Workplace Incivility, Lateral Violence and Bullying Among Nurses. A

Acta Biomed for Health Professions 2018; Vol. 89, S. 6: 51-79 DOI: 10.23750/abm.v89i6-S.7461 © Mattioli 1885

Original article: Organizational features in the healthcare environment

Workplace incivility, lateral violence and bullying among nurses. A review about their prevalence and related factors Stefano Bambi1, Chiara Foà2, Christian De Felippis3, Alberto Lucchini4, Andrea Guazzini5, Laura Rasero6 1 Medical & Surgical Intensive Care Unit, Careggi Teaching Hospital, Florence, Italy; 2 Department of Medicine and Surgery, University of Parma, Italy; 3 Clinical Nurse Coordinator, IMCU, Saint James Hospital, Sliema, Malta; 4 Nurse Chief, General Intensive Care Unit, ASST Monza - S.Gerardo Hospital, University of Milan-Bicocca, Italy; 5 Department of Education and Psychology, University of Florence, Italy; 6 Associate Professor in Nursing Science, Department of Health Sciences, University of Florence, Italy

Abstract. Background: Negative interactions among nurses are well recognized and reported in scientific literature, even because the issues may have major consequences on professional and private lives of the victims. The aim of this paper is to detect specifically the prevalence of workplace incivility (WI), lateral violence (LV) and bullying among nurses. Furthermore, it addresses the potential related factors and their impact on the psychological and professional spheres of the victims. Methods: A review of the literature was performed through the research of papers on three databases: Medline, CINAHL, and Embase. Results: Seventy-nine original papers were included. WI has a range between 67.5% and 90.4% (if WI among peers, above 75%). LV has a prevalence ranging from 1% to 87.4%, while bullying prevalence varies between 2.4% and 81%. Physical and mental sequelae can affect up to 75% of the victims. The 10% of bullied nurses develop Post-Traumatic Stress Disorder Symptoms. Bullying is a predictive factor for burnout (β=0.37 p<0.001) and shows a negative correlation with job efficiency (r=-0 322, p<0.01). Victims of bullying recorded absenteeism 1.5 times higher in comparison to non-victimized peers (95% CI: 1.3-1.7). 78.5% of bullied nurses with length of service lower than 5 years has resigned to move to other jobs. Conclusions: There is lack of evidence about policies and programmes to eradicate workplace incivility, lateral violence and bullying among nurses. Prevention of these matters should start from spreading information inside continue educational settings and university nursing courses.

Key words: workplace incivility, lateral violence, bullying, nurses, prevalence, review

Background physical one (NPV). In Europe, there was an exposure of the 35% to PV and 59.5 % to NPV, the latest being Currently, negative relationships among nurses usually perpetrated by other nurses or physicians (1). are an issue well-recognized worldwide and reported In view of this evidence, this work focused on the by the literature, even because this phenomenon can three main forms with which dysfunctional interac- determine negative consequences for the professional tions among nurses can occur: lateral violence, bullying and private lives of the victims. and workplace incivility. A review performed by Spector et al. in 2014 Lateral violence is as a subset of the global con- (1), showed that on a total sample of 151307 nurses, cept of ‘workplace violence’ (2), as well as bullying. derived from 136 studies, the 36.4% was exposed to Since clear definitions and classifications of these physical violence (PV) and the 67.2% to the non- antisocial behaviours at workplace are still lacking and 52 S. Bambi, C. Foà, C. De Filippis, et al. sometimes debatable, epidemiologic comparisons be- ‘Population’ is related to the nurse professional tween these issues can be problematic. category. ‘Exposure’ is defined as experiencing incivil- The most common manifestation of lateral vio- ity, lateral violence and, bullying. ‘Comparison’ is the lence is the psychological harassment resulting in hos- act to evaluate the exposed and non-exposed subjects. tility, as opposed to physical aggression. ‘Outcome’ represents the negative collateral effects in These harassments include: verbal abuses, threats, private and professional lives of the targets. humiliations, intimidations, criticism, innuendo, social Three different biomedical databases were investi- and professional exclusion, discouragement, disinter- gated: Medline, CINAHL and Embase. est, and denied access to information (3). The keywords used for the research of papers Vice versa bullying has been described as an en- were: “incivility”, “nursing”, “hostility”, “bullying”, during offensive and insulting behaviour worsened by “mobbing”, “lateral”, “horizontal”, “violence”. an intimidating, malicious, and insulting pattern (4). The inclusion criteria settled for the research This specific type of harassment amounts to pow- were: English-Italian language and human being sub- er-abuse, while the victims experience feelings of hu- jects. None limitation of time was applied. miliation, menace, vulnerability and distress (4). Google Search (provided by Google©) was also A further distinction between bullying and lateral used in the process of gathering information, as an ad- violence refers to their frequency of occurrence. Later- junct to the three databases explored (8). al violence can be isolated and sporadic while bullying The exclusion criteria were: studies on workplace is displayed when the negative acts are repeated weekly violence against students and inside the academic set- or more often, for six or more months (5). tings, qualitative research studies, and all the second- In literature, many labels have been used to define ary literature. workplace’s bullying. In Europe, the most common After the preliminary removal of double records term for bullying is ‘mobbing’ (6). and non-pertinent abstracts, we retrieved all the full- The antecedents of these workplace’s deviant be- text articles matching the inclusion criteria (quantita- haviours are related with a professional incivility at- tive research studies, original mixed methods studies, titude, described as deterioration in the workplace re- systematic reviews and meta-analysis). lationships among peers. For example: to leave a paper After the screening, seventy-nine original papers jammed printer unfixed, withholding important infor- were selected. mation, unauthorised use of victims’ personal items and, social exclusion. Workplace incivility differs from (physical or ver- Results bal) workplace violence for its ambiguity in the intent Workplace incivility: prevalence and related factors to damage the victim (7). Therefore, workplace violence is displayed as soon as the intent of negative be- The number of papers focused on workplace inci- haviours becomes clearly to harm the person (7). vility among nurses was 16 (Table 1). The aim of this review is to highlight the extent Most of these original studies have been carried of workplace incivility, lateral violence and bullying out in Canada and a minority in the USA. among nurses. Moreover, their related factors and the Workplace incivility point prevalence and period theoretical basis of their genesis are showed. prevalence are seldom investigated within the studies. Published studies mainly reported average values of specific scores as the Workplace Incivility Scale tool. Methods However, when reported, the overall percentage of workplace incivility still remains remarkable: be- We performed a review of the available literature tween 67.5% (9), and 90.4% (10). Furthermore, work- according to the following PECO: Population-Expo- place incivility among peers, account for values higher sure-Comparison-Outcome. than 75% (9, 10). Workplace incivility, lateral violence and bullyng among nurses 53

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with productivity. with

r=0.33 nd the emotive exhaustion emotive the in the 1 m ( 0.25), 0.25), espectively A linear correlation exists WIbetween professional and in burnout WI from peers correlate WI correlate intention ( Turnover Turnover : positions 8.9% in nurses was nurses in WI from immediate superiors correlate and patients The mean cost for reduction of of reduction for The mean cost nurses in productivity annual assistants respectively in the 2 exhaustion ( exhaustion the global empowerment global the - productivity productivity p=0.006, r=0.204, e r cynis satisfaction (r=0.23), other direct care factors d factors care direct other correlate correlate Professional impact ). r=0.17 ( with physical

NR NR WI among peers correlate symptoms symptoms NR NR Psychophysical disorders

No correlations between No WI correlations and demographics. respondents’ NR NR NR Related factors

ly res 51.3 51.3 aby aby B y over y over WI mean

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erbal abuse recorded in abusein recorded erbal nd scorefrom peers was (median scoreofWI from all was 63.5 professionals (median NR. 634); 634); 2 V the 1 NR. Only average sco Mean WI frequency was intended for slightl “rarely” for used scales the from study. the There were no statistical significantdifferences in meanlevels ofWI from betweenpeers “ the “X the and boomers” generation” 2.13 ( 2.13 Prevale

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low -

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statistical studied ighest hostility behavio exeperienced (59percentage of This model suggests that pay should managers nursing and growth the to attention in new of nurses development the practice of nursing management, and new of nurses resilience This anxiety. their reducing burn job reduce to help will thereby new of nurses, out work efficiency the promoting management cost. saving and differences in the loss of of loss the in differences work real between productivity work healthy and environments there However, environments. was correlation a negative WIbetween productivity. and WI correlate intention (p=0.001), (p=0.005). No H Professional impact

NR NR NR NR Psychophysical disorders

out out

found =0.240, =0.240,

β out for (z=23.896; (z=23.896; rs) - was

incivility

out ( out =0.364, =0.364, - 0.564, p<0.01). p<0.01). 0.564, β civility

score of − surgical wards - the WI = β

p=0.001**). p=0.001**).

