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Bullying among nursing staff: Relationship with

psychological/behavioral responses of nurses and

medical errors
Wright, Whitney; Khatri, Naresh
Aim: The aim of this article is to examine the relationship between three types of bullying
(person-related, work-related, and physically intimidating) with two types of outcomes
(psychological/behavioral responses of nurses and medical errors). In addition, it investigates if
the three types of bullying behaviors vary with age or gender of nurses and if the extent of
bullying varies across different facilities in an institution.
Background: Nurses play an integral role in achieving safe and effective health care. To ensure
nurses are functioning at their optimal level, health care organizations need to reduce negative
components that impact nurses job performance and their mental and physical health. Mitigating
bullying from the workplace may be necessary to create and maintain a high-performing, caring,
and safe hospital culture.
Methods: Using an internal e-mail system, an e-mail requesting the participants to complete
the questionnaire on Survey Monkey was sent to a sample of 1,078 nurses employed across three
facilities at a university hospital system in the Midwest. Two hundred forty-one completed
questionnaires were received with a response rate of 23%. Bullying was measured utilizing the
Negative Acts Questionnaire-Revised (NAQ-R). Outcomes (psychological/behavioral responses
of nurses and medical errors) were measured using Rosenstein and ODaniels (2008) modified
Results: Person-related bullying showed significant positive relationships with
psychological/behavioral responses and medical errors. Work-related bullying showed a
significant positive relationship with psychological/behavioral responses, but not with medical
errors. Physically intimidating bullying did not show a significant relationship to either outcome.
Whereas person-related bullying was found to be negatively associated with age of nurses,
physically intimidating bullying was positively associated with age. Male nurses experienced
higher work-related bullying than female nurses.
Conclusion: Findings from this study suggest that bullying behaviors exist and affect
psychological/behavioral responses of nurses such as stress and anxiety and medical errors.
Health care organizations should identify bullying behaviors and implement bullying prevention
strategies to reduce those behaviors and the adverse effects that they may have on
psychological/behavioral responses of nurses and medical errors.

Bullying is a term commonly associated with childrens playgrounds and high school hallways.
However, the prevalence of bullying in the workplace is increasing and the impact of this
behavior is severe, specifically in the health care industry ( Cleary, Hunt, & Horsfall, 2010;Hutchinson, Wilkes, Jackson,
& Vickers, 2010 Olender-Russo, 2009
). Multiple studies have determined that many health care workplaces
possess negative environments that foster disrespectful attitudes, inappropriate behaviors, and
bullying (Cleary et al., 2010). These behaviors are found to create financial costs such as turnover,
physical costs in the form of symptoms experienced by the bullying victim, and psychological
and behavioral costs such as stress and anxiety that can impact job performance ( Center, 2011; Felblinger,
2009 Laschinger, Grau, Finegan, & Wilk, 2010 Lindy & Schaefer, 2010 MacIntosh, Wuest, Gray, & Cronkhite, 2010 Vessey, Demarco, Gaffney, & Budin,
2009 Yildirim, 2009
Nursing professionals make up the largest group of health care providers in the United States.
According to the U.S. Department of Labor, there were 2,737,400 registered nurses and 752,300
licensed practical/vocational nurses in 2010. Throughout nurses careers, studies suggest that
80% of them experience bullying (Hutchinson et al., 2010). Nurses play an integral role in achieving safe
and effective health care. To ensure nurses are functioning at their optimal level, health care
organizations need to reduce negative components that impact nurses job satisfaction and their
mental and physical health. Reducing bullying from the workplace may be necessary to create
and maintain a high-performing, caring, and safe hospital culture (Piper, 2006).
Bullying is generally defined as a situation in which a person perceives himself/herself as the
target of negative actions, persistently over time, by one or several others ( Rodwell & Demir, 2012). It
often presents as repetitive acts of verbal aggression and criticism but may take more subtle
forms, such as placing someone under increased scrutiny or talking behind anothers back
(Szutenbach, 2013). Bullying may include mistreatment, incivility, disruptive behavior, disrespectful
attitudes, or inappropriate behaviors. For example, Read and Laschinger (2013) used the term workplace
mistreatment consisting of incivility and bullying in work place. Incivility is low-intensity rude
or disrespectful behaviors with an ambiguous intent to harm others. In contrast, bullying is an
intentional and intense form of workplace mistreatment that targets particular individuals and not
others. Workplace bullying tends to be sophisticated and involve psychological cruelty. Another
concept that is related and can be treated as part of bullying is disruptive behavior, which is
defined as any inappropriate behavior, confrontation, or conflict, ranging from verbal, physical,
or sexual harassment (Rosenstein & ODaniel, 2008). Unlike, physician disruptive behavior, which is usually
more overt and direct, nurse disruptive behavior is more passiveaggressive in nature and is
directed at the peers (Rosenstein & ODaniel, 2008).
Bullying does not include normal instruction, constructive feedback, safe workplace practices, or
differing opinions (Cleary et al., 2010). As discussed by Cleary et al., bullying acts may be overt or
covert and consist of a variety of behaviors. Some of the common bullying behaviors reported

