Consequences of Workplace Bullying for Individuals, Organizations and Society
The past three to four decades have provided solid evidence that workplace bullying can be a severe stressor that may affect the mental and physiological health as well as the well-being of the targets. Other consequences of workplace bullying remain, however, widely unexplored. The goal of the present chapter is to provide a state-of-the-art overview of the existing international evidence about the different effects of workplace bullying that, reaching beyond reduced individual well-being and poor mental and physiological health, focus on the further consequences for individuals, organizations and society. To this end, the chapter begins by introducing the key theoretical approaches within this field of research, including Leymann’s model of the development of workplace bullying, the transactional theory of stress, the cognitive activation theory of stress (CATS), the stress-as-offence-to-self (SOS) perspective, the structural empowerment theory and the self-determination theory (SDT). After this introduction, the chapter summarizes the existing research investigating the impact of workplace bullying on a diverse array of individual, organizational and societal problems, including sickness absence, job turnover, unemployment and drop-out from a trade, early retirement and disability retirement, quality of care and patient safety in the healthcare sector as well as suicidal ideation and suicidal behaviour. The concluding remarks outline the main gaps in the current knowledge and discuss future research directions that are needed to enrich our understanding of the individual, organizational and societal consequences of workplace bullying. Finally, the limitations of the present chapter are highlighted.
The past three to four decades have provided compelling evidence that workplace bullying is a strong social stressor that may substantially affect the mental (see Conway et al., this volume) and physiological health (see Hansen et al., “Health Consequences of Workplace Bullying: Physiological Responses and Sleep as Pathways to Disease”) as well as the well-being of targets. Research into the phenomenon of workplace bullying started with case studies and cross-sectional studies; later on, longitudinal studies were published; and finally, in recent years, a number of register-based studies have confirmed the significant association between bullying and health outcomes. The effects of workplace bullying are, however, not measurable only in terms of reduced individual well-being and poor health; indeed, bullying may also have economic consequences for individuals as well as for organizations and society. Previous studies have found bullying being associated with long-term sickness absence (Clausen, Hogh, & Borg, 2012; Grynderup et al., 2016; Nabe-Nielsen et al., 2016; Ortega, Christensen, Hogh, Rugulies, & Borg, 2011; Stromholm, Pape, Ose, Krokstad, & Bjorngaard, 2015), higher job turnover and early retirement. Recently, studies have also found that workplace bullying is a predictor of unemployment (Glambek, Skogstad, & Einarsen, 2015). Other consequences that will be covered in this chapter are disability retirement, low quality of care and patient safety in the healthcare sector as well as suicidal ideation and behaviour as potential effects of bullying. These consequences impact individuals, organizations and society, though the extant literature does not include many studies designed and executed at the latter two levels. Moreover, when it comes to the individual-level consequences, it has to be noted that the present chapter is primarily centred on the long-term effects on the targets—that is, the economic effects on perpetrators and bystanders will not be considered. Furthermore, this being a relatively new field of research, many aspects related to workplace bullying, particularly with regard to studies undertaken to capture the organizational and societal levels, still remain unexplored. Finally, while the early studies in this area have mainly been cross-sectional, this chapter will focus primarily on recent studies employing a longitudinal design and register-based data.
2 Key Theoretical Approaches
No single theory has emerged in the area of the development and consequences of workplace bullying being able to guide the approaches to examine the associations between exposure to workplace bullying and the consequences to the individual, the organization and society. Thus, different theories have been used in the studies examining the consequences of bullying, which are reviewed in this chapter.
2.1 Leymann’s Model of the Development of Workplace Bullying
Based on a large number of case studies from the 1980s and 1990s, Leymann (1996) developed a four-phase model of the development of bullying—from conflict to expulsion from the organization. The first phase concerns the critical incident, most often a conflict, whereby bullying can be understood as an escalated conflict. In the second phase, bullying activities are identified, as well as the stigmatization of the target. The observed behaviours are often based on an intention to “get the person” or punish him or her. Aggressive manipulation is the main characteristic of the events that occur in this phase (Leymann, 1996, p. 171). The third phase involves interference from the personnel management. Due to the previous stigmatization, the management often misjudges the situation as being the fault of the target and generates explanations that focus on personal characteristics rather than environmental factors (Jones, 1984 in Leymann, 1996, p. 172). The management tends to take over the previously produced prejudices about the target. These acts can result in serious violations of rights. In this phase, the target becomes ultimately stigmatized. In the last phase, which Leymann called the expulsion phase, the target leaves the organization either voluntarily or by force. This situation can be responsible for the development of serious health issues (Leymann & Gustafsson, 1996). Leymann’s model is still relevant, as the review of the different consequences associated with workplace bullying will show in the next section. While Leymann’s model may set an outline of the course of events from conflict to experience of bullying and expulsion, no single theory can explain the mechanisms involved during such process.
2.2 Transactional Theory of Stress
Lazarus and Folkman’s (1987) transactional theory of stress and coping behaviour sheds light on some of the mechanisms involved in the relationship between stressors and reactions (Lazarus & Folkman, 1987). This theory proposes that the severity of the emotional reactions that occur after being exposed to stressors such as workplace bullying may be a function of a dynamic interplay between event characteristics, individual appraisals and coping processes. Strain outcomes are expected to arise only when the person has insufficient coping resources available. Workplace bullying is often described as a prolonged exposure to negative interpersonal acts the target is unable to cope with. This configures a highly stressful situation for the target that is characterized by a pervasive lack of control (Hogh, Giver, Hannerz, & Pedersen, 2012).
