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International Journal of Nursing Practice 2014; 20: 283–292
RESEARCH PAPER
The use of cognitive reappraisal and humour as coping strategies for bullied nurses Julia Wilkins PhD Research Associate, National Dropout Prevention Center for Students with Disabilities, Clemson, South Carolina, USA
Accepted for publication January 2013 Wilkins J. International Journal of Nursing Practice 2014; 20: 283–292 The use of cognitive reappraisal and humour as coping strategies for bullied nurses This article explores the repercussions of workplace bullying on nurses and the health-care profession as a whole. I discuss the nature of workplace bullying and draw upon prior studies to explore some of the barriers that prevent witnesses to bullying from intervening, as well as barriers faced by targets in taking action to stop the bullying. As overt forms of resistance are often not feasible in situations where nurses occupy subordinate positions to their bullies, I propose that cognitive reappraisal can be an effective coping strategy, and situate this perspective within the research on humour, hope and optimism. Key words: cognitive reappraisal, coping strategies, humour, workplace bullying.
INTRODUCTION Workplace bullying is a widespread problem that has serious personal and economic consequences. According to the World Health Organization,1 there is a shortage of 4.3 million health-care workers worldwide. In the United States, the shortage of registered nurses (RNs) is particularly acute and is projected to grow to 260 000 by 2025.2 One reason for this shortage is the high turnover rate of nurses who leave the profession due to poor working conditions.3 Workplace bullying, in particular, has been identified as a growing occupational stressor among health-care professionals.4,5 The health-care profession is a high stress field in general, but when workers are targets of workplace bullying, they are likely to experience ‘severe social, psychological, and psychosomatic problems’ (p. 3)6 that could result in their seeking alternative employment. This situation has been recognized as so serious that the Joint Commission, as a follow-up to its
Correspondence: Julia Wilkins, Clemson University, 205 Cliffstone Drive, Easley, SC 29640, USA. Email: [email protected] doi:10.1111/ijn.12146
Sentinel Event Alert: Behaviors That Undermine a Culture of Safety, made it a requirement for accreditation that hospitals/organizations have a code of conduct defining acceptable, disruptive and inappropriate behaviours, and that leaders create and implement a process for managing disruptive and inappropriate behaviours.7
What is workplace bullying? Workplace bullying can involve a variety of hostile behaviours in which targets are publicly humiliated, belittled or criticized; ignored or excluded; accused of lack of effort; assigned constantly changing, or overly simple tasks; given impossible deadlines; threatened with violence, or subjected to actual violence.8–11 Research indicates that the problem of bullying in the health-care profession is pervasive. A study of medical students found that over half had been, ‘yelled at in front of others’ while in their residency training programmes.11 Although students desire clinical experiences in which unit RNs explain things to them, allow them to ask questions, include them in planning, and are friendly, receptive and understanding,12–16 the reality is that many nursing © 2013 Wiley Publishing Asia Pty Ltd
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students feel vulnerable and experience humiliation and abuse at the hands of RNs.15,17,18 It was found that even before students began their clinical experiences, 60% (n = 91) had been the targets of incivility from their university nursing professors, and over one third of targets reported feeling anxious, nervous or depressed in response to this incivility.19 Unfortunately, such experiences foreshadow what might become a regular feature of the work environment for these health-care professionals. In a study of Canadian health-care workers, 89% reported that they had experienced exposure to workplace aggression in the previous year.20 A British study found that one in six nurses (17%) had been bullied by a staff member at some time in the previous 12 months, and in over 40% of cases, the bully was the immediate supervisor or manager.21
What are the consequences of workplace bullying? The negative repercussions of workplace bullying on health-care workers have been well documented; in particular, compared with non-targets, targets report higher rates of depression, anxiety, obsessive thoughts and nightmares, and psychosomatic symptoms.22–27 In addition, targets of bullying sometimes experience posttraumatic stress disorder (PTSD) symptoms comparable with those of victims of war or prison camps.8 Just as these war-time victims are prone to alcohol and substance abuse, targets of bullying also report higher rates of substance abuse than non-targets.28,29 The stress that targets experience as a result of being bullied severely compromises their ability to function at work.30–34 In fact, the whole workplace is affected when employees are bullied. Witnesses to bullying might live in constant fear of becoming the next target and often experience high levels of stress themselves.35–37 Low levels of job satisfaction and organizational commitment also characterize hostile work environments. In a study of workplace incivility, Pearson et al.38 found that over 30% of targets intentionally reduced their job performance and withdrew from tasks and activities that went beyond their job specifications. Bullied nurses are also absent more than non-bullied nurses,39 and are more likely to search for alternative employment.29 Clearly, bullying is too detrimental to workers, healthcare settings and the health-care profession in general, to be ignored. It is important to understand how and why bullying occurs, and also how the negative effects of © 2013 Wiley Publishing Asia Pty Ltd
bullying can be reduced in health-care settings. These topics are explored in the following section.
