Ethical Haressment in ICU Workplaces Volume 5 - Issue 5

Evangelia Michail Michailidou^1,2,3,4* and Antigoni Hampla⁵

• ¹Consultant Anesthesiologist-Intensivist, Intensive Medicine Department, Hippokration General Hospital, Greece
• ²Senior Student in the Department of Business Administration, University of Macedonia, Greece
• ³Masters Degree, International Medicine-Health Crisis Management, Greece
• ⁴Member of Health Response team to Crisis Situations of GHT Hippokration
• ⁵Internist, ICU Resident Hippokration General Hospital, Greece

Received: September 03, 2020;   Published: September 22, 2020

Corresponding author:Evangelia Michail Michailidou, Consultant, Anesthesiologist-Intensivist, General Hospital Hippokratio of Thessaloniki, Konstantinoupoleos, Thessaloniki, Greecechikhi Meryem, Department of Medical Imaging and Radiodiagnosis, Children’s Hospital, CHU Ibn Sina, Faculty of Medicine and Pharmacy, Mohamed V University, Rabat, Morocco

DOI: 10.32474/SCSOAJ.2020.05.000225

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Abstract

The aim of this study was to determine to what extent, healthcare practitioners in ICU worry about Workplace bullying (WPB) and whether it affects the quality of care and patient safety from their perception. The behaviors of individuals as well as some elements of their personality emerge the phenomenon and contribute to it becoming more intense. Interventions, therefore, aim to change perceptions, attitudes, and behaviors, i.e. the way in which individuals perceive and approach their work. They should also aim to educate individuals so that they respect the personality and accept the diversity of their colleagues, resist manipulation, respect themselves and dare to do self-criticism. For this reason, it should investigate the reasons that cause it in a workplace and review those characteristics of the organization’s functioning that directly or indirectly favor its existence. Researches have highlighted the positive effects of replacing authoritarian management and regular confrontation with employees with a form of management based on the principles of cooperation, meritocracy, and practical interest in the needs of individuals and the team as a whole. The intervention of competent bodies in the ICU and in every professional sector of the hospital is considered necessary to address the problem, as individual solutions usually lead to the victim’s submission or removal or leaving the perpetrator in the workplace and the continuation of unacceptable behavior of. Such solutions succeed in protecting the victim but fail in the administration of justice.

Abbreviations: Health care workers; regression model; working conditions; workplace bullying

