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Open Access 01.12.2025 | Research

Resilience as a moderator of the effects of types of workplace bullying and job performance

verfasst von: Yu-Chia Chang, Shi-Ting Huang, Chih-Chun Wang, Cheng-Chia Yang

Erschienen in: BMC Nursing | Ausgabe 1/2025

Abstract Background Methods Results Conclusions

Workplace bullying is a problem that can occur in any occupation or organization and is a stressful and negative experience for employees; resilience helps employees to better resist workplace bullying. The purpose of this study was to examine whether resilience moderates the effects of workplace bullying on job performance and to determine whether this moderating effect differs between three types of bullying: personal, work-related, and physical bullying.
A self-administered, paper-based questionnaire was distributed to full-time nurses at three regional hospitals in Taiwan. Cross-sectional data on workplace bullying behaviors, resilience and job performance were collected from 422 nurses using a questionnaire survey. Data were collected using the Job Performance Scale, the Negative Acts Questionnaire, and the Resilience Scale (CD-RISC-10), and the resulting data were analyzed using SPSS 21 and the PROCESS macro.
Resilience moderated the positive relationship between personal, physical bullying and job performance (b = .11, p < .05; b = .17, p < .05), but did not moderate the effects of work-related bullying.
The findings of this study highlight the need for organizations to be proactive in preventing work-related bullying and to promote and enhance individual resilience. Managers need to be aware of the detrimental effects of work-related bullying, which can damage employees' physical and mental health and contribute to workplace toxicity.
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Supplementary Information

The online version contains supplementary material available at https://​doi.​org/​10.​1186/​s12912-025-02888-2.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction

Workplace bullying describes an ongoing and long-term perception of employees in the workplace, that they are being severely bullied or harmed by members of the organization, and that it is difficult to protect themselves from such behavior [1]. Bullying can generally be categorized into three types [2]: work-related bullying, which involves being burdened with unreasonable workloads or being withheld crucial work information; personal bullying, which involves gossip, rumors, and verbal abuse; and physical bullying, which involves physical contact and threatening gestures and actions. Bullying can originate from anyone, including supervisors, colleagues, and subordinates [3]. Approximately 15% of employees have experienced workplace bullying [4]. Workplace bullying is more prevalent in the nursing sector, with up to 40% of nursing staff having experienced workplace bullying [5]. This suggests that individuals in the nursing sector are at greater risk of experiencing workplace bullying than are those in other sectors [6].
Workplace bullying can lead to a variety of physical and mental health problems, including stress, burnout, anxiety, nervousness, fear, depression, frustration, helplessness, and posttraumatic stress disorder [713], further leading to increase the possibility of absenteeism or resignation. Workplace bullying can also reduce job satisfaction, productivity, and job performance [8, 11, 12, 1417], and even affect interpersonal relationships [18]. Workplace bullying (e.g., verbal and physical violence) among nurses affects their job performance [19] and may affect nursing quality and patient safety [5, 20].
Solving workplace bullying among nurses involves increasing awareness of workplace bullying and creating an environment that serves to minimize bullying [8, 21]. The impact of workplace bullying also depends on an individual's ability to cope with workplace bullying [22]. Improving the conflict management skills [23] of nurses and teaching nurses how to be resilient can moderate the negative effects of workplace bullying [24, 25].
Resilience is generally defined as a psychological trait in which an individual is capable of quickly recovering from adversity and depression when faced with major adversity, risk, or pressure [26]. Resilience helps employees better defend themselves against workplace bullying [27, 28]. Enhancing employee resilience improves individual productivity [29]. Resilience is recognized as a beneficial psychological trait in the workplace context. Research has demonstrated a positive correlation between resilience and job performance [30]. Nursing staff with high levels of resilience have been shown to have better job performance [31].
Resilience moderates the relationship between stress and negative emotions [27] and buffers the impact of burnout and poor mental health on nurses [28]. Some studies have shown that personal resilience positively moderates workplace bullying and psychological distress [3239]. For example, Anasori [32] found that resilience can moderate the effects of workplace bullying and psychological distress on employee creativity. Similarly, resilience has been shown to reduce the adverse effects of workplace bullying on organizational commitment [33]. Gupta and Bakhshi [34] found that resilience moderates the relationship between workplace bullying and perceived victimization, and moderates the negative effects of perceived victimization on employee well-being. Zhou [35] further demonstrated that resilience moderates the effects of workplace bullying on personal well-being, with individuals possessing lower resilience experiencing greater declines in well-being when confronted with workplace bullying. Additionally, resilience serves as a protective factor for nursing staff, helping to mitigate the effects of emotional exhaustion [36].
Perspectives on the moderating effects of resilience differ by study. Kang and Han [38] investigated how resilience moderates the effects of workplace bullying on work achievement and found that resilience did not moderate the relationship between bullying and work achievement. According to Annor and Amponsah-Tawiah [39], resilience acts as a reverse moderator of the relationship between workplace bullying and subjective well-being. They found that the effects of workplace bullying on subjective well-being are greater among individuals with low resilience than among those with high resilience. Employees with high resilience might rely on their personal resources to cope with or tolerate bullying.
In most studies, workplace bullying is treated as a single integrated variable. However, in practice, workplace bullying can be divided into several types, including reputational attacks, excessive criticism, interference, physical harm, and coercion [4042]. Some types of workplace bullying are worse than others [43]. Resilience moderates the relationship between different types of bullying and mental well-being [44]. A study involving adolescents revealed that resilience serves as a form of psychological immunity, mitigating the adverse effects of physical bullying and reducing the threat of physical harm to cognitive health. Nevertheless, with regard to language-related bullying (rumors, and verbal abuse) behaviors, resilience may exacerbate negative effects [44]. This highlights the complexity of resilience's moderating effect on bullying and behavioral outcomes. Few studies in the nursing sector have investigated the moderating effect of resilience on the relationship between workplace bullying and job performance. The present study suggested that more resilient employees are better able to face workplace bullying behaviors. Furthermore, more resilient employees are better able to take advantage of external resources to mitigate the effects of workplace bullying [45]. Resilience moderates the effects of negative factors in the workplace on job outcomes [27]. Therefore, this study posited that employees with high resilience perceive themselves as having sufficient ability to cope with excessive workloads. In addition, workplace bullying affects how an individual consumes resources, which affects the moderating effect of resilience. In summary, the purpose of this study was to investigate whether resilience moderates the effects of workplace bullying on job performance and determine whether this moderating effect differs between three types of bullying: personal, work-related, and physical bullying. The following hypotheses were established (Fig. 1): resilience moderates the relationship between personal bullying and job performance (H1), the relationship between work-related bullying and job performance (H2), and the relationship between physical bullying and job performance (H3).

