Psychological harassment in the workplace, or mobbing, is a practice that has become today a health problem that affects not only the victim but also society as a whole; however, nursing professionals, who are both victims and perpetrators, are no exception. The present study allows, within the framework of the research, to gather more sources of information in order to provide the basis for the creation of protocols, public policies and measures to protect and promote a healthy work environment, free of violent practices and based on the ultimate goal of the profession: to take care of oneself in order to take care of others.

Objective: To identify the effects of workplace violence on the mental health of nursing professionals within the in-hospital setting at the national and international level.

Method: An exhaustive analysis of the world literature on workplace mobbing among nursing professionals from different countries was carried out. For this purpose, databases such as Web of Science, Scielo, ResearchGate, PubMed, Science Direct, Redalyc, Google Scholar and the Repositorio Académico de la Universidad de Chile were used, where a series of key words corresponding to the research topic were used.

Results: There are effects on health, interpersonal relationships and job performance in nurses when exposed to workplace bullying. Coping and prevention strategies used by nurses from various countries against mobbing were identified.

Conclusions: It was possible to identify the negative effects of workplace mobbing among nursing professionals, as well as their respective coping and prevention strategies. It is recommended to increase research on the subject and implement urgent regulations at the national level.

Keywords: workplace violence, nurses, hospitals, mobbing, nurse bullying

Workplace violence is a concept that has been installed in society for years, which has been maintained and even increased over time. More and more people report having suffered violence or mobbing at work, being the nursing professional one of the main victims of this situation among the different health workers who work at the intrahospital level. This situation, besides being recently evidenced in Chile with the suicide of two nurses victims of mobbing, also has a great incidence at international level, which generates great impact not only in the nursing profession but also at all levels, in the same way as the increase in mental health pathologies, the precarious system and the normalization of this act, whose victims suffer from various consequences that affect both their mental health and their personal and professional development in the work environment. The limited development of studies and research on mental health in the context of mobbing in nursing at the local level generates a limited vision, which makes it even more difficult to implement actions that allow a continuous improvement in the approach to mobbing, both in prevention and support to those who are affected.

The importance of taking care of those who take care of them is becoming essential in these times, so this study aims to address the issue of workplace violence or mobbing and its effects on all aspects; either in their mental and physical health in a comprehensive manner in nursing professionals who perform their work at the intrahospital level. For this purpose, a bibliographic review of different scientific articles and high impact national and international journals was carried out.

Frame of reference

Worldwide, mobbing or harassment in the workplace, specifically in the health sector, has begun to be increasingly visualized in recent years, which is a form of aggression that generates an unfavorable work environment. From the beginning, workplace harassment has been implemented in our system, and has been addressed in different countries. Sweden, for example, was the first country to implement the term harassment at work (1993), through the Basic Law on Risk Prevention, of national scope, which focuses on prevention, support to victims as a sanction and expulsion of whoever assaults and fosters a bad working environment, and since then it began to be included in different countries with specific legislation such as Italy, Belgium and the United Kingdom. While in Latin America, although there is little development in this area, Colombia stands out as one of the few countries with a national law (Law 1010, January 23, 2006) which seeks to prevent, correct and punish harassment at work within the framework of labor relations, followed by Argentina and Brazil at regional level¹ and Chile since 2012.

In 2010, the World Health Organization (WHO) described this type of aggression as a "major problem" of public health, which has been called a "global silent epidemic", because it not only affects the victim but also the entire circle that surrounds her, as well as her physical health and psychological integrity; and even more specifically in the health work area, since those who make up this area are confronted day by day with a greater stress load, either due to personal situations, complex situations with patients, lack of emotional support and/or being considered as a support for families and communities, thus affecting the quality of care in health. For these reasons, the approach to this situation becomes complex, since being a "silent disease" characterized by fear on the part of the victim due to the psychological or physical violence exercised by both service colleagues and bosses, it becomes even more difficult to carry out, this added to the existence of a precarious health system, inefficient health measures and/or the low awareness and importance of promoting a safe environment free of practices that affect the health of the workers.

