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Bullying In the Workplace: Changing Nursing Behaviors

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Contact Hours: 3

This educational activity is credited for 3 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of bullying in healthcare settings, define its attributes and psychological effects, and tools and intervention methods to resolve and reduce future occurrences.

Overview

Bullying is a complex and detrimental phenomenon characterized by persistent, aggressive, and harmful behaviors directed towards one or more individuals within the healthcare workplace. It extends beyond occasional conflicts and disagreements, involving a pattern of mistreatment that creates an intimidating, hostile, and often abusive environment. Bullying can manifest in various forms, including verbal, physical, or psychological abuse, as well as manipulation or sabotage of professional relationships. This course discusses bullying in healthcare settings, defining its attributes and psychological effects. It also addresses how bullying can be reduced, nursing behaviors can be changed, tools for victims, and intervention methods to resolve and reduce future occurrences.

Course Objectives

Upon completion of this course, the learner will be able to:

  • Identify various forms of bullying.
  • Differentiate bullying from other types of behaviors.
  • Recognize how organizational culture can influence nursing behaviors.
  • Understand the psychological effects of bullying.
  • Review the steps to intervene when bullying occurs.

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
BullyingA distinctive pattern of repeatedly and deliberately harming and humiliating others, especially those who are smaller, weaker, younger, or more vulnerable.
CyberbullyingThe act of intentionally and consistently mistreating or harassing someone through electronic devices or other forms of electronic communication.
Death ThreatsA threat, often made anonymously, by one person or a group of people to kill another person or group of people.
DepressionA mood disorder that causes a persistent feeling of sadness and loss of interest.
Explicit BullyingBehaviors that are obvious and easily observed by others.
Gang-UpUniting in opposition to someone or something.
HCAHPS Patient Satisfaction ScoresThe first national standard for patient satisfaction measurement, according to the Centers for Medicare and Medicaid Services (CMS).
Horizontal HostilityOccurs between groups with whom one would expect to have close affinities.
Implicit BullyingRefers to subtle or indirect forms of mistreatment or aggression that may not be immediately obvious but can still cause harm.
IncivilityA general term for social behavior lacking in civility or good manners.
Lateral ViolenceAlso referred to as horizontal violence or bullying, lateral violence is defined as non-physical, aggressive, hostile, and/or harmful behavior between coworkers. 
MicroaggressionsA subtle, often unintentional, form of prejudice that often takes the shape of an offhand comment, an inadvertently painful joke, or a pointed insult.
Nurse BullyingA frequent problem that affects nurses’ productivity, morale, and health.
PerpetratorA person who conducts a harmful, illegal, or immoral act.
Physical BehaviorPhysical qualities, actions, or things relate to a person’s body, rather than with their mind.
Relational AggressionA type of aggression in which harm is caused by damaging someone’s relationships or social status.
Self-HarmAlso known as non-suicidal self-injury (NSSI), occurs when someone hurts themself directly and intentionally, but without the goal of ending your life.
Social ExclusionThe social disadvantage and relegation to the fringe of society.
StereotypingA kind of mental shortcut that we all use to categorize and evaluate people, places, and things. 
SuicideTaking you own life.
SupernurseExtraordinary powers used for good; cloak of invulnerability; no sidekick; Kryptonite, and an alter ego.
Post-Traumatic Stress DisorderA mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations.
TransgressorA verb that means to violate a command or law, to go beyond a limit or boundary, or to pass beyond or go over a limit or boundary. 
Two-FacedAn adjective that describes someone who is not sincere and says unpleasant things while seeming to be pleasant. 
Verbal AbuseA type of emotional abuse where a person uses their words to manipulate and control the other person.
Introduction

Bullying is a complex and detrimental phenomenon characterized by persistent, aggressive, and harmful behaviors directed towards one or more individuals within the healthcare workplace. It extends beyond occasional conflicts and disagreements, involving a pattern of mistreatment that creates an intimidating, hostile, and often abusive environment. Bullying can manifest in various forms, including verbal, physical, or psychological abuse, as well as manipulation or sabotage of professional relationships.1

Nurse bullying is a systemic problem that can begin as early as nursing school and continues throughout a nurse’s career. Often viewed as a rite of passage, nurse bullying can be such a severe problem that nurses leave their jobs, exacerbating the growing nurse shortage. Studies suggest that within the first six months, up to 60% of nurses leave their first job due to negative behavior from their coworkers. If left unaddressed, a bullying culture can contribute to a poor nurse work environment, increased risk to patients, and lower HCAHPS patient satisfaction scores. Nurse turnover can cost the average hospital $4 – 7 million annually.3 Nurse bullying can occur in any healthcare setting and can affect any level of the nursing hierarchy. A recent study found that 60% of nurse managers, directors, and executives experienced bullying in the workplace, with 26% considering it “severe.” 4

This course discusses bullying in healthcare settings, defining its attributes and psychological effects. It also addresses how bullying can be reduced, nursing behaviors can be changed, tools for victims, and intervention methods to resolve and reduce future occurrences.