Who are the bullies and targets? A study conducted in a variety of workplace settings revealed that bullies were three times more likely to be in a higher position of power than their targets.40 Bullying in health-care settings mirrors this trend; physicians’ abuse of nurses has been reported in several studies.41–44 Unlike other professions, however, bullying between equals, particularly between nurses, has also been well documented (e.g.44–52). This horizontal violence includes both overt and covert behaviours directed at colleagues, such as making faces while they are talking, belittling or criticizing them in front of others, making snide comments, giving abrupt responses to their questions, talking about them behind their back, withholding information needed for them to perform their job effectively, deliberately setting them up for negative situations, and excluding them from group activities.53 McKenna et al. report that 60% of nursing graduates will leave their job within 6 months due to this type of bullying.54 A national study of workplace bullying indicates that most bullying (68%) is same-gender bullying, and gendersegregated workplaces, such as hospitals, are believed to increase the likelihood of such bullying.45 Inequitable power relations are magnified in the health-care system because historically, the field of nursing has been dominated by women and the medical profession has been a patriarchal system headed by male physicians and administrators.46–49 As an oppressed group, nurses experience a lack of respect from others, along with low selfesteem. Bartholomew50 notes that, ‘When anger is suppressed, and cannot be directed upward, nurses lash out against each other’ (p. 29). According to Vickers,51 people who work in toxic environments come to see negative interactions as normal, and when bullying behaviour comes to be accepted as normal, people cease to question its harmfulness. In a study of workers in group health-care homes, it was also found that there was an association between being the target of aggression and engaging in future acts of aggression.52 In other words, bullying behaviour does more than just contribute to hostile work environments—it actually germinates and propagates in such environments.55,56 Similarly, in their study of faculty incivility towards senior nursing students, Marchiondo, et al. note that such
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interactions ‘model negative behaviour for students, implicitly teaching them that incivility is acceptable in the nursing field’ (p. 610).19 Research indicates that bullying behaviours begin early in a nurse’s education. In a study of 636 nursing students, it was found that over half had experienced bullying by their classmates.57 Similar findings have been reported from international studies. Nursing students in Turkey reported being yelled at, belittled, humiliated and treated inappropriately by both their classmates and faculty.58 A study conducted in the United Kingdom found that bullying was a routine experience for students in the process of becoming a nurse.59 Although the socialization of nurses might explain why nurses come to accept bullying as an everyday part of the workplace culture, it has been found that 46% (n = 663) of nursing staff felt that horizontal violence was a ‘very serious’ or ‘somewhat serious’ problem.60 One would assume that if nurses acknowledge there is problem, they would try to solve the problem. However, this is not the case. Namie27 reported that even when coworkers were aware that someone was being bullied, they typically did not intervene. There are many explanations for why witnesses to bullying might fail to intervene. It has been found, for example, that bullies often obstruct open communication between workers to prevent them from banding together and taking action against them.61,62 In group settings, the ‘bystander effect’ also hinders people’s willingness to single-handedly take on the role of whistleblower. Witnesses might also be reluctant to report bullying when they feel their reports will be rejected by supervisors, or when they fear being seen as troublemakers. This fear is well founded, as research indicates that supervisors often choose to support the bully rather than have the organization discredited.63 The bully’s behaviour might also be dismissed by supervisors as being symptomatic of a ‘personality clash’ or reflective of a ‘tough management style’.64 Witnesses might also resist reporting bullying for fear that they will become the bully’s next target. Unfortunately, although witnesses are faced with very real deterrents to reporting bullying, their passivity further contributes to the unsafe and hostile workplace and fuels a lack of trust among coworkers.
Why do nurses accept bullying? There is little in the way of legal protection for targets of bullying, particularly when women bully women. The accepted power relations in hospital settings can also
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make nurses feel unable to speak out against their supervisors.63 As Brodsky65 points out, in cases where bullies are in higher organizational positions than targets, they can justify their actions as being part of their supervisory roles. Sometimes targets might be accused of complaining unnecessarily,66 or could be blamed for being bullied.67,68 When the bullying behaviour is particularly disturbing, nurses might also hesitate to report it for fear that they will not be believed. And, like witnesses to bullying, targets could fear retaliation from supervisors whom they file complaints about. Given these barriers, it is understandable that nurses might feel that they have nowhere to turn and have no power to change the situation. It is important to remember that bullying is not a single negative interaction or incident, but often takes place on a daily basis over an extended period of time.67,68 The repetitive nature of bullying can break targets down and destroy their sense of self-efficacy, which, according to Bandura,69 is ‘the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations’ (p. 2). When targets try, but are unsuccessful at ending their bullying, they are also likely to feel increasingly powerless as time goes on.70–72 According to Janoff-Bulman’s73,74 cognitive theory of trauma, being victimized disrupts people’s fundamental assumptions about the world as a just and fair place in which good things happen to good people and bad things happen to bad people. As is often found with victims of domestic violence, targets of workplace bullying might internalize negative beliefs about themselves and believe that they deserve their mistreatment. Indeed, in order to control their targets, bullies often deliberately try to diminish targets’ perceptions of themselves as competent and worthy people.75 Thus, targets could come to believe they have no power to change the situation, which, given the absence of legal protection, administrator action, and coworker support, might be quite a realistic belief.76
WHAT CAN NURSES DO ABOUT BULLYING? Targets of bullying might not have legal channels through which to stop the bullying and they could be reluctant to use overt methods to respond to the bullying for fear of supervisor or coworker retaliation. The following section describes how cognitive reappraisal can be used by nurses to reframe their perspectives and associated emotional responses. The role that humour plays in hope and © 2013 Wiley Publishing Asia Pty Ltd
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optimism is also described in order to illustrate the benefits of using humour for cognitive reappraisal.
Cognitive reappraisal Cognitive reappraisal is a form of emotion regulation that involves cognitively construing a negative situation in a way that alleviates its emotional impact.77 Attribution theorists propose that people’s emotional reactions to events depend on the attributions they make about the causes of those events,78–81 suggesting that it is the appraisal of bullying as stressful that causes stress, not the bullying behaviour itself. The effectiveness of cognitive reappraisal as a coping strategy has been identified in several empirical studies. Szasz et al.,82 for example, conducted a laboratory experiment in which participants used either reappraisal, acceptance or suppression to control their anger during a frustrating task. It was found that reappraisal was more effective at reducing anger than attempts to accept or suppress it. As has been discussed, the belief in a just world makes it difficult for people to make sense of their bullying. When people blame themselves for being bullied, they are unlikely to see themselves as having the power to change the situation. Through cognitive reappraisal, targets can alter attributions about the bullying behaviour in a way that increases their self-esteem and gives them confidence in their ability to effectively deal with the bullying. According to Fredrickson,83 positive emotions can prompt individuals to ‘discard time-tested or automatic (everyday) behavioral scripts and to pursue novel, creative, and often unscripted paths of thought and action’ (p. 304). In a study of humour and hopefulness, Vilaythong et al.84 suggested that the expansion of thought-action repertoire, as described by Fredrickson,83 could lead to a greater sense of self-efficacy for dealing with stressful events. In this way, experiencing positive emotions can increase a person’s perceived ability to initiate and sustain action towards resolving a problem. Cognitive rehearsal is a strategy that involves consciously not responding to a situation that just occurred in order to take the time to process the information and decide how to respond.85 In a study in which first-year nurses were taught cognitive rehearsal strategies as a response to horizontal violence, it was reported that the nurses got extremely emotional while discussing the bullying experiences with their perpetrators. However, the goal of confronting their perpetrators was achieved; in all instances, the bullying ended. © 2013 Wiley Publishing Asia Pty Ltd
Targets must understand that being bullied is not a permanent situation. No behaviour is permanent, and there are myriad situations that could occur that would naturally result in a cessation of the bullying; the bully might move to a different department, they might seek alternative employment or they might develop a chronic disease that limits their ability to work. Belief in an ultimate justice is a core feature of the belief in a just world86 and this belief can provide reassurance for targets. Targets might come to believe, for example, that justice will occur at some later point in the bully’s life or in an afterlife.87 Hafer and Gosse87 explain that, ‘If one believes that innocent suffering brings benefits or that the victim will ultimately reap positive outcomes, one can maintain a belief that the world is a just place in which people get what they deserve’ (p. 41). Obviously, cognitive reappraisal does not come naturally; people have to consciously decide how to respond to events, which is a skill that comes easier for some people than for others. Fortunately, some reappraisal techniques come quite naturally and do not involve much training of the mind. Humour, which is described in the following section, is one such technique.
