Exploring the causes of workplace bullying among nurses in pediatric intensive care units: a qualitative study

Nurses constitute a significant proportion of healthcare providers in hospitals and play a crucial role in the delivery of healthcare services. An unhealthy work environment adversely impacts nurses’ performance and well-being, diminishes the quality of care, and negatively influences patient outcomes. Therefore, fostering and maintaining a healthy work environment for nurses is imperative [1].

One of the critical hazards in nursing workplaces is workplace bullying (WB). WB is defined as any intentional, negative behavior within interpersonal relationships that aims to harm the victim. These behaviors are typically categorized into three types: person-related bullying (e.g., humiliation, ridicule, spreading rumors, or persistent criticism of mistakes), work-related bullying (e.g., withholding essential information, disregarding opinions, or assigning excessive workloads), and physical bullying (e.g., making obscene gestures, physical pushing, or threats of violence) [2].

Research indicates that WB is alarmingly prevalent among nurses. For example, a study conducted in Egypt reported that 89% of nurses had experienced WB [3]. Similarly, a study in Singapore found that 42% of nurses had encountered WB within the past six months [4]. In Iran, another study revealed that 75% of nurses had experienced WB [5].

WB is a major source of stress within healthcare environments. Exposure to WB is strongly linked to psychological issues, including depression, anxiety, stress, and increased suicidal ideation, as well as a range of physical health problems such as insomnia, joint pain, heart palpitations, hypertension, gastrointestinal disturbances, and headaches. WB also contributes to heightened levels of burnout and diminished work motivation among nurses. Its impact extends to reduced job satisfaction, increased absenteeism, heavier organizational workloads, higher staff turnover, and escalating costs for healthcare systems [6, 7]. The literature indicates that the negative consequences of WB extend beyond nursing staff and directly impact patient care. WB distracts nurses from their professional responsibilities, thereby increasing the likelihood of clinical errors. This decline in attentiveness compromises the quality of care, jeopardizes patient safety, and negatively affects health outcomes. Furthermore, it impairs the achievement of desired treatment goals and raises the risk of complications, ultimately undermining patient prognosis and care delivery standards [7‐9].

WB is particularly prevalent in high-stress healthcare environments such as intensive care units (ICUs) [10]. In these settings, WB creates a hostile work environment and significantly increases nurses’ stress levels. This issue is especially critical in pediatric intensive care units (PICUs) due to the vulnerability of the patients and the special care needs they require. Research highlights that nurses working in PICUs face significant emotional challenges, including conflicts between personal and professional responsibilities, the necessity of providing meticulous attention to patients, the burden of making urgent and complex end-of-life care decisions, high workloads, and competitive dynamics among staff. These factors contribute to elevated stress levels and severe burnout [11, 12]. A study in Greece found that 44.9% of NICU nurses reported being victims of WB, while 83.9% had witnessed it among colleagues. The study highlighted that both direct and indirect exposure to WB can significantly impact nurses’ mental health [12].

WB is a serious threat to nurses’ physical and mental well-being and has significant adverse effects on patient care. Therefore, the development of targeted interventions to prevent and mitigate WB is imperative. Designing effective strategies for addressing WB in PICUs requires a comprehensive understanding of the underlying causes of bullying. Qualitative research methods are suited for exploring the lived experiences of nurses, examining the contextual factors that facilitate WB, and identifying the complex interplay of elements that contribute to its occurrence.

The study included 11 participants, most of whom were female (81.8%) and held a bachelor’s degree in nursing (72.7%). The participants’ ages ranged from 24 to 49 years, with an average age of 33.7 years. Their work experience varied from 2 to 25 years, with a mean of approximately 9.3 years (Table 1).

Data analysis initially produced 456 codes, which were consolidated into 136 after merging similar ones. Ultimately, 6 subcategories and 2 main categories were formed. The analysis indicated that the imposing and stereotypical atmosphere, along with the victim’s Achilles’ heel, were factors contributing to the occurrence of WB (Table 2).

Nurses in PICUs are frequently exposed to high workloads, unpredictable patient outcomes, complex medical procedures, and the emotional toll of caring for critically ill children and their families [15]. One of the significant factors affecting nurses in PICUs is WB, which exacerbates the already challenging work environment. This study aimed to elucidate the causes of WB among nurses in pediatric intensive care units.

The findings suggest that WB arises from a combination of victim-related, organizational, and environmental factors. One of the primary categories identified through data analysis was termed “The Imposing and Stereotypical Atmosphere.” Data within this theme indicate that specific characteristics of the work environment are among the leading causes of bullying. One of the sub-categories was “Prevalence of Power Imbalance.” Some individuals in the workplace possess more power due to factors such as being older, having more work experience, holding organizational positions, or having close relationships with nursing managers. These individuals consider themselves superior to others, and their elevated power allows them to start bullying. Previous studies have identified power imbalances as one of the primary antecedents of WB, which can manifest through formal structures or informally via factors such as work experience and social or interpersonal interactions [16, 17].

