Workplace Bullying, Job Stress, Intent to

Leave, and Nurses’ Perceptions of Patient

Safety in South Korean Hospitals
Hyunjin Oh ▼ Dong-choon Uhm ▼ Young Joo Yoon

Background: Negative work environments influence the ability of nurses to provide optimal patient care in a safe environment.

Aim: The purpose of the study was to test a model linking workplace bullying (WPB) and lateral violence (LV) with job
stress, intent to leave, and, subsequently, nurse-assessed patient adverse outcomes (safety issues).

Design: This descriptive-correlational study examined the relationships between study variables and used a structural
equation model to test the validity of the proposed theoretical framework.

Methods: A convenience sample of 508 clinical nurses working in eight general hospitals in Daejeon, South Korea, completed a
questionnaire on measures of WPB, LV, job stress, intent to leave, and nurse-assessed patient safety. Analysis of moment
structures was used to estimate a set of three models with competing measurement structures for WPB and LV and the

same structural model. Akaike Information Criterion was used for model selection.

Results: Among the three proposed models, the model with complex factor loadings was selected (WPB and LV were both
associated with verbal abuse and physical threat). WPB directly and indirectly influenced nurse-assessed patient safety. Job
stress directly influenced intent to leave, and intent to leave directly influenced nurse-assessed patient safety.

Conclusions: The results of the study support the proposition that WPB, job stress, and intent to leave may be associated with nurse-
perceived adverse outcomes (patient safety issues) in hospitals. Nurse perceptions of WPB were associated with nurse-assessed
patient safety outcomes (adverse events) directly and through mediating job stress and intent to leave.

LV was not associated with the mediators or nurse-assessed adverse outcomes (safety).

Key Words: bullying hospitals intent to leave nurses patient safety psychological stress South Korea

Nursing Research, September/October 2016, Vol 65, No 5, 380–388

environments on patient
safety (Aiken et al., 2012;
Van Bogaert, Kowalski,
Weeks, Van Heusden, &
Clarke, 2013).
South Korea.
Supplemental digital content is
available for this article. Direct URL
citations appear in the printed text
and are provided in the HTML and
PDF versions of this article on the

