INTRODUCTION

Life satisfaction, which forms cognitive dimension of the subjective wellbeing, is defined as “a general evaluation of one’s life quality based on his/her own criteria” (1,2). Life satisfaction demonstrates the outcome resulted from the comparison between the individual’s expectations and the reality. In other words, life satisfaction refers to how much an individual likes the way he/she lives his/her life. People who have high level of life satisfaction are those who evaluate life events and circumstances positively. Unhappy people are individuals who evaluate most of the life factors as harmful or as obstacles for their objectives (3). According to Diener et al. (4), life satisfaction covers willing to change life, satisfaction about current, past and present life and views of significant others about that person’s life. Satisfaction areas are stated as family, free time, health, money, identity, close environment and job. Employers’ negative and positive opinions about their jobs explain their job satisfaction. Job satisfaction and life satisfaction explain each other and these two concepts are nested and complementary. Employers share good or bad experiences related to work with their family members and friends. In the same manner, employers share their good or bad experiences with family members and friends with their co-workers (5). More specifically, life satisfaction means more comprehensive satisfaction which includes employers’ job satisfaction.

Stress, which has negative effects on employers’ job satisfaction and life satisfaction, might result from many factors such as physical structure of the work environment, work load, role conflict, and relationships with superiors and coworkers. One of the stressors caused by relationships between individuals in the work environment is mobbing. Theoretically, mobbing is an extreme example of social stress in work environment. According to Vartia (6) mobbing begins with attacks to employer’s honor, integrity, credibility and professional efficiency. Leymann (7) defines mobbing concept as “hostile and unethical communication, which is directed by one or more individuals, mainly toward one individual in working life”. In mobbing, one or more individuals show negative behaviors to one’s personality and violate one’s personal rights in a systematic manner (8). It is stated that individuals exposed to mobbing in organizations experience long term psychological and physical problems (9). Depression is one the most prevalent psychological effects of mobbing (10,11). The person who has been exposed to mobbing does not share this experience with anyone else, and this creates the real problem (11). Recently, mobbing is considered as an important job related stress factor due to it becomes more harmful for employers than other stress disorders (12) and its strong influence on mental health (10,13,14). Leymann (15) argues that exposure to mobbing at work leads to significant problems such as social isolation, social maladaptiveness, psychosomatic disorders, depression, obsessive behaviors, hopelessness, anger, anxiety and despair. In the literature, there are many research which show that exposure to mobbing is highly related to depression (10,11,13,16-21). In the first step of mobbing, victim usually shows some symptoms such as crying with no reason; sleep disorders, getting angry easily and difficulty in concentration. In the second step, symptoms such as high blood pressure, stomach problems, depression, reluctance to go to work, going late to job are added to the symptoms observed in the first step. At the third step, severity of depression increases. At the last step, accidents and suicide attempts are observed (22). Social outcome of mobbing is that friends of the victim leave the victim because they get bored of his/her depressive attitudes. People perceive the victim as “unsuccessful and lost what s/he has previously owned”. The person, who has been excluded at work and lost his professional identity, begins to lose his significance in his social life and in this family (23). Furthermore, mobbing causes decrement in job satisfaction and job performance, and increase in reluctance to work, pays off day after day, and sick reports (23). Getting satisfied from social environment, family relations and work have an important role in life satisfaction and productivity (24,25). Life satisfaction identified as wellbeing with respect to different aspects such as happiness and morale is an assessment about life events such as family, free time, health, money, job, good relationships. Life satisfaction is closely related to psychological health. It is known that people who are healthy have higher life satisfaction than those who are unhealthy (24). Stein and Heimberg (26) found that people with general anxiety disorder and major depression have lower life satisfaction scores than the general population. Moreover, there are research showing negative relationship between job satisfaction and harassment at work (6,16). Karakus and Cankaya (27) in their research on teachers demonstrated that mobbing directly and via stress, exhaustion and job satisfaction negatively affects life satisfaction and that stress negatively affects life satisfaction via exhaustion and job satisfaction. Cakir (28) found that mobbing victims feel themselves unhappy and emotionally alone and therefore they have low level of life satisfaction.

