Mistreatment by Patients: An Analysis of the Patient-related Social Stressors among Slovenian Healthcare Workers.

INTRODUCTION: Healthcare workers (HCWs) are often exposed to mistreatment by patients, which has negative effects on both staff and institutions. To take appropriate action to help HCWs in this context, patient-related social stressors (PSS) should be explored. The purpose of the research was to identify the most pronounced patient behaviour contributing to the social stress (SS) of HCWs, and compare PSS between different HCWs and different types of healthcare institutions.
METHODS: 750 HCWs from Slovenian public health centres and hospitals participated in the online survey. Although the non-probability sampling was used, the sample was representative according to gender and HCW type (doctors, nurses and other HCWs).
RESULTS: The results show that the most pronounced patient behaviour contributing to the SS of HCWs are attitudes and behaviour of patients that are challenging in terms of what is - from the HCWs' point of view - considered as acceptable and reasonable (disproportionate patient expectations), and unpleasant, humourless, and hostile patients. HCWs in primary institutions meet less verbally aggressive and unpleasant patients than in tertiary ones. Although among all HCWs less educated ones are more exposed to inappropriate behaviour, doctors are those HCWs who experience more inappropriate behaviour.
CONCLUSION: Managers should enable HCWs to get comprehensive patient service training, oriented towards improving relationship management and patient-HCW relationships.

Background

An HCW’s relationship with patients (HCWPR) has an important role in the delivery of high-quality healthcare. The HCWPR is a complex phenomenon, because it is a sensitive issue built on mutual trust and respect (1). The relationship can be improved if the patient has a permanent doctor, one who communicates and builds on the patient’s trust by actively involving them in a treatment process (2, 3, 4). The HCWPR involves communication about issues of vital importance, but is often emotionally laden, requires close cooperation, and is based upon interaction between individuals in unequal positions; problems with effective treatment more often arise from inappropriate communication between doctors and patients, than from the failure of technical aspects of medical care (5). Observation, deduction, and processing of the patient’s emotions and insecurities are keys to gaining the patient’s trust and open the way for better managing their expectations and fears (6). Different organizational factors (e.g. the accessibility of administrative and clinical HCWs, their courtesy level, reasonable waiting times), care models, the broader social cultural context, and patient characteristics also influence the HCWPR (7, 8).

Interacting with patients is not always a pleasure, and may cause psychological strain (9). Negative patient behaviour toward HCWs has been defined as ˝patient aggression˝, ˝difficult patients˝, and ˝mistreatment by patients˝. Such behaviour by patients and their relatives refers to different aspects of negative and aggressive emotional behaviour (e.g. expressed anger, swearing, insulting, yelling, and speaking rudely) towards HCWs, undeserved prejudicial statements, sexual harassment, discrimination, humiliation, psychological and physical punishment, inappropriate physical contact, and verbal abuse (10, 11, 12). Antisocial behaviour can be classified into various forms; (a) psychological and physical, (b) direct and indirect harmful behaviour, (c) intended or not intended or ambiguous behaviour (13). Researchers have also categorized three groups of complaining patients in hospital organizations: (a) opportunistic plotters (patients who forge scheming complaints for their personal benefit); (b) repetitive grumblers (patients who always try to file complaints when they are served); and (c) occasional tyrants (patients who voice their complaints because their unjust demands are not met) (14). Negative interpersonal interactions, referred to social stressors (SSs) (a variety of experiences that involve interactions with organisational insiders and outsiders, social in nature, related to psychological and physical strain), are important area to address (10, 14). Research shows that different patients and their relatives’ behaviour contributes to the SS of HCWs. In 2017, 41.2% of Chinese nurses experienced mistreatment by patients (15). Twenty-two percent of nurses from 10 European Countries reported frequent relatives (16). In Germany, 56% of healthcare professionals reported experiencing physical violence, and 78% had experienced verbal aggression (17). Previous research also shows that HCWs are exposed to mistreatment by patients, which has a negative effect on staff, such as greater exhaustion and SS, and lower personal safety, satisfaction, and well-being at work (4, 18, 19, 20).

Healthcare in Slovenia is governed by various legal regulations. According to the law, citizens of the Republic of Slovenia are insured by the compulsory health insurance (HI). All other forms of HI are optional, and individuals can decide to take out one of the forms of voluntary HI. All compulsorily insured persons have a selected personal doctor, but some decide to change them because they move home, their doctor retires, or they are dissatisfied with them. Such changes in personal doctor can also be caused by unfriendly nurses and crowded waiting rooms (21). Dissatisfaction with nurses or doctors might also be the consequence of Slovenian learning programs in the field of healthcare, which are not unified. All secondary schools’ healthcare programs have psychology as a core course, but courses on ethics, good manners, communication, and social values are rare. Moreover, such issues are better covered at faculties for healthcare sciences and faculties of medicine, where students get the skills needed to become a good HCWPR.

