Workplace violence (WPV) is defined as “any physical assault, threatening behavior, or verbal abuse occurring in the work setting.”1(p1) The incidence of WPV against health care workers is rising, and nursing is one of the most vulnerable occupations.2 In 2019, nurses suffered nearly 20 150 work-related injuries, and approximately 13.7% of these injuries were due to violent events.3 This incidence rate was nearly 3 times the rate of violent events for all occupations.3 The most common type of violence in health care settings is directed at health care workers by clients, including patients, their families, or visitors.2 According to a recent study on WPV toward nurses conducted in 5 European countries, patients were the most prevalent perpetrators, accounting for 70% of the verbal abuse and 92% of the physical attacks.4 Despite various efforts to prevent WPV, the rate of WPV directed at nurses has increased in the last 10 years.3
Workplace violence has consequences for the nurse's physical and psychological health and well-being and ultimately affects the patient. Nurses' experience of WPV is associated with increased depression5 and burnout,6,7 decreased job satisfaction,6,8 and increased intent to leave.9,10 Workplace violence has also been negatively associated with employee engagement10,11 and positively associated with the occurrence of increased medical errors or adverse events.10,12 Therefore, minimizing and managing the negative impact of WPV on nurses, and instituting efforts to prevent violence, are vital for ensuring safe and quality patient care.
Among the various effects of WPV on nurses, burnout has been an ongoing challenge in nursing,13 and WPV can contribute to or exacerbate nurses' burnout. Job burnout is defined as a psychological syndrome that occurs in response to chronic interpersonal stressors on the job and frequently occurs in professionals with a high level of interpersonal contact.14 According to Maslach and Leiter,15 the burnout experience may be exacerbated if nurses are subjected to violence due to negative transference. Negative transference is a psychodynamic term that refers to a patient's transfer of anger or hostility toward other significant subjects to health professionals.16 Patients' aggressive behavior can be emotionally exhausting and impossible to manage, causing nurses to be emotionally distant or disconnected from their work.15 It may also reduce nurses' confidence in their ability to care for patients and degrade their sense of nursing professionalism.15 Thus, higher burnout levels are linked to higher degrees of negative sentiment toward patients and lower quality of patient care.17 Mitigating the effects of WPV through effective burnout management is critical to maintaining the work-life quality of nurses and providing safe, quality care for patients.
Reporting of WPV incidents by nurses provides a mechanism for understanding WPV situations and creates an avenue for developing and implementing strategies to prevent and minimize the negative impacts of WPV.18,19 Unfortunately, researchers have found that nurses report WPV in only 20% to 60% of situations.18 The most common barriers hindering nurses from reporting WPV incidents include their perception that violent incidents are a routine part of the job and therefore unnecessary to report; nurses' beliefs that reporting will not lead to meaningful change in WPV; nurses' fears of being blamed for the violent incident; and nurses' perceptions of lack of hospital or supervisor support.18–20
In 2019, the American Nurses Association (ANA) published a position statement to encourage and create a culture that supports reporting of all incidents in the workplace.18 They described the WPV-reporting culture as comprising the interconnected concepts of just culture and a culture of safety.18 Just culture focuses on “creating an atmosphere of trust, [and] encouraging and rewarding people for providing essential safety-related information”21(p3) through improvements in the system versus the punishment of individuals for making mistakes. In addition, a workplace culture that promotes reporting and safety represents a significant opportunity to improve care delivery systems and work environments for patients and providers.21
Health system leaders who have implemented WPV-reporting systems may be more effective at mitigating the negative impacts of WPV through early identification of WPV causation and provision of support to those impacted by the violence. Many hospitals are attempting to foster a culture that encourages staff to report WPV. However, we were unable to find research to support the relationships among WPV, burnout, and patient outcomes, and how a WPV-reporting culture may affect these relationships. For this study, the authors examined the relationships among nurses' WPV experiences, burnout, and patient safety, and the moderating effect of WPV-reporting culture on these relationships. We sought to answer 2 research hypotheses, and the Figure presents the hypothetical model that guided this analysis.
