Impact of Workplace Bullying on Patient’s Quality-of-Care Services: A HealthCare Sector Perspective

Irfan Sabir¹, Muhammad Bilal Majid^2*, Muhammad Zia Aslam², and Asrar Ahmed Sabir³

¹Faculty of Management Sciences, University of Central Punjab, Lahore, Pakistan

²Faculty of Business and Management Sciences, The Superior University, Lahore, Pakistan

³Division of Management and Administrative Sciences, University of Education, Vehari , Pakistan

* Corresponding Author: [email protected]

Abstract

The current study aimed to measure the impact of nurse's workplace bullying on patient's quality of care with the mediating role of workplace deviance. The data was gathered from nurses in primary healthcare hospitals in Sahiwal and Faisalabad divisions of Punjab, Pakistan. The sample size was taken from a population comprising 1255 nurses through Krejcie and Morgan calculation formula and the final sample size was based on 254 nurses. Statistical analysis was performed through SPSS (v-26) software. Constructs reliability and validity were analyzed through Cronbach's alpha value which was above 0.90. The results confirmed that workplace bullying has a significant positive influence on workplace deviance and workplace deviance has significant negative influence on patient's quality-of-care. Moreover, workplace bullying has a negative influence on patient's quality-of-care and workplace deviance mediates the relationship between workplace bullying and patient's quality-of-care.

Keyword: workplace bullying, workplace deviance, patient's quality-of-care

Introduction

At workplace, the behavior of employees has a significant impact on their stakeholders. When they face psychological and physical mistreatment from vertical and horizontal axis their behavior turns in the form of frustration, job over, and deviance (Raza et al., 2022). The concept of workplace bullying has gained importance in today's business world (Jahanzeb et al., 2020).

The concept of workplace bullying has been linked with harassment (Bowling & Beehr, 2006), workplace incivility, and emotional violence. The initial concept of bullying was presented by a Swedish psychologist Heinz Leymann, referred as "mobbing". After that, the concept has been studied extensively. A mediator-moderator study conducted by (Hudson et al., 2019) examined the association between workplace bullying and turnover intentions with conflicted climate management as moderator and burnout as mediator. The outcomes confirmed that bullying is a significant factor for quitting the job in banking profession. The role of bullying in education was examined by (Nielsen & Einarsen, 2018) in which the common form of bullying included negative comments, unnecessary criticism, delaying tactics on important issues, and strict monitoring. Bergström et al. (2018) analyzed the association between workplace bullying and deviant workplace behavior in nursing profession. Due to bullying, the quality of patient's care declined and patient's health was compromised. In Australia, more than 50% nurses face bullying in a 12-month period during clinical placement. The study conducted by Mwachofi et al. (2011) postulated that bullying by experienced nurses of newly joined nurses is the root cause for the latter to leave this profession. The reason behind this bullying behavior of experienced nurses is the sense of powerlessness which may lead to the feelings of oppression and aggression.

The term ‘deviance behavior' at workplace refers to any action that breaches the norms, rules, and regulations of a particular organization. At organization levels, workplace deviance behavior could be included to humiliate a colleague, physical violence or abusive language (Bertakis & Azari, 2011). Fagbohungbe et al. (2012) divided workplace deviance into organizational (arrived late at workplace without permission) and interpersonal (co-workers humiliating). A typology of deviant workplace behavior was developed by Krinsky et al. (2014) through multidimensional scaling techniques.

Waseem (2016) examined the employee's deviant workplace behavior in Pakistan. The deviance can be further divided into organizational and interpersonal levels. Employee's deviant behavior has an adverse impact on firm productivity and performance and increases the overall cost. The deviant behavior was analyzed in a study conducted by (Litzky et al., 2006) in the supporting staff at government organizations. The variable, that is, deviant behavior is further divided into interpersonal and organization levels. Fake medical claims, underperformance, lack of integrity at work, and fraudulent practices were among different types of devianct behaviors at workplace.

Objectives

1. To determine the impact of workplace on patient's quality-of-care.
2. To evaluate that workplace deviance mediates between workplace bullying and patient's quality-of-care.

