Workplace Bullying and Patient's Safety: A Timelag Study


 Objectives. Using transformational theory and Chaos the research intends to explain the impact of workplace bullying on dental profession, threat it poses to dental patient safety and investigating the power of perceived co-worker social support to diminish the aftermath of workplace bullying.Material and Methods. The study is quantitative, descriptive and causal in nature. Data were collected in two-time lags from 267 dental professionals by using convenience sampling technique.Results. Findings of the study indicates that the workplace bullying among dental professionals is strongly linked with job stress, turnover intention and job performance which in turn challenges the safety of patient. Perceived co-worker social support is directly linked with job performance and organizational citizenship behaviour. Study highlights the power of Perceived co-workers social support in weakening the relationship between workplace bullying and turnover intention and Job performance of victim of bullying.Conclusion. The role of Perceived co-worker support on victims diminishes the cost associated with intention to leave and Job performance, offering recommendations to health care managers and medical educationists. Anti-bullying policies should be communicated among dental students, across educational institute & implemented under strict supervision of institutional management. The issue should be taken seriously, proper allocation of time, resources, anti-bullying policies should be communicated, fellows should be encouraged to help victims to report act. Bullying culture blooming among health care providers challenges the quality care to patients, only by utilizing the significant role played by co-workers this research highlights ways to overcome risks to quality care and safety of patients.


Introduction
The cruel irony among dentist, doctors and nurses is that they are driven towards health profession to improve the quality of life of their patients, contributing to community wellbeing, brightening rays of life in those who are distressed, physically and mentally vulnerable, yet the majority of them have been bullied by their colleagues and supervisors.
Workplaces are where humans interact socially, compete enthusiastically, perform under time pressure, utilizing scarce resources, have differences in goals, opinions, personalities, priorities, belonging to different cultures, religion, faith. Where there is vast range of disparity, the aggression, the con ict, the hostility and envious behaviour patterns among people could not be ignored. Workplace bullying is a tenacious continuous form of misdeed, misconduct, exploitation in the workplace by employees, fellows, colleagues, subordinates, supervisors and or others that causes severe impact and compromises psychological, social and physical wellbeing of an employee. Research on workplace bullying has been increased since past two to three decades, as, apart from psychological and physical impact, loss of costs associated with this deleterious act have been recognized by human resource practitioners and organizational psychologists. Perceived social support provided by co-workers, fellows and colleagues is related to subjective prosperity, emotional and psychological bene ts impacting in uences on cognitive behavior/ attitude and upon individual patterns of performance at workplace as well. As a consequence of occupational stress, dentist in general practice experience more physical and mental health issues as compared to other health professionals 1 . WPB and its antecedents had attained the attention of researchers since long 2 . Few researches have been conducted exploring, investigating and nding, all the above variables together, therefore, this research will help opening new avenues for future recommendations.
By gaining support from transformational and chaos and complexity theories the study explains workplace bullying and its possible consequences. Transformational theory proposed by Jack Mezirow exists when a life changing event or dilemma occurs changing the assumptions, beliefs, behaviour, attitude, overall perspective of the person's mind frame 3 . If an employee continues to face the dilemma of workplace bullying his perspectives could change, leading towards poor performance, changing behaviour, beliefs because of the extent of damage caused by workplace bullying, in form of physical, mental and nancial as well. Transformational theory is linked with victims of workplace bullying, they exhibit transformation because they don't report the act, suffer, compromising their health, resources, energy, showing poor performance issues, engaging and participating less frequently 4 . The concept behind that chaos and complexity theory is that a small change or small differences in initial conditions or state could possibly result in large differences or outcomes in a later state. Similarly, if an employee is encountered by repeated act of misconduct at workplace, the change in his state either physical or mental, if not managed or handled properly could possibly result in more disastrous effects. The study is intended to investigate the link of strong bonds of direct effects of workplace bullying on Employee's outcomes, exploring the possible transformations that are linked with workplace bullying dilemma.
