Verbal violence and work engagement in Chinese tertiary public hospitals and related factors

In this study, 43.5% of healthcare workers in Chinese tertiary public hospitals experienced verbal violence from patients during the past year, and accounted for 39.2% after excluding individuals subjected to physical and sexual violence during the past year, nearly half of the victims deserve our attention. Healthcare workers commonly experience verbal violence in hospitals due to inadequate attention and intervention by healthcare professionals or even hospital administrators. Other studies have also suggested that tertiary public hospitals can generally handle more complex cases, with much higher absolute numbers of doctors and patients, as well as higher morbidity and mortality rates, and therefore higher levels of violence.36 Our results indicate that healthcare workers suffered more abuse than threats during the past year. The results are similar to those found in the literature,37 where verbal abuse was the most frequent form of violence among healthcare workers in hospitals. Furthermore, focusing on the influencing factors of verbal violence to determine which factors affect them the most may help healthcare administrators and policy-makers improve the situation of verbal violence by prioritising the issues that must be addressed. This study shows that healthcare workers' age, education, marital status, profession, workplace, department and years of experience all have a certain impact on exposure to verbal violence.

In this study, healthcare workers of moderate age (31–50 years) and moderate work experience (5–10 years) were most vulnerable to verbal violence. We believe that healthcare workers at this stage have more adequate professional self-confidence and more complete work experience than those aged<30 years, and that bolder and more open verbal communication may trigger direct expressing of patient dissatisfaction. This life stage also included more diverse life pressures; more anxiety means more imperfect communication. In this study, both the low age and low experience groups were the least exposed to verbal violence and a combination of caution and timidity at the beginning of the job, insensitivity to verbal violence situations, vague definitions of verbal violence and fear of adverse consequences of reporting. This combination affected the consequences. Older respondents (>50 years) reported experiencing less verbal violence. Furthermore, older and more experienced healthcare workers gain skills in patient and visitor management and communication, and in reducing confrontational situations. This allows them to defuse cases of verbal violence, but may not be as helpful in avoiding physical incidents.38 This also suggests that verbal violence is more controllable than physical violence, more easily modified by healthcare worker traits and is more likely to be improved by training.

The results showed a positive correlation between the degree of verbal violence and educational level; that is, the higher the educational level of healthcare workers, the more likely they are to suffer from verbal violence. Some studies have reached similar conclusions.39 We speculated the following two reasons: First, this may be a result of patients’ higher expectations from specialists and the handling of more complex cases. Patients often perceive more educated physicians as having better medical competencies and skills. If the results do not meet patient expectations, there is an increased likelihood of verbal violence. Second, to a certain extent, healthcare workers with higher educational level have stronger professional self-confidence, with the improvement of healthcare workers’ common sense and patients’ treatment needs. When facing doubts from patients, being more confident may represent arrogance in the eyes of patients, which in turn leads to patient dissatisfaction. Third, academic qualifications may help healthcare workers have a deeper and more sensitive perception of violence, which is conducive to high-frequency reporting.

Our results further indicated that married healthcare workers were most at risk of verbal violence, which differed from the findings regarding physical violence. We believe that married healthcare workers experience pressure from work, retirement and children’s education. When physiological, safety, love and belonging, respect, self-actualization, and other needs are unmet, an individual will experience anxiety. This anxiety can inspire low morale, a negative work attitude, and a tougher tone, which, in turn, leads to verbal violence.

In other studies, nurses were generally most frequently exposed to workplace violence.40 However, in our study, doctors and medical technicians were most frequently affected by verbal violence. We believe that the most direct reason for this is that the study was conducted in a tertiary public hospital, which deals with more complex cases and has higher morbidity and mortality rates. Diagnosis and medical advice of healthcare workers are particularly important. Too many critical patients, complicated medical channels and cumbersome medical procedures also make medical technicians face more possibilities of violence, which is very different from primary care institutions that provide more basic care, rehabilitation and healthcare.

