Workplace violence and the meaning of work in healthcare workers: A phenomenological study

Abstract

BACKGROUND: Workplace violence (WPV) has been associated with turnover intentions and reduced job satisfaction, yet the mechanisms behind such associations are still nebulous. Studying the way people make sense of their work in the context of WPV could lead to a better understanding of its consequences.

PURPOSE: The objective of this exploratory study is to identify key features of meaning of work (MOW) in a group of healthcare workers and explain how these features can change following an act of WPV.

METHODS: Researchers recruited 15 healthcare workers (11 women – 4 men) who had previously been the victim of a serious physical or sexual assault by a patient. A phenomenological approach was used.

RESULTS: Two main themes were identified: MOW and relationships with others and MOW and relationship with the self. WPV might have the potential to trigger negative changes in the way some workers perceive their colleagues, their patients and their organisation. It can also interfere with their sense of self-accomplishment; all workers however, were still able to find positive meaning in ‘contribution’ and ‘autonomy’.

CONCLUSION: WPV has the potential to change certain aspects of MOW that could help explain why WPV is associated with lowered job satisfaction, compassion fatigue, and higher turnover. Also, finding meaning through contribution and autonomy can be a form of resilience.

Keywords

Workplace violence health personnel job satisfaction resilience professional burnout

1 Introduction

Each year, a large percentage of workers all around the world experience workplace violence (WPV); yet risks of exposure are not the same for all workers, some professions remain at much greater risk of violence than others [1]. Working in the fields of clinical healthcare [1 –3] and clinical psychiatry [4] are considered risk factors for violence exposure. For example, one study estimated that psychiatric nurses were the victim of 0.19 physical assaults each week [5]. A recent review of the literature illustrates numerous consequences of such violence on healthcare workers. Lanctôt and Guay [6] report that WPV is associated with a series of serious psychological, emotional, and organizational consequences such as hypervigilance, anger, and a decrease in job satisfaction. Given these serious consequences, one can reasonably assume that, following an act of violence, workers could feel differently about their job. Yet little is known about the effects of WPV on the meaning of work (MOW). Understanding the complexities of MOW could be instrumental in the context of job retention efforts in the field of healthcare, where WPV is associated with increased job turnover [7]. After all, “the meaning of work is at the core of employees’ experiences of their jobs” [8]. Despite the central importance of work and the high percentages of WPV, little is known about the impact of WPV on MOW.

2 Literature review

2.1 A brief review of workplace violence (WPV)

With regards to the healthcare sector, rates of physical violence and threats thereof are relatively common occurrences. For example, a review of violence in healthcare settings revealed that anywhere from 2 to 32% of healthcare workers were physically assaulted by a patient or a visitor during the last year and 12 to 64% of them were threatened with violence [9]. WPV is not only associated with serious psychological and emotional consequences [6] but also with turnover intentions [10 –13], worker reassignment or duty changes [7], decreased job satisfaction [11 , 13–15], increased job stress [15] and lower organizational commitment [15, 16]. Finally, sick leaves have also been reported [17, 18].

Closely related to the organizational consequences, are the impacts on the relationships between victims, their colleagues and patients. Although less studied, some authors have documented negative changes in relationships between victims and their colleagues following an act of WPV such as less effective inter-professional communication [19] and feelings of isolation at work [20]. In contrast, other studies have also identified colleagues as key actors when it comes to psychosocial support following workplace victimization [21]. With regards to patients, in their review on the consequences of WPV, Lanctôt and Guay [6] cited ten studies documenting increased fear of patients in victims of WPV and six studies reported a reduction in the quality of patient care. Other studies have reported a decreased eagerness to answer residents’ call lights, avoidance of patients, the adoption of a more passive role, and even callousness towards patients [20]. Roche and colleagues [19] also linked WPV to longer waiting periods for patient placement.

2.2 The meaning of work: What we know

Although the meaning of work (MOW) has been an interest of scholars for decades, the concept remained up until recently, poorly defined. As Pratt andAshforth [22] and Rosso, Dekas and Wrzesniewski [23] have pointed out, many closely related concepts and terms have been used interchangeably and incorrectly to refer to ‘the meaning of work’. Some of the most common examples include confounding this concept with the ‘meaningfulness of work’ which refers to the significance that a person attributes to work, or ‘work values’ which refers to concepts such as altruism, achievement, etc. [23]. For the purpose of this paper, MOW refers to both the significance and worth subjectively attributed by individuals to what they do and their representations of it and the coherence between the individuals’ expectations, values and behaviour and the job performed (often referred to as meaningfulness). An important distinction is that the meaning ascribed can be positive, neutral or negative, even though, in the literature, the term almost exclusively refers to ‘positive meaning’ [23, 24]. Studying MOW is important for many reasons. Workers who find meaning in their work are more likely to report higher levels of work engagement [25 –27], organisation identification [28], job satisfaction [29] and individual performance [25, 29]. For these reasons and others, workers who find meaning in their work are more cost-effective than their less-inspired counterparts, which could benefit the organization as a whole [24, 30].

Although these topics have been studied extensively, little is known about the relationship between workplace violence and MOW. To our knowledge, only one study has ever purposely investigated the relationship of WPV and MOW. MacIntosh and colleagues [21] found that victims of workplace bullying experience changes in MOW as a result of their work values being violated. In their study, changes in MOW were revealed through intensifying negative feelings about the workplace, going to work, and interactions with coworkers as well as impoverished health. Although their study took place in a healthcare setting, the findings are almost exclusively limited to psychological violence emanating mostly from colleagues and superiors (i.e. bullying). It should be noted that specific aspects of MOW in the context of WPV, especially concerning work values, have been documented previously, however the concept of MOW itself has received less attention(e.g. [31]).

