Health consequences of workplace bullying: experiences from the perspective of employees in the public service sector

Abstract

The aim of the study was to explore the perceived health consequences of workplace bullying. Open interviews were conducted with 22 informants; 20 bully victims and two persons working with bullying prevention. Data was assessed and analysed simultaneously in line with grounded theory methodology. A conceptual model was grounded in data, describing experiences of deteriorating psychological and physical health following bullying and efforts of returning to a “normal” life. The core category, “remaining marked for life”, illuminates the manner in which bullying was perceived as a psychic trauma or a traumatic life event causing the bullied person to be marked forever. The model includes five additional categories: “feeling guilt, shame and diminishing self-esteem”, “developing symptoms and reactions”, “getting limited space of action”, “working through the course of events” and “trying to obtain redress”. Bullying included the spreading of rumours and repeated insults aimed at changing the image of the victim and resulting in feelings of guilt, shame and diminishing self-esteem. Physical and psychosomatic symptoms gradually emerge and medical treatment and sick listing follow. The longer the bullying continues, the more limited the possibility to change the situation and the victim has a more limited space of action. Returning to a “normal” life was possible, but presupposed that the victim had worked through of the course of events. The bullied person also tried to obtain redress, such as through monetary compensation or professional confirmation. Despite this, bullying left an internal scar: the bully victim was marked for life.

• Workplace
• adult bullying
• grounded theory
• health
• self-esteem

Introduction

The distinction between bullying, harassment, conflict and violence varies considerably between studies (Rayner & Hoel, 1997). Although harassment might be viewed as the broader perspective incorporating sexual and racial harassment behaviour, bullying and harassment often co-exist and they can be seen as two sides of the same coin (Nazarko, 2001). Workplace bullying has been defined as persistent demeaning and downgrading of human beings through vicious words and cruel unseen acts, which gradually undermine confidence and self-esteem (Adams, 1997). This means that bullying differs from daily conflicts at the workplace through its repeated and prolonged insults of a person's dignity. Bullying includes that the victim feels harassed and a common rule of thumb is that frequency of actions should be more than one incident a week lasting for a period of at least six months. Harassment, defined as “recurrent negative actions directed at particular employees in a reprehensible manner that can lead to their exclusion from social interaction at the workplace” (AFS 1993, p. 3), can take a variety of expressions, but includes subtle and different treatment of harassed person from that of other people. Prevailing work culture as well as personal thresholds of acceptance affects the interpretation of behaviour as bullying and its acceptance (Rayner & Hoel, 1997).

Although bullying and harassment are reported to be major and severe problems among adults at workplaces, prevalence figures vary greatly between studies and countries. In part, the discrepancy in prevalence figures may reflect differences in definitions of bullying as well as differences in the selection of study samples. In addition, differences in assessment methods may contribute to differing results. Two main approaches in estimating the prevalence of bullying can be distinguished: (1) the so-called “subjective method” in which respondents consider their experiences to fit a “global” definition of bullying; and (2) the so-called “operational method” in which respondents report how often they have been exposed to certain negative behaviours during the previous six months without being presented with a definition of bullying.

For illustrative purposes, three studies estimating the prevalence of bullying among adults in three different countries (Norway, Sweden and Great Britain) will be briefly described. Data from 14 Norwegian surveys (n=7986), representing different organizations and professions, showed that 8.6% of respondents reported that they had been bullied at work during the previous six months (Einarsen & Skogstad, 1996). In the study, the prevalence of bullying did not differ by gender, however, significantly more men were reported to be bullies. Leymann (1996) found that 3.5% of a representative sample (n=2400) of the Swedish working population were victims of bullying (or “mobbing”, the term used by Leymann) at the workplace and that no significant gender difference could be found. In a study from Great Britain, Hoel, Cooper and Faragher (2001) found that 10.6% of the respondents from 70 organizations within the private, public and voluntary sectors (n=5288) had been bullied within the last six months.

