Apps for smoking cessation through Cognitive Behavioural Therapy. A review. / Apps para dejar de fumar mediante Terapia Cognitivo Conductual. Una revisión sistemática.

Smoking is a health and economic problem that is difficult to eradicate. Nicotine addicts also often suffer from psychological problems such as depression and anxiety. The recommended treatment according to clinical practice guidelines (CPG) is Cognitive Behavioural therapy (CBT), alone or combined with medication. Currently, health-related apps (m Health) enable wider availability and access to this treatment. The objectives of this study are to carry out a review of the smoking cessation apps that apply CBT and to describe the techniques used by them. Following the PRISMA framework, the databases EBSCOhost, Cochrane, Web of Science and Scopus were searched for publications between 2010-2019. Four hundred fifteen studies were found and, after applying the inclusion and exclusion criteria, only five articles were eligible for systematic review. Only three apps were identified as using CBT, and the techniques most commonly used were the recording of smoking history, progress visualised through graphics, psycho-educational videos, motivation, social support through social media, and elements of gamification to reinforce adherence and abstinence behaviour. The results recommend the inclusion of smoking behaviour analysis in these types of apps, as not all of them do so, as well as an interface between the health professionals and the users to provide a personalised treatment.

El tabaquismo constituye un problema sanitario y económico de difícil erradicación. Las personas más dependientes a la nicotina suelen presentar, además, problemas psicopatológicos como depresión y ansiedad. Según las Guías de Práctica Clínica (GPC), el tratamiento recomendado para abandonar el hábito es la Terapia Cognitivo Conductual (TCC), sola o combinada con medicación. Actualmente, las aplicaciones móviles (App) en salud (mHealth) permiten un acceso masivo y económico a este tratamiento. El objetivo de este trabajo consiste en llevar a cabo una revisión bibliográfica de las Apps para dejar de fumar que apliquen TCC y describir las técnicas implementadas. En el marco del protocolo PRISMA, la búsqueda se ciñó al periodo 2010-19 y se realizó en las bases de datos: EBSCOhost, Cochrane, Web of Science y Scopus. Se hallaron un total de 415 trabajos, de los cuales, tras aplicar los criterios de inclusión/exclusión, solo 5 artículos fueron objeto de revisión. Únicamente se identificaron 3 Apps (en inglés) que incluyeran TCC y, las técnicas más utilizadas fueron: el registro de cigarrillos, la visualización del progreso mediante gráficas, videos psicoeducativos, la motivación, el apoyo social mediante redes sociales y elementos de gamificación para reforzar la adherencia y la conducta de abstinencia. Los resultados sugieren incluir en este tipo de Apps el análisis de la conducta de fumar, ya que no todas lo hacen, así como una interfaz que comunique el personal sanitario con el usuario y pueda proporcionar un tratamiento personalizado.

Effects of Stress on Critical Care Nurses: A National Cross-Sectional Study.

BACKGROUND:: Health care is a demanding field, with a high level of responsibility and exposure to emotional and physical danger. High levels of stress may result in depression, anxiety, burnout syndrome, and in extreme cases, post-traumatic stress disorder. The aim of this study was to determine which personal, professional, and organizational variables are associated with greater perceived stress among critical care nurses for purposes of developing integrative solutions to decrease stress in the future. METHODS:: We conducted a correlation research survey using a cross-sectional design and an in-person survey method. The questionnaire consisted of 2 parts: (1) socioeconomic, professional, and institutional variables and (2) work stressors. Surveys were conducted between January 1, 2011, and December 1, 2015. Multistage cluster random sampling was utilized for data collection. Inclusion criteria were (1) age ≥18 years, (2) registered nurse, (3) works in the intensive care unit (ICU), and (4) willing and able to complete the survey. RESULTS:: We surveyed 21 767 ICU nurses in Iran and found that male sex, lower levels of peer collaboration, working with a supervisor in the unit, nurse-patient ratios, and working in a surgical ICU were positively associated with greater stress levels. Increasing age and married status were negatively associated with stress. Intensive care unit type (semi-closed vs open), ICU bed number, shift time, working on holidays, education level, and demographic factors including body mass index, and number of children were not significantly associated with stress levels. CONCLUSION:: As the largest study of its kind, these findings support those found in various European, North, and South American studies. Efforts to decrease workplace stress of ICU nurses by focusing on facilitating peer collaboration, improving resource availability, and staffing ratios are likely to show the greatest impact on stress levels.

