Linking Workplace Aggression to Employee Well-Being and Work: The Moderating Role of Family-Supportive Supervisor Behaviors (FSSB)

This study examines the role of family-supportive supervisor behaviors (FSSB) in influencing the relationship between workplace aggression and well-being and work outcomes. It suggests that FSSB is a trainable resource that healthcare organizations should facilitate to improve employee work and well-being in settings with high workplace aggression.

Linking Workplace Aggression to Employee Well-Being and
Work: The Moderating Role of Family-Supportive Supervisor
Behaviors (FSSB)
Nanette L. Yragui1, Caitlin A. Demsky2, Leslie B. Hammer2, Sarah Van Dyck2, and Moni B.
Neradilek3
1Washington State Department of Labor & Industries, SHARP Program, 243 Israel Rd SE, Bldg 3,
Olympia, WA 98501, USA
2Department of Psychology, Portland State University, Portland, OR, USA
3The Mountain-Whisper-Light Statistical Consulting, Seattle, WA, USA
Abstract
Purpose—The present study examined the moderating effects of family-supportive supervisor
behaviors (FSSB) on the relationship between two types of workplace aggression (i.e., patient-
initiated physical aggression and coworker-initiated psychological aggression) and employee well-
being and work outcomes.
Methodology—Data were obtained from a field sample of 417 healthcare workers in two
psychiatric hospitals. Hypotheses were tested using moderated multiple regression analyses.
Findings—Psychiatric care providers’ perceptions of FSSB moderated the relationship between
patient-initiated physical aggression and physical symptoms, exhaustion and cynicism. In addition,
FSSB moderated the relationship between coworker-initiated psychological aggression and
physical symptoms and turnover intentions.
Implications—Based on our findings, family-supportive supervision is a plausible boundary
condition for the relationship between workplace aggression and well-being and work outcomes.
This study suggests that, in addition to directly addressing aggression prevention and reduction,
family-supportive supervision is a trainable resource that healthcare organizations should facilitate
to improve employee work and well-being in settings with high workplace aggression.
Originality—This is the first study to examine the role of FSSB in influencing the relationship
between two forms of workplace aggression: patient-initiated physical and coworker- initiated
psychological aggression and employee outcomes.
Keywords
Workplace aggression; Family-supportive supervisor behaviors; Occupational stress; Health;
Conservation of resources theory
Correspondence to: Nanette L. Yragui.
HHS Public Access
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Published in final edited form as:
J Bus Psychol. 2017 April ; 32(2): 179–196. doi:10.1007/s10869-016-9443-z.
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Workplace aggression has emerged over the past 25 years as an important worldwide
research topic in occupational health psychology, and refers to physical and nonphysical
negative acts carried out against an organization or its members, which harms employees
(Neuman and Baron 2005). Limited prevalence estimates suggest that six percent of the U.S.
employees across all occupations have experienced physical violence at work in the previous
12 months, while 41.4 % of employees have experienced psychological aggression at work
within the past year (Schat et al. 2006). A recent review of workplace violence prevalence
acknowledges that much of the empirical research since 2000 has focused on employees in
professional and service occupations (e.g., nurses, social workers, police officers, etc.), as
these employees exhibit a higher likelihood of experiencing workplace violence (Piquero et
al. 2013).
Thus, while workplace aggression may be a concern for all employees, research has
indicated higher frequencies of physical and nonphysical aggression in the healthcare sector,
particularly in psychiatric settings (Gerberich et al. 2004). Recent data from the U.S.
Department of Justice suggest that those in government mental health occupations have one
of the highest levels of workplace physical violence at 7.8 %, second only to law
enforcement-security and teaching (Harrell 2013). However, these statistics should be
considered in the context of reporting practices. Healthcare workers experience patient
aggression as being “a part of the job” and subsequently underreport physical aggression
incidents to their employers (Findorff et al. 2005). More recent prevalence estimates in the
healthcare industry suggest that approximately 30 % of nurses report having experienced
some form of workplace aggression (Campbell et al. 2011). Those in psychiatric hospitals
report the highest levels of exposure to workplace aggression with 70 % of care providers
reporting patient physical aggression and 92 % reporting coworker verbal conflict (Kelly et
al. 2015). In a recent review of violence research, Spector et al. (2014) reported that in the
Anglo world region which includes the United States, 87.7 % of nurses and nursing
assistants were exposed to physical aggression from patients. In addition, 37.4 % of nurses
were exposed to nonphysical aggression from healthcare staff. While these statistics
emphasize the pervasive nature of workplace aggression for healthcare providers, some
important research gaps exist in understanding forms and sources of aggression as well as
processes that affect the impact aggression has on care provider health and work outcomes.
To address these gaps, our study examines two distinct forms (i.e., physical and
psychological) and sources (i.e., patient and coworker) of aggression—patient physical
aggression and coworker psychological aggression—in a sample of psychiatric hospital
workers. Patient physical aggression is an assault that may or may not result in injury (e.g.,
hitting, biting, etc.). Coworker psychological aggression is nonphysical aggression (e.g.,
yelling, insulting, excluding, etc.) from a hospital employee including coworkers and
supervisors (e.g., nursing, social work, psychology, etc.). While patient psychological
aggression does commonly occur in psychiatric settings, nursing staff adjust to this knowing
patients are mentally ill and are committed to the institution against their will (Chapman et
al. 2010). We chose to focus on patient physical aggression because it has greater
consequences for care providers in terms of physical harm. Prior research has documented
psychiatric hospital staff exposure to patient physical aggression (Kelly et al. 2015), and a
range of consequences may include injury (Spector et al. 2014), psychological distress
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(McKenna et al. 2003), post-traumatic stress symptoms (Gates et al. 2011; Gillespie et al.
2013), and fatality in rare circumstances (CDC 2012). In addition, coworker physical
aggression is a rare occurrence in healthcare settings; thus, we chose to focus on coworker
psychological aggression as it occurs with greater frequency (Lanza et al. 2006). Spector et
al. (2007) found that physical violence and verbal aggression were common in a hospital
setting with physical violence perpetrated primarily by patients and family members and
verbal aggression by staff members. Our choice to examine different forms and sources of
workplace aggression is in line with recent calls by researchers (e.g., Hershcovis and Barling
2010) in an effort to identify potential differential relationships with employee and
organizational outcomes.
In addition, we examine FSSB as a key element of the relational and social contexts in
which an individual is embedded at work. We propose FSSB has an influence on reactions to
workplace physical and psychological aggressions, work stressors that negatively impact
employee health, well-being, and work outcomes (Aquino and Thau 2009; Bowling and
Beehr 2006; Hershcovis and Barling 2010). We further propose that the contextual resource
of supervisor support is important in the context of psychiatric care settings where the
stressors of patientinitiated physical aggression and coworker-initiated psychological
aggression occur. In our formative research described below, psychiatric supervisors and
care providers reported on the challenges of managing employees’ work– family conflict.
Thus, family-specific supervisor support, or FSSB, is expected to serve as an important
resource for employees that creates a positive context where employees are valued and
respected and thus will moderate the negative effects of physical and psychological
aggressions on employee work and well-being outcomes. FSSB has been defined as “those
behaviors exhibited by supervisors that are supportive of families and consist of managerial-
initiated actions to restructure work to facilitate employee effectiveness on and off the job”
(Hammer et al. 2009, p. 839). The construct of FSSB is composed of emotional support,
instrumental support, role modeling, and creative work–nonwork management across the
two interrelated domains of work and nonwork.
