Journal of Transcultural Nursing http://tcn.sagepub.com/
Influence of Workplace Bullying on Turkish Nurses' Psychological Distress and Nurses' Reactions to Bullying Ezgi Bardakçi and Neslihan Partlak Günüsen J Transcult Nurs published online 5 September 2014 DOI: 10.1177/1043659614549073 The online version of this article can be found at: http://tcn.sagepub.com/content/early/2014/09/03/1043659614549073
Published by: http://www.sagepublications.com
On behalf of:
Transcultural Nursing Society
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549073
research-article2014
TCNXXX10.1177/1043659614549073Journal of Transcultural NursingBardakçı and Günüşen
Research Department
Influence of Workplace Bullying on Turkish Nurses’ Psychological Distress and Nurses’ Reactions to Bullying
Journal of Transcultural Nursing 1–6 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614549073 tcn.sagepub.com
Ezgi Bardakçı, RN1, and Neslihan Partlak Günüşen, PhD1
Abstract Purpose: The study aims to determine the influence of bullying on nurses’ psychological distress. Design: A descriptive design was adopted. The study sample included 284 nurses of a university hospital in Izmir, Turkey. The Workplace Bullying Behavior Scale and the General Health Questionnaire were used. Results: After the study was completed, it was determined that nurses with a master’s degree were exposed to bullying more and that nurses exposed to bullying suffered higher levels of psychological distress and preferred to keep silent about it. Perpetrators of bullying were mainly head nurses. Discussion/ Conclusions: Bullying is a common workplace phenomenon, and in most cases, nurses bully each other. Bullied nurses suffer more psychological distress. Implications: Managers of health care institutions should always remember that nurses have a higher risk of exposure to bullying and that measures should be taken to support nurses. Keywords bullying, mental health, nursing
Introduction Health care organizations are among the workplaces where bullying is a common phenomenon (Çamcı & Kutlu, 2011). Among health care professionals, nurses are more exposed to bullying than any other health care team member (EstrynBehar et al., 2008; Quine, 1999, 2001; Rutherford & Rissel, 2004). In the literature, 20% to 44% of nurses are reported to have been subjected to bullying (Quine, 2001; Trepanier, Fernet, & Austin, 2013; Yıldırım, 2009). The concept of bullying has been an international matter of concern for the past 20 years. When bullying was first identified, it was called as “mobbing” by Heinz Leymann (1996). He defined mobbing as psychological terror directed toward one individual by one or more persons in a systematic manner through hostile and unethical methods. In the nursing literature, generally mobbing is called bullying. Workplace bullying is defined as lateral or horizontal violence and currently attracts significant amount of international attention (Johnson, 2009). Bullied victims’ mental health is significantly affected: Victims suffer serious psychiatric, psychosomatic, and psychosocial problems (Leymann, 1996). In a study by Yıldırım and Yıldırım (2007), those exposed to bullying were reported to suffer from stress, headaches, and fatigue. A study conducted with health care providers in New Zealand revealed that people who are exposed to bullying were under more strain and their well-being was adversely affected (CooperThomas et al., 2013). In several studies of nurses exposed to
bullying, they displayed severe symptoms of anxiety and depression (Quine, 2001; Sa & Fleming, 2008; Zapf, 1999). Employees exposed to bullying reportedly suffered mental fatigue and psychological distress and displayed more psychosomatic symptoms (Agervold & Mikkelsen, 2004; Mikkelsen & Einarsen, 2002). Bullying has adverse effects not only on the health of employees but also on their work performance. Among bullied nurses, job satisfaction decreases, there is increased rates of sick leave and attrition, and there is decreased workplace productivity, satisfaction, and morale (Cleary, Hunt, & Horsfall, 2010; Quine, 2001). In a study conducted in Canada, nurses exposed to bullying had lower motivation and more intent to leave their jobs than did those who were not exposed to bullying (Trepanier et al., 2013). In order to prevent and reduce bullying, it is important to know which nurses are at risk of these behaviors, who the perpetrators of bullying are, and how nurses react to bullying. In the literature, there are studies indicating that demographic variables pose a risk in terms of bullying. It is reported that young and inexperienced nurses are more exposed to bullying (Çevik Akyıl, Tan, Sarıtaş, & Altuntaş, 1
