Journal of Forensic and Legal Medicine 69 (2020) 101874

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Journal of Forensic and Legal Medicine

journal homepage: http://www.elsevier.com/locate/yjflm

Research Paper

Burnout in physicians who are exposed to workplace violence

Teke Yasar Hacer a, Aygun Ali b, *
a
Department of Forensic Medicine, Faculty of Medicine, Ordu University, Ordu, Turkey
b
Department of Emergency Medicine, Faculty of Medicine, Ordu University, Ordu, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: Workplace violence in the health sector is one of the common problems of both developed and developing
Burnout countries. The aim of this study is to investigate the causes of violence against doctors in the health sector and to
Physician position evaluate the effect of violence on burnout.
Violence at work
Material and method: The questionnaire forms were delivered to doctors working in Ordu via internet between
Physical violence
01.03.2018 and 31.03.2018. Preliminary questionnaire form consisting of 20 questions and Maslach Burnout
Verbal violence
Psychological violence Inventory (MBI) were used in the study.
Results: It was observed that the scores of emotional exhaustion and depersonalization were statistically signif­
icantly higher in physicians who were subjected to verbal and physical violence (p < 0.05). On the other hand,
increase in emotional exhaustion and depersonalization scores and decrease in personal achievement scores were
found to be statistically significant in those exposed to psychological violence (p < 0.05).
Conclusion: It was found that doctors who were exposed to violence at work were exposed to verbal and psy­
chological violence more than physical violence and especially psychological violence had a significant negative
effect on burnout.

1. Introduction Workplace violence in health sector is one of the common problems

According to World Health Organization (WHO), violence is defined
as “the threat of intentional use of force that results in (or is likely to
result in) injury, death, psychological harm, growth retardation or
negligence against the person, someone else or a group”.1
In studies conducted, it is stated by experts that there are four types
of perpetrators in an event of violence in workplace:
a. Aggressor who has no relationship with the workplace and em­
ployees (For example: a person coming to workplace for armed
robbery)
b. Aggressor who comes to the workplace as a client or a patient (for
example: a patient under the effect of drug punching a caregiver)
c. Aggressors who are already working or were previously working in
the workplace (for example, the former manager attacking the peo­
ple who are still working in the workplace)
d. Aggressors who have personal relationships with the aggressor
outside the workplace (for example, ex-wife attacking the person
working at the workplace).2
of both developed and developing countries.3 WHO reported workplace
violence rates in various countries. According to this report, workplace
violence in health sector is 75.8% in Bulgaria, 67.2% in Australia, 61%
in South Africa, 37% in Portugal, 54% in Thailand and 46.7% in Brazil.4
According to the report of the US Bureau of Labor Statistics, there were
11370 attacks on health workers in 2010.5
The concept of burnout was used by Freudenberger (1974) for the
first time as a phenomenon of physical, emotional and mental exhaus­
tion accompanied by signs of decrease in success, depersonalization and
decreased interest in work.6 It is stated that it is frequently seen in
professions such as medicine, nursing, teaching and lawyers since they
are in face-to-face relationship with people.7 It is stated that the reasons
for burnout in healthcare workers are situations such as working under
intense stress, the existence of vital risks, lack of psychological support,
low wage levels, approaches of patients and even their relatives, the
length of work, the responsibility of providing a high level of care
continuously, limited promotion opportunities and disappointment and
frustration arising from the difference between business realities and job
expectations.8,9
The aim of this study is to investigate the causes of violence against

* Corresponding author. Ordu University, Faculty of Medicine, Department of Emergency Medicine Ordu, Turkey.
E-mail address: aliaygun@odu.edu.tr (A. Ali).

https://doi.org/10.1016/j.jflm.2019.101874
Received 18 July 2019; Received in revised form 2 October 2019; Accepted 11 October 2019
Available online 14 October 2019
1752-928X/© 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
T.Y. Hacer and A. Ali Journal of Forensic and Legal Medicine 69 (2020) 101874

doctors in the health sector and to evaluate the effect of violence on Table 1
burnout. Comparison of the internal consistency coefficients of Maslach Burnout
Inventory.
2. Material and method Original Work12 Turkish version10 Our results

