The Relationship between Workplace Bullying and Quality of Nursing Work-Life in the Intensive Care Units

Background: The World Health Organization (WHO) identiﬁed the worldwide increase in workplace bullying as a serious threat to nurses’ health, well-being and reported the need to eliminate workplace bullying (WPB) as a high priority. Nurses as the major group of health service providers need to have a satisfactory quality of work life in order to give desirable care to all patients in the hospital, and WPB is one important factor that lead to a decline in nurses’ quality of work-life, satisfaction as well as their efficiency and competency. Aim: to investigate the relationship between workplace bullying and the quality of nursing work life in the intensive care units at Damanhour Chest and Fever Hospitals. Settings : This study was conducted at the Intensive Care Units at the main two hospitals at El-Beheira governorate namely: Chest Hospital and Fever Hospital. Which are affiliated to the Ministry of Health and Population. Subjects: The subject of this study included all nurses who were working in the previously mentioned setting with experience more than 6 months (n=145). Tools: two tools were used. Tool one: “The Negative Act Questionnaire (NAQ)". Tool two: “Quality of Nursing Work Life Instrument ( QNWL)". Results: The study showed that 79.3% of the studied nurses had a moderate level of workplace bullying and the highest dimension was related to physical and psychological intimidation .Furthermore, the total level of quality of nursing work life was fair and the highest dimension was related to work warld Conclusion: The study results also indicated that there was no statistically significant correlation between workplace bullying and quality of work life among the studied nurses Recommendations: Adopt zero tolerance policies that include appropriate investigation and due process necessary to provide adequate safeguards to nurses and others who are accused of WPB, encourage nurses to report the incidence of bullying behaviors without fear and promote a culture of safety that encourages open and respectful communication among all healthcare providers.


Introduction
Workplace bullying (WPB) is a major problem in many organizations all over the world across multiple sectors.(Rosander & Blomberg, 2019).WPB is one of the most prevalent work-related psychological and physical issues in health care services (Obeidat etal., 2018).Health care individuals especially nurses, are mostly exposed to WPB, because it is in the context of health care services that includes interaction among such different groups as coworkers, supervisors, patients, families, visitors, and others (De Cieri etal., 2019).WPB is a repeated negative behavior by making the recipient of the bullying feel inferior and it can be a concept that is related to bias, since both are forms of unfair treatment in the workplace ( Moceri, 2014).
Workplace bullying can be overt or covert (Sauer,2013).Overt WPB is described as a direct bullying behavior toward a target using obvious aggressive conduct such as criticizing, threatening or blaming another individual for their own mistake ( Burgess & Curry, 2014).While, covert WPB is defined as passive or an indirect bullying behavior toward a target in an indirect aggressive conduct which can be more subtle, often hidden, a form of non-physical, aggressive behavior pointed at causing harm through peer relation , feeling of acceptance ,friendships and self-esteem that result in social and psychological harm which is more hurting than physical one ( Olsen etal.,2017;Hutchinson &Jackson, 2015).
Workplace bullying implies three main dimensions that include person and work-relating bullying, physical and psychological intimidation bullying and occupational devaluation bullying (Einarsen etal.,2010).Person relating bullying contain items that are interpreted as direct or indirect act of bullying and personal in nature.While, work related bullying means direct or indirect act of bullying that is occupational in nature.Physically and psychological intimidating bullying mean form of bullying contain items that are interpreted as direct or indirect act of bullying menacing in nature ,such as yelling while invading personal space and actual or potential violence.Finally, the occupational devaluation bullying contain two items such as being ordered to do work below your level of competence and having key area of responsibility removed or replaced with more trivial or unpleasant task (Threadgill,2013).
Workplace bullying behaviors encountered in the workplace negatively affects staff nurses physical and psychological health as well as well-being, patient (altered patient safety) and health care organization as whole (Albishi &Alsharqi,2018).The effects of WPB on staff nurses including ;physical symptoms such as headaches, hypertension , palpitations ,increase in substance abuse, gastrointestinal upset, changes in sleep patterns, excessive weight gain or loss, .etc;psychological symptoms such as difficulty concentrating, increased anxiety, depression, post-traumatic stress disorder.etc and behavioral symptoms includes irritability, loss of concentration, forgetfulness, emotional outbursts, exaggerated feeling about external stimuli, family problem, divorce, deterioration of psychological well-being, and poor quality of nursing work life ( Ganz etal.,2015;Yoo & Lee , 2018;Mahmoud etal., 2020) .
Quality of nursing work life (QNWL) is defined as "the degree to which nurses are able to satisfy important personal needs through their experiences in work while achieving the organizational goals ( Almalki etal., 2012 ;Alharbi etal.,2019).The concept of QNWL pronounces the method by which an organization can safeguard the holistic well-being of nurses rather than only concentrating on job-related features ( Devi & Hajamohideen, 2018).
Quality of Nursing Work Life implies four main dimensions that include work and home life, work design, work context, and the work world dimension.The work and home life dimension explores the interactions nurses have between their work and home life reflected in their roles as a parent, spouse or child caring for elderly relatives , while the work design dimension explores aspects of nurses' work environments that include issues related to workload, staffing, and autonomy, also the work context dimension include the practice settings in which nurses work and explores the impact of the work environment on both nurse and patient systems, finally the work world dimension which examines broader societal influences impacting nurses such as society's image of nurses (Agus & Selvaraj, 2020;Horrigan, 2018) Improving QNWL result in many advantages for nurses and patients.It has a great impact on staff nurses' satisfaction.
Nurses' satisfaction with their QWL can improve performance; reduce absence on a job, professional draining, and work-related injuries.In addition, it increases job pleasure and satisfaction with most aspects of life in general (Sinha, 2012;Elshahat etal., 2019).
A high QNWL helps Health Care Organization to attract new staff and retain a workforce.Positive results of QNWL include strengthening organizational commitment, and job satisfaction, increasing individual and organizational productivity, decreasing burnout, having individual and organizational turnover and becoming highly competitive.Further, QNWL is important for the quality of patient nursing care, the ability to encounter the patient's needs, the high standards of care, and the improvement of patient health outcomes ( Lee etal., 2015;Venkataraman etal., 2018 ;Nowrouzi etal.,2016).

