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The aim of this report is to identify how workplace bullying can be tracked over time, to indicate what measures and metrics can be used to identify change, and to provide comparators for other sectors in the UK and internationally.\ud Bullying can encompass a range of different behaviours. Deciding on a definition of workplace bullying can clarify what is regarded as bullying, but it may also narrow the focus and exclude relevant issues of concern. For example, bullying definitions typically state that negative behaviours should be experienced persistently over a period of time. The threshold for behaviours to be defined as ‘bullying’ could be set to include one or two negative acts per month over the previous six months; or more stringently to include only behaviours that occur at least weekly over the previous twelve months. Choosing an appropriate threshold for frequency and duration of behaviours raises several questions: should occasional negative behaviours be regarded as bullying? Would one or two serious episodes of negative behaviour be regarded as bullying? Some researchers use the criteria of weekly negative behaviours over six months to identify bullying, but others argue that occasional exposure to negative acts can act as a significant stressor at work (Zapf et al., 2011).\ud We have identified a range of tools and metrics that can be used to track change over time. However, there are a number of important issues to consider when measuring bullying which may affect the interpretation of the results. In particular, bullying prevalence rates vary considerably depending on the type of metric and definition of bullying used. For example, one international review found prevalence rates ranging from less than 1% for weekly bullying in the last six months up to 87% for occasional bullying over a whole career (Zapf et al., 2011).\ud There are three main types of direct measures of bullying: self-labelling without a definition, self-labelling with a definition, and the behavioural experience method. Self-labelling metrics typically ask a respondent to identify themselves as a target of bullying (e.g., “Have you been bullied at work?” with a yes/no response, or “How often have you been bullied at work?” with a frequency scale such as never/occasionally/monthly/weekly/daily). This approach is quick and easy to administer, but is more subjective as responses will be based on the respondent’s interpretation of bullying. This approach can be improved with the provision of a definition of bullying, and a request to use the definition when responding. However, following pilot work, Fevre et al. (2011) argued that respondents tended not to read and digest bullying definitions as they had already decided what bullying meant to them.\ud The behavioural experience method offers a more objective approach, but is typically longer and more time consuming. This method involves respondents rating the frequency with which they have experienced different negative behaviours (e.g., “How often has someone humiliated or belittled you in front of others?” with a frequency scale such as never/now and then/monthly/weekly/daily). These behavioural inventories may not mention bullying, but capture the prevalence of specific negative acts, and a total score may be calculated. The threshold for the frequency and number of negative acts, or a total score, required for an experience to be regarded as bullying can be chosen by the researcher. Although this enhances the objectivity of the measure, it may be that the respondent themselves may not regard their experience as bullying.\ud In a meta-analysis of bullying studies conducted across 24 countries, Nielsen et al. (2010) found an overall prevalence rate of 18.1% for self-labelling with no definition, 11.3% for self-labelling with a definition, and 14.8% using a behavioural experience checklist. For best practice, it is recommended that both the self-labelling with a definition and the behavioural experience method are used in bullying research (Zapf et al., 2011).\ud It is also important to be specific about the type of bullying being measured. In particular, if the measure is designed to capture bullying at work between co-workers this should be explicitly stated, so that bullying from patients and their relatives is excluded.\ud Interpretation of the results may also be somewhat complex. Although increases in bullying prevalence should undoubtedly be addressed, we need to be mindful that an increase in reported bullying may reflect a change in culture: changing expectations of the behaviour of colleagues and managers, or a move towards greater openness and willingness to address concerns that were previously ignored or condoned. A measure of employees’ trust in the organisation to respond appropriately to such allegations may act as a positive indicator.\ud The perceived and actual anonymity of responses is a critical factor. Employees are understandably wary about providing sensitive information on bullying and have voiced concerns regarding being identified and the potential repercussions of reporting bullying (Carter et al., 2013). There is a considerable discrepancy between the prevalence of bullying as captured in anonymous questionnaires and direct reports of bullying made to the organisation (e.g., to managers or HR; Scott, Blanshard & Child, 2008). Protecting the anonymity of respondents, and ensuring that individuals cannot be identified, will be important factors in the administration of a bullying measure.\ud Some metrics are already routinely collected by the NHS, and if examined closely could provide useful indicators of change. Direct indicators include complaints about bullying and responses to ongoing NHS staff surveys. Indirect metrics can be used to capture factors that are associated with bullying, such as psychological wellbeing (including stress, anxiety and depression), sickness rates, job satisfaction and organisational commitment. However, factors other than bullying will affect these measures. The prevalence of witnessed bullying could also be considered as an important metric. A large proportion of NHS staff report that they have witnessed bullying between staff, and this is associated with negative outcomes for individuals and teams (Carter et al., 2013).\ud Comparing the NHS prevalence rates with other sectors in the UK and internationally is complex. Ideally comparators would have used the same definition, measurement method and reporting period, but the definitions and metrics often differ. Total populations are the ideal, but are rarely provided. Single site studies are less generalisable than multi-site studies, and total samples are preferred over open invitations to unknown populations which may be more likely to attract responses from those who have experienced bullying.\ud This report begins with several definitions of bullying, describes direct and indirect measures of bullying, and compares the prevalence of bullying in the NHS to other sectors in the UK, and to the healthcare sector internationally.

WORKPLACE BULLYING is a persistent problem in the NHS (Hoel & Cooper, 2000; NHS staff surveys; Quine, 1999), with significant negative implications for individuals, teams and organisations (Illing et al., 2013; Salin, 2009). Definitions vary, but Einarsen et al. (1994) define bullying as ‘a situation where one or several individuals persistently over a period of time perceive themselves to be on the receiving end of negative actions from one or several persons, in a situation where the target of bullying has difficulty defending him or herself against these actions.’Bullying is regarded as ‘a significant source of social stress at work… and a more crippling and devastating problem for employees than all other work-related stress put together’ (Einarsen & Mikkelsen, 2003, p.127). It has been associated with poorer psychological health and well-being, including social isolation and maladjustment, depression, helplessness, anxiety, and despair (Leymann, 1990). Bullying is linked to higher levels of both psychosomatic and musculo–skeletal complaints (Einarsen & Raknes, 1997), substance abuse (Traweger et al, 2006; van Heughten, 2010), sleep problems (Lallukka et al., 2011; Vartia, 2001), suicide ideation (Brousse, 2008), and risk of cardiovascular disease (Kivimaki, 2003).

Background\ud Workplace bullying is a persistent problem in the NHS with negative implications for individuals, teams, and organisations. Bullying is a complex phenomenon and there is a lack of evidence on the best approaches to manage the problem.\ud \ud Aims\ud Research questions\ud \ud What is known about the occurrence, causes, consequences and management of bullying and inappropriate behaviour in the workplace?\ud \ud Objectives\ud Summarise the reported prevalence of workplace bullying and inappropriate behaviour. \ud \ud Summarise the empirical evidence on the causes and consequences of workplace bullying and inappropriate behaviour. \ud \ud Describe any theoretical explanations of the causes and consequences of workplace bullying and inappropriate behaviour. \ud \ud Synthesise evidence on the preventative and management interventions that address workplace bullying interventions and inappropriate behaviour. \ud \ud Methods\ud To fulfil a realist synthesis approach the study was designed across four interrelated component parts:\ud \ud Part 1: A narrative review of the prevalence, causes and consequences of workplace bullying\ud Part 2: A systematic literature search and realist review of workplace bullying interventions\ud Part 3: Consultation with international bullying experts and practitioners\ud Part 4: Identification of case studies and examples of good practice