Bullying Definition

Bullying is a form of aggressive behavior to intimidate, harm, embarrass, or distress others. It involves intentional and harmful actions, creating a hostile environment for the individual being targeted. Bullying can manifest in various forms, including incivility, verbal abuse, social exclusion, cyberbullying, physical behavior, and even death threats. Also known as relational aggression, horizontal hostility, and lateral violence, the person engaging in bullying behavior often seeks to establish control over their target.1,5

Explicit bullying is more straightforward to recognize. It includes extreme verbal criticism, micromanaging, insults, name-calling, and direct threats. Implicit bullying is indirect and passive-aggressive and can include withholding information, rumors and gossip, low grades, unfair assignments, or undesirable tasks as punishment and sabotage. Microaggressions, brief and commonplace indignities denigrating a person’s race, religion, or membership in another marginalized group, are also considered a form of covert bullying.3

Key Elements of Bullying in Healthcare

Certain key elements distinguish bullying from other types of behaviors. Understanding these signs can aid in identifying such acts to create environments that discourage and actively address such behavior. At the core of healthcare-related bullying is a power dynamic where the perpetrator wields a perceived authority or influence over the victim. This power imbalance, whether between colleagues, supervisors, subordinates, or with other healthcare team members, intensifies the vulnerability of those targeted. With this dynamic, bullying involves repeated instances of negative behavior over time, creating a sustained and pervasive impact on the targeted individual.1,3,5

Bullying is also distinguished by a deliberate intent to cause harm or distress, setting it apart from constructive feedback or professional criticism. The harmful intent is expressed through various means, including verbal abuse, humiliation, exclusion, spreading false rumors, interference with work tasks, or withholding essential information crucial for effective patient care. The prevalence of bullying is often symptomatic of the broader organizational culture within a healthcare institution. Environments that tolerate or overlook bullying behaviors contribute to a toxic workplace culture, impacting not only staff morale but also the quality of care delivered to patients.3,5

Beyond its detrimental impact on workplace dynamics, bullying in healthcare holds legal and ethical implications. It violates workplace harassment policies, breaches professional codes of conduct, and violates regulatory standards. Addressing bullying is not just an organizational imperative, it is a professional responsibility for healthcare providers. Failure to address bullying behaviors may result in legal consequences and compromise the ethical standing of those involved, emphasizing the urgent need for systemic change and a commitment to fostering a culture of respect and support among nurses across the organizations.3

Who Is Likely to Experience Bullying

While it is true that older nurses are known to target their younger colleagues, bullying behavior transcends age, gender, and experience level. New nurses, often in their early career stages, are most likely to encounter bullying due to their perceived lack of experience or knowledge. While often positioned as mentors, seasoned nurses or nurse supervisors might sometimes resort to bullying tactics, such as belittling or assigning unfairly challenging tasks, potentially undermining the confidence and professional growth of their less-experienced colleagues.6,7,8

Minority nurses, representing diverse racial, ethnic, religious, or gender identities, may encounter stereotyping, microaggressions, or overt exclusion, which can contribute to an environment conducive to bullying. Nurses who work in high-stress specialties, such as intense and fast-paced critical care or emergency departments, may create an environment where the strain of the work spills over into interpersonal relationships. Stressful interpersonal relationships, combined with caring for high acuity patients, can lead to frustration, and in some cases, manifest as bullying behavior, especially when colleagues are unable to cope effectively with the demands of their roles. Nurses occupying lower rungs of the hierarchy, such as staff nurses, may be more vulnerable to mistreatment from those in supervisory roles, including nurse managers or charge nurses. Power differentials within these hierarchies can be exploited, with those in authority exerting control through intimidation or undermining the professional standing of their subordinates.Bullying in nursing is not solely a top-down phenomenon. Lateral violence or bullying among colleagues at the same hierarchical level is a recognized issue. Experienced nurses may be targeted by their peers, particularly if they are perceived as threats or competitors. Younger nurses may criticize their elder peers’ physical limitations or appearance. Non-binary, gender fluid, or transgender nurses may also experience bullying, including undermining professional competence and personal attacks.6,7,8

