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Aggression and its consequences in nursing

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Title:
Aggression and its consequences in nursing a more complete story by adding its social context
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Book
Language:
English
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Yang, Liu-Qin
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University of South Florida
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Subjects / Keywords:
Workplace aggression
Nursing health and safety
Emotional strain
Violence prevention climate
Social burden
Dissertations, Academic -- Psychology -- Doctoral -- USF   ( lcsh )
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bibliography   ( marcgt )
non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: Using a 471-case nursing sample, the current study examined the direct and indirect relationships between workplace aggression (including physical and psychological) against nurses and their health and safety consequences. Specifically, physical and psychological aggression nurses experienced were related to their job dissatisfaction, turnover intention, physical symptoms, injuries and exposure to contagious disease directly and/or indirectly through their emotional strain (irritation, anxiety, and depression). In addition, my findings demonstrated that stronger violence prevention climate (i.e., good prevention practices/response and low pressure for unsafe practices) was related to less frequent violence and psychological aggression incidents nurses experienced.Also, my results indicated significant moderating effect of organizational violence prevention practices/response (one dimension of violence prevention climate) in the relationships of nurses' physical and psychological aggression with their anxiety and depression, such that nurses who perceived stronger (vs. weaker) violence prevention climate seemed to be more (vs. less) anxious about or depressed by aggression incidents that occurred to them. However, overall nurses who perceived stronger violence prevention climate felt less anxious and depressed at work than those who perceived weaker climate. Finally, regarding the role of social burden, there was evidence from this study supporting its positive relationship with nurses' perceived irritation, anxiety, and depression although there did not seem to be evidence supporting its moderating role between nurses' aggression experience and their emotional strain.In summary, emotional strain seemed to be a relatively consistent mediator between nurses' aggression experiences and their health or safety consequences, and nurses' perceived social context (violence prevention climate and social burden) did significantly and directly relate to their health and safety consequences, but more research is warranted before we conclude about their potential moderating role in the aggression-consequence relationships.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Liu-Qin Yang.
General Note:
Title from PDF of title page.
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Document formatted into pages; contains 90 pages.
General Note:
Includes vita.

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aleph - 002221168
oclc - 648020042
usfldc doi - E14-SFE0002926
usfldc handle - e14.2926
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ABSTRACT: Using a 471-case nursing sample, the current study examined the direct and indirect relationships between workplace aggression (including physical and psychological) against nurses and their health and safety consequences. Specifically, physical and psychological aggression nurses experienced were related to their job dissatisfaction, turnover intention, physical symptoms, injuries and exposure to contagious disease directly and/or indirectly through their emotional strain (irritation, anxiety, and depression). In addition, my findings demonstrated that stronger violence prevention climate (i.e., good prevention practices/response and low pressure for unsafe practices) was related to less frequent violence and psychological aggression incidents nurses experienced.Also, my results indicated significant moderating effect of organizational violence prevention practices/response (one dimension of violence prevention climate) in the relationships of nurses' physical and psychological aggression with their anxiety and depression, such that nurses who perceived stronger (vs. weaker) violence prevention climate seemed to be more (vs. less) anxious about or depressed by aggression incidents that occurred to them. However, overall nurses who perceived stronger violence prevention climate felt less anxious and depressed at work than those who perceived weaker climate. Finally, regarding the role of social burden, there was evidence from this study supporting its positive relationship with nurses' perceived irritation, anxiety, and depression although there did not seem to be evidence supporting its moderating role between nurses' aggression experience and their emotional strain.In summary, emotional strain seemed to be a relatively consistent mediator between nurses' aggression experiences and their health or safety consequences, and nurses' perceived social context (violence prevention climate and social burden) did significantly and directly relate to their health and safety consequences, but more research is warranted before we conclude about their potential moderating role in the aggression-consequence relationships.
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Emotional strain
Violence prevention climate
Social burden
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Aggression And Its Consequences In Nursi ng: A More Complete Story By Adding Its Social Context by Liu-Qin Yang A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Psychology College of Arts and Sciences University of South Florida Major Professor: Paul E. Spector, Ph.D. Tammy D. Allen, Ph.D. Michael T. Brannick, Ph.D. Chu-Hsiang (Daisy) Chang, Ph.D. Joseph Vandello, Ph.D. Date of Approval: March 26, 2009 Keywords: workplace aggression, nursing health and safety, emotional strain, violence prevention climate, social burden Copyright 2009 Liu-Qin Yang

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Dedication I want to dedicate my dissertation to my parents, Gongwei Yang and Youmei Xiong. I really appreciate the freedom they have provided me for developing myself, and the unconditional support that enables me to pursue my dream without any hesitation. I would also like to dedicate my dissertation to my mentor Dr. Paul E. Spector. In the past 5 years, I have been truly enjoyi ng the wonderful mentoring relationship with him. In a word, his mentoring has ma de my pleasant inte rnational journey.

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Acknowledgements First of all, I would like to thank my di ssertation committee for their great efforts in refining my research design and writing. Dr. Paul E. Specto r’s inspirations and support made the interdisciplinary part of my disse rtation possible. My growing interest in interdisciplinary research to a good extent owes to the helpful inputs from Dr. Daisy Chang. The rest of my committee (Dr. Tammy D. Allen, Dr. Michael T. Brannick and Dr. Joseph Vandello) certainly also contributed a lot to my pleasant and rewarding dissertation process. Particul arly, I liked the questions you raised during my defense! My appreciation extends to my research team, especially Mary Roman-Gallant, RN and Julie Powell, RN who have worked with me fo r this interdisciplinary research project for about two years. In addition, I tha nk Ms. Wendy Ryzner, RN and Ms. Debbie Lewandowski, RN at Martin Memorial Hospit al, and Ms. Karen Kent, RN at Bayfront Medical Center for their support fo r my data collection process.

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i TABLE OF CONTENTS List of Tables ................................................................................................................ ..... iii List of Figures ............................................................................................................... ..... iv ABSTRACT ...................................................................................................................... .. v Chapter 1: Introduction ....................................................................................................... 1 Human Aggression and Wo rkplace Aggression ............................................................. 1 Occupational Stress Framework ..................................................................................... 4 Organizational Climate and Orga nizational Violence Climate ...................................... 9 Social Burden ................................................................................................................ 14 Chapter 2: Method ............................................................................................................ 22 Participants .................................................................................................................. .. 22 Procedure ..................................................................................................................... 22 Measures ...................................................................................................................... 23 Chapter 3: Results ............................................................................................................ 31 Measurement of Distinct Constructs ............................................................................. 31 Prevalence of Workplace Aggression ........................................................................... 31 Hypothesis Testing........................................................................................................ 32 Chapter 4: Discussion ....................................................................................................... 4 9 The Link between Workplace Aggression and Health and Safety Consequences ....... 49 The Role of Emotional Strain ....................................................................................... 50 The Role of Organizational Violence Prevention Climate Perceptions ........................ 52

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ii The Role of Social Burden ............................................................................................ 54 Limitations and Implications ........................................................................................ 56 Conclusions ................................................................................................................... 58 References .................................................................................................................... ..... 60 Appendices .................................................................................................................... .... 77 Appendix A: Pilot Survey ............................................................................................. 78 Appendix B: Final Social Burden Scale ....................................................................... 82 Appendix C: Main Study Survey .................................................................................. 83 About the Author ................................................................................................... End Page

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iii List of Tables Table 1. Descriptive Statistics and Zero-O rder Correlations among Focal Variables ...... 34 Table 2. Correlations between Demographic Variab les and Focal Variables with Hospital ID Controlled for .................................................................................. 37 Table 3. Mediating Effect of Emotions between Workplace Violence and Health and Safety Outcomes ........................................................................................... 40 Table 4. Mediating Effect of Emotions between Psychological Aggression and Health and Safety Outcomes ............................................................................... 42 Table 5. Violence Prevention Prac tices/Response Moderated the AggressionEmotion Relationships ........................................................................................ 44

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iv List of Figures Figure 1. Hypothesized Relationships .............................................................................. 21 Figure 2. Violence Prevention Practices /Response Moderated the ViolenceAnxiety Relationship ........................................................................................ 45 Figure 3. Violence Prevention Pr actices/Response Moderated the ViolenceDepression Relationship ................................................................................... 45 Figure 4. Violence Prevention Practices /Response Moderated the Psychological Agression-Anxiety Relationship ...................................................................... 46 Figure 5. Violence Prevention Practices /Response Moderated the Psychological Agression -Depression Relationship ................................................................ 46

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v Aggression and its Consequences in Nursi ng: A More Complete Story by Adding its Social Context Liu-Qin Yang ABSTRACT Using a 471-case nursing sample, the cu rrent study examined the direct and indirect relationships between wor kplace aggression (including physical and psychological) against nurses and their health and safety consequences. Specifically, physical and psychological aggression nurses experienced were related to their job dissatisfaction, turnover intention, physical symptoms, injuries and exposure to contagious disease directly and/or indirectly through their emotiona l strain (irritation, anxiety, and depression). In a ddition, my findings demonstrated that stronger violence prevention climate (i.e., good pr evention practices/response a nd low pressure for unsafe practices) was related to less frequent violence and psychol ogical aggression incidents nurses experienced Also, my results indicated si gnificant moderating effect of organizational violence prevention practices /response (one dimension of violence prevention climate) in the relationships of nurses’ physical and ps ychological aggression with their anxiety and depre ssion, such that nurses who pe rceived stronger (vs. weaker) violence prevention climate seemed to be more (vs. less) anxious about or depressed by aggression incidents that occurred to th em. However, overall nurses who perceived stronger violence prevention clim ate felt less anxious and depressed at work than those

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vi who perceived weaker climate. Finally, regard ing the role of soci al burden, there was evidence from this study supporting its posi tive relationship with nurses’ perceived irritation, anxiety, and depression although ther e did not seem to be evidence supporting its moderating role between nurses’ aggressi on experience and their emotional strain. In summary, emotional strain seemed to be a re latively consistent mediator between nurses’ aggression experiences and their health or safety consequences, and nurses’ perceived social context (violence prevention climate and social burden) di d significantly and directly relate to their health and safety consequences, but more research is warranted before we conclude about their potential m oderating role in the aggression-consequence relationships.

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1 Chapter 1: Introduction This study focuses on the relationships between nurses’ experienced aggression and various assumed health and safety conse quences. In addition, it examines how affect may function as a mediator between aggression and its consequences, and investigates if contextual variables will m oderate the regression-outcome relationships among nurses. Those contextual variables are negative social interactions and organizational violence prevention climate (how much employees per ceive that the organization emphasizes the control and elimination of physical violen ce and psychological aggression, Spector, Coulter, Stockwell, & Matz, 2007). Human Aggression and Workplace Aggression Human aggression has been a major focus fo r researchers and theorists in the past few decades given the destructive effect of aggression on individuals and societies (e.g., Bandura, 1973; Baron, 1977; Baron & Rich ardson, 1994; Berkowitz, 1993; Lorenz, 1966). As defined by Baron (1977), aggression is any form of behavior aiming to harm or injure another living being in ways the inte nded target is motivated to avoid. This definition captures a broad range of behaviors includi ng physical aggression (i.e. violence) and verbal aggressi on. To be specific, there are five components in Baron’s definition. First, aggression is a type of behavi or as opposed to an emotion, an attitude or a motive. Second, aggression represents intent ional acts; that is, aggressor intends to harm the target(s). Third, the nature of the intent behind aggression is to harm or injure the target(s). Fourth, aggre ssion involves another living be ing as opposed to inanimate

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2 objects (e.g., furniture). Finally, the target of aggression is motivated to avoid the harm from the aggression. Applying the concept of aggression to the workplace, Baron and Neuman (1996) conceptualized workplace aggression as any fo rm of behavior by one or more persons in a workplace aiming to harm one or more othe rs in the same workplace (or the entire organization). Specifically, they labeled the phys ical and relatively intense harm-doing as workplace violence but named those less se vere non-physical instances of harm-doing (e.g., threats, yelling/shouting) as verbal aggression (Neuman & Baron, 2005). Given the fact that not all the non-p hysical instances of harmdoing are verbal (e.g., hostile postures), I use psychological aggression instea d of verbal aggressi on to indicate the nonphysical harm-doing, and use workplace violence to represent physical aggression, which is consistent with prior studies in the literature (e.g., Schat & Kelloway, 2003; Schat, Frone, & Kelloway, 2006). Workplace violence is a serious problem recognized worldwide that is prevalent and consequential in occupational settings li ke the healthcare indus try, particularly for nursing professionals ( Gerbrich et al., 2004; International Labour Office, International Council of Nurses, World Health Organiza tion, & Public Servi ces International 2002; Lanza, Zeiss, & Rierdan, 2006). As reported by the U.S. Bureau of Justice Statistics, on average 1.7 million episodes of victimization at work per year during the period of 1993 1999 (Duhart, 2001). In Gerberich et al. ( 2004) study of 4918 nurses across the whole Minnesota, 13.2% of them reported experienced physical violence at work in the past year. In reality, the occurrence rate is probably higher give n that many violent incidents are unreported (e.g., Ferns, 2006; Ray, 2007). Th e prevalence of workplace violence in

