Introduction

The corporate world is changing, becoming less stable, and more chaotic [1]. Boddy, et al. [2] indicated that acquisitions, mergers, buy-outs, and takeovers are becoming the norm for rapid actions and movement of leadership throughout organizations. Leaders in modern organizations leave openings for executive leaders to get in and then quickly get out before the organization settles and establishes accountability [2]. Clark [3], a leading organisational psychologist, argued that in modern chaotic organizations, it is possible for bullies to function undetected while internally damaging the organization, rewarding themselves, and bullying employees. Mathieu, et al. [4] found behaviors displayed in supervisors such as egocentricity, deceptiveness, lack of caring, impulsivity, irresponsibility and ignoring or violating organizational social norms directly and negatively related to job satisfaction, psychological distress, and work-family conflict.

Literature Review Summary

The research revealed healthcare leaders, regulatory bodies, and governmental officials have developed little if any expectations to address bullying in healthcare organizations. There are few states that have implemented bills to address workplace bullying. The research literature supports aggressive standards and action surrounding the outcomes of workplace bullying for personal and professional’s reasons in the healthcare industry. Previous qualitative studies document negative outcomes to individuals and the organizations, yet limited studies have shown a connection between workplace bullying in healthcare and patient care outcomes.

Workplace bullies tend to join various organizations particularly where abusive management is tolerated. Clark [3] found that if employees are not willing to succumb to the workplace bully, the victims may consider resigning and moving on. A submissive and passive individual may fare well working with or under a workplace bully. Perhaps these individuals might be willing to absorb the abuse, but most employees clash, suffer ill effects, demoted, reassigned, or fired. Bullies exploit and fire employees on the basis of their personal needs and can devalue and discard people because of their need to control and keep their bullying behaviors secret. These behaviors and constant exposure to interactions with a bully do result in psychological, emotional, and verbal abuse.

A large amount of research is emerging in organizational psychology studying employee-employer relationship. The findings showed frequent positive workplace interactions, engagement with co-workers and management, increased productivity, reduced psychological strain at work, and improved employee attitude. Interestingly, questions about bullies are the focus of speculation and research studies for the last two decades. The last few decades have revealed the true mystery of the workplace bully because the majority of bullies manage to ply their trade without drawing attention to their behaviors. Studying the behavioral dimension of individuals who exhibit bullying behaviors is important because their lack of control and behaviors are not always observable, but exhibited toward others. In fact, if organizational leaders cannot spot specific bullying behaviors; employees and organizations are at risk of victimization.

Personal and professional values of the nursing profession revolve around altruism, autonomy, dignity, justice, and truth [5]. Nurse’s behaviors are exhibited through their dependability, initiative, cooperation, empathy, communication, and professional presentation. Day et al. [5] indicate nurses promote positive emotions, are highly engaged during patient care, establish trusting relationships with patients and their families, find personal satisfaction and meaning in their work, and seek to accomplish making a difference in patients’ lives. Nurses explain their choice of profession as a calling for various personal reasons. These reasons are because of their dedication to others, caring about humanity, or prior experiences. Nurses, like other employees, must have a sense of well-being while caring for the most vulnerable population.

The behaviors exhibited by bullies may include:

(1) verbal abuse, (2) accomplished lying, (3) manipulation, (4) humiliation, (5) ridicule, (6) isolation of employees, (7) criticism, sarcasm, and demeaning behaviors, (8) assigning meaningless tasks, (9) work overload, (10) unexplained rages, (11) exclusion, (12) blocking of promotions, (13) contradictory instructions, (14) withholding information, (15) unexplained rages, (16) fabricating complaints, (17) interfering in work practices, (18) setting impossible deadlines, (19) constantly changing instructions, (20) physical abuse, (21) offensive email or messages, (22) hiding documents, (23) silencing.

Design and Method

The qualitative descriptive case study seeks to explore, discover, and describe nurse’s perceptions about workplace bullying behaviors by female healthcare executives. Exploration of the study is from the perspective of Seligman’s theory of wellbeing and grounded in positive psychology with five associated issues in relation to bullying: (a) perceived experience, (b) description of bullying, (c) personal outcomes, and (d) professional outcomes because of bullying.