Hypothesis 1: Workplace violence negatively affects patient safety (operationalized as both nurses' identification of an overall patient safety grade for their current unit and the number of patient events reported) due to increased burnout.
Hypothesis 2: Workplace violence–reporting culture moderates the indirect relationship between WPV experience and patient safety grade via burnout such that the relationship is weaker when WPV-reporting culture is strong (and vice versa).
Design, setting, and study population
We designed and implemented a descriptive, cross-sectional study based on a secondary analysis of data. The larger study was the 2018 Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS)22 collected at a large academic medical center in the southeastern United States. The HSOPS tool measures staff's perceptions of the patient safety culture at their hospitals and included 42 items.22 As the HSOPS allowed individual institutions to add additional questions, the medical center added 4 WPV and 4 burnout items to the survey and administered them at the same time. All health care providers and staff were invited to participate in the online survey. A total of 3601 staff from 120 units across the hospital responded. The current study investigated only nurses' responses. A total of 1781 nurses responded out of an estimated 3000 nurses, with an approximate 60% response rate.
The Workplace Violence Scale23 was developed at the medical center to assess health care workers' experiences with 3 types of violence: physical violence by a patient, verbal abuse by a patient, and verbal abuse by a visitor. Participants were asked, “Regardless of patient's mental status or medical history, how many times have you experienced each type of violence in the past 3 months?” These items were rated as 1 (none), 2 (1-5 times), 3 (6-10 times), and 4 (11 or more times). At the time of the original development, the institution tested the content validity of these items with 20 nurses from emergency department, psychiatry, and medicine units where WPV often occurs. Cronbach α value for these 3 items was 0.78 in the current study. The total mean score of the 3 items was analyzed to evaluate the overall trend of WPV experiences and their relationships with other variables, regardless of the type of violence.
Burnout was measured using 4 items from the Emotional Exhaustion subscale of the validated Maslach Burnout Inventory.24,25 The 4 items were (1) “I feel fatigued when I get up in the morning and have to face another day on the job,” (2) “I feel burned out from my work,” (3) “I feel frustrated by my job,” and (4) “I feel I am working too hard on my job.” Each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a higher score indicating higher levels of burnout. Cronbach α for this measure was 0.89 in the current study and 0.85 in the study by Sexton et al.25 The mean score of the 4 items was used for analysis.
Patient safety outcomes
To assess patient safety outcomes, we used 2 items from the HSOPS: “overall patient safety grade” and the “number of events reported.” Nurses were asked to rate the overall grade on how safe their work area/unit keeps their patients from injuries or adverse events as 1 (failing), 2 (poor), 3 (acceptable), 4 (very good), or 5 (excellent). The number of patient safety events reported in the past 12 months was measured as 0 (none), 1 (1-2 event reports), 2 (3-5 event reports), 3 (6-10 event reports), 4 (11-20 event reports), and 5 (21 event reports or more). Each of the items was included separately in the statistical analysis model as a dependent variable.
Workplace violence–reporting culture
Based on the ANA's statement18 that WPV-reporting culture should include an extension of the concept of just culture and a culture of safety, we used the HSOPS questions to measure WPV-reporting culture. One question assessing the level of hospital management support for reporting patient violence was added to the 42 items of HSOPS. Exploratory factor analysis was conducted to model the interrelationships between items. Initially, the factorability of 43 items was examined, and 24 items that had low correlations (<0.3) with the item “hospital management support for patient violence reporting” were excluded. The remaining 19 items were factor analyzed using a principal component method with Varimax rotation. The Kaiser-Meyer-Olkin test of sampling adequacy was 0.94, and Bartlett test of sphericity was significant ( = 17020.30, P < .001). The analysis yielded 3 factors explaining a total of 61.2% of the variance for the set of variables.
