The nursing profession has a problematic turnover rate –even among medical personnel–likely due to its characteristic physical and psychological stress. The turnover rate of nurses in South Korea is a staggering 16.8% compared to the average of 2.2% among healthcare workers in general. Furthermore, while there were 320,000 licensed nurses in South Korea as of 2014, only 45.5% of them were working in medical institutions [1]. This problem is expected to worsen, prompting scholars to devise measures aimed at encouraging nurses to continue working. One line of research in this regard has concerned workplace bullying among nurses.

Workplace bullying refers to verbal, emotional, and physical behaviors related to disrespecting and harming colleagues as a means of controlling them. Bullying behaviors among nurses specifically include ignoring, ostracizing, humiliating, yelling, swearing, throwing things, and disturbing performance of a task [2]. Although rates are highly contingent on assessment standards and tools, an estimated 19.0~86.5% of nurses have experienced workplace bullying [3, 4]. Workplace bullying leads to psychological symptoms of depression, anxiety, and post-traumatic stress disorder, and physical symptoms such as palpitations, headache, chronic fatigue, and insomnia [2]. It can also increase burnout and turnover intention [5], consequently increasing the burden on medical institutions and society [6]. Thus, it would be necessary to devise measures of reducing workplace bullying among nurses.

A typical intervention for reducing workplace bullying among nurses is raising awareness, for which research has found some support [7]. Nevertheless, considering that workplace bullying is entrenched in the interpersonal relationships among colleagues [8], more elaborated and active strategies to improve these interpersonal relationships, and hence reduce bullying, are required. Indeed, Vessey et al. [9] concluded that developing interpersonal relationship skills could help in handling bullying situations.

Cognitive rehearsal (CR) is a behavioral technique often used in cognitive behavioral therapies wherein individuals rehearse specific situations to practice a suitable interaction or a positive coping process in relation to such situations. It can be applied as a coping method for bullying [10] –indeed, only 3 studies, to our knowledge, have investigated CR as a workplace bullying intervention among nurses. Griffin [11] trained new nurses in skills to handle lateral violence situations through CR, and reported nurses' turnover rate decreased. Stagg et al. [12] provided CR of 10 scenarios on workplace bullying situations to nurses, which led to increased knowledge and awareness of workplace bullying, as well as confidence in managing conflict situations. In a later study, they followed up over 6 months, and reported turnover intention decreased [13]. However, none of these studies used a control group and all of them provided a onetime, short-term intervention. Thus, stricter, randomized controlled trials are needed, which prompted the design of the present study with CR program (CRP).

The first step for CRP is creating scripts and communication standards for each bullying situation [10]. We established communication standards using the technique of nonviolent communication. Nonviolent communication is an empathizing conversation conversation technique aimed at enhancing communication through compassion and empathy for others and oneself, and it essentially takes the form of “observation-feeling-need requests” [14]. Nonviolent communication has been reported to be effective for improving communication among doctors [15], nursing students [16], undergraduate students [17].

The aim of this study was to investigate the effect of CRP on the interpersonal relationships, workplace bullying, symptom experience, and turnover intention of nurses. The study hypotheses are as follows:

Hypothesis 1: The interpersonal relationships those who participated in CRP (experimental group) will differ from those of who did not participate in CRP (wait-list group).

Hypothesis 2: The workplace bullying in the experimental group will differ from that of the wait-list group.

Hypothesis 3: The symptom experience in the experimental group will differ from that of the wait-list group.

Hypothesis 4: The turnover intention in the experimental group will differ from that of the wait-list group.

Hypothesis 5: There will be differences in main variables pre-, post- and 4 weeks after the CRP in the experimental group.

Workplace bullying causes negative effects not only psychophysical symptoms but also burn out or turnover intention and makes professional nurses leave their workplace. Interpersonal relationship has been reported as a key strategy to prevent workplace bullying [2, 3, 4, 5]. In this study, we developed the CRP using nonviolent communication based on improving interpersonal relationship, and evaluated the effect of the CRP on interpersonal relationship, workplace bullying, symptom experience, and turnover intention.

First, the CRP was helpful for improving participants' interpersonal relationships. The CRP that we administered to subjects included communication training based on nonviolent communication for bullying situations. These results confirmed those of previous studies [15, 16, 17], wherein nonviolent communication improved individuals' communication and interpersonal relationship skills. Nonviolent communication is a communication technique that emphasizes the importance of empathy for the self and others, and it seeks to promote connection to others through empathizing. In this way, it helps in the development of positive interpersonal relationships [14]. We designed the present intervention based on the premise that bullying is preceded by problems in communication and interpersonal relationships [2]. However, it may also be that bullying causes problems in communication and interpersonal relationships: one study indicated that 55.8% of nurses who had experienced actual bullying eventually had problems in communicating with their colleagues and could not freely express their opinions [23]. Additionally, Taylor [24] argued that dysfunctional nurse–nurse relationships manifest as bullying and have a negative influence on subsequent professional relationships, suggesting that such problems can be resolved through obtaining skills in direct communication and coping techniques related to bullying.