The use of humour Using humour in times of stress can be effective in the reappraisal of negative situations; if something is ridiculous or silly, then it cannot also be serious or threatening. Kuiper and Martin88 propose that, ‘the stressmoderating effects of sense of humour appear to operate, at least in part, through more positive appraisals and more realistic cognitive processing of environmental information’ (p. 162). Nurses who are targets of bullying can use humour to facilitate cognitive reappraisals of their bullying. One source of humour is experiencing incongruities—that is, finding amusement in things that seem inappropriate and go against one’s expectations of what should be occurring.89 If, for example, the bully takes credit for work the target did, that could be seen as funny because it goes against what was expected in that situation—the nurse did the work and someone else took the credit. If it is too difficult to find such a situation amusing while in the midst of it, the nurse can try to think of what someone else would find funny about it.90 Joking about an incident after it has occurred helps people see the event as an outsider and thereby distance themselves from it. When people tell funny stories about the way someone treated them, they can view the
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behaviour from a different perspective. In emotionally distancing themselves from stressful events, the use of humour also facilitates the exploration of alternative perspectives to problems.91 According to May,92 humour is ‘the healthy way of feeling a “distance” between one’s self and the problem; a way of standing off and looking at one’s problem with perspective’ (p. 40). As Atkinson93 points out, humour requires individuals to be able to reflect on a situation and view their role in an abstract or distant fashion. This process allows them to consciously change their perceptions or frames of reference and restructure experiences that are out of their control. Many studies demonstrate humour’s role in promoting positive affective states and in reducing distress associated with difficult life events.94 A study of health-care workers (n = 142) found that nurses regularly used humorous communications when under general stress.95 Wanzer et al.96 examined the relationship between health-care providers’ coping efficacy and humour orientation (an individual’s predisposition to regularly use humour in communicating with others) and found that high humouroriented individuals were not only more likely to actively use humour as a coping strategy, but they also had greater coping efficacy than low humour-oriented individuals. Rim97 also found significant relationships between measures of humour and defensive mechanisms such as ‘minimization’, (e.g. looking on the bright side of things) and ‘reversal’, (e.g. trying to find something funny in a distressing situation). Laughter itself is incompatible with anger and negative affective states. The physical act of laughter results in physiological changes that stimulate feelings of mirth and cognitive release from anxiety and tension.98 Humour and laughter therefore not only aid in the reframing of a negative situation, but also help to release negative emotions associated with a perceived threat.99,100 Replacing negative affect with positive affect allows for a more lighthearted perspective of the potential threat.101–103 Studies of the relationship between cognitive appraisals of stressors and neuroendocrine responses to stress support the connection between the perception and interpretation of events and specific endocrine and sympathetic arousal.104,105 It has been proposed that the pressures on nurses, such as being short-staffed, having heavy workloads and being subjected to unrealistic expectations, along with the competitive nature of the health-care system, contribute to nurse-to-nurse conflicts and make nurses vulnerable
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to violent outbursts.106,107 If nurses understood how to relieve their stress by using laughter—a natural endorphin releaser108—it might lessen the likelihood of their having violent outbursts. In addition to helping targets reframe bullying situations, laughter can therefore also be used proactively by bullies to prevent them from acting out their aggressive impulses. Humour serves a purpose that is actually essential to survival. In fact, many theorists believe that humour evolved in humans as an adaptive coping mechanism.109–114 There are several historical accounts of individuals who used humour as a survival technique when forced to live in confined and inhumane conditions. One of the most wellknown examples is Viktor Frankl’s115 narrative of his imprisonment in a Nazi concentration camp, in which he describes the use of humour as one of the ‘soul’s weapons in the fight for self-preservation’ (p. 63). Prisoners of War (POWs) in the Vietnam War also used humour as a coping strategy. The benefits to the POWs were explained by Rahe and Geneder116 in the following way: ‘Use of humor has an immense coping value. Getting the best of one’s guards, on occasion, not only provides humorous remembrances that can be savored later, but gives captives a moment of control in what otherwise is a totally uncontrolled situation’ (p. 580). Nurses who are bullied can maintain control of their bullying through the use of humour in much the same way that other targets of abuse have done throughout history.
Hope and humour It is hope that helps people survive when faced with intolerable conditions such as those endured by Frankl and POWs. People who are high in hope believe that bad situations will pass and they focus their attention on the possibility of a better future.117 Humour is one coping strategy that is often used by individuals who are high in hope.118 In fact, Herth119 found that 94% of high-hope individuals deemed ‘lightheartedness’ to be a necessary component of dealing with stressful life events. Rather than feeling defeated by a bully, nurses who use humour are likely to remain hopeful about outcomes of the conflict and be motivated to take action towards its resolution. Individuals who use humour as a coping mechanism and are high in hope are also more likely to view situations as challenging, rather than threatening.115,120 Humour as a coping strategy has been found to operate in tandem with optimism.121 In a study of women executives, Fry122 found that high levels of optimism and © 2013 Wiley Publishing Asia Pty Ltd
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humour were associated with a reduction in the impact of daily hassles and stressful encounters, as well as a stronger resistance to burnout. Optimists tend to appraise stressful situations in a more positive light and use a wider variety of coping strategies than pessimists123–125; they also focus their attention on situations that they can control and disengage themselves from problems they cannot solve.126 Nurses who maintain an optimistic attitude about their bullying will perceive the situation as a challenge from which they can grow. As with humour, optimism helps to transform negative mood into positive mood, thereby creating a disposition more conducive to the exploration of solutions to problems.
