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

DOI: 10.1097/NNR.0000000000000175

380 www.nursingresearchonline.com

R ecent widespread policies have brought new atten-

tion to unacceptable occurrences of unsafe care. All

healthcare professionals consider providing safe, error-free
patient care as their first priority. Under conditions of a
negative work environment, such as exposure to work-place
bullying (WPB) and lateral violence (LV), nurses are not
likely to work at their best, which, in turn, may translate to
poor patient care practices (Kirwan, Matthews, & Scott,
2013). Recent studies have confirmed the impact of negative
nurse work environments on patient safety (Aiken et al.,
2012; Van Bogaert, Kowalski, Weeks, Van Heusden, &
Clarke, 2013).
Hyunjin Oh, RN, PhD, is Assistant Professor, College of Nursing,
Gachon Univer-sity, Incheon, South Korea.
Patient safety refers to achieving desired patient outcomes in
safe healthcare settings (Kim, Lyder, McNeese‐Smith, Leach, &
Needleman, 2015). Patient safety is a comprehensive con-cept,
which is influenced by various factors, such as health pro-
fessional individual characteristics, communication difficulties,
team relationships, and system factors (Kim et al., 2015). It is a
quality nursing care outcome defined as “avoiding and
preventing patient injury or adverse events during the deliv-ery
of nursing care” (Kim et al., 2015). Quality patient-centered care
aimed at protecting patient safety requires positive, collaborative
relationships among nursing colleagues. Stress-laden working
environments can be exacerbated by negative behaviors toward
nurses, such as bullying and vio-lence (Roche, Diers, Duffield,
& Catling‐Paull, 2010).

Dong-choon Uhm, RN, PhD, is Associate Professor, Department of

Emergency Medical Technology, Daejeon University, South Korea.
Taken together, WPB, LV, job stress, and intent to leave may
have a negative influence on patient safety—especially when
and if it occurs in the clinical setting. Exposure to a neg-ative
Young-Joo Yoon, PhD, is Assistant Professor, Department of
work environment can cause job stress, as well as psy-
Statistics, Daejeon University, South Korea.
chological and physiological distress (Spence Laschinger,
2014; Van Bogaert et al., 2013). Indeed, nurses have wanted

