Violence at work and its relationship with burnout, depression and anxiety in healthcare professionals of the emergency services

doi:10.4236/health.2013.52027

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Vol.5, No.2, 193-199 (2013) Health

http://dx.doi.org/10.4236/health.2013.52027

Violence at work and its relationship with burnout,

depression and anxiety in healthcare professionals

of the emergency services

Gloria M. Roldán1, Isabel C. Salazar2*, Laura Garrido1, Juan M. Ramos3

1“Virgen de las Nieves” University Hospital, Granada, Spain

2University of Granada, Granada, Spain; *Corresponding Author: [email protected]

3“La Caleta” Healthcare Center, Granada, Spain

Received 20 November 2012; revised 21 December 2012; accepted 29 December 2012

ABSTRACT

The aim of this study w as to examine the possi-

ble relationship between physical and psycho-

logical aggression suffe red in the workplace and

professional burnout, depression and anxiety

suffered by healthcare professionals of the

emergency services. Methods: 315 physicians,

nurses, orderlies and ambulance drivers of Cri-

tical Care and Emergency Devices (CCED) in the

Andalusian Public Health System, in the pro-

vince of Granada (S pain) participated. They were

interviewed about the exposure to violence at

work and answered a battery of questions that

measured burnout, depression and anxiety. Re-

sults: Physical aggression was significantly re-

lated to emotional exhaustion, personal accom-

plishment at work, depression and anxiety. Psy-

chological aggression was associated with per-

sonal accomplishment. Logistic regression show-

ed that the CCED professionals who have suf-

fered physical aggressio n were 4.2 and 2.6 times

more likely to hav e suffered anxi ety and redu ced

personal accomplishment, respectively, than

those who did not suffer physical aggression.

On the other hand, feelings of anxiety and re-

duced personal accomplishment increase the

professionals’ risk (3.4 and 2.1 times more likely,

respectively) of suffering from physical aggres-

sion. Conclusion: The results suggest that ex-

posure to violence is related to the other psy-

chological problems tested: emotional exhaus-

tion and personal accomplishment (two com-

ponents of burnout), depression and anxiety. In

addition, physical violence is a risk factor for

anxiety and diminished personal accomplish-

ment of the CCED professionals.

Keywords: Wor kp lace Violence; Aggression;

Burnout; Depression; Anxiety; Health Professionals;

Emergency Services

1. INTRODUCTION

Workplace violence is universal in the health sector,

although local characteristics may vary. Workplace vio-

lence is any situation in which the person is the subject

of abuse, threats or attacks in circumstances related to

their work (or professional activity), having their safety,

well-being or health threatened explicitly or implicitly

[1,2]. There are two types of workplace violence: physi-

cal violence, which refers to the use of physical force

against another person or group that results in physical,

sexual or psychological harm. This includes beating,

kicking, slapping, stabbing, shooting, pushing, biting,

pinching, etc. On the other hand, psychological violence,

which refers to the intentional use of power, includes

threat of physical force against another person or group

that can result in harm to physical, mental, spiritual,

moral or social development. This includes verbal abuse,

uncivil behavior, lack of respect, disparaging attitude,

intimidation, mobbing, harassment, and threats [1].

A research carried out by a joint program on work-

place violence in the health sector shows that more than

half of the health sector personnel surveyed had experi-

enced at least one incident of physical or psychological

violence in the year previous to the study. In South Af-

rica that figure reached 61%, in Thailand 54%, in Portu-

gal 60%. In Bulgaria 37% and Lebanon 41% of the re-

spondents reported incidents of verbal violence which is

a form of psychological abuse [1]. This study showed

than ambulance staff exposure to violence is extremely

high in all countries investigated. In all the studies,

nurses and physicians also report very high levels of ex-

posure to violence. Alameddine et al. showed that in

Beirut (Lebanon) over the past 12 months, four out of

five emergency department employees were verbally

G. M. Roldán et al. / Health 5 (2013) 193-199

194

abused and one in four was physically assaulted [3].

More recently, a study in 10 European countries showed

that nurses in France (39%), UK (29%) and Germany

(28%) reported the highest rates of violence [4].

In recent years, violence against healthcare profes-

sionals seems to have increased in Spain and numbers

are as high as seen in the aforementioned countries. In

Barcelona (Catalonia), one third of interviewed physi-

cians had suffered a violent episode throughout their

professional career (verbal aggression 44%, physical ag-

gression 28%, threats 26%), predominantly in the emer-

gency services (45%) [5]. In Jaen (Andalusia), out of 68

physicians of primary care, 58% had suffered aggression

(verbal abuse 85%, threats 67.5%, and physical aggres-

sion 12.5%) [6]. Between January 2007 and December

2009, 1940 violent incidents were reported in 60 health-

care centers in Catalonia. Physical violence was reported

in one third of these incidents and verbal violence in

more than half of them [7].

