Rather than repost, the following link is to a paper that describes changes to the diurnal cortisol cycle reported in victims of bullying:
Medical News Today
Tuesday, April 24, 2012
Sunday, February 5, 2012
Painting Health by Numbers
We could drown in statistics. Sometimes we look to them for quick answers to questions, or shoot them off to make a point in an arguement like a slam dunk. They have power as objective measures. A Texas politician (Pete Sessions) once asserted that "Americans have some of the greatest health care in the world." Without parsing his words it sounds like he's saying that, collectively, we have the best. Similar statements are trumpeted in rallying cries whenever a progressive attempt at health care reform is made. Many of us accept such impassioned assertions. Without objective numbers it's like judging the best blueberry pie in a bake-off at the county fair, which isn't the best way to start a debate about a topic as critical as healthcare.
A great place to find statistics about the world is in the Central Intelligence Agency's World Fact Book, which is available online. The agency collects mundane bits of data about each of the planet's nations, crunches them into neat numbers and shares them with the public. I was surprised to find that in measures of health, the United States is not at the top of most lists. For example, we have a child mortality rate of 7.07 per 1000, which ranks us at 34, just below Cuba, which seems to do better at keeping infants alive than we can. In terms of life expectancy, we rank 50 (the country with the best longevity is Monaco, the elite playground of the world's wealthiest.) Thinking that maybe the CIA got the numbers wrong, I looked at statistics kept by the World Health Organization; they are similar. Of course, an analysis of the numbers would need to be done to indicate their statistical significance so these simple rankings don't mean much in themselves. They only give a starting point for understanding where we are in relation to the rest of the world.
Perhaps measures of our health system's greatness are hidden in the statistics; we have 2.672 physicians and 3.1 hospital beds per 1000 Americans, which is more than our Canadian neighbors' socialized system. They have a paltry 1.9132 physicians, though a few more beds in hospitals. According to ranking by World Health Indicators, that puts us in the world's number 52 spot. We spend a lot more, too. According to WHO statistics, we expend 14.6% of our gross domestic product to maintaining our health, whereas the Canadians use only 9.6% of theirs, and the United Kingdom uses 7.7%. In fact, one rank in which the United States is number one is for our expenditures on healthcare. Whether or not there is significance in the figures is yet to be determined, but it might be the unidentified statistic to which opponents to health care reform refer.
During the great health care debates in which Americans considered the possibility of improved access to health care by extending low cost coverage to more of their brethren, the example of the British and Canadian systems was raised. The specter of a socialized medical system was roundly beaten down by those who feared that governmental meddling would only make us sicker at a much greater expense. Systems like that take away patients' freedom of choice and would bankrupt the nation. A quick run down of the gross numbers has to make one wonder how we could spend any more than we already do. As a country, we are not the worst in terms of our health, but we are probably doing something wrong when, within our cohort of developed economies, we rank last in positive outcomes. Maybe Americans choose to be unhealthy?
Within those numbers might be an answer to what we are doing wrong. While we spend the most on healthcare, at a rate which continues to outpace inflation, our health outcomes haven't improved. Someday I want put those raw figures into a statistics program to see if there is any meaning in them. I suspect that one significant difference is that accessibility to healthcare is mediated by a profit-based system of insurance companies. Our scheme allocates most access to care to those covered within an employer's health plan; some are less generous than others. Congress members have better access to care than a greeter at a big box store who's insurance has a high co-pay and deductible or a recently unemployed truck driver forced to choose between paying for a $10,000 COBRA or a mortgage and groceries. So much for freedom of choice; but let's not pretend that it's the best in the world.
About Pamela Lazorko
Wednesday, February 1, 2012
Is Health What We Know or What We Can Afford?
Book Review:
Fatal Years: Child Mortality in Late Nineteenth Century America.
by Samuel H. Preston and Michael R. Haines
The turn of the previous century marked a turning point in the rate of mortality in America. In Fatal Years: Child Mortality in Late Nineteenth Century America (1991), Samuel H. Preston and Michael R. Haines apply modern statistical analysis to data from the 1900 census and other information to conclude a cause for the change in the rate of mortality, a decline that began in the early 1900’s. Specifically, they use child mortality figures as a measure of the relative healthiness of various population groups of the time and attempt to identify variables that might describe risk factors.
Officially collected mortality figures available from the Death Registration Area began to be collected only after 1900 and was limited to information from ten north eastern states and the District of Columbia. Relying on this information alone would give a skewed view of mortality at the time, because it would omit statistics from the more rural and less populated regions of the country. Because the census was taken nationwide, its data could provide a more complete picture of mortality at the time just prior to the turn of the century.
Although the census did not collect detailed information on deaths in households, it did include information about the number of surviving children. The authors develop a probabilistic model to use the census data on the number of surviving children born to a woman in 1900 to estimate child mortality. The authors assume that the model is accurate because the estimates derived from the method correlate with other assays of mortality. Information directly provided from census questions was then used to form groups between which mortality differentials could be compared.
