Antecedents and consequences of bullying among nurses: a review study

Background and aims: Workplace bullying is an occupational hazard with destructive effects. The aim of this study was to assess the antecedents and the consequences of bullying among nurses. Methods: This narrative review was conducted in 2021. An online literature search was performed in several Persian and English databases, namely Magiran, SID, Noormags, Elmnet, IranMedex, PubMed, and Scopus. Search protocol was limited to the time interval between 2010 and 2020. Search key terms were, “bullying”, “coercion”, “healthcare providers”, “nurse”, and “horizontal violence”. Advanced search was also performed in Google Scholar. Inclusion criteria were publication in English or Persian, access to full-text, and publication as an original article. Results: Sixteen articles were included in this study. The two main antecedents of workplace bullying were personal and organizational factors and the three main consequences of bullying were physical, mental, and occupational consequences. Conclusion: As bullying is associated with different physical, mental, and occupational consequences, healthcare managers need to employ strategies to determine and manage bullying antecedents and reduce bullying prevalence.


Introduction
Bullying at workplace is an occupational hazard (1) with potential risks and damages. By definition, bullying is any intentional, purposeful, regular, repeated, negative, and bothering behavior in bilateral relationships by one side against the other which is associated with overt or cover harms to the target person (2). Bullying includes a wide range of behaviors from passive behaviors such as negligence and intentional or purposeful ignorance to insulting behaviors associated with implied or explicit threat (2). The prevalence of workplace bullying in western countries was reported to be 5%-28% (3,4).
Bullying is highly prevalent among healthcare providers in hospitals, particularly nurses (5)(6)(7). A study on 260 nurses showed that more than 50% of them were the victims of bullying (8). Another study showed that bullying horizontally happened in hospitals and at least 34.9% of nurses experienced bullying each month (6). Another study found that bullying was 54% more common among female nurses, 36% more common among younger nurses, and 24% less common among nurses with higher degrees (9).
Bullying at workplace can be associated with negative consequences such as disturbed inner peace, stress, and tension (8,10). A meta-analysis reported that staff bullying at workplace can lead to problems such as turnover intention, reduced organizational commitment, low job satisfaction, absence from work, depression, anxiety, strain, tension, burnout, posttraumatic stress disorder, psychosomatic problems, and physical disorders (11). Despite the serious outcomes of bullying among nurses, no review study had yet evaluated its different aspects. Therefore, the present study was performed to assess the antecedents and the consequences of bullying among nurses.

Methods
This narrative review was conducted in 2021. An online literature search was performed in several Persian and English databases, namely Magiran, SID, Noormags, Elmnet, IranMedex, PubMed, and Scopus. Search protocol was limited to the time interval between 2010 and 2020. Search key terms were, "bullying", "coercion", "healthcare providers", "nurse", and "horizontal violence". Moreover, advanced search was performed in Google Scholar both in Persian and English. Inclusion criteria were publication in English or Persian, access to full-text, and publication as an original article. Duplicate records were omitted and the abstract of the remaining studies were reviewed. Then, a summary of the main findings of each study was prepared. As the methodologies of the included studies differed from each other, the narrative method was used for data summarization and categorization.

Results
Sixteen studies were included in this study. Fourteen studies were about bullying among nurses and four studies were about bullying among female nurses. Fourteen studies were into bullying among all nurses and four studies were into bullying among female nurses. Seven studies had been conducted in Iran and other studies had been conducted in the United States, South Korea, Poland, Taiwan, Italy, Saudi Arabia, and Jordan (Table 1). Most studies were descriptive.
Most participants in the reviewed studies had experienced bullying, particularly verbal bullying ( Table  2). Bullying had significant negative relationship with hope, resilience, positive affect, and optimism. Moreover, it had significant positive relationship with gender, age, work experience, number of weekly work hours, organizational position, job-related negative affect, psychosomatic complaints, workplace incivility, emotional exhaustion, fatigue, physical complaints, humiliation, anger, malice, high occupational strain, and the depersonalization dimension of burnout.
The two main antecedents of workplace bullying were personal and organizational factors (Table 3) and the three main consequences of bullying were physical, mental, and occupational consequences (Table 4).

