RELATIONSHIP BETWEEN WORKPLACE

HARASSMENT AND POSTTRAUMATIC STRESS

SYMPTOMS AMONG PAKISTANI FEMALE

HEALTHCARE PROFESSIONALS

A THESIS SUBMITTED TO

THE UNIVERSITY OF THE PUNJAB

IN FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF

DOCTOR OF PHILOSOPHY IN APPLIED PSYCHOLOGY

BY

SADIA MALIK

DEPARTMENT OF APPLIED PSYCHOLOGY

UNIVERSITY OF THE PUNJAB

LAHORE, PAKISTAN

2011

CERTIFICATE

This is to certify that the research work described in this thesis is the orginal work of the author and has been carried out under my direct and intensive supervision. I have personally gone through all the data/results/materials reported in the manuscript and certify its authenticity. I further certify that the material included in this thesis have not been used in part or full in a manuscript already submitted or in the process of submission in the partial/complete fulfillment of the award of any other degree from any other institution. I also certify that the thesis has been prepared under my supervision according to the prescribed format and I endorse its evaluation for the award of Ph.D degree through the official procedures of the university of the Punjab,

Lahore, Pakistan.

Signature

Dr. Yasmin Nilofer Farooqi (Tamgha-i-Imtiaz) Professor Department of Applied Psychology University of the Punjab Lahore, Pakistan

DECLARATION

I, Sadia Malik, do hereby solemnly declare that the work submitted in this thesis is my own and has not been presented previously to any other institution or university for a degree.

This work has been completed under the supervision of Professor Dr. Yasmin

Nilofer Farooqi (Tamgha-i-Imtiaz) at the Dapartment of Applied Psychology,

University of the Punjab, Lahore, Pakistan.

Researcher

______

Sadia Malik

ABSTRACT

The current research was conducted to investigate relationship between workplace harassment and posttraumatic stress symptoms among Pakistani female healthcare professionals. Survey research design was used. The purposive sample was composed of 300 female healthcare professionals within age range from 20 to 59 years (100 doctors, 100 house-job doctors and 100 certified nurses). The sample was drawn from five different public hospitals (Mayo Hospital, Ganga Ram Hospital, Jinnah Hospital,

Lady Willington Hospital and Sheikh Zayed Hospital) of Lahore city. Written consent was individually obtained from all the participants. Björkquist, Osterman and Hjelt-

Beck‘s (1992) Work Harassement Scale (WHS), Kamal and Tariq‗s (1997) Sexual

Harassment Experience Questionnaire (SHEQ) and Weathers, Litz, Herman, Huska and Keane‘s (1993) PTSD Civilian Checklist (PCL-C) were individually administered to the participants to determine their reported workplace harassment and posttraumatic stress symptoms. Written permission was granted by the authors to the researcher for use of WHS (1992); SHEQ (1997); and PCL-C (1993) in the current research project. The SPSS (version 14.0) was used. Pearson Product Moment

Correlation Coefficient was performed to determine the relationship between workplace harassment and posttraumatic stress symptoms reported by the female healthcare professionals. The findings suggested significant positive relationship between general workplace harassment and posttraumatic stress symptoms (r = .52,

**p < .01); and sexual harassment and posttraumatic stress symptoms (r = .65, **p <

.01). Hierarchical Multiple Regression analysis was performed to determine the impact of demographic variables (age, education, job status, job experience, monthly income, marital status) and workplace harassment on posttraumatic stress symptoms.

The results indicated that workplace harassment and sexual harassment were the

strongest predictors for posttraumatic stress symptoms, whereas, none of the demographic variables accounted for variance. Furthermore, the results suggest statistically significant differences in posttraumatic stress symptoms reported by all the participants who were exposed to serious general and sexual workplace harassment, moderate workplace harassment and minimal workplace harassment. The findings of this research would promote our understanding of the relationship among workplace harassment, posttraumatic stress symptoms and the demographic variables; such as age, job status, education and marital status of the female doctors, house-job doctors and nurses in the Pakistani healthcare system. Furthermore, these findings have implications for the prevention of workplace harassment and posttraumatic stress symptoms as well as introduction of timely interventions for the promotion of mental health of the victims of workplace harassment in the Pakistani healthcare system.

ACKNOWLEDGMENT

I am humbly thankful to Allah Almighty, the Merciful and Hazrat Muhammad

(Peace Be Upon Him), who made my life more bountiful and blessed me with strength and endurance to cope the stress during this research project.

I am extremely grateful to my supervisor Prof. Dr. Yasmin Nilofer Farooqi, for her continuous guidance, motivation, immense knowledge and her tolerance in teaching me despite of my shortcomings. Her valuable suggestions and encouragement helped me in all the time of research and writing of this thesis. I appreciate all her contributions of time, energy and ideas to make my Ph. D. experience productive and motivating. Thank you so much madam.

My deepest gratitude goes to my family for their persistent love and support throughout my life; this dissertation is simply impossible without them. I am indebted to my father for his care and love. Although he is no longer with us, he is forever remembered. I wish to pay thanks to my mother for her kindness, spiritual support and especially her prayers and unconditional love. Mother, I love you. I feel proud of my brother Ubaid, his encouragement and support gave me the courage to face the hard and bitter realities of life. Unfortunately, he is no more with us due to untimely death; but he is always remembered. I am also grateful to my husband, Tahir, without his love, understanding and patience I could never had attained this goal.

I would like to express my deep gratitude to all the hospital administration that permitted me to collect data from their female employees. I would also like to place on record my thanks for the participants without whom this research could not have been possible.

I am also grateful to my friends who continuously encouraged me during this research period. I deeply pay my gratitude to Haris Ali, who helped me a lot in data collection phase.

I am grateful from the core of my heart to every individual, who directly or indirectly made this research project possible for me.

Sadia Malik

TABLE OF CONTENTS

Page

Abstract i

Acknowledgment iii

List of Tables v

List of Figures vii

List of Appendices viii

CHAPTER 1

1. Introduction 1

1.1. What is Harassment? 2

1.2. Harassment in Healthcare Sector 10

1.3. Consequences of Harassment 12

1.4. Posttraumatic Stress Symptoms 14

1.5. Theoretical framework 16

1.5.1. Theories of Workplace Harassment 16

i. The Natural/Biological Theory 16

ii. The Organizational Theory 17

iii. The Socio-Cultural Theory 18

iv. Sex Role Spillover Theory 19

v. Four-Factor Theory 20

1.5.2. Theories of Posttraumatic Stress Symptoms 20

i. Psychodynamic Theory 21

ii. Cognitive Theory 21

iii. Biological Theory 22

1.6. Review of Literature 23

1.7. Rationale of the study 39

1.8. Objectives 41

1.8. Research Hypotheses 42

CHAPTER II

2. Methodology 43

2.1. Research Design 43

2.2. Sample and Sampling Strategy 43

2.3. Instruments 46

2.3.1. Demographic Information Form 47

2.3.2. Work Harassment Scale (WHS) by Björkqvist, Osterman and

Hjelt-Back (1994) 47

2.3.3. Sexual Harassment Experience Questionnaire (SHEQ) by

Kamal & Tariq (1997) 48

2.3.4. PTSD Checklist- Civilian Version (PCL-C) by Weathers, Litz,

Herman, Huska and Keane (1993) 50

2.4. Procedure 51

2.5. Statistics 52

CHAPTER III

3. Results 53

3.1. Psychometric Analysis 53

3.1.1. Work Harassment Scale 54

3.1.2. Sexual Harassment Experience Questionnaire 56

3.1.3. PTSD Checklist- Civilian Version (PCL-C) 62

3.2. Main Analysis 64

3.2.1. Frequency and percentage of General Workplace

Harassment 64

3.2.2. Frequency and percentage of Sexual Harassment 65

3.2.3. Frequency and percentage of Posttraumatic Stress

Symptoms 67

3.2.4. Hypothesis 1 69

i. Sub-Hypothesis 1 70

ii. Sub-Hypothesis 2 71

iii. Sub-Hypothesis 3 72

3.2.5. Hypothesis 2 73

3.3. Additional Analysis 75

3.3.1. Differences in General Workplace Harassment, Sexual

Harassment and Posttraumatic Stress Symptoms 75

3.3.2. Categorization of Seriously Generally Harassed, Moderately

Harassed and Mildly Harassed Female Healthcare

Professionals 76

3.3.3. Categorization of Seriously Sexually Harassed, Moderately

Sexually Harassed and Slightly Sexually Harassed Female

Healthcare Professionals 77

3.3.4. Differences in PTSS reported by Seriously Generally Harassed,

Moderately Harassed And Mildly Harassed Female Healthcare

Professionals 79

3.3.5. Differences in PTSS reported by Seriously Sexually Harassed,

Moderately harassed and slightly harassed Female Healthcare

Professionals 80

CHAPTER IV

4. Discussion 82

4.1. Limitations and Recommendations 90

4.2. Conclusion 91

4.3. Implications 91

5. References 92

LIST OF TABLES

Page

Table 1: Demographic characteristics of the sample 45

Table 2: Varimax rotation of two factor solution for Work

Harassment Scale. 55

Table 3: Comparison of factor analysis of sexual harassment

experience questionnaire performed in 2011 and 1998 58

Table 4: Varimax rotation of three factors underlying sexual

harassment experience questionnaire 59

Table 5: Two factors underline PCL-Civilian Version by PCA

Varimax rotation 63

Table 6: Frequency and percentage of different types of harassment

Reported by the doctors, house-job doctors and nurses 64

Table 7: Frequency and percentage of different type of sexual harassment

reported by the female doctors, house-job doctors and nurses 66

Table 8: Frequency and percentage of different levels of posttraumatic

Stress symptoms reported by the female doctors, house-job doctors

and nurses 68

Table 9: Relationship between types of workplace harassment and

posttraumatic stress symptoms 69

Table 10: Relationship between workplace harassment and posttraumatic

stress symptoms among the doctors 70

Table 11: Relationship between workplace harassment and posttraumatic

stress symptoms among the house-job doctors 71

Table 12: Relationship between workplace harassment and posttraumatic

stress symptoms among the nurses 72

Table 13: Hierarchical multiple regressions predicting posttraumatic stress

symptoms from general workplace harassment and sexual harassment

among the female healthcare professionals 74

Table 14: Differences in posttraumatic stress symptoms reported by the

seriously harassed, moderately harassed and mildly

harassed groups 80

Table 15: Differences in posttraumatic stress symptoms reported by the

seriously sexually harassed, moderately harassed and slightly

harassed female healthcare professionals 81

LIST OF FIGURES

Page

Figure 1: Hypothetical Model of Workplace harassment and PTSS 41

Figure 2: Frequency distribution of sample from different public

hospitals of Lahore city 46

Figure 3: Mean differences in general workplace harassment, sexual

harassment and posttraumatic stress symptoms reported by the

female healthcare professionals 75

Figure 4: Distribution of the sample by general workplace harassment 76

Figure 5: Distribution of the sub-samples of doctors, house-job doctors

and nurses by general workplace harassment 77

Figure 6: Distribution of the sample by sexual harassment 78

Figure 7: Distribution of the sub-samples of doctors, house-job doctors 79

and nurses by sexual harassment

APPENDICES

Page

Appendix A: Consent Form 121

Appendix B: Demographic Information Sheet 122

Appendix C: Authority Letter 123

Appendix D: Work Harassment Scale (WHS) 124

Appendix E: Sexual Harassment Experience Questionnaire (SHEQ) 125

Appendix F: PTSD Checklist Civilian-Version (PCL-C) 128

Appendix G: Data Sheet 130 1

Chapter I

INTRODUCTION

The current research investigated relationship between types and frequency of workplace harassment and degree of posttraumatic stress symptoms (PTSS) among female healthcare professionals (doctors, house-job doctors and nurses). It also investigated the impact of different demographic variables (age, education, monthly income, job experience, job status and marital status) on workplace harassment (both general and sexual harassment) and PTSS.

Workplace harassment is a serious issue these days. Throughout the world, working people are reporting general and sexual harassment at their workplaces.

Despite all the efforts for preventive remedies, the problem of workplace harassment is continuing and adversely affecting the mental and physical health of working women across the globe. Historically, the patriarchal system and the discriminatory attitude of male dominated society towards professional women may be the reason behind workplace harassment. In traditional patriarchal Pakistani society, a woman has to face many pressures for economic autonomy and mobility. Sometimes, the traditional practices including cultural and religious traditions support female‘s suppression and affect their dignity. Among the fatal forces, which affect women‘s dignity, self-esteem and security. In a patriarchal society, men are considered authoritative and powerful; and women are perceived as dependent, incompetent and inferior. Thus, it may be argued that these gender-specific stereotypes may encourage men to harass or abuse their female subordinates or colleagues at workplace (Hassan,

1996).

The main dilemma in Pakistani society is that incidents of harassments especially workplace harassment is considered as the mistake of harassed not the 2 harasser. Niaz (1994) argues that sexual harassment is such a powerful weapon that an ordinary man can end up harming even a powerful woman in serious ways. Moreover, behaviors like intimidation, humiliation, name-calling, social isolation and unwanted physical contact have serious consequences for the physical and mental health of the employees. Neidl (1996) argues that harassment at workplace may contribute to depression, stress and lowered self-esteem especially among the female employees.

In Pakistan, very few scientific researchers have been carried out in the field of workplace harassment and posttraumatic stress symptoms, which are based upon the data drawn from the students. Therefore, the current research would be the first and unique one because it aims to explore relationship between workplace harassment and PTSS among the Pakistani female healthcare professionals. The researcher has used the terminology of posttraumatic stress symptoms (PTSS) as a reaction to workplace harassment rather than the mental disorder classified as post-traumatic stress disorders (PTSD) by the Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition. Text Revision TR (APA, 2000).

1.1.What is Harassment?

Generally speaking, workplace harassment can be defined as any improper offensive and harmful act, comment or attitude from a supervisor, a colleague, a subordinate or from any other person in the workplace to degrade, intimidate, threaten or harm a person (Skarlicki & Kilick, 2005; Treasury Board of Canada Secretariat,

2002). Jennifer, Cowie and Ananiadou (2003); Porhola, Karhunen and Rainivaara

(2006) and Rayner (1997) report that 30% to 53% of employees report incidents of harassment during their working career which shows the seriousness of this problem.

A workplace may be an office, hospital, school, store or a factory and the behavior through which a person abuses his/her colleagues verbally or physically to 3 make them feel uncomfortable by using offensive language or humiliating or isolating them is workplace harassment (Johny, 2007). Ehrenreich (1999) reported that these behaviors might include staring, filthy looks, insulting comments, intimidation, and physical harm. Historically, the terms harassment, non-sexual harassment, psychological harassment, bullying, psychological terror, victimization, workplace trauma, workplace aggression and mobbing have been used interchangeably (Adams

& Crawford, 1992; Baron & Neuman, 1996; Björkqvist, Österman & Hjelt-Bäck,

1994; Brodsky, 1976; Di Martino, Hoel & Cooper, 2003; Einarsen & Raknes, 1997;

Hubert & Veldhoven, 2001; Leymann, 1990; Namie & Namie, 2000; Niedl, 1996;

Vartia, 1996; Wilson, 1991; Zapf & Einarsen, 2001 and Zapf, Knorz & Kulla, 1996).

Unfortunately, in Pakistani society workplace harassment is a socially tabooed issue, which is often underreported especially by the female employees. In the current research project, the researcher is using the terms harassment, bullying, psychological harassment and mobbing interchangeably because according to Zapf and Einersen

(2005) practically the concepts of bullying, harassment and mobbing have only minor differences.

Einersen, Hoel, Zapf and Cooper (2011) described the workplace harassment as exploitation of a subordinate/colleague or supervisor. They further stated that if such workplace harassment persists it could become the source of different psychosocial and pathological symptoms in the target person. In fact, workplace harassment is a complex issue with many shapes, multiple factors and many levels

(Agervold, 2007).

Brodsky (1976) defines harassment as repeated and persistent attempts that frustrate or annoy a person. He further argues that harassment refers to behavior that continuously provokes, pressurizes, intimidates or in some other way discomforts 4 someone. Björkqvist et al. (1994) described work harassment as repeated activities, which cause mental and physical hurt to one or more individuals who are unable to defend themselves in a specific work setting.

Einarsen and Skogstad (1996) define harassment as a problem, which occurs repeatedly over a period in some workplace, and the target person is faced with difficulty in defending himself/herself. Hoel and Cooper (2000) argue that harassment is persistent negative actions by one or several persons towards an individual or group of people, who have difficulties in defending themselves. According to Einersen,

Raknes and Mitthesen (1994) during the initial phases of harassment, the victim has to face discrete and indirect aggressive behaviors that are difficult to mention. However, with passage of time, aggression that is more direct appears and the target person has to face definite isolation, intimidation and public humiliation. In the end, physical harassment may be used against the victim.

Psychological harassment is the repeated and persistent attack to torture, annoy, frustrate, provoke, intimidate or humiliate one or more people to injure them professionally or personally (Lopaz-Cabarcos & Vazquez-rodriguez, 2006). Logan,

Walker, Jorden and Leukefeld (2006) clustered psychological harassment into two main groups: overt harassment which includes verbally dominating, showing indifference, constantly monitoring the person and discrediting others; while subtle harassment includes undermining, discounting or discouraging a person and isolating him/her socially from others.

Björkqvist et al. (1994) described sexual harassment as a specific form of bullying and work harassment in which the harasser uses sex as a source of subjugation. They further argue that sexual harassment at workplace is unwanted sexual and verbal advances, sexually insulting comments or discriminating remarks to 5 make a person feel frightened, humiliated and harassed and to affect his/her job performance, job satisfaction, commitment and job security and create a fearful and insulting work environment.