The importance of the construct of FSSB in psychiatric settings emerged in our formative
research at the psychiatric hospitals in which we attended management meetings, conducted
direct observations on the wards as well as care provider focus groups and supervisor/
manager individual interviews (Yragui et al. 2009, 2011). We sought to learn about sources
and types of aggression as well as the context for aggression and its impact on employees’
health and work. The qualitative analyses revealed the importance of family-supportive
supervision for care providers among other themes related to social support and patient- and
coworker-initiated aggression. The results included several points: (1) care providers
reported that they wanted their supervisors to appreciate them as a whole person and
acknowledge their challenges in managing work–nonwork conflicts including assistance
with solving the problems they encountered in managing their time and effort across the two
spheres; (2) care providers took unscheduled absences as “mental health days” to cope with
stress from patient and coworker aggression; (3) care providers reported using unscheduled
sick leave to attend to nonwork responsibilities because on many units the supervisors would
not allow schedule flexibility and the hospital had no policy to support switching schedules
with another care provider. The unscheduled absences left wards understaffed which
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increased the risk of patient aggression; (4) some supervisors confirmed the lack of schedule
flexibility; however, other supervisors reported that they used their discretion to provide this
resource to their employees as a reward for reliable attendance and providing quality patient
care; 5) finally, supervisors also reported that this approach led to more satisfied staff and
therefore safer staff through reductions in patient aggression. These research results suggest
that supervisor support for employees’ work–nonwork management was variable. We found
that some supervisors provided resources to support employees’ effectiveness in both work
and nonwork domains through family-supportive supervision. These supervisors chose to
expand their support approach to include employees’ work and nonwork domains rather than
limiting their support solely to the work domain.
In sum, knowledge gained from our prior formative research informed our focus on FSSB in
the context of workplace aggression. The current study is the first to examine this particular
constellation of relationships in a setting that is understudied, namely psychiatric hospitals.
We therefore chose to examine direct effects of two types and sources of aggression as well
as supervisor support for the work–nonwork interface as a boundary condition for workplace
patient-initiated physical and coworker-initiated psychological aggression and care provider
well-being and work outcomes.
Prior research has shown FSSB improves both familyspecific and more general work and
well-being outcomes for employees (Hammer et al. 2011; Kossek et al. 2011). In validating
the FSSB measure, Hammer et al. (2009, 2013) found FSSB was significantly negatively
related to workto- family conflict, turnover intentions, and significantly positively related to
job satisfaction, over and above the effects of general supervisor support. In addition, Odle-
Dusseau et al. (2012) found significant relationships over time between employee
perceptions of FSSB and reduced turnover intentions, increased job satisfaction, and
increased supervisor ratings of employee job performance. We argue that FSSB provides
resources to employees in line with the conservation of resources theory (COR; Hobfoll
1989) and thus results in improved work, health, and well-being outcomes for employees
that are workrelated, nonwork-related, and more general, including support that leads to
increased personal resources for employees. Thus, FSSB provides employees a means to
better manage competing work and family demands and is especially relevant in the context
of the demands of workplace aggression. Supervisors that proactively provide work–
nonwork-specific support meet their employees’ need to replenish resources within and
outside the work domain (Hammer et al. 2015).
Furthermore, it is important to note that training supervisors to enact FSSBs has proven to be
effective in improving work and well-being outcomes for employees in several randomized
control trials (e.g., Hammer et al. 2011, 2015; Kelly et al. 2014; Olson et al. 2015). More
specifically, such FSSB training provides an organizational approach to improving work and
health outcomes for employees and thus provides a potential intervention for high stress
occupations such as that of psychiatric care workers who experience numerous stressors on
the job including workplace aggression.
To our knowledge, no studies have examined the role of FSSB in influencing the
relationship between workplace aggression and employee outcomes. Work–family research
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has shown that employees managing demands from multiple roles such as work and family
leads to reduced resources and increased strain (Grandey and Cropanzano 1999; Hammer et
al. 2013). In a psychiatric care context, work–nonwork support is a meaningful resource
emotionally and practically because care providers must manage work and nonwork
stressors in the context of workplace aggression. General supervisor support focuses solely
on employee performance in the work domain. Supervisor work–nonwork support facilitates
employees’ ability to effectively manage in both work and nonwork spheres (Hammer et al.
2009; Thomas and Ganster 1995). This is enacted through supervisor helping behaviors and
attitudes such as empathy with an employee’s motivation and need to balance work and
nonwork roles (Thomas and Ganster 1995).
Supervisor work–nonwork support is valuable in that it offers more than general support in
buffering stress from job demands (i.e., patient-initiated and coworker-initiated aggression)
and helps to conserve resources in the twodomains of work and nonwork (Allen 2001). For
example, a supervisor may provide schedule flexibility and time off from work with the
understanding that an employee’s unaddressed strain due to patient physical aggression may
impact their ability to manage in the domains of work and nonwork as well as understanding
that it is in the nonwork domain that the care provider may find respite from workplace
physical aggression incidents. In the case of physical aggression, sick leave may be desired
for physical recovery and rest at home if injury occurred. In many cases, psychiatric care
providers return to work in the same ward with the same aggressive patient and time away to
regroup physically and mentally may be welcome.
In addition, psychological aggression has been documented as a stressor that depletes
personal resources and may be associated with exhaustion (Estryn-Behar et al. 2008). In this
case, resource replenishment in the nonwork domain is more likely to be achieved where the
target can separate from the source of aggression either through time spent with family, with
friends, or through leisure activities. Therefore, employees who experience psychosomatic
or psychological strain due to coworker psychological aggression, may value FSSBs as a
particularly important resource in buffering the negative effects of the aggression.
Supervisors may proactively provide needed emotional support to prevent exhaustion that
may occur in work and nonwork domains and schedule flexibility that allows for separation
or recovery should negative effects occur or to prevent their occurrence.
In sum, the current study provides two important contributions to the literature. First,
workplace aggression scholars have called for examining the source of workplace aggression
(Hershcovis and Barling 2010), and in response, we examine two distinct forms and sources
of aggression— patient physical aggression and coworker psychological aggression
experienced by a sample of psychiatric hospital workers. Second, the majority of workplace
aggression literature has focused on identifying the antecedents and outcomes of various
aggression constructs (e.g., Bowling and Beehr 2006; Hershcovis and Barling 2010).
However, we identify a trainable workplace resource (i.e., FSSB; Hammer et al. 2009, 2011,
2015; Kelly et al. 2014) that may reduce the negative impacts of workplace aggression and
we examine the moderating effects of FSSB on employees’ health and work outcomes. In
this study, we examine direct relationships that allow us to replicate prior research regarding
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two types and sources of workplace aggression specific to psychiatric settings while also
providing contextual knowledge for understanding the moderating effects of FSSB.
Theoretical Rationale and Hypothesis Development
Drawing on previous empirical research, as well as the conservation of resources theory
(COR; Hobfoll 1989, 2001), we argue that workplace aggression is a workplace stressor that
depletes employees’ resources. COR theory proposes that strain results from the loss of
resources, threat of resource loss, or a lack of resource replenishment after the investment of
resources. Resources are defined as objects, valued conditions, personal resources, or
energies that serve as a means for obtaining additional resources which the individual values
and strives to obtain, preserve, and protect (Hobfoll 1989). Resources are particularly
valuable in psychiatric care environments where patient physical aggression can result in
injury, lost work time, and increased fear of patients (Myers et al. 2005; Whittington and
Wykes 1992). In addition, patient physical and coworker psychological aggression may
stimulate anxiety and frustration (Bowling and Beehr 2006) which may increase resource
loss over time through expenditures of personal energies in managing affect (e.g., distress).
