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Burnout and fear of contagion as factors in aggressive tendency of health-care workers treating people with AIDS.

Aggression is an action that is intended to cause harm to another person who does not want to be harmed (Brehem, Kassin, & Fein, 2002). Intent to harm is included in the definition to distinguish it from behaviors that may cause harm but were not intended to cause harm, such as accidental harm. However, intent is difficult to observe directly and must be inferred from the perpetrator's behavior as reported by the victim or the perpetrator (Keashly & Jagatic, 2003).

In this study, aggression is defined as a self-reported intention by health-care workers (HCWs) in AIDS care to direct hostile, antagonistic attitudes and/or physical aggression (e.g., hostile facial expression, eye contact, vocal expression, ignoring/cold treatment, and body language) toward people living with AIDS (PLWAs).

In the literature (e.g., Ayranci, 2005; Zampieron, Galeazzo, Turra, & Buja, 2010) on workplace aggression in public-health settings researchers have focused on the aggression perpetrated by patients against HCWs, with less attention devoted to the aggression perpetrated by HCWs against patients. Although some researchers (e.g., Freyne & Wrigley, 1996; Schaufeli, 1990) have examined workplace aggression from the perspective of workers who admit to having perpetrated aggression against clients, no studies have been conducted among HCWs in AIDS care in Nigeria. Nevertheless, in various international studies such as those of Jewkes, Abrahams, and Mvo (1998) in South Africa, Jeffery, Jeffery, and Lyon (1989) in North India, Mernissi (1975) in Morocco, and Sargent and Bascope (1996) in Jamaica, the authors have reported that, in order to assert their authority and to control patient behaviors, nurses in public-health settings have employed humiliation, verbal coercion, and even physical violence.

Implicit in the care provided by the health professional to the client is a cordial relationship between the two parties. Unfortunately, in the existing literature researchers have reported that patient abuse is a serious problem in most developing countries (Jeffery et al., 1989; Mernissi, 1975; Sargent & Bascope, 1996). Patient abuse is considered not only unethical, but as forming a barrier to achieving quality health care and efficient service delivery. This is considered to be the case particularly in the context of AIDS care and, specifically, in Nigeria where PLWAs depend so much on the public-health system for their care. In this context, our concern was that, as with the models of aggression perpetrated against workers, there should be models of aggression perpetrated against PLWAs in order to prevent the occurrence of actual physical aggression during service interactions. To achieve this goal, in the present study we investigated the influence of burnout and perceived fear of AIDS on aggressive tendency toward PLWAs among HCWs in AIDS care in Nigeria. We believe that this study is important because understanding the psychosocial factors associated with the tendency of HCWs to perpetrate aggression against clients will assist researchers, organizations, policymakers, and other stakeholders in designing appropriate psycho-environmental interventions to prevent this aggression.

This study was guided by the revised frustration-aggression hypothesis proposed by Berkowitz (1989), in which it is stated that a stressful work environment is a precursor of direct or displaced aggression towards others. This means that a stressful and unsafe work environment, such as the AIDS care environment, in which demands are placed on HCWs beyond the resources available for AIDS care, puts those workers at risk of burnout and heightens their anxiety concerning occupational contagion. In a scenario where, because of ethical reasons and organizational sanctions, HCWs cannot get away from the situation, or express their fears and frustrations, the HCWs may resort to aggression towards the PLWAs as a means of self-protection.

Generally, HCWs in AIDS care in Nigeria are an important group to study in relation to the associations among burnout, perceived fear of AIDS, and aggressive tendency toward the people they are treating for AIDS, because the nature of their work exposes them to a heavy workload and a work environment that is overcrowded--conditions that are partly caused by the fact that AIDS care is free in public hospitals in Nigeria. These doctors and nurses perform their work in settings full of challenges that include understaffing, poor remuneration, long working hours, occupational hazards, and inadequate resources and facilities, such as an unreliable and intermittent power supply, inadequate basic safety equipment, and recycling/reuse of instruments. Working in this situation may increase their fear of occupational contagion and make them more vulnerable to high levels of burnout. If this is so then burnout and perceived fear of AIDs should both be related to an aggressive tendency toward PLWAs among doctors and nurses working in the field of AIDS care.

Burnout is a physical, mental, and emotional response to constant levels of high stress, and it is regarded as a work-related state of mind (Maslach, Schaufeli, & Leiter, 2001). It is characterized by exhaustion (draining of mental energy as a result of emotional demands), depersonalization, cynicism (negative attitude toward or detached response to clients), and reduced personal accomplishment (feeling of underachievement regarding service delivery). A high level of burnout is common among workers in the health and social service fields who are concerned with AIDS care (Bennett, Kelaher, & Ross, 1994).

