Abstract
BACKGROUND:
Mobbing in the workplace is a critical problem affecting healthcare workers’ psychological health and performance. However, there is a lack of data on the relationship between mobbing and depression and a lack of regulations to create a decent working environment.
OBJECTIVE:
We aimed to determine the frequency of exposure to mobbing and the depression levels that may be related to mobbing among the employees of the Anesthesiology and Reanimation Clinic.
METHODS:
In this multi-center cross-sectional study, employees were evaluated with Leymann’s Inventory of Psychological Terror scale and the Beck Depression Inventory.
RESULTS:
Of the participants, 86.2% stated that they were exposed to mobbing. The presence of mobbing was also associated with the presence of psychological and depressive symptoms.
CONCLUSION:
The frequency of mobbing was relatively high among Anesthesiology and Reanimation clinic employees. Mobbing exposure was found to be associated with a high level of depression. Institutional and legal precautions should be taken, and awareness of mobbing should be increased to eliminate mobbing and its consequences on healthcare workers.
Keywords
Introduction
The concept of mobbing, defined by the World Health Organization as “repeated aggressive behavior through vindictive, cruel or malicious attempts to humiliate or weaken an employee or group of employees,” is now considered an essential factor affecting the health status and working performance of individuals [1]. Mobbing, which occurs in different conditions and different forms, is expressed with the terms “mobbing” or “bullying” in the literature and is used today in the sense of psychological harassment, intimidation, bullying, emotional attack and psychological terror [2]. Typical mobbing actions encountered in the workplace include social isolation, violation of privacy, verbal attacks, deprivation of competencies through intimidation, assignment of low-level job duties, prevention of promotion in the workplace, and heavy workload [3]. The Leymann Inventory of Psychological Terror Scale (LIPT), developed by Leymann, is the most frequently used scale to evaluate and measure mobbing behaviors.
Mobbing can be observed in all ages, gender, ethnic classes, academic achievement levels, professional environments, and socio-economic environments at rates ranging from 2 to 35% [4, 5]. However, the literature has reported that mobbing is more common in medical settings and among healthcare workers [2, 7]. Numerous factors have been defined as the underlying reasons for this situation, such as the intense work tempo, the intensity, and length of the shifts, the inadequacy of the hospital facilities against the intense tempo, the high number of patients, and the stressful hospital environment [5].
Depression is at the forefront of the mental consequences of mobbing. Depression is a common illness that severely limits psychological functioning and reduces the quality of life. World Health Organization (WHO) has reported that depression is the third disease that causes the highest disease burden worldwide. Clinicians frequently use the Beck Depression Inventory (BDI) to diagnose and detect depression.
The effect of mobbing on depressive symptoms has been evaluated in a limited number of studies on healthcare professionals [6, 8].
We aimed to investigate the mobbing exposure and the effect of mobbing on the development of depression in specialist doctors, research assistants, and anesthesia technicians working in the Anesthesiology and Reanimation clinics of various university hospitals, training and research hospitals, or private hospitals in Turkey.
Materials and methods
Ethics committee approval
The Local Ethics Committee of the Faculty of Medicine, Selcuk University approved this cross-sectional, descriptive, and analytical study on 30.10.2019 (decision number 2019/299). The study was carried out between November 2019 and November 2020 and followed the Declaration of Helsinki, Good Clinical Practices, and Good Laboratory Practices.
Inclusion and exclusion criteria of the participants
Five hundred healthcare workers were included in this study consisting of specialist doctors, research assistants, and technicians between the ages of 18–65, who were actively working in the Anesthesiology and Reanimation clinics of a university hospital, training and research hospital, state hospital or private hospitals and who agreed to participate in the study after being informed about the study via the internet. Participants who were diagnosed with depression before the study were excluded from the study.