R
journal’s Web site
Hyunjin Oh, RN, PhD, is Assistant (www.nursingresearchonline.com).
Professor, College of Nursing,
Gachon Univer-sity, Incheon,
ecent widespread policies have brought new atten- South Korea. DOI:
10.1097/NNR.00000000000001
75
tion to unacceptable occurrences of unsafe care. All healthcare Dong-choon Uhm, RN, PhD, is
professionals consider providing safe, error-free patient care Associate Professor, Department
of Emergency Medical 380
as their first priority. Under conditions of a negative work Technology, Daejeon University,
environment, such as exposure to work-place bullying (WPB) South Korea.
and lateral violence (LV), nurses are not likely to work at their www.nursingresearchonline.co
m
best, which, in turn, may translate to poor patient care Young-Joo Yoon, PhD, is
practices (Kirwan, Matthews, & Scott, 2013). Recent studies Assistant Professor, Department
of Statistics, Daejeon University,
have confirmed the impact of negative nurse work
 environments can be clinical setting. Exposure to a
Patient safety refers to achieving desired patient outcomes in safe exacerbated by negative neg-ative work environment
behaviors toward nurses, such can cause job stress, as well
healthcare settings (Kim, Lyder, McNeese‐Smith, Leach, & as bullying and vio-lence as psy-chological and
Needleman, 2015). Patient safety is a comprehensive con-cept, (Roche, Diers, Duffield, &
physiological distress
which is influenced by various factors, such as health pro-
(Spence Laschinger, 2014;
fessional individual characteristics, communication difficulties, Catling‐Paull, 2010).
team relationships, and system factors (Kim et al., 2015). It is a Van Bogaert et al., 2013).
Indeed, nurses have wanted
quality nursing care outcome defined as “avoiding and preventing Taken together, WPB, LV, job
patient injury or adverse events during the deliv-ery of nursing stress, and intent to leave may Nursing Research •
have a negative influence on September/October 2016 • Volume
care” (Kim et al., 2015). Quality patient-centered care aimed at
patient safety—especially 65 • No. 5
protecting patient safety requires positive, collaborative
relationships among nursing colleagues. Stress-laden working when and if it occurs in the
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Nursing Research • September/October 2016 • Volume 65 • No. 5 Workplace Bullying, Job Stress, and Patient Safety381
(Ariza-Montes et al., 2013; less commit-ment to the
Rodwell & Demir, 2012; organization and to patient
Simons, 2008). care. Furthermore, in-consistent
supervision and training from
the organizational perspective
to leave their jobs when exposed to negative work environ- is another reason turnover may
be related to low-quality care
ments and high job stress (Ariza-Montes, Muniz, Montero-
(Zimmerman et al., 2002).
Simó, & Araque-Padilla, 2013; Rodwell & Demir, 2012;
Nurses in stress-laden working
Simons, 2008; Spence Laschinger, Grau, Finegan, & Wilk, Exactly what fosters an environments with WPB or LV
2010). Workforce outcomes such as job dissatisfaction and environment for quality care have reported compromises in
intent to leave are significantly associated with patient safety and promotion of safe patient patient safety, such as increased
(Coetzee, Klopper, Ellis, & Aiken, 2013), but little research has care has been studied exten- frequency of adverse events
at-tempted to explore the usefulness of a theoretical model to sively. Key predictors include (Purpora & Blegen, 2012;
examine these linkages to patient safety. negative working conditions, Purpora, Blegen, & Stotts,
patient status (presence of 2014; Rosenstein & Naylor,
Two critical occurrences known to impact nurse work life and adverse events), quality of 2012). It is possible that these
potentially impact patient safety are WPB and LV. WPB refers nurse leadership negative work environments
to repeated and regular attacks or acts of social ex-clusion on management, health provider and working conditions
someone for more than 6 months in the workplace (Einarsen, relationships, nurse staffing, generate job stress and intent to
leave, which impede nurses
Hoel, Zapf, & Cooper, 2011). Different but related to WPB, LV and nurse–patient ratios.
from providing optimal patient
has been referred to broadly as horizontal vio-lence, horizontal Many factors have been as-
care in a safe environment.
hostility, bullying, and workplace incivility (Embree & White, sociated with quality and safe
2010). Although WPB and LV overlap, they have differences, patient care, and these
and each can negatively impact the work-place (Embree & In summary, recent research
multiple factors interacting
White, 2010; Rodwell & Demir, 2012). Con-ceptually, attests to the importance of
dynamically may be the key
