Volume 22, Issue 4 (12-2025)
J Res Dev Nurs Midw 2025, 22(4): 40-44 |
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Abdalhussein Obaid H, Vakilian P, Rafiei F, Mahmoudi M. Survey of workplace bullying among nurses working and related factors in the Emergency Departments of hospitals in Nasiriyah, Iraq. J Res Dev Nurs Midw 2025; 22 (4) :40-44
URL: http://nmj.goums.ac.ir/article-1-2180-en.html
URL: http://nmj.goums.ac.ir/article-1-2180-en.html
1- Health Development Research Institute, School of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
2- Clinical Care Research Center, Health Development Research Institute, Kurdistan University of Medical Sciences, Sanandaj, Iran
3- Department of Biostatistics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
4- Clinical Care Research Center, Health Development Research Institute, Kurdistan University of Medical Sciences, Sanandaj, Iran ,mahmodimokhtar85@gmail.com
2- Clinical Care Research Center, Health Development Research Institute, Kurdistan University of Medical Sciences, Sanandaj, Iran
3- Department of Biostatistics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
4- Clinical Care Research Center, Health Development Research Institute, Kurdistan University of Medical Sciences, Sanandaj, Iran ,
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As listed in Table 4, multiple linear regression analysis was conducted using the stepwise method to identify predictors of workplace bullying scores. The entry criterion was set at P ≤ 0.05 and the removal criterion at P ≥ 0.10. Prior to running the regression model, the basic assumptions - including normal distribution of residuals, linearity of the relationship between independent and dependent variables, independence of errors, and absence of multicollinearity - were examined. Variance inflation factor (VIF) and tolerance indices were used to assess multicollinearity. Finally, the coefficient of determination (R2 = 0.044) and adjusted R2 indices were reported to evaluate model fit. The significance level for all tests was set at 0.05.
Based on the regression findings, work experience in the Emergency Department (β = -0.148, P = 0.021) and interest in working in the current department (β = -0.131, P = 0.04) had a negative and significant effect on workplace bullying. In other words, the greater the work experience a nurse has in the Emergency Department, the lower the likelihood of being exposed to workplace bullying. Similarly, the stronger a nurse’s interest in working in the Emergency Department, the lower the level of workplace bullying experienced.
Discussion
The level of workplace bullying and all its dimensions among nurses working in emergency departments were examined. The results showed that overall workplace bullying across all dimensions was at a low level; however, the occupational dimension had the highest mean score compared with the personal and physical dimensions. No study conducted in Iraq was found for comparison that reported the dimensions of workplace bullying among nurses. However, a study by Al Muharraq et al. (2022) in Saudi Arabia reported bullying in the occupational dimension at 34.5%, the personal dimension at 31.1%, and the physical dimension at 25.6% during the past year (12), which are higher than the findings of the present study. In contrast, a study by Hajibabaei in Iran (2020) reported bullying in the occupational dimension at 10.11%, the personal dimension at 4.27%, and the physical dimension at 5.66% during the past year (13), which are lower than those reported in the present study. Another study by Javaheri et al. (2024) in Iran, conducted among healthcare personnel, reported the occupational dimension at 29.64%, the personal dimension at 19.59%, and the physical dimension at 7.23% (9), which are also higher than the findings of the present study.
A review of studies shows that the level of workplace bullying varies across countries, which may be attributed to individual differences among nurses and patients in terms of culture, workplace settings, and even organizational policies that support nurses. Each dimension of bullying can have both common and distinct negative consequences for nurses. Workplace bullying has significant effects on nurses’ job performance and professional behaviors. Nurses who are repeatedly exposed to bullying often experience reduced motivation and productivity, which can negatively affect the quality of clinical care (8). The personal dimension of workplace bullying mainly involves psychological and emotional consequences. Nurses who are victims of bullying frequently experience chronic stress, anxiety, and depression, along with decreased self-esteem and self-confidence. This condition can increase job burnout and impair an individual’s ability to manage professional tasks and maintain work-life balance. Social consequences, including reduced interactions with friends and family, are also observed among these nurses and adversely affect their overall quality of life.