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Nursing Research • September/October 2016 • Volume 65 • No. 5
to leave their jobs when exposed to negative work environ-
ments and high job stress (Ariza-Montes, Muniz, Montero-
Simó, & Araque-Padilla, 2013; Rodwell & Demir, 2012;
Simons, 2008; Spence Laschinger, Grau, Finegan, & Wilk,
2010). Workforce outcomes such as job dissatisfaction and
intent to leave are significantly associated with patient safety
(Coetzee, Klopper, Ellis, & Aiken, 2013), but little research
has at-tempted to explore the usefulness of a theoretical
model to examine these linkages to patient safety.
Two critical occurrences known to impact nurse work life and
potentially impact patient safety are WPB and LV. WPB
refers to repeated and regular attacks or acts of social ex-
clusion on someone for more than 6 months in the workplace
(Einarsen, Hoel, Zapf, & Cooper, 2011). Different but related
to WPB, LV has been referred to broadly as horizontal vio-
lence, horizontal hostility, bullying, and workplace incivility
(Embree & White, 2010). Although WPB and LV overlap,
they have differences, and each can negatively impact the
work-place (Embree & White, 2010; Rodwell & Demir,
2012). Con-ceptually, psychological events are more easily
categorized as WPB, whereas LV denotes actual abuse or
assault (Einarsen et al., 2011; Rodwell & Demir, 2012).
Manifestations of WPB and LV may be culture-specific.
Previous Western studies reported a low rate of physical vio-
lence among nurses (Hesketh et al., 2003; Rodwell & Demir,
2012). In contrast, physical assaults between Korean nurses
has been featured in Korea media as serious and too fre-quent
(Choi, 2015; Park, 2014). Understanding and inter-preting
mistreatment may be differently perceived (Seo, Leather, &
Coyne, 2012), and a definition of WPB that stresses the
psychological form of mistreatment might not be enough to
capture the totality of whatever physical and aggressive
assaults occur among nurses in Korea (Oh, Uhm, & Yoon,
2016).
WPB and LV have been linked with other negative work
outcomes in hospital settings (Hesketh et al., 2003; Simons,
2008; Spence Laschinger, Wong, & Grau, 2012). One fre-
quently studied outcome is job stress in nurses. Job stress is
de-fined as “a reaction to a stressful workplace situation, with
workload and professional conflict particularly identified as
Workplace Bullying, Job Stress, and Patient Safety381
main sources of job stress in nursing” (Demir & Rodwell,
2012; Spence Laschinger et al., 2012). Job stress can be
linked to job dissatisfaction, which, in turn, has been linked
to poor working relationships (Zhang et al., 2014) and one of
the main contributory factors of nurses’ intentions to leave
(Tourangeau & Cranley, 2006). Exposure to a negative work
environment may create job stress, as well as psycho-logical
and physiological distress (Van Bogaert et al., 2013). Indeed,
some nurses have wanted to leave their jobs when exposed to
negative work environments (Rodwell & Demir, 2012). WPB
and LV have been linked to job stress and intent to leave
(Ariza-Montes et al., 2013; Rodwell & Demir, 2012; Simons,
2008).
Exactly what fosters an environment for quality care and
promotion of safe patient care has been studied exten-sively.
Key predictors include negative working conditions, patient
status (presence of adverse events), quality of nurse
leadership management, health provider relationships, nurse
staffing, and nurse–patient ratios. Many factors have been as-
sociated with quality and safe patient care, and these multiple
factors interacting dynamically may be the key to understand-
ing the phenomena.
Working conditions such as higher levels of job dissatis-faction
and intent to leave have been associated with negative patient
outcomes like mortality and nosocomial infection (Aiken et al.,
2001; Coetzee et al., 2013; Lu, Ruan, Xing, & Hu, 2013).
Positive work life factors for nurses, such as quality leadership
and nurse/physician collaboration, are claimed to be related to
patient safety outcomes (adverse events) with emotional
exhaustion playing a mediating role (Spence Laschinger &
Leiter, 2006). Nurses who intend to leave their current jobs have
been reported to give lower-quality patient care compared to
those who intend to stay (Ma, Lee, Yang, & Chang, 2009). A
higher rate of turnover in nursing staff is a critical factor in the
incidence of infection and related hospi-talization in nursing
home settings (Zimmerman, Gruber‐ Baldini, Hebel, Sloane, &
Magaziner, 2002). The literature implies that nurses who intend
to leave may have less commit-ment to the organization and to
patient care. Furthermore, in-consistent supervision and training
from the organizational perspective is another reason turnover
may be related to low-quality care (Zimmerman et al., 2002).
Nurses in stress-laden working environments with WPB or LV
have reported compromises in patient safety, such as increased
frequency of adverse events (Purpora & Blegen, 2012; Purpora,
Blegen, & Stotts, 2014; Rosenstein & Naylor, 2012). It is
possible that these negative work environments and working
conditions generate job stress and intent to leave, which impede
nurses from providing optimal patient care in a safe environment.
In summary, recent research attests to the importance of
negative work environments (WPB and LV) in determining
job stress and intent to leave. These factors have been empir-
ically examined for their impact on patient safety (Purpora et
al., 2014). The focus of this study was to test a theoretical
model linking WPB and LV to job stress, intent to leave, and,
subsequently, nurse-assessed patient safety in a South Korean
context.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Purpose
The primary aim of this study was to explore the mechanisms
through which WPB and LV in the nursing environment in-
fluence nurse-assessed patient safety. Proposed mediating
var-iables were the work outcomes of job stress and intent to
leave. On the basis of Demir and Rodwell’s (2012) notion of
WPB and violence and Spence Laschinger and Leiter’s (2006)
extension of the nursing worklife model, we hypothesized
382 Workplace Bullying, Job Stress, and Patient Safetywww.nursingresearchonline.com
that nurse-perceived WPB and LV would be associated with
job stress and intent to leave and, in turn, negative judgments
about 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
indicators of LV. Three models with different measure-ment
structures were explored: (a) uncorrelated WPB and LV factors,
with verbal abuse and physical threat associated only with LV; (b)
correlated WPB and LV factors, with verbal abuse and physical
threat associated only with LV; and (c) uncorre-lated WPB and LV
factors, with both factors associated with verbal abuse and
physical threat. Figures showing each model are available as
Supplemental Digital Content 1, http://linksX
.lww.com/NRES/A189.X
METHODS
Design, Participants, and Procedures
A descriptive, cross-sectional design was used. A convenience
sample of hospital nurses was recruited from eight general hos-
pitals (each over 100 hospital beds) in Daejeon, South Korea.
Inclusion criteria were clinical registered staff nurses (not
managers) and clinical careers spanning 6 months to 5 years. We
used data collected from eight hospitals across Daejeon City in
South Korea. Data for this study were collected from February
through June 2013. The principal investigator (PI) contacted the
Director of Nursing in each of the hospitals to obtain permission
to access potential participants. Written, in-formed consent was
obtained from the participants before completing the survey.
Questionnaire packets along with an enclosed return envelope
addressed to the PI were distributed to nurses meeting the study
inclusion criteria. In order to fos-ter confidentiality, nurses were
not required to complete the survey at work. Completion of the
paper survey took approx-imately 15 minutes. The protocol for
the study was approved by the university’s institutional review
board (djomc-93).
Variables and Measurement
We used published scales that had been previously translated
to Korean to assess values on study variables. These measures
had reported good levels of validity and reliability in previous
studies, as described below.
Demographics The demographic section of the questionnaire
was designed by the research team. Questions were used to obtain
information about gender, age, religion, educational level, years
working in nursing, work hours per week, and current clinical
area.
Workplace Bullying The Negative Acts Questionnaire-
Revised (NAQ-R) was used to measure WPB (Einarsen, Hoel, &
Notelaers, 2009); the Korean version was used (Nam,
Kim, Kim, Koo, & Park, 2010). The NAQ-R measures three
interrelated factors associated with person-related bullying (12
items), work-related bullying (7 items), and intimidation-
related bullying (3 items). Person-related bullying refers to
slander, social isolation, and negative innuendos toward a
person, whereas work-related bullying refers to “being given
too much or work that is too simple or having one’s work
constantly criticized.” Intimidation-related bullying refers to
“physically aggressive acts toward people” (Einarsen et al.,
2009). For each of 22 items, the frequency of occurrence was
rated on a 5-point graded scale with response options ranging
from 1 = never to 5 = daily. An example of an item is:
Someone withholding information that affects your
performance. In an earlier study, the reliability of responses to
the NAQ-R estimated using Cronbach’s alpha was .92 (Nam et
al., 2010). In this study, subscale reliabilities in this study were
.93, .80, and .61 for person-related, work-related, and
intimidation-related bullying, respectively.
Lateral Violence LV was measured using a violence
questionnaire developed by Yun (2004) and modified by Lee, Lee,
Kang, and Park (2012). The LV questionnaire measures three
components of nurses’ 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.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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
Nursing Research • September/October 2016 • Volume 65 • No. 5 Workplace Bullying, Job Stress, and Patient Safety383