psychological events are more easily categorized as WPB, negative work environments
to understand-ing the
whereas LV denotes actual abuse or assault (Einarsen et al., (WPB and LV) in determining
phenomena.
2011; Rodwell & Demir, 2012). job stress and intent to leave.
These factors have been
Working conditions such as empir-ically examined for
Manifestations of WPB and LV may be culture-specific. higher levels of job dissatis- their impact on patient safety
Previous Western studies reported a low rate of physical vio- faction and intent to leave have (Purpora et al., 2014). The
lence among nurses (Hesketh et al., 2003; Rodwell & Demir, been associated with negative
focus of this study was to test
2012). In contrast, physical assaults between Korean nurses patient outcomes like mortality
a theoretical model linking
has been featured in Korea media as serious and too fre-quent and nosocomial infection
(Aiken et al., 2001; Coetzee et WPB and LV to job stress,
(Choi, 2015; Park, 2014). Understanding and inter-preting
al., 2013; Lu, Ruan, Xing, & intent to leave, and,
mistreatment may be differently perceived (Seo, Leather, &
Hu, 2013). Positive work life subsequently, nurse-assessed
Coyne, 2012), and a definition of WPB that stresses the
factors for nurses, such as patient safety in a South
psychological form of mistreatment might not be enough to
quality leadership and Korean context.
capture the totality of whatever physical and aggressive
nurse/physician collaboration,
assaults occur among nurses in Korea (Oh, Uhm, & Yoon,
are claimed to be related to Purpose
2016).
patient safety outcomes
(adverse events) with emotional
WPB and LV have been linked with other negative work exhaustion playing a mediating The primary aim of this study
outcomes in hospital settings (Hesketh et al., 2003; Simons, role (Spence Laschinger & was to explore the
2008; Spence Laschinger, Wong, & Grau, 2012). One fre- Leiter, 2006). Nurses who mechanisms through which
quently studied outcome is job stress in nurses. Job stress is de- intend to leave their current WPB and LV in the nursing
jobs have been reported to give environment in-fluence nurse-
fined as “a reaction to a stressful workplace situation, with lower-quality patient care assessed patient safety.
workload and professional conflict particularly identified as compared to those who intend Proposed mediating var-
main sources of job stress in nursing” (Demir & Rodwell, to stay (Ma, Lee, Yang, & iables were the work
2012; Spence Laschinger et al., 2012). Job stress can be linked Chang, 2009). A higher rate of outcomes of job stress and
to job dissatisfaction, which, in turn, has been linked to poor turnover in nursing staff is a intent to leave. On the basis
working relationships (Zhang et al., 2014) and one of the main critical factor in the incidence of Demir and Rodwell’s
of infection and related hospi-
contributory factors of nurses’ intentions to leave (Tourangeau talization in nursing home (2012) notion of WPB and
& Cranley, 2006). Exposure to a negative work environment violence and Spence
settings (Zimmerman, Gruber‐
may create job stress, as well as psycho-logical and Baldini, Hebel, Sloane, & Laschinger and Leiter’s
physiological distress (Van Bogaert et al., 2013). Indeed, some Magaziner, 2002). The (2006) extension of the
nurses have wanted to leave their jobs when exposed to literature implies that nurses nursing worklife model, we
negative work environments (Rodwell & Demir, 2012). WPB who intend to leave may have hypothesized
and LV have been linked to job stress and intent to leave
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382 Workplace Bullying, Job Stress, and Patient Safetywww.nursingresearchonline.com
Workplace Bullying The
Negative Acts Questionnaire-
Revised (NAQ-R) was used to
measure WPB (Einarsen, Hoel,
that nurse-perceived WPB and LV would be associated with job & Notelaers, 2009); the Korean
stress and intent to leave and, in turn, negative judgments about version was used (Nam,
patient safety. In three hypothesized models, WPB and LV were
expected to influence patient safety by job stress and intent to
leave playing mediating roles.
A secondary, preliminary aim was to explore the concep-tual
overlap between WPB and the verbal abuse and physical threat Kim, Kim, Koo, & Park,
indicators of LV. Three models with different measure-ment 2010). The NAQ-R measures
structures were explored: (a) uncorrelated WPB and LV factors, three interrelated factors
with verbal abuse and physical threat associated only with LV; (b) associated with person-related
correlated WPB and LV factors, with verbal abuse and physical bullying (12 items), work-
threat associated only with LV; and (c) uncorre-lated WPB and LV related bullying (7 items), and
