1. Houck, Noreen M. MS, RN, CNE
  2. Colbert, Alison M. PhD, PHCNS-BC


Workplace bullying is strongly associated with negative nursing outcomes, such as work dissatisfaction, turnover, and intent to leave; however, results of studies examining associations with specific patient safety outcomes are limited or nonspecific. This integrative review explores and synthesizes the published articles that address the impact of workplace nurse bullying on patient safety.


Article Content

WORKPLACE BULLYING (WPB) is em-erging as an important component of the broader work environment, and there is a growing body of evidence that links a nurse's work environment to the quality and safety of care in hospitals. Although there is a perceived logical connection, it is unclear how WPB as an aspect of the nurse's work environment affects patient safety. Patient falls, errors, and readmission rates are examples of nurse-sensitive indicators of patient safety. These events may cause harm or contribute to the death of patients; they also pose an economic burden to the hospital. To tackle this pervasive problem, researchers and administrators require data to connect the specific environmental issues that may be associated with causative factors, including WPB.


Bullying is symptomatic of broken professional relationships within the work environment, and its consequences extend far beyond the individuals involved. The prevalence of bullying varies across nursing studies between 26% and 77%,1-5 and the cost is estimated at $11 582 per nurse per year,6 making this a significant challenge for nursing leadership. Professional organizations, such as The Joint Commission, describe bullying, intimidation, and disruptive behaviors as factors that may contribute to errors that negatively affect patient care, though studies are unclear as to what aspects of patient care and safety are affected.7


Workplace bullying is the umbrella term for most types of workplace aggression and violence from emotional abuse, physical violence, and the threat of violence. Terms that appear frequently in nursing literature that fall under this umbrella include horizontal violence, lateral violence, and incivility. The subject is extensively studied internationally, across disciplines, and especially in health care.8 Workplace bullying occurs when individuals perceive that they are the target of negative actions from one or more persons over time.8


Victims of WPB report physical, emotional, and psychological symptoms such as severe anxiety, sleep disruption, feelings of trauma, helplessness, powerlessness, silence, anger, clinical depression, and posttraumatic stress disorder. Prolonged exposure may lead to physical effects such as decreased immunity, stress, headaches, high blood pressure, and digestive problems.9-11 These effects can be devastating to the victims. The effect of WPB on the nursing profession can be profound. Workplace bullying reduces productivity6,12 and causes an increased desire to leave the profession.13 Most studies describe the effects of bullying on the nurse such as intention to leave14,15 and job strain or burnout.16,17 Less well understood is the association between WPB and patient safety.


Nurses' education level18 and hospital staffing levels19 affect a nurse's work environment. There is evidence that the overall quality of the work environment affects the nursing workforce in the areas of nurse retention and turnover,20 burnout and emotional exhaustion,21 and job satisfaction.22 This review examines studies that describe a primary association between patient safety and evidence of an impairment in the nurse's ability to perform due to the presence of WPB. There are several studies that assess WPB and a nurse's perceived association with patient safety23,24; this review appraises the quality of the association found in the literature.



An integrative literature review was performed according to the methodology of Whittemore and Knafl.25 The approach of an integrative literature review allows the inclusion of studies with diverse methodologies and a comprehensive understanding of the phenomenon under review. This process includes a well-defined, multistep literature search strategy and the inclusion of all relevant theoretical and empirical articles. The steps used in this integrative review were the following: (1) identify the research problem, (2) collect data, (3) data evaluation and analysis, (4) data integrations, (5) and presentation of results.


Problem and data collection

The objective of this study was to discover what is known about the association between WPB directed toward the nurse and the effect on patient safety from published studies. Data collection was performed through electronic search on the databases PubMed, CINAHL (Cumulative Index to Nursing & Allied Health Literature), PsychINFO, Cochrane, and Ovid/MEDLINE between 1995 and March 2016. In addition, a search of resources used in policy statements by The Joint Commission was done, and reference lists of all studies and related policy statements were searched for related studies.


Multiple search strategies were used to find connections between the following terms: nurs* AND (horizontal violence, OR bullying, OR lateral violence, OR workplace aggression, OR disruptive behavior, OR intimidation) AND (patient safety, OR patient care, OR patient outcomes, OR errors). The search was limited to English language studies conducted in the last 20 years (1995 to March 2016). The initial search combining patient safety terms and WPB terms yielded 474 articles.


Evaluation and analysis

Selected articles were reviewed by title and abstract for primary studies that linked WPB and patient safety, reducing the review to 36 studies. These studies were assessed for the quality of the research and of the link to patient safety. The reviewers sought evidence of the harmful effects of bullying to patient safety as present or a potential hazard. Articles that examined staff retention, patient-to-nurse aggression, and physician-to-nurse aggression were excluded except where patient outcomes or patient safety were stated. Qualitative and quantitative scholarly studies were included.