Common nurse bully archetypes include the supernurse, who is often more experienced or specialized than most. This nurse communicates with a sense of superiority through an elitist attitude, a condescending manner, and making corrective comments. The resentful nurse who develops and holds grudges can encourage others to “gang up” on the transgressor. This nurse tends to create drama that can permeate the work environment. The PGR nurse uses put-downs, gossip, and rumors (PGR) to bully other nurses. This nurse is often quick to take offense to a neutral remark. The backstabbing nurse is “two-faced,” cultivating friendships that they then betray. This type of nurse uses information as a weapon to enhance their power. The green-with-envy nurse expresses bitterness toward those who possess what they do not, such as looks, status, personality, and possessions. The victims of this type of nurse often do not realize they are a target. The cliquish nurse uses exclusion as a means of aggression. This nurse shows favoritism to some while ignoring others.9,10

Psychological Effects of Bullying

The psychological effects of bullying can have profound and long-lasting impacts on the mental well-being of nurses. These effects can manifest in several ways, contributing to a range of emotional and behavioral challenges. Bullying often leads to heightened levels of anxiety and stress. The persistent fear of being mistreated, humiliated, or socially isolated can create a state of chronic stress, impacting a nurse’s overall mental health. Prolonged exposure to bullying can contribute to the development of depression. The emotional toll of enduring mistreatment, coupled with feelings of helplessness and isolation, can lead to a persistent sense of sadness and hopelessness.10

Bullying influences a nurse’s sense of self-worth and self-esteem. Continuous criticism, belittling, or exclusion can erode confidence, leading to a negative self-perception and a diminished sense of one’s own capabilities. Victims of bullying may develop a heightened fear of the perpetrator or the environment where the bullying occurs. This fear can lead to avoidance behaviors, such as avoiding specific colleagues, workspaces, or even entire work-related activities.10

Bullying can evoke strong emotions, including anger and frustration. The inability to address mistreatment or the perceived injustice of the situation can lead to the buildup of intense negative emotions. Nurses who have experienced bullying may develop difficulties trusting others, especially in professional or social settings. The betrayal or mistreatment by peers or superiors can create a lasting sense of skepticism and wariness. Bullying often leads to social isolation, as victims may withdraw from social interactions to protect themselves from further harm. The resulting loneliness can exacerbate feelings of sadness and contribute to a sense of being disconnected from others.10 The constant preoccupation with the bullying situation can interfere with cognitive functions, leading to difficulties concentrating and memory issues. This can impact job performance and overall cognitive well-being. Bullying can contribute to sleep disturbances, including insomnia or disrupted sleep patterns. The stress and anxiety associated with the bullying experience can interfere with the ability to relax and get restorative sleep. In severe cases, the psychological effects of bullying may escalate to post-traumatic stress disorder and thoughts of self-harm or suicide. The overwhelming emotional distress and feelings of hopelessness can create a significant risk to the nurse’s mental health.10

Impact on Job Performance

Bullying creates a stressful work environment, diminishing the victim’s ability to focus and perform at their best. The constant fear of mistreatment can decrease productivity as nurses struggle to concentrate on their tasks. Nurses who experience bullying may seek to avoid the hostile work environment by taking more sick days or sick leave. The increased absenteeism can disrupt workflow, strain team dynamics, and impact overall operational efficiency.3,7,10

Bullying can contribute to a high turnover rate as nurses may choose to leave the workplace to escape mistreatment. This turnover can disrupt team cohesion, lead to knowledge gaps, and require resources for recruitment and training.

Bullying erodes job satisfaction and morale. Nurses subjected to mistreatment are less likely to feel motivated, engaged, or invested in their work, contributing to a negative workplace culture. 3,7,10 Unprofessional conduct, conflicts, and interpersonal tensions can create an atmosphere that is not conducive to the high standards of care and ethical practices expected in healthcare. It contributes to a breakdown in communication, heightened stress levels, impaired decision-making abilities, and increased likelihood of medical errors. Ultimately, this has a negative impact on patient experience. Healthcare professionals who are victims of bullying may struggle to maintain a patient-centered focus. The emotional toll of mistreatment can divert attention away from patient care responsibilities, potentially impacting the holistic well-being of patients. 3,7,10