Aims of the Study
This study aims to investigate the relationship between workplace bullying and the quality of nursing work life in the intensive care units at Damanhour Chest and Fever Hospitals.In addition, nurses' personal and work related characteristics data sheet was developed by the researcher to collect data from nurses` such as age, sex, marital status, job title, educational qualifications, years of experience in nursing, hospital experience, unit experience, working hours per week and source of bullying behaviors as reported by staff nurse.

Method:
An official permission was obtained from the Dean of the Faculty of Nursing, Damanhour University and the responsible authorities of the study settings at Damanhour chest and fever Hospital, after explanation of the purpose of the study.The two tools were translated into Arabic by the researcher and were submitted into both Arabic and English languages to a jury consists of five experts in the field of the study at the Faculties of Nursing e.g., Alexandria and Damanhour University to test its content validity and translation.They were: two professors, and two lecturers from nursing administration department, Faculty of Nursing Alexandria University, and one assistant professor from nursing administration department, Faculty of Nursing Damanhour University.Accordingly, the necessary modifications were done based on their opinions.A pilot study was carried out on 10% of staff nurses (n=15), who were excluded from the study sample; in order to check and ensure the clarity of items, identify obstacles and problems that may be encountered during data collection and the necessary modifications were done.

Data collection
Data were collected from the staff nurses through distribution of self -administered questionnaire after explaining the aim of the study at the work settings using the previously mentioned tools.Instructions were given before the distribution of the questionnaire.The questionnaire was completed in the presence of the researcher to ensure the objectivity of staff nurses' responses, non-contamination of their opinions, and to check that all items were answered.Answering the questionnaire took approximately15-20 minutes.Data collection took a period of three months starting from 15/ 1/2021 -11/4/2021.All questions were answered, and explanations were given accordingly.

Ethical considerations:
The research approval was obtained from the ethical committee at the Faculty of Nursing-Damanhour University, prior to the start of the study.An informed written consent was obtained from the study subjects after explanation of the aim of the study.Anonymity of the study subject will be considered.Privacy and confidentiality regarding data collected were maintained and assured.Right to refuse to participate or withdraw from the study at any time were ensured during the study.

