Workplace bullying and its association with secondary traumatic stress and turnover intention among emergency and critical care nurses

Bullying is more likely to occur in high-pressure environments with heavy workloads and low independence areas. Nurses in Emergency Departments (EDs) and critical care units (CCUs) are particularly vulnerable to bullying by patient relatives and their colleagues.⁷ Unfortunately, many nurses employed in the CCUs have reported that no action was taken regarding bullying incidents.⁸

Nurses are among the most important human resources in the health system. The healthcare organization must provide a high—quality professional environment that retains nurses and improves their professional quality of life.^9,10 Assessment of nurses’ intention to remain in the profession and the associated factors is necessary to develop policies related to staff retention. ED nurses are more vulnerable to a violent work environment due to the high level of patient-nurse contact. Most people who are bullied choose to leave their jobs rather than face bullying.¹¹

The literature highlighted the role of organizational and personal factors associated with bullying. Some organizational and personal variables, such as age, gender, educational level, working shifts, and experience, could contribute to bullying.¹² However, limited studies have identified the consequences of bullying in terms of turnover (TO) and STS in Jordanian EDs and CCUs.

The current study is among the novel studies in Jordan that link bullying with TO and STS in EDs and CCUs. This topic is significant as the absence of clear policies in reporting bullying incidents and the lack of training programs to deal with bullying in Jordanian hospitals are taken into consideration.⁷ The results of the current study could pay more attention to the importance of having strict policies that protect nurses from the negative consequences of bullying.¹³

This study examines the relationships between bullying in the workplace, TO, and STS among Jordanian nurses employed in EDs and CCUs. These are the questions of the study:

What is the prevalence of bullying among ED and CCU Jordanian nurses?

A descriptive cross-sectional design was used.

This study was conducted in one government, one teaching, and one private hospital. The government hospital is considered the largest hospital in the country, with a capacity of 1101 beds and various EDs and CCUs including medical-surgical CCU, pediatric CCU, and neonatal CCU. The teaching hospital has a capacity of 436 beds and includes ED, medical-surgical CCU, and neonatal CCU. The private hospital has a capacity of 436 beds, ED, CCU for male, medical–surgical CCU for female, Neuro-CCU, neonatal CCU, and ED. The total number of nurses working in EDs and CCUs in the 3 hospitals is 280, of them 180 are employed in the government hospital.

The target population in this study was the Jordanian nurses employed in CCUs and EDs. The accessible population was nurses who worked in CCUs and EDs in the 3 selected hospitals. A convenience sampling technique was used. The sample size was estimated by using the G Power program version 3.1.9.4. The sample was calculated based on multiple regression; with 10 possible predictors, alpha error = 0.05, power = 0.80, and medium effect size. The required sample size was 147 participants. This number was increased to 170 to overcome the possibility of having missing or incomplete data.

Data were collected using the demographic questionnaire, the negative act questionnaire-revised, the Pro-QOL scale, and the TO intention scale.

Pilot testing was conducted with 15 staff nurses from different CCUs and EDs to ensure the tools’ clarity, feasibility, reliability, and the time needed to complete the questionnaire for each participant. The participants reported that the questionnaires were clear with no need for modifications. To assess internal consistency, the Cronbach’s alpha was computed. The Cronbach’s alpha was 0.847 for NAQ-R, 0.721 for STS, and 0.859 for TO intension scale.

A paper-based questionnaire was used for data collection; the researcher met the head nurse of each ED and CCU and explained the purpose of the study and its significance. The purpose of the study and relevant information were explained to the head nurses and nurse participants. The cover letter included detailed information explaining the purpose and significance of the study. The questionnaires were distributed by the researcher in collaboration with head nurses. The researcher confirmed that all participants met the inclusion criteria and signed the consent form. Nurses spent approximately 20 min to complete the questionnaires. The number of invited participants was 170, of them 150 agreed to participate and returned completed questionnaires. Data collection started at the end of July, 2022 and ended at the end of August, 2022.

The researcher obtained the IRB from the Ministry of Health for the government hospital and hospital administration for other selected hospitals. Anonymity was also provided to participants and the researcher referred to the participants by using numerical identifiers. Participation in the study was voluntary. All potential participants had the right to withdraw from the study at any time without any negative repercussions. The researcher provided all participants with information about the study including its purpose, significance, procedure, study risks and benefits, and time needed to complete the study.

