IMPACT OF WORKFORCE BULLYING ON PSYCHOLOGICAL WELLBEING OF DOCTORS IN HEALTH CARE SECTOR OF PAKISTAN

ABSTRACT Organizations today are globally facing the dilemma of inappropriate work behaviours especially bullying, as it has long term negative effects on target employees. Workplace bullying is a major reason for work-related distress and subsequently psychological wellbeing issues for employees. The main objective of this study was to identify the effect of bullying on the psychological well-being of doctors in Karachi, Pakistan. Data from 135 doctors were collected through a structured questionnaire. Results of the study indicated that workplace bullying significantly affects the psychological well-being of employees’ and gender plays moderating effect in the relationship between workplace bullying and the psychological wellbeing of the doctors. The findings of the study are very important for policymakers and top management of the hospitals, to prevent the healthcare sector from the detrimental impact of this unhealthy practice and to minimize the psychological effect of bullying. This study suggests management should pay attention to designing and executing rules and policies against bullying in order to minimize the adverse results of workplace bullying. Moreover, the findings demonstrated that bullying affects create more devastating effects on female doctors than their male counterparts. Further, it was observed that skills and experience are major factors to obtain positive outcomes of employee psychological wellbeing.


INTRODUCTION
Employees are the most imperative assets for organizations because they can be the source of acquiring sustainable competitive edge for organizational growth (Cui, 2021). Employees' physical and psychological wellbeing is an important concern for every organization; according to House et al. (2004) health consequences can increase or decrease the capacity of work in any person's life. People with good health incur work energetically, aid their families, and make society.
Workplace bullying is a global dilemma for organizations, because bullying has been a long deterred psychological effect on targeted employees (Xu et al., 2019). According to the stress theory, work place bullying is the major reason of work-related distress and subsequent psychological wellbeing issues of employees (Hoobler et al., 2010). Studies have been done to identify the effects of bullying in the organization as Rodríguez-Muñoz et al. (2010) claimed that workplace bullying leads to employee's dissatisfaction and employee disengagement (Berthelsen et al., 2011;Hogh et al., 2011). Bullying causes absenteeism in organizations (Kivimaki, 2000;Ortega et al., 2011). This can also create an extended emotional impact on employees (Lahelma et al., 2012).
Despite all valuable studies, most of the workplace bullying studies are focused on organizational factors rather than industry-based studies Hauge et al. (2011); Leymann (1990) specifically very little attention has been paid to identify the effect of workplace bullying on healthcare workers. According to some studies healthcare industry workers have high risk of being bullied (Einarsen, 2000;Hoel, Zapf, & Cooper, 2020;Hubert & Veldhoven, 2001).
However, few bullying studies have been carried out about nurses but rare studies are conducted to explore the bullying practices against doctors in Pakistan. Although there are significant media reports on the matter. A number of review studies indicated that public servants and healthcare workers seem to have a higher risk of being bullied in comparison to other work sectors (Einarsen, 2000;Hoel & Cooper, 2000;Hubert & van Veldhoven, 2001). However, many of these studies have included only few workplaces. As it is reported by Magin et al. (2010) that 59% doctors in Australia reported workplace violence in a period of a year.
According to Sumayya and Raziq (2019), organization politics is one of the major factor in bullying employees at workplace in the context of gender role.
Besides growing interest of researchers in identification of outcomes of bullying in organization there is strong need to explore effect of bullying on doctors' psychological wellbeing. As doctors are very important part of society especially after COVID 19 Pandemic