Statistical Analysis
Suitable statistical analysis tests were used to identify significant relations and answer research question.The collected data were coded and entered in special format to be suitable for computer feeding .Following data entry, checking and verification process were carried out in order to avoid any errors.Data were analyzed using the statistical package for social science SPSS (version 20) .Tables were constructed and graphs were developed .Quantitative data were described using numbers, percentages and the range, arithmetic mean, standard deviation and median .Significance of the obtained results was judged at the 5% level.Qualitative data were described using number and percent .Data were classified into numerical or categorical as appropriate.
The following statistical analysis measures were used : Descriptive statistical measures, which included: numbers, percentages, and averages (Minimum, Maximum, Arithmetic mean ( X ), Standard deviation (SD).Statistical analysis tests, which included: Chi square, student T test and paired T test.Associations between categorical variables were tested using Chi-Square test.The F test with used to test the significant differences between more than two means.Graphical presentation included: Bar graphs were done for data visualization.Reliability coefficient of bullying scale 0.835.Reliability coefficient of quality of nurse work life scale 0.920

Results
Table 1 shows distribution of the studied nurses according to their demographic and work related characteristics.It displays that 49 % of the studied nurses were in the age group ranged from 20 to less than 30 years old, slightly above one third of them (35.9%) were in the age group ranged from 30 to less than 40 years old.The majority of the studied nurses (84.8 %) were female.In relation to their marital status, it was found that slightly above three quarters of them( 79.3 % )were married.With respect to educational qualifications, 65.5 % of the studied nurses held Technical Nursing Institute Diploma, while, slightly more than one third (34.5%) of them held bachelor science in nursing (BScN).
Regarding years of experience in nursing , it was noticed that slightly more than one third of the studied nurses (37.2 %) had years of experience in nursing ranged from 5 to less than 10 years , and 33.1 % had years of experience ranged from 5to less than 10 years in the current working hospital.In relation to working hours per week, the vast majority of the studied nurses (93.1%) working 36 hours and above per week .As regard to source of bullying behaviors as perceived by staff nurses , slightly more than three quarters (75.9 %) of them reported that bullying persons were related to administrators, while the rest of them reported that bullying person was related to colleagues, patients and relatives (45.5%, 35.9%) respectively.
Table 2 illustrates that the highest mean score of exposure to workplace bullying behaviors as perceived by studied nurses was related to physical and psychological intimidation dimension ( 9.850 ± 2.174) with mean percentage score 65.67%.In addition, the total mean score of exposure to workplace bullying was 68.77 ± 10.69 with mean percentage score 62.52%.This indicates that the studied nurses perceived moderate exposure to workplace bullying behaviors.
Table 3 illustrates that the highest mean scores of quality of work life as perceived by the studied nurses was related to work world dimension (11.18 ± 2.117) with mean percentage score 74.53%.In addition, the total mean score of quality of nursing work life was (90.50 ± 14.45) with mean percentage score 71.83% as perceived by the studied nurses.This indicates that the studied nurses perceived moderate quality of work life.Table 4 displays that there was no statistically significant correlation between workplace bullying and quality of work life among the studied nurses.

