Workplace Violence, Anxiety and Self-Esteem in Nursing Staff of Primary, Emergency and Intensive Care Units on the Island of Crete 111
Citation: Workplace Violence, Anxiety and Self-Esteem in Nursing Staff of Primary, Emergency and Intensive Care Units on the Island of Crete. American Research Journal of Nursing. 2018; 4(1): 1-15
Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: Mobbing in the workplace occurs when someone repeatedly, for a long time is exposed to negative behaviors and may have difficulty in defending himself. In the nursing profession, labor intimidation is common. It is now accepted that anxiety and self-esteem can play a particularly important role in mental and in physical health of nurses. Purpose: The investigation of self-esteem, the existence of anxiety and the phenomena of workplace mobbing of nursing staff working in Primary Health Care, Intensive Care Unit and in the Emergency Department.
Methodology: An investigation was carried out in the area of Crete between August 2017 and January 2018 in fourteen Health Centers, two Primary National Health Networks, four Emergency Department, eleven Intensive Care Units. The study involved 213 nurses. The Leymann Inventory of Psychological Terror, the State-Trait Anxiety Inventory and the Culture-free Self-esteem Inventories had been used.
Results: The average age of the participants was 41.73. The 45.5% of the sample is working in Intensive Care Units, 24.9% in Emergency Departments and 29.6% in Primary Care Units. The mean value of trait anxiety was 40.82, state anxiety 39.03, and overall anxiety 79.85 for the overall study sample. They were exposed to at least one mobbing behavior in the past 12 months, and for at least once a week, almost daily or daily the 11.3% These 24 nurses attribute this behavior to competition problems (60.9%) and jealousy (58.7%). The most nurses of the total sample (50.5%) had a middle self-esteem.
Conclusions: The evaluation of the results shows that the nursing staff of the overall sample of the study experiences mild anxiety symptoms. Mobbing seems to be at high rates. Early recognition of the phenomenon and its management as well as enhancing of the self-esteem should be the best practice of intervention to prevent it.
Heinz Leymann was the first who defined workplace bullying that has been a part of working life for centuries (Davenport et al. 1999) and denote a specific form of workplace aggression towards employees . According to Leymann the psychologically violent behaviours he saw in workplaces in Sweden were a kind of ‘workplace terrorism’, and determined it as ‘a type of psychological terrorism that arises in the form of directed, systematic, unethical communication and competitive behaviour by one or more persons towards one person’ . (Leymann 1990).
The following definition of mobbing see widely agreed upon ,,. (Einarsen et al., 2003, Einarsen, 2000; Einarsen and Skogstad, 1996; Leyman, 1993b; Zapf, 1999a) and it is accepted for this study: Bullying at work means; ‘harassing, offending, socially excluding someone or negatively affecting someone’s work tasks. In order for the label bullying (or mobbing) to be applied to a particular activity, interaction or process it has to occur repeatedly and regularly (e.g. at least once weekly) and over a period of time (e.g. about six months).
Studies that took part in United Kingdom  and Finland  shown prevalence rates of around 10%, whereas in the country of Austria reported results ranged from 7.8% to 26% . The lack of a standardized definition and methodology applied to measure workplace bullying contribute probably to the difference in prevalence rates between populations, countries, and organizations .
Also, a survey conducted in nursing personnel of the Greek Emergency Departments showed that conflicts between colleagues related to harassment are 24%. A research work for the effect of mobbing on the professional life of nurses in seven Hospitals of the 6th Health Region in Greece showed that nurses, men and women (71%), were victims of moral harassment during the past year and had psychosomatic symptoms (anxiety 54,3%, headaches 52%, atony 41.5%, denial of work 28%, depression 16,3% e.g. 
Violence in the workplace is expressed as anger, harassment, coercion, intimidation and insult . It is mainly manifested by impacts such as cooperative difficulties, reduced resistance to rush and psychological reactions. etc . It is a chain of anti-social behaviors and an intense form of work-induced anxiety, and through this systematic and long-lasting process (systematic, repetitive, durable and progressive), the worker-victim is led to a psychological and labor extermination .
