Workplace Bullying in Nursing Özlem Ovayolu, RN, PhD; Nimet Ovayolu, RN, PhD; Gülendam Karadag, RN, PhD
ABSTRACT This research was designed to determine whether nurses are bullied by other staff members and the effects of such behaviors on the nurse victims. This study reports on nurses’ interpersonal workplace relationships in a culturally unique environment. The study was conducted with 260 nurses working in three public hospitals. Data were collected using a questionnaire. The majority of nurses were female with bachelor’s degrees and reported being assigned duties outside their usual responsibilities, held responsible for coworkers’ mistakes, and criticized for job performance although they thought they had done their work properly. Most of the nurses who were bullied experienced health and sleep problems, did not want to go to work, and had communication problems with other staff members. Nearly all of the study nurses received psychological support to solve their problems and believed that the best way to prevent bullying was education. [Workplace Health Saf 2014;62(9):370-374.]
B
ullying can occur in any workplace regardless of culture and affect both genders with serious consequences (Tinaz, 2006). Bullying at work can include all types of mistreatment, including threats (e.g., “if this happens, you will experience this from me”; “you either lose your job or continue as I tell you”), intimidation (e.g., being scolded in front of team members), and humiliation (e.g., “you cannot do this job”). Individuals in a workplace may be systematically exposed to these behaviors by their superiors, peers, or subordinates (Ozturk, Sokmen, Yilmaz, & Cilingir, 2008; Tinaz, 2006). Such behaviors are a major problem in today’s work environment and can have detrimental effects on employees by impairing organizational relationships (Dikmetas, Top, & Ergin, 2011). The health care sector is one of the fields where mobbing is commonplace (Annagür, 2010). Violence in the health sector has a negative impact not only on the professional and personal lives of health care workers, but also on the quality of care provided to patients (Kingma, 2001).
ABOUT THE AUTHORS
Dr. O. Ovayolu is Associate Professor, Dr. N. Ovayolu is Professor, and Dr. Karadag is Assistant Professor, Gaziantep University, Faculty of Health Science, Gaziantep, Turkey. Submitted: July 4, 2013; Accepted: July 10, 2014; Posted online: August 11, 2014 The authors have disclosed no potential conflicts, financial or otherwise. The authors thank all nurses who participated in the study. Correspondence: Özlem Ovayolu, RN, PhD, Gaziantep University, Faculty of Health Science, Gaziantep, Turkey. E-mail: [email protected] doi:10.3928/21650799-20140804-04
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Nursing personnel are exposed not only to abuse and violence by coworkers, but also the violent acts of patients and their relatives (Annagür, 2010). Thus, nurses are up to three times more likely to be victims of violence than other categories of health personnel, with female nurses considered the most vulnerable (Kingma, 2001). Violent acts directed at health care professionals seem to have peaked recently in Turkey, although studies specific to health care sector bullying in Turkey are scarce (Turkish Medical Association, 2008). The current study was conducted to determine the extent and effects of nurse bullying by staff members in Turkish health care facilities and to suggest needed actions to prevent such behaviors. Research Questions
1. What are the bullying behaviors nurses experience in the workplace? 2. Is there a relationship between the age, education, marital status, years worked, and weekly working hours of Turkish nurses and the bullying behaviors to which they are exposed? 3. What type of problems do nurses experience after being bullied? 4. What actions do nurses suggest to prevent bullying? METHODS This study used a cross-sectional, descriptive design. Prior to the study, 1,156 nurses working in three public
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at NORTHERN KENTUCKY UNIV on August 11, 2015
Turkish hospitals were informed about the study, including its approval by their institutions and the Gaziantep University ethics committee. Nurses on leave during the research time frame and those who did not agree to take part in the research (n = 896) were excluded from the sample. A total of 260 nurses participated in the study. Data Collection
Study data were collected using a questionnaire that included characteristics of study nurses (e.g., age, gender, marital status, education [in Turkey, individuals with a high school education or associate’s, bachelor’s, or postgraduate degree in nursing are entitled to work as nurses in clinics], years of professional service, weekly working hours, and the reason for choosing the profession) and respondents’ bullying experience (i.e., restrained nurses from proving themselves, had to face offensive behavior, prevented nurses from expressing their ideas, received negative criticism despite acceptable job performance, exposed to gossip and slander, received verbal or written threats, held responsible for others’ mistakes, assigned duties outside their responsibilities, demanded completion of assigned duties in unrealistic time frames, undervalued their successes, complained about nurses to upper management), questions about the problems experienced due to bullying (unwilling to go to work, health and sleep disorders, communication problems with hospital staff, isolated from social activities), and questions about the actions they have taken (nurses’ responses to verbal, physical, or sexual harassment, seeking psychological support after bullying). A pilot survey was conducted with 15 nurses to test the understandability of the questionnaire. These nurses were not included in the research study. Based on the results, questions were either excluded or revised. Also, nursing academicians provided their expert opinions regarding the questionnaire to enhance its understandability. Printed questionnaire forms were distributed during work hours to nurses who had consented to participate in the study. Nurses were asked to complete the questionnaire during their free time and keep it until the researchers returned to collect them. Researchers explained to the nurses that questionnaire data were confidential and would not be shared with any individuals other than study investigators. The purpose of the study was also explained and oral consent was obtained rather than written consent to preserve anonymity. Data Analysis
Percentage analysis was used to evaluate sociodemographic characteristics of the nurses, data on exposure of nurses to bullying, problems experienced due to bullying, actions taken by nurses to respond to bullying, and their suggestions for preventive actions. Chi-square analysis was used to compare certain characteristics of nurses and bullying experiences. Results were considered significant when the p value was less than .05. RESULTS Most of the nurses were married women between 26 and 33 years old and had earned bachelor’s degrees in
Applying Research to Practice Necessary measures should be taken to prevent bullying behaviors in the workplace, particularly among younger nurses who have recently entered the profession. Public and professional awareness of the negative influence that bullying has on workplace morale and patient care should be enhanced. Inservice education programs focusing on early detection, management, and prevention of bullying among health care workers in general and nurses in particular should be designed and implemented. Legal provisions for the prosecution of bullies should be established. Eradication of bullying behaviors in the health care delivery system should be a goal in each facility. Identifying bullying behaviors and the causes of such behaviors and implementing measures to counteract the behaviors should be priorities.
