HSOA Journal of Community Medicine and Public Health Care Workplace Harassment and Depression in Mental Health Nurses: A National Survey from Cyprus

Background: Workplace harassment constitutes a significant occu pational hazard in many industries including the healthcare sector. The aim of our study was to evaluate workplace harassment and explore its potential association with depressive symptoms among mental health nurses. Methodology: A national survey among mental health nurses was conducted in Cyprus using three international validated questionnaires; namely the Leymann Inventory of Psychological Terror (LIPT), evaluating “mobbing” in the workplace, the Center for Epidemiological Studies in Depression (CES-D) Scale, and a specifically designed, questionnaire for the collection of the demographic data of the participants. The data were analyzed with the statistical package SPSS 20. Results: Among 402 mental health nurses in Cyprus, 255 com- pleted the survey (response rate 62.9%) with a slight majority being women (55.7%). The prevalence of workplace harassment (mobbing) was 8.2%. In addition, about one in ten nurses (11.0%) reported depressive symptoms based on the CES-D scale. Using multi-variable adjusted logistic regression models (adjusted for age, gender, marital status, educational level, professional ranking, and years of experience), we found that mental health nurses who reported workplace harassment were 5.2 times more likely to have depressive symptoms compared to their colleagues who did not experience workplace harassment. Conclusion: Workplace harassment as well as depressive symp- tomatology is quite prevalent among mental health nurses in Cyprus. Workplace harassment was also significantly associated with depressive symptoms among mental health nurses. Further qualitative and quantitative evaluation of the above association is warranted.


Introduction
Workplace harassment or mobbing was defined for the first time in the 1980's by Heinz Leymann as "a type of psychological terror that arises in the form of systematic, directed, unethical communication and antagonistic behavior by one or more individuals towards one individual" [1]. These actions take place often (almost every day) and over a long period of time (at least for six months) and, because of such a frequency and duration, it results in considerable psychic, psychosomatic and social misery [2]. Similarly to Leymann, several researchers such as Ege et al., Zapf et al., and Einarsen et al., char-acterize the concept of harassment in the workplace with the term mobbing [3][4][5]. Furthermore, bullying in the workplace has been characterized as a gradual, often invisible and an intensely individualized and harmful experience [6].
Over recent decades, several large-scale studies across a range of industry sectors have identified the presence of workplace harassment and its damaging effects on individual employees and organizations alike [7][8][9][10].
In all fields of work, as well as in the healthcare sector there have been studies reporting on the presence of workplace harassment and/ or mobbing. The health services sector is classified as one of the work areas with the highest prevalence of workplace harassment, reaching up to 9% [11]. In particular, workplace mobbing or bullying is a significant problem confronting the nursing profession. According to research reports, nurses are at greater risk of being exposed to workplace harassment compared to other health care professionals [12][13][14][15].
However, within the Greek and Cypriot population, research in this important field is limited. In addition, research studies on workplace harassment among nurses in the mental health services of Cyprus have not been previously reported. The current study is the first attempt to capture (identify and record) the above phenomenon among the occupational group of mental health nurses. The aim of our study was to evaluate workplace harassment and explore its potential association with demographic characteristics and depressive symptoms among mental health nurses.

Methods
The study was conducted in 2016 among all nurses working in the mental health services of the public sector in Cyprus. The different departments of the mental health services included a) the Athalassas Mental Health Hospital, b) all psychiatric clinics in the general public hospitals of all districts of Cyprus, c) the community nursing services for mental health problems, d) the departments for substance abuse including drug abuse, e) the prison department, and f) the mental health services for children and adolescents. The survey was conducted within a period of two weeks in March of 2016. Authorization to conduct the current research project was obtained from the Committee for Research Promotion of the Ministry of Health, the Department of Nursing services at the Ministry of Health, the Commissioner for the Protection of Personal Information, and the National Bioethics Committee of Cyprus.
Three research instruments were used to collect demographic information, evaluate workplace harassment and document depressive symptoms. Information was collected regarding age, gender, marital status, educational level, professional ranking and work experience. The Leymann Inventory of Psychological Terror (LIPT) [1,2] was used to assess the prevalence of harassment and/or mobbing in the workplace. The Center for Epidemiological Studies-Depression Scale (CES-D) [36,37] was employed to evaluate the presence of depressive symptoms, while a specifically designed questionnaire was used to document the demographic information of study participants. Both questionnaires (LIPT, CES-D) were already translated and validated in the Greek language. Permission to use the above scales was obtained from Zahariadou Th and Pavlakis A (LIPT) and Madianos MG (CES-D), respectively. The reliability of the LIPT scale was assessed with Cronbach's Alpha (0.87).
Written informed consent was obtained from all participating nurses in a separate envelope while completed questionnaires were distributed and collected anonymously from each participating mental health nurse who had to enclose their response anonymously in a sealed envelope. Participating nurses were offered a period to two to three weeks to complete the questionnaires. The data were then entered into a computerized database and were analysed using the statistical package SPSS 20. Categorical variables were expressed as absolute (N) and relative frequencies (%). Chi-square tests were used to evaluate the potential association of demographic variables with workplace harassment.
In order to run logistic regression models, some demographic variables were transformed from categorical to dichotomous. The four-category age variable was grouped into two groups (20 -40 years versus 41 -60 + years of age). Marital status was grouped into single (single + divorced) versus married (married + cohabitation). Educational level was grouped into a bachelor's degree (college + bachelor's degree) versus higher level degree (master + doctoral degree). Work experience was transformed from a four-category variable to two groups (1 -10 years versus 11 -30 + years). Age-and multivariable-adjusted logistic regression models were used to assess the potential association of workplace harassment with depressive symptoms. Statistical significance was considered at the traditional alpha level of 0.05 and was two-sided for all tests.