place intolerance correlation out, and anxiety anxiety and out,

total - with

(r=.24

work d a predictive factor for the the for factor a predictive

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and =0.405, p<0.01), Moreover, the the Moreover, p<0.01), =0.405, (p<0.001) l lengthl of service (y β was significant incivility And between Tota The nurse managers’ awareness of WI ability to manage A climate correlate WI (p=0.007). p<0.001). ICUs medical and showed EDs between

WI has a positive prediction function function prediction WI positive a has ( anxiety generate to . Anxiety new of nurses p<0.01) also burn on job influence positive a had ( out influence of the interaction between burn on job WI resilience and p<0.01) and job burn job and p<0.01) was significant ( was significant It showed that resilience moderated moderated resilience showed that It the relationship between burn job and partially mediates the relationship burn WIbetween job and Related factors

1.89 1.89

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(rank 3); (rank 5) mean5)

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903 registered nurses in China China in nurses 903 registered were invited. Ultimately, 696 servic (<3 new nurses completed valid valid completed The effective questionnaires. was 77.1 rate response Respondents to the to Respondents (8%), 2160 400 100 Staff determining as total community hospital community tertiary hospital. (15%). Respondents to the survey: survey: the to Respondents Sa )

year 21 ) 12 ) ( ( ( hor Lewis et al. (2011) Oyeleye al. et (2013) Shy et al. (18) (2018) Slem & Seada (20) (2017) Aut Workplace incivility among nurses. Prevalence and consequences Prevalence incivility nurses. among Workplace 1. Table Workplace incivility, lateral violence and bullyng among nurses 55

- to

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- - 0.18, 0.18, (continued) - = every β

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perceived percentage WI was an independent WI wasindependent an of factor predictive work (ß= to commitment 0.189, t= 0.189, Workplace civility was a significantpredictive factor for ( exhaustion emotive NR WI was a predictive factor for for WI factor was a predictive (8.5%, intention turnover P<0.001). NR p=0.003). (sub exhaustion Emotive Inventory Burnout Maslach of is there General Survey); the >3: is score the if burnout showedmean a of respondents (DS±1.38). 3.43 exclusion day. Professional impact

els of mental health, NR NR NR The episodes of WI correlated with low lev and fear rage, i.e. p< (r=0.36, sadness of High levels 0.05). NR Psychophysical disorders score

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I (range 1 (range I 5): mean 3.67 mean 3.67 5): WI (range 1 90.4% of respondents respondents 90.4% of WI peers. from reported 77.6% of nurses nurses 77.6% of WIexperienced from 67.5% experienced peers; Workplace civility (range (range civility Workplace 1- W (rank 4) (rank Invasion WI from supervisors reported were were reported 0.85 and 0.61(SD±0.71) (SD±0.86). (SD±0.88). among nurses Conflict 1 (range 12% reported (SD±0.73); WI of from episodes daily peers. (DS±1.09). Prevale st st

nd to the 1 d 272

the survey: 117 survey: the responde

graduate nurses nurses graduate nurses graduate

mple/Settings survey, performed in 32 32 in performed survey, Nova Scotia, in wards hospital Ontario in 19 wards in and (Canada). (51%). 250 nurses (Ontario, Canada). Canada). (Ontario, 250 nurses to Respondents 1106 workers in healthcare healthcare in 1106 workers 612 which, among system, Canada). (Ontario, nurses - 245 neo 755 nurses 2 the to 573 and survey, - 833 neo Canada). (Ontario, (Ontario, Ca nada). survey. the to respondents Sa

)

year (

hor Smith et al. (10) (2010) Spence Laschinger et (*9) (2009) al. Spence Laschinger et (2009) al. (**22) Spence Laschinger et (23) (2012) al. Laschinger et (24) (2013) al. Aut Workplace incivility among nurses. Prevalence and consequences Prevalence incivility nurses. among Workplace 1. Table 56 S. Bambi, C. Foà, C. De Filippis, et al. (continued)

wilful 0.221, p<0.001), and and p<0.001), 0.221, -

r should be checked and and checked be should r Professional impact 0.286; p<0.001), general health health general p<0.001), 0.286; - absences. Empowerment with WI correlated (ß= (ß= symptoms mental health symptoms (ß=0.307, (ß=0.307, symptoms health mental p<0.001). Absenteeism which seen as work is u behavio controlled since it can lead to Toachieve conflicts. serious more put be should policy absence this, check to by organizations place in employee control and - -

NR NR 0.19), and less mental mental less and 0.19), (B= disorders health resilience were were resilience reduced to associated WI from peers (B= 0.31). Psychophysical disorders and and The ß

ß value ß value is

oderate oderate two

The . ese fective fective tment, R value Af ) is strong regress to

absenteeism Data shows that

. M 0.011 SE value 0.058, commitment organization variable OACO is type one which (Organization Commitment independent and dependent R square 0.680, R value variable SE 0.813, ß value 0.462, value of type Second 0.087. value OCCO variable moderate continuance (Organization commitment) is less regress from commiaffective ß 0.426, value R square 0.653, There is a relation between WIThere a relation is employee R (WI) value variable independent 0.200, R and square 0.447 is . 0.011 SE value 0.058, value commitment organization th between moderate Workplace incivility R value is 0.200, R and square 0.447 variables.

Related factors NR

nce (SD±5.32)

91 NR Workplace incivility: mean 48 . Prevale in

graduate nurses nurses graduate o, Canada); 546 (39%) Canada); o, mple/Settings - 1400 neo (Ontari survey. the to respondents working nurses 184 medical in organization healthcare Faisalabad City (Pakistan) Sa )

year ( Din - hor Wing et al. (25) (2013) Zia ud (2017) (19) (2017) Aut Workplace incivility among nurses. Prevalence and consequences Prevalence incivility nurses. among Workplace 1. Table Workplace incivility, lateral violence and bullyng among nurses 57

According to the available data, there are no cor-

; ; relations of workplace incivility with specific demographic features (11), except for the total years of nurs- eported ing job’s experience (p=0.007) as reported by Oyeleye

ot et al. (12).

– N Concerning emotional and physical side effects,

NR there is a weak correlation between workplace incivility among peers and physical symptoms (13). Operating Room; Operating

– Laschinger et al., highlighted how a strong resil- Professional impact OR

; ; ience attitude was related with less presence of incivility among colleagues (B=-0.19), and less symptoms of

Intensive Care Unit; Unit; Care Intensive mental discomfort (B=-0.31) (14). – Workplace incivility have a significative correlation with professional burnout (p<0.0001) (17), emotional exhaustion (r=0.25), cynicism (r=0.33) (12) and

Psychophysical disorders poor job’s satisfaction (r=-0.20) (15). Several studies also related workplace incivility

with the request of turnover (8.9%) (16) and turnover intentions (9, 12, 13), and with nurses’ job commit-

Emergency Department; ICU ment, especially if the workplace incivility arose from – patients or superiors (11). ED

0.525, SE value 0.073. 0.073. SE value 0.525, Shi el al. (18) found that workplace incivility was third type of moderate

positively related to anxiety (r=0.371, p<0.01) and job burn-out (r=0.238, p<0.01). On the contrary, work- value 0.527, SE value 0.062. SE value 0.527, value Lastly, variable is ONCO (Organization Normative Commitment), also less and affective from regress R commitment value continuance 0.379, R square 0.616, is Coefficient ommitment; ONCO: Organization Normative Commitment) place incivility was negatively related to resilience C Related factors (r=−0.191, p<0.01) and has a positive prediction function to generate anxiety (β=0.364, p<0.01, M2) and

ntinuance ntinuance job burn-out (β=0.240, p<0.01, M5) of new nurses. o C The resilience moderated the relationship between

ity; workplace incivility and job burn-out.

nce Zia-ud-Din Arif & Shabbir (19) found a sig- Certified Registered Nurse Anaesthetist; Nurse Registered Anaesthetist; Certified - nificant relationship between workplace incivility and

Prevale employee absenteeism (β=0.058, SE value 0.011), but with varying degrees to the facts of employee absen- Workplace Incivil Workplace

– teeism. Among absenteeism, withdrawal behaviours

WI was found to be the most prevalent practice of nurses

as response to incivility. Organization commitment Commitment; OCCO: Organization was negatively correlated with employee absenteeism Burnout Inventory; CRNA Inventory; Burnout and workplace incivility. The relationship was found to be negative between organization commitment and andard Deviation; Deviation; andard mple/Settings workplace incivility. – St Sa Copenhagen

) Slem & Seada (20) revealed a statistical significant – SD negative correlation between workplace civility climate year ( : CBI: atient ; d and total score of incivility behaviour while there was no P hor –