The CRP we used relied on prepared scenarios of bullying situations, role-playing, appropriate communication standards, and re-role-playing, and was helpful to train individuals in coping with workplace bullying. One research demonstrated similar effects for a technique called participatory theatre, which involved the use of scenarios to reduce workplace bullying among Canadian health care workers. This participatory theatre helped subjects in “rehearsing for reality,” and led the majority of study subjects to understand the complexity of workplace bullying and have hope in finding a solution for such situations, should they arise [25]. Another one argued the CR not only increases awareness of bullying, but also provides a safe environment for learning about and training on how to respond to bullying behaviors [12]. These behavioral interventions help identify problems and their solutions, which can then be applied for similar behavioral problems occurring in the future [26]. We suggest that the study subjects might help in identifying the true nature of bullying in their workplaces and reacting in an appropriate manner through their role-playing. In short, it can be concluded that the CRP for bullying situations can help both nurses who have not yet experienced bullying and those who have already experienced it.

It is important to note, however, that the CRP was ineffective in reducing workplace bullying and symptom experience among nurses in this study. We propose two main reasons for this. First, while the determinants of workplace bullying do include nurses' individual characteristics, such as their personality, the majority comprise organizational factors such as the culture, atmosphere, and leadership of the organization [27]. The CRP of this study only targets individual nurses and is not considered an organizational-level intervention; as such, it likely had no organizational effects. Regarding organizational interventions, Ceravolo et al. [28] aimed at enhancing awareness of bullying and self-assertive communication training with all of the nursing staff from 5 different hospitals in the US over 3 years. Nurses who took part in these workshops found that they could communicate within the nursing organization more openly, and an organizational culture of mutual respect was created. This also significantly reduced incidents of verbal affronts among nurses. Because Ceravolo et al. [28]'s intervention targeted all nursing staff working at hospitals, it seems possible that the effect of bullying reduction was achieved through changes in the atmosphere and organizational culture. Overall, it may be necessary to modify CRP to reflect various influencing factors and provide it at the level of the unit or entire hospital and examine its effect on both the organization and individual levels in follow-up studies

The second main reason for the lack of effect on bullying is that the variable measurements took place too early after the intervention. Some evidence for this comes from Stagg et al. [13] who provided 2 hours of CR and then measured bullying experience after 6 months—they found that workplace bullying incidents had decreased by around 40% compared to before the CR intervention. However, Stagg et al. [13]'s study had only 10 subjects, had no control group, and measured bullying experience with a single question rather than a standardized tool. Therefore, it would be necessary to perform a stricter experimental study that varies the schedule for examining the effects of CRP on bullying and symptom experience.

The 5 weeks of CRP did help reduce turnover intention in this study. Turnover intention is not an actual behavior, but rather a cognition. This may underlie why this short-term CRP helped bring about changes in the turnover intention but not workplace bullying or symptom experience. Additionally, it is possible that the turnover intention was decreased because of the improved interpersonal relationships after the CRP. Turnover intention among nurses is an important variable predicting actual turnover [29]. According to a study on the workplace bullying experiences and turnover of Danish health care workers conducted over 2 years, nurses who experienced frequent bullying had 2.9 times the odds of turnover intention and 3.1 times the odds of actual turnover compared to those who had not experienced bullying [30]. Nurses' turnover entails new employment and training costs, thus making it a negative influence on both the organization and society. Turnover intention is a variable influenced by a variety of complex factors, and is sensitive to changes in the policies and procedures of the organization. Accordingly, one avenue for reducing turnover intention would be to develop policies and procedures based on the CRP.

The importance of this study lies in that it used a randomized controlled trial to examine the effect of the 20-hours CRP on the interpersonal relationships and turnover intention of nurses. Therefore, we suggest that this CRP be actively utilized in nursing education and management as a coping strategy for workplace bullying. Nevertheless, it has several limitations. First, the sample size of this study might be underestimated. we estimated the sample size based on the one group repeated measure ANOVA that we had considered to be of main interest of this study. However, when considering the perspective of the controlled trial, we might have had to estimate it based on 2 group comparison. Second, the intervention was confined to targeting the individual-level factors related to workplace bullying, and it was not considered the influence of organization factors. The lack of an organizational approach, which was a limitation of CRP in this study, needs to be complemented by the development of unit or hospital based programs. Third, the duration of the CRP was long, 10 sessions for 20 hours, and all participants had to gather at the designated site. This can be a burden for nurses, so the length and mode of CRP need to be modified to a more practical form in terms of time and cost. Finally, we did not plan trial registration beforehand, and the trial was registered after the completion of the study.

In this study, we examined the effect of CRP on workplace bullying through a randomized controlled trial. Altogether, the results indicated that the intervention helped improve the interpersonal relationships of nurses and reduced their turnover intention. However, it did not reduce the workplace bullying or symptom experience of nurses. The likely reason for the CRP's lack effect on the latter two variables is the intervention's restriction to individual-level factors; thus, the influence of organizational factors on workplace bullying was not controlled. Furthermore, the evolution of workplace bullying and symptom experience may take some time. Therefore, we suggest providing the CRP on the unit level and examining its effects with a larger sample over a long period in future studies.