An investigation into the relationships between bullying, discrimination, burnout and patient safety in nurses and midwives: Is burnout a mediator?

Abstract

Background
Bullying and discrimination may be indirectly associated with patient safety via their contribution to burnout, but research has yet to establish this.

Aims
The aims of this study were to investigate the relationships between workplace bullying, perceived discrimination, levels of burnout and patient safety perceptions in nurses and midwives and to assess whether bullying and discrimination were more frequently experienced by Black, Asian and minority ethnic than White nurses and midwives.

Methods
In total, 528 nurses and midwives were recruited from four hospitals in the United Kingdom to complete a cross-sectional survey between February and March 2017. The survey included items on bullying, discrimination, burnout and individual level and ward level patient safety perceptions. Data were analysed using path analysis.

Results
The results were reported according to the STROBE checklist. Bullying and discrimination were significantly associated with higher burnout. Higher burnout was in turn associated with poorer individual- and ward-level patient safety perceptions. Experiences of discrimination were three times more common among Black, Asian and minority ethnic than White nurses and midwives, but there was no significant difference in experiences of bullying.

Conclusions
Bullying and discrimination are indirectly associated with patient safety perceptions via their influence on burnout. Healthcare organisations seeking to improve patient care should implement strategies to reduce workplace bullying and discrimination.

Full text

Accepted for publication in the Journal of Research in Nursing
An investigation into the relationships between bullying, discrimination, burnout and
patient safety in nurses and midwives
Judith Johnson, PhD, ClinPsyDabd; Lorraine Cameron, MAbe*; Lucy Mitchinson, BScaf; Mayur
Parmar, BScag; Gail Opio-te, RNch; Gemma Louch, PhDbi; Angela Grange, RN, PhDbj
aSchool of Psychology, University of Leeds, Leeds, LS29JT, UK; +44 (0)1133235719
bBradford Institute for Health Research, Bradford Royal Infirmary, Bradford, BD96RJ; +44
(0) 1274 383430
cSilsden District Nurse Team, Bradford District Care NHS Foundation Trust, Bradford, BD18
3LD; +44 (0)1274 256131
dCorresponding author; Lecturer, j.johnson@leeds.ac.uk
eHead of Equality and Diversity
fResearch and Implementation Assistant
gResearch and Implementation Assistant
hCommunity Nurse
iResearch Fellow
jHead of Nursing; Research and Innovation.
* Since the article was accepted for publication, we are sad to report that Lorraine Cameron
has died. Lorraine was passionate about equality and diversity, and was a driving force
behind this project. We are grateful to have worked with her on this piece of research.
Conflict of interest statement: The authors declare they have no conflict of interests.
Sources of support: This article presents independent research supported by the National
Institute for Health Research Collaboration for Leadership in Applied Health Research and
Care Yorkshire and Humber (NIHR CLAHRC YH). www.clahrc-yh.nir.ac.uk. (Reference:
NIHR IS-CLA-0113-10020). The views and opinions expressed are those of the authors, and
not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

An investigation into the relationships between bullying, discrimination, burnout and
patient safety in nurses and midwives: Is burnout a mediator?
Abstract
Background: Bullying and discrimination may be indirectly associated with patient
safety via their contribution to burnout, but research has yet to establish this.
Aims: To investigate the relationships between workplace bullying, perceived
discrimination, levels of burnout and patient safety perceptions in nurses and midwives, and
to assess whether bullying and discrimination were more frequently experienced by Black,
Asian and Minority Ethnic (BAME) than White nurses and midwives.
Methods: Five hundred and thirty-eight nurses and midwives were recruited from
four hospitals in the UK to complete a cross-sectional survey between February and March
2017. The survey included items on bullying, discrimination, burnout and individual level
and ward level patient safety perceptions. Data were analysed using path analysis.
Results: Results were reported according to the STROBE checklist. Bullying and
discrimination were significantly associated with higher burnout. Higher burnout was in turn
associated with poorer individual level and ward level patient safety perceptions. Experiences
of discrimination were three times more common among BAME than White nurses and
midwives, but there was no significant difference in experiences of bullying
Conclusions: Bullying and discrimination are indirectly associated with patient safety
perceptions via their influence on burnout. Healthcare organisations seeking to improve
patient care should implement strategies to reduce workplace bullying and discrimination.
Keywords: workforce and employment; burnout; diversity; discrimination; patient safety