factors, with both factors associated with verbal abuse and physical intimidation-related bullying
threat. Figures showing each model are available as Supplemental (3 items). Person-related
Digital Content 1, http://linksX bullying refers to slander,
.lww.com/NRES/A189.X social isolation, and negative
innuendos toward a person,
whereas work-related bullying
METHODS refers to “being given too
much or work that is too
Design, Participants, and Procedures simple or having one’s work
constantly criticized.”
A descriptive, cross-sectional design was used. A convenience Intimidation-related bullying
sample of hospital nurses was recruited from eight general hos- refers to “physically
pitals (each over 100 hospital beds) in Daejeon, South Korea. aggressive acts toward
Inclusion criteria were clinical registered staff nurses (not people” (Einarsen et al.,
managers) and clinical careers spanning 6 months to 5 years. We 2009). For each of 22 items,
used data collected from eight hospitals across Daejeon City in the frequency of occurrence
South Korea. Data for this study were collected from February was rated on a 5-point graded
through June 2013. The principal investigator (PI) contacted the scale with response options
Director of Nursing in each of the hospitals to obtain permission to ranging from 1 = never to 5 =
access potential participants. Written, in-formed consent was daily. An example of an item
obtained from the participants before completing the survey.
is: Someone withholding
Questionnaire packets along with an enclosed return envelope
information that affects your
addressed to the PI were distributed to nurses meeting the study
inclusion criteria. In order to fos-ter confidentiality, nurses were not performance. In an earlier
required to complete the survey at work. Completion of the paper study, the reliability of
survey took approx-imately 15 minutes. The protocol for the study responses to the NAQ-R
was approved by the university’s institutional review board (djomc- estimated using Cronbach’s
93). alpha was .92 (Nam et al.,
2010). In this study, subscale
reliabilities in this study
Variables and Measurement were .93, .80, and .61 for
person-related, work-related,
We used published scales that had been previously translated to and intimidation-related
Korean to assess values on study variables. These measures had bullying, respectively.
reported good levels of validity and reliability in previous
studies, as described below.
Lateral Violence LV was
measured using a violence
Demographics The demographic section of the questionnaire questionnaire developed by Yun
was designed by the research team. Questions were used to obtain (2004) and modified by Lee,
information about gender, age, religion, educational level, years Lee, Kang, and Park (2012).
working in nursing, work hours per week, and current clinical area. The LV questionnaire measures
three components of nurses’
Copyright © 2016 Wolters
experiences of violence: (a)
verbal abuse, (b) physical
threat, and (c) physical assault.
Respondents were asked to
indicate whether they had
experienced any of the
following types of violence:
verbal abuse (insults, crude
talk, yelling, and threats) in the
past week; physical threat in the
past month (insulting gestures,
frowning, intent to harm,
wandering in anger, and kicking
things); and physical assault in
the past 6 months (being spit
on, bitten, hit, pushed, caught
the collar, “hit by the stuff
thrown at me,” and being
scratched). The frequency of 16
items was reported using a
graded scale: “never,” “1 time,”
“2 times,” “3 times,” and “4 or
more times.” Higher scores
indicated more severe violence.
Acceptable reliability was
reported, with Cronbach’s
alphas ranging from .79 to .95
(Yun, 2004). Subscale
reliabilities in this study were .
69, .88, and .99 for verbal
abuse, physical threat, and
physical assault, respectively.
Job Stress The Korean
Occupational Stress Scale-Short
Form (Chang et al., 2005) was
used to measure job stress. The
Korean Occupational Stress
Scale-Short Form is a 20-item
inventory; an exemplar
question: “The workload has
been significantly increased.”
Respondents rated each item on
a 4-point, Likert-type scale,
from 1 = strongly disagree to 4
= strongly agree. Higher scores
indicate more severe degrees of
job stress. The Cronbach’s
alpha for responses to items on
this scale was .82.
Intent to Leave The Korean
version of the Intent to Leave
instrument developed by
Becker (1992) and translated by
Cho (1999) was used. Four
items were supplied with
response
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Nursing Research • September/October 2016 • Volume 65 • No. 5 Workplace Bullying, Job Stress, and Patient Safety383
25
(5.2)
TABLE 1. Participant Current clinical area
Characteristics