In the above-mentioned studies from Norway and Great Britain, the subjective method was used and a global definition of bullying was presented to the respondents. The operational method was used in the Swedish study, i.e. respondents reported how frequently they were exposed to certain negative acts/behaviours during the previous six months. Both over- and under-reporting of the prevalence of bullying may be possible, however the operational method is considered the most reliable way to estimate prevalence figures (Gemzøe Mikkelsen & Einarsen, 2001). Although the “true” prevalence is difficult to estimate, workplace bullying is probably more frequent in Western society than people actually realize (Björkqvist, Österman & Hjelt-Bäck, 1994).

There are many definitions of health, but to-date, no precise and commonly accepted definition exists (Karlberg, Hallberg & Sarvimäki, 2002). A bio-psycho-social model of health stresses the temporal interactions between biological, psychological and social factors in understanding health and ill health (e.g. Pennebaker, 2000). Rather than seeing health as purely the aim of living, health can also be seen as a resource for everyday life, as an important prerequisite for human life and as a fundamental right for every human being (WHO, 1986). This “resource-oriented” view of health also includes the resources in the individual's social environment. This perspective on health provides a basic rationale for health promotion work. In line with these definitions of health, national workplace environmental legislations in Sweden, Norway and Finland prescribe that employees have the right to remain physically and mentally healthy at work. Managers are required to be attentive and familiar with what goes on in the workplace and should be able to recognize early signs of harassment and bullying. This law implies that managers have the main responsibility for creating a healthy work environment including preventing and managing workplace bullying. However, research has shown that workplace managers are very insecure and inactive in these respects (Leymann, 1992) and that the organization is reluctant to take this issues seriously (Rayner, 1997). According to Rayner and Hoel (1997), insufficient work control and high levels of role conflict can be seen as precursors to bullying. In line with this, escalating conflicts at work in combination with weak and/or indistinct leadership was perceived by bully victims as a preliminary stage of bullying in the public service sector (Strandmark & Hallberg, 2006).

Several studies have shown connections between workplace bullying and ill health in the form of psychosomatic symptoms and severe psychological stress symptoms (e.g. Niedl, 1996; Einarson, Raknes, Matthiesen & Hellesøy, 1996; Einarsen & Raknes 1997; Gemzøe Mikkelsen & Einarsen, 2001). Symptoms of post-traumatic stress disorder (PTSD) and general anxiety disorders have also been identified in bully victims (Björkqvist et al., 1994; Leymann & Gustafsson 1996). Interestingly, non-bullied employees can also be negatively affected when they witness workplace bullying. Studies have shown that observers of bullying reported significantly more general and mental stress reactions than those who did not witness bullying (Einarsen & Raknes, 1997; Vartia, 2001; Quine, 2001). Bullying can even affect a victim's desire to continuing living his/her life. Leymann (1990) estimated that between 100 and 300 individuals of those who committed suicide in Sweden during one year had a history of experiencing workplace bullying. The health consequences of workplace bullying, as reported by bullied adults in their own words, have so far received little attention in research. Thus, the aim of the present qualitative study was to explore health consequences of workplace bullying as experienced and told by informants in their own words.

Method

Grounded theory

Grounded theory methodology was used in the present study. The aim of such a method is to generate concepts, models or theories from empirical data rather than to verify an existing theory. By this, the overall aim is to gain a deeper understanding of the studied area. Although in recent years the method has been advanced and developed in different directions (e.g. Glaser & Strauss, 1999; Strauss & Corbin, 1998; Charmaz, 2000), the fundamental techniques seem to be the same: open and theoretical sampling, hierarchical coding processes, constant comparison, memo writing and identification of a core category (Dellve, Henning Abrahamsson, Trulsson & Hallberg, 2002). Constant comparisons of data, as well as development of emerging categories and hypotheses are constantly present in grounded theory studies (Glaser, 1978). Theoretical sensitivity is necessary in the process of identifying categories (Glaser, 1978) and includes the researchers’ ability to think inductively without conscious preconceptions. Memo writing, which serves as an intermediate step between coding and the completed analysis, helps researchers to explore ideas about emerging categories and to keep track of the coding (Glaser & Strauss, 1999; Strauss & Corbin, 1998; Charmaz, 1995).