Reducing workplace bullying among nurses requires a multidimensional approach that simultaneously addresses occupational, personal, and physical dimensions. In the occupational dimension, developing and implementing anti-bullying policies, establishing confidential reporting systems, and strengthening a positive team culture can help prevent undesirable behaviors and increase organizational commitment and cooperation. In the personal dimension, providing psychological support, career counseling, stress management training, and creating peer support groups can help reduce psychological effects and enhance job satisfaction. In the physical dimension, ensuring a safe work environment, regulating workload and shift hours, encouraging physical activity, and implementing stress management programs can reduce the physical effects of bullying and improve overall employee health. Therefore, a comprehensive and coordinated approach across all three dimensions can enhance nurses’ health, motivation, and performance, while also ensuring the quality of clinical care.
The results showed that the mean and standard deviation of the total bullying score were 50.40 ± 14.52, within a score range of 22 - 110. The questionnaire does not have a cutoff point or categorization level; however, based on the obtained score, the overall level of bullying was low. Faeq et al. (2025) in Sulaymaniyah, Iraq reported workplace bullying among nurses to be moderate to high (14), which is higher than the findings of the present study. This difference may be attributed to differences in the research environment, as the general policies governing each sample group fall under the supervision of different ministries. Mouharaq et al. (2022) in Saudi Arabia reported bullying against nurses at 33.4% (12), Kumar et al. (2023) in Pakistan reported bullying against healthcare staff at 26.9% (15), and Aristidou et al. (2022) in Cyprus reported bullying against emergency nurses at 70% (3). Additionally, a study by Brewer et al. (2020) in the United States reported that 31% of nurses experienced bullying at least once a week or more (16). A review of studies conducted in other countries also indicated varying results regarding the level of bullying among nurses and other healthcare groups.
Differences in study results regarding the level of workplace bullying among nurses can be attributed to a combination of factors. On one hand, cultural and social differences in the perception and definition of bullying, the use of different tools and questionnaires with varying dimensions and scales, and demographic characteristics of the samples - such as age, gender, and work experience - can influence the reported levels. On the other hand, organizational and managerial conditions, the level of job support, workload, and the presence or absence of anti-bullying policies can lead to divergent findings.
Furthermore, differences in willingness to report bullying in various work environments, as well as the influence of situational factors such as health crises or economic conditions, may also contribute to this heterogeneity. Therefore, discrepancies in research findings are more reflective of cultural, organizational, and methodological differences rather than true contradictions. Workplace bullying among nurses has extensive consequences for individual health, quality of care, and organizational efficiency (17-19).
Given the negative consequences outlined above, a multilevel approach is recommended to control and reduce bullying in the nursing environment. At the organizational level, developing and implementing clear anti-bullying policies, providing confidential reporting systems, and offering legal and managerial support to victims play key roles. At the individual level, empowering nurses through coping skills training, psychological support, and resilience enhancement can help mitigate the negative effects of bullying. Overall, combining educational, supportive, and policy-based measures while promoting a positive organizational culture can provide a sustainable foundation for reducing bullying and improving the psychological and professional well-being of nurses.
Furthermore, the results of the hierarchical regression analysis showed a negative and significant correlation between work experience and interest in working in the Emergency Department. This indicates that less experienced nurses with shorter work histories experience bullying more frequently than others. Moreover, individuals who reported no interest in working in their current department had higher overall bullying scores. Muharraq et al. (2022) and Kumar et al. (2023) reported similar findings, indicating that the work-related dimension of bullying had a higher mean score than other dimensions (12,15). Their results also suggested that nurses with greater work experience were exposed to lower levels of bullying. However, a study by Javaheri et al. (2025) conducted in Iran found this dimension to be at a moderate level (9).
To reduce the experience of bullying among nurses who are inexperienced and have limited work histories, it is necessary to implement targeted supportive, educational, and managerial measures. Assigning experienced nurses as mentors, providing workshops and training in conflict management, effective communication, and resilience, as well as offering continuous managerial feedback and support, can enhance nurses’ ability to cope with bullying behaviors.