Characteristic
options on a 5-point Likert-type scale ranging from 1 = M Medical-surgical
strongly disagree to 5 = strongly agree. An exemplar item on (SD) 285
(57.6)
this scale is: “I often want to quit the job.” Scores on the Intent Special (OR, ICU, ER)
to Leave scale have previously shown acceptable reliability 129
(Cronbach’s α = .92) and construct validity (Becker, 1992; Cho, (26.1)
Other (OB/GYN, Peds, Psych)
1999). In this study, Cronbach’s alpha was .90. Age (years) 81
25.6 (16.4)
(3.79)
Patient Safety Nurse-assessed patient safety was measured Note. N = 508. ER = emergency
using the quality care and adverse events items by Aiken et al. room; ICU = intensive care unit; OB/
(2001). Nurse perception of the frequency of 10 adverse events GYN = obstetrics/gynecology; OR =
operating room; SD = standard
was assessed. Six adverse events were used by Lucero, Lake, and deviation.
Aiken (2010): Patient received wrong medication or dose,
nosocomial infections, complains from patients or their families, n
patients’ falls with injuries, work-related injuries to employees, (%) (SD = 3.79). Two-thirds
and incidents of verbal abuse toward nurses; these events were (64.5%) reported junior
linked to nurse staffing. The four additional items we used were college as the highest level of
wrong medication or dosage, nosocomial infection, complaints education received, and
from patients or their families, and patient falls that result in 32.9% were baccalau-reate
injury. Each item was rated on a 4-point Likert scale from 1 = Gender (female) prepared. Half (56%) worked
never to 4 = frequently. Higher scores indicated more frequent 492 between 41 and 50 hours per
occurrences of the adverse events. In this study, the reliability of (97.2) week, and 19.2% worked
this scale was Cronbach’s alpha = .70. Religious affiliation (no)
253 more than 50 hours a week.
(50.8) Most worked on either
Data Analysis Education (highest level) medical-surgical units
(57.6%) or spe-cial care units
(26.1%).
Descriptive statistics and reliability based on Cronbach’s alpha
were used. Pearson correlations among all study variables were Some college
computed. The Statistical Package for the Social Sci-ences 322 Means and Correlations
(64.5)
(version 19.0) was used for this analysis.
Bachelor’s degree
164 The means, standard
Structural equation modeling was used to estimate coeffi-cients (32.9) deviations, Cronbach’s alpha,
of hypothesized pathways of three competing models. The Master’s degree or higher and corre-lations among
13
Analysis of Moment Structures program (version 19.0) with (2.6) major study variables are
maximum likelihood estimation and estimation of means and Work experience (years) shown in Table 2. The mean
2 scores of the person-related
intercepts. The χ test statistic and several indices of fit were
subscale, work-related sub-
used to evaluate the models: comparative fit index (CFI),
scale, and intimidation-
incremental fit index (IFI), and root mean square error of the <1 related subscale for WPB
approximation (RMSEA; Bollen, 1989). If the values for CFI 65
(13.1) were 1.47 (SD = 0.57), 1.60
and IFI are 0.90 or higher and the values for RMSEA are
1–1.9 (SD = 0.61), and 1.40 (SD =
between 0.05 and 0.08, a model is considered to have good
120 0.50), respec-tively. The mean
model fit (Bollen, 1989; Munro, 2005). For model com- (24.3) scores of the verbal abuse,
parison, the Akaike Information Criterion (AIC) was used 2–2.9 physical threat, and physical
(Jöreskog, 1993); the model with the lowest AIC value is se- 88
(17.8)
assault subscales of LV were
lected as the best model among a set of theoretically plausible
3–3.9 1.07 (SD = 0.65), 0.86 (SD =
competing models.
83 0.51), and 0.77 (SD = 0.46),
(16.8) respectively. The mean WPB
RESULTS Q4 exposure score was 1.50 (SD
138
(27.9)
= 0.53), and LV was 0.87 (SD
Participant Characteristics Work effort (hours per week) = 0.48).