2.3 Cognitive Activation Theory of Stress (CATS)
The CATS theory (Ursin & Eriksen, 2004) represents a further development of the transactional theory of stress. It proposes that attributions of control and predictability are important characteristics of the individual’s appraisal process (Joseph, 1999; Lazarus, 1999). As such, the CATS theory may provide a theoretical standpoint to understand the link between workplace bullying and cognitive processes. It is the person’s experience and evaluation of demands and outcome expectancies that determine whether a specific demand causes a stress response and consequently affects the health of the individual (Reme, Eriksen, & Ursin, 2008). According to the CATS theory, effective coping with stressors is defined as positive outcome expectancy and is related to psychophysiology. Indeed, the CATS theory states that, when dealing with a stressful situation, it is not enough that the individual has control but also that he or she has the expectation that such control will lead to a good outcome. If such positive expectation does not occur, the individual may perceive the situation as hopeless and endure adverse health effects as a result (Reme, Eriksen, & Ursin, 2008).
2.4 “Stress-as-Offence-to-Self” (SOS) Perspective
According to the SOS perspective, an individual’s central existential motive is striving to protect his or her self-worth. Self-worth comprises feelings of personal self-esteem (i.e. a positive self-evaluation) and feelings of social esteem (i.e. the regard and respect received from others) (Semmer et al. 2007). Given the importance to build and maintain a sense of positive self-worth, the SOS perspective posits that threats to the self-esteem of the individual should be considered an important potential stressor in modern-day work lives.
In the SOS perspective, stress is a phenomenon that occurs in a social context, and, for the purpose of the present chapter, stress is conceptualized as a phenomenon that is closely related to social relations in the workplace. Accordingly, constructive social relations in the workplace are likely to imply that the employee is regarding himself or herself as a “worthwhile, capable, and valued member of a group” (Sarason et al., 1996, cited in Semmer et al. 2007, p. 44), which is expected to maintain and expand the personal and social self-esteem of the individual. Contrarily, employees exposed to bullying are likely to feel excluded from the social community in the workplace, which is expected to undermine the self-esteem of the individual.
Stress can occur in situations that threaten the personal or social esteem of the employee. In the SOS perspective, personal self-esteem may in particular be threatened in situations that are labelled as “stress through insufficiency” (SIN). In such situations, the individual blames failed efforts on personal attributes, as, for instance, a lack of task-related or social competence or experience to handle personal or work-related challenges.
Another type of stressor is “stress as disrespect” (SAD), which is caused by behaviours that signal a lack of appreciation and respect, which again may constitute a threat to the self-esteem of the targeted employee. Indeed, workplace bullying must be considered a very overt type of SAD, as workplace bullying may imply personal attacks on colleagues, making them lose face in social contexts or engendering situations where feedback is provided in a derogatory manner. In the SOS perspective, such behaviours are labelled “illegitimate behaviours”. Moreover, if the targeted employee finds it difficult to defend herself or himself against such illegitimate behaviours, the latter qualify as workplace bullying, with potentially adverse consequences for the health and well-being of those exposed. In addition to the type of illegitimate behaviours outlined above, the SOS perspective also points towards “illegitimate stressors”. These are described as acts that may not be deliberately directed towards specific individuals but instead signal a lack of consideration for the individuals. Examples of illegitimate stressors may be colleagues not completing their tasks sufficiently or not providing relevant information, which may unnecessarily complicate the task an employee has to carry out. A third form of SAD is labelled “illegitimate tasks”. These signal a lack of appreciation and respect towards the employee who must perform these tasks and can either be described as “unreasonable tasks” or “unnecessary tasks”. Both leave the employee in a situation that undermines his or her personal and social esteem in the work situation.
According to Semmer et al. (2007), the three behavioural forms described above under the concept of SAD are not completely independent and are likely to overlap. Therefore, the concepts of illegitimate behaviours, illegitimate stressors and illegitimate tasks provide different perspectives on social relations and exchanges that may threaten one’s personal and social esteem, which again may result in adverse outcomes related to the health and well-being of the individual. On these grounds, the SOS perspective offers an important lens in which the psychological dynamics related to the phenomenon of workplace bullying and its consequences can be understood as offences to the “self” of the target.
2.5 Structural Empowerment Theory
According to the structural empowerment theory (Laschinger et al. 2001), work environments that provide access to information, resources, support and opportunity to learn and develop are regarded as empowering. In these high-quality work environments, employees are encouraged by the management to act on their expertise and judgement. Because of the existing empowerment, employees are more committed to the organization, have higher levels of trust in management, are more accountable for their work and are less likely to experience job strain (Laschinger et al. 2001). Managers can take specific actions to avoid poor work environments that negate trusting and civil working relationships (i.e. allow bullying) and therefore diminish work effectiveness.
2.6 Self-Determination Theory (SDT)
The SDT postulates that in order to achieve employee well-being and optimal functioning at work, an individual needs to satisfy three basic psychological needs, that is, autonomy, competence and relatedness, which operate in interaction within the social context (Deci and Ryan 2008; Ryan and Deci 2000). The SDT further proposes that the social context plays a pivotal role in the satisfaction of these basic psychological needs and the ensuing well-being. Thus, positive work-related social environments will fulfil the individual’s needs and promote subsequent positive well-being, while poor work-related social environments will not. The latter are characterized by poor interpersonal interactions, criticism and controlling behaviour—including bullying or contexts that allow bullying—all of which prevent employees from fulfilling their basic psychological needs, leading to negative outcomes as a result (Ryan and Deci 2000).
