Does bullying in the hospital affect the health-related quality of life of health professionals?

1 Introduction

Over the last decade and during an unprecedented economic and humanitarian crisis, too many extreme and divergent attitudes have led to social marginalization. These behaviors include verbal or non-verbal (extra verbal) violence to people who do not “fit in” the “stronger” groups, either because of gender, religious or political beliefs, ethnicity, sexual orientation, or because of their physical or mental characteristics. For many workers in private and public organizations, these behaviors have become a harsh and painful reality [1] and appear in the form of mobbing syndrome/or bullying [2–8]. The mobbing syndrome is described as “psychological harassment at work” [9–14]. Mobbing may cause psychological problems such as depression, stress, and anxiety with negative consequences such as reducing productivity at work and deterioration in interpersonal relationships [15–19]. This syndrome is considered one of the most severe forms of harassment in the workplace [20], with profound corrosive and toxic effects on the entire organization [21]. One person typically perpetrates bullying, although others in a workplace may join in.

On the other hand, mobbing involves a group of people whose size is constrained by the social setting in which it is formed, such as a workplace [22–24]. It might seem as if many people are involved, but the group might be small in reality. From a sociological perspective, mobbing can be paralleled to the hostile behaviour towards the weaker members of a herd of animals exhibited by the solid and influential members. In the “real-world” workplace, it is essentially a form of racism shown by those who are hierarchically superior, or even by same grade coworkers, towards colleagues who are regarded as undesirable, in an attempt to push them even to resignation [25].

Heinz Leymann, a Swedish Psychologist, in his first studies in the 1980 s, defined the mobbing syndrome as a form of hostile and unethical communication. He pointed out that the distinction between ‘conflict’ and ‘psychological harassment’ is not focused on what is done or how it is done but on the frequency and duration of what is being done [26]. Those engaging in mobbing essentially attack or terrify their victims. They aim to traumatize their dignity and humiliate them, with a noticeable impact on physical and mental health not only of themselves but also of their families. Common characteristics of workplace harassment are aggressive and/or offensive behaviour, irony, slander, humiliation treatment, threats, etc. Harassment can be expressed by underestimating the victim’s work, the assignment of tasks with excessive obligations, and non-realistic or even unachievable deadlines that do not correspond to the employee’s certified qualifications and abilities. According to studies on mobbing in the international literature, “victims” of psychological violence usually report their superiors as the most frequent “perpetrators” of aggression, and women face workplace harassment more times than men [27, 28]. Emotional abuse consequences include sleep disorders, depression, physical fatigue, aggression, and even suicidal tendency [29]. People mobbed at work are typically unable to concentrate, lose their motivation for work, and eventually show a decrease in performance, which inevitably leads to reduced productivity and affects the entire organization [30].

In the health care sector, factors related to the occurrence and maintenance of bullying among workers are the lack of human resources in conjunction with an organizational culture that promotes competition [31, 32], increased workloads, excessive requirements, and pressing deadlines leading to long-term fatigue, unsatisfactory work and arguing among workers, absence of cohesion among the team and low levels of mutual support [33]. These factors contribute to persisting long-term work stress, which causes emotional tensions and attitudes that could increase the incidence of mobbing [34]. The hostile work environment that mobbing creates is harmful to the dedication of health professionals to their work. It decreases their performance, increases their errors and accidents, and eventually affects the quality of the services provided [35]. As public service employees (including “bullies”) generally enjoy lifelong job security, in contrast to their private sector counterparts, mobbing behaviours are more frequent in the public health sector and can last from a few weeks or months throughout many years.

According to Andrews & Whitney [36], work is one of the twelve factors related to “perceived quality of life.” Therefore, the consequences of workplace harassment and the concomitant damaged job satisfaction can negatively affect health-related quality of life (HRQoL) [37, 38]. The literature lacks studies, which investigate the relationship between workplace harassment and HRQoL in healthcare infrastructures. Considering that mobbing is a severe and increasing phenomenon that can significantly affect the efficiency of the healthcare staff, this research aims to record the frequency of professional intimidation or mobbing syndrome among employees of five public hospitals of the National Health System (NHS) in Athens, Greece. The study also focuses on the effect of mobbing on the HRQoL of various professional groups in the system, in an effort to highlight possible links between specific factors and the syndrome. This is one of the first attempts to investigate the relationship between professional bullying and HRQoL in Greece’s public health sector.

