key: cord-0918284-rfekwtdb
authors: Sommovigo, Valentina; Bernuzzi, Chiara; Setti, Ilaria
title: Investigating the association between patient verbal aggression and emotional exhaustion among Italian health care professionals during the COVID‐19 pandemic
date: 2022-03-16
journal: J Nurs Manag
DOI: 10.1111/jonm.13578
sha: 6ac9d5966a72f53dbef4e2c942686afa739c1377
doc_id: 918284
cord_uid: rfekwtdb

AIMS: To analyze whether patient verbal aggression would be related to emotional exhaustion and whether this relationship would be mediated by work–family conflict and moderated by dehumanization and resilience. BACKGROUND: Although patient verbal aggression has been identified as one of the most experienced forms of aggression, its effects on Italian health care providers during the pandemic are still poorly known. METHODS: A total of 197 Italian health care professionals completed paper‐and‐pencil questionnaires. Descriptive statistics and moderated mediation analyses were performed. RESULTS: Patient verbal aggression was positively related to health care professionals' emotional exhaustion, both directly and indirectly, as mediated by work–family conflict. Health care providers were more likely to become emotionally exhausted when they had low resilience and, simultaneously, tended to ascribe patients non‐uniquely human traits. CONCLUSIONS: Patient verbal aggression may spill over onto health care professionals' family lives. Dehumanization represents an ineffective coping strategy that exacerbates the effects of aggression on work–family conflict, whereas resilience represents a protective resource against emotional exhaustion. IMPLICATIONS FOR NURSING MANAGEMENT: Hospital organisations could benefit from providing their staff with stress management interventions, aggression management, psychological support and psychological resilience training programmes. These programmes should incorporate coping skills on establishing work–home boundaries and balancing empathy with cognitive problem‐solving abilities.

The COVID-19-related health emergency has posed unprecedented challenges for health care professionals worldwide. These include concern about transmitting the virus to their loved ones and extended shifts to handle the considerable volume of patient demand (Bhatti et al., 2021; Kakemam et al., 2021) . Additionally, an alarming increase in aggression against health care personnel has been witnessed globally, especially in the form of patient verbal aggression (Bhatti et al., 2021; Lafta et al., 2021) .

Patient verbal aggression (i.e., verbal expressions that make the professional feel devalued through words, tone or manner ; Farrell et al., 2006) represents one of the critical factors in the generation of burnout because it is the most experienced form of aggression by health care personnel during normal and pandemic times (Liu et al., 2021) . Indeed, due to their extended work shifts, health care professionals working during the pandemic were exposed longer to patients who sometimes vented on them their negative emotions elicited by the treatment received (e.g., long waiting times) through verbal aggression (Ożegalska-Trybalska, 2021) . Drawing on the Conservation of Resources (COR) theory (Hobfoll et al., 2018) , health care professionals who are exposed to patient aggression may feel that their working conditions and personal resources are threatened, or their investment of resources in relationships with patients does not generate a sufficient return of resources. This can deplete professionals' resources by eliciting negative emotions and recurrent thoughts about critical event(s) Zhou et al., 2019) . In such a situation, health care professionals who cannot compensate for this loss of resources through the conservation of resource strategies are likely to develop emotional exhaustion. This core dimension of burnout refers to feelings of being exhausted by one's work (Maslach & Leiter, 2016) . During the pandemic, the prevalence of burnout among health care providers has been estimated between 13% and 51% (Cotel et al., 2021) , resulting in adverse psychological outcomes (Ghio et al., 2021) , decreased patient care safety and quality (Kakemam et al., 2021) . Specifically, emotional exhaustion has been the major symptom experienced by burned-out professionals (Roslan et al., 2021) . Thus, understanding how to manage health care professionals' emotional exhaustion has practical implications for health care professionals and patients, affecting the health care system's ability to respond to health emergencies. However, although the frequency of exposure to patient verbal aggression was positively related to professionals' emotional exhaustion during pandemic times (Vincent-Höper et al., 2020) , it is still unclear how and when this can happen. Therefore, more research is needed to clarify the relationship between patient aggression and professionals' emotional exhaustion to design effective interventions to support health care providers during the actual health emergency and possible future outbreaks (Cotel et al., 2021) .

During the pandemic, some factors related to the Italian context put health care professionals at risk of experiencing work-family conflict (i.e., when the demands posed by the work role are incompatible with the requirements from the family domain; Bernuzzi et al., 2021) .