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3 nursing not only contributes to the decrease d healthcare quality but also negatively influences nurses’ health and well-being su ch as increased physical symptoms and emotional strain, or decreased job satisfacti on, which will in turn increases healthcare costs due to medical errors and nurse turnover (e.g., Lanza, 2006; LeBlanc & Barling, 2005; Schat et al., 2006). I focus on workplace vi olence experienced by a sample of U.S. hospital nurses in my study not only because of its prevalence in nursing environment and its serious consequences discussed above, but also because physical violence is an understudied topic, especially from the pe rspective of industrial and organizational psychology. In addition, I examined psychological aggression. There are three reasons for doing so. First, it has been shown to be even more prevalent than physical violence in the workplace including the healthcare setting (e.g., Gerberich et al., 2004; Greenberg & Barling, 1999; U.S. Postal Service Commissi on, 2000). For example, in Gerberich et al. (2004) study, 38.8% of the nurses reported expe rienced non-physical violence at work in the past year, as opposed to 13.2% occurren ce rate of physical violence. Second, the literature on family violence (e.g., Murphy & O’Leary, 1989) and that on aggression in healthcare settings (e.g., Lanza et al., 2006) suggest that psychol ogical aggression often becomes a precursor or cooccurrence to physic al violence. For example, Lanza et al.’s (2006) study showed that healthcare workers who had experienced non-physical aggression were 7.17 times more likely to be attacked physically at work than those who had not experienced non-physical aggression. Finally, similar to workplace violence, psychological aggression has been related to various negative consequences such as physical symptoms (e.g., Gerberich et al., 2004), emotional stra ins (e.g., Needham,

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4 Abderhalden, Halfens, Fischer, & Dasse n, 2005), and negative job attitudes (e.g., Gerberich et al., 2004; LeBlanc & Kelloway, 2002). Occupational Stress Framework Stressors and strains are tw o key concepts in the occ upational stress framework. As defined by Jex (1998), stressors concern as pects of the work environment that may require employees’ adaptive responses, whereas strains are the individual’s psychological, physical or beha vioral adaptive responses to the work environment. Workplace aggression represents a stressor that occurs to indivi duals at work and requires its recipients’ efforts in adjusting themse lves and recovering from the emotional and physical challenge brought by the incident. As suggested by occupational stress models (e.g., Beehr & Newman, 1978; Caplan, Cobb, French, Van Harrison & Pinneau, 1975), workplace aggression can be perceived as a stre ssful environmental incident that triggers short-term emotional, physiologi cal and behavioral responses, and if persistent over time, it may contribute to long-term health conse quences (e.g., disease). Due to the potential distraction from emotional and physical st rain brought by workplace aggression, injury may occur as a result that in and of itself can serve as a stress or, particularly if it affects the ability to complete job tasks, or requires medical treatment. To be specific, workplace aggression as a stressor may trigger recipients’ (harmed nurses’) negative emotional react ions such as irritation or anxiety (e.g., Needham et al., 2005; Schat & Kelloway, 2003; Walsh & Clar ke, 2003). The physiological component of their emotional reactions may then contribute to physical symptoms such as headache or stomach distress (e.g., LeBlanc & Kelloway, 2002; Needham et al., 2005; Schat & Kelloway, 2003; Walsh & Clarke, 2003). These nurses’ job satisfaction may decrease due

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5 to repeated negative experi ence of workplace aggression (e.g., Budd, Arvey & Lawless, 1996), and their intention to l eave may intensify as a planne d strategy to escape that kind of experience (e.g., LeBlanc & Kelloway, 2002; Rogers & Kelloway, 1997). Interestingly, a lot of the empirical ev idence on the above a ggression-consequence relationships was found in healthcare settings. Exposure to workplace aggression can be cons idered a significant stressor that is associated with emotional responses, mo st likely anxiety. Fo llowing Mandler (1979, 1984), stress response concerns autonomic a nd emotional arousal and preoccupation with the stressful event th at interferes with continuous c onscious processing. The autonomic and emotional arousal and preoccupation w ith the aggression event can serve as a distraction, which limits the av ailability of attention to daily job. Indeed, autonomic arousal has been shown to narrow attenti on (e.g., Mandler, 1975, 1993) and it also acts indirectly by occupying some of the limited cap acity of attention-cons ciousness. In doing so, it limits the remaining availability of atte ntion to those events or iginally perceived as central. The limited availability of attentiona l resources may contri bute to the decreased memory of central tasks (e.g., Deffenbacher, 1983; Loftus & Burns, 1982), and hurt the individual’s cognitive func tioning (e.g., Bekker, de Jong, Zijlstra, & van Landeghem, 2000; Hamilton, 1975; Janis, 1993; van der Li nden, Keijsers, Eling, & van Schaijkl, 2005). Such disrupted cognition can lead to errors in conducting tasks, resulting in accidental injury (e.g., Wadsworth, Moss, Si mpson, & Smith, 2003) or self-exposure to workplace hazards, such as infectious diseases. Workplace hazards, or occupational hazards include occupational injury which concerns damage to the body, and the contac ting of an illness while engaged in work

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6 activities. For nurses, major sources of o ccupational hazards include musculoskeletal injuries due to lifting of patients, needle stick incidents that lead to exposure to bloodborne pathogens (e.g., hepa titis or HIV), and workplace aggression (e.g., Ramsay, Denny, Szirotnyak, Thomas, Corneliuson, & Pa xton, 2006). As an increasingly prevalent issue in the healthcare industry (U.S. Department of Health and Human Services & Centers for Disease Control and Preventi on, 2004), occupational hazards have been significantly related to em ployee social and health consequences (Dembe, 2001 ; Keller, 2001; Walsh & Clarke, 2003). Based on the th eoretical arguments mentioned above (e.g., Mandler, 1975, 1993), as well as the limited em pirical evidence on o ccupational stressorhazard relationships in the st ress and safety literatures (e.g., Goldenhar, Williams, & Swanson, 2003; Kelloway, Barling, & Hurrell 2006; Takala, 2002), I argue that workplace aggression can be an important sour ce of injuries and as a stressor it can contribute to contagious disease exposure. However, these occupational hazards (i.e., injuries and contagious diseas e exposure) have not been rela ted to workplace aggression empirically. To shed light on this gap, thes e nursing hazards are investigated in my study as potential consequences of workplace aggr ession in addition to other ones already examined in the literature. Taking the theoretical and empirical evidence together, I posit the following hypotheses. Hypothesis 1a: Workplace violence will be positively associated with emotional strain (irritation, anxiety, and depression), physical symp toms, turnover intention, injuries and exposure to contagious dise ase, while negatively related to job satisfaction.

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7 Hypothesis 1b: Psychological aggression wi ll be positively associated with emotional strain (irritation, anxiety, and depression), physical symptoms, turnover intention, injuries and exposure to contagious disease, while negatively related to job satisfaction. Emotional strain has been associated with physical strains, occupational injuries, exposure to contagious diseas e, and various job strains in the occupational stress literature, theoretically and empirically (Fuller, Stanton, Fisher, Spitzmuller, Russell, & Smith, 2003; Smith, Roman, Dolla rd, Winefield, & Siegrist, 2005). Theoretically, nurses’ accumulated emotional strain may contribute to physical symptoms (even illness) in the long run, and increase the possibi lity of them being hurt at work due to the distraction from emotional strain or inadequate atte ntional resources. Ther efore, their turnover intention may intensify as a result of their wanting to escape the source of their emotional strain. As argued by Cosmides and Tooby ( 2000) and Lord and Harvey (2002), emotion processing (the key component of emotional strain) is a first-re sponse system when interacting with the external environment and can be the leading system that activates and coordinates subsequent cognitive behavioral and physical pro cesses. It is possible that emotional strain precedes the other types of strain (e.g., job dissatisfaction, turnover intention, or physical symptoms) and so may be related to workplace aggression more directly. Empirically, previous studies showed that emoti onal strain (i.e., irritation, anxiety, or depression) corre lates with physical symptoms (e.g., Schat & Kelloway, 2000; Smith et al., 2005; Spector & O’Conne ll, 1994), job dissatisfaction (e.g., Fuller et al., 2003; Hasson & Arnetz, 2008; Spector & O’Connell, 1994) and turnover intention (e.g.,

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8 Liu, Spector & Jex, 2005; O'Driscoll & B eehr, 1994; LeBlanc & Kelloway, 2002). Evidence has also been found for the relations hip of emotional stra in with occupational injuries/accident rate and exposure to c ontagious disease (e.g., Barling, Kelloway & Iverson, 2003; Guastello, Gershon, & Mu rphy, 1999; Siu, Phillips & Leung, 2004). Hypothesis 2: Emotional strain (irr itation, anxiety, and depression) will be positively related to turno ver intention, physical symp toms, injuries and exposure to contagious disease, while nega tively related to job satisfaction. Further, the above discussion on aggressi on-emotional strain link and emotional strain-other strains li nk seems to suggest that emotional strain mediates the relationship between nurses’ experience of workplace aggr ession and other outcome variables (i.e., job dissatisfaction, turnover intention, physical symptoms injuries and exposure to contagious disease). Indeed, there has been some limited evidence supporting the mediating effect of emotional strain in th e relationships of occupational stressors in general (e.g., job-task demands and organi zational stressors) with physical symptoms (e.g., Smith et al., 2005), job dissatisfaction (e.g., Fuller et al., 2003), injuries or nearmiss injuries (e.g., Goldenhar et al., 2003) mo stly with non-nursing samples. However, few empirical studies have investigated how nurses’ emotional strain from experiencing workplace aggression as a part icular stressor may account for their physical symptoms, job dissatisfaction and intention to quit current jobs, or even contribute to th eir potential physical injuries or exposure to contagious disease at work. Theref ore, mediation effects of emotional strain are hypothesized as following.

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9 Hypothesis 3a: Emotional strain (irritati on, anxiety, and depression) will mediate the relationship between workplace vi olence and job satisfaction, turnover intention, physical symptoms, injuries and exposure to contagious disease. Hypothesis 3b: Emotional strain (depressi on, anxiety, and irritation) will mediate the relationship between ps ychological aggression and j ob satisfaction, turnover intention, physical symptoms, injuries and exposure to contagious disease. In order to understand the connection between workplace aggression, strains, and safety outcomes more comprehensively, I put the aggression-outcome relationships into their social context by examining the role of organizational violence prevention climate and negative social interacti ons in the present study. Bringi ng in the social contextual factors should give us a more complete pi cture of the interact ions between nurses’ stressful personal experience (from workplace aggression) and their work environment. Organizational Climate and Organizati onal Violence Prevention Climate Organizational climate repr esents employees’ shared perceptions of the events, behaviors, and rules about the organizati on which are encouraged explicitly and implicitly (Schneider, 1990; Zohar, 2002). It focuses on a set of employees’ shared beliefs and perceptions in a certain aspect of the organization (Schneider & Reichers, 1983). This concept has been examined in di fferent organizational contexts (aspects), especially in organizational sa fety area (e.g., Anderson & West, 1996; Hofmann, Morgeson, & Gerras, 2003; Probst, 2004; Schneider, 1990; Zohar, 2003). In addition, it has been conceptualized at both the aggregated-level (e .g., Hofmann, et al., 2003; Zohar & Luria, 2005) and the indivi dual level as climate percep tions (Goldenhar et al., 2003;

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10 Probst, 2004) in the literatu re. Following Schneider and Reichers (1983), “employee perceptions are potentially ex cellent sources of data for climate research (p.20).” This may explain the fact that most of the safety climate res earch to date has taken the perspective of individual cl imate perception (e.g., Carr, Schmidt, Ford, & DeShon, 2003). My study focuses on individual climate perceptions. Three components are deemed important to form organizational climate: Policies, procedures, and practices (Schneider, 1990; Zohar, 2002). To be specific, policies demonstrate the strategic goals and means of goal attainment at the organization level, procedures provide guidelines for employees /management to take actions relevant to these goals and means, while practices indi cate how management in the organization executes the policies and procedures. It is impor tant to note that organizations may have multiple aspects to focus on and so climate can be formed in different domains such as safety, service, and innovation. As argued by Zohar (2002), actual management practices (e.g., the relative priority of safety as opposed to productivity) are enforced policies and procedures. They are mostly demonstrated in the actual behavi or patterns of the management in the organization, and become more important inputs than formal policies and procedures for employees to make sense of the organizational events and form their organizational climate perceptions. Safety climate, similar to other kinds of organizational climate, exists in employees’ minds and is formed through a process of organizational sense-making (Drazin, Glynn, & Kazanjian, 1999; Weick, 1995). That is, employees learn about the organization’s explicit policies and procedures on how to create and maintain a safe work environment, and observe how the management behaves to show its focus on safety

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11 issues in daily work. It pr ovides a social context for em ployees to understand and respond to safety issues. First, the strength of this context employees perc eive could explain how much they are motivated to learn safety knowledge, and do safe work behaviors, which then contributes to individua land organization-level safe ty record (Neal, Griffin, & Hart, 2000; Zohar, 2000; 2002). Second, the social context (safety climate) may also impact how employees react to environmental factors (especially safety -relevant ones) in the workplace. When employees perceive a favorable safety climate (safety prevention behaviors are encouraged), they take safety into considera tion while they interact with other people at work or other parts of their work environm ent. For example, Hoffman et al. (2003) found that team-level safety climate moderate d the relationship between leader-member exchange and safety citizenship role defi nitions such that employees expanded their safety citizenship role definitions more in responses to high-quality leader member exchange (LMX) relationships in a positive safety climate than in a less positive safety climate. As another example, Probst’s (2004) study suggested that employees’ perceived safety climate at the individual level attenuat ed the negative effect s of job insecurity on their safety outcomes. Specifically, job ins ecurity had less negative implications for employee safety outcomes when the organizatio n had a strong safety climate as opposed to weak climate. Therefore, it seems th at both group-level an d individual level organizational safety climate can moderate the relationship between environmental factors and employee outcomes. Spector et al. (2007) argued for the importance of examining organizational violence prevention climate, that is, how mu ch employees perceive that the organization