For nurses who did not wish to work in their current department and reported higher levels of bullying, this finding highlights the importance of managerial interventions and job planning based on person-environment fit to reduce bullying. To reduce the experience of bullying among nurses who are not interested in their current department, targeted organizational and psychological interventions can be implemented. Providing opportunities for transfer or rotation between departments based on nurses’ interests and competencies can increase motivation and job satisfaction and reduce their vulnerability to bullying.
The most important limitation of the present study was the limited generalizability of its results, as it examined the level of bullying only in one city in Iraq. Given the limited number of studies investigating this phenomenon among nurses in Iraq, conducting research with a broader scope that includes a larger number of nurses working in different cities across the country appears necessary.
Conclusion
The results indicated that, based on the mean scores, workplace bullying across all dimensions and the total score was at a low level. Nevertheless, these findings should not lead to neglect of this issue in academic and clinical settings, and planning to further reduce bullying remains necessary. Younger nurses with less experience, lower interest in their department, and fixed shifts are of particular concern, as they reported higher levels of workplace bullying than other nurses. These findings highlight the need for preventive and corrective measures, including academic training, refresher courses, the creation of a safe reporting environment, and appropriate actions against perpetrators of bullying. Therefore, it is recommended that psychological support be provided at the individual level, a safe working environment be ensured at the physical level, and team culture among nurses working in Emergency Departments be strengthened at the occupational level.
Acknowledgement
This article is derived from an MSc dissertation in emergency nursing. The authors sincerely thank the Vice Chancellor for Research and Technology of Kurdistan University of Medical Sciences, as well as all hospital managers and participating nurses, for their financial support and collaboration.
Funding sources
The present study received financial support from Kurdistan University of Medical Sciences.
Ethical statement
The Institutional Review Board (IRB) of Kurdistan University of Medical Sciences granted approval for this study. The IRB adheres to the provisions of the Helsinki Declaration. The Ethics Committee of Kurdistan University of Medical Sciences also approved this study, and the ethical approval number (IR.MUK.REC.1404.131) was obtained. This committee follows the ethical principles set forth in the Helsinki Declaration.
Conflicts of interest
The authors declare that there are no conflicts of interest regarding this study.
Author contributions
The idea and design of this protocol were developed by M.M. and H.A. M.M. also wrote the first draft of the manuscript and contributed to developing the search strategy and methodology. The manuscript was critically revised by P.V. and M.M. All authors provided critical revisions to the methodology and approved the final version of the manuscript. F.R. conducted the study selection, data extraction, and analysis. M.M. and H.A. supervised the study. All authors have read and agreed to the final version of the manuscript.
Data availability statement
Data will be made available upon reasonable request, subject to review by the research team and consideration of data confidentiality.
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Introduction
Violence is defined as the intentional use of physical or psychological force against oneself, another individual, or a group, and the workplace is one of the common settings where violence occurs (1). Workplace violence causes many negative consequences, including reduced job satisfaction, increased stress, job burnout, and even death. Among occupational groups, nurses are more exposed to this phenomenon than others due to the nature of their profession. Studies have indicated that 50% to 80% of nurses experience workplace violence (2).
Violence may occur in the form of verbal abuse, physical assault, sexual harassment, and bullying. Bullying, as a form of indirect violence, includes behaviors such as insulting, threatening, humiliating, ignoring, intimidating, and sabotage, which may be perpetrated by colleagues, managers, patients, or their companions against nurses. Investigations have shown that this phenomenon is widespread in healthcare organizations, and its prevalence varies across countries depending on cultural conditions, study design, and attitudes (3). For example, the rate of bullying among nurses has been reported as 57% in Cyprus (3), 82% in Saudi Arabia (4), 37% in South Korea (5), and 75% in Iran (6). In Iraq, a study showed that about 70% of nurses had experienced moderate levels of bullying (7).
The consequences of workplace bullying in nursing include psychological disorders such as depression, anxiety, fatigue, decreased concentration, and post-traumatic stress disorder, as well as increased substance use, decreased job satisfaction, reduced performance, increased clinical errors, and a greater tendency to leave the job. Additionally, this phenomenon can impose significant financial costs on healthcare organizations and exacerbate workforce shortages (8).
