Workplace Bullying in Italy: A Systematic Review and Meta-Analysis

Abstract

Background:

Within any work environment, employees may be affected by “workplace bullying”, a form of violent and repeated social behavior towards subordinates and colleagues. This review aimed to investigate the prevalence of bullied workers in Italy, the causes of the phenomenon, and the consequences at physical, psychological, and organizational levels.

Methods:

We included observational studies and systematic reviews examining the prevalence of bullied workers and the causes and consequences in Italian workplaces. Data extraction and analysis were performed on all included studies. The research strategy included three electronic databases (PubMed, Scopus, and Web of Science). A comprehensive search was done to retrieve articles based on a PRISMA-compliant protocol registered in PROSPERO: CRD 42023394635.

Results:

One hundred eighty-four articles were retrieved, and once duplicates and irrelevant articles were removed, 42 useful articles were reviewed. The mean pooled prevalence, calculated based on workers complaining of mistreatment, was 6.7% (SD: 4,09) and increased significantly to 17.0% (SD: 12.88) when considering only healthcare workplaces. Causes include how impaired mental health and high workload reinforce the possibility of being bullied in the workplace, resulting in a worsening of the worker’s quality of life (physical and psychological) and the work organization with increased absenteeism and job changes.

Conclusions:

Workplace bullying is a very present phenomenon within workplaces in Italy. In light of this, it is necessary to put prevention plans in place and find solutions to maintain optimal organizational well-being in the work environment.

1. Introduction

According to the National Institute for Occupational Safety and Health (NIOSH), workplace violence is the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty [1].

Workplace violence can come from anyone and be directed at anyone; it can be subtle or overt, deliberate or unintended, and maybe a single event or involve a continuing series of incidents. In addition, violence can victimize both men and women and may be initiated by or directed toward workers, clients, and members of the public [2].

Workplace bullying is part of this phenomenon and represents a serious form of psychological harassment conducted systematically and continuously by colleagues or superiors against an employee to cause him/her harm and exclude him/her from the workplace. The purpose of bullying is to eliminate a person who has become inconvenient by inducing him/her to resign voluntarily or by causing a reasoned dismissal [3].

It can be defined as “horizontal bullying” if it occurs between colleagues, “vertical bullying” if the victim is the employee or the employer, “corporate bullying” if it is the company that enacts this behavior against the employee, “strategic bullying” if it is carried out with well-defined strategies and “emotional bullying” if it is caused by negative feelings such as envy and jealousy [4].

Bullying may be direct or indirect aggression or a combination of both: direct bullying (physical and verbal) includes overt behaviors like hitting, threatening, and persistent humiliation in front of others; indirect bullying (non-verbal bullying) includes hidden behaviors. It is difficult to detect early and may include spreading rumors, withholding information, and intentionally isolating or excluding from a group [5].

Workplace bullying has negative effects on both the occupational well-being and the mental and physical well-being of workers. The most frequent disorders they suffer from are psychological disorders such as anxiety and depression, psychosomatic disorders such as headache, gastrointestinal and cardiovascular disorders, and behavioral disorders such as suicidal tendencies and alcohol and drug abuse [6]. The negative effects of bullying also affect work organizations with increased absenteeism due to illness [7] and the family with alterations in interpersonal relationships.

Data concerning the prevalence of workplace bullying worldwide are rather heterogeneous. There is wide variation in the reporting and recording of bullying worldwide. This may be due to several factors, such as lack of clarity in definition, variation in time frames assigned by the researcher, problems with validity and reliability of measurement, and organizational culture and structures [8].

In 2007, the Workplace Bullying Institute conducted the first representative study of adult Americans on workplace bullying. The study found that 37% of workers have been bullied [9].

According to the Fifth European Working Conditions Survey (EWCS: EUROFOUND, 2010), workplace bullying was estimated in 1.6% of the working population in the EU. However, this prevalence varied dramatically between countries, oscillating between 9.5% in France and 0.6% in Bulgaria. Since the method to estimate the prevalence of workplace bullying was the same across the countries that participated in the survey – that is, asking employees directly whether or not they considered they had been subjected to bullying over the past 12 months – it seems reasonable to think that personal and cultural factors might explain these vast differences [10].

Currently, in Italy, mobbing is not specifically recognized in the Civil or Criminal Code, though it conflicts with several regulations that sanction and regulate the proper conduct of work activities. The judgment of the Civil Cassation, Sec. labor, 6 March 2006, no. 4774, in particular, played an important role in the definition of the criminal case in Italy and linked it to Article 2087 of the Civil Code, stating that: “It can be carried out by material conduct or measures of the employer independently of the breach of specific contractual obligations provided for by the regulations of the employment relationship.” This also implies the point of view of the Criminal Code about causing, in the employee victim of mobbing, personal injury (of the body or mind), or death events that may occur in the case of serious harassment perpetrated over time. Moreover, mobbing contradicts Legislative Decree 81/08 as amended, which establishes the employer’s obligations to protect workers [11].

