Original Article

Mobbing against nurses in the workplace in Turkey inr_815 328..334

S.Y. Efe1

MSN

& S. Ayaz2 PhD

1 Specialist, 2 Assistant Professor, Nursing Department, Gazi University Faculty of Health Sciences, Ankara, Turkey

EFE S.Y. & AYAZ S. (2010) Mobbing against nurses in the workplace in Turkey. International Nursing Review 57, 328–334 Aim: The aim of the study was to determine whether the nurses have been exposed to mobbing or not, and to reveal the causes of the mobbing between 3 November 2008 and 31 December 2008. Methods: This research was a mixed method study involving survey and focus group interviews. The sample was calculated using sample calculation formula, and 206 nurses were included in the survey study. Four focus group interviews were later carried out with 16 nurses. The survey method and semi-structured question form were used to collect data. The percentage and chi-square were used to evaluate the quantitative data, and for the analysis of the qualitative data, descriptive analyses were made through direct quotations from the nurses’ statements. Findings: According to the mobbing scale, 9.7% of the nurses had been exposed to mobbing, but according to their own declarations, 33% had been exposed. Some of the nurses (25.2%) who expressed that they had been exposed to mobbing reported that the executor of mobbing was the head nurse and 9.2% said that the reason for mobbing was ‘communication problems’. Nurses under 25 years of age and those who work in intensive care units are apparently exposed to mobbing more frequently than others (P < 0.05). Conclusions: It is suggested that head nurses’ mobbing behaviours should be determined and they should be educated about leadership. Nurses should be educated about assertiveness to prevent mobbing. The necessary measures should be adopted to solve the ‘communication problems’, which are shown as a major reason for mobbing. Keywords: Harassment, Mobbing, Nurse, Turkey, Workplace

Introduction
Mobbing is the activity of a person to force someone out of the workplace through rumour, innuendo, intimidation, humiliation, discrediting and isolation (Davenport et al. 2003). Emotional harassment behaviours are difficult to determine because they are mostly psychological rather than physical. They are composed of numerous systematic events that are very small and can be unimportant and meaningless when considered in isolation. Usually, the executor is not a single person, and the activity
Correspondence address: Sultan Ayaz, Gazi Üniversitesi Saglık Bilimleri Fakültesi ˘ Hemsirelik Bölümü, 06500 Besevler, Ankara, Turkey; Tel: 0090-312216-26-23; ¸ ¸ Fax: 0090-312216-26-36; E-mail: sultan@gazi.edu.tr.

is usually prepared secretly, behind closed doors. For this reason, the verification of mobbing is practically impossible. However, the victim’s quitting work, making big mistakes or giving extreme reactions because of pressure happen publicly (Baykal 2005). In recent years, people who work in the education, social services and health-care sectors have been increasingly exposed to emotional pressure, both in developed and developing countries (Chappell & Di Martino 2006). Hospitals are crowded and intense workplaces. Hard working conditions, shift working, insufficient wages (especially in government institutions) and injustices in profession advancement can trigger emotional harassment (Davenport et al. 2003). Research shows that nurses

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are under more risk of emotional pressure than other health-care professionals (Randle 2003). Desley et al. (2003) have shown that nurses are exposed to emotional harassment more than other workers, and the executors are other health professionals, patient relatives, patients, nurse colleagues and director nurses, consecutively. People who are exposed to mobbing can have insufficient job satisfaction and motivation, high stress levels, sleep disorders, anxieties from undefined causes and blood pressure problems (Özdevecioglu 2003). Victims of mobbing have emotional and ˘ physical health problems (Hecker 2007; Laçiner 2006). Excessive stress in the work area causes pressure, exhaustion and intimidation for all workers at every level. Employees lose their feelings of dependence and faith in the organization. Higher administration levels lose all respect, and the capacity to control relationships and the organizational hierarchy start to lose functionality (Tutar 2004). Emotional pressure is a result of a ‘control culture’. In those institutions that allow the occurrence of emotional harassment, not only is the safety of staff compromised, but also all the potentials and functions of the institutions are hindered (Adams 1997). The Royal College of Nursing (RCN 2002) stated that many nurses are exposed to emotional harassment, but only 6% officially complain about it, while others prefer to remain silent out of fear of being exposed to emotional harassment (Randle 2003; Whittington et al. 1996). Mobbing is a relatively new concept, and studies performed in Turkey to reveal mobbing are not adequate. Therefore, the revealing of this situation, which potentially affects all nurses, analysing the reasons and results, and improvement of working conditions, are necessary.