Measurements of the study
A questionnaire consisting of three stages was directed to the participants. In the first stage of the survey, participants were questioned according to their demographic and socioeconomic status, title, hospital class, job satisfaction, and presence of psychological symptoms. Later, mobbing was defined to the participants as “a psychological terror applied systematically by one or more people in the workplace against another person with hostile and immoral methods". Then, it was questioned whether the participants were exposed to mobbing and how often mobbing was applied to those who reported being exposed. In the second stage, the participants were asked to answer the modified ‘Leymann Inventory of Psychological Terror (LIPT)’ scale. In the last stage, they were asked to answer the “Beck Depression Inventory (BDI)” to evaluate depressive symptoms.
Tests and scales used in the study
Leymann Inventory of Psychological Terror Scale (LIPT)
The LIPT scale was developed in 1996. It consists of 45 items aiming to measure mobbing behaviors. These 45 items consist of five parts; Effects on self-expression and communication (11 items), Effects on the occupational situation and quality of life (9 items), Effects on personal reputation (15 items), Effects on social contacts (5 items), and Effects on physical health (5 items). The different parts of the instrument assess various types of mobbing behaviors.
Each item is evaluated on a 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = undecided, 4 = disagree, 5 = strongly disagree). The total score on the scale varies between 45 and 225. As the total score of the scale approaches 45, it expresses high mobbing exposure; as it comes 225, it says low mobbing exposure. The Turkish validity and reliability study of the original scale was conducted by Korukcu et al. [9] in 2014. The original scale was translated into Turkish in this study, and six new items were added. This modified scale was preferred in our study, for which Turkish validity and reliability studies were performed, and the total score ranged from 51 to 255. As a result, the modified LIPT scale consists of 51 items and six sub-dimensions: Bullying against self-presentation and communication (10 items), bullying against social relationships (5 items), bullying against dignity (13 items), bullying against the quality of life (8 items), bullying against health (4 items), bullying against emotions (11 items).
Beck Depression Inventory (BDI)
Beck Depression Inventory (BDI) is widely used to evaluate the frequency of depressive symptoms. The scale was developed by Beck et al. [10]. It was shown that the internal consistency and test-retest reliability of the BDI scale is high [11]. The 21-item scale is filled in by the patients or participants, and the symptoms in the last week are taken into account. Each question is graded on items ranging from 0–3. The total score ranges from 0 to 63. In the scoring created by Beck et al. [10], scores between 0–13 show the absence of depression, scores between 14–19 indicate mild depression, scores between 20–28 indicate moderate depression, and scores between 29–63 indicate severe depression.
Statistical analysis
Statistical analyses were performed using SPSS version 15.0 (IBM Corp., Chicago, IL, USA). The conformity of the variables to the normal distribution was examined using visual (histogram and probability graphs) and analytical methods (Kolmogorov Smirnov, Shapiro-Wilk test). Descriptive statistics are expressed as the mean and standard deviation in normally distributed numerical data, the median in non-normally distributed data, and numbers and percentages in nominal data. Normally distributed numerical variables were analyzed using the “independent group t-test” between two groups and the “One Way ANOVA” test between three or more groups. “Chi-square analysis” was used to compare nominal data. “Pearson correlation test” was preferred for normally distributed variables in correlation analyses. According to the correlation coefficient in the correlation analyses, the correlation degree was classified as follows. Low or insignificant correlation between 0.05–0.30, low-medium correlation between 0.30–0.40, moderate correlation between 0.40–0.60, good correlation between 0.60–0.70, very good correlation between 0.70–0.75, excellent correlation between 0.75–1.00. In the statistical analysis of the study, values below p < 0.05 were considered statistically significant. Bonferroni correction was used in post-hoc analyses to obtain the result between which groups the difference was.
Results
Descriptive characteristics
Five hundred healthcare workers were included in the study. Psychological symptoms were present in 26% (n = 130) of the participants. When they applied as a result of these psychological symptoms, 10.4% (n = 52) were diagnosed with anxiety disorder, 2.4% (n = 12) with major depressive disorder, and 0.4% (n = 2) with bipolar disorder. The sociodemographic and occupational characteristics of the participants are presented in Table 1 in detail.
