Bullying does not occur only on the playground; it

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1 Evaluation of a Workplace Bullying Cognitive Rehearsal Program in a Hospital Setting Sharon J. Stagg, DNP, MS, MPH, RN, Daniel Sheridan, PhD, RN, FAAN, Ruth Ann Jones, EdD, MSN, RN, NEA-BC, and Karen Gabel Speroni, PhD, MHSA, BSN, RN HOW TO OBTAIN CONTACT HOURS BY READING THIS ISSUE Instructions: 2.3 contact hours will be awarded for this activity. A contact hour is 60 minutes of instruction. This is a Learner-paced Program. Vindico Medical Education does not require submission of the quiz answers. A contact hour certificate will be awarded 4-6 weeks following receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours: 1. Read the article: Evaluation of a Workplace Bullying Cognitive Rehearsal Program in a Hospital Setting, on pages , carefully noting the tables and other illustrative materials that are provided to enhance your knowledge and understanding of the content. 2. Read each question and record your answers. After completing all questions, compare your answers to those provided within this issue. 3. Type or print your full name and address and your Social Security number in the spaces provided on the Registration Form. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity. 4. Forward the completed Registration Form with your check or money order for $20 made payable to JCEN-CNE. Payment must be in U.S. dollars drawn on a U.S. bank. This activity is valid from September 1, 2011, to August 31, Vindico Medical Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. P188-6/ This activity is co-provided by Vindico Medical Education and The Journal of Continuing Education in Nursing. Objectives: After studying the article, Evaluation of a Workplace Bullying Cognitive Rehearsal Program in a Hospital Setting, in this issue, the participant will: 1. Define the frequency of workplace bullying in nursing. 2. Identify the consequences of workplace bullying. 3. Describe common bullying behaviors experienced by nurses. 4. List the sources of workplace bullying in nursing. 5. Summarize the components of the workplace bullying cognitive rehearsal training program. AUTHOR DISCLOSURE STATEMENT The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. COMMERCIAL SUPPORT STATEMENT All author(s) and planners have agreed that this activity will be free of bias. There is no commercial company support for this activity. There is no noncommercial support for this activity. abstract Workplace bullying is a serious problem faced by nurses nationally. This study was conducted to determine the frequency of workplace bullying and evaluate the effectiveness of a training program on cognitive rehearsal of responses to common bullying behaviors. This program to increase staff nurses knowledge of management of workplace bullying consisted of three components: pilot survey testing, a piloted Internet-based survey administered to the medical and surgical nurses, and a 2-hour cognitive rehearsal training program on management of workplace bullying. The results showed that 80% of the nurses surveyed had experienced workplace bullying over the previous year. After the training program, nurses knowledge of workplace bullying management significantly increased. Additionally, nurses were significantly more likely to report that they had observed bullying and had bullied others. Further, nurses felt more adequately prepared to handle workplace bullying. Results of the research support the provision of a workplace bullying management program for nurses and the need for a specific policy on workplace bullying. J Contin Educ Nurs 2011;42(9): Bullying does not occur only on the playground; it also prevails in the workplace. Workplace bullying is a serious problem faced by many registered nurses nationally. Bullying among staff nurses can be substantial, resulting in considerable consequences for the bullied target, the nursing profession, the organization, and Dr. Stagg is Nurse Practitioner, Shore Works/Occupational Health Services, Shore Health System, Cambridge, Maryland. Dr. Jones is Director, Acute Care, and Dr. Speroni is Chair, Nursing Research Council, Shore Health System, Easton, Maryland. Dr. Sheridan is Associate Professor, Johns Hopkins University, Baltimore, Maryland. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Sharon J. Stagg, DNP, MS, MPH, RN, 505 Byrn Street, Cambridge, MD sstagg@shorehealth.org. Received: January 3, 2011; Accepted: May 12, doi: / The Journal of Continuing Education in Nursing Vol 42, No 9,

2 the patient. Workplace bullying is defined as repetitive inappropriate behavior, direct or indirect, whether verbal, physical, or otherwise, carried out by one or more persons against another or others, at the workplace and/ or in the course of employment, which undermines the individual s right to dignity at work (Center for American Nurses, 2008). Bullying is a growing problem in the American workplace (Oppermann, 2008). According to the Workplace Bullying Institute-Zogby International (2010), 35% of the U.S. work force experienced bullying in Additionally, the Workplace Bullying Institute-Zogby International (2007) found that 41% of those bullied never reported the events, making it difficult to fully understand the problem. Coworkers were identified as the main bullies (18%). Further, 64% of the targets of bullying voluntarily left their job or were terminated