The Emergency Department, due to its specific working conditions such as overcrowding, an increased number of critically ill patients, staff shortages, and high workload, is considered an environment prone to the occurrence of bullying (3). Since there are no accurate statistics on bullying among emergency nurses in Iraq, and considering the direct impact of this phenomenon on the quality of nursing services, the aim of this study is to determine the level of workplace bullying among nurses working in the Emergency Departments of hospitals.
Methods
The study was conducted using a cross-sectional design. All nurses working in Emergency Departments were considered the target population, and nurses employed in the Emergency Departments of government hospitals in Nasiriyah, Iraq (Al-Refai = 50 or 23%, Al-Torki = 50 or 23%, Al-Haboobi = 61 or 31%, Al-Hussein = 50 or 23%) were selected as the study sample from February to June 2025.
Inclusion criteria for nurses in the study included willingness to participate, having at least a nursing associate degree, being employed in the Emergency Department, and having more than six months of work experience. The exclusion criterion was incomplete completion of the questionnaire. The sampling method was stratified random sampling using R software version 4.5.1. First, all nurses working in the Emergency Departments of the mentioned hospitals were entered into the software, and then the number of samples for each hospital was determined based on the sample size and the software output. According to the results of the study by Javaheri et al. (9), considering a correlation coefficient of 0.192, a type I error of 0.05, a type II error of 0.02, and a test power of 80%, the sample size was calculated as 242 participants. Data were collected through self-report using a demographic information form and the Negative Acts Questionnaire (NAQ).
After approval of the study plan by the university research council and obtaining permission from the ethics committee, the researcher visited the hospitals in Nasiriyah, Iraq during different shifts with an introduction letter. After explaining the study objectives to the officials and the research units (Nurses working in Emergency Departments) and obtaining informed consent, sampling was carried out. To ensure ethical considerations, the researcher provided explanations regarding how to complete the questionnaires, the confidentiality of responses, and the written informed consent form to the nurses in the Emergency Departments. The demographic information form and the Negative Acts Questionnaire (NAQ) were provided to the participants, and they completed the questionnaires after receiving sufficient explanation on how to respond to the questions. If a nurse did not have time to complete the questionnaire at the workplace due to workload, arrangements were made by the researcher for the questionnaire to be completed at home and returned later.
The NAQ, consisting of 32 items, was initially developed in 2001 by Hoel and Einarsen (10), and later revised in 2009, resulting in a version with 22 items and established psychometric properties. This instrument measures the level of workplace bullying over the past six months of nurses’ work experience and is rated on a 5-point Likert scale ranging from 1 to 5 (1 = never, 2 = sometimes, 3 = monthly, 4 = weekly, 5 = daily). Accordingly, the total score ranges from 22 to 120, with higher scores indicating greater exposure to bullying and harassment. The questionnaire evaluates three dimensions of bullying: Occupational, personal, and physical. Items 1, 2, 3, 4, 11, 13, 14, 15, 16, 18, and 21 assess the occupational dimension; items 5, 6, 7, 12, 20, and 22 assess the personal dimension; and items 8, 9, 10, 17, and 19 assess the physical dimension. The validity and reliability of this questionnaire have been confirmed, with a Cronbach’s alpha of 0.90 reported in other countries and 0.95 in Iraq (11). In the present study, the questionnaire was first translated into Arabic and then evaluated for reliability and content validity by ten faculty members of the School of Nursing and Midwifery of Nasiriyah.
The collected data were analyzed using SPSS software (Version 26). Demographic information of the participants was examined using descriptive statistics, including frequency distribution, percentage, mean, and standard deviation. Normality was assessed using the Kolmogorov-Smirnov test, and data analysis was performed using independent t-tests, ANOVA, and multiple linear regression analysis (Stepwise selection method). A significance level of P < 0.05 was considered statistically significant.
Results
A total of 242 nurses participated in the study. The mean age of the participants was 28.1 years (SD = 6.22), with an average hospital work experience of 5.3 years (SD = 5.75) and an average of 2.9 years (SD = 3.41) of experience in the Emergency Department. Participants worked a mean of 14.4 days per month (SD = 6.47) and reported an average of 5.5 overtime hours (SD = 7.95). Other demographic variables are presented in Table 1.