Emotional exhaustion 0.90 0.83 0.92

The study was conducted after the approval of Ordu University Depersonalization 0.71 0.72 0.71
Faculty of Medicine Clinical Research Ethics Committee decision num­ Personal achievement 0.79 0.65 0.75
ber 2019/11. An online questionnaire was applied to physicians work­
ing in public, private hospitals and community health centres in Ordu
(n ¼ 267) reported that they were exposed to psychological violence and
between 01.03.2018 and 31.03.2018. Male and female physicians who
22.6% (n ¼ 70) reported that they were exposed to physical violence.
volunteered to participate in the study were included in the study.
As a result of the chi-square test performed to compare sociodemo­
Physicians who were not willing to participate in the study and who did
graphic characteristics of the physicians who were subjected to violence
not answer all of the questions in the questionnaires were excluded. 310
and those who were not, it was found that the physicians who stated that
physicians working in Ordu province and districts completed the ques­
they were subjected to verbal violence were married and they were
tionnaire voluntarily.
between 31 and 40 years of age and the difference was found to be
statistically significant (p < 0.05). In addition, among the physicians
2.1. Scales used in the study
who suffered from physical violence, the states of being between the
ages of 31 and 40, spending 2–11 years in the profession and working in
i. Pre-survey form: There are a total of 20 questions in the pre-survey
state hospital were found to be statistically significant (p < 0.05).
form about socio-demographic characteristics (age, gender, marital
The distribution of sociodemographic data in terms of the state of
status, years in the occupation, health institution the physicians
being exposed to violence is given in Table 2.
worked in) and about violence (whether they were exposed to
The groups that resorted to verbal violence the most were patients,
physical, verbal and psychological violence, by whom they were
patient relatives and colleagues, respectively; while the groups that
exposed to violence, whether they used White code, whether they
resorted to psychological violence the most were stated as patient rel­
resorted to the jurisdiction and one open ended question in which
atives, superiors and patients. The groups that resorted to physical
they could write the situations they considered as the cause of
violence the most were patient relatives, patients and colleagues (Fig. 1).
violence in healthcare sector).
41.6% (n ¼ 129) of the physicians stated that they used white code
ii. Maslach Burnout Inventory (MBI): In order to determine burnout,
application once or more. The mean white code usage of the physicians
MBI, which was adapted into Turkish by Ergin, was used.10,11 The
was calculated as 2.60 � 2.21 (min: 1, max: 12). 38.4% (n ¼ 119) of the
scale consists of 22 questions, each with five-digit answer options. It
physicians stated that they resorted to the jurisdiction in case of
has three sub-dimensions as Emotional exhaustion (EE) which has
violence. 9% of the physicians stated that a weapon or similar object was
nine items (items 1-2-3-6-8-13-14-16-20), Depersonalization (DP)
used in the event of violence.
which has five items (items 5-10-11-15-22) and personal achieve­
In the pre-questionnaire form, the physicians were asked about their
ment (PA) which has eight items (items 4-7-9-12-17-18-19-21).12 EE
thoughts on the causes of violence in health as the last question in the
and DP sub-dimensions include negative items, while PA includes
form of an open-ended question.
positive items. The scores are calculated separately for each subscale.
The first three conditions that doctors emphasized were the low
Since there is no cut-off value for the scores obtained from the sub­
socio-cultural and inadequate educational status of the community
scales, it is not possible to make a distinction in the form of there is
served (16.40%), current health policies (15.90%) and current govern­
burnout or there isn’t burnout. It is expected that EE and DP scores
ment policies (13.60%). Other reasons stated with low rates were
are higher and PA scores are low in individuals with burnout.
respectively; insufficiency of the legal legislation on violence in health,
discrediting the medical profession, the media reporting unfortunate
2.2. Statistical analysis
news for health workers, current working conditions, deteriorated psy­
chology and misperceptions of the society, attitudes of the administra­
A statistical package program was used for statistical analysis.
tors, communication problems with the patient, negative point of view
Descriptive statistics of the evaluation results were given as number and
towards the doctor, high expectations of the patient, disrespectful,
percentage for categorical variables, and average, standard deviation
impatient actions and attitudes of the patient and/or the patient’s rel­
(SD), minimum (min) and maximum (max) for numerical values.
atives, high number of patients served by the physician, inadequacy in
Shapiro-Wilks test was used for normality distribution. Chi-square
the works of the professional organization, lack of qualification and
test was used to evaluate the categorical data. In the comparison of
empathy, wide application of patient rights, easy access to doctor and
paired groups, Mann Whitney U test was used for parameters that were
health care, insufficiency of existing hospitals, non-compliance with
not normally distributed. In the comparison of groups of three, Kruskal-
deontology principles, and encountering patients with alcohol and
Wallis test was used for parameters that were not normally distributed.
substance use. When the mean scores obtained from the burnout scale
For those with significant Kruskal-Wallis test, Bonferroni corrected
were evaluated according to the interpretation table of the burnout scale
Mann Whitney U test was used for binary comparisons. Statistical sig­
scores13; it was seen the sample had normal EE and DP scores and high
nificance level was accepted as p < 0.05.
PA scores. This shows that the sample had moderate level of burnout in
The Cronbach alpha internal consistency test results for the reli­
terms of EE and DP sub-dimensions and high level of burnout in terms of
ability analysis of the MBI in our study are in parallel with the original
PA sub-dimension. The answers given by the physicians who partici­
reliability study as shown in Table 1.
pated in the study to the questions about burnout constitute the scores
obtained by the sample from the EE, DP and PA sub-dimensions of the
3. Results
burnout scale. The means of these scores are presented in Table 3.
MBI subdimension scores of the physicians were summarized ac­
Of the 310 physicians who participated in the study, 47.7% (n ¼ 148)
cording to their sociodemographic data and their states of being exposed
were female and 52.3% (n ¼ 162) were male. The youngest of the
to violence. The scores of emotional exhaustion and depersonalization
physicians was 28 years old, while the oldest was 58 years old and the
subscales were statistically significantly higher in physicians who were
mean age was 35.42 � 7.89 years. 93.2% (n ¼ 289) of the physicians
subjected to verbal and physical violence (p < 0.05). On the other hand,
reported that they were exposed to verbal violence, while 86.1%