parison, the Akaike Information Criterion (AIC) was used

(Jöreskog, 1993); the model with the lowest AIC value is se-
lected as the best model among a set of theoretically plausible
competing models.

RESULTS
options on a 5-point Likert-type scale ranging from 1 =
strongly disagree to 5 = strongly agree. An exemplar item on
this scale is: “I often want to quit the job.” Scores on the
Intent to Leave scale have previously shown acceptable Participant Characteristics

reliability (Cronbach’s α = .92) and construct validity (Becker,

1992; Cho, 1999). In this study, Cronbach’s alpha was .90.
A total of 530 questionnaires were distributed, and 508 were
returned; the response rate was 95.8%. Of these 508 returned,
442 had no missing data. The demographic and work-related
Patient Safety Nurse-assessed patient safety was measured characteristics of the sample are shown in Table 1. Most of
using the quality care and adverse events items by Aiken et al. the nurses were female (97.2%), and average age was 25.6
(2001). Nurse perception of the frequency of 10 adverse events years
was assessed. Six adverse events were used by Lucero, Lake, and
Aiken (2010): Patient received wrong medication or dose,
nosocomial infections, complains from patients or their families,
patients’ falls with injuries, work-related injuries to employees,
and incidents of verbal abuse toward nurses; these events were
linked to nurse staffing. The four additional items we used were
wrong medication or dosage, nosocomial infection, complaints
from patients or their families, and patient falls that result in
injury. Each item was rated on a 4-point Likert scale from 1 =
never to 4 = frequently. Higher scores indicated more frequent TABLE 1. Participant Characteristics
occurrences of the adverse events. In this study, the reliability of
this scale was Cronbach’s alpha = .70.