Violence is defined as the intentional use of physical or psychological force against oneself, another individual, or a group, and the workplace is one of the common settings where violence occurs (1). Workplace violence causes many negative consequences, including reduced job satisfaction, increased stress, job burnout, and even death. Among occupational groups, nurses are more exposed to this phenomenon than others due to the nature of their profession. Studies have indicated that 50% to 80% of nurses experience workplace violence (2).
Violence may occur in the form of verbal abuse, physical assault, sexual harassment, and bullying. Bullying, as a form of indirect violence, includes behaviors such as insulting, threatening, humiliating, ignoring, intimidating, and sabotage, which may be perpetrated by colleagues, managers, patients, or their companions against nurses. Investigations have shown that this phenomenon is widespread in healthcare organizations, and its prevalence varies across countries depending on cultural conditions, study design, and attitudes (3). For example, the rate of bullying among nurses has been reported as 57% in Cyprus (3), 82% in Saudi Arabia (4), 37% in South Korea (5), and 75% in Iran (6). In Iraq, a study showed that about 70% of nurses had experienced moderate levels of bullying (7).
The consequences of workplace bullying in nursing include psychological disorders such as depression, anxiety, fatigue, decreased concentration, and post-traumatic stress disorder, as well as increased substance use, decreased job satisfaction, reduced performance, increased clinical errors, and a greater tendency to leave the job. Additionally, this phenomenon can impose significant financial costs on healthcare organizations and exacerbate workforce shortages (8).
The Emergency Department, due to its specific working conditions such as overcrowding, an increased number of critically ill patients, staff shortages, and high workload, is considered an environment prone to the occurrence of bullying (3). Since there are no accurate statistics on bullying among emergency nurses in Iraq, and considering the direct impact of this phenomenon on the quality of nursing services, the aim of this study is to determine the level of workplace bullying among nurses working in the Emergency Departments of hospitals.
Methods
The study was conducted using a cross-sectional design. All nurses working in Emergency Departments were considered the target population, and nurses employed in the Emergency Departments of government hospitals in Nasiriyah, Iraq (Al-Refai = 50 or 23%, Al-Torki = 50 or 23%, Al-Haboobi = 61 or 31%, Al-Hussein = 50 or 23%) were selected as the study sample from February to June 2025.
Inclusion criteria for nurses in the study included willingness to participate, having at least a nursing associate degree, being employed in the Emergency Department, and having more than six months of work experience. The exclusion criterion was incomplete completion of the questionnaire. The sampling method was stratified random sampling using R software version 4.5.1. First, all nurses working in the Emergency Departments of the mentioned hospitals were entered into the software, and then the number of samples for each hospital was determined based on the sample size and the software output. According to the results of the study by Javaheri et al. (9), considering a correlation coefficient of 0.192, a type I error of 0.05, a type II error of 0.02, and a test power of 80%, the sample size was calculated as 242 participants. Data were collected through self-report using a demographic information form and the Negative Acts Questionnaire (NAQ).
After approval of the study plan by the university research council and obtaining permission from the ethics committee, the researcher visited the hospitals in Nasiriyah, Iraq during different shifts with an introduction letter. After explaining the study objectives to the officials and the research units (Nurses working in Emergency Departments) and obtaining informed consent, sampling was carried out. To ensure ethical considerations, the researcher provided explanations regarding how to complete the questionnaires, the confidentiality of responses, and the written informed consent form to the nurses in the Emergency Departments. The demographic information form and the Negative Acts Questionnaire (NAQ) were provided to the participants, and they completed the questionnaires after receiving sufficient explanation on how to respond to the questions. If a nurse did not have time to complete the questionnaire at the workplace due to workload, arrangements were made by the researcher for the questionnaire to be completed at home and returned later.
