Accepted Manuscript

Title: Psychological Consequences of Aggressions in

Pre-hospital Emergency Care: Differences According to Type
and Frequency of Violence

Author: Mónica Bernaldo-De-Quirós Ana T. Piccini M. Mar

Gómez Jose C. Cerdeira

PII: S0020-7489(14)00153-9
DOI: http://dx.doi.org/doi:10.1016/j.ijnurstu.2014.05.011
Reference: NS 2401

To appear in:

Received date: 3-11-2013

Revised date: 14-5-2014
Accepted date: 29-5-2014

Please cite this article as: Bernaldo-De-Quirós, M., Piccini, A.T., Gómez, M.M.,
Cerdeira, J.C.,Psychological Consequences of Aggressions in Pre-hospital Emergency
Care: Differences According to Type and Frequency of Violence, International Journal
of Nursing Studies (2014), http://dx.doi.org/10.1016/j.ijnurstu.2014.05.011

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Psychological Consequences of Aggressions in Pre-hospital Emergency Care:

Differences According to Type and Frequency of Violence

t
ip
Running head: Psychological Consequences of Aggressions in Pre-hospital

cr
Emergengy Care

us
Mónica BERNALDO-DE-QUIRÓS PhD

an
Lecturer, Complutense University, Madrid (SPAIN)
M
Ana T. PICCINI

Honorary Research Fellow, Complutense University, Madrid (SPAIN)

d
te

M. Mar GÓMEZ PhD

Lecturer, Complutense University, Madrid (SPAIN)

p
ce

Jose C. CERDEIRA

Assistant Director for Emergency Nursing, SUMMA-112, Madrid (SPAIN)

Ac

No conflict of interests has been declared by the authors

Funding: Funding was provided by MAPFRE Foundation (Fundación MAPFRE) in

Support to Research 2011.

1
Page 1 of 35
TITLE: Psychological Consequences of Aggression in Pre-hospital Emergency

Care: Differences According to Type and Frequency of Violence

ABSTRACT

Background: Pre-hospital emergency care is a particularly vulnerable setting for

t
workplace violence. However, there is no literature available to date on the

ip
psychological consequences of violence in pre-hospital emergency care.

cr
Objectives: To evaluate the psychological consequences of exposure to workplace

violence from patients and those accompanying them in pre-hospital emergency care.

us
Design: A retrospective cross-sectional study.

an
Setting: 70 pre-hospital emergency care services located in Madrid region.

Participants: A randomised sample of 441 health care workers (135 physicians, 127
M
nurses and 179 emergency care assistants).

Methods: Data were collected from February to May 2012. The survey was divided
d

into four sections: demographic/professional information, level of burnout determined

te

by Maslach Burnout Inventory (MBI), mental health status using General Health

Questionnaire (GHQ-28) and frequency and type of violent behaviour experienced by

p

staff members.
ce

Results: The health care professionals who had been exposed to physical and verbal

violence presented a significantly higher percentage of anxiety, emotional exhaustion,

Ac

depersonalization and burnout syndrome compared with those who had not been

subjected to any aggression. Frequency of verbal violence (more than five times) was

related to emotional exhaustion and depersonalization.

Conclusion: Type of violence (i.e. physical aggression) is especially related to high

anxiety levels and frequency of verbal aggression is associated with burnout (emotional

exhaustion and depersonalization). Psychological counselling should be made available

2
Page 2 of 35
to professional staff who have been subjected to physical aggression or frequent verbal

violence.

Keywords: Aggressions; Burnout; Emergency; Health care workers; Mental health;

Nurses; Physicians; Pre-hospital emergency care; Violence.

t
ip
What is already known about the topic?

cr
• Violence in the health care system is a complex and dangerous occupational hazard

for health care staff that has increased in recent years.

us
• Little information about the psychological consequences of aggressions in hospital

an
Accident and Emergency departments is available.

What this paper adds?

M
• This is the first study to evaluate psychological consequences of violence in pre-

hospital emergency care.

d

• Pre-hospital emergency workers who have been exposed to physical and verbal
te

violence show greater psychological sequelae than those who have not experienced

any type of aggression (including anxiety, emotional exhaustion and

p

depersonalization).
ce

• Frequency of verbal violence (more than five times) was related to high levels of

emotional exhaustion and depersonalization in pre-hospital emergency staff.

Ac

3
Page 3 of 35
1. Introduction

Violence in the health care system is a complex and dangerous occupational

hazard for health care staff that has increased in recent years. While workplace violence

affects practically all sectors and employees at all levels, in the health sector this is a

t
major risk. Violence in this sector represents almost a quarter of all workplace violence

ip
and may affect more than 50% of health care workers overall (Cooper and Swanson,

cr
2002; Di Martino, 2002). In particular, in recent years health care professionals have

been found to be at a high risk of violence from patients or those accompanying them in

us
industrialised and developing countries, and this is a source of growing concern for

an
these professionals as shown in several studies (Atewneh et al., 2003, Di Martino, 2002;

Farrell et al., 2006; Gacki-Smith et al., 2009; Hanh et al., 2013). Not only has the
M
number of incidents increased but the severity of the impact has also had profound

traumatic effects on the primary, secondary and tertiary victims (Rippon, 2000).
d

Pre-hospital emergency care is any clinical care or intervention that an acutely ill
te

or injured person receives from trained personnel in the pre-hospital environment.

While all health sector staff in a hospital or primary care centre may be subjected to
p

violence, this is more likely for staff working in pre-hospital emergency care (Grange
ce

and Corbett, 2002). Pre-hospital care providers may be at a higher risk of workplace

violence than those who work in a hospital or primary care centre because their close
Ac

initial contact with patients, often during crisis situations, takes place without the

security and support systems that exist in those workplaces. In these circumstances, they

are exposed to unpredictable and difficult situations where they may be victims of

violent attacks. However, only a handful of scientific studies have been carried out in

this field (Boyle et al., 2007; Koritsas et al., 2009; Petzäll et al., 2011; Joa and Morken,

2012; Suserud et al., 2002).