Problem Statement

According to Kishida (2023), Pakistan has successfully worked to reduce the workplace bullying. The most chronic issue in healthcare sector is workplace bullying, particularly in the nursing profession. Bullying is a common behavior across the globe. According to O'Boyle et al. (2012), nursing is a feminized profession with more than 95% women involved directly. The severe problems related to nursing include shortage of cultural beliefs and lack of protection. They perform the duty of front-line healthcare professionals, however, face problems when they face bullying behavior from their co-workers, patients, and attendants. The bullying ratios are predicted high in developing regions of the country (News, 2016). Some researchers claimed that bullying behavior was undetected because there is lack of coordinated data (Nasir & Bashir, 2012). The current study attempted to address the undetected aspects of bullying in nursing from Pakistani perspective.

Literature Review

Social Exchange Theory

The practical application of workplace bullying and deviance behavior can be elaborated with the support of Social Exchange Theory (SET). The basic assumption of SET is that the subjective use of cost and benefit analysis is based on human affiliations and preferences. The social exchange model is one of the maximum significant instruments for empathetic employee's behaviors and attitudes. SET refers that an employee performs better in a favorable working environment and shows favorable behavior and attitude, whereas in the absence of favorable working environment, such employees adjust their behaviors and attitudes (Krinsky et al., 2014).

A study conducted by Hudson et al. (2019) analyzed the employees' behavior in the lens of SET. Various aspects of workplace bullying (perceived organizational support, psychological contract breach and justice) were studied in the light of SET. Newell and Jordan (2015) explained the theoretical perspectives and social structure of SET. They also explained the participation of wide range of actors in the social exchange process. A critical review was conducted by Robinson and Bennett (1995) to address the prominent aspects of SET and theoretical remedies. This study attempted to address the four decisive concerns of SET; define the overlap constructs, explain the positive or negative hedonic constructs, behavioral predictions, and assumption of bipolarity.

Workplace Bullying in Pakistani Nursing Profession

Nurses in Pakistan are considered as an exploited group in workplace setting and are vulnerable to workplace violent behavior. The qualitative investigation of Purpora and Blegen (2012) studied the prevalence of workplace violence on nurse's work-life and careers in Pakistan. Most of the nurses witnessed workplace violence in the last six months and verbal violence was experienced frequently. Most of them believed that violence reporting was useless and higher authorities did not take any actions to reduce the violent behavior at workplace. The recent study conducted by Houck and Colbert (2017) investigated the direct and indirect impact of ethical leadership on bullying among nurses in Pakistan. The statistical results outlined that ethical leadership has a direct negative, however, significant impact on bullying at workplace. In the presence of mediating variables; work overload, working condition, and organizational identification, the indirect impact was negative and significant. Delaney (2018) affirmed that the significant contributing factor in workplace violence towards nursing in Pakistan is lack of respect. These workplace violent behaviors were reported in the form of workplace bullying, unwanted sexual deeds, physical violence by patients and supporting staff. Most of the workplace violence cases were not reported because nurses feel a sense of fear by society and their family.

Gaffney et al. (2012) examined the influence of workplace bullying on deviant work behavior among nurses in Pakistan. The statistical results proposed that there is a constructive link between workplace bullying and deviant workplace behavior. The mixed analysis technique incorporated by Awai et al. (2021) examined the direct and indirect effect of personal bullying behavior on turnover intentions of nurses along with the mediating role of job stress and moderating role of political skills. The responses were gathered through self-administered questionnaire from registered nurses performing their jobs in public sector hospitals of Pakistan. The statistical outcomes depicted that personal bullying behavior has a direct and indirect impact on nurses' turnover intentions. The political skills attenuated the job stress effect on personal bullying behavior.

Patient's-Centered Care (PCC)

The term patient's-centered care (PCC) is acknowledged as a measurement technique of quality of healthcare (Stangl et al., 2019). A conceptual framework was presented by Hutchinson and Jackson (2013) to study the patient's safety and quality of care with horizontal violence in the nursing profession. The interactional analysis conducted by Jafree (2017) studied the PCC in primary healthcare and its association with the decrease of healthcare utilization. The statistical results confirmed that annual medical charges may reduce due to medical visits and effective PCC. The study conducted by Robinson et al. (2008) highlighted the successful impact of Picker/Commonwealth PCC program. This program was the interrelated set of eleven projects. The prime objective of all projects was to enhance communication between healthcare providers and patients. This program proposed an eight dimensions of PCC framework which is generally known as eight Picker Principles of PCC.

