Internationally, for more than four decades, researchers have been studying acts of disrespect or mistreatment that occur between and among nurses working in clinical settings. These acts have been conceptualized in multiple ways, including, but not limited to, incivility,1 horizontal (or lateral) violence,2,3 disruptive behavior4 and workplace bullying or mobbing.5-7 These individual concepts are closely related yet still distinct from one another. Incivility is a subtle violation of expected norms of conduct.8 Incivility manifests as disrespectful, inconsiderate, uncaring or rude verbal and non-verbal communication from the offender without a clear intention to harm the target. Horizontal violence, which originated in oppression theory, is explained as in-fighting within an oppressed group stemming from the inability to attack an oppressor.9,10 Roberts11 used this theory to describe the profession of nursing as an oppressed group whose members are at risk of experiencing horizontal violence—the negative workplace conduct that can occur between peers who share the same social standing in a hierarchical institution.12 Disruptive behavior is misconduct ranging from non-physical to physical to sexual harassment that occurs between and among different health professional disciplines, such as nurses and physicians, and may injure the target and potentially threaten the quality and safety of patient care.13
Although the definition of workplace bullying varies between countries and cultures, there are common features among them: Bullying is persistent, repetitive mistreatment of a target over a period of time to the extent that the target becomes defenseless.14 There is some disagreement among scholars in relation to the intentionality of bullying as a definitional feature.14 Some researchers argue that only perpetrators of bullying can confirm or deny their intent to harm the target. Others describe workplace bullying as abusive conduct, akin to domestic violence, where the perpetrator is motivated to control their victim.15
An additional concept related to problematic workplace conduct is mobbing. In his pioneering work in Sweden in the 1980s, Heinz Leymann,16 a psychologist, was the first to use the term mobbing in regards to human behaviors. As described in his first paper in English in 1990, the concept of mobbing is drawn from descriptions of animal behavior, specifically where multiple animals group together to attack an individual animal.16 Leymann defined mobbing in humans as a situation in which an individual or individuals act in concert to systematically direct “hostile and unethical communication” toward another individual on a weekly basis (minimum) for the duration of six months (minimum).17(p.168) The actions over time result in the target becoming defenseless.17 Leymann reserved the term bullying to name physical aggression between children in the school yard, differentiating mobbing as “psychological terror” among adults in the workplace.17(p.168) In the 1990s, Andrea Adams, a British journalist and activist, and Neil Crawford, a psychotherapist, used the term bullying to name behavior that terrorized adults in their place of work.18 Workplace bullying and mobbing are similar in that they occur repeatedly over time to the point that the target becomes unable to defend themselves. However, there is disagreement among scholars about whether these concepts are the same phenomenon or differ slightly, in that a group perpetrates mobbing whereas an individual perpetrates workplace bullying.14,19
While conceptually similar in that they are negative workplace conduct, scholars posit that incivility, horizontal violence, disruptive behavior and workplace bullying are not the same. The concepts of incivility and workplace bullying exist along a continuum of lesser to greater intensity of negative workplace conduct.8,20-23 Incivility is on the lower end of the continuum while workplace bullying is on the higher end due to its persistency and frequency.20-24 Horizontal violence, however, does not exist on this continuum. Instead, some investigators suggest that horizontal violence is a broader topic that includes workplace bullying.25,26 Researchers have not addressed where or if disruptive behavior exists on the continuum of negative workplace conduct, or, conversely, whether incivility or workplace bullying are types of disruptive behavior.