Most dental workplaces are aware WPB exists, but they are often unprepared when it happens. They tolerate bullying as style of leadership, also because of lack of effective policies and protocol in place or either are unable to identify or do not have authority to do something about the situation 5 . The present study aims to explore the unexplored outcomes and the consequences associated with the deleterious act of bullying. An attempt to conduct this study is also unique in a way that there are very limited studies conducted on workplace bullying specially surrounding the health sector work area. The signi cance of this research is to exemplify, investigate and bring to surface the appalling bullying culture, thus exploring the construct of bullying in the workplace and to explore the role of unexplored variable in bullying literature, perceived coworkers social support, the role played by fellows, colleagues to combat all the consequences of deleterious in uences of workplace bullying, in the broad context, specially referring to dental practitioners.

Workplace Bullying and Employees' Outcomes
The activity of workplace bullying usually happens when there is inequality and disproportion of capabilities and power, treating bullied employee as scapegoat and victim of systematic negative social act 6 . Workplace bullying is the worst type of social stress being evident at workplaces 7 . Different types of bullying evident at workplaces are 8  Vicarious Bullying, Legal Bullying, and Regulation Bullying. One of the common characteristics of bullies is narcissism. Narcissistic bullies love to take credits of others work, everything is all about them 9 . Machiavellians are cold, insincere, manipulative type of bullies, they love to act behind the scenes. Open hostile bully, gets appeased and satis ed and they bloom and prosper on rivalry, con ict, determined and loves to dominate, have no fear of concealing the activity, usually use the tactic of name calling and confrontation. Health care workers might be vulnerable to this type of bully because of their helping and caring temperament. Disturbing bullies are psychopaths, with personality disorders, they lie, cheat, threaten, may have history of mental illness, addictions or history of bullying 10 . The act of workplace bullying has been main focus of many researchers since long. In one of the studies, for investigating the prevalence and experience of bullying behaviour seen, a survey was conducted by Steadman, gathering data from two hundred and twenty-seven post graduate hospital dentists, the study concluded that 25% of respondents identi ed themselves as victims of bullying, 47% witnessed colleagues being bullied 11 .
In a report by Boorman on NHS employees, the author concluded that almost 80% of staff of the healthcare assumed that condition of their physical and mental health impacted in uences on how they treat and handle their patients 12 .
Stress due to workplace bullying is subdivided into many forms, stress generated by WPB, that poses signi cant threat and danger to personal status (including psychological and physiological states), professional status of victim employee, stress generated due to socially excluding or isolating, stress related to unmanageable and unbearable workload, stress due to destabilization and imbalance. Employees that work with narcissist tend to exhibit higher level of stress, that in turn increases staff turnovers 13 14 . A study, highlighting the impact of workplace bullying on job performance, turnover intention, OCB and stress, concluded that the intention to leave was the most critical and compelling in uence of workplace bullying, increase in stress was related to increased incidents of workplace bullying, whereas, decrease in workplace bullying was associated with better task performance and enhanced citizenship behaviour among data collected from three hundred and twenty bank employees 15 .
On the basis of above discussion, hypotheses proposed are: H1a: Workplace bullying is positively related to Job Stress H1b: Workplace bullying is positively related to Turn over Intention H1c: Workplace bullying is negatively related to Job Performance H1d: Workplace bullying negatively related to OCB-I Perceived Co-worker Social Support and Employee's Outcomes Perceived co-worker social support is deliberated as the individual's impression and subjective judgement, notion and recognition that coworker or fellow would provide aid, give backing, offer co-operations and would provide help during and at the time of distress 16 . It is multidimensional construct, different forms of Social Support provided by coworkers are: Structural Support, degree with which one is linked with the social network that surrounds him and Functional Support, particular speci c functional means that are provided and contributed by the community to whom the individual integrates. May be in a form of emotional, informational, instrumental and companionship support 17 .