Italy was one of the nations most affected by the number of people infected during the first COVID-19 wave, which overwhelmed the national health care system and its staff (Romani et al., 2021) . Italy also closed its schools longer than any other European country as a containment measure (Zampano, 2020) . In this nation, women are the vast majority of the health care workforce (MEF, 2019) . Together with extended shifts due to staff shortages, these factors made it difficult for Italian health care professionals to take care of their children and elderly family members (Giusti et al., 2020) . Like other countries, most professionals were afraid to transmit the virus to their loved ones (Roslan et al., 2021) . Additionally, many health care providers were quarantined, resulting in long isolation from their families and severe staff shortages, causing extra work and disturbances to work-life balance for their co-workers (Brooks et al., 2020) . As a result, most health care professionals had trouble balancing work and family requirements (Schiff et al., 2021) , thus experiencing work-family conflict. This is in line with the spillover theories stating that individuals may experience blurring of work-family boundaries, such that how they behave and feel in the work domain may spill over into the family domain (Bernuzzi et al., 2021) . However, it is still unclear whether patient verbal aggression may spill over onto health care professionals' family lives.

None of the previous studies on health care professionals have provided explanation models containing patient verbal aggression, work-family conflict and emotional exhaustion. Nevertheless, the positive relationship between work-family conflict and emotional exhaustion has been well-documented (Reichl et al., 2014) . However, to our knowledge, there is only one study that demonstrated that work-family conflict was a significant predictor of burnout among health care providers during the outbreak (Cotel et al., 2021) , whereas no previous study has examined whether patient aggression can spill over onto health care professionals' family lives during this time. Integrating COR theory (Hobfoll et al., 2018) with spillover theories, professionals can perceive a loss of their resources when confronted with patient verbal aggression, which undermines their ability to combine work and family. This is because victims of aggression tend to worry about the critical event(s) even outside of work and carry negative feelings home, which can make them less capable of paying full attention to family matters and more prone to vent their anger at family members (Demsky et al., 2019; Lim et al., 2018) . This leaves them with fewer resources to invest in the family domain (Hobfoll et al., 2018) , resulting in work-family conflict (Zhou et al., 2019) . When trying to reconcile work and family commitments, professionals must invest additional resources to protect those remaining from being lost, which, if unsuccessful, may lead them to lose further resources (Yeh et al., 2020) . In such a situation, health care providers may lack the resources to maintain their functioning at work, and eventually emotional exhaustion may occur. However, professionals may react differently to patient aggression due to their resources and conservation of resource strategies (Hobfoll et al., 2018) .

When investigating the effects of patient aggression, individual differences in dehumanizing tendencies (i.e., depriving patients of uniquely human qualities; Capozza et al., 2016) could help explain the different reactions of professionals to aggression (Hobfoll et al., 2018) . In this sense, ascribing patients a lower human status could represent a coping strategy that reduces the loss of resources resulting from encounters with aggressive patients. The scarcely available research suggests that because humanizing patients increases stress, health professionals tend to ascribe patients a lower human status as an unwitting form of dehumanization to cope with stressful encounters with patients (Capozza et al., 2016; Falvo et al., 2021) . For instance, Trifiletti and co-workers (Trifiletti et al., 2014) found that attributing non-uniquely human traits relates to stress reduction among nurses. Additionally, this may facilitate patient care and clinical problem-solving (Haque & Waytz, 2012) .

In addition to dehumanization, individual differences in resilience (i.e., a dynamic process that allows people to face stressful events and recover from adversities; Bernuzzi et al., 2021) could affect how professionals respond to stressors, such as work-family conflict (Hobfoll et al., 2018) . Drawing on the COR theory (Hobfoll et al., 2018) , resilience is a personal resource because it helps people face stressful situations (Maffoni et al., 2020) . More specifically, resilience can allow professionals to fulfill multiple roles by adjusting to challenging conditions (Bernuzzi et al., 2021) , thus protecting them against work-family conflict. Consequently, although some studies found that resilience buffered the negative impact of worklife conflict on employees' well-being (Balogun & Afolabi, 2021) , its moderating role in the association between work-family conflict and emotional exhaustion among health care providers during the pandemic has not received enough attention. Because (de)humanization of patients can be promoted through medical practices (Haque & Waytz, 2012) and resilience can be fostered through training (Joyce et al., 2018) , understanding their protective role against can inform practitioners about how to support health care professionals' well-being during pandemic times. Therefore, our research questions were as follows: May patient verbal aggression be related to emotional exhaustion, directly and indirectly, as mediated by work-family conflict? Can dehumanization be an effective coping strategy against patient aggression? Can resilience be a protective resource against work-family conflict? Figure 1 shows our conceptual model.