nursing. Their total years of work experience ranged between 0 and 3 years and most worked 40 hours per week. Nurses stated that they chose nursing because they were fond of the profession (Table 1). Nurses’ Exposure to Workplace Bullying
Nearly 42.7% of the study nurses stated they were restrained from proving themselves, 47.7% experienced offensive behavior, 45% could not freely express their ideas, 51.2% received negative criticism although they performed their jobs properly, 40% experienced gossip and slander, and 21.8% received verbal or written threats. More than 52% of the nurses answered “yes” to the question “Have you been held responsible for others’ mistakes?”; 54.2% answered “yes” to the question “Have you been assigned duties outside your responsibilities?”; 35% answered “yes” to the question “Have you been asked to complete duties assigned in an unrealistic time frame?”; 35.4% answered “yes” to the question “Has your success been undervalued?”; and 35.8% answered “yes” to the question “Have you been complained about to upper management?” (Table 2). Problems Experienced by Nurses Due to Bullying, Actions Taken, and Suggestions to Prevent Further Exposure
Approximately 58.5% of the surveyed nurses stated that they did not want to go to work due to the bullying experienced, 66.2% had health or sleep disorders, 55.8% had communication problems with other employees at the workplace, and 36.9% were isolated from institutional activities. The researchers also found that 13.1% of the nurses faced verbal, physical, or sexual harassment at their workplaces, 7.7% of them did not tell anyone about the harassment, 2.3% of them communicated the harassment to managers, and only 1.2% of them sought legal action. More than 98% of the nurses who were exposed
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TABLE 1
TABLE 2
Characteristics of Study Nurses
Effects of Workplace Bullying Reported by Nurses
Parameters
n (%)
Parameters
Age (years) 18 to 25
80 (30.8)
26 to 33
116 (44.6)
34 to 41
64 (24.6)
Being hindered from performing job duties to their fullest potential
Gender Male
26 (10)
Female
234 (90) 103 (39.6)
Married
157 (60.4) 31 (11.9)
Associate degree
84 (32.3)
Bachelor’s degree
136 (52.3)
Master’s/PhD degree
4 to 7
71 (27.3)
8 to 11
54 (20.8)
> 12
50 (19.2) 133 (51.2)
> 41
127 (48.8)
Yes
124 (47.7)
No
136 (52.3)
Yes
117 (45)
No
143 (55)
Yes
133 (51.2)
No
127 (48.8)
Yes
104 (40)
No
156 (60)
Verbal or written threats
Weekly working hours 40
149 (57.3)
Object of gossip and slander
Years worked 85 (32.7)
No
Negative criticism despite acceptable job performance
9 (3.5)
0 to 3
111 (42.7)
Prevented from expressing ideas
Education High school
Yes Facing offensive behavior
Marital status Single
n (%)
Yes
57 (21.9)
No
203 (78.1)
Held responsible for others’ mistakes
Reason for preferring the profession
Yes
137 (52.7)
No
123 (47.3)
Assigned duties outside job responsibilities
Prestige
10 (3.8)
Family’s wish
29 (11.2)
Yes
141 (54.2)
Ease of employment
86 (33.1)
No
119 (45.8)
Good income Liking the profession Total
39 (15)
Given tasks with unreasonable or impossible targets or deadlines
96 (36.9) 260 (100)
to bullying received psychological support from relatives or health care professionals. When they were asked “What are your suggestions to prevent bullying?”, providing education was suggested as a solution by 20% of the nurses, being respectful by 16.2%, being fair by 14.2%, implementing appropriate regulations by 7.7%, establishing empathy by 6.9%, and taking necessary measures by 5.4% (Table 3). Younger nurses who had less professional experience faced more obstacles in proving themselves, were more likely to be offended and isolated from institutional activities, and received more negative criticism (p < .05). As for education status, nurses who had bachelor’s de-
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Yes
91 (35)
No
169 (65)
Undervaluing employee success Yes
92 (35.4)
No
168 (64.6)
Complained about to upper management Yes
93 (35.8)
No
167 (64.2)
Total
260 (100)
grees seemed to face bullying behaviors more frequently (p < .05). There was no statistically significant associa-
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tion between gender, marital status, and work hours, and exposure to bullying behaviors (p < .05). DISCUSSION The findings of bullying research conducted in many parts of the world in recent years clearly demonstrate the serious dimensions of workplace bullying (Aytac et al., 2011; Tinaz, 2012; Tonini et al., 2011a, 2011b) and how violence in the health care sector is more common than in other workplaces (Annagür, 2010). It has been reported that health care professionals, and nurses in particular, are more commonly bullied than those in other professions (Gallant-Roman, 2008). It was also found in this study that most nurses received negative criticism although they reported performing their jobs properly, were held responsible for others’ mistakes, and were assigned duties outside their work responsibilities. Nurses who were bullied could not freely express their ideas, were subject