CONCLUSION Job stress has been identified as the greatest cause of job dissatisfaction among health-care providers.127 Research indicates that one common form of job stress is workplace bullying, which is rampant in health-care settings. Bullying has severe repercussions for both health-care workers and the health-care system, as it not only causes serious psychological and physical health problems among targets, but also contributes to low worker morale, high absenteeism and high job turnover.127,128 Many bullied nurses feel isolated and unsupported; coworkers typically do not intervene; management might close ranks when a complaint is made; and targets are often made to feel like the cause of the problem. In the absence of legal recourse and social support for bullied nurses, seeking alternative employment could sometimes seem like their only means of escape. It is important for nurses to understand that there are options besides suffering in their current positions or quitting their jobs. Nurses can avoid the devastating emotional and psychological effects of bullying by using cognitive reappraisal to view their bullying from a different perspective. If they can step back from the situation, find something humorous in it, or see how they can grow from it, they will learn to experience emotional reactions without feelings of distress. Using humour not only alters negative affect and helps to promote a positive perspective about the situation, but also facilitates optimistic expectations about future outcomes. Maintaining an optimistic outlook while being the target of bullying will hopefully result in decreased levels of job-related stress for nurses, and will infuse a much-needed dose of positivity into the hostile work environment. © 2013 Wiley Publishing Asia Pty Ltd
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64 Namie G. Framing the Bully’s revolution message. Paper presented at the 7th International Conference on Workplace Bullying and Harassment. Cardiff, Wales, 2010. Available from URL: http://www.workplacebullying.org/multi/ pdf/N-N-2010B.pdf. Accessed 7 January 2012. 65 Brodsky C. The Harassed Worker. Lexington, MA, USA: D.C. Heath, 1976. 66 Namie G. Workplace bullying: Escalated incivility. Ivey Business Journal 2003; 68: 1–6. 67 Leymann H. The content and development of mobbing at work. European Journal of Work and Organizational Psychology 1996; 10: 372–392. 68 Randall P. Adult Bullying: Perpetrators and Victims. London: Routledge, 1997. 69 Bandura A. Self-Efficacy in Changing Societies. Cambridge, MA, USA: Cambridge University Press, 1995. 70 Davenport N, Schwartz RD, Elliot GP. Mobbing: Emotional Abuse in the American Workplace, 2nd edn. Ames, IA, USA: Civil Society Publishing, 2002. 71 Keashly L. Interpersonal and systemic aspects of emotional abuse at work: The target’s perspective. Violence and Victims 2001; 16: 233–268. 72 Lutgen-Sandvik P, Tracy SJ, Alberts JK. Burned by bullying in the American workplace: Prevalence, perception, degree, and impact. Journal of Management Studies 2007; 44: 835–860. 73 Janoff-Bulman R. Assumptive worlds and the stress of traumatic events: Applications of the schema construct. Social Cognition 1989; 7: 113–136. 74 Janoff-Bulman R. Shattered Assumptions: Towards a New Psychology of Trauma. New York: The Free Press, 1992. 75 Yamada DC. The phenomenon of ‘workplace bullying’ and the need for status-blind hostile work environment protection. Georgetown Law Journal 2000; 88: 475–536. 76 Namie G, Lutgen-Sandvik P. Active and passive accomplices: The communal character of workplace bullying. International Journal of Communication 2010; 4: 343– 373. 77 Gross JJ, John OP. Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology 2003; 85: 348–362. 78 Lazarus RS. The stress and coping paradigm. In: Eisdorfer C, Cohen D, Kleinman A, Maxim P (eds). Models for Clinical Psychopathology. New York: SP Medical & Scientific Books, 1981; 177–214. 79 Lazarus RS. On the primacy of cognition. American Psychologist 1984; 39: 124–129. 80 Lazarus RS. Emotion and Adaptation. New York: Oxford University Press, 1991. 81 Lazarus RS, Folkman S. Stress Appraisal and Coping. New York: Springer, 1984.
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82 Szasz PL, Szentagotai A, Hofmann SG. The effect of emotion regulation strategies on anger. Behavior Research and Therapy 2011; 49: 114–119. 83 Fredrickson BL. What good are positive emotions? Review of General Psychology 1998; 2: 300–319. 84 Vilaythong AP, Arnau RC, Rosen DH, Mascaro N. Humor and hope: Can humor increase hope? Humor 2003; 16: 79–89. 85 Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing 2004; 35: 257–263. 86 Lerner MJ. The Belief in a Just World: A Fundamental Delusion. New York: Plenum Press, 1980. 87 Hafer CL, Gosse L. Predicting alternative strategies for preserving a belief in a just world: The case of repressive coping style. European Journal of Social Psychology 2011; 41: 730–739. 88 Kuiper NA, Martin RA. Is sense of humor a positive personality characteristic? In: Ruch W (ed.). The Sense of Humor: Explorations of a Personality Characteristic. Berlin/ New York: Mouton de Gruyter, 1998; 159–178. 89 Raskin V. Semantic Mechanisms of Humor. Dordrecht, The Netherlands: Reidel, 1985. 90 McGhee PE. How to Develop Your Sense of Humor. Dubuque, IA, USA: Kendall/Hunt Publishing Company, 1984. 91 Kuiper N, McKenzie SD, Belanger KA. Cognitive appraisals and individual differences in sense of humor: Motivational and affective implications. Personality and Individual Differences 1995; 19: 359–372. 92 May R. Man’s Search for Himself. New York: WW Norton and Co, 2009. 93 Atkinson C. What’s so funny? Or, why humor should matter to philosophers. Philosophy Today 2006; 50: 437– 443. 94 McCrae RR, Costa PT. Personality, coping, and coping effectiveness in an adult sample. Journal of Personality 1986; 54: 385–405. 95 Wanzer M, Booth-Butterfield M, Booth-Butterfield S. If we didn’t use humor, we’d cry: Humourous coping communication in health care settings. Journal of Health Communication 2005; 10: 105–125. 96 Wanzer M, Booth-Butterfield M, Booth-Butterfield S. Are funny people popular? An examination of humor orientation, loneliness, and social attraction. Communication Quarterly 1996; 44: 42–52. 97 Rim Y. Sense of humour and coping styles. Personality and Individual Differences 1988; 9: 559–564. 98 Dossey BM, Keegan L, Guzzetta CE. Holistic Nursing: A Handbook for Practice, 5th edn. Boston, MA, USA: Jones & Bartlett, 2008. 99 Dixon NF. Humor: A cognitive alternative to stress? In: Sarason IG, Spielberger CD (eds). Stress and Anxiety, Vol. 7. Washington, DC: Hemisphere, 1980; 281–289.