Participants

Twenty-two informants (15 women) with a mean-age of 58 years (range: 41–77 years) formed the study sample. For practical reasons, they were recruited through an advertisement in a daily newspaper and on the electronic home page of our department. Twenty of the informants had had the personal experience of being bullied and the two remaining persons worked actively in the area of bullying prevention. All informants were employed currently or previously in public service organizations in different positions, including various levels of teachers and nurses, occupational and physiotherapist, social and medical secretary, police officer and priest. At the time of the interview, ten of the informants were retired, six were on sick leave, four had recently changed workplaces, one had commenced further education and, lastly, one had begun work with the preventing of bullying at the same workplace.

Data collection and procedure

After a first telephone call to the researchers, the presumptive informants received written information about the aim and the procedure of the study and, thereafter, gave their informed consent in writing. Accordingly, participation in the study was on a voluntary basis. The informants were then invited to choose a suitable location for a taped interview, the duration of which was between one and two and a half hours. Twenty of the informants were interviewed face-to-face and two were, because of geographically long distances, interviewed over the telephone. An open interview was conducted with each of the 22 informants. An interview guide was used, comprised of open introductory questions concerning their experiences of bullying at the workplace, the perceived health consequences of bullying and the perception of their psychosocial work environment. The interviewer asked relevant follow-up and probing questions when appropriate. The researchers started with as few preconceptions as possible and remained open to what was told in the interviews. The initial open sampling of informants, aimed at maximizing variations in the data, was later followed by a more theoretical sampling. This theoretical sampling implied that emerging results (i.e. emerging categories) of the simultaneous process of collecting and analysing data directed what data would be collected next and which probing questions would be used to saturate the data. Accordingly, the theoretical sampling process was entirely controlled by the emerging categories and ceased when data was saturated. This saturation meant that new interviews did not add new information.

Data analysis

Data collection and data analysis occurred simultaneously in line with grounded theory guidelines (e.g. Glaser & Strauss, 1999). The hierarchical analysis consisted of initial coding, focused coding and memo writing. Initial line-by-line coding, in close proximity to data, opened up the data and helped the researchers to see the familiar in a new light. In the analysis the researchers interacted with data by asking questions, such as, “what is the meaning of this expression?”.Through this process, data was segmented into smaller units, or codes. These initial codes were labelled concretely and were continuously compared with each other so that similar phenomena were given the same label. The initial codes were then grouped into focused codes, which were less open-ended, more conceptual and formed potential categories/concepts. These potential categories were sorted according to meaning, patterns and processes. Constant comparisons were made between different parts of the data, different incidents and experiences and between different emerging categories in order to explore similarities and differences in the data. Theoretical sampling was conducted in order to refine and saturate each category with information. Thus, saturation meant that additional data did not add new information. Conceptual relationships between categories were hypothesized, sought and verified (grounded) in the data during the entire analysis process. A core category/core concept was identified, which was central to the data and determined the emerging conceptual framework (Glaser, 1978, 1992). During the entire process, theoretical reflections, assumptions and notes were documented in the form of memos.

Ethical considerations

In line with the ethical principles for research, an interview time was scheduled after the participants had already agreed to take part in the study (HSFR, 1994). The participants were informed about how the interview data would be documented and reported and that their confidentiality would be respected. The study design was approved by the Research Ethics Committee of the University of Gothenburg (Ö 590-99: T 065-02).

Results

In the analysis, a preliminary conceptual model was generated, describing the informants’ experiences of deteriorating psychological and physical health following adult bullying at the workplace (see Figure 1).

Figure 1.  A conceptual model of being marked for life by bullying, as experienced by informants with experiences of workplace bullying in the public service sector.