Theoretical Framework

The graphical representation of Seligman’s theoretical framework of well-being consists of five main elements of meeting individual’s well-being. Seligman’s model PERMA draws on aspects of: Positive emotions, engagement, relationships, meaning, and accomplishment [6]. When the elements of wellbeing are not met employee’s disengagement, have negative feelings, less job satisfaction, and function at a lower level. Strong evidence regarding factors that influence well-being at work is under review. Well-being has potential implications for leaders and organizations. Different features of individuals and their working lives have various degrees of influence over multiple aspects of well-being. Increasing employee’s feelings of having a sense of meaning and purpose, promoting positive experiences, motivation, morale, engagement, and building relevant relationships fosters well-being.

Research Questions

The main question for the qualitative descriptive case study is, “What are the perceptions of nurses surrounding their personal and professional perspectives about bullying behaviors and its outcomes.”

Four sub-questions include:

R1 What is the perceived experience of nurses who are bullied by female healthcare executives?

R2 How do nurses describe being bullied by female healthcare executives?

R3 What are the perceived personal outcomes, if any, on nurses who are bullied by female healthcare executives?

R4 What are the perceived professional outcomes, if any, on nurses who are bullied by female healthcare executives?

Sampling Technique

The technique is a random purposeful sampling technique relying on the judgement of the researcher to select the individuals or groups of participants. A purposeful sampling technique is used in the study not to intentionally select people from the population creating a sample to make generalizations, but from a sample of the population of interest. Denzin and Lincoln [7] indicated that in qualitative research study smaller sample sizes will allow for manageable data collection and analysis with data saturation. The potential participants will be solicited through a nurse registry and email notification. Specific demographic information will not limit eligibility. The participants must be actively working as registered nurse in 2017, in a healthcare setting indicated in the study, and report being bullied by a female healthcare executive. The final sample consisted of 30 participants through one-on-one interviews to collect data through purposive sampling. The sampling criteria are nurses (both male and female), actively employed in 2017 in a healthcare setting (Home Health, Short-Term Acute Care Hospital, Skilled Nursing Facility, or Managed Care Organization) in Milwaukee, Wisconsin, and can enter into informed consent.

Data Collection

Data collection occurred through one-on-one interviews conducted at a setting of the nurse’s choice, but away from the healthcare organization where the nurse worked. The environment enabled a quiet secure location for meeting with the nurses and increased confidentiality and identity protection. Data collection procedures included three brief interviews with participants. Eligibility determination occurred during the first interview, a dual audio-recorded interview occurred during the second interview, and interview transcription review and approval occurred during the third interview.

Significance of the Study

There are studies on general bullying, but limited studies from a scientific point of view about bullying behaviors by female executives in healthcare organizations, outcomes to employees, and the organization. The mystery surrounding bullies is confusing, and individuals may be unaware of the difference between an abusive leader, leaders with poor skills, or a bad boss.

Significance to Leadership

A successful organization is highly dependent on a leader’s ability to optimize human capital and have both a positive and negative influence on both employee and organizations. Effective leaders understand the importance of achieving goals by establishing healthy relationships with their employees through modeling behavior, setting clear standards, and recognition that include rewards for exceptional performance. Leaders must maintain a positive relationship with co-workers and other superiors because without a positive working relationships counterproductive workplace behavior spirals out of control and generate an uncivil working environment.

Significance to Organizations

Organizational professionals have faced many challenges in researching bullying. The behaviors and dynamics of bullies has many idiosyncrasies and professionals have had a difficult time exploring and describing what bullies are, do, and why they behavior in specific ways. The subject of bullying, in a business context, continues to receive attention from television documentaries and business journals. Organizational consulting work assures people that executive bullies exist in the work place across the globe. However, the extent of damage bullies cause is unknown because few studies are completed and the behaviors go unreported.

Significance to Employees

The research results do report that nurses suffer long-term emotional and psychological damage, being involved with or from being in contact with female healthcare executives exhibiting bullying behaviors. Nurse’s report witnessing emotional and psychological devastation in organizations created by leaders who exhibit abusive behaviors toward all employees. The results found that employees are not believed or feel as if they are going crazy. Last, nurses who tried to explain the behaviors of a workplace bully report their organizational leaders and human resource departments state they themselves are troublemakers, serial complainers, or have relational issues with others. Bullying in the healthcare setting by female executives do jeopardize nurse’s wellbeing and result in personal, professional, and healthcare outcomes for patients and their families.

