555367 research-article2014
JIVXXX10.1177/0886260514555367Journal of Interpersonal ViolenceGalian et al.
Article
User Violence and Nursing Staff Burnout: The Modulating Role of Job Satisfaction
Journal of Interpersonal Violence 1–14 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514555367 jiv.sagepub.com
Inmaculada Galián-Muñoz,1 Jose Antonio RuizHernández,1 Bartolomé Llor-Esteban,1 and Cecilia López-García1
Abstract Exposure to patient violence in health staff can lead to the onset of burnout in these workers. The main goal of this investigation is to study how exposure to this kind of violence affects onset of burnout and to appraise the role of job satisfaction as a modulating variable. A descriptive, cross-sectional study was carried out using a self-administered anonymous questionnaire with the nursing staff of all the public hospitals of the Region of Murcia (Spain), obtaining a sample of 1,489 health professionals. From the results obtained, we underline the modulating role of extrinsic job satisfaction in the relationship between nonphysical violence and emotional exhaustion, and the protective effect of job satisfaction on the impact of nonphysical violence and the level of cynicism. No effects of job satisfaction in the relationship between physical violence and burnout were observed. We therefore conclude that experiencing nonphysical aggression has a lower impact on the psychological health of workers who are satisfied with their job, and interventions aimed at increasing these workers’ extrinsic job satisfaction are highly recommended.
1Universidad
de Murcia, Spain
Corresponding Author: Inmaculada Galián-Muñoz, Servicio Murciano de Salud, Servicio de Prevención de Riesgos Laborales, Hospital Psiquiátrico Román Alberca, C/Lorca,58, 30120 El Palmar, Murcia, Spain. Email: [email protected]
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Keywords job satisfaction, burnout, patient violence, nursing staff
Introduction The International Council of Nurses (ICN; 2007, p. 4) defines workplace violence as “incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.” Clinical staff are among the professionals most exposed to patient violence, and some studies report that more than one half of the workers in this sector have experienced at least one incident of physical or psychological violence in the past year (Ayranci, Yenimez, Balci, & Kaptanoglu, 2006; Di Martino, 2002). Specifically, in the Region of Murcia (Spain), 71% of the nursing staff was exposed to verbal violence, and 19.9% of the sample was exposed to some manifestation of nonverbal violence, with at least a yearly frequency (Galián, Llor, & Ruiz, 2012). The importance of this risk lies in its frequency (Blando, O’Hagan, Casteel, Nocera, & Peek-Asa, 2013) but also in the severity of the possible consequences deriving from it. Numerous studies refer to the psychological consequences of patient aggression for nursing staff (Estryn-Behar et al., 2008; Franz, Zeh, & Schablon, 2010; Roche, Diers, Duffield, & CatlingPaull, 2010; Tak, & Sweeney, 2010; Zampieron, Galeazzo, Turra, & Buja, 2010), and the association between risk and burnout has frequently been observed. For example, Isaksson, Graneheim, Richter, Eisemann, and Åström (2008) detected that nurses who had been exposed to violence scored higher in burnout. Subsequently, other authors qualified this fact, indicating that this positive association occurred particularly with emotional exhaustion and cynicism (Chung & Harding 2009; Howard, Rose, & Levenson, 2009; Mills & Rose, 2011). Hensel, Lunsky, and Dewa (2012) stated that between 7% and 24% of the workers do suffer burnout or are at high risk of burnout due to aggressions experienced. But the issue is why some nurses suffer from burnout and others do not. Therefore, this work introduces job satisfaction as a moderating variable between exposure to such violence and the development of burnout, on the basis of the study of Faragher, Cass, and Cooper (2005), who reported that when job satisfaction increases, workers’ psychological well-being also improves, but if satisfaction decreases, there is greater risk of burnout. We draw on the tridimensional concept of burnout proposed by Maslach, Schaufeli, and Leiter (2001): Burnout affects individuals at the personal level (emotional exhaustion), at the social level (cynicism), and finally, at the
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professional level (professional inefficacy), and on the multidimensional theory of job satisfaction of Herzberg, Mausner, and Snyderman (1959), who stated that these dimensions are divided into factors of intrinsic work motivation (related to work content), such as the job itself or the achievements, and extrinsic factors (related to work conditions that cannot be controlled or changed directly by the worker), such as organizational policies or supervision, considering that extrinsic and intrinsic factors are related, and differentiating between manifestations of physical and nonphysical violence (Waschgler, Ruiz, Llor, & García-Izquierdo, 2013. Therefore, the goal of this study was to analyze how patient aggressions and job satisfaction influence the level of workers’ burnout, specifically, to determine whether job satisfaction modulates the relation between exposure to patient hostility and the onset of burnout in a sample of professional nurses.
Method Participants The sample was made up of 1,489 nursing professionals with an age range between 20 and 67 years (M age = 42.09, SD = 9.75). Most of them were females (82.7% vs. 16.4%) and married or living with a common-law partner (67.8%). Of them, 62.1% had a nursing diploma, and 36.7% were auxiliary nurses; their mean job tenure in the current post was 7 years and 5 months (SD = 97.57 months), and mean job tenure in the nursing profession was 15 years 4 months (SD = 112.08 months). Of the sample, 59.4% had a permanent contract.