Sociodemographic and occupational characteristics of the participants
Sociodemographic and occupational characteristics of the participants
SD: Standart Deviation.
After mobbing was defined, 86.2% (n = 431) of the participants stated that they were exposed to mobbing. The mobbing exposure frequencies of the participants who are exposed to mobbing are as follows; 6.8% (n = 34) very often, 11% (n = 55) often, 41% (n = 205) sometimes, 27.4% (n = 137) rarely.
All participants completed the 51 item modified LIPT scale. The lowest scores were observed in the questions of “ignoring successes and exaggerating failures,” “restricting the display of knowledge and skills,” and “constant criticism,” respectively. The highest scores were observed in the questions of “sexual harassment,” “physical harm,” and pressure to receive psychological treatment. The mean scores of the employees’ for each item of the LIPT scale are given in the Supplement.
Average scores were obtained by dividing the total score of the modified LIPT scale and each sub-dimension score by the number of items. Accordingly, the lowest scores were observed in the areas of “Mobbing towards self-expression and communication,” “Mobbing towards emotions,” and “Mobbing towards social relations,” respectively. The highest scores were observed in the sub-dimensions of “Health-oriented mobbing” and “Reputation-oriented mobbing” (Table 2).
The distribution of the total and mean modified LIPT scores
SD: Standart Deviation, LIPT: Leymann Inventory of Psychological Terror, min: minimum, max: maximum.
When the modified LIPT total score and sub-dimension scores were compared according to the gender of the participants, no significant difference was found between men and women.
In the comparison of the participants’ marital status, the modified LIPT total score of the married was found to be statistically significant and higher than that of the single/divorced.
In the comparison made according to the income status of the participants, the total modified LIPT score of those whose income is higher than their expenses was found to be significantly higher than those whose income is equal to their expenses and whose income is less than their expenses (Table 3). In the post-hoc analyses performed according to the income status of the participants, the LIPT scores for social relationships (p = 0.087) and health (p = 0.054) did not change according to the income status. In contrast, the LIPT scores for self-presentation and communication (p = 0.006), reputation (p = 0.036), quality of life (p = 0.002), emotions (p = 0.001), and total LUPYO scores (p = 0.015) were found to be significantly higher in those whose income was higher than their expenses compared to those whose income was less than or equal to their expenses.
Distribution of the modified LIPT scores of employees’ by gender, marital status, and income status
Distribution of the modified LIPT scores of employees’ by gender, marital status, and income status
LIPT: Leymann Inventory of Psychological Terror.
In the analysis made according to the institutions where the participants work, the total modified LIPT score of those working in a tertiary hospital was significantly lower than those working in a secondary hospital. In addition, the total modified LIPT score of those working in public hospitals was significantly lower than those working in private hospitals. In addition, the total modified LIPT score of those working in university hospitals was significantly lower than those working in institutions other than the university hospital (Table 4).
Distribution of the modified LIPT scores of the employees’ according to the classification of hospitals
LIPT: Leymann Inventory of Psychological Terror.
In the analysis performed according to the professional experience of the participants, the total modified LIPT score of those with more than ten years of experience was found to be significantly higher than those with less experience. When the titles of the participants were compared, the total modified LIPT score of the specialist doctors was significantly higher than that of the research assistants and technicians (Table 5). In the post-hoc analyses made according to the title of the participants, the LIPT scores (p = 0.195) for health did not change according to the title status. In contrast, the LIPT scores for self presentation and communication (p < 0.001), social relationships (p = 0.003), dignity (p < 0.001), quality of life (p < 0.001), emotions (p < 0.001), and total LUPYO scores (p < 0.001) were found to be significant and higher in specialist doctors compared to research assistants and technicians. However, no difference was found between research assistants and technicians. In the post-hoc analyses based on the professional experience of the participants, the LIPT scores for self-presentation and communication (p < 0.001), social relationships (p = 0.002), quality of life (p = 0.001), emotions (p < 0.001) and total LUPYO scores (p < 0.001) were found to be significantly higher in those with an experience of more than ten years compared to those with an experience of 5–10 years or 2–5 years.
