Bullying and the nursing profession in Australia: An integrative review of the literature

Abstract

Background: Bullying in nursing remains unacceptable with reports of bullying and harassment increasing. Aim: This article discusses the current state of knowledge about bullying in the nursing profession in Australia. Methods: The review was informed by the approach described by Whittemore and Knafl. A literature search was conducted using thefollowing search terms: ‘nurse OR nursing OR nurses’ AND ‘bullying OR bully OR violence OR harassment’ AND ‘Australia’. Findings: The findings highlight the many ways in which the experience of bullying in the nursing profession can be manifested and the implications for the profession as a whole. Discussion: The culture, prevalence and impact of bullying described in this paper raises concerns for practitioners, educators and policy makers. Conclusion: In order to develop effective strategies for both nurses and organisations to address the problem of bullying in nursing in Australia, the contributing factors that allow the problem to persist must first be examined.

Full text

Please
cite
this
article
in
press
as:
Hartin,
P.,
et
al.
Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature.
Collegian
(2018),
https://doi.org/10.1016/j.colegn.2018.06.004
ARTICLE IN PRESS
G Model
COLEGN-537;
No.
of
Pages
7
Collegian
xxx
(2018)
xxx–xxx
Contents
lists
available
at
ScienceDirect
Collegian
j
o
ur
nal
ho
mepage:
www.elsevier.com/locate/coll
Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature
Peter
Hartina,∗,
Melanie
Birksb,
David
Lindsayb
aCollege
of
Healthcare
Sciences,
Nursing
and
Midwifery,
James
Cook
University,
Australia
bCollege
of
Healthcare
Sciences,
Nursing
and
Midwifery,
Centre
for
Nursing
and
Midwifery
Research,
James
Cook
University,
Australia
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
3
December
2017
Received
in
revised
form
26
May
2018
Accepted
12
June
2018
Available
online
xxx
Keywords:
Australia
Bullying
Integrative
review
Nursing
a
b
s
t
r
a
c
t
Background:
Bullying
in
nursing
remains
unacceptable
with
reports
of
bullying
and
harassment
increas-
ing.
Aim:
This
article
discusses
the
current
state
of
knowledge
about
bullying
in
the
nursing
profession
in
Australia.
Methods:
The
review
was
informed
by
the
approach
described
by
Whittemore
and
Knafl.
A
literature
search
was
conducted
using
thefollowing
search
terms:
‘nurse
OR
nursing
OR
nurses’
AND
‘bullying
OR
bully
OR
violence
OR
harassment’
AND
‘Australia’.
Findings:
The
findings
highlight
the
many
ways
in
which
the
experience
of
bullying
in
the
nursing
pro-
fession
can
be
manifested
and
the
implications
for
the
profession
as
a
whole.
Discussion:
The
culture,
prevalence
and
impact
of
bullying
described
in
this
paper
raises
concerns
for
practitioners,
educators
and
policy
makers.
Conclusion:
In
order
to
develop
effective
strategies
for
both
nurses
and
organisations
to
address
the
problem
of
bullying
in
nursing
in
Australia,
the
contributing
factors
that
allow
the
problem
to
persist
must
first
be
examined.
©
2018
Australian
College
of
Nursing
Ltd.
Published
by
Elsevier
Ltd.
Contents
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What
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What
this
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1.
Introduction
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Method
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2.1.
Search
outcomes
and
synthesis
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Results.
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3.1.
Workplace
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3.2.
Pervasive
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3.3.
Impact
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4.
Discussion
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5.
Recommendations
and
limitations
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6.
Conclusion
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References
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∗Corresponding
author
at:
James
Cook
University
Angus
Smith
Drive,
Douglas,
QLD
4811,
Room
208,
Building
DB
25,
Australia.
E-mail
address:
peter.hartin@jcu.edu.au
(P.
Hartin).
Summary
of
relevance
Problem
or
issue
Bullying
is
a
recognised
phenomenon
in
nursing.
Some
attempt
has
been
made
to
examine
the
nature
and
extent
of
bullying
in
nursing,
however
it
is
important
to
integrate
findings
for
greater
https://doi.org/10.1016/j.colegn.2018.06.004
1322-7696/©
2018
Australian
College
of
Nursing
Ltd.
Published
by
Elsevier
Ltd.

Please
cite
this
article
in
press
as:
Hartin,
P.,
et
al.
Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature.
Collegian
(2018),
https://doi.org/10.1016/j.colegn.2018.06.004
ARTICLE IN PRESS
G Model
COLEGN-537;
No.
of
Pages
7
2
P.
Hartin
et
al.