When examining the places where verbal violence occurred, the frequency of verbal violence in emergencies was the highest, being significantly higher than in the outpatient and inpatient groups. This is because of several factors involved in patient pathology and the organisation and delivery of services.41 42 First, the emergency department is located at the ‘entrance gate’ of all other triage clinics in the hospital and is in a high-pressure environment throughout the day due to the urgency and uncertainty of the disease,43 the complex and diverse categories of triage, noisy working environment,44 and difficulty in meeting standardised medical procedures. Second, emergency patients are mainly characterised by an urgent onset, hidden disease and a high fatality rate. Under such circumstances, mood swings are large, and negative emotions such as irritability, tension and fear are inevitable. Third, in terms of the emergency and multiple characteristics of patients45 in the emergency, healthcare workers who are trained to be ‘more efficient and decisive’ will be more dedicated to their work and will ignore the needs of family members or other patients and slow and harmonious communication. When patient’s negative emotions are more likely to be triggered, and healthcare workers fail to suppress emotions in a more timely and rational manner and ease the relationship, verbal violence is the most used method.

Our findings indicated that healthcare workers in the department of ophthalmology and otorhinolaryngology suffered from verbal violence more frequently than other departments, which was different from the departments with a high incidence of total violence. First, the department of ophthalmology and otorhinolaryngology includes a long history of disease, high difficulty in diagnosis, misunderstandings in the cognition of the disease and poor treatment effects, which can easily cause anxiety in patients. Second, from the perspective of disease characteristics, compared with other body parts, the human facial nerve is sensitive and developed, and even the slightest discomfort has a significant impact. Symptoms such as tinnitus, nasal congestion and foreign body sensation in the throat that accompany the disease can also increase the psychological stress of the patient and lead to emotional changes. Third, in terms of the characteristics of medical practice, some patients have mild illnesses but complain of severe symptoms. This may lead patients to mistakenly believe that the doctor is irresponsible and the treatment is ineffective.46 Furthermore, the majority of patients with such diseases are young and middle-aged, which objectively increases their risk factors and makes them prone to inflicting verbal violence. We intend to convey that the demographic differences in verbal violence differ from those in workplace violence in general, due to the particularity of the verbal violence causes; thus, more research is required.

Our results indicate that the work engagement level of healthcare workers in tertiary public hospitals in China is not high; furthermore, it is lower than that in Japan,47 Brazil48 and Belgium,49 and even lower than that of rural doctors in China.50 Studies have indicated that healthcare workers in public hospitals in China experience more presenteeism,51 are extraordinarily overworked and have lower incomes than their counterparts in Europe and the USA,52 none of which is conducive to their level of work engagement. Thus in China, attention must be paid to the work engagement level of healthcare workers in tertiary public hospitals.

Emotional response of healthcare workers exposed to verbal violence

Emotional response constituted the greatest percentage of symptoms. Among healthcare workers who experienced verbal violence, 61.0% reported severe anger, 90.5% were moderately or severely anger, achieving almost complete coverage of the population; furthermore, 42.7% reported severe disgust, 33.2% reported severe fear, 26.5% reported severe distress and 27.7% said they did not believe such things would happen at all. We believe that anger, disgust, fear and distress are relatively normal physiological reactions, but do not believe that the occurrence of such incidents, contempt for verbal violence and guilt are related to the specific role of healthcare workers. In other studies, anger rates following verbal aggression were higher than those following physical aggression. In Gerberich’s study of American nurses, the emotional consequences of non-physical violence were greater and lasted longer than those of physical violence.53 Simultaneously, studies have shown that individuals who tolerate emotions/symptoms for long periods may be at risk for adverse mental health outcomes, such as acute stress disorder or post-traumatic stress disorder (PTSD).54 Flannery et al’s examination of specific threat events found that some employee victims had PTSD-like symptoms and were disturbed in grasp and meaning, a finding consistent with psychological sequelae, an aftermath of some employees suffering physical and sexual assault.55 While this study assumed negative emotional responses from healthcare workers to verbal violence, it was unexpected that such a strong emotional response from violent healthcare workers; however, this also validates the original intention of this study to encourage attention to verbal violence.