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100 Martin RA, Nicholas A, Kuiper L, Olinger J, Dance KA. Humor, coping with stress, self-concept, and psychological well-being. Humor: International Journal of Humor Research 1993; 6: 89–104. 101 Lefcourt HM, Martin RA. Humor and Life Stress: Antidote to Adversity. New York: Springer-Veriay, 1986. 102 Martin RA, Lefcourt HM. The sense of humor as a moderator of the relationship between stressors and moods. Journal of Personality and Social Psychology 1983; 45: 1313– 1324. 103 Nezu AM, Christine MN, Blissett SE. Sense of humor as a moderator of the relation between stressful events and psychological distress: A prospective analysis. Journal of Personality and Social Psychology 1988; 54: 520– 525. 104 Gaab J, Rohleder N, Nater UM, Ehlert U. Psychological determinants of the cortisol stress response: The role of anticipatory cognitive appraisal. Psychoneuroendocrinology 2005; 30: 599–610. 105 Olff M, Langeland W, Gersons BPR. Effects of appraisal and coping on the neuroendocrine response to extreme stress. Neuroscience and Biobehavioral Reviews 2005; 29: 457–467. 106 Farrell GA. Aggression in clinical settings: Nurses’ views—A follow-up study. Journal of Advanced Nursing 1999; 29: 532–541. 107 Jackson D, Clare J, Mannix J. Who would want to be a nurse? Violence in the workplace—A factor in recruitment and retention. Journal of Nursing Management 2002; 10: 13–20. 108 Dunbar R, Baron R, Frangou A et al. Social laughter is correlated with an elevated pain threshold. Proceedings. Biological Sciences/The Royal Society 2012; 279: 1161– 1167. 109 Cohen D. Humor, irony and self-detachment. In: Chapman AJ, Foot HC (eds). It’s a Funny Thing, Humour. Oxford, England: Pergamon, 1977; 157–158. 110 Greenwald H. Humor in psychotherapy. Journal of Contemporary Psychotherapy 1975; 7: 133–116. 111 Grotjahn M. Laughter in psychotherapy. In: Mendel WM (ed.). A Celebration of Laughter. Los Angeles: Mara Books, 1970; 61–66. 112 Levine J. Humour as a form of therapy: Introduction to symposium. In: Chapman AJ, Foot HC (eds). It’s a Funny Thing, Humour. Oxford, England: Pergamon, 1977; 127– 137. 113 Svebak S. Revised questionnaire on the sense of humor. Scandinavian Journal of Psychology 1974; 15: 328– 331. 114 Weisfeld GE. The adaptive value of humour and laughter. Ethology and Sociobiology 1993; 14: 141–169. 115 Frankl V. Man’s Search for Meaning. New York: Washington Square Press, 1984.
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116 Rahe R, Geneder E. Adaptation to and recovery from captivity stress. Military Medicine 1983; 148: 577–585. 117 Tennen H, Affleck G. Finding benefits in adversity. In: Snyder CR (ed.). Coping: The Psychology of What Works. New York: Oxford University Press, 1999; 279–304. 118 Snyder CR. The Psychology of Hope: You can Get There from Here. New York: Free Press, 1994. 119 Herth K. Hope in older adults in community and institutional settings. Issues in Mental Health Nursing 1993; 14: 139–156. 120 Kuiper NA, Martin RA, Olinger LJ. Coping humor, stress, and cognitive appraisals. Canadian Journal of Behavioural Science 1993; 25: 81–96. 121 Carver CS, Pozo C, Harris SD et al. How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of Personality and Social Psychology 1993; 63: 375–390. 122 Fry PS. Perfectionism, humor, and optimism as moderators of health outcomes and determinants of coping styles of women executives. Genetic, Social, and General Psychology Monographs 1995; 121: 213–233. 123 Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology 1989; 56: 267–283.
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124 Reker GT, Wong PTP. Personal optimism, physical and mental health: The triumph of successful aging. In: Birren JE, Livingston J (eds). Cognition, Stress and Aging. Englewood Cliffs, NJ, USA: Prentice-Hall, 1985; 134– 173. 125 Scheier MF, Carver CS. Optimism, coping, and health: Assessment and implications for generalized outcome expectancies. Health Psychology 1985; 4: 219–247. 126 Aspinwall LG, Richter L, Hoffman RR. Understanding how optimism ‘works’: An examination of optimists’ adaptive moderation of belief and behavior. In: Chang EC (ed.). Optimism and Pessimism: Theory, Research, and Practice. Washington: American Psychological Association, 2001; 217–238. 127 Wolfgang A. Job stress, coping, and dissatisfaction in the health professions: A comparison of nurses and pharmacists. In Perrewe P, ed. Handbook on Job Stress. [Special issue]. Journal of Social Behavior and Personality 1991; 6: 213–226. 128 Williams ES, Konrad TR, Scheckler WE, Pathman DR. Understanding physicians’ intentions to withdraw from practice: The role of job satisfaction, job stress, mental and physical health. Health Care Management Review 2001; 26: 7–19.
International Journal of Nursing Practice 2014; 20: 283–292
RESEARCH PAPER
The use of cognitive reappraisal and humour as coping strategies for bullied nurses Julia Wilkins PhD Research Associate, National Dropout Prevention Center for Students with Disabilities, Clemson, South Carolina, USA
Accepted for publication January 2013 Wilkins J. International Journal of Nursing Practice 2014; 20: 283–292 The use of cognitive reappraisal and humour as coping strategies for bullied nurses This article explores the repercussions of workplace bullying on nurses and the health-care profession as a whole. I discuss the nature of workplace bullying and draw upon prior studies to explore some of the barriers that prevent witnesses to bullying from intervening, as well as barriers faced by targets in taking action to stop the bullying. As overt forms of resistance are often not feasible in situations where nurses occupy subordinate positions to their bullies, I propose that cognitive reappraisal can be an effective coping strategy, and situate this perspective within the research on humour, hope and optimism. Key words: cognitive reappraisal, coping strategies, humour, workplace bullying.