As seen from the explanations above, mobbing has both relationships with depression and life satisfaction. Apart from this, since depression is related to life satisfaction, depression might have a mediator role in the relationship between mobbing and life satisfaction. In Turkey, health sector is one of the sectors where mobbing is very prevalent (11,29-31). People who have been working in health sector have more risks than people in other sectors. Work related problems of health employers such as high workload, irregular and unclear work circumstances, and problems associated with relations and division of labor, guard duty and associated sleep problems, financial problems lead to job related stress and tension (32). These issues increase the probability of psychological violence and level of exhaustion among health professionals (33). Thus, investigating mobbing, depression and life satisfaction of health workers is important in terms of workers quality of life as well as the quality of the provided health service.

There are many studies investigating health professionals and mobbing in Turkey. Some of these research investigated the relationship between exposure to mobbing and demographical characteristics (31,34-38). In one of these studies, for instance, it was found that male workers were more exposed to mobbing than female workers (35,37). In contrast, there are other studies showing insignificant relationship between gender and exposure to mobbing (36,38). Other studies conducted with health workers found that the higher the age of health workers the lesser their perceived mobbing scores and that auxiliary staff in health sector were more exposed to mobbing (35,36,38). Karcioglu and Akbas (37) argue that there is no relationship between age of health workers and exposure to mobbing. In Turkey, other studies related to health workers and mobbing found positive relationship between mobbing and exhaustion (33) and depression (11); but negative relationship between mobbing and job satisfaction (37).

In the present study, a model was assessed by using a sample from health workers. Model consists of three structures: life satisfaction, mobbing at workplace and depression. Considering these three variables together is one of the starting points of the present study. Moreover, the present study might be important in terms of scarcity of related research in the field and potential contribution of results for future studies. In this respect, the aim of the present study is to identify the mediating role of the depression in the relationship between health workers’ exposure to mobbing and their life satisfaction.

METHOD

Sample

Sample of the study consists of 244 health personnel who have been working for at least 6 months at the hospitals of a medium-sized city in the middle part of Turkey and who have volunteered to participate to the study. The reason why health professionals were selected is because health workers have higher risk to be exposed to mobbing than other business sectors (10,22,29,31,39). Seventy nine of participants were males (32.4%), 165 of them were females (67.6%). Sixty eight were (27.9%) doctors, 89 were (36.5%) nurses and 87 were (35.7%) other health professionals (psychologist, dietician, midwife, health officer, laboratory assistant, health technician and medical). Age range of health workers was between 18 and 58 (Mean±SD=33.50±8.04).

Measures

Negative Acts Questionnaire (NAQ): To measure mobbing at workplace, Negative Acts Questionnaire (NAQ), developed by Einarsen and Skogstad (16) was used. NAQ, consists of 21 items that measure exposure to various negative behaviors directly (verbal abuse, inappropriate statements, and mocking) or indirectly (social exclusion and calumniation). Even though there are many scales measuring mobbing in the literature, the reason why NAQ was chosen is because of its number of items (item numbers of other scales change from 33 to 68). At the same time, items in the scale are related to behaviors and mobbing concept was not explicitly stated in any of the item. The advantage of this is that the level of exposure to mobbing behavior for the responder can be measured without labeling the behavior as mobbing. This also assures more objective definition of behavior types covered by the items. NAQ is a 5 point Likert-type self-report scale ranging from “Never (1)” to “Everyday (5)”. Participants were asked how often they have been exposed to behaviors mentioned in each item within the last 6 months. The frequency order was never, sometimes, every month, every week and every day. Turkish adaptation of the scale was conducted by Cemaloglu (40). Factor analysis indicated one factor for 21 items, and total variance was 0.71, internal consistency co-efficient was 0.94 and factor loads were between 0.59 and 0.87. Cemaloglu (41-43) reports that scale items are loaded on one factor in other studies. In the present study, internal consistency coefficient was 0.90.