Distribution of the modified LIPT scores of the employees’ according to their title and professional experience
LIPT: Leymann Inventory of Psychological Terror.
In the analysis performed according to the occupational satisfaction of the participants, it was found that the scores of those who were not satisfied with their job in all sub-dimensions and the total modified LIPT score were significantly lower than the scores of those who were satisfied with their job (Table 6). In the post-hoc analyses performed according to the professional satisfaction of the participants, the LIPT scores for self-presentation and communication (p < 0.001), social relationships (p < 0.001), dignity (p < 0.001), quality of life (p < 0.001), health (p < 0.001), emotions (p < 0.001) and total LUPYO scores (p < 0.001) were found to be significantly lower in those who were not satisfied in their profession compared to those who satisfied with their work. The score of those who were satisfied with their profession was significantly lower than those who were very satisfied (p < 0.001).
Distribution of the modified LIPT scores of the employees’ according to their professional satisfaction
LIPT: Leymann Inventory of Psychological Terror.
In the analysis performed according to the presence of psychological symptoms in the participants, it was determined that the score of those with psychological symptoms in all sub-dimensions and the total modified LIPT score was significantly lower than that of those without psychological symptoms (p < 0.001 in all analyzes). When the participants were examined in terms of the frequency of exposure to mobbing, it was observed that as the exposure to mobbing increased, all sub-scores and total modified LIPT scores decreased significantly (Table 7).
Distribution of the modified LIPT scores of the employees’ according to the presence of psychological symptoms, mobbing exposure and mobbing exposure frequency
LIPT: Leymann Inventory of Psychological Terror.
The median BDI score of the participants was 9 (range 0–56). According to the BDI scores, 51.4% (n = 257) of the participants did not have depressive symptoms. However, 24.8% (n = 124) had mild depressive symptoms, 18.8% (n = 94) moderate depressive symptoms, 5.0% (n = 25) severe depressive symptoms (Table 8). When the participants were examined regarding the presence of depressive symptoms, the scores of those with depressive symptoms in all sub-dimensions and the total modified LIPT scores were significantly lower than those without depressive symptoms (p < 0.001 in all analyses). Participants were analyzed according to the severity of their depressive symptoms, and significant differences were found in mobbing for reputation, mobbing for quality of life and professional position, mobbing for emotions, and total modified LIPT scores. Accordingly, the scores of those with severe depressive symptoms were significantly lower than those with moderate depressive symptoms, and the scores of those with moderate depressive symptoms were significantly lower than those with mild depressive symptoms. When the correlation of the participants’ modified LIPT scores with BDI scores was analyzed, it was found that all modified LIPT sub-dimension scores and modified LIPT total scores were negatively correlated with BDI scores (p < 0.001 in all analyses) (Table 8). In post-hoc analyses performed according to the severity of depressive symptoms in participants with depressive symptoms, the LIPT scores for self-presentation and communication (p = 0.005), social relationships (p = 0.003), dignity (p = 0.001)), quality of life (p = 0.008), health (p < 0.001), emotions (p < 0.001) and total LUPYO scores (p < 0.001) was found significantly and lower in employees with depressive symptoms compared to those with moderate or mild depressive symptoms.
Distribution of the modified LIPT scores of the employees’ according to the presence of depressive symptoms and the severity of depressive symptoms and the correlation of modified LIPT scores with BDI scores
Distribution of the modified LIPT scores of the employees’ according to the presence of depressive symptoms and the severity of depressive symptoms and the correlation of modified LIPT scores with BDI scores
LIPT: Leymann Inventory of Psychological Terror, BDI: Beck Depression Inventory.
Mobbing is “psychological terror applied systematically by one or more people in the workplace against another person with hostile and unethical methods.” In this multicenter study conducted on Anesthesiology and Reanimation clinic employees, 86.2% of the participants stated that they were exposed to mobbing at any time. We used 5 - point Likert - type mobbing scale, which Leymann suggested to evaluate mobbing exposure in the last six months. We found that 17.8% of the participants were exposed to mobbing in the last six months. And depression was found in 53.3% of the participants exposed to mobbing.