to slander, their success was undervalued, and they were complained about to upper management. Bullying burdens the national economy due to the personal, societal, and institutional damage caused by this occupational phenomenon. Although individuals vary in tolerance to violence (Mercanlioglu, 2010), targets of bullying exhibit a wide spectrum of behavioral and mental changes, including insomnia, loss of appetite, depression, distress, anxiety, crying, forgetfulness, irritability, sudden outbursts of anger, becoming uncommunicative, loss of desire to live, and not enjoying activities they liked before (Dikmetas et al., 2011). Financial and emotional costs of treating these conditions burden the individual. Additionally, consequences such as loss of self-confidence, low productivity due to feelings of isolation, work absences and resignation, and, rarely, suicide may also be observed (Mercanlioglu, 2010). In a Turkish study, nurses who were targets of bullying reported that they did not want to go to work, experienced sleeping problems, could not concentrate on their work, and were exhausted (Yildirim & Yildirim, 2007). In another study, bullied nurses most frequently experienced sleep, emotional, and sexual problems (Punzi, Cassitto, Castellini, Costa, & Gilioli, 2007). Several studies have concluded that bullying negatively affected physical and social health and general well-being (Johnson 2009; Yildirim, Yildirim, & Timucin, 2007). In the current study, the researchers also observed that most nurses who reported being bullied also reported negative effects on their health, sleeping, and communication and they lost their willingness to go to work. Nevertheless, a large portion of the surveyed nurses received psychological support to cope with the problems they were experiencing, a positive approach to minimize the problems associated with bullying. In developed countries where employee rights are secure, awareness about psychological harassment is common and laws do not sanction bullying behavior. Considering that legal regulations can deter or prevent bullying behavior, lack of such regulations in the Turkish Legal System severely limits victims’ legal recourse (Mercanlioglu, 2010). The nurses surveyed in this study, particularly those who were sexually harassed, did not share this
TABLE 3
Problems Experienced by Nurses Due to Bullying, Actions Taken, and Suggestions for Solutions Parameters
n (%)
Unwilling to go to work Yes
152 (58.5)
No
108 (41.5)
Health or sleeping disorders Yes
172 (66.2)
No
88 (33.8)
Communication problems with staff members Yes
145 (55.8)
No
115 (44.2)
Isolated from institutional activities Yes
96 (36.9)
No
164 (63.1)
Verbal, physical, or sexual harassment at the workplace and actions taken Yes
5 (1.9)
Yes, but I did not tell anyone
20 (7.7)
Yes, I communicated them to the managers
6 (2.3)
Yes, I took legal action
3 (1.2)
No
226 (86.9)
Psychological support for bullying Yes
255 (98.1)
No
5 (1.9)
Suggestions to prevent bullying Being fair
37 (14.2)
Establishing empathy
18 (6.9)
Being respectful
42 (16.2)
Establishing appropriate rules
20 (7.7)
Providing training
52 (20)
Taking necessary measures
14 (5.4)
No suggestions
77 (29.6)
Total
260 (100)
situation with anyone and only 1.2% of them took legal action. This finding can be explained by the lack of adequate legal sanctions in Turkey; sexual matters are considered taboo and not freely communicated. Studies have found an association between sociodemographic characteristics and employment status with bullying younger workers (Chen, Sun, Lan, & Chiu,
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2009; Efe & Ayaz 2010; Yildirim, 2009) and those with less work experience (Chen et al., 2009; Yildirim, 2009). In the current study, the researchers also found that young nurses and those with less professional experience were more commonly bullied. These results are explained by the fact that experience increases with advancing age and experienced nurses may be less likely to be bullied (Ayranci, Yenilmez, Günay, & Kaptanoglu 2002). Limitations
The major limitation of this study was that only 260 of the 1,156 eligible nurses working in the health care facilities studied were included. The major reason for the small number of nurses in the study was nurses refused to participate. Some nurses did not want to complete the questionnaire because they believed their responses could potentially harm them. Although prior to the study the nurses were informed the study had been approved by their institutions and the university ethics committee and the survey data would be used only for study purposes and never disclosed individually to other parties including the unit or institution, they still refused to participate. Another limitation was the high number of females in the sample due to the restriction that only women could practice nursing in Turkey until 2007. Therefore, the results of the research cannot be generalized to both genders. CONCLUSION According to the data obtained for this study, most of the nurses experienced bullying behaviors and health and sleeping problems; as a consequence of such behaviors, they did not want to go to work. Younger nurses with less professional experience were more likely to be bullied than older, more seasoned nurses, and bullied nurses sought psychological support to cope with problems associated with bullying. Almost all nurses stated that education was essential to preventing bullying. The following recommendations are suggested based on study findings: 1. Necessary measures should be taken to prevent bullying behaviors in the workplace, particularly among younger nurses who have recently entered the profession. 