Human behaviour is best researched by a flexible and holistic approach. In this sense, in a qualitative approach, the ideas and the experiences of people participating in the study are very important (Holloway & Wheeler 1996). For this reason, focus group interviews were conducted within the study. The reasons for preferring focus group interviews for collecting qualitative data are that mobbing happens in the workplace and the witnesses are other colleagues. By using focus group interviews, the ideas and experiences of nurses who were victims of mobbing or who had witnessed it were collected. Arising from the quantitative data obtained from the research, four focus groups were held: Three focus groups were constituted with nurses from the departments in which mobbing was intensely experienced (intensive care units, emergency clinic) and one focus group was constituted with head nurses. There were four nurses in each focus group with a total of 16 participants.
Data collection

Quantitative and qualitative methods were used for data collection.
Collection of quantitative data

Methods
Design and sample

This research was a mixed method study involving a survey and focus group interviews. The aim of the study was to determine whether the nurses have been exposed to mobbing or not, and to reveal the causes of the mobbing. The questionnaire was administered between 3 November 2008 and 31 December 2008. The population of the study comprised all nurses (350) working in an Ankara teaching hospital. The sample size was calculated to be 183 using a sample calculation formula in universe-known situations (Sümbüloglu & Sümbüloglu 2005). ˘ ˘ To increase reliability, more participants were needed. For this reason, all nurses who agreed to participate were included in the study. All nurses were informed about the study and their informed consents were obtained. Approximately 60% of the nurses accepted participating in the study, and in total, 206 nurses formed the sample group.

A three-part questionnaire was used to collect data. The questionnaire was developed by the researchers, according to the literature (Davenport et al. 2003; Farrell 2001; Jackson et al. 2002; Woelfle & McCaffrey 2007). The first part included questions about the socio-demographic characteristics of nurses; the second part included open-ended questions about their opinions of mobbing. The third part comprised the mobbing scale. To determine reliability and validity of the questionnaire form, it was pre-tested on a convenience group of nurses (n = 40) who worked in another hospital. The questions considered unclear were revised. During face-to-face interviews conducted at the hospital, the questions on the form were asked with the nurse alone. Interviews lasted between 20 min and 30 min.
Collection of qualitative data

Qualitative research methods and procedures were employed in the present study because of its focus on the interaction patterns of nurses. Using qualitative methods enables the researcher to obtain or explore nurses’ perspectives and experiences in their own words. During the interviews, after getting information about the nurses’ perception of mobbing, the concept of ‘mobbing’ as a term was explained by the researcher and the interview continued. During the constitution of the groups, voluntary inclusion was the first criterion, and interviews were only carried out with nurses who gave their consent. In order to have

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richer data groups, they were constituted heterogeneously with a variety of staff posts represented. After the fourth focus group interview, as the data had started to replicate, the interviews were discontinued. A semi-structured question form was used in the focus group interviews. In the interviews, a tape recorder was used after obtaining permission from the nurses being interviewed. Each interview was completed in one session. An interview is ‘a purposeful conversation usually between two people but sometimes involving more, that is directed by one in order to get information from the other’ (Bogdan & Biklen 1998). By interviewing, qualitative research tries to understand anything that cannot be observed, such as experiences, attitudes, thoughts, intentions, comments, perceptions and reactions ¸ ¸ (Yıldırım & Simsek 2000).
Mobbing scale

For the analysis of the qualitative data, tape recordings were decoded on the same day, and notes taken during the interviews were combined with the observations and the points requiring attention were noted. After all the interviews were finished, all the decoded interviews were read once again. The common opinions, which had been mentioned at the interviews, were classified and coded according to themes that were created for content analysis of the interviews. All the interviews were read once more. Direct quotations were taken from the statements of the nurses that best emphasized/identified the ideas and experiences of nurses, and these quotations were used in the research report.