Through the lens of COR theory (Hobfoll 1989, 2001), experienced psychological
aggression from coworkers can also be conceptualized as a job stressor that depletes
employee cognitive and affective resources. In the absence of resource replenishment,
employees may experience reduced levels of well-being or poor work outcomes. In addition,
employees may be left without sufficient motivational resources to enact key behaviors in
the workplace, such as maintaining therapeutic interactions with distressed patients to
prevent patient aggression. Finally, the loss of employment may occur if the target is
severely injured in a patientinitiated aggression incident or determines the strain of coworker
psychological aggression outweighs the benefits of employment and leaves the organization
(Deery et al. 2011; Estryn-Behar et al. 2008; Sofield and Salmond 2003).
In psychiatric care settings, relationships among care providers are critical to maintain
patient and staff safety. For example, providing patient care safely requires that hospital staff
work in pairs frequently and rely on one another to monitor and communicate each patient’s
status. Social exchange theory (SET) posits that individual interactions tend to be seen as
interdependent and contingent on the actions of the other person. These interactions also
generate obligations, and can have the potential to generate high-quality relationships under
certain circumstances (Blau 1964; Cropanzano and Mitchell 2005). In a review article,
Parzefall and Salin (2010) argued that both relationships with coworkers and contextual
features are factored into employees’ judgments about their social exchange relationships at
work. Under these circumstances, it is likely that the experience of workplace aggression
from coworkers may have different effects on employees than aggression from patients who
have severe mental illness and histories of aggression associated with mental illness.
Drawing on SET (Cropanzano and Mitchell 2005; Parzefall and Salin 2010), coworker
psychological aggression may be seen as violating norms of workplace exchange-based
relationships, and thus detract from employees’ overall evaluations of the work environment.
Experiencing aggression from coworkers may be seen as a form of injustice, which has been
associated with negative employee attitudes and decreased performance (Berry et al. 2007;
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Cohen-Charash and Spector 2001). In addition, coworkers that are seen as representatives of
the organization may influence employee attitudes via social exchange processes (Chang and
Lyons 2012). In the context of psychiatric care provision, in which coworkers are vital to
work safely with patients, coworkers may play a similar exchange communication role in
promoting or undermining aggression preventative behaviors.
Patient Physical Aggression
Hogh and Viitasara (2005) reviewed a number of consequences of patient nonfatal
workplace violence and found a range of psychological symptoms including fear of the
assaultive patient, anger, and resentment toward the patient, distress, and fatigue. Aggression
from outsiders, which would include patient aggression, has been associated with increased
psychological distress, emotional exhaustion, and decreased physical well-being (Hershcovis
and Barling 2010; Speroni et al. 2014).
Empirical evidence suggests that workplace aggression from patients significantly influences
the recruitment of nurses and turnover intentions (Deery et al. 2011; Estryn-Behar et al.
2008; Sofield and Salmond 2003). In addition, recent research has suggested that employees
who perceived that their employer took steps to prevent violence were less likely to exhibit
intentions to leave the organization (Mueller and Tschan 2011). Finally, exposure to
workplace aggression from patients has been associated with higher levels of job
dissatisfaction (Merecz et al. 2009). Therefore, in line with COR theory, SET theory, and
prior empirical evidence, we propose the following:
Hypothesis 1a Patient physical aggression will be positively related to poor employee health
and psychological strain (i.e., stress-related physical outcomes, exhaustion, and cynicism).
Hypothesis 1b Patient physical aggression will be positively related to poor employee work
outcomes (i.e., job dissatisfaction and organizational turnover intentions).
Coworker Psychological Aggression
Research suggests coworker aggression is associated with reduced health and well-being and
negative work attitudes including worse physical symptoms, burnout, and job satisfaction
(Bowling and Beehr 2006; Lapierre et al. 2005; Merecz et al. 2009). Guidroz et al. (2012)
found that interpersonal conflicts with doctors, patients, and supervisors influenced nurses’
retention outcomes by increasing their emotional exhaustion. In addition, previous research
suggests that coworker psychological aggression is related to somatic symptoms such as
headaches (Bowling and Beehr 2006; Hershcovis and Barling 2010).
In a longitudinal study, evidence demonstrated a causal relationship between workplace
coworker aggression and self-reported health and work outcomes (De Raeve et al. 2008). In
this study, coworker aggression was shown to be a statistically significant risk factor for an
elevated need for recovery, prolonged fatigue, and turnover. Other research has also linked
coworker psychological aggression to turnover (Chang and Lyons 2012), a costly outcome
for organizations. Drawing on COR and SET theory and prior research, we propose the
following:
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Hypothesis 2a Coworker psychological aggression will be positively related to poor
employee health and psychological strain (i.e., stress-related physical symptoms, exhaustion,
and cynicism).
Hypothesis 2b Coworker psychological aggression will be positively related to poor
employee work outcomes (i.e., job dissatisfaction and organizational turnover intentions).
The Moderating Role of Family-Supportive Supervisor Behaviors
FSSB has been linked to a number of employee outcomes, including lower levels of turnover
intentions and higher levels of job satisfaction (Hammer et al. 2009, 2011; Odle-Dusseau et
al. 2012). COR theory suggests that job resources may buffer the impact of job demands on
stress reactions, which include burnout. FSSB serves as a workplace resource that may halt
resource loss spirals, and in turn buffer the negative effects of workplace aggression.
Furthermore, Cohen and Wills’ (1985) stress buffering hypothesis states that social support
protects employees from the negative effects of stressful experiences. Schat and Kelloway
(2003) found that organizational support moderated the effects of workplace violence on
both individual and organizational outcomes. As mentioned earlier, FSSB is a form of social
support that is specifically support provided by the supervisor (an aspect of organizational
support) that is suggested to moderate the relationship between workplace aggression and
strain outcomes. Thus, organizational researchers consider the supervisor as the linking pin
between the worker and the organization, and FSSB as a moderator serves as a proximal
indicator of a social support process that accounts for the whole person who must manage
effectively in two domains: work and nonwork.
In addition to serving as a potential buffer of the relationship between workplace aggression
and employee outcomes, we also suggest that FSSB may have a direct, preventative effect on
employee negative health and well-being and work outcomes. Though limited, some
previous research has identified the role of support as a resource for employees experiencing
workplace aggression. For example, supervisor support has been shown to decrease the odds
of both physical and psychological aggression in a healthcare organization (Findorff et al.
2004). Similarly, supervisors may provide FSSB in an exchange process that rewards
employees for their commitment to high stress psychiatric work.
In line with COR theory and SET theory (Cropanzano and Mitchell 2005; Hobfoll 2001),
supervisors play a key role in helping employees to manage work and family demands.
Psychiatric care can be psychologically demanding work and may be understood as a strain-
based form of work–nonwork conflict that supervisors address with FSSB. With regard to
the present study, we propose that employees experiencing higher levels of patient and
coworker aggression may have an increased need for support for work–nonwork
management. Supervisors who provide FSSB skillfully enact a key role in creating a positive
work environment through providing support. This support allows care providers time off to
obtain additional nonwork resources such as respite from a high demand work environment,
family and friend support, or healthcare services. Recent research has shown that work–
nonwork specific support is more strongly related to reduced work– nonwork conflict than
general supervisor support (Kossek et al. 2011), which may also be relevant in response to
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job stressors (i.e., workplace aggression) that are likely to spillover to negatively impact the
nonwork domain.
Hypothesis 3a FSSB will be negatively related to poor employee health and well-being (i.e.,
stress-related physical outcomes, exhaustion, and cynicism).