2. Public and professional awareness of the negative influence that bullying has on workplace morale and patient care should be enhanced. 3. Inservice education programs focusing on early detection, management, and prevention of bullying among health care workers in general and nurses in particular should be designed and implemented. 4. Legal provisions for the prosecution of bullies should be established. Eradication of bullying behaviors in the health care delivery system should be a goal in each facility. Identifying bullying behaviors and the causes of such behaviors and implementing measures to counteract the behaviors should be priorities. In addition to the above recommen-
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dations, additional studies are needed to measure how bullying behavior contributes to work-related stress, injury, and burnout, affects work attendance, and detracts from patient care and safety. REFERENCES
Annagür, B. (2010). Violence towards health care staff: Risk factors, after effects, evaluation and prevention. Current Approaches in Psychiatry, 2, 161-173. Ayranci, Ü., Yenilmez, Ç., Günay, Y., & Kaptanoglu, C. (2002). The frequency of being exposed to violence in the various health institutions and health profession groups. Anatolian Journal of Psychiatry, 3, 147-154. Aytac, S., Bozkurt, V., Bayram, N., Yildiz, S., Aytac, M., Akinci, F. S., & Bilgel, N. (2011). Workplace violence: A study of Turkish workers. International Journal of Occupational Safety and Ergonomics, 17, 385-402. Chen, W. C., Sun, Y. H., Lan, T. H., & Chiu, H. J. (2009). Incidence and risk factors of workplace violence on nursing staffs caring for chronic psychiatric patients in Taiwan. International Journal of Environmental Research and Public Health, 6, 2812-2821. Dikmetas, E., Top, M., & Ergin, G. (2011). An examination of mobbing and burnout of residents. Turkish Journal of Psychiatry, 22, 137-149. Efe, S. Y., & Ayaz, S. (2010). Mobbing against nurses in the workplace in Turkey. International Nursing Review, 57, 328-334. Gallant-Roman, M. A. (2008). Strategies and tools to reduce workplace violence. AAOHN Journal, 56, 449-454. Johnson, S. L. (2009). International perspectives on workplace bullying among nurses: A review. International Nursing Review, 56, 34-40. Kingma, M. (2001). Workplace violence in the health sector: A problem of epidemic proportion. International Nursing Review, 48, 129-130. Mercanlioglu, Ç. (2010). The reasons and consequences of mobbing and its legal progress in Turkey. Journal of Organizational and Managerial Sciences, 2, 37-46. Ozturk, H., Sokmen, S., Yilmaz, F., & Cilingir, D. (2008). Measuring mobbing experiences of academic nurses: Development of a mobbing scale. Journal of the American Academy of Nurse Practitioners, 20, 435-442. Punzi, S., Cassitto, M. G., Castellini, G., Costa, G., & Gilioli, R. (2007). Mobbing and its effects on health: The experience of the “Clinica del Lavoro Luigi Devoto” in Milan [article in Italian]. La Medicina de Lavoro, 98, 267-283. Tinaz, P. (2006). Psychological harassment at workplace (mobbing). Journal of Work and Society, 4, 13-28. Tinaz, P. (2012). A psychological drama in working life: Mobbing. Retrieved from http://www.toprakisveren.org.tr/2006-71-pinartinaz. pdf Tonini, S., Lanfranco, A., Costa, M. C., Lumelli, D., Giorgi, I., Mazzacane, F., . . . Candura, S. M. (2011a). Work-related stress and mobbing: Case series and gender differences [article in Italian]. Giornale Italiano di Medicina del Lavoro ed Ergonoma, 33, 409413. Tonini, S., Lanfranco, A., Dellabianca, A., Lumelli, D., Giorgi, I., Mazzacane, F., . . . Candura, S. M. (2011b). Work-related stress and bullying: Gender differences and forensic medicine issues in the diagnostic procedure. Journal of Occupational Medicine and Toxicology, 6, 29. Turkish Medical Association, Gaziantep-Kilis Chamber of Medicine. (2008). A report on violence in healthcare sector – I, 2008. Retrieved from http://www.ttb.org.tr/siddet/images/file/gaziantepsiddet.pdf Yildirim, D. (2009). Bullying among nurses and its effects. International Nursing Review, 56, 504-511. Yildirim, A., & Yildirim, D. (2007). Mobbing in the workplace by peers and managers: Mobbing experienced by nurses working in healthcare facilities in Turkey and its effect on nurses. Journal of Clinical Nursing, 16, 1444-1453. Yildirim, D., Yildirim, A., & Timucin, A. (2007). Mobbing behaviors encountered by nurse teaching staff. Nursing Ethics, 14, 447-463.