This cross-sectional study was conducted in an Italian public hospital located in the Lombardy Region between October 2020 and February 2021, during the second COVID-19 wave. This research intervention was commissioned by the Medical Direction (i.e., the board of medical directors that organizes and coordinates physician services and services provided by other professionals within the hospital), which authorized the study and informed staff about the research using email via the company intranet. The Ethical Review Board of the Hospital provided ethical approval for this research. To participate, professionals were required to be health care professionals employed in the hospital working in contact with patients during the COVID-19 pandemic and to provide an informed consent form. Additionally, a coordinator and a researcher presented the objectives of the research project to professionals during shift changes. After giving informed consent, a total of 201 participants (response rate: 41.44%) completed anonymous self-report paper-and-pencil questionnaires. Of these, four were eliminated because of incomplete responses. The questionnaire's cover sheet informed participants about the study's goals and ensured both the voluntariness of their participation and the confidentiality of the responses. Once completed, the questionnaires were placed in cardboard boxes to ensure anonymity of the data.

Patient verbal aggression was assessed using the seven-item nonphysical violence scale from the Hospital Aggressive Behaviour Scale-Users (Waschgler et al., 2013) . Participants indicated how often they experienced aggressive verbal acts by patients (e.g., Patients get angry with me because of delay; α = .90) on a 5-point Likert scale (0 = never, 4 = always). We chose this scale over other instruments because it was specifically developed to capture verbal aggression from users towards health care personnel.

Work-family conflict was measured using the Italian version of the Work-Family Conflict Scale (Colombo & Ghislieri, 2008) . This instrument comprises five items that assess the respondents' level of agreement with statements describing situations of work-to-family conflict (e.g., The amount of time my job takes up makes it difficult to fulfill family responsibilities; α = .90) on a 7-point Likert scale (1 = completely agree, 7 = completely disagree).

Emotional exhaustion was assessed using the five-item scale from the Italian version of the Maslach Burnout Inventory-General Survey (Borgogni et al., 2005) . Respondents reported how frequently they experienced a state of feeling emotionally drained due to their work lives (e.g., I feel emotionally drained by my work; α = .92) on a 7-point Likert scale (0 = never, 6 = always).

Non-humanness attributions were measured using four non-uniquely human traits (e.g., instinct; Capozza et al., 2013; α = .92) . Health care professionals reported the extent to which they perceived patients in their hospital as characterized by non-uniquely human traits on a 7-point Likert scale (1 = definitely false, 7 = definitely true).

Resilience was measured using the six-item scale of the Italian version of the Psychological Capital Questionnaire (Alessandri et al., 2018) .

This scale consists of items that measure the participants' level of agreement with statements about ways of facing stressful workrelated situations (e.g., I usually take stressful things at work in stride; α = .79) on a 7-point Likert scale (1 = completely agree, 7 = completely disagree).

We controlled for gender (0 = male, 1 = female), age (in years), job tenure (in years) and having children (0 = no, 1 = yes) because the literature indicated that women, younger and less experienced health care workers were more likely to develop burnout, whereas parents had trouble balancing work and childcare during the pandemic. Moreover, we controlled for having had colleagues diagnosed with COVID-19 (0 = no, 1 = yes) or family members vulnerable to the virus (0 = no, 1 = yes) and having lost a loved one due to COVID-19 (0 = no, 1 = yes) because these experiences could have contributed to health care professionals' state of exhaustion and work-family conflict.

A composite score was calculated for each scale by averaging its respective items. Data were checked for outliers and intercorrelations were explored using SPSS 23 (George & Mallery, 2016) . Then, we performed confirmatory factor analyses (CFAs) with the maximum likelihood method, comparing our measurement model with competing models. After testing for common method bias, we conducted structural equation models (SEMs) using bootstrapping analyses and a biascorrected 95% confidence interval (CI) with a resample procedure of 1000 bootstrap samples. In our moderated mediation model, we controlled work-family conflict and exhaustion for gender, age, job tenure, having children, having colleagues diagnosed with COVID-19, having lost a loved one due to COVID-19 and having vulnerable family members. Indirect and conditional effects were considered significant when CI did not include zero and the p value was less than .05.

CFAs and SEMs were performed using Mplus 7 (Muthèn & Muthèn, 2012) . Table 1 ).