Since mobbing is accepted as a natural result of working life, it has been neglected until recently. However, it started to be considered after it was revealed that it may causes chronic and psychological diseases that are difficult to treat, such as depression, anxiety, and suicide attempts. Also, mobbing affects employees’ performance and reduces organizations’ productivity [12]. The fact that the element of violence in health has been encountered frequently in recent years shows that mobbing has many dimensions that need to be addressed, not just as a senior-junior relationship [13].
Exposure to mobbing among healthcare workers differs between departments and statuses. It has been reported that mobbing exposure is higher, especially in emergency services, intensive care, and operating room personnel [14]. In a survey by Aykut et al. [15], mobbing exposure was investigated in research assistants working in the Anesthesiology and Reanimation clinics, and mobbing exposure was shown in 69.3% of the participants. In our study, this rate was 90.1% among the research assistants. In a study conducted by Villafranca et al. [16], approximately 3000 operating theatre personnel were examined, and 43.8% of the participants reported being exposed to mobbing at least once.
In another study, in which the exposure to mobbing in healthcare workers in the last year was investigated using the Leymann scale, it was determined that the rate of mobbing was 51.9% in state hospitals and 58.7% in primary healthcare institutions [17]. In the same study, when Leymann’s mobbing scale was used, similar to our research, it was observed that 5.9% of the participants were exposed to mobbing. In our study, the rate of mobbing exposure investigated according to Leymann’s scale in secondary and tertiary health institutions was 17.8%. The fact that a significant part of the training is carried out in a master-apprentice relationship in tertiary health institutions may have increased the exposure to mobbing or the thought of being exposed to mobbing.
Being exposed to mobbing may cause a wide variety of psychological disorders in people. Aykut et al. found that 48.5% of the residents exposed to mobbing had crying spells, 38.6% had sleep disorders, 31.6% had weight problems, 15.8% had alcohol/substance addiction, and 17.8% had severe depression [15]. Suicide attempt, which was defined as the most severe psychological symptom of depression, was detected in 2.9% of the participants. Unlike our study, the authors have not evaluated the exposure to mobbing and depression with systematic scales, and they have considered the answers given by the participants to a single question. We used the Beck Depression Inventory in our study and found depressive symptoms in approximately half of the participants (48.6%). And depression was found in 53.3% of the participants exposed to mobbing. In addition, we found that as the severity of mobbing increased, the severity of depression also increased. In a meta-analysis conducted by Lanctot and Guay [18] involving more than one hundred thousand healthcare workers, the rate of exposure to physical violence at the workplace was 4.9–65%, the rate of life-threatening injury was 4.4%, the rate of post-traumatic stress disorder after workplace violence was 5–32%, and the rate of depression was 0.8–84.3%.
Aarestad et al. [19] stated a relationship between mobbing and mental disorders in the form of anxiety, depression, and even post-traumatic stress disorder. However, although exposure to mobbing increases the susceptibility to depression, knowing that employees with depression are vulnerable may cause them to be exposed to more mobbing. Therefore, there is a reciprocal relationship between mobbing exposure and depression.
The fact that the presence of mental illness in employees may make them risky regarding exposure to mobbing may explain this situation.
The stress model can explain the relationship between mobbing exposure and depression. According to the stress model, a long-term stress period poses a risk for somatic and mental diseases [20]. Exposure to mobbing in the workplace causes long-term stress and affects emotional well-being through neuroendocrine, autonomic, and immune functions. In addition, it has been stated that mobbing exposure is not only at the time of the event but also repeated many times in the victims’ thoughts, and the stress level is prolonged [21]. Individuals with mental illnesses are more exposed to mobbing may be associated with bullies choosing weak victims [22].