Beck Depression Inventory (BDI): The inventory, developed by Beck et al. and adapted to Turkish by Hisli (44) has 21 items. There are four subscales (Impairment in performance, negative feelings toward one’s self, somatic disorders, feeling guilty). Total scores were used in the present study. Hisli (45) reported that split-half reliability of the scale was 0.74 and criterion dependent validity was 0.63. Internal consistency coefficient of the scale was 0.85 for this study.

Life Satisfaction Scale (LSS): Diener et al. (1) developed the scale, and it was adapted to Turkish by Koker (46) and Yetim (47). The scale is a 7 point Likert-type self-report scale ranging from “Does not apply at all (1)” to “completely applies (7)”. Koker (46) found that test re-test reliability of the scale, which was done with three weeks interval, was 0.85. In the present study, internal consistency coefficient of LSS was 0.82.

Procedure

After consent was taken from Health Management Office of city where the study was conducted, data collection inventories were individually applied to the participants after their office hours. Consent form was read to the participants and their consent was taken verbally. Other volunteers from the same hospital were selected to substitute for those who do not want to participate to the study. 18 individuals rejected to respond to scales due to their high workload. Each participant completed scales approximately within 30 minutes.

Statistical Analysis

Previous research showed that exposure to mobbing indicated difference with respect to gender, age and title (31,34-38). Thus, preliminary analysis of NAQ, BDI and LSS scores was done for gender, age and title differences. T-test and one-way ANOVA were used for the preliminary analyses. In the present study, mediator role of the depression in the relationship between mobbing and life satisfaction was investigated by using Pearson correlation coefficient, simple and multiple linear regression based on Baron and Kenny’s (48) proposed conditions. Conditions are as follows: (1) Two variables – mobbing at workplace and life satisfaction- should be significantly correlated. (2) Suggested mediator variable –depression– should be correlated with these two variables. (3) When mediator variable was controlled the correlation between the two variables should diminish. The significance of the decay between Beta (ß) values were analyzed by using Sobel test.

Before analyses, conformity of the data to normal distribution was tested by looking at its skewness and kurtosis values. Distribution of NAQ, BDI, and LSS scores for all independent variables were investigated in terms of their skewness and kurtosis values. Skewness values were between -1.075 and 0.462, and kurtosis values were between -0.575 and 1.003. Skewness and kurtosis values should ideally be between +1 and -1, but values between +2 and -2 are considered as acceptable (49). The fact that skewness and kurtosis values of the scores were within the limits of ±1 can be interpreted as scores do not extremely deviated from normal distribution. To test autocorrelation Durbin-Watson coefficient was used. The values of Durbin-Watson change between 1.761 and 1.934. Tolerance values were between 0.94 and 0.96 and VIF values were between 1.03 and 1.06. Thus, it was accepted that multiple covariance were not observed in the data because tolerance was not close to 0 and VIF value was not higher than 5. Data were analyzed by using SPSS 13.0.

RESULTS

Preliminary Analysis of NAQ, BDI, and LSS

Scores for Gender, Age and Title.

There was no significant gender difference of NAQ (t=1.214, p>0.05), BDI (t=1.892, p>0.05) and LSS (t=0.949, p>0.05) scores of health workers (Table 1). There was no significant age difference of NAQ (F(4-239)= 1.193, p>0.05), BDI (F(4-239)=1.291, p>0.05) and LSS (F(4-239)=0.940, p>0.05) scores (Table 2). NAQ (F(2-241)=6.936, p<0.01), BDI (F(2-241)=5.646, p<0.01) and LSS (F(2-241)=3.159, p<0.05) scores of health workers showed significant title differences (Table 3). According to this result, NAQ scores of doctors (Mean=26.955) were lower than those of nurses (Mean=31.64) and other health professionals (Mean=31.52). Based on this result, it can be argued that nurses and other health workers are more exposed to mobbing than doctors. At the same time, BDI scores of nurses and other health professionals and LSS scores of doctors were higher.

