Workplace bullying and different levels of post-traumatic stress symptoms of nurses: a

Accepted Article
quantile regression approach for effective coping strategies
• Running Title: Workplace Bullying in Nursing
• Authors:
Soyun Hong, MSN, RN, Doctoral student
College of Nursing and Brain Korea 21 FOUR Project, Yonsei University
50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 03722
Email address: rnsoyun@gmail.com
Heejung Kim, PhD, RN, GNP, Associate professor (Corresponding Author)
College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University
Room #603, College of Nursing
50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 03722
Email address: hkim80@yuhs.ac
Tel: 82-2-2228-3273, Fax: 82-2-2227-8303
Eun Kyoung Choi, PhD, RN, CPNP, Assistant professor
College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University
50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 03722
Email address: EKCHOI@yuhs.ac
Chang Gi Park, PhD, Research assistant professor
College of Nursing, Illinois University at Chicago
845 S. Damen Ave., MC 802, Chicago, IL 60612
Email address: parkcg@uic.edu
• Acknowledgments: The author gratefully acknowledges Professor Sunah Kim of Yonsei
university for her support in the development and review of this article.
• Disclosure of Grants and Funding: This research was supported by the Hanmaeum Scholarship
of the Seoul Nurses Association in 2018, and an International Collaboration Research Fund
granted by the Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University (6-
2019-0129). This research was supported by the Brain Korea 21 FOUR Project funded by
National Research Foundation(NRF) of Korea, Yonsei University College of Nursing.
• Ethical Approval: To protect participants’ rights, the study procedure was approved by the

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JONM.13388
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 affiliated Yonsei university health system institutional review board (No. Y-2018-0082). Online
Accepted Article
informed consent was obtained from all participants. To ensure participants’ anonymity and
confidentiality and prevent potential backtracking through any identifiable data obtained in this
study, we did not group them by type of online community.
• Conflict of Interest Statement: All authors declare they have no conflicts of interest.

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Accepted Article
DR SOYUN HONG (Orcid ID : 0000-0003-4847-3619)

DR HEEJUNG KIM (Orcid ID : 0000-0003-3719-0111)

PROFESSOR EUN KYOUNG CHOI (Orcid ID : 0000-0003-4622-2437)

Article type : Original Article

Workplace bullying and different levels of post-traumatic stress symptoms of nurses: a

quantile regression approach for effective coping strategies
Abstract
Aim: This study aimed to investigate effects of workplace bullying on different post-traumatic
stress symptoms and coping among hospital nurses.
Background: Workplace bullying is a traumatic event that negatively affects the quality of
patient care and nurses’ mental health.
Method: This cross-sectional, correlational study used an online survey among hospital nurses.
Ordinary least square and quantile regression analyses were conducted using Stata version 16.
Results: The study included 233 registered nurses from South Korea who had provided direct
care to patients in a hospital for at least six months. Overall, 28% self-identified as victims or
witnesses and 37% as victims and witnesses simultaneously. “Victim” and “passive coping”
were significantly associated with the 25th, 50th, and 75th percentiles groups of post-traumatic
stress symptoms, while “witness” was significant in the 95th percentile group.
Conclusion: Our study findings explore nurses’ workplace bullying, detect high-risk subgroups,
and suggest development of coping interventions for reducing workplace bullying and post-
traumatic stress symptoms.

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Accepted Article
Implications for Nursing Management: The study identified associations among bullying
experience types, severity of post-traumatic stress symptoms, and passive coping. It is critical to
explore traumatic experience types and severity of post-traumatic stress symptoms for nurses at
risk of workplace bullying.
Keywords: nurses, post-traumatic, psychological adaptation, stress disorders, workplace
bullying
Introduction
Internationally, various studies have addressed the negative effects of workplace bullying (WPB)
on turnover rate, turnover intention, or organizational commitment (Arnetz et al., 2019; Brewer,
2015; Seo & Park, 2017). However, there is a dearth of evidence on nurses’ psychological
distress and coping strategies (Brewer, 2015), especially in terms of WPB (Björklund et al.,
2019). Furthermore, considering the nature of post-traumatic stress disorder, it is necessary to
include both WPB victims and witnesses, rather than victims only, in the research (Arnetz et al.,
2019; Báez‐ León et al., 2016). Moreover, certain occupations, such as physicians, firefighters,
and police officers, have a high risk of secondary traumatic stress, compassion fatigue, or job-
related conflict due to professional characteristics similar to nursing (Anderson et al., 2020).
Consequently, such occupational groups report significantly higher post-traumatic stress
symptoms (PTSS) than that of the general population (Anderson et al., 2020) and it is
questionable to dichotomize them into traumatized and non-traumatized groups using a single
cutoff tested in the general population. Thus, the breakdown of the PTSS severity at multiple
levels may be useful for screening the most high-risk group in a certain occupation and
developing effective coping strategies. The aim of this study was to investigate WPB on different
PTSS and coping among hospital nurses (victims and/or witnesses) using quantile regression.
The specific aims were to (1) examine the general and WPB-related characteristics among nurses
who had never been either or had been both a victim and witness of WPB experiences; (2)
compare the types of WPB experiences, PTSS, and coping strategies among three subgroups;
and (3) identify factors associated with different severity of PTSS.
Background
All nurses have the right to work in a healthy working environment free from workplace
violence (International Council on Nurses [ICN], 2017). Prevalence of workplace violence
across healthcare settings ranges between 24% and 43% (American Nurses Association [ANA],