include being allocated an unmanageable workload, being ignored or excluded, having rumors
spread about an individual, being ordered to carry out work below ones competence level,
having ones professional opinion ignored, having information relevant to ones work withheld,
being given impossible target or deadlines, and being humiliated or ridiculed about ones work
Additional behaviors may include overchecking, silent treatment, belittling, excessive criticism,
scapegoating, or sabotaging (Felblinger, 2009; LaVan & Martin, 2008; Olender-Russo, 2009: Vessey et al., 2009; Yildirim, 2009). A
study completed by Yildirim found that 56% of the respondents had experienced a coworker
belittling or demeaning them in the presence of others.
Einarsen, Hoel, and Notelaers (2009)

identified three categories of bullying: work-related, person-related, and

physical intimidation. Work-related bullying may include behaviors such as being given
unreasonable deadlines, assigning tasks below a persons competency level, or withholding
information that affects performance. Person-related bullying may consist of behaviors such as
being ignored or excluded, spreading gossips and rumors, or hints and signals from others to quit
ones job. Physically intimidating behaviors may include invasion of personal space, shoving and
blocking the way, threat of violence, physical abuse, or actual abuse.
Theoretical Background
The health care industry has become a focal point of research for workplace bullying with a
significant focus on the nursing profession.MacIntosh et al. (2010) noted that workplace bullying is 16
times more likely to occur in the health care industry versus other sectors. Bullying incidents
occur laterally between nurses, vertically between nurses and their superiors, or from physicians
to nurses. There are varying degrees of bullying. Some cases are extreme and potentially lead to
acts of violence. Center (2011) stated that the Joint Commissions Sentinel Event Database includes
256 reports of assault, rape, and homicide since 1995 with 43% of those reports occurring in the
past 3 years. The frequency of bullying in the workplace is alarming and even more so because
bullying incidences are usually underreported ( LaVan & Martin, 2008; Vessey et al., 2009). Reasons for
underreporting include culture of acceptance, lack of trust in management, or fear of retaliation
for being the whistleblower. A study by Vessey et al. identified sharing bullying experiences
with family, friends, or other colleagues as a coping mechanism that further contributes to
The research literature suggests a number of presumed causes of bullying in nursing, three of
which are cited more often. First, the longstanding paternalism in health care might have led to
the oppression of nurses (Szutenbach, 2013). Oppression, by way of unfair, unjust, or cruel governance,
deprives individuals and groups of their rights. Oppressed groups feel powerless in the face of
their oppressors and turn their frustrations inward and toward other group members, especially
those who they perceive to be less powerful (Read & Laschinger, 2013; Rodwell & Demir, 2012). A second plausible
cause of bullying has to do with how and what nurses are taught. There is evidence that bullying