Out of 3 factors, 1 factor was labeled WPV-reporting culture due to the high loading by the following items: (1) “When an event is reported, it feels like the person is being written up, not the problem (reverse worded)”; (2) “Staff feel like their mistakes are held against them (reverse worded)”; (3) “My supervisor/manager seriously consider staff suggestions for improving patient safety”; and (4) “Hospital management supports staff reporting of patient violence or verbal abuse.” Cronbach α value for these 4 items was 0.77. Items were rated on a 5-point Likert scale from strongly disagree (1) to strongly agree (5). The total mean score of all 4 items was used for analysis, with a higher score indicating a more encouraging culture toward WPV reporting.
Preliminary analysis revealed a correlation between 2 variables, “unit tenure” and “type of work unit,” and the dependent variables; thus, these 2 variables were included as control variables.
Descriptive analysis of variables was completed using SPSS statistics (Version 27.0). A moderated mediation analysis was conducted with the PROCESS macro version 3.526 to evaluate whether WPV experience affects patient safety due to burnout and whether the indirect effect is further conditional on WPV-reporting culture levels. The PROCESS model 58 was used to test for conditional indirect effects of both “independent variable (X) and mediation variable (M)” and “mediation variable (M) and dependent variable (Y)” paths (see the Figure). The variables WPV, burnout, and WPV-reporting culture were mean-centered before creating product terms. The significance of the conditional effects was tested with a 95% confidence interval based on 10 000 bootstrap replications. Conditional effects were further probed by estimating and plotting the conditional effects at values of WPV-reporting culture corresponding to high (1 SD above the mean) and low (1 SD below the mean) levels.
This study was approved by the university's institutional review board (no. 20-3703).
A total of 1781 nurses responded to the survey; about 21% worked in the intensive care unit, and the remaining participants worked on the following units: medicine (19.2%), surgery (12.6%), perioperative surgery (9.3%), obstetrics (7.2%), emergency department (6.8%), pediatrics (6.5%), psychiatry (6.2%), and others (ie, rehabilitation, laboratory, radiology, etc) (10.9%). Most nurses (n = 787, 44.2%) had been employed in the current hospital for 1 to 5 years. Almost 50% had been employed in their current unit for 1 to 5 years.
Unit tenure was negatively correlated with patient safety grade (r = −0.8, P = .001) and was positively correlated with the number of events reported (r = 0.17, P < .001). There was a significant effect of unit type on patient safety grade, F8,1667 = 20.67; P < .001, and number of events reported, F8,1752 = 12.78, P < .001.
Relationships between WPV, burnout, and patient safety
The mean scores, SD, and correlations among study variables are presented in Supplemental Digital Content Table 1, available at: https://links.lww.com/JNCQ/A983. Analysis revealed significant positive associations between WPV experience and burnout (r = 0.22, P < .001), burnout and number of events reported (r = 0.10, P < .001), and WPV-reporting culture and patient safety grade (r = 0.59, P < .001). There were significant negative associations between burnout and patient safety grade (r = −0.54, P < .001) and WPV experience and WPV-reporting culture (r = −0.18, P < .001). However, WPV-reporting culture was not significantly associated with number of events reported (r = −0.03, P = .229).
Moderated mediation analysis
Moderate effect of WPV-reporting culture
The moderated mediation analysis results are provided in Supplemental Digital Content Table 2, available at: https://links.lww.com/JNCQ/A984, and Supplemental Digital Content Figure, available at: https://links.lww.com/JNCQ/A985. The association between WPV and nurse burnout was moderated by WPV-reporting culture (B = 0.17, P < .001). The level of WPV-reporting culture also moderated the relationships between burnout and patient safety grade and between burnout and the number of events reported (B = 0.07, P < .001 and B = −0.11, P < .001, respectively). To describe the nature of the interaction, simple slopes were calculated at ±1 SD of the mean WPV-reporting culture. In the relationship between WPV and burnout, a higher level of WPV-reporting culture increased the negative impact of WPV on burnout (0.22 → 0.35 → 0.47). In the relationship between burnout and patient safety grade, a higher level of WPV-reporting culture decreased the negative effect of burnout on patient safety grade (−0.35 → −0.29 → −0.24). Furthermore, the lower level of WPV-reporting culture increased the impact of burnout on the number of events reported (0.15 →0.06) (see Supplemental Digital Content Figure, available at: https://links.lww.com/JNCQ/A985).