Sub groupings by race, region of the country, urban areas vs. rural areas, husbands’ occupations, wives’ (mothers’) working status, country of nativity, literacy, and questions with indirect income implications were made so that comparisons of mortality differentials could provide a picture of groups at higher relative risk of mortality. Throughout the book, the authors use the sub groupings to correlate risks to a general socioeconomic or geographic condition. For example, African Americans had higher mortality than Caucasians; New England, as a region, was unhealthier than the South; cities were associated with higher mortality than rural areas; and except for laborers, a husband’s occupation had little overall effect on mortality.
Multivariate analysis was used to determine, considering all variables, which ones had the greatest impacts on health. The authors found that the single most important characteristic in determining mortality was race. African Americans had the highest probability of early death in childhood and, the authors noted, in adulthood as well. The assumptions used to create some of the mortality models did not work well in the analysis of black mortality. Multivariate analysis showed that size of place of residence had the second most profound effect on childhood mortality; urban areas were more unhealthy than rural ones. Larger urban areas had greater differentials than smaller urban areas. Region of residence ranked next in the analysis. Northern regions had higher mortality differentials than southern areas; the midwest had the lowest rates of child mortality of the nation.
The authors assume from their analysis that population density was the common thread linking populations with higher mortality. Cities and the relatively densely settled rural areas of New England were noted for their high mortality; analysis of homes with boarders also showed the effect of higher child mortality. The authors assert their belief that infectious disease was the most common cause of death for infants and young children at the beginning of the twentieth century. Dense population distributions would favor the spread of respiratory and gastro-intestinal diseases in a society that was unaware of the role of microorganisms in those disease processes.
The germ theory of disease was not widely understood by doctors, public health officials, or the public at large at the time. Preston and Haines view the low mortality differentials between literate and non literate mothers, and among occupational groups as evidence that people did not have the knowledge required to protect themselves and their children from disease. As there were few medical interventions available to treat disease, morbidity and mortality were distributed among the population with more favorable outcomes the consequence of geographic location. Where conditions did not favor the easy transmission of disease, mortality rates were lower. In America, a family’s wealth, education or social status did not provide significant advantages in avoiding high mortality (with the repeated exception of African Americans).
Preston and Haines refute theories that improvements in life expectancy during the twentieth century were the results of improved nutrition secondary to increased prosperity; or that improvements in medical interventions in disease treatment caused lower mortality. The authors mention a competing theory offered by McKeown which also downplays the role of medical treatment, but maintains that improved nutrition was the significant factor in mortality decline. Fatal Years establishes that although income had a significant effect on child survival, child mortality remained high because Americans had not yet embraced the germ theory of disease. The authors argue that while Americans began the twentieth century in a state of universal ignorance of germ theory, those groups that had advantages had them by virtue of geographic location and parenting practices that tended to protect children from disease (breast feeding infants for longer periods, for example). As germ theory became accepted, public health measures were undertaken to stem the transmission of pathogens. Protected water supplies, sewage collection and disposal, sterilization of milk supplies, and quarantine of infected individuals represented great strides in preventing disease transmission where few interventions were available for treatment.
They do not fully explain the wide differences in mortality between social classes existing in England and Wales at the turn of the century, however. If income effects were of little consequence in America, why are these differences associated with wide mortality differentials in England and Wales where, presumably, the same ignorance of germ theory prevailed? The authors use the opportunity to show that income differentials by occupation in the United States were lower than in England; social class structures were not as highly defined. But the comparison serves to weaken their previous argument that income effects (as measured indirectly by occupational status) were not the most significant factors in American outcomes. Further, others have argued that the wealth gap of “Guilded Age” America was as high as those seen in Europe up to the turn of the century.
Improvements in public health activity during subsequent decades were responsible for overall mortality declines, but the authors note that the more educated (and presumably more affluent) of American society enjoyed a faster rate of decline as mortality differentials between classes increased. This they attribute to greater acceptance of a scientific view of disease and changes in parental behavior - hand washing, boiling milk and infant utensils, for example, and not to income effects.
Were that view that applicable to 1991, the year Fatal Years was published, one might argue that wealth is less important to child survival than parental behavior; that universal access to health interventions regardless of economic circumstance would have less impact on child mortality or overall health of a population than education in and adoption of healthy practices by individuals. While the public health initiatives that were undertaken over the past century had benefits extending to all members of society regardless of whether they accepted the underlying principal of germ theory, educated individuals reaped the greatest benefits because they adapted their behaviors to put into practice methods to improve their own health. The authors’ position suggests that when information exists that can improve health, there will be groups in society that will accept and put it into practice, and others who will ignore it with the consequence of poorer health outcomes. Comparing the situation at the start of the century with today, they write: “In place of sharp differentiation now commonly associated with behavioral differences among classes were important variations in mortality according to factors over which individuals had little or no control” (p209).
The debate over improved access to health care by the economically disadvantaged that became a national issue in the late 1980’s and prompted some states to expand Medicaid coverage to more children (Minnesota in 1988 became the first state to increase child health coverage) continues today. Those wishing to find “objective” support for positions against the increased coverage might favor the authors’ view.
It is questionable that conclusions drawn from analysis of data describing America of a century ago can be used to describe the environment today. While there was little curative power in medicine then, medical science has made genuine progress in its ability to cure and treat illness. Infectious diseases were a primary cause of death in 1900 America, many of which are now curable with drug therapy. However treatment is not a function of individual initiative and behavior as much as of availability, which is a function of individual wealth. The position that ill health is primarily due to poor individual behavioral choices is misguided.