Discussion
This study assessed the antecedents and the consequences of bulling among nurses. Findings revealed that bullying had significant positive relationship with hope, resilience, positive affect, and optimism and significant negative relationship with job-related negative affect, emotional exhaustion, job burnout, and fatigue. Verbal bullying was the most prevalent type of bullying. Bullying had different effects on nurses.
Our findings showed that four studies were specific to bullying among female nurses (12,13,20,23). Other studies had also reported the greater exposure of female nurses to bullying and its consequences. This finding may be due to women's physical conditions. Moreover, our findings revealed that bullying had significant positive relationship with job-related negative affect and psychosomatic complaints (13,20,23) and significant negative relationship with hope, resilience, positive affect, and optimism (13,19,20). These findings imply that the more the levels of hope, resilience, positive affect, and optimism are, the lower the levels of bullying complications will be. Moreover, we found that two of the reviewed studies had reported a negative relationship between bullying and age, implying that younger nurses experienced more bullying and more stress (21,22), while a study had reported no significant relationship between age and perceived stress or anxiety (24). This contradiction may be due to the fact that those two studies had assessed the prevalence of bullying-related stress (21,22), while the other study had assessed perceived bullying-related stress (24).
Some reviewed studies had reported the higher prevalence of verbal bullying (98.1%) and the lower prevalence of non-verbal bullying (34%) (21,25). Therefore, programs are needed to help nurses accurately assess workplace bullying (15). Educational programs about effective bullying management can also reduce concerns (21).
Our findings also showed that bullying had significant relationship with turnover intention (7,14), emotional exhaustion, job burnout, and fatigue. Therefore, bullying prevention is essential to reduce job burnout and turnover among nurses (16). Moreover, we found that nurses with lower experience were more at risk for bullying and bullying was associated with a 61.7% decrease in productivity (17). However, a study showed no significant relationship between bullying and productivity (15). This contradiction highlights the necessity of further studies to   determine the consequences of bullying. Our findings also indicated that bullying had significant negative relationship with occupational commitment (23). Bullying is a destructive phenomenon at workplace

Author Title Methods Findings
Al-Surimi et al (9) Prevalence of workplace bullying and its associated factors at a multi-regional Saudi Arabian hospital: a crosssectional study Design: Cross-sectional Participants: All fulltime healthcare practitioners in a multi-regional hospital in Saudi Arabia Instrument: A self-administered questionnaire distributed via a private electronic mail Most participants reported workplace bullying (n = 684). Bullying agents were patients (36.1%), patients' family members (29.5%), hospital staff (27.2%), and managers (7.2%). The most common types of bullying were verbal abuse (98.1%), physical assault (11.8%), and sexual connotations (5.8%). While 63.7% of participants had experienced workplace bullying, only 11% of them had received education about workplace bullying. Physicians with higher degrees and lower experience were more worried about the negative effects of workplace bullying on care quality and patient safety. Previous experience of bullying was associated with higher worry, while education about bullying management was associated with lower worry. Most participants reported the experience of workplace bullying (59.5%) and 32% of them reported exposure to frequent daily bullying. Those who were exposed to bullying reported higher perceived stress and anxiety. Perceived stress and anxiety had no significant relationship with age, while posttraumatic stress disorder had significant relationship with age. Moreover, perceived stress, anxiety, and posttraumatic stress disorder had no significant relationship with work experience, gender, bullying outside work, academic progress, race, and social support. Content analysis of interview data revealed four main categories, namely construct of bullying, permissive culture of bullying, the toxic effects of bullying, and fostering a positive work culture.

Serafin and
Nasr-Esfahani and Shahbazi (25) Workplace bullying in nursing: Azerbaijan Province, Iran Participants: 162 nurses from four hospitals in West Azerbaijan Province, Iran Sixty nine percent of nurses had never experienced bullying, 9% frequently experienced bullying, and 22% had previously experienced bullying. Verbal bullying was the most common type of bullying and 40% of nurses reported the experience of verbal bullying. Moreover, 83% of nurses reported no experience of practical bullying, 22% reported occasional experience of practical bullying, and 9% of them reported frequent experience of practical bullying. The prevalence of non-verbal and functional bullying was 34% and 31%, respectively. Turnover intention, disinterest in job, job burnout, negative changes in functioning, reduced productivity, omission of benefits, reduced care quality and patient safety which may seem primarily harmless, while its negative cumulative effects can be severer than the effects of a violent action (18).

Conclusion
This study shows the prevalence of workplace bullying among nurses due to personal and organizational factors and with different physical, mental, and occupational consequences. Nursing managers need to improve their supervision of nurses' interpersonal conflicts and provide them with education about effective conflict management and bullying prevention. All healthcare managers and providers, particularly nurses, need to have close collaboration with each other in order to create a safe workplace. Further studies are needed to explore the antecedents of bullying and the most effective strategies for its prevention.
• Workplace bullying is highly prevalent among nurses. • Different personal and organizational factors contribute to workplace bullying among nurses. • Workplace bullying among nurses is associated with different physical, mental, and occupational consequences. • Close supervision and management of nurses' interpersonal conflicts and quality education about effective conflict management for them are recommended for effective bullying prevention.
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