22.01.2018 in Nursing
Workplace Bullying Among Hospital Registered Nurses


The concept of horizontal violence or workplace bullying is a serious and complex issue, which is often under-reported. According to Dunn, horizontal violence means “sabotage directed at coworkers who are on the same level within an organization’s hierarchy,” (Dunn 2003:  977). Various terms such as workplace violence or hostility, incivility, mobbing, lateral violence, and horizontal violence have been used interchangeably in the literature, but for the purpose of this study, the term workplace bullying (WPB) will be used.  Bullying is usually not physical and is often manifested in covert and overt hostility behaviors (Duffy 1995; Freire 1972). The behavior is common among oppressed groups and can take place in any area so long as unequal power relations exist, resulting in the control and suppression of underprivileged groups by the more powerful and prestigious individuals (Harcombe 1999). This behavior can either be conscious or unconscious (Taylor 1996). WPB damages the victim emotionally, physiologically, and spiritually, aside from other prolonged effects (Wilkie 1996). Though WPB is not necessarily physical, the definition encompasses hitting, shoving, and throwing objects.

Nursing literature has revealed over the last couple of decades that workplace bullying (WPB) has been connected with potentially damaging ramifications within organizations. A research by Katrinli, Atabay, Gunay, & Cangarli established that bullying may be motivated by political reasons. This implies that nurses may deliberately bully colleagues for power and to serve their own self-interests, (Katrinli et al 2010: 623). Essentially, this behavior has not only affected the workplace, but also has affected nursing practice and its image in general.

The notion that abuse of nurses has produced compromised patient care and increased turnover rates for nursing staff is reflected in the literature (e.g. Bush & Gilliland, 1995; Cox, 1991). In July 2007, the American Hospital Association reported that more than 135,000 registered nurse (RN) vacancies nationally. Dr. Peter Buerhaus estimated that the U.S. nursing shortage will grow to 260,000 registered nurses by 2025 (American Association of Colleges of Nursing, 2010).  Some authors have even suggested that abuse in the workplace contributes to the nursing shortage as a common reason for many nurses to leave their profession (Stagg &Sheridan, 2010; Aiken, Clarke, Sloane et al., 2001; Zigrossi, 1992; Cox 1991). Upon gathering a total of 396 nurses from the National Health Service community trust in England in 1996, a research survey study was conducted revealing that the majority of recipients reporting abuse experienced lower job satisfaction, higher job stress or burnout, greater depression and anxiety, and greater intent to leave the job (Quine, 2001).

The nursing profession has traditionally encountered a deficit of staff nurses. Because of the dwindling supply of nurses, it is imperative to attract and retain nurses by creating and maintaining a virile work culture.  Failure by hospital and nursing administrators to address nurse to nurse violence, sometimes also called lateral violence, can potentially increase the risk of high turnover, and hinder the development of professional pride. In line with this matter, Sofield and Salmon (2003) reported that health care organizations evaluate workplace issues with a goal of developing an environment that supports nursing in their efforts to provide quality care. One of the recent efforts to tackle this issue included adopting the 2009 Leadership Chapter Standards, the Joint Commission on Accreditation of Hospitals (2008) included requirements that leaders create protocols for managing disruptive behaviors and that they maintain a hospital culture of safety and quality. For this study, this researcher will present the main purpose and significance of the study followed by a definition of workplace bullying, burnout, and oppressed group behaviors. The impact of workplace bullying on employee retention and professional environment for nurses will be thoroughly discussed. Because retention of nurses could be related to WPB and burnout, these areas warrant investigation.

Problem Statement 

Historically, nursing literature has substantiated nurses being exposed to patriarchal oppression by hospital administrators and physicians (Reverby, 1987; Muff, 1982; Ashley, 1976). As of 2010, though awareness of the problem is increasing, there still exists a lack of awareness of oppressed group behaviors in nursing. With regard to the incidence of oppressed group behaviors in nursing, the researcher of this study will investigate WPB issues in the nursing profession by examining its prevalence and if there is a significant relationship between the demographic variables (age, gender, race, & years of experience as a nurse) and the variable WPB. The researcher will use the Negative Acts Questionnaire-Revised (NAQ-R) as a way to measure the frequency of bullying experienced by nurses in different hospital clinical areas such as medical surgical, intensive care, and psychiatric units; in relationships between bullying and burnout; and if bullying reported by hospital nurses will be positively related to intent to leave.