Anxiety was defined by Freud as “something felt”, “an emotional state that included feelings of consciousness, intensity, nervousness and anxiety accompanied by normal stimulation.’Parallel to and in conjunction with Darwin’s evolutionary theory, Freud observed and noted that stress was adaptive to the motivation of behavior that prompted individuals to deal with threatening situations, and that intense anxiety prevailed in most psychiatric disorders . It has also prevailed, the definition of anxiety as: “A normal physical or psychological reaction to external events that cause a strong emotional state to man. This is a long-standing difficulty or a serious personal event that lasts for at least four (4) weeks “.
According to Spielberger, transport concern refers to “subjective emotional state characterized by tension and asphyxia”. Permanent anxiety refers to “the predisposition of the individual to perceive specific situations as threatening and to react with the anxiety to them”.
Spielberger about permanent and temporary anxiety considers that the recruitment of the individual from both internal and external stimuli is considered as threatening, resulting in reactions of temporary anxiety. Sensory and cognitive feedback mechanisms are the ones that cause high levels of transient stress to be recognized as unpleasant by the individual. The reaction of transient anxiety is proportional to the magnitude of the intensity of the threat.
The sensory and cognitive mechanisms of feedback are those that cause high levels of temporary stress to be recognized as unpleasant by humans. The reaction of temporary anxiety is proportional to the magnitude of the intensity of the threat. Correspondingly, the duration of tension affects the stability of the trait stress response. He also notes that people with a high level of permanent anxiety perceive more situations as threatening and react with more intense transient resistance reactions. Anxiety causes people to develop specific psychological protection mechanisms to achieve the reduction of temporary anxiety .
Nursing, as a profession, is described as a “high intensity profession”, the reasons have already been extensively formulated. This in itself has negative effects on the self-esteem of the nurse, both as a person and as a professional. In Greece, a survey was conducted in three (3) public hospitals in the Prefecture of Ilia during the period 05-10 / 2008, with a sample of 167 nurses and nursing assistants aged 20-60 years old. The statistical analysis of the questionnaire showed that 56.3% of the sample of nurses has a “modest’emotional state, which affects their self-esteem .
There are no surveys in Greece related to the correlation of work harassment with permanent, temporary anxiety and self-esteem in nursing staff. The first aim of this study was to measure the prevalence and forms of workplace bullying among the nursing personnel working in the Primary Health Care, Emergency Departments (ED) and Intensive Care Units (ICU) of Crete. The first approximation comprises the measurement of the frequency and duration of exposure to one or more of the 45 forms of bullying  and the second approximation include a self-reporting question revelant to bullying within the past 12 months based on a definition according to Heinz Leymann . The second aim was to measure the existence of state and trait anxiety with two questionnaires  and the third aim was to measure the self esteem of the nursing personnel.
The general objective of the study was to investigate the state and trait anxiety, the work violence and the self esteem in nursing staff in Primary Health Care, in Emergency Departments (ED) and in Intensive Care Units (ICU) of five major hospitals and 11 Health Centers in the prefecture of Crete.
• To study the existence and to measure the prevalence of anxiety in nursing staff
• To study the existence and to measure the prevalence of work violence in nursing staff
• To measure the self esteem in nursing staff
• The work violence experienced by nursing staff of Intensive Care Units and Emergency Departments differs from that of nursing staff in Primary Health Care.
• The permanent and trait anxiety suffered by nursing staff of Intensive Care Units and Emergency Departments differs from that of nursing staff in Primary Health Care.
• The self-esteem of nursing staff of the Intensive Care Units and Emergency Departments differs from that of nursing staff in Primary Health Care.
SIGNIFICANCE OF THE STUDY
The present study is expected to be used by Human Resource Management of the Hospitals and Health Care Centres to design appropriate policies that can curb mobbing and anxiety.
The study involved 213 nurses from five hospitals in the region of Crete. Of these, 45.5% were working in Intensive Care Units while the other 24.9% were working at the Emergency Departments and 29.6% in Primary Health Care. The survey was conducted from August 2017 to January 2018 and included the voluntary and anonymous participation of nursing staff. The psychometric tools included in the study are presented below:
For the purpose of the present research, the French version of “Leymann’s Inventory of Psychological Terror’(LIPT) instrument  and the Greek Version of “Leymann Inventory of Psychological Terror’ Instrument were applied .