Methods

Participants and procedures

A self-completed questionnaire was distributed to full-time nursing staff (excluding unit supervisors, such as chief nursing officers and supervisors) at three regional hospitals in Taiwan. After obtaining consent from each hospital, the study authors visited each nursing unit in person to explain the procedures and to recruit participants. The nursing staff received information regarding the study objectives from the researchers, along with a confidentiality statement, an informed consent form, and a paper questionnaire. Participation was entirely voluntary, and no incentives were offered. Completed questionnaires were sealed in envelopes by participants and deposited into sealed collection boxes placed in each nursing unit to ensure anonymity. A total of 550 questionnaires were distributed, and 422 valid questionnaires were collected, for a response rate of 76%. The questionnaire contained 39 items, conforming to Comrey's [46] recommendation that a study’s sample size should be 10 times the number of items.

Measures

The questionnaire had four sections. In the first section, data on participant characteristics, including gender, age, educational level, marital status, nursing ability, nursing years, and organization, were collected. The second part pertained to the respondent’s experience with workplace bullying and was based on the Negative Acts Questionnaire (NAQ-R) developed by Einarsen, Hoel, and Notelaers [47], which many studies have used to assess bullying among nursing staff [2]. The NAQ-R comprises 12 items related to personal bullying (e.g., deliberately ignoring or excluding an individual, spreading rumors, and engaging in gossip), 7 items on work-related bullying (e.g., having overwhelming workloads or unreasonable deadlines), and 3 items related to physical intimidation (e.g., threats of violence or physical abuse). The participants were asked to indicate whether they had experienced a given type of bullying act in the past 6 months. Items were rated on a 5-point Likert-type scale with the points 1 (never), 2 (occasionally), 3 (monthly), 4 (weekly), and 5 (daily). A higher value indicated more frequent workplace bullying. The reliability and validity of this scale were verified in a previous study [45]. Additionally, validation studies conducted in Taiwan showed that the questionnaire had Cronbach’s alpha values ranging from 0.81 to 0.95 for the three subscales and 0.97 for the overall scale, indicating good reliability and validity [48]. In our study, the Cronbach's alpha of the overall scale was 0.89; the Cronbach's alpha of the personal bullying dimension was 0.84; the Cronbach's alpha of the work-related bullying dimension was 0.83; and the Cronbach's alpha of the physical intimidation dimension was 0.80.
The third section inquired into job performance on the basis of the seven-item in-role behaviors questionnaire designed by William and Anderson [49]. This questionnaire includes statements to which participants rate their level of agreement. The statements included “adequately completes assigned duties” and “meets the job’s formal performance requirements.” Items were rated on a 5-point Likert-type scale with endpoints ranging from 1 (strongly disagree) to 5 (strongly agree). A study conducted in Taiwan by Chu and Hsu [50] validated this employee performance rating scale for assessing the job performance of hospital nursing staff and reported good reliability (Cronbach's alpha = 0.91). In our study, the Cronbach's alpha was 0.92. The fourth section of the questionnaire was used to measure resilience by using the 10-item Connor–Davidson Resilience Scale (CD-RISC-10) developed by Campbell-Sills and Stein [51]. Items on this scale were rated on a 5-point Likert-type scale, with endpoints ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score indicated a higher level of resilience. The reliability and validity of this scale were verified in a previous study [52], In addition, the CD-RISC-10 was validated among emergency nurses in Taiwan and showed high internal consistency (Cronbach's alpha = 0.95) [53]. In our study, Cronbach's alpha was 0.95.

