The current study examined the differential empathic capacity, post-traumatic symptoms, and coping strategies in healthcare workers (HCWs) according to the exposure of verbal or physical workplace violence (WPV).
Using online survey, a total of 422 HCWs employed at a training general hospital of South Korea participated and completed self-reporting questionnaires including the WPV questionnaire with coping strategy, the Jefferson Scale of Physician Empathy.
Those who experienced either only verbal violence or both physical and verbal violence had lower Jefferson Scale of Physician Empathy scores (p<0.05). Posttraumatic stress symptom severity was higher among people who experienced verbal violence than physical violence. HCWs’ exposure to verbal violence was associated with severe posttraumatic symptoms and a low level of empathy with patients (p<0.05). More than half of the victims of verbal violence responded that they did not take any action, receive organizational protection, or peer support, while most physically-abused HCWs received institutional intervention or help from others.
Our findings highlight the critical importance of reducing verbal violence, which may represent a larger psychological burden compared to physical violence, by actively implementing effective strategies and policies at the institutional level.
Workplace violence (WPV) is defined as “incidents where staffs are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.” [
In addition to depression, anxiety, and burnout, post-traumatic stress disorder (PTSD) is one of the most frequent negative psychological consequences of WPV victims [
Despite these well-known detrimental effects of WPV on mental health, the differential impact of WPV subtypes (physical or verbal) on the empathic capacity of HCW has received little attention [
A total of 609 HCWs (including doctors, registered nurses, pharmacists, medical technicians, and non-health professionals at a training hospital) participated in the current study between March 20 and June 1, 2019. All participants were recruited through online posting and e-mails; data collection was conducted using the anonymous self-reporting questionnaires delivered via web-based link. Self-reporting questionnaires were: the WPV experiences, perceived empathic capacity for patients, posttraumatic symptoms, and demographic information (age, gender, educational level, marital status, working department, years working at the current institution, and work shift). After excluding the data with omitted response(s), finally a total of 422 responses were used for the statistical analyses. Participants were asked to provide written consent prior to the beginning of the survey and voluntarily responded to self-administered questionnaires. The study was approved by the Institutional Review Board of Seoul National University Hospital (IRB No: 1902-038-1009).
The exposures of WPV were measured using a self-reporting questionnaire [
Jefferson Scale of Physician Empathy (JSPE) was composed of 20-items [
Participant characteristics were described and frequencies of experienced violence (physical and verbal in the last year) were calculated. We performed the Shapiro-Wilk test to assess the normality of JSPE and PTSD scores. According to the violation of the normality assumption, either the Student’s t-test and analysis of variance or the Mann-Whitney test and Kruskal-Wallis test were performed to compare the differences in JSPE scores and the scores on the entire PTSD questionnaire sorted by experience, frequency, and assailant of WPV.
We classified participants into four groups according to the type of WPV they experienced (physical violence [yes or no] and verbal violence [yes or no]). We tested the differences in JSPE scores between the groups that experienced WPV and the groups that did not, while adjusting for age, gender, marital status, educational level, and job classification by using multivariate linear regression models. Finally, among those who experienced physical or verbal violence, posttraumatic symptoms were measured according to their coping strategies for WPV. The means and standard deviations (SDs) for four questions rated on a five-point Likert scale and a sum of questions were calculated for the coping strategies (no action or individual action vs. received help from family, colleagues, or organization). The differences in scores on the PTSD questionnaire were tested by using multivariate linear regression models, adjusting for age, gender, marital status, educational level, and job classification.
Among those who experienced physical violence, 38 people (69.1%) experienced it less than once a month and 17 people (30.9%) experienced it once a month or more frequently. Physical violence was frequently perpetrated by a patient or their family (n=43, 78.2%), followed by a coworker or superior (n=10, 18.2%), or a visitor (n=2, 3.6%). Those who experienced verbal violence once a month or more frequently numbered were 101 people (51.5%). Perpetrators of verbal violence were mostly patients or their family (n=112, 57%), followed by coworkers or superiors (n=57, 29.1%), or visitors of patient (n=27, 13.8%).