Lafontaine and Tredeau (1986) define sexual harassment as ―Any action occurring within the workplace whereby women are treated as objects of the male sexual prerogative… regardless of whether the victim labels it as problematic or not‖

(p.23). Thus, sexual harassment generally reflects the male attitude toward women in a patriarchal society and workplace (Pattinson, 1991). Farley (1978); Kanekar and

Menon (1992); and MacKinnon (1979) state that sexual harassment may also include leering, ridiculing, insulting remarks, repeated and unwanted sexual comments, demands for sexual favors and unwanted comments about dress or appearance.

Moreover, sexual harassment is not a mutual attraction or understanding between men and women, it affects the psychological integrity of women like other workplace stressors and it has serious health consequences for women (Bernstein, 1994).

There is sufficient empirical evidence that gender harassment is the most frequent sort of sexual harassment pursued by unwanted sexual attention whereas, sexual coercion is the less frequent type in many organizational settings (Anila, 1998;

Fitzgerald, Gelfand & Drasgow, 1995). There are many risk factors associated with the occurrence of sexual harassment at workplace including the nature of job and specifically the gender ratio at a workplace and traditionally male oriented jobs create a great risk for women to be sexually harassed. Social norms and organizational climate also play important role (Gruber, 1998). Furthermore, Bowling and Beehr‘s

(2006) suggested that workplace harassment levels are predicted by stressful work situations. The men are found to harass women more frequently when the 6 management has vague policies (Pryor, LaVite & Stoller, 1993; Pryor, Giedd &

Williams, 1995).

Hoel and Cooper (2000); Neuberger (1999) and Stone (2002) argue that bullying is another form of workplace harassment. It may include behaviors; such as persecution of a person, setting unfeasible work goals, making irrational demands, continuous disturbing and irritating supervision, use of insulting words, strict and discouraging work policies, shouting or physical attack and direct or indirect threats of removal from office or demotion.

Yücetürk and Öke (2005) further define that ―Workplace bullying is characterized by behaviors; such as intimidation, humiliation, name-calling, and the setting of impossible deadlines and the giving of meaningless tasks‖ (p. 62). These behaviors may also include verbal or written insulting comments, socially isolating a person, physical abuse and intimidation (Carey, 2003; Whitted & Dupper, 2005).

Hogh, Mikkelsen and Hansen (2011) describe bullying at work as an intense social stressor with traumatic potential.

Rayner and Höel (1997) defined workplace-bullying as ―…behaviors that threaten professional status like belittling, public professional humiliation, affecting personal standing such as name calling, insults and intimidation, isolation or preventing access to opportunities. Overwork or undue pressure and destabilization such as failure to give credit when due, meaningless tasks, removal of responsibility, repeated reminders of blunders and setting up to fail‖ (p.62). Besag (1989) argues that bullying is another form of workplace harassment because it aims to gain power over another person.

Olweus (1993) describes that open verbal and physical attacks on the victim are considered direct bullying whereas, indirect bullying include more restrained 7 behaviors; such as isolating or excluding the target person.. Moreover, bullying can be either work-related or person-related. According to Den Ouden, Bos and Sandfort

(1999); Einarsen and Hoel (2001); Kivimäki, Elovainio and Vahtera (2000);

Mikkelsen and Einarsen (2001); and Vartia (1996) work-related bullying includes unduly criticizing a person‘s performance, withholding important information, illogical deadlines or excessively monitoring a person. While person-related bullying may include commenting on a person‘s private life, humiliating and frightening behaviors, rumors and socially isolating a person.

Mobbing is another form of workplace harassment. Hecker (2007) defines mobbing as ―… devastating form of workplace conflict in which a group in solidarity intentionally creates a hostile work environment for an individual who has been ostracized‖ (p. 439). Moreover, it may also include hostile attempts against a person through unjustified blaming, humiliation, harassment and emotional abuse to force him/her out of workplace (Davenport, Schwartz & Eliot, 1999). According to

Leymann (1990, 1996) mobbing is an organized intimidating and immoral behavior or communication towards one individual to push her/him into helpless and defenseless condition; and it is constant and frequent in nature. Yücetürk and Öke (2005) found that mobbing could damage health, self-worth, interpersonal relationships and financial livelihood of the victim. Thus, different terminologies; such as psychological harassment, bullying and mobbing can be used to define workplace harassment in the context of diverse cultures and social settings (Ferrari, 2004).

DiMartino et al. (2003) describes that prevalence of workplace harassment varies from 1% to more than 50% and depends upon the management strategies, nature of job, sector and country. Leymann (1996) reported that 3.5 % of respondents of a survey in Sweden in 1992 have showed harassment; 16% of employee women 8 from Swedish Post complained about harassment (Voss, 2001). Ellis, Barak and Pinto

(1991); Cammaert (1985) and Lafontaine and Tredeau (1986) reported large variation in reporting of women‘s experiences of harassment and incidence rates range from

28% to 75 %. Gruber (1990) reviewed 18 studies and computed median percentage of

44% of the women who have experienced sexual harassment at some point at their workplaces. Bairy et al. (2007) reported higher prevalence rate of 50%, whereas, 90% of bullying incidents unreported in India.

Iqbal and Kamal (2001) argue that with increased participation of women in workforce to fulfill their financial and economical needs there is increase in their work related problems. In the industrial countries participation of women in work force may be another reason of this increase but the number of working women in traditionally men‘s job (blue and white-collar jobs) are still very small (Smith, 1991).

In most of the societies, men typically hold greater power then women, which mat precipitate workplace harassment (Lips, 1991; Mainiero, 1986; McMillan, 1991).

It is historically evident that the male dominated societies always ignored and denied the problem of sexual harassment which working women have to face, rather women themselves have been blamed for it (MacKinnon, 1979). According to Iqbal and Kamal (2001), ―…Women of all backgrounds and in all positions have been victims of harassment although a woman‘s age, marital status, etc., affect the likelihood of harassment‖ (p.110). Whereas, Fitzgerald (1992) reports that sexual harassment is found in both public and private sectors, in all types of organizations and at all levels. The reason of this harassment might be that as Bjorkqvist et al.

(1994) argues that women are taught to be less self-assertive, less hostile and more cooperative than men are and because of this when they have to face bullying at workplace they are even less able to defend themselves as compare to men. 9

Lewis and Gunn (2007) found that women in the public sector (24%) were bullied more than men (17 %). Berdhal (2007) found that those women who work in female dominated organizations experience less harassment than those working in male dominated organizations. Batool (as cited in Iqbal & Kamal, 2001) states that

―Violence against women takes many forms and it is universal in all societies.

Personal insecurity shadows women from cradle to grave, from childhood to adulthood; they are harassed and abused because of their gender. It begins at the doorstep of their home and continues, to the street, bus stop, to the entrance of the factory/organizations they work in, at the hands of their male superiors, male colleagues, down to even a male peon‖ (p.109).

Bjorqvist et al. (1994) stated that women experience harassment more frequently as compared to men. Magley, Hulin, Fitzgerald and De Nardo (1999) found that more or less 50% of women despite of any specific sample have reported unpleasant and nasty sex-related experiences at workplace or in school. Mankidy

(1986) states that women have difficulties in demanding promotions; working late; have low opinions about their own abilities and have negative attitude to accept recognition. According to Srinivasan‘s (1991) findings 50 % of women complained that always women have to do extra work, they also complained about sexual harassment from colleagues, managers, or customers. Women also felt displeased that they were not sent out for training. Some women employees discussed that these problems intensified when they were forced to adopt the behavior of a successful manager they argued that women should have their own strategies to achieve the same result (Mankidy, 1988).

There is sufficient empirical evidence that many demographic variables including age, job status, education, and marital status play important role in 10 workplace harassment. According to Brook and Perot (1991); Einarsen and Skogsted

(1996) older workers reported more experiences of harassment as compared to the younger staff. In contrast, the findings of Baker (1989), Bowling and Beehr (2006);

Coles (1986); Einarsen and Raknes (1997); Laymann (1996) Malik and Farooqi (2011 b)suggest that the younger employees are more vulnerable to workplace harassment.

Yet, DeCyper, Bailien and Dewhitte (2009); Hauge, Skogsted and Einarsen (2009) found no relationship between age and exposure to harassment.

Anila (1998) stated that less educated women reported more experiences of sexual harassment. Contrary to it, Colse (1986), Fain and Anderton (1987) and Martin

(1994) reported that highly educated women experience more harassment. Anila

(1998) further found that the women working at lower job status reported more harassment than those working at high status job. Fitzgerald and Ormerod (1993) and

Gutek (1985) found relationship between marital status and sexual harassment. They found that the unmarried or single and younger female employees reported more experiences of sexual harassment and workplace harassment.

1.2. Harassment in Healthcare Sector

Zapf, Esćartin, Einarsen, Hoel and Vartia (2011) found higher risk of being harassed for public sector in social, health and education departments. Laymann and

Gustafsson (1996) reported high prevalence of harassment in public administration of social and health sectors (Niedle, 1995; Piirainen et al. 2000; Vartia 1996). Caverley

(2005) proposes that bullying and harassment occur in public sector work settings due to the pressure caused by ―… continually shifting performance expectations and media/public scrutiny‖ (p. 401).

Wells and Bowers (2002); Zernike and Sharpe (1998) describe health sector as a suitable background for study of workplace harassment because violent behavior 11 and mistreatment in the hospitals take place all through the healthcare sector. Quine

(1999) found 38% prevalence among 1100 employees of National Health Service in

UK. Whereas, Hoel, Sparks, and Cooper, (2004) indicated that 25 % prevalence rate in employees of International Labor Organization in UK. Einarsen and Skogstad

(1996) reported in a mata analysis that 8.6% of employees had experienced harassment in Norway in Finland, Vartia (1996) reported that 10.1% of employees supposed, that they are victims of harassment. DiMartino (2003) reported the results of an International study of workplace violence in Health Care Sector. The findings indicated that violence reported in Bulgarian health sector was 30.9 % , In South

Africa 20.6 %, in Thailand 10.7 % and in Portugal 23 %. The findings further showed that 22.1 % violence was reported in Lebanon, 10.5 % in Australia and 15.2 % in

Brazil. Whereas, sexual harassment occurrence was 0.8 % in Bulgaria, 2.3 % in

Lebanon, 1.9 % in Thailand, 1 % in Portuguese and 4.6 % in South Africa.

Salin (2001) found that harassment is more frequent in public sector than in private sector probably because of the management style ― … the restructuring of the public sector in the 1990s may partly explain this, as downsizing and increased demands for efficiency and profitability may have contributed to increased stress, frustration, and insecurity. In addition, bureaucracy and the difficulties in laying off employees with permanent status may increase the value of using bullying as a micro- political strategy for circumventing rules, eliminating unwanted persons or improving one‘s own position‖ (p.435).

Farooqi (1997) reported, ―…harassment in the medical profession can be linked to Pakistani women‘s traditional non-professional role resulting in men‘s tendency to regard women as token participants rather than equally responsible and productive colleagues. Some observers believe that it may be that the majority of the 12 traditional Pakistani men are simply slow to accept women being in jobs, although medical, legal, and other professions have seen an influx of women since the late eighties. It may be argued that macho tradition of the administrative hospital settings could further contribute to the high levels of harassment reported by young Pakistani female doctors‖ (p.32).

Thus, it may be inferred that the nurses, medical students and young/junior residents are vulnerable to sexual harassment (De Martino, 2003). Bronner, Pertez and

Ehrenfeld (2003); Carr and Kazanowski (1994); Cheema et al. (2005); Farell (1999);

Newbury-Birch and Kamali (2001); and Ouine (2001, 2002) reported sexual harassment as a serious problem at workplace which affect 30-70 % nurses. Mayhew and Chappell (2001) argued that nurses might be more susceptible to harassment due to three reasons: they are female; physicians or administrators might harass them, and they might perceive themselves comparatively powerless. Harassment is critical problem in the health sector due to its possible effects on general health of staff, protection and care of patients (Firth-Cozens, 2001; Hicks, 2000; Paice, Aitken,

Houghton & Firth-Cozens, 2004).

1.3. Consequences of Harassment

Workplace harassment can have a variety of physical and psychological effects on employees; such as general stress, insomnia, mental stress, self-hatred, suicidal ideation, low self-esteem, lack of concentration and reduced self-confidence

(Einarsen & Mikkelsen, 2003; Niedle, 1996; and Thylefors, 1987).

Jenson and Gutek (1982) suggested that effects of workplace harassment could be measured within three domains, which include psychological wellbeing, somatic/physical wellbeing and job related behaviors including attendance, morale 13 and performance. Loss of motivation and distraction are also included in the negative consequences of harassment.

Gutek and Koss (1993) stated that the extent of emotional, physical and psychological damage that a woman experiences from workplace harassment in work situation also depends on the responsiveness of other people and the organization for which she works. Women suffer both the negative consequences of harassment itself and long-term damage to their career prospects. Crull ( 1982); Gutek (1985); Loy and

Stewart (1984); Salisbary, Ginorio, Remick and Stringer (1986) reported that protracted persistent experiences of sexual harassment may produce severe emotional tension which further cause many symptoms in the target person. According to

Culberston, Rosenfeld, Booth-Kewely and Magnusson (1992) sexual harassment also have an effect on women‘s organizational commitment and job satisfaction. Sexual harassment has costs for the employer as it reduces job satisfaction and increases turnover (Gutek, 1985; Fitzgerald & Ormerod, 1993; Kauppinen-toropainen &

Gruber, 1993).

According to Mikkelsen and Einarsen (2002), experiences of workplace bullying harmfully influence the health and well-being of the victim. The victims of workplace harassment often report anxiety, depression, sleep problems, somatic problems, lack of concentration, irritability, nightmares,low self-esteem and self hatred (Adoric & Kvartuc, 2007; Baruch,2005; Bilgel, Aytac & Bayram, 2006;

Björkqvist et al.,1994; Bowling & Beehr, 2006; Einarsen & Raknes, 1997; Einarsen,

Raknes, Matthiesen & Hellesøy, 1996; Hansen et al., 2006; Kaukiainen et al., 2001;

Kile, 1990; Leymann, 1990, 1996; Malik & Farooqi, 2011a; Niedl, 1996; Vartia,

1996; and Zapf, Knorz & Kulla, 1996). 14

Dansky and Kilpatrik (1997); Kilpatric, Dansky and Saunder (1994) Gutek and Koss (1993); Jorgenson and Wahl (2000) and MacKinnon (1979) reported that the victims of sexual harassment might experience physical and psychological problems. Physical problems include insomnia, headaches, digestive problems, neck and backaches, weight loss, gastrointestinal and dental problems, whereas psychological problems include irritability, anxiety, depression, guilt, fatigue, anger, confusion, denial, isolation, uncontrolled crying, shame and embarrassment.

Dansky and Kilpatrik (1997) argue that the female victims of sexual harassment and workplace harassment are significantly more vulnerable of developing posttraumatic stress disorder. There is sufficient empirical evidence that suggests similarities between symptoms of PTSD and the after-effects of workplace harassment (Hamilton & Dolkart, 1991; Jensvoled, 1991; Koss, 1990; Mikkelsen &

Einarsen, 2002). Therefore, the present research focuses on the symptoms of posttraumatic stress as a reaction to workplace harassment (both sexual and general).

In the following section the author will be discussing posttraumatic stress symptoms.

1.4. Posttraumatic Stress Symptoms

In the current research posttraumatic stress symptoms (PTSS) are defined in terms of three groups of symptoms, which include re-experience of traumatic event, avoidance of the stimuli, and hyper-arousal in the victims who are exposed to any traumatic events such as workplace harassment. Thus, PTSS is defined differently from PTSD in the current research; because it does not fulfill all the criteria for PTSD as cited in DSM-IV TR (APA, 2000).

According to the DSM-IV TR criteria (APA, 2000) for the diagnosis of

PTSD; the person must report exposure to an extreme traumatic event (Criterion A1); the person‘s reaction to any traumatic events must involve extreme fear, vulnerability, 15 or fear (Criterion A2); persistently re-experience the traumatic event (Criterion B); person constantly avoid the associated stimuli (Criterion C); persistent hyper arousal or provocation (Criterion D). furthermore, persistence of symptoms for more than one month. (Criterion E), significant impairment in functioning of the target person‘s life

(Criterion F).

Mikkelsen and Einarsen (2002) found that victims of workplace bullying might suffer from PTSD. Dansky and Kilpatrick (1997) reported that victims of sexual harassment frequently meet the symptoms criteria of PTSD. Moreover, psychosocial stress caused by workplace harassment may produce full spectrum symptoms of posttraumatic stress symptoms even in the absence of single severe and striking trauma (Scott & Stradling, 1994).

According to Fitzgerald (1992) victimized women exhibited common cognitive and emotional after-effects similar to the victims of post- traumatic stress syndrome (PTSD) which include headaches, gastrointestinal disorders, weight loss or gain, sleep disturbance, nausea sexual dysfunction, depression and anxiety.

Furthermore, prior research findings suggest that repeated exposure to several traumas such as workplace harassment increase the vulnerability to develop PTSD in the target person (Brewin, Andrews & Valentine, 2000). Dansky and Kilpatrick (1997); Golmb,

Munson, Hulin, Bergman and Drasgow (1999) reported that sexual harassment can produce symptoms of PTSD in almost a third of its targets. The psychological effects may increase due to the factors related to harassment such as investigation of the harassment, gossip related to the issue and financial problems (Avina & O‘Donohue,

2002; Gutek, 1985).

