Nurses’ Bullying Experiences: A Case study of a Caribbean Major Island Hospital

Purpose: The study was aimed at determining the self-reported experiences of the nurses in the major Island hospital in The Commonwealth of The Bahamas with regard to workplace bullying and their assessment of the support they received following the experience. Methods: A descriptive quantitative case study was undertaken using all the registered nurses in the Island Hospital. The study utilized a modified pre-validated instrument from the International Labour Office (ILO), International Council of Nurses (ICN), World Health Organization (WHO), and Public Services International (PSI). Analysis was done using the SPSS version 20. The result was presented as frequencies. Results: Eighty-one (81) respondents completed and returned their copies of the questionnaire giving a response rate of 97.5%. Also, 85.2% of the respondents reported having moderate bullying experience while 14.8% reported having maximum bullying experience. As it relates to the self-reported support for bullying, 60.5% of the respondents indicated that they received little support following a bullying experience. Further, 39.5% reported that they received some support following a bullying experience. There was no significant relationship between the respondents’ demographics and their self-reported experience of bullying or support following a bullying experience (p≤ 0.05). Recommendation/Discussion: Among others, we recommended that a more deliberate policy instrument be developed for dealing with cases of bullying and to monitor the use of this instrument, noting that the mental health of the nurses are also at risk. Conclusion: The study revealed that bullying was reportedly high while measures to support staff were reportedly low, a combination the investigators see as concerning in the Island Hospital.


Introduction
Workplace bullying is a "repeated health-harming mistreatment of one or more persons by one or more perpetrators (workplacebullying.org, 2018) characterized as a systemic a "non-physical, non-homicidal form of violence that is abusive, and emotionally harms the recipient". 1(p1-2) Bullying, be it overt or covert, is often enacted by persons in position of power or advantage (Workplacebullying.org, 2018;Power, 1999). Every employee wishes to work in a civil environment that is free of real or perceived bullying, or what referred to as lateral violence, aggression or mobbing (Leos-Sheridan, 2008). However, the aforementioned can exist anytime people work together, regardless of gender, race, and organizational structure (Leos-Sheridan, 2008). Anjum, Yasmeen and Yasmeen (2011) documents workplace bullying as a "widespread phenomenon". Further, there appears to be consensus that this unethical behavior is prevalent, indeed a serious workplace issue and permeates all strata within healthcare systems and integrates itself as a cultural norm (Aleassa & Megdadi, 2014; Ariza-Montes, Muniz, Montero-Simo, & Araque-Padilla 2013; Essen, Esquival, & Jha, 2015;McGee, 2014). Nevertheless, Gaffney et al. (2012) noted that silence as it relates to bullying continues to exist in many institutions and it is this silence that perpetuates "underreporting and insufficient and unproven interventions". become a part of the culture of the institution. This appears to be in line with what literature suggests that up to 25% of nurses' experience bullying (Quine, 2001;Wilson, 2016). However, although the Incident Forms are reviewed by the Risk Manager daily in this public hospital, a formal study to explore these perceptions or feelings, their validity and strategies used by this public healthcare institution to address bullying was never performed. In fact, despite its existence, there are no documented research findings as it relates to the bullying of nurses in healthcare institutions in the entire Commonwealth of The Bahamas. This study, therefore, is the first as it kind as it relates to the bullying experiences as well as the supports that are availed to the nurses in this respect in this major Island hospital. We envisage that the report from this study will be of assistance to the policy makers regarding incidence, management, and control of such experiences as this is related to job satisfaction and the emotional health of all and sundry (Jackson & Ashley, 2005).
The theoretical framework used to guide this research was Madeline Leininger's Culture Care Diversity and Universality Theory which was developed in 1991. While her theory is often applied to the clinical management of patients taking their cultural context into consideration, this theory can also help us to understand organizational culture and the role same can play in developing and accepting certain patterns of behaviors such as bullying; be they good and/or bad (Johnston, Phanhtharath, & Jackson, 2009). However, the theory also explores avenues for restructuring cultural behavioral norms to provide supportive mechanisms for change as needed.
Although definitions of bullying vary, as the authors looked at various manifestations or structures of it, they tend to include terms such as harassment, overt and covert intimidations, repeated show of power, power imbalance which in the end harm employees on the receiving end in more ways than one (Leos-Sheridan, 2008;Chapovalov &Van Halle, 2015;Durmus, Popcu, & Yildirim, 2018). It should also be noted that many authors have indicated the prevalence of this phenomenon range from 20% to as much as 76% in many jurisdictions including Poland, Korea, Canada, USA, and Barbados (Abed, Morris, & Sobers-Gannum, 2016;Jackson & Ashley 2005;Kang & Lee, 2016;Simnon & Mawn, 2010;Bajuma, Zdanowski, & Mendyka, 2012;Berry et al., 2012;Purpora, Cooper, & Sharifi 2015).
Additionally, a number of studies have identified the factors likely to be in place for this phenomenon to exist and for it to perpetuate. These factors are the independent variables of this study. They are (a) environment and social structure, (b) organizational structure, (c) institutional management structure, and (d) the nurses' demography (Abed, Morris, & Sobers-Gannum, 2016;Kang & Lee, 2016;Simnon & Mawn, 2010;Berry et al., 2012;Bartholomew, 2019;Purpora, Cooper, & Sharifi, 2015;Chaziioannidis, Bascialla, Chatzivalsam, Vouzas, & Mitsakos, 2018). In this study, we aim to find out if there is bullying among the nurses in the Hospital and if their demography namely, Age, Gender, Nationality, Years of Employment is related to their experiences.
Similarly, support for those who experience bullying has been identified as a factor that not only assists the employee, it also helps to stop the phenomenon. We hope to ascertain the institutional practices that may be of assistance to the employees who may be experiencing bullying. Various studies indicate that clear policies, collaborative work environment, level of organizational tolerance, and development of specific strategies for helping staff subjected to such experiences go a long to ameliorate the experiences (Gaffney et al., 2012;Meires, 2018;Kang & Lee, 2016;Berry et al. 2012;Agarwal, 2018;Hansen et al. 2006;Norton et al. 2017;Khubuchandani & Price, 2015;Nelson et al., 2014;Johnson, Boutain, Tsai, & de Catro, 2019).