Introduction
Numerous studies have found an association between higher burnout and poorer patient
safety (Hall et al., 2016; Panagioti et al., 2018; Hall et al., 2018; Johnson et al., 2017),
suggesting that reducing burnout could be an area for patient safety improvement initiatives
to target. Recent reviews of burnout reduction interventions suggest these are effective but
effect sizes are small (Panagioti et al., 2017; West et al., 2016). Organisational interventions
(e.g., work scheduling, staff training) appear to be most effective (Panagioti et al., 2018).
However, it is unclear which form of organisational interventions may work best. One
possible area organisational interventions could focus on is workplace bullying and
discrimination, but further research is needed to explore this.
Literature review
Bullying in hospitals and healthcare organisations is an issue of international concern, and
has been experienced by between 20% and 77% of nurses (Rosenstein and Naylor, 2012;
Sellers et al., 2012; Roche et al., 2010; Stanley et al., 2007; Farrell et al., 2006; Ganz et al.,
2015; Carter et al., 2013). Black, Asian and Minority Ethnic (BAME) and immigrant nurses
are more likely than White nurses to experience workplace bullying (Deery et al., 2011). This
is possibly due to a higher likelihood of bullies targeting employees whose appearance or
accent is different to the wider workplace population (Deery et al., 2011; Berdahl and Moore,
2006). Similarly, discrimination in nursing is widespread. In the UK, the National Health
Service (NHS) recruitment process favours White applicants, with White applicants 1.57
times more likely to be appointed from shortlisting as BAME applicants (Kline et al., 2017).
In the US, 40% of foreign-educated nurses report experiencing discriminatory practices in
relation to benefits, wages or shift/unit assignments (Pittman et al., 2014).
There is reason to believe that these elevated rates of discrimination and bullying could be
a patient safety concern. Previous research links bullying and discrimination with burnout
(Volpone and Avery, 2013; Laschinger et al., 2012), and some studies have also directly
linked bullying with patient safety (Houck and Colbert, 2017). However, no studies have

included UK hospital nurses, where a quarter of entry-grade nurses are BAME (Kline et al.,
2017). Furthermore, there is a lack of research into possible associations between
discrimination and patient safety, and it remains unclear whether addressing discrimination
could improve patient safety. As significant global shortages of healthcare workers have
resulted in net migration of nurses from low- to higher-income countries, proportions of
BAME nurses in higher income countries could be expected to rise, and the need to
understand these issues will become increasingly important (Aluttis et al., 2014).
When this evidence is considered together, it seems likely that bullying and
discrimination may be indirectly associated with patient safety via their contribution to
burnout, but research has yet to establish this. A proposed model of the associations between
bullying, discrimination, burnout and perceptions of patient safety is presented in Figure 1. If
supported, this would suggest interventions which reduce bullying and discrimination may
reduce burnout. Such interventions may also improve other outcomes linked with burnout
such as patient experience, quality of care, staff retention and absence rates.
Figure 1. Proposed model of the relationships between bullying, discrimination, burnout and
patient safety perceptions

In summary, our research aimed to investigate the relationships between workplace
bullying, perceived discrimination, levels of burnout and patient safety perceptions using path
analysis. We predicted that perceived bullying and discrimination would be associated with
higher burnout, which would in turn be associated with poorer perceptions of patient safety in
nurses and midwives. A corollary prediction was that experiences of workplace bullying and
perceived discrimination would be more frequent in BAME than White nurses and midwives.
Methods.
Participants
All registered and practicing hospital nurses and midwives from four hospitals within
an acute NHS Trust were invited to participate in the study in the UK between February and
March 2017. We aimed to recruit over 320 participants; this is the suggested sample size
proposed by Wolf et al. (2013) as being adequate for testing Structural Equation Models
investigating mediation where there is up to 20% missing data per indicator. All participants
provided informed consent prior to completing the study.
Procedure
Participants were informed of the study through a global email. Eligible participants,
identified from the Trust Electronic Staff Record (ESR), received a paper questionnaire pack.
We were aware that some participants may be concerned that their responses would be shared
with the trust. To address this, the information sheet informed participants that only research
team members would have access to their data, and that their responses would be entirely
confidential. The participants were asked to return questionnaires via the Trust internal mail.
After two weeks, reminders and a second paper questionnaire were sent to participants who
had not responded.
Design
The study used a cross-sectional survey design. Results were reported according to
the STROBE checklist (supplementary file 1).
Measures
Demographic information. Questionnaire items asked for information regarding
gender, ethnicity, age, job role, highest level of qualification, years qualified and time spent
working within the Trust.