2.7 Summing Up
Taken together, the theoretical perspectives presented above uphold the expectation that workplace bullying is associated with a series of adverse outcomes and that this association is likely to be mediated by reduced psychological well-being among the targets of workplace bullying.
3 Aims and Contributions to the Understanding of the Consequences of Workplace Bullying
This section provides a comprehensive coverage of existing international knowledge of workplace bullying as a predictor of long-term sickness absence, job turnover, unemployment and drop-out from a trade, early retirement/disability retirement, quality of care and patient safety in the healthcare sector and suicidal ideation and behaviour. The chapter focuses on the main findings in this field, with a special focus on longitudinal and register-based studies and on the mechanisms and processes underlying the long-term consequences of bullying. It may be noted that while the studies included in this section point to the consequences of workplace bullying for individuals, organizations and society, very few studies are designed to capture the latter levels, a point we return to in the next section. Rather, by pointing to the consequences on individuals, the extant literature highlights the impact on organizations and society.
For the present review, a series of literature searches was performed. For the association between workplace bullying and sickness absence, the following search string was employed in PubMed: (“workplace bullying” OR “workplace mobbing”) AND (“sickness” OR “absence” OR “absenteeism” OR “sick leave”). For the association between workplace bullying and job turnover, the search string, which was again inputted in PubMed, was the following: (“workplace bullying” OR “workplace mobbing”) AND (“turnover” OR “job change”). For the association between workplace bullying and unemployment or drop-out from a trade, a literature search on two databases (MEDLINE and PsycINFO) was performed using the following search string: (“workplace bullying” OR “workplace mobbing”) AND (“unemployment” OR “drop-out” OR “drop out”). For the association between workplace bullying and early retirement or disability retirement, the search string inputted in PubMed was the following: (“workplace bullying” OR “workplace mobbing”) AND (“early retirement” OR “disability retirement”). For the association between workplace bullying and quality of care, a literature search on two databases (PubMed and CINAHL) was performed using the following search string: (“Quality Indicators, Health Care” OR “Quality of Health Care” OR “Healthcare Quality” OR “Quality of Healthcare” OR “Patient Safety” OR “Patient Satisfaction”) AND (“Nursing Staff” OR “Hospital Nursing Staff*” OR “Nurses” OR “Nurse*”) AND (“Workplace Violence” OR “Bullying” OR “Horizontal Violence” OR “Lateral Violence”). Finally, for the association between workplace bullying and suicidal ideation and behaviour, the following search string was used in two databases (PubMed and PsycINFO): (“bullying” OR “mobbing” OR “harassment” OR “emotional abuse”) AND (“suicide” OR “suicidal ideation” OR “suicidal behaviour”). To identify additional relevant studies, the reference lists of the former identified studies were manually screened and the authors’ personal literature archives searched.
3.1 Summary of Existing Studies
As mentioned above, in this section we review the existing research on the consequences of workplace bullying for the individual, the organization and society, with a focus on the long-term effects. This section is divided into subsections dealing with specific outcomes, including sickness absence, job turnover, unemployment and drop-out from a trade, early retirement/disability retirement, quality of care and patient safety and suicide (ideation and behaviour). Information on mediators is also woven into the subsections.
3.2 Assessing the Evidence on the Association Between Workplace Bullying and Sickness Absence
In a recent systematic review and meta-analysis, Nielsen et al. (2016b) found 17 longitudinal high-quality studies investigating the association between workplace bullying and risk of sickness absence (Nielsen, Indregard, & Øverland, 2016b). Of the 17 reviewed studies, 16 studies reported that workplace bullying was prospectively associated with risk of sickness absence among targets of bullying. In the reviewed studies, both short-term and long-term sickness absence outcomes were investigated. The studies investigated in the review were predominantly from the Nordic countries, and 15 of the 17 studies were based on register-based measures of sickness absence. The study by Nielsen, Indregard and Øverland (2016b) also included a meta-analysis of 10 of the 17 included studies. The meta-analysis showed an increased risk of sickness absence for targets of workplace bullying (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.39–1.79). Thus, according to the aforementioned review and meta-analysis, workplace bullying systematically predicts the risk of employee sickness absence in different populations. This finding was also supported in other non-Nordic contexts (in Belgium [Janssens et al., 2016 ] and in 31 countries in Europe [Niedhammer, Chastang, Sultan-Taieb, Vermeylen, & Parent-Thirion, 2013]).
One study, conducted among Danish eldercare workers (n = 9520), found that self-reported exposure to workplace bullying increased the risk of long-term sickness absence as measured in a national register on social transfer payments (Clausen, Hogh, & Borg, 2012). In this study, the association between workplace bullying and sickness absence periods of >8 weeks was investigated. The results showed that self-reported frequent exposure to workplace bullying increased the risk of long-term sickness absence of >8 weeks (hazard ratio [HR] 2.26, 95% CI 1.50–3.42) while adjusting for self-reported exposure to threats, violence, unwanted sexual attention, psychosocial working conditions and demographic factors. The study showed no increased risk of long-term sickness absence for respondents reporting occasional exposure to workplace bullying (HR 1.10, 95% CI 0.83–1.44), as compared to a reference group reporting no exposure to workplace bullying. Moreover, in this study, the authors investigated the risk of long-term sickness absence for self-reported exposure to four types of offensive behaviours in the workplace: threats, violence, bullying and sexual harassment. Of these four types of offensive behaviours, the analyses showed that self-reported exposure to workplace bullying was the strongest predictor of long-term sickness absence.