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Volume 3, Issue 2, July 2021 the importance of this noble profession has increased and any deficiency in practices cause immense damage to society (Duignan & Bradbury, 2020). Doctor's dissatisfaction can cause severe outcomes for patient which can compromise the quality of healthcare services (Pei & Cochran, 2019;Rosenstein & Daniel, 2005;Hansen et al., 2006;Hoel et al., 2010;Razzaghian & Shah, 2011). Ultimately poor health of workers significantly affects the turnover intentions of employees and decreases the organizational efficiency (Patten, 2005).
Some studies related to workplace bullying and employee psychological wellbeing exist in established body of literature (Nielsen & Einarsen, 2012). However, very limited studies are found in health care sector. In healthcare sector particularly some studies have been conducted on nurses (Johnson & Rea, 2009;Yildirim, 2007). But it is very necessary to find out the status of bullying in physicians and how bullying effect the psychological wellbeing of doctors because the stress and related symptoms like hopelessness and anxiety are very important predictors to identify the psychological wellbeing of employees (Baillien et al., 20I7;Hauge et al., 2007;. Besides the study of relationship between bullying and psychological health of employee, it is also important to find out the moderating effect of gender on above mention relationship. According to Stansfeld and Candy (2006) gender as control variable is a very important predictor to identify the mental health of the employee.
The aim of this study was to identify the impact of workplace bullying on psychological wellbeing of physicians in Karachi with moderating effect of gender. As Smith et al. (2010) identified that there is difference of bullying copping strategies in male and females. So, it is also very important to identify how differently bullying affect the psychological wellbeing of male and female doctors. This study will significantly contribute to the existing body of knowledge by finding the moderating effect of gender on bullying and psychological wellbeing of doctors in Karachi. It will also help the higher authorities of hospitals to device such policies which help physicians to cope up with bullying issue which will lead towards organizational growth and sustainable work environment.

Workplace Bullying
Several definitions of work place bullying exist in body of research literature. Like any detrimental act which create negative impact on employee is consider as bullying (Quine, 1999). According to other definition bullying is power game among employees (Parzefall & Salin, 2010;Stammel & Singh, 2012;Zapf, Einarsen, Hoel, & Vartia, 2003). Other than this any act which harm the target's health aspect is consider as bullying either that is physical aspect or mental health of employee (Verkuil et al., 2015;Karatza et al., 2016).
Workplace bullying is further defined as an expression of hostility at work environment being repeated and showing negative behavior towards a person or number of people by an individual or number of individuals who show authority over the bullying party .
Bullying can be found in various shapes such as withholding information, rumor spreading, or threating and the cause of these acts can either be an employee of your department, superior or subordinate of the targeted individuals . Earlier research conducted by The current study is based on stress process theory as theory states that, most of the negative psychological outcomes of employees are based on personal and work-related stressors (Thoits, 2010). There are many studies which revealed the relationship between stress and psychological health of employees (Pearlin & Bierman, 2013;Turner, 2003;Turner & Avison, 2003;Wheaton, 1999). Aneshensel (1992) based on stress process theory explained that stressors are not only the part of organizations but these are existing in all societies and they vary among social status. People belong to poor social status expose more from stressors and they also have more adverse effects of stressors on their physical and psychological health especially minorities, female workers are more vulnerable for stressors (Asrar, et al., 2019;Pearlin & Bierman, 2013). One of the biggest stressors is workplace bullying (Conway et al., 2021). According to Bano et al. (2021) research, the results indicated that the workplace bullying has adverse effects on performance of health care workers such as female nurses in AJ&K, Pakistan. The study further found that workplace bullying contributes to reduce the psychological well-being of the employees which results in low employee performance that affects overall productivity of the health-related organizations in "AJ&K Pakistan". Teo et al.
(2020) observed in their study that the consequences of bullying include decreases in affective commitment in organization.
Studies on bullying among few graduate nurses have revealed very alarming results for top managements of hospitals. Both Laschinger et al. (2010) and Simons (2008) found that new graduates who were bullied at work had higher intentions to leave their jobs. Workplace