Results
Among a total of 402 mental health nurses, 255 completed the questionnaires with a response rate of 62.9%. The demographic characteristics of the study participants in association with reports of workplace harassment and depressive symptoms are shown in table 1. Females were the majority of study participants (55.7%), 73.3% were in the age group of 20-40 years old, 71.4% were married, 67.5% had a bachelor's degree, 83.1 were nurses and about half of participants had more than 10 years of experience. The prevalence of the workplace harassment «mobbing» among mental health nurses in Cyprus was estimated to be 8.2%. Among those who reported exposure to one or more workplace harassment behaviors, 47.9% of participants reported rare exposure, 23.3% reported exposure at least once a month, 20.5% reported exposure at least once a week, while a small percentage (8.2%) reported almost daily or daily exposure to workplace harassment. About one in ten study participants (11.0%) reported depressive symptomatology with a CES-D score equal or higher to 16.

Demographic Characteristics
Total n (%) The most frequent mobbing behaviours reported by the participants in the previous 6 months are shown in table 2. The most common harassment behaviour reported (18.4%) was that people were constantly being assigned new tasks, while the second most common behaviour (13.7%) was "being assigned tasks inferior to employees' abilities". Study participants also reported at a similar level (12.2%) that their decisions were being disputed and/or people were speaking badly behind their back.
In addition, according to our findings, the most common sources of mobbing behaviours towards the study participants were from their managers (69.2%), from their co-workers (46.2%), and/or from those at a lower professional ranking (6.2%). Study participants reported being exposed to workplace harassment from females (43.1%), from both males and/or females (36.9%) or were exposed to harassment only from males (20%). Furthermore, study participants reported seeking psychological support due to their exposure to workplace harassment either from a colleague (82.3%), and/or a manager (48.4%), and/or a family member or relatives (45.2%) and/or friends outside the workplace (43.5%). Study participants attributed workplace harassment to different reasons including administration problems (65.2%), job position assignment (52.2%), poor work organization (52.2%), jealousy (52.2%), workplace rivalry (47.8%), and generally poor working conditions (37.0%).
Using age-and multivariable-adjusted logistic regression models, as are shown in table 3, we examined the potential association between exposure to workplace harassment and depressive symptoms among mental health nurses. We found that mental health nurses who were being exposed to workplace harassment were about five times more likely to report depressive symptomatology with a score higher than 16. Even after adjusting for several variables in the multivariable model (age, gender, marital status, educational level, professional ranking and years of experience) the risk remained very high (OR = 5.2) and was statistically significant (P = 0.002).

