Development and Evaluation of a Workplace Bullying Cognitive Rehearsal-Based Nursing Simulation Education Program: A Mixed-Methods Study

Thank you for your valuable insights and suggestions. We have revised the sentences in the Introduction as follows:

The nature of bullying involves a persistent and systematic victimization of a colleague or subordinate through the repeated use of various kinds of aggressive behaviors over a long period of time [1,2]. Traditionally, individual and organizational factors have been investigated as antecedents of bullying [1,2]. On an individual level, there are socio-psychological factors, particularly the personalities of both the perpetrator and the victim, which may be involved as causes of both bullying behavior and perceptions of being bullied, respectively. At the organizational level, leadership, work design, and the morale of management and workforce have been investigated as major causes of bullying [1,2]. Therefore, in order to prevent bullying, a strategic approach at the individual and organizational level is required depending on the cause.

We have added the following text in the Introduction, and added a new reference:

In nursing education, preparing for the fight against bullying requires a systematic approach that takes into account the specificities of university education and clinical practice [5,6,7]. Through a scoping review, methods of nursing and school interventions to reduce bullying have been classified into various categories. There are four types of nursing interventions that can be provided to reduce the incidence of bullying and its impact, namely prevention programs, activities programs, peer group programs, and resilience programs [9].

Prevention programs include social cognitive theory-based interventions and activities such as film clips, group discussions, and exercises. There are also pragmatic school-based programs based on universal intervention education addressing internal factors that cause bullying, including cooperation/communication, empathy, goals/aspirations, problem-solving, self-awareness, and self-efficacy [9].

9. Yosep, I.; Hikmat, R.; Mardhiyah, A.; Hazmi, H.; Hernawaty, T. Method of nursing interventions to reduce the incidence of bullying and its impact on students in school: a scoping review. Healthcare (Basel) 2022, 10(10), 1835. https://doi.org/10.3390/healthcare10101835

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Leymann [1] used the term “mobbing” to describe serious interpersonal conflict in the workplace, and named “bullying” for the first time in the United Kingdom for a similar phenomenon [3]. Other terms often cited to describe bullying behaviors include mobbing, horizontal violence, relational aggression, and harassment [3,4]. “Mobbing” limits perpetrators to a group; however, “bullying” is a higher level concept that extends the concept of “mobbing” and includes bullying by one person [2,3]. According to literature, the common nature of workplace bullying includes the negative and unwanted nature of the behavior, repetition and persistence, and imbalance of power [1–3]. A negative act includes persistent and repetitive behaviors that lasts for more than 6 or 12 months and are experienced once a week or more [1,2]. An imbalance of power exists between the victim and perpetrator, and it is difficult for the victim to protect themselves from the bullying. Furthermore, it tends to be more severe due to reduced coping skills and increased feelings of helplessness [3]. Traditionally, individual and organizational factors have been investigated as antecedents of bullying [1,3, 4]. Individual factors were related to general and socio-psychological characteristics and self-esteem [3, 4]. Some studies reported that age was a significant factor and that new nurses were more to become victims of workplace bullying likely than experienced nurses [4,5]. In a systematic review, low self-esteem was an individual antecedent of workplace bullying among nurses [5]. The personalities of both the perpetrator and the victim, which may be involved as causes of both bullying behavior and perceptions of being bullied. At the organizational level, leadership, work design, and the morale of management and workforce have been investigated as major causes of bullying [1,2,4].

Compared to other occupations, nurses have a particularly serious problem with workplace bullying. The causes mainly included work load and tension in an urgent hospital environment, job stress, and role conflict and low autonomy in an organization where the hierarchy of power was obvious [6]. In a hospital environment with strong hierarchical order and high work stress, nurses were in a weak position regarding power imbalance. In addition, workplace bullying often occurred due to the characteristics of these nursing organizations [7]. Therefore, to prevent bullying, strategic approaches at the individual and organizational levels are required depending on the nature and cause.

3. Einarsen, S.; Raknes, B.I.; Matthiesen, S. Bullying and harassment at work and their relationships to work environment quality: An exploratory study. Euro J Work Organizational Psychol 1994, 4(4),381–401. https://doi.org/10.1080/13594329408410497

4. Kim, Y.; Choi, J.S. Individual and organizational factors influencing workplace cyberbullying of nurses: A cross-sectional study. Nurs Health Sci 2021, 23(3), 715–722. https://doi.org/10.1111/nhs.12858

5. Kang, J.; Lee, M. Pooled prevalence of workplace bullying in nursing: Systematic review and meta-analysis. J Korean Crit Care Nurs 2016, 9(1), 51–65. (In Korean)

6. Roberts, S.; DeMarco, R.F.; Griffin, M. The effect of oppressed group behavior on the culture of the nursing workplace: A review of evidence and interventions for change. J Nurs Manag 2009, 17(3), 288–293.

7. Baillien, E.; De Cuyper, N.; De Witte, H. Job autonomy and workload as antecedents of workplace bullying: A two-wave test of Karasek's Job Demand Control Model for targets and perpetrators. J Occup Organizational Psychol 2011, 84(1), 191–208.

-> We have added a separate section in the Introduction, and eight new references.