The core category/core concept of the model was labelled remaining marked for life, meaning that adult bullying was perceived by the informants as a severe psychological trauma or a traumatic life event. Except for the core category, the conceptual model was composed of five additional categories/concepts, labelled feeling guilt, shame and diminishing self-esteem, developing symptoms and reactions, getting limited space for action, working through the course of events and trying to obtain redress. According to the informants, bullying included the spreading of rumours and repeated insults aimed at changing the image of the bully victim negatively, resulting in “feelings of guilt, shame and diminishing self-esteem”. Physical and psychosomatic symptoms gradually emerged (“developing symptoms and reactions”) and medical treatment and sick-listing often followed. The longer the bullying continued the more limited the possibility to change the situation (“getting limited space for action”), such as changing workplace. Returning to a “normal” life might be possible but presupposed the process of “working through the course of events” related to the bullying. This process was often painful, as events from bullying were re-lived over and over again both in dreams and when awake. The bully victim was also “trying to obtain redress” through, for example, monetary compensation, professional confirmation or by gaining a new meaning in life. Despite this, bullying left an internal scar or vulnerability, which was perceived as never entirely healing; the bully victim “remained marked for life”. Each category will be further elaborated and illustrated by excerpts from the interviews below.

Remaining marked for life

The emerging core category, “remaining marked for life”, illuminated that bullying was perceived as a psychic trauma, a traumatic life event, or as a life crisis. According to the informants, bullying left an internal scar or vulnerability, which would never heal completely, but would easily reopen and continue to cause harm. Despite this, the bully victim had to continue living his/her life with the awareness of this personal vulnerability. When he/she was reminded of bullying, for example, through the media, this reopened the old internal wounds. We were told in the interviews that when this occurred and the bully victim started talking about the bullying, his/her voice became forced and tensed and painful memories were brought back to him/her again. The following excerpt from the interviews illustrates the core category:

No, I will never forget it (the bullying), never ever. There is still a large scar left inside me. I always have to carry this scar with me … and I have never managed to understand them (the bullies) either. That (the bullying) was an episode that now has passed away and now I have to continue living my life. But I think it would have been much easier to live my life without this scar inside … that is what I think … definitely. When I, for example, read in the paper about someone being bullied somewhere, the old scar reopens and it hurts. In some way I must try to repress it all the time … if it is possible.

Bullying could also be looked at as some sort of a life crisis, which was the case for some of the informants. Contrary to other life crises, bullying was most often perceived by these informants as a purely negative event rather than as an event that also provided personal development and strength or other positive gains:

I do not know if there is anything positive about this (the bullying) … it might perhaps have given me a somewhat increased understanding of other people. But personally I do not think of it (the bullying) as anything positive. It has been said that you often get strengthened through a life crisis but I am very doubtful of that statement. No, I think it (the bullying) has solely been negative for me.

Bullying could also be perceived as destroying or “cracking” the mental or physical health, professional career and personality of an exposed person. An informant, a female teacher in her forties, who was bullied by her manager, gave an example of this way of thinking:

She (the bully) has actually cracked my health. She has also cracked my professional career … and my personality as well … everything that earlier was me, that is no longer me.

Feeling guilt, shame and diminishing self-esteem

According to the informants, adult bullying included the spreading of rumours and repeated insults intended to change the image of the bullied person in a negative way. The informants experienced that this aggressive behaviour on the part of the bully created uncertainty and doubtfulness concerning the adequacy and degree of truth of the rumours and, consequently, feelings of guilt developed. The interpretation was that the feeling of being less valued as a person was projected by the bullies and then taken on by the bully victim. This transference feeling of being less valued also grew within the victim. The bullied person even felt that he/she deserved the bullying and, thereby, rapidly accepted the bullying as an adequate state. According to the informants, a fear that the bullies would reveal the victim's genuine self appeared due to feelings of incapacity and dissatisfaction with himself/herself. Feelings of shame arose, behaviour changed and health deteriorated when the bully victim blamed himself/herself for the bullying. The bullying continued, although the bully victim perceived that he/she was gradually broken down. Despite this, he/she hesitated to tell others, even the closest family and friends, about the bullying.

The informants in the study perceived that their self-esteem was failing, due to the fact that the bullies blamed them for conflicts and a lack of comfort at the workplace. Other informants perceived that their self-confidence and self-esteem were affected by the bullying. The bully victim accepted the blame due to a sense of inferiority and shame. In order to divert attention from other problems at the workplace, all negative events at the workplace were perceived to be attributed to the bullied person who thereby became a “scapegoat”. Frustration and worry at the workplace were commonly channelled through the bully victim, who thereby perceived that he/she carried the bully's burdens. The bully victim assumed feelings of guilt and blamed himself/herself, believing that he/she was disloyal, created irritation and made life difficult for colleagues. The bully victim adjusted fairly easily to the situation because of his/her understanding of being the cause of the bullying, which also affected his/her self-image:

I lost my self-image completely as well as my ability to have trust in myself. I felt that I was worthless and a really bad human being.