Samuel Preston is the Frederick J. Warren Professor of Demography at the University of Pennsylvania; Michael Haines is the Banfi Vinters Professor of Economics Colgate University. As demographers, they rely heavily on statistical analysis in constructing their story of child mortality in 1900 America. Life expectancy tables from the period and the rich descriptive data of America from the 1900 census along with a model whereby child mortality estimates could be extracted, allow the data to be analyzed in ways aggregate mortality figures cannot. There is little probing into turn of the century life beyond the numbers, however. More historical monologue might have explained the picture of life at the time and provided a context against which the reader could better interpret the statistical data. Could the statistics have been interpreted differently with better historical background? Preston and Haines note that while life in cities was associated with high mortality, the ten largest cities at the time actually had better mortality rates than the next largest cities. Without investigating, they assume that this was because these largest cities began public health efforts earlier. However, these cities also experienced the earlier growth of “suburban” areas which allowed wealthier residents to leave the congested cores; they may also have been the first to be connected to the public water and sewer facilities. Statistics may show differentials, but a deeper understanding of history might provide better insights into interpreting the results.
The authors also note repeatedly that African Americans had the highest rates of child mortality and, generally, the lowest life expectancy of any group in the United States. Despite the glaring disparity, they do not explore the issue in the text. Again, reliance on statistics alone may not be adequate to understanding all of the mechanisms related to mortality. Greater historical perspective may have shed more light on the reasons for the differences shown by the statistics, particularly when the high child mortality differentials exist to this day. While they dismiss the historical, racist presumption that genetic frailty was operative, they did note that Blacks were paid less than Whites in the same occupations, had restricted access to education, and were not included in many public health initiatives of the time.
While the present may be built upon the foundations of the past, we must be careful about extrapolating conclusions about the past to the present without considering intervening history. No one would argue that germ theory did not represent a great tool for advancing human longevity and continues to be essential in maintaining health; nor that individual behavior continues to have a tremendous impact on health. While medical practice may not have had a measurable impact on mortality in 1900 America, it does play a major role today. Improved access to medicine today may be the most effective means at further reducing mortality. The modest impact of the income variable on health at in 1900 is not necessarily true in twenty-first century America.
Reference
Fatal Years: child mortality in late nineteenth-century america (1991).
Preston, S. H. & Haines M. R.. Princeton University Press. Princeton, NJ
About Pamela Lazorko
Sunday, January 29, 2012
The Costs of Workplace Bullying in Health Care Environments
Abstract
The negative health effects suffered by victims of workplace bullying have been well described by the literature, and are in the process of being quantified by research. That employers may also bear some penalty, albeit primarily economic, has been suggested by potentially higher rates of employee turnover from socially hostile work environments. This paper will examine the course of economic loss to employers from higher rates of absenteeism, illness, and turnover in victims of workplace bullying, with a focus on health care facilities. Studies have suggested that bullying may be more prevalent in these institutions than others despite its higher cost of employee replacement. While the actual costs of bullying vary too widely by employment category, geographical location, and even institution to make a meaningful generalized calculation of economic impact to employers, the scope of the problem can be defined.
Introduction
The consequences of workplace bullying extend beyond the creation of discomfort for its victims. Exposure to the phenomenon has been associated with both physiological and psychological harm to those with exposure. Several studies have studied the prevalence of bullying. In a large scale study of French workers, Niedhammer, David, and Degioanni (2007) found that 10% of respondents reported exposure to the behavior. There is reason to suspect that in healthcare facilities the rate is much higher. Simmons (2008) found that 31% of nurses responding to an investigation of prevalence reported having been bullied. Of itself, the potential for damage to individual workers is reason to explore mitigating strategies in the work environment; however, employers are often hesitant to examine conditions within their organizations and are often disinclined to implement anti-bullying procedures (conversation with S. Simons).
The reason for the reticence has not been explored by the literature, though some suggest that employers may view hostile interpersonal employee interactions as competitive, relationships that positively influence overall work quality and eliminate the less productive or competent workers. Furthermore, bullying of employees by managers has been described as a management technique tolerated as appropriate by some organizations (Einarsen, Hoel, Zapf, Cooper, 2011). Beale and Hoel (2011) go so far as to suggest that managerial bullying is an integral part of the employer/employee contract used to maintain necessary control of the work environment. As such, reluctance on the part of employers to implement strategies and policies aimed at reducing the prevalence of workplace bullying may be understandable. Yet, as more is learned about the phenomenon, it is becoming accepted that bullying behavior in the workplace is not equivalent to healthy competition between workers, and has economic consequences which bear upon both effected employees and the employer.
The literature is largely silent on quantifying the economic impact that workplace bullying places on employers. Without a pretense of placing dollar amounts on the practice, this paper will attempt to examine the relationship in two ways. First, it will examine specific illnesses shown to correlate with bullying exposure; second, it will consider cost and prevalence of absenteeism associated with these conditions. It is notable that insofar as many American employers bear some costs of health care to employees, medical and psychological conditions caused by or exacerbated by a hostile work environment are also shouldered by the employer.