. significant correlation between group norms and work- Aut Legen OACO: Organization Affective Pt

Workplace incivility among nurses. Prevalence and consequences Prevalence incivility nurses. among Workplace 1. Table place incivility behaviours among staff nurses. Find- 58 S. Bambi, C. Foà, C. De Filippis, et al. ings suggest that perceived workplace civility climate clinic, for the 4.3% the workload and the patient den- can play a role in the incidence of incivility behaviours sity, for the 3.8% the differences in political views, and among staff nurses, while group norms for civility is not for 3.2% the physical appearance. a predictor of occurrence of incivility behaviours. Identification of specific services or units at high- risk of lateral violence can be difficult due to the broad Lateral violence: prevalence and related factors variability inside the explored settings, confirming that lateral violence is firstly a “cultural problem” in nursing The number of papers on lateral violence match- profession (33). ing the inclusion criteria was 25. This topic, compared According to the NEXT study, intensive care to the previous one, seems to be more globally wide- units and operating rooms were the most affected ar- spread than just the Northern America area. In fact, eas by lateral violence (7.4%), followed by the elderly there is a greater variability in its prevalence, according care units (7.0%) (28). In addition, an Italian survey to the studies reported (Table 2). showed the ORs as the most exposed environments to The prevalence range is wide: from the 1% of lateral violence (32). Armmer & Ball (26), up to 87.4% described by Dunn As opposed, data collected in South Africa have on a population of operating room (OR) nurses (both identified obstetrics wards as the most affected service from USA) (27). The European area shows a lower (40%) (34). range of lateral violence (1.3%-5.3%), as recorded by Finally, a survey from Purpora & Beglen (2015) the NEXT study (28). pointed out that ICUs and surgical wards were the Similar findings were reported from Italy, by most affected by lateral violence (35). Magnavita et al., showing a 9.9% of non-physical ag- Overall, gender, age, seniority and nursing educa- gressions from colleagues (29). tion are not related factors of lateral violence among Some exceptions were represented by a Spanish nurses in clinical settings (27, 31, 32, 36, 37). study (74.2%) (30) and two recent Italian surveys per- The only exception is from the study of Sellers et formed in Emergency and Intensive Care Unit (ICU) al. (38). The authors have shown higher lateral violence settings, showing values of 81.6% (31) and 79.1% (32), rates among the senior versus junior nurses (p<0.05), respectively. as well as female versus male (p<0.05) (38). Morrison et al. (49), in Jamaica, found that ex- Nurses working with daily shift are the most af- posure to lateral violence was reported by 96% of par- fected by lateral violence (28, 31). ticipants, and 3/4 rated the exposure as moderate to Natural tendency for selfishness β( =0.13) and not severe. Lateral violence created a hostile environment, yet specified peculiar work environment β( =0.13), both and the behaviours in response to lateral violence represent antecedents for work related bullying (39). among nurses included professional disengagement, Nurses involved in lateral violence experience re- retaliation, avoidance and intent to resign, as indicated ported psycho-physical consequences on a range from by half of the nurses surveyed. The Nurse Managers 3.2% (29) to 65.2% (31). The symptoms’ description is were the main perpetrators of lateral violence (63%). summarized in Table 5. The pervasiveness of lateral violence among the nurses Mild negative correlations exist between lateral studied indicates the need to implement appropriate violence and quality of patients care (r=-0.469; p<0.01), workplace violence policies. plus errors and adverse events (r=0.442; p<0.01) (35). Ayakdaş & Arslantaş (50), in Turkey, found that Authors reported that variable percentages of 47% (n=366) of nurses had suffered lateral violence and nurses victimized by lateral violence performed their the 80.1% encountered mobbing behaviors, including duties not matching the minimum safety requirements. humiliation and degradation. The reasons for colleague Some examples are: drugs administration with unclear violence reported were: for the 10.3% the jealousy, for prescription, lifting patients without support and using the 10.1% to have higher level of education, for the medical devices without asking for supervision (40). 8.2% the rivalry, for the 4.6% to be a beginner in the Furthermore, there is a significant positive corre- Workplace incivility, lateral violence and bullyng among nurses 59 ,

(continued) r, and and r,

changes in in changes . Only 6.9% . ed and tired. tired. and ed expressed the the expressed of assignation in in assignation of r, 81.7% repeatedly 81.7% repeatedly r,

NR on effects three The first to exposed nurses from violence psychological work at that: are colleagues participant the 85.5% of when sorry felt deeply nurses rememberedthey the u behavio behavio the recalled 81.1% felt stress LV correlated with the job the leave to intention p<0.05). (r=0.214, for 17.7% asked ward assignation ward of their changed really 12 last the in assignation 6.9% months. nursing the leave to desire The swap to claim unit career. was with presence associated LV to symptoms related of (13% 5%; p=0.039). vs for asked nurses 136 (11.3%) assignation ward of in change changed really 43 (3.6%) only their ward Professional impact

NR NR NR reported (65.2%) 235 nurses one symptom least at related to LV. 829 (69%) reported symptoms 829 (69%) reported related to LV Psychophysical disorders

f nurses nurses f

perienced moreperienced

shift nurses shift (93% vs shift nurses shift ex -

NR 10.3% (n=38), 10.1% (n=37), 10.1% (n=37), 10.3% (n=38), 4.3% 4.6% (n=17), 8.2% (n=30), 3.2% and 3.8% (n=14), (n=15), for reasons the reported (n=12) jealousy, as violence colleague education, of level higher a having the in beginner a being rivalry, patient and workload clinic, density, differences in political e. appearanc physical and views - LV night than p=0.0019). 78.4%; NR LV were more ED in frequent ICU (90% 77.2%, than and rather p=0.0038). respectively); Day There were no statistical LV between differences significant i even demographics, and more be seem to Italy Southern in Related factors ; ; the , rs u violence

80.8%.

- 80.1% encountered 80.1% encountered

he 42.1% (n=154) 42.1%he (n=154) NR. Virtually 100% (the asking just started survey experienced the about LV). 47% (n=366) of the the 47% of (n=366) least at reported nurses one colleague psychological 1% 294 (81.6%). experienced 951 (79.1%) LV. experienced 269 (22.4%) the behavio mobbing most including including most and humiliation degradation. T were they that reported to subjected being 1 than less for violence year Prevalence

epartment and Out of and epartment 300 nurses, Michigan Michigan 300 nurses, Respondents (USA). 104 survey: the to (36%). (EDs and 444 nurses 5 Tuscan from ICUs) hospitals (Italy). the to Respondents (81%). 360 survey: nurses 1504 Italian from Critical Care Emergency and Units D 96 U.S. nurses 96 U.S. a from (336 779 nurses university hospital, training a 243 from hospital and research 170 province; Izmir in in hospital state a from Aydin province, Turkey) Sample/Setting Sample/Setting

(2018) (2018) & ş 26 ) ş

43 ) 31 ) 32 ) Alspach G. (2008) G. (2008) Alspach ( & Ball Armmer ( (2015) Ayakda (50) (2013) al. Bambi et ( (2014) al. Bambi et ( Arslanta Author (year) Lateral violence among nurses. Prevalence and consequences Prevalence Lateral nurses. violence among 2. Table 60 S. Bambi, C. Foà, C. De Filippis, et al.

(continued)

=6.233, p<0.05). Similar Similar p<0.05). =6.233, p < 0.01). =23.022, V not mentioned for fear of of fear for V mentioned not 2 2 NR NR findings were recorded in in recorded were findings victims of lateral bullying respectively; 2.1%, and (8.5% c NR L retaliations; afraid to possible for questioning feelings unpleasant mockery; the to due job the about peers. with relationships the last 12 months. Head 12 months. last the ward of changed nurses the more than assignation (7.3%; roles nursing other c Professional impact

NR NR NR headache, Insomnia, pain, abdominal dueabsence to demoralization feedback. of Psychophysical disorders -

shift - term geriatric -

=5.887, p=0.0527). p=0.0527). =5.887, 2 c %), medical surgical (84%, vs 63%, vs (84%,

victimized compared to others others to compared victimized (88.5%, No statistical significant of between role the differences LV of and victims/perpetrators demographics NR LV occurred mainly in ICU in and mainly LV occurred long OR (7.4%), between was found No correlation the effects of LV and length of A weakcorrelation service. between LV and prevalence length Male respondents service. of LV than of effects more showed females LV was p=0.003). respectively, nurses, among junior frequent less the seemed PhD the graduates but mostvictimized (despite their number was low). respondents’ unit (7.0 wards (6.2%). LV victimized versus 6.4%, in nurses foreign of head (5.4%); nurses native day (5.2%); nurses (6.6%); nurses night (6.4%), nurses shift (5.8%). nurses Related factors

as victim

(87.4%). lateral bullying. 125 12 (47%). Range from Holland (50; (50; Range from Holland (530; Poland to 1.3%) 12.3%). w 778) 82% (n. LV, LVof witnessed or weekly or daily on a basis. Prevalence

Hospital EmergencyHospital Service Emergency and Room. Operating the to Respondents (79.9%). 1202 survey: from nurses 34.107 567 healthcare institutions in 8 countries. European the to Respondents 55.1%. survey: nurses. 955 U.S. New in 500 OR nurses Jersey(USA). the to Respondents (29%). 145 survey: newly 26 U.S. nurses. qualified Sample/Setting Sample/Setting

27 )

28 ) 37 ) erino et al.