Workplace bullying is critical for its negative consequences on victims’ health and well-being, which is why secondary and tertiary prevention interventions are the most widespread. Nevertheless, the aim is to prevent the phenomenon when it has not yet developed [12].

Primary preventive interventions should target organizational culture and climate, work organization and job design, workgroup functioning, and leadership effectiveness, reward systems, and competition, among the main ones [13].

For example, eliminating or reducing recognized hazards in the workplace is the foundation of the Total Worker Health^® approach that promotes a hazard-free work environment, including bullying, for all workers. In particular, the “Hierarchy of Controls Applied to NIOSH Total Worker Health®” provides a conceptual model for prioritizing efforts to advance all workers’ safety, health, and well-being [14].

However, in the literature, there is still very low-quality evidence that organizational and individual interventions may prevent bullying behavior in the workplace. We need large, well-designed, controlled trials of bullying prevention interventions operating on the levels of society/policy, organization/employer, job/task, and individual/job interface [15].

This systematic review assesses the prevalence of bullied workers in Italian workplaces. The target population will be the adult working population. We will assess the causes of the phenomenon, the correlation between exposure to bullying and physical and psychological consequences on workers, and the correlation between exposure to bullying and consequences at the organizational level.

2. Methods

A systematic review was conducted on adult workers to investigate the prevalence of bullying in Italian workplaces and verify causes and co-related effects. The review was recorded in PROSPERO, the international prospective register of systematic reviews, and the registration number is CRD 42023394635. The study was conducted per the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines [16].

2.1. Search Strategy

Identification of studies relevant to this review was achieved by searching electronic databases of published literature, including PubMed, Scopus, and Web of Science. The keywords used on PubMed were: “workplace (bullying OR mobbing)” AND (Italian OR Italy). Scopus and Web of Sciences used the combination of two keywords: “workplace bullying” AND (Italian OR Italy) and “workplace mobbing” AND (Italian OR Italy). The search was undertaken with no language of publication restrictions. Articles search and data extraction was done between January 31, 2023, and March 1, 2023.

2.2. Study Selection

The review process was carried out using a multi-stage approach. Four authors conducted the selection and removal of duplicates independently [CC, DS, DG, II] and handled using ZOTERO. Then, after title and abstract screening, full-text articles were assessed to determine whether they met the inclusion criteria. If an included publication was unavailable as full text in English, the Corresponding Author was contacted to verify whether the eligibility criteria were met. Discrepancies and disagreements were discussed and resolved through a consensus session with a third-party researcher [GLT].

2.3. Inclusion and Exclusion Criteria

Inclusion criteria were as follows: i) studies involving workers in Italy; ii) the focus of the research is bullying; iii) the presence of information regarding the causes and consequences of the phenomenon. Exclusion criteria were: i) irrelevance to the research topic; ii) articles studying the phenomenon in other nations. There were no limits related to the publication date of the papers.

2.4. Data Extraction

Data extraction was conducted by four independent reviewers [CC, DS, DG, II], extracting data from all included studies. A data collection sheet was developed to confirm study relevance and to extract study characteristics. The following information was extracted from the studies: name of the first author, title, country, year of publication, study design, type of workplace, sample size, aim of the study, causes of the phenomenon, physical and psychological consequences, organizational consequences, assessment of the quality of the study. To ensure accurate data collection, each reviewer compared extracted data independently. Discrepancies and disagreements were discussed and resolved through a consensus session with a third-party researcher [GLT].

2.5. Quality Assessment

A quality assessment of the observational studies was carried out using the Newcastle-Ottawa Scale (NOS). This is a validated, easy-to-use scale of 8 items in three domains: selection, comparability, and exposure/outcome for case-control or cohort studies, respectively. Each item can be given one point, except comparability, which has the potential to score up to two points. Studies are rated from 0-9, with those studies rating 0-3 (poor quality), 4-6 (fair quality), and 7-9 (good/high quality). The NOS scale adapted for cross-sectional studies was used to assess the quality of cross-sectional studies [17]. This scale was a modified version of the NOS scale, as also used by several other studies that have felt the need to adapt the NOS scale so as to appropriately assess the quality of cross-sectional studies. Through a search of the literature, we found that a NOS score of 7 or more can be considered a “good” study [18, 19]. So, we used this criterion as a cut off for good quality study.