Conditional indirect effects
Additional analyses were conducted to determine whether the conditional indirect effects of WPV on patient safety grade and the number of events reported through burnout were statistically significant at values corresponding to low (−1 SD), moderate (mean), and high (+1 SD) levels of WPV-reporting culture. In the model examining WPV, burnout, and patient safety grade, the final conditional indirect effects were negative and did not include 0 for all moderator levels (B = −0.08, 95% confidence interval [CI] = −0.12 to −0.04; B = −0.10, 95% CI = −0.13 to −0.07; B = −0.11, 95% CI = −0.15 to −0.08).
In the model examining WPV, burnout, and number of events reported, burnout mediated the relationship between WPV and the number of patient events reported at low (B = 0.03, 95% CI = 0.10 to 0.05) and moderate (B = 0.02, 95% CI = 0.004 to 0.04) levels of WPV-reporting culture but had no indirect effect at a high level of WPV-reporting culture (B = −0.01, 95% CI = −0.04 to 0.02).
This study explored the relationships among nurses' WPV experience, burnout, patient safety, and the moderating effect of WPV-reporting culture on these relationships. Workplace violence was found to negatively impact patient safety through the mediating effect of increased burnout, and that this indirect effect differed on the basis of the WPV-reporting culture. We anticipated that a higher level of WPV-reporting culture would mitigate the negative impact of WPV on patient safety arising from nurse burnout. However, we found that at higher levels of WPV-reporting culture, the negative effect of WPV on burnout increased, while the relationship between burnout and patient safety decreased. As a result, the indirect effect of WPV on patient safety grade through increased burnout was stronger at a high level of WPV-reporting culture. The indirect effect of WPV on the number of patient events reported through increased burnout was mitigated at only low to moderate levels of WPV-reporting culture.
In the relationship between WPV and burnout, it was unexpected that burnout due to WPV would increase at high levels of WPV-reporting culture. Although our findings cannot be compared with other results because there was no existing research on the relationship between WPV-reporting culture and burnout, this finding raises the question of whether current WPV-reporting systems are accessible, efficient, and trustworthy for health care workers, including nurses. In studies that have investigated why nurses are reluctant to report WPV, many nurses responded that the reporting process was time-consuming and increased their work burden.4,27 Unclear hospital policies and procedures for reporting incidents of violence have also been found to be significant factors that hinder WPV reporting.27,28 If reporting systems are time-consuming, an increased emphasis on incident reporting may further exacerbate burnout because it increases workload. In addition, considering the characteristic of distancing oneself from work as a symptom of emotional exhaustion,14 our results indicate that for nurses who were already burned out as a result of their violence experiences, a culture of encouraging WPV reporting may exacerbate burnout by requiring them to relive their experiences and interact more with their work.