Matthiesen and Einarsen (2004) reported that very few researches have been conducted to explore the relationship between workplace harassment and PTSD 16 which may suggest methodological lmtations of the researches in the field of PTSD and harassment. Avina and O‘Donohue (2002) argue in their theoretical paper that more severe forms of sexual harassment (sexual or physical attack) clearly meet the diagnostic criteria of PTSD. They further argue that even the less severe forms of sexual harassment may also meet this criterion because sexual harassment affects the financial wellbeing, personal limits, control of situation and even the physical integrity of the person.

1.5. Theoretical Framework3

1.5.1. Theories of Workplace Harassment

Historically, diverse theories have been proposed to explain workplace harassment (general and sexual harassment) based on research findings, court cases and legal defenses (Tangri, Burt & Johnson, 1982). Among these diverse theories are: natural/biological model, organization theory, socio-cultural model and sex-role spillover theory. i. The Natural/Biological Theory

The natural/biological interpretation explains sexual harassment just as sexual attraction because men have a stronger natural desire of sexual aggression, therefore, such type of sexual behaviors are not intended as harassment (Barak, Pitterman, &

Yitzhaki, 1995). These researchers further explain sexual harassment as natural, a male‘s stronger desire for sex, common magnetism between men and women and men‘s role as stronger sex initiators. It argues that men have stronger sex drive and express it in workplace when women are around (Tangri & Hayes, 1997). This theory accepts the existence of the problem but holds the position that it has no negative consequences. This explanation decreases the importance of sexual harassment as a 17 problem while at the same time admitting it as a natural phenomenon anticipated to be in the workplace (Tangri et al., 1982). ii. The Organizational Theory

The Organizational theory assumes that workplace harassment may be result of expressions of the workplace infrastructure such as power and status inequalities that provide opportunities for harassment (Tangri et al., 1982). People in higher position may use their authority of promotion and termination – which is considered legitimate in an organizational context to coerce their subordinates, who are usually women, into engaging in unwanted sexual relationships (Nieva & Gutek, 1981;

Tangri et al., 1982).

The customary pattern in western society shows that men typically are more powerful than women are. Moreover, the existing gender stereotypes which describe men as more influential, more ambitious, goal directed and aggressive, whereas, women as inactive, submissive and family oriented may support these prevailing patterns of workplace harassment (Eagly, 1987; Eagly & Mladinic, 1989; Eagly

&Wood, 1982; and Pina, Gannon & Saunders, 2009).

Cleveland and Kerst (1993) argue that the individuals with high status are considered to have right to make demands on those in lower positions and harassing attitude might be a result of that right and the people in lower positions are expected to follow them. They further posit that sexual harassment at workplace might be an attempt to get more authority. According to Einarsen and Skogsted (1996), male dominated industries and organizations with many employees had the highest prevalence of victimization during the last six months.

According to power theory, power differences facilitate sexual harassment.

However, some other factors in an organization such as gender ratio, organizational 18 environment, policies, rule and morals also increase the likelihood of sexual harassment (Dekker & Barling, 1998; Fitzgerald, Drasgow, Hulin, Gelfand, &

Magley, 1997; Gutek, 1985; Gutek & Morasch, 1982; O'Hare & O'Donohue, 1998;

Pina et al., 2009; Whaley & Tucker, 1998; Willness, Steel & Lee, 2007). Researches show organizational climate as the strongest predictor of sexual harassment

(Fitzgerald et al., 1995; & Drasgow, 1999; Pina et al., 2009; Welsh, 1999; Williams,

Fitzgerald). iii. The Socio-Cultural Theory

The origin of this theory is feminist in orientation and it examines the social and political situations in which harassment particularly sexual harassment takes place. Matchen and DeSouza (2000) argued that the feminist standpoint associate sexual harassment to male domination and power. This theory focuses on power differences of men and women and the motivation of men to maintain their dominance. Thomas and Kitzinger (1997) state that existing gender inequality and sexism creates sexual harassment in a society.

MacKinnon (1979) describes that sexual harassment is a mechanism for developing beliefs, attitudes and behaviors, which disgrace women because of their sex and sustain male dominance. Moreover, women‘s inferior position at workplace and in society is not only a result but also a source of sexual harassment. According to this interpretation, sexual harassment manages male-female interaction according to the accepted norms of the society and thus, maintains the status quo by humiliation, intimidation and degradation of women (Tangri et al., 1982). Whaley and Tucker argue that sexual harassment is an unavoidable consequence of cultural experiences.

Vaux (1993) presented another power-based socio-cultural explanation of sexual harassment as ―an instance of moral exclusion, whereby members of a relatively 19 powerful group conduct their lives in their own interest, sometimes at the expense of a relatively less powerful group, in such a way that any harm is denied, diminished, or justified‖ (p.132).

Socio-cultural theory is a synthesis of gender issues, patriarchal ideology and dominance to explain sexual harassment, which brought the issue of harassment in light (Pina et al., 2009). The previous studies show that most of the perpetrators were male and mostly harassment occurs in male dominated workplaces (European

Commission, 1998; Gruber, 1992; LaFontaine & Tredeau, 1986; Tangri et al., 1982;

Niebuhr & Boyles, 1991). iv. Sex Role Spillover Theory

Gutek (1985) proposed Sex Role Spillover Theory that integrates both situational and individual factors to explain the effects of sex-role expectations in an organizational context. Gutek & Morasch (1982) argue that this phenomenon occurs because in most cultures gender identity is more important than work identity.

According to Statt (1994), women are generally categorized by their biological sex characteristics. Eagly and Mladinic (1989) argue that women are often considered as passive–receptive, interpersonally oriented, and incompetent outside of the home in a traditional patriarchal society.

Gutek and Morasch (1982) describe sexual harassment as a result of isolation of women in male dominated jobs and males grudge about women in a particular job.

Sexual harassment by male colleagues can be seen as attempt to preserve their dominant status, which is threatened by professional women (Dall & Maass, 1999;

Rosenberg, Perlstandt & Phillips, 1993). According to Gutek and Morasch (1982) women in workplace are expected to behave according to traditional sex expectations that they are more submissive; nurturing; kind and faithful as compared to men at 20 workplace. The nontraditionally employed women are viewed just as a woman rather than a worker and they report more sexual harassment than women in traditionally female jobs do. v. Four-Factor Theory

O‘Hare and O‘ Donohue (1998) proposed the four-factor theory; it is a multifactor theory of sexual harassment that synthesize key points of different previous theories (Pina et al., 2009). O‘Hare and O‘ Donohue (1998) theorized that four conditions such as individual‘s motivation to harass; individual must overcome internal restrains; lack of external inhabitants; and overcome victims resistance. They further hypothesized that those women who considered themselves as more physically good-looking, extra feminine and less powerful would report more occurrence of harassment. Furthermore, they hypothesized that women who have more privacy and work in an equal ration work environment would show less harassment (Pina et al.,

2009). They further reported that four factor theory gave a better justification of harassment as compared to any single factor theory. Furthermore, it was found that sexiest environment, unprofessional workplace and poor knowledge about complaints procedure were the most frequent the predictors of harassment.

1.5.2. Theories of Posttraumatic Stress Symptoms

Theoretically, posttraumatic stress symptoms (PTSS) have been explained differently by learning theory, psychodynamic theory, cognitive theory and biological theory. According to learning theory, posttraumatic stress symptoms may be the outcome of classical conditioning of fear. Based on this rationale classically conditioned fear and avoidance are built up. Consequently, they are negatively reinforced by the reduction of fear that comes from not being in the presence of conditioned stimulus (Davison & Neale, 2001). 21 i. Psychodynamic Theory

A psychodynamic theory proposed by Horowitz (1990) stated that the painful

memories of traumatic event constantly come in the person‘s mind and the individual

tries to suppress them either through conscious distraction or through repression. The

person continuously engages in an internal effort to integrate the trauma into his/her

beliefs and attitudes about himself or herself and the world. Horowitz (1986) used the

term completion tendency for this particular psychological process, which reflects the

psychological ―need to match new information with inner models based on older

information, and the revision of both until they agree‖ (Horowitz, 1986; p. 92). ii. Cognitive Theory

The two most prominent cognitive notions of trauma reaction and

revitalization emphasize the significance of person‘s beliefs about the self and the

world (McCann & Pearlman, 1990) or the system of associations linking thoughts of

the traumatic incident to emotional, cognitive, physiological and behavioral reactions

of the individual (Foa & Rothbaum, 1998).

Ozer and Weiss (2004) argued that in the beliefs and linked emotions

formulation, a traumatic event shatters the prior postulation that though that though

world is an insecure place but this insecurity has an effect on other people only. They

further stated that assimilation of these shattered assumptions must be acclimatized

with person‘s beliefs about world to make sense of and integrate the event. This

process develops symptoms of intrusion and escaping, which are painful because the

victim has to remember the traumatic event and the associated pain. Improvement

takes place slowly when the victim could be able to tolerate this iterative process

without avoidance. Ozer and Weiss (2004) further concluded that the factors such as

individual‘s characteristics, environment, and the event that lessen the probability of 22 effectual assimilation and adaptation would supposedly enhance the probability of

PTSS.

The network theory (Foa & Rothbaum, 1989) describes associated information about the trauma and subsequent cognitive, emotional, physiological, and behavioral reactions. Bower (1981) stated that network theory describes how different parts of information can trigger each other and direct to the development of affect. Ozer and

Weiss (2004) stated that recovery take place by reducing the influence of links among network pieces through desensitization and by replacing more adaptive links. iii. Biological Theory

Bremner, Southwick and Charney (1991) focused on the amygdale and hippocampus which play critical part in fear response, learning and memory. They further focused on the hypothalamic-pituitary-adrenal (HPA) axis that organizes acute stress reactions. The amygdala also sends information regarding odors and other hazardous stimuli to the hippocampus. Hippocampus anatomically contiguous to the amygdala records the spatial and temporal dimensions of experience in memory as the hippocampus is very important for short-term memory (Ver Ellen & Van Kammen,

1990). Brende (1982) measured the electodermal responses of veterans to olfactory stimulants and concluded that dysfunctional cerebral laternalisation may be responsible for some of the PTSD symptoms, such as hypervigilance, intrusive images, and psychological numbing. According to Ozer and Weiss (2004), traumatic events typically produce fear and fear instigates the ‗flight or fight‘ therefore, the physiological stimulation linked with the hyper arousal symptoms of PTSD.

The HPA axis control and handle stress-related hormones in danger (Ozer &

Weiss, 2004) and evidence shows dysregulation in the activity of cortisol in individuals with PTSD (Yehuda, 1997). 23

Theories of workplace harassment and PTSS contribute another level of our understanding and all of them taken together probably account for most of the variation in incident, type, severity and consequences of workplace harassment and

PTSS.

1.6. Review of Literature

This section will review relevant researches in the field of workplace harassment and posttraumatic stress symptoms. Moreover, the terms harassment, bullying, psychological harassment and mobbing will be used interchangeably.

Bilgel et al. (2006) conducted investigated the prevalence of reported workplace bullying and its effects on health of the bullied. A bullying inventory

(Quinn, 1999) consisted of 20 items was used to assess bullying. The Job Induced

Stress Scale, The Hospital Anxiety and Depression Scale, Job Satisfaction Scale and the Propensity to Leave Scale were also used to assess the potential effects of bullying. 877 questionnaires were analyzed and found out that 55% of the participants were exposed to bullying and 47 % witnessed the bullying of others. In addition to these findings, significant differences for job satisfaction, anxiety, depression, and work related stress were found among the bullied and none bullied employees.

Vartia (2001) investigated the impact of bullying at workplace and the psychological work setting on the wellbeing of 949 victims and witnesses of bullying.

The sample was composed of 85% women with mean age 40 and 15% men with mean age 41 years for. The findings revealed that both the targets and the witnesses reported more general and mental stress responses as than respondents with no bullying did. Results further suggested that the targets expressed low self esteem and excessive use of sedatives and sleeping pills. 24

Einarsen and Rakness (1997) explored the prevalence of workplace harassment in industrial organization. The sample was consisted of 500 males; results showed that 89% employees experienced some type of harassment at some stage in the last six months. On a weekly basis, 7% of the men reported that they experienced at least one of the subsequent behaviors from their bosses or colleagues such as insulting comments, scorn, verbal mistreatment and insulting teasing, offending statements, rumors, social exclusion, violent behavior, refusal to talk, or .undervaluing of one's work. 22% of the participants reported experiences of one or more of these acts at least once a month. Einarsen and Rakness (1997) concluded that bullying seemed to be highly embedded in that culture, rather become a common phenomenon.

Moreno-Jiménez, Muñoz, Salin, and Benadero(2008) explored the existence and types of bullying in 103 Spanish employees. They further identified the risk group by examining several socio-demographic and work situation factors. Bullying at

Work Questionnaire was used to collect the data. The results suggested that respondents reported substantial experiences of bullying. Moreover, the results highlight the significance of different demographic variables; such as gender, education, nature of contract and work experience in the bullying process.

Hauge, Skogstad and Einarsen (2007) studied both situational and individual factors as predictors of being the person responsible for workplace bullying by focusing on Spector and Fox‘s (2005) stressor-emotion model of counterproductive job behavior. Sample was consisted of 2359 Norwegian workforce. Logistic regression analysis was used. Results suggested that victimization or bullying and gender are the strong predictors contributed in bullying of others. In situational factors, role differences and interpersonal clashes considerably predicted being a initiator of bullying. 25

Ohse and Stockdale (2008) investigated age comparisons in perceptions about workplace sexual harassment in a sample of 965 students and employees of a university. The results indicated a positive relationship between age and perceptions about workplace harassment. Results further suggested that student samples were found less susceptible to harassment than employees were.

Rutherford and Rissel (2004) explored nature and prevalence of workplace bullying the frequency, nature and extent of workplace bullying in a healthcare organization in New South Wales. Sample was consisted of 311 participants. A questionnaire was drafted specifically for that research. 50% (155) particpants reported experiences of one or more types of bullying during the last 12 months. The main source of bullying was colleagues (49%), clients (42%) and supervisor (38%).

Duncan et al. (2001) investigated violence in a sample of 8780 nurses from

210 hospitals in two provinces of Canada. The findings suggested that 46% had experienced one or more kind of workplace violence. The respondents reported frequency of different behaviors; such as 38% reported emotional abuse, 19% reported threat of assault, 18% reported physical assault, 7.6% reported verbal sexual harassment and 0.6% reported physical sexual violence 0.6%. Results further suggest that 70% victims did not report incidents of workplace violence.

Gerberich et al. (2004) investigated the extent and possible risk factors for violence in 6300 nuses during last 12 months. Response rate was 78%. The results suggested that patients (97%) and clients (67%) were perpetrators of physical and non-physical incidents. The findings of multivariate modeling indicated that nuses worked in intensive care units, nursing home, psychiatric or behavioral departments and with working in nursing home; in, psychiatric/behavioral or emergency 26 departments; and with elderly patients reported more incidents of both physical and non-physical violence.

Farrell, Bobrowski and Bobrowski (2006) studied workplace aggression among nurses in Tasmania, Australia. A specially constructed questionnaire was sent to all 6326 registered nurses. The response rate was 38% (2407). The findings of the study suggested that 63.5% respondents had experienced some form of aggression

(verbal or physical abuse. Main 63.5% were patients/ or their visitors pursued by medical and nursing colleagues. Results indicated that these experiences of physical or verbal abuse were the main source of distress in nurses and affected their desire to stay in nursing.

Madison (1997) explored the experiences of sexual harassment of 317 registered nurses. The results suggested that 197 respondents had experienced sexual harassment at workplace. A quarter of the nurses identified medical officers and

22%identified co-workers as their harassers.

Alexander and Fraser (2004) investigated the experiences of health professionals in Australia. The sample was consisted of 158 allied health workers, 135 doctors, and 1229 nurses. The results indicated that nurses experienced more occupational violence (68 %) than allied health providers (47%) and general practitioners (48%) for the duration of the last 12 months. findings further suggested that the of was verbal mistreatment, intimidation, insulting behavior and physical violence were the most frequently experienced forms of occupational violence .

Lemelin, Bonin and Duquette (2009) studied occurrence and types of workplace violence in a sample of 181 nurses. French translation of the Workplace

Violence Events Questionnaire was used. The results indicated that 86.5% of nurses reported incidents of violent behaviors on more than 1 time. Psychological violence 27 was reported by 86.4%, sexual violence reported by 30.7% whereas, 10.6% reported physical violence. Colleagues (65.9%), boss or supervisor (59.6%) and physicians

(59.1%) imposed violence.

Stebbing et al. (2004) conducted a research to investigate causes of stress and workplace bullying in 259 doctors. The results suggested a statistically significant relationship between those who would not proposed their post to a colleague and those who had trouble in organizing funds and in write up. Furthermore, dissatisfaction with the post, lack of support and guidance from supervisors and co- workers, desire to change the supervisors and major forms of workplace bullying were found to be significantly correlated.

Romito, Ballard and Matton (2004) investigated three forms of sexual harassment including gender harassment, unwanted sexual attention and sexual coercion among 265 female healthcare workers in Italy during the last 12 months. The results suggested that 42% participants had experienced at least one type of harassment from colleagues 29%.