Identifying the key factors behind the prevalence of WPB among the hospital nurses will assist the health care organizations in terms of understanding the negative effects of WPB and implementing a stricter policy to prevent WPB. Bullying is a direct link to nurses’ feeling of inferiority. In line with the statement, Demarco, Roberts, and Chandler (2005) stated, “oppression elicits negative behaviors – silence, a lack of voice, poor self-esteem, and the sublimation of the experience of powerlessness through the internal divisiveness known as horizontal violence” (p. 86). Based on the explanation of Demarco et al. (2005), WPB is therefore considered to be one of the salient factors of oppressed group behaviors.

Ignoring this problem could hamper determining the issues related to nursing shortages and the creation of a positive professional image. Although hospital administrators are beginning to implement policy that stipulates a safer work environment that guards again WPB, the issue is often overlooked, which is the main rationale of this investigation. This investigator hopes to contribute knowledge in this area to assist promoting job retention, professional unity, and a positive professional image among the hospital nurses. The investigator will not only examine if there is a significant relationship between WPB and the demographics variables—the frequency with which professional nurses experience bullying at work and the relationship between bullying and burnout—but will also explore and propose several strategies that will enable the health care leaders to manage and improve the problem of WPB.

Description of Variables

According to Burns and Grove (2005), variables can be described as any object, event, idea, feeling or anything that is measured in a study. Two broad forms of variables include independent and dependent variables. Independent variables are those that are the presumed cause, or those variables influencing the dependent variable.   Many independent variables are referred to as demographic variable. The following demographic data will be collected from the participants of the study:

  1. Age – Individual age is an independent variable since it cannot be affected by  other variables.  In this study, the researcher will examine if WPB is affected by the age of the nurse.
  2. Gender – Gender is an independent variable since it cannot be changed by other variables in the study. The researcher will determine whether being a male or a female has an effect on bullying.
  3. Level of education – Individual level of education is another independent variable in this study. There will be a determination whether levels of education have an effect on bullying.
  4.  Years of experience – years as a nurse will be another demographic variable unchanged by the other variables. This study will assist in revealing if it has an effect on WPB. The primary independent variable in the study is workplace bullying. The dependent variable is the effect or the consequence of the study’s independent variable.

The following will be the dependent variables in this study:

  1. Burnout – Nurse Burnout depends on the working environment, and it will be assessed by using the Maslach Burnout Inventory.
  2. Intent to leave – The intent to leave depends on many other factors in nursing environment including WPB and burnout and will  be assessed  using the Turnover Scale.  

Nature of Study

Workplace bulling is a significant problem facing the nursing profession. The dearth of literature on WPB experienced by nurses in the workplace serves as a rationale for further investigation. Despite the fact that WPB can occur in any profession, the problem is emerging as a high profile issue in the health care environment. According to Lyneham (2001), WPB is more prevalent in the health care industry that in other industries. There is growing evidence that nurses experience WPB in disproportionately high levels as compared to other workers in the health care system and other high risk environments outside the health care system (Saines, 1999). Workplace bullying (WPB) however is   still underreported and the actual scope of prevalence is underestimated (Hewitt, Levine, & Misner, 1998). It is apparent that violence has an economic cost in that health care finances will be affected as a result of low staff and increased patient acuity (Smith & McKoy, 2001).

The health care system seems to be burdened by workplace violence, which is correlated with expenditures related to nurse absenteeism, litigation and compensation, and decreased productivity (Gates, Meyer, & Fitzwater, 1999). It was not until recently that workplace violence against nurses was identified as a health hazard, physically, mentally, and emotionally (Katrinli et al., 2010).  The human costs related with this kind of violence include chronic pain, depression emotional trauma, and shifts in functional status (Gates, Meyer & Fitzwater, 1999). Bullying has been linked with burnout and job stress, in addition to attracting and maintaining nurses (Smith & McKoy, 2001).