A total of 530 questionnaires were distributed, and 508 were Before testing the model, a
returned; the response rate was 95.8%. Of these 508 returned, correlation matrix was
e40
prepared. WPB subscales and
442 had no missing data. The demographic and work-related 119
(24.8) job stress were significantly
characteristics of the sample are shown in Table 1. Most of the
41–50 associated with all study
nurses were female (97.2%), and average age was 25.6 years variables (Table 2). All of the
269
(56.0) subscales of WPB and LV
51–60 ariables showed significant
67 relationships—except for LV
(14.0)
physical assault. Person, work,
Q61
intimidation-related WPB were significantly related to job stress (r = .26, p < .001; r = .37,
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384 Workplace Bullying, Job Stress, and Patient Safetywww.nursingresearchonline.com

TABLE 2. Correlations Among Major Study Variables (N = 508)

Variable
1
2
3
4
5
6
7
8
9

1.
Personal-related
.93

2.
Work-related
.78***
.80

3.
Intimidation-related
.78***
.70***
.61
4.
Verbal abuse
.34***
.32***
.32***
.69

5.
Physical threat
.25***
.20***
.25***
.73***
.88

6.
Physical assault
0.07
0.04
.09
.66***
.86***
.99

7.
Job stress
.26***
.37***
.23***
.17***
.11**
–.01
.82

8.
Intent to leave
.25***
.32***
.17***
.16***
.06
–.06
.59***
.90

9.
Patient safety
.15***
.19***
.17***
.04
.03
.01
.13**
.21***
.70

Range
1–5
1–5
1–5
0–4
0–4
0–4
1–5
1–5
0–3
M

1.47
1.60
1.40
1.07
0.86
0.77
2.49
3.18
1.64
SD
0.57
0.59
0.50
0.65
0.51
0.46
0.32
0.98
0.49

Note. N = 508. Reliabilities estimated using Cronbach’s alpha are on the diagonal. *p < .05. **p < .01. ***p < .001.
which nurse work the three alternative models,
p < .001; r = .23, p < .001), intent to leave (r = .25, p < .001; r environment dimensions of Models A and B showed less
= .32, p < .001; r = .17, p < .001), and patient safety (r = .15, p < WPB and LV may influence adequate fit to the data than
.001; r = .19, p < .001; r = .17, p < .001). nurse-assessed patient safety. Model C. Results of our study
Mediating variables tested imply that there is conceptual
included the following work overlap between WPB and the
Verbal abuse and physical threat were related to job stress (r = .
outcome di-mensions: job verbal abuse and physical
17, p < .001; r = .11, p < .01), and verbal abuse was re-lated to
stress and intent leave. We threat in-dicators of LV.
intent to leave (r = .16, p < .001). None of the LV sub-scales
compared three alternative
showed a significant correlation with nurse-assessed patient
hypothesized models to Low rates of LV have been
safety. Intent to leave was significantly associated with all of the
explain how nurses per-ceived reported in studies in Western
variables—except physical threat and physi-cal assault. Patient
WPB would be associated countries; however, recent
safety was significantly associated with all subscales of WPB
with job stress and intent reports of physical violence, in-
and intent to leave (r = .21, p < .001; Table 2).
cluding physical threat, have
to leave and, in turn, nurse raised concern in some coun-
Model Selection judgments about patient tries such as South Korea and
Australia (Rodwell & Demir,
safety. We tested a
Using the AIC, Model C (uncorrelated factors with complex 2012). Actual physical harm
hypothesized model derived
among Korean nurses has often
factor loadings for verbal abuse and physical threat) was and generated from the been featured in the media and
selected. This model showed a better fit to the data (χ = 179.1, literature on the relationships
2
literature (Choi, 2015; Kim,
2 of perceived nega-tive work 2006; Oh et al., 2016; Park,
df = 64, χ /df = 2.8, CFI = 0.95, IFI = 0.95, RMSEA = 0.06) than environments and patient
2014). We speculate that verbal
the other models (Table 3). In addition, most pathways in Model safety outcomes. Previ-ous abuse and physical threat—
C were statistically significant except the direct path between studies and the results of this physical forms of LV—strongly
LV and job stress, intent to leave, and nurse-assessed patient study support the proposition in-fluence nurse-perceived
safety (Figure 1). The results showed that WPB directly and that nurse-assessed patient patient safety in this study.
indirectly influenced nurse-assessed pa-tient safety. Job stress safety issues may be Because LV have been defined
directly influenced intent to leave, and intent to leave directly influenced by WPB, job and studied mainly in Western
influenced nurse-assessed patient safety, as shown in Table 4. stress, and intent to leave. coun-tries, little is known about
LV was not significantly associated with job stress, intent to the prevalence, types, and
leave, or patient safety. degrees of LV in other cultures.
Our assessment of the
Answering these questions
adequacy of the model to might
DISCUSSION explain the phenomena of
work conditions and patient
outcomes is mixed. Among TABLE 3. Model Fit Statistics
The aim of this study was to explore the mechanisms through Model
AIC .900 2.8
2 .084 .951
χ b
B .952
df .060
359.658
p
273.66
χ /df
2
65 Note. AIC = Akaike Information
CFI <.001 Criterion; CFI = comparative fit index;
IFI 4.2 IFI = incre-mental fit index; RMSEA =
.912 root mean square error of
RMSEA
a .913 approximation. aTwo un-correlated,
A
.080 simple structure. bTwo correlated
387.661
C
c factors, simple structure. cTwo
303.66
267.091 uncorrelated factors, complex factor
66 loadings (both factors associated
<.001 179.09 with physical threat and verbal
4.6 64 abuse).
.899 <.001
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Nursing Research • September/October 2016 • Volume 65 • No. 5 Workplace Bullying, Job Stress, and Patient Safety385

