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Research in Nursing & Health, 2011, 34, 132–140

A New, Four-Item Instrument to Measure Workplace Bullying

Shellie R. Simons, 1 * Roland B. Stark, 2 ** Rosanna F. DeMarco 3 y

1 University of Massachusetts at Lowell, 3 Solomont Way, Suite 2, Lowell, MA 01854-5126 2 Integrative Statistics, Maynard, MA 3 Boston College, Connell School of Nursing, Chestnut Hill, MA Accepted 23 November 2010

Abstract: Studies on workplace bullying either in the U.S. or internationally rarely include nurses. We tested the concurrent validity of the Negative Acts Questionnaire—Revised (22 items) with a sample of nurses. Five hundred eleven registered nurses (RNs) responded to a mailed survey. Factor, reliability, and regression analyses tested dimensionality, reliability, and construct and criterion validity. Workplace bullying is best seen as a one- dimensional construct. A subset of four items was found to be both valid and reliable in measuring bullying in this sample. Findings support the use of a one-dimensional, four-item questionnaire to measure perceived bullying in nursing populations. Using a four-item questionnaire decreases participant and researcher burden and makes available an outcome measure for future descriptive and predictive interventional research. 2011 Wiley Periodicals, Inc. Res Nurs Health 34:132–140, 2011

Keywords: exploratory factor analysis; instrument development; nursing; principal component analysis; workplace bullying

There is a dearth of empirical research that examines bullying behavior among nurses in the United States. The ability to measure and test hypotheses related to bullying behaviors experi- enced by nurses requires a valid and reliable measure of bullying that is sensitive to nurse experiences. Einarsen and Hoel (2001) developed the Negative Acts Questionnaire—Revised (NAQ- R), a 22-item instrument, to measure perceived exposure to bullying in the workplace. The NAQ- R has drawn mixed evidence as to reliability and validity; moreover, it has been tested primarily

among European, non-nursing samples. The pur- pose of this study was to replicate dimensions previously found using the NAQ-R and to use data reduction, reliability, and regression analysis to assess dimensionality and to determine the most effective and efficient measurement tool for use with a United States nursing population.

BACKGROUND

Over the last decade, researchers have under- scored the contribution of a healthy work

This work was supported by grants from Sigma Theta Tau, Theta at Large, and Theta Alpha. The authors thank Dr. Angela Nannini for her help and support. Contract grant sponsor: Sigma Theta Tau. Contract grant sponsor: Theta at Large. Contract grant sponsor: Theta Alpha. Correspondence to Shellie Simons *Assistant Professor. **Statistician and Research Consultant. z Associate Professor. Published online 18 January 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/nur.20422

2011 Wiley Periodicals, Inc.

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environment to positive job satisfaction, the quality of nurses’ work life, and safe patient care (Beal, Riley, & Lancaster, 2008; Kramer & Schmalenberg, 2008). One of the nine elements that support a positive work environment is a collaborative practice culture involving respect- ful, collegial behavior and communication (Brady, 2010). Significant examples in the liter- ature show a direct relationship between positive nurse–physician relations and quality of the work environment, enhanced patient safety outcomes, and decreased patient mortality rates (Kazanjian, Green, Wong, & Reid, 2005; Laschinger & Leiter,

2006).

In recent years, considerable evidence has been amassed to show that workplace bullying has profound negative effects on both individuals and organizations (Einarsen & Mikkelsen, 2003; Hoel, Einarsen, & Cooper, 2003). At the individ- ual level, being the victim of bullying behavior has been linked with a variety of adverse effects rang- ing from insomnia to self-hatred and depression (Kivimaki et al., 2003; Lutgen-Sandik, Tracy, & Alberts, 2007; Mikkelsen & Einarsen, 2001; Zapf & Einarsen, 2001). Several researchers have extended their exam- ination of this issue to include the healthcare environment (McKenna, Smith, Poole, & Coverdale, 2003; Quine, 2001; Simons, 2008) and have documented considerable economic con- sequences of bullying for healthcare organiz- ations. In studies of nurses in the United Kingdom and of hospital workers in Finland, bul- lying was found to be positively associated with levels of sickness-related absenteeism among hos- pital staff (Kivimaki, Elovainio, & Vahterra, 2000; Quine, 2001). McKenna et al. (2003) found that 34% of bullied nurse respondents indicated that the problem was distressing enough to make them consider leaving the nursing profession. Simons (2008) further demonstrated that the extent of bullying experienced by nurses can in large part explain their level of intent to leave their jobs. In an attempt to decrease negative behavior in the work- place, the Joint Commission on Accreditation of Healthcare Organizations (2008) mandated that healthcare organizations create a policy that addresses disruptive and inappropriate behaviors that can contribute to medical error and poor patient outcomes.