Further, the cost of increased employee turnover, an indicator of employment dissatisfaction commonly shown to increase among bullied employees, will be examined. The economic impact of turnover varies by institution and employment classification and is modified by the cyclic nature of the labor market. As such that aspect will represent different burdens to the universe of employers. Furthermore, bullying occurring in nursing and healthcare environments generally, has been associated with increased incidences of negative patient care events which have not been quantified by systematic study. While it may not be practical (or possible) to design methods which might tease out instances of health care provider error which would not have occurred but not for bullying, it should be stressed that hostile work environments reduce worker effectiveness regardless of industry. The consequence only adds to an employer burden of decreased worker productivity.
Search Mechanisms
Several relationships are to be explored in the literature. First, information directly related to economic costs of workplace bullying; secondarily, increased risks of specific diseases and employee dissatisfaction related to the phenomenon. For comparative value the economic costs to employers of disease, absenteeism, and turnover rates due to nonspecific cause were investigated. Finally, it an understanding of employer attitudes about the phenomenon was researched.
A review of literature was conducted using Web of Science and Google Scholar using the following search terms as topic search: workplace bullying and (economic costs or employer tolerance or employer attitudes); employee absenteeism and economic costs; workplace bullying and (health or disease), which were further refined to workplace bullying and (heart disease or fibromyalgia or depression).
Impacts of Bullying on Health and Wellness
Exposure to prolonged bullying is known to be associated with negative health outcomes. It is suspected that disruptions to the hypothalmic-pituitary-adrenal (HPA) axis resulting in abnormal cortisol levels may be a root cause (Lazorko, 2009). Typically, an elevated level of cortisol is associated with the human stress response. Long term exposure to abnormally high levels of cortisol may accelerate damage bodily tissues. It is postulated that exposure to chronic stress eventually alters this response to decreases cortisol reactivity, resulting in the flattened response characteristic in victims. A better understanding of the process would require more detailed investigation than has been attempted to date. Yet, agitated levels of the hormone have been implicated in a litany of disease processes and medical conditions. Hypertensive cardiovascular disease (Walker, 2007), type II diabetes (Lundburg, 2007), fibromyalgia (Crofford, et al 1994), insomnia, and depression have been associated with abnormal cortisol profiles. Studies have found increased prevalence of these conditions among victims of bullying.
Kivimaki, Virtanen, et al. (2003) conducted a two year longitudinal study of 5432 hospital employees. While the study found that victims of bullying were more likely to suffer from cardiovascular disease, with odds ratio of 2.3 (95% CI 1.2 to 4.6), the odds ratio fell to 1.6 (95% CI .8 to 3.5) once adjusted for overweight. The study concurrently evaluated depression as a possible outcome, finding a more profound effect with an odds ratio of 4.2 (95% CI 2.0 to 8.6). While Kivimaki et al were unable to conclusively relate victimization to cardiovascular disease, we note that the study excluded departed employees from follow-up inclusion. The study indicated that cardiovascular disease was the most common reason for early departure from employment.
In a similar study of hospital employees, Kivimaki, Leino-Arjas, Virtanen, Elovainio, Keltikangas-Jarvinen, Puttonen, et al (2004) studied the incidence of fibromyalgia among hospital workers as a function of work-related stress of which bullying was a component. It was found that bullying was a significant predictor of developing the gamut of symptoms (joint and muscle pain, headache, insomnia) associated with the syndrome (odds ratio of 3.1, 95% CI from 1.2 to 8.0).
Another longitudinal study by Tuckey, Dollard, Saebel and Berry (2010) of 251 police officers found that adjusted for age, bullying was associated with increased cardiovascular disease with odds ratio of 2.6 (95% CI 1.36 to 3.13). The study also found a significantly increased likelihood of depressive symptoms in those who reported being bullied.
Cost of Absenteeism to Employers
Several studies have compiled statistics of self-reported instances of absences in direct response to bullying (Ortega, Christensen, Hough, Rugulies and Borg, 2011). However bullying exposure is correlated with increased instances of illness which employees might not associate with their exposure to hostility. The true rate of absenteeism caused by exposure to hostile work environments is much higher, as it should include instances of illness initiated by the workplace.
Ortega, et al conducted an examination of 9949 health workers in Denmark, finding that 11.8% had been bullied within the past 12 months. The 1.8% of respondents who reported being frequently bullied had a 92% higher rate of long-term sickness absence than those unaffected. While the study did not use a recognized tool for evaluating bullying, it did have access to a national registry of transfer payments detailing illness and absence from employment.
Evaluating the cost of disease to employers is confounded by the lack of a coherent strategy of record keeping. Nevertheless, there are data which relate the prevalence of conditions which result in employee absence, and gross computations relating their costs to American employers. Goetzal, Long, Ozminkowski, Hawkins, Wang, and Lynch (2004) examined employer records of several large American firms, finding that hypertension, cardiovascular disease, depression and arthritis (muscle and joint pain) were the major causes of medically-related employee absenteeism. They define another loss term, "presenteeism" that represents losses in productivity of workers suffering from ailments who present at the workplace. For conditions previously associated with bullying, the researchers calculate annual costs across the population of all workers of $718.52, representing 66% of the total costs of all illness-related healthcare and absenteeism for employers.