4
Page 4 of 35
2. Background

Although the consequences of physical aggressions are more widely reported,

the non-physical effects also cause considerable suffering (Needham et al., 2005).

t
Research has demonstrated that psychological and emotional damage may persist and

ip
interfere with normal working and leisure lifestyles for months or even years after the

cr
incident (Rippon, 2000). Nevertheless, very little information about the psychological

consequences of aggression is available.

us
an
2.1. Burnout syndrome

Burnout is linked to a specific form of chronic occupational stress (Maslach and

M
Jackson, 1981), which occurs when there is a high emotional load in the interpersonal

relationships within service organizations (Maslach and Schaufeli, 1993). More

d

specifically, burnout is a psychological syndrome of emotional exhaustion,

te

characterized by feelings of overextension and depletion of emotional and physical

resources; depersonalization, the development of a negative, callous, or excessively

p

detached response to various aspects of the job; and reduced personal accomplishment,
ce

feelings of incompetence and a lack of achievement and productivity at work (Maslach

et al., 2001).
Ac

In the health sector, some studies have examined the relationship between

burnout syndrome and workplace violence from patients or their families, finding a link

between burnout rates and exposure to physical violence (Merecz et al., 2009;

Winstanley and Whittington, 2002) or verbal aggression (Crabbe et al., 2002; Rowe and

Sherlock, 2005; Winstanley and Whittington, 2002). A cyclical model was therefore put

forward which proposed that aggressive incidents were likely to lead to higher

5
Page 5 of 35
emotional exhaustion levels, subsequently causing increased depersonalization. High

depersonalization levels were shown in behavioural changes, often resulting in

treatment of patients as objects rather than as people. These changes in both attitudes

and behaviour in response to high emotional exhaustion levels may make staff more

t
vulnerable to aggression from patients who are so predisposed (Winstanley and

ip
Whittington, 2002). In Spain, similar results have been found in relation to burnout

cr
levels and exposure to workplace violence in health staff in general hospitals and

primary care centres (Gascón et al., 2012). Health care workers exposed to physical

us
and/or verbal violence (intimidation or threats) showed high levels of burnout, and a

an
statistically significant correlation was observed between exposure to violent incidents

and high levels of emotional exhaustion and depersonalization.

M
In hospital Accident and Emergency departments, Alameddine et al. (2011)

found a significant link between exposure to verbal abuse and burnout (higher
d

emotional exhaustion and depersonalization levels and lower personal accomplishment

te

levels), highlighting that increased exposure to verbal abuse leads to staff burnout, loss

of productivity and eventually turnover.

p
ce

2.2. Mental Health status

Results of the General Health Questionnaire (GHQ) and Beck’s Depression

Ac

Inventory-Revised (BDI-R) suggested that almost 40% of nursing staff exposed to

workplace violence exhibited psychological distress, while almost 20% and almost 10%

showed moderate or severe depression (Lam, 2002). Furthermore, the results obtained

on subscale analyses of the GHQ also indicated that exposure to aggression correlated

significantly with three of the four components, including anxiety, somatic complaints

and severe depression; and anxiety was found to be the most significant. Gerberich et al.

6
Page 6 of 35
(2005) also reported differences depending on the type of aggression, with greater

psychological consequences (i.e. depression, frustration, anger, fear/anxiety/stress and

irritability) reported for non-physical than physical violence. On the other hand, another

study did not find statistically significant relationships between exposure to physical or

t
verbal violence and depressive symptomatology in Spanish health care professionals

ip
(Martínez-Jarreta et al., 2007).

cr
Belayachi et al. (2010) also found a significant link between anxiety traits and

workplace violence. The exposure of accident and emergency physicians to some form

us
of violence was greater among those with anxiety traits and was related to a significant

an
anxiety level. The authors showed that physicians who had been victims of violence

already had anxiety traits, and that violence left psychological damage as an anxiety
M
trait; i.e. that physicians with high levels of anxiety were predisposed to respond to what

they saw as provocation with aggression.

d

Previously existing information on the psychological consequences of violence

te

in health care staff working in pre-hospital emergency services is merely descriptive, as

no other study to date has evaluated these effects.

p
ce

3. Method

3.1. Aims
Ac

The aims of this study are to identify the psychological consequences of

aggression (burnout and mental health status) and to analyse differences depending on

type and frequency of aggression. Based on the literature reviewed, higher levels of

burnout and psychological distress were predicted in professionals exposed to verbal

aggression or physical violence, and these levels will be significantly higher in those

staff more frequently victimized.

7
Page 7 of 35
3.2. Design and setting

An ex post facto cross-sectional design was used to allow comparisons between

staff experiencing differing levels of aggression. It included health care professionals

t
(physicians, nurses or emergency care assistants) from 70 pre-hospital emergency

ip
services in Spain.

cr
3.3. Sample

us
SUMMA-112 is the largest pre-hospital emergency service in Europe and one of

an
the largest worldwide, and is responsible for pre-hospital accident and emergency care

in the Madrid region (Comunidad de Madrid). Health care staff were chosen at random
M
from 70 services (including physicians, nurses and emergency care assistants) following

proportional stratified sampling according to the number of the different professionals

d

(physician, nurse and emergency care assistant) for each type of service. Sample size
te

(n=441 out of 1310 professionals) was calculated using the sample size calculator

Raosoft, (http://www.raosoft.com/samplesize.html), to yield a 99% confidence level and

p

a 5% confidence interval. The inclusion criteria were: health care worker (physician,
ce

nurse or emergency care assistant) working for at least 12 months at SUMMA-112 who

agreed voluntarily to take part in the study.

Ac

The procedure of inclusion in the study is illustrated in Figure 1. A total of 545

health care professionals were contacted: 41 (7.5%) did not match the inclusion criteria

(they had worked for less than 12 months at SUMMA-112); of the 504 who met the

criteria, 35 (6.9%) declined to participate and 18 (3.6%) did not return the

questionnaire. The response rate was therefore 89.5%, with 10 (1.98%) discarded

8
Page 8 of 35
because of incomplete data. The final sample was therefore composed of 441 health

care workers: 135 physicians, 127 nurses and 179 emergency care assistants.

INSERT FIGURE 1 ABOUT HERE

3.4. Instruments

t
Data were collected using a questionnaire divided into four sections:

ip
3.4.1. Demographics

cr
The first section contained items on demographic and professional information,

including gender, age, marital status, profession, current employment status, years of

us
experience at present workplace, years of working experience and sick leave.

an
3.4.2. General Health Questionnaire, GHQ-28.

A Spanish adaptation (Lobo et al., 1986) of the General Health Questionnaire

M
(GHQ-28; Goldberg, 1981) was used. The GHQ was designed to be a self-administered

screening test to detect mild psychiatric disorders in the general population. It has been
d

widely used in clinical and research settings with well-documented reliability, validity,
te

excellent sensitivity (91.02%) and specificity (94.07%). The short form used in this

study contained 28 items divided into four subscales to measure different aspects of
p

psychological health (i.e. general somatic symptoms, anxiety and insomnia, social
ce

dysfunction and severe depression). Respondents were asked to indicate on a four point

Likert Scale (0-3) the extent of different medical and general health conditions they
Ac

have experienced recently. In this study the binary scoring method 0-0-1-1 was used

with a threshold score of 4/5 as a cut-off point to obtain optimum discrimination for

case identification. Cronbach’s alpha coefficient was 0.91.