Defining Bullying Behavior

By one definition, workplace bullying occurs when an individual perceives negative actions

Research in Nursing & Health

directed at him or her from one or more persons, continuing over at least 6 months, and when he/she has difficulty defending against these actions (Matthiesen & Einarsen, 2001). It involves a power gradient, based either on status or on per- ception, between the individuals involved (Zapf & Gross, 2001). Defined in this way, bullying between nurses can occur between a nurse man- ager and a staff nurse, a charge nurse and a staff nurse, or a more experienced nurse and a new graduate. Further, it differs from workplace har- assment in that the latter is characterized by sexual or racial motives (Pryor & Fitzgerald, 2003). Examples of bullying include excessive criticism, scapegoating (inflicting blame on others unfairly), and sabotage (withholding information needed for patient care). Bullying is often confused with horizontal or lateral violence, which Duffy (1995) described as the overt and covert non-physical hostility that occur between members of the same group. The behaviors found in horizontal violence and bullying are the same, but the points above distinguish bullying from horizontal or lat- eral violence.

Previous Instrument Development and Dimensionality Studies

Despite the well-documented presence of bullying in healthcare workplaces and its negative effects reported for nurses and patient care, the validity and reliability of measures of bullying, especially ones involving multiple dimensions, have not been thoroughly examined, particularly for nurses in the United States. A self-report instrument to measure perceived victimization by bullying that is frequently used internationally and for workers in general is the NAQ-R (Einarsen & Hoel, 2001; Mikkelsen & Einarsen, 2002). Criterion validity for this instrument has been tested to support an overall construct of bullying that relies on almost two-dozen items (Einarsen & Hoel, 2001; Simons, 2008). For example, Simons found an r of .51 (p < .001) between a logged, 22-item bullying score and a three-item scale measuring nurses’ intent to leave their jobs. This intent to leave scale was developed by Cammann, Fichman, Jenkins, and Klesh (1983) as part of the Michigan Organizational Assessment Questionnaire. Dimensionality of bullying, on the other hand, has been under-explored. In their study of 464 Norwegian industrial workers using the NAQ-R, based on their principal component analysis (PCA), Einarsen and Raknes (1997) were unsure whether to attribute two, three, four, or five

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dimensions to bullying. In their study, the terms factors and components are used interchangeably, although the two data reduction techniques of PCA and common or principal factor analysis (PFA) are quite different. PCA has a well-docu- mented tendency to inflate loadings (because the raw correlation matrix is used to extract com- ponents) and to reduce external validity when used in survey research. By contrast, PFA uses a covari- ance matrix for factor extraction, and for opinion research it has been found to be superior (Cudeck, 2000; Fabrigar, McCallum, Wegener, & Strahan, 1999; Floyd & Widaman, 1995). Einarsen and Hoel’s (2001) large-scale NAQ-R study of employees from 70 British organizations using PFA yielded two factors: Personal Bullying involving behaviors such as gossip, insulting remarks, excessive teasing, and persistent criticism, and Work-Related Bullying, measured by nine items including unreasonable deadlines, unmanageable workloads, excessive monitoring, and having vital information withheld. However, although the authors reported on these factors’ reliability and construct validity, they did not report on criterion validity of the PFA solution. Hutchinson, Wilkes, Vickers, and Jackson (2008) surveyed 102 Australian nurses, testing a new instrument designed specifically for nurses. It measured 23 aspects of bullying, each on a 7- point scale. They conducted rigorous PFA and reliability analysis of 18 of their 23 items, yielding three dimensions (Attack upon Competence and Reputation, Personal Attack, and Attack Through Work Tasks) that had Cronbach alphas of .93, .89, and .88, respectively. Confidence in their results, however, is limited by lack of evidence as to criterion validity; by the low case-to-item ratio; and by their derived eigenvalues of 8.6, 1.5, 1.5, and 1.1, which indicate a dominant unrotated first factor. Abe and Henly (2010) investigated the dimensionality of bullying among Japanese nurses using a much larger sample and found three- and five-dimensional solutions. However, their highly skewed item distributions are inconsistent with their use of maximum likelihood factor extraction (Cudeck, 2000), and the high degree of factor correlation after oblique rotation (as high as .58) calls into question the need for multiple fac- tors. Like many others, Abe and Henly did not validate their dimensions with respect to external criteria. With careful consideration of these studies, we maintain that, for multiple obtained dimensions to amount to useful constructs, they would col- lectively have to show higher correlations with criterion variables than would simpler or