2.6. Statistical Analysis

A meta-analysis was conducted to assess the prevalence of bullied workers in Italy using the SPSS package version 27.0 (IBM Analytics, IBM Corporation, Armonk, NY, USA). Pooled prevalence of bullying was calculated only for studies in which the prevalence of bullying was reported or could be calculated. Studies were weighted by the number of participants. The prevalence of bullying was also calculated by considering only good-quality studies (NOS ≥ 7). In addition, a scatter plot was created to relate the prevalence of bullying and the degree of quality. Finally, the prevalence of bullying was also calculated by considering only studies related exclusively to the health sector.

3. Results

3.1. Search Results Summary

Research began in January 2023. The initial search across different electronic databases yielded 184 citations. First, a total of 68 duplicate papers were excluded, accompanied by the removal of 59 publications from the title/abstracts screening. Among the 57 full-text articles screened, 9 were not included. Finally, among the 48 articles selected and evaluated for eligibility, 6 reports were excluded because, upon further reading of the text, no useful correlations were found for our study. At the end of the process, 42 studies remained for qualitative analysis and 15 for quantitative analysis (Figure 1).

Figure 1.

PRISMA 2020 Flow Diagram.

3.2. Characteristics of Included Studies

Forty-two studies were selected for our systematic review (Table 1). Publication dates ranged from 2006 to 2022. Regarding study design, 41 were cross-sectional and one was a cohort study with 92,036 workers.

Table 1.

Characteristics of included studies and Quality Assessment.

1st Author[ref]	Year	Type of Workplace	No.	Bullying Scales	Quality (NOS)
Arcangeli et al. [20]	2014	Hospital and Healthcare	206	NAQ-R	8
Balducci et al. [21]	2020	Hospital and Healthcare	235	NAQ-R	6
Balducci et al. [22]	2009	Hospital and Healthcare, Public and Private Services	107	NAQ	7
Balducci et al. [23]	2012	Hospital and Healthcare, Public Administration	574	NAQ	6
Balducci et al. [24]	2015	Public Administration	609	NAQ-R	6
Balducci et al. [25]	2012	Public Administration	538	NAQ	7
Bambi et al. [26]	2018	Hospital and Healthcare	904	QuINI	7
Bambi et al. [27]	2014	Hospital and Healthcare	1202	LHQ	7
Buselli et al. [28]	2006	Public Services, Hospital and Healthcare	50	CDL	6
Campanini et al. [29]	2013	Public Services, Public Administration, Industrial Services, Private Services	8992	CDL	7
Caputo et al. [30]	2018	Public and Private Services	28	..	5
Chenevert et al. [31]	2022	Public Services	159	NAQ-R, S-NAQ	6
De Sio et al. [32]	2020	Hospital and Healthcare	191	HSE-IT	7
D’Errico et al. [7]	2011	Hospital and Healthcare, Public Administration, public Services	60763	..	6
Fadda et al. [33]	2015	University and Academic	221	NAQ-R	5
Fattori et al. [34]	2015	Hospital and Healthcare	755	..	6
Fenga et al. [35]	2012	Not Specified	63	LIPT Ege	5
Fiabane et al. [6]	2015	Not Specified	113	..	4
Fida et al. [36]	2018	Hospital and Healthcare	439	NAQ	6
Fida et al. [37]	2011	Hospital and Healthcare, Public Services	467	MOHQ	8
Finstad et al. [38]	2019	Industrial Services	512	NAQ-R	7
Giorgi et al. [39]	2011	University Services	3112	NAQ-R	6
Giorgi et al. [40]	2015	Industrial Services, Public Services	1393	NAQ-R	7
Giorgi et al. [41]	2015	Hospital and Healthcare	658	NAQ-R	8
Giorgi et al. [42]	2016	Industrial Services, Public Services	326	NAQ-R	6
Giorgi et al. [43]	2012	Public Services	371	UNICLIMA, NAQ-R	8
Giorgi et al. [44]	2009	University and Academic, Hospital and Health Care, Public and private services	926	NAQ-R, MDOQ10	8
Girardi et al. [45]	2007	Not Specified	160	..	5
La Torre et al. [46]	2022	Hospital and Healthcare	3129	WVHS	7
Lo Presti et al. [47]	2019	Not Specified	151	..	4
Nolfe et al. [48]	2010	Not Specified	707	..	6
Nolfe et al. [49]	2007	Hospital and Healthcare, Public Administration, Public and Private Services	533	..	5
Nolfe et al. [50]	2012	Not Specified	234	nQ-WD	8
Paciello et al. [51]	2019	Public and Private Services	1019	NAQ	8
Perbellini et al. [52]	2012	Not Specified	449	..	8
Punzi et al. [53]	2012	Public Services, Public Administration	100	CDL	8
Raho et al. [54]	2008	Not Specified	276	QAM	8
Romano et al. [55]	2007	Public Administration, Public and Private Services	500	LIPT Ege	4
Romeo et al. [56]	2013	Public and Private Services	48	..	5
Spagnoli et al. [57]*	2017	University and Academic	141	HSE-IT	6
Spagnoli et al. [58]	2017	Public and Private Services	134	S-NAQ	6
Vignoli et al. [59]	2015	Public Services	541	S-NAQ	7

*Cohort study.