Why Bullying Occurs Amongst Nurses

Bullying among nurses is often linked to hierarchical structures within healthcare settings, where power dynamics play a significant role. The traditional hierarchy in nursing, with clear distinctions between roles and ranks, can create an environment where power imbalances thrive. Nurses in positions of authority may exert their power over subordinates, leading to instances of bullying. The impact of these power dynamics is evident in behaviors such as condescension, intimidation, or the misuse of authority. The hierarchical structure can contribute to a culture where bullying is tolerated or goes unchecked, perpetuating a cycle of mistreatment.3,11

The organizational culture within healthcare institutions also plays a role in either tolerating or discouraging bullying among nurses. In environments where bullying is tolerated, a lack of clear policies, inadequate enforcement, or a prevailing sense of complacency may perpetuate such behaviors. Conversely, organizations that actively discourage bullying through robust policies, consistent enforcement, and a commitment to fostering a respectful workplace culture are more likely to mitigate instances of mistreatment. The influence of organizational culture on workplace behavior underscores the importance of initiative-taking measures in shaping a healthy and supportive work environment.3,10

How Bullying Can Be Reduced

Reducing bullying involves a multifaceted approach that encompasses awareness, education, cultural change, and individual empowerment. First, it is essential to define what constitutes bullying behavior clearly. This includes providing employees with explicit guidelines ensuring everyone understands the various forms bullying can take. Regularly updating and publicizing reporting mechanisms further empowers victims and observers of incidents to come forward. Healthcare settings need to address workplace culture by cultivating an atmosphere of respect, empathy, and open communication. Mindfulness techniques should be encouraged to promote self-regulation among nurses. Conflict resolution workshops and role-playing scenarios can also help nurses navigate interpersonal challenges confidently. 7,12,13,14

Self-advocacy strategies form another essential component. Assertiveness training equips nurses with the skills to express themselves effectively. It also teaches them to set boundaries and clear expectations for acceptable behavior. These strategies empower victims to assert control over their professional interactions and create a more positive work environment. Seeking support is vital for victims of bullying. Utilizing employee assistance programs provides confidential resources for counseling and guidance. Building a support network within the workplace comprising colleagues, mentors, or supervisors, can offer additional layers of emotional and professional support. By implementing these comprehensive strategies, organizations can work towards not only reducing instances of bullying but also empowering individuals to navigate and overcome challenging workplace dynamics. 7,12,13,14

How to Intervene When Bullying Occurs

Intervening when bullying occurs is crucial to creating a healthy work environment. Here is a step-by-step guide on how to effectively intervene when bullying takes place. Remember, the key to successful intervention is an initiative-taking and comprehensive approach that prioritizes the well-being of all nurses and others within the healthcare team and promotes a culture of respect and professionalism within the workplace.7,12,13