Research in Nursing & Health

more one-dimensional bullying measures that

are

assumptions. Research questions.

fewer

easier

to

obtain

and

that

rely

on

(1)

the NAQ-R be demonstrated in a sample of Massachusetts nurses? (2) For any dimensions of bullying that are

found, how strong is support for concurrent validity measured via associations with three criterion variables—(a) a direct, single-item assessment of the extent of bullying experi- enced; (b) job satisfaction; and (c) intent to leave one’s job? What is the most parsimonious set of indicators (either items or multi-item dimen- sions) most strongly related to the three criterion variables listed above?

(3)

Can the dimensions previously found using

Sample

METHODS

The population of interest was non-managerial registered nurses (RNs) accessed though a data- base available from the Massachusetts Board of Registration in Nursing. Those nurses indicating that they were either a nurse manager or supervisor were excluded from the sample. The Institutional Review Board at the University of Massachusetts Boston approved this study. Completion and return of the survey was accepted as evidence of consent to participate in the study. A simple random sample numbering 1000 was drawn from nurses who became licensed in Massachusetts in the years 2001, 2002, or 2003. These nurses included both recent graduates and those graduating less recently but transferring licenses to Massachusetts in the designated years. In 2004, the survey was sent to these 1000 nurses, with 511 forms completed and 61 returned as undeliverable. The response rate was thus 51.1%, and the return rate was 54.4%. There were 34 men (6.7%) and 477 (93.3%) women, who ranged in age from 22 to 64, with a mean age of 33.1 ( SD ¼ 9.0). The length of time that partici- pants had been licensed as RNs ranged from 6 months to 35 years, with a mean of 3.7 years (SD ¼ 5.0). Most (77.9%) had been licensed 36 months. Seventy-six percent identified the hospi- tal as their practice setting, with 93% choosing staff or charge nurse as their principal role.

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Instrument

For this, correlational study using a recall survey, the NAQ-R, not previously used in the United States, was modified slightly; we refer to our version as the NAQR-US. The 22-item bullying scale yielded a Cronbach’s alpha of .88. Complete details on the instrument, data collection, sample characteristics, and descriptive findings are pro- vided in Simons (2008). As in the NAQ-R, each item that described a bullying behavior offered five response options. To create a more interval- type item response scale, rather than a mere ordi- nal one, for multivariate analyses, responses were weighted according to the estimated frequency of the behavior during the previous 6 months. These values were based on estimates of the typical number of working days in a 6-month period. The values assigned were: Never, 0; Now and Then , 2; Monthly, 6; Weekly, 25; and Daily, 125. In addition, responses to all 22 items weighted in

this way were summed to create an interval-level scale representing all facets of bullying covered on the instrument. For this summation, missing val- ues (.2–1.4% per item) were given a value of zero. This positively skewed total score variable was also transformed (log, base 10) to be more suitable to linear statistical tests and to better reveal relationships with other variables.

In addition to items on bullying and demo-

graphics, the survey included several items used

to test the criterion validity of various competing measures put forth as indicators of bullying. One such criterion was a direct, single-item assessment of the extent of bullying experienced. Respondents were provided with a definition of bullying developed by Matthiesen and Einarsen (2001) as a situation where one or several indi- viduals persistently over time perceive themselves to have received negative actions from one or several persons, in a situation where the target has difficulty in defending him or herself against these actions.

