ORIGINAL ARTICLE

Workplace bullying among nurses and their related factors in Japan: a

cross-sectional survey

Mami Yokoyama, Miho Suzuki, Yukari Takai, Ayumi Igarashi, Maiko Noguchi-Watanabe and Noriko
Yamamoto-Mitani
components of a healthy work
environment, par- ticularly staffing and
resource adequacy and good leadership,
Aims and objectives. ​To explore the association between workplace bullying and workplace
both of which can be changed within
environment factors among nurses in Japan. ​Background. ​Workplace bullying among nurses
wards. These factors may be important for
is increasing globally and occurs more frequently than among other professions. However,
reducing nurs- ing workplace bullying.
there is little informa- tion on the impact of workplace environment factors on nurse bullying
in Japan. ​Design. ​A cross-sectional survey using a self-administered questionnaire. ​Methods.
Participants were 1152 nurses recruited at seminars or training courses outside of their
workplaces in Tokyo. Workplace bullying was measured using the Negative Acts
Questionnaire-Revised. Participants were considered to have been ‘bullied’ if they reported
experiencing at least one negative act on a daily or weekly basis. Workplace environment
factors were measured using the Practice Environment Scale of the Nursing Work Index,
which comprises five domains: nurse participation in hospital affairs; nursing foundations for
quality of care; nurse manager ability, leadership and support of nurses; staffing and resource
adequacy; and collegial nurse​–​physician relationships. ​Results. ​A total of 898 (78​4​0%)
questionnaires were returned, of which 825 (71​4​6%) were analysed. Altogether, 153 (18​4​5%)
nurses were considered ‘bullied.’ The three most frequent negative acts reported as occurring
on a weekly or daily basis were ‘someone withholding information which affects your
performance’ (6​4​7%), ‘being exposed to an unmanageable workload’ (4​4​4%) and ‘being
shouted at or being the target of spontaneous anger (or rage)’ (3​4​6%). Logistic regression
analysis indicated that ‘bullied’ were associated with low scores on two work environment
thors: ​Mami Yokoyama​, MS, RN, Department of Adult Health, School of
domains: nurse manager ability, leadership and support of nurses and staffing and resource
alth Sciences and Nursing, The University of Tokyo, Bunkyo-ku, Tokyo;
adequacy. ​Conclusions. ​Effective nurse manager leadership and support as ho well as,​ PhD,
Suzuki appropri-
RN, The Cancer Institute Hospital of Japanese Foundation
ate staffing management may positively influence workplace bullying among Cancer Research,
nurses Koto-ward, Tokyo; ​Yukari Takai​, PhD, RN, Department
in Japan.
Adult Health,
Authentic leadership styles and allowing nurses to easily request days off might also be School of Health Sciences and Nursing, The University of
important. kyo, Bunkyo-ku, Tokyo; ​Ayumi Igarashi​, PhD, RN, Department of Adult
What does this paper contribute to alth, School of Health Sciences and Nursing, The Univer- sity of Tokyo,
nkyo-ku, Tokyo; ​Maiko Noguchi-Watanabe​, PhD, RN, Department of
the wider global clinical community?
ult Health, School of Health Sciences
• ​This is one of the first assess- ments of d Nursing, The University of Tokyo, Bunkyo-ku, Tokyo; ​Noriko
nursing workplace bul- lying in Japan, and mamoto-Mitani,​ PhD, RN, Department of Adult Health, School of Health
ences and Nursing, The University of Tokyo, Bunkyo- ku, Tokyo, Japan
the results indicated that it is more frequent
rrespondence: ​Mami Yokoyama, MS, RN, Department of Adult Health,
than would have been predicted. ​• hool of Health Sciences and Nursing, The University of Tokyo, 208 Faculty
Medicine Bldg.5 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
ephone: +81 3 5841 3508. ​E-mail: ​ykym-tky@umin.ac.jp
Workplace bullying is associated with
​ the

© ​2016 John Wiley & Sons Ltd ​Journal of Clinical Nursing,​ doi: 10.1111/jocn.13270 1
M Yokoyama e​ t al.

Relevance to clinical practice. ​Nurse managers’ leadership may influence nurses’ workplace
 bullying.

Key words: ​healthy work environment, leadership, nursing, staffing, workplace bullying

Accepted for publication​: 9 February 2016

2011). In the non-nursing lit- erature, a number of environmental
factors have been
found to be associated with bullying, such as lack of leader- ship,
Introduction and background team cohesion (Giorgi ​et al. ​2013), perceived human- ity, procedural
justice (Oxenstierna ​et al. ​2012), role conflict (Einarsen ​et al. 1​ 994)
Recently, workplace bullying has become a significant issue and stressful situations (Tuckey ​et al. ​2009).
worldwide. In 2003, the World Health Organization issued a warning
Several environmental factors related to bullying have also been
about increasing rates of workplace bullying (Cassitto ​et al. ​2003). In
found in the nursing literature, such as lack of leadership (Roche ​et al.