3.4.3. Maslach Burnout Inventory MBI-HSS.

A Spanish adaptation (Seisdedos, 1997) of the Maslach Burnout Inventory

(MBI) (Maslach and Jackson, 1986; Maslach et al., 1996) was used. The MBI is

9
Page 9 of 35
internationally established as a leading measure of burnout that demonstrates a similar

factorial structure and performance across many countries (Alameddine et al., 2011).

This 22-item questionnaire measures burnout syndrome on three subscales: Emotional

Exhaustion (9 items), Depersonalization (5 items) and Personal Accomplishment (8

t
items). The Emotional Exhaustion subscale measures the employee’s feelings of

ip
emotional exhaustion and fatigue at work. The Depersonalization subscale measures the

cr
degree to which the employee is impersonal and distant in providing care, treatment and

instructions to those receiving services. Finally, the Personal Accomplishment subscale

us
measures the employee’s level of competence and feeling of professional achievement

an
at work. Each of the items in the MBI investigates one of the burnout dimensions across

a seven-point scale response format from “Never” (= 0) to “Daily” (= 6). A high

M
emotional exhaustion and depersonalization score is indicative of burnout, whereas for

personal accomplishment the opposite is true. These scores were then compared to the
d

numerical cut-off points for medical professions provided by Seisdedos (1997) for
te

Spanish physicians, to determine whether each of the subscales corresponds to a high,

average or low burnout level. Cronbach’s alpha obtained in this study for the Emotional
p

Exhaustion and Personal Accomplishment subscales was 0.86 and 0.80 respectively,
ce

considered high values. On the Depersonalization subscale, however, the value was

0.58. It is worth noting here that other research carried out in Spain has obtained very
Ac

similar values for the Depersonalization subscale (Gil-Monte and Peiró, 1996; Gil-

Monte, 2005).

3.4.4. In-house questionnaire on aggression

A questionnaire was designed to collect information from health care staff on the

frequency of their experiences of aggression by patients and/or family members or those

accompanying them and to provide a more detailed analysis of the most serious

10
Page 10 of 35
aggression incident experienced. This questionnaire contained 18 items, and was

designed using the survey on aggressions in health-care services (Cuestionario sobre

Agresiones en el Medio Sanitario) devised by Martínez-Jarreta et al. (2007) as a

reference. The first part of this two-part questionnaire refers to the frequency with

t
which the health care professional has been subjected to any type of aggression

ip
(physical aggression, threats, insults/verbal abuse) during their professional career in the

cr
SUMMA-112 service, defining in each case the behaviour implied in each type of

aggression (Winstanley and Whittington, 2004). Thus, the staff member has to select the

us
frequency of the aggressions on a Likert-type 5 point scale where: 0 = never; 1 = never

an
personally, but I have witnessed this happening to colleagues; 2 = once; 3 = 2 - 5 times;

4 = more than 5 times. Then, if the subjects have experienced violence, they are asked
M
to describe the most serious incident, answering questions on the type of violence,

location, trigger factors, degree of resultant injury and whether the case required
d

medical, surgical or psychological assistance, if the incident was reported to the police
te

or relevant authority, or if sick leave was required. Cronbach’s alpha obtained in this

study for this questionnaire was 0.81.

p
ce

3.5. Procedure

This study was carried out between February 1 and May 31, 2012. 8 external
Ac

assessors were trained to carry out the evaluation of all the health care staff included in

the study sample. Through SUMMA-112, a mobile phone text message and an email

were sent to all the health care staff informing them of the aims and characteristics of

the survey, start date and evaluation method. The Assistant Director for emergency

nursing in the SUMMA-112 service contacted the managers and/or staff in the different

services by telephone to request their voluntary participation in the survey, and to

11
Page 11 of 35
inform them exactly when to expect the external evaluators at their service centre. The

evaluators went to each centre on the stated date and after a brief screening interview to

check that staff met the criteria for inclusion in the study, they explained the aim of the

survey and obtained the informed and written consent of the participants, while assuring

t
them that the results of the survey would be anonymous and confidential. Then they

ip
handed over and explained the questionnaires, answered any questions, and agreed

cr
when they would return, later on the same working day, to collect them.

us
3.6. Data analysis

an
SPSS version 19 was used to analyse the data. Descriptive statistics were used to

summarize the demographics, level of burnout and level on subscales.

M
To analyse the psychological consequences of the aggression, three groups were

set up depending on the type of aggression (no aggression; verbal violence; physical and
d

verbal aggression) and frequency of aggression (never; never but witness; once; two to
te

five times; more than five times). The differences on nominal variables between the

three groups were compared using Chi-square tests. For the quantitative variables the
p

Kolmogorov –Smirnov statistic was used to check whether the variables considered
ce

were normally distributed, and since none of them showed a normal distribution, the

Kruskal-Wallis test was used. The results were considered significant if the p value was
Ac

<0.05; all confidence intervals (CI) were 95%.

To analyse the differences in the psychological consequences depending on the

specific type of aggression, those subjects were selected who had experienced some

type of aggression and therefore had responded to the second part of the aggression

questionnaire (n=336). The differences between the professionals who had or had not

experienced each aggression type were compared using Chi-square tests.

12
Page 12 of 35
3.7. Ethical considerations

This research was approved by a university human research ethics committee.

Participants were provided with an information sheet outlining the purpose of the study,

the voluntary nature of the participation, and were given assurances that their data

t
would be treated confidentially. Consent forms were completed on agreement to take

ip
part in the study. All data were treated as confidential and stored securely, with access

cr
restricted to the immediate research team.

us
4. Results

an
4.1 Participants

The demographic profile of the sample is presented in Table 1. The majority of

M
the subjects in the sample (64.6%) were male, with mean age 45, married or living with

a partner, with a mean working experience of 18 years and regular employment status
d

(84.5%). The mean length of employment in the current service was 11 years. A mean
te

of one sick leave period over the last year was obtained for one third of the subjects.

Age was the only demographic where significant differences were observed, as staff
p

who had experienced both physical and verbal violence were younger than the
ce

professionals who had never been subjected to aggression (with an average age of 42.73

vs. 46.44).
Ac

4.2. Aggression characteristics

Out of the 358 participants who had experienced some type of aggression, 336

returned useable questionnaires. The majority of the most serious incidents involved

insults (87.2%), threats (87.2%), threatening behaviour (83.6%) and a significant

percentage reported coercion (43.2%), grabbing or pushing (42%) and damage to

furniture (41.4%). The health care staff who had experienced physical violence

13
Page 13 of 35
compared with those who had only suffered verbal abuse cited more grabbing or

pushing (65.2 vs. 25.1%) (p<0.001), kidnapping (28.4 vs. 10.3%) (p<0.001), slapping or

punching (25.5 vs. 7.2%) (0.001), kicking (30.5 vs. 8.7%) (0.001), scratching (17.7 vs.