An additional consideration for many healthcare environments that the authors did not factor into their cost analysis is the cost of absent worker replacement. Many healthcare facilities are obliged by regulation to provide specific ratios of care providers to patients. Where existing resources are inadequate to maintain mandated staffing levels, overtime wages, bonuses or expensive temporary staff must be expended to meet requirements.
Employee Turnover
Employee turnover, the voluntary separation of a worker from an institution, represents real economic cost to the employer. These represent not only costs of the recruitment process, but also of the investment in employee training which is made. There is, of course, wide variability among employment positions and geographical location. Yet, retention is often within the ability of the employer. According to Hinkin and Tracey (2000), “poor quality of supervision and working conditions” were the most commonly noted reasons for separation, not that an employee found more agreeable alternative employment. They calculated the cost of turnover for a single front desk worker (hourly wage rate of $20) at a New York City hotel to be between $11,609 and $12, 882.
In arriving at the calculation, the authors model a learning curve of new recruit proficiency (of 80 days for one hotel), and add cofactors of disruption to coworkers and supervisors for varying duration; similar models might be developed to describe operations of a nurse or technician in a hospital. What is common to all industries is the notion that while a new hire is working to develop proficiency, the employer is not able to gain full use of the labor for which they pay. Further, new hires represent an additional load on supervisory staff and tend to reduce the productive output of seasoned employees with whom the work.
Whether an employee severs after many years of service or shortly after recruitment, the expenses of a new hire will be the same assuming the worker needs to be replaced to retain optimum productive capacity. Put in context of turnover rates, Hinkin and Tracey estimate that for a hotel front desk operation of 30 associates a turnover rate of 50% represents a cost of $95,000.
In a two year longitudinal study which followed recent nursing graduates into employment, Hough, Hoel, and Carneiro (2011) found that respondents exposed to frequent bullying were at 3.6 times greater risk of leaving employment than otherwise. It was also noted that at the termination of the study, work-related health problems were cited by 20% of those bullied respondents as reason for leaving. Stevens (2002) notes that nursing retention has been identified as the major factor in international shortages of nurses, and that hostile work environments are often cited as reasons for nurse separation from employment.
Conclusion
While the cost of human dignity to those who are treated with hostility in their daily employment can not be affixed with a price tag, employers are bearing its hidden economic cost. Stevens (2002) notes the experience of a hospital in Australia in which bullying had become insinuated into the institutional culture as an appropriate management practice and by extension to employees, as normal interpersonal relations. The Hospital suffered with 50% nursing turnover rates. Hough, et al., while supporting the hypothesis that bullied workers are more likely to sever employment, also noted increased complaints of illness among that group. It has been shown that illnesses implicated in exposure to bullying are also the most expensive ailments related to absenteeism.
As the phenomenon of bullying has become better understood, research has rightly focused on the often devastating demoralization and health decline of its victims. Employers, the stake holders in the best position to implement interventions which would improve the workplace environment, have been slow to wholeheartedly embrace the role. Some have argued that the very nature of the employer/employee relationship is at play; that intimidation is often reserved as a management tool. However, literature shows that the behavior transcends organizational hierarchical structures, and it is clear that more effective, less damaging methods are available to managers.
Bullying imposes heavy costs onto the workplace, borne by both worker and employer alike. More cost/benefit analyses may be required before institutions finally recognize that self-interest coincides at times with that of its employees.
References
Beale, D., Hoel, H. 2011. Workplace bullying and the employment relationship: exploring questions of prevention, control and context. Work, Employment and Society, 25(1) 5-18
Crofford,L., Pillemer, S., Kalogeras, K., Cash, J., Michelson, D., Kling, M., Sternberg, E., Gold, P., Chrousos, G., Wilder, R. 1994. Hypothalamic–pituitary–adrenal axis perturbations in patients with fibromyalgia. Arthritis & Rheumatism. 37(11), 1583–1592
Einarsen, S. , Hoel, H., Zapf, D., Cooper, C., 2011. Bullying and harassment in the workplace: developments in theory, research and practice. CRC Press, Boca Raton, Fl. pg 289
Goetzal, Long, Ozminkowski, Hawkins, Wang, and Lynch (2004). Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers. Journal of Occupational and Environmental Medicine 2004; 46. 398-412
Hinkin, T., and Tracey, J.B.2000. The cost of turnover: putting a price on the learning curve. Cornell Hotel and Restaurant Administration Quarterly. 42 (3). 14-21
Hough, A.,Hoel, H., Carneiro, I. 2011.Bullying and employee turnover among healthcare workers: a three-wave prospective study. Journal of Nursing Management, 2011, 19: 742–751
Kivimaki, M., Virtanen,M., Vartia, M., Elovainio, M., Vahtera, J., Keltikangas-Jarvinen, L. 2003. Workplace bullying and the risk of cardiovascular disease and depression. Occup Environ Med. 2003; 60: 779–783
Kivimaki, M., Leino-Arjas, P., Virtanen, M., Elovainio, M., Keltikangas-Jarvinen, L., Puttonen, S., Vartia, M., Brunner, E., Vahtera, J. (2004). Journal of Psychosomatic Research. 57 (2004) 417-422
Lazorko, 2011
Lundburg, U. 2007.Stress hormones in health and illness: The roles of work and gender. Psychoneuroendocrinology. 30(10), 1017-1021
Niedhammer, I., David, S, Degioanni, S. 2007. Association between workplace bullying and depressive symptoms in the French working population. Journal of Psychosomatic Research 61 (2006). pages 251– 259
Ortega, A., Christensen, K., Hough, A., Rugulies, R. and Borg, V. ,2011. One-year prospective study on the effect of workplace bullying on long-term sickness absence. Journal of Nursing Management, 2011, 19, 752-759.