Japan, the Ministry of Health, Labour and Welfare (MHLW 2012)
2010, Brewer ​et al. ​2013) and poor team cohesion (Brewer ​et al.
has reported an increase in the prevalence of workplace bullying,
2013). However, these studies used only bivariate analyses. Thus, we
which led to its implementing a roundtable conference on workplace
have few details on the impact of the workplace environment on
bullying and harassment in 2012.
bullying among nurses. This impact is necessary to clarify because it
Bullying is reportedly more prevalent in the nursing workplace would help in developing interventions targeting workplace
than in other working environments. Across var- ious occupations, environment factors, which could work effectively alongside direct
4​4​8​–​31​4​4% of workers internationally (Oxenstierna ​et al. 2​ 012) and intervention on psychosocial factors. Moreover, such an intervention
9​4​0​–​15​4​5% in Japan have reported being exposed to some type of for environmental factors not only influ- ences those involved in
bullying (Einarsen ​et al. 1​ 994, Niedhammer ​et al. ​2006, Tuckey ​et al. bullying but also all other staff members.
2009, Takaki ​et al. 2​ 010, Tsuno ​et al. ​2010, Giorgi ​et al. 2​ 011,
The concept of healthy work environment (HWE) has been
Oxenstierna ​et al. 2​ 012). In contrast, 38​4​0​–​50​4​0% of nurses in the
widely studied in relation to work performance quality, and to
UK and Australia, 48​4​0​–​72​4​0% in the US, and 6​4​9​– ​32​4​2% in Japan
examine the nursing workplace environ- ment (American Association
have been exposed to bullying of some description (Japanese Nurse
of Critical-Care Nurses [AACN] 2005, Shirey 2006, Kramer &
Association 2003, International Centre for Human Resources in
Schmalenberg 2008). An HWE is defined as a ‘work setting in which
Nursing 2007, Castronovo ​et al. 2​ 015).
policies, procedures and systems are designed so that employees are
The negative consequences of workplace bullying are well able to meet organisational objectives and achieve personal
known; they include depression (Niedhammer ​et al. 2​ 006, Giorgi ​et satisfaction in their work’ (Disch 2002, p. 3). It has also been
al. 2​ 013, Sato & Miki 2013), traumatic stress reactions (Sakaguchi & described as a joyful, patient- focused and Magnet-designated
Miki 2013) and other psychoso- matic symptoms (Reknes ​et al. workplace (Shirey 2006). In nursing, fostering an HWE is believed to
2014). In nursing, there are associations between workplace bullying be essential in supporting nursing practice quality and solving the
and lower job sat- isfaction (Brewer ​et al. ​2013, Budin ​et al. 2​ 013), nursing shortage (AACN 2005, Kramer & Schmalenberg 2008, Ritter
turnover intention (Brewer ​et al. ​2013, Budin ​et al. 2​ 013) and decline 2011). Clarifying the association between an HWE and workplace
in care quality (Roche ​et al. ​2010, Laschinger 2014, Wright & Khatri bullying may help to reduce the prevalence of workplace bullying, In
2015). These studies all suggest that reducing workplace bullying in other words, if HWE is associated with less workplace bullying, then
nursing settings is an urgent issue. this could be a viable workplace-wide intervention for work- place
The causes of workplace bullying are suggested to be not only bullying, especially given that there is ample evi- dence for how to
individual but also environmental (Einarsen ​et al. ​1994, Tuckey ​et al. create and sustain an HWE (Kramer & Schmalenberg 2008).
2009, Hutchinson ​et al. 2​ 010, Roche ​et al. 2​ 010, and Giorgi ​et al.

© ​2016 John Wiley & Sons Ltd ​2

Journal of Clinical Nursing
The concept of an HWE was operationalised in this study 02). These subscales describe concepts similar to those in the tools
as the Practice Environment Scale of Nursing Work Index oposed by the AACN regarding HWE standards: namely,
(PES-NWI), which comprises five subscales: nurse participa- tion in eaningful recognition, effective decision, authentic leadership,
hospital affairs; nursing foundations for quality of care; nurse pro- priate staffing, skilled communication and true collabora- tion.
manager ability, leadership and support of nurses; staffing and me of the environmental factors mentioned in previous studies on
resource adequacy; and collegial nurse​– ​physician relations (Lake llying are similar to some of the PES- NWI items, but were not
sufficiently focused for examining correlations with workplace rpetrators were limited to colleagues because we wanted to focus on
bullying. Further examination of the relationship between workplace ori- zontal violence,’ which is a widespread problem in nursing
bullying and an HWE might help improve current understanding of astronovo ​et al. ​2015). Moreover, since the HWE domains included
the environmental elements that affect bullying. Furthermore, e leadership of nurse managers, we decided to exclude negative acts
workplace bullying is likely to differ between cultures (Power ​et al. nurse managers.
2013); to create optimal interventions for bullying, studies must be
Workplace bullying was measured using the Japanese
conducted across countries.
rsion of the Negative Acts Questionnaire-Revised (NAQ- R), which
The research question of this study was as follows: ‘Is an mprises 22 items (Tsuno ​et al. ​2010). This scale was originally
HWE related to workplace bullying?’ We hoped that learn- ing more veloped by Einarsen ​et al.​, based on their definition, and is the most
about this relationship would help in developing programs for dely used measure of workplace bullying (at the time of this study,
reducing the prevalence of workplace bully- ing. Thus, the aim of this had been used in over 40 countries; Tsuno ​et al. ​2010). The reliabil-
study was to determine the asso- ciation between workplace bullying and validity of the NAQ-R have been verified in both Japan and
and an HWE in Japan. her countries (Einarsen ​et al. ​2009, Tsuno ​et al. 2​ 010). All 22 items
scribed behaviours without using the word ‘bullying’ and asked
w often the partici- pants had experienced the respective negative
Methods s within the last six months. The response choices were ​never ​(​=​1),
w and then (​ once every two or threemonths ​=​2), ​monthly ​(​=​3),
ekly ​(​=​4) and ​daily ​(​=​5).