Developing symptoms and reactions

The interviews showed that the bullied person usually was afflicted with psychological and psychosomatic symptoms at an early stage, mere months after the bullying commences. Emotional reactions, for example, could consist of inability to concentrate and/or sleep, mood swings, anxiety, depression, despair, and fear. The informants described how they sometimes could not find words when expected to speak, lack concentration and suffered loss of memory due to feelings of a lack of reality. Psychosomatic symptoms could include, for example, headache, gastric catarrh, and hypersensitivity to sounds but could also present as respiratory and cardiac complaints, hypertension and pain all over the body. Initially, the symptoms disappeared when the bullied person was not at work, but over time, the symptoms became long-standing and more or less chronic. Sometimes the bullied person already suffered from a disease prior to the bullying, e.g. asthma, diabetes and hypertension, the symptoms of which might become worse due to the bullying:

My weak link is the breathing … the respiratory passages … so I have now been stricken by asthma … real severe asthma … I have got inhalations of medicines but the symptoms have not disappeared. I have to have medical check-ups regularly.

The informants related the occurrence of these emerging symptoms to the bullying and often physicians established a relationship between the symptoms and the work situation. It was difficult, and perhaps impossible, for physicians and other professionals to comment on a causal relationship between bullying and the emerging symptoms. According to the interviews, the informants’ perception was that they did not receive understanding, sympathy or empathy from professionals or colleagues. Two of the informants described their fear, anxiety and frustration like this:

I cried many times on my way home from work. On coming home with my shopping bags, I just dropped them on the floor and then collapsed myself. I just lay there and whimpered like a wounded animal.

I just wanted to disappear from everything … not to die … and it was not a cry for help … I just wanted to disappear. I thought that now it is 4 or 5 o'clock in the afternoon and soon it will be night and then I can go to bed and just sleep. Then I am going away. But then I realized that there will come another day tomorrow and then I felt desperation. And I realized that after that day there will be another day again. Then I felt a deep despair. Admission to the hospital could be the case with electric shocks for my depression.

The informants told that they lived in a, more or less, constant fear of both the bullies and the negative rumours that had been spread about them. They could suffer from anxiety or panic attacks, lacked strength to interact with other people and tried to avoid the bullies by any means possible. For example, the bullied person sometimes became terrified when somebody called his/her name. An informant described feeling afraid when the telephone rang while another related that his/her family had become socially isolated and had not invited anyone to his or her house for five years. Accordingly, the bullied person retreated and gradually isolated himself/herself when in almost constant fear of that the bullying would start again.

Having limited space for action

At the beginning of the bullying process, the bullied persons experienced certain opportunities to leave the workplace voluntarily and to seek new equivalent places of employment. Nevertheless, they often remained in the workplace in which they experienced the bullying. As time went on, choice to change the work situation became more and more limited and the pressure of work could become too great. In the first phase of the bullying process, the bullied person usually had the possibility to obtain good references, and could apply for and often get another equivalent job. However, he/she could be persuaded to stay at the original workplace for several reasons. A reassurance of a permanent position, as for most other people, may be important for the bullied person in order to meet his/her costs of living. There may also be limited possibilities for finding a new equivalent position in the bully victim's local area. Moving to another location was in several cases perceived as impossible, due to the fact that the bully victim lived close to a sick and/or elderly relative who needed support and help. He/she could also live in an isolated area, where there were few job vacancies available. For these reasons, the bullied person was prevented from leaving his/her current job before obtaining a suitable position elsewhere. Furthermore, according to the interviews, the bullied person considered there to be no reason for him/her to change jobs because of the bullying. This view was especially true if the bully victim had been employed in that position for several years. Generally, the possibilities for changing jobs became more limited the longer the bullying continued. The bully victim may not obtain another job due to bad references and rumours that have been spread about him/her. This dynamic is illustrated below:

Every time I applied for a position they rejected me, saying that I didn't fit in. I eventually asked what the problem was. They replied that my supervisor had told them that I was dishonest and completely inexperienced in terms of the special pedagogy involved. Then the association for victims of bullying phoned and pretended to take my details. Then it became clear to me that my employers had spread rumours.