3.1%) (0.001), damage to furniture (51.1 vs. 34.4%) (p=0.002), stabbing (17 vs. 7.2%)

t
(p=0.004), threats (92.2 vs. 83.3%) (p=0.014), pulling hair (7.1 vs. 3.1%) (p=0.044) and

ip
others (3.5 vs. 0.5%) (p=0.049).

cr
The incidents took place most often in the home (47.6%), but for the staff who

had experienced physical violence this frequency was significantly higher (56.7 vs.

us
41%) (p=0.003), while staff who had only been subjected to verbal abuse reported

an
incidents more often taking place in the consulting room (26.2 vs. 9.2%) (p<0.001).

The most common motives for the aggression were disagreement with treatment
M
(36%) and waiting time (29.3%), with no significant differences by aggression type.

Very few cases required surgical or psychological attention and in only around 11% of
d

the cases was medical assistance required and reported to the police or relevant
te

authority, and this was more frequent in incidents with physical violence (19.1 vs. 5.6%

and 19.3 vs. 6.2, respectively).

p
ce

INSERT TABLES 1 AND TABLE 2 ABOUT HERE

4.2 Burnout
Ac

437 participants responded to the questionnaire: 79 (18.1%) had not been

exposed to aggression, 208 (47.6%) had been exposed only to verbal violence and 150

(34.3%) had been exposed to physical and verbal violence.

Table 3 shows that of the staff surveyed who had not been subjected to any type

of aggression, almost all (93.7%) presented low EE levels. As the types of aggression

increased, this percentage fell gradually in staff who had been subjected only to verbal

14
Page 14 of 35
aggression (77.9%) and who had suffered physical and verbal aggression (68%). Only

2.5% of the group who had not suffered any aggression reported high emotional

exhaustion levels, but this percentage increased in the group who had experienced

physical aggression (17.3%), with these differences being statistically significant.

t
For depersonalization levels, the majority (79.5%) of the staff group who had

ip
not experienced any aggression presented low levels of depersonalization, but this

cr
percentage fell to 54.6% in the group which had experienced physical aggression. Thus,

while only 7.7% of the staff who had not experienced any type of aggression reported

us
high depersonalization levels, this percentage increased significantly in staff who had

an
experienced some type of aggression: to 14.1% for verbal aggression only, and to

15.1% when there had also been physical aggression, a statistically significant
M
difference.

An important percentage of the staff presented high personal accomplishment

d

levels (around 65%) and no significant differences were observed between the different
te

groups.

With regard to the criteria for the existence of burnout syndrome, none of the
p

staff who had not experienced any aggression met the criteria. 1% of staff who had
ce

experienced only verbal aggression met the criteria and 2.7% of those who had also

experienced physical aggression, with no significant differences between the different

Ac

groups. However, if the criterion is limited to those that presented emotional exhaustion

and depersonalization, then the percentages increase to 2.4% and 6.7% respectively,

with significant differences observed between the groups.

No significant differences were observed depending on the specific type of

aggression.

INSERT TABLE 3 ABOUT HERE

15
Page 15 of 35
4.3 Mental health status

Of the 441 participants, 438 returned useable responses: 78 (17.9%) indicated

that they had not been exposed to aggression, 208 (47.5%) had only been exposed to

verbal violence and 152 (34.6%) had been exposed to physical violence.

t
As shown in Table 4, the results of the GHQ-28 indicated that the majority of

ip
the staff could not be classified as psychologically distressed (i.e. non-case) on any of

cr
the subscales, with percentages over 90%, except on the anxiety subscale, where the

percentage fell to 84.9%. No significant differences were observed between the

us
different groups on the social dysfunction, depression and somatic symptoms subscales,

an
although the last mentioned was of borderline significance with only 2.9% of the staff

who had not experienced aggression meeting the criteria, compared with 8.6% of those
M
who had experienced physical and verbal aggression. Nevertheless, significant

differences were observed on the anxiety scale, where only 3.9% of participants who
d

had not been exposed to any aggression were psychologically distressed (i.e. case),
te

while this percentage rose to 15.1% where physical and verbal aggression had been

experienced.
p

No significant differences were observed depending on the specific type of

ce

aggression.

INSERT TABLE 4 ABOUT HERE

Ac

4.4. Frequency of violence

Table 5 shows that a higher percentage of the staff who had experienced insults

or threats more than five times reported a high level of emotional exhaustion (7.9% and

5.9%, respectively) and depersonalization (8.3% and 8%) than the other groups. A

higher percentage of professionals who had experienced threats more than five times

met criteria for burnout syndrome than the other groups (1.4 vs. 0%), and if the criterion

16
Page 16 of 35
is limited to those that presented emotional exhaustion and depersonalization,

differences were significant for professionals who had experienced insults and/or threats

more than five times (3.2 and 3% vs. 0.2% or less).

According to mental health status, a higher percentage of professionals who had

t
been subjected to insults more than five times met criteria to be considered as an anxiety

ip
case than the other groups (5.7% vs. 2.1% or less).

cr
Regarding physical violence, the differences were significant for emotional

exhaustion, depersonalization, burnout syndrome, somatic symptoms, anxiety

us
symptoms and social dysfunction. However, the group who had never experienced

an
physical violence presented similar percentages of high emotional exhaustion as the

group who had been subjected to this type of violence more than five times.
M
INSERT TABLE 5 ABOUT HERE

5. Discussion
d

Very little research to date has evaluated the aggression suffered by health care
te

professionals working in pre-hospital emergency care, and the existing studies focus on

evaluating emergency care assistants (or paramedics), probably because of the different
p

ways emergency health systems are organized: in English-speaking countries the service
ce

transferring patients to the hospital system itself tends to predominate, whereas the

model in continental Europe (e.g. France, Spain and Germany) focuses on facilitating
Ac

pre-hospital medical services in situ. Even fewer studies have been carried out on the

psychological effects of this aggression, which could provide data to facilitate the

development of relevant prevention and intervention programmes in this context.