Study design and participants
The NAQ-R has been reported to have different factor
A cross-sectional study was conducted using a self-admi- nistered ucture depending on the culture and occupation of those taking it
questionnaire. The participants were a convenience sample of 1152 inarsen ​et al. ​2009, Giorgi ​et al. ​2011). A three- factor model was
nurses, including midwives and licensed practical nurses. All nurses ported for both the original and Japanese versions of the NAQ-R,
were recruited at seminars and training courses that were not t the factors comprised different items between these two versions
affiliated with their work- places and were sponsored by a company, a inarsen e​ t al. ​2009, Giorgi ​et al. ​2011). The original author, in
publisher and two nursing associations in the Tokyo Metropolitan nsider- ing these different models, has permitted its use with a
Area in July 2014. The questionnaires were distributed to nurses gle-factor structure (Einarsen ​et al. ​2009); this approach was used
individually at the beginning of the programs and were collected at this study. The Cronbach’s alpha for the NAQ- R in this sample
the end of the same day. The programs cov- ered topics such as s 0​4​93.
emergency medical care, end-of-life care, and infection control; none The NAQ-R responses were dichotomised, as the total
were related to bullying issues. ores were not normally distributed. Participants were coded as
According to a report by the MHLW, there were 1​4​5 mil- llied ​when they reported experiencing at least one negative act
lion employed nurses in 2012 in Japan. Of them, 80% worked in ekly ​or ​daily​; otherwise, they were coded as ​not bullied.​ This
hospitals, 50% were aged under 40 years, 94% were women and 65% ocedure has been used in mul- tiple previous studies (Takaki ​et al.
were married (MHLW 2011, 2014). 10, Tsuno ​et al. ​2010, Sato & Miki 2013).
Measurements
panese version of PES-NWI ​The Japanese version of the PES-NWI
Japanese version of the NAQ-R E ​ inarsen ​et al. (​ 2009) defined gata ​et al. ​2008) was used to measure HWE. This scale has
workplace bullying as ‘the persistent exposure to interpersonal
monstrated
aggression and mistreat- ment from colleagues, superiors or
subordinates’. We drew on Einarsen’s definition in this study, but

© ​2016 John Wiley & Sons Ltd ​Journal of Clinical Nursing ​3

Original article ​Workplace bullying among nurses
sample satisfactory reliability and validity and been translated into
size, all variables were kept in the model. Multi- multiple languages (Ogata ​et al. 2​ 008). It comprises 31
collinearity was examined by checking the range of 95% items in five subscales: (1) nurse participation in hospital
confidence intervals (CIs). SAS University Edition was used affairs (nine items); (2) nursing foundations for quality of
for the analyses and the significance level was set at 0​4​05. care (10 items); (3) nurse manager ability, leadership and
The study protocol was examined and approved by the support of nurses (five items); (4) staffing and resource ade-
Ethics Committee of the Graduate School of Medicine, The quacy (four items) and (5) collegial nurse​–​physician rela-
University of Tokyo (10537). tions (three items). Participants respond to each item using a four-point Likert scale ranging from 1
(​strongly agree)​ to 4 (​strongly disagree)​ . Each item score was reversed (i.e.
Results
1 ​= ​strongly disagree ​and 4 ​= ​strongly agree)​ , so that
Of the 1152 questionnaires distributed to the nurses, 898 higher scores indicated a healthier practice environment
(response rate 78​4​0%) were returned. Of these, 73 were (Ogata ​et al. 2​ 008). The subscale scores are calculated by
excluded for the following reasons: not currently working averaging the subscale items. The Cronbach’s alphas in this
​ ​13), data for one or more NAQ-R items missing study for subscales (1), (2), (3), (4) and (5) were 0​4​75, 0​4​79,
(​n =
(​n =​ ​52), and data for more than five PES-NWI items miss- 0​4​84, 0​4​76 and 0​4​83 respectively.