Effects of verbal violence on healthcare workers and emotional exhaustion, job satisfaction and work engagement

The results showed that verbal violence had both direct and indirect effects on job satisfaction and work engagement. Verbal violence not only affects job satisfaction and work engagement directly, but also indirectly, by affecting emotional exhaustion. To the best of our knowledge, this is the first study of the above three indicators on the organisational level.

Judging from the impact of verbal violence on emotional exhaustion. According to the theory of resource conservation,56 after experiencing verbal violence in the workplace, the generation of negative emotions, doubts about the doctor–patient relationship, and concerns about future work lead to the consumption of a large amount of limited psychological energy and resources by individuals, and the consequence of the continuous ‘emotional depletion effect’ is the generation of emotional exhaustion. However, emotional exhaustion of the working state is not conducive to the quality of medical service provision and the patient’s medical experience, so it may further trigger the occurrence of violence. In other words, verbal violence and emotional exhaustion will form a vicious circle.

Considering the impact of verbal violence on job satisfaction, the high incidence of verbal violence and the more direct transmission method will make the healthcare workers feel that they are being in a negative working environment for a long time, leading to a lack of trust between the doctor and patient, and the lack of recognition of the patient’s family, which will, in turn, reduce their confidence in professional skills and communication methods, doubting their own value and status in the medical service process. Lower work efficiency means heavier workload, which impacts internal satisfaction negatively. Simultaneously, because managers and researchers do not pay more attention to verbal violence, their reporting methods, processing processes, and subsequent health restoration lack strict regulations and humanised processes. This in turn further affects the sense of fairness of the violated medical personnel to superior decision-making, organisational policies and remuneration promotion, and reduces their external job satisfaction.

Judging from the impact of verbal violence on work engagement, when verbal violence occurs, there are different degrees of emotional response. This reduces the sense of professional identity, affecting the enthusiasm of the victim to participate in the work and the willingness to devote efforts, which will reduce the vitality and dedication to the work at the conscious or unconscious level. Britt suggests that when workers are engaged or highly motivated to do well, they can quickly lose their enthusiasm and motivation if they fail to perceive the meaningfulness of or pathways to success in their job due to a lack of resources, lack of support and so on.57 Simultaneously, under the influence of negative psychological stress, physical, psychological and social functions of the victims are reduced, and they can no longer maintain a pleasant state of full concentration and immersion in work. This will inevitably lead to a reduction in the concentration of healthcare workers. We found that both job satisfaction and work engagement were negatively related to unhealthy emotional exhaustion outcomes, which is consistent with other studies.58 59

Pay attention to and deal with verbal violence

We agree that most incidents of workplace violence (as in many other social settings) stem from the individual psychopathology of the perpetrator and also from the interaction of various factors related to the environment, staff, perpetrators and their interactions. Close proximity, engaging in personal care, carrying out unpleasant duties or not complying with patients’ demands may all create potential areas for conflict,41 60 61 yet the act of verbal violence is extremely unjustifiable.62 Employees benefit from training in aggression and violence. Areas to be covered by the proposed training include understanding violations in the workplace, assessing risks, taking preventive measures, interacting with violators and reporting and monitoring procedures.63

First, by highlighting and emphasising verbal violence, we must make healthcare workers realise that this is occupational violence and not just a ‘verbal argument’, rather than being a taboo subject because of lack of specificity. Healthcare workers must be made aware that this is a prelude to a more serious level of violence and conscious action must be taken at this stage, based on the premise that verbal violence is violence after all.

