OA 2_Prevalence of Bullying _Cency Baburajan.indd Original Article IJOSH, Volume 9, No, 1, 2019 (ISSN 2091 – 0878) 8 International Journal of Occupational Safety and Health (IJOSH) DOI: https://doi.org/10.3126/ijosh.v9i1.25161 Corresponding Author Dr. Naveen Ramesh Division of Occupational Health Services, Department of Community Health, St. John’s Medical College, Bangalore 560034. India. Phone: +91 9448927400 E-mail: drnaveenr@gmail.com Available Online at https://www.nepjol.info/index.php/IJOSH International Journal of Occupational Safety and Health, Vol. 9 No. 1 (2019), 8-12 This journal is licensed under a Creative Commons Attribution- Non Commercial 4.0 International License. Prevalence of Bullying among Nurses in a Tertiary Hospital, Bangalore Cency Baburajan1, Sakthi Arasu2, Ramesh Naveen3 1Dr. Cency Baburajan, MBBS, Post Graduate, MD (Community Medicine) 2Dr. Sakthi Arasu, MBBS, Post Graduate, MD (Community Medicine) 3Dr. Ramesh Naveen, MBBS, MD (Community Medicine) ORCID ID: 0000-0001-5269-7186 Institutional affiliation: Division of Occupational Health Services, Department of Community Health, St. John’s Medical College, Bangalore 560034. India. Abstract Background: In the last decade, research conducted in different countries has shown that bullying in the health care sector especially among nurses is a widespread and serious problem. Bullying of nurses at workplace affects their quality of life, hinders delivery of quality healthcare andcontributes to increase inworkplace stress.So, this study was conducted to assess the prevalence of work place bullying among nurses working in a tertiary care hospital in Bangalore. Methodology: This study was conducted among 300 staff nurses providing in-patient services in a tertiary health care hospital located in Bangalore. The required sample was selectedutilizing the documents maintained in the office of Chief of Nursing Services and using computer generated random numbers. The data was collected using self-administered questionnaire which comprised of socio-demographic factors and Negative Acts Questionnaire- Revised. Results: Among the 297 respondents, 26.9% were victims of bullying in the past six months according to Negative Acts Questionnaire-Revised(NAQ-R). Among the participants who were bullied, those exposed to work-related bullying, person-related bullying and physical intimidation were 80%, 60% and 21.3% respectively. Conclusion: This study suggests existence of work place bullying among nurses which can adversely affect their performance as health care professionals and their quality of personal life. Key words: bullying, distress, harassment, health care, nursing staff, violence Introduction Nurses are paramount in the provision of health care. They have a signifi cant impact on the health of individual and therefore the society. There is an increasing demand for nurses due to multiple factors viz; an aging population, greater diversifi cation in society, multiculturalism, marginalized populations and increasing technologies.1According to a study, “Bullying is defi ned as a situation in which someone is exposed to hostile behavior on the part of one or more persons in the work environment which aim continually and repeatedly to off end, oppress, maltreat, or to exclude or isolate over a long period of time”.2 Verbal abuse, threats, humiliation, intimidation, and behaviors that interfere with job performance are all considered workplace bullying. Workplace bullying may also include accusations of incompetence in the area of practice, gossiping about co-workers, withholding information pertinent to patient care, constant feelings of stress and fear of additional bullying events.3Workplace bullying has negative implications on the victim’s health and work performance.4There may be an increase in incidence and severity of harassment in the health 9International Journal of Occupational Safety and Health (IJOSH) Prevalence of Bullying among Nurses in a Tertiary Hospital, Bangalore sector due to factors likeinadequate staffi ng, quality of servicesnot meeting the expectation of patients and demand of the patients family members can increase stress on health workers. Such situations contribute to co-worker harassment and reduced staff morale. There are also instances where there is observed gender based harassment against nurses.5 Intense stress and anxiety of bullying can cause a variety of physiological, psychological and social problems.2 Individuals experiencing bullying at work have poor job satisfaction, work performance, motivation and effi ciency, while their social relations suff er both at work and home.2 According to WHO, bullying reported often from workplace has adverse impact on mental health like depression and anxiety.6The National Health Policy 2017 by Government of India has identifi ed reduced stress and improved safety in workplace as one of the priority areas to improve the environment for health.7 Bullying in the nursing workplace has been identifi ed as a factor that hinders the delivery of quality healthcare causing poor patient outcome. Moreover, due to the occupational stress some choose to leave the profession.8Recognizing the occurrence of bullying in workplace and early intervention to prevent it are important to avoid the various detrimental eff ects it has on nurses. Anti-bullying policies are adopted by governments in many countries, the implementation of these policies isstill regardedineff ective.9Accurately describing the phenomenon of bullying will be the fi rst step towards strengthening nursing as a considerate and sympathetic profession. Policies that will help in reducing and ultimately eradicating the occurrence of bullying in the workplace should be implemented to protect the nurses.10 Objectives To assess the