Bullying and discrimination. Respondents were asked two items based upon the
NHS Workforce Race Equality Standards and Indicators (WRES), each requiring a ‘yes’ or
‘no’ response. The first measured discrimination: “In the last 12 months have you personally
experienced discrimination at work? (Participants were provided with the following
definition: Discrimination is when you are treated as less favourable than someone else
because of your ethnicity, age, gender, etc).” The second measured bullying, harassment and
abuse: “In the past 12 months have you experienced harassment, bullying or abuse from other
staff at work? (Participants were provided with the following definition: Harassment is
unwanted conduct which has the purpose of violating your dignity or creating an
intimidating, hostile, degrading, humiliating or offensive environment”. For both items,
‘none’ was coded as ‘1’ and occurrence of harassment/bullying or discrimination was coded
as ‘2’.
Burnout. The Oldenburg Burnout Inventory (OLBI) (Demerouti et al., 2000) consists
of two eight-item subscales, Disengagement and Exhaustion. Disengagement subscale items
include “Over time, one can become disconnected from this type of work”. Exhaustion
subscale items include “There are days when I feel tired before I arrive at work”. Items were
rated on a 4-point scale from 1 (“strongly disagree”) to 4 (“strongly agree”). Possible scores
ranged from eight to 32 on each subscale, with higher scores indicating higher burnout. The
measure demonstrated good internal consistency in our study (α = 0.80 for Emotional
Exhaustion, α = 0.79 for Disengagement, α = 0.88 for the full scale).
Patient safety perceptions. Both individual level and ward/unit level patient safety
perceptions were measured. Previous research suggests this approach provides
complementary information that varies between nurses according to individual differences
and stress (Louch et al., 2016; Louch et al., 2017).
Individual-level safety perceptions. Individual level safety perceptions were
measured using the one-item Safe Practitioner Measure (Louch et al., 2016) (“My practice is
not as safe as it could be because of work related factors/conditions”). This is scored on a

five-point scale from one (“Strongly disagree”) to five (“Strongly agree”) (Louch et al.,
2016). Responses were reverse coded in order that higher scores suggested more positive
safety perceptions.
Ward/unit-level safety perceptions. To assess ward/unit-level safety perceptions,
participants responded to a subscale from the Hospital Survey on Patient Safety Culture
(Sorra and Nieva, 2004) focusing on “Perceptions of Patient Safety”. This comprises four
items (e.g., “It is just by chance that more serious mistakes don’t happen around here”). Items
were scored on a five-point scale from one (“Strongly disagree”) five (“Strongly agree”),
with total possible scores ranging from four to 20 and higher scores suggesting more positive
perceptions. The measure demonstrated good internal consistency in our study (α = .80).
Data Analysis
Descriptive statistics and correlations were conducted for study variables. For the
purposes of the inferential statistics, ethnicity was collapsed into two categories to allow for
comparisons (White was coded as ‘1’ and Black, Asian or Minority Ethnic (BAME) was
coded as ‘2’). Spearman’s Rho correlations were conducted for most variables, as several
variables were not normally distributed. Point-biserial correlations were conducted for binary
variables (bullying, discrimination and ethnicity) with other continuous and ordinal variables.
It was not possible to assess correlations between binary variables. Odds ratios and the
Fisher’s Exact test were calculated to investigate whether experiences of bullying and
discrimination varied according to ethnicity (White vs. BAME) (McHugh, 2009).
For the purposes of path analysis, the two burnout facets were totalled to create one
burnout item. This was due to the two facets of burnout being closely related, which can
adversely affect model fit in SEM when included separately as endogenous variables.
Furthermore, previous research suggests that both facets have a similar association with
patient safety perceptions, so they would be unlikely to demonstrate different relationships
with other variables in these analyses (Johnson et al., 2017). Missing data analyses were
undertaken for variables to be included in the path analyses. Rates of missing data for