Findings

Öztürk et al. developed a mobbing scale in 2007, and validity and reliability studies were fulfilled. In the sample for this study, the Cronbach alpha value was stated as 0.97. The scale detects mobbing executions and consists of 68 items. The scale consists of positive statements and responses are: I definitely agree, I agree, I’m not sure, I don’t agree and I definitely don’t agree (Öztürk et al. 2007).
Ethical considerations

In all, 42.2% of the nurses who had participated in the research were in the 26–30 age group; 74.8% were married and 44.7% had graduated from health high schools. Sixty per cent had worked as clinical nurses; 50.5% had worked in the same clinic for 1 year or less; and 27.6% had worked for 1–5 years in total (Table 1). According to the scale, 9.7% of the nurses had been exposed to mobbing, but according to their own declarations, 33% had been exposed. In the focus group interviews, nurses described mobbing as ‘stress emerging from requesting tasks much more than they can do’ or ‘insulting behaviours from a person in any superior position’: You are alone, he wants five tasks at the same time, in fact he knows that you are alone (20 years old, health high school graduate, intensive care unit nurse). He/she insults continuously, e.g. ‘you are all morons, nobody clever is here’, . . . multiplies work stress, at that time nobody wants to do anything there . . . we are irritated when we see him/her (31 years old, 2-year associate degree, intensive care unit nurse). Some of the nurses (52, 25.2%) who expressed that they had been exposed to mobbing reported that the executor of mobbing was the head nurse and the second reported executor was the doctor (40, 19.4%). Some of them (19, 9.2%) had said that the reason for mobbing was ‘communication problems’. During the focus group interviews, nurses stated that they were exposed to mobbing generally by director nurses and that the problem originated from communication problems. People who have authority, I mean people in the position of directors makes this more often. After the first day they become directors, they start. Because they cannot get over their position, because they want people to notice them, to say ‘I’m here’ (27 years old, 2-year associate degree, emergency room nurse).

Permission was granted from the Turkish Republic Ministry of Health Directory of Ankara and informed consent was obtained from nurses by the researchers before the research began. Participation in this study was voluntary. The researchers themselves interviewed nurses included in the research. They were informed about the aims of the research and told that data collection would pose no harm to them. For the interviews, the nurses’ names were not collected. After the data collection, the nurses were informed about mobbing (causes, coping methods and solutions).
Statistical analyses

The Statistical Package for the Social Sciences version 11.5 (SPSS Inc., Chicago, IL, USA) was used to analyse the data. The percentage and chi-square were used to evaluate the data. The P-value 0.05 (95% confidence interval) was accepted as significant. The mobbing scale is evaluated between 68 and 340 points. The cut-off point of the scale is 204. Points below 204 mean that mobbing had occurred and points above 204 mean that mobbing had not occurred. The scale is graded as: ‘I definitely agree: 5 points’, ‘I agree: 4 points’, ‘I’m not sure: 3 points’, ‘I don’t agree: 2 points’ and ‘I definitely don’t agree: 1 point’.

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Table 1 Opinions of nurses exposed to mobbing Opinions n 206 % 100

Some of the nurses (30, 14.6%) said that they had a passive character and (22, 10.7%) said that the executor of the mobbing had an aggressive character. During the focus group interviews, nurses described people who mob as people behaving harshly to others in inferior positions. If you [she means herself] threaten, she will keep clear of me, I can make her do what I want easier . . . their authority is conducted by shouting at people (31 years old, 2-year associate degree, intensive care unit nurse). The harsh attitude of hospital administration make us nervous against nurses (32 years old, bachelorette degree, head nurse). Some nurses (31, 15.05%) said that their working performances had decreased because of mobbing and 38 of them (18.4%) had expressed that mobbing caused unhappiness in their private life. It affects my work a lot, I can’t do what I [am able] (20 years old, health high school graduate, intensive care unit nurse). Then I cared much about the patients, now I do my job and leave, I don’t care much (37 years old, baccalaureate graduate, clinic nurse). Though I don’t wish to, I reflect to my husband and children, when I arrive home I become more tired and aggressive (35 years old, health high school graduate, clinic nurse). Some of the nurses (24, 11.6%) believed that nothing could be done to solve the mobbing problem according to the quantitative data. Similarly, the following sentences were stated during the focus group interviews: They do not punish them, instead they change your clinic (44 years old, health high school graduate, outpatient clinic nurse). If you respond, they bear down on you more, so I think it is better to shut up (27 years old, baccalaureate graduate, emergency room nurse). When the situations of being exposed to mobbing according to the mobbing scale are examined with regard to the ages of the nurses and their working areas, it is found that nurses under 25 years of age and those who work in intensive care units are exposed to mobbing more than others (P < 0.05) (Table 2).