/
Collegian
xxx
(2018)
xxx–xxx
awareness
and
understanding
of
bullying
as
a
complex
phe-
nomenon
in
nursing.
What
is
already
known
The
statistics
and
prevalence
of
bullying
in
the
nursing
work-
force
is
widely
reported
in
the
nursing
literature.
What
this
paper
adds
By
synthesizing
current
research
about
bullying
in
the
nursing
profession
in
Australia
this
integrative
review
identifies
gaps
in
the
literature
to
focus
future
research.
1.
Introduction
Workplace
bullying
is
not
a
recent
phenomenon,
yet
for
the
nursing
profession
it
is
a
problem
of
increasing
concern.
As
far
back
as
1987,
Cox
warned
of
the
damaging
nature
of
verbal
abuse
in
nursing
in
the
USA
(Cox,
1987).
Now
30
years
on,
the
problem
has
clearly
not
diminished.
Anecdotally,
some
nurses
have
compared
their
clinical
setting
to
that
of
a
battlefield
and
describe
the
envi-
ronment
in
which
they
work
as
a
place
of
professional
turmoil.
The
insidious
nature
of
the
problem
has
seen
it
overlooked
as
a
threat
to
the
nursing
profession
and
reduced
to
a
belief
that
bullying
is
a
‘rite
of
passage’
(Birks,
Budden,
Biedermann,
Park,
&
Chapman,
2018).
The
prevalence
of
workplace
bullying
in
the
nursing
profes-
sion
is
troubling
(Allen,
Holland,
&
Reynolds,
2015;
Hegney,
Eley,
Plank,
Buikstra,
&
Parker,
2006;
Levett-Jones,
Pitt,
Courtney-Pratt,
Harbrow,
&
Rossiter,
2015;
Magin
et
al.,
2011;
Rodwell,
Demir,
Parris,
Steane,
&
Noblet,
2012).
International
research
indicates
that
bullying
is
widespread
with
65%
of
nursing
professionals
in
the
US
reporting
frequently
observing
lateral
violence
among
co-workers
(Stanley,
Martin,
Michel,
Welton,
&
Nemeth,
2007).
Research
in
Turkey
by
Yildirim
(2009)
revealed
that
21%
of
nurses
had
been
exposed
to
bullying
in
the
preceding
12
months.
Further,
in
a
survey
of
3000
nurses
in
the
United
Kingdom,
nearly
25%
of
respondents
reported
being
bullied
or
harassed
at
work
in
2005
(Lipley,
2006).
Laschinger,
Grau,
Finegan,
and
Wilk,
(2010)
found
that
33%
of
Cana-
dian
new
graduate
nurses
had
experienced
workplace
bullying
in
hospital
work
settings.
These
studies
indicate
the
level
of
inter-
national
concern
about
the
magnitude
of
bullying
in
the
nursing
profession.
In
the
Australian
context,
a
survey
of
registered
nurses
and
mid-
wives
in
Victoria
found
that
52%
of
nursing
staff
had
witnessed
some
type
of
bullying
behaviour
(Farrell
&
Shafiei,
2012).
The
increasing
presence
of
bullying
in
Australia
is
reflected
in
recent
national
and
Nursing
and
Midwifery
Board
of
Australia
policies.
On
the
27th June
2013
Australia’s
federal
parliament
passed
amend-
ments
to
the
Fair
Work
Act
setting
out
new
standards
and
specific
provisions
on
workplace
bullying
(Australian
Government,
2013).
The
Nursing
and
Midwifery
Board
of
Australia
has
published
a
new
Code
of
Conduct
for
Nurses,
effective
from
1st March
2018.
This
Code
has
a
specific
section
on
bullying,
clearly
stating
a
zero-
tolerance
approach
(Nursing
&
Midwifery
Board
of
Australia,
2018).
Some
attempt
has
been
made
to
examine
the
nature
and
extent
of
bullying
in
nursing,
as
reflected
in
a
number
of
empirical
studies
and
reviews
(see,
for
example,
Farrell
&
Shafiei,
2012;
Hutchinson
&
Jackson,
2015).
Although
this
research
has
advanced
our
under-
standing
of
the
incidence
and
prevalence
of
bullying
in
nursing,
it
is
important
to
integrate
these
findings
to
better
understand
this
complex
phenomenon.
Such
understanding
can
inform
the
development
of
strategies
to
address
the
problem.
To
that
end,
this
integrative
review
synthesizes
current
research
about
bully-
Box
1:
Inclusion
and
exclusion
criteria.