According to the interviews, when the bullying showed no sign of abating, the bullied person realised that the decision to remain at the workplace was wrong. At that point, he/she no longer had the necessary energy to look for other jobs, in addition to this, a fear of applying for other positions took over. When the bullied person's career was over and his/her health severely damaged, he/she realized that it would have been better to follow the advice of others and leave the job at an earlier stage. Afterwards, the job itself was perceived as overestimated as regards its costs in terms of the bullied person's failing health.

Working through the course of events

According to the informants, the painful process of returning to a normal life started with working through of the course of events related to the bullying. The bullying was relived when the victim described the course of events orally or in writing, met the bullies or was exposed to something that reminded him/her of the bullies. When the victim met the bully, the fear returned and he/she sometimes experienced physical sensations such as palpitations, breathing difficulties and blurred vision. The bullied person could also have bad nightmares and dreams about the bullies and his/her negative experiences of what had transpired between them. In the dream, the bully was even more evil than in reality and the victim could awoke in a cold sweat. Suddenly, without warning, the fear overtook the victim, again showing the victim that he/she was still in the bully's power because the relationship with the tormentor persisted. In the immediate aftermath of the bullying, the victim often experienced flashbacks:

I had a flashback after six months when thinking about it because it coincided with a major fire tragedy. I was in church and when a candle was being lit, I cried copiously. I was ashamed of sitting there crying to myself but then the clergyman said that the light evokes a lot of other emotions and that it's nothing to be ashamed of.

According to the interviews, thoughts of suicide offered a final solution when the bullied person was incapable of changing the situation. Perceived meaning in life then disappeared and the bullied person became weary of life. In this situation, the desire for death could surface, as the bullied person considered him/her to be unworthy and life meaningless. In the interviews, some informants described having made careful plans of ways to commit suicide and described how they came close to carrying out these plans. Informants also described how family, children, medical treatment and religious faith could assist in preventing a bullied person from committing suicide.

The bullied person perceived a great need to talk about the course of events repeatedly in the presence of a sympathetic and emphatic listener. The victim had to convince himself/herself that the bullying was unjust and not his/her own fault. Working through the bullying and the course of events, both consciously and in dreams, was described as a painful process. This work took a long time, and in this process, the bullied individual sometimes required professional help. Occasionally, this process also had to be complemented by medical treatment.

Trying to obtaining redress

At the time for the interviews, the informants turned out to be at different stages of the bullying process. Some of them were actually returning to a normal life by working through the course of events and addressing issues such as redress, revenge, and reconciliation. At this stage, the bullied person felt relieved that he/she was not totally destroyed by the bullies and that he/she has had the power and tenacity to raise himself/herself up again:

I can say that I sold myself as dearly as I possibly could … I dare say I fought for every square metre. I thought that they were unfair and in the wrong because I had devoted all my energy to the school … I haven't won any victories over people … but I try to console myself with the fact that I have learnt a great deal from it … I'm glad that I have managed to do what I've done but it's very much thanks to my wife who has supported and helped me.

In internal and external processes, the bully victim fought for justice and for confirmation that the bullying was unfair and not his/her fault. It seemed to be difficult, or impossible, for bullied individuals to move on from the bullying without obtaining some form of redress. The victim battled against both the bullies and the authorities to obtain redress in the form of monetary compensation or professional confirmation. Some bully victims said that they wished for revenge, while others desired reconciliation. Revenge implied that the bully victim would like to repay the bullies for the injuries they had experienced. The victim often wanted to chastise the bullies, report them to authorities, tell others about them and punish them in other ways. Alternatively, other bully victims desired reconciliation by forgiving the bullies in line with their religious beliefs. At the time of the interviews, some bully victims expressed that they now had to make healthy choices in order to be resilient in life. Some informants had left the workplace and moved elsewhere in order to start a new life, a new job, a different ward or to resume further education.