This present study is the first to evaluate the psychological consequences of

aggression in pre-hospital emergency care, and evaluates the most extensive pre-

hospital emergency service in Europe and one of the most important worldwide, and

17
Page 17 of 35
can therefore be taken as an excellent indicator of the problem existing in this sector.

Most previous studies have been carried out with health care professionals working in

different hospital departments (Crabbe et al., 2002; Merecz et al., 2009; Rowe and

Sherlock, 2005; Winstanley and Whittington, 2002) and although they also assess

t
Accident and Emergency departments, their analyses of the psychological consequences

ip
do not provide specific data referring only to the emergency services. Our study is based

cr
on a wide-ranging sample of staff in different professional categories, with results

obtained from a stratified random sample using strictly controlled procedures.

us
This study detected a high percentage of violence from patients or those

an
accompanying them: 34.5% of physical violence, 75.3% of threats and 76.2% of insults

(Bernaldo-de-Quirós et al., 2013). Age was the only demographic where significant
M
differences were observed, staff who had experienced both physical and verbal violence

were younger than those professionals who had never been subjected to aggression.
d

Studies on the link between age and workplace aggression yield mixed results. Whereas
te

some studies yield a negative correlation between age and workplace aggression, others

yield no significant correlation (Belayachi, 2010).

p

The majority of the aggressions included insults, threats and threatening

ce

behaviour not involving serious aggression and this may be one of the reasons why only

a small percentage of health care professionals report the aggressions and in most cases
Ac

do not require assistance. These results agree with those obtained by Speroni et al.

(2013) who report the highest percentages of verbal aggression involve shouting or

yelling and swearing or cursing, and the most usual physical aggressions include

grabbing, scratching or kicking, where only 7.9% reported the aggression. Logically, in

those cases were the health care professionals report having been subjected to some type

18
Page 18 of 35
of physical aggression, the nature of the most serious incident was more often a serious

physical aggression.

According to the results of this study and those by other authors (Grange and

Corbett, 2002; Koritsas et al., 2009), the home address where the assistance is provided

t
seems to be the location where most physical aggression occurs, but the consulting

ip
room is where verbal aggressions are most common. It may therefore be appropriate to

cr
establish different action protocols depending on the environment where the aggression

takes place, with possible preventive measures and/or management of physical

us
aggression in the home environment and of verbal threats in the consulting room.

an
Especially important is managing situations involving disagreement with the treatment

and waiting times, since this and other studies (Alameddine et al., 2011; Gacki-Smith et
M
al., 2009; Kowalenco et al., 2005) have all found that these are the main reason for

aggression.
d
te

5.1 Burnout syndrome

The results indicate that these health care professionals reported low levels on all
p

burnout syndrome subscales (Emotional Exhaustion, Depersonalization and Personal

ce

Accomplishment), in contrast to the results of other studies (Crabbe et al., 2002; Merecz

et al., 2009; Rowe and Sherlock, 2005; Winstanley and Whittington, 2002). It should be
Ac

noted that different cut-off points are normally used in each country, with a lower cut-

off point more usual in US studies. In fact the difference in the normal cut-off levels,

due to socio-cultural differences (Gil-Monte and Peiró, 2000), is one of the main

problems when comparing the results of burnout in studies carried out in different

countries. Nevertheless, the data obtained on emotional exhaustion and

depersonalization in our study are compatible with other studies, as staff who had been

19
Page 19 of 35
exposed to physical violence presented a significantly higher percentage of emotional

exhaustion (17.3 vs. 2.5%) and depersonalization (15.1 vs. 7.7%) than those who had

not been subjected to any aggression. Similarly, staff who had suffered verbal

aggression presented a significantly higher percentage of depersonalization than those

t
who had not suffered any aggression (14.1 vs. 7.7%).

ip
No significant differences were observed in personal accomplishment levels

cr
depending on whether or not staff had been subjected to aggression, or on the type of

violence experienced, which differs from the results of previous studies (Alameddine et

us
al., 2011; Crabbe et al., 2002; Rowe and Sherlock, 2005), where lower personal

an
accomplishment levels were reported in staff who had been exposed to physical or

verbal violence. One possible hypothesis to explain these results is that staff working in
M
pre-hospital emergency care are highly motivated and in spite of the aggression, still

feel that their potential is realized.

d

Significant differences were found in the analysis of burnout levels between staff
te

who had suffered physical violence and those who had not experienced any aggression

(6.7% vs. 0), using the emotional exhaustion and depersonalization levels presented as
p

the criteria, but not when low personal accomplishment was also required (only 2.7%
ce

met this requirement). These results coincide with those obtained in the Spanish study

carried out in general hospitals and primary level health centres (Gascón et al., 2012).
Ac

5.2 Mental health status

On all the GHQ-28 subscales the majority of the health care professionals did

not fulfil the criteria to be considered as clinical cases in any of the groups. Significant

differences between the different groups only appeared on the anxiety subscale, where

the staff who had been subjected to physical violence met the criteria for clinical cases

20
Page 20 of 35
to a greater extent than those who had not experienced any aggression (15.1% vs.

3.9%), with the staff who had suffered only verbal violence falling midway between

them (6.2%). These results agree with the other studies which use the GHQ-28 as a

measurement tool for the anxiety subscale, where significant correlations have also been

t
observed between exposure to violent incidents and higher scores on this subscale

ip
(Lam, 2002; Merecz et al., 2009). Although some studies suggest that verbal violence

cr
produces greater psychological sequelae, the results of our study suggest that physical

violence has more important repercussions, although it may be accompanied by verbal

us
violence (El-Gilany et al., 2010; Gerberich et al., 2005; May and Grubbs, 2002;

an
Nachreiner et al., 2007). The differences on the somatic symptoms subscale were not

very significant but were borderline. In contrast, no significant differences were

M
observed in social dysfunction or depression, in contrast to what can be seen in other

studies (Lam, 2002; Merecz et al., 2009) although the results obtained here coincide
d

with those of Martínez-Jarreta et al (2007) which did not find statistically significant
te

relationships between exposure to physical or verbal violence and depressive

symptomatology in Spanish health care professionals.

p
ce

5.3 Frequency of aggression

Regarding verbal violence, a higher percentage of professionals who were more

Ac

frequently victimized (more than five times) reported high levels of emotional,

exhaustion and depersonalization. These results are in accordance with those of

Winstanley and Whittington (2002) who found that respondents who experienced

frequent verbal aggression also displayed significantly higher levels of emotional

exhaustion and depersonalization than did those who experienced verbal aggression

infrequently.

21
Page 21 of 35
 Nevertheless, the influence of frequency of physical aggression is not clear. As

Winstanley and Whittington (2002) realized, verbal violence might act as a confounding

variable because many professionals who had been subjected to physical aggression

experienced verbal aggression frequently.

t
ip
6. Limitations

cr
The limitations to be taken into account when drawing conclusions from these

findings are: first, the cross-sectional and retrospective design of the study; secondly,

us
that all violent incidents occurring during the whole professional career of the SUMMA

112 staff were taken into account, as we consider that any violent incident is serious

an
enough to have a lasting effect on the member of staff and to affect their current

professional behaviour. Most other studies, however, only consider incidents occurring
M
during the previous year, which makes comparison with them more difficult. Thirdly,

there is the low internal consistency of depersonalization; in spite of this,

d

depersonalization is a relevant variable which should be considered in the study, since

te

high levels of both depersonalization and emotional exhaustion are better criteria for
p

diagnosing burnout-related disorders than emotional exhaustion alone. Finally, we have

ce

no evidence of the coping styles used by participants. Future research should consider

the use of prospective designs with objective measures to double check self-reported
Ac

assessment and the role of coping styles in preventing aggression. It is also important to

clarify the role of the frequency of different specific aggressions in their psychological

consequences.

