Evaluation of general health,exposure to workplace violence,and predicting its consequences in health care employees in Iran

1 Introduction

The assessment of workplace violence in working environments is a global concern. Researchers have proposed various theories and models to define and cause violence. However, in any case, all studies and sources cover a range of behaviors, from verbal abuse to physical assault [1]. According to the definition of the Department of Occupational Health and Safety, violence in the workplace is any behavior or threat of physical injury, harassment, intimidation, or other destructive, threatening behavior in the workplace [2]. The World Health Organization (WHO) also considers occupational violence to be the deliberate use of physical force against oneself, another person, or against a group or community that results in injury, death, trauma, and depression to the victim [3].

Violence in the workplace is a harmful occupational factor that is considered a warning for mental health and includes such things as harassment, beatings, racial insults, and sexual assault [1]. Violence also includes a range of intentional acts of physical, mental, emotional, and verbal violence that hurt a person’s physical and psychological health [4]. Psychological violence is defined as the deliberate use of power, including the threat of physical force against another person or group that could cause physical, psychological, spiritual, moral, or social harm. Psychological violence consists of verbal violence (insults), coercion, bullying, harassment, and threats [5]. Physical violence also includes injuring a person by e.g. hitting, cutting, kicking and slapping [6].

Workplace violence (WPV) is usually categorized into four types based on the perpetrator’s relationship with the abused person. The first type of violence is common in healthcare workers (HCWs), including nurses, paramedics, and physicians [7, 8]. The second type involves criminal activities such as robbery committed by an offender who has no direct connection to the workplace. The third type includes cases in which the client is abused in the workplace, such as the patient being abused by healthcare workers (HCWs). The Fourth type includes co-workers’ violence against each other, and the fourth type is violence inflicted by the client on employees and service providers [2].

Nurses and paramedics are in close contact with patients and their families, resulting in countless interactions that expose them to violent incidents [9]. HCWs exposed to violence experience increased stress and decreased job satisfaction, with adverse long-term health consequences [10]. In addition to increasing negative emotions and physical and psychological effects, violence reduces nurses’ quality of care and work ethic [11, 12]. In a longitudinal study, Magnavita found that WPV and work-related distress were interrelated [13]. Nurses who suffered from violence in the workplace were under much stress. High workloads increase interpersonal conflict and decrease efficiency and teamwork, which may predict the occurrence of non-physical violence in the future [14].

Exposure to violence has been associated with adverse health effects on HCWs, such as anxiety, depression, insomnia, stress-related disorders, and loss of self-esteem [15, 16]. Moreover, suicidal ideation [17], irritability, aggression, and psychotropic substance abuse can negatively affect the quality of healthcare services provided by traumatized HCWs [15]. As a result of their work performance, nurses experience psychosocial conditions such as high levels of stress, anxiety, and fatigue, mainly due to the nature and location of the job [18, 19]. These unfavorable psychosocial conditions are also related to reduced quality of life at the level of perceived health. It is also associated with increased absenteeism as well as cardiovascular, musculoskeletal, and mental healthdisorders [20].

Studies have revealed that HCWs who have experienced violence in the workplace have more burnout and less job satisfaction, which increases the desire to leave the job [21, 22]. Burnout is an emotional experience that represents a long-term response to interpersonal stressors in the workplace [23], and reflects a person’s psychological reaction to specific work-related events [24]. Burnout has been noted among hospital HCWs due to its high prevalence [25]. Previous studies has demonstrated that the rate of burnout among people working in the healthcare sector in Iran is usually reported to be moderate to high, and it is generally believed that the risk of burnout in HCWs is higher than compared to other employees [26–28].

In the nursing team, high rates of burnout cause more musculoskeletal disorders, occupational injuries, absenteeism, job dissatisfaction, and abuse of alcohol and other drugs [29]. In addition, it hurts the quality of care received by patients and the mental health of nurses, which can lead to depression, anxiety, low self-esteem, etc. [30]. Previous researchers have suggested that high levels of burnout in nurses can contribute to increased psychological distress and reduced job productivity [23, 24]. It can be said that productivity is a combination of efficiency and effectiveness, which includes achieving the organization’s goals, reducing costs, providing high-quality services, and reducing absenteeism [31]. In other words, the high level of clinical productivity of nurses ensures the achievement of hospital goals, improves the effectiveness of nursing care, and reduces absenteeism [32].