In this same way, in our country, mental health problems and their correlation in the labor aspect have been increasing; this is indicated by the data of the Superintendence of Social Security regarding mental health medical licenses in 2019, leading the pathologies in mental health and behavior with a total of 23.6%.² Likewise, for 2020, establishing a balance of the first four months, it is determined that out of a total of 1,419,155 electronic medical licenses issued between January and April, 417,301 correspond to mental disorders. If the figures for the first four months of 2020 are compared with the same months of 2019, the increase in medical leave for this disorder increases by nearly 15%, from 307,913 to 417,301 permits.³ It should be noted that although mental disorders are considered in medical leaves at the national level, there is no specific information that these are caused by mobbing. Following the same line, with respect to professional agents in the health area, it is necessary to talk about percentages in nursing and the risk factors of the phenomenon, so it can be said that different studies converge in characteristics that favor this type of situation, among which are being younger, being considered less skilled and having less experience in the management of adverse situations; these may constitute influential factors for being victims of violence.^4–6 It should be noted that there are few recent studies and little precise information on the extent of the problem, consequences and manifestations of this issue, specifically in the nursing area.

To enter a legal framework on the situation of mobbing in Chile, it should be noted that, based on the different definitions established by the Legal Department of the Labor Directorate, since 2008 are considered as possible complaints of harassment at work, all those whose subject matter denounced is related to some violation of the worker, such as: violation of the respect and protection of the private life and honor of the person and his family; violation of the inviolability of all forms of private communication; violation of the freedom of conscience; the manifestation of all beliefs and the free exercise of all religions that do not oppose morality, good customs or public order; infringement of the freedom to express opinions and to inform, without prior censorship, in any form and by any means, without prejudice to answer for crimes and abuses committed in the exercise of these freedoms; infringement of the freedom to work; infringement of the right to non-discrimination of remuneration on the basis of sex; violation of the right to non-discrimination based on national or social origin; violation of the right to non-discrimination based on age; violation of the right to non-discrimination based on nationality; violation of the right to non-discrimination based on political opinion; violation of the right to non-discrimination based on religion; violation of the right to non-discrimination based on unionization; violation of the right to non-discrimination; violation of the right to life, physical and psychological integrity of the worker; violation of the right to not be subject to retaliation in the workplace for the exercise of administrative or judicial actions.⁷ Therefore, there are several aspects that can be considered as labor harassment at the national level and that can be reported, however, there is a probability that not all cases of labor harassment are reported correctly and in a timely manner.

Regarding public policies implemented in Chile, the Code of Good Labor Practices (CBPL) of the National Directorate of the Civil Service (2006) stands out, which aims to "contribute to the design and implementation of prevention actions and strategies to address this problem in the services". (Dirección Nacional del Servicio Civil, June 2010); Law 20.607 that modifies the labor code, sanctioning labor harassment practices (2012); the Protocol of Surveillance of Psychosocial Risks (2013) within which mobbing is mentioned in it as one of the six Psychosocial Risk Factors (FRPS), being pointed out as "violence and harassment", and described as the existence of situations of emotional, physical or sexual harassment. At this point, it is necessary to mention that the SUSESO ISTAS 21 Questionnaire (instrument that allows the evaluation and measurement of psychosocial risks at work), includes five major dimensions in which psychological harassment at work is not specifically and/or explicitly incorporated, and the National Policy on Safety and Health at Work of the Undersecretariat of Social Welfare mentions "Respect for the life and physical and psychological integrity of male and female workers as a fundamental right" (N°1) and "Gender equity" (N°3).

Regarding the physical and psychological integrity of male and female workers as a fundamental right, it establishes "to persevere in strengthening the focus on the rights of people in the world of work, guiding the design of institutions, their policies and action programs so that they are consistent with the legal assets that protect this guarantee, such as the right to life, physical and psychological integrity, health and dignity of male and female workers". In relation to gender equity, it points out the importance of incorporating the gender perspective to become standard practice in all public policies and national programs in this area.⁸ However, these measures have not been sufficient, since although mechanisms have been implemented to promote a safe work environment and/or there is a regulatory framework against harassment at work, it has not been carried out efficiently. There are still shortcomings in this regard, without a technical standard or flowchart specifying the steps to follow in a simpler way for general understanding, or to implement reliable investigations at the national level of those who exercise this type of violence in the workplace.

