Occupational Medicine Advance Access published July 1, 2015 Occupational Medicine doi:10.1093/occmed/kqv089

Associations of chronic embitterment among NHS staff T. Sensky1,2, R. Salimu1, J. Ballard1 and D. Pereira1 1 Health at Work Service, West London Mental Health NHS Trust, Canal Mews, Uxbridge Road, Southall, Middlesex UB1 3EU, UK, 2Centre for Mental Health, Department of Medicine, Imperial College, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.

Correspondence to: T. Sensky, Health at Work Service, West London Mental Health NHS Trust, Canal Mews, Uxbridge Road, Southall, Middlesex UB1 3EU, UK. E-mail: [email protected]

Aims

To investigate the associations of chronic embitterment with procedural justice, the psychological work contract, depression and the Health & Safety Executive’s Management Standards Indicator Tool as well as selected employment variables.

Methods

A sample of consecutive attendees at occupational health in a single NHS Trust were asked to complete a set of validated questionnaires and give further information about sickness absence and their work.

Results

The sample (n = 236) was representative of those attending this occupational health department. Staff showing embitterment rated procedural justice and organizational support lower than other staff and were significantly more likely to have taken sickness absence, uncertified as well as certified. Uncertified sickness absence was almost universal in embittered staff. Although depression was significantly more prevalent among embittered staff, the majority of embittered staff were not depressed. Of those who scored as embittered and depressed or anxious, 93% had had certified sickness absence in the previous 12 months. On the Management Standards Indicator Tool, embittered individuals had significantly lower scores than others on Manager and Peer Support, Role, and Change subscales.

Conclusions Although the data are cross-sectional and self-reported, they provide evidence of the burden on organizations of chronic embitterment among their staff, particularly in terms of sickness absence. Staff who are embittered perceive their organization as unsupportive of them, and as showing low levels of procedural justice. Key words

Chronic embitterment; depression; organizational justice; sickness absence.

Introduction Occupational health professionals regularly encounter employees who express a conviction that they have been treated unfairly or unjustly by their managers or by their employer. Consultations often involve detailed accounts of the injustice, frequently highlighted by references to exhaustive documentation, together with expressions of anger or frustration. Employees may be referred because they have presented similarly to their manager. Such presentations are characteristic of chronic embitterment. Embitterment has been defined as an emotion encompassing persistent feelings of being let down,

insulted or being a loser, and of wanting revenge but feeling helpless [1]. Linden and colleagues [1] have proposed the term post-traumatic embitterment disorder to encompass the features of such presentations. They have made the case that this should be considered a discrete syndrome, distinct from current psychiatric diagnoses [2], and have developed and validated a rating scale [3]. There are some similarities with post-traumatic stress disorder (PTSD), notably the experience of distress and flashbacks in response to cues to previous traumatic incidents, and also features of hypervigilance and hyperarousal [2]. Previous studies have reported symptoms of PTSD among employees who have been bullied, although these

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Background Chronic embitterment is commonly recognized among people seen by occupational health professionals, but its associations remain unclear.

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Methods The study was approved by the Ealing and West London Research Ethics Committee, part of the NHS National Research Ethics Service (REC reference number 09/ H0710/42).

It was a cross-sectional survey, with questionnaires completed by staff of an NHS Trust attending its occupational health department for a new or follow-up appointment. Responses were anonymous hence all the data collected depended entirely on the individual responses to the questionnaires and could not be corroborated by, or cross-referenced with, other records. All staff presenting during a 3-month period during September–November 2009 to occupational health were invited, after their appointments, to complete a series of paper-based questionnaires, detailed below. These were completed in the department. Staff who had already completed the questionnaires were excluded. Respondents were asked about their gender, age and employment, whether they were referred by their manager and how many days of certified and uncertified sickness absence they had had in the previous 12 months. Chronic embitterment was measured using the 19-item scale developed by Linden and colleagues [3]. The scale items describe features of chronic embitterment, with each item rated on a 0–4 scale (0  =  not at all true (of me), 4 = extremely true). The mean score of the 19 items is taken as the overall embitterment score. Respondents were defined as showing chronic embitterment if they had a mean score of 1.6 or above on the questionnaire, as recommended by Linden and colleagues [3]. In previous work, this cut-off score showed 90% sensitivity and 92% specificity when compared with a diagnostic interview [14]. The scale itself has been reported to have good internal consistency (Cronbach’s alpha of 0.94) and good test–retest reliability [14]. Depression and anxiety were measured by the widely used and well-validated Hospital Anxiety and Depression Scale (HADS) [15]. Following convention, scores of 8–10 were taken as indicative of ‘possible’ depression or anxiety and scores above 10 were considered to indicate ‘probable’ depression or anxiety. Attitudes to work were measured using 27 questions taken from two separate sources. Six items assessed each of the six criteria for procedural justice originally reported by Leventhal and colleagues [16]: procedures should be ethical, bias-free, include accurate and comprehensive information and a mechanism to correct flawed decisions, and ensure that account has been taken of all those involved. The remaining 21 questions aimed to assess three aspects of the psychological work contract—perceived organizational support, the individual’s felt obligations to the organization and what has been termed ‘employee exchange ideology’ (the extent to which employees base their concern with the organization’s welfare, and their effort at work, on their perception of their treatment by the organization). These questions have been shown to have adequate psychometric properties in a US sample [17]. The two sets of questions were presented to respondents as a single questionnaire, labelled ‘Attitudes to Work’, because all