NAQ – Negative Acts Questionnaire; NAQ-R – Negative Acts Questionnaire-Revised; S-NAQ – Short Negative Acts Questionnaire; QuINI – Questionnaire on Negative interactions between nurses; LHQ – Lateral Hostility Questionnaire; CDL – Questionnaire on bullying action; HSE-IT – Health Safety Executive Indicator Tool; LIPT Ege – Leymann Inventory of Psychological Terror Ege Professional; MOHQ – Multidimensional Organizational Health Questionnaire; UNICLIMA - Organizational Climate Questionnaire; MDOQ10 – Majer D’Amato Organizational Questionnaire 10; WVHS – Workplace Violence in the Health Sector Country Case Studies Research Instruments Survey;nQ-WD – Naples Questionnaire Work Distress; QAM – Self-perceived bullying Questionnaire.

The studies consider various workplaces, particularly public services (that included drivers, workers in airports, stations, etc.) with 19 studies, hospital and healthcare with 17 studies, private services with ten studies, public administration (that include municipality, local government, unions, etc.) with nine studies, university, and academia with four studies, industrial services with four studies; type of workplace was not specified in 8 studies. In assessing bullying risk, studies used different scales: the most widely used, in 22 studies, was the Negative Acts Questionnaire (NAQ), also in Short (S-NAQ) and Revised (NAQ-R) forms. The quality of each study was evaluated independently by four reviewers [CC, DS, DG, II] using the NOS scale: the lowest rating given was 4, the highest 8, with an average rating of 6.42.

3.3. Prevalence of Bullied Workers

Fifteen studies (Table 2) reported the aggregate prevalence of bullied workers. The median prevalence was 16.4% in studies scoring 8, 14.3% in those scoring 7, and 15.2% in those scoring 6. The prevalence in the study scoring 5 was lower (10.1%).

Table 2.

Prevalence of bullied workers.

1st Author[ref]	Year	Sample Size	Prevalence of the Phenomenon	Absolute Number	Quality Assessment (NOS)
Arcangeli et al. [20]	2014	206	21.4 %	44	8
Balducci et al. [25]	2012	538	13.4%	72	7
Bambi et al. [26]	2018	904	15.2%	137	7
Bambi et al. [27]	2014	1202	22.4%	269	7
Campanini et al. [29]	2013	8992	7.2%	645	7
D’Errico et al. [7]	2011	60763	4.8%	2897	6
Fadda et al. [33]	2015	221	10.1%	22	5
Fattori et al. [34]	2015	755	16.3%	123	6
Fida et al. [37]	2011	467	5.0%	23	8
Giorgi et al. [39]	2011	3112	15.2%	473	6
Giorgi et al. [43]	2012	371	19.0%	70	8
Giorgi et al. [44]	2009	926	16.4%	152	8
La Torre et al. [46]	2022	3129	15.3%	478	7
Paciello et al. [51]	2019	1019	14.0%	143	8
Vignoli et al. [59]	2015	541	3.51%	19	7

3.4. Causes of Workplace Bullying

There is not enough research to establish the causes of mobbing but that, if anything, the phenomenon is linked to a combination of factors, and it is unclear which is the cause and which is the effect. Assuming that bullying is independent of people’s character and no credence can be given to theories that want to identify groups most at risk, in our work, we have categorized causes according to Zapf’s subdivision [60], which investigated the factors influential in the experience of mobbing behavior in Germany and found them to be factors concerning the social system of the working group and organizational factors.

Considering the forty-two articles selected (Table 3), only eight investigate the causes of workplace bullying. Of these eight articles, three identify social system and organizational causes [28, 30, 39], and five are only organizational causes [21, 24, 38, 57, 58]. From the perspective of social causes, victims of bullying suffer from gossip and rumors, being ignored/excluded, suggestions of dismissal, repeated reminders of mistakes or errors [39], unfair accusations, and emotional abuse [30].

Table 3.

Causes of workplace bullying.