In Aragon and Castilla-La Mancha, out of 1845 medi-

cal professionals evaluated, 64% had been a victim of

psychological violence (threats, coercion or insults) and

11% had suffered physical aggression. The percentage of

insults received was higher for physicians (61.6%) and

the threats were primarily aimed at managers (65%) and

secondarily at physicians (60.9%). Again, the emergency

services were the most affected (87%). The percentage of

physical aggression was higher for physicians (19.4%),

followed by orderlies (18.2%) and nurses (17%) [8].

In Castilla and Leon, medical professionals (especially

physicians) and nursing staff were the most affected by

violence directed at them personally followed by atten-

dants and orderlies, although the percentage of affected

individuals in each category is not reported. The majority

of aggression was verbal (6 5% ) [9] .

In Granada (Andalusia), Roldán et al. found high per-

centages of professionals in emergency services who had

suffered from some sort of aggression durin g their work-

ing years (physicians 98.9%, nurses 95.3%, orderlies and

ambulance drivers 91.8%). Psychological aggression was

distributed similarly (99% physicians, 94.1% nurses, and

89.7% for orderlies and ambulance drivers). However,

there was variation in respect to physical aggression, the

nurses (27.1%) being the ones who were most affected,

followed by the physicians (26.3%) and finally the or-

derlies and ambulance drivers (13.4%) [10].

Violence at work can trigger a range of physical and

psychological outcomes in victims. Most victims of

workplace violence report being affected emotionally by

the experience. Emotional experiences to physical and

emotional violence can include anger, frustration, shock,

annoyance, fear, anxiety, stress depression, and sleep dis-

ruption [11]. In the work environment, exposure to vio-

lence has recently been linked to other psychological

problems such as burnout. Maslach and Jackson defined

burnout as a syndrome characterized by emotional ex-

haustion (being emotionally overextended and exhausted

by one’s work), depersonalization (having an unfeeling

and impersonal response toward recipients of one’s ser-

vices), and diminished personal accomplishment (having

diminished feelings of competence and successful achi-

evement in one’s work with people) [12]. Some studies

have shown that exposure to violence is associated with

burnout. For example, Moreno et al. report that family

physicians who had suffered violence were 2.9 times

more at risk of burnout than those who had not been as-

saulted [6], and in later years, Estryn-Behar et al. also

found a risk number very similar although sligh tly lower

(OR = 2.4) in a cohort of nurses [4]. Specifically, it has

been found that physical violence is associated with

burnout [8] and that psychological violence is associated

with serious outcomes including significantly higher

levels of anx iety [8] and burnou t [3,8].

Just as violence can have negative psychological con-

sequences, it has also been found that burnout can in-

crease the risk of exposure to violence in the workplace.

Alameddine et al. found that respondents reporting a

high level of emotional exhaustion had more than 2.1

times higher odds of exposure to a higher level of verbal

abuse compared to respondents with an average level of

emotional exhaustion. Similarly, respondents with a low

level of personal accomplishment had 2.7 times higher

odds of being exposed to higher levels of verbal abuse

compared to their counterparts with average levels of

personal accomplishment. Finally, the employees with a

high and aver age level of deperson alization had 3.40 and

3.74 times higher odds of being exposed to higher levels

of verbal abuse compared to employees with low levels

of depersonalization [3].

All of the aforementioned is very significance because

there is empirical support for some psychological prob-

lems (e.g., depression, anxiety, etc.) associated with ex-

posure to violence at work also being predictors of burn-

out [13,14].

Taking into consideration that emergency departments

are identified as a place where workers are dispropor-

tionally exposed to violence compared to their counter-

parts in other departments [1,4,7,11], the aim of this

study is to examine the relationship between physical

and psychological aggression in the workplace and anxi-

ety, depression and burnout, as suffered by healthcare

professionals in the Critical Care and Emergency De-

vices of the Andalusian Health Service (Spain).

2. METHODS

2.1. Participants

315 sanitary professionals in the Critical Care and

G. M. Roldán et al. / Health 5 (2013) 193-199 195

Emergency Devices (CCED) of the Andalusian Health

Service in the province of Granada (Spain) were inter-

viewed. Table 1 provides socio-demographic and occu-

pational data of participants.

2.2. Instruments

The CCED professionals were interviewed. Each in-

terview took 55 minutes (a pproximately) and th ere was a

psychologist in charge who traveled to the workplaces of

the participants. In some cases, the length of the inter-

view went over the allotted time and prevented dedica-

tion of more time to finalize it, and that is why the sam-

ple considered for each different statistical analysis var-

ies.