Inclusion
Published
after
1991
Topic
addressed
nurse
to
nurse
bullying
Primary
research
Study
location
was
Australia
Published
in
English
language
Exclusion
Published
after
2016
Topic
did
not
address
nurse
to
nurse
bullying
Article
other
than
primary
research
Study
location
outside
of
Australia
Published
in
language
other
than
English
ing
in
the
nursing
profession
in
Australia
and
identifies
gaps
in
the
literature
to
focus
future
research
(Whittemore
&
Knafl,
2005).
2.
Method
An
integrative
review
was
conducted
to
identify,
appraise
and
examine
literature
exploring
the
problem
of
nurse
to
nurse
bul-
lying
in
Australia.
An
integrative
review
provides
an
avenue
to
systematically
explore
both
experimental
and
non-experimental
studies
in
order
to
describe
the
overall
state
of
the
evidence
(Whittemore
&
Knafl,
2005).
The
integrative
review
framework,
informed
by
Whittemore
and
Knafl
(2005),
was
implemented
because
it
enhances
rigour
when
reviewing
a
combination
of
pri-
mary
studies
with
various
methodologies.
Search
terms
relating
to
bullying
in
nursing
were
reviewed
and
the
following
terms
developed:
‘nurse
OR
nursing
OR
nurses’
AND
‘bullying
OR
bully
OR
violence
OR
harassment’
AND
‘Australia’.
The
parameters
for
the
search
term
were
determined
based
on
the
def-
inition
provided
by
the
Australian
Human
Rights
Commission
of
workplace
violence,
harassment
and
bullying
(Australian
Human
Rights
Commission,
2011).
Searches
were
conducted
using
the
fol-
lowing
electronic
databases:
(i)
Medline,
(ii)
Cumulative
Index
to
Nursing
and
Allied
Health
Literature
(CINAHL)
and
(iii)
Scopus
(Fig.
1).
The
time
period
was
limited
to
between
January
1991
and
December
2016.
This
timeframe
was
chosen
as
it
represents
when
the
search
terms
were
first
indexed.
Inclusion
and
exclusion
criteria
are
summarised
in
Box
1.
Social
and
cultural
context
can
influence
the
problem
of
bullying
(Ariza-Montes,
Muniz,
Montero-Simó,
&
Araque-Padilla,
2013),
therefore
this
review
is
limited
to
the
situ-
ation
in
Australia.
The
potential
confounding
impact
of
numerous
variables
that
define
the
profession
internationally
is
reduced
by
containing
the
search
to
this
specific
jurisdiction.
2.1.
Search
outcomes
and
synthesis
In
the
initial
search
a
total
of
255
articles
were
identified.
Each
abstract
was
reviewed
to
determine
if
the
publication
met
the
inclusion/exclusion
criteria.
Articles
retrieved
from
the
initial
search
were
hand-searched
to
limit
bias
and
maximize
the
number
of
relevant
studies
identified
(Whittemore
&
Knafl,
2005).
Fig.
1
provides
an
overview
of
the
identification,
screening,
eli-
gibility
and
final
inclusion
of
papers
and
follows
the
Preferred
Reporting
Items
for
Systemic
Reviews
and
Meta-Analysis
(PRISMA)
schema.
The
final
sample
for
analysis
was
23
publications.
From
the
23
publications
that
met
the
inclusion
criteria,
data
were
extracted
and
organised
according
to
year,
author,
study
design
(as
identified
by
the
authors),
description
of
study
sample
and
summary
of
key
findings
(Table
1).
Whittemore
and
Knafl
(2005)
assert
that
there
is
no
gold
standard
for
appraising
quality
in
research,
with
the
use
of
a
formal
quality
appraisal
tool
being
more
conducive
to
reviews
in
which
the
sampling
frame
and
research
design
is
identical.
Owing

Please
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Hartin,
P.,
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Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature.
Collegian
(2018),
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3
Table
1
List
of
included
studies.
Data
analysis
matrix
Author
(year)
Study
Design
Data
Collection
Sample
Description
Key
Findings
Theme
Farrell
(1999)
Quantitative
Questionnaire
270
nurses
in
Tasmania
Nurses
from
both
the
public
and
private
sector
were
more
worried
about
colleague
aggression
than
aggression
from
other
sources
Pervasive
nature
of
bullying
Chaboyer
et
al.
(2001)
Quantitative
Survey
555
Registered
Nurses
in
three
large
territory
Australian
hospital
The
item
rated
least
positive
was
‘staff
can
be
really
bitchy
towards
each
other’
for
both
Level
I
and
II/III
nurses
Workplace
culture
Deans
(2004a)
Qualitative
Phenomenological
approach
33
nurses
in
Victoria
The
feeling
of
professional
incompetency,
the
expectation
to
cope
and
emotional
confusion
Impact
Deans
(2004b)
Quantitative
Survey
380
nurses
in
Victoria
Perception
nurse
managers
not
interested
Impact
Hutchinson
et
al.