Method and origin of reviewed studies

Through careful comparison and assessment, the final analysis yielded 11 studies that made an association between perceived WPB with patient safety. The terms for WPB assessed in these studies included horizontal hostility, disruptive behaviors, violence, vertical violence, bullying, incivility, mistreatment, workplace aggression, physical violence, threat of violence, emotional abuse, and verbal abuse.


The countries of origin for the final studies include the United States (7), Canada (1), United Kingdom (1), and Australia (2). Supplemental Digital Content, Table 1 (available at: provides the aims, design, and sample of each study in the final review. The majority, 9 studies, used surveys in descriptive and correlation designs. One case study26 was included and 1 content analysis of narrative description.27 The sample sizes varied from 1, in the case study, to 4530 health care professionals in a large multisite health network (see Supplemental Digital Content, Table 1, available at: In each study, WPB was determined as a perceived variable. From the final studies, 7 themes were identified as shown in Supplemental Digital Content, Table 2 (available at: that harmed patients or posed a risk to patients and these are (1) patient falls, (2) errors in treatments or medications, (3) delayed care, (4) adverse event or patient mortality, (5) altered thinking or concentration, (6) silence or inhibits communication, and (7) patient satisfaction or patient complaints (Table).

Table. Summary of Fi... - Click to enlarge in new windowTable. Summary of Findings Related to Patient Safety Themes Associated With Workplace Bullying

Patient falls

An association between the nurse's perception of physical violence, threat of violence, and emotional abuse was found in a study to be all correlated with a rise in patient falls over the 7 days of data collection.3 This study examined that the impact of violence on unit operations, the nursing skill mix (percentage of RNs), and degree level (percentage with BSN) were associated with fewer perceptions of emotional violence but did not have an effect on the threat of violence or an actual assault.


Error in treatment or medication

Error in treatment or medication was the most frequently identified theme associated with WPB. In 5 studies, the subjects perceived that WPB contributed to error in treatment or medications.5,29-32 In 1 study, patient safety data were directly measured over a week; findings indicated a positive association with medication errors in the presence of physical violence, the threat of violence, and emotional abuse.3


Delayed care

The only study that found care delayed in the presence of WPB directly collected patient safety data for a week. In this study, all 3 types of violence assessed, physical violence, threat of violence, and emotional abuse, were associated with delays in care.3


Adverse event or patient mortality

Patient mortality rates and adverse events are key measures of effective care and were identified in 3 final studies. A series of studies on disruptive work environments have had significant impact on policy and are used to describe the effect on patient safety. The growing nursing shortage in 2010 led to an investigation on the relationship between disruptive behaviors by physicians and the impact on nurse satisfaction, retention, recruitment, and turnover.34 Later studies sought to connect all sources of disruptive behaviors to patient safety,31 and more recent studies sought to link the perception of disruptive behaviors to patient satisfaction, patient complaints, and malpractice.1,31,35


This series of studies involves a large multisite health care network and a nonrandomized cross-sectional survey with open-ended questions. The 2005 survey found that 94% of the respondents believed that WPB could have a negative impact on patient outcomes, 60% were aware of an adverse event as a result of disruptive behavior, and 17% were aware of a specific adverse event that occurred as a result of the behavior.32 The 2008 survey found similar results in which 67% felt that there was a linkage between disruptive behavior and an adverse event, 27% believed that there was a link to patient mortality, and 18% were aware of a specific adverse event that was the result of disruptive behavior.31 The 2012 survey continues to support these perceptions finding 32.8% of respondents perceive that disruptive behavior could be linked to patient safety; however, 13% state that they were aware of an adverse event that occurred because of disruptive behaviors.1 Nurses and physicians perceive a connection between bullying and adverse events and patient safety risks.28 Each of these studies mentions patient safety or risk factors; however, they do not directly measure patient outcomes.


Altered thinking

Workplace bullying changes the way the victim thinks and poses a threat to patient safety. Altered thinking may affect decision making, assessments, and reactions that have the potential to impair the delivery of safe care. Two studies report that victims of WPB noted alterations in thinking as a result of the trauma they experience. A case study shared the experiences of a nurse victim of WPB who suffered posttraumatic stress disorder after the event.26 The narrative expression of the therapy experience revealed that the victim retained suppressed creativity and freezing thoughts following therapy. A large multisite study with 370 nurse respondents found that 51.8% of nurses perceived that WPB impaired their ability to concentrate within the range of sometimes, frequently, and constant.