Conceptual framework

The term "mobbing", coming from the English verb "to mob", which means to harass or harass, began to take root in the 1960s, when the Austrian professor Konrad Lorenz conducted a study on animal aggressiveness. Among his results, Lorenz highlights that animals have a behavior similar to humans within institutions, which consists of the attack of a group of weak individuals of a species against a stronger one, or the attack by a group against a third party outside it. In view of this, for the first time the concept is coined as "the attack of a coalition of weak members of the same species against a stronger individual; or that of the majority of them against a different individual because of some significant difference, defect or trait".⁹ In the 1980s in Sweden, German-born Dr. Heinz Leymann used the term "mobbing" for the first time in the field of psychology, and applied it to human behavior as the "chaining over a fairly short period of time of hostile attempts or actions consummated, expressed or manifested by one or more persons towards a third person: the target".¹⁰ Leymann differentiates this concept from the term "bullying", since the latter is attributed to physical and psychological violence exercised in the school environment, between children and adolescents, while "mobbing" refers to the same behavior but in the adult stage and must have a minimum duration of 6 months.

On the other hand, in 1993, the Swedish Agency for the Improvement of the Working Environment (AFS) describes it as "a series of recurring reprehensible or clearly negative actions that are directed against individual employees in an offensive manner and may result in the marginalization of these employees from the working community".¹¹ In 2001, the European Commission's Advisory Committee on Safety, Hygiene and Health Protection defined workplace violence as "a form of negative behavior or action in relations between two or more persons, characterized by aggressiveness, usually of a repetitive nature, often unexpected, which has harmful effects on the safety, health and well-being of the employee in the workplace".¹² Einarsen and Skogstad are not far behind, since in 2010, they conceived the term Leymann and added that workplace bullying occurs when a person is subjected to persistent negative actions by another individual or a group of people, and also faces various difficulties in defending him/herself against them.¹³ All the definitions described above have elements that allow a common consensus, since, in summary, workplace violence or harassment constitutes hostile or negative actions taken against a person.

Theoretical framework

Having reviewed the concept of harassment at work according to different authors and organizations worldwide, it is necessary to go deeper into the types of harassment existing to date. In the first place, vertical downward harassment, also known as "bossing", is that which comes from a hierarchical superior, i.e. the harasser occupies a higher position in the company than the victim. This type of harassment is the most common, where the fundamental assumption is the use of abuse of power. Secondly, horizontal harassment is that which occurs between equals, i.e., between co-workers. Here, one person or a group of people have an identity of their own in the eyes of the bullied, since they see everyone as a victimizer. In the third instance, mixed harassment is that which is generated from workers towards another of the same hierarchical level, but in which the superior becomes aware of this situation and does not adopt remedial measures, thus becoming an accomplice in this act. Finally, upward vertical harassment, which is caused by a subordinate worker towards a superior, however, this is one of the least frequent.¹²

With the aim of studying this problem from an organizational perspective, Leymann establishes four phases that allow a better understanding of the model and thus, to be able to diagnose it within a labor organization. The phases, detailed in the Research Experiences of Rico, Hernández et al.,¹⁴ are mentioned below:

Conflict phase: In this stage, the victim perceives initial harassment pressures but does nothing to remedy it, as he/she tends to think that later on the hostility will pass and he/she will be able to integrate into the work team. If this situation is maintained over time, he/she begins to reflect on his/her mistakes and to insist repeatedly on analyzing them, so that symptoms of anxiety in relation to the maintenance of work status, sleep disorders and eating habits tend to become evident.

Stigmatization or mobbing phase: here, the harassment by the victimizer(s) begins. In this phase we can speak of psychological harassment, since the purpose of these people is to ridicule and socially isolate the victim. Here the victim cannot give evidence of what happened, unless other coworkers testify to the facts, however, they decide whether to be accomplices in the harassment or to withdraw from the situation.