A three-item subscale (score range 3–18)

of the Michigan Organizational Assessment Questionnaire (Cammann, Fichman, Jenkins, & Klesh, 1981) gauged each nurse’s level of intent to leave his or her job. The first item asked the like- lihood of looking for a new job in the next year (1 ¼ Not at All Likely to 4 ¼ Extremely Likely ). The next two asked about agreement (1 ¼ Strongly Disagree to 7 ¼ Strongly Agree ) with ‘‘I often think about quitting’’ and ‘‘I will probably look for a new job in the next year.’’ One other item asked further about respondents’degree of job satisfaction.

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Analysis

Factor and principal component analysis and reliability analysis were used to identify any underlying dimensions of bullying that might be present. Linear regression was used to validate these dimensions as well as other, more parsimo- nious indicators of bullying. Lowess regression was also used in validation; this allowed for the appearance of relationships that might not match preset forms such as linear or quadratic. Data were analyzed using SPSS Version 12 (SPSS, Inc., Chicago, IL).

RESULTS

Descriptive Statistics

The most common bullying behaviors experi- enced were being given an unmanageable work- load (71%) and being ignored or excluded (58%). The least common was threats of violence or actual physical abuse (5%). Most respondents reported at least some degree of bullying: only 6% responded never to all 22 items, and 74% reported a frequency other than never for at least five. Scores on the 22-item bullying scale (log

transformed) ranged from 0 to 3.3, median ¼ 1.4, 1.4, mean ¼ 1.5 ( SD ¼ .8). The middle 50% of these scores fell in the range .9–2.1 which suggests that, over a 6-month period, the middle 50% of participants experienced between 8 and 125 bul- lying behaviors. The three criterion variables all showed non- normal distributions, which no doubt attenuated any underlying correlations. For the single ques- tion as to whether or how often nurses were bullied at work (by definition provided), positive skewness was high at 2.5; 79% responded No, and decreasing numbers chose each of the remaining four options.

ThesingleJobSatisfactionitem,in7-optionformat,

was negatively skewed ( .8) with 48% choosing agree or strongly agree. The intent to leave scale (Cronbach’s alpha ¼ .87) showed an idiosyncratic distribution that recodes and transformations failed to normalize. Intent to leave and bullied at work were positively correlated (r ¼ .31); the single- item job satisfaction measurewas negatively corre- lated with each of the above two variables

(r ¼ .67 and .30, respectively).

Dimensionality

The dimensionality of bullying was first evaluated using exploratory factor analysis, specifically with

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principal axis (PFA) extraction and oblique rotation to allow for a moderate amount of corre- lation among factors. The Kaiser–Meyer–Olkin measure produced a strong .80 for the 22 items, indicating a high correlation-to-partial-correlation ratio that made the items well-suited to factor analysis. However, whether in a two-, three-, or four-factor solution, correlations between obtained factors were as high as .55–.68. Item loadings were often low, and their patterns lacked interpretability. The eigenvalue was approxi- mately 6.7 for the first extracted factor but below 1.4 for subsequent factors. These results called into question the usefulness of any model that attributes more than one underlying dimension. Varimax rotation was also used in search of interpretable, multidimensional results, but it pro- duced unclear solutions. Most items loaded on so many factors that it made more sense to attribute a single latent factor. Partly in an attempt to replicate the findings of Einarsen and Raknes (1997), PCA was also attempted as an alternative method of uncovering dimensions—despite the caveats documented above about use of PCA in survey research and scale development. In an initially promising

solution, four components each showed several loadings above .50, and these four components explained 56% of 21 items’ total variance. The four components had eigenvalues of 6.9, 1.9, 1.7, and 1.3. One item, ‘‘being humiliated or ridi- culed,’’ was dropped because all its loadings were below .4. Table 1 provides more detail on this model. These dimensions were fairly interpretable, with the exception of excessive overlap in the content (if not the loadings) of the first two com- ponents. Moreover, correlations between com- ponents were encouragingly low, ranging in absolute value from .18 to .28, and Cronbach’s alphas were respectable at .74, .82, .77, and .75, respectively. Admittedly, the solution presented certain difficulties. For example, it was not clear why the Punishment loadings should be inversely related to those of the other components. Additionally, the loadings for excessive teasing, hints that you should quit, excessive amount of work, and your opinions ignored cut across fac- tors. Despite these flaws, this solution seemed a plausible description of four interpretable dimen- sions of bullying and thus was worth at least attempting to validate with respect to identified external criteria.