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at NORTHERN KENTUCKY UNIV on August 11, 2015
ABSTRACT This research was designed to determine whether nurses are bullied by other staff members and the effects of such behaviors on the nurse victims. This study reports on nurses’ interpersonal workplace relationships in a culturally unique environment. The study was conducted with 260 nurses working in three public hospitals. Data were collected using a questionnaire. The majority of nurses were female with bachelor’s degrees and reported being assigned duties outside their usual responsibilities, held responsible for coworkers’ mistakes, and criticized for job performance although they thought they had done their work properly. Most of the nurses who were bullied experienced health and sleep problems, did not want to go to work, and had communication problems with other staff members. Nearly all of the study nurses received psychological support to solve their problems and believed that the best way to prevent bullying was education. [Workplace Health Saf 2014;62(9):370-374.]
B
ullying can occur in any workplace regardless of culture and affect both genders with serious consequences (Tinaz, 2006). Bullying at work can include all types of mistreatment, including threats (e.g., “if this happens, you will experience this from me”; “you either lose your job or continue as I tell you”), intimidation (e.g., being scolded in front of team members), and humiliation (e.g., “you cannot do this job”). Individuals in a workplace may be systematically exposed to these behaviors by their superiors, peers, or subordinates (Ozturk, Sokmen, Yilmaz, & Cilingir, 2008; Tinaz, 2006). Such behaviors are a major problem in today’s work environment and can have detrimental effects on employees by impairing organizational relationships (Dikmetas, Top, & Ergin, 2011). The health care sector is one of the fields where mobbing is commonplace (Annagür, 2010). Violence in the health sector has a negative impact not only on the professional and personal lives of health care workers, but also on the quality of care provided to patients (Kingma, 2001).
ABOUT THE AUTHORS
Dr. O. Ovayolu is Associate Professor, Dr. N. Ovayolu is Professor, and Dr. Karadag is Assistant Professor, Gaziantep University, Faculty of Health Science, Gaziantep, Turkey. Submitted: July 4, 2013; Accepted: July 10, 2014; Posted online: August 11, 2014 The authors have disclosed no potential conflicts, financial or otherwise. The authors thank all nurses who participated in the study. Correspondence: Özlem Ovayolu, RN, PhD, Gaziantep University, Faculty of Health Science, Gaziantep, Turkey. E-mail: [email protected] doi:10.3928/21650799-20140804-04
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Nursing personnel are exposed not only to abuse and violence by coworkers, but also the violent acts of patients and their relatives (Annagür, 2010). Thus, nurses are up to three times more likely to be victims of violence than other categories of health personnel, with female nurses considered the most vulnerable (Kingma, 2001). Violent acts directed at health care professionals seem to have peaked recently in Turkey, although studies specific to health care sector bullying in Turkey are scarce (Turkish Medical Association, 2008). The current study was conducted to determine the extent and effects of nurse bullying by staff members in Turkish health care facilities and to suggest needed actions to prevent such behaviors. Research Questions
1. What are the bullying behaviors nurses experience in the workplace? 2. Is there a relationship between the age, education, marital status, years worked, and weekly working hours of Turkish nurses and the bullying behaviors to which they are exposed? 3. What type of problems do nurses experience after being bullied? 4. What actions do nurses suggest to prevent bullying? METHODS This study used a cross-sectional, descriptive design. Prior to the study, 1,156 nurses working in three public
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at NORTHERN KENTUCKY UNIV on August 11, 2015
Turkish hospitals were informed about the study, including its approval by their institutions and the Gaziantep University ethics committee. Nurses on leave during the research time frame and those who did not agree to take part in the research (n = 896) were excluded from the sample. A total of 260 nurses participated in the study. Data Collection
Study data were collected using a questionnaire that included characteristics of study nurses (e.g., age, gender, marital status, education [in Turkey, individuals with a high school education or associate’s, bachelor’s, or postgraduate degree in nursing are entitled to work as nurses in clinics], years of professional service, weekly working hours, and the reason for choosing the profession) and respondents’ bullying experience (i.e., restrained nurses from proving themselves, had to face offensive behavior, prevented nurses from expressing their ideas, received negative criticism despite acceptable job performance, exposed to gossip and slander, received verbal or written threats, held responsible for others’ mistakes, assigned duties outside their responsibilities, demanded completion of assigned duties in unrealistic time frames, undervalued their successes, complained about nurses to upper management), questions about the problems experienced due to bullying (unwilling to go to work, health and sleep disorders, communication problems with hospital staff, isolated from social activities), and questions about the actions they have taken (nurses’ responses to verbal, physical, or sexual harassment, seeking psychological support after bullying). A pilot survey was conducted with 15 nurses to test the understandability of the questionnaire. These nurses were not included in the research study. Based on the results, questions were either excluded or revised. Also, nursing academicians provided their expert opinions regarding the questionnaire to enhance its understandability. Printed questionnaire forms were distributed during work hours to nurses who had consented to participate in the study. Nurses were asked to complete the questionnaire during their free time and keep it until the researchers returned to collect them. Researchers explained to the nurses that questionnaire data were confidential and would not be shared with any individuals other than study investigators. The purpose of the study was also explained and oral consent was obtained rather than written consent to preserve anonymity. Data Analysis
Percentage analysis was used to evaluate sociodemographic characteristics of the nurses, data on exposure of nurses to bullying, problems experienced due to bullying, actions taken by nurses to respond to bullying, and their suggestions for preventive actions. Chi-square analysis was used to compare certain characteristics of nurses and bullying experiences. Results were considered significant when the p value was less than .05. RESULTS Most of the nurses were married women between 26 and 33 years old and had earned bachelor’s degrees in
Applying Research to Practice Necessary measures should be taken to prevent bullying behaviors in the workplace, particularly among younger nurses who have recently entered the profession. Public and professional awareness of the negative influence that bullying has on workplace morale and patient care should be enhanced. Inservice education programs focusing on early detection, management, and prevention of bullying among health care workers in general and nurses in particular should be designed and implemented. Legal provisions for the prosecution of bullies should be established. Eradication of bullying behaviors in the health care delivery system should be a goal in each facility. Identifying bullying behaviors and the causes of such behaviors and implementing measures to counteract the behaviors should be priorities.