ing (​n ​= ​8). A total of 825 participants (valid response rate 71​4​6%) were included in the analyses. Frequencies for the
Demographic and work-related variables
NAQ-R items are shown in Table 1. Of the 825 partici- The demographic variables included age, gender, marital
pants, 153 (18​4​5%) were categorised as ​bullied​. The three status, highest educational level and qualifications. Work-
most commonly reported negative acts that participants related variables included years of nursing experience, years
experienced on a ​weekly o​ r ​daily b​ asis were ‘someone with- of experience in current workplace, position title, working
holding information which affects your performance’ at a hospital or not and workplace type (e.g. ward, outpa-
(6​4​7%), ‘being exposed to an unmanageable workload’ tient, homecare). Furthermore, work-related variables that
(4​4​4%), and ‘being shouted at or being the target of sponta- might reflect the nurses’ busyness included number of night
neous anger (or rage)’ (3​4​6%). In contrast, most partici- shift hours worked, average number of overtime hours per
pants (97​4​8%) had never experienced ‘threats of violence or day, average number of days off worked per month, paid
physical abuse or actual abuse,’ and no one was categorised vacation usage and opportunities to request days off. Paid
as bullied because of this item. vacation usage referred to whether nurses could take addi-
Demographic and work-related characteristics are shown tional vacation days according to the labour standards law,
in Table 2. The mean [standard deviation (SD)] age of the while opportunities to request days off referred to whether
sample was 36​4​9 (10​4​1) years, 95​4​2% were women, 45​4​6% the nurses had some degree of control over their weekly
were married and 14​4​5% held a bachelor’s or higher degree. holiday (i.e. could adjust it according to their convenience).
The mean (SD) years of nursing experience and years of working in their current workplace were 12​4​6 (9​4​3) and 4​4​1
Statistical analysis
(4​4​2) respectively. Most study participants (92​4​4%) worked in a hospital and 69​4​3% worked in general inpatient wards.
Descriptive statistics were used to examine the distribution
The PES-NWI subscale scores are also shown in Table 2. of responses. Cronbach’s alphas were calculated for the
The mean scores of the subscales were as follows: (1) nurse NAQ-R and the PES-NWI.
participation in hospital affairs, 2​4​44; (2) nursing foundations Following the bivariate analyses among variables, multi-
for quality of care, 2​4​54; (3) nurse manager ability, leadership, variate logistic regression analysis was conducted to exam-
and support of nurses, 2​4​60; (4) staffing and resource ade- ine the association between PES-NWI scores and workplace
quacy, 2​4​16 and (5) collegial nurse​–​physician relations, 2​4​51. bullying. The dependent variable was the dichotomised
Thirteen demographic and work-related characteristics NAQ-R ​bullied ​or ​not bullied ​coding, while the primary
were associated with being bullied in the bivariate analyses independent variables were the PES-NWI subscale scores.
​ ​0​4​10; Table 2) and were consequently entered into the Control variables were selected from the demographic and
(​p <
logistic regression model: unmarried, holding a bachelor’s work-related variables that had significant (​p ​< ​0​4​10)
degree or higher, having registered nurse and additional associations with the dependent variable in the bivariate
qualifications, fewer years of nursing experience, fewer analyses according to the Mann​–​Whitney ​U​-test, ​t-​ test, or
years of experience in current workplace, more overtime chi-square test (Katz 2011). Given that there was a sufficient
hours per day, not always having the opportunities to
© ​2016 John Wiley & Sons Ltd ​4 ​Journal of Clinical Nursing
M Yokoyama ​et al.
Table 1 ​Frequency of negative acts received in last six months (​n ​= ​825)
NAQ-R item
n ​(%)
Never Now and then Monthly Weekly Daily
1. Someone withholding information which affects your performance 353 (42​4​8) 305 (37​4​0) 112 (13​4​6) 45 (5​4​5) 10 (1​4​2) 2. Being humiliated or
ridiculed in connection with your work 577 (69​4​9) 170 (20​4​6) 49 (6​4​0) 23 (2​4​8) 6 (0​4​7) 3. Being ordered to do work below your level of
competence 643 (78​4​6) 130 (15​4​8) 27 (3​43​ ) 18 (2​4​2) 7 (0​4​9) 4. Having key areas of responsibility removed or replaced with more
trivial or unpleasant task