The effect of progressive muscle relaxation on daily cortisol secretion.

Abbreviated progressive muscle relaxation (APMR) is a much used stress-management technique. Its efficacy relevant to placebo control is already established in the literature and the primary aim of the present study was to ascertain whether its proven impact on psychological stress measures is matched by a decrease in prevailing levels of the stress-associated hormone cortisol, using accurate and robust measurement based on multiple sampling of full diurnal cortisol secretion profiles. First-year university students can face significant stress in adjustment to academic demands and immersion in a novel social network and provided a convenient study population. One hundred and one first-year students completed APMR with prevailing stress levels assessed a week before and after intervention. Both cortisol and self-report measures were significantly reduced post-intervention by 8% and 10%, respectively. The efficacy of the intervention was independent of, and not modulated by neuroticism, gender, age and smoking status. We also demonstrated that cortisol reduction was unlikely to have been a consequence of adaptation to any initial cortisol elevation prompted by the challenge of the demanding saliva collection protocol. We conclude that the efficacy of APMR in this population extends to reduction in biologically expressed stress levels as well as levels based solely on self-report.

NoFumo+: Mobile Health App to Quit Smoking Using Cognitive-Behavioral Therapy.

This paper describes the development and test of a smartphone application to quit smoking using cognitive behavioral therapy (CBT). The tool includes recommendations from US Clinical Practice Guidelines (USCPG), drawing on the potential of smartphones and complying with the health App (mHealth) assessment standards. The mHealth created, called NoFumo+, is structured by 4 weeks treatment, implements the USCPG 5A recommendations (ask, advise, assess, assist, and arrange) and incorporates a CBT. It also includes complementary information, monitoring of the smoking behavior, social support for users, proposals for alternative activities to smoking, and innovative gamification to encourage and reward adherence. To technical development, a multidisciplinary team was formed (healthcare, research, and software engineers) that made theoretical decisions on both technical issues and the incorporation of therapeutic techniques. The validation was carried out in two phases; the first in the laboratory by a group of experts in information and communication technologies and CBTs (n = 15) and the second, a field study with smokers (n = 10). The standards for the development of mHealth recommended by the Andalusian Healthcare Quality Agency and the App quality evaluation guidelines of the Catalonian ICT Foundation for Social Health were used as assessment protocols by the experts' panel and the smokers' group, respectively. Experts' assessment results were satisfactory and some improving changes were suggested, such as to add more gamification elements. The group of smokers rated the mHealth as 100% easy to use and effective for quit smoking and understandable by the 83.3%. They also found No Fumo + quite useful to have the information available at all times. The obtained evidence after a complete two-phased validation study, with experts and potential users, shows a mHealth with high quality and easy to use. Finally, investigation project registered in ClinicalTrials.gov with reference to this trial is registered with NCT045402004.

Stress and neuroticism in Spanish nursing students: a two-wave longitudinal study.

The aim of this study was to clarify the direction of the stress-neuroticism relationship in a sample of 200 nursing students from three Spanish universities before their entry into the work force using a two-wave longitudinal design. The Stressful Life Events Scale and NEO-FFI Neuroticism subscale were administered at the beginning (T1) and end (T2) of nursing studies. Female students reported higher scores in both perceived stress due to life events and neuroticism than males. Older students scored higher in life events stress than younger ones. High neuroticism was associated with a high level of stress. Finally, neuroticism scores rose in the group in which stress increased from T1 to T2. Our findings partially support the stress causation interactionist model of stress in which life events can modify personality traits.

NoFumo+: A Clinical Trial of an mHealth for Smoking Cessation with Hospitalized Patients.

Smartphone applications (apps) improve accessibility to smoking cessation treatments. The NoFumo+ app administers a cognitive behavioral therapy program for smoking cessation. This study evaluates the efficacy of NoFumo+ for quitting smoking or reducing cigarette consumption versus the usual information-based treatment. A clinical trial was conducted with 99 hospitalized smokers, 54 pseudo-randomly assigned to the app treatment and 45 to the usual treatment. The two groups had homogeneous baseline characteristics to ensure comparability. Abstinence was evaluated at post-treatment (two months) and at a six-month follow-up. The results obtained indicate that participants who receive the usual treatment are 5.40 times more likely to continue smoking than those who undergo the app treatment (95% CI = [1.35; 20.15]). Participants who do not succeed in quitting smoking with the app manage to decrease their habitual consumption. Users who successfully complete treatment with NoFumo+ access all its contents and use the chat, but without requesting professional support. There is not enough empirical evidence to attribute this success to any specific element of the app. NoFumo+ achieves better abstinence rates than the usual information-based treatments, and the goal of generalizing its use to the non-hospitalized smoking population may be achievable in the future.