Stevens, S. 2002.Nursing workforce retention: challenging a bullying culture. Health Affairs, 21(5) 189-193
Simons, S. (2008). Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. Advances in Nursing Science. volume31, issue 2. pages 48-59
Tuckey, M., Dollard, M., Saebel, J., Berry, N. 2010. Negative workplace behaviour: temporal
associations with cardiovascular outcomes and psychological health problems in Australian police. Stress and Health. 26: 372–381
Walker, B. 2007. Cortisol and cardiovascular disease. Endocrine Abstracts (2007) 14 EJE1 About Pamela Lazorko
The negative health effects suffered by victims of workplace bullying have been well described by the literature, and are in the process of being quantified by research. That employers may also bear some penalty, albeit primarily economic, has been suggested by potentially higher rates of employee turnover from socially hostile work environments. This paper will examine the course of economic loss to employers from higher rates of absenteeism, illness, and turnover in victims of workplace bullying, with a focus on health care facilities. Studies have suggested that bullying may be more prevalent in these institutions than others despite its higher cost of employee replacement. While the actual costs of bullying vary too widely by employment category, geographical location, and even institution to make a meaningful generalized calculation of economic impact to employers, the scope of the problem can be defined.
Introduction
The consequences of workplace bullying extend beyond the creation of discomfort for its victims. Exposure to the phenomenon has been associated with both physiological and psychological harm to those with exposure. Several studies have studied the prevalence of bullying. In a large scale study of French workers, Niedhammer, David, and Degioanni (2007) found that 10% of respondents reported exposure to the behavior. There is reason to suspect that in healthcare facilities the rate is much higher. Simmons (2008) found that 31% of nurses responding to an investigation of prevalence reported having been bullied. Of itself, the potential for damage to individual workers is reason to explore mitigating strategies in the work environment; however, employers are often hesitant to examine conditions within their organizations and are often disinclined to implement anti-bullying procedures (conversation with S. Simons).
The reason for the reticence has not been explored by the literature, though some suggest that employers may view hostile interpersonal employee interactions as competitive, relationships that positively influence overall work quality and eliminate the less productive or competent workers. Furthermore, bullying of employees by managers has been described as a management technique tolerated as appropriate by some organizations (Einarsen, Hoel, Zapf, Cooper, 2011). Beale and Hoel (2011) go so far as to suggest that managerial bullying is an integral part of the employer/employee contract used to maintain necessary control of the work environment. As such, reluctance on the part of employers to implement strategies and policies aimed at reducing the prevalence of workplace bullying may be understandable. Yet, as more is learned about the phenomenon, it is becoming accepted that bullying behavior in the workplace is not equivalent to healthy competition between workers, and has economic consequences which bear upon both effected employees and the employer.
The literature is largely silent on quantifying the economic impact that workplace bullying places on employers. Without a pretense of placing dollar amounts on the practice, this paper will attempt to examine the relationship in two ways. First, it will examine specific illnesses shown to correlate with bullying exposure; second, it will consider cost and prevalence of absenteeism associated with these conditions. It is notable that insofar as many American employers bear some costs of health care to employees, medical and psychological conditions caused by or exacerbated by a hostile work environment are also shouldered by the employer.
Further, the cost of increased employee turnover, an indicator of employment dissatisfaction commonly shown to increase among bullied employees, will be examined. The economic impact of turnover varies by institution and employment classification and is modified by the cyclic nature of the labor market. As such that aspect will represent different burdens to the universe of employers. Furthermore, bullying occurring in nursing and healthcare environments generally, has been associated with increased incidences of negative patient care events which have not been quantified by systematic study. While it may not be practical (or possible) to design methods which might tease out instances of health care provider error which would not have occurred but not for bullying, it should be stressed that hostile work environments reduce worker effectiveness regardless of industry. The consequence only adds to an employer burden of decreased worker productivity.
Search Mechanisms
Several relationships are to be explored in the literature. First, information directly related to economic costs of workplace bullying; secondarily, increased risks of specific diseases and employee dissatisfaction related to the phenomenon. For comparative value the economic costs to employers of disease, absenteeism, and turnover rates due to nonspecific cause were investigated. Finally, it an understanding of employer attitudes about the phenomenon was researched.
A review of literature was conducted using Web of Science and Google Scholar using the following search terms as topic search: workplace bullying and (economic costs or employer tolerance or employer attitudes); employee absenteeism and economic costs; workplace bullying and (health or disease), which were further refined to workplace bullying and (heart disease or fibromyalgia or depression).
