Bullying among nurses and its effects


Dr Dilek Yıldırım, Assistant Professor, Nursing Department, Health Science Faculty, Gazi University, Besevler, Ankara, Turkey; Tel:+90-312-2162616; Fax:+90-312-2162636; E-mail: dilekyildirim2005@hotmail.com.


Background:  The victims of bullying are subjected to being terrorized, annoyed, excluded, belittled, deprived of resources, isolated and prevented from claiming rights. The victims of bullying have decreased job satisfaction, work performance, motivation and productivity. Bullying also negatively affects victims' social relationships inside and outside the institution.

Objectives:  This study was conducted as a cross-sectional and descriptive study for the purpose of assessing the workplace, bullying of nurses in Turkey and the effects it has on nursing practices.

Method:  The sample was composed of 286 nurses, and all of the respondents were female. The research instrument was a questionnaire in five parts. The first section included the participants' demographic information; the other variables were measured in four categories: psychologically violent behaviours, workload, organizational effects and depression.

Findings:  Thirty-seven per cent of the nurses participating in the research had never or almost never encountered workplace bullying behaviour in the last 12 months, 21% of the nurses had been exposed to these behaviours. There were no differences between position and educational level in workplace bullying. Workplace bullying leads to depression, lowered work motivation, decreased ability to concentrate, poor productivity, lack of commitment to work, and poor relationships with patients, managers and colleagues.

Conclusion:  Workplace bullying is a measurable problem that negatively affects the psychology and performance of the nurses in this study.


The number of attacks and acts of violence workers direct at each other in the workplace is alarmingly high. It is clear from various statistical studies and analyses that this situation is alarming for the workers and damaging for the facility. The point of agreement in the international studies is that there are more victims of workplace psychological violence than other types of violence and harassment (Chappell & Di Martino 2000). As a result of legal regulations, the significant sanctions for physical violence in public facilities in particular have led to an increase in psychological violence. The number of research studies on psychological violence in the workplace, which has a damaging effect on the victim's well-being and facility, are increasing, and there is also increasing awareness and actions being taken on the issue in many countries (Bilgel et al. 2006; Hansen et al. 2006; Jackson et al. 2002; Quine 1999, 2001; Yildirim & Yildirim 2007).

Bullying behaviours involved

Heinz Leymann first defined psychological violence that has been a part of working life for centuries but has often been ignored in 1984 (Davenport et al. 1999). Leymann stated that the psychologically violent behaviours he saw in workplaces in Sweden were a kind of ‘workplace terror’, and defined it as ‘a type of psychological terror that arises in the form of systematic, directed, unethical communication and antagonistic behaviour by one or more individuals towards one individual’ (Leymann 1990). Workplace bullying constitutes repeated offensive behaviour through vindictive, cruel, malicious or humiliating attempts to undermine an individual or group of employees (Chappell & Di Martino 2006, p. 20). Leymann (1996) also identified five different negative effects of terrorizing behaviours. Victims routinely struggle with communicating, maintaining social contacts, maintaining their personal reputation, poor occupational situation and physical health problems. Similarly, Rayner & Höel (1997) grouped workplace bullying into five categories: threats to professional status (e.g. belittling, public or professional humiliation, and accusations of lack of effort); threats to personal standing (e.g. name-calling, insults, intimidation and devaluing regarding age); isolation (e.g. preventing access to opportunities, physical or social isolation, and withholding information); overwork (e.g. undue pressure, impossible deadlines and unnecessary disruptions); and destabilization (e.g. failure to give credit when due, assigning meaningless tasks, removal of responsibility, repeated reminders of blunders and setting one up to fail). The major difference between ‘experienced’ bullying and ‘intentional’ bullying is the frequency and longevity of the negative behaviours. In order for the bullying label to be applied to a particular activity, interaction or process, it has to occur repeatedly and regularly (e.g. weekly) and over a period of time (e.g. about 12 months) (Björqvist et al. 1994; Dilek & Aytolan 2008; Fox & Stallworth 2003). These behaviours can be inflicted on the individual by facility administrators, supervisors, co-workers at the same level or subordinates (Einarsen 2000; Fox & Stallworth 2003). The individual or individuals who are psychologically abusive mount an organized front against the individual with systematic, long-term and frequently occurring bullying behaviours that also affect others. Others who work in the facility often act oblivious to these behaviours or even provoke them. The victim feels helpless facing so many powerful people when mobbing occurs (Cowie et al. 2002; Einarsen 2000; Leymann 1990).

