Family-Supportive Supervisor Behaviors: Aggression and Well-Being

This case study investigates the moderating effects of family-supportive supervisor behaviors (FSSB) on the relationship between workplace aggression (patient-initiated physical and coworker-initiated psychological) and employee well-being and work outcomes in psychiatric hospitals. Data from 417 healthcare workers were analyzed using moderated multiple regression. The findings indicate that FSSB moderates the relationship between patient-initiated physical aggression and physical symptoms, exhaustion, and cynicism, as well as the relationship between coworker-initiated psychological aggression and physical symptoms and turnover intentions. The study highlights the importance of family-supportive supervision as a resource that healthcare organizations can facilitate to improve employee work and well-being in high-aggression settings, suggesting that FSSB training for supervisors can be an effective intervention. The research contributes to the understanding of how FSSB influences the impact of workplace aggression on employee outcomes, addressing a gap in prior research.

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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J Bus Psychol. Author manuscript; available in PMC 2018 March 19.
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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