INTRODUCTION Workplace bullying is a widespread problem that has serious personal and economic consequences. According to the World Health Organization,1 there is a shortage of 4.3 million health-care workers worldwide. In the United States, the shortage of registered nurses (RNs) is particularly acute and is projected to grow to 260 000 by 2025.2 One reason for this shortage is the high turnover rate of nurses who leave the profession due to poor working conditions.3 Workplace bullying, in particular, has been identified as a growing occupational stressor among health-care professionals.4,5 The health-care profession is a high stress field in general, but when workers are targets of workplace bullying, they are likely to experience ‘severe social, psychological, and psychosomatic problems’ (p. 3)6 that could result in their seeking alternative employment. This situation has been recognized as so serious that the Joint Commission, as a follow-up to its
Correspondence: Julia Wilkins, Clemson University, 205 Cliffstone Drive, Easley, SC 29640, USA. Email: [email protected] doi:10.1111/ijn.12146
Sentinel Event Alert: Behaviors That Undermine a Culture of Safety, made it a requirement for accreditation that hospitals/organizations have a code of conduct defining acceptable, disruptive and inappropriate behaviours, and that leaders create and implement a process for managing disruptive and inappropriate behaviours.7
What is workplace bullying? Workplace bullying can involve a variety of hostile behaviours in which targets are publicly humiliated, belittled or criticized; ignored or excluded; accused of lack of effort; assigned constantly changing, or overly simple tasks; given impossible deadlines; threatened with violence, or subjected to actual violence.8–11 Research indicates that the problem of bullying in the health-care profession is pervasive. A study of medical students found that over half had been, ‘yelled at in front of others’ while in their residency training programmes.11 Although students desire clinical experiences in which unit RNs explain things to them, allow them to ask questions, include them in planning, and are friendly, receptive and understanding,12–16 the reality is that many nursing © 2013 Wiley Publishing Asia Pty Ltd
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students feel vulnerable and experience humiliation and abuse at the hands of RNs.15,17,18 It was found that even before students began their clinical experiences, 60% (n = 91) had been the targets of incivility from their university nursing professors, and over one third of targets reported feeling anxious, nervous or depressed in response to this incivility.19 Unfortunately, such experiences foreshadow what might become a regular feature of the work environment for these health-care professionals. In a study of Canadian health-care workers, 89% reported that they had experienced exposure to workplace aggression in the previous year.20 A British study found that one in six nurses (17%) had been bullied by a staff member at some time in the previous 12 months, and in over 40% of cases, the bully was the immediate supervisor or manager.21
What are the consequences of workplace bullying? The negative repercussions of workplace bullying on health-care workers have been well documented; in particular, compared with non-targets, targets report higher rates of depression, anxiety, obsessive thoughts and nightmares, and psychosomatic symptoms.22–27 In addition, targets of bullying sometimes experience posttraumatic stress disorder (PTSD) symptoms comparable with those of victims of war or prison camps.8 Just as these war-time victims are prone to alcohol and substance abuse, targets of bullying also report higher rates of substance abuse than non-targets.28,29 The stress that targets experience as a result of being bullied severely compromises their ability to function at work.30–34 In fact, the whole workplace is affected when employees are bullied. Witnesses to bullying might live in constant fear of becoming the next target and often experience high levels of stress themselves.35–37 Low levels of job satisfaction and organizational commitment also characterize hostile work environments. In a study of workplace incivility, Pearson et al.38 found that over 30% of targets intentionally reduced their job performance and withdrew from tasks and activities that went beyond their job specifications. Bullied nurses are also absent more than non-bullied nurses,39 and are more likely to search for alternative employment.29 Clearly, bullying is too detrimental to workers, healthcare settings and the health-care profession in general, to be ignored. It is important to understand how and why bullying occurs, and also how the negative effects of © 2013 Wiley Publishing Asia Pty Ltd
bullying can be reduced in health-care settings. These topics are explored in the following section.
Who are the bullies and targets? A study conducted in a variety of workplace settings revealed that bullies were three times more likely to be in a higher position of power than their targets.40 Bullying in health-care settings mirrors this trend; physicians’ abuse of nurses has been reported in several studies.41–44 Unlike other professions, however, bullying between equals, particularly between nurses, has also been well documented (e.g.44–52). This horizontal violence includes both overt and covert behaviours directed at colleagues, such as making faces while they are talking, belittling or criticizing them in front of others, making snide comments, giving abrupt responses to their questions, talking about them behind their back, withholding information needed for them to perform their job effectively, deliberately setting them up for negative situations, and excluding them from group activities.53 McKenna et al. report that 60% of nursing graduates will leave their job within 6 months due to this type of bullying.54 A national study of workplace bullying indicates that most bullying (68%) is same-gender bullying, and gendersegregated workplaces, such as hospitals, are believed to increase the likelihood of such bullying.45 Inequitable power relations are magnified in the health-care system because historically, the field of nursing has been dominated by women and the medical profession has been a patriarchal system headed by male physicians and administrators.46–49 As an oppressed group, nurses experience a lack of respect from others, along with low selfesteem. Bartholomew50 notes that, ‘When anger is suppressed, and cannot be directed upward, nurses lash out against each other’ (p. 29). According to Vickers,51 people who work in toxic environments come to see negative interactions as normal, and when bullying behaviour comes to be accepted as normal, people cease to question its harmfulness. In a study of workers in group health-care homes, it was also found that there was an association between being the target of aggression and engaging in future acts of aggression.52 In other words, bullying behaviour does more than just contribute to hostile work environments—it actually germinates and propagates in such environments.55,56 Similarly, in their study of faculty incivility towards senior nursing students, Marchiondo, et al. note that such
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interactions ‘model negative behaviour for students, implicitly teaching them that incivility is acceptable in the nursing field’ (p. 610).19 Research indicates that bullying behaviours begin early in a nurse’s education. In a study of 636 nursing students, it was found that over half had experienced bullying by their classmates.57 Similar findings have been reported from international studies. Nursing students in Turkey reported being yelled at, belittled, humiliated and treated inappropriately by both their classmates and faculty.58 A study conducted in the United Kingdom found that bullying was a routine experience for students in the process of becoming a nurse.59 Although the socialization of nurses might explain why nurses come to accept bullying as an everyday part of the workplace culture, it has been found that 46% (n = 663) of nursing staff felt that horizontal violence was a ‘very serious’ or ‘somewhat serious’ problem.60 One would assume that if nurses acknowledge there is problem, they would try to solve the problem. However, this is not the case. Namie27 reported that even when coworkers were aware that someone was being bullied, they typically did not intervene. There are many explanations for why witnesses to bullying might fail to intervene. It has been found, for example, that bullies often obstruct open communication between workers to prevent them from banding together and taking action against them.61,62 In group settings, the ‘bystander effect’ also hinders people’s willingness to single-handedly take on the role of whistleblower. Witnesses might also be reluctant to report bullying when they feel their reports will be rejected by supervisors, or when they fear being seen as troublemakers. This fear is well founded, as research indicates that supervisors often choose to support the bully rather than have the organization discredited.63 The bully’s behaviour might also be dismissed by supervisors as being symptomatic of a ‘personality clash’ or reflective of a ‘tough management style’.64 Witnesses might also resist reporting bullying for fear that they will become the bully’s next target. Unfortunately, although witnesses are faced with very real deterrents to reporting bullying, their passivity further contributes to the unsafe and hostile workplace and fuels a lack of trust among coworkers.