Discussion
To our knowledge, this is the first study in Cyprus and one of very few studies internationally focusing on the issue of workplace harassment among mental health nurses. In this study we found that the prevalence of workplace harassment among mental health nurses in Cyprus was estimated to be about 8.2%. In addition, more than one in ten nurses (11.0%) reported depressive symptoms based on the CES-D scale. Using multi-variable adjusted logistic regression models (adjusted for age, gender, marital status, educational level, professional ranking and years of experience), we found that mental health nurses who reported workplace harassment were 5.2 times more likely to have depressive symptoms compared to their colleagues who did not experience workplace harassment.
On the basis of the Leymann criteria, Sà and Fleming conducted a study in a public hospital in Portugal using the LIPT questionnaire and reported a rate of mobbing of 13% [38]. In a similar study, Fontes et al., reported from Brazil in 2013 that 11.6% of nurses had experienced mobbing in the previous 12 months [39]. In a another survey among registered nurses (n=286) in Ankara training hospital of Turkey, Yildirim D showed in 2009 that 21% of participants were directly exposed to mobbing behaviours during the previous 12 months, while 37% never or almost never were exposed to such behavior [33]. Much higher rates of workplace harassment (86.5%) have been reported by Yildirim A & Yildirim D among nurses (n=505) from public and private hospitals in Turkey [32].
The results of the 5th European research conducted in 2012 by the European Foundation for the Improvement of Living and Working Conditions in the EU-27 Member States, including Albania, Croatia, Kosovo, Montenegro, Norway and Turkey, showed that 4.1% of respondents in the EU-27 reported exposure to bullying or harassment at work. Higher exposure rates to intimidation or harassment were seen in France (9.5%), Belgium (8.6%), the Netherlands (7.7%), and in Austria and Luxembourg (7.2%). For workers in the health sector the prevalence of mobbing was 11.3% [40].
The results of our study showed that psychological violence was exercised, in most cases, from females and from people holding a higher hierarchical position such as managers. Results from other surveys also showed that women are more often the perpetrators of psychological violence, [41] as well as people who have leading positions in the organization [8,12,34,[42][43][44]   of workplace harassment at a higher level than that of females [9,45,46]. The results of the present study showed that there was no correlation between gender and the victims of workplace harassment since both males and females were exposed to workplace harassment at a similar rate. Similar findings have also been reported by other researchers [43,45,47]. On the other hand, based on the results of other studies, females were shown to have a higher exposure to workplace harassment than males [40]. A particular variation was observed among females from the younger age group (15-29 years) being exposed to a higher rate of workplace harassment (8.5%), compared to the level of exposure of the older age groups (5.5%) [11]. Furthermore, in our study there was no statistically significant relationship between workplace harassment and the different age groups, educational levels, professional rankings and/or the work experience. Similar results have been demonstrated also by other researchers such as Görgülü et al., [48] who did not find any statistically significant relationship between workplace harassment and professional experience [43].
The most common mobbing behaviours reported by the participants of our study were that people were constantly being assigned new tasks, and/or were being assigned tasks inferior to employees' abilities". Study participants also reported that their decisions were frequently being disputed and/or people were speaking badly behind their back. Relevant results were seen in other studies such as Yildirim D [33] who reported that the most common type of mobbing behavior was the attacks against participant's professional position followed by attacks on their personality. Selič et al., reported in their study that the most frequent type of workplace harassment was a behavior affecting interpersonal communication, threats to personal reputation, behavior affecting the professional position and/or people's social contacts [49].
Another important finding of our study was the statistically significant association between workplace harassment and depressive symptomatology. Mental health nurses who reported exposure to workplace harassment were five times more likely to have depressive symptoms compared to their colleagues who did not experience workplace harassment. Similar results were seen in other studies in this field. For example, Yildirim D showed that 45% of the study sample (nurses) had symptoms of moderate or severe depression according to the Beck Scale Inventory (BDI) and there was a positive correlation between exposure to workplace bullying and depression among nurses (p < 0.001) [33]. Furthermore, the results from the national studies reported in the Fourth European Working Conditions Survey (EWCO) conducted in 2005 highlighted the correlation between bulling and workplace violence with increased stress levels and reduced mental well-being. Specifically, the most frequently reported symptoms associated with workplace bullying were stress (52.2%), fatigue/exhaustion (48.2%), sleeping problems (30.5%), and anxiety (27.3%) [11].
One of the limitations of our research was the relatively low response rate although it was above 60%. In addition, another limitation was the short period of time provided for survey completion (about 2 weeks). As a result, study participants working with night shifts and being away from work were not given equal opportunity to participate in the survey, a limitation which is believed to have affected the response rate of our study. Furthermore, the collapsing of categorical variables into dichotomous ones may also have resulted in the loss of valuable information in the statistical analyses concealing perhaps useful data. Finally, the limited number of studies reported in the international literature with respect to mental health nurses in this particular field did not allow us to present additional comparisons.

Conclusion
Workplace harassment as well as depressive symptoms are quite prevalent among mental health nurses in Cyprus. Out study showed that there is a statistically significant association between workplace harassment and depressive symptoms among mental health nurses. Further exploring this important association with qualitative and quantitative research is warranted and may offer valuable insight into the possible causal pathways and open up opportunities for effective workplace interventions to improve physical and mental well-being of nurses.

Relevance for Clinical Practice
This is the first study to capture (identify and record) the phenomenon of mobbing among the occupational group of mental health nurses in Cyprus. Our findings provide a valuable insight into the contributory and etiological factors implicated in the development and propagation of workplace harassment and mental health among health professionals. The current study constitutes an important stepping stone for further research to explore clinical pathways and adverse metal health outcomes among nurses, as well as to develop appropriate clinical policies and workplace interventions to curb this phenomenon and improve physical and mental well-being among nurses.

Authorship Statement
EAP, ESS and DK conceived of the idea for the study and participated in the study design, data collection and evaluation. EAP and ESS supervised the statistical analyses. All authors reviewed and participated in the interpretation of statistical analyses. EAP and ESS wrote the first draft of the manuscript. All authors contributed to subsequent versions of the manuscript. All authors contributed and approved of the final version of the manuscript.

Disclosure Statement
The authors declare that they have no conflict of interest.