The International Council of Nurses accepted the issue of workplace violence as a critical issue in the health care system and made a recommendation for an appropriate action to be taken in dealing with such issues regarding competence of the nursing professions and other related issues (Duncan, Reimer, & Estabrooks, 2000). Nurses have a key role in the identification and management of bullying in the workplace. Although Farrell described managers as the culture carriers of an organization, seasoned nurses also share responsibility in eradicating WPB. As leaders, nurses must be perceptive and detect bullying behaviors that can lead to creating alliances that serve to disseminate the behaviors and perpetuate a bullying culture (Olender-Russo, 2009).

While nurses are in a position to influence healthcare policy and legislation, they are innovative and have the ability to utilize their influence to empower others and challenge the status quo of an otherwise problematic work environment.  As advocates, nurses are capable of initiating change developing an environment of open communication.  WPB requires secrecy, shame, and silent witnesses to persist, and all of these elements exist in a close system (Namie & Namie, 2000). Nurses are change agents to build a framework for guiding organizational change to abolish WPB. Bartholomew (2006) asserts as leaders success in eliminating WPB will depend on the nurses: (a) the ability to acknowledge the problem, (b) communication system, and (c) the response. As change agents, nurses must acknowledge the fact that they are under a social contract to do good and avoid harm to society. Nurses need to understand and steer clear of political motives for bullying which may only serve to satisfy individual interests and significantly affect the way they respond to incidents of bullying, (Katrinli et al 2010: 623).

Research Hypotheses

The research questions developed for this study are as follows:

  1. There is a statistically significant relationship between age, gender, race, education level, and bullying.
  2. There is a statistically significant greater occurrence of bullying experienced by nurses in different clinical areas – medical surgical, ICU, ER, and psychiatric units.
  3. There is statistically significant relationship existing between bullying and burnout.
  4. There is a greater statistically significant relationship between nurses who are bullied than those who are not with intent to leave current position.

5. There is a statically significant relationship between burnout and nurses’ intent to leave current position.

Purpose of the Study

The purpose of this study is to identify and examine the factors of WPB, burnout, and nursing turnover rates as they relate to the untoward effects on the nursing profession.  It is the hope of this investigator that the findings from the study will help nurses understand the extent, if any, to which WPB is a contributing factor of the nursing turnover crisis. Research on the nature of WPB is essential to refining existing institutional policy and confronting the related issues that could prevent a productive and safe work environment.

Conceptual Framework

Freire’s (1971) model of oppressed group behavior will be used to frame the concept of WPB in nursing.  His framework was chosen for its importance to the literature regarding other groups’ plight with WPB. Many managers are not aware of the effects of oppressed group behavior on organizations. Nurse Managers are in a key position to assist with and improve policy based on the findings from this research as well as others’ findings.

It is the belief of this researcher that the findings from this study will accentuate the importance of WPB as it relates to RNs and will assist administrators in comprehending the nature of workplace bullying and its effects on the work place. The results of this study will potentially assist organizations and others participating to identify and understand the importance of WPB and the related key factors that affect RNs. These factors have been linked directly to individuals’ feeling of inferiority. Demarco et al. (2005) stated, “Oppression elicits negative behaviors; silence, a lack of voice, poor self-esteem, and the sublimation of the experience of powerlessness through the internal divisiveness known as horizontal violence” (p.86). WPB is one of the salient factors of oppressed group behaviors. Nurses experiencing WPB are more likely to exhibit these behaviors since they are oppressed and hence they can be understood within the framework of Freire’s model. 

Freire’s Model of Oppressed Group Behavior

 Freire’s (1971) model of oppressed group behavior has been the basis for several credible studies in nursing and other disciplines.  Freire established the model based on his work with Brazilians, who had been dominated by Europeans. These natives were restricted and exploited by those possessing greater influence, reputation, and status.

Oppressed group behaviors reflect a consistent pattern in society. The influential and dominant Europeans identify their norms and values as the proper ones in society and then use their power to impose them. The Europeans determine which attributes (e.g. skin color, language, food, and clothing) are to be respected and rewarded. In turn, subordinate groups learn to hate their own attributes. The oppressed group’s belief of their own inadequacy, their powerlessness in the system, and the absence of pride in their own culture lead to feeling of low self esteem and lack of respect for their attributes and each other (Roberts, 2005). Oppression continues by an educational system that propagates the values and beliefs of the dominant group.  Eventually, both groups internalize the values and begin to consider that the oppressed group is inherently inferior.