FIGURE 1. Path model with parameter estimates; p-values are shown for significant structural paths only. Patient safety refers to nurses'
perceptions of safety. LV = lateral violence; WPB = work place bullying.
work environments, perceived impact patient safety is-sues.
also benefit from qualitative study approaches that would quality of care, and pa-tient WPB had a direct influence
encourage a fuller explanation of the situations that nurses safety are related (Coetzee et on patient safety through job
experience. al., 2013; Purpora & Blegen, stress and intent to leave,
2012). Nurses intending to highlighting the fundamental
leave their hospitals because im-portance of preventing
WPB showed a direct and positive relationship with job stress,
of job dissatisfaction had WPB for patient safety issues.
intent to leave, and nurse-assessed patient safety components of
higher levels of burnout and Future studies examining the
the model. This is congruent with previous re-search linking
were more likely to interrelationships of these
WPB to other correlates of lower job satisfac-tion (Quine,
jeopardize patient safety. workplace factors are needed
2001), the primary mechanism for intent to leave (Simons,
to increase our understanding
2008), and negative patient outcomes such as falls and
of the phe-nomena and the
medication errors (Roche et al., 2010). These findings highlight
potential consequences for
the potential importance of WPB in impacting work conditions
patient care qual-ity and
and patient care outcomes.
Intent to leave had a safety. Another area not fully
explored is the impact of
Job stress has been repeatedly identified as a potential predictor direct influence on WPB on nurse morale that
and key mediating factor for many negative hospital outcomes, threatens specific deficits in
including nurse intent to leave and patient quality care. Previous
research found an association of increased job stress causing nurse-assessed
TABLE 4. Direct, Indirect, and
decreased work capacity. Job stress was a pre-dictive factor for patient safety. Total Effects (Structural
intent to leave (Zhang et al., 2014). Job dissat-isfaction and Model)
intent to leave one’s job are the strongest predictors of actual In our study, WPB seemed to
turnover (Zhang et al., 2014), and in-creased turnover rates have a significant influence Path
exacerbate organizational burden and decreased quality care due on well-known nurse DE
to the decline of nursing care con-tinuity, which finally have a retention factors, such as job IE
negative impact on patients (Purpora & Blegen, 2012). stress and intent to leave. Our TE
findings also provided some
Intent to leave had a direct influence on nurse-assessed patient insight into how these
safety. This is congruent with research showing that nurses’ concepts may interrelate to