I have a heck of a fighting spirit. When I become involved in something and I'm in the right, then I just won't give in. They never got to know the person I was. Having made something positive out of something basically negative has strengthened my self-confidence.

In other cases, the bully victim ended the employment due to his/her own will, failing health or was forced to quit for other reasons. Voluntary work, such as sport training or studies of interesting topics seemed to provide strength, motivation and confirmation, as well as gave new meaning to life and inspired the victim to go on. According to the interviews, psychological and religious knowledge could also help the bully victim to understand the bullying as such, and some victims received power and consolation from religious faith. The interviews also indicated that bullying in a few cases resulted in positive experiences. For example, a bullied person experienced that he/she, because of the bullying, had become more humble and attentive towards other people.

Some informants perceived that they had obtained the mental strength to dare to continue with life instead of burying themselves in unpleasant past experiences. According to these informants, the whole situation improved when they left the workplace in which the bullying occurred. However, despite leaving the workplace, they still believed that the bullying was wrong and unjust and could not forgive the bullies.

Discussion

The result of our study is presented as a conceptual model including a core category showing a person exposed to workplace bullying as being marked for life. Based on our data, we argue that adult bullying can be seen as a serious psychological trauma leaving internal wounds that will never entirely heal. Despite this, returning to a “normal” life may be possible but requires a long and painful process of working through of the course of the unpleasant events that the victim has experienced. In addition, some form of redress seems to be necessary for a bullied individuals’ return to as normal a life as possible. The redress can be in the form of, for example, receiving economic compensation, getting professional confirmation and/or finding a new meaning in life. Some of the informants in the study had actually returned to a normal life. The bullied person then fights for redress, which in itself, may give a new meaning to life. Redress also provides the confirmation that the bully victim is in the right and has done no wrong, which relieves feelings of guilt and shame. According to our informants, when the bullying is ongoing, support is sparse and lacking from colleagues, managers, unions and occupational health services. The bullied person's view of what has happened or is happening is often questioned or judged by the listeners as the victims’ perceived misconception of the situation. The lack of empathic listeners may be understood as the listeners’ way of defending themselves from heightened emotions, such as anger, grief and despair, through dissociating and questioning the reliability of the stories told by bully victims (Tehrani, 2004).

The willingness to address issues of bullying and harassment among practioners and researchers appear to be strongly associated with the perception of their significance as serious health and safety hazards (Hoel, 2004; Vartia, 2004). In addition to this, there is an apparent risk that bully victims are being marginalized or excluded from the labour market; this provides considerable cost to society. Our study aims to explore the perceived health consequences of bullying and includes informants from the public service sector. Downwards bullying (by managers or employers), as well as horizontal bullying (from one colleague to another) was described by the informants. It is obvious in the data that bullying leads to severe psychosomatic symptoms, yielding self-esteem and failing general health, which is also found in several self-report studies (e.g. Leymann, 1992; Björkquist et al., 1994; Einarsen et al., 1996; Niedl, 1996; O'Moore, Seigne, McGuire & Smith, 1998; Quine, 2001).

Our data show that bullying includes rumours, slander and gossip, which at an early stage, lead to failing self-esteem and self-confidence in the bully victims. Self-esteem describes an individual's assessment of his/her self-worth, which depends on how the surrounding culture values the individuals’ qualities and how well his/her behaviour matches the prevailing standard of worthiness (Bandura, 1997). Accordingly, based on self-evaluative attitudes, or the perception of oneself, the self-esteem is built up or damaged in social interactions (Randle, 2003). Bullied individuals are depreciated by the bullies’ experience that the bully victims’ own standard of worthiness is invalid and that the bullies are right. According to the data, the bullied individuals adjust themselves to the bullies, due to fear that it will be revealed how bad the victim actually is as a person and that, for example, their true selves will be revealed. Thus, victims feel insecure and doubtful about whom they actually are as human beings; which releases their feelings of guilt and shame. In this situation, the bullied person tries to isolate himself/herself from the bullies in order to protect his/her identity.

