Workplace violence against healthcare workers has been on the rise since the COVID-19 pandemic[1]. Assaults against healthcare workers are increasing at an alarming rate globally, especially verbal attacks by patients[2, 3]. In 2022, led to the pandemic outbreak of neo-coronavirus pneumonia in Shanghai, with mass infected patients arising nationwide in a short period of time. Fangcang shelter hospitals were quickly established and used to isolate and treat patients with mild to moderate COVID-19. Such hospitals were large-scale, temporary hospitals built by converting public venues such as stadiums and exhibition centers into healthcare facilities. Healthcare professionals in Fangcang shelter hospitals also suffer from patient mistreatment. Patients who enter the concentration isolation sites of these hospitals are more likely to suffer from mental health problems, such as anxiety, because they are in a relatively narrow space[4]. This may cause patients to act aggressively toward the healthcare staff. Numerous studies have shown that workplace violence adversely affects the quality of patient care and reduces the organizational commitment, job performance, and job satisfaction of healthcare workers[5–8]. Patient mistreatment negatively affects the role behaviors of healthcare workers[9]. However, there are few studies on how and when this occurs. Therefore, the current research aimed to clarify the relationship between patient mistreatment and healthcare workers' role behaviors. Specifically, we focus on two types of role behaviors: service performance and patient-oriented organizational citizenship behavior (OCB hereafter). Effective interventions are necessary to support healthcare workers during health emergencies and possible future outbreaks.
Previous studies have elaborated on the negative impact of customer mistreatment on employees, and it is important to explore the boundary conditions behind it. For example, accountability and supervisor support can weaken the impact of customer mistreatment on employees' negative emotions[10, 11]. At present, there is no perspective from the self-verification of healthcare workers to explore the boundary conditions that alleviate the negative effects of patient mistreatment. Based on the self-verification theory, healthcare professionals constantly accept and process external information to enhance their self-concept. This study proposes that displaced aggression by patients (DAP hereafter) may have a moderating effect between patient mistreatment and emotional exhaustion. Healthcare professionals with extensive work experience are able to sharply detect changes in patient behaviors and emotions during this emergency epidemic, while standing in the patient's perspective to think about problems and empathize with the patient. The patients "indiscriminate" aggression may stimulate empathy among healthcare workers, reducing the depletion of their own self-efficacy and emotional resources, thereby influencing service performance and patient-oriented OCB.
Therefore, we aimed to study the impacts of patient mistreatment on the service performance and patient-oriented OCB of healthcare workers and explore the mechanisms and boundary conditions behind this relationship. This study attempted to answer the following questions: Is patient mistreatment related to service performance and patient-oriented OCB through emotional exhaustion? Can healthcare professionals perceive DAP as a protective resource to reduce emotional exhaustion?
Patient mistreatment and emotional exhaustion
Customer mistreatment refers to unfair and low-quality interpersonal treatment of service personnel by customers during the service process, including cruel hostility, insult, and other acts of intensity less than physical violence[12]. Walker et al. (2014) found that customer mistreatment as a source of stress can induce negative emotions in employees[13]. Customer mistreatment indirectly affects the organization’s negative reputation through employees’ OCB[14]. Specifically, in the healthcare service industry, customer mistreatment is referred as patient mistreatment. However, there are limited academic studies on the impact of patient mistreatment on healthcare workers, particularly in Fangcang shelter hospitals.
Based on the conservation of resource theory, individuals always tend to strive to acquire, maintain and preserve valuable resources[15]. Being criticized by others (such as leaders, customers or patients) leads to a loss of emotional resources[16–19]. Especially for healthcare workers, serving patients is itself a process of consuming psychological resources. The COVID-19 has exacerbated emotional exhaustion among medical staff[20]. The occurrence of patient mistreatment at this time is not only unable to replenish the original emotional resources of healthcare providers but also require them to consume additional emotional resources to cope with it. Based on the above analyses, the following hypothesis is proposed:
H1: Patient mistreatment is positively associated with emotional exhaustion of healthcare workers.