Therefore, due to the lack of similar studies, the importance of this issue among HCWs, and also considering the high impact of occupational violence on burnout, general health, and employee productivity, especially in medical settings as a highly interactive, challenging, and stressful work environment, this study examined general health, occupational violence, and its relationship with burnout and job productivity among nurses and paramedics in medical settings.

2 Method

3 Results

4 Discussion

According to the present study’s findings, the GHQ-12 score was higher than the cut-off point for about one-third of the studied participants (34.1%). This finding indicates that psychological distress is almost common among this group of healthcare professionals and is generally consistent with results reported in other countries. Su et al. reported a 42% prevalence of psychiatric disorders among Taiwanese nurses [44]. A study of Spanish nurses reported a rate of mental illness of 41.1% [45]. Another study in Spain reported that 32.3% of participants suffered from psychiatric disorders [46]. Findings show that in the general population of Iran, about 21% of the population suffers from mental disorders such as depression and anxiety [47]. This fact suggests that Iranian nurses may be at greater risk of mental health than the general Iranian population. In addition, some variables can increase this risk, such as having a low work commitment, and working in a high-stress environment, which also reveals a direct link between the nature of the job and the lives of others.

Rahmani et al., in their study among hospital staff in Iran, reported that some jobs, such as anesthesiologists and operating room staff, experienced high job stress and had less job satisfaction [28]. In another study, Rahmani et al. showed that the burnout rate among medical staff is high, especially during the COVID-19 pandemic. This issue requires the implementation of control measures as soon as possible [26].

In the present study, 74.5% of the nurses and paramedics experienced one type of violence in their workplace at least once during the last year. This is in line with a study conducted in China [48]. In the study conducted among Turkish nurses, Thales et al. Concluded that 85.2% of the study participants were exposed to at least one type of violence, that 41.1% were physically violent [49].

Men obtained lower mental health scores than women and nurses compared to paramedics who experienced higher levels of violence, which is confirmed by the results of predicting the prevalence of occupational violence among HCWs based on mental health scores. According to the regression results, by fixing other variables, general health had the most direct and significant relationship with the prevalence of physical violence among male nurses (β= 0.421) and verbal violence among male paramedics (β= 0.356). The most important reason for the higher prevalence of violence among nurses than paramedics, in addition to their mental health status, is the more direct exposure of these people to patients and their companions. According to the research findings, physical and verbal conflicts with the patient’s relatives are the most crucial factor in violence in HCWs. The studied nurses expressed the concern of the patient’s relatives about their patient’s health condition, which increases their anxiety, stress, and irritability as one of the reasons for the increase in the prevalence of violence. Another reason cited by HCWs that can contribute to the prevalence of violence is the large number of patients compared to the number of caregivers. The high volume of patients in hospitals may help to create tension between patients and HCWs because HCWs may not provide proper services due to time constraints [1]. The findings also demonstrate that insufficient skills of HCWs that provoke patients and their companions can be critical factors in increasing the prevalence of violence in medical settings [48].

Examination of the burnout results displayed a significant and direct relationship between increasing levels of burnout in nurses and paramedics with experience of verbal violence. The extent of this relationship in men’s emotional burnout, depersonalized burnout, and personal accomplishment in women is equal to β= 0.442, β= 0.341, and β= 0.340, respectively. The present study’s findings explained that the burnout rate among HCWs was moderate, which can be attributed to job insecurity, limited job opportunities, injustice, lack of incentive policies for nurses, lack of nursing staff, hard work, frequent night shifts, and sleep problems. Higher levels of burnout were associated with lower quality of patient care. This relationship between burnout and poor care is manifested by changes in behavior and mood [50].

The present study’s findings demonstrated that nurses experience high job stress due to their job characteristics and work environment conditions. Job stress, in turn, leads to burnout. Researchers have shown that nurses who have experienced violence in the workplace have more burnout and more negative attitudes toward work, including lower job satisfaction and increased dismissal [22]. The researchers also found that high levels of burnout in nurses could contribute to psychological disorders, decreased performance, and job productivity [24].

According to the present study, most of the studied nurses and paramedics reported average job productivity. One way for organizations to reduce staff shortages is to create extensive work shifts. Nowadays, instead of the standard 8-hour shift, HCWs work 10, 12, 16, or more shifts to provide ongoing patient care. The study of job productivity showed a significant and inverse relationship in reducing productivity in nurses and nurses with experience of verbal violence. The rate of this relationship in men and women is equal (β= –0.424 and β= –0.293, respectively). There is no doubt that a change in the traditional 8 hours increases employee fatigue, health care errors, decreased alertness, and ultimately reduced productivity [51]. The present study indicated that men were more exposed to violence than women. Similar to this study, in another study of clinical staff exposure to occupational violence, women experienced less physical violence than men [52]. In contrast, a study conducted in Australia shows that female nurses are the most victims of violence. [53]. This discrepancy can be more respect for women’s privacy in the culture of the Iranian people.