Reactions to bullying behaviours

The effects of deliberate and systematically repetitive psychological oppression become evident as a collection of injuries that develop gradually in the individual. They experience a variety of physiological, psychological and social problems that are related to the intense stress and anxiety of bullying (Björkqvist 2001; Cowie et al. 2002; Einarsen 2000; Fox & Stallworth 2003; Leymann 1990, 1996). The literature reports that the victims of long-term and continuous workplace bullying have decreased self-esteem and self-confidence (Einarsen 2000; Randle 2003), and experience social isolation, social stigmatization, social maladaptation (Leymann 1996), anxiety, aggression, depression and symptoms related to depression (Bilgel et al. 2006; Quine 1999, 2001). Many victims of mobbing experience symptoms of post-traumatic stress disorder (Bilgel et al. 2006; Fox & Stallworth 2003; Leymann 1996) and some have even attempted suicide (Leymann 1990, 1996).

Exposure to bullying behaviours such as verbal abuse has been known to have negative effects on nurses' self-esteem, job satisfaction, morale, patient care, work productivity and professional error rates (Braun et al. 1991; Cox 1991). In addition, the victims of workplace psychological violence have decreased job satisfaction, work performance, motivation and productivity, and disturbances in social relationships inside and outside the institution (Björkqvist 2001; Cowie et al. 2002; Einarsen 2000; Niedl 1996). Individuals exposed to workplace psychological violence become unable to do their work because of the damage that has been inflicted. Individuals exposed to bullying begin to use sick time to alleviate the pressure and torture, resign under pressure or willingly, or are fired or forced to retire early because of psychological violence (Davenport et al. 1999; Jackson et al. 2002; Tınaz 2006). Employees experiencing bullying have a higher propensity to leave the organization (Quine 2002), and links have been drawn between bullying and the current recruitment and retention crisis in the nursing workforce (Jackson et al. 2002).

Literature review

Studies of violence suggest that a valid means of resolving the problem of violence is still being sought today (Jackson et al. 2002; Leymann 1996; Salin 2003). In addition, in studies conducted about nurses who are victims of violence, it has been shown that nurses are at a higher risk of being exposed to violence than other healthcare personnel (Ferrinho et al. 2003; Mayhew & Chappell 2001; Quine 1999; Rutherford & Rissel 2004). The fact that there are more female healthcare personnel and that the overwhelming majority of nurses are women also has an effect on this frequency (Mayhew & Chappell 2001). Ferrinho et al. (2003) determined that compared with men, women experience more of every type of violent behaviour in healthcare facilities. On the other hand, because people in high-level positions in the nursing profession consider psychologically violent behaviours in the workplace to be a part of their position within the hierarchical structure and professional practices (Lewis 2001), there is a lack of sensitivity to these types of behaviours, and in many healthcare facilities, incidents of bullying go unreported (Jackson et al. 2002; Quine 1999). Cox (1987) determined that 97% of nurses have been exposed to verbal violence, while Yildirim & Yildirim (2007) determined that 86% of nurses have faced one or more bullying behaviours within the last 12 months and that the source of a large percentage of these behaviours stemmed from their managers. In a survey of 1100 employees from the National Health Service (NHS), including nurses, 70% of respondents reported that they had experienced bullying in the previous year (Quine 1999).

In a further study of the NHS nursing workforce by the same author, 44% of respondents reported being bullied (Quine 2001). Niedl (1996) determined that 26.6% of nurses face hostile actions in the workplace once or more a week. A Norwegian study concluded that 20% of nurses were exposed to bullying behaviours and that these behaviours were frequently inflicted by nurses, assistant nurses and head nurses in their own department (Einarsen et al. 1998). Previous studies have determined that the most common type of violence that healthcare personnel face is verbal violence, followed by bullying/mobbing (Cox 1991; Ferrinho et al. 2003; Lewis 2001; Yildirim & Yildirim 2007). These behaviours frequently include shouting, reprimanding and belittling in front of patients and/or other employees in the ward by people in high-level positions (Lewis 2001).

