3.1 Impact of bullying

The literature has demonstrated that nursing staff are more likely to experience uncivil behaviors and bullying compared to other healthcare professionals [13] . Bullying has an impact at both the organizational and individual levels, though research in the field has focused primarily on the individual-level impacts. Exposure to bullying and other uncivil behaviors is a predictor of nurses’ intention to stay on the job [13] . Bullying has been found to be related to job satisfaction, burnout, commitment to work, and intention to leave [1,14-18]. One study estimated that up to 25% of nurses who are bullied actually leave the profession [3] .

At the organizational level, poorly organized places of work increase the prevalence of negative behaviors, leading to increased turnover rates, lower workplace morale, and decreased revenues [19] . Psychologically-related medical conditions may become more common, thereby increasing the company’s costs of production [20,21]. In the event that employees choose to legally address their plight, worker compensation payouts will also increase company costs [22] .

On the individual level, the impact of bullying on a target may be psychological or physiological and almost certainly will reduce job performance [23,24]. Bullies’ communications demean their victims, shame them, and make them less likely to speak up [25] . However, bullying tends to affect even the non-targeted employees of an organization [26] . Olender-Russo [27] asserts that employees who witness incidents of negative behavior at their places of work tend to suffer similar sequelae compared to the actual targets of bullying.

Bullying has been associated with a greater number of health complaints and more mental health symptoms, including perceived stress, anxiety, and symptoms of post-traumatic stress disorder, all of which may reduce quality of life and negatively affect patient care and safety [2,14,16,28,29]. Poor sleep, distress, depression, poor work attitudes, and ineffective communication with other staff members are often the outcomes of bullying [3,17,30]. It has also been suggested that bullying may not affect health directly, but rather indirectly, mediated by burnout [31] .

These impacts have a significant effect on victims of bullying, however there are other victims who themselves may not have been the direct target of bullies. These include witnesses who may experience some of the same discomfort as the actual victims, and who may also experience fear of retaliation. The evidence suggests this fear may help to explain why some witnesses fail to help the victims of bullying, even when they want to help [32] .

The evidence suggests that the support of family and friends may serve to reduce the impact of bullying and that being a parent may serve as a protective factor for victims [33] . A study in India among nursing students suggested that most students did not have the means to cope with bullying behavior [34] . On the other hand, a U.K. study found that some nursing students followed up the incidents of bullying with questions and a challenge, unlike the majority of the medical students who generally accepted the bullying without defending themselves [35] . These data indicate that bullying behaviors appear to be common enough in the nursing profession to warrant serious focus from managerial and supervisory staff.

Senior nurses and those in supervisory positions are often the perpetrators of bullying, though there is a vast range of individuals who engage in bullying behaviors. A study in Singapore found that some senior nurses used the euphemism “tough love,” though the authors more appropriately termed the behavior “abusive,” to rationalize their negative behaviors towards new nurses [36] . Though these behaviors negatively affect the transition of new nurses into practice and may influence their willingness to remain with the facility and even in the profession, these behaviors continue to be perpetrated.

3.2 Factors that allow continuance

There are a number of factors—interpersonal and environmental that contribute to the continuation of bullying behaviors in nursing, though there is strong evidence that the work environment, rather than individual characteristics may have a greater impact on bullying and its prevention [37] . On the environmental side, organizational culture and the characteristics of the job affect the extent to which bullying is allowed to thrive in the workplace [38] . The factor most discussed in the literature as a contributory factor to bullying is the existence of a hierarchical, as opposed to a relation-oriented, work environment [3,39,40]. Bullying often has been reported as more likely to be vertical, from higher level to lower level staff [4,15].

A bullying culture, that is, one where the behavior is known to exist and appears to be accepted by those in power, disempowering work environments, a lack of teamwork, and the sense that the workplace is not safe contribute to bullying [3,15,39,41]. In addition, when job characteristics are not well-defined and when organizational processes are misused, bullying occurs [42,43]. Bullying also seems to increase with lack of sufficient staff resources or a nursing shortage [15,44].These factors suggest strongly that there is a need to revise the organizational processes that contribute to bullying [43] .