Silence or inhibits to communication

Silence and inhibitions to communication pose a significant threat to patient safety. This threat was identified in 5 of the studies. A startling result surfaces from a repeat survey of a 2003 study with more than double the number (4884) of health care professionals, including nurses, pharmacists, and health care administrators, reporting that intimidating behaviors persist in health care.36 The respondents stated that their past experiences with intimidation altered the way they handled clarifications or questions about medication orders.30


Not seeking clarification, using silence, and avoiding communication are serious problems for the functioning of the health care team. The breakdown in communication or nurses not speaking up poses a real threat to patients. This problem is seen again and again in other studies in the review. For example, in 2013, respondents would seek clarification from a colleague rather than interact with an intimidating prescriber, and nearly half (45%) felt pressured to administer a medication despite their concerns.30 The study at a teaching hospital of 213 RNs and LPNs identified that their response to WPB was first, adaptive coping and second, silence and passivity.33 A third study of 130 nurses in the United States found that in the presence of horizontal hostility, nurses avoid asking for help to clarify an order (30%) or lift a patient (10%).29


A Web-based survey of a large multisite health care network had physicians, nurses, and administrations share their perceptions of the impact of disruptive behaviors of nurses and physicians on patient outcomes; disruptive behaviors reduced communication (55.6%). The personality of the aggressor was the primary barrier to communication (66.3%), followed by training (31.3%), gender (22.3%), age (22.1%), and culture (16.5%).1 Barriers to effective communication pose a clear risk to patient safety.


Patient satisfaction/complaints

There is some evidence in studies unrelated to WPB that better patient experience is associated with better patient safety in hospitals.37 The nature or causal relationship between these measures has not been determined. Patient satisfaction was measured in 1 study, with 55.6% of the participants perceiving a linkage between WPB and patient satisfaction32; in another study, complaints from patients were found to be the highest factor associated with WPB.28



These results indicate that WPB in the nurse's work environment jeopardizes patient safety. In 9 of 11 of the final studies, the participants perceived WPB as a patient safety issue (Table). Other studies identified that WPB silenced or inhibited communication. The Joint Commission established a policy that is consistent with these findings. By stating that a relationship exists between intimidation and poor communication, as our findings confirm, WPB is believed to be detrimental to patient safety.7


This review offers managers and nurses the opportunity to view their patient safety data through a new lens. Bullying in the workplace creates a disruptive work environment and undermines management credibility and trust.26,38,39 Yet, nurses continue to identify bullying as a persistent problem in the nursing workforce. The ubiquitous nature of bullying in nursing culture perhaps desensitizes nurses and managers to the destructive nature of the problem.40 The acceptance of incivility in the workplace leads to escalation in the intensity of WPB from verbal abuse to physical threats or actual physical abuse. It is imperative that nurses and managers partner to create and sustain healthy work environments free from bullying.41 The Australian study also found that emotional abuse was higher when the patient acuity level was high and lower when nurse autonomy was high and nursing leadership favorable.3


The failure of nursing to change its culture to one characterized by respectful and equitable inter- and intraprofessional relationships poses a real threat to patients and nurses. The findings from this study support policies that seek a change in culture of health care and support civil and respectful work environments. Nursing leaders can assure that systematic processes are in place to identify and intervene in the presence of WPB. Managers can raise awareness of the types of behaviors that may be perceived as bullying and have open discussion about strategies to change behaviors; however, additional strategies are needed to resolve this issue. At the root of bullying is the need for power over another individual.42 Exposing the darker motivations that allow these behaviors to persist may help nurses and managers to address the behaviors.


Hospitals have the responsibility to include WPB issues as part of their quality improvement assessments. While nurses may not want to accept the presence of bullying in the workplace, as they perceive that it makes nursing appear weak, denying its existence poses a threat to patients and nurses.



The effect of bullying on nurses work has not been sufficiently explored to reveal all risks or hazards to patients. It is possible that the search methodology failed to discover all relevant studies; however, few studies examined this experience and the effect on the work environment or patients. The number of participants in the studies ranged from a case study of 1 to larger survey studies of 130 nurses to 3099 nurses. Various methods, tools, and regions and countries were included. The search criteria limited inclusion to English language, and this may have excluded relevant studies. Inconsistent definitions and methodologies are used in these studies for WPB. Furthermore, patient safety measures are primarily reported as staff perceived outcomes and seldom related to direct patient measures.



This review affirms the presence of WPB in the hospital environment; however, only 1 study in the past 20 years sought to directly measure the effect on patient safety. All studies that met the review criteria reveal significant risks to patient safety. A nurse's work often occurs in hostile and unsafe conditions. While conventional wisdom might assume that hostile work environments translate into substandard patient care, these data are difficult to capture and correlate. Nursing leaders face a significant challenge to develop and sustain organizational systems that support quality care.


The broad scope of the harmful effects of WPB should ignite the health care industry to make positive changes in nursing's work environment. Bullying and hostility are inconsistent with a profession that has caring as a core defining value, action, and intention of work. Bullying may well be so ingrained in the culture of nursing that it undermines credibility, professional values, and nursing's self-identify. It is critical to understand the association between WPB and patient safety so that effective policies and interventions are developed that support a change in the culture of health care to one that is respectful of all individuals.




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bullying; patient safety; patient satisfaction; work environment; workplace bullying