Assessment of Turkish junior male physicians’ exposure to mobbing behavior

Aim To determine the extent of Turkish junior male physicians’ exposure to mobbing behavior and its correlation with physicians' characteristics. Methods The study included physicians recruited for compulsory military service in April 2009. No sampling method was used, questionnaires were delivered to all physicians, and 278 of 292 (95%) questionnaires were returned. We used Leymann Inventory of Psychological Terror including 45 items for data collection and structural equation model for data analysis. Results A total of 87.7% of physicians experienced mobbing behavior. Physicians who worked more than 40 hours a week, single physicians, physicians working in university hospitals and private hospitals, and physicians who did not have occupational commitment were more exposed to mobbing (P < 0.05). Mobbing was not associated with specialty status, service period, age, and personality variables (P > 0.05). All goodness-of- fit indices of the model were acceptable (χ2 = 1.449, normed fit index = 0.955, Tucker Lewis index = 0.980, comparative fit index = 0.985, and root mean square error of approximation = 0.040). Conclusions Workplace mobbing is a critical problem for junior male physicians in Turkey. We suggest an introduction of a reporting system and education activities for physicians in high-risk groups.

Mobbing has been shown to negatively affect the welfare and development of workers and organizations by increasing the rates of leave and absenteeism, lowering the morale, and causing anger, burnout, underperformance, and deterioration of corporate image and relationships among workers (1)(2)(3)(4)(5).
To minimize the number of cases, the issue of mobbing must first be thoroughly investigated (6). Although no definition has been generally accepted, mobbing usually refers to actions when someone is subjected to social isolation or exclusion, when their work and efforts are devaluated, and when they are threatened, worn down, or frustrated (7-10). The International Labour Organization (ILO) has defined the term as acting in unison against a coworker and exposing that individual to psychological harassment (11). The term mobbing has been used synonymously with suppression, attack, violence, bullying, psychological harassment, social isolation, threatening, and discrimination in the business life, and workplace trauma (12)(13)(14).
Mobbing has become a major problem in the health and other sectors (15)(16)(17)(18)(19). In the health sector, it can be increased by 24-hour service provision and intense work pace and correlates negatively with job satisfaction and performance, posing a threat to patients' safety (20)(21)(22).
In the ILO's report from 2002, the health sector workers' rate of exposure to mobbing in the USA has been sixteen times higher than in other sectors. More than half of the health personnel in different countries has in the previous year experienced at least one incident of physical or psychological violence (23,24). Although, there is no national study investigating the prevalence of mobbing in the health sector in Turkey, there have been some local studies focusing on the limited number of female nurses, indicating that mobbing is an important issue (25-28).
Although there are several studies on physicians' exposure to mobbing, none of these investigated male physicians because it is generally thought that women are more often subjected to mobbing (29)(30)(31)(32)(33). However, negative and discomforting acts and interactions may not only be of a sexual nature or be solely directed toward women (9). This study aimed to determine the extent of junior male physicians' exposure to mobbing behavior and to investigate its association with physicians' characteristics.

Sample
The research included 292 male physicians who started compulsory military service in the Ministry of Defense Samsun Military Medical Command in April 2009. All physicians gave informed consent and the participation was voluntary. A total of 278 (95%) questionnaires were returned.

data collection
To assess mobbing behavior, we used the Leymann Inventory of Psychological Terror (LIPT) scale, including 45 mobbing behavior types (7). The scale has 45 items classified into five dimensions: the items 1-11 refer to "behavior threatening communication, " the items 12-16 refer to "behavior threatening social contacts, " the items 17-31 refer to "behavior threatening personal reputation, " the items 32-40 refer to "behavior threatening occupational situation, " and the items 41-45 refer to "behavior threatening physical health. " Frequency of exposure to mobbing is assessed with the following scores: 1 -every day, 2 -a few times a week, 3 -a few times a month, 4 -a few times a year, and 5 -never. Exposure to even one of the 45 types of behavior is enough to classify the participant as a victim of mobbing (7). The exposure to mobbing is assessed subjectively based on participants' views and perceptions, but since the LIPT scale had been used in several previous studies (7,27,34,35) and its validity and reliability had been assessed, it was deemed suitable for the purposes of this study.
The participants who selected the answers between "every day" and "a few times a year" were united and classified as "people who were exposed to mobbing, " whereas the participants who selected "never" were classified as "people who were not exposed to mobbing" (1).
The reliability score for behavior threatening communication was 0.87, for behavior threatening social contacts 0.71, for behavior threatening personal reputation 0.90, for behavior threatening occupational situation 0.89, for behavior threatening physical health 0.74, and the general reliability value was 0.95.