Procedure This is a descriptive cross-sectional study, carried out with nursing staff from all the public hospitals of the Region of Murcia during the year 2010. That year, there were 11 hospitals in the Health Service of Murcia (10 general hospitals and 1 psychiatric hospital), with a staff of 19,550 people, of whom 6,103 were nursing personnel (nurses and auxiliary nursing staff). A total of 30% of the nursing staff was sampled, stratified as a function of the size of the units and the hospital staff. Of the surveys handed out, we obtained a global response rate of 81.36% (1,489 workers), which is 28.98% of the entire nursing staff and 18.96% of the entire auxiliary nursing staff. This sample leads to a 99% confidence level and a sampling error of 1.75%. To obtain the sample, we informed the nursing department directors of the hospitals in detail about the study, and, after they agreed to participate in the
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investigation, we held meetings in each center with all the nursing supervisors. In these meetings, supervisors were requested to hand out the questionnaire randomly to 30% of their staff (selecting one worker from every three, according to the schedule of shifts) and, after the questionnaires had been completed by the workers, to collect them in a sealed envelope with no identification marks. The supervisors had a maximum time limit of 2 weeks to return the surveys (questionnaires that were not handed in after that date were counted as missing). Collection was carried out by collaborators (people from the research group who visited the hospitals twice a week to verify the process of data collection) and the people proposed by the hospitals (normally in charge of teaching and research).
Instruments The Hospital Aggressive Behaviour Scale–Users (HABS-U) was used to assess exposure to violence (Waschgler et al., 2013). This scale addresses patients’ low-intensity hostile nonphysical and physical manifestations that are perceived by the worker as violent. The questionnaire has 10 items, with Cronbach’s alpha of .839, explaining 57.36% of the variance. It is divided into two factors: nonphysical violence (α = .85, explaining 36.39% of the variance, with a factor loading of .636-.756) with 7 items; and physical violence (α = .74, explaining 20.96% of the variance, with a factor loading of .713-.782). To appraise the frequency of exposure, a 6-point Likert-type scale, ranging from 1 (never in the past year) to 6 (daily) was used (Waschgler et al., 2013). To appraise the level of job satisfaction, we used the Overall Job Satisfaction (OJS) Scale, developed by Warr, Cook, and Wall in 1979, adapted to Spanish by Pérez and Hidalgo. This scale has 15 items, which are rated on a 7-point Likert-type scale, ranging from 0 (very dissatisfied) to 6 (very satisfied). The OJS is divided into two subscales: Intrinsic Factors subscale, which is made up of 7 items, and the Extrinsic Factors subscale, made up of 8 items. With regard to internal consistency of the questionnaire, Cronbach’s alpha index ranged between .85 and .88; for the extrinsic factors subscale, it was .74 to .78, and the intrinsic factors subscale had a reliability of .79 to .85 (NTP 394, 1984). We used the Maslach Burnout Inventory–General Survey (MBI-GS), translated and validated in Spanish by Gil-Monte (2002), to analyze levels of burnout. The MBI-GS has 16 items, divided into three subscales: Professional Efficacy (6 items), Emotional Exhaustion (5 items), and Cynicism (5 items). Participants rate the frequency with which they have experienced each item of the questionnaire on a 7-point Likert-type scale ranging from 0 (never) to 6 (daily). The reliability values of the scales according to Cronbach’s alphas Downloaded from jiv.sagepub.com at UNIV MASSACHUSETTS AMHERST on October 6, 2015
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in the study of Gil-Monte (2002) were .85 for Professional Efficacy, .83 for Emotional Exhaustion, and .74 for Cynicism.
Data Analysis Descriptive statistics, internal consistency (Cronbach’s α), and correlations of the target variables were calculated. To determine the effect of interaction, we conducted hierarchical regression analysis (Cohen & Cohen, 1983) for each one of the possible combinations of manifestations of violence and dimensions of job satisfaction with the diverse burnout components (dependent variable). The independent variables were entered in the regression equations in two steps (Jaccard, Turrisi, & Wan, 1990). In Step 1, we entered one of the dimensions of patient violence (nonphysical violence–physical violence) and one of the dimensions of job satisfaction (extrinsic satisfaction–intrinsic satisfaction). In Step 2, we introduced the interaction of the independent variables used.
Ethical Considerations The project was approved and financed by the Instituto de la Mujer del Ministerio de Sanidad, Asuntos Sociales e Igualdad (Women’s Institute of the Ministry of Health, Social Affairs and Equality) in a public summons. Its diffusion was financed by the Official Nursing Association of the Region of Murcia. The managers and nursing directors of all the hospitals involved agreed to participate in the study. Information was included with the questionnaires so that participation was informed and voluntary. Participation was also anonymous, and confidentiality was guaranteed because the questionnaires were returned in sealed envelopes, which were opened by members of the research team, who then assigned a code to each questionnaire for data analysis. In view of all these guarantees, it was considered that the study did not need to be authorized by the ethics committee.
Results Table 1 shows the descriptive analyses and internal consistencies of the target variables. The mean score for violence was 15.18; for extrinsic job satisfaction, 30.11; for emotional exhaustion, 14.07; and for cynicism, 11.81. In all the scales, the correlation coefficients are equal to or higher than the criterion of .70 recommended by Nunnally and Bernstein (1967/1994). Job satisfaction and its dimensions correlated negatively with violence and its dimensions and with emotional exhaustion and cynicism, and positively with
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SD
10.45 5.28 4.71 1.8 15.16 6.36 25.57 7.29 30.11 6.96 55.7 13.47 14.07 5.39 11.81 5.08 27.8 8.71
M 3 7 10 7 8 15 9 5 8
Item
2 .85 .96*** −.15*** −.14*** −.16*** .26*** .23*** −.04*
1 .74 .48*** .68*** −.12*** −.10*** −.12*** .09*** .13*** .01
Note. The reliability of the variables of the study is on the diagonal. *p < .05. **p < .01. ***p < .001.
1. Physical violence 2. Nonphysical violence 3. Total violence 4. Intrinsic job satisfaction 5. Extrinsic job satisfaction 6. Total job satisfaction 7. Emotional exhaustion 8. Cynicism 9. Professional efficacy
Variables
.83 −.16*** −.15*** −.17*** .25*** .23*** −.04
3
Table 1. Descriptive Statistics, Reliabilities, and Correlations Between Variables. 5
6
7
8
9
.84 .78*** .70 .94*** .94*** .87 −.35*** −.36*** −.38*** .85 −.38*** −.33*** −.38*** .50*** .70 .13*** .10*** .12*** −.06 −.10*** .85
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Table 2. Regression Equation Predicting Emotional Exhaustion From Nonphysical Violence and Extrinsic Job Satisfaction.