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12 emphasizes control and elimination of physi cal violence and psyc hological aggression. Their argument is in line with the idea th at organizational climate measures should be specific to the domain of interest (e.g., Sc hneider, Bowen, Ehrhart, & Holcombe, 2000; Zohar, 2003). Indeed, Kessler, Spector, Chang, and Parr (2008) found preliminary evidence for the construct validity of an or ganizational violence cl imate measure and its relation to employees’ violence exposure and strains at the individual level. Consistent with Zohar’s (1980, 2002) concep tualization of safety climat e, Kessler et al.’s (2008) violence prevention climate scale measures three components: Policies and procedures, practices and response, and pr essure for unsafe practices. Th e “policies and procedures” dimension captures employees’ awareness of the formal rules and regulations about preventing aggression, and the communicating pr ocess of these rules and regulations. The “practices and response” dimension measur es employees’ assessment of the degree to which the management actually enforces the formal aggression prevention policies and responds appropriately to aggression inci dents. Finally, the “pressure for unsafe practices” dimension reflects th e extent of employees’ percei ved pressure to ignore the aggression prevention policies and procedures in order to meet their other job demands, which reflects if aggression prevention is ta ken as a priority over productivity (Zohar, 2002). Following the literature of safe ty climate (Neal & Griffin, 2004; Zohar, 2002), presumably violence prevention climate can be one of the antecedents of aggression/violence occurrence, and as a social context it modifies the strength of certain relationships between aggressi on-related variables and outcomes. In an organization with a favorable climate emphasizing aggression prevention, the management and employees

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13 themselves take actions to prevent workplac e aggression, which may contribute to a low occurrence rate of physical violence and psyc hological aggression (e .g., Spector et al., 2007). Conceivably, if employees perceive that aggression prevention is strongly emphasized in the organizational environmen t (context), they may be more alert to aggression-related issues, but they will feel less emotional strain when encountering aggression incidents, due to their high accessibi lity to resources (e.g., rules, regulations or training) from colleagues or the organization management to handle these types of issues. Therefore, I predict that, with a strong perception of viol ence prevention climate, nurses tend to experience less physical violence a nd psychological aggressi on, and they will be less emotionally reactive to the inciden ce of physical violence and psychological aggression, compared to their counterparts who perceive weak violence prevention climate. One important thing to point out is that my study examines the individual-level organizational violence climate, namely vi olence prevention climate perception, given that individual differences in organizational climate per ception exist among employees even if they are in the sa me work environment (e.g., Ottinot, 2008). This is along the same direction as Carr et al .’s (2003) efforts in investig ating the association between organizational climate perceptions and assume d work outcomes, but specifically in the domain of workplace aggression. Hypothesis 4a: Organizational violence prevention climate will be negatively associated with the occurrence of workplace violence. Hypothesis 4b: Organizational violence prevention climate will be negatively associated with the occurren ce of psychological aggression.

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14 Hypothesis 5a: Organizational violence prevention climate will moderate the relationship between workplace viol ence experience and emotional strain (irritation, anxiety and depression) such t hat nurses who percei ve strong violence prevention climate will have a weaker viol ence-emotional strain relationship than those who perceive weak climate. Hypothesis 5b: Organizational violence prevention climate will moderate the relationship between psychological aggre ssion experience and emotional strain (irritation, anxiety and depression) such t hat nurses who percei ve strong violence prevention climate will have a weaker psychological aggression-emotional strain relationship than those who perceive weak climate. Social burden The dual nature of social relations has been well addressed by social exchange theorists (Heller, 1979; Homa ns, 1974; Thibaut & Kelley, 1959). As stated by Heller (1979), “It is apparent that in terpersonal relations can be ei ther supportive or stressful. What is crucial is discovering the conditions that lead either to positive or negative outcomes” (p.356). Originally pointed out by Rook (1984, 1992), the negative side of social exchange can make a big difference in explaining people’s health and stress. She argued that the negative fee lings aroused by negative soci al exchange may be more salient and so more strongly impact people’ s health and behaviors than positive social exchange because of the less frequent occurr ence of negative interactions than positive ones in both short-term and long-term persp ectives. Rook (1998) suggested that negative social exchange scenarios could include denial of support, criticism, rejection,

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15 interference, demands or control attempts deception or betrayal, and exploitation. Primarily, she approached this construct by m easuring negative social ties in people’s social network (e.g., number of negative social ties or negative feelings aroused by them), as opposed to positive social ties they have. Along similar lines, researchers operati onalized negative soci al exchange in different ways such as social conflict (e .g., Abbey, Abramis, & Caplan, 1985), social negativity (Finch, Okun, Pool & Ruehlman, 1999), social undermining (Vinokur & van Ryan, 1993; Vinokur, Price, & Caplan, 1996), and negative social interactions (e.g., Lakey, Tardiff, & Drew, 1994). As descri bed by Okun and Lockwood (2003), social negativity (i.e., negative social exchange) is not as well defi ned as social support, which explained why they used 21 search terms (e.g., problematic support, social rejection, social hindrance, or social insensitivity) to make sure that they got a complete list of studies on this topic for their meta-analysis. To be specific, Abbey et al. (1985) defined social conflict as the poten tial negative aspects of inte rpersonal relations, such as expressions of negative affect and disconfir mation. Finch et al. (1999) focused on anger, insensitivity and inte rference/hindrance as three component s of negative social exchange, and developed a 3-dimension measure of nega tive social exchange (social negativity) accordingly based upon Ruehlman and Karoly ’s (1991) Test of Negative Social Exchange. Vinokur and van Ryan (1993) concep tualized social undermining as behaviors directed towards a target person that displa y negative affect (anger or dislike), negative evaluation of this person in terms of his/her attributes, actions, and efforts (e.g., criticism), and those that ma ke difficult or hinder the targ et person’s goal attainment. Lakey et al. (1994), however, modeled the In ventory of Socially Supportive Behaviors

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16 (Barrera, Sandler, & Ramsey, 1981) to deve lop an Inventory of Negative Social Interactions (INSI), a general measure whic h consists of various stressful social interactions. All the above conceptualiza tions and the research based upon them approached negative social exchange by meas uring the frequency of negative behaviors in social interactions. To date, the literature has shown that ne gative social exchange is a construct relatively independent from social suppor t (e.g., Finch et al., 1999; Okun & Lockwood, 2003), and is an important antecedent of ps ychological distress /emo tional strain (e.g., Okun, Finch, & Kasje, 2000; Rook, 1992, 1998). More interestingly, there has also been evidence for its being a moderator which exac erbates the relationship between stressors and strains (e.g., Axelrod, Myers, Durvasul a, Wyatt, & Cheng, 1999; Cranford, 2004). In addition to the above efforts in the social and clinical psychology domains (specifically the area of in terpersonal relationships), Duffy and colleagues (2002, 2006) have drawn industrial and orga nizational psychologists’ atte ntion to negative social exchange at work by defining social undermin ing in the work context. Different from previous researchers in the area of negativ e social exchange, they defined social undermining as behaviors intended to hinder (o ver time) the target person’s ability to build and maintain positive interpersonal rela tionships, a favorable reputation, and workrelated success. Specifically, they emphasized that social undermining behaviors are intentional, insidious in that they weak en the target person gradually, and can be displayed directly or indirec tly, physically or verbally. Duffy and colleagues’ efforts to date have shown to some degree that thei r construct of social undermining from both coworkers and supervisors seems to function as a social stressor associated with

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17 employees’ affective, cognitive and behavioral outcomes at the individual-level and group-level. However, I am arguing that more efforts need to be made in investigating the role of negative social exchange (interactions) in organizational res earch by bringing in a concept of social burden at work, from a perspective different from Duffy and colleagues’. There are a coupl e of reasons for doing so. First, Duffy and colleagues’ conceptualization of social undermining views negative social interactions as a social stressor but has paid little attention to the process of how these negative social interactions can mediate or moderate th e relationships betw een individual or organizational phenomena. For example, soci al undermining (as de fined by Vonikur and van Ryan, 1993) may mediate the process of work-family crossover from one spouse to another such that the strain of one spouse increases hi s/her social undermining behaviors towards his/her partner and so elevates he r/his strain level such as depression (e.g., Westman, 2001). As another example, nega tive social interactions may exacerbate employees’ negative reactions towards certain st ressors such that those exposed to more negative interactions with their social ties at work demonstrate higher strains at work in response to stressors than their counterparts w ith fewer negative soci al interactions (e.g., Axelrod, et al., 1999; Cranford, 2004). My conc eptualization of social burden taps the perspective of being a process variable in addi tion to being a social stressor, especially when it is measured at multiple time points. Second, Duffy and colleagues confound behaviors with their po tential outcomes (i.e., weaken the ability to build/maintain social relationships, good reputations and job success) while defining social undermining. My conceptualization of social bur den only focuses on negative behaviors occurring in social

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18 interactions. Third, Duffy and colleagues em phasized the “intenti onal” component of social undermining. However, their measur e of social undermining doesn’t measure intention. My standpoint of defining social bur den is that the behaviors are perceived to be negative by the target employee no matter if they are intentional or not. The target employee’s attribution (intentional or not) proces s of the behaviors in social interactions is not the focus of this construct. Finall y, Duffy and colleagues’ definition of social undermining includes both one-onone interactions (e.g., belittl ed you or your ideas) and indirect strategic behaviors (e.g., spre ad rumors about you). However, my conceptualization of social burden only includes one-on-one interactive behaviors at work. Therefore, by integrating the literatu re built on Vinokur and van Ryan’s (1993) framework and Rook’s (1984, 1992, 1998) framewor k, I conceptualize so cial burden as behaviors occurring in commonplace social intera ctions at work which are perceived as negative by the target person. Sp ecifically, these behaviors co uld be those that display negative affect in the presen ce but not towards the target employee (e.g., act emotionally upset in the presence of the ta rget nurse), or those that inte rfere with his/her job tasks or goal attainment (e.g., give bad advice about his/ her work).One of the original components in Vinokur and van Ryan’s (1993) conceptua lization of social undermining – behaviors that indicate negative evaluation of the target person’s at tributes, actions and efforts (e.g., expressing dislike) – was dr opped to avoid the conceptual overlap with workplace incivility (Andersson & P earson, 1999). Social burden addressed here can be differentiated from Duffy and colleagues’ so cial undermining in that social undermining is done intentionally but soci al burden only focuses on behavi ors perceived as negative

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19 by the target person (intention is not important ). Social burden also differs from the construct of workplace incivility in that inci vility covers a broad range of colleagues’ rude/impolite interpersonal behaviors in th e workplace with ambiguous intention to harm the target person (Andersson & Pearson, 1999), but social burden focuses on one-on-one commonplace negative exchanges (non-necessar ily rude; e.g., a coworker’s complaining in front of you) which may drai n the target person’s resource s that can otherwise be used to enhance his/her job performance or cope w ith stressful work situ ations. Finally, social burden can be differentiated from wor kplace aggression (Baron & Neuman, 1996) because some social burden behaviors can be displayed in a positive or neutral manner but be perceived as negative (e.g., give bad advice) by the target person, however, workplace aggression always manifests it self in negative ways. Plus, workplace aggression is normally shown with clear inten tion to harm the target person at work; in contrast, intention is not important for social burden. Following the literature on negative social exchange in the area of social and clinical psychology (e.g., Finch et al., 1999; Okun & Lockwood, 2003), I expect that social burden from colleagues positively relate s to negative affect at work. That is, the more negative social interac tions the nurses experience, the higher emotional strain (i.e., irritation, anxiety and depre ssion) will occu r to them. Hypothesis 6: Social burden will be positivel y associated with the target nurses’ emotional strain (irritati on, anxiety, and depression). Further, from the perspective of occ upational stress, exposure to aggression at work will require resources to handle it. Under such circumstances, social burden is

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20 especially salient due to that fact that it demands of th e target nurses’ attentional resources and distracts them fr om their regular tasks or the recovering process from their aggression experience (e.g., Rook, 1998). Therefore, nurses with high so cial burden from their social network should demonstrate a hi gher aggression-emotiona l strain association than their counterparts with low social burde n. Some (albeit limited) empirical evidence in the literature (e.g., Axelr od, et al., 1999; Cranford, 2004) has demonstrated the stressexacerbation effect of negative social interactions in stress process. Hypothesis 7a: Social burden will modera te the relationship between workplace violence experience and emotional strain (irritation, anxiety and depression) such that nurses who perceive high social bur den will demonstrate stronger violenceemotional strain relationship than th ose who perceive low social burden. Hypothesis 7b: Social burden will m oderate the relationship between psychological aggression experience and em otional strain (irritation, anxiety and depression) such that nurses who perceive high social burden will demonstrate stronger psychological aggre ssion-emotional strain relationship than those who perceive low social burden. In sum, the current study investigates the following model shown in Figure 1.

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21 Figure 1 Hypothesized Relationships

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22 Chapter 2: Method Participants My participants were 471 nurses, including 230 and 241 from each of two medium-size public hospitals ( 750-800 nurses each) in Florid a, respectively. Ninety-four point two percent of them were female, and 90.9% worked in direct patient care areas. Ninety-three point five of them were regi stered nurses, while the rest were licensed practical nurses or nurse pract itioners. These nurses had an average age of 43 years old (SD = 11.5), an average tenure of 17.5 years (SD = 12.3), and average weekly work hours of 36.7 (SD = 9.4). In addition, 140 of our respondents responded to paper surveys and 323 of them responded online, while 8 of them did not report the survey mode they used. Procedure Two local hospitals in Florida agreed to participate in my study, provided that I share with them a hospital-le vel report on the aggression s ituation against their nurses and its association with the nurses’ hea lth and safety status. Hardcopy anonymous surveys were handed out at nursing staff mee tings, in nurses’ break rooms, or in the onsite cafeteria of these hosp itals, with prepaid envelopes provided for participants to mail the completed surveys back. All the nurses were also given an option of doing the survey online which was hosted by Surveymonkey.com via a paid secure account. A

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23 small gift (a pen with USF logo) was provide d for each nurse participant in one of the hospitals; a half continuing education point wa s provided for each nurse participant in the other hospital. Measures Nursing Aggression Scale Twelve items were ad apted to assess workplace violence (7 items) and psychological aggres sion (5 items) exposure from several sources in the literature (i.e., Bar ling, Rogers, & Kelloway, 2001; La nza et al., 2006; Neuman & Keashly, 2004; Rogers & Kelloway, 1997; Specto r et al., 2007). Nurses were instructed to respond to the items by indicating the freque ncy of exposure to each violent act during the prior 12 months, from never (1) to daily (6). An example item for workplace violence is “Been hit with an object,” and one for ps ychological aggression is “Been insulted.” Higher scores indicate more frequent physic al violence or ps ychological aggression, respectively for each subscale. The alpha coe fficient of the workplace violence scale and the psychological aggressi on in this sample was .82 and .87, respectively. Social Burden Scale (SBS) From Lakey et al.’s ( 1994) 40-item INSI scale, Vinokur and van Ryan’s (1993) 7-item scale of social undermining, and Finch et al.’s (1999) revised 21-item Test of Negative Social Exchange (Ruehlman & Karoly, 1991), I adapted nine items, wrote another three item s as a complement, and tailored them into work context when appropriate so as to meas ure social burden at work. Participants were instructed to respond to the items on a 1-5 Like rt scale ranging from 1 (Not at all) to 5 (About every day). An example item is “Wasted my time with their problems.” Higher scores indicate more frequent negative social interactions.