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[433] violence may have many negative ramifications for health care employees. Workplace violence has been associated with lower job satisfaction and higher levels of turnover intentions in nurses and home healthcare assistants (Quine, 2001). According to (Kravitz et at,n.d.) 27.5% of surveyed obstetrician-gynecologists were either somewhat or very dissatisfied with their careers in medicine. Distinct from career satisfaction, burnout and depression is characterized as a global, clinical syndrome pervading all aspects of a person's life (Anasori, Bayighomog & Tanova, 2020).
There is direct relationship between workplace bullying and general health issues of employees (Karatza et at., 2016). Bullying becomes more adverse for those people who are unable to protect themselves from negative actions of bullying (Einarsen & Skogstad, 1996;Nielsen & Einarsen, 2012). Samnani and Al Karim (2013) found that this is not mandatory that higher status employee bullied their juniors, it can be vice versa. Irrespective of hierarchal position any one can be perpetrator like peers, senior or supervisor (Nielsen & Einarsen, 2012).

Psychological Wellbeing of Employees
Well-being is a wide notion that refers to employee's experiences Bandura (1986) which makes them effective and committed in their task performances (Huang et al., 2016). According to Diener (2009) well-being is a subjective term; it labels people's contentment, the satisfaction of needs, gratification, capacities and job accomplishments (Mubeen, et al., 2014).
Employee well-being greatly affects the organizational success and performance (Balkker et al., 2019). Studies have acknowledged that employee well-being is the prerequisite of many organizational outcomes like improved productivity or vice versa (Hewett et al., 2018).
Hopeless ness, Anxiety and depression are negative psychological states of employees which can be the outcome of harmful work settings experienced by employees (Thoits, 2010).
Psychologically drained employees have reduced decision power and they always feel like that they have very limited resources to fulfill their jobs which reduced their productivity (Elovainio et al., 2015). Elovainio et al. (2015) also said that as they are unable to fulfill their job demand, consequently stress produce adverse health issues. Einarsen and Nielsen (2014) conducted a study in Norway with 1613 employees and they found that those employees are exposed with bullying exhibit 2 times higher psychological distress as compare to those who are not bullied. Among educational level, age and other organizational and personal factors, bullying is the major risk factor for depression (Kivimeaki et al., 2003;Niedhammer et al., 2006).

Work Place Bullying and psychological wellbeing of employees
Bullying has direct significant impact on most of Stress related illnesses (Verkuil et al., 2015).

Work Related Bullying and Psychological Wellbeing of Doctors
It has been observed that 15 % of work-related bullying is due to work environment which greatly affect the psychological wellbeing of employees (Nielsen et al., 2010). Work-related bullying contains handing over unjustified targets and tasks, persistent negative criticism on employee's performance and excessive monitoring (Wilson, 2016). Work devaluation is someone keeps on giving low weightages to the work of employee (Etienne, 2014).
There is high occurrence rate of Work-related bullying in nursing, with a frequency ranging from 27.3% to 86.5% over the globe (Rayan, Sisan, & Baker, 2019;Tsai, Han, Chen, & Chou, 2014;Wilson, 2016). It is essential to explore the relationship between work-related bullying and psychological wellbeing of doctors in Pakistan. Hence the second hypothesis of this study is stated as: H1A: There is positive association among work related bullying and psychological wellbeing of doctors.

Person Related Bullying and Psychological Wellbeing of Doctors
Person-related bulling includes slander, social isolation, and gossiping about an individual.
Person related bullying also includes physical violence or the threat of physical violence (Etienne, 2014). However previous studies identified the impact of bullying on employee emotional exhaustion (Demerouti et al., 2009;Martinez & Ferreira, 2012)