prevalence of work place bullying among nurses working in a tertiary health care hospital in Bangalore. Methodology This was a cross-sectional study conducted over a period of six months. Approval from the Institution Ethics Committee and the Chief of Nursing Services of the concerned hospital were obtained prior to the study. Written informed consent was obtained from the participants. The required sample size was 270 (prevalence of bullying was taken as 30% based on a previous study).11 After obtaining the list of staff nurses, simple random sampling technique using computer generated random numberswas adopted to select the study participants. We distributed the questionnaire to 300 female nursing staff , providing in-patient services in medical and surgical wards in a tertiary hospital with a work experience of at least six months. Excluding the three participants who returned incomplete questionnaire, the fi nal number was 297. We have adopted self-labeling method in this study which explicitly asks if the subjects are exposed to bullying. The defi nition of bullying was included in the questionnaire based on which the respondents were requested to answer. Study tool Study tool included demographic details and NAQ-R (Negative Acts Questionnaire Revised).12Prior permission was obtained from the author to use NAQ-R which has a Likert scale 1-5 (never, now and then, monthly, weekly, and daily). Three subclasses of bullying are work-related bullying, personal bullying and physical intimidation. In order to do the analysis we have followed the Leymann criteria according to which, bullying acts take place on regular basis (at least once a week) over a long period of time (at least once in six months). A person is called a bullying target if he/she has been subjected to two negative acts (Mikkelsen and Einarsen).8A pilot study was conducted among 50 nursing personnel to measure reliability and face validity of NAQ-R questionnaire. Reliability was measured using Cronbach’s alpha, which was 0.8.the pilot study data was not included in this analysis. Data analysis Data was entered in Microsoft excel and analyzed using Statistical Package for Social Sciences (SPSS) version 16. Categorical variables were expressed in terms of absolute and relative frequencies. Quantitative variables were expressed in terms of mean, standard deviation and range. Chi-square test was used to detect potential association between two categorical variables. Chi-square value less than 0.05 was considered signifi cant. Results The response rate in this study was 99%. Socio-demographic profi le Among the 297 participants, mean age was 21.6±5.526 years (Range:21-53). The participants were from 14 diff erent states and majority, 158(53.2%) were from Kerala. Majority of them, 234(78.8%) were Christians 10 International Journal of Occupational Safety and Health (IJOSH) Cency Baburajan et al. and 233(78.5%) were unmarried. Among those who were married, 26(40.6%) had no children, 21(32.8%) had one child, 15(23.4%) had two children and the rest had three children. Majority 28(95.6%),spoke the local language which was Kannada. Table 1: Demographic distributio n of the study participants. Age distribution of the study participants Age Frequency Percentages 21 - 25 202 68.0 26 – 30 58 19.5 31 – 35 16 5.4 36 – 40 07 2.4 41 – 45 08 2.7 > 45 06 2.0 Study population by religion Religion Frequency Percentages Hindu 47 15.8 Christian 234 78.8 Muslims 01 0.3 Others 15 5.1 Marital Status of the study population Marital Status Frequency Percentages Unmarried 233 78.5 Married 62 20.9 Divorced 01 0.3 Widow 01 0.3 Predominant language spoken by study participants Mother Tongue Frequency Percentages Malayalam 173 58.2 Tamil 56 18.9 Kannada 30 10.1 Telugu 16 5.4 Hindi 03 1.0 Others 19 6.4 Socio-economic Classifi cation (based on modifi ed Kuppuswamy Classifi cation). Socio-economic Class Frequency Percentages Upper Class Upper Middle 169 56.9 Lower Middle 108 36.4 Upper Lower 18 6.1 Lower 2 0.7 Institution where studies (nursing course) Class Interval Frequency Percentages Study Institution 74 24.9 Diff erent Institution 223 75.1 Work profi le of the participants Among the study subjects, 132(44.4%) had work experience between six months to one year, 127 (42.8%) had up to two years and the rest had three or more years of experience working in the present hospital. Among the participants, 121(40.7%) had experience of working in other private hospitals. Qualifi cation wise, 133(44.7%) had completed General Nursing and Midwifery (GNM) course and 164(55.3%) had completed B.Sc. Nursing course. At the time of the study, 170(57.2%) and 127(42.8%) of nurses were working in medical and surgical related specialty wards respectively. Out of the total participants, 282(95%) of them were staff nurses and the rest were head nurses. None of them ever got any warning or suspension for misconduct in the work place. All the staff nurses were on six hour shifts and head nurses were on eight hour shifts. We explored the health profi le of the participants in terms of any physical deformities, health problems and if they were on any medication for psychiatric illness. One participant had physical deformity and another reported being on psychiatric medication. Lower back pain was the most common complaint among 25(8.4%) of participants who reported to have a health problem. Negative Acts Questionnaire Results A total of 80(26.9%) participants were targets of bullying, i.e., those who experienced two or more negative acts on a regular basis for the past six months. This was based on the response given by the subjects to the items in the questionnaire that were the examples of negative acts in the workplace. Assessing the prevalence of types of bullying based on the sub classes of the 22 item