Review Article

Workplace bullying (WPB) is a physical or emotional harm that may negatively affect health care services.
The term ‘moral harassment’ is considered an old phenomenon that occurs in all societies. Moral harassment is found both in everyday life, but also in the workplace. But what do we mean by moral harassment? There is no clear and commonly accepted definition among researchers of moral harassment internationally. The phenomenon has been approached internationally by countries with different cultural characteristics but also by various scientific disciplines such as psychology, work psychology, sociology, law, etc. However, researchers, regardless of their country and industry, agree that they refer to the same phenomenon and attribute common features to it [1]. Moral harassment is referred to as the attempt to mentally exterminate the other with words, with nods, with implication, without the use of physical force [2]. According to Hirigoyen, some perversions are so common and every day that they are considered the norm. The beginning is made with a simple lack of respect, a lie, or an exploitation. All this is considered unbearable only when they harm us immediately. Later, if the scientific team to which the specific behaviors are applied does not react, the behaviors gradually turn into proven perverts, with serious consequences for the mental health of the victims. Fearing that no one will hear them, the victims are silent and suffering. Thus, the phenomenon remains hidden and the perpetrator is perceived as the master of the medical team, with the result that his manipulations are done in a special way that allows them to be interpreted as a form of conflict or power within the ICU. But in order to better understand the moral harassment or otherwise perverse violence in the ICU, we need to keep in mind that for this to happen there may be an emotional lack of people involved or even an over-intimacy. Thus, excessive intimacy causes fear, with the result that the most intimate people become the object that will suffer the most violence.
In this case, the perpetrator perceives this professionalinterpersonal relationship as particularly close and therefore suffocating, so he tries to keep the other person in a relationship of dependence or property in order to be able to maintain his self-control and omnipotence. On the other hand, the victim is overwhelmed by guilt feelings and doubts, so he stays there without reacting. Such a situation does not have to occur from the beginning, but usually occurs in times of crisis where the perpetrator cannot take responsibility for a difficult choice or decision. Thus, due to the perpetrator’s complete refusal to accept the choice, a reaction begins that resembles a persecuting delusion against the victim, usually existing [3]. The other side enters a state of intense stress, experiencing intense anger, but also shame after enduring humiliation feeling unable to react. In such cases, Hirigoyen [3] suggests that victims should remain calm, not doubt themselves and ignore the attacks they receive. Ethical harassment in the workplace has preoccupied researchers and the phenomenon is referred to by the term “mobbing” which means to attack. One of the first researchers to address ethical harassment in the workplace is Leymann, who refers to the phenomenon as psychological violence perpetrated by an individual or group of individuals, against an individual or group of individuals. It is expressed through a chain of unethical behaviors which, while seemingly unrelated to each other, are in fact all part of a strategy of intimidation, humiliation and weakening of the goal. In other words, what happens in interpersonal relationships also happens with the difference that the phenomenon can occur because there is prejudice due to gender, age, physical disability, origin, religious or political beliefs. In addition, the attitude of an employee may be different from that of others, so his conscientiousness, consistency and formality may be taken as a threat as this can “erase” the work environment from long-established and convenient tactics [4]. According to research, moral harassment in the workplace occurs suddenly and unexpectedly and the victim is shocked when he realizes where he is and as a result this experience becomes even more traumatic. This is likely to lead to social stigma, due to the fact that the individual feels exposed to the work environment as it has now become the focus of discussions between colleagues. This increases the chances of a victim to identify socially with the concept of victim and thus be characterized as a weak personality. In addition, according to Toukas, Deliha and Karageorgiou [4], the phenomenon of mobbing as a form of psychological harassment in the workplace, is characterized as a syndrome with specific clinical symptoms, which can be psychosomatic type to be expressed as physical symptoms, psycho-emotional type (anxiety, phobias, uncontrollable aggression) and behavioral type such as problems related to addictive behaviors.
Imagine the effects of the phenomenon on ICU staff and the devastating consequences it can have on the team and medical decisions. The important thing is to be able to recognize what is happening and try to avoid the trap that will keep one stuck and passive recipient of such a perverted attack on one’s person. We must recognize our own personal limits, strengths and weaknesses so that in the possibility of our exposure to such a phenomenon we can remain steadfast, defend its position and not forget that ‘the fact that there are some cases of micro-paranoid who favored to appear as victims, does not mean that there are no real victims of harassment ‘Hirigoyen [3]. The paradox is that some people who, from their position, are responsible for dealing with such phenomena, in the area of their responsibility, not only do not support the person who suffers the aggressive behavior, but also participate themselves, strengthening the unethical process. By doing so, they endanger not only the safety and professional interests of the employee, but also the ICU itself, whether in the private or public sector.

Categories of Moral Harassment

Moral harassment according to the origin and direction of psychological violence is classified into the following two main categories.

From Director to incumbent or downhill harassment

It is considered by researchers to be the most common form. It involves the abuse of power, in the sense of overstepping one’s authority and arbitrary conduct contrary to the rule of law. The reasons that can cause this form of harassment are varied. Many times, a Chief adopts such a tactic, because of the feeling of inadequacy he has and his fear of losing “control”. Often an insecure boss can feel “threatened” by the presence in the ICU of an employee who is very capable and efficient or has higher formal qualifications than himself. It is also common for a Director who demands “blind submission” to target a person who, as a person, does not comply with this requirement and does not accept authoritarian behavior. It is “The ability of the worker to resist power, despite the pressures that make him a target” [3]. In cases where the harassment is perpetrated by a boss or a person with a strong personality, it is often observed that people under his influence who want to be liked or are afraid of his anger, in case they openly disagree with him. Under these circumstances, the target is under even greater psychological pressure and feels even weaker, as he lacks support from his colleagues [3].

Peer-to-peer or horizontal harassment

Moral harassment between colleagues can be due to the denial of difference, to the envy of someone who has something that others do not have, to personal dislikes, extreme conflicts, competitions, etc. [5,6] Many times, the target is a group of people, usually small. In cases where there is a conflict of interest between groups, offensive tactics are initially reciprocal and continue to be so, until one side is weakened and the other takes the lead in power. It is observed that the phenomenon of moral harassment, especially in highly competitive and closed areas such as the ICU, is contagious, as its appearance triggers the dark side of the character of people who have not shown such behavioral patterns in the past. When this pathological interaction is consolidated, a vicious circle of situations is created and the crisis generalizes, the consequences for individuals and for the company can be disastrous, if one does not intervene to stop it [3].