JSPE and PTSD scores according to experiences and characteristics of WPV (physical and verbal) are presented in
Total scores for PTSD symptoms according to the type of WPV and coping strategies are depicted in
In our study, victimized HCWs showed a low level of empathy with patients. This finding is similar to previous researches indicating that WPV hinders understanding patients and causes inappropriate care with weakened empathy toward patients [
Our study confirms that the impact on HCW’s empathy depends on the types of violence: physical and verbal. Experiences of verbal violence heightened the risk of lowered empathy, whereas physical violence did not show significant effects. This result aligns with previous study in which verbal violence had a significant effect on depression, anxiety, and physical symptoms in comparison with injuries inflicted by physical violence [
In our study, the number of participants with PTSD scores of 14 points or above was higher for those who experienced verbal (without physical) abuse than for those who experienced physical (without verbal) abuse. This result is consistent with previous study in which the percentage of participants with PTSD scores of 14 points or higher was 28% for cases of verbal violence and 19.6% for cases of physical violence [
Owing to the urgent nature of medical care, medical workers who endure verbal violence cannot be easily repositioned. HCWs are usually trained be tolerant of verbal abuse resulted from patients’ disease. If the perpetrator is a patient, rejection or eviction of perpetrators is often legally or ethically difficult, owing to medical staff’s beliefs and common sense that “refusal of care is not ethically right.” These factors play a role in aggravating “re-experience” symptoms of PTSD [
Physical restraint has no effect on verbal violence [
Most verbally abused victims in this study reported that they did not take any action or report incidents. Similar trends were found in previous studies conducted in other Asian countries [
In summary, verbal violence impedes HCWs’ ability to be empathetic and leads to a higher risk of PTSD symptoms compared to physical violence. For regulating verbal as well as physical WPV, legal and systemic assistance and well-designed medical literacy plans for the public should be further developed. If medical institutions focus mainly on physical violence, overlooking the negative impact of verbal violence, HCW’s work efficiency will be impeded. The lack of appropriate legal actions and less developed training program related to WPV may be another fundamental reason why most victims take no action or pretend the violence never happened [
Preventive measures such as public campaigns and teaching of de-escalation at the institutional level also need to be implemented. Considering the heavy workload and irregular work schedules of HCWs, practical intervention including brief intervention or online-based platform for the prevention of WPV is needed. In recent previous study, WPV prevention program using online modules for 2 hours has been demonstrated [
Our study has several limitations. First, the cross-sectional design limits causal inferences concerning WPV and empathy. Second, we used self-reporting questionnaire to measure the exposure of WPV, despite the controversies on the objective evidences in defining WPV. Personal threshold of WPV may be also unalike according to susceptibility of each person and situational differences. However, subjective report is important, especially for managing psychological sequelae, despite lack of objective measuring devices on individual traumatic events. In addition, HCWs are well known to report WPV less than they actually went through since they are afraid of being criticized not to adept to defend themselves and evaluated to be less qualified by their supervisors and hospital managers. WPV is often misinterpreted as a clinical failure for being less empathetic. In our study, self-report procedure using smartphone answering method protecting confidentiality might enhance to report WPV more than person-to-person interview or formal recording using paper. Third, all the respondents in this survey were working in a general training hospital in a metropolitan area where the workload is more diverse and serious than other smaller local hospitals or clinics at rural area. Therefore, the findings of this study regarding WPV cannot be generalized to most healthcare workers. Finally, although physical violence and verbal violence groups are interdependent, we compared two groups using between-group differences tests in order to emphasize the traumatic effect of solitary verbal abuse for several reasons: Public health strategy against violence has focused preventing physical violence rather than verbal violence. Guards and material equipment protecting health care workers from physical violence have been prepared, while overlooking the effect of prevailing verbal abuse in hospitals.
Nevertheless, this study raises important issues as the findings have implications for the health of both patients and medical practitioners. Effective intervention techniques and policies can be developed taking into consideration our findings that healthcare workers who are subjected to verbal violence feel low empathy toward patients and experience stress while providing healthcare services.
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
The authors have no potential conflicts of interest to disclose.
Conceptualization: Nami Lee, Yun-Chul Hong, Soo-hyun Nam. Data curation: Nami Lee, Soo-hyun Nam. Formal analysis: Soo-hyun Nam, Dong-Wook Lee. Methodology: Dong-Wook Lee, Sung-jun Cho. Visualization: Dong-Wook Lee, Hwa-yeon Seo. Writing—original draft: Soo-hyun Nam, Nami Lee. Writing—review & editing: Yun-Chul Hong, Je-Yeon Yun.