Dokuz Eylül University, Izmir, Turkey
Corresponding Author: Neslihan Partlak Günüşen, Psychiatric Nursing Department, Dokuz Eylül University Faculty of Nursing, 35340 Balçova, Izmir, Turkey. Email: [email protected]
Downloaded from tcn.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
2
Journal of Transcultural Nursing
2012; Efe & Ayaz, 2010; Simons & Mawn, 2010; Yıldırım, 2009). On the other hand, some studies indicate that demographic variables do not pose any risk in terms of bullying (Mikkelsen & Einarsen, 2002; Yıldırım & Yıldırım, 2007). It has been reported that perpetrators of bullying, a serious problem for nurses, are mostly other nurses. Several studies have reported that those who perpetrate bullying the most are head nurses, followed by physicians (Çevik Akyıl et al., 2012; Efe & Ayaz, 2010). In a study conducted in New Zealand, it was revealed that the majority of the nurses were exposed to bullying by senior and older nurses (Clendon & Walker, 2012). The findings of several studies observed that although nurses’ mental health and work performance are adversely affected by the consequences of bullying, they prefer to remain silent and tend to share their discontent only with friends (Çevik Akyıl et al., 2012; Efe &Ayaz, 2010). Yıldırım and Yıldırım’s (2007) study indicates that nurses exposed to bullying try to avoid being bullied by working harder and more carefully. Bullying in the workplace is a serious issue for nurses and needs immediate attention. Nurses are responsible for protecting and improving the health of society and of individuals, so they should be mentally healthy if they are to fulfill their duties and responsibilities as expected (Özgür, Gümüş, & Gürdağ, 2011). Organizations providing health care should make protecting the mental health of nurses a top priority. Studies on bullying have been increasing in recent years. However, the number of the studies on the rate Turkish nurses are exposed to bullying, how they react when they are exposed to bullying, who the perpetrators of bullying in the workplace are, and how the nurses’ mental health is affected by bullying is limited. The results of this study are expected to contribute to an understanding of the nature of bullying, its impact on nurses, and nurses’ reactions to bullying. In addition, these results can contribute to attempts to raise awareness of this issue, and to reduce and even prevent bullying in the workplace. The aim of this study is to determine variables affecting bullying, the rate of exposure of nurses to bullying, perpetrators of bullying, nurses’ reactions toward bullying, and the level of psychological distress of nurses exposed to bullying.
Research Questions Research Question 1: Is there a relationship among the nurses’ workplace, age, educational status, total years of service, years of service at their current institution, position, and the bullying to which they are exposed? Research Question 2: What percentage of nurses are exposed to bullying? Research Question 3: Who are the perpetrators? Research Question 4: How do nurses react to bullying? Research Question 5: Is there a difference between the psychological distress levels of nurses who are the victims of bullying and who are not?
Method Design and Sample This descriptive study was conducted in 2013 on a sample of nurses working in a university hospital in Izmir, Turkey. Nurses at this 1,000-bed university hospital work 12-hour shifts for 180 hours a month and provide care for an average of 15 to 20 patients per shift. There are 757 nurses working in the hospital. The sample size was calculated to be 262 using a sample calculation formula in universally known situations (Sümbüloğlu & Sümbüloğlu, 2005). To increase reliability, more participants were needed. For this reason, all the nurses (N = 757) were invited to participate in the study; 284 nurses completed and returned the questionnaires. The participation rate was 37.5%.