677 (82​4​1) 102 (12​4​4) 33 (4​4​0) 7 (0​4​9) 6 (0​47​ )
5. Spreading of gossip and rumours about you 614 (74​4​4) 162 (19​4​6) 27 (3​4​3) 15 (1​4​8) 7 (0​4​9) 6. Being ignored, excluded or being ‘sent to
Coventry’ 732 (88​4​7) 61 (7​4​4) 18 (2​4​1) 6 (0​47​ ) 8 (1​4​0) 7. Having insulting or offensive remarks made about your person,
your attitudes or your private life
675 (81​4​8) 111 (13​4​5) 24 (2​4​9) 11 (1​4​3) 4 (0​45​ )
8. Being shouted at or being the target of spontaneous anger 579 (70​4​2) 180 (21​4​8) 36 (4​4​4) 25 (3​4​0) 5 (0​4​6) 9. Intimidating behaviour such as
finger-pointing, invasion of
personal space, shoving, blocking/barring the way
737 (89​4​3) 63 (7​4​6) 19 (2​4​3) 5 (0​4​6) 1 (0​41​ )
10. Hints or signals from others that you should quit your job 767 (93​4​0) 40 (4​4​9) 14 (1​4​7) 4 (0​4​5) 0 (0​4​0) 11. Repeated reminders of your errors
or mistake 662 (80​4​2) 126 (15​4​3) 19 (2​4​3) 17 (2​41​ ) 1 (0​4​1) 12. Being ignored or facing a hostile reaction when you approach 702 (85​4​1) 86
(10​4​4) 22 (2​4​7) 13 (1​4​6) 2 (0​4​2) 13. Persistent criticism of your work and effort 681 (82​4​6) 106 (12​4​9) 23 (2​4​8) 13 (1​4​6) 2 (0​4​2) 14. Having
your opinions and views ignored 624 (75​4​6) 158 (19​4​2) 27 (3​4​2) 14 (1​4​7) 2 (0​4​2) 15. Practical jokes carried out by people you don’t get on with
773 (93​4​7) 39 (4​4​7) 9 (1​4​1) 4 (0​4​5) 0 (0​40​ ) 16. Being given tasks with unreasonable or impossible targets or deadlines 663 (80​4​4) 123 (14​4​9) 29
(3​4​5) 6 (0​4​7) 4 (0​4​5) 17. Having allegations made against you 722 (87​4​5) 82 (9​4​9) 15 (1​4​8) 4 (0​4​5) 2 (0​4​2) 18. Excessive monitoring of your
work 726 (88​4​0) 65 (7​4​9) 17 (2​4​1) 11 (1​4​3) 6 (0​47​ ) 19. Pressure not to claim something which by right you are entitled to 683 (82​4​8) 99 (12​4​0)
25 (3​4​0) 9 (1​4​1) 9 (1​4​1) 20. Being the subject of excessive teasing and sarcasm 754 (91​4​4) 47 (5​4​7) 14 (1​4​7) 7 (0​4​9) 3 (0​4​4) 21. Being exposed
to an unmanageable workload 624 (75​4​6) 134 (16​4​2) 31 (3​4​8) 26 (3​4​2) 10 (1​4​2) 22. Threats of violence or physical abuse or actual abuse 807
(97​4​8) 17 (2​4​1) 1 (0​4​1) 0 (0​4​0) 0 (0​4​0)
NAQ-R, Negative Acts Questionnaire ​– R ​ evised.
request days off, working on more days off, and a less HWE (defined by lower than average scores on the five PES-NWI
subscales). Spearman’s correlation coefficients for the five PES-NWI subscales and ​bullied r​ anged from 0​4​30​– ​0​4​60. All five
subscale scores were entered into the logistic regression model.
Table 3 shows the results of the multivariate logistic regression analysis. ​Bullied ​was significantly associated with the following
factors [odds ratio (OR), 95% CI]: less years of experience in current workplaces (0​4​93, 0​4​87​–​0​4​99); not always (in comparison
to always) having the opportunity to request days off (1​4​79, 1​4​15​–​2​4​80); and lower scores on the nurse manager ability,
leadership and support of nurses (0​4​59, 0​4​39​–​0​4​90) and staffing and resource adequacy sub- scales of the PES-NWI (0​4​55,
0​4​34​–​0​4​90).
Discussion
This study explored the association between workplace bul- lying and HWE (operationalised by using the PES-NWI) among
nurses in Japan, and represents one of the first attempts to specifically address this relationship.
© ​2016 John Wiley & Sons Ltd ​Journal of Clinical Nursing ​5
Original article ​Workplace bullying among nurses
Negative acts among nurses in Japan
​ elative to the 2011 National Nurses’ Survey, fewer partic- ipants in our sample were
Frequency of reports of being bullied R
married (45​4​6% in this study vs. 65​4​6% in national data) but more of them worked in hospi- tals (92​4​4 vs. 79​4​1%; MHLW
2011). Most topics covered in the seminars and training courses were relevant to hospi- tal settings, which could be the reason that
the majority of attendees were hospital workers. The other demographic characteristics of the participants were generally
compara- ble to those observed in the national survey.
In this study, 18​4​5% of participants reported that they had been bullied. This proportion was much higher than were those of other
studies, at 9​4​0% for civil servants (Tsuno ​et al. ​2010), 15​4​5% for manufacturing company workers (Takaki ​et al. 2​ 010) and
9​4​7% for nurses (Sato & Miki 2013). The high number of bullying reports calls for immediate action to understand the situation
more clearly and consider possible measures to address it.