nursing. Their total years of work experience ranged between 0 and 3 years and most worked 40 hours per week. Nurses stated that they chose nursing because they were fond of the profession (Table 1). Nurses’ Exposure to Workplace Bullying
Nearly 42.7% of the study nurses stated they were restrained from proving themselves, 47.7% experienced offensive behavior, 45% could not freely express their ideas, 51.2% received negative criticism although they performed their jobs properly, 40% experienced gossip and slander, and 21.8% received verbal or written threats. More than 52% of the nurses answered “yes” to the question “Have you been held responsible for others’ mistakes?”; 54.2% answered “yes” to the question “Have you been assigned duties outside your responsibilities?”; 35% answered “yes” to the question “Have you been asked to complete duties assigned in an unrealistic time frame?”; 35.4% answered “yes” to the question “Has your success been undervalued?”; and 35.8% answered “yes” to the question “Have you been complained about to upper management?” (Table 2). Problems Experienced by Nurses Due to Bullying, Actions Taken, and Suggestions to Prevent Further Exposure
Approximately 58.5% of the surveyed nurses stated that they did not want to go to work due to the bullying experienced, 66.2% had health or sleep disorders, 55.8% had communication problems with other employees at the workplace, and 36.9% were isolated from institutional activities. The researchers also found that 13.1% of the nurses faced verbal, physical, or sexual harassment at their workplaces, 7.7% of them did not tell anyone about the harassment, 2.3% of them communicated the harassment to managers, and only 1.2% of them sought legal action. More than 98% of the nurses who were exposed
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TABLE 1
TABLE 2
Characteristics of Study Nurses
Effects of Workplace Bullying Reported by Nurses
Parameters
n (%)
Parameters
Age (years) 18 to 25
80 (30.8)
26 to 33
116 (44.6)
34 to 41
64 (24.6)
Being hindered from performing job duties to their fullest potential
Gender Male
26 (10)
Female
234 (90) 103 (39.6)
Married
157 (60.4) 31 (11.9)
Associate degree
84 (32.3)
Bachelor’s degree
136 (52.3)
Master’s/PhD degree
4 to 7
71 (27.3)
8 to 11
54 (20.8)
> 12
50 (19.2) 133 (51.2)
> 41
127 (48.8)
Yes
124 (47.7)
No
136 (52.3)
Yes
117 (45)
No
143 (55)
Yes
133 (51.2)
No
127 (48.8)
Yes
104 (40)
No
156 (60)
Verbal or written threats
Weekly working hours 40
149 (57.3)
Object of gossip and slander
Years worked 85 (32.7)
No
Negative criticism despite acceptable job performance
9 (3.5)
0 to 3
111 (42.7)
Prevented from expressing ideas
Education High school
Yes Facing offensive behavior
Marital status Single
n (%)
Yes
57 (21.9)
No
203 (78.1)
Held responsible for others’ mistakes
Reason for preferring the profession
Yes
137 (52.7)
No
123 (47.3)
Assigned duties outside job responsibilities
Prestige
10 (3.8)
Family’s wish
29 (11.2)
Yes
141 (54.2)
Ease of employment
86 (33.1)
No
119 (45.8)
Good income Liking the profession Total
39 (15)
Given tasks with unreasonable or impossible targets or deadlines
96 (36.9) 260 (100)
to bullying received psychological support from relatives or health care professionals. When they were asked “What are your suggestions to prevent bullying?”, providing education was suggested as a solution by 20% of the nurses, being respectful by 16.2%, being fair by 14.2%, implementing appropriate regulations by 7.7%, establishing empathy by 6.9%, and taking necessary measures by 5.4% (Table 3). Younger nurses who had less professional experience faced more obstacles in proving themselves, were more likely to be offended and isolated from institutional activities, and received more negative criticism (p < .05). As for education status, nurses who had bachelor’s de-
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Yes
91 (35)
No
169 (65)
Undervaluing employee success Yes
92 (35.4)
No
168 (64.6)
Complained about to upper management Yes
93 (35.8)
No
167 (64.2)
Total
260 (100)
grees seemed to face bullying behaviors more frequently (p < .05). There was no statistically significant associa-
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tion between gender, marital status, and work hours, and exposure to bullying behaviors (p < .05). DISCUSSION The findings of bullying research conducted in many parts of the world in recent years clearly demonstrate the serious dimensions of workplace bullying (Aytac et al., 2011; Tinaz, 2012; Tonini et al., 2011a, 2011b) and how violence in the health care sector is more common than in other workplaces (Annagür, 2010). It has been reported that health care professionals, and nurses in particular, are more commonly bullied than those in other professions (Gallant-Roman, 2008). It was also found in this study that most nurses received negative criticism although they reported performing their jobs properly, were held responsible for others’ mistakes, and were assigned duties outside their work responsibilities. Nurses who were bullied could not freely express their ideas, were subject to slander, their