Statistical analysis

All statistical analyses were performed using SPSS version 21.0 and PROCESS macro version 3.4.1 [54]. Data were analyzed using descriptive statistics (including frequencies, percentages) and Pearson correlation analysis. We then used the PROCESS macro to perform a regression-based path analysis, which is similar to structural equation modeling but takes into consideration irregular sampling distributions [55]. All regression coefficients were tested using the bi-as-corrected percentile Bootstrap method [56]. To evaluate our theoretical model, which controlled for age and sex, we estimated the 95% confidence intervals (CIs) for the moderation effects and used 5,000 resampled samples. When a 95% CI did not include 0, the result was considered statistically significant. We selected Model 1 in PROCESS to examine the simple moderation effect of resilience on the association be-tween workplace bullying (personal bullying, work-related bullying, and physical bullying) and job performance.

Ethical considerations

The study adhered to ethical guidelines by obtaining prior approval from the hospital management, and all methods were performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects. Anonymity and confidentiality of questionnaires were maintained, participants could withdraw at any time, and only reliable sources were used for data collection. The study was reviewed and approved by the institutional review board (IRB) of Taichung Jen-Ai Hospital (No. NO 111–81).

Results

Among the participants, 43.13% were 30–39 years old and 39.1% were 20–29 years old. The majority of the participants were women (90.28%), and 9.72% were men, and 50.95% were married. Regarding educational level, 68.96% had completed university, 17.06% had completed junior college, and 13.98% had completed graduate school. Regarding nursing experience, 58.06% had 2–5 years, 15.4% had 6–10 years, and 18.25% had > 10 years of experience. Most participants worked at outpatient departments (38.39%), followed by general wards at 18.96% (Table 1).
Table 1
Basic characteristics of study participants (n = 422)
Variables
Frequency
Percentage
Gender
 Male
41
9.72%
 Female
381
90.28%
Age
 20-29Y
165
39.10%
 30-39Y
182
43.13%
 40-49Y
58
13.74%
 > 50Y
17
4.03%
Educational level
 Junior college
72
17.06%
 Bachelor
291
68.96%
 Master
59
13.98%
Marital status
 Married
215
50.95%
 Single/divorced
207
49.05%
Nursing Clinical Ladder
 N0
42
9.95%
 N1
209
49.53%
 N2
128
30.33%
 N3
28
6.64%
 N4
15
3.55%
Type of unit
 Outpatient
162
38.39%
 Emergency
47
11.14%
 General ward
80
18.96%
 Operating room
42
9.95%
 Intensive care unit
49
11.61%
 Others
42
9.95%
Nursing experience
 Under 2 years
35
8.29%
 2–5 years
245
58.06%
 6–10 years
65
15.40%
 Over 10 years
77
18.25%
Nursing clinical ladder (N0–N4) classification: N0 (Novice)—Nurses with less than 2 months of work experience; N1 (Advanced Beginner)- Nurses with basic clinical competency who provide fundamental patient care; N2 (Competent)-Nurses capable of managing more complex patient care scenarios; N3 (Proficient)-Nurses who modify care plans based on patient responses and contribute to quality improvement; N4 (Expert)-Nurses with advanced decision-making skills who participate in teaching, management, and quality initiatives [57]
Table 2 presents the descriptive statistics, including the means, standard deviations, and correlation coefficients, of the variables employed in this study. The participants in the study reported moderate levels of job performance and resilience and experienced relatively low levels of workplace bullying. An inverse correlation between workplace bullying and resilience was observed, and a positive correlation between resilience and job performance was observed. Nursing experience was positively associated with resilience.
Table 2
Mean, standard deviations, and correlations of the main variables of the study (N = 422)
 