As Freire explained, the oppressed groups internalize the values of the oppressor and “in their alienation, the oppressed wants at any cost to resemble the oppressor, to imitate and follow them” (Freire, 2003, p.62). According to Freire, the oppressed group believes that internalizing the values of the oppressor will make acceptance and power possible. The dominant group depicts the oppressed as lacking in values, knowledge, and dignity, and views themselves as everything good and valuable in society. Consequently, the oppressed people come to have contempt and reject identification with their own culture, which they view negatively.

Oppressed Group Theory Related to RNs in the Workplace

Sometimes the oppressor will use humanitarianism as a basis for preserving a profitable situation or will mandate or suggest actions “for the safety and good of the people” and the oppressed will have limited inabilities to come up with initiatives to tackle the problems and challenges in the working environment. This system thrives on lack of transformation, creativity, and knowledge of the oppressed group, who is misplaced and misguided within the system. This approach promotes inhumanness in the oppressors and facilitates their thoughts that the oppressed are powerless, initialing a vicious cycle of oppression. Freire labeled this phenomenon as the banking concept which gives the oppressors credence that they are more knowledgeable than the oppressed.

Freire explored the banking concept through teacher-student relationships where the oppressors are the depositors, the oppressed are the depositories, and education or information becomes the act of depositing. The depositor uses the depositories as containers to be filled with information and behaviors to be received, memorized, and repeated. In the hospital setting, new nurses would be the depositories while experienced nurses would be depositors. The banking concept in the RN workplace exhibits itself in relationships between the new RNs and the seasoned, experienced RNs. The new RNs are the depositories, being delegated to and receive commands from the experienced nurses, who are the depositors, thus an all inclusive constructive communication.

Freire noted that the banking concept implies the notion that human beings are adaptable and manageable beings. He illustrated that the more students worked at storing the effects of those deposits that have been entrusted to them, the less they form the critical thinking that will lead to interventions possibly to transform their environment, (freire, 2005). In other words, the more completely the new nurses accept the role imposed on them, the more they tend to adapt to that environment as it is and to the disruptive behaviors deposited in them.  Depending on oppressor-oppressed relationships, new nurses should develop their own initiative to tackle the problems and challenges in their working environment.

RNs are more limited in creativity, as are other people, when they are oppressed; impeding their ability to think of initiatives to tackle the challenges they face in hospitals. In a hospital setting, there is the horizontal flow of command although the vertical flow is where nurses receive instructions from their managers and managers receive instructions from their top administrators, and so forth.  In a dyad relationship, the vertical relationship between seniors and juniors is more defined than horizontal relationship between those who occupy the same rank, such as juniors and juniors or seniors and seniors.WPB is open to different interpretations, depending on the way it occurs in a dyad relationship. For example, in a vertical relationship, WPB may not be clearly visible because of the confusion over the higher ups having power over the lower-level RNs. In a horizontal relationship, WPB is more pronounced because all individuals are equal in rank but they are not necessarily equal in age, gender, levels of education, or years of experience.

According to common practices in the workplace, those with experience have the moral obligation of guiding those who are new to and less experienced in the work place in order to deliver quality services. This guidance is even more important in a hospital arena where the mission is to protect and save lives. The ANA Code of Ethics for Nurses (2001) serves as a guide to promote quality nursing care and ethical obligations of the profession. In Provision 1.5 of the Code of Ethics for Nurses (2001) the ANA discussed on the relationship with colleagues and others stating:

“The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring with colleagues and others with a commitment to the fair treatment of individuals to integrity-preserving compromise and to resolve conflict. Nurses function in many roles, including direct care provider, administrator, educator, researcher, and consultant. In each of these roles the nurse treats colleagues, employees, assistants, and students with respect and compassion. The standard of conduct precludes any and all prejudicial actions, any form of harassment, or threatening behavior or disregard for the effects of one’s actions on others. The nurse values the distinctive contribution of individuals or groups, and collaborates to meet the shared goal of providing quality health services”, ( ANA Code of Ethics for Nurses 2001).