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Accepted Article
2015). Nurses may experience actual and attempted incidents of physical and verbal violence at
work, which may include various types of assault or abuse, incivility, and bullying (ANA, 2015).
Since bullying among nurses is underreported (ICN, 2017), international organizations and
studies have focused on the early detection and prevention of bullying and its impact on work
sites (ANA, 2015; ICN, 2017).
WPB is defined as repeated, unfavorable, and persistent behaviors that go on for more
than six months and cause distress among employees (ANA, 2015). WPB can include: (1) verbal
attacks, which refers to the behavior of forcefully criticizing, insulting, or denouncing another
person; (2) improper work instructions, which include providing unclear job directions with
incorrect deadlines and the excessive monitoring of progress; and (3) physical threats, which are
behaviors such as hand-pushing, poking, and tripping, as well as damage to a person's work area
or property (Lee & Lee, 2014). WPB negatively affects not only nurses but also patients and
organizations. Nurses who have experienced WPB suffered from psychological symptoms such
as anxiety, depression, and PTSS. Other negative consequences include increased medication
errors and diminished work performance, and dissatisfaction with nursing jobs leading to high
turnover intentions (Brewer, 2015; Hong et al., 2021; ICN, 2017). Therefore, it is important to
develop effective prevention, management, and early detection of WPB among nurses.
Some researchers have also linked WPB to PTSS (Laschinger & Nosko, 2015; Hong et
al., 2021). Following stressful conditions, a traumatized person experiences specific symptoms at
least one month afterward, including hyper-arousal, avoidance and numbing, and symptoms of
intrusion (Lim et al., 2009). In a meta-analysis examining WPB and PTSS, 43-84% of victims
reported PTSS after experiencing bullying among adult workers (Nielsen et al., 2015). However,
these studies focus on victims with direct exposure rather than witnesses with indirect exposure.
Meanwhile, several studies reported that more than 50% of nurses have witnessed bullying in
their work environments (Arnetz et al., 2019; Báez‐ León et al., 2016). Similar to the victims,
witnesses reported negative consequences of WPB, including high-level stress, poor work
performance, and increased intention to leave (Arnetz et al., 2019; Báez‐ León et al., 2016).
Thus, recent studies emphasized that more research is needed to include nurses who witness
WPB (Arnetz et al., 2019; Báez‐ León et al., 2016).
The conceptual framework for this study is based on Lazarus and Folkman’s (1984)
transactional model of stress and coping (Figure 1). The person becomes stressed when demands

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Accepted Article
exceed resources, and the interpretation of the stressful event and the coping ability become
more important than the stressor itself. For example, some nurses who witness WPB toward
other nurses remained silent because they felt afraid of becoming targets themselves (ICN,
2017), which is a passive coping strategy with WPB. In contrast, nurses using active coping
sought help from managers to deal with the causes of WPB and resolve problems at work
(Björklund et al., 2019). Therefore, it is necessary to differentiate nurses’ active and passive
coping strategies as protective factors when they become WPB victims or witnesses.
Methods
Study design
This study used a cross-sectional, correlational design. Data were collected using an online
survey by following the Strengthening the Reporting of Observational Studies in Epidemiology
guidelines (Von Elm et al., 2014).
Participants
A total of 236 hospital nurses were invited to fill out the online survey. Of these, 233 participants
provided consented and completed the survey, and three participants, who did not meet the
inclusion criteria, were excluded. The inclusion criteria were: (1) must be a registered nurse in
South Korea; (2) currently working at a hospital or had a recent reassignment from a hospital job
within the past six months; and (3) at least six months’ experience in direct patient care. The
exclusion criterion was working for the quality improvement team or information management
departments.
The number of required participants for statistical significance was 118. This number
was estimated using G*Power 3.1, with effect size = .15, ⍺ = .05, power = .80, and ten
independent variables in a multivariate linear regression. Moreover, more than 100 samples are
generally considered appropriate for applying a quantile regression (Lê Cook & Manning, 2013).
Considering that the non-response rate for online surveys is approximately 50% (Fan & Yan,
2010), the final sample of this study (N = 233) was sufficient to conduct multivariate linear
regression and quantile regression.
Data collection
Given confidential, privacy concerns and irregular schedules, an online survey was a more
appropriate method for collecting data regarding WPB. After obtaining approval by the affiliated
university’s institutional review board (No. Y-2018-0082), the participants were recruited from