7. Conclusions

In conclusion, health care staff who have suffered physical and verbal violence

presented greater anxiety, emotional exhaustion, depersonalization and higher levels of

22
Page 22 of 35
burnout than those who had not experienced any aggression. Type of violence (i.e.

physical aggression) is especially related to high anxiety levels and frequency of

aggression is associated with burnout syndrome (emotional exhaustion and

depersonalization).

t
The existence of adverse psychological consequences of physical and verbal

ip
violence makes it clear that psychological counselling should be offered to staff who

cr
have been subjected to physical aggression or frequent verbal violence. As other studies

have shown, when staff report high anxiety levels and/or burnout syndrome, there is an

us
increased likelihood of aggression re-occurring, probably because of the approach to

an
conflict adopted.

All in all, it is necessary to provide psychological care to professionals who have

M
experienced some type of violence. Only 2.7% of health care professionals reported

having received psychological help, but it is also true that this counselling is not
d

provided in their working environment and they have to find it themselves.

te

Occupational risk prevention services need to include this help. Prevention of these

negative effects may involve several aspects: a) the development of overall

p

psychological coping strategies (such as empathy, communication skills, problem-

ce

solving, etc.), b) the identification of psychological consequences from the beginning,

and c) the development of regular group sessions with professionals to analyse conflict
Ac

situations and their actions.

However, any psychological intervention - either individual or collective - will

not be effective unless it is accompanied by other interventions at the community level

(policies of zero tolerance for aggression and awareness campaigns for the general

public) and the organizational level (increased safety measures, particularly for home

23
Page 23 of 35
assistance, and measures to attempt to reduce waiting times). However, these

interventions come up against the pressure which health care systems often have to face.

t
ip
cr
us
an
M
d
p te
ce
Ac

24
Page 24 of 35
References

Alameddine, M., Kazzi, A., El-Jardali, F., Dimassi, H., Maalouf, S., 2011. Occupational

violence at Lebanese emergency departments: prevalence, characteristics and

associated factors. Journal of Occupational Health 53, 455-464. doi:

t
10.1539/joh.11-0102-OA

ip
Atawneh, F.A., Zahid, M.A., Al-Sahlawi, K.S., Shahid, A.A., Al-Farrah, M H., 2003.

cr
Violence against nurses in hospitals: prevalence and effects. British Journal of

us
Nursing 12, 102-107.

Belayachi, J., Berrechid, K., Amlaiky, F., Zekraoui, A., Abouqal, R., 2010. Violence

an
toward physicians in emergency departments of Morocco: prevalence, predictive

factors, and psychological impact. Journal of Occupational Medicine and

M
Toxicology 5, 27-37. doi: 10.1186/1745-6673-5-27
d

Bernaldo-de-Quirós, M., Cerdeira, J.C., Gómez, M.M., Piccini, A.T., Crespo, M.,
te

Labrador, F.J., 2013. Physical and verbal aggression encountered by out-of-

hospital emergency responders in the autonomous community of Madrid:

p

differences between urgent and emergent care settings. Emergencias 25

ce

(Advanced on line).
Ac

Boyle, M., Koritsas, S., Coles, J., Stanley, J., 2007. A pilot study of workplace violence

towards paramedics Journal of Emergency Medicine 24, 760-763. doi:

10.1136/emj.2007.046789

Cooper, C., Swanson, N., 2002. Workplace violence in the health sector – State of the

Art Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in

the Health Sector. Available at:

http://whqlibdoc.who.int/publications/9221134466.pdf (accessed 06/01/2012).

25
Page 25 of 35
Crabbe, J., Alexander, D.A., Klein, S., Sinclair. J.P., 2002. Dealing with violent and

aggressive patients: at what cost to nurses? Irish Journal of Psychological

Medicine 19, 121-124.

Di Martino, V., 2002. Workplace Violence in the Health Sector - Country Case Studies.

t
ip
Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional

Australian Study: Synthesis Report; Geneva: ILO/ICN/WHO/PSI Joint

cr
Programme on Workplace Violence in the Health. Available at:

us
http://www.who.int/violence_injury_prevention/injury/en/WVsynthesisreport.pd

f (accessed 06/01/2012)

an
El-Gilany, A.H., El-Wehady, A., Amr, M., 2010.Violence against primary health care

workers in Al-Hassa, Saudi Arabia. Journal of Interpersonal Violence 25, 716-

M
734. doi: 10.1177/0886260509334395
d

Farrell, G.A., Bobrowski, C., Bobrowski, P., 2006. Scoping workplace aggression in
te

nursing: findings from an Australian study. Journal of Advanced Nursing 55,

778–787. doi: 10.1111/j.1365-2648.2006.03956.x

p
ce

Gacki-Smith, J., Juarez, A.M., Boyett, L., Hoymeyer, C., Robinson, L., MacLean, S.L.,

2009. Violence against nurses working in US emergency departments. Journal of

Ac

Nursing Administration 39, 340-349. doi: 10.1097/NNA.0b013e3181ae97db

Gascón, S., Leiter, M.P., Pereira, J.P., Cunha, M.J., Albesa, A., Montero-Marín, J.,

García-Campayo, J., 2012. The role of aggressions suffered by healthcare

workers as predictors of burnout. Journal of Clinical Nursing. Published online

on 16 September 2012. doi: 10.1111/j.1365-2702.2012.04255.x

26
Page 26 of 35
Gerberich, S.G., Church, T.R., McGovern, P.M., Hansen, H., Nachreiner, N.M.,

Geisser, M.S., Ryan, A.D., Mongin, S.J., Watt, G.D., Jurek, A., 2005. Risk

factors for work-related assaults on nurses. Epidemiology 16, 704-709. doi:

10.1097/01.ede.0000164556.14509.a3

t
ip
Gil-Monte, P.R., Peiró., J.M., 1996. Un estudio sobre antecedentes significativos del

síndrome de quemarse por el trabajo (burnout) en trabajadores de centros

cr
ocupacionales para discapacitados psíquicos. [A significant background study of

us
burnout in occupational workers of mentally disabled centers]. Revista de

Psicología del Trabajo y las Organizaciones 12, 67-80. (In Spanish).

an
Gil-Monte, P.R., 2005. El síndrome de quemarse por el trabajo (Burnout): Una

enfermedad laboral en la sociedad del bienestar. [Burnout syndrome. An

M
occupational disease in the welfare society]. Madrid: Pirámide. (In Spanish)
d

Gil–Monte, P.R., Peiró, J.M., 2000. Un estudio comparativo sobre criterios normativos
te

y diferenciales para el diagnóstico del síndrome de quemarse por el trabajo

(Burnout) según el MBI–HSS en España. [A comparative study on normative

p

and differential criteria for burnout syndrome measured using the MBI-HSS in
ce

Spain]. Revista de Psicología del Trabajo y las Organizaciones 16(2), 135–149.