Seasoned RNs in the profession have the obligation to ensure that young RNs are well instructed so they function as required. The outcome of working as one in a health care team moves them toward a common aim. Experienced nurses have sometimes exploited this moral duty by bullying new nurses; instead of giving clear guidance and instructions to the novice RNs, in a clear and concise manner, experienced RNs command and delegate duties that new RNs often perceive as inappropriate to their profession or inappropriate as a professional.

Operational Definitions


Bullying is be measured by scores on the Negative Acts Questionnaire – Revised (NAQ-R) (Einarsen & Hoel, 2001), which was designed to measure perceived exposure to bullying at work.  The 22 items are rated on a 5-point Likert Scale ranging from never to “daily” measuring three underlying factors: personal bullying, work-related bullying and physical intimidating forms of bullying.


Burnout is measured by score on the Maslach Burnout Inventory (MBI) by Maslach, Jackson, and Leiter (1996). It is a 22 item questionnaire that measures three features of burnout.  These are Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA).

Intention to Leave

The intention to turnover scale (Cammann, Fichman, Jenkins & Klesh, 1981), a subscale of the Michigan Organizational Assessment Questionnaire (MOAQ), will be used.  It is a 3-item index of employees’ intention to leave their job.

Theoretical Definitions

  1. Burnout is defined as:  “exhaustion of physical or emotional strength usually as a result of prolonged stress or frustration.” (Miriam-Webster Online, 2009, para.2).
  2. Depersonalization is defined as:  “Negative, cynical, detached, and impersonal attitudes and behavior” (Schutte, Toppinen, Kalimo, Schaufeli, 2000, p.53).
  3. Emotional Exhaustion – “Key aspect of the syndrome and refers to feelings of being over-extended and drained from one’s emotional resources” (Schutte et al., 2000, p.53, 54).
  4. Horizontal Violence is defined as:  “sabotage directed at co-workers who are on the same level within an organizations hierarchy.” (Dunn, 2003, p. 977).
  5. Oppressed Group Behaviors is defined as: the work behavior of employees who have low self-esteem and lack of self-confidence (Powerless individuals) within a particular work environment (Roberts, 2005, p. 24).
  6. Workplace Bullying is defined as: “persistent, offensive, abusive, intimidating or insulting behavior, abuse of power or unfair penal sanctions which makes the recipient feel upset, threatened, humiliated or vulnerable, which undermines their self-confidence and which may cause them to suffer stress.” (Bully Offline, 2009).


There are several assumptions for this study.

  1. Variables other than status variables of age, gender, and level of education could affect workplace bullying.

2        Because each nurse does not share the same circumstances, experiences and the understanding of stressors vary.

  1. The self-reporting by nurses on the surveys will be honest and truthful.
  2. Nurses can accurately report their subjective responses.

The independent variable workplace bullying may not be the only effect on the dependent variables, burnout and intent to leave.

  1. The selected instruments chosen accurately represent the concepts and variables examined.


The limitations the study included:

  1. The research participants will be obtained by way of a convenience sampling consisting of nurses in southeastern Alabama which could decrease representativeness of the population under study and generalization of the findings.
  2. The sample will consist of volunteers who self-report which may have response bias.
  3.  The questionnaires will be administered at multiple sites, possibly by different data collectors.
  4. Participants may freely choose not to answer some of the items.

Scope and Delimitations of the Study

This researcher will examine an understudied topic. The study’s sample will include up to 600 RNs in eight different local hospitals within one southern city.  The support and participation in this research from hospital nursing employees (RNs) will enable the researcher a convenient access to hospital nurses. The study’s findings will fill a gap in the literature in understanding this overlooked subject, in order to retain nurses and improve the nursing environment.

The delimitations of this study are that nurses experiences WPB live in other areas besides one city in the south. Because of the time frame and resources available for the study, the scope of sample selection will be confined to registered nurses in a southern state resulting in others being delimited to participate in the study. Therefore the sample may not be representative of the U. S. populations of hospital RNs and findings from the study cannot be generalized to the rest of the populations of RNs. Most participants involved in the study will have associate degrees; therefore the results may not be generalized to RNs with higher degrees.  Finally, the scope of the sample may not accurately represent males and may not represent male RNs in the US population.