This study was supported by donated grants to Seoul national university hospital under the name of “the Rhie blended family Foundation” with support from Dr. Rhie SooBum. Dr. Rhie JungYeon and secretary general Rhie JuneKyue (Grant No: 900-00086).
Types of experience of workplace violence and healthcare workers’s empathy. **differences between the groups with and without experience, adjusted for age, gender, marital status, education, and job classification.
Participants’ characteristics and experience of workplace violence
Total |
Experienced workplace violence |
Experienced physical violence in the last year |
Experienced verbal violence in the last year |
||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
N (%) | Yes |
No |
p | Yes |
No |
p | Yes |
No |
p | ||
N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | ||||||
Total | 422 (100) | 215 (51.0) | 207 (49.0) | 55 (13.0) | 376 (87.0) | 196 (46.5) | 226 (53.5) | ||||
Gender | <0.001 | 0.102 | <0.001 | ||||||||
Male | 98 (23.2) | 65 (66.3) | 33 (33.7) | 8 (8.2) | 90 (91.8) | 31 (31.6) | 67 (68.4) | ||||
Female | 324 (76.8) | 150 (46.3) | 174 (53.7) | 47 (14.5) | 277 (85.5) | 165 (50.9) | 159 (49.1) | ||||
Age (y) | 0.014 | 0.040 | 0.045 | ||||||||
<30 | 114 (27.0) | 54 (47.4) | 60 (52.6) | 22 (19.3) | 92 (80.7) | 56 (49.1) | 58 (50.9) | ||||
30–39 | 195 (46.2) | 91 (46.7) | 104 (53.3) | 25 (12.8) | 170 (87.2) | 98 (50.3) | 97 (49.7) | ||||
40–49 | 78 (18.5) | 44 (56.4) | 34 (43.6) | 7 (9.0) | 71 (91.0) | 33 (42.3) | 45 (57.7) | ||||
>50 | 35 (8.3) | 26 (74.3) | 9 (25.7) | 1 (2.9) | 34 (97.1) | 9 (25.7) | 26 (74.3) | ||||
Marital status | <0.001 | 0.002 | 0.002 | ||||||||
Single | 206 (48.8) | 87 (42.2) | 119 (57.8) | 38 (18.5) | 168 (81.5) | 110 (53.4) | 96 (46.6) | ||||
Marriage | 213 (50.5) | 128 (60.1) | 85 (39.9) | 16 (7.5) | 197 (92.5) | 83 (39.0) | 130 (61.0) | ||||
Divorced | 3 (0.7) | 0 (0) | 3 (100) | 1 (33.3) | 2 (66.7) | 3 (100.0) | 0 (0) | ||||
Education | 0.071 | 0.059 | 0.026 | ||||||||
High school | 12 (2.8) | 10 (83.3) | 2 (16.7) | 1 (8.3) | 11 (91.7) | 1 (8.3) | 11 (91.7) | ||||
College | 261 (61.9) | 129 (49.4) | 132 (50.6) | 42 (16.1) | 219 (83.9) | 123 (47.1) | 138 (52.9) | ||||
Graduate school | 149 (35.3) | 76 (51.0) | 73 (49.0) | 12 (8.1) | 137 (91.9) | 72 (48.3) | 77 (51.7) | ||||
Job | <0.001 | 0.008 | <0.001 | ||||||||
Doctors | 80 (19.0) | 52 (65.0) | 28 (35.0) | 5 (6.3) | 75 (93.8) | 27 (33.8) | 53 (66.3) | ||||
Medical technicians | 52 (12.3) | 35 (67.3) | 17 (32.7) | 2 (3.9) | 50 (96.2) | 17 (32.7) | 35 (67.3) | ||||
Pharmacist | 13 (3.1) | 5 (38.5) | 8 (61.5) | 1 (7.7) | 12 (92.3) | 7 (53.9) | 6 (46.2) | ||||
Nurse | 227 (53.8) | 87 (38.3) | 140 (61.7) | 43 (18.9) | 184 (81.1) | 132 (58.2) | 95 (41.9) | ||||
Assistant nurse | 10 (2.4) | 7 (70.0) | 3 (30.0) | 1 (10.0) | 9 (90.0) | 2 (20.0) | 8 (80.0) | ||||
Non-health professionals | 40 (9.4) | 29 (72.5) | 11 (27.5) | 3 (7.5) | 37 (92.5) | 11 (27.5) | 29 (72.5) | ||||
Duration (y) | 0.301 | 0.118 | 0.556 | ||||||||
<3 | 95 (22.5) | 52 (54.7) | 43 (45.3) | 11 (11.6) | 84 (88.4) | 41 (43.2) | 54 (56.8) | ||||
3–5 | 69 (16.4) | 33 (47.8) | 36 (52.2) | 15 (21.7) | 54 (78.3) | 34 (49.3) | 35 (50.7) | ||||
6–10 | 113 (26.8) | 49 (43.4) | 64 (56.6) | 16 (14.2) | 97 (85.8) | 59 (52.2) | 54 (47.8) | ||||
11–15 | 65 (15.4) | 37 (56.9) | 28 (43.1) | 7 (10.8) | 58 (89.2) | 27 (41.5) | 38 (58.5) | ||||
>15 | 80 (19.0) | 44 (55.0) | 36 (45.0) | 6 (7.5) | 74 (92.5) | 35 (43.8) | 45 (56.3) |
Chi-squared test was performed to test the differences.