Unfortunately, little is known about the most pronounced patient behaviours that contribute to the SS of HCWs (in the main and supporting activities of their work), or what the differences are between the different HCWs and different types of healthcare institutions in this regard. As such, this study carried out empirical research into these issues, with the results presented in this paper. The purpose of the research was to (a) identify the most pronounced patient behaviour contributing to the SS of HCWs, (b) compare patient-related SS between different HCWs (nurses, doctors, other HCWs), and (c) compare patient-related SS between different types of healthcare institutions (primary, secondary, tertiary). In this work ˝patient mistreatment˝ refers to the low-quality interpersonal behaviour that HCWs receive from patients; such behaviour is usually a response to patients’ perceptions of the healthcare system, their subordinate positions with regard to the HCWs, and their loss of trust in HCWs. The hypotheses tested in this research were:

H1: The most pronounced patient behaviour contributing to the SS of HCWs is disproportionate patient expectations.

H2: Nurses, doctors, and other HCWs differ in the experience of at least one of the measured patient-related stressors.

H3: Primary, secondary, and tertiary institutions differ in the experience of at least one of the measured patient-related stressors.

The results of this research will have theoretical and practical implications in the field of human resources management of healthcare institutions.

Methods

The research was carried out from October 2019 until December 2019 among nurses, doctors and other HCWs. A link to the online questionnaire, with a request to forward it to all HCWs (in the main and supporting activities), was sent twice to the official email addresses of 57 health centres and 21 hospitals, available on the webpage of the Ministry of Health (22). Psychiatric hospitals were not included in the research to exclude potential PSS caused by patients with mental disabilities.

Sample description

A total of 750 respondents participated in the research. Since the researchers were not notified whether the recipients of the email did indeed forward the link to all HCWs, and due to the survey’s anonymity (not all participants provided an answer to which healthcare centre or hospital they worked in), it was not possible to determine an accurate response rate. Judging by the number of HCWs employed in Slovenia, as reported in the statistical health yearbook (23) for 2018, the estimated response rate was ~2%. Not all of the respondents that decided to participate in the survey provided answers to all questions. The items measuring patient-related SS, were answered by 605 participants. Not all of them provided demographic data.

The sample description for those who also answered the demographic questions is provided in Table 1. The majority (88.9%) of the participants are women. According to the statistical health yearbook (23), the share of women among HCWs in Slovenia is 87%, and thus the sample share does not significantly differ statistically from the population share (p=0.192). The mean age (SD) is 41.6 (10.5) years, while the mean (SD) number of years working in the current health institution is 11.6 (10), and the overall number of working years equals 18.3 (11.1). According to statistical data from the National Institute of Public Health, out of all the HCWs in Slovenia 21% of these are doctors, 58% nurses, and 26% other HCWs (23). The shares of doctors, nurses, and other HCWs in the sample are 22.7%, 58.2%, and 19.1%, respectively. The share of HCWs in the sample does not statistically significantly differ from that in the whole population (p=0.734).

Table 1

Sample description.

	Hulbert index of sexual assertiveness
Gender
Male	60 (11.1)
Female	480 (88.9)
Mean age (SD) (n=538)	41.6 (10.5)
Education
High school or less	127 (23.6)
University degree or more	411 (76.4)
No of years in current health institution (n=529)	11.6 (10)
No of working years (n=530)	18.3 (11.1)
HCW
Doctors	118 (22.7)
Nurses	302 (58.2)
Other HCW	99 (19.1)
Institution
Primary	372 (69.7)
Secondary	82 (15.4)
Tertiary	80 (15)

The multiple regression analysis included 512 respondents who provided answers to all the variables included in the regression model. These 512 respondents did not differ from the 93 remaining participants who provided answers to SS, but did not respond to the demographic variables, with regard to the variables disproportionate patient expectations (p=0.088), patient verbal aggression (p=0.521), disliked patients (p=0.757), and ambiguous patient expectations (p=0.139).

Measures

The PSS scale was adopted from Dormann and Zapf (9). The items were translated from the English language into the respondents’ native language (Slovene) using a standard back-translation process (24).

The PSS scale has 21 items, each measured on a 5-point scale ranging from 1=completely disagree to 5=completely agree. The scale measures four dimensions. Disproportionate patient expectations are measured by 8 items, and example being “Some patients always demand special treatment”. Cronbach’s α for this scale was 0.86. Patient verbal aggression is measured by 5 items (α=0.89). An example item is “Patients often shout at us”. The disliked patient dimension includes 4 items (α=0.70), and an example is “One has to work together with patients who have no sense of humour”. The ambiguous patient expectation scale has 4 items (α=0.77), with one example being “Patients’ instructions can complicate our work”.