(2005)
Mixed
methods
In-depth,
semi-structured
interviews
16
interviews
Bullies
could
co-opt
organizational
processes
with
the
intentional
outcome
of
harming
targets
Impact
Farrell
et
al.
(2006)
Quantitative
Questionnaire
2407
nurses
in
Tasmania
Majority
of
respondents
experienced
bullying,
influence
on
desire
to
stay
and
their
productivity
and
potential
for
errors
yet
were
reluctant
to
make
their
complaints
official
Impact
Hegney
et
al.
(2006)
Quantitative
Survey
1349
Queensland
nurses
Increasing
reports
of
workplace
violence
Pervasive
nature
of
bullying
Hutchinson
et
al.
(2006)
Qualitative
In-depth,
semi-structured
interviews
26
nurses
recruited
from
two
Australian
organizations:
a
rural
and
a
metropolitan
health
service
Relationships
between
bullies
were
embedded
within
informal
organisational
alliances,
enabling
bullies
to
control
work
teams
and
means
of
enforcing
rules
of
work
Workplace
culture
Eagar
et
al.
(2010)
Qualitative
Focus
groups
30
Registered
nurses
and
Enrolled
nurses
in
New
South
Wales
Nurses
reported
that
confusion
surrounding
scope
of
practice
particularly
in
the
areas
of
medication
administration,
patient
allocation
and
workload
result
in
situations
whereby
nurses
feel
bullied,
stressed
and
harassed.
Workplace
culture
Hegney
et
al.
(2010)
Quantitative
Cross-sectional
survey
1192
Queensland
nurses
Existence
of
workplace
policy
did
not
decrease
levels
of
workplace
violence
Pervasive
nature
of
bullying
Hutchinson,
Vickers,
Wilkes,
and
Jackson,
(2010)
Qualitative
In-depth,
semi-structured
interviews
26
nurses
from
two
Australian
area
health
services
The
typology
of
behaviours
provides
detailed
insights
into
the
complexity
of
bullying
experienced
by
nurses
Pervasive
nature
of
bullying
Hutchinson,
Wilkes
et
al.
(2010)
Mixed
methods
Survey
370
across
Australia
Organisational
characteristics
were
confirmed
to
be
critical
antecedents
of
bullying
Pervasive
nature
of
bullying
Jackson
et
al.
(2010)
Qualitative
Narrative
inquiry
18
nurses
Reported
the
need
to
facilitate
a
climate
in
which
it
is
safe
for
nurses
to
raise
concerns
Impact
Opie
et
al.
(2010)
Quantitative
Cross
sectional
questionnaire
349
nurses
Increasing
incidence
of
violence
in
the
workplace
Pervasive
nature
of
bullying
Demir
and
Rodwell
(2012)
Quantitative
Cross-sectional
survey
design
207
nurses
and
midwives
from
a
large
Australian
hospital
High
frequencies
of
reported
exposure
to
workplace
bullying
and
internal
and
external
emotional
abuse
violence
types.
In
terms
of
antecedents,
bullying
was
linked
to
high
negative
affectivity
(NA),
as
well
as
low
supervisor
support
and
coworker
support
Impact
Farrell
and
Shafiei
(2012)
Qualitative
Questionnaire
1495
nurses
in
Victoria
32%
experienced
bullying
from
colleagues
Workplace
culture
Rodwell
and
Demir
(2012a)
Quantitative
Cross
sectional
survey
273
nurses
at
1
Australian
hospital
Psychological
distress
was
noted
as
an
impact
of
bullying
Workplace
culture
Rodwell
and
Demir
(2012b)
Quantitative
Cross
sectional
questionnaire
233
hospital
nurses
and
208
aged
care
nurses
High
levels
of
bullying
and
concerning
levels
of
emotional
abuse
Impact
Rodwell
et
al.
(2014)
Quantitative
Cross
sectional
survey
250
nurses
across
5
Australian
hospitals
Abusive
supervision
impacted
nurse
outcomes
Impact
Hutchinson
and
Jackson
(2015)
Qualitative
Cross-sectional
survey
3345
respondents
in
one
state
of
Australia
Tension
between
workplace
policy
and
embedded
institutional
practices;
chronic
from
the
top
level
down
Workplace
culture
Terry
et
al.
(2015)
Qualitative
Phenomenology
narrative
inquiry
15
community
nurses
13
health
facilities
in
Tasmania
Vertical
violence
identified
as
the
biggest
issue
that
impacts
on
health
Workplace
culture
Hurley
et
al.