Second, we should assess the risks and took preventive measures. We propose specific measures in four aspects: prevention, in-process response, post-treatment and patient management. From the prevention point of view, older and more experienced healthcare workers gained skills in communication and reducing confrontational situations, which allowed them to resolve the cases of verbal violence. This also reminds us that verbal violence is more controllable than physical violence, is easier to change according to the characteristics of healthcare workers, and easier to improve through training. The period of verbal violence is also the period for healthcare workers to start protecting themselves to avoid more serious violence. Experiential interpersonal interaction training using feedback and manipulation methods, such as the Balint Group method,64 to improve the communication and conflict resolution skills of healthcare workers and to experience negative communication incidents first-hand through role swapping and role playing is recommended. Some studies have also proved that de-escalation training is beneficial for healthcare workers to deal with and manage verbal attacks,65 there are a lot of detailed suggestions in the relevant literature.66 67 In the existing hospital violence process, when physical violence occurs, human resources and hospital security are alerted, and they respond to the report. However, we must let healthcare workers realise that the occurrence of verbal violence is often the best time for reporting. During the period when patients’ moods fluctuate gradually, a relatively hidden button can be set up for healthcare workers to connect to the intranet reporting system and relevant hospital departments. Timely response, communication and handling will most effectively calm the conflict between doctors and patients and avoid more serious violence. In the follow-up treatment of verbal violence, healthcare workers are often unaware of the protective cover of the application system. If patients’ verbal insults and abuse of the doctor are serious and violate the doctor’s personality and reputation, the doctor can sue on the grounds of insult and defamation. If it is only a civil offence and does not constitute a crime, the infringed party may demand an apology or claim moral compensation. If the circumstances are particularly serious, they may constitute a crime of insult, defamation and so forth, with legal consequences. In violence research and hospital management, the rules of the behaviour of healthcare workers toward patients have been generally concerned and formulated, but the rules of behaviour of patients toward healthcare workers have received little attention. We believe that it is necessary to popularise a clear definition, follow-up treatment, and related legislation and regulations for violent behaviour in a fixed location in the hospital. This undoubtedly has implications for verbal violence and serious violence.

Third, the verbal violence reporting and monitoring procedures should be improved. Despite the high incidence of verbal violence, many participants did not report it. A comparison of self-reported and recorded incidents of non-physical violence in US hospitals showed that 88% of incidents were not recorded, and proposed understanding the magnitude of under-reporting and characteristics of healthcare workers who are less likely to report may assist hospitals in determining where to focus violence education and prevention efforts.17 Presently, many healthcare workers choose to tolerate workplace violence by not responding, ignoring and conceding to avoid more serious consequences. And a study found that the reasons for the non-reaction to workplace violence were uncovered, which included fears of a deteriorating incident scene, harming the patient and ineffective follow-up of workplace violence,68 let alone verbal violence that causes no visible damage. Studies have found that nurses tend to tolerate mild violence and report only serious violence. They argued that tolerance to psychological violence can prevent conflict from escalating into physical violence, thereby preventing secondary psychological harm. Despite policies supporting zero tolerance, staff do not enact these because they prioritise duty of care to consumers before duty of care to self.69 Some healthcare workers think that they should deal with violence as a part of their jobs.6 70 In some cases, it is believed that management will not take action.71 72 Most hospitals do not have processes for dealing with psychological violence that are difficult to implement.73 Therefore, we must recognise that effective management, monitoring and reporting of incidents of verbal violence must be part of clinical practice. Simultaneously, it is necessary to determine the magnitude of the problem and convince staff that their concerns are being taken seriously. Furthermore, we are aware that the results of this survey may be highly biased in response, as healthcare workers who declined to be studied for violence may have suffered trauma from workplace violence that they did not want to recall and mention. We call attention to such groups on the basis of encouraging reports of verbal violence.

Limitations

(1) Participant self-reports: Insufficient awareness of verbal violence, unclear definitions and refusal to report due to postviolence psychological trauma all make the study potentially biased. (2) We collected data on whether verbal violence had occurred among healthcare workers in the past 12 months. Therefore, there may have been a recall bias in the results. (3) This study used a cross-sectional design, which precludes causal conclusions. Thus, longitudinal studies are needed to examine the causal relationships among the variables.