  • Recognize the Signs of Bullying
    • Intervention begins by recognizing the signs of bullying. This crucial process demands identifying subtle and overt indicators of bullying, such as changes in behavior among their colleagues. This may include increased irritability, withdrawal, or a noticeable shift in interpersonal dynamics. Additionally, monitor patterns of absenteeism, as victims of bullying may seek to distance themselves from the hostile environment by taking more sick days. Equally important is the awareness of decreased work performance, as bullying can significantly impact an individual’s ability to concentrate, collaborate, and contribute effectively to the team. 7,12,13,14
  • Create a Reporting System
    • Creating an effective reporting system is pivotal to developing a culture of openness and accountability. The establishment of clear and confidential reporting mechanisms provides employees with a safe avenue to bring forward their concerns. To implement this system, healthcare settings must develop easily accessible channels, such as dedicated hotlines, online platforms, or confidential email addresses, where individuals can report incidents without fear of reprisal.It is imperative to ensure that employees are well informed about the existence and functionality of these reporting systems. This involves conducting regular training sessions to educate staff on the purpose of the reporting mechanisms, how to access them, and the confidentiality measures in place to protect those who come forward. Additionally, healthcare organizations should consider appointing a designated individual or team responsible for managing these reports. This ensures that each case is treated with the utmost seriousness and that investigations are conducted impartially. 7,12,13,14
  • Maintain Confidentiality
    • Maintaining confidentiality during workplace bullying investigations is paramount. Confidentiality protects all parties involved, reducing the risk of retaliation, and ensuring a safe space for reporting. Confidentiality not only encourages victims and witnesses to come forward without fear, but also safeguards the reputations of those involved in the investigation. Healthcare facilities should communicate this commitment clearly to instill trust in the reporting process, emphasizing that confidentiality is a priority and that breaches will be treated seriously. By upholding confidentiality, organizations create a foundation for a fair and unbiased investigation, promoting a workplace culture that prioritizes the well-being and security of its members. 7,12,13,14
  • Involve Human Resources
    • Before addressing workplace bullying, it is essential to involve Human Resources (HR) as they possess the expertise to conduct impartial investigations, ensuring fairness and adherence to organizational policies. Their involvement contributes to a transparent and systematic approach, fostering trust among employees. Additionally, HR serves as a crucial support system, assisting both the victim and the accused throughout the investigation. This dual role helps to maintain a balanced perspective, recognizing the rights and well-being of all parties involved. 7,12,13,14
  • Implement Temporary Measures
    • In response to reported workplace bullying, temporary measures should be implemented to mitigate ongoing tensions. These measures, such as modifying work assignments or schedules, are instrumental in creating physical and emotional distance between the individuals involved during the investigation period. This strategic intervention helps prevent further conflict, safeguarding the well-being of both the victim and the accused. By instituting these temporary changes, potential escalations can be proactively addressed. This approach underscores the importance of maintaining a conducive work environment and can assist in better-resolving issues of workplace bullying. 7,12,13,14
    • In addition to temporary measures, it is essential to provide support for the victim. This includes offering emotional assistance as well as resources, such as counseling and therapy, if needed. This care not only aids the individual in coping with the emotional toll but also acknowledges the impact of the incident, making the victim feel supported. 7,12,13,14
  • Conduct Mediation (If Appropriate)
    • In situations where both parties are willing, consider conducting mediation sessions facilitated by a neutral third party to promote communication and resolution. Mediation provides a constructive platform for the involved individuals to express their perspectives openly, fostering a dialogue aimed at resolving conflicts. This alternative dispute resolution method encourages mutual understanding and collaboration, seeking common ground for a more harmonious working relationship. The neutral mediator ensures fairness and impartiality, guiding the conversation toward constructive outcomes. While mediation may not be suitable for all cases, when appropriate, it offers an initiative-taking and inclusive approach to resolving workplace conflicts, emphasizing cooperation and mutual respect as essential components of a healthy work environment. 7,12-14
  • Enforce Consequences
    • If bullying has indeed occurred, it is imperative to enforce appropriate consequences. This involves adhering to established organizational policies and meeting legal requirements in determining suitable disciplinary actions. Consistent enforcement of consequences serves as a deterrent, discouraging inappropriate behavior and upholding a standard of accountability. This step not only provides justice for the victim but also sends a clear message about intolerance for bullying, contributing to a culture where all employees feel valued, protected, and treated fairly. 7,12-14
  • Seek External Assistance (If needed)
    • If internal interventions prove insufficient in addressing workplace bullying, consider seeking external assistance from external consultants or resources with specialized guidance and expertise. External assistance can bring a fresh perspective, impartiality, and a wealth of experience in dealing with workplace issues. These consultants can conduct an independent assessment of the situation, recommend targeted interventions, and assist in implementing effective strategies.7,12-14
Nursing Considerations

In a healthcare setting where bullying is noted, nurses play a crucial role in reporting instances and ensuring the quality of patient care does not suffer because of a hostile environment. Observers should be attuned to signs of distress in their colleagues, fostering a supportive network and utilizing available resources to provide assistance. Intervening when bullying occurs is necessary, but intervention must be done through the proper channel to ensure instances of bullying are resolved effectively without further harm to the victim. Participating in regular training programs to raise awareness, improve communication, and supplement team building is important to equip all nursing staff with the tools to rectify behaviors and prevent further bullying incidents. Regular assessments of workplace dynamics, along with encouragement of open communication and teamwork contribute to creating a culture where bullying is not tolerated. Victims should contact their human resources immediately to prevent instances from becoming regular occurrences.7,14

Maintaining patient care in an environment where bullying is occurring poses significant challenges for nurses. For victims of bullying, it is crucial to prioritize their mental and emotional well-being while continuing to deliver quality patient care, by exploring temporary solutions such as adjusting schedules or work assignments to minimize direct interactions with perpetrators. Seeking support from both within and outside the workplace is crucial for emotional well-being, as is communicating challenges with supervisors to explore potential adjustments. On the observer’s front, offering assistance to victims and stepping in when necessary to take over patient duties may be necessary while an investigation is underway. 3,6,7,12, 14

Conclusion

Addressing bullying among nurses is imperative for creating a healthy and supportive healthcare environment. Bullying can affect nurses across various experience levels, and identities extend beyond occasional conflicts. Bullying is a persistent harmful behavior that affects mental health and job performance. It causes anxiety and stress, decreased work productivity, and increased absenteeism, and creates a toxic workplace culture with potential consequences for patient safety.