Results related to Mean, Standard Deviation

and Correlation Values of NAQ, BDI and

LSS Scores

There was a positive correlation between NAQ and BDI scores of health workers (r=0.415, p<0.01), and there was as negative correlation between NAQ and LSS scores (r=-0.330, p<0.01) and there was a negative correlation between BDI and LSS scores (r=-0.497, p<0.01; Table 4).

Results of Mediator Test

Regression analysis to predict the mediator role of depression in the relationship between mobbing at workplace and life satisfaction was conducted within three steps and results were presented in Table 5. Since pre-tests of NAQ, BDI and LSS scores showed differences for titles, first “title” was entered as a control variable in the first block. Doctor category was coded as “0” and after title variable was defined as “dummy variable” it was included to the regression analysis.

According to the results, at the first step, mobbing negatively and significantly predicted life satisfaction (ß=-0.313, p<0.001) and it explained 11.6% of the total variance. In other words, as the level of exposure to mobbing increases health workers’ life satisfaction decreases. At the second step, mobbing positively and significantly predicted depression (ß=0.388, p<0.001) and it explained 19% of the total variance. Based on this result, as the level of exposure to mobbing increases health workers’ depression level also increases. At the third step, depression defined as mediator variable negatively and significantly predicted life satisfaction (ß=-0.431, p<0.001). This finding indicates that as depression level increases life satisfaction decreases. Depression and mobbing together explain 26.7% of the total variance. Furthermore, the relationship between mobbing and life satisfaction decreases (ß=-0.146, p<0.05) when mobbing is considered together with the mediator variable (depression) (Table 5). This shows that depression partly mediated the relationship between mobbing and life satisfaction (Sobel z=-5.767, p<0.001). Thus, mobbing influences life satisfaction both directly and via depression.

DISCUSSION

In the present study, the mediator role of the depression in the relationship between health workers’ exposure to mobbing at workplace and their life satisfaction was investigated. First, at the preliminary analysis, gender, age and title differences for NAQ, BDI and LSS scores were investigated. Results showed that there were no significant differences for gender and age. This finding supported related findings that showed no difference for gender (36,38) and age (37) in terms of exposure to mobbing. However, in the related literature there are studies showing that males were more exposed to mobbing than females (35,37) and that as the age of workers increases mobbing decreases (35,36,38). In terms of title, it was observed that NAQ scores of doctors were lower than those of nurses and other health personnel. At the same time it was found that BDI scores of nurses and other health professionals were higher than those of doctors. In contrast, LSS scores of nurses and other health workers were lower than those of doctors. In conclusion, it can be argued that nurses and other health professionals are more exposed to mobbing, more likely to experience depression, and have less satisfied with their lives than doctors. Consistent with these findings, related literature showed that nurses are more exposed to mobbing (10,31,34) and that life satisfaction of doctors are higher than those of nurses, health officers and physical therapists (50). Furthermore, Ozgur et al.’s (51) study conducted with nurses demonstrated that 50.3% of nurses had high depression scores. Nurses do not have opportunity to get rest due to their heavy work load and shift working system. At the same time, most of the nurses are females. Thus, nurses are more risky group in terms of exposure to mobbing (52). Yildirim and Yildirim (31) found that nurses were exposed to mobbing by mostly their managers and coworkers. Björkqvist (53) also reported that women were more exposed to mobbing by females, and females who applied mobbing preferred psychological harm and passive-aggressive behaviors as methods of mobbing. The reason why nurses are more exposed to mobbing than doctors might be due to this factor.

On the other hand, the analysis done to see the mediator role of depression on the relation between mobbing and life satisfaction showed that mobbing significantly and negatively predicted life satisfaction and positively predicted depression. The people who have high life satisfaction are those who assess their life events and life circumstances in a positive way. A person who is the victim of mobbing loses his self-confidence in every aspect; and he gets surprised, becomes ineffective, gets afraid, feels shame and hesitates. This continues not only in work environment but also in inter personal relations (54). All these negative outcomes also negatively influences life satisfaction, which is a general assessment of one’s life quality (24,25,55). Consistent to the results of this research, in the present study it was found that victims of mobbing have lower level of life satisfaction (27,28).