Nonphysical violence Extrinsic job satisfaction Nonphysical violence × Extrinsic job satisfaction
β
R2
ΔR2
.429*** −.237*** −.233*
.181
.003
.184
*p < .05. **p < .01. ***p < .001.
Table 3. Regression Equation Predicting Cynicism From Nonphysical Violence and Extrinsic and Intrinsic Job Satisfaction.
Nonphysical violence Extrinsic job satisfaction Intrinsic job satisfaction Nonphysical violence × Intrinsic job satisfaction Nonphysical violence × Extrinsic job satisfaction
β
R2
ΔR2
.530*** −.150** −.270*** −.173* −.370***
.148
.002 .007
.183 .155
*p < .05. **p < .01. ***p < .001.
professional efficacy. Violence correlated positively and significantly with emotional exhaustion and cynicism, but its relation with professional efficacy was nonsignificant, so this dimension was not included in the regression analysis of burnout. We conducted regression analyses for each one of the possible combinations of the dimensions of violence and job satisfaction to determine their effects on emotional exhaustion and cynicism, obtaining significant relationships when entering the interaction effect of nonphysical violence and extrinsic job satisfaction (Table 2) on emotional exhaustion, and the interaction effect of nonphysical violence and extrinsic and intrinsic job satisfaction on cynicism (Table 3). Table 2 presents the analysis of the dimension of emotional exhaustion through regression analysis, in which the first block of variables includes nonphysical violence and extrinsic job satisfaction, with both variables revealing a significant relation with emotional exhaustion, positive in the case of violence, and negative in the case of job satisfaction (β = .429, p < .001; β = −.237, p < .001). These factors explain 18.1% of the variance of emotional exhaustion. In Step 2, we entered the interaction of these variables, which was negatively significant (β = −.23, p < .05), obtaining an increase of .003 in the explained variance. Downloaded from jiv.sagepub.com at UNIV MASSACHUSETTS AMHERST on October 6, 2015
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Journal of Interpersonal Violence Emo onal exhaus on score
21 Low Extrinsic Job Sa sfac on
19 17 15
High Extrinsic Job Sa sfac on
13 11 9 Low Non-physical Violence
High Non-Physical Violence
Figure 1. Effect of the interaction of nonphysical violence and extrinsic job satisfaction on the level of emotional exhaustion.
The results of the same regression analysis on cynicism showed that cynicism is positively related to nonphysical violence (β = .530, p < .001), and extrinsic job satisfaction has a negative main effect (β = −.150, p < .01). As shown in Table 3, these variables explain 14.8% of the variance of cynicism, which rises to 15.5% when taking into account the interaction (β = −.370, p < .001). Table 3 shows that, on one hand, nonphysical violence has a positive main effect on the level of cynicism (β = .530, p < .001), whereas intrinsic job satisfaction has a negative main effect (β = −.270, p < .001) on cynicism, in this case, explaining 18.3% of the variance. The effect of the interaction of these variables on the dependent variable cynicism was negative (β = −.173, p < .05), with an increase in R2 of .2%. Figures 1 and 2 present the interpretation of these results, showing the significant effects of the interactions, with the quartiles as reference; thus, a high value in the variable corresponds to scores in Q4, and a low value corresponds to Q1, discarding the values of Q2 and Q3. Figures 1 and 2 show that for the same level of violence, low levels of job satisfaction correspond to higher mean scores in emotional exhaustion and cynicism. Figure 1 shows that for low job satisfaction, there is a greater difference than for high job satisfaction in the mean scores of emotional exhaustion when comparing high and low levels of exposure with nonphysical violence (2.51 vs. 3.12). This aspect is more pronounced in cynicism, where high levels of intrinsic and extrinsic job satisfaction both lead to similar mean cynicism scores, even if the level of nonphysical violence increases (see Figure 2).
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Cynicism score 17 16 15 Low Intrinsic Job Sa sfac on
14
High Intrinsic Job Sa sfac on
13
Low Extrinsic Job Sa sfac on
12
High Extrinsic Job Sa sfac on
11 10 9 Low Non- Physical Violence
High Non-Physical Violence
Figure 2. Effect of the interaction of nonphysical violence and extrinsic and intrinsic job satisfaction on the level of cynicism.