1st Author[ref]	Year	Causes of Workplace Bullying
		Social system	Organizational
Balducci et al. [21]	2020	..	Poor Working Conditions
Balducci et al. [24]	2015	..	Job Demands (Workload and Role Conflict) and Job Resources (Decision Authority, Co-Worker Support and Salary/Promotion Prospects)
Buselli et al. [28]	2006	Personality of the Bullying (Opportunistic, Authoritarian, Perverse), Manager Unfit; Incompatibility of Interpersonal Relations; Precarious Worker’s Health Conditions; Misunderstandings with the Union	Company Restructuring/Changes at the Top; Non-Agreement on Company Procedures or Strategies;
Caputo et al. [30]	2018	Unjust Accusations, Emotional Abuse	Organizational Constraints, Treatment Discrimination, Job Duty Changes, Precariousness, Lack of Recognition, Feeling of Exclusion and Job Disengagement
Finstad et al. [38]	2019	..	Workload, Lack of Control, Lack of Support
Giorgi et al. [39]	2011	Gossip And Rumors, Being Ignored/Excluded, Hints to Quit, Repeated Reminders of Errors or Mistakes (Private > Public)	Unmanageable Workload (Public > Private)
Spagnoli et al. [57]	2017	..	Workload, Psychological Strain, Organizational Change
Spagnoli et al. [58]	2017	..	High Workload

Buselli et al. [28] reports the opportunist, authoritarian, and perverse personality of the bully, the unsuitable role of the manager, incompatible interpersonal relationships, and misunderstandings with the union as causes. Work organization also plays a key role in the causes of bullying. The high workload [38, 57, 58], psychological tension, organizational change [57], organizational constraints, discriminatory treatment, job changes, precariousness, lack of recognition, sense of exclusion, job disengagement [30], poor working conditions [21], lack of control and support [38], corporate restructuring, changes at the top and failure to agree on procedures or business strategies [28] can be classified as organizational causes.

3.5. Physical and Psychological Consequences

Of the forty-five articles reviewed, thirty-two highlight the physical and psychological consequences of workplace bullying (Table 4). Of these, two highlight only physical consequences [43, 59], and eighteen highlight only psychological consequences [20, 22, 23, 30-33, 35, 38, 41, 42, 48-51, 55, 56]. Twelve identify both types [6, 45, 53, 23, 26-28, 34, 37, 47, 52, 54]. Prolonged bullying has been associated with worsening the victim’s quality of life, leading to physical and psychological consequences causing permanent problems [34, 37, 43]. Among the physical consequences, pathologies affecting the gastrointestinal system, such as colitis, irritable colon, and diarrhea, have been found [6, 23, 26, 28, 52]; affecting the nervous system, such as headaches, the feeling of diffuse muscle tension [26, 28, 52], choking sensation [26, 28], panic attacks [28]; dizziness and paresthesia [28]; excessive food consumption or loss of appetite [26, 28, 52]; affecting the muscular system with disorders of the lower back, upper back and neck [59]; affecting the cardiovascular system with tachycardia, chest oppression and chest pain [26, 27, 52]; sleep disorders such as insomnia, sleepiness and tiredness upon waking [53, 26]. Bambi et al. [26] also finds apathy and depression resulting in reduced concentration at work [26, 54]. Decreased libido can also be classified as a physical but also psychological consequence [28]. Regarding the consequences on a psychological level, Fattori A [34], highlights an important deterioration in the quality of life linked to bullying in the workplace.

Table 4.

Physical and psychological consequences.