1
2
3
4
5
6
7
8
9
1. age
1
        
2. education level
.05
1
       
3. nursing clinical ladder
.37**
.13*
1
      
4. nursing experience
.55**
-.12*
.55**
1
     
5. personal bullying
.16**
-.16**
-.04
.13*
1
    
6. work-related bullying
.31**
-.13*
.14*
.29**
.73**
1
   
7. physical bullying
-.03
-.04
-.01
-.01
.46**
.27**
1
  
8. resilience
-.30**
.19**
-.09
.38**
-.47**
-.52**
-.19**
1
 
9. job performance
-.13*
.03
-.04
.19**
-.47**
-.42**
-.39**
.70**
1
*: p < 0.05; **: p < 0.01
To evaluate moderating effects, three regression models, namely Models I, II, and III, were generated (Table 3). These models corresponded to separate test hypotheses H1, H2, and H3, respectively.
Table 3
Moderating effects of resilience on relation between exposure to bullying and job performance
Predictor
b
S.E
95% CI Lower limit
95% CI Upper limit
Model I
 Personal bullying
-.15***
.05
-.25
-.04
 Resilience
.38***
.03
.32
.45
 Personal bullying * resilience
.11*
.05
.02
.21
Model II
 Work-related bullying
-.05
.04
-.13
.03
 Resilience
.34***
.06
.35
.50
 Work-related bullying * resilience
.05
.04
-.03
.14
Model III
 Physical bullying
-.18**
.06
-.30
-.07
 Resilience
.44***
.03
.38
.49
 Physical bullying * resilience
.17*
.06
.06
.29
*: p < 0.05; **: p < 0.01; ***: p < 0.001; b: Unstandardized coefficients; S.E.: standard error; CI Confidence interval. Control variables: age, gender, education, and work experience
In Model I (adjusted R2 = 0.52, p < 0.001), job performance was predicted by personal bullying (b = − 0.15, p < 0.01) resilience (b = 0.38, p < 0.001), and the interaction between personal bullying and resilience (b = 0.11, p < 0.05; Fig. 2). The model suggested that resilience moderates the positive relationship between personal bullying and job performance. However, in Model II (adjusted R2 = 0.48, p < 0.001), job performance was predicted by resilience (b = 0.34, p < 0.001) but was not predicted by work-related bullying (b = − 0.05, p > 0.05) or the interaction between work-related bullying and resilience (b = 0.05, p > 0.05). In Model III (adjusted R2 = 0.57, p < 0.001), job performance was predicted by physical bullying (b = − 0.18, p < 0.01), resilience (b = 0.44, p < 0.001), and the interaction between physical bullying and resilience (b = 0.17, p < 0.05; Fig. 3). The model suggested that resilience moderates the positive relationship between physical bullying and job performance.