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24 Two pilot studies were conducted to provide evidence for the c onstruct validity of the SBS. First, 19 Subject Matter Expert s (either industrial and organizational psychologists with doctoral degree or senior doctoral students majo ring in industrial and organizational psychology) were instructed to sort the 12 items into one of the two dimensions “negative affect display” and “interference” based upon provided definitions of the two dimensions. Two items were dropped due to the fact that inter-rater consistency was lower than .90 (i.e., simply the number of SMEs who categorized the target item into the proposed dimension di vided by the total numb er of SMEs); i.e., “Burdened me by complaini ng,” and “Burdened me by talking about their work problems.” Therefore, four items were categor ized into the dimension “negative affect display,” and six were categorized into the dimension “interference.” Second, 125 employed students (average w eekly work hours = 25.8; average age = 21.8 years old; average tenure = 1.8 years) recruited from the University of South Florida were surveyed. In addition to the so cial burden measure (SBS), a few relevant variables were also measured in order to check the nomological network of social burden. There variables included job sa tisfaction (3 items, alpha = .89), physical symptoms (13 items, alpha = .84), anxiety (4 items, alpha = .61), irr itation (3 items, alpha = .88), depression (5 items, alpha = .83), and emotiona l support (5 items, alpha = .88), most of which were measured by the same scales u tilized in the main study (see page 28-29 towards the end of this section) except for emotional support. Specifically, this construct was measured by the part A of the Social Support Questionnaire for Transactions (Suurmeijer et al., 1995), with items tailored to work c ontext when appropriate (e.g., “people” was changed into “my colleagues”). Th e pilot survey is attached in Appendix A.

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25 With this 125-case sample, item analysis was run to check inter-item correlation pattern and item discrimination, and no pr oblematic items in SBS were identified. Exploratory factor analysis wa s then conducted to check the f actor structure of the SBS, which confirmed the two-dimension structure of social burden, with four items loaded on ”negative affect display” and six items on “int erference” in a way consistent with SME’s categorization. Further, correlational analys es were used to check the nomological network of the construct “social burden.” Speci fically, both “negative affect display” (4 items, alpha = .83) and “interference” (6 it ems, alpha = .86) were significantly and negatively related to job satisfaction ( r = -.21, p < .05 and r = -.28, p < .01, respectively), but significantly and positively re lated to physical symptoms ( r = .35, p < .01 and r = .41, p < .01, respectivel y), anxiety ( r = .25, p < .01 and r = .28, p < .01, respectively), irritation ( r = .37, p < .01 and r = .34, p < .01, respectively), and depression ( r = .30, p < .01 and r = .37, p < .01, respectively). Interestingly, th ere was no significa nt relationship between either dimension of social bu rden and emotional support although the correlations were negative ( r = -.09, ns. and r = -.11, ns. respectively), in a way consistent with the conceptualization of so cial burden. Another observation from the pilot survey was that there was relatively high corr elation between negativ e affect display and interference ( r = .72) and these two dimensions seemed to correlate with other relevant variables (i.e., those in their nomological network) in similar patterns. Though, in most of the cases (except for the rela tionships with irritation and emotional support ) interference had significantly stronger relationships with other variables than ne gative affect display. In summary, conceptual and preliminary empirical evidence from the pilot studies supported the two-dimension structure of the construct “social burden.”

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26 Given some mislabeling of items in desi gning the main study, one of the ten final items (i.e., “Distracted me when I was doing something important at work”) was not put in the final survey. Therefore, confirmatory factor analysis of the 9-item social burden scale was conducted in Amos 4.0 (Arbuckle, 2000) with the 471-cas e sample from my main study, with four items loaded on “negativ e affect display” and six items loaded on “interference” as specified by my pilot studi es. Results demonstrated inadequate model fit (CFI = .94, TLI = .91, RMSEA = .12, and 2/df = 7.3), with a high correlation between the two factors (standardized estimation as .90). Based upon the modification indices, three items were eliminated due to their high correlations with other items in the same dimension and their relatively low factor lo adings; i.e., “Wasted my time with their personal problems” from the “negative aff ect display” dimension, “Asked me to do something for him/her in the middle of my wor k.” and “Tried to get me do things I didn't want to” from the “interference” dimensi on. The 7-item scale (w ith three items for “negative affect display” dimension and f our ones for “interference” dimension) had a significantly better fit than the original 9-item scale ( 2/df = 11.8). However, there was still a high correlation between these two dimensions ( r = .88). Alternatively, another two-factor measurement model (7 items) wa s run with the correlation between the two factors fixed as 1 (i.e., the two di mensions are perfectly correlated). It showed significantly worse fit than the two-factor model with the inter-factor correlation freely estimated in that its 2 increased significantly ( 2/df = 9.07). Therefore, negative affect display and interference are two unique (albeit related) dimensions of social burden (see more about this scale in Appendix B). The alpha coefficient was .86 for negative affect display and .83 for interference in my sample.

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27 Organizational Violence Prevention Climate Scale The 12-item shortened organizational violence prevention climate scal e was utilized (Kessl er et al., 2008), with 4 items for each of the three subscales: Polic ies and procedures, pr actices and response, and pressure for unsafe practi ces. All items use 1-6 Likert scale with 1 as “Strongly Disagree” and 6 as “Strongly Agree.” An exam ple item for the dimension “policies and procedures” is “In my unit, violence preven tion procedures are detailed,” one for the dimension “practices and response” is “Man agement encourages employees to report physical violence,” and one for the dimension “pressure for unsafe practices” is “In my unit in order to get the work done, one must ignore some violence prevention policies.” Due to miscommunication in the project implem entation process, one item in each of the first two dimensions was inconsistent acr oss online and hard-copy survey. Therefore, three items (consistent across the two survey media) were used for “practices and response,” and “policies and procedures” in th e final analysis, with alpha coefficient as .86 and .90, respectively. The alpha coefficien t for the 4-item dimension “pressure for unsafe practices” was .88 in th e current study. Higher scores i ndicate better policies and procedures, and better violence prevention pr actices and response, but less pressure for unsafe practices. Emotional Strain Scale Anxiety and irritation were measured by the 4-item and 3-item subscales of the Emotional Strain Scale (Caplan, Cobb, French, Van Harrison & Pinneau, 1980), respectively. Participants were instructed to respond to the items based upon their experience in the past month on a 14 Likert scale ranging from 1 (Never or a little) to 4 (Most of the time). An example ite m for anxiety is “I f eel nervous,” and one for irritation is “I have gotten angry.” The alpha coefficient was .65 and .91 in the current

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28 study, respectively. Higher scores for the s ubscales indicate higher anxiety and irritation, respectively. Depression Scale The 5-item short versi on (Bohannon, Maljanian & Goethe, 2003) of Radloff’s (1977) Epidemiological St udies Depression Scale (CES-D) was used to measure nurses’ depression. Participants we re instructed to respond to items about how they felt in the past week on a 4-point Likert scale with 1 as “Rarely or none of the time (less than 1 day)” and 4 as “M ost or all of the time (5-7 days).” An example item is “I feel lonely.” The alpha coefficient of this scale was .77 in this study. Higher scores indicate higher levels of depression. Physical Symptoms Inventory A 13-item short version of the Physical Symptoms Inventory (Spector & Jex, 1998) was used to measure physical symptoms. Participants were asked how often they experienced each symptom over the past month. The response choices range from 1 (Less than once per mont h or never) to 5 (Several times per day). An example item is “An upset stomach or naus ea.” The alpha coefficient of this scale was .84 in the current study. Higher scores for this scale indicate more physical symptoms. Job Satisfaction Job satisfaction was assessed with the 3-item job satisfaction subscale from the Michigan Organiza tional Assessment Qu estionnaire (Cammann, Fichman, Jenkins, & Klesh, 1979). The scale ha s 6 response choices that range from 1 (Strongly disagree) to 6 (Strongl y agree). An example item is “All in all, I am satisfied with my job.” The coefficient alpha of th is scale was .82 in the current study. Higher scores indicate higher le vels of job satisfaction. Turnover Intention Scale Intention to quit the job was assessed by the 3-item scale of turnover intention from the Michigan Organizational Assessment Questionnaire

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29 (Cammann et al., 1979). Response choices range from 1(Strongly disagree) to 6 (Strongly agree). An example item is “Recently, I often think of changing the current job.” The alpha coefficient of this s cale was .91 in this study. Hi gher scores indicate stronger turnover intention. Injuries The nine-item Standardized Nord ic Questionnaire (Kuorinka et al., 1987) was used to measure nurses’ injuries. Pa rticipants were instructed to respond if they experienced any injury in each pa rt of their body (e.g., b ack) over the past 12 months and over the past week, respectively. Back injury in particular is of interest given its frequency among nurses due to improper pa tient lifting (Meier, 2001). This scale has been widely used to measure physical inju ries in the occupational safety area (e.g., Hagen, Magnus, & Vetlesen, 1998; Lei, Dempsey, Xu, Ge, & Liang, 2005; Smith, Mihashi, Adachi, Koga, & Ishitake, 2006). Higher scores indicate more injuries. Contagious disease exposure. Exposure to contagious diseases was assessed with five items such as “I had a bloodborne pat hogenic exposure,” and “I had a needlestick while doing injections.” The items were deve loped based upon the l iterature in nursing hazard of being exposed to contagious disease (e.g., Ramsay et al., 2006), and were assessed and revised by two SMEs (experienced RN). Participants were instructed to reply about the frequency of experiencing those exposures during the prior 12 months, from 1 (never) to 5 (four or more times). Hi gher scores indicate more frequent exposure to contagious disease. Demographic variables Finally, nurses’ gender, age, tenure as a nurse, area of patient care (direct vs. indirect ), job type (licensed practical nurse, registered nurse, or nurse practitioner), and hours of work per week were also measured. In addition, one

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30 item about nurses’ interest in the study topic was added at th e end in order to check if there was a self-selection eff ect in the respondents (e.g., R ogelberg & Stanton, 2007); i.e., if the nurses who are really interested in this research topic select themselves to participate in this study. This item reads “How much are you interested in this research topic (workplace violence and injuries)?” with a 1-5 Likert scale ranging from “1 = Not at all” to “5 = To a great extent.” All the above scales are attached in Appendix C which contains the complete questionnaire used for this study. Scales that use the same anchors are combined into the same section.

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31 Chapter 3: Results Measurement of Distinct Constructs A measurement model with specific item s loaded on specific constructs (i.e., organizational violence prevention climate— prevention policies/procedures, prevention practices/response, and pressure for unsafe practices, social burden—negative affect display and interference, job dissatisfaction, emotional stra in— irritation, anxiety, and depression, and turnover intention) was test ed. This model was compared with its baseline model in which all the correlations be tween the constructs were forced to 1 (i.e., all the constructs were essential one genera l factor). There was significant improvement in fit indices from the baseline model to the expected model; i.e., decreased Chi-square with 2/df equal to 13.9, decreased Root M ean Square Error of Approximation, RMSEA, increased Comparative Fit Index, CFI, and Non-Normal Fit Index, NNFI. Therefore, it provided evidence for the discrimi nant validity of all the measures I used; that is, the different scales in my study meas ure different constructs It is important to note that workplace violence, psychologi cal aggression, physical symptoms, physical injuries and exposure to contagious disease were not included in this analysis due to their being causal indicator constructs instead of effect indicator cons tructs (e.g., Bollen & Lennox, 1991; Edwards & Bagozzi, 2000). Prevalence of Workplace Aggression

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32 Among the 471 nurses we surveyed, 51.6% of them experienced at least one of the seven kinds of physical violent behaviors, and 85.2% of them experienced at least one of five types of psychological aggression. Specifically, the oc currence rate of individual physical violent behaviors va ried from 1.3% (Been assaulted with weapon) to 38.4% (Been pushed, grabbed or shoved). The occu rrence rate of indi vidual non-physical (psychological) aggressive be haviors varied from 25.4% (Had something thrown at you) to 78.6% (Been yelled or shouted at). Hypothesis Testing Based upon the literature on musculoskeletal disorders (MSD; e.g., Bernard, 1997; Bork et al., 1996), specifically, that on sa fety research of healthcare workers and epidemiology research in general (e.g., Manek & Macgregor, 2005; Shaw, Pransky, Patterson, & Winters, 2005), I combined the in juries in hand/wrist and elbow into upperextremity injuries, those in n eck and shoulder into neck/shou lder injuries, and those in hips/thighs, knees, and ankles/fee t into lower-extremity injuries. Given the prevalence of back injury, especially low back injury (e.g., Meier, 2001) among nurses, low back injury and upper back injury were examined as tw o separate categories along with the other three ones (upper-extremity, neck/shoulder, and lower-extremity) in my hypothesis testing. Correlational analysis was run to test Hypotheses 1, 2, 4 and 6 Preacher and Hayes’s (2008) bootstrap anal ysis was used to test Hypothesis 3 the mediation effect. Moderated multiple regression (Bar on & Kenny, 1986) was run to test Hypotheses 5 and 7 For all the analysis, hospital ID was cont rolled in that the two hospitals where my study took place are located in different cities, and have somewhat different nursing unit

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33 structures and management styles, which ma y account for some differences in the focal relationships of my study. But as a refere nce, the zero-order correlations among study focal variables were also provided (see Table 1).