Aim of the study

Workplace bullying became a topic of discussion at the beginning of the 2000s in Turkey. Because this is a relatively new topic in Turkey, there have been a limited number of research studies on bullying to which nurses are exposed. For this reason, this study was conducted as a cross-sectional and descriptive study for the purpose of determining the rate and nature of workplace bullying experienced by nurses who work in healthcare facilities in Turkey and the effects on nurses' practice and depression status. The research questions were as follows:

  • 1What are the most common workplace bullying behaviours nurses are exposed to and by whom are these being inflicted?
  • 2Are there any relationships between bullying behaviours and the nurses' age, educational level, total years of experience, years of employment at current facility, or current position and workload?
  • 3What are the effects of nurses' exposure to bullying behaviours on nursing practice?
  • 4Are the nurses who are victims of bullying depressed? Is there a correlation between depression and having been exposed to bullying behaviours?



The sample for this research study included a total of 286 registered nurses employed at a teaching hospital in Ankara, Turkey. This hospital, which is one of the largest teaching hospitals in Ankara, has 992 beds, 18 operation rooms and a total of 630 nurses. The average bed occupancy rate at this hospital is 75%, and an average of 150 surgical procedures are performed per day. The hospital in which we planned to conduct the research was sent a written request explaining the purpose and the method of the study. After obtaining written permission from the institution, data collection was begun. The data collection forms were distributed to the research sample of 495 staff nurses who worked at the hospital and voluntarily agreed to participate. Completed forms were received from 286 staff nurses (a 58% return rate). Forty-two nurses could not be reached because they were on vacation or on sick leave or because of their work schedules. Ninety-three nurses opted out of participating in the study. The data were collected between May and July 2007. While collecting the data, the purpose of the study was explained to the nurses, and their verbal consent to participate was received. In addition, the participants were told that the data collected would be kept confidential, that their names were not to be written on the forms, and that they were to complete the forms at a time and place that was convenient for them. The nurses were instructed to place the completed forms in a sealed envelope to be returned to the researcher within a week. In an effort to reach all the participants, the researcher returned to the wards 4 days after the deadline expired in order to reach the participants who were not present on the specified date. At the time of the research, only women could be employed legally as nurses, so all of the participants were female.

Sample characteristics

The following describes the demographic characteristics of the nurses who participated in the research: their mean age was 28.66 (±5.10) years; they worked a mean of 45.3 (±4.42) h/week; their total number of years of employment was a mean of 6.77 (±5.77); and their mean number of years of employment at their current institution was 5.74 (±4.37). The majority of the nurses had a baccalaureate degree (62%) or an associate degree (25%). The majority of the participating nurses worked as either bedside nurses in the wards (55%) or in special care areas (such as the ICU or operating rooms). The remaining 13% were ward head nurses.

Data collection tools

A five-section survey form was used for the collection of research data. The first section consisted of the participants' demographic information, such as gender, age, education, position and experience. The other variables were collected in four groups: workplace bullying behaviours, workload, organizational effects and depression.

Workplace bullying behaviour

To measure the nurses' perception of bullying in the workplace, a 33-item tool developed by Dilek & Aytolan (2008) was used. The nurses were asked to mark the frequency within the last 12 months that they had incurred the items listed as antagonistic and unethical behaviours in the workplace resulting in a negative effect on work performance and to mark from whom every behaviour they had been exposed to had originated (supervisor, co-worker, subordinate, etc.). The tool had four subcategories: ‘individual's isolation from work’, ‘attack on professional status’, ‘attack on personality’ and ‘direct attack’. The items were evaluated on a 6-point Likert-type scale from 0 (‘I have never incurred’) to 5 (‘I constantly incur this’). The total score received was divided by the total number of items (total score/33) the number obtained over one showed that the employee had been intentionally exposed to psychologically violent behaviours. The tool's internal consistency in this study was determined to be α = 0.93.


An 11-item tool developed by Duxbury & Higgins (1994) and adapted for Turkish by Aycan & Eskin (2005) evaluated the participants' workload, flexibility and control of experiences related to their jobs. The tool included items such as ‘I have to make sacrifices in my personal life in order to do my job properly’; ‘I am being overburdened by my workload and responsibilities’; and ‘My job requires me to work a lot and for long hours’. The items were evaluated on a 5-point Likert type scale from 1 (‘I absolutely disagree’) to 5 (‘I absolutely agree’). A high score indicated excessive work demands and little flexibility. The internal consistency of the tool in this study was determined to be α = 0.89.

