Workplace bullying and its impact on the quality of healthcare and patient safety

Workplace civility is one of the key elements of professionalism in the healthcare industry [1], where an environment of interactive behavior among healthcare practitioners becomes the foundation for a robust hospital performance [2]. Workplace bullying (WPB) is a disruptive behavior that might occur. The World Health Organization (WHO) stated that WPB is an incident during which individuals face a repeated and health-harming mistreatment by perpetrators [3, 4]. It is often characterized by its persistence and long-term duration [5] and caused by psychosocial, cultural, and/or individual factors [6]. WPB includes direct attacks such as hitting, cursing, mocking, or indirect ones such as spreading rumors [7]. One of the major types of bullying is social bullying, i.e., “offensive conduct,” which involves unacceptable jokes related to the gender, public insulting, practical jokes, slander, and exploitation [8].

A multisite study published by the WHO stated that healthcare practitioners, in Brazil 39.5%, in Bulgaria 32.2%, in South Africa 52%, in Thailand 47.7%, in Portugal 27.4%, in Lebanon 40.9%, and in Australia up to 67%, had experienced verbal abuse in a year [9]. Reports showed that the prevalence of WPB among nurses ranged between 27 and 31% [10]. Another study asserted that one in ten family physicians reported an exposure to WPB [11] and that 69.8% of medical residents have been exposed to WPB during their training [12]. In Saudi Arabia, few studies reported that 50–56% of nurses [13, 14], 36.8% of dental interns [15], and 28–84% of medical students or residents reported WPB [16, 17]. Therefore, it is imperative to investigate and analyze the implications of WPB in regions with unique and conservative work cultures such as the Middle East.

While WPB is a common phenomenon worldwide, its implications and tolerability vary according to the cultures, morals, and values of healthcare practitioners embedded in their community and reflected in the healthcare environment. On an individual level, WPB among healthcare workers has been associated with an increase in sickness and/or absenteeism [18]. In retrospect, healthcare practitioners were mostly affected by their stressful work conditions [19]. Likewise, the organizational consequences of WPB can be manifested in a toxic or hostile work environment, which is strongly linked to a compromised quality of care and patient safety. It inhibits teamwork, obstructs communication, disrupts behavior, and increases medical errors by affecting the quality of healthcare organization [20].

Authors of this study believe that determining whether a healthcare practitioner is worried or not about WPB serves a number of purposes. Being worried signifies that either the practitioner has been exposed to WPB, or witnessed an incident encountered by a colleague. Another purpose is that constant worrying over WPB creates a high-risk environment for the employees. It also affects their productivity and level of concentration, which, in turn, increases the likelihood of committing errors and jeopardizing the quality of care and patient safety. Last, worried practitioners might develop fear due to their lack of knowledge about preventing, handling, and reporting a WPB incident. While investigating actual WPB incidents is more reflective of the situation, a survey to determine whether healthcare practitioners are worried about WPB provides some insights into the bullying incidents given that not all WPB incidents are officially reported and documented. Accordingly, there is a pressing need to determine if healthcare practitioners in Saudi Arabia worry about WPB and its effect on the quality of care and patient safety.

A worried practitioner about WPB might have developed a certain level of anxiety or fear based on an actual bullying incident or a potential escalating situation. The exact prevalence of WPB is debatable and often under-reported [27]. The authors believe that victims of WPB might refrain from disclosing such unfortunate incidents for fear of causing a scandal or jeopardizing their career. While it seems rational for any health practitioner to feel worried about WPB, hospital administrators are compelled to investigate the reasons behind such worries. Similar to other cases, HCWs in this study admitted that WPB affected various themes of patient safety and quality of care (stress management, concentration, workload, communication, delivery of care, medical errors) [28]. Accordingly, this requires a large-scale plan to fight WPB by raising awareness among HCWs, enforcing stringent rules and enacting disciplinary actions. The focus of this study was also to caution hospital administrators about high-risk groups and advise such groups to attend education/training programs on handling/reporting WPB. Furthermore, administrators can attempt to alleviate worker’s concerns and enhance their readiness in case of exposure to WPB.

Female and single practitioners in this multi-regional healthcare facility showed the highest levels of worry about WPB. Female engagement in the workforce has increased drastically in Saudi Arabia, and compared with male workers, females are more prone to WPB [29]. For some practitioners, their need for the job outweighs the aftermath of WPB, yet every hospital administrator should strive to guarantee their safety and satisfaction. The authors also believe that young and single employees might lack some of the skills that help avoid, handle, and confront WPB perpetrators. Surprisingly, more educated practitioners had the highest levels of worry about WPB. One of the possible reasons is that this category of practitioners could be more envied by their colleagues of the same career levels or by their management (downward or upward envy). Envy is a predictor of hostility, competition, or aggressive behaviors which are demonstrated in WPB, and associated with counterproductive work behavior as well [30].

The impact of WPB on practitioners and continuity of patient care is dangerous, not only in terms of errors or substandard care, but also on the high turnover rate for both experienced and inexperienced personnel [31, 32]. A group of practitioners in this multi-regional healthcare facility have admitted that they were, to some degree, exposed to WPB. This group clearly expressed higher levels of worry about WPB being a negative influence on various aspects such as patient care, safety, interaction with other practitioners, and work performance. Even though this self-reported incident occurred at a certain point of time, its emotional residue remains [33]. The authors speculate that a survivor of WPB might develop more experience in handling future incidents. However, personal experience is not enough to guarantee a safe work environment especially if patient care is attenuated by WPB [34]. In this facility, participants had a positive history of WPB, yet their worry scores remained high.

Any issue related to the quality and safety of patient care should not be overlooked since its rating implied a significant relationship with WPB; hence, the responsibility of the hospital administrators is amplified. From the standpoint of practitioners, WPB increases stress, impairs performances, affects communication, and alters thinking, all of which would jeopardize the quality of healthcare and its delivery. Previous literature has proven that the two aspects are significantly linked, as WPB affected both team work and staff retention [23], resulting in depressed practitioners and higher frequency of medical errors [35]. Authors speculate that worrying about WPB exists in all healthcare settings—to a degree—therefore, patient safety can be predicted based on an assessment of this worry. In other words, any patient safety survey or assessment, whether being a key performance indicator, an accreditation pre-requisite, or a research questionnaire should incorporate a domain tackling WPB. For instance, the WHO patient safety tool kit failed to provide any assessment of WPB, which is also neglected by the Safety Competencies to enhance patient safety across the health professions issued by the Canadian Patient Safety Institute [36]. On the other hand, the Registered Nurses Association of Ontario published a better practice guideline which provides recommendations and information about bullying tools [37]. Fifteen evidence-based recommendations for HCWs were displayed so that they can recognize, prevent, and manage WPB and focus on patient care. Therefore, patient safety officers and accrediting bodies are advised to be vigilant with the levels of worry over WPB among health practitioners and to integrate it within their assessment tools.

Most healthcare practitioners worry about WPB, especially its negative impact on the quality of care and patient safety. Being worried about WPB signified that healthcare practitioners were true advocates and safety guardians of their patients. WPB not only exerts stress on practitioners on a personal level but also threatens the patient-practitioner relationship. A greater proportion of practitioners with higher levels of education and those with less working experience were more worried about WPB. Previous exposure to a WPB incident amplifies the practitioner’s worry, but being trained on how to counteract bullying incidents makes them less likely to be worried.