William (1996) studied the occurrence and impact of sexual harassment and violence. 1130 nurses were randomly selected to participate in the mail survey. Nurse

Assault Survey developed by the nurses assault project team in Ontario, Canada and modified by the researcher was used. Response rate was 30%; only three hundred and forty five participants completed the survey. 26% reported experiences of physical assault at workplace. Patients and clients were the most frequent instigator of sexual harassment and physical assault while the physicians committed half of the sexual assaults. Bivariate analysis showed that sexual harassment was positively correlated with job satisfaction. 28

Hossen and Callaghan (2004) conducted a postal survey to investigate the experience and prevalence of bullying by psychiatrist doctors in West Midlands. The survey was consisted of two parts. Firstly, demographic information regarding age, gender, ethnicity, residential status and job position was collected. In the second part a questionnaire (Quine, 2002) was used to measure experiences and prevalence of bullying. Bullying behaviors were divided in 6 categories including job related threats; personal threats; isolation; overwork; undermining and racial/ gender discrimination. The findings indicated that 47% of the trainees experienced one or more bullying behaviors.

Scott, Blanshard and Child (2008) investigated frequency, nature and extent of workplace bullying in 373 junior doctors in Auckland. The questionnaire collected information about participants‘ age, gender, country, and nature of training. A table of

14 bullying behaviors was presented to participants and they were asked to identify whether they had experienced any of the behavior in last term. SAS was used for analysis and the results indicated that 58% of the doctors reported at least one episode of bullying behavior and that registrars under the age of 25 reported bullying more frequently as compared to those who were above 25. The findings further suggested that consultants and nurses were the main perpetrators and the most prevalent bullying behavior was unjustified criticism from consultants

O‘Hare and O‘Donohue (1998) conducted a study on risk factors of sexual harassment experienced by female teachers and students at a large Midwestern

University in the USA. They found that the unprofessional work setting, sexist environment and lack of knowledge about the complaint procedures of organization were the main risk factors, which were most strongly correlated with sexual harassment. 29

Barling et al. (1996) found that the sufferers of sexual harassment also experience the same sort of troubles related with other major workplace stressors such as lack of concentration, negative mood, and psychosomatic problems.

McKenna Smith, Poole and Coverdale (2003) found in a study on nurses that bullying might be linked to job experience. Brennan (1999) investigated the prevalence of different types of bullying among nurses and found that different types of bullying took place between these professional groups. Quine (2003) also investigated the occurrence of inter-professional bullying among junior doctors and found the nature of the bullying was different from that of McKenna et al. (2003) and

Brennan‘s (1999) research. It might be inferred that inter-staff bullying in student nurses might be different from bullying that occurs between senior nurses and junior nurses.

Hallberg and Strandmark (2006) investigated the perceived health consequences of workplace bullying. The interviewed 22 informants, 20 bully victims and two persons working with bullying prevention. Grounded theory methodology was used to analyze the data. A conceptual model related deteriorating psychological and physical health because of bullying and returning to normal life was presented. It was found that the persistent bullying reduce the chances to change or improve the situation because the target person has the possibility to change the situation and the victim has insufficient opportunity. They further found returning to a ‗normal‘ life possible.

Dansky and Kilpatrick (1997) conducted a survey of 3020 women, which provides prevalence data for sexual harassment in a nationally representative sample of women of whom 2720 had been in a job at some stage in in their lives. The data was collected by a random-digit-dial telephone survey. Measurement included 30 standard questions to assess both major depression and PTSD as defined by DSM-III

(R). Women who suffered from depression and PTSD and depression were more probably experienced sexual harassment than women who have never experienced

PTSD or depression which suggests that sexual harassment may cause PTSD or depression. Women who were diagnosed as having PTSD or depression reported more types of harassment than did employed women in general. 37% of the women, having PTSD and 31% of women at present suffering from depression reported that their supervisor told sex stories than 17% of the whole sample of employed women.

16% and 14% of women suffering from PTSD and depression respectively, compared to 8% women in general, said they were touched sexually by a supervisor, and 17% and 15% of PTSD and depressed women, respectively, compared to 6% of employed women in general, reported that they were kissed or fondled by a supervisor. Among those women who reported themselves being sexually harassed, women suffering from PTSD or depression appeared to have more negative beliefs about the effects of sexual harassment than the women who were not suffering from PTSD or depression.

Palmieri and Fitzgerald (2005) conducted a factor analytic research of the

PTSD. The sample was consisted of 1218 sexually harassed women at workplace and was involved in sexual harassment court case against a big financial firm. During survey, 42.2% women had settled their claim while 51.5% had not. The results indicated that considerable level of trauma exposure and posttraumatic symptoms were found in the sample. The Results further suggested positive correlation between posttraumatic stress symptoms and frequency of sexual harassment. Significant differences were found in trauma exposure and symptoms of posttraumatic stress symptoms based on the status of case-settlement. Those women who had not settled 31 their cases during data collection reported more sexual harassment and symptoms severity than those women who had already settled.

Balducci, Fraccaroli and Schaufeli (2011) investigated work-environmental and personality and factors as the antecedents of bullying and posttraumatic stress symptoms. The sample was consisted of 609 public sector employees in Italy. The results indicated that both the work-environmental and personality factors were personality and work-environmental factors were associated to bullying; though personality was not found to be a sufficient factor for understanding bullying. The results further suggested that there was strong relationship between bullying and

PTSD symptoms.

Matthiesen and Einarsen (2004) investigated symptoms of PTSD among 102 victims of bullying (74% were women). Results indicated that 64% of the participants had experienced bullying during last 2 years. The victims showed more score of

PTSD as measured on Revised Impact of Event Scale and Post-Traumatic Stress Scale than three comparison groups of parents of schoolchildren involved in a fatal bus accident, UN personnel returned from one war zone and medical students.

Furthermore, majority of the victims surpassed suggested threshold of PTSD, however it was also found that symptoms seemed to be disappeared with the passage of time.

Tehrani (2004) examined the type and impact of bullying in 165 healthcare professionals. The results indicated that 40% had experienced bullying and 68 % had witnessed in a period of 2 year The findings further suggested that among 67 healthcare professionals who had experienced bullying 44 % reported high levels symptoms of PTSD. 32

Nielsen, Matthiesen and Einarsen (2005) investigated symptoms of PTSD among 199 members of two organizations and found that 84% had experienced bullying when measured on IES-R scale. These findings were more than previous findings of studies of victims of other traumatic events. The findings further showed that among women 65%-75% had PTSD.

Abbas, Fiala, Abdel Rahman and Fahim (2010) studies a extent, nature and frequency of workplace violence against nurses in Egypt. Furthermore, they explored the risk factors and how nurses managed workplace violence. A questionnaire for data collection was used to collect information about demographic data, characteristics of workplace violence events, and risk factors contributing to workplace violence.

Sample consisted of all the nursing staff in four hospitals and twelve Primary Health

Care (PHC) Centers, randomly selected from Ismailia. Out of 1600 distributed questionnaires, completed 970 questionnaires were returned (55% response rate). The findings indicated that 269 (27.7%) of nurses reported abuse of any kind, 187 (69.5%) verbal abuse; and 25 (9.3%) physical abuse. No significant differences were found between married or unmarried (34.8% vs 31.2%, respectively). The results further revealed that changing shifts to night time had a higher risk for being assaulted than working a morning shift and working in a place crowded with colleagues was not protective and had a higher odds of being exposed to violence than working with low number of colleagues.

Celik, Celik, Ağirbaş and Uğurluoğlu (2007) explored the verbal and physical violence in 622 nurses in Turkey. Verbal and physical abuse questionnaires were administered individually to the participants. The results suggested the prevalence of verbal mistreatment was 91.1% and physical 33.0%. It was also found that colleagues were the most significant source of verbally insulting behaviors. Results further 33 indicated nurses reported various negative effects of verbal and physical violence at workplace including low job performance, headache and poor mental health.

Yildirim (2009) explored the effects of workplace bullying in 286 female nurses in Turkey. The questionnaire was categorized in five parts including demographic information, psychologically aggressive behaviors, depression, work burden and organizational effects. The results suggested that 73% nurses had never experienced workplace bullying during the 12 months, whereas, 21% of the nurses had experienced these behaviors. No differences were found between level of education and job status in workplace bullying. The findings further suggested that workplace bullying might cause low job motivation, concentration problems, depression, low work commitment, low productivity and poor interpersonal relationships in workplace.

Celik and Celik (2007 identified the existence and causes sexual harassment in nurses. Sample was consisted of 622 nurses. A self-constructed sexual harassment questionnaire related to socio-demographic characteristics, different kinds of sexual harassment, causes and cope behaviors with sexual harassment was used. The results indicated that 37.1% nurses experienced sexual harassment primarily by physicians.

The nurses reported poor work performance, troubled mental health and headaches as the common negative effects of sexual harassment.

Yildirim and Yildirim (2007) studied the experiences of mobbing and its emotional, social and physiological effects on the nurses in healthcare facilities in

Turkey. The sample was consist of 505 female (325 (64%) from public and 180

(36%) from private hospitals). A self-constructed questionnaire consisted of four parts including information about demographic variables, mobbing behaviors, response to mobbing incidents and actions to avoid mobbing was administered for data 34 collection. Findings suggested that 86.5% of the nurses reported mobbing experiences during last 12 months. The nurses in private hospitals reported more mobbing behaviors than those work at public hospitals. The results further indicated that the most common behaviors to avoid mobbing were hard work and more organized and careful work behavior to avoid criticism.10% of the participants reported that they have suicidal ideation.

Kisa and Dziegielewski (1996) investigated sexual harassment in 229 female nurses in Turkey. The translated survey questionnaires related to experiences of sexual harassment during nursing practice were distributed to selected 229 nurses.

The results suggested that 75% of the respondents reported experiences of sexual harassment. The participants reported sexual messages, comments, jokes and pressure for dates as most common forms of sexual harassment. The main sources of harassment were physicians (44%), patients (34%), and relatives of patients (14%).

The results further indicated significant relationship between sexual harassment of nurses and in outpatient or inpatient clinics.

Kwok et al. (2006) studied the prevalence and nature of workplace violence against nurses in University teaching hospital, Hong Kong. 420 nurses returned the completed questionnaire so response rate was 25%. 76% (320) nurses reported verbal abuse, 73%; bullying, 45%; physical abuse, 18%; and sexual harassment, 12%. 82% of the nurses shared their experience with friends, family members, or colleagues.

42% reported that they ignored the incident.

Lin and Liu (2005) studied the prevalence of workplace violence committed by patients and their family members against healthcare workers in south Taiwan.

Sample was consisted of 205 nurses from a medical facility in south Taiwan. The results indicated that 62% of the nurses reported experiencing workplace violence. 35

The majority of the cases consisted of verbal abuse including threats of violence or threatening words from patients or families.

Kamchuchat, Chongsuvivatwong, Oncheunjit, Yip and Sangthong (2008) investigated the workplace violence against nursing staff,. Survey and interviews were used at to collect data from general hospital in southern Thailand. The findings suggested that the nurses reported verbal abuse 38.9%, physical abuse 3.1% AND sexual harassment 0.7% during last 12 months The main perpetrators in physical and verbal abuse where as colleagues were found to be the main perpetrators in sexual harassment. The results logistic regression analysis indicated that younger nurses were more vulnerable. Results further reported that working in trauma and emergency unit, outpatient unit, medical or surgical unit and operating room increased the chances of violence by 80%.

Chen, Hwu and Wang (2009) investigated the responses of 222 healthcare workers at a psychiatric hospital in Taiwan including nurses, assistant nurses and clerks towards workplace violence and treatment of aggressive patients. The results suggested incidents of physical violence (78), verbal abuse (113), bullying (35), sexual harassment (21) and racial harassment (10) during one year. Among staff, 31% had experienced physical violence and less than 10% of had experienced other categories of violence. The findings further revealed that most of the victims of verbal abuse did not consider the incident essential to report

Chuang and Lin (2006) explored the rates of sexual harassment among nurses.

The purposive sample of 307 nurses was drawn from six teaching hospitals of

Taiwan. The results showed that 175 (57%) participants reported experiences of sexual harassment at workplace. Moreover, the rate of recurrence of verbal sexual 36 harassment was 55.7%; non-verbal sexual harassment was 40.1% and physical sexual harassment was 39.1%.

Takaki et al. (2010) investigated role of workplace bullying in relationships between job strain and symptoms of depression and sleep disturbance. The sample consisted of 2,634 workers from 50 organizations in Japan. The Japanese versions of the Job Content Questionnaire, the Negative Acts Questionnaire, the Center for

Epidemiologic Studies Depression Scale, and the Pittsburgh Sleep Quality Index were used. The results indicated statistically significant positive effects of job strain index on depression or sleep disturbance in both genders. The findings further suggested significant positive mediation effects of workplace bullying.

Chaudhuri (2007) conducted a study to explore the experiences of sexual harassment among working women in health sector. The sample was consisted of 135 doctors, nurses, healthcare attendants, administrative and other non-medical staff from

2 government and two private hospitals in Kolkata, India. The results suggested that

77 women experienced 128 incidents of sexual harassment; such as psychological harassment (45), verbal harassment (41), unwanted touch (27) and sexual gestures and exposure (15). The results further indicated that none of the female healthcare worker reported rape or attempt of rape but most of them knew their colleagues who had experienced these. Women were found to be reluctant to complain due to their job insecurity or fear of being stigmatized.

Lone, Lone, Amin, Nawaz and Lone (2009) studied junior doctors in training working in various hospitals of Kashmir to find out the prevalence of bullying.

Convenient sample strategy was used to draw the sample of 96 junior doctors. A self- constructed questionnaire including was used. Furthermore, basic information about participants‘ age, sex, job grade and specialization were also collected. Results 37 indicated that 56% junior doctors reported experiences of bullying the past six months, whereas, 82% had observed bullying of others. Furthermore, the female doctors reported more experiences of bullying (39%) than male doctors (17%).

Iqbal and Kamal (2001) explored the difference in sexual harassment experience among Ground and Air-hostesses of an airline. The sample consisted of 60 women. The findings indicated that the most frequent type of sexual harassment among the working women was gender harassment, which included appreciation of dresses, face, makeup or hair, gazing, evocative songs or jokes and using pornographic material; such as videos and magazines. The women also reported unwanted sexual attention, which included discussions of personal and sexual matters, requests for dates, attempts to establish romantic relations, touch or fondle, obnoxious calls and rape. The least common was sexual coercion. The findings also indicated that there is no significant difference in sexual harassment experience between two groups regarding different variables, although all women had experiences of sexual harassment at one time or other.

Anila (1998) studied women's experiences of sexual harassment at the workplaces, its effects on harassed female workers and the coping strategies used by them. The sample was consisted of 205 women working with male bosses, colleagues, and subordinates. Sexual Harassment Experience Questionnaire (SHEQ), Coping with

Harassment Questionnaire (CHQ), Personal Strain Questionnaire (PSQ) of

Occupational Stress Inventory, and a demographic Information sheet which collected information on age, job status, education, organization, marital status and reasons for doing job were individually administered. The results showed positive relationship among different demographic variables and sexual harassment. The findings further suggested that experiences of sexual harassment at workplaces affect working women 38 in terms of vocational, psychological, interpersonal, and physical strain. The women who experienced more sexual harassment used more externally focused coping approaches than to intern ally focused coping strategies.

Ahmer et al. (2009) conducted a research to investigate bullying of trainee psychiatrists in Pakistan. The sample consisted of 60 psychiatry trainees. The results suggested that 80% of the participants reported experiencing bullying behavior in the last one year.

Imran, Jawaid, Haider and Masood (2010) conducted a cross-sectional survey to examine the incidence of bullying at workplace among junior doctors. 654 junior doctors were selected from three different hospitals of two provinces of Pakistan. The results indicated that 67% (436) doctors witness bullying of others. Consultants (52%) were found the most common source of bullying. 73% (306) participants reported that they did not make complaint against bullying.

Ahmer et al. (2008) conducted a survey on 342 final year medical students in six medical colleges of Pakistan. 52% participants reported that they had been bullied or harassed whilst at medical college. The most common form of harassment was verbal abuse (57%). The students reported consultants were the most (46% of cases) perpetrators of bullying.

Gadit and Mugford (2008) conducted a pilot study to measure the types and degree bullying and harassment among psychiatrists. A yes/no response type questionnaire were developed and administered to a random sample of 60 psychiatrists. The results indicated that out of the 60 psychiatrists, 57 reported bullying and harassment. 40% of the participants reported rumors; defamation 20% ; passing remarks 20%; fake accusations 15%; intimidation 13.3%; verbal violence

13.3% (n = 8); baseless complaints 13.3% ; promotion blocked 13.3%; disgrace 13%; 39 and offensive comments were reported by 1.7%. Furthermore, 30% of the participants reported mild distress, 40% reported moderate distress and 11.7% reported severe distress.

Farooqi (1997) conducted a study of 100 female doctors on house job in

Pakistan, Results showed that 75% reported experiences of constant staring, obscene gestures, malicious whistling, provocative remarks, verbal threats, seductive behavior, body violence, unnecessary chasing, unwanted phone calls, sexual jokes or remarks and letters from their male colleagues in the hospital premises.

1.7. Rationale of the study

In the light of the above stated review of the literature and relevant researches, it may be argued that harassment and PTSS may be serious problems for Pakistani healthcare professionals probably due to the traditional patriarchal Pakistani society.

It may be argued that in a typical Pakistani society women do not feel themselves secure even in boundaries of their home and this feeling of insecurity remains with them throughout their life and in all domains. Especially at workplace, it is a crucial problem because its presence affects the working women‘s physical and mental health as evidenced by the studies quoted throughout this chapter.