For the data collection the following was used: 1) an

ad hoc interview which gathers socio-demographic and

occupational data as well as data related to exposure to

violent events in the workplace. Th e interview allows for

identification of participants who have been assaulted,

the source of the assault, the type of assault, the number

of assaults suffered during the years worked, if they have

been off work, the treatment received, the areas affected

as a consequence of the assaults, if they know of the

Prevention Plan and Assault Assistance for Andalusian

Health Service Professionals and their perception on in-

stitutional support. 2) The Maslach Burnout Inventory

(MBI), a 22-item questionnaire that measures burnout

syndrome across three subscales: Emotional exhaustion,

Depersonalization, and Personal accomplishment. The

Emotional exhaustion subscale measures workers’ feel-

ings of emotional wear-out and fatigue at work. The De-

personalization subscale measures workers’ degree of

being impersonal and distant in delivering care, treat-

ment and instructions to recipients of services. Further-

more, the Personal accomplishment subscale measures

an employee’s level of competence and feeling of pro-

Table 1. Socio-demographic and professional characteristics of

participants.

Variables n %

Male 196 62.6

Gender Female 117 37.4

Yes 243 77.4%

Living with

partner No 71 22.6%

Physician 111 35.2

Nurse 94 29.8

Professional

category Ord. & amb.a 110 34.9

n M SD Min.Max.

Age (years) 312 43.92 9.05 22 63

Years worked 311 14.30 7.46 1 35

aOrd. & amb. = Orderlies & ambulance drivers.

fessional achievement at work. Each of the questions in

the MBI is scored on a 7-point Likert scale (from 0 =

“never” to 6 = “daily”). The internal consistency (Cron-

bach’s alpha) of the MBI was of 0.68, 0.81 for the Emo-

tional exhaustion subscale, 0.68 for the Depersonaliza-

tion subscale, and 0.71 for the Personal accomplishment

subscale. 3) The Beck Depression Inventory (BDI), a

21-item inventory that measures the magnitude of the

depression. Each of the questions has four alternative

answers (ranging from 0 - 3 points) that are listed ac-

cording to the severity. The total score allows recognition

of whether the subject presents clinical symptoms of de-

pression. The alpha of the BDI was 0.87. 4) The Beck

Anxiety Inventory (BAI), a 21-item inventory that mea-

sures the severity of physical symptoms related to anxi-

ety experienced throughout the past week. It uses a 4-

point Likert scale (from 0 = “not at all” to 3 = “se-

verely”). The total score allows recognition of whether

the subject presents clinical anxiety symptoms. The alpha

of the BAI was of 0.93.

2.3. Statistical Analysis

Data was entered in the Statistical Package for the So -

cial Sciences (SPSS), version 13.0. Exposure to physical

aggression and psychological aggression were consid-

ered two separate variables and were analyzed separately

in order to better understand the factors associated with

each. The anxiety and depression (that were originally

measured on a 4-point scale) were regrouped into two

categories. Chi-square (χ2) or Fischer (F) tests were used.

Subsequently, logistic regression was used to test whe ther

physical and psychological aggression in the workplace

acted as a risk factor for the rest of the psychological

variables evaluated, and vice versa.

2.4. Ethical Considerations

Participation in the study was voluntary. Informed

verbal consent to the interview was obtained from all

respondents, who were free to withdraw at any time or to

refuse to answer any of the questions. Respondents were

not compensated fin ancially. This study was appr oved by

the Ethics Committee of “Virgen de las Nieves” Hospi-

tal’s clinical research department and it does not break

the agreements of the Helsinki Declaration.

3. RESULTS

3.1. Co-Relational Analysis

Correlations between physical and psychological ag-

gression and other psychological variables assessed (an-

xiety, depression and 3-components of burnout: emo-

tional exhaustion, depersonalization and personal accom-

plishment) were analyzed. Chi-square or Fischer tests

G. M. Roldán et al. / Health 5 (2013) 193-199

196

were used for this analysis. It was found that exposure to

physical aggression was associated with anxiety (p =

0.000), personal accomplishment (p = 0.006), emotional

exhaustion (p = 0.025), and depression (p = 0.19). On the

other hand, exposure to a psychological aggression was

associated with personal accomplishment (p = 0.044)

(Table 2).

3.2. Multivariate Analysis

Psychological consequences of exposure to physical

and psychological violence. A binary logistic regression

analysis was conducted to study the significant associa-

tions with exposure to physical or psychological aggres-

sion among the CCED professionals. This analysis was

based on the fact that physical aggression and psycho-

logical aggression are dichotomous variables.