Our informants perceived that the bullying caused long-standing stress conditions. Psychologically influenced by this stress, victims experienced difficulties in concentrating, thinking and, in some cases, finding the right words when expected to talk. According to the social cognition tradition (e.g. Piaget, 1971), beliefs, values and assumptions are constructed by the individual and stored as cognitive schemas in his/her brain guiding subsequent perceptions and appraisals. These individual patterns of cognitions and beliefs are vulnerable to disruption at times of stress and trauma (Tedeschi & Calhounn, 1995), such as bullying at the workplace. In an experimental study, Björklund (2004) found reduced ability to process cognitive information (i.e. prolonged response time and higher error rate) among bully victims as compared to a control group, indicating that bullied persons are more disturbed in their daily living. This deviates from intentions formulated in the national work environmental legislations prescribing that employees have the right to remain physically and mentally healthy at work. According to the law, managers have the main responsibility for creating a healthy workplace and for preventing workplace bullying. However, Leymann (1992) argues that managers are still very insecure and inactive in these respects. In line with this, Einarsen et al. (1996) have found correlations between high occurrence of workplace bullying and leadership style (i.e. lack of leadership). In addition, weak or indistinct leadership was perceived by bully victims as contributing to those conflicts escalated into systematic bullying at workplaces in the public service sector (Strandmark & Hallberg, 2006).

A bullied person often loses his/her job and, as a result of the rumours that have been spread, is unable to obtain a new equivalent position. In that way his/her opportunity for action becomes more and more limited, which agrees with Björk's (1995) findings that one intention of bullying is to increase the bullies’ space of action. Rayner (1997) found that several bullied individuals did absolutely nothing, and remained in their jobs and were less active than their non-bullied peers were in confronting the bully and in consulting personnel, unions and colleagues. Such behaviour is an example of the bullied persons reduced space of opportunity for action whereas the bullies’ space of action presumably increases. Accordingly, our study reveals that the bullied person loses not only human dignity, health and social life, but also career prospects (O'Moore et al., 1998). However, some informants also described that bullying may result in positive experiences, for example, that they as bully victims had become more humble and attentive towards other people. The concept of post-traumatic growth is commonly used to describe such positive changes in the individual after a traumatic exposure (Tedeshi & Colhoun, 1996) such as bullying. In line with this, Tehrani (2004) argues that adjusting to the aftermath of a psychological trauma may result in a positive self-worth and improved interpersonal relationships.

The present data emanated from individuals who had personal experiences of workplace bullying: twenty of the informants had been bullied and two had worked actively with prevention of workplace bullying. Grounded theory methodology, with its systematic collection, organization and interpretation of written data, aims to improve the understanding of the studied area; in this case the health consequences of bullying as described by informants with experiences of workplace bullying. The result of a qualitative study, like the present study, might be strengthened by two contributory researchers’ supplementing and contesting each others’ statements (Malterud, 2001). We entered the field with as few opinions as possible about what we could expect to find. Continuously, emerging categories and hypotheses were critically discussed in relation to our possible preconceptions. Theoretical sensitivity (Glaser, 1978) meant that categories were grounded in the data rather than the data being forced into preconceived categories. Using theoretical sampling and memo. writing, the emerging categories were saturated with information. The rigorous and systematic procedures, briefly described in the method section of this paper, contributed to the validity and the quality of the study. Qualitative research does not provide findings that are generally transferable (Malterud, 2001), but should be seen as containing descriptions or models applicable within specified settings. This means that the present findings are transferable to bullied victims in the public service sector in Sweden. Different European studies illuminate that employees in the public service sector are more exposed to bullying and harassment as compared to employees in the private sector, indicating the importance of exploring organizational aspects through further research on bullying (Hoel, 2004). In future research, we plan to investigate the roles of the organization and the leadership in workplace bullying in the public service sector. The overall aim of such research is to illuminate factors contributing to a healthy workplace and, thereby, to prevent the occurrence of workplace bullying and subsequent health consequences.

This study, which is a part of a larger project, was financed by a grant to Professor Lillemor Hallberg from the Swedish Council for Working Life and Social Research (FAS). We are also grateful to university student Gabriella Hallberg, who skilfully transcribed the interviews and to PhD student Anastasia Pharris, Karolinska Institute, Stockholm for professional language editing.