2
T.Y. Hacer and A. Ali Journal of Forensic and Legal Medicine 69 (2020) 101874

Table 2
Distribution of sociodemographic data of physicians who have been subjected to violence.
Verbal violence Psychological violence Physical violence

n % p n % p n % p

Gender
Women 142 45.80 0.069 133 42.90 0.069 30 9.67 0.352
Men 147 47.41 134 43.22 40 12.90

Age groups

22-30 age 90 29.03 0.019 88 28.38 0.976 10 3.22 0.002

31-40 age 125 40.32 110 35.48 34 10.96
41-50 age 64 20.64 60 19.35 22 7.09
�41 age 10 3.22 9 2.90 4 1.29

Marital Status

Married 184 59.35 0.001 166 53.54 0.217 55 17.74 0.600

Single 99 31.93 95 30.64 12 3.87
Widow 6 1.93 6 1.93 3 0.96

Professional experience

0-1 years 34 10.96 0.091 33 10.64 0.875 1 0.32 0.008

2-11 years 138 44.51 126 40.64 33 10.64
12- 21 yıl years 91 29.35 83 26.77 27 8.70
�22 years 26 8.38 25 8.06 9 2.90

Institution

TRH 74 23.87 0.029 67 21.61 0.120 15 4.83 0.301

PH 129 41.61 121 39.03 27 8.70
FMC 63 20.32 59 19.03 19 6.12
Others 23 7.41 20 6.45 9 2.90

TRH: Training and Resarch Hospital, PH: Public Hospital, ASM: Family Health Center, Others: Forensic council, Ambulance, Workplace doctors, Private hospital.