questionnaire showed that among the 26.9% of participants who were victims of bullying, 64(80%) of the participants were subjected to work place bullying, 48(60%) reported personal bullying and 17(21.3%) had faced physical intimidation. Concerning the 23rd item in the questionnaire stating “Have you been bullied at work?” with a defi nition of bullying given along with it, 241(81.1%) subjects stated that they were never bullied at work in the past six months, 37(12.5%) stated that they were bullied rarely, 14(4.7%) stated that they were bullied now and then, 5(1.7%) subjects stated that they were bullied several times in a week. Among the 56(18.9%) subjectswho were bullied based on the response to this question, 11International Journal of Occupational Safety and Health (IJOSH) Prevalence of Bullying among Nurses in a Tertiary Hospital, Bangalore 2(3.6%) of them reported that they were bullied by their immediate superiors and patients, 2(3.6%) subjects were bullied by doctors and colleagues, 1(1.8%) by other superiors and the rest of them did not disclose who bullied them. Based on gender, 7(12.5%) and 2(3.6%) of participants reported that they were bullied by female and male perpetrators respectively the rest reported that they were being bullied by both. During the process of bivariate analysis, no signifi cant association was found between bullying and socio- demographic factors like age, religion, state of origin, marital status, mother tongue, number of children if married and monthly family income. No statistically signifi cant association was found between bullying and work related factors of the participants including course completed, years of experience working in current /previous organization, department where the participant is posted, designation duty timings. No statistically signifi cant association was found between bullying and health related factors like presence of a health issue or physical deformity. Discussion In this study among nurses working in a tertiary care hospital, prevalence of bullying using NAQ-R was 26.9% among the 297 respondents. Majority were found to be the victims of work related and personal bullying. Even though only a smaller percentage of nurses reported to be subjected to physical intimidation it is also an issue of signifi cance. There are not many studies done in similar settings to compare the results that we have obtained, but studies done across the globe portrays the similar results.13-15Though the work conditions and exposure factors may vary, the presence of bullying in whatever form cannot be ignored. International Labor Organization reports that in the world of work there are several circumstances which increase the chance of harassment.14 These circumstances arise while working in contact with public, unsocial working hours like evening and night duties or working in areas providing public and emergency services. Nurses encounter such circumstances daily in their working environment. In a study conducted in Washington, 27.3% were victims of bullying experiencing 2 or more negative acts daily or weekly.15 Studies report varying prevalence of bullying like, study conducted in Northwest pacifi c reported 48% of bullying8, study conducted in public hospitals in Greece reported a prevalence of 30.2%.11 Underreporting of actual incidence of harassment is an actual fact16and which could be a reason for the diff erence in results between the present study and other studies. In our study, among those who were bullied, prevalence of workplace bullying is 80% and personal bullying is 60% which is similar to another study conducted in Turkey17 where most nurses faced hostility towards their status at work place and personality there was no statistically signifi cant association with age group, position, education and years of study. The study done in Turkey17 reports that depression symptoms of nurses were positively associated with experience of bullying.17Study conducted in United Kingdom on work place bullying reported that 29.6% of staff reported psychological distress.18 In the present study, the victims had faced bullying from their immediate senior, other seniors, colleagues and doctors. Being an educated community these individuals are expected to have high social intelligence and empathy. Work place bullying implies a lack of conscience and incapability to experience empathy which is dangerous for the nursing community who are supposed to be caring and show compassion to the community and their patients.19Bullying victims are four times more likely to experience depression and three times more likely to report problems in sleeping and twice likely to experience stress.20Our study has shown that bullying does exist, and the fi ndings are not very diff erent from other studies as mentioned above. Limitation In our study, we were only able to understand whether the participants perceived themselves to be bullied by administering the questionnaire.This is subjective since individuals have diff erent threshold of dealing with circumstances. Conclusion Bullying among nurses is a problem that needs to be addressed with care and concern. Work place bullying was the most common, followed by personal and physical intimidation. The perpetrators were either their immediate supervisors, doctors, patient or their attenders and colleagues and belonged to same or opposite gender. Work place counseling, professional and/or peer support and healthy working environment are of paramount importance to tackle workplace bullying. 12 International Journal of Occupational Safety and Health (IJOSH) Cency Baburajan et al. References 1. Clarke C. The eff ects of bullying behaviors on student nurses in the clinical setting. 2009;148. 2. 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