In western countries, many researchers have been carried out on relationship between workplace harassment and posttraumatic stress syndrome; but in Pakistan, which has a quite different culture; this issue has not been thoroughly investigated. It is a common observation that an overwhelming number of working women who step out of their homes and go out for work, at some point in their life have been harassed and it occurs in all type of places, organizations and in all job levels (Pakistan

National Report, 1995). 40

Health sector is the most suitable setting for the study of workplace harassment in Pakistan. Though the intensity and level of harassment against female healthcare workers is mostly undocumented in Pakistani society, facts from developed countries suggest the occurrence of workplace harassment against working women in healthcare sector. The main reason of this could be the power inequity and susceptible working situation of women employees It may be due to the fact that majority of traditional Pakistani men are slow to accept women being in jobs. Pakistani women do not even know about their rights and/or national policies about workplace harassment. They seem to have accepted harassment an implicit part of life for their gender. It may be argued that the socialization process might have taught them to accept general workplace harassment and sexual harassment as an unpleasant fact.

Consequently, the suppressed feelings of humiliation and helplessness affect their mental health, as evident from relevant researches; victims of harassment at work may suffer from posttraumatic stress symptoms. The present research is planned to study this relationship.

As more and more women in Pakistan are stepping out into workplace, the issue of workplace harassment is getting increased importance to tackle. It has to be recognized as a real and crucial problem, which requires in-depth understanding. This research probed into workplace harassment with a focal interest to know the types and frequency of workplace harassment and its relation with degree of posttraumatic stress symptoms among Pakistani female healthcare professionals.

The findings of the current research would promote our understanding of workplace harassment and PTSS among doctors, house-job doctos and nurses in

Pakistani healthcare system in order to introduce timely and effective interventions as 41

well as preventive measures against workplace harassment in Pakistani healthcare

system.

The following model was proposed by the researcher:

Figure 1:

Hypothetical Model of Workplace Harassment and PTSS

Workplace Harassment Posttraumatic Stress Symptoms

DisorderDisorder

General Sexual Harassment Harassment

Demographics

Job Age Job Marital Monthly Educatio Duration Status Status Income n

1.8. Objectives

This research aimed at achieving the following objectives:

1. To investigate the frequency and type of workplace harassment reported by

the female healthcare professionals (doctors, house jobbers, nurses) in the

public hospitals of Lahore.

2. To find out the relationship between workplace harassment and PTSS among

working women; 42

3. To explore the impact of different demographic variables (such as age,

education, job experience, job status, monthly income and marital status) on

workplace harassment and PTSS reported by female healthcare professionals.

1.9. Research Hypotheses

In the light of the above-mentioned literature and relevant researches, the following research hypotheses were formulated:

1. More the workplace harassment (general and sexual harassment) greater the

posttraumatic stress symptoms would be reported by female doctors, house-

job doctors and nurses.

2. There would be positive relationship between workplace harassment (both

general and sexual) and posttraumatic stress symptoms among doctors.

3. More the workplace harassment (both general and sexual) the greater the

posttraumatic stress symptoms would be among female house-job doctors.

4. There would be positive relationship between workplace (both general and

sexual) harassment and posttraumatic stress symptoms among nurses.

5. Workplace harassment (general and sexual) would be the strongest predictor

of posttraumatic stress symptoms.

43

CHAPTER 2

METHODOLOGY

This chapter provides description of sample and sampling strategy, measures, procedure for data collection and statistical analyses.

2.1. Research Design

Survey research design was used in this research project because it was not possible for the researcher to manipulate the independent variable (workplace harassment which includes both general workplace harassment and sexual harassment) in order to determine its effect on the dependent variable that is posttraumatic stress symptoms. Farooqi (2010) argues that the survey research design is in fact a correlation strategy because it can only explore the possibility of any relationship between two or more than two variables.

Since ―…the research design is the program that guides the investigator in the process of collecting, analyzing and interpreting observations‖ (Farooqi, 2010, p.91); the survey research design was considered the most suitable design for the current research project to explore the relationship between workplace harassment and posttraumatic stress symptoms among Pakistani female healthcare professionals.

2.2. Sample and Sampling Strategy

According to Wells and Bowers (2002) harassment, hostility and mistreatment in the hospital settings is a common practice throughout the healthcare sector; therefore, in the current research project the Pakistani healthcare sector was selected to explore the relationship between workplace harassment and PTSS. In this research project, only female healthcare workers were included in the sample; because there is sufficient, research based empirical data that suggest that female workers are more at risk for workplace harassment and PTSD. The researcher selected all the non-teaching 44 public hospitals of Lahore city. Unfortunately, no statistically systematic data is currently available about Pakistani healthcare professionals, which could be used as the target population. Therefore, in the absence of the sampling frame, it was not possible to use any type of probability sampling technique. Another major methodological limitation was the tabooed and sensitive nature of the very topic under study. The fact of the matter is that the workplace harassment is a socially and culturally inhibited topic for women which is often under reported in the Pakistani society. Therefore, the researcher selected purposive sampling strategy for this research project. According to Farooqi (2010) in purposive sampling technique, the participants are selected on the basis of the predetermined inclusion criteria set by the researcher as was done in the current research project.

The researcher contacted a total of 437 female doctors, house-job doctors and nurses from five public hospitals of Lahore city who met the following inclusion criteria for inclusion in the research sample:

1. Age range from 20-59 years.

2. At least 1 year working experience as licensed doctors and nurses in a public

hospital of Lahore city approved by Pakistan Medical Council.

3. At least 1 month working experience for house-job doctors in a public hospital

of Lahore city after completion of MBBS degree approved by Pakistan

Medical Council.

4. Negative past history of mental illness.

5. Willingness to participate in the current research project without any coercion

or persuasion.

However, only 300 females (doctors = 100; house-job doctors =100; nurses =

1000) of the total 437 female healthcare professionals gave their written consent to 45

voluntarily participate in this research project and completed the task assign to them.

Therefore, the response rate was 69%; and the dropout rate was 31%. This ratio of

response rate and dropout rate (2:1) is satisfactory considering the sensitive and

socially inhibited nature of this research project.

The sample was drawn from five different public hospitals of Lahore city of

Pakistan (Mayo Hospital, Ganga Ram Hospital, Jinnah Hospital, Lady Willington

Hospital and Sheikh Zayed Hospital). The demographic characteristics of the sample

are given in Table 1.

Table 1

Demographic Characteristics of the Sample (N=300)

Female House Sample Nurses Doctors Job Doctors (N = 300) (n = 100) (n = 100) (n = 100) Characteristic f % f % f % f % Age 20 – 29 215 71.7% 59 59% 100 100% 56 56% 30- 39 51 17.0% 21 21% - - 30 30% 40 – 49 34 11.3% 20 20% - - 14 14% Education Matric 20 6.7% 20 20% - - - - F.A/Nursing 18 6.0% 18 18% - - - - B/sc/B.A 62 20.7% 62 62% - - - - M.BBS/FCPS 200 66.7% - - 100 100% 100 100% Monthly Income 15000-25000 167 55.7% 61 61% 100 100% 6 6% 26000-35000 133 44.3% 39 39% - - 94 94% Duration of experience < 1 year 101 33.7% - - 95 95% 6 6% 1 – 5 year 121 40.3% 52 52% 5 5% 64 64% More than 5 years 78 26.0% 48 48% - - 30 30% 46

Marital Status Married 131 43.7% 55 55% 21 21% 55 55% Unmarried 169 56.3% 45 45% 79 79% 45 45%

The distribution of the sample by hospital is given in Figure 2

Figure 2

Frequency Distribution of Sample from Different Public Hospitals of Lahore City

(N=300)

Mayo Doctors= 24 House- Nurses Freq=81 Hospital jobbers=38 =19

Ganga Ram Hospital Doctors= 19 House- jobbers=37 Nurses=8 Freq=64

Lady Willengton Doctors=14 House- Hospital jobbers =0 Nurses=26 Freq= 40

General N=300 Hospital

Gulab Devi Hospital

Jinnah Hospital Doctors=18 House- Nurses=21 Freq=61 jobbers =22

Services Hospital

Sheikh

Zayed Doctors=25 House- Nurses=26 Freq=54 Hospital jobbers =3

Note: The administration authorities of the hospitals named in gray blocks did not allow data collection

2.3. Instruments

The following instruments were used for data collection:

1. Demographic Information Form 47

2. Work Harassement Scale (WHS) by Björkquist, Osterman and Hjelt-Beck

(1994)

3. Sexual Harassment Experience Questionnaire (SHEQ) by Kamal and Tariq

(1997)

4. PTSD Civilian CheckList (PCL-C) by Weathers, Litz, Herman, Huska and

Keane (1993)

2.3.1. Demographic Information Form

Demographic Information Form was developed by the researcher in order to gather information about age, education, job status, monthly income, job experience and marital status of the research participants (copy attached in appendix B).

2.3.2. *Work Harassment Scale (WHS) by Björkqvist and Osterman and Hjelt-

Beck (1994)

Work Harassment Scale (WHS) is a copyrighted instrument to measure the workplace harassment of an individual. WHS was developed by Björkqvist, Osterman and Hjelt-Beck (1994). WHS consists of 24 items. Each item has five optional responses, which are scored on a 5-point Likert Scale, as follows:

Optional responses Scores

Never 0

Seldom 1

Occasionally 2

Often 3

Very often 4

* Copyright© by Kaj Bjrorkqvist, K Osterman & M. Hejlt-Beck (1994), Abo Akadeni University, Finland. Do not use without express written permission from Dr. Kaj Bjr;rkqvist as advised by Dr. Kaj Bjrorkqvist on August 19, 2008, 4.18 P.M vide his e-mail message to Sadia Malik, Doctoral scholar under the supervision of Dr. Yasmin Nilofer Farooqi (Tamgha-e-Imtiaz), Professor, Department of Applied Psychology, University of the Punjab, Lahore, Pakistan.

48

The respondents can obtain scores from 24-96 on WHS. Written permission was granted by the authors of WHS for its use in the current research project (copy attached in appendix D). Björkquist et al. (1994) reported that work harassment scale has high internal consistency with Cronbach‘s α =. 95. WHS was found to have high internal consistency with Cronbach‘s α = .93 in the current research project.

Therefore, it may be argued that WHS is a reliable and valid self-report inventory for assessment of general work place harassment in the Pakistani sample.

2.3.3. **Sexual Harassment Experience Questionnaire (SHEQ) by Kamal and

Tariq (1997)

Sexual Harassment Experience Questionnaire (SHEQ) is a copyrighted self- report instrument to measure the type and frequency of sexual harassment at workplace. SHEQ was developed by Kamal and Tariq (1997) and it consists of 35 items. According to Kamal and Tariq (1997) the seven items of SHEQ (1, 3, 5, 7, 10,

23, 25) measure gender harassment; twenty-one items (2, 4, 6, 8, 9, 11, 13, 14, 15, 16,

18, 19, 20, 21, 22, 24, 29, 31, 33, 34 and 35) measure unwanted sexual attention; and seven items (12, 17, 26, 28, 30, 32) measure sexual coercion. Each item has four optional responses which are scored on a 4-poitn scale, as follows:

Optional responses Scores

Never 1

Once 2

A few times 3

Very frequently 4

Copyright © Anila Kamal & Naeem Tariq‗s (1997) National Institute of Psychology, Quaid-e-Azam University, Islamabad, Pakistan. Do not uses without express written permission from National Institute of Psychology, Quaid-e-Azam University, Islamabad, Pakistan as advised by Dr. Anila Kamal on October 28, 2008, 10.34 P.M vide her e-mail message to Sadia Malik, Doctoral scholar under the supervision of Dr. Yasmin Nilofer Farooqi (Tamgha-i-Imtiaz, Professor, Department of Applied Psychology, University of the Punjab, Lahore, Pakistan. 49

The respondents can obtain scores from 35 to 140 on SHEQ. The higher scores on SHEQ indicate the higher frequency of sexual harassment experienced by the respondent.

The respondent‘s scores on SHEQ could be evaluated on three different dimensions based on the rationale underlying Gelfand, Fitzgerald and Drasgow‘s

(1995) three dimensional model of sexual harassment. Anila and Kamal (1997) and

Gelfand et al. (1995) argue that gender harassment; unwanted sexual attention and sexual coercion are the adequate types to categorize any specific incident of sexual harassment.

The first of category of gender harassment includes such type of verbal and non-verbal behaviors that express humiliating, aggressive and offensive statements about women such as taunts, display of pornographic material, threatens and intimidation (Gelfand et al., 1995).

Whereas, unwanted sexual harassment includes such verbal and non-verbal behaviors which are easily recognized as harassing, intimidating and coercive by most individuals. Furthermore, it may include repeated requests for dates, obnoxious calls and letters, touching and grabbing reported by the victims (Gelfand et al., 1995).

The third category of sexual coercion consists of such type of behaviors, which refers to direct or indirect bribe or threats for sexual cooperation. Gelfand et al.

(1995) further state that although these sorts of behaviors are more or less universally recognized as harassment; they are least commonly reported by the female workers.

Written permission was granted by the author (Anila & Tariq, 1997) to use

SHEQ in the current research project (copy attached in appendix E). Kamal and

Tariq‘s findings (1997) supported that SHEQ has significantly high reliability with 50

Cronbach‘s α = .94. In the current research project the SHEQ was found to have significantly high internal consistency with Cronbach‘s α = .95.

2.3. 4.**PTSD Checklist- Civilian Version (PCL-C) by Weathers, Litz, Herman,

Huska and Keane (1993)

PTSD CheckList-Civilian Version (PCL-C) was developed by Weathers, Litz,

Herman, Huska and Keane (1993) which measures level of PTSD of an individual.

PCL-C has three versions; i) military (M); ii) civilian (C); and iii) specific stressful experience (S). PCL-C is useful because it can be used with general population including adolescents, adults and elderly people (Weathers et al., 1993). Therefore,

PCL-C can be used as a measure of PTSD symptom severity by summing scores across the 17 items (Weathers et al., 1993). Each item has five optional responses which are scored on a 5-point Likert Scale, as follows:

Optional responses Scores

Not at all 1

A little Bit 2

Moderately 3

Quite a bit 4

Extremely 5

The respondents may obtain scores from 17 to 85. The highest score on this checklist indicates highest level of posttraumatic stress symptoms reported by the respondents.

In the present research, PCL-C was used to check the posttraumatic stress symptoms and not for the diagnosis of PTSD as a type of mental disorder specified by

*** Copyright © by Frank Weathers., Brett Litz., Debra Herman., Jennifer Huska., & Terence Keane. (1993). ―This is a Government document in the public domain and may be used without further permission or charge; however, please do not modify the scale‖ as advised by Dr. Frank Weathers on October 13, 2009, 2.00 A.M vide his e-mail to Sadia Malik , Doctoral scholar under the supervision of Prof. Dr. Yasmin Nilofer Farooqi (Tamgh-e-Imtiaz), Department of Applied Psychology, University of the Punjab, Lahore, Pakistan. 51

DSM-TR (2002). Written permission was granted by the authors of PCL-C for its use in current research project to determine posttraumatic stress symptoms in the female doctors, house-job doctors and nurses (copy attached in appendix F).

According to Weathers et al. (1993) PCL-C has significantly high reliability with Cronbach‘s α =.96. In the current research project PCL-C is found to have significantly high reliability as supported by the Cronbach‘s α = .90.

2.4. Procedure:

Official permission was sought from the hospital authorities for data collection from the female doctors, house-job doctors and nurses (Copy attached in appendix C).

A total of 8 public hospitals of Lahore city were approached by the researcher and only 5 of them allowed their female doctors, house-job doctors and nurses to participate in the current research. The authorities of the three of the hospitals which did not grant permission to the researcher argued that their hospital policy did not allow participation in any such research project which deals with socially tabooed topics; such as sexual harassment. Before administration of English version of Work

Harassment scale (1992); Sexual harassment Experiences Questionnaire (1997) and

PTSD Checklist Civilian-Version (1993), the participants were briefed about the nature and purpose of the study. Rapport was established by assuring them of the confidentiality of their personal information and its use for research purpose only.

Written consent was obtained from all the participants individually (Copy attached in appendix A). Then Work Harassment Scale (1992) Sexual harassment Experiences

Questionnaire (1997) and PTSD Checklist (1993) were individually administered to all the research participants.

52

2.5. Statistics:

SPSS (Version 14.00) was used to perform Principle Component Analysis

(PCA) and Hierarchical Multiple Regression Analysis. PCA with varimax rotation was performed to determine the factors underlying Work Harassment Scale, Sexual

Harassment Experience Questionnaire and PTSD CheckList Civilian-version.

Hierarchical multiple regression analysis was performed to explore the strength of general workplace harassment, sexual harassment and demographic variables (age, education, job status, job experience, monthly income and marital status) as the predictors for posttraumatic stress symptoms among female healthcare professionals.

53

Chapter III

RESULTS

This chapter deals with the statistical analysis of the data collected from various public hospitals of Lahore city. SPSS (14.00) was used for statistical analysis

(data sheets are attached in appendix G).

The chapter is further divided into two sections. In section 1 psychometric analysis of the scales/questionnaire/checklist used for data collection is described.

Principle Component Factor Analysis with Varimax Rotation was performed to determine the psychometric properties of the instruments used in this research project.

In section 2, main analysis of the data collected from 300 female healthcare professionals is discussed in the context of the five hypotheses given in Chapter I (p.

44). Pearson Product Moment Correlation and Hierarchal Multiple Regression analysis were performed to test these hypotheses.

3.1. Psychometric Analysis

Principle Component Factor analysis and reliability analyses of the scales were performed on the data drawn from the female doctors, house-ob doctors and nurses (N = 300) in order to determine the internal consistency of the scales. Before performing the factor analyses, the suitability of the data for analysis was checked.