 In nursing education, preparing for the fight against bullying requires a systematic approach that takes into account the specificities of university education and clinical practice [9,10,11]. Effective nursing interventions to reduce bullying should be adjusted according to the developmental stage of nursing students [13]. Through a scoping review, methods of nursing and school interventions to reduce bullying were classified into various categories [14]. Prevention programs that were applied to schools and proved to be effective included a social cognitive theory-based intervention (reduced bullying and victimization) [15], bullying prevention program (improved social skill) [16], and pragmatic school-based universal intervention (improved mental health) [17]. Therefore, it is necessary to provide nursing students with interventions that have been proven effective in preventing bullying. Furthermore, it is necessary to consider mastering the correct techniques for dealing with bullying along with an accurate understanding of its causes and mechanisms [18–20]. In addition, education climates directly affects students. Faculty, clinical administrators, and educators should create an environment in which bullying is not taken for granted and must take the lead in supporting students to overcome bullying experiences in a positive and constructive manner [8,10,11].

 Cognitive rehearsal is a strategy for negotiating emotional or stressful situations and is based in cognitive behavioral therapy [22,23]. Its core elements include knowledge and best practices, personal perceptions and recognizing bullying behavior, managing personal reactions, rehearsing responses in a safe and collaborative environment, and increasing skill and confidence [22,23]. However, the effectiveness of these programs has remained inconsistent, and very few interventions have targeted nursing students in their critical phases of learning and practice [25,26].

 13. Selkie, E.M.; Fales, J.L.; Moreno, M.A. Cyberbullying prevalence among US middle and high school–aged adolescents: A systematic review and quality assessment. J Adolesc Health 2016, 58(2), 125–133. https://doi.org/10.1016/j.jadohealth.2015.09.026

14. Yosep, I.; Hikmat, R.; Mardhiyah, A.; Hazmi, H.; Hernawaty, T. Method of nursing interventions to reduce the incidence of bullying and its impact on students in school: A scoping review. Healthcare (Basel) 2022, 10(10), 1835. https://doi.org/10.3390/healthcare10101835

15. Salimi, N.; Karimi-Shahanjarini, A.; Rezapur-Shahkolai, F.; Hamzeh, B.; Roshanaei, G.; Babamiri, M. The effect of an anti-bullying intervention on male students’ bullying-victimization behaviors and social competence: A randomized controlled trial in deprived urban areas. J Res Health Sci 2019, 19(4), e00461

16. Axford, N.; Bjornstad, G.; Clarkson, S.; Ukoumunne, O.C.; Wrigley, Z.; Matthews, J.; Berry, V.; Hutchings, J. The effectiveness of the KiVa bullying prevention program in Wales, UK: Results from a pragmatic cluster randomized controlled trial. Prev Sci 2020, 21(5), 615–626. https://doi.org/10.1007/s11121-020-01103-9

17. Dray, J.; Bowman, J.; Campbell, E.; Freund, M.; Hodder, R.; Wolfenden, L.; Richards, J.; Leane, C.; Green, S.; Lecathelinais, C.; et al. Effectiveness of a pragmatic school-based universal intervention targeting student resilience protective factors in reducing mental health problems in adolescents. J Adolesc 2017, 57, 74–89. https://doi.org/10.1016/j.adolescence.2017.03.009

18. Nguyen, A.J.; Bradshaw, C.; Townsend, L.; Gross, A.L.; Bass, J. A latent class approach to understanding patterns of peer victimization in four low-resource settings. Int J Adolesc Med Health 2016, 32(1), 202–213. https://doi.org/10.1515/ijamh-2016-0086

19. Nguyen, A.J.; Bradshaw, C.; Townsend, L.; Bass, J. Prevalence and correlates of bullying victimization in four low-resource countries. J Interpers Violence 2020, 35(19–20), 3767–3790. https://doi.org/10.1177/0886260517709799

20. Pandey, A.R.; Neupane, T.; Chalise, B.; Shrestha, N.; Chaudhary, S.; Dhungana, R.R.; Bista, B. Factors associated with physical and sexual violence among school-going adolescents in Nepal: Findings from global school-based student health survey. PLoS ONE 2021, 16(3), e0248566. https://doi.org/10.1371/journal.pone.0248566

->We have revised and added the following text to the Conclusion:

The bullying experienced by nursing students in clinical practice has existed for a long time. However, it must be tolerated. In addition, it is difficult to recognize bullying and take effective and immediate action against bullying. Workplace bullying in clinical nursing education requires a systematic approach according to the developmental stage of nursing students, while considering individual and organizational characteristics. This study developed, implemented, and evaluated a cognitive rehearsal-based simulation education program to develop bullying awareness and coping skills among nursing students. A mixed-method research design was applied, which included a focus group interview and a quasi-experimental research design. Quantitative analyses revealed that the role-play simulations program improved participants’ knowledge and perceptions, but not their symptoms. Regarding the results of the qualitative assessments, nurse students experienced positive feedback on workplace bullying perceptions, their fear disappeared, and their confidence in coping with bullying improved. These results provide a basis for assessing educational needs and effectiveness against bullying in future studies or education programs. In addition, if a cognitive rehearsal-based simulation education program that allows nursing students to continuously experience various situations of workplace bullying in the nursing curriculum is developed, it will contribute to the development of practical nursing education that can prevent and manage workplace bullying.