Instruments Nurse Information Form. This questionnaire included factors such as age, educational status, total years of service, years of service, and position at their current institution, all of which can affect bullying. In addition, in the questionnaire, the nurses were asked about the identities of their perpetrators and how they react to bullying. Workplace Bullying Behaviors Scale. To measure the nurses’ perception of bullying in the workplace, a 33-item tool developed by Yıldırım and Yıldırım (2007) was used. The nurses were asked to mark the frequency of bullying behaviors that they had been exposed to within the last 12 months and which had negative effects on their work performance. The tool had four subcategories. Psychological violence in the workplace was discussed under four main headings: “isolation from work,” “attack on professional status,” “attack on personality,” and “direct attack”. The items were evaluated on a 6-point Likert-type scale ranging from 0 (I have never been exposed to this) to 5 (I am constantly exposed to this). The total score received was divided by the total number of items (total score = 33); the score over one showed that the employee had been intentionally exposed to psychologically violent behaviors. The tool’s original internal consistency was 0.93. It was 0.95 in this study. General Health Questionnaire. The 12-item version of the General Health Questionnaire (GHQ-12) was developed by David Goldberg in 1972 to assess nurses’ psychological distress levels. The GHQ-12 is a scale surveying psychological distress observed within the last few weeks. The items were evaluated on a 4-point Likert-type scale. Scoring was as follows (a) and (b), 0 points; (c) and (d), 1 point; and the total possible score ranged between 0 and 12 points. A Turkish validity and reliability study of the questionnaire was conducted in 1996 by Kılıç. The tool’s internal consistency was 0.78 in Kılıç’s study. It was 0.91 in this present study.
Downloaded from tcn.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
3
Bardakçı and Günüşen
Data Collection The research team distributed the questionnaires to the nurses in the sample from May to July 2013. Each questionnaire included a cover page explaining the purposes and procedures of the study. The questionnaires were collected by the research team on completion.
Data Analysis Statistical Package for the Social Sciences (SPSS) for Windows version 16.0 (SPSS Inc., Chicago, IL) was used to conduct the data analysis. In order to assess the relationship between the nurses’ sociodemographic characteristics and their exposure to bullying behaviors, chi-square analysis was used. When the nurses’ psychological distress scores were compared with their exposure to bullying, the data were analyzed using the Mann–Whitney U test, because they did not conform to the normal distribution.
Ethical Considerations Ethical approval to conduct the study was obtained from the Ethical Committee of the Dokuz Eylül University Institute of Health Sciences (decision numbered 154 and dated March 3, 2011). The relevant university ethics committee approved this research. All the questionnaires were answered anonymously. A description of the survey provided the purpose of the study and clearly stated that the data would only be used for scientific exploration. Contact information was provided along with the questionnaire. The nurses were asked to seal the completed questionnaires in individual envelopes provided by the research team.
Results The relationship between the sociodemographic characteristics of the nurses and their exposure to bullying behaviors is given in Table 1. Of the nurses, 97.5% were female, and 65.4% were married. The majority of respondents had a bachelor’s degree in nursing (83.3%). Most of the participants worked in intensive care units (30.6%). Of the nurses, 31.7% had 0 to 5 years of professional experience, whereas 29.2% had 16 or more years. Their mean age was 34.14 ± 7.69 years. There was a significant difference between the nurses in terms of the relationship between their education levels and their exposure to bullying behaviors. The factor that led to this difference was the mean score of nurses with master’s degrees. According to this study, these nurses were exposed to more bullying than the others. In terms of other variables (age, total years of service, years of service, and position at their current institution), no statistically significant difference was determined (p > .05). Table 2 shows exposure to bullying behaviors, perpetrators of bullying behaviors, and nurses’ reactions to bullying
Table 1. Relationship Between Demographic Characteristics of the Nurses and Their Being Exposed Bullying (N = 284). Exposure to bullying
Yes (≥1) n
%
No (
Influence of Workplace Bullying on Turkish Nurses' Psychological Distress and Nurses' Reactions to Bullying Ezgi Bardakçi and Neslihan Partlak Günüsen J Transcult Nurs published online 5 September 2014 DOI: 10.1177/1043659614549073 The online version of this article can be found at: http://tcn.sagepub.com/content/early/2014/09/03/1043659614549073
Published by: http://www.sagepublications.com
On behalf of:
Transcultural Nursing Society
Additional services and information for Journal of Transcultural Nursing can be found at: Email Alerts: http://tcn.sagepub.com/cgi/alerts Subscriptions: http://tcn.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Sep 5, 2014 What is This?