variables varied between 0.9% (gender) to 12.5% (Burnout). Little’s chi-square statistic was
not significant, suggesting no systematic pattern to the missing data (x = 26.74, df = 21, p = .
18) (Little, 1988), and as overall missing data rates were <20%, data imputation was
conducted (Garson, 2015). This was undertaken with regression imputation in AMOS 22.
This imputes predicted values in place of missing values using linear regression, which
estimates these values based on the observed (i.e., non-missing) values of that individual
(Arbuckle, 2013).
To test the proposed model of the relationships between bullying, discrimination,
burnout and each of the patient safety perception scales, SEM path analyses were conducted
in AMOS 22. This enabled use of the bootstrapping method to estimate model fit and
regression weights, which is a powerful non-parametric approach. As it uses a resampling
procedure, data distributions do not need to conform to assumptions of parametric tests. In
order to reduce estimation error we followed the advice of Cole and Preacher (2014): the
multiple-item scales we included (burnout; ward-level patient safety perceptions) were highly
reliable measures, and we kept our models simple.
Bootstrapping was used to test two models (5000 bootstrap samples; 95% confidence
interval), both of which controlled for age and gender. Model 1 tested a proposed relationship
between study variables whereby bullying and discrimination were associated with higher
burnout, which in turn was associated with lower individual-level patient safety perceptions.
Model 2 repeated this, replacing the outcome variable with the ward/unit-level perceptions of
patient safety measure. Bias-corrected bootstrap confidence intervals were reported (Cheung
and Lau, 2007). For each path tested in the analyses, Standardised beta coefficients were
reported followed by confidence intervals (lower limit, upper limit) and the significance
value, in line with previous similar studies (Johnson et al., 2017; Holden et al., 2011).
To assess model fit, we reported chi-square value, the root mean square error of
approximation (RMSEA) and the Comparative fit index (CFI), in line with recommendations
by Hooper et al. (2008). Hooper et al. (2008) note that the chi-square has several severe

limitations, namely that it assumes multivariate normality and rejects properly specified
models that do not meet this assumption, and that it is nearly always significant when
samples are large. As such the RMSEA and CFI were also reported to provide alternative fit
indices. RMSEA values <0.08 were deemed to signal acceptable fit and values <0.06 were
deemed to signal good fit. CFI values >0.90 were used to indicate acceptable fit and values
>0.95 were used to indicate good fit (Hooper et al., 2008).
Results
Participant Characteristics
One thousand, seven hundred and four participants were contacted and 538 responded
(M age= 43.55, SD= 12.72, 90.5% female, gender data missing for 1.5% participants),
producing a response rate of 31.6%. We were unable to gather information regarding why
non-responders chose not to participate. Demographic information for participants is
presented in Table 1. Participants had been qualified on average 16.89 years (SD = 11.29) and
had been working for the Trust on average for 11.91 years (SD = 10.39).
Table 1: Demographic information for participants
Number %
Ethnicity White 428 79.6
Asian 83 15.4
African-Caribbean 12 2.2
Mixed ethnicity 7 1.4
Other ethnicity 2 0.4
Preferred not to state 2 0.4
Missing 4 0.7
Education (highest attainment) PhD or Doctoral degree 2 0.4
Masters degree 42 7.8
Postgraduate diploma 81 15.1
Bachelors degree 256 47.6
Advanced diploma 99 18.4
A-Levels or equivalent 19 3.5
Other attainment 27 5.0
Missing 12 2.2
Discipline Nursing 458 85.1
Midwifery 79 14.7
Missing 1 0.2

Band 8a or above (e.g.,
matron/lead nurse)
38 7.1
7 (ward manager) 113 21.0
6 (ward sister/charge
nurse)
159 29.6
5 (staff nurse grade) 217 40.3
Missing 1 0.2
Bivariate Associations
Descriptive statistics and bivariate associations are presented (Table 2). Occurrence of
bullying was associated with higher disengagement (rpb = 0.18, p<0.001) and exhaustion (rpb =
0.15, p = 0.001), and lower individual level and ward level safety perceptions (rpb = -0.14, p
= 0.001 and rpb = -0.16, p<0.001, respectively). Occurrence of discrimination was also
associated with higher disengagement (rpb = 0.15, p = 0.001) and exhaustion (rpb = 0.15, p =
0.001) and lower individual level and ward level safety perceptions (rpb = -0.11, p = 0.016,
and rpb = -0.10, p = 0.023, respectively). Disengagement and exhaustion were positively
associated with each other (rs = 0.62, p<0.001) and both burnout facets were inversely
associated with safety perceptions (rs = -.41, p<0.001 for individual perceptions and rs = -.39,
p<0.001 for ward perceptions for disengagement,; rs = -.41, p<0.001 for individual
perceptions and rs = -.35, p<0.001 for ward perceptions for exhaustion).
Table 2: Means, Standard deviations a and correlations for variables
Mean
2 3 4 5 6 7
1. Bullyingb--- ---- .18*** .15** -.14** -.16**
*
---
2. Discriminationb--- .15** .15** -.11* -.10* ---
3. Disengagement
(burnout facet)
16.90
3.43
.62*** -.41**
*
-.39**
*
.07
4. Exhaustion
(burnout facet)
20.05
3.67
-.41**
*
-.35**
*
-.07
5. Individual-level
safety (Safe
practitioner
measure)
3.46
1.20
.52*** -.03