data analysis
To analyze the questionnaire data, SPSS, version 14.0 (SPSS Inc., Chicago, IL, USA) and AMOS, version 6.0 (Amos De-velopment Corporation, Spring House, PA, USA), software programs were used. While descriptive statistics was used to present the percentage of participants' exposure to mobbing behavior, structural equation model (SEM) was used as a multivariate statistical method to determine the factors (physicians characteristics) affecting the level of exposure to mobbing behavior (36-38).

Structural equation model
SEM encompasses two major components: measurement and structural model. The measurement model establishes the relationships between latent (unobserved) variables and multiple observable items. This is the confirmatory factor analysis portion of a model. The structural model tests a set of hypothesized associations between two or more variables. It includes a set of paths (regression coefficients) or correlations between the various measured and unmeasured variables in the overall model (36-41).
In this research, in order to obtain the model that best explains whether there was a significant relation between the level of physicians' exposure to mobbing behavior and their characteristics, two models were developed and tested. There are various indices to evaluate the goodness of fit of SEM. Most commonly used are χ 2 value, comparative fit index (CFI), normed fit index (NFI), Tucker-Lewis index (TLI), and root-mean-square error approximation (RMSEA) (40).
A high χ 2 value indicates that the model fit is poor; as it is dependent on sample size and both observed and ex-pected covariance matrix, it has only a limited use. As the sample size increases with the residual covariance matrix, the χ 2 value and the probability for rejecting the model will increase (42). Frequently used CFI, NFI, and TLI fitness measures have values between 0 and 1, with values closer to 1 indicating better fitness (36). For RMSEA, it has been argued that values less than or equal to 0.05 indicate excellent fit, between 0.08 and 0.10 indicate acceptable fit, and higher values indicate unacceptable fit (41).