Impacts of Bullying on Health and Wellness
Exposure to prolonged bullying is known to be associated with negative health outcomes. It is suspected that disruptions to the hypothalmic-pituitary-adrenal (HPA) axis resulting in abnormal cortisol levels may be a root cause (Lazorko, 2009). Typically, an elevated level of cortisol is associated with the human stress response. Long term exposure to abnormally high levels of cortisol may accelerate damage bodily tissues. It is postulated that exposure to chronic stress eventually alters this response to decreases cortisol reactivity, resulting in the flattened response characteristic in victims. A better understanding of the process would require more detailed investigation than has been attempted to date. Yet, agitated levels of the hormone have been implicated in a litany of disease processes and medical conditions. Hypertensive cardiovascular disease (Walker, 2007), type II diabetes (Lundburg, 2007), fibromyalgia (Crofford, et al 1994), insomnia, and depression have been associated with abnormal cortisol profiles. Studies have found increased prevalence of these conditions among victims of bullying.
Kivimaki, Virtanen, et al. (2003) conducted a two year longitudinal study of 5432 hospital employees. While the study found that victims of bullying were more likely to suffer from cardiovascular disease, with odds ratio of 2.3 (95% CI 1.2 to 4.6), the odds ratio fell to 1.6 (95% CI .8 to 3.5) once adjusted for overweight. The study concurrently evaluated depression as a possible outcome, finding a more profound effect with an odds ratio of 4.2 (95% CI 2.0 to 8.6). While Kivimaki et al were unable to conclusively relate victimization to cardiovascular disease, we note that the study excluded departed employees from follow-up inclusion. The study indicated that cardiovascular disease was the most common reason for early departure from employment.
In a similar study of hospital employees, Kivimaki, Leino-Arjas, Virtanen, Elovainio, Keltikangas-Jarvinen, Puttonen, et al (2004) studied the incidence of fibromyalgia among hospital workers as a function of work-related stress of which bullying was a component. It was found that bullying was a significant predictor of developing the gamut of symptoms (joint and muscle pain, headache, insomnia) associated with the syndrome (odds ratio of 3.1, 95% CI from 1.2 to 8.0).
Another longitudinal study by Tuckey, Dollard, Saebel and Berry (2010) of 251 police officers found that adjusted for age, bullying was associated with increased cardiovascular disease with odds ratio of 2.6 (95% CI 1.36 to 3.13). The study also found a significantly increased likelihood of depressive symptoms in those who reported being bullied.
Cost of Absenteeism to Employers
Several studies have compiled statistics of self-reported instances of absences in direct response to bullying (Ortega, Christensen, Hough, Rugulies and Borg, 2011). However bullying exposure is correlated with increased instances of illness which employees might not associate with their exposure to hostility. The true rate of absenteeism caused by exposure to hostile work environments is much higher, as it should include instances of illness initiated by the workplace.
Ortega, et al conducted an examination of 9949 health workers in Denmark, finding that 11.8% had been bullied within the past 12 months. The 1.8% of respondents who reported being frequently bullied had a 92% higher rate of long-term sickness absence than those unaffected. While the study did not use a recognized tool for evaluating bullying, it did have access to a national registry of transfer payments detailing illness and absence from employment.
Evaluating the cost of disease to employers is confounded by the lack of a coherent strategy of record keeping. Nevertheless, there are data which relate the prevalence of conditions which result in employee absence, and gross computations relating their costs to American employers. Goetzal, Long, Ozminkowski, Hawkins, Wang, and Lynch (2004) examined employer records of several large American firms, finding that hypertension, cardiovascular disease, depression and arthritis (muscle and joint pain) were the major causes of medically-related employee absenteeism. They define another loss term, "presenteeism" that represents losses in productivity of workers suffering from ailments who present at the workplace. For conditions previously associated with bullying, the researchers calculate annual costs across the population of all workers of $718.52, representing 66% of the total costs of all illness-related healthcare and absenteeism for employers.
An additional consideration for many healthcare environments that the authors did not factor into their cost analysis is the cost of absent worker replacement. Many healthcare facilities are obliged by regulation to provide specific ratios of care providers to patients. Where existing resources are inadequate to maintain mandated staffing levels, overtime wages, bonuses or expensive temporary staff must be expended to meet requirements.
Employee Turnover
Employee turnover, the voluntary separation of a worker from an institution, represents real economic cost to the employer. These represent not only costs of the recruitment process, but also of the investment in employee training which is made. There is, of course, wide variability among employment positions and geographical location. Yet, retention is often within the ability of the employer. According to Hinkin and Tracey (2000), “poor quality of supervision and working conditions” were the most commonly noted reasons for separation, not that an employee found more agreeable alternative employment. They calculated the cost of turnover for a single front desk worker (hourly wage rate of $20) at a New York City hotel to be between $11,609 and $12, 882.
In arriving at the calculation, the authors model a learning curve of new recruit proficiency (of 80 days for one hotel), and add cofactors of disruption to coworkers and supervisors for varying duration; similar models might be developed to describe operations of a nurse or technician in a hospital. What is common to all industries is the notion that while a new hire is working to develop proficiency, the employer is not able to gain full use of the labor for which they pay. Further, new hires represent an additional load on supervisory staff and tend to reduce the productive output of seasoned employees with whom the work.