Data were analyzed using the IBM SPSS (SPSS) version 26 (IBM Corporation, Armonk, New York, United States). Descriptive statistics were used to describe the characteristics of the study participants. Descriptive statistics were also employed to identify the scores of the main variables in the study including bullying, TO, and STS. An independent t-test was used to examine the difference in continuous variables based on the dichotomous variables. To examine the difference in continuous variables based on variables with >2 categories, one-way ANOVA test was used. Pearson correlation coefficient test also was used to examine the relationships between the continuous variables (bullying, STS, TO intention, experience, and age). Multiple regression analyses were used to examine the unique role of bullying in predicting STS and TO intention.

A total of 150 nurses participated in the study. The mean age was 28 years (SD = 4). The sample is almost equally split into male (n = 73, 48.7%) and female (n = 77, 51.3%) participants, and more than half were single (n = 78, 52.0%). In terms of educational level, the majority had an undergraduate degree (n = 135, 90.0%).

As for the workplaces, more than half of the participants were employed by the government hospital (n = 80, 53.3%) followed by the teaching hospital (n = 40, 26.7%) and the private hospital (n = 30, 20.0%). The majority of the participants worked in the EDs (n = 61, 40.7%) while the rest worked in CCUs namely medical-surgical CCU (n = 43, 28.7%), neonatal CCU (n = 19, 12.7%) and pediatric CCU (n = 27, 18.0%). The mean length working experience as a nurse was 5.6 years (SD = 3.4) while the mean length of working in the current department was 3.4 years (SD = 2.6 years). The average number of patients taken care of on a daily basis was 14 (SD = 20) patients. Last, in terms of monthly salary, the mean pay was 508.7 Jordanian Dinar (JD) (SD = 87.3 JD). Table 1 shows the sociodemographic characteristics of participants.

Table 2 shows the M, SD, range, frequencies, and percentages of experiencing bullying. The mean scores for overall bullying behavior was 62.1 (SD = 11.6) which meant that participants had overall severe experiences/victim of bullying in their workplaces. In addition, it was found that about 10.7% and 89.3% were categorized as “occasionally bullied” and “victims of workplace bullying” subsequently. The mean scores for STS were 29.7 (SD = 5.8), suggesting moderate levels of STS among participants. The overall mean scores of TO intention were 52.0 (SD = 7.3), indicating high TO intention and a desire to leave the organization among the nurse participants.

Bullying behavior had a significant moderate positive relationship with TO intention (r = 0.46, P < 0.001), which meant that nurses who had higher levels of bullying experience demonstrated higher intention to leave the organization. Results are similar to that of bullying behavior and STS, as nurses who had higher levels of bullying experience reported higher scores on STS (r = 0.36, P < 0.001). Finally, a significant moderate positive relationship was found between TO intention and STS, with nurses expressing lesser desire to stay in the organization being those who reported higher levels of STS (r = 0.36, P < 0.001).

Inferential tests were performed to determine whether significant differences or relationships existed among bullying behavior, TO intention and STS of emergency and critical care nurses based on their sociodemographic characteristics (Table 3). In terms of bullying, significant differences were found based on the hospital and department participants were working in. Nurses working in the government hospital had significantly higher levels of bullying experience than nurses working in the private hospital (P < 0.001). In addition, nurses working in the EDs had significantly higher levels of bullying experience than nurses working in the medical-surgical CCUs (P < 0.001) and pediatric CCUs (P < 0.05). Moreover, a significant weak positive relationship was found between the average number of patients taken care of in a shift and overall bullying behavior, which meant that nurses who had higher patient load also reported higher levels of bullying experience (r = 0.23, P < 0.05). No other significant differences or relationships were found based on other sociodemographic characteristics.

On the other hand, there was a significant weak negative relationship between TO intention and the nurses’ age (r = –0.18, P < 0.05), length of experience working as a registered nurse (r = –0.18, P < 0.05), and length of experience working in the current department (r = –0.21, P < 0.05). These results suggested that nurses who were younger and had shorter years of experience working as a registered nurse and working in their current departments expressed a higher desire to leave the organization. In addition, nurses working in the government hospital had significantly higher levels of TO intention than nurses working in the private hospital (P < 0.001). No other significant differences or relationships were found based on other sociodemographic characteristics.