Significance to Patient Outcomes

The research study did show errors in patient care with nurses attributing these to the physical, emotional, and psychological effects of bullying by their female executives. The study found a relationship between bullying behaviors and employee emotional withdrawal, poor training, decreased concentration, lack of organization, inadequate communication, and poor overall wellbeing. These conditions decrease morale, lower self-esteem, and cause low self-confidence, thus negatively influencing the job and outcomes. The study showed victims of a workplace bully suffer from poor concentration, insomnia, headaches, depression, exhaustion, fear, suspicion, anxiety, forgetfulness, and fatigue possibly resulting in poor patient outcomes.

Emergent Themes

Four major themes emerged from sub-question R1: feeling incompetent, others not believing them, constant thoughts about events, and feeling hopeless, depressed, and alone. Eight additional themes emerged from sub-question R2: undermining work, constantly changing directions, fabricating complaints, verbal abuse, patronizing and sarcasm, ridicule and criticism, threatening action, and argumentative. Four themes that emerged from subquestion R3: fear, hypersensitivity, relational dysfunction, and thoughts of worthlessness. Four themes emerged from sub-question R4: errors, job hopping, career derailment, and reputation. As nurses shared personal experiences with bullying, a pattern emerged that helped explain the emerging themes. Although experiences differed for each participant, those experiences consistently revealed situations in which the participants questioned their abilities. As emotional and psychological obstacles increased their personal lives suffered and the desire to continue to work in the nursing profession reduced. Nurses justified the feelings and beliefs as being the result of internal barriers and external influences of being bullied by a female healthcare executive.

Obstacles were similar for many of the nurses including a lack of support from human resources, organizational leaders, and other nurses. Nurses struggled with the suggestions provided by human resources such as tips to have a better relationship with their executive leader. The nurses felt left alone to deal with the recommendations and had difficulty trying to figure the problems of bullying out by themselves. The nurses believed no matter what they tried it would continue to be detrimental to their personal and professional lives. The nurses would have liked some guidance and support to help them deal with the emotional and psychological effects of bullying. Nurses indicated there were no additional recommendations from anyone in the organization to address the bullying behaviors leaving them even more alone.

Twenty additional themes emerged from this study:

(a) feelings of incompetence, (b) others would not believe them, (c) constant thoughts of the events, (d) hopeless, depressed, and alone, (e) undermining work, (f) constantly changed instructions, (g) fabricating complaints, (h) verbal abuse, (i) patronizing and sarcasms, (j) ridicule and sarcasm, (k) threatening action (write ups/termination), (l) argumentative (not allowing opinions/discussions/input), (m) fear, (n) hypersensitive, (o) dysfunctional relationships and interactions, (p) thoughts of worthlessness/different from others, (q) errors, (r) job hopping, (s) career derailment, (t) reputation. Although nurses identified these behaviors, most shared frustration and confusion in knowing how to deal with their experience. If nurses had knowledge about bullying behaviors and strategies, then the potential damage of bullying behaviors might decrease or disappear.

Interpretation of Results

The analysis indicated a definite reluctance in healthcare organizations towards addressing bullying behaviors by female healthcare executives. Nurses discussed reluctance in reporting the behaviors and provided reasons for that reluctance including human resources and other organizational leaders not believing them and a lack of action to address the behaviors. Healthcare leaders need to identify and ensure complaints of bullying are taken seriously. If nurses are not supported and provided available strategies to improve the work environment, success (both personal and professional) becomes unreachable and patient care is in jeopardy.

Healthcare leaders need to accept responsibility for the actions of leaders in their organizations, act quickly on issues surrounding bullying, and seek out opportunities to educate individuals on workplace bullying. Human resource officials need to be more proactive in supporting nurses and execute strategies to reduce the negative personal and professional outcomes of bullying behaviors. When nurses are struggling with a female healthcare executive that is exhibiting bullying behaviors, nurses need to find resources to guide them towards strategies to deal with the experience. Expecting nurses to independently deal with bullying when already experiencing negative emotional and psychological trauma will not help nurses heal.

