Interventions for Preventing and Resolving Bullying in Nursing: A Scoping Review

Bullying in the workplace is a serious problem in nursing and has an impact on the well-being of teams, patients, and organisations. This study’s aim is to map possible interventions designed to prevent or resolve bullying in nursing. A scoping review of primary research published in English and Italian between 2011 and 2021 was undertaken from four databases (Cochrane Collaboration, PubMed, CINAHL Complete, and PsycInfo). The data were analysed using Arksey and O’Malley’s framework, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) Checklist was followed to report the study. Fourteen papers met the review eligibility criteria. The analysis revealed four main themes: educational interventions, cognitive rehearsal, team building, and nursing leaders’ experiences. Interventions enabled nurses to recognise bullying and address it with assertive communication. Further research is needed to demonstrate these interventions’ effectiveness and if they lead to a significant decrease in the short-/long-term frequency of these issues. This review increases the available knowledge and guides nurse leaders in choosing effective interventions. Eradicating this phenomenon from healthcare settings involves active engagement of nurses, regardless of their role, in addition to support from the nurse leaders, the organisations, and professional and health policies.


Introduction
Bullying, incivility and workplace violence are widespread issues in nursing [1].Before approaching research projects or implementation studies on these phenomena, it is necessary to understand the meaning of the terms used in the literature to refer to them.Some definitions claim that bullying is persistent negative actions aimed at damaging the target's professional and personal relationships through social exclusion and harassment [2], with unwanted, repeated, and harmful actions with the aim of humiliating, offending, and causing distress in the recipient [1].Bullying can be carried out by managers or supervisors (vertical bullying) when managers do not recognise the abilities of employees, deprive them of career opportunities, and deny them promotion or training, or gossip to damage their reputation, or by colleagues (horizontal bullying) when a nurse is yelled at, belittled, or receives demeaning and impertinent remarks from colleagues, sometimes in front of other nurses, patients, and their families [3,4].Lateral violence can occur as an isolated incident with no gradient of power between individuals (peers) in a shared culture.Conversely, bullying comprises repeated occurrences for at least six months [5].Bullying and lateral violence share behaviours such as sabotage, internal fighting, scapegoating, and excessive criticism [2].It has been hypothesised that workplace violence is rarely a sudden event, but rather the culmination of an escalation of negative interactions between people, beginning with low-intensity abuse typical of incivility [3].Incivility is defined as "one or more rude, discourteous, or disrespectful actions that may or may not have negative intent" [1].

Aim of Study
To map possible interventions designed to prevent or resolve bullying in nursing.

Research Design
A scoping review was conducted between April and July 2021, and followed the first five steps of the methodological framework proposed by Arksey and O'Malley [15]: (a) identify the review question on a broad domain of a discipline; (b) identify relevant studies; (c) study selection; (d) data charting; and (e) reporting results.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) Checklist was followed to report the study [16].

Identifying the Review Questions
Are there interventions that enable the prevention of bullying in the nursing profession in healthcare settings?
Are there interventions that enable the resolution of bullying in the nursing profession in healthcare settings?

Identifying Relevant Studies
We began by consulting a librarian for recommendations on the most relevant databases for this topic: the Cochrane Collaboration, PubMed, CINAHL Complete, and PsycInfo.MeSH and free terms were used, adapting them to the specific search methods of each database.The keywords bullying, lateral violence, horizontal violence, mobbing, workplace incivility, harassment, nursing, nurse, prevention, intervention, and solving were combined variously using the Boolean AND and OR operators, resulting in a search strategy that best answered the review questions (Table 1).

Study Selection
Two reviewers conducted the search simultaneously by applying predetermined inclusion and/or exclusion criteria to all papers independently at each stage of the selection process [17].The inclusion criteria for articles were: (1) concerning bullying, lateral violence, or incivility between employees; (2) pertained to all healthcare settings and the nursing profession, specifically related to graduate nurses; (3) published between January 2011 and March 2021; (4) published in English and Italian; and (5) all study design types (quantitative, qualitative, and mixed-methods).Given the large number of empirical studies on the topic, we excluded conference papers, editorials, reports, books, and grey literature.
Each researcher conducted a selection process to determine article eligibility with an initial screening phase based on the information provided in the title and abstract, followed by mutual comparison and subsequent full-text screening, resulting in a classification of included, excluded, or uncertain studies.The comparison at the end of each stage aimed at maintaining an approach consistent with the review questions [17].To resolve disagreements or doubts regarding the selected articles, the researchers consulted an experienced external researcher [17].