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34 Table 1 Descriptive Statistics and Zero-Order Correlations among Focal Variables VariablesMeanSD123456789101112131415161718192021222324 1Violence1.31.45.82 2Psyaggr2.09.97.71.87 3Anxiety1.83.76.17.16.80 4Irritation2.37.85.14.27.41.91 5Depression1.52.58.07.16.47.39.77 6Negaffect2.02.85.22.37.25.46.27.86 7Interference1.88.79.28.46.32.45.30.74.83 8Practices4.881.26-.23-.29-.23-.22-.21-.34-.37.86 9Policies4.241.54-.12-.15-.19-.24-.17-.34-.29.69.90 10Pressure2.281.31.18.27.21.12.14.26.29-.35-.17.88 11Physym1.76.54.21.27.52.41.54.36.43-.24-.21.15.84 12Jobsat4.931.14-.14-.16-.24-.23-.35-.20-.22.26.16-.28-.35.82 13Intent2.871.60.17.20.25.28.29.19.24-.27-.12.25.38-.61.91 14Contgexp1.09.24.07.13.16.06.13-.01.04-.07-.02.03.20-.11.09N/A 15Lowback_y.67.48.18.18.06.12.13.05.06-.11-.08.11.26-.09.17.13N/A 16Upextremity_y.26.33.06.11.17.11.27.17.12-.05-.08.06.30-.18.18.09.22N/A 17Neck.shoulder_y.61.44.15.21.11.18.11.20.19-.15-.17.15.27-.15.20.02.37.33N/A 18Upperback_y.47.50.12.15.10.11.10.15.10-.07-.07.15.27-.22.22.09.36.27.54N/A 19Lowextremity_y.33.35.12.19.12.16.24.17.13-.13-.14.13.34-.20.21.17.36.47.39.30N/A 20Lowerback_w.26.44.03.11.07.18.20.13.14-.14-.12.10.32-.21.21.05.43.22.33.29.36N/A 21Upextremity_w.07.21.03.08.12.14.30.16.14-.10-.07.08.30-.18.16.13.07.43.15.09.20.12N/A 22Neck.shoulder_w.21.36.03.10.09.09.15.20.16-.11-.15.12.22-.18.17.01.11.17.47.30.15.31.12N/A 23Upperback_w.16.37-.01.05.09.07.13.17.09-.13-.12.13.23-.30.25.05.17.13.34.45.16.41.16.46N/A 24Lowextremity_w.09.31.09.12.10.16.26.14.16-.14-.07.09.34-.18.19.18.17.22.17.14.41.20.44.17.18N/A Note : r > .10, p < .05; r > .13, p < .01; values on the diagonal indi cate coefficient alphas of the co rresponding scales. In jury variables ended with “_y” indicate injuries in th e past year, while those ended with “_w” indicate injuries in the past week.

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35 Hypothesis 1a stated that nurses’ experienced workplace violence would be positively associated with their emotional strain (irritation, anxiety, and depression), physical symptoms, job dissatisfaction, tur nover intention, injuries and exposure to contagious disease As shown in Table 2, nurses’ e xperienced workplace violence was significantly and positively re lated to irritation, anxiety, turnover intention, physical symptoms, low back problems, upper back problems, neck/shoulder problems, and lower extremity problems (i.e., hips/thighs, knees, & ankles/feet) in the prior 12 months, while negatively related to job satisfaction. Therefore, Hypothesis 1a was fully supported for job satisfaction, turnover intention, and phys ical symptoms, partially supported for emotional strain and injuries, and not s upported for contagious disease exposure. Hypothesis 1b stated that nurses’ experienced psychological aggression would be positively associated with their emotional strain (irritation, anxiety, and depression), physical symptoms, job dissatisfaction, tur nover intention, injuries and exposure to contagious disease. As shown in Table 2, nurses’ experienced psychological aggression was significantly and positively related to al l the negative emotions (anxiety, irritation, and depression), physical symptoms, turnover intention, contagious disease exposure in the past 12 months, and all injuries (l ow back, upper back, neck/shoulder, upper extremity, and lower extremity) in the past 12 months. Also, it was significantly and negatively related to nurses’ job satisfaction. In addition, it was positiv ely associated with nurses’ low back problems, and lower extrem ity problems in the past week. Therefore, Hypothesis 1b was fully supported for emotional strain, job satisfaction, turnover

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36 intention, physical symptoms and contagious disease exposure, a nd partially supported for injuries. Hypothesis 2 posited that emotional strain (i rritation, anxiety, and depression) would be positively related to physical symp toms, job dissatisfaction, turnover intention, injuries and exposure to contagious diseas e. As demonstrated in Table 2, all three emotions (anxiety, irritation, a nd depression) were significantly and pos itively related to physical symptoms and turnover intention, while negatively related to job satisfaction. They also positively related to contagious di sease exposure in the past 12 months, and all the injuries in the past 12 months or in th e past week, with a fe w exceptions: Irritation was not related to contagious disease exposur e, or neck/shoulder problems or upper back problems in the past week; anxiety was not a ssociated with low back problems either in the past 12 months or past week, nor w ith neck/shoulder problems or upper back problems in the past week. Therefore, this hypothesis was fully supported for physical symptoms, job satisfaction, and turnover intent ion, and partially suppor ted for contagious disease exposure and injuries.

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37 Table 2 Correlations between Demogra phic Variables and Focal Variables with Hospital ID Controlled for VariablesMeanSD12345 1Gender.95.23N/A 2Age43.9910.72-.01N/A 3Tenure16.9711.87.15.80N/A 4Area.92.28-.01.20.21N/A 5Workhrs36.438.42-.08.08.09.25N/A 6Violence1.30.45-.10.00-.06-.04.08 7Psyaggr2.09.97-.09.12-.01-.02.09 8Anxiety1.81.74.00.12-.12-.06-.13 9Irritation2.36.84-.03-.05-.05.00.05 10Depression1.50.56.01.01-.01-.04-.09 11Negaffect2.02.84-.05-.01.02.03.09 12Interference1.87.79-.07-.07-.04.04.10 13Practices4.891.25.02.07.06-.04.02 14Policies4.241.55.04.02.02-.06.01 15Pressure2.271.31-.09-.04-.10-.09-.03 16Physym1.75.51.03-.07-.08-.05-.01 17Jobsat4.951.14-.02.00.03.04.04 18Intent2.841.58-.07-.07-.08-.06-.04 19Contgexp1.10.24-.01.03.03-.09-.04 20Lowback_y.69.47-.03.03.00-.11.11 21Upextremity_y.26.33.05.16.12.00.02 22Neck.shoulder_y.62.43-.01.06.01-.03.03 23Upperback_y.48.50.13-.06-.03-.04-.01 24Lowextremity_y.34.35.07.12.07-.06.04 25Lowerback_w.26.44.06.01-.03-.03.08 26Upextremity_w.08.21.00.13.10-.08-.05 27Neck.shoulder_w.23.37.02.08.10.09.03 28Upperback_w.17.38.08-.01-.06-.06-.05 29Lowextremity_w.09.21.02.09.07-.05.05 Note : r > .11, p < .05; r > .14, p < .01; “Tenure” was measured by years, “Area” indicates direct or indirect patient car e (with direct care coded as “1 ”), and female was coded as “1”; values on the diagonal indicate alpha co efficients of the corre sponding scales; “N/A“ indicates “Not Applicable.”

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38 Table 2 (Con’t) Correlations between Demographic Variables and Focal Variables with Hospital ID Controlled for VariablesMeanSD67891011121314151617181920212223242526272829 6Violence1.30.45.82 7Psyaggr2.09.97.70.87 8Anxiety1.81.74.15.14.80 9Irritation2.36.84.13.30.33.91 10Depression1.50.56.07.17.40.36.77 11Negaffect2.02.84.24.41.23.45.25.86 12Interference1.87.79.30.49.30.43.27.72.83 13Practices4.891.25-.28-.31-.21-.18-.19-.31-.35.86 14Policies4.241.55-.17-.16-.18-.19-.18-.29-.26.69.90 15Pressure2.271.31.17.29.20.13.13.27.30-.38-.20.88 16Physym1.75.51.23.30.45.40.52.34.40-.20-.21.15.84 17Jobsat4.951.14-.15-.16-.29-.23-.33-.22-.23.27.20-.27-.31.82 18Intent2.841.58.17.20.31.30.30.24.27-.29-.19.24.35-.61.91 19Contgexp1.10.24.09.13.17.07.13.02.06-.09-.08.02.19-.08.06N/A 20Lowback_y.69.47.15.15.10.15.18.09.10-.13-.13.11.31-.08.15.11N/A 21Upextremity_y.26.33.07.12.16.12.28.18.13-.05-.08.05.32-.17.17.09.22N/A 22Neck.shoulder_y.62.43.15.22.14.19.14.22.22-.16-.18.15.31-.16.19.01.35.31N/A 23Upperback_y.48.50.10.15.11.13.12.18.13-.07-.09.14.29-.21.19.07.35.24.52N/A 24Lowextremity_y.34.35.12.16.14.17.25.19.15-.14-.15.12.36-.19.20.15.33.48.38.29N/A 25Lowerback_w.26.44.01.11.09.20.23.15.16-.16-.17.10.34-.20.20.03.40.23.31.27.34N/A 26Upextremity_w.08.21.02.09.12.12.31.15.14-.08-.04.08.30-.16.15.13.05.43.14.07.19.11N/A 27Neck.shoulder_w.23.37.04.12.08.10.16.19.16-.11-.12.12.24-.19.19.02.11.13.48.29.15.21.09N/A 28Upperback_w.17.38-.01.06.09.07.14.18.10-.12-.12.13.23-.30.26.05.16.12.34.46.15.39.13.47N/A 29Lowextremity_w.09.21.07.11.10.16.27.16.18-.12-.05.09.35-.16.18.16.14.22.15.12.38.22.43.18.17N/A Note : r > .10, p < .05; r > .13, p < .01; values on the diagonal indi cate alpha coefficients of the co rresponding scales. Injury variables ended with “_y” indicate injuries in the pa st year, while those ended with “_w” indica te injuries in the past week; N/A indicat es “Not Applicable”.

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39 Hypothesis 3a stated that emotions would mediate the relationship between workplace violence and various health and safety outcomes. Hypothesis 3b stated that emotions would mediate the relationship be tween psychological a ggression and various health and safety outcomes. To test Hypothesis 3a Preacher and Hayes’s (2008) bootstrap analysis was used with bootstrap run for 5000 times for each analysis. Specifically, all three emotions were examin ed as mediators at the same time between each of workplace violence and each of the work outcome variables (i.e., job satisfaction, turnover intention, physical symptoms, contagi ous disease exposure a nd each of the five categories of injuries), with hospital ID cont rolled for. Given the fact that workplace violence was measured with the timeframe “i n the past 12 months,” and emotions (except for depression) were measured with the ti meframe “over the past month,” injuries measured with the timeframe “in the past w eek” (as opposed to “in the past 12 months”) were used when the mediation role of em otions between violence and injuries was examined. Similar analysis strategy was used to test Hypothesis 3b corresponding to psychological aggression. As shown in Table 3, evidence suggested that anxiety was the most consistent mediator for the relationship of wor kplace violence with physical symptoms, job satisfaction, and turnover intenti on (all partial mediation effects). In addition, there was evidence that irritation partially mediated the relationship of workplace violence with physical symptoms and turnover intention. Emotions did not seem to mediate the relationship of workplace violence with contag ious disease exposure and injuries that occurred to nurses in the past week. Therefore, Hypothesis 3a was partially supported.

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40 Table 3 Mediating Effect of Emoti ons between Workplace Violen ce and Health and Safety Outcomes IVMediatorDVIV-->MediatorMediator-->DV Indirect Effect Mediation Direct Effect (with indirect effect partialled out) Total model (R2) Violenceanxietyphysym.24**.15**.04*Partial.17**.42 irritation.23*.12**.03*Partial depression.08.36**.03No Violenceanxietyjobsat.22**-.24**-.05*Partial-.27*.18** irritation.22*-.11-.02No depression.07-.47**-.03No Violenceanxietyintent.24**.36**.09*Partial.46**.19** irritation.23*.33**.07*Partial depression.08.38**.03No Violenceanxietycontgexp.26**.19*.05No.18.06** irritation.24**-.01.00No depression.09.15.02No Violenceanxietylowback.24**-.04-.01No.02.06** irritation.23*.08**.02No depression.08.13**.01No Violenceanxietyupperback.02**.02.00No.00.02 irritation.05**-.03.00No depression.02**.09*.00No Violenceanxietyupextremity.24**-.01.00No.01.09** irritation.23*.01.00No depression.08.22**.02No Violenceanxietyneck/shoulder.04**.03.00No.00.03* irritation.04**.02.00No depression.01.15*.00No Violenceanxietylowextremity.24**-.04-.01No.08.08** irritation.23*.06.01No depression.08.28**.02No Note : “0”s in the table indicate va lues lower than .01; all the injuries were measured with the time frame “in the past week.” Hospita l ID was controlled for in the mediation analyses.

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41 As demonstrated in Table 4, there was ev idence suggesting that anxiety mediated the relationship of psychological aggression with job satisfaction, turnover intention, physical symptoms and contagious disease exposure, either pa rtially or fully. In addition, there was evidence that depression fully mediat ed the relationship between psychological aggression and job satisfaction; irritati on and depression partially mediated the relationship of psychological a ggression with physical symp toms and turnover intention. When it came to predicting injuries, depression seemed to fully mediate the relationships of psychological aggression with low back and lower extrem ity problems. In addition, irritation fully mediated the relationship be tween psychological aggression and low back problems in the past week. Hereto, Hypothesis 3b was partially supported.