Intervention phase from the organization: the victim seeks support from higher levels of the organization, such as heads of the unit or service directors in order to face and solve the problem, however, upon seeing that the situation does not stop, he/she begins to feel rejected and marginalized, which tends to trigger symptoms of severe anxiety and depressive outbreaks.

Phase of marginalization or exclusion from working life: the victim chooses to resign from the job or request a change of position or transfer, which could have an impact on the victim's family environment. Older people opt for retirement, while younger people, if they do not resign, prefer to stay on the job under pressure until the work environment becomes nothing more than an instrumental job with no interpersonal relationships.

As for the characteristics of the personalities mentioned:

Victim profile

The person who suffers from the aggressions of the harasser has not established a profile that stands out from the rest of individuals, but it can be said that depending on the case are subjects who usually maintain success, being that they are possible victims by the fact that within the work area they stand out from the rest, but unlike other employees are very likely to have low self-esteem, they may not be able to withstand the pressure, being there where the victimizer would take advantage of the situation.

Offender profile

The harasser is the person who assaults an individual in this case within a company, the profile that defines it in individuals who maintain superiority complex, are those who stand out as aggressors in this type of work context, devising their own skills and abilities over others, also attaching paranoid and narcissistic traits that complement it, taking into account that they have the need to hide or conceal their own shortcomings, they hold their perspective of control or manipulation of their environment and exactly the people around them.¹⁵ In order to address in a more comprehensive way the subject under study and focused on the nursing environment, the use of Jean Watson's Theory of Human Care was chosen, which is based on the harmony between mind, body and soul, through a relationship of help and trust. The principles that stand out in this theory are the ten Caring Factors, which since 2002-2007 have been transformed into the Caritas Process and are summarized in the following table:

Modification of: Table 2.2 The original carative factors and the evolved caritas processes. Extracted from the book Nursing: philosophy and science of care 1st ed (pages 60-61).

The third process and factor "cultivation and sensitivity to self and others" is described by the author as the core of professional human-to-human relationships and caring and healing practices. Likewise, if a nursing professional is not sensitive to his or her own feelings, it will be difficult for him or her to be sensitive to another person, as it would be in the case of psychological violence or mobbing in the workplace with his or her own co-workers. In addition, Jean Watson emphasizes that nursing is capable of transforming and affecting different aspects at a personal and environmental level, contributing to change.

On the other hand, the fourth process of "developing and sustaining a caring relationship of help and trust" encompasses in part the different types of levels in the relationship that is established between people, which in this aspect, would be the relationship between nursing professionals. For this relationship to be harmoniously constituted, Watson mentions the importance of managing ontological skills and competencies of human care such as: the ability to do for others; to listen authentically; to consider others with a loving-kindness attitude; and to know how to respond to the feelings and moods of others with authentic affective congruence. It mentions then, that the quality of the relationship with another person is one of the most important elements in determining the efficiency in helping and delivering care. If there is a lack of these factors, the consequences of a feeling of hardening, automation and a sense of wear and tear on the part of the nurse will predominate. This same process is based on the American project in which the author participated, called the Pew Fetzer Report on Relationship-Centered Care (1994), which identifies and describes a set of knowledge, skills and values associated with the health-professional to professional care relationship, that to strengthen and build this relationship, one must honor the unique subjective world of the other, listen openly with the intent to hear the other and be able to communicate agreements and differences effectively, and thus confront disagreements in a constructive manner.¹⁶

In Halldórsdóttir's model there is a direct relationship with the Cáritas process called by the author as a care-healing relationship. This model defines the classification between the nurse-patient relationship based on the patients' experiences, which was extended by Jean Watson to the Caritas process, thus defining the following types of relationship:

1. Type 1. Biocidal: life-destroying (toxic, leading to anger, despair and decreased well-being).
2. Type 2. Biostatic: life restrictive (cold, or a patient treated as a nuisance).
3. Type 3. Biopassive: neutral to life (apathetic or disinterested).
4. Type 4. Bioactive: life sustaining (the classic nurse-patient relationship that is kind, caring and benevolent).
5. Type 5. Biogenic: life giver (life receiver).