6. Work area/unit
level safety
(AHRQ subscale)
12.90
3.41
.03
7. Ethnicityb---
Note. *p<0.05, **p<.01, ***p<0.001. AHRQ = Agency for Healthcare Research and Quality.
aStandard deviations appear in italics below the means. Spearman’s Rho correlations are
reported unless point biserial correlations are indicated. bThese variables were binary.
Ethnicity was divided into White and Black, Asian or Minority Ethnic (BAME) categories.
As such, no mean was calculated for these variables and point-biserial correlations were
conducted.
Path Analyses of the Associations Between Bullying, Discrimination, Burnout and
Safety Perceptions
Two path analyses were tested, the first with ward-level patient safety perceptions as
the outcome and the second with individual level patient safety perceptions as the outcome.
Ward level safety perceptions. When ward level safety perceptions was the outcome
(Figure 2), the pathway between bullying and burnout was significant (B = 0.157, CI = 0.073,
0.239, p= 0.001), the pathway between discrimination and burnout was significant (B =
0.129, CI = 0.041, 0.219, p = 0.003) and the pathway between burnout and patient safety was
significant (B = -0.404, CI = -0.473, -0.326, p < 0.001). Model fit indices were X2 (6) =
17.652, p = 0.007; CFI = 0.94; RMSEA = 0.06, suggesting that although the chi-square was
significant there was overall acceptable model fit.
For completeness, we also tested the model when paths between discrimination and
ward-level safety perceptions and bullying and safety perceptions were also specified. In this
model, the pathway between bullying and burnout was significant (B = 0.157, CI = 0.073,
0.239, p = 0.001), the pathway between discrimination and burnout was significant (B =
0.129, CI = 0.041, 0.219, p= 0.003) and the pathway between burnout and patient safety was
significant (B = -0.387, CI = -0.459, -0.308, p < 0.001). However, the pathways between
bullying and patient safety (B = -0.079, CI = -0.184, 0.025, p = 0.143) and discrimination and
patient safety (B = -0.008, CI = -0.102, 0.085, p = 0.857) were not significant. Model fit

indices showed no consistent improvement upon the previous model (X2 (4) = 13.473, p =
0.009; CFI = 0.95; RMSEA = 0.07); as such the previous model was retained due to its
parsimony.
Figure 2. Structural equation model of the relationships between bullying, discrimination,
burnout and ward level patient safety perceptions
Individual Level Safety Perceptions. Similarly, when individual level safety
perceptions was the outcome (Figure 3), the pathway between bullying and burnout was
significant (B = 0.157, CI = 0.073, 0.239, p = 0.001), the pathway between discrimination and
burnout was significant (B = 0.129, CI = 0.041, 0.219, p = 0.003) and the pathway between
burnout and patient safety was significant (B = -0.473, CI = -0.543, -0.395, p<0.001). Model
fit indices were X2 (6) = 18.926, p = 0.004; CFI = 0.95; RMSEA = 0.06. Although the X2 test
was significant this might be expected given our sample size; however, the other model fit
indices suggest good model fit.
For completeness, we also tested the model when paths between discrimination and
individual-level safety perceptions and bullying and safety perceptions were also specified. In
this model, the pathway between bullying and burnout was significant (B = 0.157, CI =
0.073, 0.239, p = 0.001), the pathway between discrimination and burnout was significant (B
= 0.129, CI = 0.041, 0.219, p = 0.003) and the pathway between burnout and patient safety
was significant (B = -0.461, CI = -0.536, -0.378, p<0.001). However, the pathways between

