Violence exposure and burnout in healthcare sector mediating role of work ability

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Daniela Converso
Ilaria Sottimano
Cristian Balducci


Violence on the workplace, health care workers, burnout, work ability


Introduction. An important problem faced by healthcare professionals is exposure to verbal and physical violence from patients and family members. Some studies have shown that healthcare workers, especially nurses, are at up to 16 times greater risk of violence than other workers. Aims. Analyse the relationship between exposure to violence, work ability, and burnout. Methods. Data were collected through a questionnaire that investigated the exposure to violence (Violent Incident Form, VIF), burnout (Maslach Burnout Inventory, MBI), and work ability (Work Ability Index, WAI). A total of 300 healthcare workers participated in this study. Results. 36% of participants declared being victims of violence in the past 12 months. 62.1% of violence was perpetrated by relatives. The data analysis highlighted that the WAI, emotional exhaustion, and depersonalization differed significantly among healthcare workers who were victims of violence and those who were not: WAI, t = 5.2, p = .00; emotional exhaustion, t = -4.2, p = .00; depersonalization, t = -3.1, p =.00. Finally, a mediation effect of WAI emerged between exposure to violence and burnout (emotional exhaustion, indirect effect: b= 2.8, BCa CI [1.43, 4.52]; depersonalization, indirect effect: b = 1.1, BCa CI [0.50, 1.95]). Discussion. This study is one of the first to consider the mediation effect of work ability between workplace violence experienced and burnout in the healthcare sector; it reports the complexity and severity of the consequences of workplace violence in healthcare sector.


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1. Al-Azzam M, AL-Sagarat AY, Tawalbeh L, Poedel RJ: Mental health nurses’ perspective of workplace violence in Jordanian mental health hospitals. Perspect Psychiatr C 2017; 54: 477–487. DOI: 10.1111/ppc.12250
2. Al-Shiyab AA, Ababneh RI: Consequences of workplace violence behaviors in Jordanian public hospitals. Empl. Relat. 2018; 40, 3: 515-528. DOI: 10.1108/ER-02-2017-0043
3. Arnetz JE: The Violent Incident Form (VIF): A practical instrument for the registration of violent incidents in the health care workplace. Work and Stress 1998; 12: 17-28
4. Arnetz JE, Hamblin L, Russel J, et al: Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention. J Occup Environ Med 2017; 59(1): 18-27. DOI: 10.1097/JOM.0000000000000909
5. Azami M, Moslemirad M, MektaKooshali MH, et al: Workplace Violence Against Iranian Nurses: A Systematic Review and Meta-Analysis. Violence Vict. 2018; 33, 6: 1148-1175. DOI: 10. 1891/ 0886- 6708. VV- D- 17- 00079
6. Balducci C, Fraccaroli F: Stress lavoro-correlato: Questioni aperte e direzioni future (Work-related stress: Open issues and future directions). Giornale Italiano di Psicologia 2019; 46 (1-2): 39-65
7. Camerino D, Conway PM, Van der Heijden BIJM, et al: Low‐perceived work ability, ageing and intention to leave nursing: a comparison among 10 European countries. JAN 2006; 56 (5): 542-52. DOI:10.1111/j.1365-2648.2006.04046.x
8. Cannavò M, Fusaro N, Colaiuda F, et al: Studio preliminare sulla presenza e la rilevanza della violenza nei confronti del personale sanitario dell’emergenza. Clin ter 2017; 168 (2): 99-112. DOI: 107417/CT.2017.1990
9. Cashmore AW, Indig D, Hampton SE, et al: Workplace violence in a large correctional health service in New South Wales, Australia: a retrospective review of incident management records. BMC Health Serv Res 2012; 12 (245): 1-10
10. Chen S, Lin S, Ruan Q, et al: Workplace violence and its effect on burnout and turnover attempt among Chinese medical staff. Arch Environ Occup Health 2016; 71: 330–337. DOI: 10.1080/19338244.2015.1128874
11. Choi SH and Lee H: Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention. Nurs. Manag 2017; 25 (7): 508–518. DOI:10.1111/jonm. 12488