Although here we are talking about a nurse-patient relationship, it is important to know these types of relationships because they are also extrapolated to the field of work development and interpersonal relationships between nurse - nurse, so it could be defined that in the field of mobbing the types of biocidal relationships imply that there is a decrease in the welfare of the victim by a toxic work environment. Then, in favor of the aforementioned, Jean Watson establishes the importance of maintaining a set of knowledge, skills and values associated with the health professional and the relationship of care at levels such as: the relationship of the professional with himself; the relationship of the professional with the patient; the relationship of the professional with the community; and the relationship of professional to professional. This last point is of vital importance as Watson indicates that a fundamental model for the education of health professionals must be outlined, which ultimately generates professionals who work together to serve the complex matrix of people's needs in health, illness and care-healing processes and outcomes, while cultivating and deepening biogenic relationships with self and others; for this, one of the main skills is to cultivate personal and professional practices for self-growth, intuition and reflection.¹⁶

As a whole, the use of this theory allows us to encompass in a holistic manner all the perspectives and angles of this problem of mobbing as a new psychosocial risk in the nursing profession, including the values and ethics that characterize it and how the lack of knowledge about the processes and systematization of violence affect the quality of care provided to patients and generate harmful effects on health both at the personal and interpersonal level as well as in the community.

Justification

The essence of the nursing profession is care, and as such it must ensure well-being. In many opportunities, the "otherness" is left aside in the professional practice, given that the labor field, characterized by the biomedical model and high technologization in health care, added to the scarce nursing staff and high levels of stress combine as a barrier at the time of providing care. Horizontal violence in the nursing profession has been reported several years ago. Jean Watson, nursing theorist, has pointed out the dehumanization in the professional work due to the high complexity and technologization of the biomedical system. Through her Caring Theory, she focuses on the understanding of the victim and the phenomenon, highlighting the formation of a humanistic-altruistic system of values, the development of a relationship of help-trust and the creation of an environment of support, mental, physical and social protection, assumptions which allow the recovery of this essence.¹⁷

Continuing along the same line, we can see that currently the level of workplace violence continues to be reflected in our country, as there have been cases such as those of Florencia Elgueta and Vanessa Araya, two young nurses who ended their own lives, counting among their reasons the systematic harassment and mistreatment they experienced in their work and which became commonplace and normalized, ending with a fatal outcome.¹⁸ These cases only give us a slight and absolutely limited vision of the real situation that nursing professionals live in hospitals, and not only in Chile, but also around the world. In this context, the Chilean College of Nurses made a public statement to the authorities on the urgency and importance of implementing Psychosocial Risk protocols and effective Mental Health Programs. (Colegio de enfermeras de Chile, Public statement May 02, 2021. Available at https://twitter.com/colegioenfermer/status/1388906091145224194). There are several studies that address the issue of workplace violence, however in Chile these studies are still scarce, for this reason this systematic review will provide a global overview of how mental health manifests the effects of workplace violence, and determine strategies to prevent and address it, as input for the development of public policies and/or standardized protocols that account for the importance and protect mental health, both in situations of mobbing and/or physical and psychological workplace violence.

Problem statement

Health care workers, and in particular nursing professionals, have a high mental workload, frustration, fatigue due to long working hours, lack of contact with family members and even negative treatment by patients or other workers, which evidently affect both their quality of care and their interpersonal relationships, due to the high work pressure they face.¹⁹ With respect to the integrated profile of the nursing professional from their academic training, the overvaluation of techniques and the attitudes and skills adopted by the professional, as well as the sociocultural factors to which they are rooted, there could be several triggering factors that lead this person to exercise workplace violence towards other nursing professionals.²⁰ One of the main causes of mobbing is that a service worker (superior, colleague or subordinate) is threatened by the presence of a professional who is mostly trained,²¹ a frequent situation in several countries. However, despite being a topic of current interest, the situation has rarely been taken seriously, since the effects that this could have on the mental health of nursing professionals who play the role of victims have been little studied and/or substantiated in order to implement effective policies or protocols that value fundamental rights and promote respect and empathy in the workplace. All nursing interventions should be based on the same foundation: caring for oneself in order to care for others. For this reason, the recognition of these effects on mental health and their impact on the interpersonal relationships of nursing professionals is a problem that must be solved, since in addition to affecting mental health, routine work and interpersonal relationships between workers, the quality of patient care may also be affected.