Statistical analysis

Means and standard deviations were calculated for continuous various and frequencies, and percentages for categorical variables. The average score on each dimension of the PSS scale was calculated and used in the analysis. Repeated measures analysis of the variance was used to compare the average scores on the four dimensions and to evaluate which SS are most pronounced in the healthcare institutions. The Sidak post-hoc test was used for paired comparisons. Four multiple linear regression models were built with the type of institution and type of HCW as independent variables, gender, age, and education as control variables, and each of the four dimensions of the PSS scale as dependent variables. Results with p<0.05 were treated as statistically significant. SPSS version 26 was used for all statistical analyses.

Results

The mean scores along with 95% confidence intervals for each dimension of the PSS scale are shown in Figure 1. A statistically significant difference exists between the scores of the four dimensions (p<0.001). The mean score is highest on the disproportionate patient expectations dimension, and differs from the scores on patient verbal aggression and ambiguous patient expectation dimensions, but not from the score on the disliked patients dimension. The mean score of the patient verbal aggression dimension is statistically significantly lower than the scores on all the other dimensions. The second lowest mean score was for the ambiguous patient expectation dimension, which statistically significantly differs from the scores on all the other dimensions. According to the results of the research, the first hypothesis (H1), which proposed that the most pronounced patient behaviour contributing to the SS of HCWs is disproportionate customer expectations, is only partially confirmed. The results indicate that there are in fact two most pronounced kinds of patient mistreatment behaviour, namely disproportionate patient expectations and disliked patients.

Figure 1

Mean (95% CI) on each PSS dimension.

The results of the multiple linear regression analysis are summarized in Table 2. The second hypothesis (H2) proposed that nurses, doctors, and other HCWs differ in experiencing at least one of the measured SS. The results show that doctors experience more ambiguous patient expectations (std. B=0.15; p<0.001), have more disliked patients (std. B=0.18; p=0.003), meet more verbally aggressive patients (std. B=0.15; p=0.011), and experience more disproportionate patient expectations (std. B=0.15; p=0.008) than other HCWs. The results show that nurses also experience more disproportionate patient expectations than other HCWs (std. B=0.12; p=0.04). According to these results, the second hypothesis is confirmed.

Table 2

Relationships between gender, education, age, HCW type, type of institution, and score on each dimension of the PSS scale (results of the multiple linear regression analysis).

Beta (β)	Ambiguous patient expectations		Disliked patients		Patient verbal aggression		Disproportionate patient expectations
	Std. B	P	Std. B	P	Std. B	P	Std. B	P
Male gender	0	0.956	0.03	0.561	-0.04	0.364	-0.07	0.096
University degree or more	-0.21	<0.001	0.01	0.889	-0.3	<0.001	-0.23	<0.001
Age	0.04	0.405	0.08	0.062	-0.03	0.447	-0.04	0.308
Doctors vs. other HCW	0.15	0.011	0.18	0.003	0.15	0.011	0.15	0.008
Nurses vs. other HCW	0.07	0.201	0.05	0.414	0.1	0.062	0.12	0.04
Primary vs. tertiary	0.04	0.49	-0.13	0.028	-0.15	0.01	0.01	0.83
Secondary vs. tertiary	0.04	0.471	-0.07	0.259	-0.07	0.203	-0.01	0.874
F (P)	3.91 (<0.001)		3.04 (0.004)		8.21 (<0.001)		5.13 (<0.001)
R2	0.05		0.04		0.10		0.07

*std. B = standardized regression coefficient

Education is also an important factor associated with PSS. HCWs with higher education perceive fewer cases of ambiguous patient expectations (std. B=-0.21; p<0.001), verbal aggression (std. B=-0.3; p<0.001), or disproportionate patient expectations (std. B=-0.23; p<0.001).

The third hypothesis (H3) proposed that primary, secondary, and tertiary institutions differ in terms of the HCWs experiencing at least one of the measured SS. The results of the research show that patients are less verbally aggressive in the primary institutions in comparison to the tertiary institutions (std. B=-0.15; p=0.01). HCWs working in primary institutions meet fewer disliked patients in comparison to their colleagues working in tertiary institutions (std. B=-0.13; p=0.028). According to these results, the third hypothesis is confirmed.

Although some statistically significant relationships between predictor variables and each dependent variable were found, the low R2 value suggests that the low percentage of variance of each dependent variable is explained by the predictors included in the regression model.