The main objective of this study is to understand how experiencing an act of WPV can influence how healthcare employees perceive their work and the meaning they assign to it. Given the exploratory nature of this study, a qualitative approach was deemed most appropriate. Phenomenology, inparticular was deemed the most promising type of analysis to answer the research question. Focusing first and foremost on describing the participants’ lived experiences, as is phenomenology’s forte, was considered a judicious choice in light of the scarcity of documented evidence on the change in MOW following an act of violence.

3 Methodology

This study focuses on the experience of 15 healthcare workers, all of whom were victims of workplace violence (11 women and 4 men). The participants were recruited in a psychiatric hospital in Canada (i.e. convenience sample). This institution was selected because it is one of the largest mental healthcare settings in the area, providing thousands of patients every year with a wide range of services ranging from short-term specialized acute emergencies to long-term institutionalized care. The hospital also has a strong, long-standing and mutually-benefiting relationship with the academic sector. Selection criteria were as follow: to have been the victim of violence within the last 10 years while working at the hospital, to have gone on a leave of absence as a consequence of WPV, and to be psychologically and physically able and willing to discuss the topic of interest. In the context of this study, an act of WPV is defined as any behaviour that could potentially result in physical harm and includes the threat of such behaviour, for example: physical injury, robbery, physical assault, unwanted sexual touching, threat of injury or death. In accordance with ethical regulations, researchers had to disclose a priori the maximum number of participants they were planning on interviewing before the project started. For this reason, researchers could not rely on theoretical saturation as a guideline for optimal recruitment. The final sample (N = 15) nevertheless constitutes a large sample size for a phenomenological study [32 –34]. In order to protect participant confidentiality, each worker was given a pseudonym. Vignette 1 provides a brief overview of the participants’ sociodemographic background and experiences.

Vignette 1 - Participants’ background and experiences

Catherine, 55, a nurse, was pushed violently to the ground by an angry patient who did not want to return to the isolation room. She suffered a fractured wrist as a result. She found her injury particularly hard to get over.

Cecilia, 35, was assaulted while she was working as a nurse in intensive care; one of her patient suffered from paranoia and became confused. He grabbed a hard object, cornered her, and threatened to bludgeon her with it. Had it not been for her colleagues who came to her help immediately, Cecilia believes she could have been killed.

Diane, 52, worked as an orderly when she was assaulted by a patient who had a history of violence. While she was serving lunch, the patient became agitated; he grabbed her by the wrists and started kicking her violently. A week after the incident it was still too painful for her to walk more than a few steps.

Dorothy, 53, was a specialized educator working in the intensive rehabilitation unit when she was assaulted. On a particularly busy day, a female patient hid behind a door and jumped on Dorothy while she was checking on another patient. The patient scratched her as hard as she could. She finished her shift that day, but eventually felt the need to take some time off.

Henry , 35, was working as an orderly when he was assaulted. While he was serving breakfast, a patient came up behind him and started strangling him, they struggled and both men fell to the floor. His colleagues called for help but nobody physically intervened to save him. He was physically injured during the incident and had trouble walking for a few weeks.

Katy, 33, was working as an orderly when she ran to a colleague’s help; he was being strangled by a patient. She and another colleague tried to contain the patient but he managed to push her away and kick her repeatedly with his feet and knees. Katy is disappointed that the rest of the team took refuge behind the nursing station instead of coming to her help.

Lisa, 43, an orderly, was helping a patient get out of the shower when she became agitated after seeing another patient naked; Lisa tried to contain her but it was no use. The patient aimed for her eyes, scratching her cornea and punching her several times in the face and upper body. She had to wait two and a half years before her shoulder was healed enough to go back to work.

Maria, 58, was working as a nurse with people with intellectual disabilities. One day, she offered a patient with a history of racially-motivated violence his medication. Not liking the fact that Maria was black, the patient suddenly jumped at her and pushed her so hard she hit her head against the wall before falling to the ground. Her neck was badly injured.

Maeve, 29, started working at the hospital as a specialized educator a few years before being assaulted. While she was helping another patient, a man jumped on her back and started rubbing his hands on her breasts and in between her legs. She had a hard time fighting him off of her. She said she was too proud to end her shift early or accept help that same night, but she eventually felt the need to receive counseling.

Eva, 32, was working with patients recovering from their first psychotic episode when she was assaulted. On a particularly busy day, a patient followed her into the hallway and punched her in the face, almost knocking her out. Then, the patient threw her across the hall and started kicking her while she was on the floor. Colleagues helped restrain her.

Rosalind, 28, was a nurse working in longer-term care for psychotic patients when she rushed to help a colleague who was being strangled by a patient. Rosalind thought her colleague was about to die, she fought with his attacker and managed to get him off. Her other colleagues hid behind the nursing station during the attack but she decided to stay and guard her unconscious colleague until security arrived.

Peter, 46, an orderly, had the difficult task of helping a patient with her personal hygiene; she did not want to shower. One day, this patient got really upset because she caught him using an air freshener in her room so she snuck up behind him. She was able to punch him violently several times before the nurse could get her off of him.

Russell, 62, an orderly, was making coffee for his colleagues when a patient walked into the break room and punched him by surprise, breaking his nose. The patient was angry because his doctor had just told him he wasn’t allowed to go outside for now.

Sylvia, 32, was working as an assistant nurse taking vital signs when she was attacked. It was a busy day and a patient did not want to wait for her assistance; she grabbed the nursing assistant by the hair and threw her on the ground. Sylvia froze; she believed she was going to die. Luckily her colleagues were able to intervene and get the patient off of her.