is a learned behavior, and nurses are encultured to bully one another ( Szutenbach, 2013; Vessey et al., 2009).
When bullying goes unchecked by nurse managers, other staff members consider such activity as
appropriate because these behaviors have become culturally normalized (Vessey et al., 2009). A third
plausible explanation for bullying behavior in nursing is the existence of numerous rigid rules
and procedures and authoritarian management practices (Brees, Mackey, & Martinko, 2013).
There are financial, physical, and psychological costs associated with bullying. Pearson and Porath
estimate that incivility or mundane slights and disrespect cause stress that costs U.S.
companies $300 billion a year, which is avoidable. The average cost per victim can range from
$30,000 to $100,000 (Lindy & Schaefer, 2010). Financial, physical, and psychological costs are
experienced by the bullying victim, the patients they are responsible for, their coworkers, and the
organization. Costs to the organization are in the form of job dissatisfaction; absenteeism;
turnover; poor morale; low productivity; staffing shortages; and loss of expertise, loyalty, and
commitment to the organization. If nursing staff is dissatisfied with their jobs, they are at higher
risk of calling in frequently, changing departments, or resigning.
Research Objectives
The purpose of this study was to add to the refinement of our current understanding of bullying
behavior in health care settings. Specifically, we focused on bullying behavior among nurses
only and investigated the relationships of three types of bullying behaviors, work-related, personrelated, and physically intimidating, with nurses psychological/behavioral responses and
medical errors. Research on the relationship of bullying with medical errors is limited, and thus,
the findings of this study can fill this void in existing research. In addition, we examined if
bullying varies with gender and age or across locations/facilities in the same institution
Settings and Sample
Approximately 1,078 registered nurses and licensed practical nurses employed at a university
hospital system in Midwest were targeted as potential study participants. The university hospital
system is composed of three facilities located within the same community, a main hospital with
trauma center, a womens and childrens hospital, and an orthopedic hospital. The purpose of the
study was reviewed with the Director of Nursing for support and consent to proceed. The
research study was also reviewed and approved by the University of Missouri Institutional
Review Board before data collection. The survey was conducted using an internal e-mail system.
An email was sent to the respondents explaining the purpose of the study and inviting them to
participate. Completion of the survey indicated their consent to participate in the study. In
addition, participants were informed that the data being collected were voluntary and would be
confidential and responses would not be identified individually. The email included a link to the

online survey located on the Survey Monkey Web site. The survey included four demographic
questions, 22 questions related to specific bullying behaviors, and 14 questions related to
psychological/behavioral responses and medical errors. Incomplete surveys were discarded. Of
the 248 surveys returned, 241 were complete and used in data analysis. The response rate was
A demographic information form was created to collect data regarding participants age, gender,
years of experience, and the facility where the employee worked. The investigator utilized the
NAQ-R to define the frequency of bullying and bullying characteristics. The NAQ-R is a
reliable, valid, and a short questionnaire that can be used in a range of occupations and has been
adapted to the Anglo-American culture (Einarsen et al., 2009;Laschinger et al., 2010). The NAQ-R consists of 22
questions that focus on the varying aspects of bullying behaviors. Three categories emerge
among these questions: work-related bullying, person-related bullying, and physically
intimidating bullying. Questions are written in behavioral expressions and do not reference
harassment or bullying. The questionnaire has a Cronbachs of .92 ( Einarsen et al., 2009; Laschinger et
al., 2010
). Bullying behaviors were examined using the 22 questions from the NAQ-R to measure
exposure over the course of work within the university facilities. Response alternatives included:
never, now and then, monthly, weekly, and daily.
The investigators also utilized a survey created by Rosenstein and ODaniel (2008) that assessed job
performance. This survey was modified to meet the investigation goals and assimilate with the
structure of the NAQ-R. Response alternatives were changed from never, rarely, sometimes,
frequent, and constant to never, now and then, monthly, weekly, and daily. The original
survey consisted of 12 questions. Two questions were added addressing physical symptoms
and absenteeism to make a total of 14 questions. Another modification included replacing the
question regarding adverse events with a question about medical errors as the investigators
felt the original question was too broad. The survey concluded with an additional free-text option
to allow respondents to voice any comments regarding the survey content or share personal
experiences, thoughts, or concerns.
After examining the participating nurses demographic characteristics, it was determined that 1%
of participants were less than 20 years old, 44% were between 21 and 39 years old, 50% were
between 40 and 59 years old, and 5% were over 60 years old. There were 17% of nurses with
less than 2 years of experience, 29% between 3 and 10 years, 16% between 11and 20 years, 22%
between 21 and 30 years, and 16% with over 31 years of experience. Most nurses were women
(91%). A significant number of nurse participants were employed at the main hospital (67%),