Consequences of moral harassment

The exponential course of moral harassment in the workplace has serious consequences for employees, their families, patients, the hospital and society as a whole. The symptoms and the effects (physical and psychological) on the health of the “victim” are what differentiate moral harassment from other situations, such as false complaints. Research over more than three decades shows that systematic exposure of workers to situations of moral harassment has devastating consequences for the health and well-being of those exposed. The phenomenon was found to be associated with chronic fatigue, with psychosomatic, psychological, physical problems and problems related to stress and insomnia and wrong medical choices and decisions. In workplaces where, in the long run, conditions of moral harassment prevail, there is a gradual weakening of the medical staff as the intention of employees to leave the ICU is increased. People who are crucial to its operation, because of their knowledge, skills and experience, are more likely to leave it, regardless of whether they have the same harassment goals or know that it is to the detriment of others. This has a particularly negative effect on ICUs and hospitals with reduced staff or difficulty finding qualified staff. Harassment behaviors absorb a large part of the employees’ time and energy on a daily basis, which in a healthy and pleasant working environment would be invested in productive work. The financial cost of having this phenomenon in an ICU is borne by the process of finding and training new employees. This image of the ICU is usually reflected in its public image and plays the role of negative advertising [7]. It is also a slander in the labor market and negatively affects the potential interest of very capable executives to work on it [8].

Impact on employees

Moral harassment is manifested mainly with serious consequences such as increased difficulties of cooperation, reduced resistance to stress, physical discomfort, abuse and psychological reactions. It can cause the employee difficulty sleeping, depression, mania, sometimes intense aggression, physical fatigue or even suicidal tendencies. If the harassment does not stop immediately, the causes that caused it in the workplace are not investigated and the appropriate measures are not taken, there is a risk that the problems become so serious that long-term medical and psychotherapeutic treatment is needed (Salin, 2003). The negative effects on the ICU of the workplace in terms of efficiency and financial impact are also significant, as it has been observed that the level of performance of a worker who is morally harassed can be reduced by 80% in terms of his abilities, his resistances to work stress and his attention. When an employee experiences aggressive behavior, he or she experiences high levels of stress. Until the necessary measures are taken by the management to deal with these behaviors, the stress mechanism is constantly activated, developing intense biological reactions resulting in the manifestation of mental or physical illness that will lead him to absence from safety work. The consequences can vary, depending on the degree to which each employee has experienced aggressive behavior, the duration, and the intensity of the stress they have. Experience, the way he perceives an event as well as his ability to manage the situation. In a survey conducted in Ireland, 40% of respondents said that harassment had a negative effect on their physical health and 43% on their mental health. 26% and 92%, respectively, needed medical and psychiatric treatment, while 20% started taking medication as a result of moral harassment. Research suggests that long-term psychosomatic and mental impairment experienced by workers who have been exposed to moral harassment is likely to affect their ability to work.

some cases, the employee feels so incapable of meeting the requirements of his position that he forms the view that he is incapable of any decisive decision. In particular, in the medical field, there has been a weakness for initiatives or personal interventions, even if they know that it would be right. The personality of the employee is the one that plays a decisive role, not only in the way one experiences moral harassment in the workplace, but also in the way one will react. Studies have shown that some workers become seriously ill after six months of exposure to severe moral harassment, while other workers after several years of exposure. Difficulty finding work, possible defamation from the theta in possible new work environments and fear of unemployment are the main reasons why the employee continues to endure the negative situations his experiences in the workplace, as a result of which he sinks more and more. more in a personal and work quagmire with consequences in his family environment as well as in the outcome of patients.