Recent studies concluded that the bene ts that are associated and connected with perceiving the social support are more than the actual received one (enacted) emphasising that functional support provided is critical in stressful conditions. PCS plays an important signi cant role on employee outcomes, helps to combat stressful conditions at work thus reducing turnover intention Perceived co-worker support has received considerable attention in past, and is signi cantly associated with performance, organizational citizen ship behaviour and other factors contributing towards employee's wellbeing. The co-worker social support plays crucial and decisive role in employees' motivation, enhancing behaviour patterns and work-related outcomes 18 .
Thus, it is hypothesized: H2a: Perceived co-worker social support is negatively related to Job Stress H2b: Perceived co-worker social support is negatively related to Turnover Intention.
H2c: Perceived co-worker social support is positively related to Job Performance.
H2d: Perceived co-worker social support is positively related to OCB-I Moderating Role of Perceived Co-worker Social Support Between Workplace bullying and Employees' Outcomes Sarasons highlighted the relationship between social support, personalities and performance particularly in sports, described the concept linked between perceived support and its relation to development of skills and performance at work 19 . Park and Kim 20 found, in a study of employees of health care, that high social support was positively linked and associated with higher levels of work performance. One of the studies conducted on nurses working in NHS, concluded that 40% of nurses, who experienced workplace bullying, con rmed that the level of job satisfaction diminished to critical levels, intentions to turn over the employment were ignited, raised levels of anxiety and depressions and compromised performance issues were reported and co-workers support endorsed lacked the capabilities of coping with deleterious act of bullying as reported by respondents 21 .
The above discussion concludes following hypotheses: H3: Perceived co-worker social support moderates the relationship between workplace bullying and Job stress in such a way that high Perceived coworker social support weakens the relationship H4: Perceived co-worker social support moderates the relationship between workplace bullying and turnover intention in such a way that high Perceived co-worker social support weakens the relationship H5: Perceived co-worker social support moderates the relationship between workplace bullying and job performance in such a way that high Perceived coworker social support weakens the relationship H6: Perceived co-worker social support moderates the relationship between workplace bullying and OCB-I in such a way that high Perceived co-worker social support weakens the relationship Methods It is a time lag study. T1, Sect. 1 questionnaire are distributed among participants, during this period, the data for variables WPB and PCS are collected. The interval between T1 and T2 is approximately 4 to 5 weeks. During, time lag 2, T2, Sect. 2 questionnaire are distributed among same participants who responded to Sect. 1, questionnaire regarding employees' outcomes are distributed.
The Population and sample of this study consist of 267 dental professionals. Convenience sampling under nonprobability sampling technique is used. Online collection of data is conducted by distributing questionnaire using google form. Workplace bullying questionnaire is adopted from R-NAQ 22  Participants are ensured that their names and identities will be kept con dential and special numbers are allotted to respondents, for ease of collecting data, and data are collected from same participants using special numbers, in Time lag 2.
Ethical Protocol and Consent. Consent form is attached along with questionnaire, for ethical reason. Participation is on voluntary bases. Participants are ensured that their names and identities will be kept con dential and special numbers are allotted to respondents.

Results
Data analysis is done using SPSS 23rd version. The correlation coe cient value between Perceived coworker social support and workplace bullying (r= -0.32**), Turnover intention with workplace bullying (r = 0.48**), between Job performance and WPB (r=-0.38**), Job performance and Perceived co-worker social support (r = 0.50**), OCB-I and   103) result shows that the combined effect of workplace bullying and perceived co-worker social support will signi cantly increase the job performance level up to .103 units more. R 2 value of .38 indicates that the impact of combined effect of workplace bullying and perceived co-worker social support contribute up to 38% on Job Performance. To support the moderation effect of Perceived co-worker social support on WPB and Job performance, moderation graph is plotted. Figure 3. shows when PCS is high it shows relatively the upward tilted slope of job performance as compared to downward directed slope when perceived co-worker social support is low in case of high workplace bullying, thus, supporting the hypothesis 5. Results of regression on OCB-I (β = .32, R 2 = .24, change in R 2 = .15) is indicating that one unit increase in Perceived Co-worker Social Support will increase the organizational citizenship behaviour at individual level signi cantly by .32 units thus supporting the hypothesis 2d.