Confirmatory factorial analysis of the Maslach Burnout Inventory - Human Services Survey in health professionals in emergency services.

OBJECTIVE: to confirm the factorial validity of the Maslach Burnout Inventory - Human Services Survey version in a sample of health professionals from the emergency services. METHOD: a quantitative, exploratory, descriptive and analytical study. Two hundred and eighty-two health professionals participated in the study. For data collection, a sociodemographic questionnaire and the Maslach Burnout Inventory were used. The psychometric sensitivity for the MBI-HSS items was estimated by measures of central tendency, variability and the distribution shape. Internal consistency was estimated using Cronbach's alpha coefficient and the adequacy of the sample was verified using the Kaiser-Meyer-Olkin (KMO) index. As indexes for assessing the quality of fit of the model, the chi-square ratio by the degrees of freedom (χ2/DoF), the comparative fit index (CFI), the goodness of fit index (GFI), the Tucker Lewis index (TLI) and the root mean square error of approximation (RMSEA) were considered. To test data fit, the maximum likelihood method was used. RESULTS: the three-factor structure of the Maslach Burnout Inventory was confirmed. Items 9, 12, 15 and 16 had a factorial weight below what was considered appropriate and were removed from the model. The second order hierarchical model with the aforementioned modifications presented an adequate adjustment to the data and can be considered the best and most parsimonious model tested according to the information theory indexes. The internal consistency of the instrument's factors was recalculated considering the exclusion of the items and the three factors were considered adequate. CONCLUSION: the results obtained show that the Maslach Burnout Inventory is a reliable and factorially valid instrument for measuring the burnout syndrome in emergency service professionals in Brazil.

The Role of Neuroticism in Predicting Psychological Harassment in Nursing: A Longitudinal Study.

Psychological harassment is a serious occupational risk for nurses, but little is known about its related factors and possible predictors. The objective of the present study was to investigate whether nursing students' neuroticism trait and coping styles can predict psychological harassment at work when they later become nurses. A non-experimental, longitudinal, three-wave prospective study with a time lag of 6 years was carried out, following nursing students from three Spanish universities until they joined the health labor market. The age range of the sample was 20⁻48 years, and the mean age was 26.99 ± 5.72; the majority of the sample were women (88.5%). Predictor variables were neuroticism and coping styles (emotional and behavioral coping). The criterion variable was psychological harassment. To examine the model fit between the predictor and criterion variables, we conducted structural equation modelling. Results confirmed a high correlation between neuroticism and psychological harassment. In addition, a direct effect of neuroticism on psychological harassment was found; however, emotional and behavioral coping styles did not show a good fit. Proactive interventions to improve emotional self-control are needed in order to prevent negative effects of psychological harassment at work on nurses.

Coping, stress, and personality in Spanish nursing students: A longitudinal study.

The purpose of this study was to examine the dominant stress coping style in nursing students, its relationships with stressful life events and personality traits, and the students' changes during their academic training. A non-experimental two-wave longitudinal design was carried out in 199 nursing students recruited from three Spanish nursing schools. The Stressful Life Events Scale, NEO-FFI, and COPE questionnaire were administered at the beginning (T1) and end (T2) of their nursing studies. Descriptive statistics, Anova(s), NPar tests, and Pearson correlations were carried out. Results show that nursing students' dominant coping style was emotion-focused coping, both at T1 and T2. Highly significant correlations between emotional coping and the neuroticism trait were found. Coping, stress, and personality changed positively during the training program. At T2, the use of problem-focused strategies increased, and participants became more extroverted, agreeable, and conscientious. Coping and personality changes experienced by nursing students throughout their degree program seem to mirror the professional competences needed by future licensed nurses.