Data Charting
The authors constructed a tool that considered the elements of the review objective and question (author, year, country, objectives, study design and data collection instruments, participants/contexts, type of intervention, and key findings).This tool was used to graphically represent the data extraction process.

Ethical Considerations
As the scoping review did not involve human beings, the approval of an ethics committee was not necessary according to the Swiss Federal Human Research Legislation [18].

Results
Of the 1066 articles initially identified, after removing duplicates and studies considered irrelevant, 88 articles were selected for full-text screening and 14 met the review eligibility criteria.The selection process is depicted in Figure 1 [19].
As the scoping review did not involve human beings, the approval of an ethics committee was not necessary according to the Swiss Federal Human Research Legislation [18].

Results
Of the 1066 articles initially identified, after removing duplicates and studies considered irrelevant, 88 articles were selected for full-text screening and 14 met the review eligibility criteria.The selection process is depicted in Figure 1 [19].The included studies (Table 2) were mainly conducted in the United States of America (twelve) and South Korea (two).The acute setting characterised all included studies, most of which were conducted in a single institution (ten), some in multiple institutions (two), and others were national surveys (two).Quantitative approaches were dominant (nine), followed by mixed-methods (three) and qualitative approaches (two).The main objectives common to the studies aimed at understanding the effectiveness of interventions by increasing the awareness and recognition of the phenomenon among nurses, reducing bullying in the analysed contexts, and acquiring knowledge and skills to deal with and respond to bullying situations.A qualitative study investigated the effectiveness of interventions based on nurse leaders' experiences; another pursued the goal of The included studies (Table 2) were mainly conducted in the United States of America (twelve) and South Korea (two).The acute setting characterised all included studies, most of which were conducted in a single institution (ten), some in multiple institutions (two), and others were national surveys (two).Quantitative approaches were dominant (nine), followed by mixed-methods (three) and qualitative approaches (two).The main objectives common to the studies aimed at understanding the effectiveness of interventions by increasing the awareness and recognition of the phenomenon among nurses, reducing bullying in the analysed contexts, and acquiring knowledge and skills to deal with and respond to bullying situations.A qualitative study investigated the effectiveness of interventions based on nurse leaders' experiences; another pursued the goal of understanding the prevalence of the phenomenon.The narrative synthesis of results identified four themes: educational interventions, cognitive rehearsal, team building, and nurse leaders' experiences.The education sessions for the nurses included case studies, review of the literature about the effects of incivility in the workplace, and an overview of recommendations for a healthy work environment along with resources for the nurses.Then a facilitated discussion was conducted describing personal experiences of nurses in the adult ICU setting.This included discussions about professionalism, behaviors, attitudes, and ways to prevent workplace incivility.Five education sessions of one hour took place.
The postintervention score had a higher mean than the preintervention score in each of the dimensions.Higher scores indicate incivility; thus, lower scores indicate civility.Therefore, more instances of incivility were identified after intervention to increase awareness of incivility.The results of the current study found that incivility perceptions were higher in the postintervention survey; these findings suggest that the education was effective, thus creating more awareness of incivility.

Walrafen et al. 2012 [24]
United States The purpose of the study was to determine the prevalence of horizontal violence in a multi-institutional hospital system.
A mixed-method descriptive design was used, using the Horizontal Violence Behaviour Survey and the participants were asked to respond to three open-ended qualitative questions.
All nurses in the multi-institutional health care system were invited to participate in the study.The final project consisted of 6 sessions with each session rolled out at 2-to 3-week intervals.Each session consisted of (1) a 30to 60 min in-service group activity embedded into standing unit meetings, (2) online journal club readings, and (3) morning huddles prior to when care of study patients commenced where the key information from the group activities and readings was discussed and reinforced.Didactic content on BLV was culled from the empiric and policy literature and additional pedagogical resources were identified.Each session began with an overview of the objectives to be covered, a brief review of previous material, and a short didactic session and supportive experiential activities, followed by group discussion.
Throughout this project, it was clear that the topic of BLV was meaningful to participants.For some of the experienced nurses, the information helped explain and label incidents they may have encountered earlier in their careers.