Hypothesis 3b FSSB will be negatively related to poor employee work outcomes (i.e., job
dissatisfaction and organizational turnover intentions).
Hypothesis 4 FSSB will moderate the relationship between patient physical aggression and
poor employee health and well-being outcomes (i.e., stress-related physical outcomes,
exhaustion, and cynicism), and poor work outcomes (i.e., job dissatisfaction and
organizational turnover intentions), such that high FSSB will attenuate the relationship
between patient physical aggression and employee outcomes.
Hypothesis 5 FSSB will moderate the relationship between coworker psychological
aggression and poor employee health and well-being outcomes (i.e., stress-related physical
outcomes, exhaustion, and cynicism), and poor work outcomes (i.e., job dissatisfaction and
organizational turnover intentions), such that high FSSB will attenuate the relationship
between coworker psychological aggression and negative employee outcomes.
Method
Participants and Procedure
Survey data were collected from hospital employees working at two public psychiatric
healthcare hospitals in the Northwestern United States. The hospitals were in the same
healthcare system and had similar organizational structures, policies, procedures, and
resources such as staffing levels and training programs. They were located in different
geographic areas and provided treatment for voluntarily and involuntarily committed
patients with severe mental illnesses such as schizophrenia, major depression, and bipolar
disorder including some patients with criminal histories of violence. The larger hospital
operated with 806 beds and the smaller hospital with 287 beds. Of the 1200 surveys
distributed, 496 were returned for a response rate of 41.3 %. Seventeen cases with missing
data were deleted. In addition, 62 cases identified as participants with no direct patient
contact such as those in managerial, clerical, and administrative positions were removed
from the analysis leaving a sample of N1 = 257 for the first hospital and N2 = 160 for the
second hospital with a combined final sample of N= 417.
Participants were recruited through email notices and through union meetings. We staffed
each hospital area in available conference rooms during each of the three shifts over the
course of a week to recruit and administer paper surveys; surveys were returned directly to
study researchers. Participants completed the surveys during their work time. In addition, an
online survey was set up for hospital care providers. Of the final sample of 417 participants,
43 completed the survey electronically.
In terms of demographic characteristics, participants were mostly female (56.5 %) and
predominately European American/White (63.3 %). The majority of participants were in the
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40–49 (26.3 %) or 50–59 (33.5 %) age ranges, and 65.2 % were married or living as married
with 42.6 % of the sample reporting one or more children living at home. Fifty-four percent
of the participants had an associate’s degree or a bachelor’s degree and 56.3 % reported an
annual household income of $50,000–$60,000 or less. Participants reported contact with
their supervisor with 76.5 % reporting one to multiple face-to-face contacts daily.
Disciplines represented in the sample included 38.4 % licensed nursing, 36.2 % nonlicensed
nursing, 8.4 % psychology, 5.5 % occupational therapies, 2.4 % social work, and 9.1 %
other care provision.
Measures
Participants rated their supervisor’s family-supportive supervisory behaviors with four items
from the FSSB-SF (Hammer et al. 2009, 2013; α = 0.92), and indicated their level of
agreement with items such as “Your supervisor makes you feel comfortable talking to
him/her about your conflicts between work and non-work.” The items were rated on a five-
point Likert-type scale (1 = strongly disagreeto 5 = strongly agree) with higher scores
indicating greater FSSB. Following common practice in studies of nursing violence (Arnetz
et al. 1998; Camerino et al. 2008; Erikson and Einarsen 2004; Niedhammer et al. 2008; Pai
and Lee 2011; Spector et al. 2007), patient physical aggression was measured with one item
asking when the participant experienced physical assault from a patient in the past 2 years.
The response set was 5 = past month, 4 = past 3 months, 3 = past 6 months, 2 = past year, 1
= past 2 years, and 0 = never. The variable was dichotomized, 0 = No, 1 = Yes, to
conceptually clarify whether or not there was exposure to patient physical aggression. We
determined a single-item measure was appropriate as a recall measure of unidimensional and
concrete events, meaning that it consists of one object that is readily and uniformly
imagined, and the attribute of the construct is concrete, again meaning that it is readily and
uniformly imagined (Bergkvist and Rossiter 2007). In this case, we followed practices in
organizational research to reduce survey response burden with the use of a singleitem
measure with the goal of preserving response rates and minimizing nonresponse bias
(Rogelberg and Stanton 2007).
A 2-year reporting time frame was chosen for patient physical aggression, which has a low
base rate. Hulin and Rousseau (1980) reported that a common means of studying infrequent
events is to gather criterion data over longer time intervals. That is, because physical
aggression incidents are low base-rate events, longer time periods for gathering incident data
are often necessary for amounts of variance to be sufficient for detection of relationships
between incidents and health and work outcomes. Moreover, these low-frequency physical
events are very memorable to workers, therefore, a 2-year time frame captures enough
incidents while limiting recall bias effects.1
1Psychiatric hospitals are complex high demand work environments where psychiatric care providers may calm an agitated patient,
assist coworkers in restraining a patient, or be targeted in an aggressive incident. It can be very dangerous work and injury and stress
reactions may occur as strains immediately after an incident or in a delayed response. During the time of our research, there were
patient fatalities and staff hospitalizations due to patient physical aggression, and these events were potentially traumatizing for the
staff on those wards that were directly exposed to the aggression or witnessed it. The strain of health worker psychosomatic or
physical symptoms resulting from patient physical aggression may be long lasting or not depending on the individual response,
severity of injury (hospitalization), disability or impairment, and many other factors. For example, research has found posttraumatic
stress symptoms in health workers exposed to patient physical aggression (Gillespie et al. 2013) and somatic symptoms may emerge
immediately or over time with as much as a 6 month delay before appearing (Gupta 2013). Therefore, stressors and strains can be
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In addition, a 1-year time period is considered in psychological aggression research to be
what individuals can recall accurately on more subtle, covert, and frequently occurring
forms of behavior such as psychological aggression (Chang and Lyons 2012; Deery et al.
2011; Lanza et al. 2006; Schat et al. 2006).
We measured coworker psychological aggression with the Negative Acts Questionnaire–
Revised (Einarsen et al. 2009; α = 0.94) which assessed the frequency of employees’
exposure to workplace psychological aggression from coworkers within the past year.
Participants responded to twenty-two items on a five-point Likert-type scale ranging from 1
(never) to 5 (daily). Items include “Spreading gossip or rumors about you.”
The well-being outcome measures included physical symptoms and the burnout dimensions
of exhaustion and cynicism. Participants reported the frequency of eight stress-related
physical symptoms (e.g., headaches or trouble sleeping) experienced in the past month
(Brim et al. 2004). The items were rated on a five-point scale (1 = neverto 5 = very often; α
= 0.87). Two dimensions of burnout were assessed including exhaustion and cynicism with
the Maslach Burnout Inventory (Maslach and Jackson 1981; α = 0.91 and 0.78,
respectively). Items were measured with a seven-point Likert type scale ranging from 1
(never) to 7 (every day). Exhaustion was measured with nine items (e.g., “I feel burned out
from my work.”) and cynicism with five items (e.g., “I worry that this job is hardening me
emotionally.”).
We also measured the work outcomes of job dissatisfaction and intent to quit the
organization. Respondents’ experience of job satisfaction was assessed with three items
(Cammann et al. 1983; α = 0.89). A sample item included “All in all, I am satisfied with my
job.” All items were measured on a five-point scale (1 = strongly disagreeto 5 = strongly
agree). After reverse coding, higher scores indicated greater job dissatisfaction. To assess
participants’ intent to leave the organization, we used three items (Hom et al. 1984; α =
0.89) which were measured on a five-point agreement scale (1 = strongly disagreeto 5 =
strongly agree). A sample item was “If I have my own way, I will be working for some other
organization one year from now.”