Confirmatory factorial analysis of the Maslach Burnout Inventory - Human Services Survey in health professionals in emergency services / Análise fatorial confirmatória do Maslach Burnout Inventory - Human Services Survey em profissionais de saúde dos serviços de emergência / Análisis factorial confirmatorio del Maslach Burnout Inventory - Human Services Survey en profesionales de la salud de los servicios de emergencia

Objective: to confirm the factorial validity of the Maslach Burnout Inventory - Human Services Survey version in a sample of health professionals from the emergency services. Method: a quantitative, exploratory, descriptive and analytical study. Two hundred and eighty-two health professionals participated in the study. For data collection, a sociodemographic questionnaire and the Maslach Burnout Inventory were used. The psychometric sensitivity for the MBI-HSS items was estimated by measures of central tendency, variability and the distribution shape. Internal consistency was estimated using Cronbach's alpha coefficient and the adequacy of the sample was verified using the Kaiser-Meyer-Olkin (KMO) index. As indexes for assessing the quality of fit of the model, the chi-square ratio by the degrees of freedom (χ2/DoF), the comparative fit index (CFI), the goodness of fit index (GFI), the Tucker Lewis index (TLI) and the root mean square error of approximation (RMSEA) were considered. To test data fit, the maximum likelihood method was used. Results: the three-factor structure of the Maslach Burnout Inventory was confirmed. Items 9, 12, 15 and 16 had a factorial weight below what was considered appropriate and were removed from the model. The second order hierarchical model with the aforementioned modifications presented an adequate adjustment to the data and can be considered the best and most parsimonious model tested according to the information theory indexes. The internal consistency of the instrument's factors was recalculated considering the exclusion of the items and the three factors were considered adequate. Conclusion: the results obtained show that the Maslach Burnout Inventory is a reliable and factorially valid instrument for measuring the burnout syndrome in emergency service professionals in Brazil.

Objetivo: confirmar a validade fatorial do Maslach Bunout Inventory - versão Human Services Survey numa amostra de profissionais da saúde dos serviços de emergência. Método: estudo de abordagem quantitativa, exploratório, descritivo e analítico. Participaram do estudo 282 profissionais de saúde. Utilizou-se para a coleta de dados, um questionário sociodemográfico e o Maslach Burnout Inventory. A sensibilidade psicométrica dos itens do Maslach Bunout Inventory - versão Human Services Survey foi estimada pelas medidas de tendência central, variabilidade e forma da distribuição. A consistência interna foi estimada por meio do Coeficiente alfa de Cronbach e a adequação da amostra verificada por meio do índice de Kaiser-Meyer-Olkin (KMO). Como índices para a avaliação da qualidade de ajustamento do modelo foram considerados a razão de qui-quadrado pelos graus de liberdade (χ2 /gl), comparative fit index (CFI), goodness of fit index (GFI), índice de Tucker Lewis (TLI) e root mean square error of aproximation (RMSEA). Para testar o ajustamento dos dados utilizou-se o método de máxima verossimilhança. Resultados: confirmou-se a estrutura trifatorial do Maslach Burnout Inventory. Os itens 9, 12, 15 e 16 apresentaram peso fatorial abaixo do considerado adequado e foram removidos do modelo. O modelo hierárquico de segunda ordem, com as modificações mencionadas, apresentou ajustamento adequado aos dados e pôde ser considerado o melhor e mais parcimonioso modelo testado de acordo com os índices da teoria da informação. A consistência interna dos fatores do instrumento foi recalculada considerando-se a exclusão dos itens e foi considerada adequada nos três os fatores. Conclusão: os resultados obtidos mostram que o Maslach Burnout Inventory é um instrumento confiável e fatorialmente válido para medir a síndrome de o burnout em profissionais dos serviços de emergência no Brasil.