(In Spanish).
Ac

Goldberg ,D., 1981. General Health Questionnaire; GHQ-28. NFER-NELSEN, Oxford.

Grange, J.T., Corbett, S.W., 2002. Violence against EMS personnel. Prehospital

Emergency Care 6, 86-190.

Hahn, S., Müller, M., Hantikainen, V., Kok, G., Dassen, T., 2013. Risk factors

associated with patient and visitor violence in general hospital: Results of a

27
Page 27 of 35
 multiple regression analysis. International Journal of Nursing Studies 50, 374-

385. doi: 10.1016/j.ijnurstu.2012.09.018

Joa, S.T., Morken, T., 2012. Violence towards personnel in out-of-hours primary care:

A cross-sectional study. Scandinavian Journal of Primary Health Care 30, 55–

t
ip
60. doi: org/10.3109/02813432.2012.651570

cr
Koritsas, S., Boyle, M., Coles, J., 2009. Factors associated with workplace violence in

paramedics. Prehospital Disaster Medicine 24, 417-421. doi:

us
10.1017/S1049023X0000724X

an
Kowalenko T, Walters BL, Khare RK, Compton S. Michigan College of Emergency

Physicians Workplace Violence Task Force. Workplace violence: a survey of

M
emergency physicians in the state of Michigan. Ann Emerg Med.

2005;46(2):142-7.
d

Lam, L.T., 2002. Aggression exposure and mental health among nurses. Advances in
te

Mental Health 1, 1-12. doi: 10.5172/jamh.1.2.89

p

Lobo, A., Pérez-Echevarría, M.J., Artal, J., 1986. Validity of the scaled version of the
ce

General Health Questionnaire (GHQ-28) in a Spanish population. Psychological

Medicine 16, 135-140.

Ac

Martínez-Jarreta, B., Gascón, S., Santed, M.A., Goicoechea, J., 2007 Análisis médico-

legal de las agresiones a profesionales sanitarios. Aproximación a una realidad

silenciosa y a sus consecuencias para la salud. [Medical-Legal analysis

aggression toward care professionals. An approach to a silent reality and its

consequences on the health]. Medicina Clínica 128, 307-310. (In Spanish).

28
Page 28 of 35
Maslach, C., Schaufeli, W.B., 1993. Historical and conceptual development of burnout.

In Professional Burnout: Recent Developments in Theory and Research

(Schaufeli, W.B., Maslach, C., Marek, T., eds.) Taylor and Francis, Washington,

DC, pp. 1-16.

t
ip
Maslach, C., Jackson, S.E., Leiter, M.P., 1996. Maslach Burnout Inventory manual (3rd

edn).Consulting Psychologists Press, Palo Alto, CA.

cr
Maslach, C., Schaufelli, W.B., Leiter, M.P., 2001. Job burnout. Annual Review of

us
Psychology 52, 397-422. doi: 0.1146/annurev.psych.52.1.397

an
Maslach, C., Jackson, S., 1981. The measurement of experienced burnout. Journal of

Occupational Behaviour 2, 99-113.

M
Maslach, C., Jackson, S., 1986. The Maslach Burnout Inventory. Consulting

Psychologists Press, Palo Alto, CA.

d

May, D.D., Grubbs, L.M., 2002. The extent, nature, and precipitating factors of nurse
te

assault among three groups of registered nurses in a regional medical center.

p

Journal of Emerging Nursing 28, 191-197. doi: 10.1067/men.2002.121835

ce

Merecz, D., Drabek, M., Mościcka, A., 2009. Aggression at the workplace:

Psychological consequences of abusive encounter with coworkers and clients.

Ac

International Journal of Occupational Medicine and Environmental Health 22,

243–260. doi: 10.2478/v10001-009-0027-2

Nachreiner, N., Gerberich, S., Ryan, A., McGovern, P., 2007. Minnesota Nurses' study:

Perceptions of violence and the work environment. Industrial Health 45, 672-

678. doi: 10.2486/indhealth.45.672

29
Page 29 of 35
Needham, I., Abderbalden, C., Halfens, R., Fischer, J., Dassen, T., 2005. Nonsomatic

effects of patient aggression on nurses: a systematic review. Journal of

Advanced Nursing 49, 283-296. doi: 10.1111/j.1365-2648.2004.03286.x

Petzäll, K., Tällberg, J., Lundin, T., Suserud, B.O., 2011. Threats and violence in the

t
ip
Swedish pre-hospital emergency care. International Emergency Nursing 19, 5-

11. doi: 10.1016/j.ienj.2010.01.004

cr
Rippon, T., 2000. Aggression and violence in health care profession. Journal of

us
Advanced Nursing 31, 452-460. doi: 10.1046/j.1365-2648.2000.01284.x

an
Rowe, M.M., Sherlock, H., 2005. Stress and verbal abuse in nursing: do burned out

nurses eat their young? Journal of Nursing Management 13, 242-248. doi:
M
10.1111/j.1365-2834.2004.00533.x

Seisdedos, N., 1997. Manual MBl, Inventario Burnout de Maslach. [The Maslach
d

Burnout Inventory Manual]. TEA Ediciones, Madrid. (In Spanish).

te

Speroni, K.G., Fitch, T., Dawson, E., Dugan. L., Atherton, M., 2013. Incidence and cost
p

of nurse workplace violence perpetrated by hospital patients or patients visitors.

ce

Journal of Emergency Nursing. doi: 10.1016/j.jen.2013.05014

Suserud, B.O., Blomquist, M., Johansson, I., 2002. Experiences of threats and violence
Ac

in the Swedish ambulance service. Accident and Emergency Nursing 10, 127-

135. doi: org/10.1054/aaen.2002.0361

Winstanley, S., Whittington, R., 2002. Anxiety, burnout and coping styles in general

hospital staff exposed to workplace aggression: a cyclical model of burnout and

vulnerability to aggression. Work Stress 16, 302-315. doi:

10.1080/0267837021000058650

30
Page 30 of 35
Winstanley, S., Whittington, R., 2004. Aggression towards health care staff in a UK

general hospital: variation among professions and departments. Journal of

Clinical Nursing 13, 3-10. doi: 10.1111/j.1365-2702. 2004.00807.x

t
ip
cr
us
an
M
d
p te
ce
Ac

31
Page 31 of 35
Figure 1: Flow diagram of participants

Contact with
n = 545

Do not match criteria Match criteria

t
n = 41 n = 504

ip
cr
Acept but not
return Acept and return
Decline questionnaires

us
n = 35 (6.9 %) questionnaires
n = 451 (89.5%)
n = 18 (3.6%)

an
Discarded Included

n = 10 n= 441
M
d
p te
ce
Ac

32
Page 32 of 35
 i
cr
us
TABLE 1. Demographics of sample and differences according to type of violence

an
Verbal Verbal and Overall χ2 df P
No aggression Violence Physical N=441
n=80 N=209 Violence
n=152
Gender n (%)

M
Male 53 (66.3) 131 (62.7) 100 (65.8) 284 (64.6) 0.517 2 0.772
Female 27 (33.8) 78 (37.3) 52 (34.2) 157 (35.6)
Age M (SD) 46.44 (8.88) 44.99 (9.49) 42.73 (9.03) 44.5 (9.3) 9.861 2 0.007
Marital status n (%)

ed
Single 24 (30.4) 80 (38.2) 50 (32.7) 152 (34.9) 2.011 2 0.366
Married or living with a partner 56 (69.6) 129 (61.8) 102 (67.3) 284 (65.1)
Professions n (%)
Emergency care assistant 40 (50) 74 (35.4) 65 (42.8) 179 (40.6) 6.758 4 0.149
Nurse 16 (20) 77 (32.1) 44 (28.9) 127 (20.8)
pt
Physician 24 (30) 68 (32.5) 43 (28.3) 135 (30.6)
Current employment status n (%)
Regular 66 (82.5) 181 (86.6) 124 (82.1) 371 (84.5) 1.907 2 0.385
Casual 14 (17.5) 28 (13.4) 28 (17.9) 68 (15.5)
ce

Experience at present workplace M (SD) 10.25 (7.14) 11.42 (8.78) 11.24 (8.03) 11.14 (8.24) 0.847 2 0.655
Working experience M (SD) 17.11 (7.81) 19.15 (8.65) 17.68 (8.29) 18.28 (8.40) 4.182 2 0.124
Sick leave required n (%) 22 (27.5) 72 (34.6) 60 (39.5) 154 (35.0) 3.329 2 0.189
Number of sick leaves M (SD) 1.6 (1.14) 1.34 (1.03) 1.24 (0.62) 1.34 (0.91) 1.726 2 0.422
Ac

Number of days M (SD) 27.05 (34.32) 39.5 (71.65) 23.19 (52.81) 31.48 (60.91) 1.887 2 0.389

33

Page 33 of 35
 TABLE 2. Characteristics of the most serious incident and differences according to type of violence
Verbal Verbal and Overall χ2 df p
Violence Physical
Violence
Location %
Consulting room 26.2 9.2 19.0 15.21 1 <0.001
Triage 13.3 10.6 12.2 0.55 1 0.284
Waiting room 7.7 6.4 7.1 0.21 1 0.407
Home 41.0 56.7 47.6 8.09 1 0.003
Home entrance 3.6 7.1 5.1 2.09 1 0.117

t
Street 12.8 9.2 11.3 1.05 1 0.197

ip
Ambulance 1.5 2.8 2.1 0.67 1 0.327
Other location 0.9 0.9 1.8 0.16 1 0.497
Triggering reasons %
Disagreement with identification 2.1 1.4 1.8 0.19 1 0.501

cr
Waiting time 28.0 31.2 29.3 0.41 1 0.302
Disagreement with policy 21.6 17.0 19.7 1.11 1 0.181
Disagreement with treatment 36.9 34.8 36.0 0.16 1 0.385
Report a death 7.2 6.4 6.8 0.83 1 0.478

us
Pathology or social situation 9.2 14.2 11.3 0.16 1 0.108
Unknown /without reason 6.2 3.9 5.3 0.93 1 0.628
The aggression involved…%
Insults 89.4 85.6 87.2 1.01 1 0.201
Threats 83.6 92.2 87.2 5.43 1 0.014

an
Threatening behaviours 81.5 86.5 83.6 1.48 1 0.142
Coercions 43.1 43.3 43.2 0.01 1 0.531
Kidnapping 10.3 28.4 17.9 18.3 1 <0.001
Damage to furniture 34.4 51.1 41.4 9.41 1 0.002
Grabbing or pushing 25.1 65.2 42.0 54.08 1 <0.001
M
Slapping or punching 7.2 25.5 14.9 21.75 1 <0.001
Kicking 8.7 30.5 17.9 26.46 1 <0.001
Bitting 2.6 6.4 4.2 2.98 1 0.074
Pulling hair 2.5 7.1 4.5 3.93 1 0.044
Scratching 3.1 17.7 9.3 20.83 1 <0.001
d

Throwing objects 23.6 28.4 25.6 0.98 1 0.194

Chocking 1.5 2.8 2.1 0.67 1 0.327
Stabbing 7.2 17.0 11.3 7.9 1 0.004
te

Shooting 3.1 7.1 4.8 2.96 1 0.073

Spitting 0.7 0.5 0.6 0.05 1 0.664
Others 0.5 3.5 1.8 4.29 1 0.049
Aggression required… %
p

Medical assistance 5.6 19.1 11.3 14.88 1 <0.001

Surgical assistance 1.0 1.4 1.2 0.107 1 0.559
ce

Psychological assistance 2.1 3.5 2.7 0.701 1 0.307

Reported to the police/ authority 6.2 19.3 11.6 13.66 1 <0.001
Sick leave 3.1 8.5 5.4 4.76 1 0.027
Ac

34
Page 34 of 35
 TABLE 3. Burnout level and differences according to type of violence

No Verbal Verbal and χ2 Df P

aggression Violence Physical
Violence
EE (%)
High 2.5 5.8 17.3
Average 3.8 16.3 14.7 28.68 4 <0.001
Low 93.7 77.9 68.0

t
DP (%)
High 7.7 14.1 15.1

ip
Average 12.8 28.6 30.3 14.91 4 0.005
Low 79.5 57.3 54.6
PA (%)

cr
High 66.7 63.1 64.0
Average 16.7 22.3 18.0 2.06 4 0.724
Low 16.7 14.6 18.0

us
Burnout:
EE+DP+PA (%) 0 1.0 2.7 3.14 2 0.208
Burnout:
EE+DP (%) 0 2.4 6.7 8.07 2 0.018
EE (Emotional exhaustion), DP (Depersonalization), PA (Personal Accomplishment

an
M
d
p te
ce
Ac

35
Page 35 of 35