When looking at STS, significant differences on scores were only found based on the workplace. No other significant differences or relationships were found based on other sociodemographic characteristics. Nurses working in the teaching hospital had significantly higher levels of STS compared to nurses working in the private hospital (P < 0.05).

Hierarchical multiple linear regression was performed to determine the unique role of bullying in STS and TO intention of EDs and critical care nurses, controlling for demographic characteristics (Tables 4 and 5). Private workplace was significantly associated with STS in bivariate analysis. Therefore, it was entered into the first step of regression analysis while bullying was entered into the second model. Both models were significant (P < 0.001). Private workplace accounted for only 3.5% of the variance and bullying for about 10.1% of the variance. However, in the second model, only bullying was significantly associated with STS (t = 4.146, B = 0.341, P < 0.001).

To assess the role of bullying in TO intention, the demographic variables associated with TO were entered in the first model, while bullying was entered in the second model. Both models were significant (P < 0.001). Demographic variables accounted for 25.1% of the variance and bullying accounted for about 9.6% of the variance in TO intention. However, in the second model, only private workplace (t = 4.52, B = 0.33, P < 0.001) and bullying (t = 4.59, B = 0.34, P < 0.001) were significantly associated with TO intention.

Healthcare organizations must implement a zerotolerance policy regarding bullying behaviors. However, the results of the previous studies showed the persistent prevalence of bullying suggesting that the existence of policies may not be enough as a preventive measure. As such, the implementation of policies must be monitored through regular audits and continuous quality improvement efforts. Nurse managers and hospital administrators must monitor whether policies are strictly followed as demonstrated by timely reporting observed or experienced bullying events, disciplinary actions for perpetrators, adequate managerial support for victims, resolution of the bullying event, and evidence of learning and sharing based on the event. Managers and hospital administrators must take advantage of the possibility of reversing TO intention and perform targeted approaches that can enjoin staff nurses to remain and continue working for the organization.

The results revealed that workplace was the most significant factor associated with TO intention apart from lesser years of experience suggesting that the quality of the healthcare environment encountered by new members of staff largely dictated their desire on whether to remain or leave the organization. As such, healthcare organizations should ensure that their workplaces are safe and healthy for nurses and other members of staff to grow personally and professionally, and that support systems are available to manage any issues or concerns that nurses encounter during the performance of their daily duties and responsibilities.

Nurse educators should develop and formulate educational and training programs on how to recognize, report, and deal with any observed or experienced traumatic behaviors. Literature has shown that some of the reasons why negative behaviors exist are because nurses don’t have the skills to recognize them when it happens, and don’t have the self-efficacy to report said behaviors for fear of repercussions from the perpetrators. Therefore, there is value in implementing educational and training programs that can equip nurses with the ability to recognize, report, and act on any witnessed or experienced events of bullying regardless of who the perpetrator is.

Future research should center on investigating why bullying persists among nurses in healthcare environments that are supposed to champion positive behaviors such as caring, compassion, kindness, and respect. Nurse researchers should also aim to examine what interventions might prove effective in reducing, and eventually eliminating, bullying behaviors, taking into account sociodemographic and professional characteristics that allow the persistence of negative behaviors. Moreover, while healthcare organizations claim to possess policies that prevent and discourage bullying behavior, very little research has been done to measure the effect of actual policy implementation on the elimination of bullying behaviors. Future research has the potential to address these concerns.

Theoretically, the primary strength of the study is its contribution to the body of knowledge that can help planners, managers, and future researchers to better understand the phenomenon of bullying and its consequences on ED and CCU nurses. Methodically, the primary strength of the study is its adequate sample size and use of valid and reliable tools to measure the variables of interest. On the other hand, the study has some limitations. First, the study is cross-sectional in nature, which means that variables were only measured at one point in time. Therefore, there are no data available as a trend, and nurse managers and administrators do not have any idea about changes on the levels of bullying behavior, TO intention, CS, and STS over a period of time. Second, the study was limited to emergency and critical care nurses who are already exposed to highly stressful and emotionally laden environments.