Discussion The goal of this study was to analyze how exposure to patient violence influences the level of workers’ burnout, specifically to determine whether the dimensions of job satisfaction analyzed modulate the relation between physical and nonphysical violence and the three dimensions of burnout. The results obtained in a sample of nursing professionals indicate that the scores in job satisfaction are lower than those provided as reference by the authors of the scale (Warr et al., 1979) both at the global level and at the levels of extrinsic and intrinsic job satisfaction. This is coherent with diverse articles and recent studies of nurses, such as that of the American Association of Critical Care Nurses (AACN), reporting high levels of job dissatisfaction and quitting the profession in nursing professionals (AACN, 2005). However, if we compare the mean scores obtained in our sample in the burnout dimensions with the data obtained by other authors (López-Montesinos,
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2009), our mean scores in emotional exhaustion and cynicism are higher, although there is some variability in professional efficacy. With regard to exposure to violence, we could not compare our results with those of other studies due to the novelty of the use of the HABS-U scale as the assessment instrument. In the analyses conducted to predict burnout from exposure to patient violence, we found that exposure to physical and to nonphysical violence were both positively correlated with the level of emotional exhaustion and cynicism, coherently with our expectations (Chung & Harding, 2009; Howard et al., 2009; Mills & Rose, 2011). Likewise, both dimensions of job satisfaction were significantly and negatively correlated with burnout. We coincide with Figueiredo-Ferraz, GrauAlberola, Gil-Monte, and García-Juesas (2012) in stating that there is a bidirectional relationship between these variables. Through regression analyses, we detected that extrinsic job satisfaction modulates the relationship between nonphysical violence and emotional exhaustion and cynicism, whereas intrinsic job satisfaction influences the relationship between nonphysical violence and cynicism, although the explained variance is low in both cases (values of R2 < .2). This indicates that these burnout dimensions are also influenced by other stressors. It has been shown that with the same exposure to nonphysical violence, people with low levels of job satisfaction have higher levels of emotional exhaustion and cynicism. Likewise, we observed that when workers with high levels extrinsic job satisfaction are exposed to high levels of violence, their levels of emotional exhaustion and cynicism are lower than those of workers with low levels of extrinsic satisfaction. The same can be stated about intrinsic satisfaction and cynicism: High levels of intrinsic job satisfaction lead to lower levels of cynicism even in the presence of high levels of exposure to violence. Therefore, we consider that job satisfaction, particularly extrinsic job satisfaction, plays a protective role in the psychological health of workers exposed to nonphysical violence; that is, if workers are satisfied with their jobs, they will be less likely to suffer burnout even if they experience an act of patient aggression. This is consistent with other studies such as those of Blegen (1993), Irvine and Evans (1995), and McVicar (2003), which propose increasing support from coworkers, superiors, and directors (factors addressed in extrinsic satisfaction) as measures to counteract nurses’ chronic stress, because they consider that, if workers are satisfied with such support, the impact of an aggression on their psychological health will be lower. We think that nonphysical violence and burnout have a cyclical relation such that frequent exposure to situations of nonphysical violence will increase
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levels of cynicism and emotional exhaustion (Chung & Harding, 2009; Howard et al., 2009; Mills & Rose, 2011) and, in turn, cynicism and exhaustion will favor the onset of new aggressions (Whittington, 2002), but extrinsic job satisfaction could buffer that relationship. Although the results found in this study should be considered taking into account the limitations associated with studies using self-report questionnaires as a possible selection bias, we think that influencing workers’ job satisfaction could work as a strategy to decrease the levels of burnout in workers frequently exposed to nonphysical violence. When analyzing the data obtained, it should be taken into account that if a low level of institutional support can reduce extrinsic job satisfaction and contribute to violence, such support can be the cause of the reduction of violence, but it may also be a confounding factor. Even so, on the basis of the results obtained, considering prevention of occupational hazards, we suggest the development of psychological health programs including improvement of job satisfaction in organizations whose workers are affected by patient violence. According to Singh and colleagues (2009), such intervention programs for burnout prevention should address the problem at various levels. A first step would consist of actions targeting the organization and the environment, eliminating or reducing stressful factors to a minimum through proactive management strategies; in the case of risk of violence, this would mean early identification of the workers who suffer greater exposure and the establishment of preventive measures aimed at the reduction of challenging patient behaviors, such as the development of zero tolerance policies of violent behavior (Nachreiner et al., 2005). At a second level, according to our results, interventions should focus on staff members, with the organization combating the effects of stress and increasing worker satisfaction to decrease the psychological effects of exposure to violence, as well as to identify those persons who, because of their kind of job involvement, may be more susceptible to problems of occupational stress, as proposed by López-Araujo, OseSegovia, and Peiró (2007). Acknowledgments We wish to thank all the workers who completed the questionnaire for their time and dedication, the directors of the participant centers for their collaboration, and the postgraduate students (collaborators) for their work.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work presented herein is a part of a more extensive research project on workplace violence in nursing staff, financed by the Ministerio de Trabajo y Asuntos Sociales, Secretaría General de Políticas de Igualdad, Instituto de la Mujer (Ministry of Work and Social Affairs, General Secretariat of Policies of Equality, Women’s Institute; File 152/07). This article received the aid to the diffusion of scientific works 2012 from the Official Nurses’ Association of Murcia.
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Galián, I., Llor, B., & Ruiz, J. A. (2012). Violencia de los usuarios hacia el personal de enfermería en los hospitales públicos de la Región de Murcia [Patient violence towards nursing staff in public hospitals of the Region of Murcia]. Revista Española de Salud Pública, 86, 279-291. Gil-Monte, P. R. (2002). Validez factorial de la adaptación al español del Maslach Burnout Inventory General Survey [Factor validity of the adaptation to Spanish of the Burnout Inventory General Survey]. Salud Pública de Mexico, 44, 33-40. Hensel, J. M., Lunsky, Y., & Dewa, C. S. (2012). Exposure to client aggression and burnout among community staff who support adults with intellectual disabilities in Ontario, Canada. Journal of Intellectual Disability Research, 56, 910-915. doi:10.1111/j.1365-2788.2011.01493 Herzberg, F., Mausner, B., & Snyderman, B. B. (1959). The motivation to work. New York, NY: John Wiley. Howard, R., Rose, J., & Levenson, V. (2009). The psychological impact of violence on staff working with adults with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 22, 538-548. International Council of Nurses. (2007). Directrices para hacer frente a la violencia en el lugar de trabajo [Guidelines to deal with workplace violence]. Geneva, Switzerland: Author. Irvine, D. M., & Evans, M. G. (1995). Job satisfaction and turnover among nurses: Integrating research findings across studies. Nursing Research, 44, 246-263. Isaksson, U., Graneheim, U. H., Richter, J., Eisemann, M., & Åström, S. (2008). Exposure to violence in relation to personality traits, coping abilities, and burnout among caregivers in nursing homes: A case-control study. Scandinavian Journal of Caring Sciences, 22, 551-559. Jaccard, J., Turrisi, R., & Wan, C. (1990). Interaction effects in multiple regression. Beverly Hills, CA: SAGE. López-Araujo, B., Ose-Segovia, A., & Peiró, J. M. (2007). El papel modulador de la implicación con el trabajo en la relación entre el estrés y la satisfacción laboral [The moderating role of work engagement in the relationship with stress and job satisfaction]. Psicothema, 18, 81-87. López-Montesinos, M. J. (2009). Consecuencias psicosociales del trabajo en el personal de enfermería como indicadores subjetivos de rendimiento desde el enfoque de la gestión de recursos humanos [Psychosocial consequences of work in nursing staff as subjective indicators of performance from the viewpoint of human resources management] (Doctoral thesis). Universidad de Murcia, Murcia, Spain. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397-422. McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of Advanced Nursing, 44, 633-642. Mills, S., & Rose, J. (2011). The relationship between challenging behaviour, burnout and cognitive variables in staff working with people who have intellectual disabilities. Journal of Intellectual Disability Research, 55, 844-857. Nachreiner, N. M., Gerberich, S. G., McGovern, P. M., Church, T. R., Hansen, H. E., Geisser, M. S., & Ryan, A. D. (2005). Relation between policies and work related
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Author Biographies Inmaculada Galián-Muñoz is occupational health nurse at Health Service of Murcia and professor associated of “Psychosocial sciences applied to nursing at the University of Murcia. Jose Antonio Ruiz-Hernández is a PhD in Psychology . He works as professor in the School of Psychology at the University of Murcia. Bartolomé Llor-Esteban is a medical doctor and he works as a professor in the Faculty of Nursing at the University of Murcia. Cecilia López-García is a nurse and she is doing a PhD in Nursing Care Research at the University of Murcia.