1st Author[ref]	Year	Individual consequences
		Physical	Psychological
Arcangeli et al. [20]	2014	..	Loss of Self-Confidence, Social Consequences, Depression, Anxiety
Balducci et al. [22]	2009	..	Neurotic Component (Hypochondriasis, Depression, Hysteria) and Paranoid Component, Posttraumatic Stress Disorder, Suicidal Ideation and Behavior
Balducci et al. [23]	2012	..	Depressive Disorder
Balducci et al. [25]	2012	Irritable Bowel Syndrome	Psychological Distress, Depression
Bambi et al. [26]	2018	Chronic Fatigue, Gastrointestinal Disorders, Apathy, Reduced Concentration During Worktime, Headaches, Depression, Diffuse Muscular Tension, Excessive Food Consumption, Reduced Appetite, Sensation of Difficult Breathing, Chest Pain, Palpitations	Anxiety, Sleep Disorders, Irritability and Anger, Susceptibility, Sensation That the Working Life Exerts Negative Influences on the Private Life, Reduced Self-Esteem, Fear of Going to the Workplace, Lack of Desire to Go to the Workplace, Frequent Flashbacks About the Episodes of Abuse, Sensation of Remoteness/Alienation, Frequent Feeling of Guilty, Increased Consumption of Tobacco, Alcohol and Drugs
Bambi et al. [27]	2014	Chronic and Cardiovascular Illnesses, Psychosomatic Symptoms	Generally High Stress Levels, Reduced Self-confidence, Psychological Symptoms, Reduced Work Satisfaction
Buselli et al. [28]	2006	Decreased Libido, Tachycardia, Chest Oppression, Panic Attacks, Poor Sleep Quality (Insomnia, Sleepiness), Headache, Feelings of Suffocation, Gastralgias, Paresthesias, Dizziness, Diarrhea, Loss Of Appetite, Drug Addiction	Decreased Libido, Concentration Deficit, Irritability, Asthenia, Anxiety, Mood Disorders, Social Withdrawal
Caputo et al. [30]	2018	..	Job Disengagement (Affective Detachment and Powerlessness in Accomplishing Duties)
Chenevert et al. [31]	2022	..	Neuroticism
De Sio et al. [32]	2020	..	Worse Perception of Psychosocial Risks
Fadda et al. [33]	2015	..	Mental Health Problems
Fattori et al. [34]	2015	Worse Health-Related Quality-of-Life Scores (Above and Beyond the Effect of Concurrent Medical Conditions)	Worse Health-Related Quality-of-Life (Above and Beyond the Detrimental Effect of Other Concurrent Medical Conditions)
Fenga et al. [35]	2012		Depression, Hysteria, Paranoia
Fiabane et al. [6]	2015	Dyspnea, Palpitations, Gastrointestinal Diseases	Mood Disorders; Insomnia; Panic Attacks, Sleep Disturbances, Social Dysfunction, Post-Traumatic Stress Disorder
Fida et al. [37]	2011	Health Symptoms	Negative Emotions, the Three Discrete Emotions (Anger, Fear, And Sadness), Moral Disengagement
Finstad et al. [38]	2019	..	General Health (Anxiety, Loss of Security, Social Dysfunction)
Giorgi et al. [40]	2015	..	Job Dissatisfaction, Particularly Among Blue Collars; Women Reported Less Psychological Well-Being Than Men; Blue-Collar and White-Collar Employees Reported Less Mental Health Than Managers
Giorgi et al. [42]	2016	..	Psychological Distress (Workplace Bullying Was Indirectly Negatively Associated with Self-Management Ability Via Increased Psychological Distress)
Giorgi et al. [43]	2012	Health Problems	..
Girardi et al. [45]	2007	Somatic Symptoms	Depressed Mood, Difficulty in Making Decisions, Change-Related Anguish, and Passive-Aggressive Traits, Need for Attention and Affection.
Lo Presti et al. [47]	2019	Physical Negative Symptoms	Psychological Negative Symptoms (Anxiety and Depression)
Nolfe et al. [48]	2010	..	Anxiety Disorders, Mood Disorders and Adjustment Disorders
Nolfe et al. [49]	2007	..	Adjustment Disorders, Anxiety Disorders (Post-traumatic Stress Disorder) and Mood Disorders (Depression)
Nolfe et al. [50]	2012	..	Mood Disorders, Anxiety Disorders, Mainly Somatoform
Paciello et al. [51]	2019	..	Negative Emotions (Fear, Anger, Sadness), Disengagement and Compensatory Behavior
Perbellini et al. [52]	2012	Sleep Disorders, Gastrointestinal Problems, Eating Disorders, Cardiovascular Disorders	Post-Traumatic Disorder, Chronic Adjustment Disorder
Punzi et al. [53]	2012	Fatigue Upon Waking, Frequent Awakenings, Muscle Tension, Antidepressant Use	Depression, Anhedonia
Raho et al. [54]	2008	Difficulty at Work	Anxiety, Obsession, Depression, Anger, Antisocial Behavior, Family Problems
Romano et al. [55]	2007	..	Depressive State
Romeo et al. [56]	2013	..	Hypochondria, Depression, Hysteria, Paranoia, Suicidal Ideation (Common Among Victims)
Vignoli et al. [59]	2015	Musculoskeletal Disorders of The Low Back, Upper Back and Neck	..

Health issues include negative emotions such as anger, fear and sadness, moral [26, 37] and occupational [30] disengagement, fear of going to work, lack of desire to go to work, frequent flashbacks on the episodes of abuse [26], psychological and social distress [20, 26, 28, 32, 38]; lower self-management skills, reduced self-esteem, difficulty in making decisions, anxiety related to change and passive-aggressive traits resulting in a need for attention and affection [4, 20, 27, 40, 42]. Bullying also causes mental health problems such as anxiety disorders, mood and adjustment disorders, attention difficulties, hypochondria, depression, hysteria and paranoia, suicidal ideation and behavior, neuroticism, post-traumatic stress disorder, chronic adjustment disorder, anhedonia, psychosomatic and stress disorders [6, 53, 20, 22, 23, 25, 27, 28, 31, 33, 35, 38, 47-56]. Drug addiction, antidepressant use, and increased tobacco use can be identified in both groups of consequences [53, 26, 28].

3.6. Organizational Consequences

Analyzing the forty-five selected articles, ten report organizational consequences of workplace bullying. Three studies [7, 29, 34] highlight how absenteeism in the workplace is a frequent consequence of bullying, while two of them [6, 27] describe it as a consequence of the victim’s desire to change departments or jobs (Table 5). This leads to a loss of productivity through absenteeism [34] and a distorted perception of workers as invisible, interchangeable, and unnecessary, thus contributing to their affective detachment from work contexts [30]. The worker then reports making mistakes while at work [26]. Giorgi [43] investigates how bullying affects the organizational climate by interfering with work, autonomy, communication, and development. Finally, Giorgi [41] showed an indirect relationship with burnout.