Discussion

This study demonstrated that resilience moderates the effects of personal bullying and physical bullying on job performance. Hypotheses H1 and H3 were validated. Most past studies on this topic have investigated the moderating effect of resilience on the relationship between workplace bullying and psychological distress or well-being [3239]; few studies have investigated the moderating effect of resilience on the relationship between workplace bullying and job performance. In addition to investigating this effect, the present study explored whether the effects of resilience on the relationship between workplace bullying and job performance differ by the type of workplace bullying. The study findings were consistent with other studies that have shown that workplace bullying has a negative effect on productivity and job performance [8, 58, 59].
The findings of this study highlight the value of resilience in the face of workplace bullying. This study hypothesized that resilience moderates the effects of workplace bullying on job performance through the creation of protective mechanisms. After examining three different types of workplace bullying, this study found that resilience moderates the negative effects of personal bullying and physical intimidation on job performance. Physical intimidation is a direct form of bullying that involves physical aggression, such as hitting, kicking, pinching, pushing, and bumping. Personal bullying is another direct form of bullying that involves reviling, teasing, and making verbal threats [41]. Personal bullying can lead to anxiety, depression, and traumatic stress disorder [710]. Resilience is thought to counteract the negative effects of external stressors, especially in the field of nursing. Resilience ameliorates many adverse psychological outcomes, such as anxiety, depression, and posttraumatic stress disorder [60]. In short, resilience is significantly associated with improved mental health [61] because it helps the individual maintain their emotional stability in the face of negative emotions. Several studies on this topic have reported similar findings. According to a study [62], resilience can be regarded as a resource that individuals can draw on to perform well and remain satisfied with their job in spite of stress in the workplace. According to a study [28], improving personal resilience improves the health and job performance of nursing staff. Resilience plays a crucial role in enabling individuals to positively face challenges and adapt to adversity [63]. Our results were consistent with the idea that resilience enables people to respond effectively to personal bullying and physical bullying in the work environment and to positively adjust to external threats, thereby mitigating the negative effects of workplace bullying on job performance.
Our findings indicate that resilience is not a panacea for all forms of workplace bullying. Specifically, resilience does not moderate the adverse effects of work-related bullying; such bullying (in the form of excessive workloads and unreasonable work demands and deadlines) reduces workplace performance regardless of an individual’s level of resilience. This occurs because excessive workloads deplete employees' cognitive, physical, and emotional resources. Nonetheless, our findings suggest that although resilience can moderate the negative effects of personal bullying and physical intimidation, resilience alone cannot moderate the negative effects of resource depletion caused by unreasonable treatment at work [64]. In the past, work-related bullying was often mistakenly perceived as the implementation of strict management practices by the organization or its leadership [65]. Therefore, work-related bullying was more likely to be ignored than was personal bullying or physical intimidation [43, 65], especially in Asia, which has a performance-oriented workplace culture in which individuals tend to attach more importance to achievement and competition, which also leads to a culture of tolerance toward work-related bullying [66, 67]. In addition, nursing workplaces tend to place particular emphasis on efficient and real-time cross-team professional collaboration [68]. In nursing environments, all team members are expected to be patient-centered [69]. Nurses may mistakenly believe that workplace bullying does not violate workplace norms [66]. Due to the combined pressure of group misperception and the focus on team performance, victims of bullying may overlook the fact that they are experiencing unfair treatment at work. Consequently, they might not know how to effectively utilize resilience to mitigate these negative effects.
According to the correlation analysis in this study, age was significantly positively correlated with both personal and work-related bullying, suggesting that older nurses are more likely to experience workplace bullying. This finding contrasts with results from U.S.-based studies [21, 70]. A possible explanation for this discrepancy may lie in the differing work cultures in the nursing field across countries. In Taiwan, for example, senior nurses typically bear heavier workloads—not only are they assigned additional tasks by unit supervisors, but they are also responsible for educating, training, and supporting junior nurses. This increased burden elevates their exposure to interpersonal conflicts and hierarchical tensions. Moreover, the advanced professional competence, work enthusiasm, and innovative thinking of senior nurses may provoke conflicts of opinion and power struggles with colleagues or supervisors, potentially escalating into workplace bullying incidents [21, 71]. Future research should further investigate the role of resilience across different age groups.