According to our results, there was no significant relationship between age and occupational violence, which is consistent with the results of the Aghili Nejad study [54]. No significant relationship was found between marital status and occupational violence. In the study of Rodriguez et al., no significant association was found between marriage and violence [55].

Also, this study found no significant relationship between body mass index (BMI) and occupational violence. The purpose of using BMI in this study was to reject or accept the hypothesis that people who are overweight and do not look very fit are more exposed to occupational and psychological violence. However, the results did not show a significant relationship between BMI and being overweight with violence. In line with the results of this study, in a cross-sectional study conducted by Chadaga et al. to examine violence among graduates of the US medical education system, they found no statistically significant relationship between different BMI groups and the risk of violence [56].

The type of hospital ward as a place of service for nurses and paramedics is also an important factor. Occupational violence is more prevalent among nurses and paramedics working in the emergency, intensive care, and inpatient wards. Violence in the workplace can also contribute to burnout through psychological trauma and insecurity. These results suggest that job planning and the type of workplace can be considered key points in planning interventions to reduce occupational violence. In the mountain study et al., A significant relationship was found between the working part of the study participants and the amount of psychological violence they faced. Mental and physical violence was significantly higher than in emergency and psychiatric wards [54].

Among the strengths of the study are the simultaneous investigation of occupational violence, burnout, and job productivity, as well as the relationship between these factors and their relationship with the general health status of HCWs, the participation of a relatively considerable number of nurses, and paramedics in the study and noted burnout with their subscales.

According to OSHA guidelines for the prevention of violence in the workplace for health and social workers, hospitals must have a written plan to prevent violence in the workplace as part of their overall health and safety plan, which includes components such as management commitment and employee participation, workplace analysis, risk prevention and control, safety and health education, and record-keeping and program evaluation. It is essential to have a comprehensive medical and psychological counseling program and policies that ensure incident reporting, recording, and monitoring [57]. Kumari et al. presented that techniques to mitigate violent outbreaks could be helpful to healthcare specialists and administrators in their endeavors to create safer workplaces in the healthcare environments [58].

Educating all staff on violence prevention in the workplace is essential to ensure they are aware of potential hazards and protect themselves and their colleagues. These domains of training should include methods of de-escalation, behavior management and how to prevent an attack, training of crisis prevention interventions (CPI) on behaviors that can lead to crisis, effective response to behaviors that prevent aggravation of the situation, use of verbal and non-verbal techniques to prevent the spread of hostile behaviors and to cope with individual fears.

Considering the adverse effects of burnout on nurses’ job performance and quality of care, strategies for its prevention and management are needed. A key strategy in this area is establishing a valid and reliable measure of burnout screening among nurses. In addition, the possibility of managerial and organizational improvements can help prevent and manage burnout. Items such as attracting more nurses to reduce staff shortages and reduce the workload of nurses, allocating funds for timely payment of salaries, providing recreational facilities, in-service training programs on various aspects of the job, interpersonal communication and stress management, improving physician-nurse relationships, promoting nurses ‘job independence, defining the role of nurses’ professions, and promoting managerial and organizational support for HCWs can be effective in reducing burnout and increasing the productivity of nurses and paramedics as people at the forefront of medical settings.

One of the limitations of this study is the adoption of a retrospective self-reporting approach in data collection so that data can be associated with recall bias. In addition, the study may have underestimated the prevalence of violence in the workplace because it did not include sexual and racial violence. Also, due to time and economic constraints, we could not conduct interventional studies in this research, so it is suggested that researchers perform interventional and prospective cohort studies in the future and report the effectiveness of the measures taken.

Finally, the present study suggests further research to examine the hospital’s internal culture of WPV and its effects.

5 Conclusion

This study revealed that exposure to violence among nurses and paramedics is high. Exposure to such violence increases the risk of mental disorders among HCWs. Given the critical nature of clinical decisions made in treatment settings and the interactions between nurses, paramedics, and patients, the potential negative impact on staff mental health is significant. Therefore, interventions are needed to effectively manage violent incidents in the workplace to reduce the risk of mental illness in HCWs. Finally, more studies are required in order to improve the understanding of violence in the workplace and its harmful consequences in the health sector.