Results showed that healthcare professionals who

were physically assaulted had 4.24 times (95% CI: 1.96,

9.16; p-value: 0.000) greater odds of suffering anxiety

and 2.58 times (95% CI: 1.35, 4.93; p-value: 0.004)

greater odds of not feeling personal accomplishment in

their work than those professionals who had not been

physically assaulted.

Psychological variables of risk from physical and psy-

chological violence. A multivariate logistic regression

model was built taking physical aggression as a depend-

ent variable and as independent variables those that were

statistically significant in the bivariate analysis (emo-

tional exhaustion, personal accomplishment, anxiety and

depression).

The results showed that healthcare professionals with

anxiety and reduced personal accomplishment had higher

risk of physical aggression. Specifically, CCED profes-

sionals with anxiety had 3.4 times (95% CI: 1.53, 7.58;

p-value: 0.003) greater odds of being exposed to physical

aggression compared to their colleagues without anxiety.

Similarly, respondents with reduced personal accom-

plishment had 2.06 times (95% CI: 1.03, 4.10; p-value:

Table 2. Distribution of the subjects between emotional exhaustion, personal accomplishment, depression and anxiety according to

the type of aggression.

Physical aggression Psychological aggression

Variables Yes No Total Yes No Total

N 36 151 187 174 13 187

No % 19.3 80.7 100.0 93.0 7.0 100.0

N 22 43 65 64 1 65

Yes % 33.8 66.2 100.0 98.5 1.5 100.0

N 58 194 252 238 14 252

Emotional exhaustion

Total % 23.0 77.0 100.0 94.4 5.6 100.0

N 21 35 56 56 0 56

No % 37.5 62.5 100.0 100.0 0.0 100.0

N 37 159 196 182 14 196

Yes % 18.9 81.1 100.0 92.9 7.1 100.0

N 58 194 252 238 14 252

Personal accomplishment

Total % 23.0 77.0 100.0 94.4 5.6 100.0

N 44 172 216 203 13 216

No % 20.4 79.6 100.0 94.0 6.0 100.0

N 14 21 35 35 0 35

Yes % 40.0 60.0 100.0 100.0 0.0 100.0

N 58 193 251 238 13 251

Depression

Total % 23.1 76.9 100.0 94.8 5.2 100.0

N 42 178 220 206 14 220

No % 19.1 80.9 100.0 93.6 6.4 100.0

N 16 16 32 32 0 32

Yes % 50.0 50.0 100.0 100.0 0.0 100.0

N 58 194 252 238 14 252

Anxiety

Total % 23.0 77.0 100.0 94.4 5.6 100.0

G. M. Roldán et al. / Health 5 (2013) 193-199 197

0.040) greater odds of being exposed to physical aggres-

sion compared to their colleagues with higher personal

accomplishment.

4. DISCUSSION

This study allowed evaluation of the relationships be-

tween physical and psychological aggression suffered in

the workplace and professional burnout, depression and

anxiety suffered by healthcare professionals of the emer-

gency services, in the province of Granada (Spain).

Study results showed that the exposure to violence is

associated with burnout, anxiety and depression in

CCED professionals. However, once each type of vio-

lence (physical/psychological) is analyzed separately,

some differences in relation to the other psychological

variables were found. Physical aggression showed a sig-

nificant link with anxiety, depression, emotional exhaus-

tion and low personal accomplishment (aspects of burn-

out), whereas psychological aggression was associated

solely with low personal accomplishment.

According to Estryn-Behar et al., a high and medium

frequency of violence is associated with higher levels of

burnout; also, violence appears to be an important risk

factor for burnout as it increases the risk 1.4 and 1.9

times in those who have been assaulted monthly and

weekly respectively, compared to those who have not

been assaulted [4]. The relationship between the different

types of assault suffered by professionals and the pre-

sence of burnout is not explained. This could be an im-

portant question due to the fact that different types of

aggression happen at different frequencies and can have

a different impact on people.

According to the present investigation, physical ag-

gression suffered by healthcare professionals throughout

their working years increases the risk of suff ering anxiety

and reduced personal accomplishment, in comparison to

those who have not exp erienced any ph ysical aggression;

whereas exposure to psychological aggression does not

lead to any significant risk for professionals in th is sense.