Whether an employee severs after many years of service or shortly after recruitment, the expenses of a new hire will be the same assuming the worker needs to be replaced to retain optimum productive capacity. Put in context of turnover rates, Hinkin and Tracey estimate that for a hotel front desk operation of 30 associates a turnover rate of 50% represents a cost of $95,000.
In a two year longitudinal study which followed recent nursing graduates into employment, Hough, Hoel, and Carneiro (2011) found that respondents exposed to frequent bullying were at 3.6 times greater risk of leaving employment than otherwise. It was also noted that at the termination of the study, work-related health problems were cited by 20% of those bullied respondents as reason for leaving. Stevens (2002) notes that nursing retention has been identified as the major factor in international shortages of nurses, and that hostile work environments are often cited as reasons for nurse separation from employment.
Conclusion
While the cost of human dignity to those who are treated with hostility in their daily employment can not be affixed with a price tag, employers are bearing its hidden economic cost. Stevens (2002) notes the experience of a hospital in Australia in which bullying had become insinuated into the institutional culture as an appropriate management practice and by extension to employees, as normal interpersonal relations. The Hospital suffered with 50% nursing turnover rates. Hough, et al., while supporting the hypothesis that bullied workers are more likely to sever employment, also noted increased complaints of illness among that group. It has been shown that illnesses implicated in exposure to bullying are also the most expensive ailments related to absenteeism.
As the phenomenon of bullying has become better understood, research has rightly focused on the often devastating demoralization and health decline of its victims. Employers, the stake holders in the best position to implement interventions which would improve the workplace environment, have been slow to wholeheartedly embrace the role. Some have argued that the very nature of the employer/employee relationship is at play; that intimidation is often reserved as a management tool. However, literature shows that the behavior transcends organizational hierarchical structures, and it is clear that more effective, less damaging methods are available to managers.
Bullying imposes heavy costs onto the workplace, borne by both worker and employer alike. More cost/benefit analyses may be required before institutions finally recognize that self-interest coincides at times with that of its employees.
References
Beale, D., Hoel, H. 2011. Workplace bullying and the employment relationship: exploring questions of prevention, control and context. Work, Employment and Society, 25(1) 5-18
Crofford,L., Pillemer, S., Kalogeras, K., Cash, J., Michelson, D., Kling, M., Sternberg, E., Gold, P., Chrousos, G., Wilder, R. 1994. Hypothalamic–pituitary–adrenal axis perturbations in patients with fibromyalgia. Arthritis & Rheumatism. 37(11), 1583–1592
Einarsen, S. , Hoel, H., Zapf, D., Cooper, C., 2011. Bullying and harassment in the workplace: developments in theory, research and practice. CRC Press, Boca Raton, Fl. pg 289
Goetzal, Long, Ozminkowski, Hawkins, Wang, and Lynch (2004). Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers. Journal of Occupational and Environmental Medicine 2004; 46. 398-412
Hinkin, T., and Tracey, J.B.2000. The cost of turnover: putting a price on the learning curve. Cornell Hotel and Restaurant Administration Quarterly. 42 (3). 14-21
Hough, A.,Hoel, H., Carneiro, I. 2011.Bullying and employee turnover among healthcare workers: a three-wave prospective study. Journal of Nursing Management, 2011, 19: 742–751
Kivimaki, M., Virtanen,M., Vartia, M., Elovainio, M., Vahtera, J., Keltikangas-Jarvinen, L. 2003. Workplace bullying and the risk of cardiovascular disease and depression. Occup Environ Med. 2003; 60: 779–783
Kivimaki, M., Leino-Arjas, P., Virtanen, M., Elovainio, M., Keltikangas-Jarvinen, L., Puttonen, S., Vartia, M., Brunner, E., Vahtera, J. (2004). Journal of Psychosomatic Research. 57 (2004) 417-422
Lazorko, 2011
Lundburg, U. 2007.Stress hormones in health and illness: The roles of work and gender. Psychoneuroendocrinology. 30(10), 1017-1021
Niedhammer, I., David, S, Degioanni, S. 2007. Association between workplace bullying and depressive symptoms in the French working population. Journal of Psychosomatic Research 61 (2006). pages 251– 259
Ortega, A., Christensen, K., Hough, A., Rugulies, R. and Borg, V. ,2011. One-year prospective study on the effect of workplace bullying on long-term sickness absence. Journal of Nursing Management, 2011, 19, 752-759.
Stevens, S. 2002.Nursing workforce retention: challenging a bullying culture. Health Affairs, 21(5) 189-193
Simons, S. (2008). Workplace bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organization. Advances in Nursing Science. volume31, issue 2. pages 48-59
Tuckey, M., Dollard, M., Saebel, J., Berry, N. 2010. Negative workplace behaviour: temporal
associations with cardiovascular outcomes and psychological health problems in Australian police. Stress and Health. 26: 372–381
Walker, B. 2007. Cortisol and cardiovascular disease. Endocrine Abstracts (2007) 14 EJE1 About Pamela Lazorko
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