The results revealed that differences in age and experience serve as a source of power in the PICU, potentially contributing to WB. This finding may be due to the organization typically respecting and valuing experienced nurses more. The lack of support for newly hired nurses, coupled with different perspectives toward them, creates a power imbalance rooted in age and work experience differences. Similar to our findings, a study conducted in Poland revealed that young nurses had higher scores of perceived WB [18]. Another study conducted in Saudi Arabia reported an inverse relationship between age and perceived WB, consistent with our findings [19]. Additionally, a study conducted on emergency department nurses in Jordan reported that those with fewer years of experience were more likely to experience or be exposed to WB [20]. The findings of previous studies suggest that power imbalance due to differences in age and work experience is a worldwide issue, affecting not only ICUs but also many other wards.

According to our findings, organizational position is another source of power imbalance in the nursing workplace. Power is a fundamental aspect of organizations and is exerted on employees by the organization and its managers to ensure that they fulfill their responsibilities [21]. In this regard, many managers believe that exercising power and influence over subordinates is essential for ensuring compliance and maintaining control. However, some belive that achieving organizational goals and asserting authority effectively is not possible without resorting to bullying tactics. This perspective reinforces the perception of WB as a common occurrence in the workplace and a necessary strategy. In alignment with our findings, Hutchinson et al. (2010) identified organizational position as a significant source of power that enables individuals to engage in bullying behaviors within the workplace [22]. Additionally, another study reported that nursing managers had significantly lower scores of perceived WB compared to clinical nurses, consistent with our study [18].

One of the sub-categories identified in our results was “Work Challenges in the Intensive Care Unit.” The results suggest that the stress and heavy workload faced by nurses in PICUs, primarily due to the critical condition of patients, are significant factors contributing to WB. The exposure to these stressors, coupled with both physical and psychological pressures, poses a serious threat to nurses’ mental health, leading to decreased resilience and increased job burnout [23, 24]. This deterioration in mental well-being can heighten tensions and conflicts among nursing staff, ultimately resulting in bullying behaviors. Consistent with the findings of the present study, previous research has identified staff shortages, inadequate equipment, and limited resources as key factors contributing to WB [16, 17].

The findings indicated that immature behaviors within the workplace are linked to the occurrence of WB. These behaviors reflect a lack of maturity in interpersonal relationships among staff members. A primary source of bullying behaviors arises from the attitudes individuals hold toward one another, which are significantly influenced by their interactions in the workplace. The prevalence of unprofessional behaviors, coupled with a decline in intimacy and teamwork among nurses, cultivates negative attitudes, ultimately fostering an environment conducive to violence and bullying [17]. Interestingly, one of the immature behaviors reported by participants was retaliation. It appears that individuals often initiate bullying behaviors in environments where they have previously been victimized. Once they gain power or identify an appropriate situation, they engage in negative behaviors to assert control over the environment or to satisfy themselves mentally. In line with our findings, a study conducted in South Korea found that WB is significantly related to organizational culture [25]. Consistent with our findings, another study also highlighted the role of organizational culture in shaping WB [26].

Another sub-category was “Passive reactions of nursing managers.” A significant factor hindering nursing managers from addressing WB effectively is that many of them perceive WB as a necessary and inherent aspect of the nursing profession, which leads them to normalize such behaviors. Therefore, they often view these actions as permissible and refrain from implementing the necessary punitive measures when they receive reports of WB [22]. This issue enables bullies to initiate their negative actions, as they are aware that no punitive interventions will be implemented. Aligning with our findings, Anusiewicz et al. (2019) identified poor leadership and management as antecedents of WB [16]. Confirming our results, Karatuna et al. (2020) explained that due to the passive reaction of managers, there is an organizational culture that tolerates bullying and normalizes it [27]. However, it is essential to educate nurses on the importance of upholding a zero-tolerance policy toward WB and actively reporting any occurrences they witness or experience [28].

Another primary category derived from the data analysis was termed ‘The Victim’s Achilles’ Heel.’ This category underscores various vulnerabilities of the victim, including inadequate clinical skills and poor communication skills, which can embolden the bully to engage in negative behaviors. It is reasonable to assume that bullies often exploit their victims’ vulnerabilities to initiate negative behaviors. According to the participants, nurses who demonstrate strong competence, confidence, and assertiveness are less likely to become targets of bullying. Aligning with our findings, Fang et al. (2020) indicated that nurses exhibiting lower levels of assertiveness are more frequently subjected to WB [29]. Supporting our results, a concept analysis identified several individual factors, such as low self-esteem, feelings of powerlessness, and ineffective coping strategies in the victim, as contributors to the prevalence of WB [17].

This study identified both organizational and individual factors contributing to WB in PICUs. The “Imposing and Stereotypical Atmosphere” category highlights power imbalances, organizational culture, and managerial inaction as potential causes of WB. The “Victim’s Achilles’ Heel” category underscores the role of clinical and communication deficiencies in the occurrence of WB. Our study contributes to the body of knowledge by emphasizing that addressing WB requires a holistic approach focusing on both nurses and the organization. According to the results, reducing WB requires targeted interventions, including leadership training, structured mentorship, and professional development in clinical and communication skills. Future research should focus on the effectiveness of interventions, such as enhancing communication skills and clinical competencies, in reducing perceived WB.