to identify patterns of bullying behavior according to several factors that could sustain these acts of violence in the nursing environment. The variables organizational culture(17,33), burnout(33) and intention to quit the job(21,35) were related to bullying in the models proposed in this review.

The identification of a category related to bullying in nursing that proposes the construction of theoretical models on the subject shows that researchers still need to identify essential assumptions and characteristics for bullying that can relate several aspects of nursing to the occurrence of bullying in health institutions.

By knowing the variables that determine this behavior in the nursing work environment, it is possible to support the implementation of actions that prevent bullying among nursing professionals and occupational programs that favor a positive perception of the nursing practice in health care.

CONCLUSIONS

The findings of this review indicate that studies on bullying in the nursing work environment sought to identify the profile of this behavior in health institutions and highlight the repercussions of these acts on workers and the institution.

Nursing professionals exposed to bullying may develop negative manifestations in their overall health and feel dissatisfied with their work, peers and superiors, culminating in weak social relations at work and the desire to quit their jobs.

The characteristics of bullying behavior found in the publications of this study justify the need to map social relationships among nursing workers by highlighting the main indicators of bullying. Consequently, the early identification of such behavior in the work environment can help service managers develop programs to prevent and control this behavior in health institutions.

The limitation identified in this review is the absence of studies addressing effective strategies to prevent bullying or proposals for institutional policies that have presented important results in identifying and controlling this behavior in the nursing practice environment.

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Received: May 01, 2019; Accepted: July 10, 2019

Corresponding author: Roberta Nazario Aoki: E-mail: rubi.rc@bol.com.br

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