Educational Interventions
Some authors proposed educational interventions to address bullying [20][21][22][23][24].These interventions considered the characteristics and consequences of bullying and were designed and carried out heterogeneously.Nikstaitis and Simko [23], starting with a literature review of the effects of incivility in the workplace and an overview of recommendations for a healthy work environment, stimulated a discussion among participants that included personal experiences, professionalism, attitudes, behaviours, and ways to prevent incivility.Howard and Embree [21] proposed an e-learning training, "Bullying in the Workplace: Solutions for Nursing Practice", with content on bullying, reacting under stress, identifying conflict management styles, and creating safe environments.It was an online activity that used scenarios to enable participants to practise what they had learned.The use of scenarios for cognitive training of nurses to handle workplace bullying was also proposed by Kang and Jeong [22] in the form of a smartphone app, which included an introduction to nonviolent conversation as standard communication, six bullying scenarios, and a question and answer board.Chipps and McRury [20] followed up an educational moment on bullying with an online registry and checklist of negative behaviours for nurses to record behaviours observed or experienced during each shift over seven months.
Walrafen et al. [24] conducted a survey to determine the prevalence of horizontal violence that showed that the majority of participants witnessed/experienced eight of the nine behaviours associated with horizontal violence.They proposed a training program, "Sadly Caught Up in the Moment: An Exploration of Horizontal Violence", which contained a review of each behaviour and appropriate responses.

Cognitive Rehearsal
Authors of four studies implemented cognitive rehearsal training, a communication technique taught to participants as a strategy to stop uncivil behaviour [25][26][27][28].After a training intervention on incivility, Razzi and Bianchi [28] engaged participants in cognitive rehearsal training using cards with written responses to uncivil behaviour and providing examples of how to respond to such behaviour.This was followed by a role-play session in which they practised applying these responses.Kang et al. [26] investigated the effects of a cognitive rehearsal program on bullying among nurses using four phases.In the first phase, "scenario development", nine bullying scenarios were created from the results of previous studies and interviews with nurses.In the "creation of communication standards" phase, participants made desirable communication for the scenarios by employing four components of the nonviolent communication technique.In the "role-playing" phase, they simulated the nine situations in a safe environment to express/manage the experienced anger, preventing the vicious cycle of bullying.Finally, in the "re-role-playing" phase, they developed cognitive training for means of coping transferable to similar situations in the future.Additionally, Kile et al. [27] proposed a training intervention on incivility with definitions, examples, ways of manifestation, and effects on nurses, patient safety, and organisations.They taught the cognitive rehearsal technique using visual cues written on cards to instruct participants on the main forms of incivility and appropriate responses.To personalise the training, they provided ten incivility scenarios specific to the care context in the role-play and application phases of cognitive rehearsal.Balevre et al. [25] started with a policy of non-tolerance of bullying and leadership empowerment as support for employee empowerment and structured training on the psychodynamics of bullying and coaching in cognitive rehearsal.Through cognitive rehearsal exercises and role-playing with scenarios designed to practise learned responses, they taught nurses defensive techniques against bullying.An effective and professional alternative to lateral violence for communicating needs, expectations, and conflicts was proposed by Ceravolo et al. [29] through the use of workshop moments to improve assertive communication skills, healthy conflict resolution, elimination of a culture of silence, and awareness of the impact of lateral violence.