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42 Table 4 Mediating Effect of Emotions between Psychological Aggres sion and Health and Safety Outcomes IVMediatorDVIV-->MediatorMediator-->DV Indirect Effect Mediation Direct Effect (with indirect effect partialled out) Total model (R2) Psyaggranxietyphysym.10**.16**.02*Partial.06**.41** irritation.25**.10**.03**Partial depression.09**.35**.03**Partial Psyaggranxietyjobsat.10**-.25**-.03*Full-.09.17** irritation.25**-.09-.02No depression.09**-.46**-.04*Full Psyaggranxietyintent.09**.39**.04*Partial.19**.18** irritation.24**.29**.07*Partial depression.09**.36*.03*Partial Psyaggranxietycontgexp.11**.20*.02*Full.12.06** irritation.26**-.03-.01No depression.10**.13.01No Psyaggranxietylowback.10**-.04.00No.03.07** irritation.24**.07*.02*Full depression.09**.13**.01*Full Psyaggranxietyupperback.04**.03.00No.00.02 irritation.04**-.01.00No depression.02**.09*.00No Psyaggranxietyupextremity.10**-.01.00No.02.09** irritation.24**.01.00No depression.09**.22**.02No Psyaggranxietyneck/shoulder.02**.02.00No.01.04** irritation.05**-.01.00No depression.02**.19**.00No Psyaggranxietylowextremity.10**-.03.00No.04.08** irritation.24**.05.01No depression.09**.27**.02*Full Note : ‘0’s in the table indicate va lues lower than .01; all the in juries were measured with the time frame “in the past week.” Hospita l ID was controlled for in the mediation analyses. Hypothesis 4a and 4b posited that organizational violence prevention climate would be negatively associated with the occurrence of workplace violence and psychological aggression, respectively. Ta ble 2 showed the significant negative relationships of nurses’ perceived vi olence prevention practices/response and

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43 policies/procedures with the frequencies of both their violence and psychological aggression experience. As also shown in Ta ble 2, nurses’ perceived pressure for unsafe practices was positively related to the frequencies of both their violence and psychological aggression experience. In ot her words, the better violence prevention climate nurses perceived, the less frequently workplace violence and psychological aggression tended to occur to them. Alternatel y, the more frequently workplace violence and psychological aggression occurred to nurse s, the worse violence prevention climate they perceived. Therefore, Hypothesis 4a and 4b were fully supported. Hypothesis 5a and Hypothesis 5b posited that organizati onal violence prevention climate would moderate the relationshi ps of nurses’ workplace violence and psychological aggression experiences with thei r emotional strain (irritation, anxiety and depression) such that nurses who perceive strong violence (preve ntion) climate would have weaker relationships of their expe rienced workplace violence and psychological aggression with emotional strain than thos e who perceive weak climate. My results indicated significant moderating effect s of organizational violence prevention practices/response in th e relationships of nurses’ expe rienced workplace violence and psychological aggression with their anxiet y and depression (Table 5). However, the direction of the moderating pattern was oppos ite to the hypotheses in that nurses who perceived strong violence prevention practices /response tended to be more emotionally reactive to their experienced workplace vi olence and psychological aggression (i.e., feeling anxious and depressed), as opposed to those who perceived weak prevention practices. The moderating effects of violence prevention practices/response were further illustrated in Figure 2-5. In sum, Hypotheses 5a and 5b were not supported.

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44 Table 5 Violence Prevention Practices/Response Moderated the Aggression-Emotion Relationships Predictors AnxietyDepression Predictors AnxietyDepression Step 1 Control VariableStep 1 Control Variable Hospital ID-.03-.08Hospital ID-.02-.07 F .021.1 F .011.06 R2 .00.00 R2 .00.00 Step 1 Direct effectsStep 1 Direct effects Violence.13*.04Psy. Aggression.09.12* Violence Prevention Practices-.23**-.24**Violence Prevention Practices-.24**-.21** F 13.74**10.71** F 13.16**12.74** R2 .06**.05** R2 .06**.06** Step 3 InteractionStep 3 Interaction Violence X Practices.11*.11*Psy. aggression X Practices.11*.10* F 4.88*4.47* F 4.72*4.04* R2 .01*.01* R2 .01*.01* Full model F 8.16**6.80**Full model F 7.82**7.71** Full model R2 .07**.06** Full model R2 .07**.07** Workplace ViolencePsychological Aggression Note : The coefficients are the standardized be ta weights from the final step of the multiple regression. p < 0.05; ** p < 0.01.

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45 Figure 2 Violence Prevention Practice s/Response Moderated the ViolenceAnxiety Relationship Figure 3 Violence Prevention Practice s/Response Moderated the ViolenceDepression Relationship

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46 Figure 4 Violence Prevention Practices/ Response Moderated the Psychological AggressionAnxiety Relationship Figure 5 Violence Prevention Practices/ Response Moderated the Psychological AggressionDepression Relationship Hypothesis 6 proposed that social burden is pos itively associated with the target nurses’ emotional strain (irr itation, anxiety, and depression) As shown in Table 2, both negative affect display and in terference nurses experienced fr om their social ties were significantly and positively related to their ir ritation, anxiety and de pression. Therefore, Hypothesis 6 was fully supported.

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47 Hypotheses 7a and 7b posited that social burden w ould moderate the relationships of nurses’ experienced workplace violence and psychological aggression with their emotional strain (irritation, anxiety and depr ession) such that nurses who perceive high social burden would demonstrate stronger relationships of workplace violence and psychological aggression with emotional stra in, as opposed to those who perceive low social burden. Moderation analyses showed that neither negative affect display nor interference moderated the rela tionships of nurses’ experi enced workplace violence and psychological aggression with their emoti onal strain. Importantly though, both nurses’ experienced negative affect di splay and interference from their colleagues consistently contributed to nurses’ feeli ngs of anxiety, irritation a nd depression over and above the main effect of their workplace violence or psychological aggression experience. In summary, nurses’ experienced workplace violence and psychological aggression were significantly associated wi th various assumed health and safety outcomes. Evidence was found that nurses’ emo tional strain seemed to be a relatively consistent mediator in th e aggression-outcome relati onships. In addition, nurses’ perceived social context (viole nce prevention climate and soci al burden) did significantly and directly relate to their health and sa fety consequences, but limited evidence was found regarding the potential moderating role of these two contextu al variables in the aggression-consequence relationships. Gender, area of patient care and job type were not c ontrolled in the hypotheses testing due to the potential limiting of statistical power by the uneven split among categories (e.g., only 25 males, 39 in indirect patient care, and 27 licensed practical nurses and 1 nurse practitioner out of 471 partic ipants). Other demographics (i.e., weekly

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48 work hours, age and tenure as a nurse) and the variable about particip ants’ interest in the study topic were also controll ed in the hypothesis testing one at a time (to preserve statistical power) along with hos pital ID. There was no differen ce in the results of all the hypothesis tests before and after controlling work hours or interest in the study topic. Given the high correlations between age and tenure (.80), only tenure as a nurse was examined as a control variab le given its relevance to th e focal relationships, and the results were compared before and after c ontrolling it. No difference was found for the mediation analysis except that irritati on lost its significance in mediating the psychological aggression low back injury relationship after c ontrolling for tenure. However, I lost all the significant mode rating effects after controlling tenure. Interestingly, there did not seem to be evidence from the correlation matrix for collinearity between tenure, aggression and violence prevention climate, nor was the main effect of tenure on emotional strain si gnificant in any of the regression models. Possibly, such a loss of signi ficance was due to decreased statistical power in the moderated regression analysis after adding tenu re as another predictor and/or relatively low effect size (i.e., th e moderating effects).

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49 Chapter 4: Discussion The current study examined the relations hips of nurses’ experienced workplace violence and psychological aggression w ith various assumed health and safety consequences, and also investigated how nur ses’ emotional strain and two contextual variables (violence prevention climate perceptions and social burden) accounted for these relationships. Evidence from a 471-case nursing sample generally supported a significant association of nurses’ expe rienced physical violence and psychological aggression with various assumed health (i.e., emotional stra in including irritation, anxiety and depression, physical symptoms, job dissatisfaction, and turn over intention) and sa fety (i.e., injuries and contagious disease exposur e) consequences. My findings also supported the idea that emotional strain generally works as a signi ficant mediator between nurses’ experienced physical violence and psychologi cal aggression and various assumed consequences. In addition, organizational violen ce prevention climate perceptions were found to be significantly associated with the occurrenc e of workplace violence and psychological aggression against nurses, and to signif icantly moderate the aggression-emotion relationships (only for anxiet y and depression, but not for ir ritation) although not in the expected direction. Finally, perceived soci al burden was shown to be a significant predictor of nurses’ various assumed health and safety consequences over and above their experienced workplace violence and psychological aggression.

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50 The Link between Workplace Aggression and Health and Safety Consequences Consistent with the previous literatu re (e.g., Gerberich et al., 2004; LeBlanc & Kelloway, 2002; Lanza, 2006; LeBlanc & Barl ing, 2005; Needham et al., 2005; Schat et al., 2006), in my study nurse s’ experienced physical violence and psychological aggression were significantly associated with various assumed health outcomes including emotional strain, job dissatisfaction, turnove r intention, and physical symptoms. Aligned with the theoretical frameworks and limited em pirical evidence in occupational stress and safety area (e.g., Duhart, 2001; Kelloway et al., 2006; Mandler, 1975, 1993; Peterson & Mayhew, 2005) but going beyond the previous empirical research, my study found that nurses’ experienced physical violence and psychological aggression were also significantly related to various assumed safety outcomes in cluding injuries of some body parts and contagious disease exposure. Specifically, both workplace violence and psychological aggression against nurses seemed to have negative implications for their physical injuries (including upper extremity, neck/shoulder area, upper back, low back, and lo wer extremity) and exposure to contagious disease (e.g., due to needles ticks). That is, the more frequently nurses experience physical violence or psychologi cal aggression from their colleagues or patients, the more likely they will get injured or expose themselves to contagious disease (e.g., contacting bloodborne pathogens) at wor k. Such empirical evidence from my study should inform healthcare management of the necessity of addressing both workplace aggression and nursing safety issu es (injury and contagious di sease exposure) at the same time. The Role of Emotional Strain

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51 Following Cosmides and Tooby (2000) a nd Lord and Harvey (2002), emotional processing functions as a firstresponse system while individuals encounter with events that happen in their surrounding envir onment. As argued by Mandler (1979, 1984), emotional arousal is one of the most cri tical individual reactions following stressful incidents, and it should play an important ro le in explaining the link between stressors and possible physical and behavioral strains; i.e., the link between nurses’ perceived workplace aggression and possible health and sa fety consequences. Consistent with the above theoretical arguments a nd limited empirical evidence in the literature (e.g., Fuller et al., 2003; Goldenhar et al., 2003; Smith et al., 2005), my findings indicated that emotional strain did function as a first -response mechanism that accounted for the associations of nurses’ expe rienced violence and psychologi cal aggression with various assumed health and safety outcomes. That is, nurses might have felt emotional strain or distraction (including irritati on, anxiety, and depression) afte r being attacked physically or psychologically. Their emotional strain c ould then build up and contribute to their increased physical symptoms (e.g., troubl e in sleeping or stomach problems), dissatisfaction with their job, more frequent thoughts of quitting thei r job (as one way of escaping the source of attacks), and accidental physical injuri es or exposure to contagious disease (due to emotional dist raction and inadequate attentional resources resulting from that distraction). Overall, results with emotional strain including irritation, anxiety and depression suggest that they may function as a crit ical mechanism underlying the association between nurses’ experienced violence and ps ychological aggression and various assumed health and safety outcomes. This is consistent with the literature of nursing stress (e.g.,

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52 McVicar, 2003; Needham et al., 2005). Fu rther, such a finding has gone beyond the previous literature that primarily fo cused on psychological and physical health consequences of workplace aggression against nurses. That is, emotional strain may also mediate the relationships of nurses’ experienced violence and psychological aggression with safety outcomes that have generall y low occurrence rate (i.e., injuries and contagious disease exposure). The Role of Organizational Violen ce Prevention Climate Perceptions My results showed that nurses’ percei ved violence prevention climate perceptions in the hospital were significantly related to the frequency of thei r experienced physical violence and psychological aggression at wo rk. In other words, the better violence prevention climate nurses perceived, the fewe r physical or psychological attacks nurses tended to report having experienced at wor k. Such a finding is consistent with the literature of violence prevention climate per ceptions (Kessler et al., 2008; Spector et al., 2007) and that of safety climate in ge neral (Zohar, 1980, 2002). However, the causal direction between violence prevention climate perceptions and aggression occurrence in the workplace can not be determined unle ss evidence is accumulated from data of multiple time points. When it comes to the potential modera ting role of violence prevention climate perceptions in the relationshi p between aggression and emotional strain, an unexpected pattern was found among this sample of nurse s. To be specific, nurses who perceived better violence preventio n practices/response were more emotionally reactive (in terms of anxiety and depression) to phys ical or psychological attack s that occurred to them at work than those who perceive d worse practices/response. In other words, nurses seemed

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53 to become more sensitive (at least emotionally ) to aggressive behaviors against them at work when they observed and perceived that hospital management was trying to enact violence prevention policies or procedures and to appropriately respond to incidents of physical violence or psychological aggressi on. One possible reason is that nurses who perceived good violence prevention practices/r esponse might have high expectations that few aggression incidents should occur in th eir unit. Therefore, those nurses who bore such an expectation would have trouble in reconciling the inc onsistency between good violence prevention climate they perceived a nd bad aggression events against them and so experience high emotional strain, when aggressive behaviors actually happened to them. From another perspective, Figure 25 could also indicate that good violence prevention climate perceptions did not seem to make a difference in terms of reducing nurses’ anxiety or depression when the o ccurrence rate of workplace aggression was high. However, good violence prevention climate perceptions were related to less anxiety or depression when the occurrence rate of workplace aggression was low. It is important to note though that nu rses who perceived better violence prevention practices/response generally felt less irritated, anxious and depressed than their counterparts who perceived weaker clim ate, possibly owing to higher management support they perceived. Therefore, nurses’ be liefs in hospital mana gement’s appropriate violence prevention practices/response coul d to some extent protect them from experiencing emotional strain in general, but the protection effect will be counteracted when aggression incidents happen to them. Ho wever, more investigation is warranted before we conclude about the potential mode rating role of perceived violence prevention climate perceptions in the aggr ession-emotional strain relationships. For example, with