Individual perception could influence aggressive tendency. According to Gross (2010, p. 225) perception is the organization and interpretation of incoming sensory information to form inner representations of the external world. Individuals can perceive the same stimulus differently, meaning that two HCWs in AIDS care may perceive the risk of contracting HIV differently. HCWs in AIDS care have to deal with many social, psychological, medical, and legal challenges in their work--such as the social stigma associated with caring for PLWAs, blame for infection, fear of infection, lack of right to refuse care, conflict of interest between the worker's need to protect self and the need to provide medical care to PLWAs without discrimination, and the stress associated with AIDS care. Thus, real or imagined fear about contracting HIV during contact with PLWAs can result in HCWs resorting to aggression in an attempt to shield themselves from infection by directing their hostility toward the PLWAs.

Some researchers have found associations between aggression and various psychosocial antecedents--such as mental fatigue (Kaplan, 1987), stress (Bolger, Thomas, & Eckenrode, 1997), and irritability (Kavoussi & Coccaro, 1998). Social cues in the environment have been implicated in human behavior (Bandura, 1977). In this context, Greenberg and Barling (1999) identified associations among the changing nature of work, increasing stress, and counterproductive workplace behaviors. Bennett et al. (1994) reported that nurses who worked in HIV/AIDS wards experienced burnout more often compared with those working in oncology and geriatric wards. Mackintosh and Tibandebage (2000) submitted that feelings of overload and abandonment by doctors were associated with a culture of abuse directed at patients by nurses. Jewkes et al. (1998) and Ehlers (2006) reported incidences of aggression, disrespect, and insensitive behavior by health workers towards PLWAs.

Following on from this literature review, we developed the following hypotheses:

Hypothesis 1: There will be a significant positive relationship among burnout, perceived fear of AIDS, category of staff (medical practitioners or nurses), and aggressive tendency toward PLWAs.

Hypothesis 2: Burnout, perceived fear of AIDS, age, job tenure, gender, education level, and category of staff (medical practitioners or nurses) will all influence aggressive tendency toward PLWAs.

Method

Sample

The sample consisted of 242 AIDS care workers (130 [35.7%] medical practitioners and 112 [46.3%] nurses) in Nigeria, of whom 122 (50.45%) were women and 120 were men (49.6%). The average age of the respondents was 33.83 years (SD = 13.85), with a range from 19 to 63 years. With regard to marital status, 158 (65.3%) were married, 77 (31.8%) were single, 3 (1.2%) were separated, and the remaining 4 (1.7%) were divorced. In terms of professional qualifications the largest group in the sample (112; 46.3%) reported having a Bachelor of Medicine/Bachelor of Surgery or a Bachelor of Science degree and others reported various levels of education comprising registered nurse (49; 20.2%), Higher National Diploma (21; 8.7%), postgraduate degree (5; 2.1%), and nursing students on internship (55; 22.7%). Participants' religious affiliation was as follows: Christians, 71.5%; Moslems, 27.7%; and those who follow indigenous or traditional religions, 0.8%. The average tenure was 6.76 years (SD = 8.0), with a range of from 1 to 32 years. Almost 74% of participants were interns, about 49% were matrons, 11.2% were doctors, 15% were chief nursing officers, and the remaining 31.8% did not indicate their employment status.

Instruments

In addition to providing the above demographic information, participants completed the following measures.

Perceived fear of AIDS. Perceived fear of AIDS was measured using the 50-item Multidimensional AIDS Anxiety Questionnaire (MAAQ; Finney & Snell, 1989; Snell & Finney, 1996), which is rated on a 5-point Likert scale ranging from 0 = not characteristic of me to 4 = very characteristic of me. Higher scores correspond to greater AIDS-related anxiety. Cronbach's [alpha] was .96 in this study.

Burnout. Burnout was assessed using the Maslach Burnout Inventory-Human Services Form (MBI; Maslach, Jackson, & Leiter, 1996). The MBI consists of 22 items divided into three subscales: emotional exhaustion (eight items), depersonalization (five items), and personal accomplishment (seven items). The items are scored on a 7-point Likert scale, from 1 = never to 7 = daily. The scores on each subscale are added up to indicate a total burnout score, with higher scores indicating a greater degree of burnout. In this study, the word client(s) used in the inventory items was replaced by patient(s). Cronbach's [alpha] was .95 in this study.

Aggression. Aggressive tendency was measured using the 29-item Aggression Questionnaire (AQ; Buss & Perry, 1992), which is rated on a 5-point Likert scale ranging from 1 = extremely uncharacteristic of me to 5 = extremely characteristic of me. There are four subscales: physical aggression (nine items), verbal aggression (five items), anger (seven items), and hostility (eight items). An aggressive tendency score is reached by summing up all scale items, with higher scores indicating a more aggressive tendency. Cronbach's [alpha] was .85 in this study.