Team Building
Some authors have proposed activities aimed at team building through member interactions [30][31][32].Vessey and Williams [32], starting with a bullying situation, implemented a cognitive program in which each session included an overview of the objectives to be addressed, a brief review of the material, a didactic session, supportive experiential activities, and a group discussion.These sessions were held during morning meetings before patient care started through journal club activities.
Armstrong [30], through the Civility, Respect, Engagement in the Workforce (CREW) intervention, aimed to increase civility in the workplace as a response to what employee evaluations indicated about the interpersonal climate [34].The four-week intervention included one meeting per week.In the first meeting, she used the "Anything Anytime" tool, which started with a discussion of a generic topic and enabled an understanding of group members' varying perspectives.In the second meeting she used the "Geometry of Work Styles" tool, which requires participants to choose from four geometric shapes that relate to a personality type.On the third day, using cues from nursing research, she stimulated a discussion on the definition and characteristics of incivility and assertive responses to it.Finally, participants practised actively replying to incivility scenarios in an interactive and safe setting.Each session concluded with a discussion of how a civil workplace can be reached, regardless of individual differences.Keller et al. [31] explored the perceptions, attitudes, and experiences of nurses who completed the Bullying Elimination Nursing in a Care Environment (BE NICE) Champion program.This program taught them how to recognise signs of bullying and provide support to their peers, facilitating the creation of bullying intervention strategies through didactic training and role-plays simulating bullying scenarios and the correct way to deal with them using the 4S strategy.The first S, "Stand by", requires facilitators to be close to the bullying victim to convey the message that they are not alone."Support" implies that facilitators show empathy, actively listen, and acknowledge the victim's feelings.Involved people who report bullying to nurse leaders apply the "Speak up" component of the 4S strategy."Sequester" implies that facilitators remove the victim from the situation.

Nursing Leaders' Experiences
Skarbek et al. [33] highlighted which interventions are considered effective in addressing bullying from nurse leaders' perspectives.While institutional "mandatory programs" are not perceived as effective, nurse leader-initiated individual unit-level interventions, in collaboration with administrative and institutional support, were seen as effective ways to address bullying.They agree that to establish a healthy work environment, the behavioural characteristics of collaboration, respect, effective interpersonal communication, collegiality, and mutual support must be evident to those entering the profession, senior nursing staff, and nurse leaders to build positive social practices.

Discussion
The magnitude of bullying in nursing has led nurse leaders to question more about the extent of the phenomenon within their own institutions, an aspect confirmed by an exponential increase in publications in recent years.Bullying often occurs with a peer form of hostility towards novices, but nurses with more years of service and nurse leaders are also exposed to this phenomenon [2,9,35,36].Therefore, it is necessary to know if there are interventions to prevent or resolve bullying among nurses in healthcare settings.The findings from the 14 identified studies highlight different interventions designed with the aim of testing their effectiveness in addressing and curbing bullying.Despite the heterogeneity of the proposed interventions, the common goal was to increase the awareness and recognition of bullying among nurses, develop the ability to respond assertively to uncivil behaviour, and reduce bullying in the analysed contexts.Educational interventions have been offered in the form of training sessions [20,23,24], e-learning [21], and a smartphone application [22].Some of these facilitated knowledge creation about bullying through case discussions, literature reviews, and discussions of uncivil behaviour and consequences [20,23].Others have found it necessary to increase knowledge regarding types of communication, such as conflict management, crucial conversations, and nonviolent communication [21,22], and still others have used prevalence results on lateral violence to create training on the behaviours that emerged from the study [24].In terms of evaluating intervention effectiveness, post-intervention measurements have been used that have given varying results, including an increase in perceptions and experiences of bullying; this is considered a positive indicator as it allows for the identification of negative behaviours and increased awareness [20,23].Evaluations of the educational interventions revealed their influence on communication skills, which resulted in a positive effect on conflict management strategies among nurses and decreases in work-related bullying experiences and turnover intention [21,22].The impact of the educational program on the behaviours noted in their own care settings [24] has been linked to the development of dialogue among nurses and their sense of professional responsibility, which are useful in breaking the cycle of horizontal violence in work environments.
Cognitive rehearsal [25][26][27][28], the most widely used intervention, is a therapeutic technique in which an individual imagines situations that tend to produce anxiety or self-destructive behaviours and then repeats positive coping statements or mentally rehearses a more appropriate behaviour [37].For its implementation, the authors used bullying scenarios, provided positive coping responses to those scenarios, and included role-play in which participants could practise the learned responses [25][26][27][28].An evaluation of its effectiveness has shown that this approach improves interpersonal relationships, trains people to cope with bullying, decreases turnover intention [26], causes a perceived change in group behaviour in dealing with bullying, creates positive cultural change [25], and results in an increase in the ability to both recognise incivility and deal with it [27], an increase in awareness of incivility [28], and a reduction in the incidence of exposure to incivility [27,28].Another type of intervention is related to healthy conflict resolution through assertive communication and eliminating the culture of silence among nurses [29].To achieve this, nurse leader-focused workshops were held in which their roles in demonstrating learned behaviours to employees was emphasised, followed by interventions to foster peer learning.The effectiveness of this intervention was observed in decreased verbal abuse, increased perception of a respectful workplace, and a higher rate of nurses determined to solve the issue after an episode of lateral violence.
Finally, team-building interventions have been proposed in different formats and settings.Vessey and Williams [32] presented a cognitive program starting from an actual bullying case, integrating discussions on the topic and experiential and journal club activities into daily nursing unit meetings.Armstrong [30] adopted the CREW method with the goal of team building and creating awareness of how a civil workplace can be achieved, regardless of individual differences.Keller et al. [31] emphasised the recognition of bullying and peer support using the 4S intervention to convey messages of closeness to the bullying victim, to show active listening, encouraging the reporting of bullying to superiors, and actively intervening when it occurs to remove the victim from the situation, discouraging the vicious cycle of the phenomenon.The effectiveness of team-building interventions has been demonstrated through the detection of positive and proactive engagement among participants [32], an increase in nurses' competence to recognise workplace bullying, and the ability to respond when it occurs [30,31].
In addition, this review found that nurse leaders' organisational engagement and support, through behaviours that model for co-workers, is a vital component of empowerment and is crucial and effective in addressing workplace bullying [25,29,31,33], and that it is important to intervene at all levels (society/policy, organisation/employer, work/task, and individual/work interface) to prevent it [38].In contrast, implementing zero-tolerance policies and passive dissemination of information about bullying have proven ineffective [39].
The studies predominantly considered interventions implemented in the acute hospital setting to address a problem present in the analysed settings evidenced by pre-intervention measurements [20][21][22][23][24][26][27][28][29].Although the implementation of these interventions was related to solving the problem, they are believed to have the potential to reduce bullying and consolidate a positive and civil culture in the workplace, and can be used with preventive intent and implemented by all nurses (novice and experienced).