Implications for management

Nursing units and their leaders must pay special attention to the issue of workplace bullying and its underlying causes, and they should declare and implement a zero-tolerance policy [37, 72]. This study found that resilient nursing staff can effectively deal with the stress resulting from personal bullying and physical bullying, further moderating the effects of these two types of bullying on job performance. This is an important finding because resilience is an individual resource and capability that can be developed through training [73, 74]. Therefore, nursing units may adopt various educational and training programs for nurses (including new staff) to help them enhance their adaptability and boost their self-confidence, enabling them to confront challenges and stress proactively and view such challenges as opportunities for growth [75].
However, our study revealed that resilience does not moderate the relationship between work-related bullying and job performance. Essentially, the causes of work-related bullying are more complex and rooted in systemic and structural organizational issues, such as excessive workloads, unreasonable deadlines, or the withholding of critical work-related information. Such bullying behaviors can be viewed as a form of control over employees' work capabilities [76] and often result in the deindividuation effects of the victims [68], particularly in performance-driven environments. According to Leong and Crossman (2016), bullying behaviors in nursing workplaces are sometimes perceived as "tough love," where scolding, sarcasm, and negative feedback are seen as necessary for fostering independence and professional competence [77]. This phenomenon is particularly pronounced in Asian contexts, where Confucian values emphasize hierarchical relationships and obedience to authority, leading nurses to view such inappropriate treatment as a normal aspect of workplace culture.
To address this issue, nursing units and supervisors should clearly define work-related bullying [78]. For example, improper patient assignments, unfair shift allocations, or the deliberate withholding of critical patient care information can all be considered forms of work-related bullying, which not only harm employees' physical and mental health but also create a harmful work environment [45]. Establishing clear guidelines on acceptable workloads and information sharing can promote fairness and transparency. Additionally, healthcare organizations should implement streamlined, secure, and accessible reporting mechanisms, given that nurses often hesitate to report bullying due to fears of retaliation and power imbalances [79]. Moreover, since managers frequently lack the confidence and skills to address bullying effectively [80], organizations should offer training programs to equip them with the necessary abilities to identify bullying, handle complaints, and implement preventive measures. Proper training will enable managers to create a supportive work environment, ensure fair workload distribution, and maintain transparent communication channels [81].

Limitations

This study has several limitations. First, the study design was cross-sectional; future research should adopt a longitudinal study design to further verify the temporal relationship between workplace bullying and job performance. In addition, because the questionnaires were self-completed, issues related to common variance and correlation among factors may have arisen, although the anonymous nature of the study may have reduced these effects. Furthermore, because the questionnaires were collected at the nursing-unit level, the respondents might have been cautious about disclosing instances of workplace bullying, potentially leading to an underestimation of workplace bullying. Finally, the generalizability of the findings is limited by the fact that nursing staff from only three regional hospitals in Taiwan were included.

Conclusion

This study investigated the moderating effect of resilience on the relationship between different types of workplaces bullying and job performance. Resilience is a protective resource for nursing staff facing complex work environments. Moreover, resilience helps individuals adapt and deal with pressure, threats, and adversity. Resilience also moderates the negative effects of personal bullying and physical intimidation on job performance. Nursing units should strengthen resilience among nursing staff through education and training. Notably, resilience was not found to have a significant moderating effect on work-related bullying, possibly because work-related bullying might be misinterpreted as a request or challenge from organizations, further increasing tolerance to this type of bullying. Given the negative effects of workplace bullying on job performance, organizations should adopt clearer explanations and norms for work-related bullying and be more proactive in mitigating work-related bullying.

Acknowledgements

We would like to thank the anonymous participants who took part in this study

Declarations

The study adhered to ethical guidelines by obtaining prior approval from the hospital management, and all methods were performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects. Anonymity and confidentiality of questionnaires were maintained, participants could withdraw at any time, and only reliable sources were used for data collection. The study was reviewed and approved by the institutional review board (IRB) of Taichung Jen-Ai Hospital (No. NO 111-81).
Not applicable.

Competing interests

The authors declare no competing interests.
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Anhänge

Supplementary Information

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Metadaten
Titel
Resilience as a moderator of the effects of types of workplace bullying and job performance
verfasst von
Yu-Chia Chang
Shi-Ting Huang
Chih-Chun Wang
Cheng-Chia Yang
Publikationsdatum
01.12.2025
Verlag
BioMed Central
Erschienen in
BMC Nursing / Ausgabe 1/2025
Elektronische ISSN: 1472-6955
DOI
https://doi.org/10.1186/s12912-025-02888-2