12. CIIP, Consulta interassociativa italiana per la prevenzione (2017). Libro d’argento Ciip sull’invecchiamento al lavoro. Disponibile online all’indirizzo: (ultimo accesso 20/05/2020)
13. Costa G, Sartori S, Bertoldo B et al: Work ability in health care workers. Int. Congr. Ser. 2005; 1280:264-269
14. Elliott P: Violence in health care: What nurse managers need to know. Nurs Manage 1997; 28 (12): 38-41
15. Erdur B, Ergin A, Yuksel A et al: Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey. Ulus Travma Acil Cerrahi Derg 2015; 21: 175–181. DOI: 10.5505/tjtes.2015.91298
16. Esmaeilpour M, Salsali M, Ahmadi F: Workplace violence against Iranian nurses working in emergency departments. Int Nurs Rev 2011; 58: 130–137
17. Fafliora E, Bampalis VG, Zarlas G, et al: Workplace violence against nurses in three different Greek healthcare settings. Work 2016; 53: 551–560. DOI: 10.3233/WOR-152225
18. Ferri P, Reggiani F, Di Lorenzo R: I comportamenti aggressivi nei confronti dello staff infermieristico in tre differenti aree sanitarie. Professioni Infermieristiche 2011; 64 (3): 143-150
19. Field A: Discovering statistics using IBM SPSS Statistics (4th edition). Sage Publications Ltd, London 2000
20. Fischer FM, Da Silva Borges FN, Rotenberg L, et al: Work Ability of Health Care Shift Workers: What Matters? Chronobiol. Int. 2006; 23(6):1165-79
21. Fischer FM, Martinez MC: Individual features, working conditions and work injuries are associated with work ability among nursing professionals. Work 2013; 45: 509-517. DOI: 10.3233/WOR-131637
22. Hayes AF. Introduction to mediation, moderation, and conditional process analysis. A regression based approach (2nd edition). The Guilford Press, NY, London 2018
23. Hegney D, Tuckett A, Parker D, Eley RM: Workplace violence: Differences in perceptions of nursing work between those exposed and those not exposed: A cross-sector analysis. Int J Nurs Pract 2010; 16: 188–202. DOI: 10.1111/j.1440-172X.2010.01829.x
24. Ilmarinen J, Tuomi K, Seitsamo J: New dimensions of work ability. Int. Congr. Ser. 2005; 1280: 3 – 7
25. Ilmarinen V, Ilmarinen J, Huuhtanen P. et al: Examining the factorial structure, measurement invariance and convergent and discriminant validity of a novel self-report measure of work ability: work ability – personal radar. Ergonomics 2015; 58(8): 1445-1460. DOI: 10.1080/00140139.2015.1005167
26. International Labour Office: International Council of Nurses, World Health Organization, Public Services International: Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva: International Labour Office; 2002
27. Itzhaki M, Bluvstein I, Bortz AP, et al: Mental health nurse’s exposure to Workplace Violence leads to Job stress, Which leads to reduced Professional Quality of life. Front. Psychol. 2018; DOI: 10.3389/fpsyt.2018.00059
28. Jeong IY and Kim JS: The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence. J Clin Nurs. 2018; 27: 1692–1701. DOI: 10.1111/jocn.14228
29. Kim H, Kim JS, Choe K, et al: Mediating effects of workplace violence on the relationships between emotional labour and burnout among clinical nurses. J Adv Nurs. 2018; 74: 2331–2339. DOI: 10.1111/jan.13731
30. Kvas A and Seljak J: Sources of workplace violence against nurses. Work 2015; 52: 177–184. DOI: 10.3233/WOR-152040
31. Laeeque SH, Bilal A, Babar S, et al: How Patient-Perpetrated Workplace Violence Leads to Turnover Intention Among Nurses: The Mediating Mechanism of Occupational Stress and Burnout. J. Aggress. Maltreatment Trauma 2018; 27, 1: 96–118. DOI: 10.1080/10926771.2017.1410751
32. Loera B, Converso D, Viotti S: Evaluating the Psychometric Properties of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) Among Italian Nurses: How Many Factors Must a Researcher Consider? PLoS One 2014; 12 9(12): e114987. DOI: 10.1371/journal.pone.0114987
33. Lu L, Lok KI, Zhang L, et al: A Prevalence of verbal and physical workplace violence against nurses in psychiatric hospitals in China. Arch Psychiat Nurs 2019; 33: 68–72. DOI: 10.1016/j.apnu.2019.07.002
34. Magnavita N: Workplace violence and occupational stress in healthcare workers: A chicken-and-egg situation-results of a 6-year follow-up study. J. Nurs. Scholarsh. 2014; 46(5): 366–376