(2016)
Qualitative
Cross-sectional
study
3345
respondents
in
one
state
of
Australia
Palpable
mental
distress
and
illness
stemming
from
exposure
to
workplace
bullying
Workplace
culture

Please
cite
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article
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press
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Hartin,
P.,
et
al.
Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature.
Collegian
(2018),
https://doi.org/10.1016/j.colegn.2018.06.004
ARTICLE IN PRESS
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xxx
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Fig.
1.
PRISMA
flow
chart
summarising
search
and
outcomes.
to
the
heterogeneity
of
studies,
quality
was
not
evaluated
compar-
atively.
A
modified
version
of
the
criteria
suggested
by
Birks
et
al.
(2014)
was
used
to
conduct
a
prima
facie
evaluation
of
papers
that
met
the
inclusion
criteria,
thus
ensuring
they
were
of
a
standard
to
justify
their
use.
None
were
excluded
as
a
result
of
this
assessment.
The
goal
of
data
analysis
is
grouping
the
data
into
themes
to
identify
patterns
(Whittemore
&
Knafl,
2005).
Qualitative
data
anal-
ysis
software
(NVivo)
was
used
to
manage
the
data
and
facilitate
coding
to
identify
these
themes
and
patterns.
The
N7
+
1
peda-
gogy
to
write
a
literature
review
(O’Neill,
Booth,
&
Lamb,
2018)
and
Domain
and
Taxonomic
Coding
(Salda˜
na,
2013)
was
used
to
construct
a
detailed
index
of
major
themes
and
commonalities
identified
across
the
articles,
which
were
noted
and
categorised
to
capture
important
recurring
concepts.
The
recurring
concepts
were
then
used
to
determine
patterns
within
the
data
which
informed
the
current
thematic
findings.
3.
Results
A
total
of
23
papers
were
included
in
this
review.
These
papers
described
22
separate
studies.
Of
these,
10
were
descriptive,
qual-
itative
designs
that
employed
various
methods
including
surveys,
interview,
focus
group
and
narrative
analysis.
11
were
quantita-
tive.
The
remaining
two
studies
used
mixed
methods.
Where
it
was
not
explicitly
stated,
the
study
design
has
been
interpreted.
Results
have
been
placed
in
chronological
order
to
provide
a
trajectory
of
bullying
research
in
Australia
and
facilitate
interpretation
of
the
results.
The
themes
to
which
the
studies
relate
are
indicated
in
this
table
and
presented
graphically
in
Fig.
2.
Fig.
2.
Themes
derived
from
the
literature.
3.1.
Workplace
culture
Bullying
is
so
ingrained
in
the
nursing
profession
that
it
now
exists
as
workplace
culture.
Workplace
culture
refers
to
the
social

Please
cite
this
article
in
press
as:
Hartin,
P.,
et
al.
Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature.
Collegian
(2018),
https://doi.org/10.1016/j.colegn.2018.06.004
ARTICLE IN PRESS
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5
contexts
that
influence
the
way
people
behave
and
the
social
norms
that
are
accepted.
The
nursing
culture
in
Australia
has
been
described
as
toxic,
hostile
and
harmful
(Hutchinson,
Jackson,
Wilkes,
&
Vickers,
2008;
Rodwell
&
Demir,
2012a),
and
fueled
by
cliques
of
power,
inflated
personalities
and
displaced
aggression
towards
one
another.
Differentials
of
power
between
nurses
has
been
suggested
as
a
contributor
to
a
workplace
culture
of
bullying
among
nurses.
Hurley,
Hutchinson,
Bradbury,
and
Browne,
(2016)
describe
power
as
a
central
mechanism
for
bullying
behaviour.
However,
the
differentials
of
power
are
evident
not
only
between
the
novice
nurse
and
senior
nurse
but
also
within
groups
of
nurses
who
hold
equal
positions
(Chaboyer,
Najman,
&
Dunn,
2001).
Hutchinson,
Vickers,
Jackson,
and
Wilkes,
(2006)
study
provides
a
fascinating
insight
into
the
power
relations
of
nurses,
including
how
bullying
behaviour
is
often
a
function
of
peer
group
forma-
tion.
Farrell
and
Shafiei
(2012)
later
reported
that
a
perpetrator’s
own
personality
is
a
key
contributing
factor
to
the
bullying
culture
in
nursing.
In
addition,
Hutchinson
and
Jackson
(2015)
revealed
a
nursing
culture
that
sustained
a
power
dynamic
of
distortion,
fueled
by
competing
truth
claims
and
silencing.
Displaced
aggression
and
stress
towards
one
another
is
often
the
result
of
the
workload
required
of
nurses
(Terry,
Le,
Nguyen,
&
Hoang,
2015).