42 )

Cam ( (2008) Dumont et al. ( (2012) ( Dunn H. (2003) Griffin M. (2004) ( Author (year) Lateral violence among nurses. Prevalence and consequences Prevalence Lateral nurses. violence among 2. Table Workplace incivility, lateral violence and bullyng among nurses 61

(continued)

r in response to to response in r avoidance and and avoidance u he nurses included included nurses he

29 (30.5%); thinking thinking 29 (30.5%); - ehavio

intent to resign. NR 24/170 (14%) reported (14%) reported 24/170 absence from workplace, to (34%) planning 58/170 profession. nursing the leave Intent to change the job’s job’s the change to Intent career The b LV among t disengagement, professional retaliation, NR

to modify personal behaviour behaviour personal modify to 18 (18.9%). Professional impact

9 - 11 - 42 19 (20.2%), 19 (20.2%), - -

confidence, and and confidence, esteem, fear, fear, esteem, - 8 (8.2%), to feel y. - - 10 (10.5%), believe believe 10 (10.5%),

12 (12.8%), desire of of desire 12 (12.8%), - . 3 (3.2%), annoyance - annoyance 3 (3.2%), %), rage13 (13.8 - -

NR Reduced self sadness, frustration, irritability, headache, weight, of loss depression, of cases Rare fatigue. self increased energ of load Fear NR NR (9.6%), irritation anxiety (44.7%), humiliation guilty lack of sensation 27 (28.7%), - help of revenge revenge (11.6%) the others are wrong are others the Psychophysical disorders

41, 41,

settings -

LV occurred: 40% in obstetrics, 40% obstetrics, LV in occurred: 20% and in wards, 32% general in psychiatric units. NR NR NR Negative affectivity is statistically significantpredictor for theall bullying. workplace of subsets work of antecedents Significant individualism are bullying related work special and (ß=0.13),

(ß=0.13). Verbal abuse predictors predictors abuse Verbal (ß=0.13). ≥ hours working weekly were: type of hospital, and negative negative and hospital, of type Related factors

the

Nurse

by 96% of .

physical aggressions aggressions physical 29%. 188 (34%); major 170 (31%) reported levels of distress from 9 nurses (9.9%) reported reported (9.9%) 9 nurses non - by colleagues. LV to Exposure was reported rated 3/4 and participants, exposuremoderate as the to severe NR. LV of Only mean values are scales bullying and reported. Managers were main the perpetrators of LV (63%). incidents. are The perpetrators nurses, with different positions job and roles Prevalence

471 nurses from Cape from 471 nurses Town Africa (South a from 275 nurses hospital general (Italy). New from 1159 nurses RespondentsZealand. 551 survey: the to (47%). nurses 114 registered of Kingstone a of (Jamaica) Hospital The was response rate 93% 107) (n= 4 from 255 nurses in hospitals university Korea. South Sample/Setting Sample/Setting

39 )

29 ) 3)

4) Khalil D. (2009) D. (2009) Khalil (3 Magnavita al. et ( (2011) McKenna al. et ( (2003) Morrison et al. (49) (2017) ( (2016) al. Oh et Author (year) Lateral violence among nurses. Prevalence and consequences Prevalence Lateral nurses. violence among 2. Table 62 S. Bambi, C. Foà, C. De Filippis, et al. - - - ly (continued)

NR NR LV to wasrelated negatively the job satisfaction levels (r= LV negative p<0.01). 0.466; affect the job satisfaction: ß= (F(1,172)=46.63, 0.462 p<0.001). the LV affect negatively ß= among peers: relationship (F(1,172)=119.92, 0.641 p < 0.001). Professional impact

NR NR NR Psychophysical disorders

0.469; 0.469; - =0.17, =0.17, 2

surgical areas areas surgical

d to errors and and errors d to

0.640; p<0.01). p<0.01). 0.640; 0.641; p<0.01). 0.641; - - etween LV and relationship LVetween relationship and LV was more outside frequent ICUs medical and a without nurses for and (p<0.05), education university certified (p<0.05). program There was correlation a negative b among peers (r= Gender, nursing basic education education basic nursing Gender, service of length and program, LV. of ICUswere predictors not more LV other than experienced wards. F=3.64). affectivity (adjusted R There was correlation a negative LVbetween relationships and among peers (r= LV was a predictor for reduction reduction for LV was predictor a among peers. relationships of to LV correlated negatively patients’ quality of care (r= p<0.01). p<0.01). quality poor of LV was predictor a care. of LV was relate adverse events (r=0.442; p<0.01). p<0.01). (r=0.442; events adverse LV and wasof errors a predictor events. adverse Related factors

37 (21.1%) nurses nurses 37 (21.1%) weekly or daily reported LV frequency. 37 (21%). 139 (79.4); NR Prevalence

18.8%).

215 nurses from from 215 nurses California (USA). the to Respondents 175. survey: nurses. 1278 U.S. the to Respondents (13.8%). 175 survey: from 234 nurses California (USA). the to Respondents ( 175 survey: Sample/Setting Sample/Setting

35 ) a et al. (2012) (2012) al. et a

) (41 015) 36 ) Purpor ( & Blegen Purpora (2 & Blegen Purpora (** (2015) Author (year) Lateral violence among nurses. Prevalence and consequences Prevalence Lateral nurses. violence among 2. Table Workplace incivility, lateral violence and bullyng among nurses 63 (continued)

NR NR NR NR NR NR Professional impact

NR NR NR NR NR NR Psychophysical disorders al

related related - -

0.40). 0.38) and team and 0.38) -

related stress were were stress related

male nurses groups groups nurses male

=38.45, DS=12.27, t(58)=2.40, t(58)=2.40, DS=12.27, =38.45, p The total score of hostilities was score of hostilities The total reported with association in higher outcomes negative patients’ unlike SD=8.73) (mean=47.50, negative report who not did outcomes ( NR higher appears LV frequency (p<0.05), nurses experienced for fe in and (p<0.05). LV work was to associated (r=0.34, stress p<0.01),team support- (r= NR LV were more medic in frequent wards. surgical and p=0.02). identity (r= showedLinear regression LV that work and - p< (ß=0.23, associated positively LV while was negatively 0.01), and support team to associated e p<0.05 (ß=0.14, identity team respectively). p<0.01, ß=0.22, Related factors

itnessed LV

29.4%. 53.3%; 77% w - - -

LV among nurses was other than lar ger categories. professional 24.3% NR 74.2% 19.9% 46% of respondents 46% respondents of of levels high reported LV. LV 65% from reported peers.

28.4% Prevalence

63 nurses from a a from 63 nurses a in service perinatal Californian hospital Respondents (USA). 62. survey: the to New York 108 nurses, (USA). from 2659 nurses New of York hospitals Respondents (USA). NR. survey: the to 2 from 388 nurses hospitals. Spanish (USA). 227 nurses 1850 nurses and and 1850 nurses nurses assistants Respondents (USA). 601 survey: the to (91%). nurses Sample/Setting Sample/Setting

30 ) 47) 44 ) (

45 ) 38 ) 46 ) Reynolds et al. (2014) Sellers et al. (2009) ( Sellers et al. (2012) ( (2007) al. et Stanley ( Topa & Moriano ( (2013) al. Walrafen et ( (2012) Author (year) Lateral violence among nurses. Prevalence and consequences Prevalence Lateral nurses. violence among 2. Table 64 S. Bambi, C. Foà, C. De Filippis, et al.

lation between lateral violence and work-related stress

(β=0.23, p< 0.01) (30). In addition of these data, lateral violence exerts leave leave

a negative impact on job’s satisfaction (β=-0.462; F

US: United (1,172)=46.63, p<0.001) (41).

At last, literature pointed out the link between lateral violence and the intent to quit from nursing career (r=0.214, p<0.05) (26). A range from 11.3% (31) The main effects on patients’ The on main patients’ effects were: safety administration 30 (13%) drugs unclear despite by nu rses asking without prescriptions, for clarifications; 11 (25.6%) patients’ obese performing asking without mobilization used nurses 5 (10%) help; for unfamiliar medical equipment supervision. without 23 (19%) decided to 23 (19%) decided their current job position. Professional impact to 30.5% (29) of nurses victimized, decided to resign

Standard Deviation; Deviation; Standard from their position. From 6.9% (31) up to 34% (3) of : the targets even consider quitting the profession. Nurses that have witnessed lateral violence re-

atient; SD port and share the experience with other people up to P : 58% (40) of the episodes (recipients are line managers, peers, friends, relatives…).