Significance of Study

According to American Association of Colleges of Nursing ([AACN], 2010), the United States’ nursing shortage is projected to grow to 260,000 registered nurses by 2025. It is anticipated by 2015 that 114,000 RN positions will go unfilled (Auerbach, Beurhaus, & Staiger, 2000). Aiken, Clarke, Sloan, and Sochalski (2001) discovered over 40% of hospital nurses are dissatisfied with their jobs and have burnout levels that exceed the norms for health care workers. According to study by Sounart, up to 90 percent of nurses have witnessed or were the targets of workplace bullying, and some experts fear this trend could push more nurses out of the clinical setting.  “ ‘Lateral bullying’ among nurses was also noted in the survey…[which] include[s] making inappropriate remarks about other nurses’ skills in front of patients, doctors or other staff members, refusing to assist a fellow nurse or making inappropriate personal comments” (Sounart,  2008, p. 7).

Workplace bullying is labeled as a major dissatisfier within the health care organization. WPB does not only increase employee burnout, it also increases employee turnover rate and the number of absences and sick leaves. As an end result, the work satisfaction and work performance of hospital nurses are negatively affected. Institutional administrators being able to comprehend the rationale to and related factors of WPB will provide the basis for reducing WPB.  Significant improvement could result in the profitability of the health care organization as well as the level and quality of RN work performance.WPB among RNs is hurtful and devalues the recipient of the abuse, both personally and professionally.  WPB hinders a process of developing cohesiveness within the nursing profession and institution.

Results from a survey (Namie and Namie, 2003) indicated that victims waste time defending themselves and soliciting support, becoming demotivated and stressed, and taking sick leave due to stress-related illnesses. Bullies sabotage their work environment through their own fear, anger, anxiety, and low morale (Canada Safety Council, 2002; Vartia-Vaananen, 2003). A bully’s behavior causes other people to suffer shame, humiliation, and depression which can affect their personal life as well as their job performance (Namie and Namie, 2003).

According to Wilkie (1996), WPB has serious ramifications on the professional, psychological, and physical development of its victims. Individuals experiencing WPB will transition through different specific states that could hinder their emotional composure, their career or job, and their environment. The first stage involves sleep disorders, low morale, impaired self esteem, and floating anxiety. The second stage encompasses hypertension, nervous conditions, loss of emotional control, burnout, and apathy. The third stage manifests in the form of intolerance, depression, negative effects on personal relationships, disconnectedness, and suicide. These side effects have far more of a negative influence on employee productivity that once believed and are known to be the primary source for employees leaving their job.

Bullying has consequences on the victim, the society, and the organization. As already discussed in this section, the effects on the recipient of WPB can be highly destructive, ranging from irritation to psychosomatic complaints (Leymann, 1996; Quine, 2001; Katrinli et al., 2010). The Finish researchers Kivimaki, Elovainio & Vahetera (2000), conducted a study in measuring the rate of sickness absence for victims versus non-victims of bullying; 5,000 nurses participated. Two categories were used to describe sickness absence.  Medically- certified spells were absences of 4 or more days and self -certified spells of sickness absence (spells of 3 days or fewer).  These researchers found that medically- certified illness was 26% greater in bullied victims than medically-certified illness of those not bullied. 

Little has been done to understand and rectify high turnover rates and to acknowledge and address WPB among hospital nurses.  Patients rely on RNs to administer safe and high level care.  WPB could lead to potentially life threatening errors.  WPB among RNs needs to be managed and reduced so that professional unity, retention of RNs, and quality health care can exist. As part of increasing our knowledge in terms of main causes of WPB, this study’s findings will broaden the readers’ understanding of the factors that trigger aggressive behavior at work including some useful strategies on ways to diffuse the mounting tension that WPB causes within the work environment.

Transitional Statement

As WPB continues to escalate, the strain is felt in areas of recruitment and retention of adequately competent and trained RNs.  Nurses are essential to providing quality health care.  The problem of WPB needs to be addressed as one cause of burnout and nursing turnover rates. The investigator of this study will address an important gap in the literature regarding WPB as a significant problem in nursing and will examine WPB as it relates to burnout, nursing turnover rates, and development of organizational strategies.  In Chapter II, the investigator will present a comprehensive review of the literature related to the concept of WPB, burnout, nurse retention and turnover, and organizational prevention strategies. The literature review will reveal profound negative effects of WPB.

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