Stephen, 43, was a nurse who accepted to take in a patient with a history of substance abuse to relieve a swamped colleague in another department. When Stephen refused to give this patient the pain medication he wanted, the patient started punching him. Stephen ran away but eventually had to tackle the patient down to ensure the safety of other patients nearby; in the struggle, he was strangled and almost had one of his eyes gouged out before a nurse came to his aid and medicated the patient.

The interview format was semi-structured and each interview lasted approximately one hour. Participants were interviewed on two separate occasions, first to discuss MOW before the act of violence and then later to discuss MOW after the act of violence (note: both interviews took place after the act of violence in question). The main objectives of the interview were broad. Mostly, the interviewer sought to understand the participants’ initial motivations to work in the field of healthcare, their expectations, and to discuss their general impressions of working in a psychiatric setting. From the beginning, exploring the meaningful aspects of work according to healthcare workers was deemed a central aspect of the interviews. Informed consent was obtained from all individual participants included in the study. Interviews were recorded and then transcribed before being analyzed according to Giorgi’s [35] “Empirical Phenomenological Psychological” method. This method consists of 1) reading and re-reading transcripts in order to get a general sense 2) dividing the interviews into units of meaning 3) identification and interpretation of the themes 4) summarizing themes for each participant and lastly 5) to present a general portrait of the themes and sub-themes of each participant. Two research-trained organizational psychologists coded the interviews and the final analysis was conducted by a supervised graduate student.

In accordance with the phenomenological approach, the goal of this study is to provide a rich description of participants’ experiences regarding MOW and their experience of WPV. And so, even though the before/after format at the core of the study might be limiting in its imposed dichotomization of participants’ experience, participants were not expected to have experienced changes in each and every aspect of MOW. As a final methodological note, although the concepts of ‘thematic saturation’ and ‘theoretical saturation’ have been hugely influential in the field of qualitative research, the authors agree with their critics [36 –38] especially since the notion of ‘saturation’ contradicts the very premise of phenomenology which places value on the lived experiences of people rather than the standardization of such experiences [37, 38]. Ironically, if theoretical saturation and thematic saturation had been the main objectives of this study, the number of participants would have likely been less than 15 since and the number of themes and sub-themes would have remained the same given that the views and opinions discussed in the interviews very frequently overlapped.

Upon reviewing and classifying the interviews, the researcher opted to regroup the units of meaning into two broad categories; MOW as it applies to 1) relationships with others and 2) the relationship with the self. Each theme has three sub-themes. The final product is an ensemble of key themes and sub-themes that are simple to understand yet retain their utility to inform for further research. With regards to the first theme, participants spoke at length about how their relationships with others brought positive meaning to their work; relationships with colleagues (sub-theme 1) and patients (sub-theme 2) were especially important while some participants also discussed their changing relationship with their organisation (sub-theme 3). Alternatively, participants also discussed more personal components of MOW that were then regrouped into three sub-themes; self-accomplishment, contribution, and autonomy. Figure 1 presents a thematic map of the findings.

4 Findings

4.1 MOW: Relationships with colleagues, patients and the organisation

Most participants shared that they greatly valued the people they work with. Colleagues and patients especially, seem to play an important role in people’s MOW. Despite giving positive meaning to their work, the risk of violence when interacting with others, especially with patients, always remains a possibility. It is not surprising, therefore, that some workers reported changes in their way of interacting with others following an act of violence. The interviews with participants revealed that relationships with colleagues, patients and the organisation are central to MOW.

4.1.1 Relationships with colleagues

For many participants, the presence of colleagues is an important aspect of work. Colleagues also play a role in many of the participants’ social lives as well. They can offer support, understanding, and enjoyment. During the interviews, most participants shared how colleagues added positive meaning to their work.

“I like working at (name of place), it’s the social aspect too. At (name of place), we were 3 guys together, 3 orderlies, and we got along well together [… ] we would help each other out. [… ] And being here, eating at the cafeteria, meeting people, sometimes when you leave work you can even have conversations with people you haven’t seen in a while” – Russell

“(Before the act of violence) I liked the contact with people. I liked my colleagues; I also liked the work climate that was always respectful” – Katy

Relationship dynamics, however, might be complex. Even when workers value and seek the positive presence of colleagues, some of them also feel the need to refocus on themselves following an act of violence. A few participants expressed a desire for isolation:

“I trust them a little bit more now but there’s something still, a bond that is broken [… ] you always ask yourself ‘hey are they really going to be there if it blows up?’ [… ] It’s always a risk that you’re taking, you don’t know if they are going to intervene if there’s something.”

Interviewer: “Do you still see your colleagues outside of work?”

“Less and less, a lot less. I still see them but a lot less. I’m less available. I’m less interested [… ]” – Rosalind

Although most participants agreed that relationships with colleagues are important, many of the interviews illustrate how the perception of these relationships can change following violent victimization. The reported changes varied from temporary disappointment, to a desire to withdraw to the more serious feelings of betrayal. In any case, changes in the relationships with colleagues interfered with the positive meaning they previously contributed to.

4.1.2 Relationships with patients

Of all the possible relationships to be enjoyed at the hospital, the relationship with patients played a central role in the participants’ discourse. Nearly all participants discussed the significance of helping patients as an important part of MOW:

“The interaction that I had with the clients (is what I loved about my job). That’s something I liked at lot with others. But you know in my job it’s not necessarily the contact with the secretary or the nurse, it’s really my contact with the patient in and of itself; to take care of him, to make sure that he’s got everything he needed that day to go about his things, doing his activities, it’s really that.” – Lisa

“I liked being in contact with them. I liked trying to understand them, to help them, and to see the result at the end of the line. When I saw them getting discharged, I think I was just as happy as them.” – Rosalind

Given the vulnerable state of many patients, the risk of violence is always present for healthcare workers. Unfortunately, this ever-present risk and its distressing consequences can prove difficult to handle, especially when it comes to the relationship with patients. Participants reacted differently to this violence. Half of the participants noticed changes in their way of interacting with patients ranging anywhere from a mild and temporary form of hypervigilance to a more serious form of apathy.