Discussion
The World Health Organization (WHO) identified that the worldwide increase in workplace bullying as a serious threat to nurses' health and well-being .Also, WHO identified the need to eliminate workplace bullying (WPB) as a high priority (WHO,2010).Nurses as the major group of health service providers need to have a satisfactory quality of work life in order to give desirable care to all patients in the hospital.WPB is one important factor that lead to a decline in nurses' worklife quality, satisfaction as well as their efficiency and competency (Asadi etal., 2019: Eslamian etal.,2015).Nurses working in the intensive care units ( ICUs ) providing care for critically ill patients, contact with health care staff from numerous departments, and must keep up-to-date with the most advanced treatment and medical technology.Therefore, it is known that they are exposed to more work-related stress rather than any other nurses (Yun etal.,2014: Chatziioannidis etal.,2018).
The result of this study concluded that the highest mean scores WPB dimension was related to physical and psychological intimidation.In this respect, Threadgill (2014) stated that physically and psychologically intimidating bullying is a form of bullying behaviors interpreted as the highest act of bullying threatening in nature.From a different point of view, this result is antagonized by Kim etal., (2019), Yun et al., (2014) and Simon (2008) who reported that the frequency of intimidation-related bullying among nurses was relatively low.
Regarding to the bullying person, the present study revealed that the majority of the studied nurses reported that the highest bullying person was related to nursing administrators From the researcher's point of view, this may be due to higher power distance, excessive supervision from head nurses, supervisors and hospital director to monitor staff nurses' adherence to all hospital policies, especially infection control practices to avoid prevalence of covid 19.In addition, irregular schedules that interfere with family life, excessive work monitoring with lack of resources and scares from transmit infection to their family..This result is supported by Chatziioannidis et al., (2018) andMcMahon et al., (2013) who detected that the most common source of bullying was related to supervisors and managers.On the other hand, this result is contradicted with Hassan andRashwan (2021), butler etal., (2018) and Khoshknab et al., (2015) who reported that the most bullying behaviors was related to patients and visitors.
As for the perception of quality of nursing work life (QNWL), the result of this study concluded that the highest mean score QNWL dimensions was related the work world dimension.Based on the result finding nurses believes that the salary is adequate and the society has correct image about nursing.From the researcher's point of view, this may be due to the high cost of living and poor economic conditions, so nurses are pressured and forced to work to achieve financial demands to satisfy personal and family needs.In addition, the hospital management provides incentives and rewards for nurses who work hard during quarantine time as the majority of nurses work double shifts to gain money during covid period.This result is supported by Mosisa et al., (2018) who stated that about half of studied nurses responded as society has good image for their profession.This result is antagonized with Davoodi et al., (2020) and Elshahat et al.,(2019) who stated that the work world dimension had the lowest scores.
The study results also indicated that there was no statistically significant correlation between WPB and QNWL among the studied nurses.This result contradicted with Peng et al.,(2021) who stated that WPB had negative and direct effects on the professional quality of life of nurses.In addition, Kim and Bae (2019) who stated that the QNWL had negative correlations with the experience of WPB.Also, Kim etal., (2019) showed that there was a statistically significant correlation between WPB and QNWL.As regard workplace violence as sub-dimension of WPB, Eslamian etal., (2015) concluded that workplace violence is a negative element reducing nurses' work life quality and demonstrated that there is a negative correlation between the quality of work and the frequency of exposures to physical and verbal violence.

Conclusion
The finding of this study concluded that more than three quarter of the studied nurses had moderate levels of workplace bullying and the highest mean score was related to physical and psychological intimidation.In addition, more than half (55.9%) of the studied nurses had moderate level of quality of nursing work life and work world dimension was perceived as being the highest means score.There was no statistically significant correlation between nurse's workplace bullying levels and quality of work life.

Recommendations
Based on the findings of the present study, the following recommendations are suggested : The hospital administrators should : Adopt zero tolerance policies that include appropriate investigation and due process necessary to provide adequate safeguards to nurses and others who are accused of WPB.
Be held accountable for modeling professional behaviors and acts as role model Hold mediation and reconciliation programs to intervene and achieve harmony among nurses whose relationships have been affected by workplace bullying to ensure peaceful and adequate communication between them.
Promote a culture of safety that encourages open and respectful communication among all healthcare providers.Develop a positive no blame culture in the work environment that supports a high level of professionalism through leading by example, champion respect, and set the tone and expectations for behaviors essential for fostering a harmonious and collaborative environment.
Encourage victims to report incidence of bullying behaviors in the hospital to functional disciplinary committees.

The nurse managers should :
Encourage staff nurses to adhere to policy and procedure that prevent workplace bullying Design manual/brochure to identify the antecedent's behavior of workplace bullying from nurses to nurses, manger to nurses, from patient to nurse and from relative to nurses Encourage nurses to report incidence of bullying behaviors without fear.

Nurses should:
Attend workshops for nurses about coping strategy to manage workplace bullying Encourage nurses to document the incident of bullying and submitted it to first line nurse manager .
be educated to accept only a zero tolerance to bullying and to report incident of WPB Further researches are needed to : • Identify the effective strategies to eliminate bullying behaviors .
• Investigate the impact of workplace bullying on the patient safety and organizational outcomes .
• Investigate relationship between nurses 'exposure to workplace bullying and their organizational citizenship behaviors.