Characteristic
M
Data Analysis (SD)

Descriptive statistics and reliability based on Cronbach’s

alpha were used. Pearson correlations among all study
variables were computed. The Statistical Package for the
Social Sci-ences (version 19.0) was used for this analysis. Age (years)
25.6
(3.79)

Structural equation modeling was used to estimate coeffi-

cients of hypothesized pathways of three competing models.
The Analysis of Moment Structures program (version 19.0)
with maximum likelihood estimation and estimation of means
and intercepts. The χ test statistic and several indices of fit
2

were used to evaluate the models: comparative fit index

(CFI), incremental fit index (IFI), and root mean square error n
of the approximation (RMSEA; Bollen, 1989). If the values (%)
for CFI and IFI are 0.90 or higher and the values for RMSEA
are between 0.05 and 0.08, a model is considered to have
good model fit (Bollen, 1989; Munro, 2005). For model com-
 (5.2)
Current clinical area
Gender (female)
492
(97.2)
Religious affiliation (no)
253
Medical-surgical
(50.8)
285
Education (highest level)
(57.6)
Special (OR, ICU, ER)
129
(26.1)
Other (OB/GYN, Peds, Psych)
81
Some college
(16.4)
322
(64.5)
Bachelor’s degree
164 Note. N = 508. ER = emergency room; ICU = intensive care unit; OB/ GYN
(32.9) = obstetrics/gynecology; OR = operating room; SD = standard deviation.
Master’s degree or higher
13
(2.6)
Work experience (years) (SD = 3.79). Two-thirds (64.5%) reported junior college as
the highest level of education received, and 32.9% were
baccalau-reate prepared. Half (56%) worked between 41 and
50 hours per week, and 19.2% worked more than 50 hours a
week. Most worked on either medical-surgical units (57.6%)
<1 or spe-cial care units (26.1%).
65
(13.1)
1–1.9
120
(24.3) Means and Correlations
2–2.9
88
(17.8)
3–3.9
83
The means, standard deviations, Cronbach’s alpha, and corre-
(16.8) lations among major study variables are shown in Table 2.
Q4 The mean scores of the person-related subscale, work-related
138 sub-scale, and intimidation-related subscale for WPB were
(27.9) 1.47 (SD = 0.57), 1.60 (SD = 0.61), and 1.40 (SD = 0.50),
Work effort (hours per week)
respec-tively. The mean scores of the verbal abuse, physical
threat, and physical assault subscales of LV were 1.07 (SD =
0.65), 0.86 (SD = 0.51), and 0.77 (SD = 0.46), respectively.
The mean WPB exposure score was 1.50 (SD = 0.53), and LV
was 0.87 (SD = 0.48).
e40
119
(24.8)
41–50
269 Before testing the model, a correlation matrix was prepared.
(56.0) WPB subscales and job stress were significantly associated with
51–60 all study variables (Table 2). All of the subscales of WPB and LV
67 ariables showed significant relationships—except for LV
(14.0)
physical assault. Person, work, intimidation-related WPB were
Q61
25 significantly related to job stress (r = .26, p < .001; r = .37,

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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.

Model Selection

p < .001; r = .23, p < .001), intent to leave (r = .25, p < .001; r
= .32, p < .001; r = .17, p < .001), and patient safety (r = .15, p
< .001; r = .19, p < .001; r = .17, p < .001).
Verbal abuse and physical threat were related to job stress (r
= .17, p < .001; r = .11, p < .01), and verbal abuse was re-lated
to intent to leave (r = .16, p < .001). None of the LV sub-scales
showed a significant correlation with nurse-assessed patient
safety. Intent to leave was significantly associated with all of
the variables—except physical threat and physi-cal assault.
Patient safety was significantly associated with all subscales
of WPB and intent to leave (r = .21, p < .001; Table 2).
Using the AIC, Model C (uncorrelated factors with complex
factor loadings for verbal abuse and physical threat) was
2
selected. This model showed a better fit to the data (χ = 179.1,
df = 64, χ /df = 2.8, CFI = 0.95, IFI = 0.95, RMSEA = 0.06)
2
than the other models (Table 3). In addition, most pathways in
Model C were statistically significant except the direct path
between LV and job stress, intent to leave, and nurse-assessed
patient safety (Figure 1). The results showed that WPB
directly and indirectly influenced nurse-assessed pa-tient
safety. Job stress directly influenced intent to leave, and intent
to leave directly influenced nurse-assessed patient safety, as
shown in Table 4. LV was not significantly associated with job
stress, intent to leave, or patient safety.
 prevalence, types, and degrees of LV in other cultures. Answering
these questions might
DISCUSSION