Implications

The many implications of workplace bullying on individuals and the organization are impressive. The cost of bullying on organizations include employees leaving, reduced productivity, loss of creativity and innovation. Individuals that use sick day’s increases and efficiency is likely to decline. These costs will have a domino effect creating additional organizational decline. Employees that are non-targets are also pulled into the fray suffering emotional and psychological stress that has implications on their ability to work effectively. Legal measures by employees might deflect organizational funds for legal defense needs, potential unemployment insurance, and workman’s compensation claims leading to financial bottom-line consequences. However, the greatest cost to the organization is the loss of qualified personnel. Turnover results in large costs because of orientation, training, and hiring processes. The cost to hire, orient, and train one employee can cost between $30,000 and $75,000 for each individual subjected to workplace bullying adding more cost and stress to the organizational bottom line.

The implications on the employee are frightening. Workplace bullying has a significant negative outcome on well-being and health to an alarming extent including depression, aggression, insomnia, anxiety, stress, psychosomatic effects, physical and mental ill health, and workplace bullying. The linkage between workplace bullying and Post-Traumatic Stress Disorder in studies further solidifies the negative outcomes of bullying in the workplace. The long-term outcomes of being bullied and victimized creates in targets the need to protect their image and work even harder trying to no avail to strengthen their self-respect through any means possible.

Significance for Health Care Organizational Leadership

Employees of harassment and bullying undergo various types of retaliation on an ongoing basis. Bullying, as described in this study, shows that bullying contributes to negative outcomes on victim’s health and well-being as well as patient outcomes including a connection to workplace bullying and high turnover rates, increased absenteeism, sickness rate, and turnover rate in conjunction with disruptive workplace behaviors. The financial cost of responding to workplace bullying should be centered on turnover, sick leave, absenteeism, and productivity. Millions of dollars a year in financial losses is devastating for healthcare organizations. The intangible costs of workplace bullying in healthcare includes patient errors involve quality of care, financial aspects of these errors, and additional medical expenses incurred because of errors related to workplace bullying.

Healthcare leaders might make a valuable contribution to initiating a zero-tolerance policy, mandating accountability, and training leadership to promote a safe work environment limiting or eliminating workplace bullying in healthcare organizations. Organizations, governments, and communities must put an emphasis on responsibility, honesty, fairness, and environmentalism as part of ethical values and visions. Developing ethics in leadership within organizations will encompass processes of change in relationships between economic, social, a and natural systems. Healthcare leaders will meet their needs without jeopardizing future generations ability to meet their needs and producing ethical leaders. The importance of elevating, shaping, altering, and motivating values and goals of followers is crucial. A relationship-oriented trust between leaders and employees is significance for positive change. This relationship can produce positive outcomes including productivity and effectiveness. Motivating and encouraging followers to become committed to organizational goals and looking past their personal interests might be appealing to their higher order needs and well-being.

Recommendations for Future Research

Further research in the area of workplace bullying bears important implications for healthcare leaders, accreditation bodies, governmental officials, and victims of bullying. One of the critical issues in a successful organization is building an effective human organization where all employees work efficiently and harmoniously together. Leaders in healthcare organizations display abusive behaviors toward employees with negative outcomes while disrupting processes, productivity, efficiency, and morale. The literature shows workplace bullying behaviors undermine follower’s self-esteem and well-being in many ways; personally, and professionally. Progress has been made over the last 20 years, but research remains sparse in certain areas.

Suggestion for future research into workplace bullying include:

(a) research on organizational culture and workplace bullying behaviors that study if bullying behaviors are contagious, permeate the organization, and have implications on interpersonal relationships with co-workers, professional bonds, and commitment to colleagues and the organization, (b) explore workplace bullying behaviors and outcomes with family and friends, (c) integrate other frameworks including organizational and personality factors to help understand what workplace bullying is, (d) study organizations where bullying does not exist to identify and understand the culture and positive organizational behaviors, (e) research ways to study bullies themselves in their natural environments, (f) explore the role and reactions of witnesses of workplace bullying, (g) use qualitative research studies highlighting the meaning, behaviors, observations, process, subtleties, and other aspects of a work relationship with a bully, (h) consider prospective and longitudinal studies providing a more robust base of evidence, (i) research the organizational responses to reports of workplace bullying, (j) study healthcare accreditation bodies and their influence on incidences of workplace bullying, (k) investigate adverse events to patients because of workplace bullying in healthcare organizations, (l) examine states and countries were anti-bullying laws are implemented and their outcomes.