Similar findings are reported by (Ortega et al. 2011) in a Danish study on healthcare workers. They reported that self-reported exposure to frequent workplace bullying increased the risk of long-term sickness absence of >6 weeks (HR 1.92, 95% CI 1.29–2.84), also after adjusting for age, gender, health behaviour, demographic factors and psychosocial working conditions. No increased risk was observed for respondents reporting exposure to occasional bullying.
A recent study investigated unwanted sexual attention—which is considered a special form of bullying wherein sexual behaviour or attention is used as negative behaviour—and risk of long-term sickness absence (Hogh et al. 2016). This prospective study is based on a pooled sample of 14,605 employees from Danish surveys conducted in 2000, 2004 and 2005, adding up to 19,366 observations in total. Even though women were more exposed to unwanted sexual attention than men (women, 2.9%; men, 1.6%), the latter had a higher risk of long-term sickness absence after exposure to unwanted sexual attention. Among the exposed, 1% were exposed to unwanted sexual attention from colleagues, managers and/or subordinates (women, 1.3%; men, 0.7%). These associations were adjusted for age, influence of work, work pace, occupational group and mode of data collection (Hogh et al. 2016). A gender-stratified HR indicated that the exposure to unwanted sexual attention from colleagues, managers and/or subordinates was significantly associated with subsequent long-term sickness absence among men but not among women, also after adjusting for age and occupational group (HR 2.15, 95% CI 1.18–3.91). Including work and work pace did not considerably change the associations (HR 2.47, 95% CI 1.32–4.65). The study points at different explanations as to why men seem to differ from women in the way they perceive, cope and react to unwanted sexual attention. For instance, men may perceive being a target of sexual harassment as a bigger threat to their self-esteem than women. This might be a consequence of the societal understanding of traumas of sexual nature as being less accepted among men, which can lead to shame among the male targets. This shame may lead men to avoid talking about the problem and take action to fix the situation. The major limitations of the study include limited statistical power, the fact that exposure to unwanted sexual attention is based on self-reports and that the data were collected in 2000 and 2005, which might not be applicable to today’s situation. These results need therefore to be confirmed in future studies. Further research could also investigate whether low self-esteem can be a mediator of the risk of being a target of unwanted sexual attention (Hogh et al. 2016).
In the review performed by Nielsen and colleagues (Nielsen, Indregard, & Øverland, 2016b), no studies investigated potential mediators in the association between workplace bullying and sickness absence. Yet, recent studies from Denmark indicate that reduced sleep quality (Grynderup et al., 2016; Nabe-Nielsen et al. 2016) and perceived stress (Grynderup et al., 2016) can be considered mediators in the association between self-reported exposure to workplace bullying and sickness absence (for more information, see Hansen et al., this volume). In addition, a Belgian study reported that workplace bullying could be considered a mediator in the association between psychosocial working conditions and risk of long-term sickness absence, so that a strained psychosocial working environment increased the prevalence of workplace bullying, resulting, in turn, in a heightened long-term sickness absence (Janssens et al., 2016).
In sum, the presented evidence supports the hypothesis that work-related bullying is associated with an increased risk of sickness absence.
3.4 Assessing the Evidence on the Association Between Workplace Bullying and Job Turnover
Turnover can be conceptualized as the voluntary or involuntary departure of employees from their workplace (Campion, 1991; Estryn-Behar et al., 2008). Many studies on the association between workplace bullying and job turnover have investigated turnover intentions of employees and not actual turnover behaviour as outcome (Djurkovic, McCormack, & Casimir, 2008; Estryn-Behar et al., 2008; Hauge, Skogstad, & Einarsen, 2007; Hayes et al., 2012; LeBlanc & Kelloway, 2002; Wilson, Diedrich, Phelps, & Choi, 2011). In addition, many studies have focused on turnover among healthcare workers (Chu, Wodchis, & McGilton, 2014; Coomber & Barriball, 2007; Duffield, Roche, Homer, Buchan, & Dimitrelis, 2014; Ejaz, Bukach, Dawson, Gitter, & Judge, 2015), which implies that more research may be needed on the association between workplace bullying and the risk of turnover in other occupational groups.
In a three-wave prospective cohort study in Denmark, Hogh et al. (2011) found that self-reported exposure to workplace bullying at time 2 increased the risk of turnover in newly educated healthcare workers in the year after graduation (time 3). In this study, turnover was assessed using the following single item in a questionnaire: Have you changed your job within the past year? According to the results, self-reported exposure to frequent and occasional bullying (time 2) increased the prospective risk of self-reported turnover at time 3 (for frequent bullying, OR 2.6, 95% CI 1.2–5.9; for occasional bullying, OR 1.5, 95% CI 1.0–2.3), when adjusting for age, turnover intentions at time 2, working conditions at time 2 and health (i.e. mental health, vitality and somatic stress) at time 1. In this study, the participants who reported bullying at time 2 were also asked to list the reasons for their turnover at time 3. The results showed that participants who reported bullying both at time 1 and time 2 were significantly more likely to report “poor leadership”, “exposure to bullying, violence, threats or sexual harassment” and “(work-related) health problems” as reasons for turnover, as compared to participants who reported bullying only at time 2. This is one of the few studies examining the reasons why employees are leaving their job. With regard to such reasons, a significant difference was found between bullied and non-bullied respondents (Hogh et al. 2011). The most frequent reasons were poor leadership, which was chosen by 57% of the respondents, and exposure to bullying, violence, threats or sexual harassment, which was chosen by 25.7% of the respondents.