Procedure

We conducted a cross-sectional survey in three hospitals in Ondo State, Nigeria, of which one was a federal medical center and two were state hospitals. The inclusion criterion was that the hospitals had clinics dedicated to AIDS care. To gain access to the participants, the researchers had preliminary contact with the management authorities of the selected hospitals to get approval for data collection. Our purpose in the study was explained to them and they were assured that the names of the hospitals and individuals who participated in the study would not be revealed in any way. Moreover, we stressed the fact that the participants would not come to any harm by participating in the study and that they could complete the surveys anonymously. The authorities were also informed that the study outcome was for research purposes only. The survey was collated presenting the MAAQ first, the MBI second, and the AQ last, and took between 20 and 26 minutes to complete. We personally handed over 300 survey forms to administrative officers at the hospitals, who could contact us if they needed additional information. The administrative officers were asked to encourage the HCWs in AIDS care to complete the survey forms. In order to enhance the response rate we made a repeat visit to the hospitals two weeks after the survey forms had been distributed. At the end of the third week, we had collected 242 valid completed survey forms, yielding a response rate of 80.67%.

Statistics

We conducted statistical analyses with SPSS version 17.0. Descriptive analyses, Pearson's r correlations, and linear multiple regression analyses were used to test the hypotheses. The level for significance was set at p < .05.

Results

To examine whether or not AIDS anxiety and burnout were significantly correlated with aggressive tendency, we computed Pearson's r correlation among the variables. Intercorrelations, means, and standard deviations for all continuous measures used in this study are presented in Table 1.

The correlation between AIDS anxiety and aggressive tendency was significant, meaning that an increase in perception of fear of AIDS was associated with an increase in aggressive tendency. Burnout was moderately but significantly associated with aggressive tendency, suggesting that the tendency to perpetrate aggression increases as levels of burnout become greater. Also, staff category correlated negatively with aggressive tendency, indicating that nurses were more likely than others to score highly on aggressive tendency. These results confirm the first hypothesis.

The results of the linear multiple regression analyses for the variables influencing aggressive tendency are presented in Table 2.

The results showed a significant joint influence of AIDS anxiety, burnout, and staff category on aggressive tendency. This shows that the three predictors jointly accounted for 49% of the variance in aggressive tendency. In relative terms, AIDS anxiety made the largest contribution to the explanation of aggressive tendency, followed by burnout, suggesting that an increased level of AIDS anxiety is associated with an increase in aggressive tendency. An increased level of burnout was also associated with an increase in aggressive tendency. Lastly, staff category contributed significantly to the explanation of aggressive tendency. Thus, Hypothesis 2 was supported because the three independent variables significantly influenced aggressive tendency.

Discussion

The results show that psychosocial factors were associated with tendency to perpetrate aggression against PLWAs by HCWs in AIDS care. First, taken together, AIDS anxiety, burnout, and staff category were related to aggressive tendency, jointly accounting for about 49% of the variance and suggesting that other variables not considered in the study accounted for about 51%. Independently, the findings indicated that AIDS anxiety had a stronger and more significant relationship with aggressive tendency. Aggression toward PLWAs may be a response to real or imagined susceptibility to HIV infection. One of the social costs of a stressful and unsafe work environment may be the displacement of aggression, so that it is directed towards the clients.

Our finding that there was an association between burnout and aggressive tendency suggests that working in an environment that places demands on workers beyond the availability of necessary job resources increases the vulnerability of those workers to burnout, and aggression towards patients may also be a negative outcome. At the interpersonal level, workers may direct their aggression toward those they perceive to be responsible for their frustration. But because of ethical reasons/organizational sanctions, directing aggression toward the management is not a viable option for HCWs. Subordinates and coworkers are not in positions in which they have the capability to be able to remove the frustration of HCWs, and would not necessarily be perceived as being the cause of the frustration. In this situation--as shown by the results in this study--PLWAs become a group vulnerable to being the target of aggressive tendencies of HCWs because of their health condition and the stress associated with caring for them. Thus, doing a job in which the demands are high and in which there are few resources generates burnout, and excessive burnout is a precursor to displacement of aggression. Our findings in this study are consistent with the frustration-aggression hypothesis of Berkowitz (1989) and with findings in studies conducted in the specific area of health-care research (Bolger et al., 1997; Greenberg & Barling, 1999; Kaplan, 1987; Kavoussi & Coccaro, 1998).

Furthermore, in our study staff category explained about 10% of the variance in aggressive tendency; one reason for this may be that the sample was substantially composed of interns. The fact that they were not in permanent employment and received no remuneration, yet were performing similar functions to those who were in paid permanent employment may have increased their fear of contagion and burnout, and may have lessened their commitment to PLWAs. Nevertheless, Bennett et al. (2004) reported that nurses working in AIDS care experienced more burnout compared to nurses working in oncology and geriatric wards. This was because they felt overloaded and abandoned by doctors who were responsible for patient care (Mackintosh & Tibandebage, 2000). In previous research it has been reported that this feeling was responsible for aggression, disrespect, and insensitive behavior directed against PLWAs (Ehlers, 2006; Jewkes et al., 1998).