Moderating Effect of Gender on Workplace Bullying
Due to the detrimental effect of bullying on employee physical and psychological health.
Researchers tried to find out the variables which can strengthen or weaken the relationship between bullying and its negative effects on target population. Although workplace bullying is in interesting scope of research for researchers from past few decades but very little attention has been given to find out the gender difference in bullying experiences and outcomes (Asrar, et al., 2019). Simpson and Cohen (2004) discovered that male and female experiences are absolutely different in work settings. They also said that man and women are also different in outcomes of bullying like males report the bullying however female try to avoid them as much as possible. Mostly female workers do not report bullying, do not ask for help and try to avoid the situation (Salin & Hoel, 2013). Males and females' responses and coping strategies are also different, males respond by hostility and fighting action which is absolutely opposite to their counter parts (Salin, 2003;Simpson & Cohen, 2004).
Giorgi (2015) claimed that organizational status and gender moderate the relationship of bullying and employee job satisfaction. Although the percentage of female physicians is increasing day by day in health care sector Seabury, Chandra and Jena (2013); Kaatz and Carnes (2014) but, still gender differences and evaluation biasness exist in industry (Lockwood, 2004). Health care workers and professionals are more on risk of gender-based harassment and bullying. Healthcare industry has been studied for nursing related issues (Longo & Hain, 2014;Dellasega, 2009

Research Design
The present study is based on quantitative descriptive approach, where we tested the already established theory into healthcare sector of Karachi. It was a cross-sectional study where researcher collected data from doctors in Karachi, Pakistan. Data was collected in period of one month from 15th June, 2021 to 15th July, 2021. Data was collected by self-administered structured questionnaire. Questionnaires were distributed through Google doc as well as in hardcopy. Before conducting survey, written permission was taken by hospitals and consent form was also get filled by respondent to fulfill the ethical demands of the study .175 questionnaire were distributed and researcher received 135 completely filled responses so the response rate was 77% which more than sufficient in such type of survey based cross sectional studies (Baruch & Holtom, 2008).

Sampling Design
Our population was all doctors working in tertiary care hospitals in Karachi, Pakistan. Due to unavailability to government statistics researcher made the jubilee life insurance as a source of data. According to which there are 78 tertiary care hospitals. Out of 78 hospitals researcher collected data from 10 different hospitals with 135 respondents. Non probability, purposive sampling approach was employed to collect data because when exact population is not known so better to choose non probability sampling technique (Greener, 2008).
Out of 135 responses male responses were slightly higher than female responses. In terms of gender 63(47%) females and 72(53%) were males. With reference of age, the baseline age was between 25 to 30 year 75(56%).

Research Instrument
In current study the impact of workplace bullying is measured by 22 items. The Negative Acts Questionnaire-Revised (NAQ-R) is the most frequently used questionnaire to assess workplace bullying (Einarsen et at. 2009). Responses were collected on 5 points likert scale ranging from 1 to 5 ('never, 'now and then,' 'monthly,' 'weekly' and 'daily'). Cronbach's alpha for the NAQ-R was higher than the baseline (.817).To study the psychological wellbeing of doctor in response of bullying researcher used Beck inventory (Beck & Arlene, 1976

Respondents' Profile
Questionnaire were distributed in different hospitals in Karachi. The table below shows the result of demographic variables. In terms of gender 72(53%) were male and 63(47%) were female doctors. Their age ranged between 25 years to 60 years (Mean=1.69, SD=0.918). in terms of salary ranges between less than 20k to above 50 k highest number of responses observed with above 50k 62(50%). 69 (51%) doctors were single however 66 (49%) were married. In terms of total experience 08(6%) doctors had above 16 years' experience while 40(30%) had between 03 to 05 years' experience.

Descriptive Statistics
Normality of data is prerequisite of all statistical analysis. To ascertain the univariate validity researcher performed the descriptive analysis by using SPSS 23. Following are the results of descriptive analysis.

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[439] However highest kurtosis is observed in workplace bullying (Mean=1.96, SD=0.54. All constructs are within range of _+ 3.5 which full fill the requirement of normality of data (Hair Jr. et al., 2010).

Reliability of the Constructs
The instruments used to collect the data in this study were already published scales. There reliability and validity were known but to confirm their reliabilities in current context researcher performed reliability test. NAQ-R Einarsen et al. (2009) was used for bullying and Beck inventory Beck and Arlene (1976) was used to find out employee's psychological wellbeing.