In the recent study of Jayadevappa (2017), the PCC refers to an emerging approach in order to improve the healthcare services in Australia. This approach emphasizes on the patient's values and improved communication among patient's healthcare providers and family members. The qualitative study of Hudson et al. (2019) elaborated the role of nurses as navigators in PCC approaches. The role of a navigator is pivotal between patients and their family and friends. The study concluded that nurses' role as a navigator has the potential to improve the patient's quality of care and safety of varying medical conditions and ages. The idea of PCC was analyzed by Lima et al. (2016) in Pakistan through patient's-pathway analysis in tuberculosis related care. The outcomes depicted that more than 90% of the patients start their tuberculosis treatment from private hospitals. More than 50% of tuberculosis laboratories are operated in public health facilities, however, the likelihood of patients reaching those health facilities were very low due to poor PCC. Kolcaba et al. (2006) analyzed the concept of PCC as an organizational framework. In this framework different attributes and behavioral aspects are needed for PCC which were discussed from nursing care perspective.

Workplace Deviance

Any abnormal behavior of organizational employees or employers falls under the term ‘deviance' at workplace. Previous literature indicated that employee deviant behavior includes organizational injustice, hostile behavior, and violence. Workplace deviance has a negative impact on individual and organizational performance and productivity which also increases financial cost. Vicdan (2020) examined the association between different behavioral factors and workplace deviance in Pakistan. The behavioral factors included organizational sabotage, intention to quit, political deviance, production deviance, employees' hostility, leader mistreatment, and job satisfaction. The statistical results depicted that all predictor variables had a positive association with workplace deviance except job satisfaction. Somani and Khowaja (2012) analyzed the association between employees' organizational reactions (supervision, company identification, kind of work, amount of work, co-workers, physical working conditions, financial rewards, and career future) and different types of deviant behaviors (property, personal, and production). They further analyzed the deviant behavior on gender basis. There was a significant association among all study variables, whereas male deviant behavior was higher and different from female employees.

Koh (2016) examined the association between organizational factors (ethical work climate, organizational justice, perceived organizational support and trust in organization) and deviance (interpersonal and organizational) among supporting staff in government organizations. The results indicated that organizational factors had a negative association with deviance behavior. The systematic analysis conducted by Kolcaba (2001) highlighted the various dynamics and concepts of workplace deviant behavior. This systematic work supports that transformational leadership would incorporate as a moderator between deviance workplace behavior and individual factors. A general overview of workplace deviance has been conducted by Wilson and Kolcaba (2004) and previous researchers analyzed the association between personality characteristics and deviance behavior. Now-a-days, researchers are giving more attention to study the association between individual behaviors and deviance behavior.

Theoretical Model

Figure 1

Theocratical Model

I.V                                                 M.V                                         D.V

Research Hypotheses

H2: Workplace deviance has a significant negative influence on patient's quality-of-care.

H3: Workplace bullying has a negative influence on patient's quality-of-care.

H4: Workplace deviance mediates between workplace bullying and patient's quality-of-care.

Research Methodology

Research Approach

The current study was based on the hypotheses that were derived from past research theories. These assumptions were tested through some well-defined tests and tools and were concluded in the light of results. Therefore, deductive research approach was employed to study the causal association between variables.

Research Strategy

In the current research, the survey method was used to collect the data. The deductive approach is generally associated with survey strategy. This strategy allows the researcher to collect large set of data from a sizeable population in an economical manner. The researcher has the capacity to collect quantitative data that can be analyzed through inferential statistics.

Population and Sample Size

In the current study, the target population comprised of nurses performing their jobs in government healthcare hospitals in Sahiwal and Faisalabad divisions Punjab, Pakistan. Krejcie and Morgan (1970) affirmed that the sample taken from larger population was the true representation of study population. In order to take sample size from population, two aspects must be considered; confidence interval and confidence level. The degree of variation is called confidence interval and expressed in percentage (+/- 3 to +/-1). Whereas, the assurance of sample results is known as confidence level and expressed in 90%, 95%, and 99%. In case of small sample size, confidence interval would be 90%, whereas in large sample size confidence interval would be 99%.