Impact on Hospitals as organizations

The effects of moral harassment on the health of employees have similar consequences in the Hospital. They affect the efficiency and effectiveness of the medical staff as well as the quality of the services offered [5]. As mentioned above, ethical harassment affects job satisfaction, commitment to the organization, innovation and creativity. Studies show that employees who have been harassed have low job performance and reduced effort, resulting in reduced productivity and quality. Harassment situations have a negative impact on the ICU’s reputation which may lead to a possible reduction in the quality of medical services, a reduction in the overall scientific development of the ICU, staff layoffs and a reduction in the number of new staff. The damage that can be done to an ICU should not be underestimated in the current period of economic crisis. The existence and tolerance, on the part of management - of moral harassment negatively affects its relationship with employees and the way they see it. In these cases, employees’ confidence in the manager and management and their commitment to ICU goals is shaken. In these circumstances, it has been observed that the motivation and the disposition for taking positive initiatives and the search for innovative ideas decrease. Workers often resort to long-term absences and increased use of sick leave in order to escape moral harassment. The experience of moral harassment also has a serious negative impact on the victim’s family, as it transfers the full range of negative emotions, chronic stress and frustration that the victim experiences both from work and from himself. The family experiences the effects of moral harassment on quality of life, health, social life, and economic status almost daily. The effects of moral harassment on the health of employees have similar consequences in the hospital itself. They affect the efficiency and effectiveness of the organization as well as the quality of services offered.
As mentioned above, ethical harassment affects job satisfaction, commitment to the organization, innovation and creativity. Studies show that employees who have been harassed have lower job performance and reduced effort, resulting in reduced productivity and quality of health services. Harassment situations have a negative impact on the organization’s reputation which can lead to possible resentment among patients, suppliers, potential sponsors, staff departures as well as reduced attendance of new employees. The damage that can be caused to an organization should not be underestimated in the current period of economic crisis. The existence and tolerance, on the part of management, of moral harassment negatively affects its relationship with employees and the way they view it. In these cases, employees’ confidence in the manager and their commitment to ICU goals is shaken. In these circumstances, it has been observed that the motivation and the disposition for taking positive initiatives and the search for innovative ideas decrease. Workers often resort to long-term absences and increased use of sick leave in order to escape moral harassment.

Dealing with moral harassment

Moral harassment not only damages working relationships, but also offends the dignity of the individual, threatening the safety of his professional life, the safety of patients, his mental and physical integrity. Dejours considers that moral harassment is rarely an individual phenomenon and its deepest causes should be sought in the organization of social relations in the workplace and especially in the methods of administration and management, in the particular culture of the ICU, in the shortcomings of the organization, in the complexity and pace of work. Moral harassment is an effective strategy of “psychological terrorism” deliberately used by some. At the same time, it expresses the anti-peer cunning that aims at the elimination of competition, underlining the stigma of individualism that prevails in the modern medical community. The dramatic increase in harassment requires strategies to combat conflict and malicious moral behavior.

Conclusion

In this light, the activation of managers and directors is crucial, who must be trained to recognize and deal with the phenomenon from the earliest stages or to ensure the awareness and information of subordinates. At the political level, legislation is considered necessary, as it would be the cornerstone of prevention and provide for ways to resolve and restore the dignity and health of victims. Equally imperative is the conduct of extensive research to better understand the parameters of the phenomenon of moral harassment. Dealing with the phenomenon of moral harassment is part of the general framework of prevention and protection of employees from occupational psychosocial risks and requires the consideration of a holistic approach to working conditions. This includes extended and collaborative interventions, encompassing all aspects of problematic situations, both on a personal and organizational level that aim to reduce the intensity of symptoms and eliminate the occurrence of the phenomenon. The behaviors of individuals as well as some elements of their personality emerge the phenomenon and contribute to it becoming more intense. Interventions, therefore, aim to change perceptions, attitudes and behaviors, i.e. the way in which individuals perceive and approach their work. They should also aim to educate individuals so that they respect the personality and accept the diversity of their colleagues, resist manipulation, respect themselves and dare to do selfcriticism.
Working conditions play a key role in the development of psychological violence. For this reason, interventions in the workplace should be aimed at preventing and dealing with the phenomenon by modifying the work environment, the organization of work and enhancing the proper functioning of each ICU. Prevention is achieved on the one hand by raising awareness, recognition and knowledge about the phenomenon of moral harassment and on the other hand by reducing the potential risks to the psychosocial work environment. In addition, training managers and directors on workplace crisis and conflict management, conflict resolution, crisis investigation, case analysis, and mediation can reduce or slow down the development of a conflict or stop the occurrence of recurring abusive behaviors. Also, the goal of interventions at this level is to reduce the organic and psychological effects of moral harassment on employees as well as to maintain a safe and healthy work environment in ICU. At the organizational level, the hospital administration has the greatest responsibility, but also the ability to influence the appearance and development of the phenomena of moral harassment in the workplace. For this reason, it should investigate the reasons that cause it in a workplace and review those characteristics of the organization’s functioning that directly or indirectly favor its existence. Researches have highlighted the positive effects of replacing authoritarian management and regular confrontation with employees with a form of management based on the principles of cooperation, meritocracy and practical interest in the needs of individuals and the team as a whole. The intervention of competent bodies in the ICU and in every professional sector of the hospital is considered necessary to address the problem, as individual solutions usually lead to the victim’s submission or removal or leaving the perpetrator in the workplace and the continuation of unacceptable behavior of. Such solutions succeed in protecting the victim but fail in the administration of justice.

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