Exposure to mobbing according to mobbing scale Yes No Exposure to mobbing according to own declaration Yes No Executor of the mobbing* Head nurse Doctor Clinical chief Not exposed to mobbing Reasons for mobbing thought by nurses Arising from executor’s psychological problems Arising from decreased performance of executor Arising from communication problems Non-answered Not exposed to mobbing Characters of nurses exposed to mobbing according to own declaration Passive Aggressive Non-answered Not exposed to mobbing Character of the executor of the mobbing as to nurses Has aggressive character Has psychological disorder Non-answered Not exposed to mobbing Negative affects of mobbing on work Psychological effects Decreases working performance Non-answered Not exposed to mobbing Negative affects of mobbing on private life Causes unhappiness No effect Non-answered Not exposed to mobbing Nurses’ solution suggestions to the mobbing Discuss the problem with a friend Nothing that can be done Non-answered Not exposed to mobbing *n is multiplied because more than one choice is marked.

20 186 68 138 52 40 20 138 17 6 19 26 138

9.7 90.3 33.0 67.0 25.2 19.4 9.7 67.0 8.3 2.9 9.2 12.6 67.0

30 17 21 138 22 19 27 138 31 31 6 138 38 7 23 138 21 24 23 138

14.6 8.3 10.1 67.0 10.7 9.2 13.1 67.0 15.05 15.05 2.9 67.0 18.4 3.4 11.2 67.0 10.2 11.6 11.2 67.0

‘Why is here like this? Why is here like that?’ he/she always criticizes (27 years old, health high school graduate, clinic nurse). Also the doctors execute mobbing to us because there is a strict hierarchical order at the clinic (38 years old, 2-year associate degree, head nurse).

Discussion
In recent years, people who work in the health sector have been increasingly exposed to emotional harassment. In this research, according to the mobbing scale, 9.7% of nurses were exposed to mobbing, but according to their own declaration, 33% of them were exposed to mobbing. In Turkey, mobbing studies about

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Table 2 Exposure to mobbing from the mobbing scale according to the age groups and working areas of the nurses Exposure to mobbing Yes n Age groups 25 years 26–30 years 31–35 years 36 years Working area (n = 190) Intensive care unit Inpatient clinic Outpatient clinic Nursing directory unit % No n % P

– 17 2 1 13 6 – –

0.0 19.5 4.0 2.4 27.1 5.3 0.0 0.0

27 70 48 41 35 108 19 9

100.0 80.5 96.0 97.6 72.9 94.7 100.0 100.0

X: 17.998 P < 0.05

X: 21.337 P < 0.05

nurses have recently started to be conducted, and in two mobbing studies conducted to date, it is stated that nurses are exposed to mobbing at rates of 70% and 84%, respectively (Dilman 2007; Yildirim & Yildirim 2007). Mobbing is not verbal violence; while the verbal violence is applied as rude behaviour and words, mobbing is defined as every type of humiliating and offending behaviours (Tutar 2004). To consider a behaviour as mobbing, it must occur repeatedly (at least twice a week or more) in situations where targets find it difficult to defend against and stop the abuse (Lutgen-Sandvik et al. 2007). A single event is not mobbing, nor is an event categorized as mobbing if two equally strong parties are in conflict (Zapf & Gross 2001). Also, in an office, not all of the staff are exposed to mobbing; one or two victims are selected, and mobbing behaviour is directed towards them intentionally with the aim of forcing the victim or victims out of the workplace (Arpacıoglu 2005). ˘ In studies conducted in various countries, verbal abuse is described as a common experience among health-care providers, with a prevalence of 80–90% being reported (Sofield & Salmond 2003). However, mobbing prevalence rates have also been reported between 1% and 4% (Einarsen et al. 2003). The rate of being exposed to mobbing found in this study by means of the scale shows concordance with the world literature, but the rate of mobbing that nurses declare in this study and the results of other mobbing studies in Turkey are higher. It is thought that this results from the nurses’ perception of mobbing as verbal violence. Nurses who claim that they are exposed to mobbing tend to say that the executor is the head nurse. A total of 75.8% of the nurses in Yildirim & Yildirim (2007) and 65% of the nurses in