followed by womens and childrens hospital (27%), and orthopedic hospital (2%), with 4% of
the participants not responding to this question.
The descriptive statistics and zero-order correlations between the study variables are presented
in Table 3. The mean scores for work-related and person-related bullying suggest that the extent
of person-related bullying (mean = 2.28) was higher than work-related bullying (mean = 1.78).
The extent of physically intimidating bullying was the lowest (mean = 1.26). Furthermore, the
mean score of 2.14 for psychological and behavioral responses was higher than the mean score
of 1.79 for medical errors.
The results show that person-related and work-related bullying have a significant relationship
with psychological/behavioral responses and medical errors. The person-related bullying could
be viewed as an informal bullying composing of behaviors such as gossip, practical jokes, or
being excluded. The person-related behaviors could come from peer groups or cliques and may
be fostered by organizational culture. Study participants commented in the open-ended question
that bullying behaviors were more behind the scenes, showed lack of teamwork/cooperation, a
figure it out yourself attitude, snarky comments, and a lot of negative gossips.
Work-related bullying could be viewed as formal bullying including behaviors such as
assignment of unmanageable workloads and deadlines. These are more likely to be driven from
superiors and are supported by the structure of the organization. Multiple study participants
commented that bullying behaviors derived from supervisors or management. A study participant
commented that more and more tasks are added with zero recognition given and faults are
pointed out by management whereas the good outcomes are ignored.
Work-related bullying did not show a direct relationship with medical errors but showed an
indirect relationship through psychological/behavioral responses. This could be explained
utilizing the participants example; more and more tasks are given with no recognition. This may
not directly impair the quality of care delivered, but lack of recognition could affect morale,
which in turn affects quality of care. Study participants did not perceive physically intimidating
bullying behaviors as related to psychological/behavioral responses or medical errors.
As participants age increased, the amount of bullying reported decreased. This could be
explained by normalization of person-related bullying as participants become accustomed to
those behaviors, bullying behaviors become encultured, or alternatively actual bullying behaviors
decline (Hutchinson et al., 2010).
In terms of individual items constituting the three types of bullying behaviors, the prevalent
person-related bullying behaviors included being ignored or excluded and excessive

monitoring of your work (see Table 1). The prevalent work-related bullying behaviors were
having your opinions ignored and being exposed to an unmanageable workload (see Table
1), and the prevalent psychological/behavioral responses included poor staff morale and
feelings of frustration (see Table 2). These results confirm that bullying behaviors are related
to morale, job satisfaction, and diminished quality of care and are consistent with previous
studies (Cleary et al., 2010; Felblinger, 2009; Olender-Russo, 2009; Vessey et al., 2009; Yildirim, 2009)
Relationship of Bullying With Gender, Age, and Facility
Work-related bullying did not change with age/experience. This could be explained by staffing
shortages resulting in high workloads, which potentially impact ability to meet deadlines, or
being assigned work below competency levels. Person-related bullying is perceived higher with
younger/less experienced nurses and decreases as age/experience increases. This finding is
consistent with the previous research. In this study, men experienced more work-related bullying.
This can be explained because women dominate the nursing profession and men are the minority
(Deltsidou, 2009). For example, Salin and Hoel (2013) observe that women tend to utilize social manipulation,
social relationships, and social reputation as forms of bullying. Those behaviors align with peerto-peer, person-related bullying. There was no significant difference in bullying behaviors or
outcomes among the three locations studied. This can be explained because the three locations
are within the same community and employees often float from one facility to the other. The
locations are all part of a large organization with the same mission, vision, values, and
Implications for Practice
The findings of this study suggests that the overall level of bullying behaviors at the university
hospital system is not severe; however, there is a prevalence of person-related and work-related
bullying that directly and indirectly impact behavioral/psychological responses and medical
errors. Person-related bullying is more common with a mean score of 2.28, whereas work-related
bullying had a mean score of 1.78. A mean score of 2.0 would suggest bullying behaviors occur
now and then. As the score rises to 3.0, the frequency of bullying behaviors increases to monthly.
Mean scores above 3.0 would indicate a serious problem with bullying as the behaviors occurs
weekly or daily. These study findings reinforce the necessity to identify bullying behaviors and
implement prevention strategies in the workplace. Organization leaders hold the primary role to
address workplace bullying behaviors. As leaders, they must set the example of how employees
should conduct themselves within the workplace and with their coworkers. Their behaviors
trickle down and impact organizational culture. An organizations culture may contribute to
continued bullying behaviors. Leadership should evaluate the current cultures tolerance of
bullying behaviors. Center (2011) provided a set of assessment questions to aid leadership in creation
of a culture that does not tolerate bullying. Questions include the following:

How are incidents handled when they occur? Are they ignored, indirectly teaching staff they are
Are incidents acknowledged as an opportunity for improvement and growth, empowering staff to
confront the issues as quality improvement? How can these issues be addressed in team
How is the incident investigated? Are there assumptions of individual blame, or are breakdowns
considered a system issue requiring a system investigation?
How many incidents of bullying behavior are tolerated before action is taken to change
Utilizing these or similar questions to assess current practices and culture will help leadership
determine what prevention strategies they must take to counter bullying.
Person-related bullying includes gossip, being ignored, criticism, practical jokes, or teasing.
Prevention should be focused on the bullying instigator, target, and culture. Conflict resolution is
required to address and resolve poor behaviors as stated by Johnson (2011). Encouraging all employees
to practice emotional intelligence, crucial conversations, and collaboration through sensitivity
training, education about staff relationships, and team communication programs is essential ( Cleary
et al., 2010 Piper, 2006 Rosenstein & ODaniel, 2008
). Behaviors are taught and often passed down from mentors
and experienced coworkers. In the free-text comments of the survey, study participants
mentioned feeling intimidated by preceptors during orientation and that senior nurses were
hesitant to teach new nurses. To prevent bullying behaviors becoming accepted in the
organizational culture, it is important to modify orientation and mentoring of new employees to
ensure behaviors are not being passed down (Center, 2011). Early education such as open discussion
of bullying behaviors during orientation and continuous coaching will allow young professionals
to develop skills required to collaborate, communicate, and be accepting of differences. Early
introduction to workplace bullying will also eliminate norms that have developed regarding
hazing and rites of passage (Center, 2011; Laschinger et al., 2010; Olender-Russo, 2009;Vessey et al., 2009). Improper
reporting mechanisms have been found to be a huge barrier to successful implementation of
workplace bullying initiatives. Study participants comments revealed that there was a fear of
being reprimanded for reporting bullying behaviors and that the current reporting system served
as a form of tattling on coworkers versus being a useful tool for process improvement. Clear and
trustworthy mechanisms must be in place for employees to report bullying behaviors such as a
reporting hot-line (Rosenstein & ODaniel, 2008; Vessey et al., 2009). The human resources department needs to
own the investigation and grievance procedures. It is vital that those involved with the
investigation have no connection or regular interaction with the individuals involved ( Hutchinson et al.,

Work-related bullying includes being ordered to complete work below ones competence level,
being given unreasonable deadlines, having ones opinions ignored, and being given
unmanageable workloads. Work-related bullying may be the product of staffing shortages,
workplace design, policies, or structure of the organization. Examining workplace design and
policies is important to discover if they are the fertile ground for bullying. Characteristics that
contribute to bullying are a rigid, vertical organization structure, informal alliances and
hierarchies, imbalance of power, job insecurity, and organizational wide restructuring and
downsizing (Cleary et al., 2010; Hutchinson et al., 2010;Johnson, 2011; LaVan & Martin, 2008; Olender-Russo, 2009). Controlling,
power-driven and rigid cultures do not encourage communication, group work, or collaboration
(Khatri, Brown, & Hicks, 2009). Hierarchical workplaces create power imbalances that fuel bullying and
dehumanize employees (Khatri, Baveja, Boren, & Mammo, 2006). It is important for organizations whose goal
is to prevent and eliminate bullying to restructure their workplace design.

Participation was an important limitation in this research. Of the 1,078 nurses employed at a
university hospital system in Mid-Missouri, 248 returned the survey. Of the 248 responses, 241
were complete and usable, leaving 837 nurses not participating. The reasons for the low response
rate may be that the survey was distributed via email through nursing managers and supervisors.
Surveys may have not been forwarded to staff especially by managers having bullying
tendencies, surveys may have not been forwarded in a timely manner, reminders may have not
been forwarded, or nurses may have not had private access to complete the survey. Subject
sensitivity is a limitation. Bullying behaviors are highly underreported because of fear and
mistrust. Those feelings may inhibit an individual from completing a survey. Reviewing the freetext comments from survey results revealed that nurses felt other people such as physicians,
leadership, and patients families often act as bullies. Level of bullying may be higher if the
study included other sources such as physicians and families of patients. Some nurses also
expressed their opinions about the importance of this topic and recommended expanding the
research to include other professions.
The use of the NAQ-R and survey created by Rosenstein and ODaniel are reliable tools to
identify the existence of bullying, what type of behavior is experienced most frequently, who is
likely to experience these behaviors, and the relationship to job performance. Findings from this
study suggest that bullying behaviors exist and affect psychological/behavioral responses, such
as stress and anxiety, and medical errors. Implications from bullying behaviors can be costly in
the form of low morale, frustration, reduced collaboration, poor communication, and impaired
quality. Health care organizations should identify bullying behaviors in their culture and

organization and implement bullying prevention strategies to reduce bullying behaviors and their
effects. Additional research is recommended after prevention strategies are implemented to
evaluate success.