Why do nurses accept bullying? There is little in the way of legal protection for targets of bullying, particularly when women bully women. The accepted power relations in hospital settings can also
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make nurses feel unable to speak out against their supervisors.63 As Brodsky65 points out, in cases where bullies are in higher organizational positions than targets, they can justify their actions as being part of their supervisory roles. Sometimes targets might be accused of complaining unnecessarily,66 or could be blamed for being bullied.67,68 When the bullying behaviour is particularly disturbing, nurses might also hesitate to report it for fear that they will not be believed. And, like witnesses to bullying, targets could fear retaliation from supervisors whom they file complaints about. Given these barriers, it is understandable that nurses might feel that they have nowhere to turn and have no power to change the situation. It is important to remember that bullying is not a single negative interaction or incident, but often takes place on a daily basis over an extended period of time.67,68 The repetitive nature of bullying can break targets down and destroy their sense of self-efficacy, which, according to Bandura,69 is ‘the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations’ (p. 2). When targets try, but are unsuccessful at ending their bullying, they are also likely to feel increasingly powerless as time goes on.70–72 According to Janoff-Bulman’s73,74 cognitive theory of trauma, being victimized disrupts people’s fundamental assumptions about the world as a just and fair place in which good things happen to good people and bad things happen to bad people. As is often found with victims of domestic violence, targets of workplace bullying might internalize negative beliefs about themselves and believe that they deserve their mistreatment. Indeed, in order to control their targets, bullies often deliberately try to diminish targets’ perceptions of themselves as competent and worthy people.75 Thus, targets could come to believe they have no power to change the situation, which, given the absence of legal protection, administrator action, and coworker support, might be quite a realistic belief.76
WHAT CAN NURSES DO ABOUT BULLYING? Targets of bullying might not have legal channels through which to stop the bullying and they could be reluctant to use overt methods to respond to the bullying for fear of supervisor or coworker retaliation. The following section describes how cognitive reappraisal can be used by nurses to reframe their perspectives and associated emotional responses. The role that humour plays in hope and © 2013 Wiley Publishing Asia Pty Ltd
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optimism is also described in order to illustrate the benefits of using humour for cognitive reappraisal.
Cognitive reappraisal Cognitive reappraisal is a form of emotion regulation that involves cognitively construing a negative situation in a way that alleviates its emotional impact.77 Attribution theorists propose that people’s emotional reactions to events depend on the attributions they make about the causes of those events,78–81 suggesting that it is the appraisal of bullying as stressful that causes stress, not the bullying behaviour itself. The effectiveness of cognitive reappraisal as a coping strategy has been identified in several empirical studies. Szasz et al.,82 for example, conducted a laboratory experiment in which participants used either reappraisal, acceptance or suppression to control their anger during a frustrating task. It was found that reappraisal was more effective at reducing anger than attempts to accept or suppress it. As has been discussed, the belief in a just world makes it difficult for people to make sense of their bullying. When people blame themselves for being bullied, they are unlikely to see themselves as having the power to change the situation. Through cognitive reappraisal, targets can alter attributions about the bullying behaviour in a way that increases their self-esteem and gives them confidence in their ability to effectively deal with the bullying. According to Fredrickson,83 positive emotions can prompt individuals to ‘discard time-tested or automatic (everyday) behavioral scripts and to pursue novel, creative, and often unscripted paths of thought and action’ (p. 304). In a study of humour and hopefulness, Vilaythong et al.84 suggested that the expansion of thought-action repertoire, as described by Fredrickson,83 could lead to a greater sense of self-efficacy for dealing with stressful events. In this way, experiencing positive emotions can increase a person’s perceived ability to initiate and sustain action towards resolving a problem. Cognitive rehearsal is a strategy that involves consciously not responding to a situation that just occurred in order to take the time to process the information and decide how to respond.85 In a study in which first-year nurses were taught cognitive rehearsal strategies as a response to horizontal violence, it was reported that the nurses got extremely emotional while discussing the bullying experiences with their perpetrators. However, the goal of confronting their perpetrators was achieved; in all instances, the bullying ended. © 2013 Wiley Publishing Asia Pty Ltd
Targets must understand that being bullied is not a permanent situation. No behaviour is permanent, and there are myriad situations that could occur that would naturally result in a cessation of the bullying; the bully might move to a different department, they might seek alternative employment or they might develop a chronic disease that limits their ability to work. Belief in an ultimate justice is a core feature of the belief in a just world86 and this belief can provide reassurance for targets. Targets might come to believe, for example, that justice will occur at some later point in the bully’s life or in an afterlife.87 Hafer and Gosse87 explain that, ‘If one believes that innocent suffering brings benefits or that the victim will ultimately reap positive outcomes, one can maintain a belief that the world is a just place in which people get what they deserve’ (p. 41). Obviously, cognitive reappraisal does not come naturally; people have to consciously decide how to respond to events, which is a skill that comes easier for some people than for others. Fortunately, some reappraisal techniques come quite naturally and do not involve much training of the mind. Humour, which is described in the following section, is one such technique.
