Bullying and Its Prevention Among a National Sample of Israeli ICU Nurses

Friday, 25 July 2014: 1:30 PM

Freda DeKeyser Ganz, RN, PhD
School of Nursing, Hadassah Hebrew University, Faculty of Medicine, Jerusalem, Israel


     The purpose of this study was to describe the prevalence of bullying as well as what measures were taken to prevent it, as perceived by a national sample of Israeli ICU nurses


     Bullying refers to repeated, offensive, abusive, intimidating, or insulting behaviors; abuse of power; or unfair sanctions that make recipients feel humiliated, vulnerable, or threatened, thus creating stress and undermining their self-confidence (Embree, & White, 2010; Hutchinson, Wilkes, Jackson & Vickers, 2010; Murray, 2009; Rowell, 2005; Yildrim & Yildrim, 2007).  This phenomenon has been shown to be widespread within nursing in many different countries around the world (For example, Johnson & Rhea, 2009; RCN, 2002; Vessey, DeMarco, Gaffney & Budin, 2009; Yildrim & Yildrim, 2007).

     Bullying has been shown to have both physical and psychological consequences for the victim (Murray, 2009; Rowell, 2005; Katrini) and to affect patient care (Woelfle & McCaffrey, 2007), leading to decreased job satisfaction and increased burnout (Laschinger, Grau, Finegan & Wilk, 2010).

     There has been some literature that has described how to prevent bullying (Katrini, Atabay, Gunay & Cangarli, 2010).  These measures include increased awareness about the potential presence of bullying and the development of institutional protocols that call for the documentation of bulling with disciplinary action against it (Katrini, et al., 2010; Lewis, 2006; MacIntosh, 2006)

     At present there are no reports that describe the prevalence of bullying among nurses in Israel nor are there reports of what actions are taken to prevent its occurrence.  Furthermore, no study was found that investigated bullying only among critical care nurses, despite the fact that these units have been shown to have a high prevalence of bullying. 

Methods: This was a cross sectional, correlational, descriptive survey. 

       Sample: The sample was a convenience sample of 155 ICU nurses. Members of the Evidence Based Practice Subgroup of the Israeli Society of Cardiology and Critical Care Nursing recruited ICU nurses from five medical centers.  As the primary purpose of the study was to describe the prevalence of bullying and its perceived prevention, it was determined that data collectors would try and recruit a maximum amount of respondents without concern for statistical power. 

     Data collection: Data were collected after institutional and ethical approval at each institution.  Head nurses were contacted and asked to approve participation of members of their units.  A pilot test of the initial 25 respondents was conducted. Questionnaires were found to be clear and so the results of the pilot were included in the final results.  Questionnaires were administered according to the preference of the local administration, either in staff meetings or participants were approached individually on their respective units. All responses were placed in an envelope at a central location and were anonymous. 

     Instruments: Three questionnaires were used:

     a. Demographic and work characteristics questionnaire, including personal demographic and work-related data.

     b. Negative Acts Questionnaire-Revised: a 22 item, Likert-style questionnaire developed by Einarsen, and colleagues in 1994 and revised in 2009 (Einarsen, Hoel & Notelaers, 2009) to measure the level of exposure to bullying in the workplace.  It was found to have acceptable levels of reliability and validity.

     c. Bullying Prevention Questionnaire: developed by the investigators to determine measures currently available to prevent bullying.  This questionnaire contains 42 items on a 4 point Likert scale and lists measures conducted by institutions, units and individuals.  The questionnaire is based on a review of the bullying literature and underwent content review. 

     Data Analysis:  Descriptive statistics were conducted on all of the questionnaires. Bivariate analyses were conducted to determine if there are any demographic or work characteristic variables associated with bullying or perceived prevention. Those characteristics found to be significantly associated were used as predictor variables in a logistic regression model with bullying as the criterion variable.


     The sample consisted of 155 ICU nurses.  The majority of the sample was female (n=102, 69%), married (n=112, 77%) and Jewish (n = 96, 67%).    Most worked as staff nurses (n=111, 76%), had a baccalaureate nursing education (n=87, 60%) with post-basic ICU certification (n=122, 83%) with a mean age of 41.3 (SD= 9.9) and 11.5 years experience as an ICU nurse (SD=9.0). 

     Almost one third of the respondents (n= 43, 29%) reported being the victim of some bullying, although no one reported being bullied on a daily basis.   The mean total score on the NAQ-R was 33.3 (SD=11.6) with a mean item score of 1.6 (SD= 1.4) out of 5.  The mean Bullying Prevention total score was 96.8 (SD=14.4, range: 48-140, out of a possible 168) with an item mean score of 2.4 (out of 4) (SD= 0.3); Results for the subscale scores were: institutional prevention: item mean= 2.7 (SD= 0.5); unit prevention: item mean = 2.2 (SD=0.4) and individual prevention: item mean 2.4 (SD=0.3).

    A significant difference in the level of bullying was found between hospitals (F (4,155) = 2.7, p=.039). The mean scores on the Prevention Scale was found to differ between type of unit (F (5,143) = 3.4, p=.006) and hospital (F (4,155) = 2.9, p.026). However post-hoc Bonferroni analyses did not find significant differences between specific hospitals or units.   The Prevention Scale was found to significantly correlate with that of the NAQ-R (r= .58, p < .001). No other variables were found to be associated with either the bullying or prevention scores, therefore regression models were not created.


An alarming percentage of nurses were found to have been victims of bullying in their workplace.  The prevalence of bullying fell between levels presented in the literature (RCN, 2002; Johnson and Rhea, 2009; Yildrim & Yildrim, 2007).  This result is despite current policies of zero tolerance for bullying.  On the other hand, those who reported being bullied, were not bullied on a daily basis and levels were low to moderate for specific bullying actions. 

     The level of prevention was weak to moderate with little difference between measures taken by the individual, unit or institution.  Prevention and perceived level of bullying significantly differed between hospitals and types of units while no other demographic or work characteristic was found to be associated.  These results imply that bullying and its prevention happen for the most part at a unit and hospital level.  Others have found some individual characteristics related to bullying but this finding was not seen in this study.  


     The results of this study suggest that on a policy and administrative basis, more measures must be taken and adhered to, related to prevention of bullying.  Nurses must be educated to accept only a zero tolerance to bullying and to report bullying when confronted with it.  More research should be conducted to determine what other factors are associated with bullying, and based on these results, to design interventional studies to prevent it.