Downloaded from tcn.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
549073
research-article2014
TCNXXX10.1177/1043659614549073Journal of Transcultural NursingBardakçı and Günüşen
Research Department
Influence of Workplace Bullying on Turkish Nurses’ Psychological Distress and Nurses’ Reactions to Bullying
Journal of Transcultural Nursing 1–6 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614549073 tcn.sagepub.com
Ezgi Bardakçı, RN1, and Neslihan Partlak Günüşen, PhD1
Abstract Purpose: The study aims to determine the influence of bullying on nurses’ psychological distress. Design: A descriptive design was adopted. The study sample included 284 nurses of a university hospital in Izmir, Turkey. The Workplace Bullying Behavior Scale and the General Health Questionnaire were used. Results: After the study was completed, it was determined that nurses with a master’s degree were exposed to bullying more and that nurses exposed to bullying suffered higher levels of psychological distress and preferred to keep silent about it. Perpetrators of bullying were mainly head nurses. Discussion/ Conclusions: Bullying is a common workplace phenomenon, and in most cases, nurses bully each other. Bullied nurses suffer more psychological distress. Implications: Managers of health care institutions should always remember that nurses have a higher risk of exposure to bullying and that measures should be taken to support nurses. Keywords bullying, mental health, nursing
Introduction Health care organizations are among the workplaces where bullying is a common phenomenon (Çamcı & Kutlu, 2011). Among health care professionals, nurses are more exposed to bullying than any other health care team member (EstrynBehar et al., 2008; Quine, 1999, 2001; Rutherford & Rissel, 2004). In the literature, 20% to 44% of nurses are reported to have been subjected to bullying (Quine, 2001; Trepanier, Fernet, & Austin, 2013; Yıldırım, 2009). The concept of bullying has been an international matter of concern for the past 20 years. When bullying was first identified, it was called as “mobbing” by Heinz Leymann (1996). He defined mobbing as psychological terror directed toward one individual by one or more persons in a systematic manner through hostile and unethical methods. In the nursing literature, generally mobbing is called bullying. Workplace bullying is defined as lateral or horizontal violence and currently attracts significant amount of international attention (Johnson, 2009). Bullied victims’ mental health is significantly affected: Victims suffer serious psychiatric, psychosomatic, and psychosocial problems (Leymann, 1996). In a study by Yıldırım and Yıldırım (2007), those exposed to bullying were reported to suffer from stress, headaches, and fatigue. A study conducted with health care providers in New Zealand revealed that people who are exposed to bullying were under more strain and their well-being was adversely affected (CooperThomas et al., 2013). In several studies of nurses exposed to
bullying, they displayed severe symptoms of anxiety and depression (Quine, 2001; Sa & Fleming, 2008; Zapf, 1999). Employees exposed to bullying reportedly suffered mental fatigue and psychological distress and displayed more psychosomatic symptoms (Agervold & Mikkelsen, 2004; Mikkelsen & Einarsen, 2002). Bullying has adverse effects not only on the health of employees but also on their work performance. Among bullied nurses, job satisfaction decreases, there is increased rates of sick leave and attrition, and there is decreased workplace productivity, satisfaction, and morale (Cleary, Hunt, & Horsfall, 2010; Quine, 2001). In a study conducted in Canada, nurses exposed to bullying had lower motivation and more intent to leave their jobs than did those who were not exposed to bullying (Trepanier et al., 2013). In order to prevent and reduce bullying, it is important to know which nurses are at risk of these behaviors, who the perpetrators of bullying are, and how nurses react to bullying. In the literature, there are studies indicating that demographic variables pose a risk in terms of bullying. It is reported that young and inexperienced nurses are more exposed to bullying (Çevik Akyıl, Tan, Sarıtaş, & Altuntaş, 1