Conclusion and Implications of Findings

Our findings in this study indicated that perceived fear of AIDS was related to HCWs' tendency to perpetrate aggression against PLWAs. Therefore, in order to prevent acts of aggression toward PLWAs, the initial concern of health-sector management should be to reduce, if not totally eliminate, fear of occupational contagion by, for example, ensuring that HCWs are not working in an unsafe work environment. In order to alleviate the perceived fear of AIDS among HCWs, and to maximize their safety, stakeholders in the health sector should focus on implementing infection prevention strategies, such as the provision of safer personal protective equipment and devices, adherence to universal precautions (e.g., use of protective eyewear, recapping of contaminated needles), effective postexposure management, and injury surveillance.

We found that burnout was positively related to aggressive tendency. This finding implies that health-sector organizations should embark on the identification of stress factors in AIDS care with the aim of preventing HCWs suffering from these factors before they degenerate to the level of burnout and negative behavioral outcomes such as aggression. Burnout prevention/intervention programs can be either person-directed, or organization-directed, or a combination of the two. Person-directed intervention programs may include cognitive-behavioral measures such as counseling, coping and communication skills training, organizational support, and exercises for relaxation. Organization-directed interventions may include changes in the work procedures, such as decreasing job demands through task restructuring, provision of more and better job resources, increasing job control, and training for stress management. Our findings in this study intensify the need for health organizations to provide a positive and supportive working environment for the HCWs in order to reduce tendency to perpetrate aggression against patients.

The study has some limitations. First, the data are cross-sectional, making causal inferences regarding relationships problematic. Further, data on physical aggression were not available, but in the literature a link between psychological aggression and physical aggression has been reported. In addition, given the nature of the topic under investigation, social desirability may have affected the likelihood of obtaining accurate reports of aggressive tendency. In future studies, researchers should control for social desirability. The generalizability of results is limited because all respondents were employed at only three public hospitals within a single state in Nigeria. Therefore, replication of this research across the whole state and other states in Nigeria would be valuable.

In conclusion, our findings in this study help in closing the gap in knowledge about tendency to perpetrate aggression against PLWAs among HCWs in AIDS care in Nigeria, and provide a starting point for addressing the influence of certain psychosocial factors in client-directed aggression. Those who are implementing strategies to reduce aggressive tendency among HCWs should focus on fear of occupational infection and workplace factors such as burnout. Finally, future researchers should investigate the extent to which additional organizational factors (e.g., perception of equity) and person behavioral traits influence employee aggression.

http://dx.doi.org/10.2224/sbp.2013.41.10.1625

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OLUYINKA OJEDOKUN, ERHABOR SUNDAY IDEMUDIA, AND VICTORIA OPEOLUWA KUTE

North-West University

Oluyinka Ojedokun, Erhabor Sunday Idemudia, and Victoria Opeoluwa Kute, Department of Psychology, North-West University.

Correspondence concerning this article should be addressed to: Oluyinka Ojedokun, Department of Psychology, Faculty of Human and Social Sciences, North-West University, Private Bag X2046, Mmabatho 2735, South Africa. Email: yinkaoje2004@yahoo.com
Table 1. Correlation Showing the Relationship Among the Variables

Variable                1        2         3        4       5

Aggressive tendency   --
Fear of AIDS          .60 **   --
Burnout               .52 **   .34 **   --
Age                   .10      .13 *    .17 **    --
Length of service     .13      .18 **   .17 **    .61 **   --
Staff category       -.16 *    .04     -.43 **    .01     .12
Gender               -.01     -.04     -.01      -.06     .01

Variable                6      7      M       SD

Aggressive tendency                  85.90    32.76
Fear of AIDS                        113.25    43.34
Burnout                              66.43    21.49
Age                                  33.83    11.53
Length of service                     6.76    10.70
Staff category        --            --        --
Gender               .42 **    --   --        --

Note. N = 242; * p < .05, **p < .01.

Table 2. Simple Linear Multiple Regression of Antecedents
of Aggressive Tendency in HCWs

Variable                P       t        p     R

Fear of AIDS          .47    9.36    < .001
Burnout               .36    7.08    < .001   .70
Staff category       -.10    -2.20   < .05

Variable         [R.sup.2]      F        P

Fear of AIDS
Burnout               .49    44.56   < .001
Staff category
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Author:Ojedokun, Oluyinka; Idemudia, Erhabor Sunday; Kute, Victoria Opeoluwa
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:6NIGR
Date:Nov 1, 2013
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