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54 data from multiple time points, stronger evidence will be provided regarding if violence prevention climate perceptions in the hosp ital could buffer the negative impact of workplace aggression against nurses on thei r emotional well-being and even physical well-being and their safety outco mes in the long run. In addition, efforts need to be made to identify the best timing when violence pr evention programs could take effect for certain organizations; that is if such programs could onl y be effective before the occurrence rate of workplace aggression goes beyond a certain threshold in certain organizations. The Role of Social Burden In my study, both dimensions (negative a ffect display and interference) of social burden were positively associated with emotiona l strain including irritation, anxiety and depression. To be specific, the more negative affect display or interference from their social ties, the more likely nurses felt irri tated, anxious and depre ssed. Such a finding is consistent with the literature of soci al negativity (Okun et al., 2000; Rook, 1992, 1998). That is, negative social interactions, partic ularly when nurses’ social ties demanded emotional support from them or constantly in terfere with their work process, could be emotionally draining for these nurses. More im portantly, such negative social interactions (social burden) predicted nur ses’ emotional strain over and above their experienced physical violence and ps ychological aggression. Following transactional stress theory (Lazarus, 1991) and conservation of resources theory (Hobfoll, 1989), the resource -draining characterist ics of social burden should have important implications for the re lationship between nurses’ experiences of being attacked and their emotional strain. In other words, while nurses who were attacked

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55 try to cope with such a si gnificant stressor (aggression) at work, the social burden from their social network may become particular sa lient in that it fights for nurses’ available resources including attention, energy and time. Interestingly, the re sults of my study did not support such an exacerbating effect of so cial burden in the rela tionships of nurses’ experienced workplace violence and psychol ogical aggression with their emotional strain; i.e., neither “negative affect display” nor “interference” m oderated the aggressionemotional strain relationships. However, further moderated regression anal yses were run to explore the potential moderating effects of social burden between emo tional strain and va rious other assumed health and safety outcomes (e.g., physical symptoms, turnover intention or injuries). That is, one of the indices of emotional strain (e .g., anxiety) and one of the two social burden dimensions were added in the first step, and their interaction term was added in the second step. The results showed that both di mensions of social burden did significantly moderate the relationships of emotional st rain with various outcomes. For example, negative affect display from nurses’ social ties exacerbated the positive relationship between their anxiety and physical symptoms, while interference from their social ties intensified the positive relationships of thei r anxiety with their physical symptoms and turnover intention. Therefore, further investigat ion is warranted before we conclude about the potential moderating role of social burden in the aggres sion-outcome relationships. For example, with a sufficient sample size and longitudinal design, moderated mediation analysis could be conducted to examine in the same framework th e potential moderating role of social burden and the mediating role of a certain negative emotion (e.g., anxiety) in between nurses’ experienced aggression and various outcomes.

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56 Limitations and Implications A few limitations of this study deserve me ntion here. First of all, the hypotheses related to violence prevention climate were only able to be tested at the individual level. Efforts were made to include as many nursing units as possible in this study. However, the final sample only had 15 units from one hos pital and 13 units from the other hospital, with three or more nurses in each unit. Su ch low numbers of units within hospitals limited the statistical power of multi-level analyses (i.e., aggression-outcome relationship at individual level and aggregated unit-leve l violence prevention climate perceptions to be used at the unit level, with hospital-level variance partialle d out). Future research need to focus on getting participants from sufficient number of units or even hospitals so as to examine the role of violence prevention climate (perceptions) in aggression-outcome relationship from a cross-leve l perspective. Second, even at the individual level of analysis, the sample size of my study onl y provided limited statistical power for the mediation and moderator analyses (e.g., Aguinis, 1995; Frit z & Mackinnon, 2007; O’Connor, 2006). Therefore, the data from this study provided a conser vative test of my hypotheses. In addition, the data in this study were si ngle-source data from nurses’ self-report. A better design that could be used in future research is to collect objective health and safety records (e.g., number of tim es of calling in sick, number of days of sick leave due to injury, or actual injury accident report) at individual and/or unit or even hospital level (if a sufficient number of units or hospitals were available for multi-level analysis). Alternatively, supervisor report of nurses’ injury incidents or errors at work could serve as a good complement to nurses’ self-report sa fety outcomes. Finally, the cross-sectional

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57 design of this study precludes me from making conclusions regarding the causal relationships among focal variables such as the relationship between violence prevention climate perceptions and aggression occurren ce, or that between nurses’ experienced aggression, emotional strain, and ot her health or safety outcomes. Nonetheless, my study was based upon a moderate-size field sample and it should contribute to the literature on workplace a ggression in the following ways. First, occupational safety issues, namely physical inju ries and exposure to contagious disease in this case, were investigated as potential consequences of workplace aggression in addition to the variables examined in previous research which were mentioned previously (i.e., physical symptoms, emotional strain su ch as anxiety or depression, negative job attitudes such as job dissatisfaction, and tur nover intention). My study is one of the first attempts to integrate aggression and safe ty in the same study. Second, organizational violence prevention climate is a relativel y new concept derived from organizational safety climate (Zohar, 1980). Bringing this concept into the res earch design, my study furthered the understanding of this construct through examini ng its potential role as an antecedent of aggression occurrence and a moderator in the aggression-consequence relationships. Finally, my st udy also explored the possible mechanisms through which social burden explains some of the aggre ssion-outcome dynamics, which hopefully will draw more attention to this interesting construct in future organizational research. Future research should seek to furthe r investigate the relationships between workplace aggression and various safety issues in addition to the variables included in the current study. Echoing the focus of the Nati onal Institute of Occ upational Safety and Health (NIOSH)’s National Occupational Rese arch Agenda (Marras, Cutlip, Burt, &

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58 Waters, 2009; NIOSH, 1996; Occupational Safety and Health Administration, 2004), such research should have the potential to link workplace a ggression exposure and workers’ safety (e.g., injuries, infectious di sease exposure, or safety behaviors), which may then inform organizations how to address these two pr oblems with common solutions. In addition, more research, especi ally multi-level and l ongitudinal research, needs to be done to understand the role of violence prevention clim ate (perceptions) in the aggression-outcome dynamics. In the long run, such research will be able to inform potential interventions (e.g., to enhance vi olence prevention climate or employees’ perceptions of it) that aim at reducing workplace aggression occurrence or safety concerns. It is also importan t to note that social burden deserves more attention from researchers who are interested in occupational health or in terpersonal relationships at work. Due to social burden’s close connecti on with individuals’ health status (e.g., depression symptoms as suggested by th e clinical psycholog y literature; Okun & Lockwood, 2003), it will be interesting to inve stigate long-term hea lth consequences of individuals’ social burden by using longitudina l designs with multiple time points. Given its root in social psychology, it will be inform ative to further examin e this construct in contrast with other variables related to in terpersonal relationships such as emotional support within the same study. Finally, social network analysis (Brass, Galaskiewicz, Greve, & Tsai, 2004; Scott, 1991; Wasserman & Faust, 1994) could add a lot to research on social burden since it is conceivable that social burden from differe nt social ties may not be weighted equally (given that the strength of the relationships between target individuals and different social ties could be different). Conclusions

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59 With a 471-case nursing sample, th is study found generally significant relationships of workplace violence and psyc hological aggression with various assumed consequences (i.e., physical symptoms, job dissatisfaction, turnover intention, physical injuries and contagious disease exposure) Such a finding went beyond the previous literature in terms of empi rically linking workplace aggre ssion (an occupational stressor) with low-occurrence-rate safety outcomes ( physical injuries and contagious disease exposure), and addressing occ upational health and safety issues within the same study. More importantly, both nurses’ personal fee lings (emotional strain ) and the psychosocial context (violence prevention cl imate perceptions) they percei ved at work were found to play a role (mediator and moderator, respec tively) in explaining the link between their experienced workplace aggression and assumed health and safety consequences. Future research should investigate this aggressionconsequence link in a more specific way such as examining aggression from a specific sour ce (patient or physician, in the case of nursing), examining safety behaviors that help prevent accidents, or investigating injuries from improper body movements such as lifting. Also, it would be really interesting to investigate how certain psychosocial risk factors (e.g., workplace aggression) are transferred via emotional, cognitive, physiolo gical or psychophysical route to accidents or injuries. Research along this line will be able to inform intervention programs that aim at improving workers’ health and safety not only in the healthcare industry but also in other industries and organizations.

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74 Spector, P., & O'Connell, B. (1994). The cont ribution of personali ty traits, negative affectivity, locus of control and Type A to the subsequent reports of job stressors and job strains. Journal of Occupational and Organizational Psychology 67 112. Suurmeijer, T. P. B. M., Doeglas, D. M., Briangon S., Krijnen, W., Krol, B., Sanderman, R., Mourn, T., Bjelle, A. & van den Heuvel, W. J. A. (1995). The measurement of social support in the "European res earch on incapacitating diseases and social support": The development of the Social Support Questionnaire for Transactions (SSQT). Social Science & Medicine, 40, 1221-1229. Takala, J. (2002, May). Introductory report: Decent work—safe work Paper presented at the XVIth World Congress on Safety and Health at Work, Vienna. Thibaut, J.W., & Kelley, H.H. (1959). The social psychology of groups New York, Wiley. U.S. Department of Health and Human Serv ices [DHHS], Centers for Disease Control and Prevention [CDC]. (2004, December 20). Year in review: TB outbreak investigations 2003 [Online]. Available at http://www.cdc.gov/nchstp/tb/notes /TBN_2_04/SEOIB_year_in_review.htm U.S. Postal Service Commission on a Sa fe and Secure Workplace. (2000). Report of the United States Postal Service Commissi on on a Safe and Secure Workplace. New York: Columbia University, National Cent er on Addiction and Substance Abuse. van der Linden, D., Keijsers, G., Eling, P., & van Schaijk, R. (2005). Work stress and attentional difficulties: An initial study on burnout and cognitive failures. Work & Stress 19 23-36.

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75 Vinokur, A., & Van Ryn, M. (1993). Social support and undermining in close relationships: Their independe nt effects on the mental h ealth of unemployed persons. Journal of Personality and Social Psychology 65 350-359. Vinokur, A., Price, R., & Caplan, R. (1996) Hard times and hurtful partners: How financial strain affects depression and relationship satisfaction of unemployed persons and their spouses. Journal of Personality and Social Psychology 71 166179. Wadsworth, E., Moss, S., Simpson, S., & Smit h, A. (2003). Preliminary investigation of the association between psychotropic medica tion use and accidents, minor injuries and cognitive failures. Human Psychopharmacology: Clinical and Experimental 18 535-540. Walsh, B. R., & Clarke, E. (2003). Post-traum a symptoms in health workers following physical and verbal aggression. Work & Stress 17 170_181. Wasserman, S., & Faust, K. (1994). Social network analysis: Methods and applications New York, NY US: Cambridge University Press. Weick, K. E. (1995). Sensemaking in organizations. Thousand Oaks, C A Sage. Westman, M. (2001). Stress and strain crossover. Human Relations, 54 717-751. Zohar, D. (2000). A group-level model of safe ty climate: Testing the effect of group climate on microaccidents in manufacturing jobs. Journal of Applied Psychology, 85 587596. Zohar, D. (2002). Safety Climate: Conceptual and Measurement Issues. In J. C. Quick & L. E. Tetrick (eds). Handbook of Occupatio nal Health Psychology Washington, DC: APA

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76 Zohar, D. (2003). The influence of leadersh ip and climate on occupational health and safety. In D. A. Hofmann, & Lios. E. Tetrick (Eds), Health and safety in organizations: A multilevel perspective (pp. 201_230). San Francisco: JosseyBass. Zohar, D., & Luria, G. (2005). A multileve l model of safety climate: Cross-level relationships between organiza tion and group-level climates. Journal of Applied Psychology, 90 616-628.