Discussions
The There are certain implications of this study. As highlighted by the literature, signi cant nancial cost is associated with workplace bullying. Costs to victim in form of loss of income by sickness absence, ill health, due to job stress, absentees to avoiding bullies, reduction in salary due to poor performance, early retirement or quit the job, additional costs due to medical consultation, medicines, hospitalization 27 . As the ndings of this research shows the signi cant impact of PCS on turnover intention and job performance thus indicating the loss of cost associated could be minimized to some extent.
The current study offers certain recommendations to the managers working in different organizations. The issue of bullying at workplace should be taken more seriously, proper allocation of time and resources for the prevention and control of this global issue is highly recommended. Development of departments and divisions where victims should register complaints against the act should be the initial most step of human resource management units or division.
As critical and crucial part of prevention programs at workplaces relies upon the commitment and determination of management and how well these commitments are communicated and executed. Prevention and control of workplace bullying must be led by example from the top management. Anti-bullying policies should be communicated among employees and implemented under strict supervision of management for providing bullying free culture at workplace. Policies should and must administer de nite illustrations and patterns of despised abhorred conduct and unacceptable working circumstances and situations. Policies must be rigid and clarify accurately the disciplinary actions and punishments related regarding conducting and or showing abusive behaviour and actions. Policies formed should be such that victims and witness should feel encouraged in reporting and communicating incidents of unacceptable conducts to come under the notice of the concerned authority or management. Must be reviewed regularly. All the complaints should be treated seriously and con dentially. Investigations must be impartial, fair and fulsome. Enforcing punishments should be in accordance with the degree and kind of this speci c notorious act. Fellows should be encouraged to help victim to report such incidents, motivating the morale and making the bond. Implementation should be followed by regular training and counselling sessions/ programs among employees with the purpose of creating awareness and providing a platform where there is enhancement of relationship among employees, focusing on the team calibration and cooperative behaviour, thus creating positive, friendly, work environment.
In this alarming situation, where there is less awareness of the matter in developing countries, an attempt of exploring the impact of workplace bullying, highlighting the consequences, investigating and nding possible outcomes, suggesting ways for preventing and controlling this global dilemma of workplace bullying, the current study possesses distinctive advantage.

Conclusion
The dilemma of appalling bullying culture generates wide range of challenges to all occupations possessing ethical and leadership crisis, ourishing in any context, where human beings interact. The key contribution by this research is that it mainly highlights dental workplaces, opening new avenues in bullying literature by advocating and justifying the ndings that perceived co-worker social support can help diminish the negativity associated with workplace bullying, therefore, also reducing the loss of nancial costs both at personal and organizational levels associated with poor performance issues and turnovers, thus, contributing towards lling the gap in the bullying literature. The notorious association between bullying and stress at workplace could not be ignored, this research is distinctive in nature that it advocates well the disastrous relationship, recommending and suggesting researchers to ll the gap by exploring and investigating possible factors which would help to combat and break this strong connection.
According to previous studies, barriers were evident in reporting the incidences of deleterious act, the main reasons behind were the victims might perceive that they would be taken as agitator, the fear from bullies and the apprehension that there would be no advancement regarding the control and prevention of bullying act. Mere developing policy against growing incidents of WPB will not do any good, enforcing and implementing of policies are highly recommended. To get rid of this appalling culture encouragement and backing shall be provided to victim and witness both, by concerned authority and also by fellow workers. Generating awareness among health care staff and community as a whole is the preliminary step in maintain and protecting the dignity, enhancing the physical and mental capabilities of employee, nurturing the best behavioural outcomes bene cial for organization, employee and above all for the wellbeing of community as a whole.