Kaiser-Myer-Olkin measure (KMO) of sampling adequacy was calculated to see the sufficient sample size. If the value of KMO is near to zero it indicates insufficient sample size and if the value is close to 1 it shows that sample size is suitable to perform factor analysis (Pallent, 2001). Bartlett‘s test of sphericity was carried out to determine the degree of correlation coefficient. Significant value at the Bartlett‘s test of sphericity indicates that variables are reasonably correlated with each other 54

(Pallent, 2001). Kaiser‘s (1960) criterion of retaining as many factors as many Eigen value greater than 1 was used. The researcher kept only those items in a specific factor if the factor loadings were greater than .40 on that that particular factor.

Otherwise the items below .40 loadings were dropped. Furthermore, to determine the internal consistency of the scale Cronbach alpha was calculated which is discussed in detail in the following section.

3.1.1. Work Harassment Scale

Björkqvist, Osterman and Hjelt-Beck (1994) performed factor analysis of the

Work Harassment Scale indicated two subscales of covert or disguised aggression which are referred to as: i) rational-appearing aggression subscale and ii) social manipulation subscale. The authors further state that the sub-scale of rational- appearing aggression assesses types of harassment behavior and the scale of social manipulation measures the respondent‘s experience of insulting experiences private life from his/her colleagues at workplace.

Moreover, the current researcher applied Principal Component Analysis

(PCA) with varimax rotation on 24 items of Work Harassment Scale by using SPSS

(14.00). Prior to performing PCA, Kaiser‘s (1960) criterion (eigenvalue higher than 1) was applied to extract the principle factors and to assign items to these factors.

Moreover, the factor loadings equal to or higher than .40 were considered in PCA.

The correlation matrix revealed the presence of many coefficients of .30 or above.

The Kaiser-Mayer –Oklin (KMO) yielded the value of .93, which suggests the appropriateness of sample size for factor analysis. Bartlett‘s test of sphericity was significant (χ2 (27, N = 300) = 3897.65, p < .001) which shows that items were sufficiently correlated.

55

Table 2

Varimax Rotation of Two factor Solution for Work Harassment Scale.

Rational- Social Items appearing manipulations aggression 21 Ridiculed in front of others .89 .78 22 Work judged in an incorrect .90 .73 manner? 3 Unduly disruption .90 .72 14 Belittling of opinion .90 .71 18 Given meaningless tasks? .90 .65 11 Accusations? .90 .65 5 Unduly criticized .90 .65 10 Insinuative glances .90 .64 12 Sneer at .90 .62 .44 4 Shouted loudly .90 .60 23 Sense of judgment questioned .90 .59 19 Given insulting tasks? .90 .52 .51 1 Unduly reduced opportunities .90 .49 17 Words aimed at hurting .92 .43 13 Refusal to speak .87 .77 16 Treated as non existent .88 .73 8 Sensitive details revealed? .88 .70 6 Insulting comments about private .88 .69 life 7 Isolated? .88 .67 15 Refusal to hear .88 .63 24 Accusations Mentally disturbance .88 .62 20 Malicious rumors .89 .61 9 Direct threats .88 .60 R² 26.89 23.41 α .91 .89

Note: Boldface indicates the items belonging to the factor. 56

Principle Component Analysis further revealed the presence of four factors with Eigen values above 1, which explained 43.4 %, 6.8%, 5.8% and 4.3% of the variance, respectively. Using Cattlle‘s (1966) Sacree test it was decided to retain two components instead of four factors for further investigation. Varimax rotation was performed. The two factor solution explained that Factor 1 comprised of 14 items including; 1, 3, 4, 5, 10, 11, 12, 14, 17, 18, 19, 21, 22, and 23, which assesses the rational-appearing aggression at workplace. The Factor 2 consisted of 9 items; 6, 7, 8,

9, 13, 15, 16, 20 and 24 which measures social manipulations. The rational-appearing aggression factor contributed 26.89 % of the total variance of the scale, while the social manipulations factor explained 23.41 % of the variance. The factor loadings for these two factors ranged between .43 to78.

3.1.2. Sexual Harassment Experience Questionnaire

Principal Component Analysis (PCA) with varimax rotation was performed on

35 items of the Sexual harassment Experience Questionnaire to explore the underlying components of SHEQ. Before the analysis, psychometric adequacy of the items of SHEQ was explored. Bartlett‘s test of sphericity indicated that all the items were significantly correlated (χ2 (59, N = 300) = 6139.31, p < .001). Moreover, the

Kaiser-Mayer-Olkin (1970) was higher than the recommended value of .50 (KMO =

.936). Therefore, it may be argues that the good sample sufficiency and significant correlations of the items suggest its appropriateness for PCA with varimax rotation.

Kaiser‘s (1960) criterion (Eigen value higher than 1) was performed to extract the number of factors and to assign items to the factors. Moreover, factor loading equal to or higher than .40 was considered in PCA.

Principle component analysis suggested the presence of five factors with

Eigen values above 1, which explained 38.8 %, 8.4%, 4.2%, 3.9% and 3.4% of the 57 variance, respectively. Therefore, the researcher using Cattlle‘s (1966) Sacree test decided to keep three components for further exploration using varimax rotation.

The results given in Table 3 suggest that Factor I assesses gender harassment.

This factor and is comprised of 12 items (1, 2, 3, 4, 5, 12, 18, 19, 23, 24, 25, 29) and contributed 19.85 % of the total variance. These findings are partially consistent with those of Anila and Tariq (1997) who found seven items (1, 3, 5, 7, 10, 23, and 25) loaded for Factor I that is gender harassment. However, in the current research item no. 2, 4, 18, 19, 24, 29 were highly loaded for Factor I which measures gender harassment; whereas these items were loaded for unwanted sexual attention and item no 12 was loaded on sexual coercion as per Anila and Tariq‘s (1997) findings.

Factor II consists of 13 items (11, 16, 17, 21, 22, 26, 27, 28, 30, 31, 32, 33, 35) which measures sexual coercion and contributed 17.32% variability. These findings are also partially consistent with those of Anila and Tariq (1997) who found 7 items

(12, 17, 26, 27, 28, 30, 32) to be loaded on Factor II. In the current research item no.

11, 16, 21, 22, 31, 33, 35 were highly loaded for Factor II which measure sexual coercion; whereas according to Anila and Tariq‘s (1997) findings these items were loaded for unwanted sexual attention rather than gender harassment.

Factor III consisted of 10 items (6, 7, 8, 9, 10, 13, 14, 15, 20, 34) which measures unwanted sexual attention. This factor explained 14.31 % of the total variance. The loadings on this factor are partially consistent with those of Anila and

Tariq (1997)

58

Table 3

Comparison of Three Factors underlying Sexual Harassment Experience

Questionnaire

Factor Analysis by Malik (2011) Factor Analysis by Anila (1998) Gender Unwanted Sexual Sexual Gender Unwanted Sexual Sexual Coercion Harassment Attention Coercion Harassment Attention 1 6 11 1 2 12 2 7 16 3 4 17 3 8 17 5 6 26 4 9 21 7 8 27 12 10 22 10 9 28 18 13 26 23 11 30 19 14 27 25 13 32 23 15 28 14 24 20 30 15 25 34 31 16 29 32 18 33 19 35 20 21 22 24 29 31 33 34 35

who found 21 items loaded for Factor III (2, 4, 6, 8, 9, 11, 13, 14, 15, 16, 18, 19, 20,

21, 22, 24, 29, 31, 33, 34, 35). In the current research item no. 7, 10 were highly 59 loaded for Factor III which measures unwanted sexual attention; whereas these items were loaded for gender harassment as per Anila and Tariq‘s (1997) findings

Thus, it may be argued that the above-mentioned differences in items for three factors could be due to the different demographic characteristics of the two samples which were used by Anila (1998) and the current researcher (Malik, 2011). It is worth-mentioning here that the female healthcare professionals consisting of doctors, house-job doctors and nurses were used as sample by the present researcher; whereas,

Anila (1998) took the sample from different government and private organizations, which included bank operators, steno typists, receptionist, air ticketing staff, secretary, diplomatic counselor, air hostess, nurses and government officers. Thus, the two samples were different in terms of their demographic characteristics. Another reason for differences in the factor loadings might be the time factor between the two researches: the present research was conducted in the year 2010-2011; whereas, Anila conducted research in 1997-1998.

Further analysis of the differences is given in Table 4 ( see pages )

Table 4

Varimax Rotation of Three factors underlying Sexual Harassment Experience Questionnaire

Factor Loading Unwanted α Gender Sexual Items Sexual harassment Coercion Attention 24 Tried to have body touch with you while sitting for some .90 .761 work. 12 Withheld(delayed) your work .90 .727 so that you might go to him 60

again and again regarding that work 3 Stared from head to toe .90 .718 18 Collided with you while .90 .717 passing by. 23 Admired your face or hair. .90 .706 2 Appreciated your figure .90 .676 19 Try to touch your hand while .90 .669 giving something. 4 Try to make you sit with him .95 .639 5 Admired dress or make-up .91 .627 1 Told a dirty joke to you .91 .513 .420 25 Tried to talk with you about some vulgar movie or a .91 .505 television program. 29 Tried to have an immoral (bad) .91 .485 .401 talk with you. 28 Try to defame you when not .89 .760 fulfilled his bad demands. 30 Exploit you to fulfill his bad .90 .741 32 Threats of removal from job if you do not have physical/ .90 .656 sexual contacts with him. 26 Threatened you to be fired (turn out of the job) if you do .90 .653 not develop romantic relations with him. 35 Tried to rape you. .90 .644 33 Put his hand on your hand while posing to teach you something, e.g., how to work on .90 .486 .618 a computer, or any other such task. 61

31 Tried tom pat on your shoulder or back while praising your .89 .500 .577 work. 22 Tried to give you a love letter. .90 .544

27 you face some loss in job when .91 .532 do not fulfill his bad 21 Put his hand on your shoulder .89 .514 .525 or back while working. 17 Assured you of promotion in the job or of some other .90 .509 .508 benefits if you could fulfill his immoral (bad) demands. 16 Tied to probe your sexual frustration and deprivations, .90 .500 .450 and pretended to be a sympathizer. 11 Tried to give you a card. .90 .475 13 Made obnoxious call to you on .81 .680 the phone 15 Try to discuss your or his .81 .661 sexual life. 7 Tried to show you a magazine containing pornographic .82 .597 material. 20 Called you "darling", 'sweet .82 .576 heart", etc. 34 Tried to kiss you .82 .440 .564 6 Invite you for outgoing or going to restaurant with him to .81 .545 eat. 10 Hummed filthy songs in your .82 .422 .534 presence. 62

9 Offered you lift in his car .81 .489 8 Tried to flirt with you. .82 .434 .462 14 Took interest in your personal life with the intention that you .87 might start responding favorably to him. 2 R 19.85% 17.32% 14.31%

α .91 .91 .84

Note: Boldface indicates the items belonging to the factor.

3.1.3. PTSD Checklist- Civilian Version (PCL-C)

The researcher performed PCA with varimax rotation on the 17 items of

Posttraumatic Stress Disorder Checklist-Civilian version to explore the underlying factors. SPSS (Version 14.00) was used. Prior to performing PCA, Kaiser‘s (1960) criterion (Eigen value more than 1) was used to extract the factors and to allocate items to the factors. Moreover, factor loading equivalent to or higher than .40 was considered in PCA. The Kaiser-Mayer –Oklin (KMO) yielded the value of .90, which suggests the appropriateness of sample size for factor analysis. Bartlett‘s test of sphericity was significant (χ2 (13, N = 300) = 2156.08, p <.001) which suggested that all items were sufficiently correlated.

Principle component analysis suggested three factors with Eigen values above

1, which explained 39.8 %, 9.6%, and 7.1% of the variance, respectively. Using

Cattlle‘s (1966) Sacree test it was decided to keep three factors for varimax rotation.

The results given in Table 4 indicate that Factor I is comprised of 6 items (1, 2, 3, 4,

6, 7) which assesses re-experiencing of traumatic event. This factor contributed 21.72

% of the total variance. Factor II consisted of 6 items (12, 13, 14, 15, 16, 17) which measures hyper-arousal. This Factor explained 20.64 % of variance. Factor III 63

comprised of 5 items (5, 8, 9, 10, 11) which measures avoidance. This Factor

contributed 14 .22% of variability (Table 5).

Table 5

Two Factors underlying PCL-Civilian Version by PCA-Varimax Rotation

Items α Re- experience Hyperarousl Avoidance 3. Sudden feeling of that traumatic incident .76 .755 were occurring again 4. Feeling very upset when remember .78 .718 traumatic incident 1. Repeated, disturbing dreams .78 .717 2. Frequent, upsetting memories and .79 .696 thoughts 6. Avoid thinking or talking about that .77 .662 traumatic incident 7. Avoiding activities or situations .83 .560 13. Sleep problems .82 .706 15. Lack of concentration .81 .705 17. Easily startled? .81 .690 14. Feeling irritable .82 .668 12. Future concerns. .81 .645 .400 16. Being ―super alert‖ .89 .490 .641 8. Difficulty in remembering key parts of a .75 .734 traumatic incident. 11. Feeling emotionally numb .71 .712 9. Lack of interest .70 .568 10. Feeling cut off from other people? .71 .501 .525 5. physical reactions when remember .77 .480 .511 traumatic incident R² 21.72% 20.64% 14.22% α .81 .84 .77 Note: Boldface indicates the items belonging to the factor.

64

3.2. Main Analysis

Main analysis was conducted to test the hypotheses. Frequency distribution and percentages of the female doctors, house-job doctors and nurses on Work Harassment

Scale and Sexual Harassment Experience Questionnaire and PTSD CheckList

Civilian-version were calculated.

3.2.1. Frequency and percentage of General Workplace Harassment

The results given in Table 6 indicate that 90 % of the total sample reported experience of ―words aimed at hurting” them from their bosses, colleagues or subordinates. 88% of the respondents reported ―undue criticism”; 86% reported

―belittling of their opinion”; 85% reported “reduced opportunities to express” themselves; ―question about their sense of judgment” and 50% reported experience of

―isolation” at workplace.

Table 6

Frequency and percentage of Different Types of Harassment Reported by the Doctors,

House-job Doctors and Nurses (N = 300)

Sample Doctors House -Job Nurses

(N = 300) (n =100) Doctors (n = 100)

(n = 100) Items f % % % % 1 Reduced opportunities to express 264 85 83 84 87 2 Lies about you? 249 83 81 74 94 3 Unduly disruption 252 84 794 86 87 4 shouting loudly 253 84 86 78 89 5 Unduly criticism 264 88 82 88 84 6 Insulting comments about private 168 61 53 50 65 life 7 Isolation? 203 50 69 62 72 8 Revealing sensitive details about 165 61 48 52 65 private life 65

9 Direct threats 160 53 36 57 67 10 Negative gestures 239 80 77 83 79 11 Accusations 220 73 68 76 76 12 Sneer at 224 75 74 75 75 13 Refusal to speak 163 54 42 60 61 14 Belittling opinion 259 86 92 83 84 15 Refusal to hear 194 65 61 67 66 16 treated as non existent 180 60 44 65 71 17 Words aimed at hurting 240 90 72 82 86 18 Giving meaningless tasks 242 81 73 90 79 19 Giving insulting tasks 191 64 52 61 78 20 Spread malicious rumors 207 69 60 66 81 21 Ridiculing in front of others 223 74 71 79 73 22 Incorrect judgment 232 77 78 76 78 23 Questions about sense of 256 85 89 86 81 judgment 24 Accusations of mental 176 57 44 63 69 disturbance

3.3.2. Frequency and percentage of Sexual Harassment

The Table 7 shows 83% of the total sample reported ―staring from head to toe” and ―admiring dress or make up” by their bosses, colleagues or subordinates.

79% participants reported experience of “…touch while giving something”; 78% reported ―appreciation of figure” and ―collide while passing” and 13 % reported

―rape attempt” by their male colleagues.

66

Table 7

Frequency and Percentage of Different Type of Sexual Harassment reported by the

Female Doctors, House-job Doctors and Nurses (N = 300)

Sample Doctors House -Job Nurses (N = 300) (n =100) Doctors (n = 100) (n = 100) f % % % % Items 1 Dirty jokes 172 57 49 71 52 2 Appreciation of figure 235 78 77 85 73 3 Staring from head to toe. 250 83 81 93 74 4 Try to make you sit with him 230 77 72 83 75 5 Admiration of dress or make-up 248 83 90 85 73 6 Invitation for outgoing. 184 61 50 72 62 7 Display of pornographic 149 50 35 56 58 magazine. 8 Flirtation. 183 61 56 69 58 9 Offered lift in car 188 63 58 70 60 10 Hummed filthy songs. 146 49 38 55 53 11 Try to give a card. 140 47 35 48 57 12 Withholding work 218 73 69 82 67 13 Obnoxious call 168 56 51 63 54 14 Take interest in personal life. 211 70 67 78 66 15 Try to talk about sexual life. 130 43 27 51 52 16 Try to probe your sexual 120 40 26 43 51 frustration. 17 Assurance of promotion in/ 152 51 38 54 60 benefits if fulfill his immoral (bad) demands. 18 Collide with while passing by. 233 78 71 84 78 19 Try to touch your hand while 237 79 72 87 78 giving something. 20 Call you darling or sweet heart 151 50 41 61 49 67

21 Try to put his hand on your 173 58 46 68 59 shoulder. 22 Try to give a love letter. 69 23 14 22 33 23 Admiring your face or hair. 225 75 73 82 70 24 Try to have body touch while 205 68 65 76 64 sitting for some work. 25 Try to talk about some vulgar 207 69 67 72 68 movie/ television program. 26 Threats of turn out of the job if 106 35 22 35 49 do not develop romantic ties with him. 27 Face some loss in your job if do 109 36 35 29 45 not fulfill his bad demands. 28 Try to defame you when not 118 39 45 28 45 fulfill his bad demands. 29 Immoral (bad) talk with you. 191 64 51 73 59 30 Force to fulfill his immoral 94 31 22 26 46 (bad) demands by exploiting your hardship. 31 Pat on your shoulder or back 166 55 51 60 55 while praising your work. 32 Threats to put you out of job if 79 26 14 28 37 you do not have physical/ sexual relations with him. 33 Put his hand on your hand while 132 44 37 51 44 posing to teach you something. 34 Try to kiss 86 29 13 38 35 35 Try to rape. 40 13 2 13 25

3.3.3. Frequency and percentage of Posttraumatic Stress Symptoms

The Table 8 shows 84% of the total sample reported experiences of ―repeated disturbing memories, thoughts, or images” of their harassment experience; 83% 68 reported “that they feel very upset when something reminded them” of that incident;

80% reported ―difficulty in concentration” and 33 % reported ―being super alert”.