reSultS
The mean age and service period of male physicians were 32.4 ± 2.5 years and 5.3 years ±2.9, respectively (Table 1).
More than a half of the physicians (72.4%) were serving in hospitals affiliated to the Ministry of Health and the remaining were working in university and private hospitals. All of them were civilian physicians doing military service, rather than military personnel. A total of 18.3% had an administrative position such as head physician and vice head physi- A total of 87.7% of 278 participants were exposed to at least one of the 45 types of mobbing behavior defined in the questionnaire: 79.5%, reported "behavior threatening communication, " 64.7% reported "behavior threatening personal reputation, " 57.2% reported "behavior threatening occupational situation, " 48.9% reported "behavior threatening social contacts, " and 31.3% reported "behavior threatening physical health" ( Table 2) (Figure 1).
The measurement model shows the validity of the LIPT scale used to determine the level of male physicians' exposure to mobbing behavior ( Figure 1). To show whether the suggested model was compatible with the research data, a confirmatory factor analysis was conducted. As the standardized regression parameter values of five dimensions were higher than 0.50 (between 0.573-0.915), and all dimensions significantly related to the latent variable for mobbing (P < 0.001), it was accepted that the suggested measurement model was compatible with the research data and it had convergent validity. Furthermore, confirmatory factor analysis (Table 3) showed that mobbing behavior threatening occupational status and social contacts had more weight to explain the latent variable of mobbing. In other words, these dimensions best explained the variance in latent variable. On the other hand, the goodness-of-fit criteria of the measurement model were acceptable, except for the χ 2 value, which was sensitive to the size of the sample (χ 2 = 2.573, NFI = 0.984, TLI = 0.980, CFI = 0.990, and RMSEA = 0.075) (Figure 2).  The next step was to determine which independent variables influenced the extent of exposure to mobbing ( Figure 2). In the initial structural equation model, eight personal characteristics were used as the explanatory variable: specialty status, working place, marital status, age, service period, weekly working hours, personality and occupational commitment. Working place (t = -2.226; P = 0.023), marital status (t = -2.103; P = 0.035), weekly working hours (t = -4.007; P = 0. <001), and occupational commitment (t = -2.504; P = 0.012) significantly affected the extent of exposure to mobbing (Table 4), while specialty status, service period, age, and personality variables did not (P > 0.05). Moreover, the goodness-of-fit criteria of the suggested initial structural equation model pointed out that the model was not within acceptable limits (χ 2 = 4.416, NFI = 0.771, TLI = 0.728, CFI = 0.809, and RMSEA = 0.111).
The four independent variables that were proven to be non-significant in the initial structural equation model were excluded and a revised new structural equation model was constituted (Figure 3) to achieve higher goodness-of-fit values and higher compatibility of the model to the data (Table 5).  The revised and improved model showed that the four independent variables (weekly working hours, marital status, working place, and occupational commitment) had a significant influence on mobbing (Table 5). Physicians who worked more than 40 hours a week, single physicians, and physicians working in university hospitals and private hospitals were more likely to be exposed to mobbing. A negative relationship was found between occupational commitment and exposure to mobbing -physicians who did not have occupational commitment were more exposed to mobbing.
The goodness-of-fit indices of the revised structural equation model increased significantly in comparison with the initial structural equation model, and all indices were within acceptable limits (χ 2 = 1.449, NFI = 0.955, TLI = 0.980, CFI = 0.985, and RMSEA = 0.040). Therefore, as goodnessof-fit values improved, the model was adopted as the final model. Total explanatory coefficient of the model was 12%. In other words, four independent variables that were found to be significant in the revised structural equation model were able to clarify only 12% of the variance of physicians' level of exposure to mobbing (Table 5).
In this study, the most common mobbing behavior was "behavior threatening communication" and the least common was "behavior threatening physical health. " "Behavior threatening communication" was the most common mobbing behavior in other studies on health workers (16,19,27,43,53,56).
Another interesting finding was that the extent of exposure to mobbing was higher in the university hospitals and private hospitals than in the Ministry of Health hospitals, similar as in the study by Sahin and Dundar (27). This could be attributed to the greater complexity of university hospitals and a more stressful working environment (45,47).
While most of the mobbing victims in this study were single, in the study by Kowalczuk et al (57) they were mostly married. Greater exposure of single physicians to mobbing can be explained by their younger age and lack of experience. Also, married physicians can be positively discriminated in terms of lower work load, especially working the night shifts. We also found that physicians work- ing more than 40 hours were exposed to mobbing more than those working less than 40 hours. This could be attributed to the hectic work environment that paves the way for mobbing, or working more than others might be regarded as unfair and as mobbing behavior. Finally, we also found that physicians who did not show occupational commitment complained about mobbing behavior more than those showing occupational commitment. This can be explained by a greater exposure to mobbing of physicians without occupational commitment or loss of occupational commitment in physicians exposed to mobbing.
As this study is a descriptive study of physicians doing compulsory military service, the results cannot be generalized to all male physicians. Also, due to study design we were not able to determine the causal relationship between the variables. Also, a recall bias might have occurred because physicians had to report their experiences in the past year and some of the physicians may not have wanted to share their personal experience. Cowie et al (58) found that questionnaire formats were not sufficient in investigating mobbing. Another limitation was that four variables (working place, marital status, weekly working hours and occupational commitment) that had significant effects on the frequency of exposure to mobbing explained only 12% of variance. The advantage of this study is the use of SEM, which is a multivariate statistical analysis method.
In conclusion, we found that the physicians working in university or private hospitals, working more than 40 hours in a week, single physicians and those without professional commitment were more exposed to mobbing. In order to take proper preventive measures against mobbing, its exact causes must be determined and legal regulations should be introduced. Health care providers should also be informed about mobbing and their legal rights. Thus, hospital department heads must monitor the development of mobbing behavior, come up with solutions by making a risk analysis, and provide an environment in which employees are able to express their complaints.
Funding None.
ethical approval Not required.
declaration of authorship All authors contributed to design, data collection, analyses, and writing and revision of the manuscript.

Competing interests All authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.