On the contrary, a direct facing with the aggres- NR NR Psychophysical disorders sor appears to have a broad range of percentage: from 17.3% (36) to 100% (42). Operating Room; Pt Operating : Bullying. Prevalence and related factors

The number of papers focused on bullying among

Reported; OR Reported; nurses was 38 (Table 3). t

No The prevalence reported also for this topic is widely variable, from 2.4% (51) to 81% (52). NR :

; ; Unlike the lateral violence, the variability of preva- NR NR Related factors lence recorded in the studies on bullying, is mainly con- nected to its operational definition, then to studied settings and instruments used to record this phenomenon.

Bullying (as lateral violence) is not related to specific demographic factors, levels of education and

nurses’ job position (5, 53). Exceptions are given by data retrieved from Paki- 105 (85%) observed LV 105 (85%) observed towards others or themselves in the last 6 months. episodes towards other other towards episodes people. 78 (60%) witnessed LV. of presence Prevalence stan (54) and Iran (55). Findings have shown that female nurses are sig-

nificantly more prone to experience abuses, if compared to the male colleagues (56).

In Turkey, Yildirim (58) and Çevik Akyil et al.

(59), have identified the younger age as a main risk 130 (26%) nurses 130 (26%) nurses the to respondent survey,from a in hospital community USA. U.S. a from 500 nurses Respondents hospital. 130 survey: the to (26%). Sample/Setting Sample/Setting factor for bullying in nursing profession (58). In a study conducted in Neonatal Intensive Care Units in

Greece, the female professionals and those with a job experience ranging from 5 to 10 years were more ex- 40 ) posed to bullying (57).

tes; USA: United States of America Vessey et al. showed that a length of service of less 48 ) Wilson & Phelps &Wilson Phelps ( (2013) Wilson et al. (2011) (2011) al. et Wilson ( Author (year) ED: Emergency Department; ICU: CareLV: Violence Unit; Intensive Lateral Sta

Lateral violence among nurses. Prevalence and consequences Prevalence Lateral nurses. violence among 2. Table than five years was a risk factor for bullying (76). A Workplace incivility, lateral violence and bullyng among nurses 65 -

(continued)

her than not than her

dictor of burnout burnout of dictor

NR have bullied not Nurses job of level higher showed to compared when satisfaction (72.1% victims bullying’s the 47.2%and respectively) nurses victimised (p=0.0001); to intention stronger reported rat job change (73% vs nurses victimized p=0.005). respectively, 57.2%, These also are findings to by willingness confirmed profession nursing the leave respectively, 67.2, vs (81.2% moved to 3 nurses p=0.011). job. another burnout and Bullying positively were syndrome related bullying p<0.001); (r=0.38, was a pre p<0.001). (ß=0.37, NR There was a negative Professional impact

R - .05),

showed correlation with loss loss with correlation showed p<0 (r=0.38, safety of NR showed bullying of Victims in score anxiety higher were those with comparison not victimised, despite clinically speaking, it was not significant. p=0.001). 2.18, vs (2.78, NR score of NAQThe total (r=0.30, consequences social and anxiety p<0.05), p<0.05), (r=0.37, depression General and of Health a score 12 (r=0.40, Questionnaire p<0.05). NR Psychophysical consequences

NR NR Bullying was correlated with the work hours number of weekly p<0.05). (r=0.11, NR NR Related factors

81%. 88 (17.1%). 2 least at 61% reported the in bullying of episodes 12 months. last of None21.4%. mention by perpetrated bullying peers. 43 (21.3%) nurses were were nurses 43 (21.3%) Prevalence

ralian nurses. ralian

881 nurses from 19 from 881 nurses Tokyo in hospitals (Japan). a from 650 nurses in hospital university Respondents Turkey. 538 survey: the to (82.7%). 762 Aust 3 from 206 nurses and central in hospitals Italy. north 5000 nurses in 3 states 3 states in 5000 nurses Sample/Setting Sample/Setting

78 ) 66 )

sakaletal. 52 ) 60 ) Abe & (2010) Henly ( Ak ( (2015) Allen et al. (2015) ( Arcangeli et al. ( (2014) (2012) al. et Berry Author (year) s and consequence Prevalence Bullying nurses. among 3. Table 66 S. Bambi, C. Foà, C. De Filippis, et al.

(continued)

0.322, p<0.01). 0.322, −

correlation between bullying bullying between correlation work and productivity r= (F=0.045, NR NR NR NR Professional impact

12.9±5.7 12.9±5.7 (

NR psychological of Lower level employees for status health bullied being respectively, 8.5±4.6, NR the PTSD > 14 for score 17.6%. P<0.001) Psychophysical consequences

10 - -

ack of

1.845, 1.845, - bullying was bullying 10 years

≥ tly more exposed more exposed tly for

.048)

certifications

0 30 pts in a day a in 30 pts

25 years (mean=160.16, (mean=160.16, 25 years – .009); professionals with 5 with professionals .009); 0 p<0.005). < 0.05). (p 16.388) Predictive factor factor Predictive the participative leadership (ß= l a with p<0.05) 1.035, (ß= human resources Female significan (56.4%vs36%, bullying to p= by more perceived is Bullying features: following the with nurses age 18 SD= ± (mean=167.33, of Higher moderate than levels of probability the increased anxiety abuses verbal SD= ± 14.858), married married SD= ± 14.858), absence ± 14.226), (media=161.62 university of SD= ± 9.220), (mean=160.55, worked in a clinical settings SD= ± 14.872), (mean=156.56, < experience 1 year professional length ± 13.846), (media=159.44 workplace current the in service of SD= ± = (mean 160.97, < 1 year the in s ervice of length 12.731), workplace current and SD= ± 8.338), (mean=162.15, caring for ≥ years of job experience experience job of years to exposed more significantly (p= bullying Related factors

1.4% of cases, the 1.4% the cases, of 53.1% doctors and 53.6% and 53.1% doctors nurses exposed to bullying on a on a bullying to exposed 36 (18.2%) basis; daily more exposed were nurses a week. in times at were 59 (34%) nurses bullying. of risk to 53.5% exposed bullying; NR, mean the of score perception bullying were how nurses reflects exposed often SD ± 155.51, (mean 14.956). nu rses 94 (58.9%) by acts bullying suffered 4 supervisor, direct by bullied were (2.4%) instead. peers 15.8%; In 1 was a staff perpetrator Prevalence ,

of USA. Respondents USA.of Respondents 197 survey: the to (3%). Italy. from 238 nurses the to Respondents (73.5%). 175 survey: 398 healthcare s (doctor professionals working nurses) Neonatal intensive Greece in units care a from 256 nurses in hospital university Respondents Turkey. 180 survey: the to (70.3%). nurses and 231 nurses assistants in a psychiatric hospital in Sample/Setting Sample/Setting

(57) 61 ) 59 )

72 ) 62 ) ( Bortoluzzi et al. ( (2014) Chatziioannidis et (2018) al. Çevik Akyil et al. ( (2012) (2008) al. Chen et ( Author (year) s and consequence Prevalence Bullying nurses. among 3. Table Workplace incivility, lateral violence and bullyng among nurses 67

(continued)

1.7) and 1.2 1.2 and 1.7) 1.4) times -

certified absences certified -

48; p<0.001), p<0.001), 48;

NR wasBullying with associated commitment to the job p <0.001), (r=0.49; work on the concentration (r=0. (r=0.46; productivity motivation p<0.001), p<0.001), (r=0.44; patient with relationship manager p<0.00), (r=0.42; and p<0.001) (r=0.47; (r=0.45; colleagues p< 0.001). NR NR absences illness for Certified and self were - 95%:1.3 (CI 1.5 (CI 95%: 1.1 higher than the rest of staff staff of rest the than higher Professional impact

n the not n the

=0.05) and verbal verbal and =0.05) 2

Bullied victims were more chronic experience to prone and had a BMIillnesses tha higher slightly NR

NR was positively Bullying depression to associated Depression p<0.001). (r=0.51; by bullying was determined (ß=0.54; workloads and P < 0.001). F=56.61; Females exposed workplace to mean (adjusted aggression 95% CI 0.3, 1.5, difference 2.7, R aggression (adjusted mean (adjusted aggression victims. Psychophysical consequences -

surgicalwards nurses, -

NR from work bullying The absences the to dependent not were related demographic. 8.1% by ED nurses, and 13.4% and 8.1% by ED nurses, services. other from nurses from (adjusted OR 4.3, CI95%: 1.5 OR 4.3, (adjusted service: of length the so and 11.8), > 20 years. <5 years, by were reported abuses Emotional 10.5% % ICU 25.5 of nurses, the by medical mostby The affected settings ED, community were: bullying and traumatology services, nursing department orthopaedic NR Related factors