A recent Danish study by Nabe-Nielsen and colleagues (Nabe-Nielsen et al., 2017) showed that self-reported exposure to workplace bullying increased the risk of turnover and unemployment as measured in national register data, that is, the national Danish labour force register and the Danish register of sickness absence compensation and social transfer payments. Specifically, the study demonstrated that employees reporting to be bullied had an increased risk of changing jobs (OR 1.35, 95% CI 1.06–1.72) or becoming unemployed (OR 4.90, 95% CI 3.18–7.55) during the 12-month follow-up period. In addition, the findings indicated that the association between workplace bullying and the two outcomes was partially mediated by psychological stress reactions.
In another study by Clausen et al. (2016), which was also conducted in Denmark, the association between workplace bullying and risk of turnover was investigated in three job groups, namely, human service and sales workers, office workers and manual workers. This study, where turnover was measured in a national register, showed that employees who reported exposure to workplace bullying did not in general have an increased risk of turnover (OR 1.24, 95% CI 0.86–1.79), when adjusting for age, gender, tenure and psychosocial work conditions. When looking at the three job groups, the results showed, however, that office workers who reported exposure to workplace bullying did have an increased risk of turnover as compared to a reference group of non-bullied office workers (OR 2.03, 95% CI 1.05–3.90), when adjusting for age, gender, tenure and psychosocial work conditions. For the other two job groups, that is, manual workers and human service and sales workers, the study showed no statistically significant associations.
In a longitudinal study of nurses working in the public sector in Quebec, Canada (Trépanier et al. 2013), found that self-reported workplace bullying at T1 was associated with an increased risk of low psychological health (i.e. burnout) and poor job attitude (i.e. turnover intention and low work engagement) 12 months later (T2). Additionally, the authors found that the effect of workplace bullying at T1 on all three outcomes at T2 (i.e. burnout, low work engagement and turnover intention) was mediated by the satisfaction of the needs for autonomy and relatedness at T2.
Finally, a longitudinal study among Danish eldercare workers showed that self-reported frequent exposure to workplace bullying was associated with an increased risk of self-reported turnover (OR 1.91, 95% CI 1.23–2.96), when adjusted for age, gender and psychosocial working conditions (Clausen, Hogh, Carneiro, & Borg, 2013). Employees reporting occasional exposure to workplace bullying had an elevated but not statistically significant risk of turnover. Moreover, the results of this study suggest that the association between workplace bullying and turnover was partially mediated by the respondents’ psychological well-being. This indicates that exposure to workplace bullying had an adverse impact on the psychological well-being of the participants, which, in turn, increased the risk of turnover.
To summarize, the reviewed literature suggests that self-reported exposure to workplace bullying increases the risk of job turnover and that this association may be mediated by the psychological well-being of employees. Workplace bullying may thus be costly to an organization in terms of turnover and recruitment and training of replacements (Hogh et al. 2011).
3.5 Assessing the Evidence on the Association Between Workplace Bullying and Unemployment and Drop-Out from a Trade
Only a few studies have empirically investigated the association between workplace bullying and unemployment and drop-out from a trade. This subsection presents the existing studies in this specific research area.
A recent study summarized the findings of 12 studies on the consequences of workplace bullying (Sansone & Sansone, 2015). In addition to a number of psychological and medical consequences (including work-related suicide), workplace bullying was associated with socio-economic consequences on societal, organizational and individual levels. These included absenteeism due to sick days and unemployment through either job loss or voluntary quitting, a finding based on qualitative interviews (n = 40) with a community sample of Canadian women (MacIntosh, 2015 in Sansone & Sansone, 2015).
Hogh, Giver, Hannerz and Pedersen (2012) examined whether bullying, violence and/or threats of violence among Danish healthcare trainees were predictors of subsequent drop-out from the eldercare sector among employees who had graduated from college 2 years earlier. This study used questionnaires administered to participants 2 weeks before graduation and then 2 years after graduation utilized register-based data from the national employment registers (n = 5000). The study found that workplace bullying during training was a predictor of subsequent drop-out from the eldercare sector (OR 1.39, 95% CI 1.08–1.79) (Hogh, Giver, Hannerz, & Pedersen, 2012). Studies focusing on turnover suggest that stressful events such as bullying may create a shock and subsequently precipitate a psychological process, which can lead to the bullied person leaving the organization. Ultimately, bullying can result in the target leaving his or her profession altogether (Holtom, Mitchell, Lee, & Inderrieden, 2005; Lee, Holtom, McDaniel, & Hill, 1999 in Hogh, Giver, Hannerz, & Pedersen, 2012).
Glambek, Skogstad and Einarsen (2015, 2016) conducted an investigation on workplace bullying as an antecedent to indicators of dismissal either from the workplace or from working at all. The study took place in Norway and used a quantitative, 5-year prospective survey (n = 1613). Their results indicate that targets of bullying are at greater risk of expulsion from the workplace or working at all, whereas perpetrators’ occupational status is largely unchanged (Glambek, Skogstad, & Einarsen, 2015, 2016). A study in Denmark (Nabe-Nielsen et al., 2017) also investigated the association between workplace bullying and change of job/unemployment through two observation periods in 2007 and 2009. The study used questionnaire-based and register-based data, including n = 3527 for analyses on unemployment in 2007 and n = 2343 for analyses on unemployment in 2009. Findings showed that workplace bullying has important consequences for the organization and the labour market, including an association between workplace bullying and increased unemployment (OR 4.90, 95% CI 3.18–7.55), potentially mediated by psychological stress reactions (Nabe-Nielsen et al., 2017).