“The first weeks, it changed for sure; but with time, things came back to how they were. I like my work, and it’s in that sense I want to continue” – Eva

“I’m keeping a distance. Let’s say a patient asks me for something in his room, honestly, I’ll think about it twice. And if, when I go in the room to open the drawer, I’m careful when I’m opening it, I’m always looking. Before I would give him my back, now, I try to at least, when I do something, I have view on what he’s doing, of what he’s in the midst of doing” – Henry

“It’s not less interest. It’s, I have less sympathy toward clients. Really, I’m a little bit disillusioned. I don’t know how to say it” – Cecilia

Although it is obvious that WPV has had consequences for some participants, the severity and range of reactions are very diverse from one participant to another. These changes were sometimes persistent other times temporary. By virtue of their jobs, these professionals are required to continue to care for patients, yet for some participants, the quality of their relationship with patients was affected.

4.1.3 Relationship with the organisation

Discussions on the role of the organisation concerning MOW were notably absent from the first interviews (i.e. work before WPV). It seemed that when work went on without any violent incidents employees had little to say about the hospital, but when an assault did occur, suddenly unmet expectations of support led to changes in MOW. Almost half mention changes in their perceptions of management, hospital policies and organizational commitment following WPV. Given that any effort to prevent and handle WPV would require the support of management, they were included in this subsection.

“What changed is my attitude toward my employer. The obvious lack of support [… ] Maybe, the complete lack of interest regarding maybe hospital policies, I don’t know. Because we know it’s hogwash, you know? We’re going to talk about it for a week and after that everything will remain exactly same as before” – Peter

Before, I used to think it was important to get involved in your work, in the decision-making; and now, I don’t find it important anymore. [… ] I have this ‘I-don’t-care’ attitude, like, ‘[… ] do whatever you want, I don’t care’ [… ] If they ask me for my opinion on something, I’ll tell them that I don’t care, that they can do whatever [… ] It’s really like that” – Sylvia

“But no, that’s it, I lost all of my trust in (the organization) and in the (hospital in general) [… ]”, – Cecilia

Trust in and support from the organisations were not explicitly mentioned by the participants as meaningful unless they were perceived to have been violated following an assault in which case half of the sample expressed genuine anger and resentment. Furthermore, based on the declarations of the participants, it could be possible that the impact of WPV can also be indirectly damaging to their organizations in many ways. For example, a few participants discussed making changes to their jobs in the form of reduced availability for overtime, reassigned responsibilities or worst, turnover intention.

“I stopped working overtime, I think last April. Well of course I did some at (name of ward) [… ] but now, I don’t want to do more, its part of my requests to doctors, to avoid overtime.” – Cecilia

“The thing that changed is that I realized even more, or it just confirmed to me, it accelerated the fact that I should maybe leave.” – Maeve

One participant changed careers following an act of WPV. She was an orderly when she was attacked, but then decided to revert back to her previous position as a janitor (she still works at the same hospital). During the second interview, she admitted to not liking janitorial work, finding it less interesting but also inoffensive. When probed she explained:

“I don’t have the same responsibilities, if someone is sleeping or they don’t want me to come into their room, well I’ll just go to the next one, and that’s it. I don’t need to argue [… ] we do the common areas, we do the bathrooms, and we don’t do anything that entails big risks.” – Katy

Reflecting on her career, this participant mentioned being particularly drawn to the challenge of working as a medical orderly. Experiencing an act of violence dampened her enthusiasm for the job, and consequently she switched careers; a tangible change for both her and her employer. From the discourse of participants, it seems that experiencing WPV can have an influence on how employees view their place in the organization. Again, these changes varied greatly in intensity from one participant to another and they were only discussed by half of the sample.

4.2 MOW, self and WPV: Self-accomplishment, contribution and autonomy

The relationship between the self and employment is complicated and multifaceted. Employees contribute their time and talent in return for financial compensation and less tangible forms of compensations such as for an opportunity to feel fulfilled or to have an impact. During the interviews, participants shared their impression of their work and also disclosed which aspects were meaningful to them. Judging from the interviews, it these employees might find meaning in self-accomplishment, autonomy, and contribution.

4.2.1 Self-accomplishment

All participants expressed that they found enjoyment in various aspects of their work. Aspects related to personal ambition, overcoming challenges and living with the satisfaction of work well done were found to be especially enjoyable by many participants. These experiences were labelled as examples of ‘seeking self-accomplishment’, some of which are described below.