Work hours

The total number of hours worked per week was evaluated with the question, ‘How many hours a week do you work?’

Organizational effects

The fourth section included a questionnaire that had been prepared based on the information in literature about workplace bullying that affects job performance (Davenport et al. 1999; Einarsen et al. 1994 ; Höel & Cooper 2000; Lewis 2001; Salin 2003; Tutar 2004). The participants were asked how exposure to bullying behaviours in the workplace affected their job performance. This section assessed the following issues: job motivation, ability to concentrate on a job, relationships with patients, relationships with supervisors, relationships with co-workers, effects on teamwork, job productivity, ability to finish duties on time, planning duties, use of time, commitment to work, desire for career advancement and energy level. The participants answered these questions from 0 (not affected at all) to 4 (very negatively affected).


The Beck Depression Inventory (BDI) by Beck et al. (1961) was used to determine the participants' depression status. The BDI was adapted for Turkish respondents, and its validity and reliability was tested in 1980 by Tegin, who found a reliability coefficient of 0.65. The tool includes 21 categories. Every category had four items. These items were scored from 0 to 3 with the lowest possible total score being zero and the highest being 63. This total score determined the level or severity of symptoms of depression. Beck classified the scores from the tool for depression as follows: 0–13 points indicated no depression; 14–24 points indicated a moderate degree of depression; and 25 or more points indicated severe depression as stated in Savaşır & Şahin (1997). The internal consistency of the tool in this study was α = 0.90.

Data analysis

The statistical analysis of the data was conducted using the SPSS programme, version 11.5 (SPSS Inc., Chicago, IL, USA). Primarily descriptive statistics (frequency, percentage, mean, standard deviation) was used in the data analysis. An analysis of variance (ANOVA) test was used to determine whether there was a difference between position and education level. Correlation and regression analysis were used to determine the factors that were associated with workplace violent behaviours.


Workplace bullying behaviours

Thirty-seven per cent of the participating nurses had never or almost never encountered workplace bullying during the last 12 months, but 21% of the participants had been directly exposed to bullying (Supporting Information Fig. S1). The bullying behaviours that nurses were exposed to are shown in Supporting Information Table S1. The most common type of bullying behaviours was attacks on professional status, followed by attacks on personality. The most common bullying behaviour experienced by the participants was ‘Having someone speak about you in a belittling and demeaning manner while in the presence of others’ (56%). When asked from whom they experienced this behaviour, 40% of the participants reported that it was from their administrators, 34% from their co-workers, and 5% from their subordinates. The second most common bullying behaviour experienced by the nurses was ‘Making you feel like you and your work are being controlled’ (49%). Forty-two per cent (42%) experienced this from administrators, 22% from co-workers and 8% from subordinates. The third most commonly experienced bullying behaviour was ‘Being blamed for things you are not responsible for’ (48%). Thirty-nine per cent (39%) experienced this from administrators, 33% from co-workers and 7% from subordinates.

The relationship of bullying to age, education level, position and workload

The ANOVA tests were conducted to examine the differences between position and education level. There were no significant differences noted between position and educational level in regard to workplace violent behaviours (P > 0.05). Relationships between bullying and workload, nurses' age and total years of work experience were tested through Pearson's product–moment correlations. Correlations revealed that bullying was positively associated with work overload (P < 0.01) and total years of work in nursing (P < 0.05). However, bullying was negatively associated with nurses' age (P < 0.01). Regression analysis was used to examine the connection between nurses being exposed to bullying and their age, workload and total years of services (β = 0.48; F = 39.70; P < 0.00). It was determined that 45% (P < 0.00) of the nurses facing bullying behaviours were affected by their workload and 15% (P < 0.01) were affected by their age (being younger). The total number of years working in nursing showed no effect on bullying behaviours (P > 0.05).

