Workplace aggression is a common and concerning occurrence within healthcare [1,2,3,4]. Healthcare professionals, including physicians, have been found to have a heightened risk of experiencing workplace aggression compared to other service workers , with estimated one tenth to two thirds of healthcare workers having encountered aggression [2, 5,6,7]. It is generally agreed that the nursing staff is at highest risk of experiencing aggression , but the problem is prevalent among physicians as well [2, 4]. The prevalence of workplace aggression is likely even higher than reported because the incidents tend to be underreported [2, 4], which presents an alarming picture of the state of experiencing workplace aggression in healthcare. Because the prevalence rates of workplace aggression depend on its conceptualization, it is challenging to compare prevalence estimates for aggression across different studies.
Workplace aggression can be physical or non-physical in nature and it can manifest for example as verbal abuse, physical assaults, harassment, bullying, intimidation, threatening, and obscene behaviors . Consequently, there is an abundance of proposed constructs of workplace aggression seeking to define the phenomenon. However, many of these constructs lack in definition, as they show considerable overlap and do not have uniform attributes 8. Therefore, the definition of “workplace aggression” in this study will encompass simply all these manifestations and behaviors towards employees that can result in psychological, social or physical harm to the victim, as suggested in previous literature . In healthcare environments, violence arises typically from patient interactions, but much of the non-physical violence experienced in the healthcare workplace is perpetrated by colleagues and superiors as well [2, 5,6,7]. However, studies examining workplace aggression have focused mostly on the aggression carried out by patients.
Workplace aggression has consequences for both the well-being of healthcare professionals and quality of patient care. Experiencing workplace aggression is associated with negative psychological outcomes for the healthcare worker (e.g. burnout, anxiety, depression), regardless of whether aggression is physical or non-physical [1, 3, 7]. Instances of workplace aggression have also been associated with worse quality of patient care [1, 5]. There is also evidence that physicians may deliver worse care if they are afraid of patients , and being a victim of aggression can change the way a healthcare worker feels and behaves around a patient . Finally, workplace aggression may also have organizational consequences, as workplace aggression is associated with absences from work [1, 4] and the negative psychological consequences resulting from encountering aggression can cause some physicians to leave the organization altogether .
Given that workplace aggression has severe consequences, it is important to understand factors that may increase its risk. Work-related stress has been recognized as one of the factors that might increase the risk of suffering from workplace aggression from both patients and other healthcare staff [5,6,7]. This is especially concerning considering that work stress among healthcare workers is becoming increasingly common . Indeed, rapid digitalization of healthcare has brought forth one major stressful work characteristic for healthcare workers, namely constantly changing, difficult, and poorly functioning information systems [11,12,13,14]. Information systems (IS) refer to technological systems that manage healthcare data, e.g. electronic health records, which can be used for storing, sharing, searching and retrieving digital patient information . In theory, information systems can offer improvements in quality of care and access to patient information remotely , but it is still debated whether information systems actually hinder physicians’ job more than they help it [15, 16].
According to previous studies, information systems respond poorly to the needs of physicians, thus accumulating masses of criticism and contributing to poor well-being [11, 14, 17, 18]. Physicians’ complaints regarding information systems often include aspects related to poor functionality and usability [11, 17, 19, 20], and several IS-related factors have been directly associated with distress, stress, and burnout for healthcare professionals [13, 20]. Moreover, coping with poorly functioning or difficult to use information systems is especially difficult if there are other stressful work factors, such as time pressure [12, 19]. Unfortunately, frequently changing systems require physicians to continuously update their knowledge on information systems, and learning to use these systems requires time and training [17, 21].
There are several mechanisms as to how stress attributed to information systems (SAIS) and work aggression might be connected. First, stress in general has a negative impact on social relationships, which might lead to interpersonal conflict and aggression . Emotional exhaustion, a common consequence of stress , can lead to depersonalization, and subsequently, to negative behavioral changes toward patients and colleagues . Secondly, changing, difficult, and poorly functioning information systems may constitute an especially frustrative and stressful work-related stressor for physicians because it may hinder their work, create additional time-pressure, and interfere with patient interaction. Thus, SAIS is likely to arouse frustration and negative affect, which may create aggressive inclinations and aggressive behavior (frustration-aggression theory) . Thirdly, according to social learning theories , people acquire aggressive behaviors by observing others. Hence, the aggressive behavior of a stressed health care worker might get modeled by patients, relatives, or other healthcare workers. Moreover, the negative affect of a physician (e.g. anxiety, irritability, anger) might influence the mood of patients, relatives, and staff (emotional contagion) . This means that the negative affect of a physician might arouse negative affect in others. Indeed, it has been found that the mood of a healthcare worker is associated with the mood of patients  and other healthcare workers [29, 30].
Because workplace aggression is a major concern both for the wellbeing of physicians and quality of patient care, it is critical to understand risk factors that are associated with its occurrence. Previous research has shown that stressful work characteristics increase the risk of workplace aggression, potentially by inducing frustration and negative affect. Information systems have been consistently recognized as a major stressful work characteristic for physicians. However, previous studies have not, to our knowledge, examined the association between SAIS and workplace aggression. Therefore, the current study examined the association between physicians’ SAIS and their experiences of workplace aggression (physical and non-physical) perpetrated both by patients and healthcare staff.
This study aims to answer the following main study question:
Are physicians who experience higher levels of SAIS more likely to encounter workplace aggression?
Based on the main study question, following questions were formed:
Is SAIS associated with non-physical and physical aggression?
Is SAIS associated with non-physical aggression perpetrated both by patients and relatives, and co-workers and superiors?