The NAQ, consisting of 32 items, was initially developed in 2001 by Hoel and Einarsen (10), and later revised in 2009, resulting in a version with 22 items and established psychometric properties. This instrument measures the level of workplace bullying over the past six months of nurses’ work experience and is rated on a 5-point Likert scale ranging from 1 to 5 (1 = never, 2 = sometimes, 3 = monthly, 4 = weekly, 5 = daily). Accordingly, the total score ranges from 22 to 120, with higher scores indicating greater exposure to bullying and harassment. The questionnaire evaluates three dimensions of bullying: Occupational, personal, and physical. Items 1, 2, 3, 4, 11, 13, 14, 15, 16, 18, and 21 assess the occupational dimension; items 5, 6, 7, 12, 20, and 22 assess the personal dimension; and items 8, 9, 10, 17, and 19 assess the physical dimension. The validity and reliability of this questionnaire have been confirmed, with a Cronbach’s alpha of 0.90 reported in other countries and 0.95 in Iraq (11). In the present study, the questionnaire was first translated into Arabic and then evaluated for reliability and content validity by ten faculty members of the School of Nursing and Midwifery of Nasiriyah.
The collected data were analyzed using SPSS software (Version 26). Demographic information of the participants was examined using descriptive statistics, including frequency distribution, percentage, mean, and standard deviation. Normality was assessed using the Kolmogorov-Smirnov test, and data analysis was performed using independent t-tests, ANOVA, and multiple linear regression analysis (Stepwise selection method). A significance level of P < 0.05 was considered statistically significant.
Results
A total of 242 nurses participated in the study. The mean age of the participants was 28.1 years (SD = 6.22), with an average hospital work experience of 5.3 years (SD = 5.75) and an average of 2.9 years (SD = 3.41) of experience in the Emergency Department. Participants worked a mean of 14.4 days per month (SD = 6.47) and reported an average of 5.5 overtime hours (SD = 7.95). Other demographic variables are presented in Table 1.
|
Table 1. Demographic characteristics of nurses in emergency departments, Nasiriyah, Iraq (N = 242)
.PNG) |
|
Table 2. Descriptive statistics for the negative Acts questionnaire among emergency department nurses in Nasiriyah, Iraq (N = 242)
.PNG) |
As listed in Table 4, multiple linear regression analysis was conducted using the stepwise method to identify predictors of workplace bullying scores. The entry criterion was set at P ≤ 0.05 and the removal criterion at P ≥ 0.10. Prior to running the regression model, the basic assumptions - including normal distribution of residuals, linearity of the relationship between independent and dependent variables, independence of errors, and absence of multicollinearity - were examined. Variance inflation factor (VIF) and tolerance indices were used to assess multicollinearity. Finally, the coefficient of determination (R2 = 0.044) and adjusted R2 indices were reported to evaluate model fit. The significance level for all tests was set at 0.05.
Based on the regression findings, work experience in the Emergency Department (β = -0.148, P = 0.021) and interest in working in the current department (β = -0.131, P = 0.04) had a negative and significant effect on workplace bullying. In other words, the greater the work experience a nurse has in the Emergency Department, the lower the likelihood of being exposed to workplace bullying. Similarly, the stronger a nurse’s interest in working in the Emergency Department, the lower the level of workplace bullying experienced.
|
Table 3. Comparison of workplace bullying questionnaire (WBQ) Scores by demographic characteristics among emergency department nurses in Nasiriyah, Iraq (N = 242)
.PNG) ED = Emergency Department; SD = Standard Deviation; t = t-test statistic; F = ANOVA F-statistic. Table 4. Results of hierarchical multiple regression analysis for predicting Workplace Bullying Questionnaire (WBQ) scores among emergency department nurses (N = 242) .PNG) Model statistics: R2 = 0.044, adjusted R2 = 0.036, F (2, 239) = 5.486, P = 0.005. Regression equation: WBQ = 46.899 - 0.629 (Experience in ED) - 5.352 (Interest in Dept.) b = Unstandardized coefficient; SE = Standard Error; β = Standardized coefficient; CI = Confidence Interval; t = t-test statistic. The "Interest" variable was dummy coded (1 = Yes, 0 = No). |
Discussion
The level of workplace bullying and all its dimensions among nurses working in emergency departments were examined. The results showed that overall workplace bullying across all dimensions was at a low level; however, the occupational dimension had the highest mean score compared with the personal and physical dimensions. No study conducted in Iraq was found for comparison that reported the dimensions of workplace bullying among nurses. However, a study by Al Muharraq et al. (2022) in Saudi Arabia reported bullying in the occupational dimension at 34.5%, the personal dimension at 31.1%, and the physical dimension at 25.6% during the past year (12), which are higher than the findings of the present study. In contrast, a study by Hajibabaei in Iran (2020) reported bullying in the occupational dimension at 10.11%, the personal dimension at 4.27%, and the physical dimension at 5.66% during the past year (13), which are lower than those reported in the present study. Another study by Javaheri et al. (2024) in Iran, conducted among healthcare personnel, reported the occupational dimension at 29.64%, the personal dimension at 19.59%, and the physical dimension at 7.23% (9), which are also higher than the findings of the present study.