Control Variables—We selected control variables based on prior organizational research.
In analyses with work-related outcomes, time spent with supervisor was selected because
more contact with a supervisor allows for more opportunities for FSSB (Hammer et al.
2009). The single item was rated on a sixpoint scale 1 (never) to 6 (multiple times daily) ( M
= 5.42, SD= 1.06). We controlled for income because lower income nonlicensed care
providers tend to have greater contact with patients and coworkers on the ward in residential
psychiatric settings and are at greater risk for aggression (Myers et al. 2005). Income was
measured on a 9-point scale in $10,000 increments from 1 = less than $25,000 to 9 = over
$100,000 ( M= 4.52, SD= 2.41). Hospital (coded as Hospital1 = 1, Hospital2 = 2) was
controlled for because the two hospitals were of different sizes and in different geographic
locations which could account for potential differences in participant responses. In analyses
linked over varying periods of time. In addition, Ford et al. (2014) conducted a meta-analysis to examine stressor– strain effects over
time and found that lagged effects were initially small and increased in magnitude over time.
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with well-being outcomes, we controlled for age reported in 10-year increments to protect
respondent confidentiality in light of the sensitive nature of aggres sion research (Bordia et
al. 2008). Age was coded as 1 = 18–29 years, 2 = 30–39 years, 3 = 40–49 years, 4 = 50–59
years, 5 = 60–69 years, and 6 = 70 or more years. We also controlled for relationship status
(single = 0, partnered = 1), income, and hospital.
Analytical Strategy—A series of moderated multiple regressions was performed to
examine potential relationships between workplace aggression and care provider well-being
and work outcome variables, and to evaluate the moderating effects of FSSB on the
workplace aggression and care provider well-being and work relationships. The control
variables (Step 1), the predictor, the moderator (Step 2), and the interaction term (Step 3)
were entered into the regression equation in successive order. To increase the interpretability
of the analysis output, both the predictors and the moderator in these hypotheses (i.e., patient
physical aggression, coworker psychological aggression, and FSSB) were centered around
the grand mean of each independent variable (Aiken and West 1991). We created
multiplicative interaction terms to test for moderation effects. All regression coefficients ( β)
were standardized, and calculations were carried out in R version 3.0.2 (R Development
Core Team 2013). All tests are two-sided and were not adjusted for multiple comparisons. A
pvalue <0.05 was used to denote statistical significance.
Results
Descriptive statistics and correlations among all study variables are presented in Table 1.
The majority of participants reported exposure to patient physical aggression (57 % of the
sample) with 90 % exposed to coworker psychological aggression. While many participants
reported exposure to coworker psychological aggression, the mean was low ( M= 1.58; SD=
0.69). Patient physical aggression, coworker psychological aggression, and FSSB were all
significantly correlated with each other in the hypothesized directions. Furthermore, patient
physical aggression was significantly and positively related with exhaustion, cynicism, and
turnover intentions, while coworker psychological aggression was significantly and
positively correlated with all employee health and well-being outcomes and the work
outcomes of job dissatisfaction and turnover intentions. FSSB was significantly and
negatively correlated with all health, well-being, and work outcomes. The means of job
dissatisfaction ( M= 2.24; SD= 0.89) and intent to quit ( M= 2.50; SD= 1.21) were low
considering the high demands of residential psychiatric care provision. Even though the jobs
are difficult in some respects, they are valued by health workers in part because they are
union-represented positions in the public sector and provide employees stability and a
pension upon retirement. In addition, the research was conducted during the weak recovery
period following the Great Recession in the U.S. when unemployment was high.
Hypothesized Results
Results from the patient and coworker aggression analyses respectively can be found in
Table 2 for health and wellbeing outcomes and in Table 3 for work outcomes. We present the
results thematically as they relate to the study hypotheses.
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Health and Well-Being Outcomes—As shown in Table 2, Step 2, patient physical
aggression was significantly and positively related to exhaustion ( β= 0.30; p< 0.01), and
cynicism ( β= 0.36; p< 0.01), but was not significantly related to physical symptoms. Thus,
Hypothesis 1a was partially supported. FSSB was significantly and negatively associated
with all health and well-being outcomes (Tables 2, Step 2): physical symptoms ( β= −0.20; p
< 0.01), exhaustion ( β= −0.34; p< 0.01), and cynicism ( β= −0.27; p< 0.01).
Coworker psychological aggression was significantly and positively associated with all
health and well-being outcomes (Table 2, Step 2): physical symptoms ( β= 0.31; p< 0.01),
burnout-exhaustion ( β= 0.46; p< 0.01), and burnout-cynicism ( β= 0.41; p< 0.01)
providing full support for Hypothesis 2a. FSSB was significantly associated with burnout-
exhaustion ( β= 0.14; p< 0.01) but was not significantly associated with the other health and
wellbeing outcomes despite the significant bivariate correlations between the variables and
their significant associations in the multivariate models with patient physical aggression.
Consequently, Hypothesis 3a was partially supported.
Work Outcomes—As displayed in Table 3, Step 2, patient physical aggression was
significantly and positively related to the work outcome of organizational turnover intentions
( β= 0.22; p< 0.05) but was not significantly related to job dissatisfaction providing partial
support for Hypothesis 1b. FSSB was significantly associated with job dissatisfaction ( β=
−0.45; p< 0.01) and turnover intentions ( β= −0.25; p< 0.01) in full support of hypothesis
3b.
Coworker psychological aggression was significantly and positively associated with job
dissatisfaction ( β= 0.30; p< 0.01) and organizational turnover intentions ( β= 0.22; p<
0.01); see Table 3, Step 2). FSSB was significantly and negatively associated with job
dissatisfaction ( β= −0.32; p< 0.01) and, turnover intentions ( β= −0.17; p< 0.01). The
pattern of significant relationships provides full support for Hypotheses 2b and 3b.
Moderating Effects of FSSBs
Hypotheses 4 and 5 test the moderating influence of FSSBs on the relationships between the
patient physical aggression and coworker psychological aggressions, and health, well-being,
and work outcomes.
Health and Well-Being Outcomes—As Table 2, Step 3 shows, FSSB moderated the
relationship between patient physical aggression and physical symptoms ( β= −0.30; p<
0.01; see Fig. 1), exhaustion ( β= −0.22; p< 0.05; see Fig. 2), and cynicism ( β= −0.28; p<
0.01; see Fig. 3). The relationship between patient physical aggression and well-being
outcomes was less pronounced for employees who reported high FSSB compared with
employees who reported low FSSB. Thus, consistent with Hypothesis 4, high levels of FSSB
served as a protective factor, or buffer of the effects of patient physical aggression, with care
providers reporting fewer physical symptoms, as well as less exhaustion and cynicism under
conditions of high FSSB.
Consistent with Hypothesis 5, FSSB also moderated the relationship between coworker
psychological aggression and physical symptoms ( β= −0.14; p< 0.01; see Fig. 4), with no
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other significant moderating effects found for any other health and well-being outcomes
(Table 2, Step 3). This finding suggests that care providers who reported high FSSB had a
less-pronounced positive relationship between psychological aggression and physical
symptoms than did care providers with low FSSB.
Work Outcomes—The relationships between patient physical aggression and work
outcomes were not significantly moderated by FSSB (Table 3, Step 3). However, FSSB did
moderate the relationships between coworker psychological aggression and turnover
intentions ( β= 0.13; p< 0.05; see Fig. 5). Care providers with high FSSB reported reduced
turnover intentions compared to those with low FSSB. However, the moderating effect of
FSSB on turnover intentions is stronger when psychological aggression is low.