The use of humour Using humour in times of stress can be effective in the reappraisal of negative situations; if something is ridiculous or silly, then it cannot also be serious or threatening. Kuiper and Martin88 propose that, ‘the stressmoderating effects of sense of humour appear to operate, at least in part, through more positive appraisals and more realistic cognitive processing of environmental information’ (p. 162). Nurses who are targets of bullying can use humour to facilitate cognitive reappraisals of their bullying. One source of humour is experiencing incongruities—that is, finding amusement in things that seem inappropriate and go against one’s expectations of what should be occurring.89 If, for example, the bully takes credit for work the target did, that could be seen as funny because it goes against what was expected in that situation—the nurse did the work and someone else took the credit. If it is too difficult to find such a situation amusing while in the midst of it, the nurse can try to think of what someone else would find funny about it.90 Joking about an incident after it has occurred helps people see the event as an outsider and thereby distance themselves from it. When people tell funny stories about the way someone treated them, they can view the
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behaviour from a different perspective. In emotionally distancing themselves from stressful events, the use of humour also facilitates the exploration of alternative perspectives to problems.91 According to May,92 humour is ‘the healthy way of feeling a “distance” between one’s self and the problem; a way of standing off and looking at one’s problem with perspective’ (p. 40). As Atkinson93 points out, humour requires individuals to be able to reflect on a situation and view their role in an abstract or distant fashion. This process allows them to consciously change their perceptions or frames of reference and restructure experiences that are out of their control. Many studies demonstrate humour’s role in promoting positive affective states and in reducing distress associated with difficult life events.94 A study of health-care workers (n = 142) found that nurses regularly used humorous communications when under general stress.95 Wanzer et al.96 examined the relationship between health-care providers’ coping efficacy and humour orientation (an individual’s predisposition to regularly use humour in communicating with others) and found that high humouroriented individuals were not only more likely to actively use humour as a coping strategy, but they also had greater coping efficacy than low humour-oriented individuals. Rim97 also found significant relationships between measures of humour and defensive mechanisms such as ‘minimization’, (e.g. looking on the bright side of things) and ‘reversal’, (e.g. trying to find something funny in a distressing situation). Laughter itself is incompatible with anger and negative affective states. The physical act of laughter results in physiological changes that stimulate feelings of mirth and cognitive release from anxiety and tension.98 Humour and laughter therefore not only aid in the reframing of a negative situation, but also help to release negative emotions associated with a perceived threat.99,100 Replacing negative affect with positive affect allows for a more lighthearted perspective of the potential threat.101–103 Studies of the relationship between cognitive appraisals of stressors and neuroendocrine responses to stress support the connection between the perception and interpretation of events and specific endocrine and sympathetic arousal.104,105 It has been proposed that the pressures on nurses, such as being short-staffed, having heavy workloads and being subjected to unrealistic expectations, along with the competitive nature of the health-care system, contribute to nurse-to-nurse conflicts and make nurses vulnerable
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to violent outbursts.106,107 If nurses understood how to relieve their stress by using laughter—a natural endorphin releaser108—it might lessen the likelihood of their having violent outbursts. In addition to helping targets reframe bullying situations, laughter can therefore also be used proactively by bullies to prevent them from acting out their aggressive impulses. Humour serves a purpose that is actually essential to survival. In fact, many theorists believe that humour evolved in humans as an adaptive coping mechanism.109–114 There are several historical accounts of individuals who used humour as a survival technique when forced to live in confined and inhumane conditions. One of the most wellknown examples is Viktor Frankl’s115 narrative of his imprisonment in a Nazi concentration camp, in which he describes the use of humour as one of the ‘soul’s weapons in the fight for self-preservation’ (p. 63). Prisoners of War (POWs) in the Vietnam War also used humour as a coping strategy. The benefits to the POWs were explained by Rahe and Geneder116 in the following way: ‘Use of humor has an immense coping value. Getting the best of one’s guards, on occasion, not only provides humorous remembrances that can be savored later, but gives captives a moment of control in what otherwise is a totally uncontrolled situation’ (p. 580). Nurses who are bullied can maintain control of their bullying through the use of humour in much the same way that other targets of abuse have done throughout history.
Hope and humour It is hope that helps people survive when faced with intolerable conditions such as those endured by Frankl and POWs. People who are high in hope believe that bad situations will pass and they focus their attention on the possibility of a better future.117 Humour is one coping strategy that is often used by individuals who are high in hope.118 In fact, Herth119 found that 94% of high-hope individuals deemed ‘lightheartedness’ to be a necessary component of dealing with stressful life events. Rather than feeling defeated by a bully, nurses who use humour are likely to remain hopeful about outcomes of the conflict and be motivated to take action towards its resolution. Individuals who use humour as a coping mechanism and are high in hope are also more likely to view situations as challenging, rather than threatening.115,120 Humour as a coping strategy has been found to operate in tandem with optimism.121 In a study of women executives, Fry122 found that high levels of optimism and © 2013 Wiley Publishing Asia Pty Ltd
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humour were associated with a reduction in the impact of daily hassles and stressful encounters, as well as a stronger resistance to burnout. Optimists tend to appraise stressful situations in a more positive light and use a wider variety of coping strategies than pessimists123–125; they also focus their attention on situations that they can control and disengage themselves from problems they cannot solve.126 Nurses who maintain an optimistic attitude about their bullying will perceive the situation as a challenge from which they can grow. As with humour, optimism helps to transform negative mood into positive mood, thereby creating a disposition more conducive to the exploration of solutions to problems.
CONCLUSION Job stress has been identified as the greatest cause of job dissatisfaction among health-care providers.127 Research indicates that one common form of job stress is workplace bullying, which is rampant in health-care settings. Bullying has severe repercussions for both health-care workers and the health-care system, as it not only causes serious psychological and physical health problems among targets, but also contributes to low worker morale, high absenteeism and high job turnover.127,128 Many bullied nurses feel isolated and unsupported; coworkers typically do not intervene; management might close ranks when a complaint is made; and targets are often made to feel like the cause of the problem. In the absence of legal recourse and social support for bullied nurses, seeking alternative employment could sometimes seem like their only means of escape. It is important for nurses to understand that there are options besides suffering in their current positions or quitting their jobs. Nurses can avoid the devastating emotional and psychological effects of bullying by using cognitive reappraisal to view their bullying from a different perspective. If they can step back from the situation, find something humorous in it, or see how they can grow from it, they will learn to experience emotional reactions without feelings of distress. Using humour not only alters negative affect and helps to promote a positive perspective about the situation, but also facilitates optimistic expectations about future outcomes. Maintaining an optimistic outlook while being the target of bullying will hopefully result in decreased levels of job-related stress for nurses, and will infuse a much-needed dose of positivity into the hostile work environment. © 2013 Wiley Publishing Asia Pty Ltd
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