Introduction

Workplace harassment and burnout syndrome among healthcare personnel have psychopathological and behavioral consequences that affect health at individual and organizational level ^1,2. Burnout is defined as a psychological syndrome characterized by emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals while performing their work with other people. This may affect workers psychologically, thus damaging their work (absenteeism, accidents, lack of motivation and negativism) and family (divorces and indifference), and even induce them to commit suicide ^3-5. Furthermore, such condition is associated with poor patient care and malpractice increase among physicians ^4,5. The frequency in which burnout is present among healthcare workers is very different: it may range between 3 % and 78 % in different studies ^6-8.

Workplace harassment is defined as the systematic exposure to humiliation, hostile and violent behaviors, and oppressive unethical communication against one or more workers ². Harassed subjects experience high levels of stress, musculoskeletal disorders, sleep disturbances, headaches, hypertension and gastrointestinal distress ⁹. Rates range between 8 % and 40 % among healthcare personnel ^2,9. A study found that over 70 % of hospitals had cases of discrimination and workplace and sexual harassment by surgeons ¹⁰. Other studies found that 64 % of surgical residents, 57 % of females and 30 % of family physicians suffered workplace harassment ^11,12.

Workplace harassment and burnout syndrome involve psychological and psychosomatic consequences that affect productivity and thus increase working hours lost ^1,2,13.

Although exposure to harassment could be an important factor associated with the development of burnout syndrome, there are few studies ^13,14 that have determined this association among healthcare workers. The present study aimed to determine the association between workplace harassment and burnout syndrome among health personnel at a referral hospital in Lima, Peru.

Materials and methods

Results

A total of 207 healthcare workers from the Medicine and Surgery departments were evaluated. Only one participant was excluded because of missing data in the survey. Among the 206 evaluated participants, 22 (10.7 %) experienced burnout. The mean age was 37 ± 12 years, and the number of female participants in the study was 128 (62 %) (Table 1). Most of the participants were nurses and nursing technicians. Table 2 shows the classification by type of personnel with and without burnout.

The number of participants who suffered low and moderate to severe workplace harassment was 178 (86 %) and 28 (14 %), respectively (Table 3). No worker experienced very severe harassment. The mean NAQ-R score in the total population was 34. Table 4 shows the comparison of burnout with harassment by occupational group.

Concerning the bivariate analysis, it was found that age with OR 0.94 (95 % CI 0.89-0.99; p = 0.02), marital status with OR 2.85 (95 % CI 1.01-8.06; p = 0.04) and NAQ-R scores with OR 5.20 (95 % CI 1.92-14.09; p = 0.009) (work-related harassment, person-related harassment and physical intimidation) were statistically significant. Participants with burnout were significantly younger (median age 30 years vs. 36 years; p = 0.012) and had a steady partner (22.7 % vs. 45.6 %; p = 0.04).

When analyzing the NAQ-R as a categorical variable, by dichotomizing it in low (22 to 44 points) and moderate to severe (> 44 points) levels of harassment, it was found that 36 % of the participants with burnout suffered at least moderate harassment, while among those without burnout only 10 % experienced this level of harassment (p < 0.01).

In the multivariate analysis, the NAQ-R score was the only significant burnout predictor. The presence of moderate harassment was associated with OR 4.00 (95 % CI 1.4-11.3; p = 0.009) compared to a low level of harassment (Table 5).

Discussion

The main finding of the study is the strong association between workplace harassment and the presence of burnout. This association was consistent in both the raw and adjusted analysis. Healthcare workers who did not suffered harassment had a very low frequency of burnout, while those harassed had a frequency of burnout of near 90 %, regardless of other factors. Although the high frequency evidenced in the study, there are few publications in the region that have associated burnout with harassment among healthcare personnel ^{13,14,20,21,22}. Research studies conducted in Korea ^13,22, Portugal ¹⁴ and France ²⁰ have shown results consistent with this work.

The frequency of burnout in research studies conducted among healthcare workers has been extremely variable ^4,5,8: the results have ranged between 2.8 % ⁸ and 52 % ⁴, depending on the population studied.

Regarding the frequency of workplace harassment among healthcare personnel, the finding of 14 % is different from the figures determined in other two studies ^10,23, which showed a prevalence of 39 % among surgeons and 57 % among residents in their first years in Oceania. Nevertheless, such result is similar to that found by Sá et al., who reported a prevalence of 13 % of workplace harassment among nurses of the public health system in Portugal ¹⁴.

On the other hand, the frequency of 30.7 % of burnout and 23 % of moderate to severe harassment among residents from the Medicine and Surgery departments is different from that found by Llewellyn et al. ²³, who determined 57 % of harassment in residents in their first years in Australia in 2015. Hu et al. ²⁴, in the United States in 2018, identified that harassment was frequent among general surgery residents, especially females, and was associated with exhaustion and suicidal ideation.

In addition, the present study found 33.3 % of moderate to severe harassment among surgeons, which is similar to the figure determined by Ling et al. ¹¹. Surgical specialty is not excepted from cases of workplace harassment since surgical assistants and residents are more likely to be victims of harassment compared to other personnel members ¹¹.

The frequency of 6.4 % of burnout and 4.8 % of moderate to severe harassment among nursing personnel differs from the finding of Udho et al. ⁵, who reported a frequency of burnout of 36 % among nurses in Uganda. Sá et al. ¹⁴ found a prevalence of 13 % of harassment among nurses of the public health system in Portugal. Harassed nurses reported absenteeism and high job turnover ⁹. Harassment among nurses may be associated with organizational culture, including hierarchical management and the lack of empowerment among nursing personnel ^25-29.

The results are important because they allow identifying healthcare workers who experience workplace harassment as a risk group that may develop burnout syndrome. Interventions addressed to solve this problem may be useful to prevent the development of burnout syndrome. However, the usefulness of these possible interventions should be assessed by properly designed intervention studies.

The present study is considered the first one in Peru that relates exposure to workplace harassment with the presence of burnout syndrome among healthcare workers. However, its findings must be considered carefully due to some limitations. The main limitation of this study is that the NAQ-R as a tool might not reflect the real magnitude of harassment. Though it does not invalidate the results, it should be complemented with qualitative studies to have a more comprehensive view.

In conclusion, it is important to identify health workers suffering workplace harassment due to its strong association with burnout syndrome. It is essential to carry out further research to understand and address the problem of workplace harassment and its influence on the development of burnout, as well as studies to evaluate interventions aimed at preventing both workplace harassment and burnout. Finally, it is a priority to include the mental health of healthcare workers themselves and its determinants as a part of human resource management in healthcare services.