The mediating role of emotional exhaustion
In a service environment characterized by uncertainty and interdependence, employees need to go beyond the narrow scope of work to serve customers[21]. The distinction between in-role and extra-role behavior is reflected in the discretionary and formalization of employee service behaviors[22]. In-role behavior refers to the organization’s members’ activities within the provisions that must be performed to receive the corresponding remuneration[23]. Essentially, it belongs to the employees’ daily work tasks, usually for service performance[24]. The extra-role behavior is the spontaneous initiative of employees, which transcends the role and organizational remuneration system[25], such as autonomous work effort and OCB.
Resources are a set of important factors that can help individuals achieve their goals or meet their psychological needs[26]. Faced with customer mistreatment, employees must consume emotional resources to engage in effective self-motivation to maintain good performance[27]. Studies have shown that emotional exhaustion during COVID-19 has a significant negative effect on unhealthy diets of healthcare workers[28]. Due to the loss of emotional resources, workers may spend time and attention calming themselves down, which reduces their involvement and attention at work and leads to a decline in service performance[29]. Additionally, to prevent further loss of resources, resource-deficient healthcare workers will be better protective of available resources. Thus, they may reduce their commitment and responsibility to patients by reducing patient-oriented OCB[30]. Patient mistreatment leads to a loss of emotional resources, which may further lower the initiative and motivation of healthcare professionals to provide services, thereby reducing their interests and willingness to serve patients[31]. Accordingly, we propose the following hypotheses:
H2a: Emotional exhaustion is negatively related to service performance.
H2b: Emotional exhaustion is negatively related to patient-oriented OCB.
Combining H1 and H2, this study proposes the following hypotheses regarding the mediating effects of emotional exhaustion:
H3a: Emotional exhaustion mediates the association between patient mistreatment and service performance.
H3b: Emotional exhaustion mediates the association between patient mistreatment and patient-oriented OCB.
The moderating role of displaced aggression by patients
Dodge et al. (1987) considered reactive aggression as an individual's defensive response to anger when faced with frustration[32]. DAP is a particular type of reactive aggression. To eliminate anger, the attacked person will try to retaliate against the attacker[33]. However, they are often unable or unwilling to attack the attacker (e.g., their supervisor), then they often turn to attacking other innocent parties[34]. For example, workers show negative emotional and behavioral reactions toward their families after feeling dissatisfied with their leader[35]. and studies have also shown that work-family conflicts can lower employees’ emotions and even engage in aggressive behavior toward those around them[36].
Based on the above study, we attempted to use displaced aggression as a boundary condition to explore ways to mitigate the negative effects of patient mistreatment. According to self-verification theory, individuals in the process of self-concept formation will continuously receive, integrate, interpret, and modify external information, thereby affecting their self-concept[37, 38]. Self-verification theory emphasizes how healthcare professionals see themselves and what they see from their patients[39]. Healthcare workers tend to view being mistreated as a failure of service, thereby reducing their self-esteem and self-concept[40]. However, when workers see patients frequently expressing anger toward themselves, other healthcare providers, and/or shelter hospital managers, they catch those signals through their empathic abilities. Subsequently, they may construct a personal understanding of the mistreatment and build an interpretation that patients "indiscriminately" attack people around because of anxiety, nervousness, or depression rooted in the treatment of coronavirus disease in Fangcang shelter hospitals. Being mistreated by patients should not be attributed to the workers’ own professional and technical competence, thus reducing the risk of depletion of their self-concept and the consumption of their own emotional resources. Accordingly, we propose the following hypothesis:
H4: DAP moderates the relationship between patient mistreatment and emotional exhaustion such that the relationship is weaker when DAP is high versus low.
Based on the reasoning above, the following hypotheses are proposed:
H5a: DAP moderates the indirect effect of patient mistreatment on service performance through emotional exhaustion such that the indirect effect is weaker when DAP is high versus low.
H5b: DAP moderates the indirect effect of patient mistreatment on patient-oriented OCB through emotional exhaustion such that the indirect effect is weaker when DAP is high versus low.
We summarize our theoretical model in Figure 1.
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Insert Figure 1 about here
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