Bullying
occurs
because
nurses
either
overtly
or
covertly
redirect
their
dissatisfaction
towards
each
other.
Rodwell
and
Demir
(2012a)
found
there
was
a
positive
relationship
between
the
work
schedule
of
morning
shift
and
bullying,
with
morning
shift
workers
more
inclined
to
experience
this
behaviour.
Varia-
tions
in
work
distribution
across
these
shifts
may
feed
the
problem,
as
Eagar,
Cowin,
Gregory,
and
Firtko,
(2010)
found
that
perceived
inequities
in
the
distribution
of
the
day-to-day
workloads
was
a
contributing
factor
in
bullying.
3.2.
Pervasive
nature
of
bullying
The
pervasive
nature
of
bullying
in
the
nursing
profession
in
Australia
is
a
matter
of
significant
concern.
The
increasing
preva-
lence
and
experience
of
bullying
in
the
nursing
profession
is
the
most
prevalent
theme
in
the
literature.
Opie
et
al.
(2010)
reported
a
statistically
significant
increase
in
the
incidence
of
bullying
between
1995
and
2008
and
Farrell
(1999)
found
nurse-to-nurse
aggression
as
the
most
distressing
type
of
bullying
to
deal
with.
Hegney
et
al.
(2006)
reported
significant
evidence
from
2001
to
2004
of
the
percentage
of
nurses
citing
other
nurses
or
nursing
management
as
a
source
of
bullying
incidents.
Allen
et
al.
(2015)
set
out
to
explore
the
relationship
between
bullying
and
burnout
with
61%
of
respondents
reporting
they
had
experienced
bullying
within
the
last
12
months.
When
read
as
a
single
discourse,
these
studies
reinforce
the
pervasive
nature
of
bullying
and
the
notion
that
many
nurses
work
within
a
culture
that
features
bullying.
Most
agree
that
these
statistics
are
likely
to
be
underreported
(Hegney,
Tuckett,
Parker,
&
Eley,
2010;
Hutchinson
et
al.,
2010;
Hutchinson,
Wilkes,
Jackson,
&
Vickers,
2010).
The
experience
of
bullying
by
nurses
includes
threats,
personal
attacks
or
attack
through
work
roles
(Hutchinson,
Vickers,
Jackson,
&
Wilkes,
2005;
Hutchinson,
Vickers,
et
al.,
2010).
3.3.
Impact
The
workplace
culture
and
pervasive
nature
of
bullying
has
a
sig-
nificant
negative
impact
on
the
nurse,
profession
and
organisation.
For
the
nurse,
bullying
effects
each
dimension
of
the
individual:
psychological,
physical,
emotional
and
social.
Bullying
increases
the
prevalence
of
psychological
distress
and
depression
(Rodwell
&
Demir,
2012b)
resulting
in
significantly
higher
levels
of
burnout.
The
aggressive
and
destructive
nature
of
bullying
can
undermine
the
professional
confidence
of
the
nurse
and
decrease
self-worth
(Deans,
2004a,
2004b).
In
addition,
it
can
create
powerlessness,
decrease
motivation
and
damage
the
nurse’s
work
ethic.
Professionally,
bullying
decreases
job
satisfaction
with
the
intent
to
quit
among
nurses
significantly
impacted
as
a
result
of
these
experiences
(Rodwell,
Brunetto,
Demir,
Shacklock,
&
Farr-
Wharton,
2014).
Hutchinson
et
al.
(2005)
reported
many
nurses
considered
leaving
their
current
position
or
reducing
workload
hours
as
a
result
of
bullying.
In
their
study
on
workplace
aggression
among
nurses,
Farrell,
Bobrowski,
and
Bobrowski
(2006)
reported
24%
of
respondents
had
considered
resigning
during
the
preced-
ing
four
working
weeks.
Bullying
in
nursing
compromises
the
standards
of
care.
Farrell,
Bobrowski,
and
Bobrowski,
(2006),
for
example,
reported
that
bullying
frequently
contributed
to
the
potential
to
make
errors
and
a
decrease
in
productivity.
In
such
an
environment
of
decreased
job
satisfaction
and
decreased
productivity,
the
impact
of
bullying
also
permeates
the
organisation.
Organisations
suffer
when
such
a
culture
creates
a
hostile
workplace
(Jackson
et
al.,
2011)
and
higher
turnover
of
staff.
Furthermore,
from
a
functional
perspective,
organisations
have
to
deal
with
increased
absenteeism
(Farrell
et
al.,
2006;
Terry
et
al.,
2015),
decreased
productivity
(Hegney
et
al.,
2010)
and
recruit-
ment
and
retention
difficulties
(Farrell
et
al.,
2006;
Hegney
et
al.,
2006;
Hutchinson
et
al.,
2005).