Contrary to our hypothesis, the moderating effects of FSSB on the coworker psychological
aggression with turnover intentions was less pronounced under conditions of high coworker
psychological aggression which suggests that high coworker psychological aggression is a
strong stressor limiting the influence of FSSB on this work outcome. The pattern of
significant moderation relationships provides partial support for Hypotheses 4 and 5.
Finally, the effect sizes for the significant moderation results were in the range of 1 % to
2 %. These findings are in line with the literature that states interaction effects in real data
typically range from explaining 1 % to 3 % of the variance in the dependent variable
(Dawson 2013; McClelland and Judd 1993). In light of these findings, we discuss the
meaning and implications of the study results in the following section.
Discussion
Psychiatric healthcare providers’ exposure to various forms of workplace aggression has
been well documented (Campbell et al. 2011; Kelly et al. 2015; Spector et al. 2014) and the
exposures found in the current study are in alignment with those reported in the most recent
studies of psychiatric care providers (Kelly et al. 2015; Spector et al. 2014).
We sought to test the link between workplace aggression and health, well-being, and work
outcomes and examine the role of FSSB as a boundary condition for these relationships.
Drawing on COR theory (Hobfoll 1989, 2001) and SET (Blau 1964; Cropanzano and
Mitchell 2005), we developed and tested a model that examined relationships and the
interaction between two types of workplace aggression and FSSB to predict health, well-
being, and work outcomes.
Consistent with COR theory and prior research, results demonstrated that patient physical
aggression has a deleterious effect on care provider health and well-being (Hogh and
Viitasara 2005; Lasalvia et al. 2009; Laschinger and Grau 2012). However, contrary to prior
research, patient physical aggression was not related to work outcomes (Deery et al. 2011;
Estryn-Behar et al. 2008; Sofield and Salmond 2003). Coworker psychological aggression,
also in alignment with prior research, was negatively related to well-being and work
outcomes (Bowling and Beehr 2006; Hershcovis and Barling 2010; Walrath et al. 2010).
FSSB served as a resource that provided protection against resource threat and loss due to
patient physical aggression on health and well-being outcomes and from coworker
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psychological aggression on physical symptoms outcomes. We also found that FSSB
interacted with patient physical aggression and coworker psychological aggression to predict
health, well-being, and work outcomes.
Theoretical Implications
In the current study, we examined the unique effects of two sources and types of workplace
aggression—patient physical and coworker psychological aggression—and found direct
effects wherein patient physical aggression led to poor health and well-being outcomes, but
did not impact work outcomes; and coworker psychological aggression led to poor health,
well-being, and work outcomes. These findings suggest that in line with COR theory
(Hobfoll 1989, 2001), patient- and coworker-initiated aggression are stressors that deplete
resources through a health and wellbeing impairment process. An important contribution of
the study findings suggests that FSSB might improve care providers’ health, well-being, and
work outcomes; FSSB mitigated the adverse effects of patient physical aggression on health
and well-being outcomes, but not work outcomes, and FSSB mitigated the adverse effects of
coworker psychological aggression on physical symptoms and the work outcome of turnover
intentions. Although we did not specifically hypothesize differences between the effects of
patient physical aggression and coworker psychological aggression, since there was no
theoretical guidance as to how these differences would specifically manifest, our findings
show that FSSB as a moderator of these two types of aggression has demonstrated effects in
terms of employee work and health outcomes that identify FSSB as an important resource in
the context of workplace aggression.
With regard to patient- and coworker-initiated aggression, there are several reasons that these
two sources of aggression may differ for employees. For example, physical aggression from
patients tends to be much less frequent than other forms of workplace aggression, such as
psychological aggression from coworkers, which can occur daily (Gerberich et al. 2004).
Patient physical aggression may result in injury and loss of work time (Lanza et al. 2006;
Myers et al. 2005); thus, health and well-being are likely to be compromised. Our findings
demonstrate that FSSB provided a resource that ameliorated the negative effects of patient
physical aggression on health and wellbeing.
Concerning coworker psychological aggression, our findings show that FSSB allows care
providers to remain engaged at work and maintain the care they give to patients under
conditions of low coworker psychological aggression but fails to provide an ameliorative
influence under high coworker psychological aggression. This finding illustrates the strength
of coworker aggression as a stressor and the limitations of FSSB to provide resources that
fully address the stressor–strain relationship. It is possible that in work environments or
climates where coworker aggression is tolerated, the supervisor influence may be limited
especially if the team is interdisciplinary, as in healthcare, where coworkers may have
different supervisors. A recent meta-analytic study examined the influence of workplace
mistreatment climate (specific to incivility, aggression, and bullying) and found significant
mean correlations between psychological mistreatment climate and employee and
organizational outcomes such as mistreatment exposure, strains, and job attitudes (Yang et
al. 2014).
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In light of COR theory, the findings that FSSB moderates the relationships between patient
aggression and employee well-being outcomes make a strong case for developing
interventions that target building supervisory resources to support employees’ successful
work–nonwork management and that can help defray negative effects of patient physical
aggression. The FSSB moderating effects between the coworker psychological aggression
and turnover intentions were opposite to the expected direction and indicate that
organizations need to provide additional resources to prevent or diminish the negative effects
of coworker psychological aggression.
Practical Implications
Our study suggests several ways that family-supportive supervision may foster a work
environment in which care providers are less susceptible to work stressors such as patient
and coworker aggression. In the first place, regarding patient physical aggression, FSSB may
serve a preventive function in creating a positive work context for employees’ need to
effectively manage in work and nonwork domains. Secondly, FSSB may be critical in the
event of care providers sustaining injuries from patient-initiated physical aggression. For
example, supervisors engaging in FSSB may be more equipped to accommodate a care
provider’s need to schedule days away from work for recovery and doctor’s appointments,
as well as the care provider’s need to discuss the effects of an injury at work and at home. In
addition, FSSB may facilitate a difficult transition from home back to work, as a care
provider may once again be working with the same patient who initiated the aggression.
Based on the current findings for coworker psychological aggression, it is possible that
supervisors engaging in FSSB may also ameliorate the negative effects of coworker
psychological aggression for employee physical symptoms and turnover intentions. Such
work–nonwork support acknowledges the importance of managing both work and nonwork
domains under highly stressful working conditions of handling coworker psychological
aggression when also providing care to severely mentally ill patients. However, under
conditions of high coworker aggression, our findings indicate that FSSB is not sufficient as a
sole resource for care providers who may seek work in another setting. Supervisors may also
encourage employees experiencing coworker aggression to utilize leisure or family activities
to separate from work demands while the source of coworker aggression is being addressed
in the workplace.
Although our study findings suggest it is fruitful to increase FSSB, our findings also suggest
organizational attention should be paid to implementing additional interventions toward
preventing and decreasing patient and coworker aggression. Patient physical aggression may
result in serious injury and, in extreme circumstances, fatality to other patients or care
providers, making it all the more critical for organizations to create a range of interventions
including implementing engineering controls to address hazards in the physical
environment. With regard to coworker psychological aggression, our findings suggest that
high levels of FSSB ameliorate the adverse consequences on physical symptoms. However,
high FSSB improves negative effects only under the condition of low psychological
aggression on the work outcome of turnover intentions, indicating that high psychological
aggression is a very strong stressor and, as previously stated, organizations should provide
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additional resources that are salient to address this form of aggression. For example,
attention should be paid to providing relevant policies and procedures to address coworker
psychological aggression, as well as supervisor training to prevent or intervene in coworker
aggression, role model civil and respectful interactions, build positive team interactions to
develop team cohesion, and coach the team on professional behaviors in the workplace.