302 (5%). Incidence in period of 2 of period in Incidence 33(3.1%). cases years:

The nurses were most the after perpetrators frequent pts. and relatives. member. abuses 56% emotional of by was peers. perpetrated Verbal 73%; abuse: 40% between bullying 50%.and to 27.3%sed expo in aggression workplace 12 months previous the Prevalence

rvey: 420 (25%). rvey: Taiwan. the to Respondents 222. survey: a in 157 nurses psychiatric hospital in Taiwan. Respondents 87%. survey: the to from 12332 Nurses (Canada’s Alberta province). the to Respondents (52.8%). 6526 survey: employees,Hospital 4981 and 647 male (Finland). female a in 1650 nurses Hong of hospital to Kong. Respondents the su Nurses 341 Palestinan Sample/Setting Sample/Setting

73 ) 80 ) ) (65)

79 ) 77 ) (2000) ( (2000) Chen et al. (2009) (2009) al. Chen et ( Hesketh al. et ( (2003) Kivimäki et al. (2006) Kwok al. et ( & Niensen Jaradat (2018 Author (year) s and consequence Prevalence Bullying nurses. among 3. Table 68 S. Bambi, C. Foà, C. De Filippis, et al.

(continued)

victimised their current

- related to

bullied nurses nurses bullied -

Victims of bullying showed bullying of Victims intention to leave job at least 2 times more not than frequent NR NR was Bullying nurses (p<0.001); victims of of victims (p<0.001); nurses possible a reported bullying nursing leave to intention 2 next the in profession more 3 times years often not than (p<0.001). Professional impact

=0.04) reported higher higher reported =0.04) =0.09). 2 2

difference 1.4, 95% CI 0.2, 95% CI 0.2, 1.4, difference 2.6, R NR NR NR NR hosomatic symptoms than symptoms than hosomatic psyc unexposed. bullying to Males exposed higher reported symptoms than psychosomatic mean (adjusted unexposed 95% CI 1.0, 3.2, difference 5.5, R Psychophysical consequences

No correlation was found with with was found No correlation and level, education demographics, position. job promoting factors 3 organizational bullying: informal alliances, and rewards in tolerance, of use negative organization, legitim authority, processes and procedures. NR NR Related factors

year of

68 (27.3%). 68 (27.3%). (38%) reported 17 nurses by peers. bullied be to NR 53.2%. respondents 46.7% of bullying experienced 1 the during NR lateral bullying. work. 48% cases was of Prevalence

on in on in 767 nurses member of 767 nurses Emergencythe Nurses Associati (USA). Washington the to Respondents (32.5%). 249 survey: from 5000 nurses public and private healthcare institutions. the to Respondents 370. survey: 3 from 282 nurses public and private Turkey. in hospitals from 641 nurses Sample/Setting Sample/Setting al.

) ) 5 6

81 ) Johnson & Rea & Rea Johnson ( (2009) et Hutchinson ( (2010) (2014) al. Korhan et ( Laschinger HK. Author (year) s and consequence Prevalence Bullying nurses. among 3. Table Workplace incivility, lateral violence and bullyng among nurses 69

for pts

R was - GS -

(continued) MBI

GS cynism - related bullying bullying related - the quality of care

to R work 0.23).

- nosocomial infections infections nosocomial risk perceived (r=0.18), complaints relatives’ (r=0.33), of amount total (r=0.26), (r=0.23). events adverse was negatively Bullying related (r= NR NAQ - correlated with (r=0.53; subscale exhaustion NAQ of total p<0.01); NR related to MBI to related p<0.01). 0.53, (r= subscale Professional impact

NR NR nced experie nurses 32.3% of 1/4 anxiety; of levels variable reported victims the of PTSD. of symptoms Psychophysical consequences

ence a victim. as

s of bullying. To be be To bullying. of s 4.46) and high level level high and 4.46)

R were statistically – - 6.93) were associated to to were6.93) associated victims and contemporary contemporary and victims 2 were bullying of perpetrators The associated. strongly conditions mostof characteristics of bully narcissism, (machiavellianism, of measures and psychoticism) with associated are aggression experi bullying’s No statistical significant between in males and differences females victim significantin relation with the syndrome burnout of aspects MBI. through measured All the bullying aspects measured aspects bullying the All NAQ with Age < 30 years (OR= 2.4; CI (OR=Age <2.4; 30 years 95%=1.34 of anxiety (OR = 4.7; IC 95% (OR = = 4.7; anxiety of – 1.09 violence. verbal Related factors

isor were

place (after pts pts (after place

Only mean values of of Only mean values study the in used scales were reported. 37.5%. nurses 261 (51.4%) psychological reported 155 (29.8%) violence; experienced nurses 67 (12.9%) and bullying, harassment. sexual andPeers superv at the 3 33% of the newly newly 33% the of were nurses qualified bullied. and relatives) in the perpetrators’ of frequency role. Prevalence

hospitals in Ontario Respondents (Canada). 336 survey: the to (52%). length with 415 nurses < in 3 years service of (Canada Ontario students 224 university (Canada). from 700 nurses Taiwan. Respondents 521 survey: the to (74.4%). Sample/Setting Sample/Setting

74 ) 53 )

014) (** 014) 63 ) (2 al. Laschinger et (70) (2010) & PowerLinton ( (2013) & Pai Lee (2011) ( Author (year) s and consequence Prevalence Bullying nurses. among 3. Table 70 S. Bambi, C. Foà, C. De Filippis, et al.

(continued)

0.46), 0.46), -

nal exhaustion exhaustion nal 0.31).

0.37), turnover (r=0.19), (r=0.19), turnover 0.37),

- – NR NR job with correlated Bullying (r= satisfaction NR to willingness and Bullying work organization the leave (r=0.51; correlated are NR turnover (r=0.19), and and (r=0.19), turnover emotio (r=0.46). WI from peers correlated to job satisfaction (r= exhaustion emotional and (r= Professional impact

.01) .01) .01) .01) 0 0 p<

.06, .06, 0 0 =

= β β ed to bullying and to WI to and bullying to ed

NR NR NR Physical health status is relat 0.28, and (r=0.39, by peers mental Reduced respectively). correlated wellbeing health WI and by peers bullying with 0.25, and (r=0.32 respectively). bullying to Exposure an increase behaviour predicts ( anxiety in ( fatigue and NR one later year Psychophysical consequences

- .027) 0.19). - more

is vs 4.5%,

were vs

9.8%, p= 0 9.8%,

capital vs

.12,p<.01), and and .12,p<.01),

0 moralharassment .11,p<.01), .11,p<.01), = .10,p<.01) predict an an predict .10,p<.01) 0 β .002) racial 0 = and and

= β

β ed to physical violence violence physical to ed .001) .001) .015) .030) 0 0

0 expos (p= (p= p= comparedNurse to technicians, physicians, and nurses 16.1%, p= 0 16.1%, (12.1% discrimination NR moral harassment (32.5% harassment moral to physical Females more physical exposed to (19.7% violence NR The psychological (r= bullying to related negatively (r= WI to by peers and 0.21) ( Anxiety ( depression ( fatigue NR increase in bullying behaviour behaviour bullying in increase reporting Related factors

; 2.5% ;

8.7% racial

tion

242 (39%). sexual harassment sexual discrimina 15.2% phy sicalviolence; 48.7% psychological 24.9% moral violence; harassment; respondents 91 (2.4%) bullying; experienced abuses were verbal 1701 (56%) in reported cases. NR. of Only mean values study the in used scales were available. NR 159 (31%) Prevalence

Canada). 269 healthcare 269 healthcare in professionals Brazil Southern and 4343 nurse Turkey. in obstetrics qualified 342 newly Ontario in nurses (Canada). 1582 Norvegian Nurses from 245 nurses Colombia Britannica ( nurses. 511 U.S. Sample/Setting Sample/Setting

(2014) (2014)

68 ) et al.