Reducing bullying requires a multifaceted approach that builds awareness, education, and self-advocacy to bring cultural change. Implementing clear guidelines, reporting systems, and temporary measures are essential steps during investigations and resolution strategies. Maintaining patient care in a bullying environment is also critical. Victims must prioritize their well-being and seek support, while observers should offer assistance and step in when necessary to ensure patient duties are managed appropriately.

To change nursing behavior and eliminate the culture of bullying in nursing, a collective commitment is required from the nursing staff and organization. Implementing comprehensive strategies and dedicated efforts to cultivate a culture of respect and support can contribute to a positive work environment, ultimately changing workplace dynamics so respectful nursing behavior can flourish.

References
  1. Edmonson, C., & Allard, J. (2013). Finding Meaning in Civility: Creating a “No Bullying Zone.” Clinical Scholars Review, 6(2), 131–137. https://doi.org/10.1891/1939-2095.6.2.131
  2. Clarke, C. M., Kane, D. J., Rajacich, D. L., & Lafreniere, K. D. (2012). Bullying in Undergraduate Clinical Nursing Education. Journal of Nursing Education, 51(5), 269–276. https://doi.org/10.3928/01484834-20120409-01
  3. Edmonson, C., & Zelonka, C. (2019). Our Own Worst Enemies: The Nurse Bullying Epidemic. Nursing Administration Quarterly, 43(3), 274-279. https://doi.org/10.1097/NAQ.0000000000000353
  4. Hampton, D., Tharp‐Barrie, K., & Kay Rayens, M. (2018). Experience of nursing leaders with workplace bullying and how to best cope. Journal of Nursing Management, 27(3), 517–526. https://doi.org/10.1111/jonm.12706
  5. American Nurses Association. (2015). Incivility, bullying, and workplace violence. ANA. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/.
  6. Dellasega, C. (n.d.). When nurses hurt nurses : recognizing and overcoming the cycle of nurse bullying. (No Title). Retrieved November 22, 2023, from https://cir.nii.ac.jp/crid/1130000793844827776
  7. Smith, C. R., Palazzo, S. J., Grubb, P. L., & Gillespie, G. L. (2020). Standing up against workplace bullying behavior: Recommendations from newly licensed nurses. Journal of Nursing Education and Practice, 10(7), 35. https://doi.org/10.5430/jnep.v10n7p35
  8. Homayuni, A., Hosseini, Z., Aghamolaei, T., & Shahini, S. (2021). Which nurses are victims of bullying: the role of negative affect, core self-evaluations, role conflict and bullying in the nursing staff. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00578-3
  9. American Nurses Association. (2015). Incivility, bullying, and workplace violence. ANA. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/
  10. Sansone, R. A., & Sansone, L. A. Workplace Bullying: A Tale of Adverse Consequences. Innovations in Clinical Neuroscience, 12(1-2), 32-37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4382139/
  11. Hartin, P., Birks, M., & Lindsay, D. (2020). Bullying in nursing: How has it changed over 4 decades? Journal of Nursing Management, 28(7), 1619-1626. https://doi.org/10.1111/jonm.13117.
  12. Ceravolo, D. J., Schwartz, D. G., Foltz-Ramos, K. M., & Castner, J. (2012). Strengthening communication to overcome lateral violence. Journal of Nursing Management, 20(5), 599-606. https://doi.org/10.1111/j.1365-2834.2012.01402.x
  13. Parker, Karen M. DNP, FNP-C, RN; Harrington, Ann MPA, BSN, RN, NEA-BC; Smith, Charlene M. DNS, MSEd, WHNP, RN-BC, CNE, ANEF; Sellers, Kathleen F. PhD, RN; Millenbach, Linda PhD, RN. Creating a Nurse-Led Culture to Minimize Horizontal Violence in the Acute Care Setting: A Multi-Interventional Approach. Journal for Nurses in Professional Development 32(2):p 56-63, March/April 2016. | DOI: 10.1097/NND.0000000000000224
  14. Jean, J. (2022, January 20). Ask a Nurse: How to Combat Nurse Bullying in the Workplace. NurseJournal. https://nursejournal.org/ask-a-nurse/how-to-combat-bullying-in-nursing/
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