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Accepted Article
two major web-based communities of nurses, accessible via personal computers or mobile
devices. Data were collected between September 22 and October 24, 2018. The participants were
recruited through online advertisements on the communities’ communication bulletin boards,
and they completed an online survey created using Google Forms, on a computer or a mobile
device. The first page of the survey included an informed consent form that described the study’s
purpose and methods and assured protection of participants’ data. After starting the survey, the
respondents could proceed to the next page after answering all of the questions on a page.
Instruments
Workplace bullying
Nurses’ WPB was assessed using the Workplace Bullying in Nursing-Type Inventory (WPBN-
TI; Lee & Lee, 2014). The WPBN-TI consists of 16 items related to verbal attacks and alienation
(10 items), improper work instructions (4 items), and physical threat (2 items). Each item was
measured on a 4-point Likert-type scale (1 for strongly disagree to 4 for strongly agree). A
higher score indicated that a nurse experienced more WPB (ranges: 16-64). Overall, Cronbach’s
α for the total score was .91 in the study by Lee and Lee (2014) and .93 in the present study.
Regarding subscales, Cronbach’s α was .93 for verbal attacks and alienation, .71 for improper
work instructions, and .73 for physical threat in this study.
In addition, two yes-or-no questions were used to define the WPB victim and witness.
When the participants answered “yes” to the question, “Have you experienced workplace
bullying as a victim during the last six months?” the participant was classified as a “victim.” The
participant was classified as a witness if they answered “yes” to the question, “Have you
witnessed workplace bullying during the last six months?” Based on our preliminary analyses,
the groups with only WPB victims (n = 18) or only WPB witnesses (n = 48) were much smaller
than the group with neither victims nor witnesses (n = 82, hereafter, referred to as “none”), and
the group with both victims and witnesses (n = 85, hereafter, referred to as “both”). Therefore,
the groups with either WPB victims or witnesses were combined into one group (n = 66,
hereafter, called “either”).
Posttraumatic stress symptoms
Nurses’ PTSS was assessed using the Korean version of the Impact of Event Scale-Revised (Lim
et al., 2009), including 22 items across three subscales: hyper-arousal (6 items), avoidance and
numbing (8 items), and symptoms of intrusion (8 items). Each item was measured on a 5-point

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 Likert scale (0 for “not at all” to 4 for “extremely”). Higher scores indicated higher severity of
Accepted Article
PTSS (range: 0-88). Cronbach’s α was .93 in the study by Lim et al. (2009) and .97 in the present
study for the total score.
Coping strategies
Nurses’ coping strategies were assessed using a Korean version of the Ways of Coping Checklist
(WCCL; Park & Lee, 1992), which was modified from the WCCL developed by Folkman and
Lazarus (1985). The WCCL includes 39 items with two subscales consisting of active coping (24
items) and passive coping (15 items). Each item was measured on a 4-point Likert scale (0 for
“did not use it at all” to 3 for “used it a great deal”). Higher scores indicated more frequent use of
a specific coping strategy (range: 0-63). Overall, the Cronbach’s α was .92 in the study by Park
and Lee (1992), and Cronbach’s α for subscales in this study were .87 for active coping and .77
for passive coping.
Statistical analysis
The software used for the data analysis were SPSS version 25 (IBM Corp., Armonk, NY, USA)
and Stata version 16 (Stata Corp, College Station, TX, USA). Chi-squared statistics were used to
describe the general characteristics among the three groups (none, either, or both). The type of
WPB, PTSS, and coping strategies were compared among the three groups using a one-way
analysis of variance with Scheffé’s test. The Ordinary least squares (OLS) method was used to
identify the factors associated with varying PTSS severity. A quantile regression analysis was
used to examine the association between WPB and coping strategies with the five levels of
severity for PTSS, and was statistically significant at the .05 level in the two-tailed tests.
Because OLS can only explain the data based on normal data distribution and mean
values (Lê Cook & Manning, 2013), the use of OLS is limited in terms of explaining extremely
low or high severity of PTSS. The quantile regression analyses enable the analysis of the effects
of independent variables on the different distribution points of asymmetric dependent variables
(Lê Cook & Manning, 2013). The quantiles were based on the distribution of the PTSS values,
where the 5th, 25th, 50th, 75th, and 95th percentiles were considered (Lê Cook & Manning,
2013). High percentiles indicated more severe PTSS. The 5th percentile represents a score of 1
for PTSS, the 25th percentile a score of 22, the 50th percentile a score of 38, the 75th percentile a
score of 56, and the 95th percentile a score of 74 from the Korean version of the Impact Event
Scale-Revised (Lim et al., 2009), which indicates urgent medical treatment is required.