2 Method

3 Results

Overall, 343 healthcare professionals agreed to compete with the survey (response rate of 85.8%). The mean age of the entire sample was 43.1 years (SD = 8.9 years). Table 1 shows the characteristics of the sample. Most of the participants were women (67.0%), married (53.2%), and university alumni (52.2%). Also, 47.8% of the participants were nurse/paramedical personnel, and 12.0% had a responsible position. Table 2 presents the harassment behaviors that participants faced in their working environment. The mean number of actions regarding harassment of freedom in speech and communication was 2.34 (SD = 2.00), and the mean number of behaviors regarding harassment of personal reputation was 1.40 (SD = 1.56). The mean number of actions regarding harassment in all sectors was 5.34 (SD = 3.99). One hundred twenty-eight participants (37.5%) had experienced mobbing, and 55.7% had experienced psychological violence in their work.

Multiple regression analysis for some harassment behaviors regarding freedom in speech and communication showed that, after controlling for demographics and occupational characteristics, participants with postgraduate studies had faced significantly fewer harassment behaviors regarding liberty in speech and communication than high school graduates. The participants from organizational mergers had faced considerably more of these behaviors [data not shown]. Also, participants with postgraduate education and university graduates had faced significantly fewer harassment behaviors regarding social interaction than only high school graduates. Technical personnel had faced significantly fewer harassment behaviors regarding social interaction compared to nurse/paramedical personnel, university graduates compared to participants who were high school graduates and those within a position with responsibility. The number of harassment behaviors regarding personal reputation was not significantly associated with any demographical or occupational characteristics.

Regarding physical health, substantially less harassment had been experienced by university graduates compared to high school graduates and those with responsible positions. In total, participants with postgraduate studies and university alumni had faced significantly fewer harassment behaviors in all sectors combined compared to participants who were high school graduates. In contrast, those who came from organizational mergers faced markedly more of these behaviors. Almost half the victims (49.2%) face harassment in their working environment virtually daily (Table 3). The mean duration for experiencing such actions is 85.4 months (SD = 56.2 months).

Additionally, 93.8% of the participants were dealing with harassment behaviors at present. The majority of the participants dealt with such actions from coworkers of the same or higher level. The median number of harassers was 3 (IQR: 2-4), and the harassers were mainly women. Of the victims, 68.5% had discussed that they were facing these behaviors with someone.

Table 4 presents the results from multiple logistic regression analyses with mobbing as a dependent variable. According to the table, women had a 2.60 times greater probability of dealing with mobbing than men. Also, technical personnel had almost four times greater likelihood of experiencing mobbing than nurse/ paramedical personnel. Moreover, after controlling for participants’ demographics and occupational characteristics, facing more harassment behaviors regarding work status and quality of life was associated with significantly lower scores in role physical, emotional role, and the mental component summary score, indicating worsening physical role, worse emotional position and worse mental health in total [data not shown]. Participants who had experienced Mobbing had significantly worse quality of life in all sectors and capacities (Table 5). The results were similar when the demographics and occupational characteristics of the participants were adjusted.

This study recorded the incidence of workplace harassment among 343 employees in various services of five large Public Hospitals of Athens and investigated how this negative phenomenon affected their HRQoL. The analysis and assessment of the results were based on Leymann’s definition, according to which mobbing is a bullying behavior at the workplace that is systematically directed towards a single person by one or more people, frequently (at least once a week) or over a long time (over six months) [10]. According to the survey results, over one-third of the study participants from the five Hospitals (37.5%) had been on the receiving end of at least one mobbing behavior, which is a quiet percentage overall. The research of the European Foundation for the Improvement of Living and Working Conditions, carried out in Greece in 2015, showed that 12% of the workers had suffered from work [46]. Our study recorded behaviors that constitute professional bullying at a higher rate than the European average (14%) recorded by Eurofound.

It is worth mentioning that the third European survey [47] conducted by Paoli and Merllie on behalf of Eurofound in 2000 showed that 9% of the European Union workers had suffered from job harassment over the last 12 months. This survey also reflected the difference in rates of bullying between the northern and southern EU countries. Finland (15%), the United Kingdom (14%), and Sweden (12%) exhibited the higher mobbing percentages, while in the Mediterranean countries (Portugal, Italy, Spain, Greece), this percentage was about 4-5% [47]. At the same time, the United Nations Commission on Human Rights survey showed that moral harassment at work was 31% in Bulgaria, 22% in Lebanon, 21% in South Africa, 15% in Brazil, and 10% in Australia Thailand [48]. In 2011, a global poll among 16,517 workers found that 64% of the workers had fallen victim to mobbing, while 16% admitted that they were witnesses of mobbing to their colleagues [49]. It has been suggested that the cultural differences between hospitals generate differences in harassment prevalence and perpetrators [50].