“When I leave at night, I like having the satisfaction of having done my job, that’s what allows me to come home and move on to something else” – Dorothy

“The most important part of my work is the satisfaction of having accomplished my work. That I did everything possible to, even of a short period, offer my help to the person, that’s all I think about” – Henry

“(My job) was invigorating. You could see that the patients were motivated, they had life goals. We would do our interventions, they would leave. They would go on and live, we would do follow ups. [… ] Working is stimulating.” – Catherine

For many, being the victim of WPV did not seem to have interfered with their ability to enjoy their work. They still enjoyed seeking out and overcoming challenges and found satisfaction in doing so. This reality however, is not common to all participants. Some stories highlight the potential for WPV to have serious consequences on the ability of victims to continue to enjoy their work. In this study, some participants were unable to derive the same satisfaction following an act of violence:

“My job used to be very dynamic, it was changing, I think we had innovative approaches, working in teams, the fact that I used to learn a lot [… ] I’m a lot less invested at work in general; I come to do my work that’s all. I complete the tasks but before I used to take it to heart a lot, I was super involved, passionate. Not now, not at all. [… ]I come to work, I provide care, and even sometimes I tell myself ‘Cecilia, you have to … ’ you know? I don’t give bad care but I tell myself I have to get into it. [… ] I do what I have to do but not much more” – Cecilia

“You realize your potential, in your professional life or in your personal life. Often you strike a balance between to two, it’s not easy. Me, I decided that I only wanted to find fulfillment when it comes to family right now” – Katy

The stories of Katy and Cecilia are especially telling. Both mentioned having been originally drawn to their respective careers because they enjoyed the challenge, but after having experienced violence from a patient, Katy found a ‘safer’ position and consequently gave up on the idea of finding self-fulfillment at work. Cecilia kept working as a nurse but shared that she no longer enjoyed her job and performed tasks in a very mechanical fashion. Both are still working, but they are finding it increasingly difficult to achieve self-accomplishment through their respective career.

4.2.2 Contribution

By the very nature of their employment, people who work clinically in the fields of healthcare and social services aim to improve the wellbeing of patients. The participants in this study cared deeply about their patients and expressed at length how important it was for them on a personal level to see their patients prosper. This sub-theme is about more than the importance of patient/professional relationship described previously; it is about the fundamental beliefs and motivations behind patient care and the personal satisfaction derived from the feeling of practicing a profession that brings about social change. As nearly all participants explained, through their work, they have found a way to contribute not only to their patients, but also to others and society in general.

“I feel really useful; I like it, to see my clients in the community. So we follow clients into the community. No, as a matter of fact, I am very proud, happy to have made that choice [… ] we go in their homes, we go see them, we go visit them at their place. I’m a part of the team that helps progress, helps them stay in the community, that helps them become independent citizens, that’s what I’m doing right now” – Catherine

“I had the impression I was making a difference in the lives of the people I was working with, of my patients” – Katy

“I think there’s beautiful care to give, there are beautiful things happening, in a sense, it’s exciting to see people arriving completely disorganized, and then quickly, in a few days, the person falls back on their two feet, and we offer them services” – Stephen

In the context of this study, no participant reported changes in this aspect of their work; they still valued the idea of patient care (even if some of them still practiced in fear) and strongly believed that their profession made an important contribution to people’s lives (even if their heart was less into it). No one openly wished harm to their violent patients during the interviews. They still expressed pride in their work and insisted on the importance of their contribution to patients’ wellbeing. Despite having been the victim of violence, all participants still believe their work had a real impact. The desire to contribute to people’s welfare and pursue social change might be a source of resilience in the face of WPV that offers positive MOW.

4.2.3 Autonomy

One of the most obvious benefits of working is financial compensation. Interestingly, despite having chosen a career path most often described as a “vocation”, when asked, all participants shared the importance of receiving a salary for their efforts, not only as a form of compensation but also in terms of what a salary actually means to them: autonomy.

“But without work, you can’t do anything. Work is freedom. It’s autonomy. Yes, I have a gratifying job, yes we have a salary in return but it’s because of work that we get to live, it’s because of work that we get to pay everything. I think the dignity of Man is to be able to pay for everything, to be able to take care of my family “ – Henry

The independence and autonomy work provides remained important themes throughout the participants’ narrative (i.e. before and after the act of violence). Two of the participants (Stephen and Henry) even suggested that they had started valuing this aspect of his work even more. Both found increased positive meaning in being a provider following an act of violence:

“I changed my way of doing things when it comes to my role as a nurse. I tell myself no, I’m going to fall back on my role as a provider, a form of resignation if you want” – Stephen

The story of Stephen is interesting. Disappointed by the hospital’s lack of an appropriate response regarding his experience and other factors, and still suffering from symptoms indicative of trauma(i.e. hypervigilance), Stephen decided to fall back on his role as a provider. This central aspect of work, therefore, became even more important in his eyes after experiencing WPV. This citation was isolated in this section because Stephen specifically refers to his ability to provide for himself and his family as a source of meaning and not just as a lost opportunity for self-accomplishment.

Despite being in a line of work normally associated with being a vocation, all participants talked at length about the importance of their salary. Participants enjoyed the autonomy it provided them (covering their basic needs, financing leisure, supporting a family, etc.). It is noteworthy that in the light of changing MOW, the positive attribution associated with autonomy and independence did not lose in significance. This might be another source of resilience for workers victim of WPV.

5 Discussion

This study attempted to provide a description of MOW in people who have been victims of WPV. The architecture of findings consists of two large themes (relationships with others and the self) comprising three sub-themes each: 1) MOW and others: relationships with colleagues, patients and the organisation; 2) MOW and the self: self-accomplishment, contribution, and autonomy. To the researchers’ knowledge, this is the first study to have specifically explored the impact of violence from patients on the meaning of work in healthcare professionals. With regards to changes in MOW, often time changes occurred in varying degrees, from the most subtle forms (e.g. a temporary period of uncertainty) to the most severe forms (e.g. desire to change jobs). In some cases, changes did not occur at all and specific aspects of MOW continued to provide positive meaning (i.e. autonomy, and contribution). In any case, the findings coupled with the dearth of literature on the subject warrant further investigation into the changing nature of MOW in people who have experienced WPV.