As it is known, mobbing refers to behaviors systematically directed to employers by their superiors, subordinates, or their peers such as bad treatment, threat, violence, and insult (23). Mobbing puts one in a situation in which the victim cannot defense himself against negative behaviors because of disproportionate power dynamics in parties (7). Thus, mobbing has quite serious physical and psychological outcomes for the victim. Social damages are damage to public image, exclusion at workplace and losing professional identity, losing his status in social environment and in family (23). One of the psychological consequences of mobbing is depression (21,31,56). How the individual perceives negatively himself, his life experiences and his future is named as “negative trilogy” by Beck and it explains almost all symptoms of depression (57). A person who is in depression perceives himself as worthless, inefficient, morally handicapped, and he blames himself for his negative experiences, and he thinks that others do not like him. Furthermore, he thinks that too many things were demanded from him, and that the world is full of insurmountable obstacles. He perceives the future as dark, prone to failure, and as a hopeless situation (57). It is not surprising that systematic exposure of the individual to bad treatment, threats, violence and insults together with inability to defend herself/himself due to disproportionate power dynamics causes depression symptoms. In parallel with this research results, it is reported in the literature that mobbing is highly correlated with depression (10,11,13,16-21).

The main finding of the present study is that depression partly mediates the relationship between mobbing and life satisfaction. This result shows that mobbing negatively influences life satisfaction both directly and via depression. According to Davenport et al. (22), mobbing begins with conflicts between parties, and it continues with negative behaviors and attitudes towards the victim by one or more individuals. In this process, superior(s) support assailant(s) against victim because they misinterpret the situation under the influence of assailant(s). Assailant(s) in collaboration to superiors label the victim as mentally ill or difficult person. In general, the victim at this level, the victim is fired by giving way or he is compelled to resign. At the final step, if the victim feels hopeless against mobbing he experiences psychological problems, psychosomatic complaints due to his intense emotional tension and trauma. Life satisfaction is closely related to psychological health. There are studies in the literature reporting that depression negatively affects life satisfaction (24,26,27,32). Based on this study, it can be argued for interactions between mobbing-depression and life satisfaction.

Results of the present study conducted with health workers demonstrate that depression mediates the relationship between mobbing at workplace and life satisfaction. In sum, exposure to mobbing at workplace for a person (especially health worker) results in the emergence of depressive symptoms and this leads person to view his life quality as negative. When consider this in terms of the individual and the health sector, this situation creates reduction in job satisfaction, decrease in job performance, reluctance, feeling of boredom to work and decrement in productivity of the health institution. Therefore, seminars, conferences can be organized to increase the awareness of the mobbing victim, other workers and managers related to mobbing problem. Victim can acquire skills to cope with this life, to empower himself, to regain the control and to recover. Moreover, agencies helping mobbing victims and supportive groups can be formed. As also shown in this study, exposure to mobbing has serious outcomes for the individual. Therefore, to remove managerial and organizational factors related to mobbing, necessary precautions should be taken to generate an organization culture in which healthy personal relationships are considered as important.

In the present study, among the personal outcomes of mobbing depression and life satisfaction was emphasized. There might be other mediators besides depression (self-esteem, exhaustion, job satisfaction, stress, loneliness) in the relationship between mobbing and life satisfaction. In the future, studies that provide the clearer picture of the current situation can be conducted by working on a model who also considers the variables mentioned above. One of the limitations of the study is that the sample constitutes health personnel who have been working for at least 6 months at the hospitals of a medium-sized city in the middle part of Turkey. Thus, results cannot be generalized to whole health professionals in Turkey. In the present study, gender, age and title variables among socio-demographical variables were studied. “Working conditions” can also be an important socio-demographical variable for mobbing, depression and life satisfaction. The fact that this variable was not studied is another limitation of the present research. Certainly, studies which control more variables and use a broader sample would provide more comprehensive results. Another limitation is that data is based on health workers’ self-report. Responses provided by choosing items from the scale may not truly represent real behaviors of the health workers. Therefore, results should be interpreted within the limitations of the scales.

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