Vol.5, No.2, 193-199 (2013) Health
http://dx.doi.org/10.4236/health.2013.52027
Violence at work and its relationship with burnout,
depression and anxiety in healthcare professionals
of the emergency services
Gloria M. Roldán1, Isabel C. Salazar2*, Laura Garrido1, Juan M. Ramos3
1“Virgen de las Nieves” University Hospital, Granada, Spain
2University of Granada, Granada, Spain; *Corresponding Author:
3“La Caleta” Healthcare Center, Granada, Spain
Received 20 November 2012; revised 21 December 2012; accepted 29 December 2012
ABSTRACT
The aim of this study w as to examine the possi-
ble relationship between physical and psycho-
logical aggression suffe red in the workplace and
professional burnout, depression and anxiety
suffered by healthcare professionals of the
emergency services. Methods: 315 physicians,
nurses, orderlies and ambulance drivers of Cri-
tical Care and Emergency Devices (CCED) in the
Andalusian Public Health System, in the pro-
vince of Granada (S pain) participated. They were
interviewed about the exposure to violence at
work and answered a battery of questions that
measured burnout, depression and anxiety. Re-
sults: Physical aggression was significantly re-
lated to emotional exhaustion, personal accom-
plishment at work, depression and anxiety. Psy-
chological aggression was associated with per-
sonal accomplishment. Logistic regression show-
ed that the CCED professionals who have suf-
fered physical aggressio n were 4.2 and 2.6 times
more likely to hav e suffered anxi ety and redu ced
personal accomplishment, respectively, than
those who did not suffer physical aggression.
On the other hand, feelings of anxiety and re-
duced personal accomplishment increase the
professionals’ risk (3.4 and 2.1 times more likely,
respectively) of suffering from physical aggres-
sion. Conclusion: The results suggest that ex-
posure to violence is related to the other psy-
chological problems tested: emotional exhaus-
tion and personal accomplishment (two com-
ponents of burnout), depression and anxiety. In
addition, physical violence is a risk factor for
anxiety and diminished personal accomplish-
ment of the CCED professionals.
Keywords: Wor kp lace Violence; Aggression;
Burnout; Depression; Anxiety; Health Professionals;
Emergency Services
1. INTRODUCTION
Workplace violence is universal in the health sector,
although local characteristics may vary. Workplace vio-
lence is any situation in which the person is the subject
of abuse, threats or attacks in circumstances related to
their work (or professional activity), having their safety,
well-being or health threatened explicitly or implicitly
[1,2]. There are two types of workplace violence: physi-
cal violence, which refers to the use of physical force
against another person or group that results in physical,
sexual or psychological harm. This includes beating,
kicking, slapping, stabbing, shooting, pushing, biting,
pinching, etc. On the other hand, psychological violence,
which refers to the intentional use of power, includes
threat of physical force against another person or group
that can result in harm to physical, mental, spiritual,
moral or social development. This includes verbal abuse,
uncivil behavior, lack of respect, disparaging attitude,
intimidation, mobbing, harassment, and threats [1].
A research carried out by a joint program on work-
place violence in the health sector shows that more than
half of the health sector personnel surveyed had experi-
enced at least one incident of physical or psychological
violence in the year previous to the study. In South Af-
rica that figure reached 61%, in Thailand 54%, in Portu-
gal 60%. In Bulgaria 37% and Lebanon 41% of the re-
spondents reported incidents of verbal violence which is
a form of psychological abuse [1]. This study showed
than ambulance staff exposure to violence is extremely
high in all countries investigated. In all the studies,
nurses and physicians also report very high levels of ex-
posure to violence. Alameddine et al. showed that in
Beirut (Lebanon) over the past 12 months, four out of
five emergency department employees were verbally

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194
abused and one in four was physically assaulted [3].
More recently, a study in 10 European countries showed
that nurses in France (39%), UK (29%) and Germany
(28%) reported the highest rates of violence [4].
In recent years, violence against healthcare profes-
sionals seems to have increased in Spain and numbers
are as high as seen in the aforementioned countries. In
Barcelona (Catalonia), one third of interviewed physi-
cians had suffered a violent episode throughout their
professional career (verbal aggression 44%, physical ag-
gression 28%, threats 26%), predominantly in the emer-
gency services (45%) [5]. In Jaen (Andalusia), out of 68
physicians of primary care, 58% had suffered aggression
(verbal abuse 85%, threats 67.5%, and physical aggres-
sion 12.5%) [6]. Between January 2007 and December
2009, 1940 violent incidents were reported in 60 health-
care centers in Catalonia. Physical violence was reported
in one third of these incidents and verbal violence in
more than half of them [7].
In Aragon and Castilla-La Mancha, out of 1845 medi-
cal professionals evaluated, 64% had been a victim of
psychological violence (threats, coercion or insults) and
11% had suffered physical aggression. The percentage of
insults received was higher for physicians (61.6%) and
the threats were primarily aimed at managers (65%) and
secondarily at physicians (60.9%). Again, the emergency
services were the most affected (87%). The percentage of
physical aggression was higher for physicians (19.4%),
followed by orderlies (18.2%) and nurses (17%) [8].
In Castilla and Leon, medical professionals (especially
physicians) and nursing staff were the most affected by
violence directed at them personally followed by atten-
dants and orderlies, although the percentage of affected
individuals in each category is not reported. The majority
of aggression was verbal (6 5% ) [9] .
In Granada (Andalusia), Roldán et al. found high per-
centages of professionals in emergency services who had
suffered from some sort of aggression durin g their work-
ing years (physicians 98.9%, nurses 95.3%, orderlies and
ambulance drivers 91.8%). Psychological aggression was
distributed similarly (99% physicians, 94.1% nurses, and
89.7% for orderlies and ambulance drivers). However,
there was variation in respect to physical aggression, the
nurses (27.1%) being the ones who were most affected,
followed by the physicians (26.3%) and finally the or-
derlies and ambulance drivers (13.4%) [10].
Violence at work can trigger a range of physical and
psychological outcomes in victims. Most victims of
workplace violence report being affected emotionally by
the experience. Emotional experiences to physical and
emotional violence can include anger, frustration, shock,
annoyance, fear, anxiety, stress depression, and sleep dis-
ruption [11]. In the work environment, exposure to vio-
lence has recently been linked to other psychological
problems such as burnout. Maslach and Jackson defined
burnout as a syndrome characterized by emotional ex-
haustion (being emotionally overextended and exhausted
by one’s work), depersonalization (having an unfeeling
and impersonal response toward recipients of one’s ser-
vices), and diminished personal accomplishment (having
diminished feelings of competence and successful achi-
evement in one’s work with people) [12]. Some studies
have shown that exposure to violence is associated with
burnout. For example, Moreno et al. report that family
physicians who had suffered violence were 2.9 times
more at risk of burnout than those who had not been as-
saulted [6], and in later years, Estryn-Behar et al. also
found a risk number very similar although sligh tly lower
(OR = 2.4) in a cohort of nurses [4]. Specifically, it has
been found that physical violence is associated with
burnout [8] and that psychological violence is associated
with serious outcomes including significantly higher
levels of anx iety [8] and burnou t [3,8].
Just as violence can have negative psychological con-
sequences, it has also been found that burnout can in-
crease the risk of exposure to violence in the workplace.
Alameddine et al. found that respondents reporting a
high level of emotional exhaustion had more than 2.1
times higher odds of exposure to a higher level of verbal
abuse compared to respondents with an average level of
emotional exhaustion. Similarly, respondents with a low
level of personal accomplishment had 2.7 times higher
odds of being exposed to higher levels of verbal abuse
compared to their counterparts with average levels of
personal accomplishment. Finally, the employees with a
high and aver age level of deperson alization had 3.40 and
3.74 times higher odds of being exposed to higher levels
of verbal abuse compared to employees with low levels
of depersonalization [3].
All of the aforementioned is very significance because
there is empirical support for some psychological prob-
lems (e.g., depression, anxiety, etc.) associated with ex-
posure to violence at work also being predictors of burn-
out [13,14].
Taking into consideration that emergency departments
are identified as a place where workers are dispropor-
tionally exposed to violence compared to their counter-
parts in other departments [1,4,7,11], the aim of this
study is to examine the relationship between physical
and psychological aggression in the workplace and anxi-
ety, depression and burnout, as suffered by healthcare
professionals in the Critical Care and Emergency De-
vices of the Andalusian Health Service (Spain).
2. METHODS
2.1. Participants
315 sanitary professionals in the Critical Care and

G. M. Roldán et al. / Health 5 (2013) 193-199 195
Emergency Devices (CCED) of the Andalusian Health
Service in the province of Granada (Spain) were inter-
viewed. Table 1 provides socio-demographic and occu-
pational data of participants.
2.2. Instruments
The CCED professionals were interviewed. Each in-
terview took 55 minutes (a pproximately) and th ere was a
psychologist in charge who traveled to the workplaces of
the participants. In some cases, the length of the inter-
view went over the allotted time and prevented dedica-
tion of more time to finalize it, and that is why the sam-
ple considered for each different statistical analysis var-
ies.
For the data collection the following was used: 1) an
ad hoc interview which gathers socio-demographic and
occupational data as well as data related to exposure to
violent events in the workplace. Th e interview allows for
identification of participants who have been assaulted,
the source of the assault, the type of assault, the number
of assaults suffered during the years worked, if they have
been off work, the treatment received, the areas affected
as a consequence of the assaults, if they know of the
Prevention Plan and Assault Assistance for Andalusian
Health Service Professionals and their perception on in-
stitutional support. 2) The Maslach Burnout Inventory
(MBI), a 22-item questionnaire that measures burnout
syndrome across three subscales: Emotional exhaustion,
Depersonalization, and Personal accomplishment. The
Emotional exhaustion subscale measures workers’ feel-
ings of emotional wear-out and fatigue at work. The De-
personalization subscale measures workers’ degree of
being impersonal and distant in delivering care, treat-
ment and instructions to recipients of services. Further-
more, the Personal accomplishment subscale measures
an employee’s level of competence and feeling of pro-
Table 1. Socio-demographic and professional characteristics of
participants.
Variables n %
Male 196 62.6
Gender Female 117 37.4
Yes 243 77.4%
Living with
partner No 71 22.6%
Physician 111 35.2
Nurse 94 29.8
Professional
category Ord. & amb.a 110 34.9
n M SD Min.Max.
Age (years) 312 43.92 9.05 22 63
Years worked 311 14.30 7.46 1 35
aOrd. & amb. = Orderlies & ambulance drivers.
fessional achievement at work. Each of the questions in
the MBI is scored on a 7-point Likert scale (from 0 =
“never” to 6 = “daily”). The internal consistency (Cron-
bach’s alpha) of the MBI was of 0.68, 0.81 for the Emo-
tional exhaustion subscale, 0.68 for the Depersonaliza-
tion subscale, and 0.71 for the Personal accomplishment
subscale. 3) The Beck Depression Inventory (BDI), a
21-item inventory that measures the magnitude of the
depression. Each of the questions has four alternative
answers (ranging from 0 - 3 points) that are listed ac-
cording to the severity. The total score allows recognition
of whether the subject presents clinical symptoms of de-
pression. The alpha of the BDI was 0.87. 4) The Beck
Anxiety Inventory (BAI), a 21-item inventory that mea-
sures the severity of physical symptoms related to anxi-
ety experienced throughout the past week. It uses a 4-
point Likert scale (from 0 = “not at all” to 3 = “se-
verely”). The total score allows recognition of whether
the subject presents clinical anxiety symptoms. The alpha
of the BAI was of 0.93.
2.3. Statistical Analysis
Data was entered in the Statistical Package for the So -
cial Sciences (SPSS), version 13.0. Exposure to physical
aggression and psychological aggression were consid-
ered two separate variables and were analyzed separately
in order to better understand the factors associated with
each. The anxiety and depression (that were originally
measured on a 4-point scale) were regrouped into two
categories. Chi-square (χ2) or Fischer (F) tests were used.
Subsequently, logistic regression was used to test whe ther
physical and psychological aggression in the workplace
acted as a risk factor for the rest of the psychological
variables evaluated, and vice versa.
2.4. Ethical Considerations
Participation in the study was voluntary. Informed
verbal consent to the interview was obtained from all
respondents, who were free to withdraw at any time or to
refuse to answer any of the questions. Respondents were
not compensated fin ancially. This study was appr oved by
the Ethics Committee of “Virgen de las Nieves” Hospi-
tal’s clinical research department and it does not break
the agreements of the Helsinki Declaration.
3. RESULTS
3.1. Co-Relational Analysis
Correlations between physical and psychological ag-
gression and other psychological variables assessed (an-
xiety, depression and 3-components of burnout: emo-
tional exhaustion, depersonalization and personal accom-
plishment) were analyzed. Chi-square or Fischer tests

G. M. Roldán et al. / Health 5 (2013) 193-199
196
were used for this analysis. It was found that exposure to
physical aggression was associated with anxiety (p =
0.000), personal accomplishment (p = 0.006), emotional
exhaustion (p = 0.025), and depression (p = 0.19). On the
other hand, exposure to a psychological aggression was
associated with personal accomplishment (p = 0.044)
(Table 2).
3.2. Multivariate Analysis
Psychological consequences of exposure to physical
and psychological violence. A binary logistic regression
analysis was conducted to study the significant associa-
tions with exposure to physical or psychological aggres-
sion among the CCED professionals. This analysis was
based on the fact that physical aggression and psycho-
logical aggression are dichotomous variables.
Results showed that healthcare professionals who
were physically assaulted had 4.24 times (95% CI: 1.96,
9.16; p-value: 0.000) greater odds of suffering anxiety
and 2.58 times (95% CI: 1.35, 4.93; p-value: 0.004)
greater odds of not feeling personal accomplishment in
their work than those professionals who had not been
physically assaulted.
Psychological variables of risk from physical and psy-
chological violence. A multivariate logistic regression
model was built taking physical aggression as a depend-
ent variable and as independent variables those that were
statistically significant in the bivariate analysis (emo-
tional exhaustion, personal accomplishment, anxiety and
depression).
The results showed that healthcare professionals with
anxiety and reduced personal accomplishment had higher
risk of physical aggression. Specifically, CCED profes-
sionals with anxiety had 3.4 times (95% CI: 1.53, 7.58;
p-value: 0.003) greater odds of being exposed to physical
aggression compared to their colleagues without anxiety.
Similarly, respondents with reduced personal accom-
plishment had 2.06 times (95% CI: 1.03, 4.10; p-value:
Table 2. Distribution of the subjects between emotional exhaustion, personal accomplishment, depression and anxiety according to
the type of aggression.
Physical aggression Psychological aggression
Variables Yes No Total Yes No Total
N 36 151 187 174 13 187
No % 19.3 80.7 100.0 93.0 7.0 100.0
N 22 43 65 64 1 65
Yes % 33.8 66.2 100.0 98.5 1.5 100.0
N 58 194 252 238 14 252
Emotional exhaustion
Total % 23.0 77.0 100.0 94.4 5.6 100.0
N 21 35 56 56 0 56
No % 37.5 62.5 100.0 100.0 0.0 100.0
N 37 159 196 182 14 196
Yes % 18.9 81.1 100.0 92.9 7.1 100.0
N 58 194 252 238 14 252
Personal accomplishment
Total % 23.0 77.0 100.0 94.4 5.6 100.0
N 44 172 216 203 13 216
No % 20.4 79.6 100.0 94.0 6.0 100.0
N 14 21 35 35 0 35
Yes % 40.0 60.0 100.0 100.0 0.0 100.0
N 58 193 251 238 13 251
Depression
Total % 23.1 76.9 100.0 94.8 5.2 100.0
N 42 178 220 206 14 220
No % 19.1 80.9 100.0 93.6 6.4 100.0
N 16 16 32 32 0 32
Yes % 50.0 50.0 100.0 100.0 0.0 100.0
N 58 194 252 238 14 252
Anxiety
Total % 23.0 77.0 100.0 94.4 5.6 100.0

G. M. Roldán et al. / Health 5 (2013) 193-199 197
0.040) greater odds of being exposed to physical aggres-
sion compared to their colleagues with higher personal
accomplishment.
4. DISCUSSION
This study allowed evaluation of the relationships be-
tween physical and psychological aggression suffered in
the workplace and professional burnout, depression and
anxiety suffered by healthcare professionals of the emer-
gency services, in the province of Granada (Spain).
Study results showed that the exposure to violence is
associated with burnout, anxiety and depression in
CCED professionals. However, once each type of vio-
lence (physical/psychological) is analyzed separately,
some differences in relation to the other psychological
variables were found. Physical aggression showed a sig-
nificant link with anxiety, depression, emotional exhaus-
tion and low personal accomplishment (aspects of burn-
out), whereas psychological aggression was associated
solely with low personal accomplishment.
According to Estryn-Behar et al., a high and medium
frequency of violence is associated with higher levels of
burnout; also, violence appears to be an important risk
factor for burnout as it increases the risk 1.4 and 1.9
times in those who have been assaulted monthly and
weekly respectively, compared to those who have not
been assaulted [4]. The relationship between the different
types of assault suffered by professionals and the pre-
sence of burnout is not explained. This could be an im-
portant question due to the fact that different types of
aggression happen at different frequencies and can have
a different impact on people.
According to the present investigation, physical ag-
gression suffered by healthcare professionals throughout
their working years increases the risk of suff ering anxiety
and reduced personal accomplishment, in comparison to
those who have not exp erienced any ph ysical aggression;
whereas exposure to psychological aggression does not
lead to any significant risk for professionals in th is sense.
These results partially contradict what Alameddine et al.
suggest, given that in their study verbal abuse was sig-
nificantly associated with the three subscales of burnout
(Emotional exhaustion, Depersonalization and Personal
accomplishment) in the Beirut emergency departments
[3]. A possible explanation for the results of the present
study is that patients and those accompanying them (who
tend to be those exert more actions of this kind against
CCED professionals) [10,11] tend to psychologically
assault professionals, alluding to a lack of competence or
professional efficiency at the time they are taken into
care. The insults, humiliations and even threats come
from people who, at the time (in the emergency services
department) see their situation as difficult, sometimes
critical, and which overcomes their coping skills. It is
clear that even though it does not justify the verbal abuse,
it is understandable that in said circu mstances some peo-
ple (due to a coping skills deficit) express their discom-
fort through these kinds of aggressive responses and that
professionals consider this reaction from patients as
something to expect from their job, the reason for which
is, in some way, a method of “protecting themselves”
from suffering reduced personal accomplishment and, in
general, from suffering burnout.
Another question that was analyzed in this investiga-
tion was the psychological impact of different types of
violence against professionals. In agreement with the
data obtained, the consequences derived from exposure
to physical violence are different from the data obtained
for psychological violence. Physical aggression, unlike
psychological aggression, increases the probability of
suffering anxiety and reduced personal accomplishment,
the reason for this is thought to be that physical aggres-
sion has a higher psychological impact in healthcare
professionals than psychological aggression. The pres-
ence of anxiety problems in the cases of physical aggres-
sion is clearly justified by the nature of the stimulus (a
strike, a push, an injury, etc.), because this is in itself
harmful and automatically trigg ers an emotional reaction
of fear. This kind of response implies an increased phy-
siological activation which, if not handled adequately,
can lead to the person subsequently developing problems
with anxiety. In short, a physical stimulus is potentially
stronger and more harmful than a psychological (or ver-
bal) stimulus and therefore, it is expected that physical
aggression increases the risk of suffering from anxiety, as
well as low personal accomplishment, in comparison to
psychological aggression. As has been previously de-
scribed, psychological aggressio n, despite being aimed at
attacking the self-efficiency and professional competence,
does not have as high an impact as to affect an individ-
ual’s personal accomplishment in the workplace.
Until recently, this relationship has been analyzed in
only one sense: the psychological effects of violence.
Many studies indicate that violence is a risk factor for
burnout and can entail emotional experiences such as
anxiety, depression, sleep problems, etc. However, there
are also studies that indicate the opposite. With regards
to this, the present investigation was able to determine
that the presence of a high level of anxiety and reduced
personal accomplishment increased the probability of
suffering physical aggression, compared to those subjects
who did not have the aforementioned psychological pro-
blems.
This risk model indicates that those people who suffer
from anxiety and reduced personal accomplishment have
a greater chance of being physically assaulted. Said
model could be better understood if anxiety was consid-

G. M. Roldán et al. / Health 5 (2013) 193-199
198
ered to be an emotional reaction to disproportionate fear
or worry (apprehensive expectation) in light of situations
in which healthcare professionals feel themselves inca-
pable of managing. If this preoccupation and physio-
logical-emotional activation is significant, it is highly
probable that behavior is negatively affected and at the
moment of interacting with the patients they manifest
their nervousness and will not use (or will not have) the
sufficient and appropriate repertoire of skills to manage
difficult situations that can arise in an emergency ser-
vices department.
Unlike what has been said up until now, there are
some studies with nursing staff that revealed no associa-
tions between reported violence and burnout [15,16]. The
contradiction between these cases could be due to the
complexity of the phenomenon. The idea of “zero toler-
ance” towards violence is promoted socially, but it is
feasible that some healthcare professionals consider that
violence coming from patients is “expected” and that “it
is part of the job” [15,16]. It is an attitude which could
moderate the appearance of burnout, but further investi-
gation is required.
5. CONCLUSION
Physical violence is linked to anxiety and burnout.
Physical aggression is a risk factor for anxiety and low
personal accomplishment at work. Nevertheless, the op-
posite also occurs. That is to say, subjects with anxiety
and low personal accomplishment have a greater risk of
suffering physical aggression. This is possibly the first
investigation performed in Spain that provides informa-
tion on exposure to violence and the risk of finding im-
portant psychological problems linked to it (such as
burnout and anxiety). However, more investigation will
be necessary in order to clarify the causal relationship
between these phenomena.
6. ACKNOWLEDGEMENTS
We thank the healthcare professionals of the Andalusian Public
Health System in the province of Granada, who agreed to be part of the
cohort in this study. This work has been possible thanks to the funding
from the Andalusian Public Fund for Bio-Sanitary Investigation of
Oriental Andalusia—Alejandro Otero (FIBAO B15/2006), the Carlos
III Health Institute and European Regional Development Fund (ERDF)
(FIS 07/0440).
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