The number of bullying reports in this study was also higher than that in another study involving Japanese nurses
Table 2 ​Demographic and work-related characteristics and scale scores
Variables
​ ​825)* Not bullied (​n ​= ​672)* Bullied (​n =
All (​n = ​ ​153)* ​n (​ %) or
n ​(%) or
n ​(%) or mean ​+ ​SD
mean ​+ ​SD
mean ​+ ​SD
p-​ value
Age​† ​36​4​9 ​+ ​10​4​1 37​4​1 ​+ ​10​4​1 36​4​2 ​+ ​9​49​ 0​4​35 Gender Male 37 (4​4​5) 30 (4​4​5) 7 (4​4​6) 0​4​95
Female 785 (95​4​2) 640 (95​4​2) 145 (94​4​8) Marital status Married 376 (45​4​6) 322 (47​4​9) 54 (35​4​3) 0​4​01
Unmarried 442 (53​4​6) 346 (51​4​5) 96 (62​4​7) Highest educational
level
 Lower than bachelor’s degree 697 (84​4​5) 577 (85​4​9) 120 (78​4​4) 0​4​02 Bachelor’s degree or higher 120 (14​4​5) 89 (13​4​2) 31 (20​4​3)
Qualifications Licensed practical nurse (LPN) 45 (5​4​5) 38 (5​4​7) 7 (4​4​6) 0​4​03
Registered nurse (including who
also have LPN)
617 (74​4​8) 517 (76​4​9) 100 (65​4​4)
Registered nurse and additional
qualification (e.g. midwives)
104 (12​4​6) 76 (11​4​3) 28 (18​4​3)
Years of nursing experience​‡ ​12​4​6 ​+ ​9​4​3 12​49​ ​+ ​9​4​3 11​40​ ​+ ​9​4​1 0​4​01 Years of experience in current workplace​‡ ​4​4​1 ​+ ​4​4​2 4​4​3 ​+ ​4​4​4 3​4​2 ​+
3​4​5 0​4​00 Position title Staff nurse 629 (76​4​2) 507 (75​44​ ) 122 (79​4​7) 0​4​10
Nurse manager or Leader 184 (22​43​ ) 158 (23​4​5) 26 (17​4​0) Working at a hospital Yes 762 (92​4​4) 617 (91​48​ ) 145 (94​4​8) 0​4​25
No (Clinic, visiting nurse
station, other)
61 (7​4​6) 53 (8​4​2) 8 (5​4​2)
Workplace type Ward 572 (69​4​3) 471 (70​4​1) 101 (66​4​0) 0​46​ 2
Outpatient 99 (12​4​0) 81 (12​4​1) 18 (11​4​8) Critical care unit, ER, or OR 104 (12​4​6) 80 (11​4​9) 24 (15​47​ ) Other 46 (5​4​6) 37 (5​4​5) 9 (5​4​9) Number
of night shift
hours worked
0 hours 87 (10​4​5) 68 (10​4​1) 19 (12​4​4) 0​4​73 8​–9​ hours 117 (14​4​2) 97 (14​4​4) 20 (13​4​1) 10​–​14 hours 54 (6​4​5) 46 (6​48​ ) 8 (5​4​2) Over 15 hours
543 (65​4​8) 441 (65​46​ ) 102 (66​4​7) Average number of
overtime hours per day
0​–​1 hours 217 (26​4​3) 186 (27​4​7) 31 (20​4​3) 0​40​ 7 1​–​2 hours 285 (34​4​5) 236 (35​4​1) 49 (32​4​0) 2​–​3 hours 186 (22​4​5) 152 (22​4​6) 34 (22​4​2) Over
3 hours 107 (13​4​0) 79 (11​4​8) 28 (18​4​3) Average number of days off worked per month​‡ ​1​4​8 ​+ ​2​4​0 1​4​8 ​+ ​1​4​9 2​4​1 ​+ ​2​4​2 0​4​03 Paid vacation
usage Can use 335 (40​4​6) 280 (41​4​7) 55 (35​4​9) 0​4​20
Cannot use 480 (58​4​2) 384 (57​4​1) 96 (62​4​7) Opportunities to
request days off
Always available 625 (75​4​8) 535 (79​4​6) 90 (58​48​ ) ​<​0​40​ 01 Not always available 194 (23​4​5) 132 (19​46​ ) 62 (40​45​ ) PES-NWI subscales​† ​Nurse
participation in hospital
affairs
2​4​44 ​+ ​0​4​43 2​4​49 ​+ ​0​4​41 2​4​25 ​+ ​0​4​45 ​<​0​4​001
Nursing foundations for quality
of care
2​4​54 ​+ ​0​4​43 2​4​58 ​+ ​0​4​41 2​4​35 ​+ ​0​4​44 ​<​0​4​001
Nurse manager ability, leadership
and support of nurses
2​4​60 ​+ ​0​4​58 2​4​67 ​+ ​0​4​54 2​4​30 ​+ ​0​4​65 ​<​0​4​001
Staffing and resource adequacy 2​4​16 ​+ ​0​4​54 2​42​ 1 ​+ ​0​4​51 1​4​94 ​+ ​0​4​58 ​<​0​4​001 Collegial nurse​–​physician relations 2​4​51 ​+ ​0​4​59 2​4​56 ​+ ​0​4​58
2​4​31 ​+ ​0​4​62 ​<​0​4​001
p-​values were based on chi-square test except the variables with ‘​†​’ and ‘​‡​’. SD, Standard deviation; PES-NWI, Practice Environment Scale
Nursing Work Index; ER, emergency room; OR, operating room. *Some numbers in these columns do not match the total number of the sample

because of missing values. ​†​t-​ test. ‡​​ Mann​–​Whitney ​U​-test.

using the NAQ-R. This may be due to the study setting. These data were purposefully collected outside of partici- pants’
workplaces to capture a more accurate rate of bully-
© ​2016 John Wiley & Sons Ltd ​6 ​Journal of Clinical Nursing
M Yokoyama ​et al.