Discussion

The results of this study research, similar to those of previous research (e.g. 9, 15-17, 19), confirm that HCWs are exposed to mistreatment by patients. The results show that disproportionate patient expectations and disliked patients are the most pronounced patient behaviours contributing to the SS of HCWs, confirmed an earlier study (20). Adding to the previous research, the results of the current study show that doctors and nurses, in comparison to other HCWs, experienced disproportionate patient expectations to a higher extent and have to deal with disliked patients more often. It should be stated that the relationships that doctors and nurses have with patients are on a much more personal level than those that other HCWs have with them, as also noted by other authors (1), and more direct. Furthermore, patients consider doctors responsible for the treatment they provide and thus might more easily lose trust in them. Trust is built through the way doctors communicate with patients, their empathy, emotional intelligence, and ability to recognise patients’ untold stories, but all this takes time, which is problematic because of the overwhelming number of patients and responsibilities that doctors have. The loss of patients’ trust is also impacted by the patients’ personality traits, stress, their fear of the health-related procedure, long waiting times, and lack of awareness of the complex treatment process. Increasing the number of HCWs could enable better HCW-patient relationships, especially in terms of communication (5). Furthermore, the results show that higher educated HCWs perceive fewer cases of ambiguous patient expectations, verbal aggression, and disproportionate patient expectations, and that the type of the healthcare institution (primary, secondary, tertiary) is also associated with PSS. More specifically, patients are less verbally aggressive in primary institutions in comparison to tertiary institutions, and HCWs in primary institutions meet fewer disliked patients than those in tertiary institutions. Patients’ less verbal aggressiveness at primary level compared to tertiary level may be the result of patients having more contact with their personal doctor at primary level, which can enable a more trusting relationship, even though the patients are in a subordinate relationship. In addition, patients may have higher expectations from HCWs at tertiary level, because they think that such doctors, as specialists, should be more knowledgeable and able to help them more than their personal doctor. HCW managers should recognize mistreatment by patients by helping HCWs to cope with SS and react appropriately, which was also found by an earlier study (18). According to the results of the current work, institutions (managers) should make sure that HCWs, especially nurses, get comprehensive patient service training, oriented to content that includes developing appropriate personal relationships with patients. Curriculums in Slovenian secondary schools in the field of healthcare are not unified, and should be updated, because not all HCWs (nurses) get training in the areas of ethics, good manners, communication, and social values. Such training would contribute to better healthcare delivery systems for patients and their relatives and minimize the loss of patients’ trust. Furthermore, this would also contribute to the development of professional competencies of nurses so that they are better able to cope with the SS due to mistreatment by patients, and to the safety culture in healthcare institutions, which is, according to research (19), also an important part of the effective leadership process. HCWs should be trained to cope with patient behaviours and attitudes which challenge acceptable service expectations, and to appropriately react to patients who are unpleasant, humourless, hostile, critical, and verbally aggressive, or if it is unclear what patients expect from them; or, as argued by (20), HCWs could be better able to deal with their job demands, which may also foster greater work engagement.

In addition to the above-mentioned practical implications, the findings of the current study make several important contributions to the existing literature. A new definition of mistreatment by patients, which represents the low-quality interpersonal behaviour that HCWs receive from persons under medical treatment (patients) and is usually a response to the patients’ perception of the healthcare system, their subordinate relationship and the loss of their trust in HCWs, was developed called ˝patient mistreatment˝. The research also contributes to the social-relationship theory, and literature on the vulnerability of HCWs in the patient-HCW worker relationship, because the vulnerability of HCWs in the patient-HCW relationship was surveyed independently, and the results clearly show that HCWs are exposed to patients´ mistreatment.

The current study has some limitations that should be acknowledged. One is possible self-selection bias. As non-probability sampling was used, the HCWs included in the research might differ from those who decided not to participate in the study. Nevertheless, the sample is representative regarding the gender and type of HCWs (nurses, doctors, and other HCWs). Moreover, our findings are reinforced by the similar findings of other researchers in this area.

Conclusions

The research findings presented in this paper refer to the vulnerability of HCWs in the patient-HCW relationship and attempt to identify the most pronounced patient behaviours contributing to the SS of HCWs, and compare PSS between different HCWs and different types of healthcare institutions in Slovenia. The results show that HCWs in primary, secondary, and tertiary institutions are exposed to mistreatment by patients. The most exposed are the HCWs in tertiary institutions, less educated HCWs, and medical doctors. Managers should thus enable HCWs (nurses) to get comprehensive patient service training, oriented to developing good personal relationships with patients. Patients’ trust should be built through appropriate communication between HCWs and patients, which could also minimize their stress and fear of the complex treatment procedures. Curriculums in Slovenian secondary schools in the field of healthcare should be unified and updated; and the employment of HCWs should also be increased, which could enable better HCW-patient relationships. The analysis of the results offers several useful insights, and has theoretical and practical implications in the field of human resources management of healthcare institutions.