The results of the CFA testing the five-construct dimensions of our conceptual model (see Table 2 ) showed that the five-factor model single-factor test indicated that the first factor explained only 29.85% of the variance. Moreover, the hypothesized five-factor model generated a better fit to the data after including the unmeasured latent method factor. This factor explained 24.00% of the total variance (less than 25.00%, the average amount of method variance observed in self-report studies; Podsakoff et al., 2012) , indicating that common method variance is unlikely to be a major concern.

In our moderated mediation model (see Table 3 Abbreviations: CFI, comparative fit index; df, degree of freedom; RMSEA, root mean square error of approximation; SRMR, standardized root mean square residuals; TLI = Tucker-Lewis index. a Previous model with the inclusion of a common method latent variable on which make all the items loaded. b Patient verbal aggression, resilience, dehumanization, work-family conflict and emotional exhaustion load on their respective factors.

c Resilience loads on one factor, work-family conflict loads on a second factor, patient verbal aggression loads on a third factor, dehumanization and emotional exhaustion load on a fourth factor. d Resilience loads on one factor, work-family conflict loads on a second factor, patient verbal aggression, dehumanization and emotional exhaustion load on a third factor. e Resilience loads on one factor, patient verbal aggression, work-family conflict, dehumanization and emotional exhaustion load on a second factor. f All indicators load on a single factor. g Fit indices of the mediation model having work-family conflict as a mediator of the relationship between patient verbal aggression and emotional exhaustion, while controlling work-family conflict and emotional exhaustion for gender, age, job tenure, having children, having colleagues diagnosed with COVID-19, having lost a loved one due to COVID-19 and having family members vulnerable to to balance work and family, which can, in unsuccessful cases, exacerbate their loss of resources and then make it challenging to maintain their work functioning, thus resulting in exhaustion (Bernuzzi et al., 2021) .

Second, to our knowledge, this is the first study to support the protective role of resilience against work-family conflict experienced by health care professionals facing aggressive patients during the pandemic. In this view, resilience represents a personal resource that allows professionals to perceive incompatible demands between work and family roles as a challenge to address by adopting effective coping strategies (Hobfoll et al., 2015) . Indeed, given that resilient people tend to have a sense of control over their own life and an optimistic T A B L E 3 Path coefficients and conditional effects for the moderated mediation model view of the future, they are more likely to see the bright sides of demanding situations (Bernuzzi et al., 2021) . Moreover, resilient workers have a vast reservoir of resources on which to draw to handle challenging situations (Hobfoll et al., 2015) . Thus, they are wellequipped to reconcile work and nonwork role demands and recover their emotional resources, thereby being less vulnerable to emotional exhaustion (Maffoni et al., 2020) . 

Hospital organisations should implement a zero-tolerance policy for patient aggression, ensuring institutional support, systematic monitoring and feedback practices (Dafny & Muller, 2021) . Reporting of patient verbal aggression incidents should be encouraged by ward managers to identify strategies to prevent and de-escalate these events (Jakobsson et al., 2021) . To this end, the ward managers could conduct periodic sharing and debriefing sessions where professionals are encouraged to share their experiences with aggressive patients and home problems, reflecting in teams on possible solutions. Health care professionals could benefit from stress management interventions, aggression management and scenario training programmes on de-escalating communicative skills to decrease the potential for aggression (Dafny & Muller, 2021) . These programmes should also incorporate psychological resilience training and coping skills to establish work-home boundaries (Maffoni et al., 2020) .

Additionally, work-hour regulation programmes and services should be implemented, such as on-site childcare facilities or food delivery to workers' elderly family members. Furthermore, health care professionals should be aware of the risks related to the dehumanization of patients and educated on how to effectively balance empathy with cognitive problem-solving abilities through interpersonal skill training programmes (Haque & Waytz, 2012) . Finally, hospital organisations could consider introducing psychological support programmes to support needy workers during normal and pandemic times.

Open access funding was provided by Università degli Studi di Pavia within the CRUI-CARE Agreement. Sincere gratitude is expressed to each single health care professional who contributed to this study. Finally, special thanks to Dr. Deirdre O'Shea who provided us with the items to measure COVID-19-related variables.

The authors declare that they have no conflicts of interest.

The study was commissioned by the Medical Direction (i.e., the board of medical directors that organizes and coordinates physician services and services provided by other professionals within the hospital, including the Ethical review board of the Hospital) and the Dean of Medicine with a protocol of understanding between the Hospital and the University of Pavia approved on 11 August 2020 (number 372) in which all parties agreed to conduct the study. In this protocol, the Ethical Review Board of the Hospital provided ethical approval for this research.

The data that support the findings of this study are available from the corresponding author (V.S.) upon reasonable request. 

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