ing, as participants would not have to worry about their colleagues; this might have resulted in more reports of bul- lying. Another
possible reason for the higher bullying rate
Table 3 ​Multivariate logistic regression analysis of reports of being bullied (​n ​= ​825)
Independent variables (reference category) Odds ratio 95% CI* ​p​-value
Marital status (Married) Unmarried 1​4​21 0​47​ 5​–​1​4​96 0​4​43 Highest educational level
(Lower than bachelor’s degree)
Bachelor’s degree or higher 1​4​23 0​4​53​–​2​4​86 0​4​64
Qualifications (Licensed practical nurse) Registered nurse (including who also have LPN) 1​4​60 0​4​61​–​4​4​21 0​4​34 Registered nurse and additional
qualification
(e.g. midwives)
2​4​32 0​4​64​–​8​4​37 0​4​20
Years of nursing experience 0​4​98 0​4​96​–​1​4​01 0​42​ 2 Years of experience in current workplace 0​4​93 0​4​87​–​0​4​99 0​4​03 Average number of
overtime hours
per day (0​–​1 hour)
1​–​2 hours 1​4​07 0​4​60​–​1​4​91 0​4​83 2​–3​ hours 1​41​ 3 0​4​59​–​2​4​15 0​4​72 Over 3 hours 1​4​42 0​4​68​–​2​4​95 0​4​35 Average number of days off
worked per month
1​4​08 0​4​98​–​1​4​20 0​4​11
Opportunities to request days off
(always available)
Not always available 1​4​79 1​4​15​–​2​4​80 0​4​01
PES-NWI subscales Nurse participation in hospital affairs 0​4​84 0​4​40​–​1​4​76 0​4​64 Nursing foundations for quality of care 0​4​63 0​4​32​–​1​4​26 0​4​19
Nurse manager ability, leadership and
support of nurses
0​4​59 0​4​39​–​0​4​90 0​4​01
Staffing and resource adequacy 0​4​55 0​4​34​–​0​4​90 0​40​ 2 Collegial nurse​–​physician relations 0​4​75 0​4​50​–​1​4​13 0​4​17
*Confidence interval.
in our study was that the data were only collected in urban and suburban areas of the Tokyo Metropolitan Area. A previous survey
reported a higher rate of bullying in urban areas than in rural areas (Japanese Nurse Association 2003). It is unclear why bullying
is observed more fre- quently in urban areas. However, it is possibly because urban areas have more hospitals, and nurses working
in these areas tend to change workplaces more frequently; this would result in a larger proportion of nurses having little
experience at their current hospital, and these nurses may be more likely to experience bullying.
Indeed, in this study, participants who had worked for less than six months in their current workplace reported higher rates of
being bullied; however, this result should be interpreted with caution. As the NAQ-R asks about one’s experience in the past six
months, it is unknown in which workplace (i.e. previous or current) these experienced those negative acts. Further examination is
required to better understand the rates of workplace bullying among new- comer nurses.
Item analysis of the NAQ-R O ​ f the NAQ-R items, the frequencies for ‘withholding information’ and ‘unmanageable workload’
were high in this study as well as in other studies (Johnson & Rea 2009, Sakaguchi & Miki 2013, Sato & Miki 2013), whereas
those of ‘violence and physical abuse’ were consistently low
© ​2016 John Wiley & Sons Ltd ​Journal of Clinical Nursing 7​
Original article ​Workplace bullying among nurses
(Chipps ​et al. 2​ 013, Sakaguchi & Miki 2013, Sato & Miki 2013). Other items showed varied frequencies across stud- ies.
Notably, frequencies of ‘withholding information’ appear to be high regardless of occupation (Giorgi ​et al. 2​ 011); however, the
high frequency of this item among nurses is particularly concerning because delays or a com- plete lack of information can cause
serious problems for patients/clients. As such, appropriate information transmis- sion methods should be reviewed carefully in
each work- place.
Unmanageable workloads have been frequently reported in nursing studies (Johnson & Rea 2009, Sato & Miki 2013). This may
be due to the overall busyness of nursing workplaces, which might cause nurses to feel as if they are the only ones who have been
given a higher workload. Moreover, nursing workloads are difficult to predict and allocate among staff. It may be important for
nurse man- agers to make workload division more visible to all staff members and to consider predictability as much as possible
during allocation.
Workplace bullying and the healthy work environment
We found for the first time among nurses in Japan that nurses’ perceptions of being bullied were negatively associ- ated with an
HWE, after controlling for other variables. Among the subscales of the PES-NWI, nurse manager lead-
An ership and adequate staffing were significant correlates of
interesting aspect of the PES-NWI is that the five items being bullied. These findings suggest that bullying might be
constituting the leadership scale of the PES-NWI (e.g. ‘super- reduced by improving ward environments in terms of nurse
visors use mistakes as learning opportunities rather than crit- managers’ leadership and staffing; however, the causality of
icism’) suggest that leaders should possess the characteristics this relationship must be further confirmed, as this was only
of ‘authentic leaders’ (George 2003). According to an AACN a cross-sectional study.
report, authentic leaders are considered trustworthy, reli- able, and believable (George 2003, AACN 2005), and ​Scores on the
PES-NWI
appear to be associated with staff members’ job satisfaction Practice Environment Scale of Nursing Work Index scores
(Giallonardo ​et al. 2​ 010) and work engagement (Gial- were somewhat lower than were those found in previous
lonardo ​et al. ​2010, Wong ​et al. 2​ 010), as well as a greater studies conducted abroad (Aiken ​et al. 2​ 011), but were
sense of community among colleagues (Wong & Cummings comparable with the findings of several domestic studies
2009). This study adds to the literature by pointing out that (Aiken ​et al. 2​ 011, Ogata ​et al. 2​ 008). One previous study
authentic leadership might prevent workplace bullying. A noted that average PES-NWI scores vary considerably
possible explanation for this is that when leaders are authen- across countries (Aiken ​et al. ​2011). Although it is possible
tic, nurses may feel able to speak out safely and impartially; that Japanese nurses understated the phenomenon in the
furthermore, authentic leaders may serve as role models, self-administered questionnaire because of the Japanese cul-
which could prevent bullying in the first place. tural characteristic of modesty, we believe that the work environment in Japan
nevertheless needs improvement.