This review will focus on workplace bullying. While there are many definitions of workplace bullying in the literature, Einarsen et al.'s14 definition will be used in this review: “Bullying at work means harassing, offending, socially excluding someone or negatively affecting someone's work tasks. In order for the label bullying (or mobbing) 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 six months). Bullying is an escalating process in the course of which the person confronted ends up in an inferior position and becomes the target of systematic negative social acts. A conflict cannot be called bullying if the incident is an isolated event or if two parties of approximately equal strength are in conflict.”(p.22)
The most frequently used measure of exposure to workplace bullying is the Negative Acts Questionnaire (NAQ).27 The Negative Acts Questionnaire-Revised (NAQ-R) is the English language version of the original Norwegian NAQ designed for use in Anglo-American cultures.22 The NAQ-R is a 22-item measure with three subscales: i) work-related bullying (seven items), e.g. “someone withholding information which affects your performance”; ii) person-related bullying (12 items), e.g. “being ignored or excluded or isolated from others”; and iii) physically-intimidating bullying (three items), e.g. “being shouted at or being the target of spontaneous anger”.22(p.32) The NAQ-R, however, is not without limitations.22,28 Respondents may interpret each of the questionnaire's items differently. The authors of the NAQ-R conclude that the questionnaire does not consider study participants’ perception of each negative act through the lens of their occupation or organizational culture. In one occupation, an item may be viewed as a negative act while that same act in another field may be viewed as a normal aspect of work-life. For example, nurses may frequently select “being exposed to an unmanageable workload”, but this item might reflect the work of nursing, not bullying.12,29 While nursing is the only occupation addressed in this review, it is important to consider the NAQ-R's limitation, as the pool of included studies will likely be from different countries and organizational cultures.
The NAQ-R instrument has been widely used internationally to measure workplace bullying in nursing.26,30-32 Researchers have assessed workplace bullying using the full 22-item measure,26,33 a 14-item modified version,33 or the three subscales separately.34 The prevalence of workplace bullying reported in studies where researchers used any version of the NAQ-R ranges from 13% to 54%.26,31,32,34-36
Researchers around the world have conducted studies that aim to describe workplace bullying among nurses and its association with nurse related outcomes such as burnout.37-40 In 1981, Maslach and Jackson published the Maslach Burnout Inventory (MBI).41 They defined burnout as a group of psychological symptoms that a person develops in response to his or her occupational life experiences. Since 1981, Maslach and colleagues have developed additional versions of this measurement tool for use in a variety of work settings. Researchers administered various versions of the MBI in several nursing studies internationally, including the 22-item MBI Human Services Survey (MBI-HSS)32,40-42 and the 16-item MBI General Survey (MBI-GS).37,43,44
The 22-item MBI-HSS contains three subscales: i) emotional exhaustion (nine items): feeling overly stretched emotionally and exhausted from work; ii) depersonalization (five items): unfeeling and impersonal response toward people served; and iii) personal accomplishment (eight items): feelings of competence and success in work with people.45 The 16-item MBI-GS measure is also composed of three subscales, though slightly different: i) exhaustion (five items), ii) cynicism (five items): feelings of indifference, and iii) professional efficacy (six items): feelings of effectiveness at work.46 While often administered, the MBI has limitations.47 Study participants may respond to items differently based on occupation and country. Research has not provided insight into whether cultural and organizational influences may explain these differences. Thus, the MBI is limited in its ability to measure burnout across occupations and countries. While nursing is the only occupation of interest in this review, it is important to consider this limitation in the MBI, because the pool of included studies will likely be from different countries.
Since the NAQ-R is frequently utilized in research on workplace bullying among nurses, only studies in which the NAQ-R was used to measure workplace bullying will be included in this review to allow for accurate comparisons between studies. Likewise, the MBI has been administered extensively in studies investigating the association between workplace bullying and nurse burnout. Therefore, only studies in which the MBI was used to measure burnout will be included in this review. Studies that utilize any of the previously stated MBI measurement tools will be included.
In studies using the NAQ-R and the MBI, workplace bullying was associated with burnout in nurses. Burnout is an important variable to study because of its relationship to outcomes such as nurses’ intent to quit, job dissatisfaction, reduced empathy and patient satisfaction.42-44,48
A preliminary search of PROSPERO, MEDLINE via PubMed, CINAHL, the JBI Database of Systematic Reviews and Implementation Reports, and the Cochrane Database of Systematic Reviews did not reveal any systematic review currently underway or completed on the topic of workplace bullying and nurse burnout. However, in the JBI Database of Systematic Reviews and Implementation Reports, there was one protocol and two reviews published on similar topics: a qualitative review protocol on incivility in online nursing education,49 a quantitative systematic review about the impact of horizontal violence on nurses’ job satisfaction and retention and the effectiveness of programs to decrease its prevalence and attenuate its effects,50 and a quantitative review of successful interventions for managing disruptive behavior within the nursing work environment.51 Further, in the Cochrane Library, there was one systematic review that focused on interventions for prevention of bullying in the workplace for a broad population of employees in paid work within public, private or voluntary organizations.52 Those reviews, whether proposed or completed, differ from this review, which will focus on the association between workplace bullying and nurse burnout.