Table 8

Frequency and Percentage of Different Levels of Posttraumatic Stress Symptoms reported by the Female Doctors, House-job Doctors and Nurses (N = 300)

Sample Doctors House -Job Nurses (N = 300) (n =100) Doctors (n = (n = 100) 100) Items Freq Percent Percent Percent Percent 1 Frequent, upsetting memories 252 84 81 90 81 and thoughts 2 Repeated, disturbing dreams 154 51 41 47 64 3 Sudden feeling that traumatic 176 59 49 60 67 incident is occurring again. 4 Feeling very upset when 250 83 78 84 88 remember traumatic incident 5 physical reactions when 171 57 53 55 67 remember traumatic incident 6 Avoid thinking or talking about 235 78 77 84 74 that traumatic incident 7 Avoiding activities or situations 226 75 71 81 74 8 Difficulty in remembering key 120 40 46 32 42 parts of a traumatic incident 9 Lack of interest 176 59 49 65 62 10 Feeling cut off from other 200 67 53 80 67 people? 11 Feeling emotionally numb 169 56 51 62 66 12 Future concerns. 176 59 51 64 61 13 Sleep problems 196 65 62 73 61 14 Feeling irritable 233 78 72 80 82 15 Having difficulty concentrating? 239 80 78 86 75 16 Being ―super alert‖ 202 33 57 76 69 17 Easily startled? 178 59 47 70 61 69

3.2.4. Hypothesis 1:

That more the workplace harassment (general and sexual harassment)greater

the posttraumatic stress symptoms would be reported by the female doctors,

house-job doctors and nurses.

Findings related to Hypothesis 1:

Table 9

Relationship between Types of Workplace Harassment and Posttraumatic Stress

Symptoms (N=300)

Mean SD 1 2 3 4 5 6

1. General Workplace 33.94 17.78 - Harassment

2. Sexual Harassment 65.41 18.14 .64** -

3. Gender Harassment 14.79 4.08 .55** .90** -

4. Unwanted Sexual 39.28 11.24 .63** .98** .85** - Attention

5. Sexual Coercion 11.34 3.86 .58** .87** .69** .82** -

6. Posttraumatic Stress 35.72 11.16 .52** .65** .56** .65** .55** - 7. Syndrome

**p < 0.1, *p < 0.5

The results given in Table 9 indicate statistically significant positive correlation between general workplace harassment and posttraumatic stress symptoms

(r = .52, **p < .01); as well as between sexual harassment and posttraumatic stress symptoms (r = .65, **p < .01). These findings support the first hypothesis that more the workplace harassment (general and sexual harassment) greater the posttraumatic 70 stress symptoms would be reported by the female doctors, house-job doctors and nurses.

Further analysis of these results suggests significant positive relationship between sexual harassment experience (gender harassment, unwanted sexual attention, and sexual coercion) and posttraumatic stress symptoms (see Table 9).

Sub-Hypothesis i:

There would be positive relationship between workplace harassment (both

general and sexual) and posttraumatic stress symptoms reported by the

doctors.

Findings related to Sub-Hypothesis i:

Table 10

Relationship between Types of Workplace Harassment and Posttraumatic Stress

Symptoms among the Doctors (N=100).

Mean SD 1 2 3 4 5 6

1. General Workplace 27.76 13.67 - Harassment

2. Sexual Harassment 60.14 12.35 .41** -

3. Gender Harassment 13.87 3.06 .28** .81** -

4. Unwanted Sexual 35.89 8.41 .41** .97** .72** - Attention

5. Sexual Coercion 10.38 2.44 .30** .68** .37** .58** -

6. Posttraumatic Stress 32.44 10.39 .38** .49** .33** .51** .31** - Syndrome

**p < 0.1, *p < 0.5 71

The results given in Table 10 indicate significant positive correlation between general workplace harassment and posttraumatic stress symptoms (r =. 38, **p <

.01); as well as between sexual harassment and posttraumatic stress symptoms (r =

.49, **p < .01) among the sub-sample of the female doctors (n= 100). The findings supported the first sub-hypothesis that there would be positive relationship between workplace harassment (both general and sexual) and posttraumatic stress symptoms reported by the doctors.

Sub-Hypothesis ii:

The more the workplace harassment (both general and sexual) the greater the

posttraumatic stress symptoms would be among the female house-job doctors.

Findings related to Sub Hypothesis ii:

Table 11

Relationship between Workplace Harassment and Posttraumatic Stress Symptoms among the House-Job Doctors (N=100).

Mean SD 1 2 3 4 5 6

1. General Workplace

Harassment 34.19 18.74 -

2. Sexual Harassment 69.03 18.64 .74** -

3. Gender Harassment 15.75 4.09 .66** .89** -

4. Unwanted Sexual Attention 42.03 11.72 .75** .99** .85** -

5. Sexual Coercion 11.25 3.72 .60** .90** .69** .88** -

6. Posttraumatic Stress 37.46 10.77 .58** .66** .56** .66** .62** - Syndrome

**p < 0.1, *p < 0.5 72

The results given in Table 11 indicate significant positive relationship between

general workplace harassment and posttraumatic stress symptoms (r =. 58, **p <

.01); and between sexual harassment and posttraumatic stress symptoms (r = .66, **p

< .01) among the sub-sample of the female house-job doctors (n= 100). These results

supported the second sub-hypothesis that the more the workplace harassment (both

general and sexual) the greater the posttraumatic stress symptoms would be among

the female house-job doctors.

Sub Hypothesis iii:

There would be positive relationship between workplace (both general and

sexual) harassment and posttraumatic stress symptoms among the nurses.

Findings related to Sub Hypothesis iii:

Table 12

Relationship between Workplace Harassment and Posttraumatic Stress Symptoms

among the Nurses (N=100)

Mean SD 1 2 3 4 5 6

1. General Workplace 39.86 18.52 - Harassment

2. Sexual Harassment 67.05 21.22 .65** -

3. Gender Harassment 14.74 4.72 .60** .93** -

4. Unwanted Sexual 39.93 12.39 .63** .99** .89** - Attention

5. Sexual Coercion 12.38 4.82 .64** .94** .83** .90** -

6. Posttraumatic Stress 37.26 11.66 .52** .71** .68** .71** .62** - Syndrome

**p < 0.1, *p < 0.5 73

The results given in Table 12 suggest significant positive correlation between general workplace harassment and posttraumatic stress symptoms (r =. 52, **p <

.01); as well as between sexual harassment and posttraumatic stress symptoms (r =

.71, **p < .01) among the sub-sample of the female nurses (n= 100) from various public hospitals of Lahore city. The results supported the third sub-hypothesis that there would be positive relationship between workplace (both general and sexual) harassment and posttraumatic stress symptoms among the nurses.

3.2.5. Hypothesis 2:

Workplace harassment (general and sexual) would be the strongest predictor

of posttraumatic stress symptoms.

Findings related to Hypothesis 2:

Hierarchical multiple regression analysis was performed to determine the impact of demographic variables (age, education, job status, job experience, monthly income and marital status), general workplace harassment and sexual harassment on posttraumatic stress symptoms. Among the demographic variables two variables were nominal which are job status and marital status.

Therefore, the sample was categorized into three groups based upon their job status and were coded as: doctors =1; house-job doctor = 2 and nurses = 3. For marital status the sample categories were coded as married = 1 and unmarried = 2.

Hierarchical multiple regression analysis was performed in two steps. In the first Model, demographic variables (age, education, job status, monthly income, job experience and marital status) were entered and none of these variables were found statistically significant. 74

Table 13

Hierarchical Multiple Regressions Predicting Posttraumatic Stress Symptoms from

General Workplace Harassment and Sexual Harassment among the Female

Healthcare Professionals (N=300)

Predictors Β R² ∆R² ∆F

Model 1 .081 .062 4.28

Age -.05

Education .09

Job .14

Income .03

Experience -.06

Marital Status -.07

Model 2 .457 .442 100.80 workplace harassment .18 sexual harassment .52

Total ∆R² .538 .504

***p<.001, **p < .01, *p < .05

The results given in Table 12 indicate that all the demographic variables explained only 8.1 % of the variance in posttraumatic stress symptoms. In the second

Model, general workplace harassment and sexual harassment were entered. These variables were found to be the strongest predictors for posttraumatic stress symptoms reported by the female doctors, house-job doctors and nurses (β = .18, p < .05; and β

= .52, p < .001, respectively) and accounted for 45.7 % of the variance in posttraumatic stress symptoms. Overall it explained 58.3 % variability. These results 75 further supported the second hypothesis that workplace harassment (general and sexual) will be the strongest predictor of posttraumatic stress symptoms.

3.4. Additional Analysis:

3.4.1. Differences in General Workplace Harassment, Sexual Harassment and

Posttraumatic Stress Symptoms

The Figure 3 shows that the nurses reported more general workplace harassment as compared to the house-job doctors and doctors, whereas sexual harassment experiences were most frequently reported by the house-job doctors when compared to these of the doctors or nurses. Moreover, the house-job doctors and the nurses reported approximately the same level of posttraumatic stress symptoms as compared to the doctors (Mean = 37.46, 37.26 and 32.44, respectively).

Figure 3

Mean Differences in General Workplace Harassment, Sexual Harassment and

Posttraumatic Stress Symptoms Reported by the Female Healthcare Professionals

(N= 300)

76

3.4.2. Categorization of Seriously Generally Harassed, Moderately Harassed

And Mildly Harassed Female Healthcare Professionals

In order to differentiate between the harassed and the non-harassed female healthcare professionals, the Mean and standard deviation scores of the participants on general workplace harassment and sexual harassment were computed.

The Mean score of the total sample for general workplace harassment was

33.94 and SD was 17.78. The range for average scores on Work Harassment Scale was found to be 16.16 - 51.72. The upper and lower values of this range were rounded off as 16 and 52. Those participants who scored below 16 were considered as mildly harassed; those who scored between the ranges of 16-52 were considered as moderately harassed and those participants who scored above 52 were categorized as the seriously harassed group. The Figure 4 shows distribution of the mildly harassed, moderately harassed and seriously harassed female healthcare professionals.

Figure 4

Distribution of the Sample by General Workplace Harassment (N = 300)

77

The Figure 5 shows distribution of seriously generally harassed, moderately harassed and mildly harassed participants among the sub-samples of doctors (n=100),

House-job doctors (n =100) and nurses (n = 100).

Figure 5

Distribution of the Sub-Samples of Doctors, House-job Doctors and Nurses by

General Workplace Harassment (n= 100 in each sub groups)

3.4.3. Categorization of Seriously Sexually Harassed, Moderately Sexually

Harassed and Slightly Sexually Harassed Female Healthcare

Professionals

The Mean score of the total sample on Sexual Harassment Experience

Questionnaire was 65.41 and SD was 18.14. The range for average scores on SHEQ was found to be 47.27- 83.55. The upper and lower values of this range were rounded off as 47 and 84. The participants who scored below 47 were categorized as slightly harassed; those who scored between the ranges of 47- 84 were considered as 78 moderately sexually harassed and those participants who scored above 84 were taken as the seriously sexually harassed group. The Figure 6 shows distribution of the slightly harassed, moderately sexually harassed and seriously sexually harassed female healthcare professionals.

Figure 6

Distribution of the Sample by Sexual Harassment (N = 300)

The Figure 7 shows distribution of seriously sexually harassed, moderately harassed and slightly harassed participants among the sub-samples of the doctors

(n=100), house-job doctors (n =100) and nurses (n = 100). 79

Figure 7

Distribution of the Sub-Samples of Doctors, House-job Doctors and Nurses by Sexual

Harassment (n = 100 in each sub groups)

3.4.4. Differences in PTSS reported by Seriously Generally Harassed,

Moderately Harassed And Mildly Harassed Female Healthcare

Professionals

The results given in Table 14 suggest statistically significant differences in posttraumatic stress symptoms reported by all the participants who were exposed to serious general workplace harassment, moderate workplace harassment and minimal workplace harassment (F (2, 297) = 46.55, p < .005). The seriously harassed group reported greater posttraumatic stress symptoms as compared to the moderately harassed and mildly harassed groups (Mean = 46.25, 35.13 and 28.26, respectively).

80

Table 14

Differences in Posttraumatic Stress Symptoms Reported by the Seriously Harassed,

Moderately Harassed and Mildly harassed Groups (N=300)

95.0% C.I.

N M SD F P LL UL

Mildly Harassed 57 28.26 10.61 25.44 31.07 46.55 < .000

Moderately harassed 192 35.13 9.73 33.75 36.52

Seriously harassed 51 46.25 8.93 43.74 48.76

F= 46.55, df = 297, p < .05

3.4.5. Differences in PTSS reported by Seriously Sexually Harassed, Moderately

harassed and slightly harassed Female Healthcare Professionals

The results given in Table 15 indicate statistically significant differences in posttraumatic stress symptoms reported by all the participants who were exposed to serious sexual harassment, moderate sexual harassment and minimal sexual harassment (F (2, 297) = 68.13, p < .005). The seriously sexually harassed group reported greater posttraumatic stress symptoms as compared to the moderately sexually harassed and slightly sexually harassed groups (Mean = 48.12, 34.94 and

26.68, respectively).

.

81

Table 15

Differences in Posttraumatic Stress Symptoms Reported by the Seriously Sexually

Harassed, Moderately harassed and slightly harassed Female Healthcare

professionals (N=300)

95.0% C.I.

N M SD F p LL UL

Slightly Harassed 50 26.68 8.29 24.32 29.03 68.31 < .000

Moderately harassed 201 34.94 9.83 35.57 36.31

Seriously harassed 49 48.12 7.69 45.91 50.33

F= 68.31, df = 297, p < .05

82

CHAPTER IV

DISCUSSION

This chapter deals with discussion in the light of the review of literature and relevant researches given in chapter I (pp. 1-44). Moreover, conclusions, their implications, limitations of the current research project and suggestions for the future researches are given in this chapter.

The main finding of the current research is that there is statistically significant positive relationship between workplace harassment (general and sexual harassment) and posttraumatic stress symptoms reported by all the female doctors, house-job doctors and nurses. Thus, it supports the first hypothesis that more the workplace harassment (general and sexual harassment) greater the posttraumatic stress symptoms would be. Furthermore, significant positive relationship was found between workplace harassment (general and sexual harassment) and posttraumatic stress symptoms among the three sub-samples composed of doctors, house-job doctors and nurses separately which supported the other three sub-hypotheses that proposed positive relationship between workplace harassment (both general and sexual) and posttraumatic stress symptoms among the sub-samples of doctors, house- job doctors and nurses.

The current research findings are consistent with those of Bonafons, Jehal and

Croller-Bequet (2010); Dansky and Kilpatrick (1997); Glomb et al. (1999); Laposa,

Adlen and Fullerton (2003); Larsen and Fitzgerald (2010); Leymann and Gustafsson

(1996); Mikkelsen and Einarsen (2002); Matthiesen and Einarsen (2004); Rodriguez-

Munoz, Moreno-Jimenez, Vergel and Hernandez (2010); Tehrani (2004) and

Veenstra, Lindenberg, De Winter, Zijlstra, Verhulst, & Ormel (2007); Wolfe,

Sharkansky, Dawson, Martin and Ouimette (1998) who found significant positive 83 relationship between workplace harassment and posttraumatic stress disorder/symptoms.

There is sufficient empirical evidence, which suggest that being harassed in the workplace setting is associated with mental distress (Hansen et al. 2006;

Niedhammer, David and Degioanni, 2006; Rayner, Hoel and Cooper, 2002; Skarlicki and Kilick, 2005; Vartia, 2001; Zapf, Knorz and Kulla, 1996). The previous research findings suggest that victimization and unfair treatment caused by the hostile and violent behavior of colleagues and other individuals may produce high level of distress and symptoms of PTSD (Creamer, 2000). Furthermore, Scott and Stradling

(1994); and Vitanza, Vogel and Marshall (1995) found that that even slight and subtle type of psychological mistreatment may produce clear symptoms of PTSD.

The findings of the current research are further supported by Nolfe, Peterella,

Blasi, Zontani and Nolfe (2008) who found greatest subjective perception of mobbing among 733 workers of high and medium positions. They further reported that adjustment disorders, mood disorders especially major depression and anxiety disorder particularly PTSD were the most frequent diagnosis. The authors concluded that depression and PTSD are the most frequent psychiatric diseases related to workplace harassment at workplace.