Objetivo: confirmar la validez factorial del Maslach Bunout Inventory - versión Human Services Survey en una muestra de profesionales de la salud de los servicios de emergencia. Método: estudio cuantitativo, exploratorio, descriptivo y analítico. Participaron en el estudio 282 profesionales de la salud. Para la recopilación de datos, se utilizó un cuestionario sociodemográfico y el Maslach Burnout Inventory . La sensibilidad psicométrica de los ítems del Maslach Bunout Inventory - versión Human Services Survey se estimó mediante medidas de tendencia central, variabilidad y forma de distribución. La consistencia interna se estimó usando el Coeficiente alfa de Cronbach y la adecuación de la muestra se verificó usando el índice de Kaiser-Meyer-Olkin (KMO). Como índices para evaluar la calidad de ajuste del modelo fueron considerados la razón chi-cuadrado para los grados de libertad (χ 2 /gl), comparative fit index (CFI), goodness of fit index (GFI), índice de Tucker Lewis (TLI) y root mean square error of aproximation (RMSEA). Para probar el ajuste de los datos, se utilizó el método de máxima verosimilitud. Resultados: se confirmó la estructura de tres factores del Maslach Burnout Inventory . Los ítems 9, 12, 15 y 16 presentaron un peso factorial por debajo de lo que se consideraba adecuado y se eliminaron del modelo. El modelo jerárquico de segundo orden, con las modificaciones antes mencionadas, presentó un ajuste adecuado a los datos y puede considerarse el mejor y más parsimonioso modelo probado de acuerdo con los índices de teoría de la información. La consistencia interna de los factores del instrumento se recalculó ponderando la exclusión de los ítems y se consideró adecuada en los tres factores. Conclusión: los resultados obtenidos muestran que el Maslach Burnout Inventory es un instrumento confiable y factorialmente válido para medir el síndrome de burnout en los profesionales de los servicios de emergencia en Brasil.

Intervening variables of Burnout in health professionals of emergency services / Variables de intervención del Burnout en los profesionales sanitarios de los servicios de emergencia / Variáveis interventoras do Burnout em profissionais de saúde dos serviços emergenciais

ABSTRACT Objective: to analyze the association between Burnout, stress, mental suffering and other personal and work factors associated with this syndrome. Method: cross-sectional, descriptive and correlational study with 282 health professionals from the emergency services of the city of Ribeirão Preto, Brazil, collected from October 2015 to March 2016. The instruments used were: sociodemographic questionnaire, Maslach Burnout Inventory, Childhood Trauma Questionnaire, Stress Symptom Inventory, Perceived Stress Scale, Psychiatric Screening Questionnaire, Fantastic Lifestyle Checklist, Hospital Anxiety and Depression Scale and Holmes-Rahe Social Readjustment Rating Scale. Descriptive writing of the data. Pearson's Chi-Square or Fisher's Exact Tests to check the association between variables and later regression analysis, in which ORs were calculated, with 95% CI and 5% significance level. Results: there was statistical evidence of an association between Burnout and education, early stress, stress, common mental disorders, lifestyle, anxiety and depression. The regression analysis shows that the variables that influence Burnout are: type of service (p=0.032; OR=0.187), education (p=0.029; OR=2.313), perception of stress (p=0.037; OR=1.67) and social readjustment (p=0.031; OR=1.279). Conclusion: this study points to a profile for the development of Burnout, consisting of health professionals with higher education, who suffered early stress, who have symptoms and perception of stress, who do not have a healthy lifestyle and show symptoms of mental suffering. Such results can assist in the development and implementation of strategies aimed at reducing both work stress and the prevalence of Burnout syndrome.

RESUMEN Objetivo: analizar la asociación entre Burnout, estrés, sufrimiento mental y otros factores personales y laborales asociados a este síndrome. Método: estudio transversal, descriptivo y correlacional entre 282 profesionales sanitarios de los servicios de emergencia de la ciudad de Ribeirão Preto, Brasil, recolectados de octubre de 2015 a marzo de 2016. Utilizados os instrumentos: Los instrumentos utilizados fueron: cuestionario sociodemográfico, Inventario de Burnout de Maslach, Cuestionario de Trauma Infantil, Inventario de Síntomas de Estrés, Escala de Estrés Percibido, Cuestionario de Exploración Psiquiátrica, Cuestionario de Estilo de Vida Fantástico, Escala de Ansiedad y Depresión Hospitalaria y Escala de Reajuste Social de Holmes-Rahe. Redacción descriptiva de los datos. Prueba Chi-Cuadrado de Pearson o Prueba exacta de Fisher para comprobar la asociación entre variables y posterior análisis de regresión, en el que se calcularon OR, con IC del 95% y nivel de significancia del 5%. Resultados: hubo evidencia estadística de asociación entre Burnout y educación, estrés temprano, estrés, trastornos mentales comunes, estilo de vida, ansiedad y depresión. El análisis de regresión muestra que las variables que influyen en el Burnout son: tipo de servicio (p=0.032; OR=0.187), educación (p=0.029; OR=2.313), percepción de estrés (p=0.037; OR=1.67) y reajuste social (p=0.031; OR=1.279). Conclusión: Este estudio apunta a un perfil para el desarrollo del Burnout, conformado por profesionales sanitarios con educación superior, que sufrieron estrés temprano, que presentan síntomas y percepción de estrés, que no tienen un estilo de vida saludable y presentan síntomas de sufrimiento mental. Dichos resultados pueden ayudar en el desarrollo e implementación de estrategias destinadas a reducir tanto el estrés laboral como la prevalencia del síndrome de Burnout.