TABLE 3. Model Fit Statistics

The aim of this study was to explore the mechanisms through
Model
which nurse work environment dimensions of WPB and LV AIC
may influence nurse-assessed patient safety. Mediating
χ
2
variables tested included the following work outcome di-
df
mensions: job stress and intent leave. We compared three
p
alternative hypothesized models to explain how nurses per-
χ /df
2
ceived WPB would be associated with job stress and intent
CFI
IFI
RMSEA
a
A
to leave and, in turn, nurse judgments about patient safety. We
387.661
tested a hypothesized model derived and generated from the
303.66
literature on the relationships of perceived nega-tive work 66
environments and patient safety outcomes. Previ-ous studies <.001
and the results of this study support the proposition that nurse- 4.6
assessed patient safety issues may be influenced by WPB, job .899
.900
stress, and intent to leave.
.084
b
B
359.658
273.66
Our assessment of the adequacy of the model to explain the 65
phenomena of work conditions and patient outcomes is mixed. <.001
Among the three alternative models, Models A and B showed 4.2
less adequate fit to the data than Model C. Results of our study .912
.913
imply that there is conceptual overlap between WPB and the
.080
verbal abuse and physical threat in-dicators of LV. c
C
267.091
179.09
64
Low rates of LV have been reported in studies in Western <.001
countries; however, recent reports of physical violence, in-cluding 2.8
physical threat, have raised concern in some coun-tries such as .951
South Korea and Australia (Rodwell & Demir, 2012). Actual .952
physical harm among Korean nurses has often been featured in .060
the media and literature (Choi, 2015; Kim, 2006; Oh et al., 2016;
Park, 2014). We speculate that verbal abuse and physical threat—
Note. AIC = Akaike Information Criterion; CFI = comparative fit index; IFI =
physical forms of LV—strongly in-fluence nurse-perceived
incre-mental fit index; RMSEA = root mean square error of approximation.
patient safety in this study. Because LV have been defined and a
Two un-correlated, simple structure. bTwo correlated factors, simple
studied mainly in Western coun-tries, little is known about the
structure. cTwo uncorrelated factors, complex factor loadings (both factors
associated with physical threat and verbal abuse).

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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.

also benefit from qualitative study approaches that would
encourage a fuller explanation of the situations that nurses
experience.
WPB showed a direct and positive relationship with job stress,
intent to leave, and nurse-assessed patient safety components
of the model. This is congruent with previous re-search
linking WPB to other correlates of lower job satisfac-tion
(Quine, 2001), the primary mechanism for intent to leave
(Simons, 2008), and negative patient outcomes such as falls
and medication errors (Roche et al., 2010). These findings
highlight the potential importance of WPB in impacting work
conditions and patient care outcomes.
how these concepts may interrelate to impact patient safety is-
sues. WPB had a direct influence on patient safety through job
stress and intent to leave, highlighting the fundamental im-
portance of preventing WPB for patient safety issues. Future
studies examining the interrelationships of these workplace
factors are needed to increase our understanding of the phe-
nomena and the potential consequences for patient care qual-
ity and safety. Another area not fully explored is the impact of
WPB on nurse morale that threatens specific deficits in
TABLE 4. Direct, Indirect, and Total Effects (Structural Model)
Path
DE
IE
TE

Job stress has been repeatedly identified as a potential

predictor and key mediating factor for many negative hospital
outcomes, including nurse intent to leave and patient quality
care. Previous research found an association of increased job
stress causing decreased work capacity. Job stress was a pre-
dictive factor for intent to leave (Zhang et al., 2014). Job
dissat-isfaction and intent to leave one’s job are the strongest
predictors of actual turnover (Zhang et al., 2014), and in-
WPB !Job stress
creased turnover rates exacerbate organizational burden and 0.34
decreased quality care due to the decline of nursing care con-
tinuity, which finally have a negative impact on patients
(Purpora & Blegen, 2012). 0.34
WPB !Intent to leave
0.10
0.19
Intent to leave had a direct influence on nurse-assessed patient 0.29
WPB ! Patient safety
safety. This is congruent with research showing that nurses’ 0.15
work environments, perceived quality of care, and pa-tient 0.04
safety are related (Coetzee et al., 2013; Purpora & Blegen, 0.19
2012). Nurses intending to leave their hospitals because of job LV ! Job stress
dissatisfaction had higher levels of burnout and were more −0.01
likely to jeopardize patient safety.