What is the association between workplace bullying and nurse burnout?
The review will consider studies that include licensed nurses working in clinical settings in any country. For the purposes of this review and given possible differences in terminology internationally, the term “licensed nurse” pertains to, but is not limited to, registered nurse (RN), licensed practical nurse (LPN) and licensed vocational nurse (LVN). Likewise, “clinical setting” refers to any setting where nursing care is delivered to people including, but not limited to, hospitals, long-term care facilities, skilled nursing facilities, home care, ambulatory care clinics and outpatient clinics. Therefore, all terms for “licensed nurse” and “clinical settings” will be considered. Furthermore, “any country” refers to countries that are considered low-, middle- or high-resource/income.
Exposure of interest
This review will consider studies in which researchers administered the NAQ-R to measure licensed nurses’ exposure to workplace bullying in clinical settings. As identified in this protocol's introduction, Einarsen et al.'s14 conceptual definition of workplace bullying will be used in this review. Features of workplace bullying include patterning (diversity of negative acts), repetition (the frequency of negative acts), and duration (over time).22 Based on these features, the NAQ-R's operational criteria for bullying include exposure to two negative acts (patterning), at least weekly (repetition), within the last six months (duration). Einarsen et al. quoted Leymann's 1997 unpublished manuscript that established at least one negative act as a criterion for mobbing.22 Einarsen et al. selected two negative acts.22,28 Their rationale for this stricter criterion was to address a limitation in the NAQ-R; the measure does not consider study participants’ perception of each negative act through the lens of their occupation, organizational culture or work setting where an item may reflect the work, not a negative act associated with bullying. Consistent with Leymann's research,16 the authors established the frequency of exposure as at least weekly, the second criterion for bullying.22 They use a frequency response scale: “never,” “now and then,” “monthly,” “weekly,” and “daily.”22(p.28) For the third criterion, the authors of the NAQ-R used research to decide on a exposure duration of within the last six months to assure the persistence of negative acts while minimizing the potential for recall difficulty and memory bias.17,53,54
This review will consider studies in which the researchers administered the MBI to measure burnout in licensed nurses. The response scales for the MBI-HSS and MBI-GS are in the form of a frequency rating scale including: “never,” “a few times a year or less,” “once a month or less,” “a few times a month”, “once a week,” “a few times a week,” and “everyday.”45(p.13),46(p.41) Burnout has relevance for researchers and policy makers because of its relationship to outcomes such as nurses’ intent to quit, job dissatisfaction, reduced empathy and patient satisfaction.42-44,48 Furthermore, these burnout-related outcomes are important because nurses are costly to replace,55 nurses’ job satisfaction is related to patient care,56,57 empathy is a vital component of good nursing practice,42,58 and patient satisfaction is an indicator of patient perception of care received, which is valuable information for quality improvement in healthcare institutions.48,59
Types of studies
STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) is a global, collaborative initiative of scientists and journal editors who are committed to the conduct and dissemination of observational studies.60 To improve the quality of reporting, collaborators created checklists, focusing on three primary, analytic designs used in observational research: cohort, case-control and cross-sectional. Thus, this review of workplace bullying and risk for burnout in nurses will consider prospective and retrospective cohort (longitudinal) studies, case-control studies and analytical cross-sectional studies for inclusion. Studies published in English will be included. Studies published from 1990 to the present will be considered for inclusion. The reviewers have selected 1990 as a starting point to coincide with Leymann's pioneering work and first publication in English on mobbing.16
The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of etiology and risk.61
The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE via PubMed and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for CINAHL (Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.
The databases to be searched include: CINAHL, Embase, PsycINFO, MEDLINE via PubMed, and Scopus.
Sources for gray literature will include Google Scholar, MedNar, New York Academy of Medicine Grey Literature Report, and ProQuest Dissertations and Theses.