Fig. 1. Distribution of groups that resort to violence by type of violence.

physicians in terms of PA sub-dimension of the scale, it was seen that the

Table 3
mean scores of female physicians were higher in EE and DP sub-
Mean scores and levels of sub-dimensions of Burnout Scale.
dimensions (p < 0.05). In terms of age, it was seen that there was a
Sub-dimensions Burnout level Mean � SD statistically significant difference in the subscales of DP and PA
Low Normal High (p < 0.05). In the Bonferroni corrected Mann Whitney U test which was
Emotional exhaustion 0–16 17–26 �27 21.37 � 7.00 performed in order to determine the difference between the subgroups,
Depersonalization 0–6 7–12 �13 7.95 � 3.47 while there was no statistical difference between EE and DP sub-
Personal achievement �39 32–38 0–31 20.16 � 3.73 dimensions between the groups, the mean PA score was found to be
higher in the 41–50 age group than in the 22–30 age group (p < 0.05). In
the assessment made in terms of marital status; while there was no
increase in EE and DP scores and decrease in personal achievement
significant difference in EE sub-dimension, statistically significant dif­
scores were found to be statistically significant in those who were
ference was found in PA and DP sub-dimensions (Table 5), (p < 0.05).
exposed to psychological violence (Table 4), (p < 0.05).
While there was no significant difference between female and male

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T.Y. Hacer and A. Ali Journal of Forensic and Legal Medicine 69 (2020) 101874

Table 4
Maslach Burnout Inventory subscale scores according to physicians’ sociodemographic data and their states of being exposed to violence.
n Emotional exhaustion Depersonalization Personal achievement

Mean � SD p Mean � SD p Mean � SD p

Gender
Women 148 22.16 � 7.21 0.037 8.53 � 3.40 0.005 19.84 � 3.88 0.321
Men 162 20.65 � 6.74 7.41 � 3.45 20.45 � 3.56

Age groups

22-30 age 102 21.01 � 8.16 0.771 8.63 � 3.45 0.036 19.25 � 4.00 0.027
31-40 age 127 21.18 � 6.58 7.70 � 3.41 20.36 � 3.61
41-50 age 70 22.11 � 5.89 7.68 � 3.51 20.95 � 3.46
�41 age 11 22.18 � 7.09 6.18 � 3.15 21.18 � 2.52

Marital Status

Married 194 21.36 � 6.48 0.749 7.51 � 3.36 0.008 20.62 � 3.46 0.011
Single 110 21.30 � 7.91 8.62 � 3.54 19.48 � 4.01
Widow 6 23.33 � 5.98 9.83 � 3.37 17.50 � 4.32

Professional experience

0-1 years 40 19.57 � 9.70 0.360 8.75 � 4.11 0.006 18.10 � 4.57 0.001
2-11 years 144 21.75 � 6.40 8.46 � 3.15 19.89 � 3.28
12- 21 yıl years 97 21.14 � 6.80 7.29 � 3.56 21.14 � 3.76
�22 years 29 22.62 � 5.90 6.48 � 2.97 21.03 � 3.19

Institution

TRH 75 21.74 � 6.43 0.252 7.76 � 3.22 0.533 20.60 � 3.41 0.956
PH 139 21.50 � 7.70 8.26 � 3.56 19.58 � 3.94
FMC 68 21.36 � 6.59 7.77 � 3.65 20.54 � 3.66
Others 28 19.78 � 5.81 7.32 � 3.20 20.89 � 3.33

Verbal violence

Exposed 289 21.67 � 6.85 0.013 8.07 � 3.44 0.033 20.19 � 3.67 0.443
Unexposed 21 17.23 � 7.87 6.28 � 3.43 19.66 � 4.54

Psychological violence

Exposed 267 22.21 � 6.76 <0.001 8.32 � 3.44 <0.001 19.92 � 3.67 0.008
Unexposed 43 16.16 � 6.25 5.60 � 2.66 21.62 � 3.79

Physical violence

Exposed 70 23.31 � 5.91 0.005 8.88 � 3.24 0.010 20.08 � 3.37 0.746
Unexposed 240 20.81 � 7.20 7.67 � 3.49 20.18 � 3.83

TRH: Training and Resarch Hospital, PH: Public Hospital, ASM: Family Health Center, Others: Forensic council, Ambulance, Workplace doctors, Private hospital.