Our study determined that married people and those with a high-income level are less exposed to mobbing. Palaz et al. [23] reported that exposure to mobbing is higher in single or widowed workers than married workers. The fact that single or widowed workers are seen as more vulnerable than married workers may cause them to be exposed to more mobbing. Pihl et al. [24] showed that the probability of being bullied increased significantly for people with low social capital in their study of a sample representing a sizeable working population. A high-income level or high social capital can increase employees’ awareness about being exposed to mobbing and may deter those who apply mobbing.
In our study, the rates of exposure to mobbing were lower in specialist doctors than in research assistants and technicians. Although the higher frequency of making mistakes in the profession seems to be why they are exposed to more mobbing, the perception of non-mobbing behaviors as mobbing by inexperienced employees may also be the reason for these individuals’ higher mobbing exposure rates. The high level of education and professional competence of specialist doctors may cause them to be less exposed to mobbing. On the other hand, individuals direct failures to less powerful group members. In this way, they try to minimize the danger to themselves. In addition, responsible people think that they protect their power by putting pressure on people who are weak in terms of careers [25]. A multicentered study from four university hospitals in Europe showed that mobbing is a common problem even among specialists and academics. It was found that the most critical predictor of mobbing among doctors is role conflict. In addition, in this study, it has been shown that while horizontal mobbing is common in Scandinavian cities, vertical harassment is dominant in Italy, so it is stated that even cultural differences affect the character of mobbing. The same study showed that doctors who spend most of their time on research are exposed to more mobbing, and this has proven that competition for status and advancement is a reason that increases the frequency of mobbing in university hospitals [26].
We found that the exposure to mobbing is lower in private hospitals compared to public hospitals and tertiary hospitals. The fact that tertiary hospitals constitute the highest level of health and provide fewer financial opportunities may have affected the thought of being exposed to mobbing. Moreover, it is known that mobbing is more common in large and bureaucratic institutions. Vaez et al. [27], showed that public sector workers are more likely to be exposed to work-related mobbing than private sector workers.
We showed that there is a strong relationship between occupational dissatisfaction and exposure to mobbing. Employees exposed to mobbing in the workplace face the risk of being completely excluded from working life due to lower occupational satisfaction, more sick leave, lower ability to work, and preference for job change [19].
Limitations
According to the results of our study, it can be mentioned that there is a relationship between exposure to mobbing and depression. However, multicenter studies with more participants are needed to reveal the cause-effect relationship between mobbing and depression in all its aspects. In addition, the fact that the Anesthesiology and Reanimation clinic employees are faced with long working hours and heavy workloads as a requirement of their profession may have affected the rates of mobbing exposure. Finally, the relationship between psychological and physical symptoms due to exposure to mobbing in the workplace is known. Not questioning the negative physical symptoms of the participants in detail is a limitation of our study [24].
Conclusion
This study reports essential results showing that the employees of Anesthesiology and Reanimation clinics are both exposed to high levels of mobbing and experience depression, anxiety, and other psychological problems that can be associated with mobbing exposure. Prevention of mobbing is only possible if it is taken into account that it has a complex structure formed by the influence of organizational and cultural factors as well as individual characteristics. In this context, minimizing mobbing and its consequences on health workers will be possible by taking organizational and legal measures, eliminating resources, and increasing mobbing awareness. Each institution should be encouraged and controlled by the lawmakers to develop and implement different strategies according to their own working culture to reduce the level of mobbing exposure. In this context, studies to be built on the design and implementation of legal regulations to deter mobbing perpetrators to protect health workers who are most exposed to mobbing will be the cornerstone that can ensure the protection of workers worldwide.
Ethics statement
The study was approved by the Local Ethics Committee of the Faculty of Medicine, Selcuk University (decision number 2019/299). Participants agreed to participate in the study after being informed about the study via the internet.
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
Acknowledgments
The authors have no acknowledgments.
Funding
The authors report no funding.
Author contributions
PS, OO, SEA, KA: conceived and designed the study; collected the data; or analyzed and interpreted the data. PS, OO, SEA: wrote the manuscript or provided critical revisions that are important for the intellectual content. OO, SEA, KA: approved the final version of the manuscript.