as a result of workplace bullying. In a U.S. nursing survey, 70% of staff nurses reported being bullied at work (Vessey, Demarco, Gaffney, & Budin, 2009). As a result of the bullying, significant consequences may occur. According to Johnson (2009), workplace bullying may involve physical, psychological, and social aspects. Additionally, workplace bullying influences the recruitment and retention of nurses. An organizational consequence of workplace bullying is absenteeism. Interpersonal conflicts from workplace bullying affect patient safety and quality of care. This article describes the frequency of workplace bullying among staff nurses and the effectiveness of a workplace bullying training program identified as the best management strategy from the literature. Study methods, implementation, and results are discussed. Finally, the article discusses the implications for nursing practice. LITERATURE REVIEW The literature review identified quasi-experimental and nonexperimental evidence on preventing and managing workplace bullying. A comprehensive literature review of workplace bullying prevention and management programs in the business, education, and health care disciplines was recently published and provided the basis for this article (Stagg & Sheridan, 2010). Four health care strategies to prevent and manage workplace bullying were identified. One strategy to prevent workplace bullying reported by Latham, Hogan, and Ringl (2008) teamed nurse mentors with academic participants. This approach allowed front-line nurses to improve the culture of support through effective communication, collaboration, and conflict resolution with colleagues. As a result, the organization realized improvements in patient and nurse satisfaction and nurse vacancy and retention rates, but the changes seen could not be attributed entirely to the mentoring program. Second, the Griffin (2004) workplace bullying management intervention provided information about bullying, used cognitively rehearsed responses as a defense against the negative effects of bullying, and allowed time for skills performance. Interviews of nurses 1 year after the intervention showed that 100% of the bullying behaviors had stopped. Third, the strategy reported by Oostrom and Van Mierlo (2008) provided instruction on assertiveness and aggression. This study found significant effects of insight into assertiveness and aggression (p =.01) and the ability to cope with adverse working conditions (p <.01). The last workplace bullying strategy identified in the literature (Grenyer et al., 2004) piloted aggression and violence minimization modules. This study significantly improved participants perceived confidence in dealing with aggressive incidents (p =.00). The review suggested that there is no clear solution to the workplace bullying phenomenon. The program with the greatest effectiveness in managing bullies was cognitive rehearsal of responses to common bullying behaviors. This intervention provided staff nurses with basic information on bullying and offered a safe environment for learning and practicing responses to bullying behaviors, increasing staff nurses knowledge of workplace bullying management. PURPOSE AND OBJECTIVES This research study was conducted to determine whether cognitively rehearsed responses to common bullying behaviors decreased bullying by increasing staff nurses knowledge of workplace bullying management. The study objectives were to determine the frequency of workplace bullying among medical and surgical nurses and increase knowledge of workplace bullying management using cognitive rehearsal of responses to common bullying behaviors. METHODS This descriptive, quasi-experimental study had three components: pilot survey testing, survey administration, and an intervention with a pretest and posttest study design. The study involved a pilot of an Internet-based workplace bullying survey of staff nurses on the neuroscience unit of the study facility. No changes to the survey instrument resulted from the pilot. The main study was conducted at two affiliated rural community hospitals, using the piloted Internet-based survey instrument and one 2- hour training program. This research study was approved by the appropriate institutional review boards, and signed 396 Copyright SLACK Incorporated

3 informed consent was obtained before any study-related procedures. Participation in the study was voluntary. Study Instruments The instruments used in the study included an Internet-based survey and a training program pretest and posttest. The Internet-based survey portion of the study consisted of three components. The first part of the survey was an informed consent form. The second portion of the survey collected participant demographic information. This included work unit, current work status, age, gender, marital status, highest educational level, length of time worked as a nurse, length of time worked at the study site, and usual work schedule. Third, an adapted Workplace Bullying Inventory (WBI) was used with permission from Hutchinson, Wilkes, Vickers, and Jackson (2008). The 16-question WBI gathered information about bullying behaviors experienced during the previous year. The bullying behaviors included the following: reputation was damaged by false allegations, achievements and contributions were ignored, abilities were questioned, work above skill level was given and help was refused, developmental