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Accepted Article
Characteristics of study participants
Results

The analyses included 233 participants with a response rate of 100%. The majority of
respondents were younger than 40 years old (n = 212; 91.3%), held a bachelor’s degree or higher
(n = 192; 82.4%), and had over five years of clinical experience (n = 126; 54.0%). Further,
among all female nurses, most were staff nurses (n = 197; 84.9%). In total, 23.6% of them (n =
55/233) had recently resigned from their jobs at hospitals, and 80.3% of nurses (n = 187/233)
perceived that bullying was a serious concern at their workplaces. The results indicated that the
“both” group had a significantly higher percentage of hospital nurses who were at an early career
stage (less than five years with p < .001) compared to the “none” or “either” groups (see Table
1). Overall, 28% of the participating nurses were self-identified either victims or witnesses, while
37% was both victim and witness simultaneously. The victim and witness groups were mostly
younger than 29 years old, held a bachelor’s degree, had 1 to 5 years of clinical experience, most
were staff nurses, and perceived severe WPB. There were no demographic characteristic
differences between the victim and witness groups (see Table 1).
Group comparison of WPB, PTSS, and types of coping strategies
There were significant differences in WPB types and PTSS subscales among the groups. The
“both” group reported the highest scores of all the three WPB types, followed by the “either” and
then the “none” groups (p < .001). Unlike verbal attacks or improper work, there was no
difference in physical threats among the “either” and the “none” groups. The highest scores of
total and subscale PTSS were reported in the “both” group, followed by the “either” and then the
“none” groups (p < .001). However, the symptom of intrusion as a PTSS subscale did not differ
between the “either” or the “none” groups. Moreover, there were no differences regarding active
and passive coping among the three groups (see Table 2).
Factors associated with PTSS examined by OLS and quantile regression analyses
Factors associated with the PTSS severity of nurses were identified using the OLS regression.
The variance inflation factors ranged from 1.15 to 5.45, and tolerance was < 0.1, suggesting no
multicollinearity (O’Brien, 2007). When the R2 values of the OLS regression were .36, F =
32.02, p < .001), each R2 value was estimated at .11, .22, .27, .21, and .13 for the 5th, 25th, 50th,
75th, and 95th percentiles, respectively. The variables that were significantly associated with
PTSS severity were victims (B = 16.78, p < .001) and passive coping (B = 0.89, p < .001). The

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Accepted Article
estimated coefficients of selected variables from the quantile regression analysis are shown as
the 25th, 50th, 75th, and 95th percentiles of the PTSS severity of nurses. “Victim” and “passive
coping” were significant factors for the 25th, 50th, and 75th percentiles. “Witness” became
significant when hospital nurses reported severe PTSS at the 95th percentile, and the interaction
between “victim” and “witness” was significant at the 50th percentile (see Table 3 and Figure 2).
Discussion
Our study findings emphasize the effect of PTSS for nurses who witnessed WPB. Victims or
witnesses would use passive coping for minimum or moderate PTSS severity and active coping
for high PTSS severity.
Over half of hospital nurses reported they were victims or witnesses to WPB, which is
similar to previous studies (Chang et al., 2019; Obeidat et al., 2018). We found the “both” group
reported higher severity of PTSS when it was early on in their career (less than 5 years), when
they were younger (≤ 29 years), and when they worked as a staff nurse. These findings are
consistent with previous study findings reporting that newly graduate nurses were more likely to
be victims of WPB (Chang et al., 2019; Obeidat et al., 2018). Moreover, higher occupational
positions decrease the likelihood of becoming a bully at work (Chang et al., 2019; Obeidat et al.,
2018). Conflicts between senior and new nurses often occur during the intensive practical
training and onboarding (Chang et al., 2019). New nurses are strictly trained to adjust to the
clinical workplace and perform new roles (Chang et al., 2019). However, new nurses tend to
have insufficient occupation and interpersonal relationship experience, which makes them less
prepared to identify or prevent potentially abusive situations (Chang et al., 2019; Obeidat et al.,
2018). Thus, new nurses should be educated about early identification of, accurate reporting of,
and proper management against WPB in both nursing schools and worksites.
Hospital nurses who were both victims and witnesses of WPB indicated higher severity
of PTSS in comparison to the “none” and “either” groups when all three types are considered.
Interestingly, our study shows that most nurses experienced verbal attacks and improper work
instructions, which was similar to the findings reported by previous studies (Chang et al., 2019;
Obeidat et al., 2018). While WPB via verbal attacks negatively affects individuals’ physical
health, professional performance, and psychological state (Chang et al., 2019; Obeidat et al.,
2018), improper work assignment or conflict were found to be two of the most common reasons
to leave a job (Chang et al., 2019). In this context, all nurses need to learn more effective