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77 Appendices

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78 Appendix A: Pilot Survey Department of Psychology 4202 East Fowler Ave. Tampa, Florida 33620 We are conducting a study on working peopl e. The following questions ask you to reflect on yourself and your experiences in your current job. The entire survey should take 5-8 minutes to complete. The survey is anonymous, so do not put your name or identifying information on it. No one but you will know how you responded. You are free to participate in this study or to withdraw at any time. Your decision to participate or not to participate will not impact your employment status. Your taking this survey indicates your agreement to participate. If you have any questions about this research study or would like to receive results, please contact Liu-Qin Yang at lyang2@mail.usf.edu. If you have questions about your rights as a person participating in a res earch study, you may cont act the Division of Research Integrity and Compliance of the Un iversity of South Florida at (813) 974-5638. Thank you very much for your time and participation! Sincerely, Liu-Qin Yang, Doctoral Candidate Paul Spector, Professor Department of Psychology University of South Florida

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79 Please think of your interactions with your colleagues and feelings over the past month Please indicate how often these things have happened to you at work in dealing with coworkers or supervisors during the past month Not at all Once or Twice About Once a Week Several Times a Week About Every Day 1. Wasted my time with their personal problems. 1 2 3 4 5 2. Acted emotionally upset in my presence (not towards me). 1 2 3 4 5 3. Wanted me to take care of their work responsibilities. 1 2 3 4 5 4. Asked me to do something for him/her in the middle of my work. 1 2 3 4 5 5. Made my job difficult. 1 2 3 4 5 6. Lost his/her temper in my presence (not towards me). 1 2 3 4 5 7. Gave bad advice on my work. 1 2 3 4 5 8. Tried to get me do things I didn't want to. 1 2 3 4 5 9. Acted in an angry manner in my presence (not towards me). 1 2 3 4 5 10. Distracted me when I was doing something important at work 1 2 3 4 5 11. Burden me by complaining. 1 2 3 4 5 Over the past month how often have you experienced each of the following? Never or a little Some of the time A good part of the time Most of the time 12. I have felt nervous. 1 2 3 4 13. I have felt jittery. 1 2 3 4 14. I have felt calm. 1 2 3 4 15. I have felt fidgety. 1 2 3 4 16. I have gotten angry. 1 2 3 4 17. I have gotten aggravated. 1 2 3 4 18. I have gotten irritated or annoyed. 1 2 3 4

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80 Over the past month how often have you experienced each of the following symptoms? Less than once per month or never Once or twice per month Once or twice per week Once or twice per day Several times per day 19. An upset stomach or nausea 1 2 3 4 5 20. A backache 1 2 3 4 5 21. Trouble sleeping 1 2 3 4 5 22. Headache 1 2 3 4 5 23. Acid indigestion or heartburn 1 2 3 4 5 24. Eye strain 1 2 3 4 5 25. Diarrhea 1 2 3 4 5 26. Stomach cramps (Not menstrual) 1 2 3 4 5 27. Constipation 1 2 3 4 5 28. Ringing in the ears 1 2 3 4 5 329. Loss of appetite 1 2 3 4 5 30. Dizziness 1 2 3 4 5 31. Tiredness or fatigue 1 2 3 4 5 Now, please think of your feelings in the past week to answer the following 5 questions! Below is a list of ways you may have felt or behaved. Please describe how you have felt during the past week Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days) Occasionally or moderate amount of time (3-4 days) Most or all of the time (5-7 days) 32. I felt depressed. 1 2 3 4 33. My sleep was restless. 1 2 3 4 34. I felt lonely. 1 2 3 4 35. I had crying spells. 1 2 3 4 36. I could not ‘get going’. 1 2 3 4

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81 Finally, please think of your job in general to answer the rest of the questions (almost there!) 1 2 3 4 5 6 Strongly Disagree Moderately Disagree S l ightly Disagree Slightly Agree Moderately Agree Strongly Agree Please use the seven-point rating scale above to indicate how much you agree that each statement describes your job and yourself at work SD MD SLD SLA MA SA 37. In general, I don't like my job. 1 2 3 4 5 6 38. All in all, I am satisfied with my job. 1 2 3 4 5 6 39. In general, I like working here. 1 2 3 4 5 6 40. My colleagues at work are warm and affectionate towards me. 1 2 3 4 5 6 41. My colleagues at work are friendly to me. 1 2 3 4 5 6 42. My colleagues at work sympathize with me when I am in a difficult situation. 1 2 3 4 5 6 43. My colleagues at work show their understanding for me. 1 2 3 4 5 6 44. My colleagues at work are willing to lend me a friendly ear. 1 2 3 4 5 6 45. I often think of leaving this organization. 1 2 3 4 5 6 46. It is very possible that I will look for a new job next year. 1 2 3 4 5 6 47. Recently, I often think of changing my current job. 1 2 3 4 5 6 Background 48. I am ______Male ______Female 49. I am ____________ years old 50. My occupation is ________________________ 51. I work __________ hours per week 52. I have been working in this job _______ years_______ months 53. I consider my current j ob is in _______________ _______ industry 54. Questions # ______________ _________ in this survey were not clear to me

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82 Appendix B: Final Social Burden Scale Please indicate how often these things have happened to you at work in dealing with coworkers, supervisors or physicians during the past month Not at all Once or Twice in Total Once or twice per week Once or twice per day Several times per day 1*. Acted emotionally upset in my presence (not towards me). 1 2 3 4 5 2. Wanted me to take care of their work responsibilities. 1 2 3 4 5 3. Asked me to do something for him/her in the middle of my work. 1 2 3 4 5 4. Made my job difficult. 1 2 3 4 5 5*. Lost his/her temper in my presence (not towards me). 1 2 3 4 5 6. Gave me bad advice about my work. 1 2 3 4 5 7*. Acted in an angry manner in my presence (not towards me). 1 2 3 4 5 Note : Items marked with “*” form the dimensi on “negative affect display,” and the rest of the items form the dimension “Interferences.”

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83 Appendix C: Main Study Survey Department of Psychology 4202 East Fowler Ave. Tampa, Florida 33620 We are conducting a study of nurses experien ced with injuries and workplace violence. The following questions ask you to reflect on yourself and your experiences in your current job. The entire survey should take 10-15 minutes to complete The survey is anonymous, so do not put your name or identifying information on it. No one but you will know how you responded. You are free to participate in this study or to withdraw at any time. Your decision to participate or not to participate will not impact your employment status. Your taking this survey indicates your agreement to participate. If you have any questions about this research study or would like to receive results, please contact Liu-Qin Yang at lyang2@mail.usf.edu. If you have questions about your rights as a person participating in a res earch study, you may cont act the Division of Research Integrity and Compliance of the Un iversity of South Florida at (813) 974-5638. Thank you very much for your time and participation! Sincerely, Liu-Qin Yang, M.A., Doctoral Candidate Paul Spector, Ph.D., Professor Department of Psychology University of South Florida

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84 In the table on this page, you will be as ked to check whether certain things have happened to you at work. How often have you been subjected to this behavior in your workplace over the past 6 months ? [Please check only one for each behavior] Never Once or Twice A few times Monthly Weekly Daily 1. Been hit with an object 2. Been assaulted with weapon (e.g., knife, gun, etc.) 3. Been kicked or punched 4. Been slapped 5. Been pushed, grabbed or shoved 6. Been bitten 7. Been spat upon 8. Been yelled or shouted at 9. Been sworn at 10. Been threatened verbally or in a written message or note (including e-mail) 11. Had something thrown at you 12. Been insulted 13. Did you report to hospital authority any of the above behaviors you were subjected to? Yes No N/A 14. If yes, how did you repo rt the incident? Wrote an incident report Told the charge nurse Told the unit manager Others (specify) _____________

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85 How many times have the following things happened to you at work over the past 12 months ( Check only one)? Never Once Twice Three times Four or more times 15. I had bloodborne pathogenic exposure. 16. I had a needlestick while doing injections. 17. I had a needlestick while doing suturings. 18. I had a needlestick while drawing blood. 19. I had to go through post exposure prophylaxis (PEP).

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86 Physical Injury Checklist How to answer the questionnaire In the following picture, you can see the approximate position of the parts of the b ody in which you might have had an injury (if any). Please answer by putting a cross in the approximate box-one cross for each question. You may be in doubt as to how to answer, but please do your best anyway. Note that the quest ionnaire is to be answered, even if you have never had trouble in any part of your body. To be answered by everyone To be answered only by those who have had trouble Have you at any time during the last 12 months had trouble (ache, pain, discomfort) in: Have you at any time during the past 12 months b een prevented from doing normal work (at home or away from home) because of the trouble? Have you had trouble at any time during the last 7 days (Note: This time frame is different from the previous questions)? 20. Neck No Yes No Yes No Yes 21. Shoulders No Yes No Yes No Yes 22. Elbows No Yes No Yes No Yes 23. Wrist / Hand No Yes No Yes No Yes 24. Upper Back No Yes No Yes No Yes 25. Low Back ( Small of the back ) No Yes No Yes No Yes 26. One or both hips/thighs No Yes No Yes No Yes 27. One or both knees No Yes No Yes No Yes 28. One or both ankles/feet No Yes No Yes No Yes

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87 Now, please think of your interactio ns with your colleagues and feelings over the past month Please indicate how often these things have happened to you at work in dealing with coworkers, supervisors or physicians during the past month Not at all Once or Twice in Total Once or twice per week Once or twice per day Several times per day 29. Wasted my time with their personal problems. 1 2 3 4 5 30. Acted emotionally upset in my presence (not towards me). 1 2 3 4 5 31. Wanted me to take care of their work responsibilities. 1 2 3 4 5 32. Asked me to do something for him/her in the middle of my work. 1 2 3 4 5 33. Made my job difficult. 1 2 3 4 5 34. Lost his/her temper in my presence (not towards me). 1 2 3 4 5 35. Gave me bad advice about my work. 1 2 3 4 5 36. Tried to get me do things I didn't want to. 1 2 3 4 5 37. Burdened me by complaining. 1 2 3 4 5 38. Acted in an angry manner in my presence (not towards me). 1 2 3 4 5 Over the past month how often have you experienced each of the following symptoms? Not at all Once or Twice in Total Once or twice per week Once or twice per day Several times per day 39. An upset stomach or nausea 1 2 3 4 5 40. A backache 1 2 3 4 5 41. Trouble sleeping 1 2 3 4 5 42. Headache 1 2 3 4 5 43. Acid indigestion or heartburn 1 2 3 4 5 44. Eye strain 1 2 3 4 5 45. Diarrhea 1 2 3 4 5 46. Stomach cramps (Not menstrual) 1 2 3 4 5 47. Constipation 1 2 3 4 5 48. Ringing in the ears 1 2 3 4 5 49. Loss of appetite 1 2 3 4 5 50. Dizziness 1 2 3 4 5 51. Tiredness or fatigue 1 2 3 4 5

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88 Over the past month how often have you experienced each of the following? Not at all Once or Twice in Total Once or twice per week Once or twice per day Several times per day 52. I have felt nervous. 1 2 3 4 5 53. I have felt jittery. 1 2 3 4 5 54. I have felt calm. 1 2 3 4 5 55. I have felt fidgety. 1 2 3 4 5 56. I have gotten angry. 1 2 3 4 5 57. I have gotten aggravated. 1 2 3 4 5 58. I have gotten irritated or annoyed. 1 2 3 4 5 Now, please think of your feelings in the past week to answer the following 5 questions! Below is a list of ways you may have felt or behaved. Please describe how you have felt during the past week Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days) Occasionally or moderate amount of time (3-4 days) Most or all of the time (5-7 days) 59. I felt depressed. 1 2 3 4 60. My sleep was restless. 1 2 3 4 61. I felt lonely. 1 2 3 4 62. I had crying spells. 1 2 3 4 63. I could not ‘get going’. 1 2 3 4 Finally, please think of your job in general to answer the rest of the questions (almost there!) 1 2 3 4 5 6 S trongly D isagree M oderately D isagree SL ightly D isagree SL ightly A gree M oderately A gree S trongly A gree Using above 1-6 scale, to what extent do you agree or disagree with each of the following statements? SD MD SLD SLA MA SA 64. In general, I don't like my job. 1 2 3 4 5 6 65. All in all, I am satisfied with my job. 1 2 3 4 5 6 66. In general, I like working here. 1 2 3 4 5 6 67. Reports of workplac e violence from other employees are taken seriously by management. 1 2 3 4 5 6 68. Management in this organization quickly responds to episodes of violence. 1 2 3 4 5 6

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89 SD MD SLD SLA MA SA 69. Management encourages employees to report physical violence. 1 2 3 4 5 6 70. Management encourages employees to report verbal violence. 1 2 3 4 5 6 71. My employer provides adequate assault/violence prevention training. 1 2 3 4 5 6 72. In my unit, violence prevention policies are detailed. 1 2 3 4 5 6 73. In my unit, violence prevention procedures are detailed. 1 2 3 4 5 6 74. In my unit, there is training on violence prevention policies and procedures. 1 2 3 4 5 6 75. In my unit in order to get the work done, one must ignore some violence prevention policies. 1 2 3 4 5 6 76. In my unit, whenever pressure builds up, the preference is to do the job as fast as possible, even if that means compromising violence prevention. 1 2 3 4 5 6 77. In my unit, human resource shortage undermines violence pr evention standards. 1 2 3 4 5 6 78. In my unit, violence prevention policies and procedures are ignored. 1 2 3 4 5 6 79. I often think of leaving this hospital. 1 2 3 4 5 6 80. It is very possible that I will look for a new job next year. 1 2 3 4 5 6 81. Recently, I often think of changing my current job. 1 2 3 4 5 6 OVER (Continued on Back)

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90 Background Items 82. Your gender ______Mal e ______Female 83. Your age ____________ years 84. Have you completed the CPI ( Crisis Prevention Institute, Inc. ) training? Yes ; No 85. Your job type: (LPN) Licensed Practical Nurse ; (ARN) Associate Registered Nurse ; (BRN) Bachelor Registered Nurse ; (MRN) Master Registered Nurse ; (ARNP) Nurse Practitioner ; Other (please Specify): ________________ 86. Which area are you primarily working at? Direct patient care ; Indirect patient care 87. How many hours do you work per week? __________ hours 88. How long have you been working as a nurse? _______ years_______ months 89. Your primary departm ent/unit/area is _________. Outpatient department Medical/surgical Psychiatric/behavioral Telemetry Obstetrics Gynaecology Procedural diagnostic Neuro-intensive care unit Progressive care unit Coronary care unit Intensive care unit Emergency Operating/recovery room Nursery Rehabilitation Occupational health Float Other (please specify) ____________ 90. How much are you interested in this research topic (workplace violence and injuries)? Not at all; To a slight extent; To some extent; To a large extent; To a great extent

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91 About the Author Liu-Qin Yang was born and raised in Fujian Province, Mainland China. She graduated with her Bachelor of Science in Psychology, Ba chelor of Art in English Language and Literature in 2001, and Master of Arts in Industrial and Organizational Psychology in 2004, all from Beijing Normal Univ ersity, Mainland China. In that Fall, she attended the University of South Florida to pursue her do ctoral degree in Industrial and Organizational Psychology. During her gradua te career, she developed interests in and conducted research on economic psycholog y, person-environment fit, cross-cultural psychology, occupational stress, quantita tive methodology, workplace aggression and safety. In addition, she also worked as a c onsultant and manager of consulting projects for the public and private sector, as part of her graduate career in China. Starting from this Fall, Liu-Qin Yang will work as an assist ant professor at Portland State University.