Research question

What are the effects of workplace violence on nursing professionals in the intra-hospital setting at the national and international level and what are the strategies for dealing with it?

1. Objectives
2. Overall objective
3. To analyze the effects of workplace violence on nursing professionals in the in-hospital setting at the national and international level.
4. To determine strategies for the prevention of workplace violence among nursing professionals in the in-hospital environment.

Specific objectives

1. To recognize the impact of workplace violence on the interpersonal relationships of nursing professionals in the in-hospital setting.
2. To determine the effect of violence at the intrahospital level on the mental health of nursing professionals in various countries.
3. Analyze the various strategies used in the prevention of workplace violence in nursing professionals.
4. To establish prevention methods and interventions to reduce workplace violence in the in-hospital setting among nursing professionals.

Bibliographic search strategy

The study was based on an exhaustive analysis of national and international literature available on the Internet, of a qualitative and quantitative nature. This included the reading of systematic reviews, original articles and institutional authored documents available on the websites of governmental and non-governmental organizations such as PAHO and WHO. Initially, in order to screen the review of these documents, it was determined that the age of publication should not exceed 5 years, i.e. from 2016 to 2021. In addition, the literature reviewed had to be in Spanish, English and Portuguese and be freely accessible. For the search strategy, two phases were determined. The first one, with the purpose of fulfilling the general objective N°1 determined in our research, and the second one, focused on the fulfillment of the general objective N°2 based on prevention strategies of mobbing among nurses within the intrahospital environment.

Phase 1: To analyze the effects of workplace violence on nursing professionals in the in-hospital setting at the national and international level

Keywords defined according to the Health Sciences Descriptor DeCS²² and Medical Subjects Heading (MeSH)²³ were included and the Boolean operators "and" and "and" were used. The keywords are listed below, with their respective unique identifiers:

1. Workplace violence (violência no local de trabalho): Threat or actual attempt to harm others in the workplace. Unique identifier D064450.
2. Nurses (enfermeiras): Qualified professionals graduated from an accredited school of nursing and by passing a national licensing examination for the practice of nursing. They provide services to patients in the recovery or maintenance of their physical or mental health. Unique Identifier: D009726.
3. Hospitals (hospitais): Institutions with an organized medical staff that provides medical care to patients. Unique identifier: D006761.
4. Mobbing (assédio moral): Definition not found in DeCS or MeSH. However, it was considered relevant in the research process due to its frequent use in scientific articles and high impact journals.
5. Nurse bullying (enfermeira intimidação): Definition not found in DeCS or MeSH. However, it was considered relevant in the research process due to its frequent use in scientific articles and high impact journals.

In order to obtain the information, articles were searched in the following databases:

1. Scielo (Scientific Electronic Library Online): Corresponds to an Internet database for the publication of scientific journals and articles. It is a decentralized model that includes national and international documents with collections from Argentina, Brazil, Chile, Colombia, Cuba, Spain, Portugal and Venezuela, whose objective was initiated by the need to increase the visibility and dissemination of Latin American scientific literature and to have an electronic publishing methodology that takes advantage of the Internet and the new technologies available.²⁴
2. MEDLINE (Pubmed): It is a free resource that supports the search of biomedical and life sciences literature with the goal of improving health, both globally and personally. It also contains more than 32 million citations and abstracts of biomedical literature. It does not include full-text journal articles; however, links to the full text are often present when available from other sources.²⁵
3. Science Direct: corresponds to Elsevier's full-text, peer-reviewed database of more than 1.4 million scientific articles, journals and books. In addition, it offers content from a wide variety of external sources in the form of audio, video and datasets.²⁶