These results partially contradict what Alameddine et al.

suggest, given that in their study verbal abuse was sig-

nificantly associated with the three subscales of burnout

(Emotional exhaustion, Depersonalization and Personal

accomplishment) in the Beirut emergency departments

[3]. A possible explanation for the results of the present

study is that patients and those accompanying them (who

tend to be those exert more actions of this kind against

CCED professionals) [10,11] tend to psychologically

assault professionals, alluding to a lack of competence or

professional efficiency at the time they are taken into

care. The insults, humiliations and even threats come

from people who, at the time (in the emergency services

department) see their situation as difficult, sometimes

critical, and which overcomes their coping skills. It is

clear that even though it does not justify the verbal abuse,

it is understandable that in said circu mstances some peo-

ple (due to a coping skills deficit) express their discom-

fort through these kinds of aggressive responses and that

professionals consider this reaction from patients as

something to expect from their job, the reason for which

is, in some way, a method of “protecting themselves”

from suffering reduced personal accomplishment and, in

general, from suffering burnout.

Another question that was analyzed in this investiga-

tion was the psychological impact of different types of

violence against professionals. In agreement with the

data obtained, the consequences derived from exposure

to physical violence are different from the data obtained

for psychological violence. Physical aggression, unlike

psychological aggression, increases the probability of

suffering anxiety and reduced personal accomplishment,

the reason for this is thought to be that physical aggres-

sion has a higher psychological impact in healthcare

professionals than psychological aggression. The pres-

ence of anxiety problems in the cases of physical aggres-

sion is clearly justified by the nature of the stimulus (a

strike, a push, an injury, etc.), because this is in itself

harmful and automatically trigg ers an emotional reaction

of fear. This kind of response implies an increased phy-

siological activation which, if not handled adequately,

can lead to the person subsequently developing problems

with anxiety. In short, a physical stimulus is potentially

stronger and more harmful than a psychological (or ver-

bal) stimulus and therefore, it is expected that physical

aggression increases the risk of suffering from anxiety, as

well as low personal accomplishment, in comparison to

psychological aggression. As has been previously de-

scribed, psychological aggressio n, despite being aimed at

attacking the self-efficiency and professional competence,

does not have as high an impact as to affect an individ-

ual’s personal accomplishment in the workplace.

Until recently, this relationship has been analyzed in

only one sense: the psychological effects of violence.

Many studies indicate that violence is a risk factor for

burnout and can entail emotional experiences such as

anxiety, depression, sleep problems, etc. However, there

are also studies that indicate the opposite. With regards

to this, the present investigation was able to determine

that the presence of a high level of anxiety and reduced

personal accomplishment increased the probability of

suffering physical aggression, compared to those subjects

who did not have the aforementioned psychological pro-

blems.

This risk model indicates that those people who suffer

from anxiety and reduced personal accomplishment have

a greater chance of being physically assaulted. Said

model could be better understood if anxiety was consid-

G. M. Roldán et al. / Health 5 (2013) 193-199

198

ered to be an emotional reaction to disproportionate fear

or worry (apprehensive expectation) in light of situations

in which healthcare professionals feel themselves inca-

pable of managing. If this preoccupation and physio-

logical-emotional activation is significant, it is highly

probable that behavior is negatively affected and at the

moment of interacting with the patients they manifest

their nervousness and will not use (or will not have) the

sufficient and appropriate repertoire of skills to manage

difficult situations that can arise in an emergency ser-

vices department.

Unlike what has been said up until now, there are

some studies with nursing staff that revealed no associa-

tions between reported violence and burnout [15,16]. The

contradiction between these cases could be due to the

complexity of the phenomenon. The idea of “zero toler-

ance” towards violence is promoted socially, but it is

feasible that some healthcare professionals consider that

violence coming from patients is “expected” and that “it

is part of the job” [15,16]. It is an attitude which could

moderate the appearance of burnout, but further investi-

gation is required.

5. CONCLUSION

Physical violence is linked to anxiety and burnout.

Physical aggression is a risk factor for anxiety and low

personal accomplishment at work. Nevertheless, the op-

posite also occurs. That is to say, subjects with anxiety

and low personal accomplishment have a greater risk of

suffering physical aggression. This is possibly the first

investigation performed in Spain that provides informa-

tion on exposure to violence and the risk of finding im-

portant psychological problems linked to it (such as

burnout and anxiety). However, more investigation will

be necessary in order to clarify the causal relationship

between these phenomena.

6. ACKNOWLEDGEMENTS

We thank the healthcare professionals of the Andalusian Public

Health System in the province of Granada, who agreed to be part of the

cohort in this study. This work has been possible thanks to the funding

from the Andalusian Public Fund for Bio-Sanitary Investigation of

Oriental Andalusia—Alejandro Otero (FIBAO B15/2006), the Carlos

III Health Institute and European Regional Development Fund (ERDF)

(FIS 07/0440).

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