success was undervalued, and they were complained about to upper management. Bullying burdens the national economy due to the personal, societal, and institutional damage caused by this occupational phenomenon. Although individuals vary in tolerance to violence (Mercanlioglu, 2010), targets of bullying exhibit a wide spectrum of behavioral and mental changes, including insomnia, loss of appetite, depression, distress, anxiety, crying, forgetfulness, irritability, sudden outbursts of anger, becoming uncommunicative, loss of desire to live, and not enjoying activities they liked before (Dikmetas et al., 2011). Financial and emotional costs of treating these conditions burden the individual. Additionally, consequences such as loss of self-confidence, low productivity due to feelings of isolation, work absences and resignation, and, rarely, suicide may also be observed (Mercanlioglu, 2010). In a Turkish study, nurses who were targets of bullying reported that they did not want to go to work, experienced sleeping problems, could not concentrate on their work, and were exhausted (Yildirim & Yildirim, 2007). In another study, bullied nurses most frequently experienced sleep, emotional, and sexual problems (Punzi, Cassitto, Castellini, Costa, & Gilioli, 2007). Several studies have concluded that bullying negatively affected physical and social health and general well-being (Johnson 2009; Yildirim, Yildirim, & Timucin, 2007). In the current study, the researchers also observed that most nurses who reported being bullied also reported negative effects on their health, sleeping, and communication and they lost their willingness to go to work. Nevertheless, a large portion of the surveyed nurses received psychological support to cope with the problems they were experiencing, a positive approach to minimize the problems associated with bullying. In developed countries where employee rights are secure, awareness about psychological harassment is common and laws do not sanction bullying behavior. Considering that legal regulations can deter or prevent bullying behavior, lack of such regulations in the Turkish Legal System severely limits victims’ legal recourse (Mercanlioglu, 2010). The nurses surveyed in this study, particularly those who were sexually harassed, did not share this
TABLE 3
Problems Experienced by Nurses Due to Bullying, Actions Taken, and Suggestions for Solutions Parameters
n (%)
Unwilling to go to work Yes
152 (58.5)
No
108 (41.5)
Health or sleeping disorders Yes
172 (66.2)
No
88 (33.8)
Communication problems with staff members Yes
145 (55.8)
No
115 (44.2)
Isolated from institutional activities Yes
96 (36.9)
No
164 (63.1)
Verbal, physical, or sexual harassment at the workplace and actions taken Yes
5 (1.9)
Yes, but I did not tell anyone
20 (7.7)
Yes, I communicated them to the managers
6 (2.3)
Yes, I took legal action
3 (1.2)
No
226 (86.9)
Psychological support for bullying Yes
255 (98.1)
No
5 (1.9)
Suggestions to prevent bullying Being fair
37 (14.2)
Establishing empathy
18 (6.9)
Being respectful
42 (16.2)
Establishing appropriate rules
20 (7.7)
Providing training
52 (20)
Taking necessary measures
14 (5.4)
No suggestions
77 (29.6)
Total
260 (100)
situation with anyone and only 1.2% of them took legal action. This finding can be explained by the lack of adequate legal sanctions in Turkey; sexual matters are considered taboo and not freely communicated. Studies have found an association between sociodemographic characteristics and employment status with bullying younger workers (Chen, Sun, Lan, & Chiu,
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2009; Efe & Ayaz 2010; Yildirim, 2009) and those with less work experience (Chen et al., 2009; Yildirim, 2009). In the current study, the researchers also found that young nurses and those with less professional experience were more commonly bullied. These results are explained by the fact that experience increases with advancing age and experienced nurses may be less likely to be bullied (Ayranci, Yenilmez, Günay, & Kaptanoglu 2002). Limitations
The major limitation of this study was that only 260 of the 1,156 eligible nurses working in the health care facilities studied were included. The major reason for the small number of nurses in the study was nurses refused to participate. Some nurses did not want to complete the questionnaire because they believed their responses could potentially harm them. Although prior to the study the nurses were informed the study had been approved by their institutions and the university ethics committee and the survey data would be used only for study purposes and never disclosed individually to other parties including the unit or institution, they still refused to participate. Another limitation was the high number of females in the sample due to the restriction that only women could practice nursing in Turkey until 2007. Therefore, the results of the research cannot be generalized to both genders. CONCLUSION According to the data obtained for this study, most of the nurses experienced bullying behaviors and health and sleeping problems; as a consequence of such behaviors, they did not want to go to work. Younger nurses with less professional experience were more likely to be bullied than older, more seasoned nurses, and bullied nurses sought psychological support to cope with problems associated with bullying. Almost all nurses stated that education was essential to preventing bullying. The following recommendations are suggested based on study findings: 1. Necessary measures should be taken to prevent bullying behaviors in the workplace, particularly among younger nurses who have recently entered the profession. 