WPB !Job stress
0.34
0.34
WPB !Intent to leave
0.10
0.19
0.29
WPB ! Patient safety
0.15
0.04
0.19
LV ! Job stress
386 Workplace Bullying, Job Stress, and Patient Safety
clinical practice. At a very practical level, what particular
types of patient care issues are impacted by the interaction of a
negative workplace and impaired nurse performance caused in
part by the abusive nature of WPB. A range of questions
surface about the cultural dimensions of nurse-to-nurse
relationships, what is expected, and how nurses adapt to and
cope with negative work environments. Along this line is how
WPB and LV are expressed in different set-tings and cultures.
There is some evidence, for example, that LV is more
prevalent in some instances such as South Korea; qualitative
data might bring these taboo sub-jects to the surface for
discussion and reveal how these more aggressive behaviors
are impacting nurses and their perceptions of patient care.
Implications for Practice
WPB can have a pervasive, destructive impact on not only
nurses but possibly on patients as well. It is important that
nursing leaders and managers reexamine their policies and
procedures, making sure that they respect the potential conse-
quences of WPB. Providing a supportive work climate by dis-
couraging WPB may play an important role in retaining
clinical nurses and reducing patient care errors. Nurse
managers have a key role in developing safe and supportive
hospital work environments, and research has shown that
leader-ship styles may result in reduced instances of WPB.
Organi-zational efforts to develop positive leadership skills
and competencies at the nurse management and clinical nurse
levels may reduce the occurrence of negative exchanges and
potential consequences for nurse work life and patient
outcomes.
Limitations
Some limitations should be considered when interpreting
study results. Inferences about cause and effect are inappro-
priate. This was a cross-sectional study, and we surveyed a
convenience sample of nurses in one area of South Korea.
Furthermore, the topic of the study may have raised con-cern
and influenced nurses’ responses to survey questions,
particularly those relating to WPB and the perception of pa-
tient safety issues. Along these lines, response bias may have
occurred because of the fact that the hospital nursing directors
were gatekeepers of the distribution of study sur-veys. The
response rate in this study was noticeably very high, leading
−0.01 0.56
Job stress ! Patient safety
−0.04
−0.01
0.11
LV ! Intent to leave
0.07
−0.06
Intent to leave ! Patient safety
−0.00
0.20
−0.06
LV ! Patient safety
−0.00 0.20
−0.01
−0.01
Note. N = 508. DE = direct effect;
Job stress ! Intent to leave IE = indirect effect; LV = lateral
0.56 violence; TE = total effect; WPB =
workplace bullying.
Kluwer Health, Inc. All
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Copyright © 2016 Wolters
one to wonder about any pressure nurses may have felt to
participate. We did, however, provide questionnaire packets
with stamped return envelopes to protect their anonymity. In
the future, online survey for-mats using anonymous features
might make nurses feel more comfortable.
This study relied on nurse perceptions of their work
environments—perceptions that could not be further substan-
tiated with observational or record data that would lend
www.nursingresearchonline.com
credibility to nurses’ judgments. Nurse perceptions of quality
care and patient safety have been used as a proxy in other
studies linking work environmental conditions with patient
outcomes. Although not ideal, they do give some evidence of
important work outcome consequences.
We acknowledge the limitations of our model in captur-ing the
many structures, processes, and primary and second-ary
outcomes associated with such complex phenomena as nurse
and patient care outcomes. Furthermore, any differ-ences
across hospitals were not captured; differences at the unit or
hospital level might reveal important contributions of nurse
leadership and hospital level policies impacting the practice
environment (Kirwan et al., 2013). Given the com-plexity of
studies of this kind, significant resources are needed to add to
the body of knowledge about the impact of WPB on nurse and
patient outcomes.
Conclusion
We explored linkages among WPB, LV, job stress, intent to leave,
and patient safety. The results of this study provide important
implications for future research examining the mechanisms by
which WPB may influence patient safety via job stress and intent
to leave. Workplace environment issues are critical matters for
healthcare professionals—not just to the quality of nurses’ work
life but to patient outcomes as well.
Accepted for publication May 18, 2016.
The authors acknowledge that research was partly supported by
the Basic Science Research Program through the National
Research Foundation of Korea (NRF) funded by the Ministry of
Science, ICT & Future Planning (NRF-2014R1A1A1005049).
We express our sincere gratitude to editors, Susan J. Henly and
Sherry Handfinger for their expertise and support.

The authors have no conflicts of interest to report.
Corresponding author: Dong-choon Uhm, RN, PhD, Department of
Emergency Medical Technology, Daejeon University, 62 Daehak-ro,
Dong-gu, Daejeon 300-716, South Korea (e-mail: dchuhm@dju.kr). X
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