Leymann’s Inventory of Psychological Terror consists of 45 items, each item measuring the exposure to workplace bullying the last 12 months with two response options (yes or no). In addition, two questions on the frequency were included (monthly basis, weekly, or daily) as well as the duration of bullying (years and months). In five sections are grouped the 45 bullying behaviors (1) social relationships at work (criticism, no possibility to communicate, and indifference and verbal aggression), (2) exclusion (isolation, avoidance and rejection ), (3) job tasks (too many tasks, no tasks, uninteresting tasks, humiliating tasks, tasks superior, or inferior to skills), (4) personal attacks (attacks on origins or opinion, rumors, ridicule and gossiping), and (5) physical violence (physical threats and sexual annoyance). According to Leymann, those who report exposure to at least one of the 45 behaviors that concerns bulling the last 12 months, weekly or more, and for six months or longer are defined as victims of bullying .
Moreover, in the present study will be used questions included in the French version of LIPT instrument. The instrument includes the definition of workplace bullying: “Bullying may be defined by a situation in which someone is exposed to a hostile behavior on the part of one or more persons in the work environment that aim continually and repeatedly to offend, oppress, maltreat or to exclude or isolate over a long period of time’. a. Nurses are asked whether they aware themselves as being victims of bulling within the previous year. For those considering themselves as being victims, contributing factors are further researched. b. In addition, nurses are asked whether they witnessed bullying at the current work to another employee during the past 12 months.
The State-Trait Anxiety Inventory (STAI) is a psychological inventory based on a 4-point Likert scale. It consists of 40 questions. The STAI measures two types of anxiety - state anxiety, or anxiety about an event and trait anxiety or anxiety level as a personal characteristic. Higher scores are positively correlated with higher levels of anxiety.
State anxiety (S-anxiety) can be defined as discomfort, fear, nervousness, etc. and the arousal of the autonomic nervous system induced by different situations that are apprehend as dangerous and is considered temporary. Trait anxiety (T-anxiety) can be defined as feelings of worry, stress discomfort, etc. that one experiences and how people feel across typical situation daily. The State-Trait Anxiety Inventory assess both state and trait anxiety separately. Each type of anxiety has its own scale of 20 questions and the scores range from 20 to 80, with higher scores correlating with higher levels anxiety. Each scale asks twenty questions each and based on a 4-point Likert scale. Low scores show a mild form of anxiety. Median scores indicate a moderate form of anxiety and high scores shows a severe form of anxiety. Anxiety absent questions impersonate the absence of anxiety in a statement like, “I feel secure.’Anxiety declares questions represent the presence of anxiety e.g. “I feel worried.’More examples from the STAI on anxiety absent and present questions are below. The 4-point scale for S-anxiety is as follows: 1.) not at all, 2.) somewhat, 3.) moderately so, 4.) very much so and for the 4-point scale for T-anxiety is: 1.) almost never, 2.) sometimes, 3.) often, 4.) almost always .
The Culture-free Self-esteem Inventories is a self-referencing questionnaire, which includes (without the lie scale) 32 statements. These statements seek to measure the general, personal and social perception of themselves (self-perception) and are divided into two groups: those that are high and those showing low self-esteem. Each question answers either with “yes’or with “no”. Three self-assessment sub-scales are included: general (16 statements), social (8 statements) and personal (8 statements). There is also a lie scale o (8 statements) .
Permissions were obtained from the developers of the French version of LIPT instrument, the Greek version of LIPT instrument, the State-Trait Anxiety Inventory (STAI) and Culture-free Self-esteem Inventories. The time needed to fill out the questionnaire was 8–10 minutes. was performed in the following departments: 14 Health-care Centers, 4 Emergency Departments (ED) and 11 Intensive Care Units (ICU). The study was performed during August 2017 to January 2018.
• Selected participants had to be nursing staff
• Selected participants had to be staff coming from all Intensive Care Units, Emergency Departments and Primary Health Care Centres of Crete
• Selected participants had to work to Hospitals and Health Centers that had been included in the National Health System and had the same system of shift to ensure the homogeneity of the sample.