4. Discussion necessary to conduct a risk assessment in the company in order to take

The European working conditions survey shows that more than 20%
of healthcare workers in the European Union (EU-27) have experienced
verbal abuse, unwanted sexual behavior, threats, degrading behavior,
physical violence, bullying, harassment and sexual harassment in the
past year. It is an important survey for showing a constantly increasing
serious and dangerous occupational situation to healthcare personnel
which is mainly conducted by patients and their relatives.14
Psychosocial hazards and risks can often be understood by analysing
the structural and organizational characteristics of a person’s work, and
physical, psychological and sexual violence and harassment are
considered psychosocial risks in many jurisdictions.15 EU Directive
89/131, which was put into force in 1989 with the recognition of psy­
chosocial risks in European countries, requires legal arrangements to
prevent psychosocial risks and conduct risk analyses in enterprises. In
Turkey, 6631 numbered “Occupational health and safety law” makes it
Table 5
Differences in scores from the subscales D and EE in terms of marital statusa.
Average difference Standard error
Depersonalization Married 1.147 0.439
Single
Personal achievement Married 1.116 0.409
Single
a
Mann Whitney u-test results with Bonferroni correction.
preventive measures.16
In epidemiological studies about the incidence of being exposed to
violence especially conducted within the context of nurses, the rate of
being exposed to violence was found as 9.5% in the UK, as 66.8% in
China and as 86.7% in Turkey.17–19 In previous studies on workplace
violence against doctors in Turkey, verbal violence was reported to be
between 46.7% and 100%, physical violence was reported to be between
1.8% and 22.5% and psychological violence was reported to be 33.3%.20
In our study, the results that 93.22% of the doctors were exposed to
verbal violence, 22.58% were exposed to physical violence, and 86.12%
were exposed to psychological violence are in parallel with other
studies, but it is remarkable that they are close to the upper limits. This
brings to mind that violence at work has increased as a problem that
cannot be solved over the years. When we look at the numbers of
physical violence in the last year in the literature; they were 7.5% in
Bulgaria, 6.4% in Brazil, 5.8% in Lebanon, 10.5% in Thailand.4 In our
study, the rate of physical violence was very high (22.58%) and it is an
important issue that approximately half of the physicians who were
subjected to physical violence stated that a weapon or similar device was
used in these incidents. According to a literature review, it was stated
p that physical injury during workplace violence in the health sector is
0.026
between 4.9% and 65% and 4.4% of these injuries are serious
life-threatening injuries.21
0.018 It is thought provoking that in our study, the first three conditions
that health workers emphasized as the cause of violence were low socio-
cultural and inadequate educational status, current health policies and

