Workplace bullying, psychological hardiness, and accidents and injuries in nursing: A moderated mediation model


Workplace bullying, psychological hardiness, and accidents and injuries in nursing: A moderated mediation model Stephen T. T. TeoID

1*, Diep Nguyen1, Fiona Trevelyan2, Felicity Lamm3, Mark Boocock4

1 School of Business and Law, Edith Cowan University, Western Australia, Australia, 2 School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand, 3 The Centre for Occupational Health and Safety Research, Auckland University of Technology, Auckland, New Zealand, 4 Department of Physiotherapy, Auckland University of Technology, Auckland, New Zealand



Workplace bullying are prevalent among the nursing workforce. Consequences of work-

place bullying include psychological stress and workplace accidents and injuries. Psycho-

logical hardiness is proposed as a buffer for workplace bullying and psychological stress on

workplace accidents and injuries. This study adopted the Affective Events Theory and Con-

servation of Resources Theory to develop and test a moderated mediated model in two field

studies. Study 1 (N = 286, Australian nurses) found support for the direct negative effect of

workplace bullying on workplace accidents and injuries with psychological stress acting as

the mediator. The mediation findings from Study 1 were replicated in Study 2 (N = 201, New

Zealand nurses). In addition, Study 2 supplemented Study 1 by providing empirical support

for using psychological hardiness as the buffer for the association between psychological

stress and workplace accidents and injuries. This study offers theoretical and empirical

insights into the research and practice on psychological hardiness for improving the psycho-

logical well-being of employees who faced workplace mistreatments.


Workplace bullying is a typical psychosocial risk factor universally prevalent in most work- places around the world. The Workplace Bullying Institute’s 2017 survey reported approxi- mate 40% of the bullied targets reported suffering adverse health effects and this incidence affected 60.4 million Americans [1]. Fevre and colleagues reported that approximately half of the participants in the United Kingdom experienced some forms of unreasonable treatment at work and 40% reported workplace disrespect to be the most common phenomenon [2]. Other studies showed that health sector employees are one of the most vulnerable population to expose to psychosocial risk at work [3]. As previously reported, 65% of nursing professionals in the USA observed lateral violence among co-workers [4]. These statistics highlighted the severity of workplace bullying on the stress of the nursing workforce.

Despite several definitions of workplace bullying [5], the present study adopts the definition of workplace bullying by Einarsen and colleagues [6] as “harassing, offending, socially


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Citation: Teo STT, Nguyen D, Trevelyan F, Lamm F, Boocock M (2021) Workplace bullying, psychological hardiness, and accidents and injuries in nursing: A moderated mediation model. PLoS ONE 16(1): e0244426. journal.pone.0244426

Editor: Sergio A. Useche, Universitat de Valencia, SPAIN

Received: May 2, 2020

Accepted: December 9, 2020

Published: January 8, 2021

Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here:

Copyright: © 2021 Teo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability Statement: The full data set cannot be shared publicly because formal approval was not granted by the Ethics Committee. However, all relevant data necessary to replicate

excluding someone or negatively affecting someone’s work tasks.” Workplace bullying is a major source of psychosocial stressors [7, 8] and it is associated with workplace injury com- pensation claims [9].

An outcome of psychosocial risk factors is accidents and injuries [10]. Common forms of workplace accidents and injuries among hospital workers include overexertion, falling slips, trips, and falls, contact with objects or equipment, violence, and an exposure to harmful sub- stances [10]. These injuries lead to employees taking sick leaves from work. However, there is inconclusive of the association of psychological stress with workplace accidents and injuries [10, 11]. Therefore, more attention is needed to enhance the workplace safety of nurses [12].

Scholars have been urged to investigate into workplace bullying in the context of workplace safety [12]. A meta-analytical review by Christian et al. showed most studies examine the impact of safety climate and personality factors [13]. Research showed that psychological har- diness could be treated as an important ‘resistance’ resource [14] which helps employees effec- tively cope with stressful situations and/or negative work-related events because of the ability of psychological resilience [15], as explained by the Conservation of Resources (COR) theory [16]. However, very little is currently known about the moderating role of psychological hardi- ness in assisting nurses to cope with workplace bullying and its consequent outcomes although this factor is a potential moderator of stress [17]. We will take up this challenge by proposing that psychological stress is a mediator and psychological hardiness is a resource which could be used to buffer the influences of workplace bullying on workplace accidents and injuries among nurses (Fig 1).

Theoretical background and hypotheses

Workplace bullying and psychological stress

A “good” work environment is associated with better work outcomes such as lower stress and injury rates [18]. Workplace bullying is an example of “unsafe” psychosocial work environ- ment [19]. Studies showed that bullying leads to burnout [20], which adversely affects the physical and mental health of nurses [35]. These symptoms are prevalent in nursing, irrespec- tive of gender, age, race, education levels, or work history [21]. In Australia and New Zealand, nurses also experienced workplace bullying and work harassment [22].