4.
Discussion
As
can
be
seen
from
Fig.
2,
a
workplace
culture
of
bullying
increases
the
pervasive
nature
of
this
hostility
and
impacts
neg-
atively
on
the
individual,
the
profession
and
the
organisation.
As
Daiski
(2004)
identified,
bullying
is
fuelled
by
a
lack
of
respect,
poor
intra-professional
relationships
and
mutual
non-supportiveness.
Even
nursing
students
begin
to
adopt
bullying
into
their
own
prac-
tice.
Research
suggests
that
bullying
in
nursing
is
so
culturally
integrated
into
the
workplace
that
nursing
students
can
quickly
learn
to
become
bullies
as
well
(Randle,
2003).
For
nursing
students
who
are
typically
eager
and
willing
to
learn
new
ways
of
practice
and
thinking,
it
becomes
one
more
learned
behaviour.
In
today’s
healthcare
environment,
in
which
professional
auton-
omy
and
independence
are
crucial,
nurses
are
gaining
increased
momentum
in
authority.
This
shift
results
in
power
struggles
(Hutchinson
&
Jackson,
2015),
hierarchy
differentials
(Eagar
et
al.,
2010)
and
differing
attitudes
(Demir
&
Rodwell,
2012)
where
team
cohesion
gets
destroyed
and
a
bullying
culture
rears
its
ugly
head.
Power
imbalances
can
then
occur
when
groups
of
nurses
in
a
work-
place
unconsciously
(and
also
consciously)
adopt
inflated
feelings
and
attitudes
of
superiority,
even
when
performing
the
same
or
similar
role.
Bullying
in
nursing
is
rarely
one-to-one;
evidence
indi-
cates
that
there
are
usually
many
nurses
involved
in
a
bullying
incident
(Hutchinson
et
al.,
2006,
2008;
Lewis
&
Orford,
2005).
Without
such
a
cultural
milieu
a
bully
would
find
it
difficult
to
maintain
their
bullying
behaviour
without
the
support
of
peers.
This
review
reinforces
the
many
ways
in
which
the
experience
of
bullying
in
the
nursing
profession
can
be
manifested.
Bullying
can
be
expressed
in
an
overt,
blatant
fashion
or
covertly
in
a
more
insid-
ious,
subtle
manner
in
forms
of
silencing
and
exclusion
(Jackson
et
al.,
2011).
Regardless
of
how
it
is
manifested,
the
impact
of
bul-
lying
upon
those
bullied
can
be
linked
to
low
self-esteem,
anxiety,
increased
sick
leave,
impaired
concentration,
changed
work
envi-
ronment,
resignation
from
a
position,
leaving
nursing
completely
or
worse
still,
depression
and
even
suicide.
Each
individual
inci-
dent
of
workplace
bullying
may
seem
inconsequential,
but
over
a
period
of
time,
it
can
erode
the
self-confidence
and
self-esteem
of
the
employee.
Workplace
bullying
can
also
create
physiological
symptoms
such
as
hypertension,
cardiac
palpitations
and
irritable
bowel
syndrome
(Hallberg
&
Strandmark,
2006).

Please
cite
this
article
in
press
as:
Hartin,
P.,
et
al.
Bullying
and
the
nursing
profession
in
Australia:
An
integrative
review
of
the
literature.
Collegian
(2018),
https://doi.org/10.1016/j.colegn.2018.06.004
ARTICLE IN PRESS
G Model
COLEGN-537;
No.
of
Pages
7
6
P.
Hartin
et
al.
/
Collegian
xxx
(2018)
xxx–xxx
The
trajectory
of
bullying
in
Table
1
reveals
that
the
pervasive
nature
of
bullying
in
nursing
is
gaining
increased
recognition.
The
nursing
profession
is
subject
to
the
growing
prevalence
of
bully-
ing
and
its
resultant
contagious
effects.
The
literature
examined
in
this
review
suggests
that
the
phenomenon
has
no
boundaries
or
affinity
for
any
particular
nursing
workplace
or
location.
This
literature
is
part
of
a
significant
international
body
of
work
that
has
greatly
contributed
to
our
understanding
of
this
complex
phe-
nomenon,
yet
bullying
remains
a
major
concern
for
the
profession
as
the
consequences
are
widespread.
Job
satisfaction
among
nurses
drops
significantly
as
a
result
of
bullying
and
this
has
an
impact
on
career
directions,
which
also
shapes
the
public’s
perception
of
the
nursing
profession.