opportunities were denied, and target was ignored. Additionally, target was belittled in front of others, target was watched and followed, target was blamed, target was publicly humiliated, target was threatened, work was excessively scrutinized, work was organized to inconvenience target, work life was made difficult, target was excluded from receiving information, and work was organized to isolate target were other behaviors on the WBI. The survey questions used a five-point Likert-type scale with responses ranging from never to daily. Two questions of interest to the researchers were added to the WBI. These questions asked whether the respondent had been pressured into doing something and asked the respondent to identify the major source of bullying. The original 16-question WBI had a Cronbach s alpha of 0.93 (Hutchinson et al., 2008). Testing of the cognitive rehearsal training program was based on a study conducted by Griffin (2004). The pre- and posttests were identical and included 25 questions (Appendix A; Twenty-one of the questions pertained to the information covered in the training. The other four questions asked about the staff nurse s attitude toward bullying experiences, adequacy of training in managing a bully, and confidence in defending oneself against a bully. Study Population The study drew from a population of 62 medical and surgical staff nurses. The eligibility criteria were the same for the survey and the program. Those included in the study were nurses working full-time, part-time, or weekend alternative on medical and surgical units; were able to communicate in English; and provided a signed informed consent form. There were no exclusion criteria. Participants were recruited through direct contact during walking rounds, distribution of survey postcards and cognitive rehearsal program brochures, and an article describing the study that appeared in the internal nursing newsletter. Participants were given work time to complete the survey and attend the cognitive rehearsal program. Data Analysis The Internet-based survey contained a total of 27 questions, 9 demographic questions and 18 questions on different bullying behaviors experienced during the last year. Sixteen of the questions about bullying were from the original survey. Internal consistency of the survey was measured using coefficient alphas (Cronbach s). The current research using the original 16 items on the WBI had an alpha of 0.92 compared with the previous alpha of 0.93 on the same 16 questions (Hutchinson et al., 2008). The alpha on the total 18 items was These results further support the reliability of the original survey items and the additional items. Before the 2-hour training on responses to common workplace bullying behaviors, participants completed a 25-question pretest (T1). The training provided information on workplace bullying, responses to common bullying behaviors, and the cognitive rehearsal technique, along with application of the technique to common bullying behaviors. At the end of the 2-hour training, participants completed the identical 25-question tool (T2). Test-retest reliability was analyzed. In addition, the results of each perception item from T1 and T2 were examined, using the Wilcoxon matched-pairs test. A paired t test was used to evaluate the total mean test score from T1 to T2. Finally, descriptive statistics for all data were analyzed. Within the survey analysis, the examiner determined the frequencies for each unit and a combined total for the units. For the pretest and posttest knowledge comparisons, frequencies of responses to the test questions were calculated. In addition, the researchers assessed the frequency of correct test answers on both pretests and posttests. RESULTS Twenty (32%) of the 62 staff nurses from the medical and surgical units completed the survey. Of these, 90% (n = 18) worked on a medical unit. Workplace bullying was experienced by 80% (n = 16) of the respondents, and 75% (n = 15) of the bullying occurred on the medical units. The Journal of Continuing Education in Nursing Vol 42, No 9,

4 The majority of the nurses were employed full-time (80%, n = 16). Forty percent (n = 8) of the respondents were 41 to 50 years old. All 20 respondents were female and 60% (n = 12) were married. A bachelor s degree was the highest educational level attained by the nurses (45%, n = 9). The greatest number of nurses had worked as a nurse for more than 20 years (35%, n = 7), and the highest number of nurses had worked at the institution for 3 to 5 years (40%, n = 8). The largest group worked split shift days (7:00 a.m. to 7:00 p.m.) (35%, n = 7). Numerous bullying behaviors were reported. The bullying behavior most commonly seen was having accomplishments and contributions disregarded, which was experienced by 50% (n = 10) of the sample. The bullying behavior work life made challenging also ranked high, at 47% (n = 9). Another common bullying activity reported by 45% (n = 9) of the nurses involved being overlooked. Other frequent bullying behaviors included questioned skills (35%, n = 7), assigned work above her/his competency level (30%, n = 6), deprived of learning opportunities (30%, n = 6), held responsible (25%, n = 5), and work was excessively examined (25%, n = 5). Additionally, nurses experienced denial of information (21%, n = 4), pressured into doing something (20%, n = 4), work organization made difficult (15%, n = 3), publicly