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Accepted Article
communication strategies to improve interpersonal competence (Vertino, 2014) and emotional
intelligence through theory-based training programs (Shin et al., 2018). Thus, nurse managers
intervening in actual and potential WBP should have supportive attitudes as mediators when
talking with any nurse experiencing WPB, by minimizing pre-existing interpersonal conflicts
(Björklund et al., 2019).
Based on this conceptual framework, we expected that PTSS would improve as hospital
nurses used active coping; however, tend to use active coping to a similar degree to passive
coping and thus, their use of active coping is not associated with PTSS. A qualitative study
reported specific findings about how nurse managers used active and passive coping strategies
when dealing with WPB (Björklund, et al., 2019). Their active coping strategies included
seeking support from the organization and colleagues in confronting their bully, having mandates
issued, and the power structure reconsidered. However, while their passive coping strategies
include seeking support from family, friends or social networks, solitary coping, and avoidance
coping, the different severity levels of stress seem to affect the selective uses of coping. Nurses
with excessive stress use passive coping more than active coping (Karatuna, 2015; Rodríguez-
Rey et al., 2019). Thus, it is necessary to further evaluate PTSS severity and specific types of
coping.
In addition, nurses using more passive coping reported an intermediate severity of PTSS
in the quantile of 25-75. This is consistent with the findings of existing literature; however, it is
not associated with very mild (quantile 5) or very severe PTSS (quantile 95) (Nielsen et al., 2017;
Rodríguez-Rey et al., 2019). Nurses' coping strategies after experiencing WPB were generally
passive, such as continuing to work without reacting, staying silent, and avoiding the bully
(Karatuna, 2015; Rodríguez-Rey et al., 2019). Passive coping also includes emotional responses
such as crying, feeling anxiety and fear, and avoiding social gatherings (Björklund, et al., 2019;
Karatuna, 2015). Therefore, passive coping is considered a process by which emotional distress
can be relieved (Karatuna, 2015). Our findings also show that a minimum or moderate PTSS
severity is needed to activate passive coping.
While WPB victimization relates to a wide range of PTSS, from the 25th to 75th
percentiles, our quantile regression provided new findings about the significant association of the
most severe PTSS with being a witness. This finding is dissimilar to previous studies (Gullander
et al., 2014; Magee et al., 2015), which reported that the victim had the worst outcomes, while

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Accepted Article
the witness was less stressed (Gullander et al., 2014; Magee et al., 2015). However, our findings
emphasize secondary trauma for witnesses. In this context, many studies have reported that
bullying at work is as serious a problem for nurses who witness it as those who experience it
personally (Arnetz et al., 2019; Brewer, 2015). Further, nurses who witness WPB may distrust
their organizations, and show doubts, anger, and disappointment toward their coworkers and/or
work environment (Arnetz et al., 2019; Brewer, 2015). Building safe working environments must
include (1) a respectful culture among coworkers, (2) a confidential reporting system, (3) a WPB
preventive awareness campaign, (4) and effective inter-professional collaboration (ANA, 2015).
At the individual level, we suggest that those who witness bullying also need to receive timely
psychological counseling services, as victims do.
Limitations
There are several limitations in this study. First, the participants used a structured questionnaire,
which results in the possibility of self-reporting bias and limitations in the in-depth
phenomenology of WPB in a certain culture. Moreover, it is possible that bullying at work has
been underestimated or over-reported over the past six months because the study participants
rely on their recollection of WPB experiences and subjective perceptions. Therefore, it is
necessary to use a mixed-method study with both a quantitative estimation of WPB prevalence
and a qualitative investigation of personal perception and lived experiences among nurses with
recent WPB. Second, the participants’ eligibility was verified by self-reporting, and they
preferred online surveys about this sensitive topic. Further, to collect a representative sample of
these nurses, 10% of male and non-tech savvy nurses should be recruited using the purposive
sampling method. Third, we could not consider the characteristics of different working
environments, thus, further studies should investigate organizational culture and tolerance,
penalties for bullying.
Conclusion
Being a victim and witness of WPB had different impacts on the severity of nurses’ PTSS. In
addition, passive coping functions increased PTSS severity when compared to active coping.
Accounting for the influence of experience types, severity, and PTSS severity may enhance our
understanding regarding the relationship between WPB and PTSS. Effective WPB prevention
can make work environments safer and more comfortable not only for nurses who are victims
but also those who are witnesses. Therefore, it is necessary to develop early detection systems

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Accepted Article
for vulnerable nurses along with timely interventions. Moreover, staff education and institutional
support can help identify WPB, decrease its negative consequences such as PTSS, and increase
timely coping.
Implications for nursing management
Nursing leaders should develop strategies to prevent the incidence of WPB for hospital nurses, to
promote the quality of patient care and improve the retention of hospital nurses. There are
several implications for nursing leaders to protect nurses and their well-being through policy and
practice changes. In this context, nursing leaders have implemented changes at the management
level to prevent WPB, including mentoring, coaching, and other coping programs (ANA, 2015).
Most policies on WPB have focused on the effect it has on the perpetrator or victim (Seo & Park,
2017). While this focus can have great impact on the short-term impact, it aggravates the
bullying situation in the long term. Moreover, our findings are consistent with the findings by the
ICN (2017), which stated that the negative effects of bullying could affect both victims and
witnesses. Thus, nursing leaders should consider both victims and witnesses in their efforts to
create safe and supportable nursing work environments, and provide effective coping strategies
(ICN, 2017).