While we cannot infer causality, it is also possible that FSSB could help to prevent
workplace aggression from the start. The statistically significant correlations between FSSB
and patient physical ( r= −0.10, p< 0.05) and coworker psychological ( r= −0.44, p< 0.01)
aggression suggest this could be a possibility, especially in the case of coworker
psychological aggression. Further investigation is warranted. In a review of intervention
studies, Kelloway and Barling (2010), propose that leadership training is an effective
occupational health psychology intervention. Training supervisors on FSSB (see Hammer et
al. 2011) can increase their support for employee’s work–nonwork management, providing a
resource which, in turn, could facilitate employees’ efforts toward aggression prevention and
could be trained in conjunction with other aggression prevention trainings.
FSSB has potential as an organizational and relational approach to foster a positive
workplace context. Training for healthcare supervisors might include teaching the
importance of redefining their supervisory role to embrace a stronger identification with
promoting aggression prevention and supporting employee work–nonwork management.
Specific behaviors to enact this expanded role identity can be taught to supervisors in the
context of aggressive incidents at work where family-supportive supervision is offered as a
proactively presented resource that could mutually benefit the organization and the
employee. Supervisor training might also address the concept of employee work–nonwork
integration in the context of stressful work and teach supervisors specific behaviors for
differential response to employees based on their preference and needs for work–nonwork
support that may change over time. Providing such support has been shown in a recent FSSB
intervention group-randomized control trial to protect against declines in safety compliance
and organizational citizenship behaviors in workers employed by extended healthcare
facilities (Hammer et al. 2015). Another intervention approach is to facilitate supervisors
and healthcare staff in discussions and exercises that specifically address coworker
aggression prevention and behavior change similar to the Civility, Respect, and Engagement
in the Workplace (CREW) intervention (Osatuke et al. 2009; Leiter et al. 2011). This
approach could include discussions of the importance of effective work–nonwork
management in the context of patient physical and coworker psychological aggression
stresses.
Limitations and Directions for Future Research
In describing the limitations of our study, we simultaneously suggest future research
directions. Self-report measures were used in a cross-sectional design which may lead to
issues regarding response bias. For example, responses to earlier measures in the surveys
might have affected responses to later instruments. We attempted to limit the potential for
common method effects by following the recommendations of Podsakoff et al. (2003), who
suggested careful scale placement through physically spacing the predictor and criterion
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variables in different locations in the survey instrument. Doing so reduces the salience of the
predictor and moderator when the dependent variable is being assessed, thereby reducing
recall-related biases and demand effects. Furthermore, measurement of the aggression
constructs was based on reports of specific behavior, rather than subjective labeling. We also
protected the confidentiality of the respondents to diminish evaluation apprehension, which
reduces the effects of socially desirable responding (Podsakoff et al. 2003) and the fear of
retaliation for any reporting of aggression. Moreover, the cross-sectional design impacts our
ability to draw definitive conclusions about causality of workplace aggression relationships
with health, well-being, and work outcomes and the moderating role of FSSB. Researchers
should consider further exploring the nature of these relationships utilizing longitudinal
research designs, as reviews of the literature have noted the reliance on cross-sectional
designs and need for increased longitudinal research, which would be useful for inferring
causation (Casper et al. 2007; Zapf et al. 1996).
Many work stress researchers have called on fellow researchers to create study designs that
incorporate multiple sources of data, including objective administrative data. In future
studies that focus on workplace settings, collecting administrative data on objective
outcomes such as actual reported aggression incidents and employee turnover would
strengthen the study design. In addition, multilevel and longitudinal designs linking
supervisors to their care provider groups would allow an examination of the relationships at
two levels to examine team processes and outcomes over time that encompass the interaction
and coordination between team members and their supervisors with discrete context (Johns
2006) variables such as aggression prevention climate, sources of social support, and
workplace aggression sources and types.
We expected to find more significant direct relationships between patient physical
aggression and work outcomes than we did, and this may indicate a potential limitation in
using a single item to assess patient aggression which may not be optimal. External
confirmation from hospital incident reports is a potential source of measurement. However,
it may be difficult to get accurate information from these records due to underreporting
(Findorff et al. 2005). Single-item measures have been critiqued for lack of validity, because
they tend to insufficiently capture the conceptual domain of most constructs (Nunnally and
Bernstein 1994), and for unreliability (Spector 1992). However, when a construct is judged
to be concrete and unidimensional, the use of single-item measures is considered reasonable
(Bergkvist and Rossiter 2007; Wanous et al. 1997) and some single-item measures have been
validated in recent organizational research (Fisher et al. 2015). Our single-item measure of
patient physical aggression included the term, assault, which is the term used by the hospital
to describe the construct with the meaning; to use force or violence to do bodily harm to
another without their permission and any unwanted touch whether or not injury occurs,
intentional or unintentional. Patients are involuntarily committed to psychiatric hospitals
because they are assessed to be at risk for physically harming themselves or others, and for
the purposes of this study we did not seek to examine the multidimensionality of patient
physical aggression because our hypotheses did not include tests requiring a
multidimensional measure.
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Even so, one way to improve this single-item measure of patient physical aggression would
be to create an index measure of items specific to objectively observable physically
aggressive acts (e.g., hitting, kicking, etc.) as recommended by Spector and Fox (2003). In
addition, future research should measure aggression utilizing a fully crossed design to allow
for a more thorough comparison of type (physical and psychological) and source (coworker,
patient) of aggression. Future research could investigate if patient psychological or verbal
aggression is a factor in subsequent physical aggression from patients. Coworker physical
aggression, even if a rare event, may be particularly distressing and consequential for
healthcare workers.
Other explanations for the lack of relationship with the patient physical aggression and care
provider outcomes exist. Care providers have greater control over work resources to address
patient aggression situations such as silent alarm systems to call for assistance or working
with the treatment team to incorporate aggression management strategies in the patient’s
treatment plan. Care providers likely have patient aggression prevention training and greater
supervisor and coworker support on the job to manage patient physical aggression which
may result in fewer strains. In contrast, coworker aggression can occur daily, and often
supervisors and care providers are not trained to identify or respond effectively to manage
negative interactions with coworkers, and may have little control over its occurrence.
Moreover, patients are severely mentally ill, physical aggression can be part of that illness,
and psychiatric care providers may adjust to accept patient aggression as part of the job
(Chapman et al. 2010).
Coworkers, in comparison to patients, are mentally healthy, are not expected to be
psychologically aggressive, and are important sources of support for patient aggression
prevention; critical support for safety that may be lacking under circumstances of coworker
hostility. Therefore, in the context of coworker psychological aggression, care providers may
experience greater strain reactions. An additional suggestion for future research includes
asking whether employees intend to leave the profession due to aggression as this is a
consequential outcome in the context of future nursing shortages especially if younger
health workers are choosing to leave their profession. We also suggest employing COR to
develop and test integrated interventions through field research (Halbesleben et al. 2014)
that focuses on increasing supervisor support for aggression prevention and work and
nonwork—building on recent research on work–nonwork interventions (Hammer et al.
2015) and including assessment of intervention effects on the nonwork or family domain. It
would also be worthwhile to examine additional workplace resources that may reduce the
frequency and impact of workplace aggression, building on recent research by Lepping et al.
(2009).