Staffing and resource adequacy T ​ he PES-NWI staffing and resource adequacy subscale was ​Nurse managers’ leadership
significantly correlated with reports of being bullied. This Although the notion that leadership is associated with
finding corresponds to a Japanese qualitative study indicat- workplace bullying was implied in previous studies (Einar-
ing that staff shortage was associated with workplace bully- sen ​et al. 1​ 994, Johan Hauge ​et al. 2​ 007, Budin ​et al.
ing (Kitaide & Nara 2012), and to a study that 2013, Giorgi ​et al. ​2013), our study is among the first to
demonstrated an association between inadequate staffing specifically examine this relationship. Our result here sup-
and communication problems among healthcare workers ports the MHLW’s proposal that organisational
(Buerhaus ​et al. ​2005). Inadequate staffing may produce a approaches, leaders’ understanding of situations, and the
vicious cycle: inadequate staffing may influence workplace education of staff members are important factors for pre-
bullying, which in turn leads to staff turnover; this, in turn, venting or reducing the prevalence of workplace bullying
would exacerbate the staffing shortage and lead to further (MHLW 2012). It should be noted that this proposal was
bullying, etc. (Niedhammer ​et al. 2​ 006, Brewer ​et al. 2​ 013, drafted only based on consultations with experts; the study
Budin ​et al. ​2013, Sakaguchi & Miki 2013, Sato & Miki is the first to verify this relationship statistically.
2013, Reknes ​et al. ​2014). Although our findings should be Despite the apparent importance of leaders, several
examined further using objective data on staffing, our study reports have indicated that nurse managers do not effec-
suggests that staffing should be examined in relation to tively deal with bullying, even when they have been
workplace bullying, in addition to other care quality issues. informed of the bullying directly by the victims (Dzurec & Bromley
2012). In addition, even when nurse managers
Opportunities to request days off t​ ry to handle the matter, they often ascribe the causes of
Reports of being bullied were associated with not always the bullying to personal or interpersonal factors rather
having the opportunity to request days off. The ability to than organisational factors (Johnson ​et al. ​2015), and
request days off is usually at the discretion of the nurse man- reach out only to individuals actually involved in the bul-
agers and help to improve the work​–​life balance of staff lying (Johnson 2015). Furthermore, most organisations
nurses. This finding may have reflected how busy the work- have no clear policies in place to prevent workplace bully-
places were, but given that this relationship was significant ing (Johnson ​et al. ​2015). Our findings suggest that nurs-
even in the multivariate analysis, not being able to request ing leaders might be able to effectively prevent workplace
days off may have an independent impact on bullying. We bullying, which underlines the need for additional
have two possible explanations for this finding: nurse man- education and training for nurse managers regarding the
agers’ lack of skills regarding schedule development, and a importance of leadership as well as the nature of work-
workplace culture of not allowing requests. Staff shortages place bullying.
have always been a problem in Japan, and it is often difficult
© ​2016 John Wiley & Sons Ltd ​8 ​Journal of Clinical Nursing
M Yokoyama e​ t al.
This for nurse managers to maintain a shift schedule. Due to the
study has notable implications for practice. First, complexity of developing staff schedules, some ward cultures
nurse managers should recognise that the elements of an do not heed requests for days off. Thus, nurse managers
HWE, particularly their own leadership and support and would need to acquire skills to develop staff schedules effec-
the adequacy of the workplace resources, are important for tively, and ward leaders, who are primarily responsible for
reducing workplace bullying. Adopting an authentic leader- creating the ward culture, must be aware of the importance
ship style and allowing nurses to request days off might of being able to request days off among staff nurses.
also be important.
Limitations of the study and implications for
Conclusion future research and practice
In this study, workplace bullying and its correlates were There were several limitations to this study. First, we
examined among nurses in Japan. The findings suggested employed a cross-sectional design, which prevents causal
that approximately 18% of nurses had experienced bully- relationships from being inferred. Second, the study was
ing. A healthier work environment, effective leadership and based on a questionnaire survey, and all of the variables,
support by nurse managers, and staffing management may including workplace bullying and workplace environment,
reduce workplace bullying among nurses in Japan. Being were measured in terms of participants’ subjective percep-
able to request days off may also be important for nurses. tions. Because the items of the NAQ-R can be influenced by individual
cognitive style or mental health states, in future studies, we might include third-party personnel to
Contributions
report bullying to obtain a more detailed picture of work-
Study design: MY, YT, NY-M; Data collection and analy- place bullying among nurses. Nevertheless, we made efforts
sis: MY, MS, NY-M; Manuscript preparation: MY, MS, to control for the personal and professional characteristics
AI, MN-W, NY-M. of participants to provide the clearest possible picture of workplace bullying among nurses in Japan. Further
careful examination using multiple modes of inquiry should be
Conflict of interest
performed on this topic.
None declared.
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