Similarly, according to Hoel et al., a percentage of 10.6% of the workers in Great Britain admitted to experience behaviours of psychological violence, which supports the criteria of Leymann [51]. In Turkey, researchers recorded a high rate (31.1%) of occupational bullying among workers in primary healthcare [52]. Health professions appear to be among the most affected by intimidating behavior [48]. The present research results show that nurses have encountered more aggressive bullying behaviors in social contacts than technical personnel. Nursing staff also met significantly more harassment behaviors according to Leymann’s scale of physical health compared to participants who held administrative positions.

Many international studies have used Leymann’s questionnaire and typology to identify mobbing syndrome among health professionals. A Brazilian study showed that 11.6% of the nurses experienced systematic work harassment during the last 12 months [53]. In Portugal, 13% of the nurses working in public hospitals reported psychological violence [54]. A relevant Greek study reported that 30.2% of the nurses experienced psychological harassment [55]. The above results may be justified by the structure of the healthcare workplace, which is occupied mainly by women who, based on previous research, are more often the perpetrators of bullying and intimidate primarily other women. At the same time, men tend to intimidate both genders [56].

In contrast, the 2017 Review of the Workplace Bullying Institute (WBI) showed that 70% of harassers were male, following the results of other similar international studies [57]. This study shows that the sex of the mobbing abuser in the public hospitals studied is 45% female. The response to the question “What was the gender of the person(s) who were against you” showed an increase in the percentage of women who practiced psychological violence by 40.5%. A percentage of 14.9% of the participants received psychological harassment from men at work.

Studies that used Leymann’s questionnaire and the sex of the abuser also consider the position of the perpetrator in the workgroup. Our survey showed that 66.7% of the workers suffering psychological work-related violence did so from coworkers at the same hierarchical level (horizontal harassment) and 58.7% from their supervisor (top-down harassment). In public hospitals, upwards harassment is also present, with 23.8% of the employees receiving bullying by subordinates. The majority of the literature concludes that psychological harassment is mainly practiced from the upper hierarchical levels to the lower ones. For example, one study showed that 74.7% of the harassment came from the supervisors, compared with 36.7% by peers and 6.7% by subordinates [51]. The largest proportion of harassing supervisors was recorded in Turkey, reaching 70.3% [52]. Nurses are almost equally bullied by supervisors and doctors and from patients and their families and subordinate assistant nurses [58].

By investigating the association between experiencing mobbing (dependent variable) and demographic and work-related data (independent variables), our study showed that women were 2.60 times more likely to have been mobbed than men. Some researchers suggest no correlation between the victim’s gender and psychological harassment and that the recipients are equally distributed between the genders [56, 60]. However, other studies have shown the important role of gender differences when predicting bullying at work [61]. According to Hirigoyen [62], however, mobbing affects mostly women (70%). Mobbing behaviors related to freedom of expression and communication appear to be the most common among healthcare workers, according to evidence from a study in which 79.5% of the victims received at least one behaviour that falls under these categories, based on the typology of Leymann’s questionnaire. In the same survey, 64.7% were bullying behaviours that threatened personal reputation, 57.2% of those were affecting occupational status and quality of life, 48.9% were behaviours that negatively affect social contacts, and 31.3% were threatening actions against the physical health of the victims [63].

Using the SF-36 questionnaire, HRQoL was reported, and dimension scores were computed for the entire sample, regardless of the respondents had reported being victims of workplace harassment or not. The results indicated a deterioration in all health dimensions, compared to the average scores reported obtained from an earlier Greek study using the same instrument on a similar-sized sample of workers in the Greek health care system [64]. In the present study, the worker’s separation into those having received mobbing and those not highlighted the negative effect of the mobbing syndrome on the HRQoL of the victims, as the differences in the average scores of some dimensions reached approximately 20 points (0–100 scale). In the “harassed” subsample, correlations among SF-36 dimensions and harassment behaviors showed less harassment was linked to better physical health and mental health. The linear multiple regression models using each time the SF-36 dimensions as dependent variables showed that the two SF-36 role dimensions, i.e., physical and emotional, had a significant relationship with the harassment behaviours.

This study has some limitations that should be taken into consideration. Firstly, its cross-sectional design outlines bullying behaviors among the Greek NHS hospitals’ health care workers within a given timeframe. As these behaviors are subject to drastic changes and alterations over time, the findings’ validity is time-sensitive. Furthermore, the sample consisted of workers from five Athens-based hospitals, i.e., an urban population, and thus it is not possible to generalize the results to the entire public health sector in Greece.

5 Conclusion

This research has provided evidence on mobbing in Greek public hospitals and that workplace harassment negatively affects HRQoL. Since a healthy working population is usually more efficient, preventing workplace harassment should be high on policymakers’ agendas to improve human resource management and health system performance.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval was obtained from the Open University of Cyprus and the Research and Ethics Committees of the participating hospitals.

Informed consent

Informed consent was obtained from all individual participants included in the study.