A review of studies shows that the level of workplace bullying varies across countries, which may be attributed to individual differences among nurses and patients in terms of culture, workplace settings, and even organizational policies that support nurses. Each dimension of bullying can have both common and distinct negative consequences for nurses. Workplace bullying has significant effects on nurses’ job performance and professional behaviors. Nurses who are repeatedly exposed to bullying often experience reduced motivation and productivity, which can negatively affect the quality of clinical care (8). The personal dimension of workplace bullying mainly involves psychological and emotional consequences. Nurses who are victims of bullying frequently experience chronic stress, anxiety, and depression, along with decreased self-esteem and self-confidence. This condition can increase job burnout and impair an individual’s ability to manage professional tasks and maintain work-life balance. Social consequences, including reduced interactions with friends and family, are also observed among these nurses and adversely affect their overall quality of life.
Reducing workplace bullying among nurses requires a multidimensional approach that simultaneously addresses occupational, personal, and physical dimensions. In the occupational dimension, developing and implementing anti-bullying policies, establishing confidential reporting systems, and strengthening a positive team culture can help prevent undesirable behaviors and increase organizational commitment and cooperation. In the personal dimension, providing psychological support, career counseling, stress management training, and creating peer support groups can help reduce psychological effects and enhance job satisfaction. In the physical dimension, ensuring a safe work environment, regulating workload and shift hours, encouraging physical activity, and implementing stress management programs can reduce the physical effects of bullying and improve overall employee health. Therefore, a comprehensive and coordinated approach across all three dimensions can enhance nurses’ health, motivation, and performance, while also ensuring the quality of clinical care.
The results showed that the mean and standard deviation of the total bullying score were 50.40 ± 14.52, within a score range of 22 - 110. The questionnaire does not have a cutoff point or categorization level; however, based on the obtained score, the overall level of bullying was low. Faeq et al. (2025) in Sulaymaniyah, Iraq reported workplace bullying among nurses to be moderate to high (14), which is higher than the findings of the present study. This difference may be attributed to differences in the research environment, as the general policies governing each sample group fall under the supervision of different ministries. Mouharaq et al. (2022) in Saudi Arabia reported bullying against nurses at 33.4% (12), Kumar et al. (2023) in Pakistan reported bullying against healthcare staff at 26.9% (15), and Aristidou et al. (2022) in Cyprus reported bullying against emergency nurses at 70% (3). Additionally, a study by Brewer et al. (2020) in the United States reported that 31% of nurses experienced bullying at least once a week or more (16). A review of studies conducted in other countries also indicated varying results regarding the level of bullying among nurses and other healthcare groups.
Differences in study results regarding the level of workplace bullying among nurses can be attributed to a combination of factors. On one hand, cultural and social differences in the perception and definition of bullying, the use of different tools and questionnaires with varying dimensions and scales, and demographic characteristics of the samples - such as age, gender, and work experience - can influence the reported levels. On the other hand, organizational and managerial conditions, the level of job support, workload, and the presence or absence of anti-bullying policies can lead to divergent findings.
Furthermore, differences in willingness to report bullying in various work environments, as well as the influence of situational factors such as health crises or economic conditions, may also contribute to this heterogeneity. Therefore, discrepancies in research findings are more reflective of cultural, organizational, and methodological differences rather than true contradictions. Workplace bullying among nurses has extensive consequences for individual health, quality of care, and organizational efficiency (17-19).