Effect on nurses' job performance

Pearson's product–moment correlation test was conducted to analyse the effects of bullying behaviours on nurses' job performance. According to the findings, bullying behaviours also had a negative effect on the victims' job performance (Supporting Information Table S2). The areas of nurses' job performance that were most affected were job motivation, energy level and commitment to work. Workplace bullying behaviour status was also positively associated with depression (r = 0.51; P < 0.00), work motivation (r = 0.49; P < 0.00), concentration of work (r = 0.48; P < 0.00), productivity (r = 0.46; P < 0.00), commitment to work (r = 0.44; P < 0.00), and relationship with patients (r = 0.42; P < 0.00), managers (r = 0.47; P < 0.00) and colleagues (r = 0.45; P < 0.00).

Effect on nurses' depression status

Forty-five per cent (130 individuals) of the nurses participating in this research had symptoms of moderate or severe depression (Supporting Information Fig. S2). A positive correlation was found between the nurses' depression status and being exposed to bullying behaviours and also their workload (P < 0.00). A regression analysis conducted on the nurses' depression status determined that exposure to bullying behaviours and excessive workload had significant effects (β = 0.54; F = 56.61; P < 0.00), and according to this, 33% (P < 0.00) of the nurses who experienced depression were affected by bullying behaviours and 30% (P < 0.00) by excessive workload.


Workplace bullying behaviours

Although bullying behaviours at the workplace are seen in every sector, it has been determined that they are more common in healthcare institutions (Chappell & Di Martino 2000). In this study, a significant percentage (82%) of the participants had faced workplace bullying behaviours one or more times in the last 12 months; of these 21% had been exposed to these behaviours intentionally and their supervisors were frequently the source of these behaviours. Other research results on this subject were similar to our findings indicating that the majority of nurses were exposed to workplace bullying behaviours and that these behaviours were frequently inflicted on them by nurses, assistant nurses or head nurses in their own departments (Cox 1987; Einarsen et al. 1998; Ferrinho et al. 2003; McKenna et al., 2003; Quine 1999, 2001; Rutherford & Rissel 2004; Yildirim & Yildirim 2007).

In addition, the most common workplace bullying behaviour that nurses experienced was ‘being spoken to in a belittling manner around others’ (56%), which is both a verbal and a personal attack. Frequent bullying was also directed at the nurses' personalities and professional status, and attempts were made to isolate the victims (Supporting Information Fig. S2 and Table S1). Similar to our results, other studies showed that the most commonly faced bullying behaviours were getting their goal posts shifted; having necessary information withheld from them; receiving undue pressure to produce; being frozen out, ignored or excluded (Quine 1999); being belittled, sneered at, shouted at or ordered, being spoken to in disrespectful tones (Rutherford & Rissel 2004); not having their work and accomplishments valued; being belittled in front of others; and being ridiculed (Einarsen et al. 1994). Adams (1992) emphasized that the continuous, unfair criticism and attacks on one's personality and professional status were usually done while in the presence of others and within a group, but that it is difficult to determine this tactic clearly and that this is related to the perception of this situation by the victim of this behaviour. For this reason, more than the contents of the negative behaviour the victim is exposed to, the difficulty that the person experiences in protecting himself or herself against these attacks is emerging as an important conceptual factor. In addition, women frequently face mobbing from other women, and women try to harm their enemies psychologically more than physically (Björkqvist 2001; Salin 2003).

The relationship between bullying and age, education level, position and workload

Our research showed that regardless of educational level and position, every nurse can face workplace bullying behaviours. However, young nurses faced more types of negative behaviours. Other studies conducted on this subject supported our results that young employees are frequently victims of direct attacks and negative behaviours from older and more experienced employees (Einarsen & Skogstad 1996). On the other hand, Höel & Cooper (2000) and Quine (2001) determined that workload was the most significant factor that affected workplace psychological violence. In this study it was determined that excessive workload and youth had significant effects on nurses' exposure to workplace bullying behaviours, and this supports previous research results. Workload is related to inadequate staffing. Inadequacy relates not only to the number of staff but also to the skills and knowledge base that those individuals possess in relation to the needs of their patients (Jasper 2007). Because of excessive workload and time pressure, nurses cannot finish their duties in a timely manner, often resulting in nurse managers treating other nurses, especially the younger staff in the workplace, in a negative manner. Because of excessive workload, and only the working outcome being emphasized by the nurse managers, it is concluded that the nurse manpower is considered an expenses account. Consequently, this situation can devalue nursing care and the nursing professional practice.