Table 1. Principal Component Loadings After Oblimin Rotation

Components

1, Belittlement

2, Punishment

3, Managerial

Misconduct

4, Exclusion

Intimidating behavior

.71

.04

.10

.08

Being shouted at

.63

.21

.03

.36

Excessive teasing and sarcasm

.58

S.44

.07

.10

Gossip about you

.53

.17

.06

.21

Insulting remarks

.48

.23

 

.03

.19

Threats of violence or abuse

.10

S.78

.20

.02

Practical jokes against you

.07

S.71

.10

.18

Reminders of errors

.34

S.58

.21

.03

Hints that you should quit

.02

S.53

.36

.14

Persistent criticism of work

.17

S.53

.23

.19

Accusations against you

.40

S.41

.30

.01

Responsibilities removed

.21

.22

.77

.09

Unmanageable workload

.25

.02

.66

.29

Ordered to work below competence

.25

.07

.61

.06

Given impossible targets

.29

.31

.54

.31

Pressure not to use job benefits

.28

.14

.44

.10

Excessive monitoring of work

.06

.37

.42

.04

Someone withholding information

.04

.14

.02

.71

Being ignored or excluded

.22

.13

.01

 

.70

Ignored or facing hostility

.12

.16

.00

.69

Your opinions ignored

.06

.17

 

.50

.50

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Validation

To enable evaluations of the effectiveness of any tailored interventions that address bullying, one first needs to develop reliable measurement of the outcomes of such interventions. Our findings argue for the use of a small subset of items on the NAQ-RUS to create a shortened version of the scale and facilitate easy yet reliable measurement of bullying. With such data in hand, one can then gauge the relationship between bullying and other variables. Here we discuss the ways in which such simply derived bullying indicators associate with other indicators of workplace distress, and we compare the performance of these simple vari- ables with that of more labor-intensive quantifi- cations that might otherwise be used to represent

bullying. Table 2 shows, via regression analysis and R 2 estimation, the performance of our four obtained principal components (row a) when used in regressions to predict three variables chosen as criteria: Intent to Leave, Job Satisfaction, and Bullied at Work. Examination of scatter plots, drawing on lowess fitlines, uncovered no nonlin- ear relationships, making linear R 2 a reasonably workable indicator of association despite the non- normal distributions. The table also shows the performance of several simpler predictors or sets of predictors. These are listed in increasing order by expected ease of measurement in a work setting. Most of these indicators rely on responses weighted for 6-month frequency, as doing so tended to maximize corre- lations with the criterion variables. Besides the components listed in row (a), the indicators of bullying that were tested for validity include (b) an overall score—the logged sum of 21 bullying item scores; (c) the logged sum of just four items (Unmanageable Workload, Being Ignored or Excluded, Being Humiliated or Ridiculed, and Someone Withholding Information), each chosen

Table 2. Validation of Indicators of Bullying

through a stepwise regression predicting Intent to Leave; (d) these same four items used indivi- dually as regression predictors; and (e) a simple mean of the four items (in this case unweighted; range ¼ [0,4], mean ¼ 1.0, median ¼ .9, SD ¼ .9). Table 2 shows that the indicators requiring the most intensive data collection and computation— (a) and (b)—are generally the least effective in predicting the outcomes. The four items as used in (d) and especially in (e), despite their strong positive skew, are the most consistently effective predictors while making the least demand on researcher and respondent.

In this analysis, we used reliability analysis as outlined by Spector (1992) to further evaluate the four items used in rows (c), (d), and (e) and to try new combinations. Cronbach’s alpha for these four was .75; adding Hints That You Should Quit, for example, brought the projected alpha estimate to .78 but added a trivial increase in prediction. Projected alpha estimate also increased to .78 if Unmanageable Workload (an item with low variation) was dropped, but then R 2 with these outcomes dropped by .05, .05, and .01, respectively. This seems to exemplify the tradeoff described by Dawis (2000) between internal con- sistency (a form of reliability) and coverage (which enhances validity). More importantly, a fairly wide variety of combinations produced similar results in terms both of reliability (as measured by projected alpha estimates) and

with the criterion

validity (as measured by R

variables). Various sets, each including just three

to six items, performed better than the four com- ponents that reflected scores on 21 items.