2. Public and professional awareness of the negative influence that bullying has on workplace morale and patient care should be enhanced. 3. Inservice education programs focusing on early detection, management, and prevention of bullying among health care workers in general and nurses in particular should be designed and implemented. 4. Legal provisions for the prosecution of bullies should be established. Eradication of bullying behaviors in the health care delivery system should be a goal in each facility. Identifying bullying behaviors and the causes of such behaviors and implementing measures to counteract the behaviors should be priorities. In addition to the above recommen-
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dations, additional studies are needed to measure how bullying behavior contributes to work-related stress, injury, and burnout, affects work attendance, and detracts from patient care and safety. REFERENCES
Annagür, B. (2010). Violence towards health care staff: Risk factors, after effects, evaluation and prevention. Current Approaches in Psychiatry, 2, 161-173. Ayranci, Ü., Yenilmez, Ç., Günay, Y., & Kaptanoglu, C. (2002). The frequency of being exposed to violence in the various health institutions and health profession groups. Anatolian Journal of Psychiatry, 3, 147-154. Aytac, S., Bozkurt, V., Bayram, N., Yildiz, S., Aytac, M., Akinci, F. S., & Bilgel, N. (2011). Workplace violence: A study of Turkish workers. International Journal of Occupational Safety and Ergonomics, 17, 385-402. Chen, W. C., Sun, Y. H., Lan, T. H., & Chiu, H. J. (2009). Incidence and risk factors of workplace violence on nursing staffs caring for chronic psychiatric patients in Taiwan. International Journal of Environmental Research and Public Health, 6, 2812-2821. Dikmetas, E., Top, M., & Ergin, G. (2011). An examination of mobbing and burnout of residents. Turkish Journal of Psychiatry, 22, 137-149. Efe, S. Y., & Ayaz, S. (2010). Mobbing against nurses in the workplace in Turkey. International Nursing Review, 57, 328-334. Gallant-Roman, M. A. (2008). Strategies and tools to reduce workplace violence. AAOHN Journal, 56, 449-454. Johnson, S. L. (2009). International perspectives on workplace bullying among nurses: A review. International Nursing Review, 56, 34-40. Kingma, M. (2001). Workplace violence in the health sector: A problem of epidemic proportion. International Nursing Review, 48, 129-130. Mercanlioglu, Ç. (2010). The reasons and consequences of mobbing and its legal progress in Turkey. Journal of Organizational and Managerial Sciences, 2, 37-46. Ozturk, H., Sokmen, S., Yilmaz, F., & Cilingir, D. (2008). Measuring mobbing experiences of academic nurses: Development of a mobbing scale. Journal of the American Academy of Nurse Practitioners, 20, 435-442. Punzi, S., Cassitto, M. G., Castellini, G., Costa, G., & Gilioli, R. (2007). Mobbing and its effects on health: The experience of the “Clinica del Lavoro Luigi Devoto” in Milan [article in Italian]. La Medicina de Lavoro, 98, 267-283. Tinaz, P. (2006). Psychological harassment at workplace (mobbing). Journal of Work and Society, 4, 13-28. Tinaz, P. (2012). A psychological drama in working life: Mobbing. Retrieved from http://www.toprakisveren.org.tr/2006-71-pinartinaz. pdf Tonini, S., Lanfranco, A., Costa, M. C., Lumelli, D., Giorgi, I., Mazzacane, F., . . . Candura, S. M. (2011a). Work-related stress and mobbing: Case series and gender differences [article in Italian]. Giornale Italiano di Medicina del Lavoro ed Ergonoma, 33, 409413. Tonini, S., Lanfranco, A., Dellabianca, A., Lumelli, D., Giorgi, I., Mazzacane, F., . . . Candura, S. M. (2011b). Work-related stress and bullying: Gender differences and forensic medicine issues in the diagnostic procedure. Journal of Occupational Medicine and Toxicology, 6, 29. Turkish Medical Association, Gaziantep-Kilis Chamber of Medicine. (2008). A report on violence in healthcare sector – I, 2008. Retrieved from http://www.ttb.org.tr/siddet/images/file/gaziantepsiddet.pdf Yildirim, D. (2009). Bullying among nurses and its effects. International Nursing Review, 56, 504-511. Yildirim, A., & Yildirim, D. (2007). Mobbing in the workplace by peers and managers: Mobbing experienced by nurses working in healthcare facilities in Turkey and its effect on nurses. Journal of Clinical Nursing, 16, 1444-1453. Yildirim, D., Yildirim, A., & Timucin, A. (2007). Mobbing behaviors encountered by nurse teaching staff. Nursing Ethics, 14, 447-463.
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