bullying and patient safety (B = -0.045, CI = -0.126, 0.039, p = 0.294) and discrimination and
patient safety (B = -0.017, CI = -0.109, 0.071, p = 0.69) were not significant. The model fit
indices were poorer than the previous model (X2 (4) = 17.099, p = 0.002; CFI = 0.94;
RMSEA = 0.08), leading us to reject this model in favour of the former.
Figure 3. Structural equation model of the relationships between bullying, discrimination,
burnout and individual level patient safety perceptions
Ethnicity and Experiences of Bullying and Discrimination
A higher rate of BAME participants (18 of 102; 17.6%) reported experiencing
bullying in the previous year compared with White participants (52 of 419; 12.4%). The odds
of experiencing bullying were 1.5 times higher for BAME participants (odds ratio = 1.51,
95% CI [0.84, 2.72]). However, Fisher’s exact test suggested this was not significant, p =
0.19.
A higher rate of BAME participants (21 of 102; 20.5%) reported experiencing
discrimination at work in the previous year compared with White participants (33 of 421;
7.8%). The odds of experiencing discrimination were three times higher for BAME
participants (odds ratio = 3.04, 95% CI [1.68, 5.54]) and Fisher’s Exact test suggested this
was significant, p < 0.001.
Discussion
This study reports results from a survey of UK nurses and midwives from four
hospitals in one acute NHS organisation. We investigated the relationships between bullying,
perceived discrimination, levels of burnout and patient safety perceptions. The results

supported our hypothesised model. Both bullying and discrimination were significantly
associated with higher burnout. Higher burnout was in turn associated with poorer
perceptions of patient safety at both the individual and ward level. Experiences of
discrimination were three times more common in Black, Asian and Minority Ethnic (BAME)
than White nurses and midwives, however while more BAME nurses and midwives
experienced bullying than White nurses and midwives, this difference was not significant.
A large number of studies have found that burnout is linked with poorer patient safety
(Hall et al., 2016; Panagioti et al., 2018). This finding is less clear when patient safety
outcomes are measured using objective measures such as incident reports, possibly due to
reporting variability, but consistent and robust when patient safety outcomes are self-reported
(Hall et al., 2018; Panagioti et al., 2018). Together, this body of work suggests that reducing
burnout could be one target for patient safety initiatives to address. However, burnout
reduction interventions have only limited effectiveness (West et al., 2016). While
interventions targeted at the organisation level, addressing areas such as work scheduling and
staff training seem to be most effective (Panagioti et al., 2017), it is unclear which types of
organisational interventions produce the greatest reductions in burnout. The present study
extends this literature by 1) providing the first evidence that perceived discrimination is
associated with patient safety in nurses and midwives and 2) proposing and testing the first
proposed framework of the associations between bullying, discrimination, burnout and
perceptions of patient safety, and reporting that bullying and discrimination have an indirect
relationship with patient safety perceptions which is mediated by burnout. This suggests that
reducing bullying and discrimination at an organisational level may be one way to reduce
burnout, and could be useful targets for patient safety initiatives to address. It should be
noted, however, that the size of the associations between bullying and burnout, and
discrimination and burnout was small; one possible avenue for future research to explore

could be to investigate whether there are factors which moderate the strength of these
relationships.
Global healthcare staff shortages have led to increased migration of nurses and
doctors from low- to higher- income countries (Aluttis et al., 2014). Countries including the
UK, Netherlands and Australia actively recruit from overseas (WHO, 2014); an analysis of
2011 census data indicated that over 30% of nurses and midwives in Australia were born
overseas (Negin et al., 2013) and in the UK in 2017, 20% of nurses joining the NHS were not
from the UK (Baker, 2018). The present findings suggest that a fair and equal approach to
recruitment and promotion for all nurses may support patient safety, and countries who
recruit nurses from overseas should take particular care to ensure that any discrimination in
their recruitment and promotion practices is reduced.
The present study is the first to investigate associations between bullying and patient
safety within UK hospital nurses and midwives. Previous research has focused on nurses in
the US, Canada and Australia, and has reported that bullying is linked with outcomes such as
medication errors (Rosenstein and Naylor, 2012) and fall rates (Roche et al., 2010). The
current study extends this by finding a similar association in the UK, where 20% of registered
nurses have experienced bullying in the last 6 months (Carter et al., 2013). This adds further
evidence that this association may be universal, and reducing bullying could be a target for
patient safety initiatives to focus on internationally. However, further research is needed to
explore these associations in non-English speaking and developing countries.
Our finding that perceived discrimination was higher in BAME nurses and midwives
than White nurses and midwives is consistent with previous NHS reports suggesting the
likelihood of being appointed to a post following shortlisting is 1.57 higher for White
applicants (Kline et al., 2017). It is also consistent with research from the US suggesting that
40% of foreign educated nurses have experienced discrimination (Pittman et al., 2014).
However, although BAME nurses and midwives reported higher levels of bullying than
White nurses and midwives, this difference was not significant. This contrasts with previous