Exploratory Factor Analysis (EFA)
Exploratory factor analysis was performed to reveal the hidden variables and their relationship in constructs. Principle factor analysis was applied by Varimax rotation. All parameters of correlation and linear relation were meeting the standard. KMO for all construct is > 0.6 which is satisfactory except work devaluation which is 0.50 but this does not spoil the construct if one or two construct are < 0.6 so it is acceptable situation (Leech, 2005). However, Barley test of sphericity is <0.05 which is normal.

Correlation Analysis
Correlation analysis is prerequisite of regression analysis. It analyzes the relationship of two variables and also identifies the multicollinearity (Bryman & Bell, 2005). Above table 5 shows that all variables have significant relationship among themselves. Value of all relationship is more than > 0.20 and not more than >0.90. This confirms that all variables are unique from one another and significantly distinguishing (Hair Jr. et al., 2010).

Moderation Analysis
Moderating variables can strengthen or weaken the relationship between independent and dependent variables (Aiken & west, 1991). In current study moderation analysis was performed to prove the H2: Gender difference significantly affects the relationship between workplace bullying and psychological wellbeing of employees. Here in relationship of work place bullying; and psychological wellbeing of employees, gender has been checked as moderating variable. Moderation analysis was conducted to assess the moderating effect of gender on the relationship between IVs and DV. The results revealed a significant moderating role of gender on the relationship between workplace bullying and psychological wellbeing of employees.

CONCLUSION AND DISCUSSION
Workplace bullying is a serious concern for all organizations globally (Hogh et al., 2011). The physical and emotional damage to targets of bullying has been extensively documented (Dereshiwsky, 2020). Workplace bullying produce sever long term harmful effect on mental health of employee (Notelaers & Einarsen, 2012). Although very few researches have been done to investigate the bullying effects on psychological wellbeing of healthcare workers specially physicians. Another aim of the current study was to identify the moderating effect of gender in relationship between workplace bullying and psychological wellbeing of doctors.
Results of current study proved that workplace bullying develops serious harmful effects on psychological wellbeing of the doctors (Hogh et al., 2011;Lahelrna et al., 2012). These results are consistent with previous studies in terms of relationship. Extending the existing body of knowledge, this research also showed that gender difference is a moderator of relationship between workplace bullying and psychological wellbeing of the employees. Females are more prone to workplace bullying and face more harmful psychological effects as compare to their counterparts (Vie et al., 2011).
This study supports all research hypotheses. H1, H1a and H1b were based on stress process theory and study revealed that continuous exposure of workplace bullying either work related or person related develops the negative psychological effects on target employees (Nielsen & Einarsen, 2012). This result is consistent with previous studies held on nurses which confirmed the negative effect of workplace bullying on employee wellbeing (Jamil & Ali, 2021).
The second hypothesis of study was, gender difference significantly affects the relationship between workplace bullying and psychological wellbeing of employees also supported by results. There is a difference of severity of psychological effects on mental health of males and females being a target of workplace bullying (Kompier & Taris, 2011).

RECOMMENDATIONS
Besides many strengths of current study there were few limitations which can provoke the new researchers to examine the same phenomena with new dimensions. First of all, this study had time and financial resource constrained. In future the same study can be conducted with much wider scope of sample size to solve the generalizability issues. Future researches can also be conducted with mediating effect of job satisfaction and organizational commitment as they are an important dimension of organizational settings.

RESEARCH IMPLICATIONS
The present study showed that there, is significant positive relationship between workplace bullying and psychological wellbeing of the doctors as well as gender plays a significant moderating role. The findings of the study are very important for Policy makers and top management of the hospital to prevent the healthcare sector from harmful effects of workplace bullying and to minimize the psychological effect of bullying. This study also provides the base to make effective policies against bullying specially related to person related bullying as it has more devastating effect on psychological health of the doctors. Health care managers will have to work on organizational factors to make it safer for female doctors because study showed that bullying effects are strengthen due to gender difference. Hence, further victimization can be reduced by bold steps and realistic approach.