verbal violence and/or physical violence
Experiences of workplace violence, empathy with patients, and posttraumatic symptoms
Physical violence |
Verbal violence |
|||||
---|---|---|---|---|---|---|
JSPE |
PTSD score |
JSPE |
PTSD score |
|||
N (%) | Mean±SD | N (%) | N (%) | Mean±SD | N (%) | |
Experience of violence | ||||||
No | 367 (87.0) | 92.9±16.8 |
- | 226 (53.6) | 94.3±16.5 |
- |
Yes | 55 (13.0) | 87.8±20.8 | - | 196 (46.4) | 89.9±18.1 | - |
Frequency |
||||||
<1/month | 38 (69.1) | 89.5±21.4 | 12.8 (3.4) | 95 (48.5) | 91.0±16.6 | 13.4 (3.8) |
≥1/month | 17 (30.9) | 84±19.5 | 14.1 (3.0) | 101 (51.5) | 84.1±19.0 | 15.5 (3.1) |
Assailants |
||||||
Patients (or their families) | 43 (78.2) | 88.9±20.2 | 12.9 (3.2) | 112 (57.1) | 90.9±17.8 | 13.3 (3.6) |
Coworkers (or superiors) | 10 (18.2) | 80.7±23.5 | 14.3 (4.0) | 57 (29.1) | 89.5±19.4 | 14.7 (3.5) |
Others (visitors, external workers, general public) | 2 (3.6) | 99.5±21.9 | 13.0 (2.8) | 27 (13.8) | 86.5±16.8 | 15.3 (2.9) |
Differences in JSPE scores according to experiences of physical or verbal violence were tested using the Student’s t-test or ANOVA. The Mann-Whitney test and Kruskal-Wallis test were performed to assess the differences in JSPE and PTSD scores according to the frequency of violence and the perpetrator of the violent events.
p<0.05;
among participants who experienced physical or verbal violence in the last year.
JSPE, Jefferson Scale of Physician Empathy; PTSD, Posttraumatic Stress Disorder
Posttraumatic symptoms according to the coping strategies used to handle workplace violence
PTSD Score≥14 |
PTSD Score |
||||
---|---|---|---|---|---|
N (%) | N (%) | p value | Mean±SD | p value | |
Physical violence | 55 (100.0) | 30 (54.6) | 0.637 | 0.487 | |
No action or individual action | 18 (32.7) | 9 (50.0) | 13.2±3.5 | ||
Received help from family, colleagues, or organization | 37 (67.3) | 21 (56.8) | 13.2±3.3 | ||
Verbal violence | 196 (100.0) | 120 (61.2) | 0.231 | 0.433 | |
No action or individual action | 116 (59.2) | 67 (57.8) | 13.8±3.9 | ||
Received help from family, colleagues, or organization | 80 (40.8) | 53 (66.3) | 14.3±3.1 |
Chi-squared test and multivariate linear regression test were performed to test the differences. Differences in PTSD score were tested with the adjustment for age, gender, marital status, education, and job classification. PTSD, Posttraumatic Stress Disorder; SD, standard deviation