Stockdale, Loagan and Weston (2009) found that positive correlation between sexual harassment experiences and PTSD symptoms controlling for prior abuse, trauma, prior psychological history and prior PTSD among 445 women. Their findings indicated that sexual harassment experiences were positively correlated

PTSD symptoms controlling for previous abuse, trauma, past psychological history and earlier PTSD. They further discussed that sexual harassment experiences were 84 autonomously related with PTSD symptoms and were sufficient for the diagnosis of

PTSD despite of history of trauma or abuse.

Similar findings were reported by Laymann and Gustafsson (1996) on mobbing and the development of posttraumatic stress disorder. They investigated 64 victims of bullying from a private clinic with specialized treatment program for the victims of psychological trauma including mobbing, bank robberies, and industrial accidents.The results indicated that 92% participants were found to have PTSD.

Furthermore, the severity of the symptoms in mobbed employees were higher than the train drivers and similar to raped women.

The second major finding of this research project is that among all the predictors (age, education, job status, job experience, monthly income, marital status, general workplace harassment and sexual harassment) general workplace harassment turned out to be the strongest predictor for PTSS among doctors, house-job doctors and nurses. This finding supports the second hypothesis that proposes that workplace harassment (general and sexual) will be the strongest predictor of posttraumatic stress symptoms. The research findings of Avina and O‘Donohue (2002); Balducci,

Fraccaroli and Scaufeli (2011); Finne, Knardahl, and Lau (2010); Glomb, et al.

(1999); Mol, et al. (2005); Rospenda, Richman, Ehmke and Zlatoper (2005); Wolfe, et al. (1998) also suggest that bullying and sexual harassment at workplace can produce posttraumatic stress symptoms in the employees. Fontana and Rosenheck

(1998) found that among all sort of duty-related stresses, sexual abuse and harassment were the most significant in the development of PTSD among 327 female veterans.

The frequency distribution and percentages of the female doctors, house-job doctors and nurses on Work Harassment Scale and Sexual Harassment Experience

Questionnaire and PTSD CheckList Civilian-version showed that 90 % of the total 85 sample reported exposure to the words aimed at hurting them from their bosses, colleagues or subordinates; 88% reported “undue criticism”; 86% reported ―belittling of their opinion”; 85% reported “reduced opportunities to express” themselves; and

―question about their sense of judgment”. These findings are consistent with those of

Bjorkqvist, et al.(1994); Brown, Chesney-Lind and Stein (2007); Hoel and Cooper

(1997); Moreno-Jiménez, et al. (2008) which suggest workplace harassment is a significant issue for working women because of its comparatively high rate of occurrence or prevalence among the female employees.

The findings of Kisa (2008) indicated that the nurses reported criticism, accusations, judgmental behavior of the authorities, blaming, abusive language and violence as the most frequent and severe types of verbal violence. The results further showed that the most common emotional responses were shame, anger, frustration and humiliation it was also found that most nurses used negative behaviors to deal with with verbal mistreatment. Gacki-Smith et al. (2009) found that approximately

25% of respondents from US emergency units reported experiences of physical violence and 20% reported experiences of verbal abuse. The findings further suggested that those participants who experienced frequent physical and/or verbal violence pointed out fear of revenge and lack of support from hospital management.

As far as the issue of sexual harassment at workplace is concerned the findings of the current research suggest that 83% of the total respondents reported experiences of ―staring from head to toe” and ―admiring dress or make up” by their bosses, colleagues or subordinates. 79% reported experience of “…touch while giving something”; 78% reported ―appreciation of figure” and ―collide while passing” and the least frequent experience was rape reported by 13%. The findings of this research are consistent with those of Anila, 1998; Fitzgerald et al., 1988; Fitzgerald, et al. 86

1995; and Iqbal and Kamal, 2001 who found that females employees reported unwelcome sexual contact and hostile work environment including display of pornography material, sexual suggestions and comments about their appearance and dressing from their male bosses or colleagues.

Cogin and Fish (2009) reported that among the sample of 538 nurses from 8 different hospitals of Australia, the prevalence rate of sexual harassment for female nurses was 60% and for male 34%. The further reported that patients were the most possible perpetrators while results of interview indicated physicians as the major perpetrators.

It may be argued that the typical patriarchal system and the discriminatory attitude of the male-dominated Pakistani society towards professional women may be one of the reasons behind workplace harassment in Pakistan. The general assumption of men about working women is that these women or their families have low morale and ethical values that she is working outside the home (Anila, 1995). This schema is so much prevailing in our society that if a woman steps out of her home she has to face harassment because usually it is considered that those women who are working along with men do not have a good moral character. This explanation is in accordance with socio-cultural theory, which stated that the existing gender inequality and prejudice creates sexual harassment in a society (MacKinnon, 1979; Thomas &

Kitzinger, 1997).

Another finding of the present research is that the most prevalent kind of posttraumatic stress symptoms reported by 84% of the female doctors, house-job doctors and nurses was ―repeated disturbing memories, thoughts, or images” of their harassment experience; 83% reported ―…feel very upset when something reminded them”; 80% reported ―difficulty in concentration” and less frequent experience was 87

―being super alert” reported by 33%. These findings are consistent with those of

Balducci et al. (2011); Dansky and Kilpatrick (1997); Kinchin (2005); Leymann and

Gustafsson (1996); Rodriguez-Munoz et al. (2010); and Palmieri and Fitzgerald

(2005) which suggest the victims of harassment more often experienced re-experience and arousal symptom because harassment is a subjective and personal experience and the harassed people usually hide their feelings from others and especially the harasser.

The current results further suggest statistically significant differences in posttraumatic stress symptoms reported by all the participants who reported serious general and sexual workplace harassment, moderate workplace harassment and minimal workplace harassment. These findings are consistent with those of Arias and

Pape (1999); Bonafons, et al. (2009) Campbell and Morrison (2007); Finne, Knardahl and Lau (2010; Glasø, Nielsen, Einarsen, Haugland and Matthiesen (2009); Hirigoyen

(1998); Laposa et al. (2003); Larsen and Fitzgerald (2010); Mikkelsen and Einarsen

(2002); Rospenda et al. (2005). The findings of these researches suggests that PTSD is most possible to take place when there is certain harassment and victims of bullying/harassment as a group reveal more symptoms of post-traumatic stress disorder (PTSD) than those who were not harassed.

The findings of Dansky and Kilpatrick (1997) provide support to the findings of the current research as they reported that the current and lifetime risk of developing

PTSD diagnosis was significantly higher among victims of sexual harassment than among non victims. They further found that even after estimating the effects of other physical and sexual assault victimization, the relationship between sexual harassment victimization and PTSD exists,.

It has been noticed that the nurses reported more general workplace harassment than both the house-job doctors and doctors in the current research 88 project; whereas sexual harassment was more frequently reported by the house-job doctors than both the doctors and nurses, although, these findings are not significant statistically. These research findings are consistent with the earlier research findings of Ahmer et al. (2009); Bronner, et al. (2003); Cai, Deng, Liu and Yu (2011);

Chapman, Styles, Perry and Combs (2010); Celik and Celik (2008); DeMartino

(2003); Diaz and McMillan (1991); Farrel, et al. (2006); Farooqi (1997); Hegney,

Plank and Parker (2003); Imran et al. (2010); McKenna, et al. (2003); Quine (2003); and Velente and Bullough (2004) which suggest that workplace harassment and sexual harassment are common practices in healthcare system. They further reported that junior doctors and nurses are more exposed to general and sexual workplace harassment.

Matthiesen, Rakness and Rokkum (1989) found that 10% of nurses felt exposed to bullying at work. Cox (1987) found that in 175 American registered nurses, 64% reported experiences of verbal abuse from a physician at least once every second month, while almost as many reported being verbally insulted. Diaz and

McMillan (1991) investigated abuse and mistreatment in nurses, some 82% of them reported experiences of verbal abuse by physicians and supervisors. Libbus and

Bowman (1994) found that 70% female nurses reported sexual harassment by male patients and colleagues. Sexual remarks and touch were the most common behaviors of harassment.

It may be argued that the differences in the reported general workplace and sexual harassment by the Pakistani nurses and house-job doctors may be attributed to differences in their job status; age; monthly income; education; marital status and work schedule for these three sub-samples which might have enhanced vulnerability of the nurses to experience more general workplace harassment. Nevertheless, these 89 demographic variables did not turn out to be statistically significant predictors for harassment and PTSS.

Anila (1998) argues that in Pakistan, less educated women working on inferior positions at workplace are to some extent more vulnerable to harassment by their male colleagues and bosses as supported by the organizational theory. It may be inferred that the men use their organization power to harass women because they usually work at high status as compare to women and they used harassment as a weapon to maintain their dominance at workplace (Backhouse & Cohen, 1991;

Cleveland & Kerst, 1993; Mackinon, 1979).

The findings further suggest that the doctors (who were more senior to house- job doctors and nurses in terms of age, education, job status, monthly income and job experience) reported lowest level of PTSS probably because they reported less workplace harassment (both general and sexual harassment) than both the house-job doctors and nurses. Contrary to it the house-job doctors and the nurses reported approximately the same level of posttraumatic stress symptoms. It may be argued that workplace harassment is a socially tabooed subjective experience; therefore it can be inferred that the victims of workplace harassment would either not report or under- report their experiences of workplace harassment and PTSS (Dickson, 2005; Ishmael

& Alemoru, 2002; Saunders, Huynh & Goodman-Delahunty, 2007).

A hypothetical model was proposed by the current researcher to find out the relationship between workplace harassment (both general and sexual) and posttraumatic stress symptoms and to determine the impact of different demographic variables such as age, education, job status, job experience, monthly income and marital status on workplace harassment or PTSS. The statistical analysis showed significant positive relationship between workplace harassment and PTSS, but none 90 of the demographic variables was found to have has significant impact on workplace harassment or PTSS.These findings are consistent with those of DeCyper, Bailien and Dewhitte (2009); Fitzgerald et al, 1995; Hauge, Skogsted and Einarsen (2009) which stated that

4.1. Limitations and Recommendations

The main limitation of the current research was use of self report questionnaire/scale/checklist which might have resulted in under reporting of workplace harassment (general and sexual harassment) and posttraumatic stress symptoms due to the socially tabooed nature of the problem under study. Therefore, it is strongly recommended that in future researches focus group and interview techniques must be used in addition to self report questionnaire in order to gather more comprehensive information about the degree and nature of workplace harassment as well as posttraumatic stress symptoms among the female healthcare professionals. It is further recommended that qualitative analysis in addition to the quantitative analysis of the responses of the participants must be carried out.

Another methodological limitation of the current research is that three public hospitals in Lahore city did not allow their staff to participate in the current research project. Moreover, the female healthcare professionals (doctors, house-job doctors and nurses) were found to be reluctant to discuss their experiences of workplace harassment (general and sexual harassment). As a result, it was extremely difficult to draw the probability sample from all the public hospitals of Lahore city of Pakistan which might have threatened the internal validity of this research project. The findings of the current research cannot be generalized to the public and private sector.

Therefore, it is strongly recommended that the future researches must include larger samples of male and female doctors, house-job doctors and nurses from both the 91 public and the private hospitals of different cities of Pakistan in order to generalize the findings to the overall Pakistani healthcare system

4.2. Conclusion

It is concluded that there is positive relationship between workplace harassment and posttraumatic stress disorder reported by all the female doctors, house-job doctors and nurses. Moreover, the workplace harassment (both general and sexual harassment) turned out to be the strongest predictor for PTSS. The nurses reported more general workplace harassment than the house-job doctors and doctors, whereas sexual harassment experiences were most frequently reported by the house- job doctors than the doctors or nurses probably due to the fact that both of them have different job status, different responsibilities and different job timings which affect the frequency and types of workplace harassment.

4.3. Implications

The findings of this research have implications for promoting our understanding of workplace harassment and PTSS among female workers in Pakistani healthcare system in order to introduce effective preventive measures to reduce the incidents of workplace harassment.

92

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4, 126–133. 121

Appendix A:

CONSENT FORM

I, ______state that voluntarily agree to participate in the Ph. D level research project on Relationship between Workplace Harassment and

Posttraumatic Stress Symptoms among Pakistani Female Healthcare Professionals conducted by Miss. Sadia Malik under the supervision of Prof. Dr. Yasmin, Nilofer

Farooqi (Tamgha-e-Imtiaz), Department of Applied Psychology, University of the

Punjab, Lahore, Pakistan.

I acknowledged that I have been fully informed about the purpose and objectives of the research project. Furthermore, I have every right to withdraw from the participation in this research project without any penalty or prejudice. Moreover, I have been assured that all the information I gave, will be kept confidential and will not be utilized for any other purpose except for current research project.

Signature of Researcher______Date:______

Signature of Participant ______Date:______

Signature of Witness ______Date:______

122

Appendix B:

DEMOGRAPHIC INFORMATION

Age: ______

Education: ______

Profession: ______

Designation/Job-status______

Monthly Income ______

Job Experience/ Duration______

Marital Status ______

Previous Psychological History______123

Appendix C: 124

Appendix D:

From:

"Kaj Bjorkqvist"

View contact details

To: [email protected]

Dear Dr. Farooqi,

Most certainly! She may use it free of charge. If you make a translation of it for instance into urdu, please provide me with a copy. And, I wish her the best of luck with her research.

Warm regards, Kaj Björkqvist

At 22:02 18.8.2008, you wrote:

>Dr. Bjorkqvist

>Good Morning

>One of my students Miss Sadia Malik is conducting her PhD research

>thesis on Relationship Between Workplace Harassment and PTSD in

>Working Women In Pakistan. she wants to use your Work Harassment

>Scale in her research. Please grant her permission to use your scale.

>Looking forward to hearing from you soon.

>Warm Regards

>Dr. Yasmin Farooqi

125

Appendix E:

Re: Urgent Request from Dr. Yasmine Farooqi

Friday, October 10, 2008 10:34 AM

From:

This sender is DomainKeys verified

"anila kamal"

View contact details

To:

[email protected]

Dear Dr Farooqi,

On my behalf your student is allowed to use the questionnaire. but the policy of NIP is that the copy right of the questionaires developed here are with NIP you just have to request the incharged Test Resource centre of NIP. Mr Naeem Aslam on a "request form" available with him and have to deposit Rs 500.you can contact him through [email protected]

He will send you all the details and a proper permission letter best regards,

Prof. Dr Anila Kamal

--- On Thu, 10/9/08, Sadia Malik wrote:

> From: Sadia Malik

> Subject: Urgent Request from Dr. Yasmine Farooqi

> To: [email protected]

> Date: Thursday, October 9, 2008, 2:31 PM

> Dear Prof. Dr. Anila Kamal,

> One of my students Ms.Sadia Malik is conducting her Ph.D 126

> research thesis on Workplace harassment and PTSD among

> Pakistani women under my supervision. She wants to use your

> questionnaire entitled Sexual harassment Experience

> Questionnaire for her doctoral research.

> I request you to kindly grant permission for use of

> Sexual Harassment Experiences Questionnaire.

>

> An early response in this regard will be highly

> appreciated.

>

> Warm regards,

>

> Prof. Dr. yasmin N Farooqi

127

128

Appendix F:

Re: Urgent Request for permission

Tuesday, October 13, 2009 2:00 AM

From:

"Frank Weathers"

View contact details

To:

"Sadia Malik" Message contains attachments 3 Files (114KB) | Download All

Pcl_s.doc

Pcl_c.doc

Pcl_m.doc Hi, Sadia. I'm attaching the three versions of the PCL. These are in the public domain and may be used without further permission or charge. However, please do not modify the scales, except for minor formatting changes, without permission. You may translate the scales if you wish. If you do, please send me a copy of the final translations so that I can pass them on to the National Center for PTSD and make them available for other investigators. As far as scoring, as you may be aware there really aren't norms per se for any of the PCL versions, nor is there a manual or a single source that summarizes the empirical literature. Unfortunately you need to search the primary source literature to find articles relevant to your assessment needs. Your best bet is to search the PILOTS database. If you are not already a PILOTS user, here's a summary of the steps to access the appropriate studies.

129

1. go to www.ptsd.va.gov

2. click on "search PILOTS"

3. click on "advanced search"

4. click on "search tools: indexes"

5. select "tests and measures index"

6. type in "PTSD checklist"

7. select any of the boxes that include "Weathers" in the reference.

8. click on search.

This will give you all the studies that used the PCL.

The PCL is most often used as a continuous measure of PTSD. Each item is rated by the respondent on a 1-5 scale. To get a total PCL score, simply add the 17 items together to get a score ranging from 17-85. You may also wish to calculate severity scores for each DSM sx cluster, i.e., for reexperiencing sx add PCL items 1-5, for avoidance and numbing add PCL items 6-12, and for hyperarousal add PCL items 13-17.

The PCL has also been used to derive a dichotomous diagnostic variable. To do this, treat each item rated as a 3=moderately or higher as a symptom endorsed, then follow the

DSM diagnostic rule for PTSD, i.e., at least 1 B sx, at least 3 C sx, and at least 2 D sx.

Hope this helps. Good luck with your project. Frank

>>> Sadia Malik 10/7/2009 4:24 AM >>>

Dear Professor

Good Afternoon!

I am a student of Ph.D here in Pakistan at a local University and conducting my PhD research thesis on Relationship Between Workplace Harassment and PTSD in

Working Women In Pakistan. I want to use your PTSD checklist (Civilian version) in my research. Please grant me permission to use your scale.

Looking forward to hearing from you soon.

Warm Regards

Sadia Awan