Dilman (2007) said that they were exposed to mobbing by the nursing directors. In Australia, in a study in which 99% of the participants were registered nurses, first, directors and supervisors, and then their colleagues, customers and employers consecutively were reported as being responsible for mobbing (Australian Nursing Federation 2000). Mobbing within nursing is primarily intra-professional (i.e. between nurse and nurse) (Lewis 2006). Mobbing signifies an unsolved social conflict that has reached a particularly high level of escalation with an increased imbalance of power (Zapf & Gross 2001). Given the central focus of caring in nursing, it is paradoxical that the literature reveals interpersonal conflict among nurses as a significant issue confronting the nursing profession (McKenna et al. 2003). In this study, 19 nurses (9.2%) expressed the opinion that the reason for mobbing is ‘communication problems’. Interpersonal conflict, usually called horizontal violence, most commonly takes the form of psychological harassment that often creates hostility in the work environment (Woelfle & McCaffrey 2007). Many nurses report that intra-staff aggression is more upsetting to deal with than patient assault or the aggression that they sometimes experience from colleagues from other disciplines (Farrell 1999). Some of the nurses (30 nurses, 14.6%) who were defined as being exposed to mobbing claimed that they had a passive character and 10.7% of them said that the executor of mobbing had an aggressive character. In the literature, there is no definition of people who are exposed to mobbing, but it is reported that the person who is exposed to mobbing loses self-confidence and starts to think, ‘Why can’t I achieve, is my personality bad, is my knowledge and experience insufficient, can I really be a foolish person?’ (Arpacıoglu 2005, p. 269). ˘ According to Leymann (1996), the executors of mobbing behave in this way to compensate for their own inadequacies and their fear concerning their reputation, name and career. Most of the behaviours of the mobbing executor originate from jealousy and envy that originate from their own fears and inadequacy (Davenport et al. 2003). In Turkey, during nursing education, leadership and assertiveness are not taught sufficiently; they are only included as a subject in ‘management in nursing’ course. This finding shows that leadership and assertiveness must be a part of in-service training programmes. People who are exposed to excessive mobbing cannot work properly and they go to work in fear and anxiety (Davenport et al. 2003). These situations cause a decrease in working performance. In this survey, it is shown that nurses who are victims of mobbing lose their capacity to perform at work and that mobbing causes unhappiness in their private lives as well. Indeed, some nurses have been reported to leave the profession as a consequence (Quine 1999). Victims of mobbing are unable to

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cope with the problems at work bring this into their private lives, cannot live life to the fullest and their relationships with their family and other people are affected or destroyed (Davenport et al. 2003). In this study, it is suggested that younger nurses are exposed to higher rates of mobbing. It was found that age was not a significant factor concerning mobbing (Yildirim & Yildirim 2007). In a study, the average age of the people who were exposed to mobbing was 27.94 5.22, but no statistical difference was found between the groups (Dilman 2007). Most surveys indicate that bullying happens in many different social contexts and at different age levels (Einarsen & Skogstad 1996; Olweus 2003). However, in surveys related to nurses (Desley et al. 2003; Randle 2003), it is shown that horizontal violence (the violence that colleagues apply to each other) is common in nursing and that the victims are especially the younger nurses (experienced nurses applying more emotional harassment to inexperienced nurses) (Curtis et al. 2007; Desley et al. 2003; Farrell 2001; Jackson et al. 2002; Leiper 2005; Randle 2003). It can be thought that this situation occurs because the younger nurses do not have sufficient experience and self-confidence. In this study, it is also shown that intensive care unit nurses are exposed to emotional harassment more than other nurses. Similarly, Dilman (2007) determined that intensive care nurses and operating theatre nurses are exposed to mobbing at a higher rate. It is thought that, in intensive care units, the need for working quickly and faultlessly causes this situation.

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Conclusion
Nurses in our study reported being exposed to mobbing, and this behaviour was applied mostly by directors of nursing. This situation reduces working performance and negatively affects the victims’ private lives. The main reason for mobbing was defined as ‘communication problems’, and the nurses who work in the intensive care units and who are young are apparently confronted more frequently with this problem. It is suggested that this situation should be exposed and understood, that larger surveys should be conducted to analyse the reasons and results, and that the necessary measures should be adopted to solve the ‘communication problems’, which are shown as a major reason for mobbing.

Author contributions
Study conception/design: S.Y.E. and S.A. Data collection/analysis: S.Y.E. and S.A. Drafting of manuscript: S.Y.E. and S.A. Critical revisions for important intellectual content, statistical expertise: S.Y.E. and S.A.

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© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses