Among nursing staff, the risk of experiencing violence, especially verbal aggression, is particularly relevant. The present study, developed in the theoretical framework of the Job Demands-Resources model (JD-R), has two main aims: (a) to examine the association between verbal aggression and job burnout in both nurses and nurse’s aides and (b) to assess whether job content, social resources, and organizational resources lessen the negative impact of verbal aggression on burnout in the two professional groups. The cross-sectional study uses a dataset that consists of 630 workers (522 nurses and 108 nurse’s aides) employed in emergency and medical units. High associations were found between verbal aggression and job burnout in both professional groups. Moderated hierarchical regressions showed that, among nurses, only the job content level resources moderated the effects of the verbal aggression on job burnout. Among nurse’s aides, the opposite was found. Some resources on the social and organizational levels but none of the job content level resources buffered the effects of verbal aggression on workers burnout. The study highlights the crucial role of different types of resources in protecting nursing staff from the detrimental effects of verbal aggression on job burnout.
In the workplace, nursing staff are exposed to various factors that are likely to jeopardize their health and safety. Among these, the risk of experiencing violence is particularly relevant. Work-related violence includes both physically and psychologically violent incidents in which staff members are abused, threatened, or assaulted. It can be defined as “any threat, physical, and/or psychological, that is directed toward a person while at work” [
More specifically, in the health care sector, the most common violence is the so-called Type II category, described as the following in the Californian Occupational Safety and Health Administration classification [
Europe is recently witnessing a progressive increase of Type II violence, which is considered an “emerging epidemic” [
Because a higher level of violence is expected in those units where patients may initiate more verbal or physical threats (i.e., psychiatric wards or elderly patient areas) or where emergencies and workload are massive (i.e., out-of-hours primary care, emergency, and ICU units), most of the research has been conducted in these specific contexts [
The present study focused on verbal aggression, which is one of the most common forms of Type II violence incurred by nursing staffs. Using the framework of the Job Demands-Resources model (JD-R [
Verbal aggression is a form of direct psychological aggression that includes yelling at the service provider or making sarcastic or offensive remarks [
The fact that being exposed to verbal aggression may lead to burnout is suggested by one of the main assumptions of the JD-R model [
The
However, whereas the research is well-developed for most job demands and provides evidence in that direction, as regards verbal aggression, the attention on the variables of the workplace that may buffer its detrimental effects is quite limited [
In that direction, the present study includes eight specific resources at the job content, social, and organizational levels. The choice was driven by previous research that recognized the importance of these job characteristics in moderating the effects of the various job demands, including verbal aggression on job burnout, both among the general population and among nursing professionals [
At the job content level, skill discretion, job autonomy, role clarity, and work meaning were taken into account. According to Karasek [
At the social level,
At the organizational level, organizational support, fairness, and social utility of the service were considered in the present study.
According to Maslach and Leiter [
According to the
The literature developed in the framework of the JD-R model regarding the nursing context [
Empirical evidence also suggests that merging these groups may obscure the specificity that each category has regarding job stress experience. For example, Seago and Faucett [
The present study may advance the past knowledge on the buffering role of job resources in the demands-burnout relationship because it focuses on some aspects neglected in the previous literature: (a) it considers a wide range of resources (i.e., task level, social level, and organizational level) as possible moderators of the relationship between verbal aggression and burnout and (b) it analyses the buffering mechanism separately within the categories of nurses and nurse’s aides.
Data were collected during a multi-centre intervention-research conducted in four hospitals in Northwest Italy in 2012. Hospital administrations evaluated, endorsed, and authorized the research, allowing researchers to use the data for scientific purposes. Upon approval, department chiefs and nurse coordinators from each ward were asked for authorization to administer the questionnaire to the nurses. An additional ethical approval was not required because no medically invasive diagnostics or procedures were involved to cause psychological or social discomfort for the participants, nor were the patients the subjects of the data collection. However, the research conforms to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000), and all ethical guidelines were followed as required for conducting human research, including adherence to the legal requirements of the study country (Italy).
Participants volunteered for the research and were not asked to sign consent forms, but returning the questionnaire implied consent. The cover sheet clearly explained the research aim, the voluntary nature of participation, the anonymity of the data, and the elaboration of the findings.
The sample consisted of 630 workers: 522 (82.90%) nurses and 108 (17.10%) nurse’s aides. The majority were women (81.9%,
The average period during which participants had been working in the health-care sector was 13.31 years (sd = 9.02) and ranged from 1 month to 39 years. They were employed in emergency (40.30%) and medical (59.70%) units. Sociodemographic and profession details for nurses and nurse’s aides are reported in Table
Sociodemographic and professional characteristics of nurses and nurse’s aides.
Nurses | Nurse’s aides | |||
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% |
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% | |
Gender | ||||
Female | 429 | 82.2 | 87 | 80.6 |
Male | 90 | 17.2 | 19 | 17.6 |
Age | ||||
≤40 | 288 | 55.2 | 33 | 30.6 |
>41 | 234 | 44.8 | 75 | 69.4 |
Marital status | ||||
Married/living with partner | 297 | 56.9 | 64 | 59.3 |
Single/divorced/widowed | 221 | 42.3 | 43 | 39.8 |
Ward | ||||
Emergency | 220 | 42.1 | 28 | 25.9 |
Medicine | 302 | 57.9 | 80 | 74.1 |
Years in the health sector | ||||
≤15 | 307 | 58.8 | 79 | 73.1 |
>16 | 215 | 41.2 | 29 | 26.9 |
The data were obtained by means of a self-reported questionnaire that included two sections. The first section collected sociodemographic (gender, age, and marital status) and professional (occupation, units, and years in the health sector) data. The second section included scales aimed at measuring job demand, job resources, and worker outcomes.
Three categories of factors referring to the job content, the social, and the organizational levels were considered. At the job content level, we included four subscales:
Responses on all subscales were given on a four-point scale with a range between 1 (“strongly disagree”) and 4 (“strongly agree”).
Job burnout was measured thought two subscales from the Italian version of Maslach Burnout Inventory (MBI [
Gender (0 = male; 1 = female), age, marital status (0 = not living with partner; 1 = living with partner), job seniority, and type of ward (0 = nonacute care ward; 1 = acute care ward) are potential confounders for burnout [
Table
Descriptive statistics (means and standard deviations) and Pearson’s correlations for all subscales considered in the study.
M (ds) | ( |
( |
( |
( |
( |
( |
( |
( |
( |
( |
( |
( |
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1.88 (.77) | 1 | |||||||||||
( |
3.38 (.48) |
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1 | ||||||||||
( |
3.34 (.53) |
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1 | |||||||||
( |
3.36 (.55) | −.03 |
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1 | ||||||||
( |
2.68 (.60) | −.08 |
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1 | |||||||
( |
2.84 (.60) |
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1 | ||||||
( |
3.07 (.59) |
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1 | |||||
( |
2.36 (.50) |
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1 | ||||
( |
2.51 (.62) |
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1 | |||
( |
2.73 (.54) |
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1 | ||
( |
2.06 (1.28) |
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1 | |
( |
1.21 (1.18) |
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1 |
Note:
All the analyses were performed using SPSS 21. Moderated hierarchical regression analyses were employed to examine the main effect of verbal aggression and of job resources on job burnout, as well as the moderating (buffering) role of job resources on the relationship between verbal aggression and burnout. For each moderated hierarchical regression performed, predictor variables were entered within three successive steps. In the first step, demographical (gender, age, and marital status) and occupational (years in the health sector and type of unit) variables were entered as control variables. In the second step, standardized indexes of verbal aggression and job resources were entered. In the third step, the interaction term, which is the product between verbal aggression and job resource, was entered. When the interaction term showed significant value, the simple slope procedure recommended by Aiken and West [
The risk of multicollinearity between independent variables was controlled by standardizing all indexes. Analyses indicated that there were no signs of multicollinearity in any of the regression models. For each independent variable, the tolerance index (1/VIF) never exceeded the score of .70 (cut-off < .20 [
Table
Moderated hierarchical regressions to measure main and interaction effects of verbal aggression and job resources on emotional exhaustion among nurses.
Nurses | M1_JR | M2_JR | M3_JR | M4_JR | M5_JR | M6_JR | M7_JR | M8_JR | M9_JR | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Meaning of the work | Role clarity | Skill discretion | Job autonomy | Support from superior | Support from colleagues | Fairness | Organizational support | Organizational social utility | ||||||||||
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Step |
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Gender (1 = female) |
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|
.09 | 1.87 | .09 | 1.85 | .80 | 1.72 | .07 | 1.48 | .08 | 1.77 | .09 | 1.81 | .07 | 1.51 | .07 | 1.67 |
Age (1 |
.05 | .95 | .05 | .84 | .05 | .89 | .03 | .07 | .05 | .89 | .06 | 1.16 | .04 | .67 | .40 | .70 | .05 | .85 |
Marital status (1 = married/partnered = 1) | −.02 | −.32 | −.01 | −.09 | −.02 | −.40 | −.04 | −.87 | −.05 | −1.08 | −.04 | −.85 | −.40 | −.82 | −.04 | −.91 | −.17 | −.37 |
Year health sector (1 |
.03 | .55 | .05 | .92 | .04 | .71 | .04 | .75 | .02 | .45 | .05 | 1.05 | .04 | .75 | .01 | .34 | .03 | .55 |
Type of unit (1 = emergency) |
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( |
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Verbal aggression |
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Job resource |
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−.077 | −1.58 |
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( |
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Verbal aggression × job resource |
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−.44 | −.86 |
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.02 | .40 |
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−.06 | −1.25 |
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−.01 | −.164 | −.07 | −1.46 |
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( |
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( |
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.00 |
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.00 | .01 | .00 |
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.00 | .00 | |||||||||
Adj |
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Note:
Regarding the main effect, all the resources we considered, except skill discretion, helped lessen emotional exhaustion. The smallest
The interaction effect between verbal aggression and job resources was found to be significant in models 1, 3, 5, and 7, suggesting that meaning of work (
In all these cases, the simple slope analysis (see Figures
Interaction between verbal aggression and meaning of the work for emotional exhaustion among nurses.
Interaction between verbal aggression and skill discretion for emotional exhaustion among nurses.
Interaction between verbal aggression and support from superior for emotional exhaustion among nurses.
Interaction between verbal aggression and fairness for emotional exhaustion among nurses.
Table
Moderated hierarchical regressions to measure main and interaction effects of verbal aggression and job resources on depersonalization among nurses.
Nurses | M1_JR | M2_JR | M3_JR | M4_JR | M5_JR | M6_JR | M7_JR | M8_JR | M9_JR | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Meaning of the work | Role clarity | Skill discretion | Job autonomy | Support from superior | Support from colleagues | Fairness | Organizational support | Organizational social utility | ||||||||||
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Step |
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Gender (1 = female) |
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Age (1 |
.04 | .74 | −.00 | −.02 | .01 | .12 | −.01 | −.18 | .02 | .27 | .01 | .25 | −.01 | −.16 | .03 | .43 | .01 | .08 |
Marital status |
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−.07 | −1.38 | −.09 | −1.91 |
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−.10 | −1.78 |
Year health sector (1 |
−.03 | −.63 | −.00 | −.07 | −.02 | −.40 | −.01 | −.21 | −.04 | −.65 | −.01 | −.16 | −.03 | −.63 | −.04 | −.71 | −.02 | −.28 |
Type of unit (1 = emergency) | .08 | 1.52 | .07 | 1.48 | .07 | 1.36 | .07 | 1.43 | .06 | 1.19 | .03 | .51 | .05 | 1.05 | .06 | 1.17 | .06 | 1.26 |
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( |
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Verbal aggression |
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Job resource |
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( |
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Verbal aggression × Job resource |
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−.04 | −.73 | −.06 | −1.29 | −.01 | −.10 | −.01 | −.10 | .02 | .33 | −.08 | −1.72 |
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( |
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.00 | .00 | .00 | .00 | .00 | .01 | |||||||||
Adj |
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Note:
Figures
Interaction between verbal aggression and meaning of the work for depersonalization among nurses.
Interaction between verbal aggression and role clarity for depersonalization among nurses.
Interaction between verbal aggression and skill discretion for depersonalization among nurses.
These results confirm H1a because, among nurses, verbal aggression was found significantly associated with both emotional exhaustion and depersonalization in all the models. On the other hand, H2a is partially confirmed because the buffer effect of the resource was found in four cases for emotional exhaustion and three cases for depersonalization.
Table
Moderated hierarchical regressions to measure main and interaction effects of verbal aggression and job resources on emotional exhaustion among nurse’s aides.
Nurse’s aides | M1_JR | M2_JR | M3_JR | M4_JR | M5_JR | M6_JR | M7_JR | M8_JR | M9_JR | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Meaning of the work | Role clarity | Skill discretion | Job autonomy | Support from superior | Support from colleagues | Fairness | Organizational support | Organizational social utility | ||||||||||
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Step |
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Gender (1 = female) | .01 | .09 | .02 | .24 | .04 | .35 | .01 | .11 | −.02 | −.21 | .01 | .14 | −.08 | −.85 | −.04 | −.42 | −.05 | −.54 |
Age (1 |
.01 | .09 | .01 | .08 | .01 | .09 | .01 | .12 | −.03 | −.27 | −.07 | −.66 | .01 | .06 | −.06 | −.46 | .03 | .29 |
Marital status (1 = married/partnered = 1) | −.09 | −.86 | −.07 | −.68 | −.10 | −1.03 | −.10 | −.99 | −.06 | −.62 | −.10 | −1.06 | −.11 | −1.23 | −.06 | −.66 | −.07 | −.78 |
Year health sector (1 |
.07 | .71 | .06 | .59 | .08 | .75 | .09 | .90 | .10 | 1.04 | .12 | 1.24 | .08 | 91 | .05 | .50 | .11 | 1.13 |
Type of unit (1 = emergency) | −.10 | −.94 | −.09 | −.97 | −.07 | −.70 | −.06 | −.67 | −.01 | −.14 | .03 | .39 | .05 | .57 | −.04 | −.50 | −.07 | −.79 |
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( |
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Verbal aggression |
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Job resource | −.02 | −.23 | −.10 | −.99 | −.16 | −1.50 | −.16 | −1.60 |
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( |
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Verbal aggression × Job resource | .04 | .42 | .17 | 1.80 | .14 | 1.21 | −.07 | −.68 |
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−.06 | −.69 |
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( |
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.00 | .03 | .01 | .00 |
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Adj |
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Note:
Concerning verbal aggression, nurse’s aides results are similar to the nurses’:
Interaction between verbal aggression and support from superior for emotional exhaustion among nurse’s aides.
Interaction between verbal aggression and support from colleagues for emotional exhaustion among nurse’s aides.
Interaction between verbal aggression and fairness for emotional exhaustion among nurse’s aides.
Interaction between verbal aggression and organizational support for emotional exhaustion among nurse’s aides.
Further evidence of the moderating role of these job resources was provided by the slope test. As regards support from colleagues, the relationship between verbal aggression and emotional exhaustion was significant at −1 SD (low support from colleagues;
Table
Moderated hierarchical regressions to measure main and interaction effects of verbal aggression and job resources on depersonalization among nurse’s aides.
Nurse’s aides | M1_JR | M2_JR | M3_JR | M4_JR | M5_JR | M6_JR | M7_JR | M8_JR | M9_JR | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Meaning of the work | Role clarity | Skill discretion | Job autonomy | Support from superior | Support from colleagues | Fairness | Organizational support | Organizational social utility | ||||||||||
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Gender (1 = female) | −.14 | −1.35 | −.15 | −1.56 | −.17 | −1.66 | −.16 | −1.63 | −.20 | −2.22 | −.12 | −1.34 |
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Age (1 |
.08 | .73 | .08 | .80 | .11 | .98 | .09 | .86 | .11 | 1.09 | −.01 | −.10 | .11 | 1.07 | .08 | .74 | .09 | .93 |
Marital status (1 = married/partnered = 1) | −.04 | −.36 | .02 | .23 | −.01 | −.14 | −.01 | −.08 | −.03 | −.29 | .04 | .37 | −.45 | −.48 | −.02 | −.25 | −.02 | −.19 |
Year health sector (1 |
.04 | .33 | .01 | .02 | .02 | .23 | .04 | .37 | −.05 | −.58 | .00 | .04 | .02 | .21 | −.07 | −.73 | .07 | .80 |
Type of unit (1 = emergency) | .02 | .21 | .02 | .18 | .03 | .28 | .02 | .17 | .08 | .93 | .13 | 1.40 | .11 | 1.21 | .03 | .31 | .03 | .30 |
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Verbal aggression |
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Job resource | −.09 | −.99 | −.08 | −.85 | −.02 | −.18 | −.03 | −.26 | −.13 | −1.38 | −.14 | −1.43 | −.10 | −1.04 | −.06 | −.65 |
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( |
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Verbal aggression × Job resource | −.10 | −1.00 | −.15 | −1.56 | .06 | .47 | −.09 | −.78 |
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.01 | .03 | .00 | .00 | .00 |
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Adj |
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Note:
On the contrary, no resources, except for social utility, showed a direct effect in lessening the depersonalization level among nurse’s aides. As highlighted in step three, support from superiors (
According to the slopes test (see Figures
Interaction between verbal aggression and support from superior for depersonalization among nurse’s aides.
Interaction between verbal aggression and support from colleagues for depersonalization among nurse’s aides.
Interaction between verbal aggression and fairness for depersonalization among nurse’s aides.
Interaction between verbal aggression and support from organization for depersonalization among nurse’s aides.
Interaction between verbal aggression and organizational social utility for depersonalization among nurse’s aides.
The results confirm H1b because verbal aggression was significantly associated with both emotional exhaustion and depersonalization in all models carried out among nurse’s aides. On the other hand, H2b is partially confirmed because the buffer effect of the resource was found in five cases for emotional exhaustion and in four cases for depersonalization.
The first aim of the present study was to verify the relationship between verbal aggression and job burnout. The high and significant associations found in both professional groups confirmed the hypothesis that verbal aggression is a predictor of burnout (H1a, H1b). These results suggested that not only in emergency and psychiatry units, as usually pointed out by the literature [
The second aim of the study was to explore whether any job content, social, and organizational level resources are capable of moderating the effect of the exposure to verbal aggression on burnout. The hypothesis that the resources considered moderate the relationship between verbal aggression and the burnout symptoms was only partially confirmed (H2a, H2b). Overall, in 45% of the cases, the cross-product between verbal aggression and the resource was found to be significant. From a general point of view, the findings obtained contribute to enforce the buffering hypothesis of the Job Demands-Resources Model (JD-R, [
Considering the job content level among nurses, most of the resources work as moderators of the effect of verbal aggression on burnout. On the contrary, no job content resources work as buffers among nurse’s aides. These results could be attributed to the different nature of the work of these two categories. The nurses’ work, at the job content level, is richer and more complex than that of nurse’s aides and, thus, may offer more resources to successfully deal with the aggressive patients.
These results are also in accordance with those studies which, in the Job Demand Control (JDC) perspective, highlighted that nurses fall into the active strain category, whereas nurse’s aides are in the high strain category [
On the other hand, it is also interesting to note that among nurses, in most cases, social and organizational resources (with the exception of support from superiors and fairness) did not moderate burnout. These results are difficult to interpret because previous literature rarely pays attention to these aspects. However, an explanation of these results can be found in the Job Characteristic Model by Hackman and Oldham [
Finally, it is interesting to note that the findings do not support the
Further studies should look more deeply at the difference of the mechanisms that lead to burnout among the two subcategories. Moreover, another suggestion concerns the exploration of the “positive side” of the patient-nurse relationship as a resource able to buffer specifically the “negative side” represented by verbal aggression and exceeding demands [
The present study contributes to enlarging empirical evidence developed in the framework of the JD-R model, in particular, by focusing on understudied demands (i.e., verbal aggression) and considering a wide range of resources as its potential moderators.
Moreover, it indicates that more attention should be paid to the study of the stress phenomenon
The present study is not without limitations. One concern is that a nonrandomized sampling procedure was used. Even if the sample is quite large, it can limit the generalizability of the results founded. Another important limitation is its cross-sectional design. Therefore, caution must be exercised in the interpretation of the observed associations. It is assumed that job demands and resources are antecedents of burnout, but the opposite could also be true. In fact, elevated rates of burnout could lead workers to develop negative attitudes toward jobs, workplace contexts, and organizations.
The authors declare that there is no conflict of interests regarding the publication of this paper.