Aim
To ascertain if there are experiences of bullying among nurses in the major Island Hospital and to determine if there are support services available to the nurses.

Objectives
This study is hinged on the following objectives: 1) To describe the nurses' self-reported experiences of bullying at this Major Island public hospital.
2) To describe the support the nurses at this hospital receive following their experiences of bullying.
3) To determine if nurses' self-reported (a) experiences and (b) support received; are associated with their socio-demographic characteristics.

Design
It is a descriptive case study of this Caribbean Island public hospital related to nurses' experiences of bullying. We chose to investigate this phenomenon in this major hospital hoping that it will give an indication of what may be gjhs.ccsenet.org Global Journal of Health Science Vol. 12, No. 12;2020 likely in the other smaller health care institutions in the Island Country (Houser, 2018).

Population and Sampling
All of the nurses in the hospital were engaged provided they gave and signed the informed consent and were not in a managerial position. We surmised that those in the managerial positions are not likely to be bullied by the nurses in the lower positions as the investigation is limited to bullying among nurses and to nurses. In all there were 83 nurses and so no sampling was necessary (Zhao, Tian, Cai, Claggett, & Wei, 2013). Only 81 consented. Table 1 shows the distribution of the nurses.

Ethical Consideration
We sought for and secured the ethical approval from the University of the West Indies, as well as the Research & Ethics Committee, Public Hospitals Authority (PHA) and Ministry of Health, Bahamas. Permission was gained from the hospital as well as from the participants who signed their respective informed consent.

Instrument
We adapted the self-administered standardized, validated questionnaire, a Workplace Violence in the Health Sector Country Case Study Research Instruments Survey Questionnaire English (ILO/ICN/WHO/PSI, 2003) instrument that was jointly developed in Geneva Switzerland by the International Labor Office (ILO), the World Health Organization (WHO), the International Council of Nurses (ICN) and the Public Services International (PSI). The document has been effectively and widely employed in several research studies and has also been instrumental in the development of strategies and policies to mitigate violence in the workplace in institutions globally (ILO/ICN/WHO/PSI, 2003). The adaptation included the use of the questions from bullying/mobbing aspect of the tool while we modified slightly the demography to include nationalities that were reflected in the nursing population of this major hospital. The questionnaire consists of two sections with the first section requesting data related to personal demographics and workplace characteristics as it relates to the perpetrators of bullying. There are a total of 10 items in this section. The second part of the adjusted questionnaire is related to workplace bullying/mobbing in terms of the participant's personal experience with bullying, its prevalence and measures taken by the institution to deal with same. This section has 12 items. The adjusted instrument was pretested and with a Cronbach's of .709 we deemed the instrument good enough for the full study.

Statistical Analysis Plan
The data collected was coded, analyzed, and tested using the Statistical Package for the Social Sciences (SPSS) version 20. The chi-squared test was used to determine the association between the respondents' experiences of bullying and their demographic characteristics. P≤ 0.05 is used to denote statistical significance.

Scoring of Self-Reported Experiences of Bullying
The data was assembled in three categories namely, demographics, nurses' experiences with bullying and the support nurses' received post a bullying experience. The mean scores for nurses' experiences with bullying and the support nurses' received post a bullying experience were calculated and used to determine the nurses self-reported experiences and self-reported support levels related to bullying respectively. Based on the mean score which is expected to range between 0 and 14, the self-reported experiences of bullying were categorized in Table 2.