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JIVXXX10.1177/0886260514555367Journal of Interpersonal ViolenceGalian et al.
Article
User Violence and Nursing Staff Burnout: The Modulating Role of Job Satisfaction
Journal of Interpersonal Violence 1–14 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514555367 jiv.sagepub.com
Inmaculada Galián-Muñoz,1 Jose Antonio RuizHernández,1 Bartolomé Llor-Esteban,1 and Cecilia López-García1
Abstract Exposure to patient violence in health staff can lead to the onset of burnout in these workers. The main goal of this investigation is to study how exposure to this kind of violence affects onset of burnout and to appraise the role of job satisfaction as a modulating variable. A descriptive, cross-sectional study was carried out using a self-administered anonymous questionnaire with the nursing staff of all the public hospitals of the Region of Murcia (Spain), obtaining a sample of 1,489 health professionals. From the results obtained, we underline the modulating role of extrinsic job satisfaction in the relationship between nonphysical violence and emotional exhaustion, and the protective effect of job satisfaction on the impact of nonphysical violence and the level of cynicism. No effects of job satisfaction in the relationship between physical violence and burnout were observed. We therefore conclude that experiencing nonphysical aggression has a lower impact on the psychological health of workers who are satisfied with their job, and interventions aimed at increasing these workers’ extrinsic job satisfaction are highly recommended.
1Universidad
de Murcia, Spain
Corresponding Author: Inmaculada Galián-Muñoz, Servicio Murciano de Salud, Servicio de Prevención de Riesgos Laborales, Hospital Psiquiátrico Román Alberca, C/Lorca,58, 30120 El Palmar, Murcia, Spain. Email: [email protected]
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Keywords job satisfaction, burnout, patient violence, nursing staff
Introduction The International Council of Nurses (ICN; 2007, p. 4) defines workplace violence as “incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.” Clinical staff are among the professionals most exposed to patient violence, and some studies report that more than one half of the workers in this sector have experienced at least one incident of physical or psychological violence in the past year (Ayranci, Yenimez, Balci, & Kaptanoglu, 2006; Di Martino, 2002). Specifically, in the Region of Murcia (Spain), 71% of the nursing staff was exposed to verbal violence, and 19.9% of the sample was exposed to some manifestation of nonverbal violence, with at least a yearly frequency (Galián, Llor, & Ruiz, 2012). The importance of this risk lies in its frequency (Blando, O’Hagan, Casteel, Nocera, & Peek-Asa, 2013) but also in the severity of the possible consequences deriving from it. Numerous studies refer to the psychological consequences of patient aggression for nursing staff (Estryn-Behar et al., 2008; Franz, Zeh, & Schablon, 2010; Roche, Diers, Duffield, & CatlingPaull, 2010; Tak, & Sweeney, 2010; Zampieron, Galeazzo, Turra, & Buja, 2010), and the association between risk and burnout has frequently been observed. For example, Isaksson, Graneheim, Richter, Eisemann, and Åström (2008) detected that nurses who had been exposed to violence scored higher in burnout. Subsequently, other authors qualified this fact, indicating that this positive association occurred particularly with emotional exhaustion and cynicism (Chung & Harding 2009; Howard, Rose, & Levenson, 2009; Mills & Rose, 2011). Hensel, Lunsky, and Dewa (2012) stated that between 7% and 24% of the workers do suffer burnout or are at high risk of burnout due to aggressions experienced. But the issue is why some nurses suffer from burnout and others do not. Therefore, this work introduces job satisfaction as a moderating variable between exposure to such violence and the development of burnout, on the basis of the study of Faragher, Cass, and Cooper (2005), who reported that when job satisfaction increases, workers’ psychological well-being also improves, but if satisfaction decreases, there is greater risk of burnout. We draw on the tridimensional concept of burnout proposed by Maslach, Schaufeli, and Leiter (2001): Burnout affects individuals at the personal level (emotional exhaustion), at the social level (cynicism), and finally, at the
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professional level (professional inefficacy), and on the multidimensional theory of job satisfaction of Herzberg, Mausner, and Snyderman (1959), who stated that these dimensions are divided into factors of intrinsic work motivation (related to work content), such as the job itself or the achievements, and extrinsic factors (related to work conditions that cannot be controlled or changed directly by the worker), such as organizational policies or supervision, considering that extrinsic and intrinsic factors are related, and differentiating between manifestations of physical and nonphysical violence (Waschgler, Ruiz, Llor, & García-Izquierdo, 2013. Therefore, the goal of this study was to analyze how patient aggressions and job satisfaction influence the level of workers’ burnout, specifically, to determine whether job satisfaction modulates the relation between exposure to patient hostility and the onset of burnout in a sample of professional nurses.