The present study adds to the literature on MOW by supporting findings on the importance of others in the sense making process [39]. The current findings on the changing perceptions of patients following an act of WPV are in agreement with most of the literature on this topic [6, 20]. With regards to relationships with colleagues, in this study, colleagues were not cited as a source of support following an act of violence, a fact that had previously been documented by others [21]. This is somewhat surprising given the importance placed on relationships with colleagues. Some workers admitted trusting their colleagues a little bit less following an act of WPV. In fact, nearly all of the workers who reported changes in their relationship with colleagues explained that their coworkers hid behind the nursing station instead of rushing to help them when they were assaulted. This is unfortunate since it could cancel out two known protective factors in the context of workplace violence: the possibility of receiving positive support from colleagues which could alleviate common symptoms associated with WPV [21] and the feeling of safety that comes with working as part of a team and acts as a buffer against fear of future victimization [40].

Results from other studies suggest that support from superiors and the organization plays a unique and special role in the adaptation of workers following an act of client violence [40]. Yet in this case, the organisation did not seem to offer much positive meaning before the act of violence but became a source of negative meaning shortly thereafter for half the sample. Although this may seem contradictory at first glance; in essence, the participants confirmed the premises of Organisational Support Theory (OST) which posits that employees and organisations engage in a psychological contract which “reflects employees’ beliefs about their social exchange relationships with their organization, mutual obligations, and the extent to which these obligations are fulfilled. The obligations could be based on explicit promises made by the organization or implicit expectations held by employees [emphasis added] [41].” According to OST, a breach of contract (i.e. when employees feel the organizations did not meet their implicit expectations) has a greater impact on employee’s perceived organizational support than when the contract is honored. And so, organizational support could be very influential in the adaptation of healthcare workers before and after an assault, as other studies have shown [40]; however, employees in this study preferred discussing their dashed expectations rather than their implicit expectations being met. Perhaps these sections could have been explored more during the interviews. In all, close to half of all workers in this study reported feelings similar to being abandoned by the organisation. This feeling was also reported in other studies [20]. Losing trust in colleagues and the organisation and feeling isolated could be important mechanisms underlying the increased likelihood of turnover intentions following an act of violence.

Furthermore, with regards to the self, Tzafrir, Enosh and Gur [31] and MacIntosh and colleagues [21] both identified changes in values following an act of WPV. Their study suggests a process of re-evaluation of professional values and changes in practice, whereas the current study did not report such important changes. This study identified both variability with regards to the nature and degree of change of specific work values (e.g. self-accomplishment), but also stability with regards to other work values (i.e. autonomy, contribution). In present study, not all workers experienced changes in MOW following an act of violence, and in those that did, the changes did not appear to follow specific patterns that could be indicative of a more “global process of changes in work values”[31]. The reason for these different findings is unclear; perhaps the workers in this study had less latitude in their practice than the participants in those two studies, or maybe the workers in Tzafrir and colleagues’ study had greater faith in their client’s ability to respond differently to their new value-driven work practices (i.e. child welfare clients vs. psychiatric patients) [31]. In any case, the study of work values following WPV is complex yet crucial to understand why workers return to work after being assaulted.

On a related point, the sub-themes ‘autonomy’ and ‘contribution’ might be important sources of resilience for these workers. With regards to the feeling of contribution, studies on the concept of ‘vocation’ (which applies to the workers in this study) have demonstrated that infusing work with prosocial values contributes positively to wellbeing especially when MOW ‘fits’ with the meaning in life [42, 43]. This could explain why workers in this study chose to return to work after being assaulted. As for the focus on autonomy, the participants in this study seem to derive sufficient positive meaning from this aspect to remain at work. Perhaps this is because in the light of reduced work satisfaction some participants can use their salary to find meaning in other aspects of their lives (caring for a family etc.) or perhaps, the pride that comes with being able to provide for oneself and one’s family is a good enough reason to stay at work even when faced with the risk of violence. Regardless, more studies are needed to corroborate why and how these two potential sources of resilience could and should be harnessed to inform work rehabilitation programs. There is an increasing number of studies on resilience factors in people victim of bullying at work [16, 21] but comparatively few studies have been able to identify sources of resilience amongst victims of WPV [44] and patient aggression in particular. The current study highlights not only the existence of factors of resilience amongst these people but also provides interesting starting points for future research.

Similarly, MacIntosh and colleagues [21] concluded that changes in MOW leads to less commitment on behalf of workers toward the organisation. The association between MOW and commitment at work has also been reported in numerous quantitative studies [24 –27]. This study supports their findings; some workers did share feelings and impressions that could be indicative of lowering organisational commitment. More specifically, after an act of WPV some workers experienced changes in their pursuit of self-accomplishment at work, their relationships with colleagues and the organisation all of which are closely related to the concept of organisational commitment. The current study however, documents this process differently by isolating specific aspects of MOW. Lastly, this study demonstrated that changes in MOW are not unequivocal. Some participants identified negative changes in the way they extract meaning from work but were still able to identify positive MOW with regards to other specific aspects, such as relationships with colleagues for example.

Finally, one consequence of WPV, the concept of compassion fatigue, is generating increasing interest in the literature [45]. Studying MOW could help inform the process through which compassion fatigue sets in and develops over time. Even when they are not victims of violence, healthcare workers are at high risk of experiencing compassion fatigue [46]; research indicates that working with dying and suffering patients can take its toll on the wellbeing of nurses [47]. It is possible that patient aggression only accelerates this process through a loss of positive meaning regarding relationships with others and the self. For example, one of the most widely used instruments to measure compassion fatigue includes items related to the themes discussed in this article (e.g. “I get satisfaction from being able to help people”, “I feel connected to others”, “I believe I can make a difference through my work”, “I have beliefs that sustain me”) [48]. As this study shows, after an act of violence, suddenly providing care to patients could bring about constant feelings of anxiety and fear but also increasing apathy (i.e. symptoms related to compassion fatigue). In addition, as this study shows, changes in MOW could result in more strenuous relationships with colleagues. Yet, supportive relationships at work and supervision have been shown to prevent compassion fatigue in healthcare workers [49]; this could render these workers even more vulnerable. The association however remains speculative; the possibility of MOW acting as a mediator between experiencing aggression and compassion fatigue should to be empirically tested. Nevertheless, changes in meaning could be an important indicator of more serious consequences to come such as compassion fatigue, loss in job satisfaction and turnover.