Interpersonal contributors to bullying include the presence of informal negative alliances that serve to isolate and intimidate those who are not members of the clique [43] . Leadership styles that may be more hierarchical and not perceived as supportive may encourage bullying [4,15,38]. In addition, the quality of staff relationships affect the extent to which bullying is allowed to thrive in the workplace [38] .

There appears to be a lack of training and standardization for supervisors on how to manage bullying behaviors on the job, although supervisors who have witnessed, been victims or supervised nurses for more than 20 years were more likely to recognize and act upon bullying behaviors [45] . It was interesting to note that being able to identify bullying behaviors was not strongly correlated with responding to these behaviors [45] . When managers are silent, do nothing, when supervision is abusive, or when there are no support structures for victims, these behaviors flourish [3,42,46]. In many cases, policies are not clear on how managers should respond to bullying, suggesting that managers may not have sufficient guidance, and may enforce policies without standardization [47] .

3.3 Interventions to address bullying

There are no standard, or universally accepted approaches to reduce the incidence and impact of bullying among nurses. A review of the literature over the past 30 years shows that very few interventions have been developed to address the problem of bullying or the power dynamics that cause these behaviors to begin. It is clear that while some nurse managers have the experience and/or training to address workplace bullying, others may not be equipped to resolve the issues [48] .

It is clear that bringing the issues out into the open, allowing for discussion and staff input, and incorporating conflict management may reduce the problems [49,50]. Trying to strengthen the relationship between leaders and staff, utilizing transformational and authentic leadership styles, and empowering staff to improve the work environment has also been associated with reduced bullying behaviors [50,51]. On the interpersonal side, there must be an effort to resolve interpersonal conflicts that might escalate to bullying, and individuals must be held accountable for their behaviors [16,41].

In terms of individual level interventions, there have been attempts to use cognitive rehearsal, which allows an individual to practice how they would react in specific situations, as well as incorporating assertiveness and aggression training for the victims [52,53].This type of intervention has been successful in reducing incivility in the workplace.

A critical factor in the continuance of bullying is the fear of retaliation among witnesses who want to, but who are afraid of reporting these negative behaviors. Therefore, efforts must be made to reduce the fear of retaliation if witnesses intervene. Without this approach, even though many witnesses want to help victims, their intention to help is often not converted to concrete behaviors because of fear of retaliation [54] .

A critical factor in the continuance of bullying is the fear of retaliation among witnesses who want to, but who are afraid of reporting these negative behaviors. Therefore, efforts must be made to reduce the fear of retaliation if witnesses intervene. Without this approach, even though many witnesses want to help victims, their intention to help is often not converted to concrete behaviors because of fear of retaliation [55] .

Making it clear to all staff what types of behaviors are unacceptable, though a seemingly simple and obvious step, is often not undertaken in many workplaces. A program in the U.S. developed a comprehensive code of conduct regarding uncivil behaviors. A study conducted before and after implementation of the code resulted in the perception of significant reduction in uncivil behaviors as a result of establishment of the codes of conduct [56] . In addition, a zero-tolerance policy, clear and prompt responses by managers, and policies, performance reviews and education have all been shown to reduce the incidence of bullying [3,57].

Consistent and continuous efforts to measure and respond to the perception of bullying behaviors may reduce the incidence of bullying. For example, the Negative Acts Questionnaire-Revised (NAQ-R), a widely-used instrument, has been utilized by organizations attempting to assess and develop interventions to address bullying [13] . Without an accurate understanding of the incidence and impact of bullying, management may not be aware of the extent of the problem, and will have no metrics to determine if any improvements have occurred.

3.4 Recommendations

Although the phenomena of bullying in nursing are not new, very few interventions have been systematically studied and published in the literature. Due to this shortcoming, much of the intervention literature is “grey” literature, which has been published by agencies and organizations, with the U.K. in the lead of national approaches to the issue. For example, the Royal College of Nursing [58] in the U.K. published best practice guidelines that include having a written policy on bullying and harassment in the workplace, and ensuring that these policies are communicated to employees when they first join the organization and at regular intervals thereafter. The College also strongly advises against ignoring complaints, delay, or preventing or discouraging staff from reporting incidents. Many of these same recommendations are repeated in a Northern Ireland publication [59] .