Method Participants The sample was made up of 1,489 nursing professionals with an age range between 20 and 67 years (M age = 42.09, SD = 9.75). Most of them were females (82.7% vs. 16.4%) and married or living with a common-law partner (67.8%). Of them, 62.1% had a nursing diploma, and 36.7% were auxiliary nurses; their mean job tenure in the current post was 7 years and 5 months (SD = 97.57 months), and mean job tenure in the nursing profession was 15 years 4 months (SD = 112.08 months). Of the sample, 59.4% had a permanent contract.
Procedure This is a descriptive cross-sectional study, carried out with nursing staff from all the public hospitals of the Region of Murcia during the year 2010. That year, there were 11 hospitals in the Health Service of Murcia (10 general hospitals and 1 psychiatric hospital), with a staff of 19,550 people, of whom 6,103 were nursing personnel (nurses and auxiliary nursing staff). A total of 30% of the nursing staff was sampled, stratified as a function of the size of the units and the hospital staff. Of the surveys handed out, we obtained a global response rate of 81.36% (1,489 workers), which is 28.98% of the entire nursing staff and 18.96% of the entire auxiliary nursing staff. This sample leads to a 99% confidence level and a sampling error of 1.75%. To obtain the sample, we informed the nursing department directors of the hospitals in detail about the study, and, after they agreed to participate in the
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investigation, we held meetings in each center with all the nursing supervisors. In these meetings, supervisors were requested to hand out the questionnaire randomly to 30% of their staff (selecting one worker from every three, according to the schedule of shifts) and, after the questionnaires had been completed by the workers, to collect them in a sealed envelope with no identification marks. The supervisors had a maximum time limit of 2 weeks to return the surveys (questionnaires that were not handed in after that date were counted as missing). Collection was carried out by collaborators (people from the research group who visited the hospitals twice a week to verify the process of data collection) and the people proposed by the hospitals (normally in charge of teaching and research).
Instruments The Hospital Aggressive Behaviour Scale–Users (HABS-U) was used to assess exposure to violence (Waschgler et al., 2013). This scale addresses patients’ low-intensity hostile nonphysical and physical manifestations that are perceived by the worker as violent. The questionnaire has 10 items, with Cronbach’s alpha of .839, explaining 57.36% of the variance. It is divided into two factors: nonphysical violence (α = .85, explaining 36.39% of the variance, with a factor loading of .636-.756) with 7 items; and physical violence (α = .74, explaining 20.96% of the variance, with a factor loading of .713-.782). To appraise the frequency of exposure, a 6-point Likert-type scale, ranging from 1 (never in the past year) to 6 (daily) was used (Waschgler et al., 2013). To appraise the level of job satisfaction, we used the Overall Job Satisfaction (OJS) Scale, developed by Warr, Cook, and Wall in 1979, adapted to Spanish by Pérez and Hidalgo. This scale has 15 items, which are rated on a 7-point Likert-type scale, ranging from 0 (very dissatisfied) to 6 (very satisfied). The OJS is divided into two subscales: Intrinsic Factors subscale, which is made up of 7 items, and the Extrinsic Factors subscale, made up of 8 items. With regard to internal consistency of the questionnaire, Cronbach’s alpha index ranged between .85 and .88; for the extrinsic factors subscale, it was .74 to .78, and the intrinsic factors subscale had a reliability of .79 to .85 (NTP 394, 1984). We used the Maslach Burnout Inventory–General Survey (MBI-GS), translated and validated in Spanish by Gil-Monte (2002), to analyze levels of burnout. The MBI-GS has 16 items, divided into three subscales: Professional Efficacy (6 items), Emotional Exhaustion (5 items), and Cynicism (5 items). Participants rate the frequency with which they have experienced each item of the questionnaire on a 7-point Likert-type scale ranging from 0 (never) to 6 (daily). The reliability values of the scales according to Cronbach’s alphas Downloaded from jiv.sagepub.com at UNIV MASSACHUSETTS AMHERST on October 6, 2015
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in the study of Gil-Monte (2002) were .85 for Professional Efficacy, .83 for Emotional Exhaustion, and .74 for Cynicism.
Data Analysis Descriptive statistics, internal consistency (Cronbach’s α), and correlations of the target variables were calculated. To determine the effect of interaction, we conducted hierarchical regression analysis (Cohen & Cohen, 1983) for each one of the possible combinations of manifestations of violence and dimensions of job satisfaction with the diverse burnout components (dependent variable). The independent variables were entered in the regression equations in two steps (Jaccard, Turrisi, & Wan, 1990). In Step 1, we entered one of the dimensions of patient violence (nonphysical violence–physical violence) and one of the dimensions of job satisfaction (extrinsic satisfaction–intrinsic satisfaction). In Step 2, we introduced the interaction of the independent variables used.
Ethical Considerations The project was approved and financed by the Instituto de la Mujer del Ministerio de Sanidad, Asuntos Sociales e Igualdad (Women’s Institute of the Ministry of Health, Social Affairs and Equality) in a public summons. Its diffusion was financed by the Official Nursing Association of the Region of Murcia. The managers and nursing directors of all the hospitals involved agreed to participate in the study. Information was included with the questionnaires so that participation was informed and voluntary. Participation was also anonymous, and confidentiality was guaranteed because the questionnaires were returned in sealed envelopes, which were opened by members of the research team, who then assigned a code to each questionnaire for data analysis. In view of all these guarantees, it was considered that the study did not need to be authorized by the ethics committee.