Table 5.

Organizational consequences.

1st Author	Year	Organizational Consequences
Bambi et al. [26]	2018	Reported Making Errors During Work
Bambi et al. [27]	2014	Change Departments/Services of Assignation
Campanini et al. [29]	2013	Sickness Absence
Caputo et al. [30]	2018	Workers Perception of Being Progressively Invisible, Interchangeable, Unnecessary, Thus Contributing to Their Affective Detachment from Work Contexts
Chenevert et al. [31]	2022	Role Conflict Influences Posttraumatic Stress Disorder Symptomology Through Exposure to Bullying, Which Differs Based on the Level of Managerial Competencies
D’Errico et al. [7]	2011	Sickness Absence
Fattori et al. [34]	2015	Productivity Losses (Absenteeism and Presenteeism)
Fiabane et al. [6]	2015	Change Of Job or Department
Giorgi et al. [43]	2012	Workplace Bullying Influenced Organizational Climate (Job Description, Autonomy, Development, Communication, Job Involvement)
Giorgi et al. [40]	2015	Workplace Bullying Partially Mediated the Climate-Burnout Relationship and Influenced Health Only Indirectly

4. Discussion

This systematic review aimed to assess the prevalence of the phenomenon in the Italian workplace and to investigate the causes and consequences it has on the physical and psychological health of the worker as well as on the organization. The average prevalence of bullied workers in Italian workplaces was 11.9%, excluding D’Errico’s [7] study, and 6.7%, including this large study. Considering only good-quality studies, the prevalence was 11.2%, rising to 17.0% if only studies conducted in the health sector were considered. Regarding the prevalence of the phenomenon worldwide, a meta-analysis, in which samples from twenty-four different countries and a multinational sample were represented, reports an overall prevalence of 14.6% [61]. Among European countries, from a survey conducted in 2000, Finland shows the highest rate (15%), followed by the Netherlands and the United Kingdom with a rate of 14%, Sweden 12%, Belgium 11%, France and Ireland 10%, Denmark 8%, Germany and Luxembourg 7%, Austria 6%, Spain and Greece 5%, Italy and Portugal 4% [62]. Workplace bullying has also been prevalent in non-European countries, e.g., in Japan, the reported rate is 15% [43].

The prevalence rates of workplace bullying vary considerably depending on cultural and geographical characteristics, the method used to detect it, and the work environment investigated. Considering only the studies conducted in the healthcare sector, this systematic review revealed a much higher prevalence (17%). This result is very important and in line with other studies in the literature according to which employees in the healthcare sector have a high risk of exposure to workplace bullying [63-66]. According to Kingma [67], people working in the health sector, in particular, doctors and nurses, have a sixteen times higher risk of being exposed to negative behavior than in other work sectors; the risk for nurses is also three times higher than for other employees in the health service.

A recent cross-sectional study conducted in Italy reported a prevalence of 15.3% among health workers, with nurses being the most affected category. According to this study, no significant differences exist in the phenomenon’s prevalence among the department healthcare workers belong to [46]. Another study also points out that the professional category of nurses is particularly at risk of bullying, without any demographic or gender differences [20]. Although no type of healthcare worker can be considered free from this risk, as shown by most studies investigating this phenomenon, the most at-risk departments are emergency and psychiatry [68-71] and radiology and infectious diseases [68, 72-74].

The scientific literature often focuses on detecting the phenomenon and the consequences in terms of the victim’s quality of life. Still, it is equally important to identify the causes to be able to intervene preventively.

Regarding the causes of workplace bullying, it was found that only a low number of them investigate this aspect. In discussing these issues, it is important to premise that there is a difference between finding a cause, what our work is intended to achieve, and attributing blame or responsibility. Leymann and other authors make a critique against all those who identify victims as having “problems” or inherent character frailties. Rather, bullying directly expresses a pathology of production and decision-making processes within companies and workplaces [75].

Considering this, in analyzing the causes of the phenomenon, we have considered social and organizational factors. The work environment and the social context can be factors that favor the presence of the phenomenon. A worker subjected to unfair accusations, emotional abuse, gossip, repeated reprimands, and suggestions of dismissal, who is excluded from his or her work environment, or who has misunderstandings with his or her union affiliation is at high risk of frustration resulting in bullying attacks. A study conducted in Germany confirms how exposure to the demands and pace of work is correlated with an increased risk of being exposed to bullying. In contrast, job resources, including leadership quality and job influence, acted as protective factors [76].