The search for Phase 1 articles with the respective keywords and Boolean operators is detailed below Table 1:

The search for scientific articles with exact keywords is detailed below:

Phase 2: To determine strategies for the prevention of workplace violence among nursing professionals in the in-hospital environment

Keywords defined according to the Health Sciences Descriptor DeCS²² and the Medical Subjects Heading (MeSH)²³ were included and the Boolean operators "and" and "and" were used. The keywords are listed below, with their respective unique identifiers:

1. Workplace and nurse violence (enfermeira de violência no local de trabalho): Definition not found in DeCS or MeSH. However, it was considered relevant in the research process due to its frequent use in scientific articles and high impact journals.
2. Violencia lateral y bullying (lateral violence and bullying): Definition not found in DeCS or MeSH. However, it was considered relevant in the research process due to its frequent use in scientific articles and high impact journals.

In order to obtain the information, articles were searched in the following databases:

1. MEDLINE (Pubmed): It is a free resource that supports the search of biomedical and life sciences literature with the goal of improving health, both globally and personally. It also contains more than 32 million citations and abstracts of biomedical literature. It does not include full-text journal articles; however, links to the full text are often present when available from other sources.²⁵

The search for Phase 2 articles with the respective keywords and Boolean operators is detailed below Table 2:

 Article eligibility criteria

The scientific articles used throughout this review were chosen according to different eligibility criteria, among which the following stand out: original qualitative and quantitative scientific articles, full text freely accessible, in Spanish, English and Portuguese, with a maximum publication age of 5 years, i.e., covering the period 2016 - 2021. In addition, the participants in the studies reviewed had to meet certain requirements, among which were: they had to be nursing professionals whose professional practice was within the in-hospital setting. Documents such as essays, bibliographic or narrative reviews, and letters to the editor were excluded from the search and review.

Study of methodological quality and level of evidence

Regarding the choice of articles and studies, files were made to evaluate the methodological quality of each article (Annex 9.1) using as a reference files available on the FLC 3.0 Platform (Critical Reading Files)^26,27 in order to address all the items present in a scientific article and then the corresponding results were arranged in a PRISMA Flowchart with the selected documents. During this methodological quality study, the articles were divided into 3 levels of quality (high, medium and low), according to the percentage obtained in the methodological quality form; for this purpose, it was determined that the articles would be of high quality if they met 75% or more of the criteria evaluated per item, of medium quality those with a percentage lower than 75% and of low quality those with a percentage lower than 50%. In view of the fact that qualitative and quantitative scientific articles were reviewed, some criteria had to be excluded according to the type of study, due to variables that sometimes do not apply to the study, so the final criteria for the use of the documents were discussed by the researchers using the aforementioned instruments as a basis. On the other hand, the level of evidence was evaluated based on the Level of Evidence Classification according to Sackett²⁸ (Annex 9.2), which corresponds to a systematization that ranks the evidence in levels ranging from 1 to 5, with level 1 being the "best evidence" and level 5 the "worst evidence". 

Data matrix

In order to structure the studies and maintain order in the review of each document, a data matrix was created to systematize the information in each article. The matrix has a total of 11 columns detailing the components of an article and in the columns the unit of analysis of each research.

Work plan

The organization and planning of the work was carried out by means of activities stipulated in the Gantt Chart (Annex 9.3), which details the necessary activities and the time determined for carrying out the work in an efficient and structured manner. As for communication and counseling with the tutor, this was done through the Zoom platform, during class hours on Thursdays, as well as via Whatsapp to facilitate the speed of questions and answers related to the work that arose during the rest of the week. For the data storage on the Internet provided by Google Drive, it was possible to carry out the present study synchronously by the researchers, where a Google Document was made for the writing of the research and an Excel Document for the realization of the Gantt Chart. On the other hand, it was necessary for one of the researchers to subscribe to the FLC 3.0 Web Platform (Critical Reading Cards) in order to deepen the analysis of the scientific articles reviewed and the determination of their methodological quality through critical reading guides obtained from the publication of cards by various users on this platform.

