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Currently, the national dialogue on components of the healthy work environment (WE) in healthcare has taken on new urgency. When a nurse leaves a unit due to an unhealthy WE, it is extremely costly with orientation of a new nurse costing approximately $60,000 (1). In addition to financial costs, there are also patient-care concerns. Poor WEs have been shown to increase the odds of patient death and failure-to-rescue (2) and are related to lower patient satisfaction (3). Administrators and managers have begun to consider strategies for promoting a more fulfilling and productive WE, but often feel poorly prepared to address conflict in the workplace (4). Relational Aggression (RA) occurs when someone uses a relationship rather than physical means to inflict social harm. RA is sometimes known as female bullying, incivility, or “mean girls,” and is more common among women than men, especially during the formative adolescent years (5). Although the study of RA began with work in children, recently, authors have begun to examine this construct and its correlates in adults (6). RA among nurses is of special interest because nursing remains predominately a female profession (7). In general, 3 different roles are associated with RA (8). The aggressor is 1 or more persons in the position of launching an attack; victim(s) are the intended target. Bystanders see the aggression and do not intervene (8). It would be overly simplistic to characterize an individual as 1 of the above because in reality these roles are most often fluid, with yesterday's victims becoming today's aggressors. The largest group appears to be bystanders, who witness abuse--possibly encourage it--and fear that if they intervene, they will become the next target (8). RA is related to a number of similar social phenomena, including bullying, workplace incivility, lateral violence and horizontal violence (9). Scholars sometimes use these words interchangeably, and a clear demarcation of language is sorely needed. For the present study, we understand RA to be broader than similar concepts, since it includes bystander and victim roles in addition to aggressor roles. Prior research has explored the frequency of workplace mistreatment in nurses. Some scholars find high rates of mistreatment: 1 study found that up to 25% of New York State nurses were often or frequently the victim of horizontal violence (10), and another study found that 38% of nurses witnessed horizontal hostility (HH) or bullying behaviors weekly or daily (11). Other research reported low levels of workplace mistreatment. In 1 of the 1st studies on workplace bullying in nurses, Johnson and Rea (2009) found that only 18% of their sample responded in the affirmative when asked if they had ever been bullied at work (6). A recent study found that new graduate nurses experience bullying only every now and then (mean bullying score was 1.57 on a 5-point Likert scale) (12). Finally, a study on workplace incivility found that nurses reported very little workplace incivility from their supervisors or their colleagues: the mean supervisor incivility score was .66, and the mean colleague incivility score was .81—both less than 1 on a 7-point scale (13). These mixed findings point toward a few different interpretations. It is possible that most nurses do not experience workplace mistreatment, but that it is a frequent experience for a small minority. Another possibility is that most nurses do experience workplace mistreatment, but only infrequently. Findings from Lewis and Malecha (2011) support this second perspective: their study showed that 85% of nurses reported experiencing workplace incivility in the last 12 months (14). Scales explicitly measuring RA have been put forth in the literature. The 1st RA instrument for adults was the Peer Assessment of RA and Social Adjustment scale, which consists of 24 items, including one 7-item sub-scale designed to measure relationally aggressive behavior (15). This was followed by the Self-Report of Aggression and Social Behavior (SRASBM), a 39-item measure that examines physical aggression, RA, relational victimization, and exclusivity (16; 17). The RA Assessment Scale (RAAS), which was the best available scale for the present study, does overlap in some ways with these other measures. However, in addition to being oriented toward a work setting and toward RA—and being gender neutral—the RAAS includes the “bystander” category, a common and under-studied group on the RA spectrum and in work mistreatment in general (18). Since work mistreatment is associated with a number of adverse effects, including nurse retention, burnout, productivity, job satisfaction and emotional exhaustion, further study of the emotional work environment is warranted (11 - 14). RA has been shown to be associated with adverse physical and mental outcomes in other populations (5; 16), and anecdotal evidence suggests that nurses who experience RA suffer from problems such as depression, anxiety, somatic symptoms, hypertension, and other negative health consequences (19; 20). Nurses who are involved in RA may leave their jobs prematurely, take extra sick days, and even deliver sub-par patient care (21; 22). Since job satisfaction and intent to remain on the job can be impacted by RA, it was the purpose of this study to explore these concepts in a large sample of nurses.

Individuals with cognitive impairment are at high risk for institutionalization; thus, they may benefit from the support provided by home health services. The authors studied a cohort of elderly persons admitted to a home health agency, after first assessing them for cognitive impairment. Comparisons were made between cognitively impaired and cognitively intact individuals. Significant differences in the volume and type of services used were found. Management issues for home health agencies are raised.