−0.01
LV ! Intent to leave
−0.06
−0.00
−0.06
LV ! Patient safety
−0.00
−0.01
Intent to leave had a direct influence on −0.01
Job stress ! Intent to leave
0.56

nurse-assessed patient safety. 0.56

Job stress ! Patient safety
−0.04
0.11
In our study, WPB seemed to have a significant influence on 0.07
Intent to leave ! Patient safety
well-known nurse retention factors, such as job stress and
0.20
intent to leave. Our findings also provided some insight into
0.20 Note. N = 508. DE = direct effect; IE = indirect effect; LV = lateral
violence; TE = total effect; WPB = workplace bullying.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

386 Workplace Bullying, Job Stress, and Patient Safety

Limitations

Some limitations should be considered when interpreting

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.
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
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
Implications for Practice

www.nursingresearchonline.com

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
credibility to nurses’ judgments. Nurse perceptions of quality
leader-ship styles may result in reduced instances of WPB.
care and patient safety have been used as a proxy in other
Organi-zational efforts to develop positive leadership skills
studies linking work environmental conditions with patient
and competencies at the nurse management and clinical nurse
outcomes. Although not ideal, they do give some evidence of
levels may reduce the occurrence of negative exchanges and
important work outcome consequences.
potential consequences for nurse work life and patient
outcomes.
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 Corresponding author: Dong-choon Uhm, RN, PhD, Department of
Emergency Medical Technology, Daejeon University, 62 Daehak-ro,
and patient care outcomes. Furthermore, any differ-ences
across hospitals were not captured; differences at the unit or Dong-gu, Daejeon 300-716, South Korea (e-mail: dchuhm@dju.kr).X
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
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CALL FOR PAPERS

Nursing Research Special Focus Issue

Theory and Theorizing in Nursing Science

th
50 Anniversary Celebration of 1968–1969 Nursing Research Papers from Three Landmark Symposia on Theory
Development in Nursing

Three symposia sponsored by the Case Western Reserve University Frances Payne Bolton School of Nursing and the University
of Colorado School of Nursing in 1967 and 1968 were “landmarks” in the development of theory

in nursing for two reasons (Nicoll, 1986). First, the symposia brought together a unique group of people who described
the meetings as “‘electrifying,’ ‘stimulating,’ and ‘challenging’” as it seemed “that everyone at these conferences recognized the
importance of the events” (Nicoll, 1986, p. 92). Second, the proceedings were published in Nursing Research.

As the first journal to have as its dedicated mission the publication of original research in nursing, Lucille Notter, Editor in 1968, took
on the task of ensuring that papers from the conference proceedings underwent rigorous and objective

peer review to ensure papers of the highest quality. The success of her efforts is obvious from the vast and lasting impact of the
papers on the development of nursing as an academic discipline.

In celebration of the golden anniversary of publication of proceedings from the three landmark symposia, Nursing Research
invites submission of papers for a special focus issue on Theory and Theorizing in Nursing Science. Papers

should address theory for research, practice, or the research-practice link. Types of papers to be considered are wide-ranging and
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personalized health care, (h) normative and idiographic theory, (i) methods and theory: quantitative, qualitative, and mixed
methods, (j) cross-cultural and international issues in nursing theory, theory development, and theorizing, (k) post-colonial
theory; theory and health equity, (l) nursing theory and the point-of-care, (m) theory in nursing education, and (n) theory and the
goals of nursing as a profession.

Papers from the 1968–1969 proceedings of the three landmark symposia are freely available in a special collection on the
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The deadline for submission of papers for the Special Focus Issue is: November 30, 2016. Submit papers at:
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Reference

Nicoll, L. H. (Ed.). (1986). Perspectives on nursing theory. Glenview, IL: Scott, Foresman and Company.
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