In summary, the literature suggests that self-reported exposure to workplace bullying increases the risk of unemployment or drop-out from a trade after 2–5 years and that this association may be mediated by the psychological stress reactions of respondents. The findings support the hypothesis that workplace bullying is associated with an increased risk of unemployment and drop-out from a trade.
3.6 Assessing the Evidence on the Association Between Workplace Bullying and Early Retirement/Disability Retirement
Like the previous subsections, only a few studies have investigated the association between self-reported exposure to workplace bullying and risk of disability retirement. An early Swedish study from 2003 investigated risk factors for disability retirement where relational factors such as bullying was one of the main risk factors for early retirement (Dellve, Lagerström, & Hagberg, 2003). A more recent Norwegian study shows that respondents reporting being targets of bullying had an increased risk of disability retirement (HR 1.55, 95% CI 1.13–2.12), when adjusting for demographic characteristics (including age and gender) and psychosocial working conditions (Nielsen, Emberland, & Knardahl, 2017). Finally, in a recent review of Nordic literature on the retention of older workers, it is concluded that there is strong evidence that conflicts at work, bullying and harassment are risk factors for early voluntary retirement (Fridriksson et al., 2017).
3.7 Assessing the Evidence on the Association Between Workplace Bullying and Quality of Care and Patient Safety
The literature on workplace bullying in healthcare has been focused on bullying against nurses, the largest group of healthcare practitioners. Workplace bullying is performed by both nurses and other healthcare professionals and has been reported for a long time. In fact, the first mention of bullying against nurses is from 1909 (Castronovo, Pullizzi, & Evans, 2016) when The New York Times (NYT) ran an article describing the abuse of young nurses by their head nurses. Newer studies report a 6-month prevalence of 48% (Berry, Gillespie, Gates, & Schafer, 2012; Dewitty, Osborne, Friesen, & Rosenkranz, 2009; Etienne, 2014). The highest rate is among new graduate nurses (Berry, Gillespie, Gates, & Schafer, 2012). The aforementioned NYT article also was the first to make the connection between nurses being bullied and the threat of suboptimal care for the patients (Castronovo, Pullizzi, & Evans, 2016). However, the effect of bullying on quality of care and patient safety has not been widely studied.
A recent review found only 11 studies in the last 20 years that linked workplace bullying to patient safety (Houck & Colbert, 2017). This included nine descriptive correlational studies, one case study and one qualitative study. The studies reported on both clinician-reported outcomes and actual rates of safety events. Workplace bullying was associated with increased behaviours that are detrimental to patient safety, such as altered thinking or concentration and silence or inhibition to communicate. Patient safety outcomes associated with workplace bullying were errors in treatment or medications, delayed care, adverse events and patient mortality. Workplace bullying was also associated with higher rates of patient falls and patient complaints.
Several other studies report on the relationship between workplace bullying and clinician’s perceptions of quality of care and patient safety (Dang, Bae, Karlowicz, & Kim, 2016; Laschinger, 2014; Oh, Uhm, & Yoon, 2016; Purpora, Blegen, & Stotts, 2015). While clinician’s perceptions of quality and patient safety may be seen as a limitation and less optimal compared to actual rates, a large multi-country study found that nurses’ assessment of patient care quality is correlated with patient satisfaction and thus is a valid indicator of actual care quality (Aiken et al., 2012).
In a study of clinicians (physicians, nurses, nurse practitioners and physician assistants) in one academic medical centre in the United States (USA), bullying was associated with increased odds of clinician-reported harm to patients (temporary or permanent) and “near misses” (defined as an error that was about to happen to a patient but did not) (Dang, Bae, Karlowicz, & Kim, 2016). Other studies have found that workplace bullying has both direct and indirect effects on nurses’ perception of patient care quality and reported frequency of adverse events in Canada (Laschinger, 2014) and South Korea (Oh, Uhm, & Yoon, 2016). In the Canadian study, perceptions of patient safety risk mediated the relationship between workplace bullying and quality of patient care or adverse events. In the South Korean study, workplace bullying influenced perceptions of patient safety through intent to leave and job stress.
In a random sample of 175 Californian nurses in the USA, two models were used to assess the effect of workplace bullying on quality of care and patient safety. In the first model, workplace bullying directly affected perceptions of quality of care. In the second model, workplace bullying was associated with errors and adverse events. However, when peer relations (positive) were added to each model, it reduced the significance of workplace bullying in the quality of care model but not in the errors and adverse events model (Purpora, Blegen, & Stotts, 2015).
Only one study was found that is in the community health area. The study analysed long-term effects of bullying among healthcare providers in the eldercare sector in Denmark (Hogh, Baernholdt, & Clausen, 2018). Bullying at T1 was not associated with quality of care at T2, 2 years later. In contrast, bullying was associated with higher self-reported missed nursing care at T2. This difference was explained by different factors that are at play for quality and missed nursing care. For the first, the provider can overcome negative perceptions of his or her work environment (bullying) and deliver high-quality care (Roch, Dubois, & Clarke, 2014; Schubert et al., 2008). However, missed nursing is associated with increased workload (Ball et al., 2016; Dabney & Kalisch, 2015), and a person that is bullied may be less likely to ask for help and therefore not complete all the needed care.