Recommendations for Healthcare Leaders

Organizational leaders should consider what characteristics are important in their leaders including authentic communication and empathy. While screening may weed out a few ineffective leaders one way to ensure workplace bullies do not establish a foothold in the organization is to build an environment of respect and value for people. A healthy culture is led from the top and supported by policies and practices that sustain a healthy workplace. Jung and Adopting a systematic approach to workplace bullying involves all departments of an organization including leaders, human resources, employees, and social partners in dialogue to promote awareness and implement bullying prevention programs. Knowing about the problem and acknowledging its existence is the first step in identifying these behaviors. Completing a risk assessment on workplace bullying is an important step in reviewing the organizational culture and environment where bullying may be ignored, tolerated, and promoted. Quantitative methods of data collection may be most useful because of the sensitive nature of bullying and employee’s reluctance to report the behaviors for fear of retribution. However, conducting staff surveys (confidential or anonymous), group, and one-on-one discussions, follow-up on complaints, absenteeism, and sick leave are methods to help leaders identify, address, and expose workplace bullies.

Leaders should create a safe and easy communication channel to express concerns about leaders and colleagues. Communicating to employees that an anonymous compliance hot line is of use when reporting incidences and encouraging leaders who suspect bullying should focus on objective indicators of the leader. For example, departments that are led by a bully may have low morale, high absenteeism, and many resignations. Assess the team of employees when the bully is not present. The team of employees may be more relaxed, joking, and talkative. Watch for blame shifting by the bully because bullies do not see themselves as part of the problem. Leadership may use triangulation of data including quality measures, key performance indicators, and the use of Human Resources when turnover is high, and 360-degree performance evaluation feedback. Various organizations have a code of conduct or code of ethics policy. Developing a formal and detailed policy addressing workplace bullying may include acceptable and unacceptable behaviors, a statement of commitment, and acknowledgement of the problem including a statement that bullying is not tolerated and will be treated with disciplinary action such as termination.

Additional policy considerations include:

(a) Outlining manager duties, (b) outline grievance and complaint and disciplinary procedure, (c) investigation and support provisions, (d) policy monitoring, and (e) maintenance of fairness and confidentiality. These policies must be disseminated to all staff by means of awareness campaigns, work contracts, posters, leaflets, email communicating, handouts, and the organizational intranet. In conjunction with the dissemination of information, education and training about bullying and its outcomes may be an effective method for prevention of workplace bullying. Informing employees about workplace bullying at meetings where the entire organization is present may be particularly useful to target leadership. These training and education sessions are useful in informing those individuals in the wider social context about workplace bullying.

Supporting work redesign and improvement in the organizational culture as an additional strategy to address bullying behaviors. Leaders should lead by example and create norms of behaviors throughout the organization encouraging corporate responsibility. Removing leaders who are not displaying positive behaviors should be dealt with promptly and organizational leaders must be willing and capable of terminating individuals who chronically bully employees from the organization. A secondary approach may require an outside representative, mediator, or a professionally trained counselor to help with workplace bullying reports. Trained professionals use numerous techniques including debriefing, narrative therapy, and cognitive behavioral therapy to analyze an individual’s situation.

Recommendations for Healthcare Accreditation Agencies

Workplace bullying may lead to increased levels of stress and frustration impairing concentration, collaboration, and communication. Failure to communicate may result in acts of omission, delayed treatment, medication errors, or failure to follow appropriate orders during patient care. Clarification of physician orders and safe patient care is a process where concentration, attention to detail, and focus is essential to avoid possible patient errors. Patient safety is dependent on various aspects of an environment including communication and collaboration. Outcomes of bullying may be a precipitating factor in patient care errors thus compromising patient safety. The Joint Commission (TJC), a healthcare accreditation body, may consider focusing on the standards set by their organizations when surveying facilities. Ensuring and promoting a culture of safety TJC should identify organizational policies addressing the standard, educate organizations about prevention, and protecting employees against disruptive bullying behaviors. Nursing associations should consider calling for a zero tolerance to bullying in the workplace as well as political activism in all states to support and enforce anti-bullying laws.