studies suggesting higher rates of bullying in BAME than White nursing staff. For example,
Deery et al (2011) found 18.2% of BAME nurses had experienced verbal harassment from
colleagues compared with 10.4% of white nurses. We found that a similar percentage of
BAME nurses and midwives reported bullying (17.65%), however slightly more White
nurses and midwives in our sample also reported bullying (12.4%) which may explain why
this difference was not significant. Our findings regarding bullying can also be compared
with studies in UK nursing students; these suggest that rates of bullying are higher in
students, with around 40% having experienced bullying (Birks et al., 2017; Tee et al., 2016).
Being bullied can lead student nurses to consider leaving nursing (Tee et al., 2016).
Furthermore, a recent study estimated that the annual cost of bullying to the NHS is
£2.281(Kline and Lewis, 2018). Taken together, it seems that experiences of bullying are
common, there is no sign that rates are declining, and this problem is financially costly as
well as psychologically harmful for those involved.
Implications for Clinical Practice
Reducing workplace bullying and discrimination in nursing and midwifery may
support the delivery of safe patient care. Bullying reduction interventions may involve
organisational changes such as the introduction of procedures to raise awareness of bullying
and provide a bullying reporting mechanism. They can also involve individual interventions
such as the provision of training and education (e.g., assertiveness training) to change
behaviours or perceptions (Gillen et al., 2017), although this approach may place
responsibility on the victims of bullying rather than the perpetrators. The strongest evidence
currently supports the Civility, Respect and Engagement (CREW) intervention, a nationwide
initiative by the US Department of Veterans Affairs (Gillen et al., 2017). This involves
facilitators meeting regularly with organisations to create respectful, civil work environments
(Osatuke et al., 2009). Interventions to reduce discrimination in recruitment practices include
introducing discrimination law, monitoring the diversity of organisations and anonymising as

much of the recruitment process as possible (Lloyd, 2010). While many of these interventions
are beyond the scope of individual organisations to implement, Lindsey and colleagues
(2013) suggest organisations should pass applications to a ‘middle person’ to anonymise them
and screen out stigmatising information before passing them to decision makers. They also
suggest using highly structured interview schedules and appointing interview panels who are
low in explicit and implicit bias (Lindsey et al., 2013).
Limitations
This study was limited by its use of a cross-sectional design, which means that
conclusions regarding causality cannot be drawn. We omitted to ask participants for
information regarding how long they had been working for before joining the trust; this
information would have been useful in providing a fuller description of the sample. We based
our bullying and discrimination questions on the NHS Workforce Race Equality Standards
and Indicators (WRES). This decision meant that we used binary items which reduced
variability for statistical analysis. It also meant that we omitted to ask participants about
indirect discrimination; this information would have complemented the data we gathered
regarding direct discrimination and may have allowed for a fuller understanding of the
relationships between discrimination, burnout and patient safety. Reponses may have been
biased by a higher rate of extreme responders participating (those who are experiencing
particularly high or low levels of bullying, discrimination, burnout and perceptions of patient
safety). Finally, it should be noted that the non-significant difference regarding bullying may
have reached significance in a larger sample.
Conclusion
Workplace bullying and discrimination are associated with higher levels of burnout,
which are in turn associated with poorer individual-level and ward-level patient safety
perceptions in hospital nurses and midwives. BAME nurses and midwives experience higher
levels of discrimination than White nurses and midwives. Healthcare organisations seeking to

improve their levels of patient safety should implement interventions to reduce bullying and
discrimination within their recruitment practices.
Key points
BAME nurses and midwives are three times more likely to experience discrimination
at work than White nurses and midwives.
Bullying and discrimination are indirectly associated with patient safety perceptions,
via their influence on burnout.
Patient safety interventions in nurses and midwives should target bullying and
discrimination.
When appointing nurses and midwives, healthcare organisations should use methods
to reduce discrimination against applicants from ethnic minority groups.

Ethical permissions
The study was approved by the University of Leeds, School of Psychology Ethics
Committee on 20th October 2016 (Ref: 16-0267) and the Health Regulatory Authority on
19th January 2017 (Ref: ID 217229).

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