The integration of the affective events theory (AET) [23] and the COR theory [16] creates a potentially useful framework to explain the negative effects of workplace bullying on nurses. Drawing from the AET, we argue that when employees experience workplace bullying that is a negatively affective event, they would react emotionally to it which would affect their subse- quent well-being [5]. Consistent with the COR perspective, an exposure to workplace bullying could result in the depletion of personal and job resources leading to poor psychological health state [24]. There has been empirical support for the negative association between workplace bullying and psychological stress, as shown in a sample of 233 hospital and 208 aged care nurses from Australia [25]. When nurses are exposed to workplace bullying, they experienced more burnout as they could not recover psychologically [26].

H1: Workplace bullying has a positive association with psychological stress.

The resulting psychological stress due to workplace bullying could lead to workplace safety outcomes among nurses. The Institute for Safe Medication Practices reported that 7% of 1,565 nurses were involved in medication errors as a result of experiencing intimidation at work [27]. Instead of asking for help in an environment where bullying is present, nurses muddle through an unclear procedure, use an unfamiliar piece of medical equipment without seeking help, lift heavy, or debilitated patients alone [28]. These actions not only are prone to cause

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the study’s results are within the paper and its Supporting Information files.

Funding: Funding was provided by the Auckland University of Technology as a research grant awarded to Teo, Lamm and Boocock. Authors Trevelyan, Lamm, and Boocock are full time employees of the funder (Auckland University of Technology).The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

accidents that compromise patient care and safety, but also can cause injuries to themselves and jeopardize their safety. Salminen et al. provided empirical support between injuries and interper- sonal relationship problems as examples of workplace bullying behaviors [11]. Other studies found that workplace bullying among nurses could result in stress-related symptoms such as acci- dents and errors [29] and negatively affects the quality and safety of patient care [30]. A recent systematic review supported the positive association between workplace bullying and injuries as “unsupportive social relationships” are related to higher levels of employee injury [31].

H2: Workplace bullying has a positive association with workplace accidents and injuries.

Psychological stress and workplace accidents and injuries

Workplace bullying has been found to lead to poor mental well-being [5] and emotional exhaustion [9]. AET perspective could be used to explain these relationships [5]. These health problems could cause a loss of concentration and vigilance at work that increases the chance of making mistakes and the likelihood of work accident and injury events, both physical (e.g., needle injuries) and psychological (e.g., violence) [32]. Bullying was perceived to be associated with occupational injuries [33]. There is also evidence supporting the association between bul- lying and suicidal ideation or attempted suicide, which is the ultimate injury due to extreme psychological stress [34].

Fig 1. Proposed moderated mediation model. Note: Control variables: tenure, gender, supervisory role, age and marker variable (social desirability), Study 1: Hypotheses 1 to 4, Study 2: Full model (Hypotheses 1 to 4 and moderation hypotheses).

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H3: Psychological stress has a positive association with workplace accidents and injuries.

Workplace bullying could also result in sleep disorders and fatigue as well as moderate and high levels of psychological stress that increase the risk of work-related accidents and injuries [35]. To reduce the physiological stress of being bullied, some employees even developed excessive alcohol consumption that is a risk factor for accidents and injuries at work to cope with bullying [36]. Others [37] argued that the association between bullying-related psycholog- ical stress and work-related accidents and injuries was caused by nurses’ cognitive failures in performing their daily tasks.

H4: Psychological stress mediates the positive association of workplace bullying on accidents and injuries at work.

Moderation effects of psychological hardiness

Psychological hardiness has received an increasing interest in high-stress, first respondent occupations such as military [38] and nursing [39]. Hardiness is “a constellation of personality characteristics that function as a resistance resource in the encounter with stressful life events” [40]. A hardy personality comprises of commitment, control, and challenge attitudes that pro- vide a pathway to resilience that facilitates the possibility to turn “stressful circumstances” from adversity into advantage and growth opportunities [14, 41]. Hardy individuals experi- ence stressful work situations in ways that they appraise the potentially stressful situations as less threatening, thus, minimizing their experience of stress [38]. Indeed, research has long rec- ognized that psychological hardiness acts as a protective or buffer factor in coping with work- related stress [42] and a resilience factor against the development of PTSD syndromes [43]. A recent study noted the importance of developing the resilience of nurses in New Zealand in creating a practice environment which reduces workplace bullying [44]. Consistent with these arguments, we argue that psychological hardiness is important in helping nurses cope with workplace bullying.

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