Recommendations for Government Officials

Governmental regulations against victimization make an important contribution, provide hope, and belief in a future where bullying in organizations is prohibited. Legislation has placed the accountability and responsibility of preventing workplace bullying on organizational leaderships with little or no support from the public health sector. There are internal economic implications to leaders who permit workplace bullying including turnover, decreased productivity, poor customer satisfaction, high employee healthcare costs because of bullying, and other poor organizational outcomes. This notion is reflected in the Swedish Work Environment Authority Act focusing on prevention. The ordinance has language preventing bullying, protecting employees, compensating targets, and penalizing employers who permit bullying. In 2010, The World Health Organization (WHO) issued a bulletin recognizing the hazards linked to bullying across the lifespan, in fact the WHO report deaths associated with bullying leading to legislative initiatives around the world. Government officials may be reluctant to support anti-bullying regulations because of the perceived cost of litigation against businesses and their leaders [8]. Government officials must understand there is more to consider in healthcare organizations than just the cost of litigation and supporting an antibullying law will help stop healthcare employee’s exposure and suffering from emotional, psychological, and physical outcomes as well as prevent adverse patient events.

Recommendations for Victims

Workplace bullies do exhibit performance failures or red flags including difficulty in forming teams, sharing ideas, giving credit to others, disparate treatment of employees, inability to accept blame, deceptiveness, deceitfulness, acting unpredictable, and acting aggressively toward employees. Workplace bullies have an impact on employees’ mood, psychological well-being, and job performance. Workplace bullies also contribute to conflicts within families and friends which in turn is related to higher psychological distress.

Employees should trust their instincts and if there is an uneasy feeling about a certain individual be cautious. Victims of bullying can advocate for themselves and regain control by recognizing the behaviors are bullying, realize they are not the source of the problem, stay logical and know bullying is about control and has nothing to do with performance, keep detailed notes about the nature of the bullying (dates, times, places, specific behaviors including non-verbal and verbal), retain copies of emails, voice mails, other paper trails, and report the behavior to human resources. Continue to establish logical thinking patterns by verifying individual perceptions with hard data to include looking at your behaviors and performance that invalidates and disconfirms what the bully is doing or saying. Check perceptions with other employees, friends, and family as well as collecting performance evaluations, peer reviews, and positive customer feedback. Document actions and verbalizations, try to have a co-worker present during meetings, build support within the organization, and request the opportunity to relocate or be reassigned, and consider pursuing additional opportunities elsewhere.

Despite the lack of anti-bullying laws in most states, victims should not hesitate to seek legal advice about workplace bullying. Intentional infliction of emotional and psychological distress, intentional interference with work relationships, and discharge may constitute workplace bullying. In conjunction with legal counsel use all available options to cope with personal distress including meditation, exercise, and professional counseling services, support of family and friends, and support groups.

Limitations

The results of this qualitative descriptive case study might not be generalizable to all healthcare settings and geographic location. Generalizations cannot occur with a single case study. While the results might be generalizable to Short Term Acute Care Hospitals, Home Health, Skilled Nursing Facilities, and Managed Care Organizations in Milwaukee County, generalizing the results to other geographic locations and healthcare settings might not be possible. There are various healthcare settings not included in this study including medical clinics, assisted living facilities, long term acute care hospitals, and hospice agencies. One county in Wisconsin, Milwaukee, was the sole geographic location. This qualitative descriptive case study was limited to 30 nurses and because of the small sample size the participants might not have been truly representative of the broader population. While nurse participants actively worked in Milwaukee county in the designated healthcare settings, previous experience, education, age, gender, and ethnicity varied between participants. Participants did not indicate level of education, ethnicity, age, and years working as a nurse, and other healthcare settings as previous experience.

Summary

Bullying is a barrier to personal and professional well-being. Bullying behaviors have negative outcomes and create difficulties in the workplace. Employees suffer from emotional, psychological, and physical ailments because of bullying behaviors by female executives. Negative professional outcomes have additional constraints on the organization including adverse outcomes to patients. Controlling and eliminating workplace bullies and their behaviors in healthcare organizations will improve employee wellbeing, increase financial viability, save company resources, and reduce the likelihood of adverse patient events.

References

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5. Day L, Ziehm S, Jessup M, Amedro P, Parish A, et al. (2017) The power of nursing: An innovative course in values clarification and self-discovery. Journal of Professional Nursing 33: 56-64.
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7. Denzin NK, Lincoln YS (2011) The Sage handbook of qualitative research (4^th Edition). Los Angeles, CA: SAGE Publication Inc.
8. World Health Organization (2010) Bulletin of the world health organization 88: 403.