Strengths and Limitations
Among the main strengths of this review are the adoption of a reproducible method and the systematic approach.To reduce the possibility of selection bias to a minimum, the study selection procedures described in the methods were rigorously adhered to.In accordance with the methodology used, a quality appraisal process was not performed on the included studies.
The geographic concentration of studies in only two countries may limit the transferability of results to other health systems, as bullying tends to be related to the culture of the setting.Limiting the review to articles published in English and Italian and to literature published in databases may have led to an incomplete overview of available data and knowledge that could have added information to this review.However, the researchers chose to include articles describing research projects on the topic to identify effective interventions to counter bullying, with a view to future research projects.

Conclusions
This review revealed that several interventions have been designed to address the problem of bullying among nurses in healthcare settings by implementing educational, cognitive, and empowering interaction approaches among team members.Although the results showed the effectiveness of the interventions concerning nurses' recognition of the phenomenon and increased skills in addressing it with assertive communication, only a slight and not always significant reduction in the presence of this phenomenon was observed.Consequently, new research projects are necessary to demonstrate the effectiveness of the interventions, including healthcare settings other than those where they have been implemented so far, robust study designs, such as RCTs, to assess their real effectiveness and adaptability to the context, and to understand whether the effects persist over time, leading to a significant decrease in the frequency of bullying among nurses.It will, moreover, be the responsibility of each nurse leader to identify the intervention that best fits their context.
Nurse leaders play a crucial role in preventing bullying in care settings.They should have a thorough understanding of the manifestations of the phenomenon and its consequences to recognise timely dysfunctional relational dynamics arising in their own teams and with peer leaders or superiors.Nurse leaders also have a responsibility to recognise and address personal, environmental, organisational, and cultural factors that may facilitate bullying in their context.This review helps to increase available knowledge on the topic and guides nurse leaders in choosing effective interventions to be adapted and implemented in the specific context.It also raises their awareness of the importance of leading by example, recognising their teams' relational patterns, and discouraging hostile peer interactions as preventive actions to foster cultural change in their context.Eradicating this phenomenon in healthcare settings involves active engagement of nurses, regardless of their role, in addition to support from the nurse leaders, the organisations, and professional and health policies.
learned, "re-role-playing" was performed to practice them."Feedback and evaluation" of the final stage, was performed in every session.In this study CRP comprised 10 sessions in a total of 20 h for 5 weeks.Each session took 2 h.