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Accepted Article References
American Nurses Association. (2015). American Nurses Association position statement on
incivility, bullying, and workplace violence. Retrieved from
https://www.nursingworld.org/~49d6e3/globalassets/practiceandpolicy/nursing-
excellence/incivility-bullying-and-workplace-violence--ana-position-statement.pdf
Anderson, G. S., Di Nota, P. M., Groll, D., & Carleton, R. N. (2020). Peer support and crisis-
focused psychological interventions designed to mitigate post-traumatic stress injuries
among public safety and frontline healthcare personnel: A systematic review. International
Journal of Environmental Research and Public Health, 17(20), 7645.
https://doi.org/10.3390/ijerph17207645
Arnetz, J. E., Sudan, S., Fitzpatrick, L., Cotten, S. R., Jodoin, C., Chang, C. H., & Arnetz, B. B.
(2019). Organizational determinants of bullying and work disengagement among hospital
nurses. Journal of Advanced Nursing, 75(6), 1229-1238. https://doi.org/10.1111/jan.13915
Báez‐ León, C., Moreno‐ Jiménez, B., Aguirre‐ Camacho, A., & Olmos, R. (2016). Factors
influencing intention to help and helping behaviour in witnesses of bullying in nursing
settings. Nursing Inquiry, 23(4), 358-367. https://doi.org/10.1111/nin.12149
Björklund, C., Hellman, T., Jensen, I., Akerblom, C., & Björk Brämberg, E. (2019). Workplace
bullying as experienced by managers and how they cope: A qualitative study of Swedish
managers. International Journal of Environmental Research and Public Health, 16(23),
4693. https://doi.org/10.3390/ijerph16234693
Brewer, G. (2015). Workplace bullying in healthcare professions. International Journal of
Occupational Health and Public Health Nursing, 2(1), 11-28.
Chang, H. E., Park, M. Y., Jang, H., Ahn, S., & Yoon, H. J. (2019). Relationships among
demands at work, aggression, and verbal abuse among registered nurses in South Korea.
Nursing Outlook, 67(5), 567-577. https://doi.org/10.1016/j.outlook.2019.04.007
Fan, W., & Yan, Z. (2010). Factors affecting response rates of the web survey: A systematic
review. Computers in Human Behavior, 26(2), 132-139.
https://doi.org/10.1016/j.chb.2009.10.015
Folkman, S., & Lazarus, R. S. (1985). If it changes it must be a process: Study of emotion and
coping during three stages of a college examination. Journal of Personality and Social
Psychology, 48(1), 150-170. https://doi.org/10.1037/0022-3514.48.1.150

This article is protected by copyright. All rights reserved

 Gullander, M., Hogh, A., Hansen, A. M., Persson, R., Rugulies, R., Kolstad, H. A., … Bonde, J.
Accepted Article P. (2014). Exposure to workplace bullying and risk of depression. Journal of Occupational
and Environmental Medicine, 56(12), 1258-1265.
https://doi.org/10.1097/JOM.0000000000000339
Hong, S., Kim, H., Nam, S., Wong, J. Y. H., & Lee, K. (2021). Nurses’ posttraumatic stress
symptoms and growth by perceived workplace bullying: An online cross‐ sectional study.
Journal of Nursing Management, 1-10. https://doi.org/10.1111/jonm.13275
International Council on Nurses. (2017). Prevention and management of workplace violence
Retrieved from https://www.icn.ch/sites/default/files/inline-
files/PS_C_Prevention_mgmt_workplace_violence_0.pdf
Karatuna, I. (2015). Targets’ coping with workplace bullying: A qualitative study. Qualitative
Research in Organizations and Management: An International Journal, 10(1), 21-37.
https://doi.org/10.1108/QROM-09-2013-1176
Laschinger, H. K., & Nosko, A. (2015). Exposure to workplace bullying and post‐ traumatic
stress disorder symptomology: The role of protective psychological resources. Journal of
Nursing Management, 23(2), 252-262. https://doi.org/10.1111/jonm.12122
Lazarus, R. S., & Folkman, S. (1984). Coping and adaptation. New York, NY: Guilford.
Lê Cook, B., & Manning, W. G. (2013). Thinking beyond the mean: A practical guide for using
quantile regression methods for health services research. Shanghai Archives of Psychiatry,
25(1), 55-59.
Lee, Y., & Lee, M. (2014). Development and validity of workplace bullying in nursing-type
inventory (WPBN-TI). Journal of Korean Academy of Nursing, 44(2), 209-218.
https://doi.org/10.4040/jkan.2014.44.2.209
Lim, H. K., Woo, J. M., Kim, T. S., Kim, T. H., Choi, K. S., & Chung, S. K., … Chae, J. H.
(2009). Reliability and validity of the Korean version of the Impact of Event Scale-Revised.
Comprehensive Psychiatry, 50(4), 385-390.
https://doi.org/10.1016/j.comppsych.2008.09.011
Magee, C., Gordon, R., Robinson, L., Reis, S., Caputi, P., & Oades, L. (2015). Distinct
workplace bullying experiences and sleep quality: A person-centred approach. Personality
and Individual Differences, 87, 200-205. https://doi.org/10.1016/j.paid.2015.08.004