56 ) 51 ) ( 2013) 82 ) 75 ) Pai et al. (2018) ( (2015) al. et Pinar ( Read & Laschinger ( Rekner (67) (2014) al. Rush et ( (2008) S. Simons ( Author (year) s and consequence Prevalence Bullying nurses. among 3. Table Workplace incivility, lateral violence and bullyng among nurses 71 (continued)

willingness to the

p< 0.001). Bullying is a a is Bullying p< 0.001). quit. NR of predictor NR NR NR NR NR Professional impact

NR NR NR NR NR NR Psychophysical consequences

and and ied than than ied

0.422; p < 0.05). p < 0.05). 0.422; -

correlation between correlation

0.398; p < 0.05). 0.398;

- Moderate Organisational of values mean and score total Inventory Culture Workplace the Mobbing in Scale total score (r= Moderate between correlation Organizational of meanvalues score total Scale Justice workplace the in Mobbing scale total score (r= NR Females were more bull 28.4% vs n=111/155 (71.6% males surgical medical/ n=44/155); ICUs (32%) and wards (21%) related more bullying reported incidents than other services. Females were more exposed to (30.71% males than bullying respectively, 10.32%, versus p=0.03). NR NR Related factors

from

NR. the of Only mean values study the in used scales were reported. 94% 33.8%; 48% nurses of by bullying experienced peers. 28.9%; the cases, 8.53% of In perpetrators were staffs’ colleagues. from behaviours Negative nurses: discriminations verbal 8.4%); (340; 17,6%). (709; abuses behaviours Negative nurses: discriminations (6.2%); (16.6%). abuses verbal Prevalence

the f Critical 01 (73%).

1000 nurses from from 1000 nurses Massachusetts (USA). the to Respondents (51.1%) 511 survey: public from 458 nurses in hospital private and Pakistan. 3 from 1034 nurses U.S. university hospitals. to Respondents (75%). 772 survey: in nurses 413 hospital Teheran (Iran). the to Respondents 3 survey: members 4346 nurses American the of o Association Care Nurses (USA). members 5562 nurses American the of Association of Critical Care Nurses (USA). Sample/Setting Sample/Setting

84 ) 55 ) ( (

83 ) 54 ) 85 ) 86 ) Simons et al. (2011) al. et Simons ( (2015) al. Somani et ( Terzioglu et al. (2016) Teymourzadeh al. et (2014) Ulrich et al. (2006) ( Ulrich et al. (2009) ( Author (year) s and consequence Prevalence Bullying nurses. among 3. Table 72 S. Bambi, C. Foà, C. De Filippis, et al.

was related related

(continued) s (23%);s 25, p<0.001). 25, related to

depression (r=0.24, (r=0.24, depression related bullying bullying related

was - to emotional emotional to related bullying was bullying related -

psychological distress distress psychological anxiety (r=0.20, p<0.001), p<0.001), (r=0.20, anxiety and p<0.001), (r=0.19, cynism p<0.001). (r=0.19, depression Personal 78.5% of nurses with a length length a with nurses 78.5% of < resigned 5 years service of job; another for looking absence from work were 48 case in recorded reported 103 (49%) nurses interest of loss progressively work. the in p<0.001), anxiety (r=0.19, (r=0.19, anxiety p<0.001), (r=0.19, cynism and p<0.001), workplace Passive ). p<0.001 bullying related p<0.001) (r=0.26, exhaustion (r=0. anxiety and Bullying by peers was by peers Bullying to anxiety p<0.001), (r=0.29, and p<0.001), (r=0.26, p< 0.001). (r=0.25, depression Work related to NR Professional impact

NR NR NR Psychophysical consequences

y associated to the the to y associated

Nurses with length of service < 5 Nurses service of with length werethe than years more bullied others. NR associated wasBullying positively total and (p<0.01) workload to length of service (p<0.05), while it was negativel regression Logistic (p<0.01). age related was bullying how showed length total and workload, age, to (ß=0.48; years service’s of p<0.001). F=39.70; 45% of bullied nurses were were nurses 45% bullied of <0.001) (p by workload affected Related factors

and and

surgical area: surgical -

interventional radiology radiology interventional 9 (5%). department: 48 (23%); ICU: 38 (18%); ICU: 38 (18%); 48 (23%); ED: OR: 25 (12%); 19 (9%); Obstetrics: 15 (7%); 12 service: Outpatients Endoscopy (6%); Medical NR 21% Prevalence

nurses.

- 212 U.S. staff and 1484 nurses nurses from assistants Murcia, in 11 hospitals to Respondents Spain. 70.48%. survey: the a from 495 nurses in hospital university Turkey. Ankara, the to Respondents (58%). 286 survey: Sample/Setting Sample/Setting

71 )

76 ) 58 ) Vessey et al. (2009) Vessey al. et ( Waschgler al. et ( (2013) Yildirim D. (2009) ( Author (year) s and consequence Prevalence Bullying nurses. among 3. Table Workplace incivility, lateral violence and bullyng among nurses 73

mild positive correlation has been found between bullying and the amount of work hours per week (r=0.11,

.20, p<0.05) (60). Moreover, the perception of inclusive 0 = Patient;

Maslach β

– leadership or understaffing represent items in the pre- -

– dictive modelling for bullying (61).

an indirect effect effect an indirect Moderate to high levels of anxiety represent a

intention (

risk factor as well, (adjusted OR 4.3, IC95%: 1.5-11.8)

smarter, 70.5% (62). This finding is also upheld by Pai & Lee (OR=4.7; .007) symptom .007) 0 IC 95%=1.09–6.93) (63). performed more attentively (to (to more attentively performed avoid criticism); 40.6% job their quit to planned position. and and 72% worked harder worked p< experience. Bullying has Bullying on turnover Professional impact

Standard Deviation; Pt. Negative psychophysical outcomes of bullying

–

Intensive Care Unit; MBI can affect up to 75% of the victims (64).

.51,

.36, s 0 – 0 =

= Jaradat & Niensen (65) found that female and β β ( ( male nurses exposed to workplace aggression and bul-

symptom lying reported higher mean levels of psychosomatic direct

symptoms than unexposed (respectively adjusted mean

75%. 2 -

Operating Room; SD Operating difference 1.5, 95% CI 0.3, 2.7, R =0.05, and adjusted .001) and total total and .001) .009) effects on effects .009)

0 – mean difference 3.2, 95% CI 1.0, 5.5, R2=0.09). 14.3% Bullying has Bullying p < 0 p < psychological psychological Psychophysical consequences The nurses targeted by bullying have shown Emergency Department; ICU

moderate correlation for loss of confidence (r=0.38,

; ; – p<0.05), social consequences (r=0.30, p<0.05), depres- Reported; OR Reported; a

.001) sion-anxiety (r=0.37, p<0.05), and a general deteriora-

Not

– tion of the wellness status in accordance to the General

effect on workplace effect 48, p < 0 48,

. Health Questionnaire 12 (r=0.40, p<0.05) (66). ori ented 0 - - = rect Also Reknes et al (67), showed through a longi- β tudinal study, that nurses exposed to bullying behav-

iour at T1 evaluation reported one year later increased NR and 15% the by the were affected (p<0.01). age younger Relationship has culture organizational di negative ( bullying Related factors symptom of anxiety (β=0.06, p<.01) and fatigue (β=0.06, p<.01) even when controlling for age, gender, night work, job demands. This study also remarked the presence of a vicious cycle causing nurses with higher

anxiety (β=0.11, p<.01), depression (β=0.12, p<.01), and fatigue ( =.10, p<.01) at T1 evaluation, to report Negative ActRevised; NR Questionnaire β 55.2%.

- – more bullying behaviour. R - 7.3% 21.9% exposed to to 21.9% exposed bullying Prevalence

Workplace Incivility. Chen et al., reported levels of symptoms of post-

–

Copenhagen Burnout Inventory; CI: Confidence Interval; ED Interval; Confidence CI: Inventory; Copenhagen Burnout traumatic stress disorder (PTSD) even higher than 14

–

in 17.6%, recognizing that 10% of that sample unfortunately developed this syndrome (62). Different authors have found a direct correlation

General Survey; NAQ

between bullying among peers and physical health sta- - 710 nurses from 6 from 710 nurses public and private Istanbul in hospitals Respondents (Turkey). 505 survey: the to (71%). South of 301 nurses Korea Hospitals Sample/Setting Sample/Setting tus (r=0.39), likewise the mental health status (r=0.32) GS

– (68). Body CBI Mass Index;

– In a recent study (69), bullying showed a direct Traumatic WI Disorder; Stress - effect on the arise of psychological symptom in nurses Post 64 )

– (β=0.36, p<.001) and an indirect effect through the reported symptom on turnover intention (β=0.20, Yildirim & Yildirim ( (2007) Yun & Kang (2018) (69) Author (year) BMILegend: Burnout Inventory Inventory Burnout PTSD

s and consequence Prevalence Bullying nurses. among 3. Table p<0.007). 74 S. Bambi, C. Foà, C. De Filippis, et al.