Among organizational causes, particular importance is given to the high workload of employees, which can generate role conflict and psychological tension among colleagues. Organizational change, corporate restructuring, and failure to agree on strategies and procedures are all triggers. Workers who have high prospects for pay or promotion or who, on the contrary, do not get the recognition they deserve or who suffer discrimination may face harassment. Numerous studies have considered psychosocial risks related to work organization as the main cause of bullying, highlighting how certain elements of organizational design could act as barriers and drivers [77, 78].

The victim of bullying then has a worsening quality of life with both physical and psychological consequences. The physical consequences that are most commonly described are gastrointestinal system disorders such as irritable bowel syndrome, diarrhea, and loss of appetite, cardiovascular system disorders that may result in disease and/or chronic. Apathy, continuous headaches, dizziness, impaired sleep quality, chronic fatigue, reduced concentration, and libido seem to be other common consequences. Work-related stressors could activate the brain aging process, leading to cognitive impairment with a risk of dementia and Alzheimer’s disease. One study reviewed looks at brain changes demonstrating decreased hippocampal volume in major depressive disorder [79].

Regarding the psychological aspect, we found several consequences related to mental health problems such as depression, anxiety, hysteria, post-traumatic stress disorder and mood disorders, suicidal behavior, paranoia, and repeated irritability and anger. The individual may face social consequences and lower job satisfaction. Studies reviewed also report increased alcohol and psychotropic drug use as both physical and psychological consequences.

Finally, the organizational consequences of workplace bullying were assessed in our work. A strong presence of absenteeism was highlighted, which can sometimes take the form of departmental change to the point of job change, particularly in the healthcare sector. This mode of action was found to be similar in an Australian study in which bullied healthcare workers initially absented themselves from duty in an attempt to recover; the next coping strategy was calling in sick or not showing up for work at all, and finally if the bullying persisted, resignation [80]. Our study also found that such absenteeism results in a loss of productivity and quality of work. Concerning healthcare workers, this aspect was also highlighted in a Swedish study in which it was shown how not only being bullied but also being a bystander can have consequences on the job and the organization, affecting the perceived quality of care, employees’ work commitment and their intention to leave the organization [81]. Bullied workers also report feeling unnecessary or even invisible in the workplace. Indeed, in the literature, although the most important effects of bullying and harassment are arguably found at the individual level (ranging from increased anxiety and reduced job satisfaction to symptoms of depression and burnout) [82], it has also been noted that bullying and harassment may be expected to hamper various variables at the work unit and organizational levels. Where bullying and harassment impede job satisfaction or internal cooperation, it is likely that factors such as turnover and absenteeism will be heightened, impeding the organization’s functioning [83].

4.1. Strengths and Limitations of the Study

This review aims to provide an overview of the bullying situation in Italy, trying to assess what could be the causes of this phenomenon and its consequences. Since the study was based on cross-sectional studies, it does not claim to identify any causal inference but to report the consequences and causes most frequently reported in the literature. Another review by D’Assisti et al. [7] examines the phenomenon of bullying in the Italian workplace and focuses on gender differences and the characterizations and ways in which they are committed. Our article aims to have a broader scope in describing the bullying phenomenon: in fact, in our review, several aspects were considered, not only the prevalence but also the causes, the consequences on workers and the organizational ones. Another strength of our study is the quality of the studies considered, which is moderate. The review, however, is subject to limitations. The first limitation is related to the fact that the causes and consequences extrapolated from the articles were formulated based on questionnaires filled out by employees of the various companies. The causes are those indicated or hypothesized by workers but not proven. Similarly, the consequences are those that might occur or that, in some studies, are associated with the experience of violence. In addition, the prevalence we found is not that of cases of bullying but that of workers complaining of being mistreated, as the authors of the articles do not point out to us that these situations have occurred. Secondly, the general prevalence refers to different survey and selection methods and different working environments: it must be considered that employees in the workplace can more or less perceive the condition of bullying based on their sensitivity and culture. for example, the prevalence is higher in European countries where civil rights are more guaranteed [84]. Thirdly, it should be noted that, as reported by numerous studies and reviews, professionals are not interested in reporting violence for a variety of reasons but mainly due to previous experiences of no subsequent/successful action or fear of the consequences and lack of management support [85, 86, 87, 88] so the calculated prevalence may be underestimated. Finally, we need to recognize that some evidence was retrieved from papers that were published as abstracts of Occupational medicine Congresses, that usually do not follow a rigorous peer review process.

5. Conclusions

Bullying in Italian workplaces is far from negligible, particularly in hospitals. Companies should develop strategies to prevent it, reducing or eliminating the risk and enabling the acquisition of skills by workers to manage and evaluate these events when they occur.

Declaration of Interest:

The Authors declare no conflict of interest.