35. Maslach J, Jackson SE, Leiter MP. Maslach Burnout Inventory (3th edition). Palo Alto CA, Consulting Psychology Press 1996
36. Monteiro I, de Santana P, Chillidab M and Contrera L: Work ability among nursing personnel in public hospitals and health centers in Campinas – Brazil. Work 2012; 41: 316-319. DOI: 10.3233/WOR-2012-0176-316
37. Ramacciati N, Ceccagnoli A, Addey B: Violence towards nurses in the Triage Area. Scenario 2013; 30 (4): 4-10
38. Ramacciati N, Ceccagnoli A, Addey B, Rasero L: Violence towards Emergency Nurses. The Italian National Survey 2016: A qualitative study. Int. J. Nurs 2018; 81: 21-29. DOI: 10.1016/j.ijnurstu.2018.01.017
39. Salvati A: Dati INAIL. 2018, 11
40. Soric M, Golubic R, Milosevic M et al: Shift work, quality of life and work ability among Croatian hospital nurses. Coll. Antropol. 2013; 37, 2: 379–384
41. Sossai D, Molina FS, Amore M, et al: Analisi degli episodi di violenza in un grande ospedale Italiano. Med Lav 2017; 108, 5: 377-387. DOI: 10.23749/mdl.v108i5.6005
42. Sottimano I, Guidetti G, Converso D, Viotti S: We cannot be “forever young,” but our children are: A multilevel intervention to sustain nursery school teachers’ resources and well-being during their long work life cycle. Plos One 2018; 13(11): e0206627. DOI:10.1371/journal. pone.0206627
43. Tuomi K, Ilmarinen J, Jahkola A, et al. Work Ability Index. 2nd revised edn. Helsinki: Finnish Institute of Occupational Health, 1998
44. UIIPRC Workplace violence. A report to the nation. Iowa City, IA: University of Iowa, 2001
45. Uronen L, Heimonen J, Puukka P, et al: Health check documentation of psychosocial factors using the WA. Occup. Med. 2017; 67: 151–154. DOI: 10.1093/occmed/kqw117
46. Viotti S, Gilardi S, Guglielmetti C, Converso D: Verbal Aggression From Care Recipients as a Risk Factor Among Nursing Staff: A Study on Burnout in the JD-R Model Perspective. Biomed Res Int 2015; 215-267. DOI: 10.1155/2015/215267
47. Viotti S, Guidetti G, Converso D: Nurses Between the Hammer and the Anvil: Analyzing the Role of the Workplace Prevention Climate in Reducing Internal and External Violence. Violence Vic 2019; 1, 34(2): 363-375. DOI: 10.1891/0886-6708.VV-D-17-00035.i
48. Wang PX, Wang MZ, Hu GX, Wang ZM: Study on the relationship between workplace violence and work ability among health care professionals in Shangqiu City. Journal of Hygiene Research 2006; 35 (4): 472-474
49. Waschgler K, Ruiz-Hernànde JA, Llor-Esteban B, Garcìa-Izquierdo M: Patient’s aggressive behaviors towards nurses: Development and psychometric properties of the hospital aggressive behavior scale-users. J. Adv. Nurs. 2012; 69: 1418–1427. DOI:10.1111/jan.12016
50. WHO (2003). Joint Programme on workplace violence in the health sector. Geneva: Workplace violence in the health sector country case studies research instruments. Survey questionnaire (ultimo accesso 20/05/2020)
51. WHO (2019). Burn-out an "occupational phenomenon": International Classification of Diseases. Disponibile on line all’indirizzo, (ultimo accesso 20/05/2020)
52. Yang BX, Stone TE, Petrini MA, Morris DL: Incidence, Type, Related Factors, and Effect of Workplace Violence on Mental Health Nurses: A Cross-sectional Survey. Arch Psychiat Nurs 2018; 32: 31–38. DOI: 10.1016/j.apnu.2017.09.013
53. Yoon HS and Sok S: Experiences of violence, burnout and job satisfaction in Korean nurses in the emergency medical centre setting. Int J Nurs Pract 2016; 22: 596–604. DOI: 10.1111/ijn.12479
54. Zafar W, Khan UR, Siddiqui SA, et al: Workplace violence and self-reported psychological health: Coping with post-traumatic stress, mental distress and burn out among physicians working in the emergency departments compared to other specialties in Pakistan. Int. J. Emerg. Med. 2015; 50: 167–177. DOI: 10.1016/j.jemermed.2015.02.049
55. Zhao SH, Shi Y, Sun ZN, et al: Impact of workplace violence against nurses’ thriving at work, job satisfaction and turnover intention: A cross-sectional study. J Clin Nurs. 2018; 27: 2620–2632. DOI: 10.1111/jocn.14311