Given the negative consequences outlined above, a multilevel approach is recommended to control and reduce bullying in the nursing environment. At the organizational level, developing and implementing clear anti-bullying policies, providing confidential reporting systems, and offering legal and managerial support to victims play key roles. At the individual level, empowering nurses through coping skills training, psychological support, and resilience enhancement can help mitigate the negative effects of bullying. Overall, combining educational, supportive, and policy-based measures while promoting a positive organizational culture can provide a sustainable foundation for reducing bullying and improving the psychological and professional well-being of nurses.
Furthermore, the results of the hierarchical regression analysis showed a negative and significant correlation between work experience and interest in working in the Emergency Department. This indicates that less experienced nurses with shorter work histories experience bullying more frequently than others. Moreover, individuals who reported no interest in working in their current department had higher overall bullying scores. Muharraq et al. (2022) and Kumar et al. (2023) reported similar findings, indicating that the work-related dimension of bullying had a higher mean score than other dimensions (12,15). Their results also suggested that nurses with greater work experience were exposed to lower levels of bullying. However, a study by Javaheri et al. (2025) conducted in Iran found this dimension to be at a moderate level (9).
To reduce the experience of bullying among nurses who are inexperienced and have limited work histories, it is necessary to implement targeted supportive, educational, and managerial measures. Assigning experienced nurses as mentors, providing workshops and training in conflict management, effective communication, and resilience, as well as offering continuous managerial feedback and support, can enhance nurses’ ability to cope with bullying behaviors.
For nurses who did not wish to work in their current department and reported higher levels of bullying, this finding highlights the importance of managerial interventions and job planning based on person-environment fit to reduce bullying. To reduce the experience of bullying among nurses who are not interested in their current department, targeted organizational and psychological interventions can be implemented. Providing opportunities for transfer or rotation between departments based on nurses’ interests and competencies can increase motivation and job satisfaction and reduce their vulnerability to bullying.
The most important limitation of the present study was the limited generalizability of its results, as it examined the level of bullying only in one city in Iraq. Given the limited number of studies investigating this phenomenon among nurses in Iraq, conducting research with a broader scope that includes a larger number of nurses working in different cities across the country appears necessary.
Conclusion
The results indicated that, based on the mean scores, workplace bullying across all dimensions and the total score was at a low level. Nevertheless, these findings should not lead to neglect of this issue in academic and clinical settings, and planning to further reduce bullying remains necessary. Younger nurses with less experience, lower interest in their department, and fixed shifts are of particular concern, as they reported higher levels of workplace bullying than other nurses. These findings highlight the need for preventive and corrective measures, including academic training, refresher courses, the creation of a safe reporting environment, and appropriate actions against perpetrators of bullying. Therefore, it is recommended that psychological support be provided at the individual level, a safe working environment be ensured at the physical level, and team culture among nurses working in Emergency Departments be strengthened at the occupational level.
Acknowledgement
This article is derived from an MSc dissertation in emergency nursing. The authors sincerely thank the Vice Chancellor for Research and Technology of Kurdistan University of Medical Sciences, as well as all hospital managers and participating nurses, for their financial support and collaboration.
Funding sources
The present study received financial support from Kurdistan University of Medical Sciences.
Ethical statement
The Institutional Review Board (IRB) of Kurdistan University of Medical Sciences granted approval for this study. The IRB adheres to the provisions of the Helsinki Declaration. The Ethics Committee of Kurdistan University of Medical Sciences also approved this study, and the ethical approval number (IR.MUK.REC.1404.131) was obtained. This committee follows the ethical principles set forth in the Helsinki Declaration.
Conflicts of interest
The authors declare that there are no conflicts of interest regarding this study.
Author contributions
The idea and design of this protocol were developed by M.M. and H.A. M.M. also wrote the first draft of the manuscript and contributed to developing the search strategy and methodology. The manuscript was critically revised by P.V. and M.M. All authors provided critical revisions to the methodology and approved the final version of the manuscript. F.R. conducted the study selection, data extraction, and analysis. M.M. and H.A. supervised the study. All authors have read and agreed to the final version of the manuscript.
Data availability statement
Data will be made available upon reasonable request, subject to review by the research team and consideration of data confidentiality.
Type of study: Original Article |
Subject:
Nursing
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