Allen et al. (60) found that bullying is a predictive the experience with significant others or other pro- factor for the burnout syndrome (β=0.37, p<0.001), fessionals/institutions, reporting the episodes to line as also reported by Laschinger et al. (70) and by managers, and to face directly the bully (67.3%). Waschgler et al. (71). Moreover there is a negative correlation between bullying and work productivity Risk factors (F=0.045, r=−0.322, p<0.01) (72). Nevertheless, Kiwimaki et al. (73) showed how Several authors state that there are two different targets of bullying usually tend to collect sick absence variables bringing the risk of bullying and negative be- from the workplace more than the average staff’s trend: haviours in the workplace (Table 4). First is the job 1.5 (IC 95%: 1.3-1.7) times, 1.2 times (IC 95%: 1.1- market’s fluctuation (local or global), forcing profes- 1.4), respectively. sionals to endlessly careers’ changes. The second is Laschinger (74). found a negative correlation be- represented by the social environment, where people tween bullying and the quality of delivered nursing according to their background and resources are cop- care delivered (r=-0.23). Findings reported a correla- ing-reacting against problems or conflicts (87). This tion with hospital-acquired infections (r=0.18), per- assumption appears to be valid for both, targets and ception of patients’ safety risk (r=0.33), relatives’ com- perpetrators. plaints (r=0.26), and overall adverse events (r=0.23). A quality analysis of incident reports related to Unsurprising, increasing of bullying experience working incivility and violence among healthcare pro- directly influences the targets’ intention to quit from fessionals has identified two main factors as possible their job position (r=0.51; p<0.001) (75), also because catalysts for their occurrence: behaviour at work and there is a negative correlation with the job satisfaction job planning. (r=-0.46) (68). The first factor includes unprofessional conducts, A survey performed in Turkey (64). showed a arguments about tasks, and disagreement on the nurs- percentage up to 40.6% (in the sample of population ing care strategy plus disappointment on peers job investigated) of nurses planning resignation due to performance. The second one includes possible con- bullying. In addition, data from Vessey et al. (76) lead flicts and aggressions due to a failure in the adherence us to a concerning scenario: the 78.5% of nurses with to protocols, right assignation of patients, limited re- a seniority less than 5 years, left their position for dif- sources, and high levels of nursing workload (89). ferent careers. Bullying seems to be more expected in clinical en- Finally, a percentage from 25% (61) to 82% (77), vironments with high technical skills demands instead put in practice different countermeasures to cope with of clinical areas where relationships are the predomi- the bullying experienced. Strategies were (64): sharing nant nursing activities (76).

Table 4. Risk factors for workplace bullying occurrence (87, 88) Variable Subject Role Characteristics Labour market Organisations Organisational issues Work control/task Work control/time Uncertainty Organizational changes

Society - Environment Persons Victim Less assertive Less competitive More conscientious Less extroverted Less balanced Workplace incivility, lateral violence and bullyng among nurses 75

In nursing settings, the bullying attitude seems Table 5. Classification of bullying related symptoms and ill- to be a consequence of previous learning of negative nesses (3, 29, 37, 62, 63, 87, 88, 94). behaviours (a sort of ‘imprinting’), a deviant attitude Typologies Symptoms and illnesses acquired from the professional pack and the existing Physical Insomnia social environment (90). Irritable Bowel Syndrome Nonetheless, different authors spotted that perpe- Sweating/Tremor trators of bullying acts, forcing to conceal themselves Stomach-ache Abdominal pain a poor self-esteem, lack of social competence, useless Fatigue leadership plus self-promotion micro-politics, because To feel/to be sick they are craving career progression (91). Others dis- Arterial hypertension tinctive features of bullies are their narcissistic person- Headache Loss of appetite, loss of weight ality, a sense for revenge, tyranny plus a bad habit to Asthma spread accusation and rage over the people (91). Rheumatoid Arthritis Often, the abuses instigators are prone to forgive Osteoarthritis themselves, assuming their misconduct is free of risks Sciatic Nerve Pain or collateral effects (92). Back pain Diabetes Finally, there is an escalation of bullying fre- Dizziness quency in published literature due to a boosted clinical complexity of patients, spending review of budg- Psychological Loss of self-confidence ets (less resources) along with a mounting workforce Rage Guilty feelings turnover (91). Lack of help sensation Getting into the details, research from the United Hyper-surveillance States of America have shown how the junior staff Want to cry sensation nurses category, especially the more youth, are at high- Anxiety, panic attack Depression est risks for bullying. It could be related to their lack- Sensation of fear ing job experience, less confidence in their fresh job Post-Traumatic Stress Disorder role and a scarce awareness of the unspoken rules inside the work environment (when compared to senior Behavioural Irritability staff) (91). Aggressiveness Unable to relax, incapability to knock off work Excessive double check for every actions; Psychological and physical impact obsessive attention at work Increase consumption of tobacco A systematic review of the literature classified the Tendency to isolation Attempting suicide/suicide contemplation bullying effects on the victims according to several categories (87): • Decreased self-confidence physical and psychological health status, are widely • High levels of stress variable (i.e. 12%-75%) (93). • Poor job satisfaction Table 5 summarises the category of symptoms • Overreaction to mental stress and disorders bullying related, according to the con- • Psychological symptoms sulted literature. • Certified sick leave • Self-certified sick leave Conclusions • Cardiovascular disease • Psychosomatic disorders The scientific literature covers a wide range of • Chronic illness prevalence of workplace incivility, lateral violence and The values of percentages reported about nurses’ bullying in nursing. 76 S. Bambi, C. Foà, C. De Filippis, et al.

Multiple reasons could be the explanation behind are not at fingertips. However, because its nature, a so many differences. For example, a workplace context cultural-based response could be a possible approach. based on various ‘in-groups’, sometimes quite dissimi- It should start from the nursing academic educa- lar within same place or unit. Also the differences in tion (basic and advanced), throughout workplace envi- the used measuring tool should be taken in account, ronments, becoming part of the continued education because its features may directly influence the detec- programs in the arrangement of ‘raising awareness’ tion of lateral violence and bullying episodes and their dedicated events. At the same time, a call for action frequencies as well. Even the operational definitions of to isolate and to contain any workplace incivility or these cases are subjects to this methodology’s choice. violence should be promoted. A clear exemplification of this issue is the bul- As an adjunct to these interventions, an official lying/mobbing definition itself: “at least one negative stance from the nurse management and leaders would act, weekly or more often, for six or more months” (95) be desirable, in synergy with a systematic monitoring or, according to other authors, “at least of two typolo- of these phenomena by occupational health depart- gies of abuses, weekly or more often, for six or more ments. months” (96). In summary, we found a lack of evidence about Finally, the complexity in the data collection pro- policies and programmes to eradicate bullying and lat- cess retrieved from summarising tables was a challenge, eral violence. Prevention of these phenomena should due to the ambiguity of terminology (as already men- start from a widespread information inside continue tioned) plus the heterogeneity of tools employed. To educational events and the university nursing courses. rule out between workplace incivility, lateral violence and bullying-mobbing sometimes was quite difficult. Key points However, this review showed that workplace incivility, lateral violence and bullying are widespread in - Workplace incivility, lateral violence and bully- the clinical settings of nursing profession, and also that ing are described as a continuum related to their the consequences of lateral violence and bullying can intensity, frequency and presence of intention to be serious for the victims and the organizations. harm the target. Psychophysical symptoms and increasing of nurs- - Prevalence of these phenomena in the nursing es’ turnover are the major expressions of these conse- profession is variable, reaching considerable val- quences. ues (87% for lateral violence, 81% for bullying). Because the emotional and physical impact on - In terms of emotional and physical impact, neg- victims cannot be neglected and the amount of people ative outcomes can seriously affect the victims having the intention to leave the profession is alarm- (up to 75% of cases). A wide range of physical ing, the prevention becomes a priority. and psychological symptoms may occur. So far, the strategies implemented were: get better - Two main factors were identified as possible cat- awareness of the issue between peers and managers, alysts with their occurrence: behaviour at work the promotion of educational campaign for preven- and job planning. tion, to provide personal resources to handle conflicts and improve communication’s skills, supporting au- thentic leadership practices and zero-tolerance policy References against abuses (97). Unfortunately, we observe a systematic response 1. Spector PE, Zhou ZE, Che XX. Nurse exposure to physical from the nursing management not fully supported by and nonphysical violence, bullying, and sexual harassment: a scientific evidence, plus the failure of zero-tolerance quantitative review. Int J Nurs Stud 2014; 51(1): 72-84. 2. Rumsey M, Foley E, Harrigan R, on behalf of Royal College and informative policies is well recognized (98). of Nursing, Australia. National Overview of Violence in the Definitive solutions for this matter, mainly based Workplace. http://www.smspsts.org/smspsts/papers/austral- on the complexity of the humans’ social interaction, ian%20overview.pdf. Access made on 04-10-2011. Workplace incivility, lateral violence and bullyng among nurses 77

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