In the current study, the unit of analysis was nurses working in government hospitals with a total population of 1255. The researchers used Krejcie and Morgan (1970), the sample size for the current study was 254 at 5% confidence interval and 95% confidence level.

Sampling Technique

Cluster sampling technique was used to select the sample from study population. Hocker et al. (2007) stated that population parameter is often drawn piercingly in cluster sampling technique.

Results

Table 1

Construct Reliability

Table describes the construct's reliability of all study constructs. The outcomes of reliability test provide base for consistent results. In this statistical test, two aspects need special attention; stability and equivalence. The reliable results with recurrent measurements with same instruments and same person are termed as stability. Whereas, equivalence aspects mean how much error is introduced in different samples (Nawaz et al., 2021). In the current research, the reliability of scale is measured through Cronbach's alpha (α). The value of alpha above 0.6 indicates that the scale is weakly reliable, whereas reliability value close to 1.0 indicates that study constructs are highly reliable. In the above table, the value of all three constructs is close to 0.9 which means that constructs are highly reliable.

Table 2

Demographic

The responses were gathered from age group of 20-51 years respondents. 85 respondents were from the age group between 20-30 and their response rate was 33 per cent. The active participated age group was 31-40 years with 90 out of 254 and 35 in per cent. The least participated respondents fell in 51 and above age group with 34 in total and 14 in per cent. The respondents' qualification was divided into intermediate, graduation, and masters. Most of the respondents had graduation qualification with frequency 165 out of 254 and 65 in per cent, 79 respondents had masters qualification with 31 in per cent. The experience of the respondents was grouped into five categories. Most of the respondents had 11-15 years of experience with 85 in frequency and 33 in per centage. 26 respondents had experience of 26 years or more and their response rate was 10 per cent. The responses are gathered from three departments; indoor, outdoor, and emergency. The most active group in this research was in door with 90 in total and 33 in per cent. There was nearly equal participation of respondents from outdoor and emergency with 32% and 33%, respectively.

Table 3

Correlation

The term correlation refers to interdependence between variables within a system. The correlation analysis gives the answer that there is an association between variables. Pearson's coefficient value lies between ± 1 where positive sign indicates a positive correlation between variables and a negative sign indicates a negative correlation between variables. In the study conducted by Sabir et al. (2020), value between ± 0.10 to ± 0.29 indicate weak correlation, value between ± 0.30 to ± 0.49 indicate moderate correlation, and value between ± 0.50 to ± 1.0 indicate a strong correlation.

In the above correlation table, there are three variables; workplace bullying, workplace deviance and, PCC. The association between workplace bullying and workplace deviance is significant, moderate, and positive with Pearson Correlation value +0.570. The association of PCC with workplace bullying is strong but negative with -0.752 and the correlation between PCC and workplace deviance is also strongly negative with -0.701.

Table 4

Mediation Analysis

Table summarizes the complete process of direct and indirect mediation process. If all three steps have significant regression results, it is possible to conduct four steps. In path c, workplace bullying is seen as an independent and PCC as dependent variables with value of R² is 0.566 and standardized beta value -0.752. The results of all tables in first path analysis are significant. In 2nd step, workplace bullying is seen as a predictor and workplace deviance as criterion variables with R² is 0.324 and standardized beta value 0.570. A multiple regression test was applied to anticipate the association among workplace bullying, workplace deviance, and PCC. The value of R2 is 0.66 and all the tables have achieved significant level. The indirect effect of mediation variable is -0.230.

Conclusion

The current study attempted to determine the impact of workplace bullying on patient's quality-of-care and via workplace deviance among nurses in Pakistan. For this purpose, a quantitative method was used with survey techniques. Statistical analysis was conducted on collected responses. In healthcare sector, most of the nurses face bullying behavior from their co-workers, patients, and attendantswhich ultimate affects the patient's quality-of-care and safety. Nurses play a vital role in patient's care and safety. Without nurses, personal and organizational support in many public hospitals would fail to achieve quality services. Lack of organizational support and silent behavior from administration on bullying incidents would further trigger adverse impacts on nursing profession.

Directions for Future Research

The current research was restricted to some districts. Statistical results showed that these variables can be used in a broader aspect. This study mainly covered the bullying behavior of nurses in government hospitals and less focus has been given to private hospitals on this sensitive issue. In the future, a comparative study should be conducted to better understand bullying behavior.

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