5.1 Limitations

Despite its contributions and strengths, this study also has several limitations. First, this study limited its recruitment efforts to people who were victims of violence and who were still working at the same hospital, thereby excluding people who had actually changed jobs and arguably had experienced more drastic changes in MOW. Interviewing participants who had left the hospital following an act of violence could have offered different experiences and consequently different results (e.g. perhaps a loss of faith in their ability to contribute to others). The authors suspect that the relative homogeneity of the sample could also explain the near perfect thematic saturation that would have been obtained had it been a goal of the study. Second, MOW is a confusing construct even for researchers [23]. Several participants spontaneously expressed that they did not understand the terms ‘work values’ and how they were different from MOW. The interviewer offered additional information when necessary, but the impact of being interviewed on a complex subject cannot be overlooked. For this reason, problems with social desirability cannot be excluded. In the end, however, the final product was rich and informative despite the occasional terminological and temporal hesitations. The interviews offered more than enough material to meet the objectives of this study.

5.2 Future directions

Future studies should consider evaluating the potential influence of MOW with regards to the psychological and organizational impacts of WPV. Identifying key aspects of MOW that could function as potential indicators of compassion fatigue, more serious consequences, or even as markers of resilience could be especially useful to inform services currently being offered to people who are victims of workplace violence. Future studies could also aim to document the experiences of workers who have changed career paths following an act of WPV; their impression of patient aggression and their changing views regarding their profession could enlighten the study of MOW.

Conflict of interest

The authors have no conflict of interest to report.

Footnotes

Acknowledgments

The authors would like to extend their gratitude to Valérie Billette, Catherine Otis, Brooke Verville and Nathalie Lanctôt.

References

Hartley

, Doman

, Hendricks

, Jenkins

. Non-fatal workplace violence injuries in the United States 2003–2004: A follow back study. Work 2012;42(1):125–35.

Foley

, Rauser

. Evaluating progress in reducing workplace violence: Trends in Washington State workers’ compensation claims rates, 1997–2007. Work 2012;42(1):67–81.

Piquero

, Piquero

, Craig

, Clipper

. Assessing research on workplace violence, 2000–2012. Aggression and Violent Behavior 2013;18(3):383–94.

Chen

, Hwu

, Kung

, Chiu

, Wang

. Prevalence and determinants of workplace violence of health care workers in a psychiatric hospital in Taiwan. Journal of Occupational Health 2008;50(3):288–93.

Ridenour

, Lanza

, Hendricks

, Hartley

, Rierdan

, Zeiss

, Amandus

. Incidence and risk factors of workplace violence on psychiatric staff. Work 2015;51(1):19–28.

Lanctôt

, Guay

. The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggression and Violent Behavior 2014;19(5):492–501.

Gerberich

, Church

, McGovern

, Hansen

, Nachreiner

, Geisser

, Ryan

, Mongin

, Watt

. An epidemiological study of the magnitude and consequences of work related violence: The Minnesota Nurses’ Study. Occupational and Environmental Medicine 2004;61(6):495–503.

Wrzesniewski

, LoBuglio

, Dutton

, Berg

. Job crafting and cultivating positive meaning and identity in work. Advances in Positive Organizational Psychology 2013;1(1):281–302.

Pompeii

, Dement

, Schoenfisch

, Lavery

, Souder

, Smith

, Lipscomb

. Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (Type II) on hospital workers: A review of the literature and existing occupational injury data. Journal of Safety Research 2013;44:57–64.

10.

Alameddine

, Kazzi

, El-Jardali

, Dimassi

, Maalouf

. Occupational violence at Lebanese emergency departments: Prevalence, characteristics and associated factors. Journal of Occupational Health 2011;53(6):455–64.

11.

Heponiemi

, Kouvonen

, Virtanen

, Vänskä

, Elovainio

. The prospective effects of workplace violence on physicians’ job satisfaction and turnover intentions: The buffering effect of job control. BMC Health Services Research 2014;14(1):1.

12.

Johnson

, Rea

. Workplace bullying: Concerns for nurse leaders. Journal of Nursing Administration 2009;39(2):84–90.

13.

Magnavita

, Heponiemi

. Workplace violence against nursing students and nurses: An Italian experience. Journal of Nursing Scholarship 2011;43(2):203–10.

14.

Schat

, Frone

. Exposure to psychological aggression at work and job performance: The mediating role of job attitudes and personal health. Work & Stress 2011;25(1):23–40.

15.

Aquino

, Thau

. Workplace victimization: Aggression from the target’s perspective. Annual Review of Psychology 2009;60:717–41.

16.

Laschinger

, Grau

. The influence of personal dispositional factors and organizational resources on workplace violence, burnout, and health outcomes in new graduate nurses: A cross-sectional study. International Journal of Nursing Studies 2012;49(3):282–91.

17.

AbuAlRub

, Al-Asmar

. Physical violence in the workplace among Jordanian hospital nurses. Journal of Transcultural Nursing 2011;22(2):157–65.

18.

Fujishiro

, Gee

, De Castro

. Associations of workplace aggression with work-related well-being among nurses in the Philippines. American Journal of Public Health 2011;101(5):861–7.