Dokuz Eylül University, Izmir, Turkey
Corresponding Author: Neslihan Partlak Günüşen, Psychiatric Nursing Department, Dokuz Eylül University Faculty of Nursing, 35340 Balçova, Izmir, Turkey. Email: [email protected]
Downloaded from tcn.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
2
Journal of Transcultural Nursing
2012; Efe & Ayaz, 2010; Simons & Mawn, 2010; Yıldırım, 2009). On the other hand, some studies indicate that demographic variables do not pose any risk in terms of bullying (Mikkelsen & Einarsen, 2002; Yıldırım & Yıldırım, 2007). It has been reported that perpetrators of bullying, a serious problem for nurses, are mostly other nurses. Several studies have reported that those who perpetrate bullying the most are head nurses, followed by physicians (Çevik Akyıl et al., 2012; Efe & Ayaz, 2010). In a study conducted in New Zealand, it was revealed that the majority of the nurses were exposed to bullying by senior and older nurses (Clendon & Walker, 2012). The findings of several studies observed that although nurses’ mental health and work performance are adversely affected by the consequences of bullying, they prefer to remain silent and tend to share their discontent only with friends (Çevik Akyıl et al., 2012; Efe &Ayaz, 2010). Yıldırım and Yıldırım’s (2007) study indicates that nurses exposed to bullying try to avoid being bullied by working harder and more carefully. Bullying in the workplace is a serious issue for nurses and needs immediate attention. Nurses are responsible for protecting and improving the health of society and of individuals, so they should be mentally healthy if they are to fulfill their duties and responsibilities as expected (Özgür, Gümüş, & Gürdağ, 2011). Organizations providing health care should make protecting the mental health of nurses a top priority. Studies on bullying have been increasing in recent years. However, the number of the studies on the rate Turkish nurses are exposed to bullying, how they react when they are exposed to bullying, who the perpetrators of bullying in the workplace are, and how the nurses’ mental health is affected by bullying is limited. The results of this study are expected to contribute to an understanding of the nature of bullying, its impact on nurses, and nurses’ reactions to bullying. In addition, these results can contribute to attempts to raise awareness of this issue, and to reduce and even prevent bullying in the workplace. The aim of this study is to determine variables affecting bullying, the rate of exposure of nurses to bullying, perpetrators of bullying, nurses’ reactions toward bullying, and the level of psychological distress of nurses exposed to bullying.
Research Questions Research Question 1: Is there a relationship among the nurses’ workplace, age, educational status, total years of service, years of service at their current institution, position, and the bullying to which they are exposed? Research Question 2: What percentage of nurses are exposed to bullying? Research Question 3: Who are the perpetrators? Research Question 4: How do nurses react to bullying? Research Question 5: Is there a difference between the psychological distress levels of nurses who are the victims of bullying and who are not?
Method Design and Sample This descriptive study was conducted in 2013 on a sample of nurses working in a university hospital in Izmir, Turkey. Nurses at this 1,000-bed university hospital work 12-hour shifts for 180 hours a month and provide care for an average of 15 to 20 patients per shift. There are 757 nurses working in the hospital. The sample size was calculated to be 262 using a sample calculation formula in universally known situations (Sümbüloğlu & Sümbüloğlu, 2005). To increase reliability, more participants were needed. For this reason, all the nurses (N = 757) were invited to participate in the study; 284 nurses completed and returned the questionnaires. The participation rate was 37.5%.