RESUMO Objetivo: analisar a associação entre Burnout, estresse, sofrimento mental e demais fatores pessoais e laborais associados a esta síndrome. Método: estudo transversal, descritivo e correlacional entre 282 profissionais de saúde dos serviços de emergências da cidade de Ribeirão Preto, Brasil, coletado de outubro de 2015 a março de 2016. Utilizados os instrumentos: questionário sociodemográfico, Maslach Burnout Inventory, Childhood Trauma Questionnaire, Inventário de Sintomas de Stress, Escala de Estresse Percebido, Psychiatric Screeming Questionnaire, Questionário de Estilo de Vida Fantástico, Escala Hospitalar de Ansiedade e Depressão e Escala de Reajustamento Social de Homes-Rahe. Redação descritiva dos dados. Testes Qui-Quadrado de Pearson ou Exato de Fisher para verificar a associação entre as variáveis e posteriormente análise de regressão, na qual foram calculados OR, com IC de 95% e o nível de significância de 5%. Resultados: houve evidência estatística de associação entre Burnout e escolaridade, estresse precoce, estresse, transtornos mentais comuns, estilo de vida, ansiedade e depressão. A análise de regressão evidencia que as variáveis que influenciam no Burnout são: tipo de serviço (p=0,032; OR=0,187), escolaridade (p=0,029; OR=2,313), percepção de estresse (p=0,037; OR=1,67) e reajustamento social (p=0,031; OR=1,279). Conclusão: este estudo aponta um perfil para o desenvolvimento de Burnout, constituído por profissionais de saúde com maior escolaridade, que sofreram estresse precoce, que apresentam sintomas e percepção de estresse, que não possuem um estilo de vida saudável e apresentam sintomas de sofrimento mental. Tais resultados podem auxiliar no desenvolvimento e implementação de estratégias visando reduzir tanto o estresse laboral como a prevalência da síndrome de Burnout.

[Mobbing in nursing. A pilot study]. / Hostigamiento psicológico (mobbing) en enfermería. Un estudio piloto.

While planning to help shed light on the phenomenon of mobbing in the work place and to develop an instrument by which to measure it, the authors carried out a pilot study in which 160 persons from varying professional classes and autonomous communities in Spain participated, 65 of whom were nurses whose ages lie between 20 and 48 years, with a medium age of 33.98. By means of a factorial analysis, the authors discovered that the most common mobbing practices are grouped in a set of eight factors; these eight factors cover 74.17% of all the various factors. The two most significant factors refer to behaviors which can be considered to be personal humiliation and professional discredit. The most common mobbing practice, according to the overall findings of this study group, consists in providing contradictory information to the victim (19.4% once or more times per week), while in nursing, this practice consists of exposing the victim to criticism by the group (50%).

[Socioprofessional variables involved in mobbing in nursing]. / Variables socioprofesionales implicadas en el hostigamiento psicológico en enfermería.

OBJECTIVE: To determine the type, frequency and cause of the most frequent hostile behaviors in a sample of nurses in the Balearic Islands and the socio-professional variables involved. METHOD: We performed a cross-sectional descriptive study. The sample was composed of 464 members of the association of nurses of the Balearic Islands (392 women and 49 men). Age ranged from 25 to 65 years (mean: 35.11; SD: 9.62); 368 worked in public institutions and 71 in private centers. The instrument used was the Psychological Mobbing Questionnaire. RESULTS: A total of 17.2% of the nurses believed they had experienced mobbing at work (men: 22.4%; women: 14.5%). Significant differences were found according to age, but not according to institution. The most frequent hostile behavior was related to distortion of information, criticism of the purported victim, and lack of professional consideration. The perpetrators of mobbing were mainly, and very significantly, the bosses. CONCLUSIONS: According to these results, one in five nurses in the Balearic Islands has experienced mobbing in the workplace. However, because of the low response rate, caution should be exercised when generalizing these results. Nevertheless, health institutions should bear these findings in mind to ensure standards of behavior that do not jeopardize workers' health and dignity.