ridiculed (15%, n = 3), observed and followed (15%, n = 3), disgraced in front of coworkers (10%, n = 2), secluded by work organization (10%, n = 2), and intimidated (5%, n = 1). Peers were found to be the major source of workplace bullying (57%, n = 8). Further, the management team, which included senior management, supervisors, and nurse managers, was reported as the bullying source by 28% (n = 4) of nurses. Fifteen (24%) of the 62 medical and surgical staff nurses participated in one 2-hour cognitive rehearsal training program. In comparing correct test scores, pretest scores ranged from 14 to 17 and posttest scores ranged from 18 to 21. The total number of possible points was 21. A paired samples t test was calculated to compare the mean pretest score with the mean posttest score. The mean on the pretest was (SD = 1.06) and the mean on the posttest was (SD = 1.10). A significant increase from pretest to posttest was found (t(14) = , p <.01). Pretest questions that were frequently answered incorrectly included the percentage of targets who quit their job as a result of workplace bullying (93%, n = 14), the definition of workplace bullying (86%, n = 13), the institutional policy regarding bullying (73%, n = 11), the prevalence of workplace bullying (60%, n = 9), and an organizational consequence of bullying (41%, n = 5). On the posttest, most of these questions were also answered incorrectly. Nearly 36% (n = 5) answered the question on the institutional policy on workplace bullying incorrectly on the posttest. In addition, on the posttest, 13% (n = 2) of the participants incorrectly answered the questions on the prevalence of workplace bullying, the definition of workplace bullying, a common bullying behavior, and the percentage of targets who quit their job as a result of workplace bullying. Test-retest reliability was calculated on the pretest and posttest questions. A Pearson correlation showed a weak positive correlation between the pretest and posttest scores that was not significant (r(2) =.298, p >.05). Differences in pretest and posttest scores on the final four attitudinal questions were examined. Significant differences were found in the results between pretest and posttest for observed bullying (Z = , p <.01), bullying of others (Z = , p <.05), and adequacy of the training on management of bullying (Z = , p <.01). On the question about confidence in the ability to defend oneself against a bully, no significant difference was seen between pretest and posttest scores. Test-retest reliability was also determined on the pretest and posttest attitudinal questions. A Pearson correlation found a moderately positive correlation for observed bullying (r(2) =.644, p <.05) and adequacy of bullying management training (r(2) =.569, p <.05). This finding indicated a significant linear relationship for each of the questions on the pretest and posttest. In evaluating the item on bullying others, a strong positive correlation (r(2) =.787, p <.01) suggested a significant linear relationship between the pretest and posttest results. Finally, the question on confidence in the ability to defend oneself against a bully showed an insignificant weak correlation (r(2) =.299, p >.05). DISCUSSION Consistent with the results observed by Vessey et al. (2009), the percentage (80%) of medical and surgical staff nurses reporting workplace bullying in this study was immense. As a result of heightened awareness of workplace bullying, nurses were significantly more likely to report that they had observed bullying and had bullied others. Further, nurses were significantly more likely to report that their training in workplace bullying management was adequate. Attendance at a cognitive rehearsal training program significantly increased staff nurses short-term knowledge of workplace bullying management. The training program used the components recommended by Griffin (2004). The theoretical concepts of bullying, the most common bullying behaviors, the consequences of bullying, organization- 398 Copyright SLACK Incorporated

5 specific workplace bullying policies, an evidence-based behavioral intervention, responses to common bullying behaviors (Appendix B; and the expected behaviors of professionals (Appendix C; were included in the training program (Sidebar). In addition, cue cards for responses to common bullying behaviors and the expected behaviors of professionals, which were made to attach to the name badge, were distributed. Understanding the concepts and meaning of workplace bullying helped the nurses to differentiate between bullying behaviors and situations in which a coworker was just having a bad day. The most common bullying behaviors were discussed during the training session and were highlighted in the workplace bullying demonstration (Table) and practice scenarios (Appendix D; that were tailored to the audience. Awareness of common bullying behaviors allowed the target to prepare responses before actually experiencing the behavior. The discussion of common bullying behaviors significantly increased nurses recognition that they had observed bullying and had in fact bullied others. Further, awareness of common bullying behaviors may have decreased bullying because nurses changed their own actions that they recognized as workplace bullying. Another portion of the program reviewed hospital policies regarding workplace bullying. The policies discussed in the study included code