The National Health Service (NHS) of Scotland [60] offers a “Dignity at Work” toolkit that focuses on five main concepts, Partnership- Understanding, Relations, Environment, and Leadership-to promote respect among all workers and to tackle the issue of bullying. The toolkit not only focuses on reducing negative aspects of the environment, but also on building a strong foundation, thereby enhancing employees’ sense of pride and motivation, and potentially reducing poor work performance and turnover. This toolkit, along with the IMatter, which is a tool designed for continuous improvement and was developed in cooperation with staff at the NHS in Scotland (n.d) [61] , to improve staff experience, as well as recently developed comprehensive guidance for employers [62] may serve as models for interventions in the U.S.

Efforts to address bullying should start at the very beginning of a new nurse’s career, when bullying often arises. A recommended intervention would be a formal program that reduces the impact of bullying as new nurses transition to their new roles and improves the experience of moving from student to practitioner [63] .

A viable solution to workplace bullying may lie in the development of anti-bullying apps. The app should focus on ways to mitigate bullying. The app should incorporate a feature of anonymous alerts to the human resources department. This approach was used successfully by Newtown Public Schools [64] (Newtown Public School District Chooses Anonymous Alerts Safety and Bullying Reporting App, n.d). The school opted to use the Anonymous Alerts app (http://www.anonymousalerts.com/webcorp/ ) to deal with bullying behavior within the institution while maintaining the confidentiality of the reporting party.

A number of apps have been developed to reduce the impact of bullying, but most of these have been developed for schools and for children, for example, Anonymous Alerts^® and Speak UP!^®(https://www.gospeakup.com/pri_sec/ ). In the workplace, one app, STOPit PRO (https://stopitcyberbully.com/workplace/), empowers each employee to monitor compliance with rules and utilizes anonymous reporting to managers. It is not specifically designed for bullying, but is targeted to all types of inappropriate behaviors. It is marketed not only to deter unethical behaviors but also to mitigate risk to the companies that use it.

The CRANAplus Bullying app (https://crana.org.au/support/bullying-app ) helps customers to identify the symptoms of bullying and facilitates the creation of an action plan to deal with the situation. It also offers a direct way to access support. It is free to remote and rural health practitioners. The program offers free phone counseling and support to health providers and families working in rural areas and also offer workshops on managing stress, counseling and other services. Bully Proof Assistant (https://play.google.com/store/apps/ details?id=com.robertrichardson.bullyproofassistantLite&hl=en), documents incidents of workplace bullying, enabling users to use the information for legal or employment cases. Users may also use the app to send incident reports. These and other similar apps may be the next wave in helping to reduce the incidence of bullying in the workplace.

Based on this review of the literature, a number of recommendations are made. It is critically important for the workplace to have policies that are communicated early on and continuously updated and reviewed. Supervisors must be trained to recognize the signs of bullying and harassment behaviors and taught how to intervene. Trainings must be very specific, for example, when a bully sabotages work, or yells, or demeans a co-worker, what actions should be taken? What types of interviewing techniques should be utilized to help ensure honesty from a bully? What kinds of corroborating evidence should be required, particularly if the bully has been careful enough to ensure that there were no witnesses? The nursing profession might take some guidance from psychology, with the understanding that bullying is generally an ingrained behaviour pattern that the perpetrator has perfected over the years. The bully is likely to offer a number of rationalizations for his/her behaviour, and thus it is critically important for human resource departments and supervisors to know the tell-tale signs to look for-in the bully, as well as in victims and witnesses. Therefore, training should be in-depth; a simple oneoff training will not be sufficient to address the widespread and insidious nature of this problem.

Employees and witnesses must feel empowered to report incidents of bullying, as the evidence suggests that many witnesses do not speak up due to fear of repercussion. This might mean making it easier to report bullying, perhaps anonymously, by use of an app or distress button in the office, or a code word to security or another designated person in the building. Most importantly, individuals must have trust in the system. If there is a designated person or supervisor to whom bullying will be reported, they must be perceived as trustworthy and willing to challenge ingrained organizational dysfunction, to ensure that workers are heard and are treated fairly.