Overall, though the studies on the association between workplace bullying and quality of care and patient safety provide interesting insights, it must be noted that the studies used either small or convenience samples, workplace bullying was measured and defined differently across studies, only one study was longitudinal and most studies used clinician-reported quality of care and patient safety data.
3.8 Assessing the Evidence on the Association Between Workplace Bullying and Suicidal Ideation and Behaviour
Suicide accounts for nearly 1.5% of all deaths worldwide, being among the top 20 leading causes of death according to recent statistics (WHO 2017). In addition, many more people attempt suicide unsuccessfully. Since workplace bullying is an established risk factor for poor mental health, and the latter is a known major cause of suicide (Van Orden et al. 2010), a link between workplace bullying and both suicidal ideation and suicidal behaviour is probable. Theoretically, the relationship between bullying and suicide can be understood when considering the interpersonal theory of suicide (Van Orden et al. 2010), which postulates that the intent and ability to die are essential prerequisites for the development of suicidal ideation and behaviour. As argued by Nielsen et al. (2015), intent to die may develop among targets of workplace bullying because of their prolonged exposure to situations involving social isolation and hopelessness. Ability to die may emerge as a consequence of repeated experiences of painful events that may lead people to overcome the instinct of self-preservation.
The available evidence about the relationship between workplace bullying and suicidal ideation/behaviour was recently examined in a systematic review by (Leach et al. 2017). Based on the studies included (up to June 2016), the authors concluded that the literature suggests there is a positive association between workplace bullying and suicidal ideation. Contrary to most of the existing evidence, which derives from cross-sectional studies, Nielsen et al. (2015) and Nielsen et al. (2016a) examined the impact of workplace bullying on suicidal ideation longitudinally. From a representative sample of the Norwegian workforce, the authors found that both workplace bullying (Nielsen et al. 2015) and specifically exposure to physically intimidating behaviours (Nielsen, Indregard, & Øverland, 2016b) were significant risk factors for suicidal ideation 2 and 5 years later, even after adjusting for baseline suicidal ideation. According to (Leach et al. 2017), however, a limitation of these studies is that the authors did not adjust for other adverse work environment characteristics that could potentially confound the association between workplace bullying and suicidal ideation.
In a cross-sectional study undertaken in France (Lac et al. 2012), examined the association between workplace bullying and suicidal behaviour. The authors observed a prevalence of 7% self-reported suicide attempts among a sample of 41 targets of workplace bullying, while the same prevalence was 0% among the 28 healthy controls examined. In a prospective study in Italy including 48 targets of workplace bullying (Romeo et al. 2013), found that those participants reporting a reduction in bullying behaviour also reported lower scores on suicidal behaviour and ideation 12 months later. This study, however, neither provided specific measures of association for suicidal behaviour nor did it adjust for individual and work-related covariates at baseline. Finally, Routley and Ozanne-Smith (2012) investigated the epidemiology of work-related suicide (n = 643) in Victoria, Australia, based on a database of all work-related deaths reported to the Victorian coroner (Routley & Ozanne-Smith, 2012). Work-related suicides, as defined broadly, comprise a substantial proportion (17%) of all suicides in Victoria, Australia. Work stressors such as unemployment or workplace bullying were associated with the risk of committing work-related suicide. The authors suggested that further research is required to understand the contribution of work stressors and effective interventions (Routley & Ozanne-Smith, 2012). In a commentary in the Journal of Occupational and Environmental Health recently, the author pointed out that in most countries, suicide is a leading cause of mortality and that it is important to find strategies to reduce suicidality (LaMontagne & Milner, 2016).
In sum, as observed by (Leach et al. 2017), the current literature on the association between workplace bullying and suicide risk is limited by the dominance of cross-sectional studies. The causal direction of the relationship between workplace bullying and suicidal ideation was confirmed by two studies (Nielsen et al. 2015; Nielsen, Indregard, & Øverland, 2016b), although insufficient adjustment for potential confounders does not permit ruling out alternative explanations. Furthermore, the lack of longitudinal studies does not allow the establishment of a causal connection between workplace bullying and both suicidal behaviour and death by suicide. Further research is thus needed to prove the independent contribution of workplace bullying to the onset of different facets of suicidality.
4 Consequences of Workplace Bullying for Organizations and Society
As mentioned earlier, though the extant literature highlights the impact of workplace bullying on individuals, organizations and society, very little research has been conducted specifically at the levels of organizations and society. Rather, it is through the impact on individuals that the effects on organizations and society can be deduced. This underscores the urgency for empirical research capturing organizations and society as units of conceptualization, inquiry and analysis vis-à-vis the consequences of workplace bullying.
While only a few studies have shown that organizational and contextual factors play a role in the occurrence of workplace bullying, these inquiries are also instrumental in speaking to the issue of consequences. The frequency of bullying, for instance, seems to be higher as the size of a company increases (Ariza-Montez, Leal-Rodriguez, & Leal-Millan, 2015). Similarly, job characteristics and the social environment may explain a substantial proportion of variance in negative behaviours at work (Aquino & Thau, 2009; Balducci, Fraccaroli, & Schaufeli, 2011). Indeed, a recent study investigated if long-term sickness absence was different in workplaces where bullying was reported compared to workplaces where bullying was not reported (Hansen et al., 2018). The authors excluded the bullied respondents and showed that non-bullied employees at workplaces where workplace bullying was reported had a higher risk of long-term sickness absence compared to employees in workplaces without workplace bullying (Hansen et al., 2018), underscoring the ripple effect of impact. Obviously, sickness absence in relation to workplace bullying has consequences not only for the individual but also for the organization and society. Whereas individual colleagues have to do more work to cover for the absent employee, organizations and society experience losses of productivity as well as decreased retention of workers and ability to recruit new employees.