Self-Reported Support after a Bullying Experiencing Performance Scores
Similarly, based on the mean score, the self-reported support after a bullying experience was as categorized in Table 3. It is expected to range between 0 and 34. Findings were interpreted and presented as frequencies.
The study findings were presented in summative form and no individual person's information was singled out. Table 4 summarizes the demography of the respondents. Eighty-one (81) sampled respondents completed and returned their questionnaires giving a response rate of 97.5%. Two respondents did not participate in the study as one was on maternity leave and the other was on industrial leave related to a work-related incident. All responses were included in the final analysis. The mean age of the respondents was 41.7 years with standard deviation of ±1.745 and 33.3% were between the age group of 30 -34 years. A little over ninety percent (90.1%) of the respondents were females and the remainder were males (9.9%). The largest groups of respondents were Bahamians at 77.8%, followed by Filipinos at 21% and one African respondent accounting for 1.2%. Forty-two percent (42%) of the study respondents had between 1-5 years of working experience and a little over thirty-two percent (32.1%) had between 6 -10 years of working experience. 3.2 Nurses' Self-Reported Experiences Figure 1 illustrates the experiences of the nurses in this Island hospital regarding bullying. It shows that 85.2% of them reported experiencing bulling at moderate level while 14.8% indicated that they experienced bullying at the maximum level. Also figure 2 shows the nurses description of the level of support they received following bullying. The figure illustrates that while 39.5% of the nurses indicate that they received "some support", 60.5% indicate that they did not received "little support". Regarding whether there are relationship between the dependent variables of study (experiences of bullying and support for bullying experience) and the independent variables (the nurses' demography), Tables 5 and 6 show that there are no associations between (a) the nurses' experiences of bullying, (b) support nurses' received following bulling; and their demographic characteristics, namely age, gender, nationality, years of employment (p<0.05).   Vol. 12, No. 12;2020

Discussion
The finding that all of the nurses in this case study reported experiences about bullying is concerning. Indeed, that the experiences range from moderate (85.2%) to maximum (14.8%) is troubling. Although this is a case study of one major Island Hospital, it should be noted that nearly all the nurses in the hospital participated in the study. This is concerning given that bullying experiences have been defined variously to include such descriptions as the personal encounter or exposure to bullying of nurses in their work environment where they are subjected to "repeated and over time offensive behavior through vindictive, cruel, or malicious attempts to humiliate or undermine an individual or groups of employees" (ILO/ICN/ WHO/PSI, 2003) It should also be noted that some of the nurses have worked in this hospital for as long as 25 years in this condition. This is dangerously unhealthy and needs to be addressed urgently. This high incidence confirms all studies reviewed in this regard (Ariza-Montes, Munix, Montero-Simo, & Araque-Padilla, 2013;Tinaz, 2006;Lipscomb, London, McPhaul, Ghaziri, Geiger-Brown, & Johnson, 2015;Oxenstierna, Elofsson, Gjerde, Hanson, & Theorell, 2012).
Equally, with the 5 categories of support indicated, ranging from little to maximum levels, it is also a surprise that the nurses in this hospital indicated that majority received little (60.5%) while 39.5 % received "some support". To juxtapose this level of support with the prevalence of the bullying experience is serious. Again, to imagine that some of the nurses have been in this work environment for 25 years should be revealing. Although many authors reviewed indicate that experiences of bullying among nurses is pervasive among nurses, none has reported these situations to this level (Gaffney et al., 2012, McMahon, McCurtain, O'Sullivan, Murphy, & Turner, 2019, Hansen, Hogh, Persson, Karlson, Garde, & Orbaek, 2006Nelson et al. 2014;Johnson & Boutain, Tai, & de Castro, 2015).
Further, that there was no significant difference between the (a) nurses experience of bullying; (b) their support for bullying and their demography is not surprising. It suggests that the nurses irrespective of their age, length of employment, gender, nationality, etc experience bullying same way, and when they do experience bullying, they do not get sufficient support from the organization. These are concerning revelations in this Island Hospital.

Study Limitations
We note that the study is a case study of an Island Hospital and may not accurately reflect what happens elsewhere in the Island. Also, the study did not take into account the fact that the data from this study is self-reported. One cannot ascertain the extent to which the nurses are completely honest. We also note that the data collection coincided with the period the Island was subjected to the Hurricane Dorian, a natural situation we could not tell if it impacted on their nurses' stress level and hence on their disillusionment. However, the investigators used their experience in the field including their training in ethics to ensure the administration of the instrument, data collection, entry and treatment were done in such a way that most of the extenuating circumstance would have been minimized that they do not to impact the truthfulness of the findings.

Conclusion
This study revealed that nurses working at this major hospital in The Bahamas do experience workplace bullying and that generally the support or management for workplace bullying in this hospital is largely insufficient.

Recommendations
We recommend that a more qualitative study to done to look at the policies, and extent of use of policies available for attending to experiences of bullying in the hospitals be conducted. We also recommend that more precise, and clear policies be developed for dealing with workplace bullying in hospitals and other healthcare institutions in the Island be developed and be seen to be in use.
who granted us the permission and approval to undertake the study.