4
T.Y. Hacer and A. Ali
current government policies. In another study conducted in our country
in 2017, it was suggested to conduct risk assessment by neutrally
respected professionals by taking violence, threats and verbal harass­
ment seriously against health workers in cooperation with health man­
agement and the whole organization and state authority.14 International
Labour Organization (ILO) 2018 Report V lists the situations that
workers can be exposed to violence in the work place as working with
the public, working with people in distress, working within the scope of
social protection and labor law and/or protection and non-compliance
with the law, working with limited resources (insufficient equipment,
inadequate personnel, etc.), working during unusual working hours and
these situations are thought to be in parallel with the working situations
of our sample.15 In terms of these working conditions, it is important to
make legal arrangements in order to prevent violence and to take
necessary measures and to provide necessary social education for health
workers and prevention of violence by using channels such as media.
In a study carried out between doctors and other professions in the
USA, the rate of EE was 29.4%, and the rate of DP was 37.9% in doctors.
In the same study, it was emphasized that the prevalence of burnout
among physicians was at alarming levels and that emergency medicine,
internal medicine and family medicine branches were the most risky
groups in terms of burnout.22 In another literature review, factors
related to the increase in burnout prevalence among physicians were
listed as: female gender, young age, long working hours, low job satis­
faction, presence of work-home conflict.23 There are some studies
consistent with observations that the symptoms of burnout may
decrease as people age.24 A study on the condition of burnout in women
suggested that being younger may come forward due to a lack of
occupational experience and ways of coping with various aspects of
work-related stress.25 Although there are studies showing that burnout
status is higher in women than men, it is reported that these differences
are small proportions.25–27 In a large-scale study of doctors working in
european countries, ıt was stated that the country of study, job satis­
faction, intention to change jobs, use of sick leave, alcohol, tobacco and
psychotropic drug use, young age and male gender variables were
related to high burnout rates.28
In our study, while there was no significant difference between the
female physicians and male physicians in terms of personal success sub-
dimension of the scale, the statistically significantly high scores of the
female physicians in DP and EE sub-dimensions (p < 0.05) suggest that
female gender should be considered as a risk factor. In a study on the
women in Sweden that was showed women which have worse socio­
economic conditions than their colleagues have higher burnout and a
more unhealthy state.25 Although there are not enough studies showing
the relationship between burnout and cultural and social status of
women in our country, we think that these factors affect our results as
we are one of the countries where violence against women is high.
In addition, the result that DP scores were statistically significantly
high and PA scores were statistically significantly low in married par­
ticipants was evaluated in terms of work-home conflict. Arnetz and
Arnetz’s study on relationship between violence and burnout of
healthcare workers revealed that healthcare workers who suffered from
violence and threat also suffered from burnout as well as a reduction in
health care quality.29 In a study conducted on physicians working in
emergency services in our country, it was shown that there is a strong
relationship between workplace violence and burnout.30 According to
the findings of the study conducted by Dursun et al. on health sector, it is
stated that being exposed to or witnessing violence increases EE and DP
levels of workers.31 In a study aimed at developing personal differences
between health workers in relation to violence and burnout in the
workplace, it is emphasized that the fear of future violence at the
interpersonal level is an important premise that disrupts the employee’s
well-being like burnout.32 While it is stated in the literature that the
rates of psychological and sexual violence are not low in fact although
the reporting rates are low,20 it is remarkable that studies in this area are
limited.
5
Journal of Forensic and Legal Medicine 69 (2020) 101874
In our study, statistically significant increase in EE and DP scores
(p < 0.001) and a significant decrease in PA scores (p ¼ 0.008), espe­
cially in doctors who were exposed to psychological violence, were
remarkable and it is an important finding that it shows that burnout
status becomes more prominent among the victims of psychological
violence.
In our country, white code is applied for health workers in cases of
workplace violence. In our study, 41.6% of physicians stated that they
applied this application once or more. This rate shows that not all
physicians who are exposed to violence use the application.
4.1. Limitations
The fact that the reasons for not using the White Code application
were not questioned is the limitation of our study. In addition, another
limitation is that sexual violence and harassment, which are forms of
workplace violence, are also not included in our study.
5. Conclusion
It was found that most of the doctors who were subjected to violence
at work were exposed to verbal and psychological violence firstly, they
were less exposed to physical violence than other types of violence and
especially psychological violence had a significant negative effect on
burnout status. We think that states should produce policies that support
working conditions and employees, prevent loss of rights, and also su­
pervise the legal rights of service users. It is important that non-
governmental organizations and occupational organizations should
determine attitudes that support the rights of workers and help the
functioning in cooperation with the state and the public should be
educated with the integration of the education system.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jflm.2019.101874.
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