PRISMA Flowchart

Annexes

Form for the evaluation of the methodological quality of the studies

Sackett's classification of levels of evidence⁽²⁸⁾

Gantt Chart

None.

The author declares there is no conflict of interest.

1. Morales M. Approach to labor harassment from comparative legislation. Mexican Bulletin of Comparative Law. 2016;49(147):71–98.
2. FONASA, SIS, SUSESO. Statistics of medical licenses and subsidies for work incapacity. 2019.
3. Undersecretary of Social Security. Increase in Medical Licenses for Mental Disorders in the first four months of 2020. 2020.
4. Morales J, Cordero J. Physical and psychological violence in primary care workers in Lima and Callao. Rev Asoc Esp Espec Med Trab. 2019;28(3):186–194.
5. Molero M, Pérez M, Gázquez J. Workplace bullying among nursing staff. Enfermería Universitaria. 2016;13(2):114–123.
6. Castro O, Leyton C, Forero J. Workplace bullying in Health Care Workers: A systematic review. 2017.
7. Baltera P. Labor harassment in companies: the union leaders' view. 2014;
8. Institute of Public Health, Department of Occupational Health, What is mobbing: psychological harassment at work?. 2017.
9. Abajo Olivares J. Mobbing. Work Harassment: Defense and proof of Damage to basic rights. Revista Ius et Praxi. 2004;1:67–90.
10. Martinez M, Irurtia MJ, Torres M, et al. Psychological harassment at work or mobbing: emerging pathology. Gac int forensic sci. 2012;3(2):1–8.
11. Barón M, Munduate L, Blanco M. The spiral of mobbing. Papers of the psychologist. 2003;23(84):71–82.
12. Fraga A. Current situation of mobbing in Chile: legal and jurisprudential regulation. Actualidad Jurídica. 2014;30:1–29.
13. Hauge L, Skogstad A, Einarsen S. The relative impact of workplace bullying as a social stressor at work. Scand J Psychol. 2010;51(5):426–433.
14. Rico M, Hernández H, Hernández T. Occupational attrition and workplace harassment: research experiences. 1st ed. Universidad Juárez del Estado de Durango. 2020;76–81.
15. Bejarano C, Castillo V. Mobbing and personality in nursing professionals. Riobamba. 2020.
16. Watson J. The Philosophy and Science of Care. 1st edn. Chihuahua, Mexico: Dirección de Extensión y Difusión Cultural; 2019. p. 53–138.
17. Alligood MR, Marriner A. Models and Theories In Nursing. 8th edn. Elsevier. Barcelona: Spain. 2014. p. 99.
18. Figueroa N, Llanos T. When bullying becomes habitual: The stories behind the suicide of nurses at Viña del Mar Hospital. 2021.
19. Almudéver L, Pérez I. The mental workload of nursing professionals in relation to their work shift. Ene. 2019;13(1):1315.
20. Dois A. Workplace violence in nurses: explanations and coping strategies. Rev Latino - Am Enfermagem. 2011;19(1).
21. Ruíz K, García M, Guevara M. Perception of mobbing among intensive care unit nurses. Rev Enferm Intensiva. 2020;31(3):113–119.
22. DeCS Server - Main Menu. Bvsalud.org. 2021.
23. Home - MeSH - NCBI. Nih.gov. 2021.
24. Bojo Canales C, Fraga Medín C, Hernández Villegas S, et al. SciELO: a cooperative project for the dissemination of science. Rev esp sanid penit. 2009;11(2):49–56.
25. Nih.gov. 2021.
26. Elsevier LAN. Quick reference guide. Edu.co. 2021.
27. FLC: Critical Reading Worksheets. Website. 2021.
28. Manterola C, Zavando D. How to interpret the "Levels of Evidence" in different clinical scenarios. Chile: Rev Chilena de Cirugía. 2009.