Most of the physical injuries caused by violence are reported using the official reporting system to receive compensation from hospitals. However, these likely represent major injury claims. It is often the case that minor injuries resulting from WPV and instances of verbal violence largely go unreported through the official reporting system because of the barriers mentioned previously.28 The prevalence of underreporting makes it difficult, if not impossible, to fully understand the nature and scope of WPV. Consequently, efforts to reduce WPV may be ineffective or counterproductive. Therefore, before promoting a culture of WPV reporting, the development of a more concise and user-centered reporting system should be prioritized by considering feedback from nurses and other health care workers on current violence-reporting systems. As previous studies have shown, a simplified incident-reporting system and the provision of immediate and appropriate feedback on incident reporting can facilitate a reduction in the burden of reporting, thereby preventing further burnout and promoting WPV incident reporting.27,29,30
Another critical point is that the most effective mode to address burnout is a combination of managerial practices at the organizational level and educational interventions to enhance individual coping skills in the workplace.14 The effects of WPV may be exacerbated by organizational and situational factors such as job characteristics or work environment,31,32 and these factors are also potential antecedents of nurse burnout.33 Although organization-level strategies are required to minimize burnout, they are insufficient. Individual-level strategies are also needed to equip individuals with effective communication and interpersonal skills, promote healthy working relationships, and improve work-related skills and attitudes. Individually focused interventions include developing resilience to combat burnout or training coping skills to manage such challenges as stress, communication, conflict resolution, and self-control.34,35 In the current study, we solely measured the level of hospital management support and culture surrounding WPV reporting. However, if adequate individual-level interventions are not provided to nurses who experience WPV, it is impossible for hospital management solely to alleviate burnout. Future studies should develop burnout interventions for nurses who have suffered WPV at both organizational and individual levels, and this should be considered in studies assessing the effectiveness of such interventions.
In the relationship between burnout and patient safety, our study showed that WPV-reporting culture weakened the adverse effect of burnout on both patient safety grade and the number of events reported. These results indicate that WPV-reporting culture can play an important role in preventing deterioration of patient safety due to WPV and burnout. The goal of encouraging safety incident reporting is to incorporate information about incidents and create learning opportunities aimed at improving the system and preventing recurrence.21 Stavropoulou et al36 analyzed 43 studies examining the effectiveness of incident-reporting systems in improving patient safety and showed that incident-reporting systems had a positive effect on health care organizations, including promotion of changes to policies, guidelines, and documentation, provision of staff training, and implementation of new technology.
Although there is little research on the positive effects of WPV-reporting systems in particular, the importance and expected effects of improving WPV-reporting culture do not differ from those that support patient safety culture. In a study of nurses' WPV experiences and support needs, nurses expressed the need for formal support, such as careful analysis of violent events, implementation of changes to reduce risk, and education to develop the ability to assess and manage risk.37 A formal WPV incident–reporting system is essential to provide support at the organizational level and to raise awareness of the importance of WPV reporting in establishing a culture that encourages reporting incidents of violence.18,27 Patient safety culture has become part of the organizational culture in health institutions after years of efforts, and improvements have been made in various areas by requiring institutions to regularly measure and manage patient safety events. Similarly, worker safety culture, encompassing WPV, should also be included and managed in the context of these efforts.
There are 2 major limitations in this study. First, patient safety outcomes were measured using 2 single items taken from the HSOPS: overall patient safety grade and the number of events reported in the last 12 months. Although these items have been used in patient outcomes studies,38 they are self-reported measures based on opinion and recall. Further studies using objective patient safety indicators are needed to more deeply examine patient safety and provide a more accurate measure that could be used to replicate this and other related studies. Second, this study was conducted only at 1 institution. Further multisite studies are needed to strengthen the generalization of research findings.
Despite these limitations, this study is among the first to examine the effect of WPV-reporting culture on the relationship between WPV, burnout, and patient safety. This research provides preliminary evidence supporting further investigation to better understand how the WPV-reporting system and culture affect the health and safety of nurses and patients.
In this study, we explored the relationships between WPV, burnout, and patient safety, and how WPV-reporting culture influences these relationships. Our findings show that WPV increased nurse burnout, which in turn negatively affected patient safety. We also found that a strong WPV-reporting culture increased the negative effect of WPV on burnout but decreased the negative effect of burnout on patient safety. This may indicate that nurses perceive WPV-reporting behavior as a stressor; thus, violence-reporting systems and procedures need to be improved to reduce the burden of reporting. Because a WPV-reporting culture is a combination of attitudes and behavior toward WPV, strengthening the WPV-reporting culture with a robust reporting system may be the essential component of preventing or reducing WPV and improving the health and safety of nurses and patients. Health care organizations need to devote more attention to improving violence-reporting procedures and culture.
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