Bullying behavior may be lead to lack of assertiveness and social competence for victims, bullies may attempt to display more extreme, difficulty engaging in cooperative decision-making with their friends, negatively affect on their performance and assertiveness for both and overt dominance in their relationships with their victims[30]. Furthermore, improve nurse intern's assertiveness is very essential to overcome bullying behavior occurring in their clinical practice areas. In this context, the current study aimed at developing bullying prevention guidelines for nurse interns and investigate its effect on their assertiveness.
The findings illustrated that there was changes in nurse interns bullying knowledge scores, indicating a statistically significant improvement in their knowledge after implementing guidelines compared with before developing guidelines. This due to bullying is a major concern because affects on physical and psychological health for nurse interns and needs more studies and need involve bullying prevention guidelines in the curriculum to help students to be aware with this important topics. They can contribute to the improvement of nursing clinical learning and decrease the gap between theory and practice. This result agreed with Albayrak, Yıldız,& Ero [31], who studied assessing the effect of school bullying prevention programs on reducing bullying, and reported that the participant showed a statistically significant increase in their knowledge regarding bullying after implementation of the program. As well as, the result consistent with Gaffney, Ttofi, & Farrington [32], who study " Effectiveness of school-based programs to reduce bullying perpetration and victimization " and concluded that the majority of study sample had satisfactory knowledge regarding bullying after implementation of the program.
Regarding negative act among nurse interns
the present study findings revealed that there was changes in score of nurse interns negative act, which the highest percentage before the receiving guidelines for "work - related bullying dimension ", Which this percentage significantly declined after-implementing guidelines indicating a statistically significant improvement in reduction of nurse interns' negative act after-implementing guidelines compared with before developing guidelines, this finding might due to nurse interns are often burdened with additional tasks and responsibilities, making them particularly vulnerable to becoming a victims of workplace bullying also, workplace culture of silence, work extended hours, lack of clear anti- bullying polices, and lack of direct judgment regarding any bullying reports.
As mentioned by Ali, Keshk & Helal [33] who conducted a study entitled "The Effect of Workplace Bullying Management Program on Nursing Personnel's Work Engagement" and reported the highest score of negative act dimensions before program was work - related bullying and statistically significant improvement in reducing negative act post implementation of program compared with pretest. Also, these findings generally came congruent with the findings of Berry et al., [34] which showed that the highest mean score was reported for work-related bullying (M = 2.08, SD = 0.78), followed by person-related bullying (M = 1.99, SD = 0.73), while the lowest mean score was reported for physically-intimidating bullying. On disagreement with this, the result of Al- Garandeau, Laninga-Wijnen &Salmivalli [35] Who conducted their study about "Effects of the KiVa Anti-bullying program on affective and cognitive empathy in children and adolescents". They reported that their statistically significant improvement in reducing negative act post implementation of program compared with pre implementation of program.
Individual Bullying Behaviors in clinical practice survey
Concerning nurse interns' sources of bullying throughout study phases, the finding of the current study clarified the highest source of bullying at before developing guidelines was staff nurses. Which this percentage declined to 18.1% after-implementing guidelines. From researchers' perspective, the staff nurses usually in position of power and authority and staff nurses most frequent contact with nurse interns in clinical practice area. In addition, nurses in the hospitals commonly face high workloads, job demands, and long term high-pressure environments, leading to heightened mental stress. Furthermore, lack experience of nurse interns with fear from the responsibility, insufficient communication contributes to misunderstandings and bullying occurrences.
This result is consistent with Hopkins et al., [36]who found that the staff nurses was the first source of bullying in critical setting and identified that younger students were more likely to be bullied than older students. This study finding was on the same line, the result of Mostafa, Shazly & Hassan [37 ] who conducted a study entitled by " Bullying Behaviors, Coping Strategies and It’s Relation to Nurse Interns Self-Esteem", found that the more than half of nurse interns consider the staff nurses is the most common source of bullying. Also, on disagreement with the study conducted Australia by Ullah et al., [ 3] who studied "Bullying experiences of dental interns working at four dental institutions of a developing country: A cross-sectional study "and found more than half of dental interns consider teaching faculty including both junior and senior faculty members were the most commonly perpetrators of bullying.
Total assertiveness level among nurse interns
The current study revealed that changes in score of nurse interns assertiveness, indicating a statistically significant improvement in their assertiveness level after implementing guidelines compared with before developing guidelines.
This finding after implementing guidelines is supported by El-said, Shazly& Mostafa [38] who conducted a study entitled by" Communication Skills Training Program and its Effect on Head Nurses' Assertiveness and Self-Esteem" showed that the majority of the head nurses working at Ain-Shams university hospitals had statistically significant improvements in their assertiveness level at the post training program. Also, Nemati et al., [39] who conducted a study entitled by" Evaluating effect of assertive training program on assertiveness communication and Self-Concept of nurses and reported that the studied sample had low assertiveness level before training program while after training program there was statistically significant improvement in nurse interns assertiveness level were revealed. Moreover, on agreement with Mohamed[40] who conducted a study entitled by "Effect of assertiveness training program on self-esteem and self-efficacy of faculty nursing students at Zagazig University and found that there were highly significant statistical differences in assertiveness pre- and post-training program implementation .
The current study revealed that there was a statistically significant relation between the studied nurse interns bullying knowledge and their negative act guidelines and their assertiveness post- implementing guidelines. This relation indicates the comprehensiveness and effectiveness of the bullying guidelines on nurse interns assertiveness. This was noticed in all areas, it indicating the persistence effect of guidelines. The improvement is certainly due to direct effect of guidelines as indicated and the importance to complete updated knowledge of nurse interns’ about bullying prevention. The present results are in agreement with a study by [41], who studied A bullying prevention program: Pairing assertiveness training to empower bully victim, and revealed that nurse interns bullying level decreased, while their knowledge and assertiveness were improved after implementation of the training program.