of conduct, harassment, and violence in the workplace. No specific workplace bullying policy was in place. Many study participants were unaware of the appropriate policy to follow when reporting workplace bullying. Additionally, the behavioral intervention involved cognitive rehearsal, which is a technique of cognitive behavioral therapy. This behavioral method helps to identify the problem and devises a solution for future occurrences (Cognitive Behavioral Therapy Techniques, 2011). In this study, the 10 most common bullying behaviors were identified as the problem and the suggested responses to each bullying behavior provided potential solutions. To immediately challenge the bully with a recommended response, the nurse needed to feel adequately prepared for the task. Practicing the responses before actual use helped to build the nurse s self-confidence in performing the technique in difficult bullying situations. Such a confrontation was accomplished by the target or a witness. The nurses in this study rated their adequacy in bullying management training more highly after the training session. However, nurses confidence in defending themselves against a bully was not significantly different after the training program, which was contrary to SIDEBAR COMPONENTS OF COGNITIVE REHEARSAL TRAINING Theoretical concepts of workplace bullying Definition of workplace bullying Other terms for workplace bullying Prevalence of workplace bullying Common theories regarding workplace bullying Target characteristics Bully characteristics Common bullying behaviors Consequences of bullying Personal Organizational Professional What to do about bullying Reporting bullying Organization-specific policy on workplace bullying Cognitive rehearsal intervention Discussion of the cognitive rehearsal technique Responses to common bullying behaviors Demonstration scenarios Practice scenarios Expected behaviors of professionals Distribution of cue cards the findings after the aggression program reported by Grenyer et al. (2004). Finally, the management team, which included senior management, supervisors, and nurse managers, was identified by the nurses as a source of bullying. Research has shown that when the bullying source was in a management role, workers lost faith in the organization (Fox & Stallworth, 2006). To prevent this loss of faith, management should be made aware of behaviors considered bullying. The management team may perhaps be victimized by bullying along with the nurses. Several study limitations were identified. First, the small sample of medical and surgical nurses increased the chances of making a type II error (Rubin, 2007). Second, the small sample size prohibits generalization of the study results to other populations. Further research is needed to assess the training program with a larger sample and in other specialties to determine whether the training program is effective. Third, the convenience sample led to a question of whether the bullying experiences of those who participated in the study differ from the experiences of those who did not participate. Fourth, measures were obtained from the use of a self-report survey. Fifth, the participants The Journal of Continuing Education in Nursing Vol 42, No 9,

6 TABLE DEMONSTRATION SCENARIOS FOR EACH BULLYING BEHAVIOR Bullying Behavior Nonverbal innuendo Verbal affront Undermining activities Withholding information Sabotage Infighting Scapegoating Backstabbing Failure to respect privacy Broken confidences Scenario Target: I am having problems with the medication dispenser again. Can you help me? Bully: Rolls her eyes while looking at another nurse who is standing nearby. Target: I have not had the training on the new lift equipment. Could you help me get Ms. Hipster up? Bully: I AM NOT THE LIFT CHAMPION FOR THIS UNIT! Walks off. Situation: You are covering for a coworker who went to lunch. She gave you a short report on her patients before leaving. About 5 minutes before your coworker is due back, one of her patients arrests. You do not see the coworker until after the code, which is an hour later. Situation: Because you were off for 2 weeks, you missed the last staff meeting at which the new policy on solicitation was discussed. None of your coworkers said anything about the new policy as you handed out a product catalog. One of your coworkers reported you to the nurse manager, who later called you into her office and verbally reprimanded you for solicitation in the workplace. Situation: You are supposed to work closely with a coworker on a project to foster implementation of the electronic medical record on your unit. Your coworker is hogging all of the work, and what little work she does throw your way she goes over with a fine-tooth comb, highlighting all supposed errors and showing them to your boss. You heard a rumor that she is trying to get you fired, but she is always syrupy-sweet to you. Today, she sent an to the unit staff regarding the project. The message said that someone relatively new to the templates (obviously you, but never named outright) had made so many mistakes that she was going to have to re-create them. This will delay implementation of the program until the next week. Now everyone is angry with you. You looked over your work log, which shows that you never worked on the templates, but it is her word against yours. Situation: With the patient s family waiting in the hall, you come out of Mr. Neaton