Conclusion
The current study addresses a gap in the literature surrounding workplace aggression and
family-supportive supervision by examining relationships between patient physical
aggression, coworker psychological aggression, FSSB, and health, well-being, and work
outcomes as well as the moderating effects of FSSB on those relationships. The study
findings advance the field through identifying FSSB as an important resource to counter the
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negative effects of work stressors of patient physical and low coworker psychological
aggression. Our study suggests that FSSB should be examined in future research as a buffer
of the negative effects of workplace aggression in combination with training that targets
direct prevention of patient physical and coworker psychological aggression. Finally, an
important study contribution of practical value is that the findings identify interactions that
are potentially useful in designing an integrated supervisor aggression prevention and
family-supportive intervention.
Acknowledgments
This research was made possible by the Grant Number 1R21OH009983-01 (N. Yragui, PI) from the Centers for
Disease Control and Prevention, the National Institute for Occupational Safety and Health (CDC/NIOSH), and the
Washington State Department of Labor & Industries. The contents of this paper are solely the responsibility of the
authors and do not necessarily represent the official views of these institutes or departments.
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Fig. 1.
FSSB as a moderator of the relationship between patient physical aggression and physical
symptoms. FSSBfamily-supportive supervisor behaviors
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Fig. 2.
FSSB as a moderator of the relationship between patient physical aggression and burnout-
exhaustion. FSSBfamily-supportive supervisor behaviors
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Fig. 3.
FSSB as a moderator of the relationship between patient physical aggression and burnout-
cynicism. FSSBfamily-supportive supervisor behaviors
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Fig. 4.
FSSB as a moderator of the relationship between coworker psychological aggression and
physical symptoms. FSSBfamilysupportive supervisor behaviors
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Fig. 5.
FSSB as a moderator of the relationship between coworker psychological aggression and
turnover intentions. FSSBfamilysupportive supervisor behaviors
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Table 1
Descriptive statistics and intercorrelations of variables
Variable N M SD 1 2 3 4 5 6 7 8 9 10 11 12 13
1. Age 400 3.35 1.17 – – – – – – – – – – – – –
2. Relationship status 405 0.65 0.48 −0.01 – – – – – – – – – – – –
3. Time spent with supervisor 417 5.42 1.06 −0.05 −0.02 – – – – – – – – – – –
4. Income 364 4.52 2.41 0.17 ** 0.29 ** −0.02 – – – – – – – – – –
5. Hospital 417 1.38 0.49 −0.09 0.00 0.04 −0.06 – – – – – – – – –
6. FSSB 408 3.17 1.05 −0.04 −0.05 0.22 ** 0.04 −0.02 – – – – – – – –
7. Patient physical aggression 417 0.57 0.50 0.01 0.03 0.07 −0.04 −0.01 −0.10 * – – – – – – –
8. Coworker psychological aggression 417 1.58 0.69 −0.06 0.02 −0.11 * −0.10 0.04 −0.44 ** 0.17 ** – – – – – –
9. Physical symptoms 405 2.19 1.25 −0.04 −0.04 −0.03 −0.20 ** 0.04 −0.16 ** 0.07 0.29 ** – – – – –
10. Burnout-exhaustion 404 3.15 1.39 −0.06 −0.04 −0.10 * −0.05 0.11 * −0.32 ** 0.14 ** 0.46 ** 0.35 ** – – – –
11. Burnout-cynicism 403 2.30 1.30 −0.12 * −0.01 −0.09 −0.08 0.07 −0.30 ** 0.18 ** 0.40 ** 0.27 ** 0.71 ** – – –
12. Job dissatisfaction 413 2.24 0.89 −0.02 −0.02 −0.04 0.00 0.13 ** −0.42 ** 0.10 0.36 ** 0.26 ** 0.55 ** 0.41 ** – –
13. Intent to quit 411 2.50 1.21 −0.03 −0.05 −0.05 0.00 0.00 −0.26 ** 0.10 * 0.24 ** 0.20 ** 0.44 ** 0.36 ** 0.54 * –
FSSBfamily-supportive supervisor behaviors
*p< 0.05;
**p< 0.01
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Table 2
odels for health and well-being outcomes
ysical aggression Coworker psychological aggression
ymptoms Burnout-exhaustion Burnout-cynicism Physical symptoms Burnout-exhaustion Burnout-cynicism
Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3
-0.01 0.01 −0.06 −0.09 −0.08 −0.11 * −0.14 ** −0.13 * 0.01 0.01 0.02 −0.06 −0.06 −0.06 −0.11 * −0.11 * −0.12 *
0.00 0.00 −0.03 −0.08 −0.08 0.02 −0.02 −0.02 0.03 0.00 −0.01 −0.03 −0.08 −0.08 0.02 −0.03 −0.03
−0.20 ** −0.21 ** −0.04 0.00 0.00 −0.08 −0.04 −0.05 −0.22 ** −0.19 ** −0.18 ** −0.04 0.02 0.02 −0.08 −0.03 −0.03
−0.07 −0.07 0.03 0.04 0.04 0.02 0.02 0.03 −0.08 −0.08 −0.06 0.03 0.02 0.02 0.02 0.01 0.00
−0.20 ** −0.02 −0.34 ** −0.21 * −0.27 ** −0.11 −0.06 −0.03 −0.14 ** −0.14 * −0.10 −0.11
0.10 0.12 0.30 ** 0.31 ** 0.36 ** 0.38 ** 0.31 ** 0.26 ** 0.46 ** 0.46 ** 0.41 ** 0.43 **
−0.30 ** −0.22 * −0.28 ** −0.14 ** −0.01 0.05
0.09 0.11 0.01 0.15 0.16 0.02 0.14 0.15 0.05 0.16 0.18 0.01 0.29 0.29 0.02 0.23 0.23
0.04 ** 0.02 ** 0.01 0.14 ** 0.01 * 0.02 0.11 ** 0.02 ** 0.05 ** 0.11 ** 0.02 ** 0.01 0.28 ** 0.00 0.02 0.20 ** 0.00
ts are shown
r behaviors
atient aggression and FSSB × coworker aggression for each analysis, respectively

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Table 3
Hierarchical regression models for work outcomes
Variable Patient physical aggression Coworker psychological aggression
Job dissatisfaction Intent to quit Job dissatisfaction Intent to quit
Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3
Time spent with supervisor −0.03 0.06 0.06 −0.02 0.04 0.04 −0.03 0.08 0.08 −0.02 0.05 0.04
Income 0.00 0.02 0.03 −0.03 −0.01 −0.01 0.00 0.04 0.04 −0.03 0.00 −0.01
Hospital 0.08 0.09 0.09 −0.04 −0.03 −0.03 0.08 0.08 0.08 −0.04 −0.04 −0.06
FSSB −0.45 ** −0.51 ** −0.25 ** −0.24 ** −0.32 ** −0.32 ** −0.17 ** −0.19 **
Aggression 0.19 0.18 0.22 * 0.22 * 0.30 ** 0.30 ** 0.22 ** 0.27 **
FSSB × aggression 0.10 −0.01 −0.01 0.14 **
R2 0.01 0.21 0.21 0.00 0.08 0.08 0.01 0.27 0.27 0.00 0.10 0.12
Δ R2 0.01 0.20 ** 0.00 0.00 0.07 ** 0.00 0.01 0.26 ** 0.00 0.00 0.10 ** 0.02 **
Standardized regression coefficients are shown
FSSB family-supportive supervisor behaviors
The interaction terms are FSSB × patient aggression and FSSB × coworker aggression for each analysis, respectively
*p< 0.05;
**p< 0.01
J Bus Psychol. Author manuscript; available in PMC 2018 March 19.