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cases usually fail to fulfil the complete criteria for PTSD, particularly because of the nature of the trauma [4–6]. With the benefit of hindsight, it is likely that these were cases of chronic embitterment [7]. However, despite the similarities with PTSD, describing such presentations as post-traumatic embitterment disorder may be misleading because this term implies that the presentation resulted from a single incident. Clinical experience suggests that, while embitterment can often be traced back to an initial trigger, a key feature of the condition is its escalation over time. For this reason, the condition is probably more accurately described as chronic embitterment [7]. In our experience, chronic embitterment can take up a disproportionate amount of time and resources from managers and human resources departments, as well as occupational health services. Anecdotal evidence indicates that chronic embitterment is associated with high rates of sickness absence. Health care staff who are embittered can undermine the motivation and functioning of their teams [8], and there is growing evidence that, in turn, this can adversely affect patients’ experiences of their care [9,10]. Levels of anxiety and depression have been reported to be high in chronic embitterment [2] though the extent of the overlap is unknown. Implicit in the experience of chronic embitterment is a perceived failure of organizational justice [7,11], i.e. of being treated grossly unfairly or unjustly. Such perceptions appear to be focused predominantly on the outcomes of these interactions (termed distributive justice). It is unclear whether these individuals also perceive unfairness or injustice in the procedures and processes that led to these outcomes (this is termed procedural justice). Perceived breaches of procedural justice have been associated with poor work performance and higher rates of sickness absence [11]. Someone with chronic embitterment perceives the organization they work for as having failed them, constituting a breach of the psychological work contract [12]. This contract is seldom made explicit but, from the employee’s perspective, it includes values and aspirations, which the employee assumes that the employer shares. This study investigated the associations between chronic embitterment and procedural justice, and aspects of the psychological work contract. These associations were investigated separately in people who were or were not depressed. In addition, the correlations between embitterment and the subscales of the Health & Safety Executive’s (HSE) Management Standards were examined [13].

T. SENSKY ET AL.: ASSOCIATIONS OF CHRONIC EMBITTERMENT IN NHS STAFF  Page 3 of 6

Results There were 236 respondents, of whom 55% (150) were female. The most frequent professional groups were nurses (n = 67, 28%) and health care assistants (n = 49, 21%). Twenty-five per cent (60) had been referred by their manager. These characteristics were representative overall of people attending the occupational health department. Fifty-nine per cent (140) were over the age of 40 years, although 45% (107) had worked for the trust for 5  years or less. Fifty per cent (119) of respondents had no supervisory responsibilities. On the HADS, 6% (14) scored as probably depressed, and 16% (38) scored as probably anxious. These low prevalences are possibly attributable to data collection late in the year, when some respondents were attending for their flu injections. For the 19-item Embitterment Scale, Cronbach’s alpha was 0.96. The six items assessing procedural justice yielded a Cronbach’s alpha of 0.90. The Perceived Organizational Support subscale yielded a Cronbach’s alpha of 0.71. However, one item showed poor item-total correlation, and removing this item yielded a 5-item subscale with Cronbach’s alpha of 0.90. Cronbach’s alpha for the original Felt Obligation subscale was 0.68, but after removal of the single item that had a negative item-total correlation, Cronbach’s

alpha rose to 0.86. The original Employee Exchange Ideology subscale yielded a Cronbach’s alpha of only 0.28. For this reason, this subscale was subjected to factor analysis, and yielded two distinct and meaningful subscales, reflecting Employer-Employee Reciprocity and employees’ perceived Work Effort. The five items reflecting reciprocity yielded Cronbach’s alpha of 0.71, as did the 3-item reciprocity subscale. The items included in the Attitudes to Work Questionnaire (and those omitted) are summarized in the Appendix (available as Supplementary data at Occupational Medicine Online). Respondents who had been in their jobs for

Associations of chronic embitterment among NHS staff.

Chronic embitterment is commonly recognized among people seen by occupational health professionals, but its associations remain unclear...
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