s room after setting him up for dinner. Bully: (meeting you at the door) Why were you in my patient s room? Target: I set up his tray so he could eat because... Bully: I WAS ON MY WAY TO DO THAT! I DO NOT WANT YOU, OF ALL PEOPLE, IN MY PATIENT S ROOM! Bully: Have you noticed that whenever there is a code, Andy is usually working? Situation: You mention to Kara that you need to complete the computerized hospital-wide satisfaction survey. Kara states, I still have to do that too. I was going to do it yesterday, but Stephanie took forever to finish her survey. She always monopolizes the computer! Bully: I know you are friends with Teresa. I heard that her son is on the psychiatric unit. What is going on? Situation: While you are in the nurses lounge, Tiffany comes in and starts telling you about Laura s marital problems. may have had difficulty accurately recalling experiences over the last year. Finally, the study measured only short-term retention of knowledge regarding management of workplace bullying behaviors. Additional research is needed to assess long-term knowledge gained from the training program to determine whether the increased knowledge decreased workplace bullying. 400 Copyright SLACK Incorporated

7 IMPLICATIONS FOR NURSING PRACTICE The study identified several implications for nursing practice. First, the findings show the need for cognitive rehearsal of responses to common bullying behaviors for medical and surgical staff nurses. This program helps nurses to recognize personal bullying behaviors and those of others. By identifying bullying behaviors, nurses can institute changes in their own behavior and protect themselves and coworkers against workplace bullying through prepared responses. Also, organizations need to institute a specific workplace bullying policy that emphasizes zero tolerance for bullying and identifies the appropriate steps to take in reporting bullying. The policy must be enforced by all levels of management, and employees need to be aware of the policy. Finally, senior management, supervisors, and nurse managers need to participate in the cognitive rehearsal training program for workplace bullying management. The program will increase management s awareness of their possible bullying behaviors along with those of others. The cognitive rehearsal technique learned from the program may help management to intercede in bullying situations. Intervening in witnessed bullying events also shows management s support of the zero tolerance policy for workplace bullying. CONCLUSION This research study validated that a number of medical and surgical staff nurses experienced workplace bullying. Staff nurse attendance at a cognitive rehearsal training program increased awareness of bullying behaviors and knowledge of workplace bullying management. Whether the training program actually decreased workplace bullying has yet to be determined, but the staff nurses reported feeling more adequately prepared to handle workplace bullying after the training session. By managing bullying coworkers, the organization will retain highly trained professional staff. Under no circumstances should workplace bullying be tolerated by medical and surgical staff nurses or the organization. REFERENCES Center for American Nurses. (2008). Lateral violence and bullying in the workplace. Retrieved from nursing/center_lateral_violence_and_bullying_position_statement_ from_center_for_american_nurses.pdf Cognitive Behavioral Therapy Techniques. (2011). Intelligent life on the web. Retrieved from Fox, S., & Stallworth, L. (2006). How effective is an apology in resolving workplace bullying disputes? Dispute Resolution Journal, 61(2), Grenyer, B., Ilkiw-Lavalle, O., Biro, P., Middleby-Clements, J., key points Workplace Bullying Stagg, S. J., Sheridan, D., Jones, R. A., Speroni, K. G. (2011). Evaluation of a Workplace Bullying Cognitive Rehearsal Program in a Hospital Setting. The Journal of Continuing Education in Nursing, 42(9), Eighty percent of the medical and surgical nurses reported being bullied at work. 2 As a result of heightened awareness of workplace bullying, nurses were more likely to identify bullying behaviors. 3 After the training, the nurses reported that their training in workplace bullying management was adequate. Comninos, A., & Coleman, M. (2004). Safer at work: Development and evaluation of an aggression and violence minimization program. Australian and New Zealand Journal of Psychiatry, 38, Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), Hutchinson, M., Wilkes, L., Vickers, M., & Jackson, D. (2008). The development and validation of a bullying inventory for the nursing workplace. Nurse Researcher, 15(2), Johnson, S. (2009). International perspectives on workplace bullying among nurses: A review. 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Bullying of staff registered nurses in the workplace: A preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. Journal of Professional Nursing, 25(5), doi: / profnurs Workplace Bullying Institute-Zogby International. (2007). U.S. workplace bullying survey: September, Retrieved from www. workplacebullying.org/docs/wbisurvey2007.pdf Workplace Bullying Institute-Zogby International. (2010) U.S. workplace bullying survey. Retrieved from org/research/2010natlsurvey/2010_survey_flyer.pdf The Journal of Continuing Education in Nursing Vol 42, No 9,

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