Effect on nurses' job performance

An excessively stressful work environment causes pressure, exhaustion and intimidation for everyone who works at the institution (Tutar 2004). In addition, employees who are the direct targets of bullying experience negative work behaviours, such as decreased job satisfaction, decreased job performance, decreased productivity, less motivation, increased possibility of making a work-related error, and decreased connectivity to the job and institution (Davenport et al. 1999; Tınaz 2006; Tutar 2004). In addition, Hansen et al. (2006) determined that workplace bullying had a negative effect on relationships with co-workers and supervisors. In this study, the job motivation, energy level, attachment to the institution, and relationships with patients, supervisors and co-workers of the nurses who were exposed to workplace bullying behaviours were negatively affected, and these results are supported in the literature. According to Pallas et al. (2006), nurses' experience of negative relationships or communication with their superiors and co-workers decreases their motivation and performance. In addition, nurses feel that their relationships with managers and co-workers are essential because it is crucial for them to cooperate with managers and co-workers as they are in constant communication with each other while caring for patients. Consequently, bullying behaviours hinder not only a positive work environment but also effective and productive patient care.

Effect on nurses' depression status

In spite of these negative behaviours, some nurses do not want to change their work because it may be difficult to find an orderly income job during crisis. It is known that mobbing victims' emotional health is significantly affected and that they experience serious psychiatric, psychosomatic and psychosocial problems. However, the victims have different perceptions of bullying, and its effects vary from person to person (Davenport et al. 1999; Einarsen 2000; Hansen et al. 2006; Leymann 1996; Quine 2001; Salin 2003). Studies recommend that victims of bullying receive expert assistance at an early stage so they do not experience serious negative health problems (Davenport et al. 1999; Leymann 1996). In our study, nearly half (45%) of the participating nurses had symptoms of depression, and in the regression analysis it was determined that the depression experienced by the nurses had a significant effect (33%) on being exposed to psychologically violent behaviours. This also shows that nurses who are exposed to workplace bullying experience symptoms of depression.

Research limitations

One of the most important limitations of this research was the small percentage of participation in the research. Fifty-nine of the 345 nurses who participated in the research did not completely fill in or incorrectly filled in the forms and thus were excluded from the research. In addition, 150 surveys were returned blank because the nurses could not find the time to complete them. Therefore, 209 of the 495 surveys that were given to the nurses were not correctly completed, or at all. Another reason for the low response rate was the lengthy questionnaire, which some nurses did not want to fill in. Furthermore, it is normal for some individuals to opt out of answering questions about sensitive subjects such as their work environment because the subject of workplace psychological violence is still considered taboo. This situation was predicted to result in a low participation rate. Nevertheless, this study shows a high-frequency (82%) and, at times, quite intensive (21%) experience of bullying behaviours in the hospital. When collecting data for this research, some of the nurses expressed their opinion about how important the topic of this research is and that the results need to be shared with themselves and with superiors. Another limitation of this research was that the results were specific to only one hospital in our country. Therefore, our results cannot be generalized to the nation as a whole.

At the time of this study, only women could be employed in the nursing profession in our country according to the nursing law. For this reason, another important limitation was that only women were included in the sample; thus, the differences between genders could not be investigated. Moreover, this study discovered a different understanding of bullying behaviours experienced by women working in a female-only work environment.


In spite of the limitations, this study showed that psychologically violent behaviours in the nursing profession in our country, while still a taboo topic, occurs frequently and even intensely at times. In addition, although mobbing is common in the workplace in our country and continues as an unnamed battle, there are no institutional or legal standards on the subject of workplace mobbing, and little research has been conducted on this subject. Workplace bullying is clearly a measurable problem that negatively affects the psychology and performance of the nurses in this study. As employees become aware of the subject of psychological violence in the workplace, they will no longer accept dishonouring or belittling behaviours as part of their jobs, and victims will seek to have the injustice addressed.

This study has potential to contribute to the research literature as well as the nursing profession by identifying that bullying experienced by nurses negatively affects nurses' job performance and can lead to depression. It is hoped that practitioners in the field will take these findings into account in order to modify the working conditions of clinical nurses and decrease bullying behaviours in the hospitals.