This article is protected by copyright. All rights reserved

Accepted Article
Nielsen, M. B., Tangen, T., Idsoe, T., Matthiesen, S. B., & Magerøy, N. (2015). Post-traumatic
stress disorder as a consequence of bullying at work and at school. A literature review and
meta-analysis. Aggression and Violent Behavior, 21, 17-24.
https://doi.org/10.1016/j.avb.2015.01.001
Nielsen, M. B., Birkeland, M. S., Hansen, M. B., Knardahl, S., & Heir, T. (2017). Victimization
from workplace bullying after a traumatic event: Time-lagged relationships with symptoms
of posttraumatic stress. International Archives of Occupational and Environmental Health,
90(5), 411-421. https://doi.org/10.1007/s00420-017-1204-4
Obeidat, R. F., Qan’ir, Y., & Turaani, H. (2018). The relationship between perceived
competence and perceived workplace bullying among registered nurses: A cross sectional
survey. International Journal of Nursing Studies, 88, 71-78.
https://doi.org/10.1016/j.ijnurstu.2018.08.012
O’Brien, R. M. (2007). A caution regarding rules of thumb for variance inflation factors. Quality
& Quantity, 41(5), 673-690. https://doi.org/10.1007/s11135-006-9018-6
Park, A. S., & Lee, Y. H. (1992). Influence of the sex role characteristics and stress perception of
married women on the coping style for stress. Korean Journal of Counseling and
Psychotherapy, 4(1), 69-79.
Rodríguez-Rey, R., Palacios, A., Alonso-Tapia, J., Pérez, E., Álvarez, E., & Coca, A., ...
Llorente, A. (2019). Burnout and posttraumatic stress in paediatric critical care personnel:
Prediction from resilience and coping styles. Australian Critical Care, 32(1), 46-53.
https://doi.org/10.1016/j.aucc.2018.02.003
Seo, Y. N., & Park, Y. (2017). Evaluation of the anti-workplace bullying legislations and
policies of the overseas countries and South Korea. Journal of Secretarial Studies, 25(2),
181-201.
Shin, Y., Lee, S., Moon, H., Jung, D., & Lee, H. (2018). Effects of Satir's model based
communication education on communication competence, emotional intelligence and
depression-happiness of regional public hospital nurses. Journal of Korean Public Health
Nursing, 32(1), 122-134. https://doi.org/10.5932/JKPHN.2018.32.1.122
Vertino, K. A. (2014). Effective interpersonal communication: A practical guide to improve your
life. OJIN: The Online Journal of Issues in Nursing, 19(3), 1-6.

This article is protected by copyright. All rights reserved

Accepted Article
Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., Vandenbroucke, J. P., &
Initiative, S. (2014). The Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) statement: Guidelines for reporting observational studies.
International Journal of Surgery, 12(12), 1495-1499.
https://doi.org/10.1016/j.ijsu.2014.07.013

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 Table 1. Characteristics of study participants
Accepted Article None Either Both Total
(n=82, (n=66, (n=85, (N=233,
Variables Categories χ2 p values
35%) 28%) 37%) 100%)
n (%) n (%) n (%) n (%)
Age ≤ 29 30 29 52 111 10.62 .031
(unit: year)† (12.9) (12.5) (22.4) (47.8)
30~39 42 32 27 101
(18.1) (13.8) (11.6) (43.5)
≥ 40 9 5 6 20
(3.9) (2.2) (2.6) (8.7)
Marital Single 33 33 24 90 7.56 .023
status (14.2) (14.2) (10.2) (38.6)
Married 49 33 61 143
(21.0) (14.2) (26.2) (61.4)
Education Associate 15 13 13 41 18.35 .001
level (6.4) (5.6) (5.6) (17.6)
Bachelor’s 44 45 67 156
(18.9) (19.3) (28.8) (67.0)
Graduate 23 8 5 36
(9.8) (3.5) (2.1) (15.4)
Length of <1 4 5 17 26 30.88 <.001
career (1.7) (2.2) (7.3) (11.2)
(unit: year) 1~<5 25 16 40 81
(10.7) (6.9) (17.2) (34.8)
5~<10 18 21 16 55
(7.7) (9.0) (6.9) (23.6)
≥ 10 35 24 12 71
(15.0) (10.3) (5.1) (30.4)
†
Position Staff nurse 63 56 78 197 8.32 .016
(27.2) (24.1) (33.6) (84.9)
Charge 19 10 6 35
nurse or (8.2) (4.3) (2.6) (15.1)