Results Table 1 shows the descriptive analyses and internal consistencies of the target variables. The mean score for violence was 15.18; for extrinsic job satisfaction, 30.11; for emotional exhaustion, 14.07; and for cynicism, 11.81. In all the scales, the correlation coefficients are equal to or higher than the criterion of .70 recommended by Nunnally and Bernstein (1967/1994). Job satisfaction and its dimensions correlated negatively with violence and its dimensions and with emotional exhaustion and cynicism, and positively with
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SD
10.45 5.28 4.71 1.8 15.16 6.36 25.57 7.29 30.11 6.96 55.7 13.47 14.07 5.39 11.81 5.08 27.8 8.71
M 3 7 10 7 8 15 9 5 8
Item
2 .85 .96*** −.15*** −.14*** −.16*** .26*** .23*** −.04*
1 .74 .48*** .68*** −.12*** −.10*** −.12*** .09*** .13*** .01
Note. The reliability of the variables of the study is on the diagonal. *p < .05. **p < .01. ***p < .001.
1. Physical violence 2. Nonphysical violence 3. Total violence 4. Intrinsic job satisfaction 5. Extrinsic job satisfaction 6. Total job satisfaction 7. Emotional exhaustion 8. Cynicism 9. Professional efficacy
Variables
.83 −.16*** −.15*** −.17*** .25*** .23*** −.04
3
Table 1. Descriptive Statistics, Reliabilities, and Correlations Between Variables. 5
6
7
8
9
.84 .78*** .70 .94*** .94*** .87 −.35*** −.36*** −.38*** .85 −.38*** −.33*** −.38*** .50*** .70 .13*** .10*** .12*** −.06 −.10*** .85
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Table 2. Regression Equation Predicting Emotional Exhaustion From Nonphysical Violence and Extrinsic Job Satisfaction.
Nonphysical violence Extrinsic job satisfaction Nonphysical violence × Extrinsic job satisfaction
β
R2
ΔR2
.429*** −.237*** −.233*
.181
.003
.184
*p < .05. **p < .01. ***p < .001.
Table 3. Regression Equation Predicting Cynicism From Nonphysical Violence and Extrinsic and Intrinsic Job Satisfaction.
Nonphysical violence Extrinsic job satisfaction Intrinsic job satisfaction Nonphysical violence × Intrinsic job satisfaction Nonphysical violence × Extrinsic job satisfaction
β
R2
ΔR2
.530*** −.150** −.270*** −.173* −.370***
.148
.002 .007
.183 .155
*p < .05. **p < .01. ***p < .001.
professional efficacy. Violence correlated positively and significantly with emotional exhaustion and cynicism, but its relation with professional efficacy was nonsignificant, so this dimension was not included in the regression analysis of burnout. We conducted regression analyses for each one of the possible combinations of the dimensions of violence and job satisfaction to determine their effects on emotional exhaustion and cynicism, obtaining significant relationships when entering the interaction effect of nonphysical violence and extrinsic job satisfaction (Table 2) on emotional exhaustion, and the interaction effect of nonphysical violence and extrinsic and intrinsic job satisfaction on cynicism (Table 3). Table 2 presents the analysis of the dimension of emotional exhaustion through regression analysis, in which the first block of variables includes nonphysical violence and extrinsic job satisfaction, with both variables revealing a significant relation with emotional exhaustion, positive in the case of violence, and negative in the case of job satisfaction (β = .429, p < .001; β = −.237, p < .001). These factors explain 18.1% of the variance of emotional exhaustion. In Step 2, we entered the interaction of these variables, which was negatively significant (β = −.23, p < .05), obtaining an increase of .003 in the explained variance. Downloaded from jiv.sagepub.com at UNIV MASSACHUSETTS AMHERST on October 6, 2015
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Journal of Interpersonal Violence Emo onal exhaus on score
21 Low Extrinsic Job Sa sfac on
19 17 15
High Extrinsic Job Sa sfac on
13 11 9 Low Non-physical Violence
High Non-Physical Violence
Figure 1. Effect of the interaction of nonphysical violence and extrinsic job satisfaction on the level of emotional exhaustion.
The results of the same regression analysis on cynicism showed that cynicism is positively related to nonphysical violence (β = .530, p < .001), and extrinsic job satisfaction has a negative main effect (β = −.150, p < .01). As shown in Table 3, these variables explain 14.8% of the variance of cynicism, which rises to 15.5% when taking into account the interaction (β = −.370, p < .001). Table 3 shows that, on one hand, nonphysical violence has a positive main effect on the level of cynicism (β = .530, p < .001), whereas intrinsic job satisfaction has a negative main effect (β = −.270, p < .001) on cynicism, in this case, explaining 18.3% of the variance. The effect of the interaction of these variables on the dependent variable cynicism was negative (β = −.173, p < .05), with an increase in R2 of .2%. Figures 1 and 2 present the interpretation of these results, showing the significant effects of the interactions, with the quartiles as reference; thus, a high value in the variable corresponds to scores in Q4, and a low value corresponds to Q1, discarding the values of Q2 and Q3. Figures 1 and 2 show that for the same level of violence, low levels of job satisfaction correspond to higher mean scores in emotional exhaustion and cynicism. Figure 1 shows that for low job satisfaction, there is a greater difference than for high job satisfaction in the mean scores of emotional exhaustion when comparing high and low levels of exposure with nonphysical violence (2.51 vs. 3.12). This aspect is more pronounced in cynicism, where high levels of intrinsic and extrinsic job satisfaction both lead to similar mean cynicism scores, even if the level of nonphysical violence increases (see Figure 2).
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Cynicism score 17 16 15 Low Intrinsic Job Sa sfac on
14
High Intrinsic Job Sa sfac on
13
Low Extrinsic Job Sa sfac on
12
High Extrinsic Job Sa sfac on
11 10 9 Low Non- Physical Violence
High Non-Physical Violence
Figure 2. Effect of the interaction of nonphysical violence and extrinsic and intrinsic job satisfaction on the level of cynicism.