19.

Roche

, Diers

, Duffield

, Catling-Paull

. Violence toward nurses, the work environment, and patient outcomes. Journal of Nursing Scholarship 2010;42(1):13–22.

20.

Needham

, Abderhalden

, Halfens

, Fischer

, Dassen

. Non-somatic effects of patient aggression on nurses: A systematic review. Journal of Advanced Nursing 2005;49(3):283–96.

21.

MacIntosh

, Wuest

, Gray

, Cronkhite

. Workplace bullying in health care affects the meaning of work. Qualitative Health Research 2010;20(8):1128–41.

22.

Pratt

, Rockmann

, Kaufmann

. Constructing professional identity: The role of work and identity learning cycles in the customization of identity among medical residents. Academy of Management Journal 2006;49(2):235–62.

23.

Rosso

, Dekas

, Wrzesniewski

. On the meaning of work: A theoretical integration and review. Research in Organizational Behavior 2010;30:91–127.

24.

Wrzesniewski

. Finding positive meaning in work. In Cameron

K.S.

, Dutton

J.E.

, & Quinn

R.E.

(Eds.), Positive Organizational Scholarship. San Francisco: Berrett-Koehler. 2003;296–308.

25.

Chandler

, Kapelner

. Breaking monotony with meaning: Motivation in crowdsourcing markets. Journal of Economic Behavior & Organization 2013;90:123–33.

26.

Ghadi

, Fernando

, Caputi

. Transformational leadership and work engagement: The mediating effect of meaning in work. Leadership and Organization Development Journal 2013;34(6):532–50.

27.

May

, Gilson

, Harter

. The psychological conditions of meaningfulness, safety and availability and the engagement of the human spirit at work. Journal of Occupational and Organizational Psychology 2004;77(1):11–37.

28.

Pratt

, Ashforth

. Fostering meaningfulness in working and at work. In Cameron

K.S.

, Dutton

J.E.

, & Quinn

R.E.

(Eds.), Positive Organizational Scholarship. San Francisco: Berrett-Koehler 2003;309–27.

29.

Wrzesniewski

, McCauley

, Rozin

, Schwartz

. Jobs, careers, and callings: People’s relations to their work. Journal of Research in Personality 1997;31(1):21–33.

30.

Ariely

, Kamenica

, Prelec

. Man’s search for meaning: The case of Legos. Journal of Economic Behavior & Organization 2008;67(3):671–7.

31.

Tzafrir

, Enosh

, Gur

. Client aggression and the disenchantment process among Israeli social workers: Realizing the gap. Qualitative Social Work 2013;14(1):65–85.

32.

Creswell

. Qualitative inquiry and research design: Choosing among five approaches. Sage 2012.

33.

Padgett

. Qualitative methods in social work research. Sage 2008.

34.

Starks

, Trinidad

. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research 2007;17(10):1372–80.

35.

Giorgi

. De la méthode phénoménologique utilisée comme mode de recherche qualitative en sciences humaines: Théorie, pratique et évaluation. La Recherche Qualitative: Enjeux Épistémologiques et Méthodologiques 1997;341–64.

36.

Carlsen

, Glenton

. What about N? A methodological study of sample-size reporting in focus group studies. BMC Medical Research Methodology 2011;11(1):1.

37.

O’Reilly

, Parker

. ‘Unsatisfactory Saturation’: A critical exploration of the notion of saturated sample sizes in qualitative research. Qualitative Research 2012;1468794112446106.

38.

Malterud

. Systematic text condensation: A strategy for qualitative analysis. Scandinavian Journal of Public Health 2012;40(8):795–805.

39.

Wrzesniewski

, Dutton

, Debebe

. Interpersonal sensemaking and the meaning of work. Research in Organizational Behavior 2003;25:93–135.

40.

Harris

, Leather

. Levels and consequences of exposure to service user violence: Evidence from a sample of UK social care staff. British Journal of Social Work 2011;42(5):851–869. doi: 10.1093/bjsw/bcr128

41.

Kurtessis

, Eisenberger

, Ford

, Buffardi

, Stewart

, Adis

. Perceived organizational support a meta-analytic evaluation of organizational support theory. Journal of Management 2015;41:1–31.

42.

Dik

, Duffy

. Calling and vocation at work definitions and prospects for research and practice. The Counseling Psychologist 2009;37(3):424–50.

43.

Dik

, Duffy

, Eldridge

. Calling and vocation in career counseling: Recommendations for promoting meaningful work. Professional Psychology: Research and Practice 2009;40(6):625.

44.

Enosh

, Tzafrir

, Gur

. Client aggression toward social workers and social services in Israel— A qualitative analysis. Journal of Interpersonal Violence 2013;28(6):1123–42.

45.

Elwood

, Mott

, Lohr

, Galovski

. Secondary trauma symptoms in clinicians: A critical review of the construct, specificity, and implications for trauma-focused treatment. Clinical Psychology Review 2011;31(1):25–36.

46.

Mangoulia

, Koukia

, Alevizopoulos

, Fildissis

, Katostaras

. Prevalence of secondary traumatic stress among psychiatric nurses in Greece. Archives of Psychiatric Nursing 2015;29(5):333–8.

47.

Sabo

. Reflecting on the concept of compassion fatigue. Online Journal of Issues in Nursing 2011;16(1), Manuscript 1.

48.

Stamm

. The concise ProQOL manual. Pocatello, ID: ProQOL. org. 2010.

49.

Ray

, Wong

, White

, Heaslip

. Compassion satisfaction, compassion fatigue, work life conditions, and burnout among frontline mental health care professionals. Traumatology 2013;19(4):255.