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 unit
Accepted Article manager
Recent job Yes 12 15 28 55 7.80 .020
resignation? (5.2) (6.4) (12.0) (23.6)
No 70 51 57 178
(30.0) (21.9) (24.5) (76.4)
Perceived Not serious 33 7 6 46 33.86 <.001
severity of (14.1) (3.0) (2.6) (19.7)
workplace Serious 49 59 79 187
bullying (21.1) (25.3) (33.9) (80.3)
†
n=one case was excluded due to missing data.

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 Table 2. Group comparison of types of workplace bullying, post-traumatic stress symptom, and
Accepted Article
coping strategies
Nonea Eitherb Bothc Total
(n=82, (n=66, (n=85, (n=233,
Variables Categories F p values
35%) 28%) 37%) 100%)
M±SD M±SD M±SD M±SD
Types of Verbal attacks and 17.99 21.29 29.53 23.13 68.53 <.001
workplace alienation ±6.13 ±7.03 ±6.54 ±8.23 (a<b<c)‡
bullying Improper work 9.07 10.20 12.25 10.55 30.78 <.001
instructions ±2.70 ±2.97 ±2.32 ±2.97 (a<b<c)‡
Physical threats 2.57 2.70 3.59 2.98 13.63 <.001
±1.04 ±1.20 ±1.70 ±1.43 (a,b<c)‡
Post- Total score 26.39 34.92 53.79 38.80 43.72 <.001
traumatic ±18.82 ±20.94 ±18.53 ±22.63 (a<b<c)‡
stress Hyper arousal 6.34 8.83 14.21 9.92 39.70 <.001
symptom ±5.32 ±6.25 ±5.96 ±6.73 (a<b<c)‡
Avoidance 9.83 13.00 18.46 13.88 29.12 <.001
and numbing ±7.47 ±7.53 ±7.19 ±8.23 (a<b<c)‡
Symptom of 10.22 13.09 21.12 15.01 48.81 <.001
intrusion ±6.94 ±8.00 ±7.25 ±8.75 (a, b<c)‡
Coping Active coping 39.38 37.47 39.44 38.86 1.15 .317
strategies ±7.81 ±8.29 ±9.94 ±8.78
Passive coping 25.93 25.30 26.22 25.86 0.32 .728
±6.80 ±6.71 ±7.66 ±7.08
‡
Scheffé’s test.

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 Table 3. Comparison of ordinary least square and quantile regression for factor associated
Accepted Article
with the post-traumatic stress symptom

Quantile Regression result

Coefficient (SE) OLS
Variable
Quantile Quantile Quantile Quantile Quantile B (SE)
5 25 50 75 95
Constant -7.34 -4.74 1.80 16.33 39.75* 6.44
(11.95) (12.92) (8.58) (9.59) (15.97) (6.34)
** *** ***
Victim 6.41 20.63 14.20 20.18 15.89 16.78***
(7.90) (7.46) (4.32) (5.32) (8.69) (4.76)
Witness -0.93 6.22 4.91 12.05 16.47** 5.99
(4.43) (4.37) (2.88) (7.09) (6.31) (3.34)
Interaction of victim 17.48 1.66 11.54* -0.33 -12.03 4.36
and witness (9.61) (9.71) (5.11) (7.50) (11.39) (5.81)
Active coping -0.04 -0.10 0.07 -0.16 0.05 -0.08
(0.34) (0.31) (0.16) (0.24) (0.15) (0.15)
Passive coping 0.42 0.87*** 0.84*** 0.93** 0.56 0.89***
(0.53) (0.22) (0.21) (0.34) (0.48) (0.18)
R2 .11 .22 .27 .21 .13 .36
2 2
R =.36 Adjusted R =.34, F=25.68, p<.001
OLS=ordinary least square, R2=coefficient of determination, SE=standard errors.
*
p=.050, **p=.010, ***p<.001.

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 jonm_13388_f1-2.docx

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Figure 1. Conceptual of study framework: A revised model of Lazarus and Folkman (1984)
stress and coping model.

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Accepted Article

Figure 2. Comparison of ordinary least square and quantile regression for factors associated
with the post-traumatic stress symptom (PTSS). Results from quantile regression and mean-
based regression are shown in Figure 2. The black line indicates estimated beta coefficients
based on the mean-based model for the PTSS severity of the nurse, showing slight
differences in mean variables and PTSS.

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