Instruments Nurse Information Form. This questionnaire included factors such as age, educational status, total years of service, years of service, and position at their current institution, all of which can affect bullying. In addition, in the questionnaire, the nurses were asked about the identities of their perpetrators and how they react to bullying. Workplace Bullying Behaviors Scale. To measure the nurses’ perception of bullying in the workplace, a 33-item tool developed by Yıldırım and Yıldırım (2007) was used. The nurses were asked to mark the frequency of bullying behaviors that they had been exposed to within the last 12 months and which had negative effects on their work performance. The tool had four subcategories. Psychological violence in the workplace was discussed under four main headings: “isolation from work,” “attack on professional status,” “attack on personality,” and “direct attack”. The items were evaluated on a 6-point Likert-type scale ranging from 0 (I have never been exposed to this) to 5 (I am constantly exposed to this). The total score received was divided by the total number of items (total score = 33); the score over one showed that the employee had been intentionally exposed to psychologically violent behaviors. The tool’s original internal consistency was 0.93. It was 0.95 in this study. General Health Questionnaire. The 12-item version of the General Health Questionnaire (GHQ-12) was developed by David Goldberg in 1972 to assess nurses’ psychological distress levels. The GHQ-12 is a scale surveying psychological distress observed within the last few weeks. The items were evaluated on a 4-point Likert-type scale. Scoring was as follows (a) and (b), 0 points; (c) and (d), 1 point; and the total possible score ranged between 0 and 12 points. A Turkish validity and reliability study of the questionnaire was conducted in 1996 by Kılıç. The tool’s internal consistency was 0.78 in Kılıç’s study. It was 0.91 in this present study.
Downloaded from tcn.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
3
Bardakçı and Günüşen
Data Collection The research team distributed the questionnaires to the nurses in the sample from May to July 2013. Each questionnaire included a cover page explaining the purposes and procedures of the study. The questionnaires were collected by the research team on completion.
Data Analysis Statistical Package for the Social Sciences (SPSS) for Windows version 16.0 (SPSS Inc., Chicago, IL) was used to conduct the data analysis. In order to assess the relationship between the nurses’ sociodemographic characteristics and their exposure to bullying behaviors, chi-square analysis was used. When the nurses’ psychological distress scores were compared with their exposure to bullying, the data were analyzed using the Mann–Whitney U test, because they did not conform to the normal distribution.
Ethical Considerations Ethical approval to conduct the study was obtained from the Ethical Committee of the Dokuz Eylül University Institute of Health Sciences (decision numbered 154 and dated March 3, 2011). The relevant university ethics committee approved this research. All the questionnaires were answered anonymously. A description of the survey provided the purpose of the study and clearly stated that the data would only be used for scientific exploration. Contact information was provided along with the questionnaire. The nurses were asked to seal the completed questionnaires in individual envelopes provided by the research team.
Results The relationship between the sociodemographic characteristics of the nurses and their exposure to bullying behaviors is given in Table 1. Of the nurses, 97.5% were female, and 65.4% were married. The majority of respondents had a bachelor’s degree in nursing (83.3%). Most of the participants worked in intensive care units (30.6%). Of the nurses, 31.7% had 0 to 5 years of professional experience, whereas 29.2% had 16 or more years. Their mean age was 34.14 ± 7.69 years. There was a significant difference between the nurses in terms of the relationship between their education levels and their exposure to bullying behaviors. The factor that led to this difference was the mean score of nurses with master’s degrees. According to this study, these nurses were exposed to more bullying than the others. In terms of other variables (age, total years of service, years of service, and position at their current institution), no statistically significant difference was determined (p > .05). Table 2 shows exposure to bullying behaviors, perpetrators of bullying behaviors, and nurses’ reactions to bullying
Table 1. Relationship Between Demographic Characteristics of the Nurses and Their Being Exposed Bullying (N = 284). Exposure to bullying
Yes (≥1) n
%
No (