Discussion The goal of this study was to analyze how exposure to patient violence influences the level of workers’ burnout, specifically to determine whether the dimensions of job satisfaction analyzed modulate the relation between physical and nonphysical violence and the three dimensions of burnout. The results obtained in a sample of nursing professionals indicate that the scores in job satisfaction are lower than those provided as reference by the authors of the scale (Warr et al., 1979) both at the global level and at the levels of extrinsic and intrinsic job satisfaction. This is coherent with diverse articles and recent studies of nurses, such as that of the American Association of Critical Care Nurses (AACN), reporting high levels of job dissatisfaction and quitting the profession in nursing professionals (AACN, 2005). However, if we compare the mean scores obtained in our sample in the burnout dimensions with the data obtained by other authors (López-Montesinos,
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2009), our mean scores in emotional exhaustion and cynicism are higher, although there is some variability in professional efficacy. With regard to exposure to violence, we could not compare our results with those of other studies due to the novelty of the use of the HABS-U scale as the assessment instrument. In the analyses conducted to predict burnout from exposure to patient violence, we found that exposure to physical and to nonphysical violence were both positively correlated with the level of emotional exhaustion and cynicism, coherently with our expectations (Chung & Harding, 2009; Howard et al., 2009; Mills & Rose, 2011). Likewise, both dimensions of job satisfaction were significantly and negatively correlated with burnout. We coincide with Figueiredo-Ferraz, GrauAlberola, Gil-Monte, and García-Juesas (2012) in stating that there is a bidirectional relationship between these variables. Through regression analyses, we detected that extrinsic job satisfaction modulates the relationship between nonphysical violence and emotional exhaustion and cynicism, whereas intrinsic job satisfaction influences the relationship between nonphysical violence and cynicism, although the explained variance is low in both cases (values of R2 < .2). This indicates that these burnout dimensions are also influenced by other stressors. It has been shown that with the same exposure to nonphysical violence, people with low levels of job satisfaction have higher levels of emotional exhaustion and cynicism. Likewise, we observed that when workers with high levels extrinsic job satisfaction are exposed to high levels of violence, their levels of emotional exhaustion and cynicism are lower than those of workers with low levels of extrinsic satisfaction. The same can be stated about intrinsic satisfaction and cynicism: High levels of intrinsic job satisfaction lead to lower levels of cynicism even in the presence of high levels of exposure to violence. Therefore, we consider that job satisfaction, particularly extrinsic job satisfaction, plays a protective role in the psychological health of workers exposed to nonphysical violence; that is, if workers are satisfied with their jobs, they will be less likely to suffer burnout even if they experience an act of patient aggression. This is consistent with other studies such as those of Blegen (1993), Irvine and Evans (1995), and McVicar (2003), which propose increasing support from coworkers, superiors, and directors (factors addressed in extrinsic satisfaction) as measures to counteract nurses’ chronic stress, because they consider that, if workers are satisfied with such support, the impact of an aggression on their psychological health will be lower. We think that nonphysical violence and burnout have a cyclical relation such that frequent exposure to situations of nonphysical violence will increase
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levels of cynicism and emotional exhaustion (Chung & Harding, 2009; Howard et al., 2009; Mills & Rose, 2011) and, in turn, cynicism and exhaustion will favor the onset of new aggressions (Whittington, 2002), but extrinsic job satisfaction could buffer that relationship. Although the results found in this study should be considered taking into account the limitations associated with studies using self-report questionnaires as a possible selection bias, we think that influencing workers’ job satisfaction could work as a strategy to decrease the levels of burnout in workers frequently exposed to nonphysical violence. When analyzing the data obtained, it should be taken into account that if a low level of institutional support can reduce extrinsic job satisfaction and contribute to violence, such support can be the cause of the reduction of violence, but it may also be a confounding factor. Even so, on the basis of the results obtained, considering prevention of occupational hazards, we suggest the development of psychological health programs including improvement of job satisfaction in organizations whose workers are affected by patient violence. According to Singh and colleagues (2009), such intervention programs for burnout prevention should address the problem at various levels. A first step would consist of actions targeting the organization and the environment, eliminating or reducing stressful factors to a minimum through proactive management strategies; in the case of risk of violence, this would mean early identification of the workers who suffer greater exposure and the establishment of preventive measures aimed at the reduction of challenging patient behaviors, such as the development of zero tolerance policies of violent behavior (Nachreiner et al., 2005). At a second level, according to our results, interventions should focus on staff members, with the organization combating the effects of stress and increasing worker satisfaction to decrease the psychological effects of exposure to violence, as well as to identify those persons who, because of their kind of job involvement, may be more susceptible to problems of occupational stress, as proposed by López-Araujo, OseSegovia, and Peiró (2007). Acknowledgments We wish to thank all the workers who completed the questionnaire for their time and dedication, the directors of the participant centers for their collaboration, and the postgraduate students (collaborators) for their work.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work presented herein is a part of a more extensive research project on workplace violence in nursing staff, financed by the Ministerio de Trabajo y Asuntos Sociales, Secretaría General de Políticas de Igualdad, Instituto de la Mujer (Ministry of Work and Social Affairs, General Secretariat of Policies of Equality, Women’s Institute; File 152/07). This article received the aid to the diffusion of scientific works 2012 from the Official Nurses’ Association of Murcia.
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Author Biographies Inmaculada Galián-Muñoz is occupational health nurse at Health Service of Murcia and professor associated of “Psychosocial sciences applied to nursing at the University of Murcia. Jose Antonio Ruiz-Hernández is a PhD in Psychology . He works as professor in the School of Psychology at the University of Murcia. Bartolomé Llor-Esteban is a medical doctor and he works as a professor in the Faculty of Nursing at the University of Murcia. Cecilia López-García is a nurse and she is doing a PhD in Nursing Care Research at the University of Murcia.
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