2

DISCUSSION

Using the NAQR-US as a measure, bullying among Massachusetts nurses is best viewed as a

R 2 in Predicting Outcomes

 

Intent

Job

Bullied at Work (by Definition Provided)

Mean

Indicators

to Leave

Satisfaction

2

R

(a)

Principal components from 21 items (log)

.17

.19

.31

.22

(b)

21 items’ sum (log)

.26

.25

.25

.25

(c)

4 items’ sum (log) a

.27

.28

.21

.25

(d)

4 items used individually a

.28

.30

.30

.29

(e)

Scale mean of 4 unweighted items a

.28

.29

.30

.29

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one-dimensional phenomenon. Even so, multiple items covering a single construct generally afford better reliability than a single item can (Podsakoff, MacKenzie, Podsakoff, & Lee, 2003; Polit & Beck, 2004; Spector, 1992). The four items suggested should be sufficient to out- perform any single item in capturing the extent of bullying experienced. Results show that one could also use any of several sets of roughly four items chosen from the NAQR-US as a parsimonious set of predictors, because various sets showed similar utility for predicting extent of bullying experi- enced, job satisfaction, and intent to leave. The superiority of these various sets of items over the components, without regard for the items’ ostensible ‘‘membership’’ in different dimen- sions, obviates any need for further discussion of multiple dimensions. Thus the particulars of the four-component PCA solution become irrelevant. Administering a four-item questionnaire will take a small fraction of the time required by the full NAQ-R or NAQR-US. Any researcher or manager can easily average each respondent’s four numbers ranging from 0 to 4 to obtain what we have found to be a valid, reliable indicator. This task will be immeasurably less daunting than any process requiring PCA or PFA. And although we do not presume to have established norms, employees or groups with scores that appear high can be offered extra support, training, or other programmatic interventions. However, even if the validity coefficients seen above reflect con- siderable attenuation due to unrepairable skew- ness or imperfect reliability, those coefficients are not high enough to support the use of any of these indicators as stand-alone measures for making determinations about individuals.

Limitations

Although invitees were selected randomly, this survey relied on a self-selected subset of respond- ents and as such involved the risk of selection bias. The sample was drawn solely from nurses newly licensed in Massachusetts, and so the question can be raised as to its applicability to other popu- lations. Response biases and, more generally, common method bias (Podsakoff et al., 2003) were not controlled except in checks for a single factor underlying responses. Criterion validity was assessed based on survey responses and could not be triangulated using objectively determined information. Because 93% of respondents were women, the data afforded little opportunity to

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inquire whether gender rather than profession might have especially colored these results. Some may argue that our analyses would have been better conducted on just those participants who, by one criterion or another, had experienced

the phenomenon of bullying on the job. We main- tain that the analyses as performed preserve an important degree of variation in responses, with- out which any examination of dimensionality would be impoverished. Moreover, very few had experienced no bullying at all, as only 6% responded never to all 22 items and 74% reported

a frequency other than never for at least five.

Finally, we do not believe it was necessary for respondents to experience the construct(s) involved to contribute meaningful data—only that they accurately reported the frequency of occurrences.

CONCLUSIONS

Bullying can exert a profound effect on the work- place environment and must be addressed as part

of an overall strategy to deal with turnover, which

exacerbates the United States nursing shortage. These findings support the use of a four-item questionnaire to measure perceived bullying. The common practice of using as many as 22 items seems to place an unnecessary burden on employees and researchers alike, given the argu-

ably one-dimensional nature of this construct. Measurement that is efficient, as well as valid and reliable, will facilitate better understanding

of bullying and better evaluations of the effective-

ness of any interventions. Future research should incorporate more com- prehensive checks for bias while investigating in other populations whether a single-factor structure applies to bullying; whether the four key NAQR- US items used here effectively characterize experiences of bullying; and whether particular groups of nurses might differ in their typical scores. Such research should involve multiple phases of data collection to assess longitudinal change.

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