Given
the
critical
shortage
and
maldistribution
of
the
nursing
work-
force
internationally
(Guo
et
al.,
2018),
this
is
concerning.
Issues
in
relation
to
recruitment
and
retention
of
nurses
in
the
work-
force,
particularly
in
rural
and
remote
areas,
have
been
a
major
concern
for
professional
organizations,
policy
makers
and
Govern-
ments,
both
within
Australia
and
internationally
(Hayward,
2016;
O’Brien-Pallas,
2006).
Major
flow-on
effects
from
the
turnover
of
staff
include
the
financial
costs
associated
with
employing
and
ori-
entating
new
staff,
and
the
potentially
de-stabilizing
impact
that
a
changing
staff
mix
has
upon
an
organization.
Importantly,
unless
the
bully
is
reported
they
are
unlikely
to
be
the
one
leaving
the
organization.
Ultimately,
the
impact
of
bullying
on
the
person,
profession
and
organisation
jeopardises
patient
safety
and
care.
Laschinger
(2014)
found
that
workplace
mistreatment
can
have
detrimental
effects
on
patient
safety.
It
is
challenging
to
deliver
compassionate,
qual-
ity
care
if
nurses
are
working
in
an
environment
of
intimidation,
humiliation
and
power
imbalance.
In
such
an
environment,
team-
work,
collaboration,
and
communication
are
impaired.
This
culture
can
influence
communication
between
nurses
which
ultimately
threatens
patient
safety
(Embree
&
White,
2010).
The
culture,
prevalence
and
impact
of
bullying
described
in
this
paper
raises
concerns
for
practitioners,
educators
and
policy
mak-
ers.
Although
anti-bullying
policies
do
exist,
research
indicates
that
nurses
feel
unsupported
and
rarely
utilise
the
policies
in
place.
In
the
UK,
Carter
et
al.
(2013)
found
that
of
the
staff
who
experienced
bullying,
only
between
2.7%
and
14.3%
reported
it.
5.
Recommendations
and
limitations
Many
of
the
studies
examined
in
this
review
used
terms
relating
to
bullying
that
were
poorly
defined.
The
lack
of
a
clear
definition
prevents
a
full
understanding
of
this
construct
and
makes
drawing
comparisons
between
studies
difficult.
Of
those
studies
that
have
presented
definitions
of
bullying,
some
have
used
global
defini-
tions
taken
from
workplace
policies;
others
have
tried
to
make
the
definition
specific
to
the
healthcare
environment
and
still
others
have
included
specific
definitions
of
direct
and
indirect
bullying.
Although
this
review
has
confirmed
that
bullying
in
nursing
is
per-
vasive,
the
definition
of
bullying
varies
among
researchers
and
the
construct
of
bullying
has
yet
to
be
consistently
defined.
Future
research
on
bullying
should
seek
to
identify
trends
in
the
broader
population
regarding
how
and
why
bullying
occurs
and
how
these
relate
to
the
problem
in
nursing.
Such
research
could
also
establish
what
Australian
nurses
themselves
conceptu-
alise
as
bullying
behaviours.
Researchers
should
consider
asking
how
factors
such
as
the
cultural
foundations
of
the
nursing
profes-
sion
in
Australia
have
allowed
bullying
to
continue.
Only
then
can
the
profession
identify
strategies
for
the
prevention
of
bullying
and
effective
interventions
to
address
the
problem
when
it
occurs.
6.
Conclusion
Bullying
in
the
nursing
profession
continues
to
be
a
problem
resulting
in
negative
impacts
on
the
individual,
profession,
organi-
zation
and,
most
importantly,
patients.
Determining
the
true
extent
of
bullying
among
the
nursing
profession
is
difficult
and
is
largely
dependent
on
how
bullying
has
been
measured
and
the
definition
that
has
been
used
in
existing
work
in
this
area.
It
is
clear,
however,
that
the
problem
exists
to
such
an
extent
that
there
is
a
risk
of
it
being
normalized
in
the
profession.
The
pervasive
bullying
culture
in
nursing
can
destroy
nurses,
the
profession
and
ultimately
place
patients
at
risk.
The
review
of
empirical
research
presented
in
this
paper
can
enhance
our
understanding
of
the
nature
and
extent
of
bullying
in
the
nursing
profession
in
Australia.
There
is
little
sub-
stantive
data
from
Australian
nurses
on
why
bullying
is
allowed
to
continue
and
the
identification,
development,
and
use
of
practices
to
counter
it.
If
nurse
leaders,
educators
and
policymakers
aim
to
develop
effective
strategies
to
address
the
problem,
they
first
must
understand
bullying
in
the
Australian
nursing
workforce
and
the
contributing
factors
that
allow
the
problem
to
persist.
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