4.1 Assessing the Financial Consequences of Workplace Bullying
A summary review from 2011 covering studies from 1990 to 2006 shows great variety in the financial consequences of workplace bullying (Hoel, Sheehan, Cooper, & Einarsen, 2011). These costs are based on very different ways of calculating as well as methodological and cultural differences. So they are not comparable. The authors of the 2011 chapter also write that the quality of the studies varied. Two studies after 2011 have calculated the costs of workplace bullying. One study estimated the cost of workplace bullying among workers in the eldercare sector in Denmark to be approximately one million euros in a cost illness estimation based on the higher risk of sickness absence for those being bullied (Schnohr, Keiding, Grynderup, Hansen, & Hogh, 2015). In the other study, researchers from Australia calculated the costs of depression due to bullying and job strain to be 693 million Australian dollars annually. The costs were calculated according to “national annual employer costs for lost productivity” (McTernan, Dollard, & LaMontagne, 2013, p. 321). More recently, Australian scholars have provided an overview of a few studies from other parts of the world. This overview has estimated workplace bullying “… to cost the Australian economy over AUD$6 billion annually, the Irish economy at least €3 billion and the US around US$300 billion” (O’Rourke & Antioch, 2016, p. 3). Another Australian study, also from 2016, has estimated that bullying costs Australian industry between AUD$6 and AUD$36 billion annually (House of Representatives Standing Committee on Education and Employment [HoR], 2012, 10, in Hanley & O’Rourke, 2016).
4.2 Summing Up
Even though workplace bullying may have consequences for organizations and society, that is, in the form of turnover and sickness absence, very little research has been conducted at this level. With regard to financial costs, studies from different countries show that these may be high. However, the studies are not comparable because of methodological and cultural differences.
5 Conclusion and Further Needs
In 2005, Zapf and Einarsen suggested that workplace bullying may be counterproductive for the individual and may potentially also be counterproductive for the organization. The present chapter confirms that this may be the case, reinforcing the relevance of various theoretical perspectives such as Leymann’s model of the development of workplace bullying, the transactional theory of stress, the CATS theory, the SOS perspective, the structural empowerment theory and the SDT, which underpin research inquiries in the area. This concluding section includes implications for research and practice and will highlight potential gaps and future avenues for research identified within the literature on the consequences of workplace bullying for the individual, the organization and society.
The present chapter has discussed studies that support the hypothesis that workplace bullying is associated with an increased risk of sickness absence. Some potential mediators were found in this association including reduced sleep quality, perceived stress and a strained psychosocial working environment. Most longitudinal and register-based studies on the association between workplace bullying and sickness absence are conducted in Nordic countries, so more studies are needed from other parts of the world to assess whether this is a general problem or something specific to Northern Europe.
The reviewed literature on the association between workplace bullying and increased risk of job turnover and increased risk of unemployment or drop-out from a trade suggests various practical consequences for the workplace. These include developing and maintaining a supportive work environment and leadership styles, reorganizing work tasks and maybe hiring new staff to substitute the ones leaving (though the latter incurs recruitment and training costs for the organization). Moreover, the association between workplace bullying and increased risk of job turnover may be mediated by the psychological well-being of the respondents, while the association between workplace bullying and increased risk of unemployment or drop-out from a trade may be mediated by the psychological stress reactions of the respondents. This has implications for the selection policies and psychosocial climate organizations have. While the association between workplace bullying and early retirement or disability retirement can also hold similar implications as those just outlined, these must be drawn cautiously since only a few studies were conducted to support these relationships.
Some studies presented in the chapter show an association between workplace bullying and quality of care and patient safety. Perceptions of patient safety risk may be a mediator of this association. However, the studies in this research area used rather small or convenience samples, only one was longitudinal and workplace bullying was measured differently from study to study. Thus, more robust studies are needed to assess whether associations between workplace bullying and quality of care and patient safety suggested in the cross-sectional studies can be verified in longitudinal ones.
The current literature on the association between workplace bullying and suicide risk is limited by the dominance of cross-sectional studies. The possibility to draw firm conclusions about cause–effect relationships between bullying and suicidal behaviour/death by suicide is therefore currently limited due to the lack of longitudinal studies. Moreover, there are no studies on suicide using objective assessments of suicide attempt and/or death by suicide.
The research on the effects of workplace bullying on the organization and society is even more limited, with only a few suggesting that organizational size and a negative effect of bullying of the work environment in general were associated with the presence of individuals being bullied. With regard to financial costs, studies from different countries show that these may be high. However, the studies are not comparable because of methodological and cultural differences. In general, there is a marked paucity of rigorous research designed to assess the impact of workplace bullying at the organizational and societal levels. Undertaking systematic inquiries to address this gap will result in accurate insights into consequences at these levels rather than relying on deductions made from the individual level.
To sum up, the authors recommend future research focused on the conduct of more longitudinal studies, including potential mediators measured at different times (and different modes of investigation), rather than inquiries relying on risk factors and outcomes. Furthermore, there is a need for more robust studies from countries outside the Nordic region investigating the consequences of workplace bullying for individuals, organizations and society, including the financial costs of workplace bullying. Designing studies with organizations and society as the units of conceptualization, inquiry and analysis is urgently required.
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