Following the search, all identified citations will be collated and uploaded into EndNote V9 (Clarivate Analytics, PA, USA) and duplicates will be removed. Two independent reviewers will screen titles and abstracts for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). Two independent reviewers will assess in detail the full text of selected citations against the inclusion criteria. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.62
Assessment of methodological quality
Two independent reviewers will appraise eligible quantitative studies for methodological quality using standardized critical appraisal instruments from the JBI SUMARI.63 Following critical appraisal, studies that do not meet a certain quality threshold will be excluded. The decision to exclude will be based on cut-off scores of less than 75% of items for each of the JBI critical appraisal tools included in this study. This represents the following amount of “yes” answers from the JBI critical appraisal checklist for each type of study: fewer than nine out of 11 for cohort studies, fewer than eight out of 10 for case-control studies and fewer than six out of eight for analytical cross-sectional studies. Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in a narrative form and a table.
Two independent reviewers will use the standardized data extraction tool from JBI SUMARI to extract data from studies used in the review.61 The extracted data will include the following information: name of author(s), year of publication, study design (cohort, case-control, cross sectional), clinical setting (i.e. hospital, clinic or other included setting), participant characteristics (i.e. age, sex, sample size, country/location), exposure of interest (workplace bullying) including different exposure categories (i.e. patterning, frequency, duration), outcome of significance (burnout) and data analysis methods of significance to the review question. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The authors of the included studies will be contacted to request missing or additional data relevant to this review.
Studies will, where possible, be pooled in a statistical meta-analysis using JBI SUMARI.61 Effect sizes will be expressed as weighted mean differences with a 95% confidence interval. Heterogeneity will be assessed statistically using the standard chi-squared and I2 tests. Statistical analyses will be performed using a random or fixed effects model based on the guidance from Tufanaru et al.64 Sensitivity analyses will be conducted to test decisions made by the reviewers. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures to aid in data presentation, where appropriate. A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed, where appropriate.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed.65 A Summary of Findings (SoF) will be created using GRADEpro (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on study limitations (risk of bias), indirectness, heterogeneity, imprecision and risk of selection bias, information bias, and publication bias of the review results. Nurse burnout will be the outcome included in the SoF.
Appendix I: Search strategy for CINAHL
Search conducted on November 10, 2018
S1: (MH “Bullying+”) (6,713)
S2: bully∗ OR incivil∗ OR “horizontal violence” OR “lateral violence” OR mobbing OR uncivil∗ (8,192)
S3: S1 OR S2 (8,384)
S4: (MH “Nurses+”) OR (MH “Nursing Practice+”) (242,994)
S5: nurs∗ (810,203)
S6: S4 OR S5 (813,863)
S7: IN negative acts questionnaire revised OR IN NAQR OR IN Maslach∗ burnout inventory OR IN Maslach∗ (1,997)
S8: measure∗ OR instrument∗ OR tool∗ OR questionnaire∗ OR inventory OR “negative acts” OR NAQR OR maslach∗ (1,117,883)
S9: S7 OR S8 (1,118,013)
S10: (MH “Personnel Turnover”) OR (MH “Personnel Retention”) OR (MH “Work Environment+”) OR (MH “Burnout, Professional+”) OR (MH “Compassion Fatigue”) OR (MH “Job Satisfaction+”) OR (MH “Productivity”) OR (MH “Absenteeism”) OR (MH “Depersonalization”) (75,041)
S11: burnout OR “compassion fatigue” OR “intent to leave” OR attrition OR “workplace satisfaction” OR “job satisfaction” OR “work environment” OR turnover OR retention OR depersonalization OR “emotional exhaustion” OR productivity OR absenteeism (105,305)
S12: S10 OR S11 (114,080)
S13: S3 AND S6 AND S9 AND S12 (261)
S14: S3 AND S6 AND S9 AND S12, Limiters - English Language, Published Date: 1990–2018 (240)
CP and CS would like to thank the University of San Francisco's Faculty Development Funds for the financial support needed to attend the Comprehensive Systematic Review training at the UCSF Centre for Evidence Synthesis and Implementation: a Joanna Briggs Institute Centre for Excellence.
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