• Selected participants could have any educational level with each working relationship
• Participants had not to be nursing student
With respect to the statistical analysis that follows, the quantitative variables are reported based on the mean ± standard deviation (mean ± sd) as well as the median and the interquartile range (IQR), while for the qualitative variables we have the corresponding frequencies and percentages. Depending on the appropriate statistical and / or graphic controls, it is recommended that median and the interquartile range (median, IQR) are used as representative descriptive measures.
The Shapiro-Wilk statistical control was used to check the regularity of the quantitative variables in the questionnaire. The existence of regularity has also been confirmed or rejected by the visual overview of the corresponding histograms, the normal Q-Q plots and box-plots of the variables. At the same time, the appropriate parametric and non-parametric statistical examinations were conducted to investigate any differences between the three structures (ICU, KY / PEDY and TEI) and the scales under study, determining the level of significance at 0.05. In all cases it was necessary to use accurate tests and / or model-carousel simulation (10000 samples). Also, where necessary, the Levene test was used for the homogeneity of the difference.
Finally, reliability and internal consistency was assessed by internal consistency using Cronbach’s alpha test. Statistical analysis was performed using the statistical software IBM SPSS statistics (version 21.0). A p value <0.05 was considered statistically significant.
The researcher submitted the research protocol for obtaining the necessary written permissions from the Research and Ethics Committees of the University General Hospital of Heraklion, General Hospital of Heraklion “Venizelio Pananio”, General Hospital of Chania, General Hospital of Agios Nikolaos, General Hospital of Rethymno and the 7th Health District of Crete. The permissions of the above organizations were given provided that the results of the study will be announced in the Administration of the 7th Health District of Crete. After the permissions of the research ware given, the participants were approached. Written consent was given by all participants to participate in the study.
Reliability of Leymann’s Inventory of Psychological Terror’(LIPT) Instrument
The reliability of LIPT instrument expressed by Cronbach α was 0.938 suggesting high internal consistency.
Characteristics of the Study Sample
In this study, the participants were nursing staff (n=213) and the majority of the participants 89.2% of the sample were women and ICU nurses represented 45.5% of the study population. Mean age for the total sample was 41.73 (SD = 7.33 years). The 75.1% (n=160) of the sample were married and followed by 23.0% (n=23%) that were unmarried. The majority of the sample 64.8% (n=138) were graduates of Technological Educational Institute (TEI) also, 8.9% of the sample (n=18) had a master’s degree and one person had a PhD. Demographic characteristics of the research population are shown in Table 1. In regard to the mean length of employment was 15.78 (SD = 8.49 years). The average of work in the current department was 8.00 years (SD = 10.50 years) as shown in the table below Table 2.
Prevalence of Workplace Bullying among Nurses
According to Leymann, mobbing is defined as the worker’s
exposure at least once a week for the past 12 months. Based on this definition,
we have the following results. Among the 213 nurses that consisted the total
sample of the study, 95 nurses (44.6%) were exposed to at least one bullying
behavior at work within the last 12 months, whereas 24 nurses (32.43%) were
exposed to at least one bullying behavior or more at least once weekly the last
12 months as shown in the table below Table 3. There is a statistically
significant difference between the three structures (p = 0.016) in the
percentages of those who said they were exposed to at least one mobbing (out of
45) in the last 12 months. We observe that the highest rate of exposure to at
least one moral harassment behavior is reported in the Emergency Department
(58.5%), while the lowest percentage in Primary Care (31.7%) as shown in the
table below Table 4. With regard to the frequency of the mobbing in the last 12
months and the answers “rarely’or “at least once a month’and “at least once a
week’or “almost daily’or “daily”, compared to the structures, there is no
statistically significant difference, as shown in the table below Table 5. The
percentage of the nurses still continuing to experience similar situations is
69.23% (n = 54). The median of the time period for which someone with these
conditions had come was 12 months (IQR = 51.75). The prevalence of the victims
of workplace bullying among nurses working at the Intensive Care Units was
10(41.7%) whereas among those working at the Emergency Departments (ED) was
10(41.7%), and among nurses working at the Primary Health Care was 4(16.6%).