JAN

JOURNAL OF ADVANCED NURSING

RESEARCH METHODOLOGY

Patients aggressive behaviours towards nurses: development and

psychometric properties of the hospital aggressive behaviour
scale- users
Kathrin Waschgler, Jose Antonio Ruiz-Hernandez, Bartolome Llor-Esteban &
Mariano Garca-Izquierdo
Accepted for publication 18 August 2012

Correspondence to K. Waschgler:
e-mail: kathrin.waschgler@um.es.
Kathrin Waschgler MSc
PhD Student
University of Murcia, Spain
Jose Antonio Ruiz-Hernandez PhD
Associate professor
Department of Psychiatry and Social
Psychology, University of Murcia, Spain
Bartolome Llor-Esteban PhD
Associate professor
Applied Psychosocial Sciences, University of
Murcia, Spain
Mariano Garca-Izquierdo PhD
Associate professor
Work and Organisational Psychology,
University of Murcia, Spain

N D E Z J . A . , L L O R - E S T E B A N B . & G A R C I A - I Z WASCHGLER K., RUIZ-HERNA

Patients aggressive behaviours towards nurses: development

and psychometric properties of the hospital aggressive behaviour scale- users.
Journal of Advanced Nursing 69(6), 14181427. doi: 10.1111/jan.12016

QUIERDO M (2013)

Abstract
Aim. This article is to report the development and psychometric testing of the
Hospital Aggressive Behaviour Scale Users.
Background. Workplace violence is present in many work spheres, but in the
healthcare sector, nurses in particular are at more risk due to the close contact
they maintain with users and clients and the special characteristics of this
relationship.
Design. Using qualitative and quantitative methodology, an instrument was
applied to a sample of 1,489 nurses from 11 public hospitals. Data collection was
carried out in 2010 and 2011.
Results. Exploratory factor analysis yielded a 10-item instrument distributed in
two factors (non-physical violence and physical violence), which was validated by
means of confirmatory factor analysis. Both the resulting questionnaire and the
factors identified present high internal consistency and adequate external validity,
analysed by means of statistically significant correlations between the Hospital
Aggressive Behaviour Scale and job satisfaction, burnout components, and
psychological well-being.
Conclusions. The results indicate that, in nursing personnel, higher exposure to
user violence leads to lower job satisfaction, more emotional exhaustion and
more cynicism, and to a lower level of psychological well-being.
The instrument developed in this study may be very useful in the sphere of
assessment and prevention of psychosocial risks for the early detection of the
problem of user violence in its two facets.
Keywords: instrument development, nursing, patients, workplace violence

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JAN: RESEARCH METHODOLOGY

Introduction
The health sector includes a series of occupations that present a high risk of workplace violence; one of every four violent occupational incidents occurs in this sector (World
Health Organisation 2002, Chappell et al. 2006). The
importance of this worldwide phenomenon has been
reflected in numerous international works (Zapf 1999, Rippon 2000, Quine 2001, Martino 2002, Anderson & Parish
2003, Estryn-Behar et al. 2008).
Following the internationally accepted categorization of
workplace violence (Cal/OSHA 2004), in this work, we
focus on Type II violence, or so-called ascending violence,
which refers to cases where the aggressor is the recipient of
a service provided by the affected workplace or by the
worker. In this article, aggressive behaviours are considered
as a part of workplace violence.

Background
The literature supports the view that nurses are more likely
to experience aggression by patients to whom they give
direct care, or by visitors, relatives or friends, rather than
by other members of the multidisciplinary team or intruders. In general, studies describe verbal or non-physical violence in terms of verbal abuse, threatening, abusive, ironic
language, glaring and contemptuous looks, whereas physical violence refers to physical intimidation, damage to
persons or property, destructive aggressive behaviour, and
also includes mild and severe physical violence (Gerberich
et al. 2004, Jansen et al. 2005, Needham et al. 2005,
Nijman et al. 2005, Ayranci et al. 2006, Farrell et al. 2006,
Luck et al. 2007, Estryn-Behar et al. 2008, International
Council of Nurses 2009).
Based on the existing literature, the risk factors of violence can be classified as follows: (a) patients: male, age,
physical alterations and pathologies, mental state, psychopathology, patients perspective and attributions, or individual factors of nursing staff, such as burnout or attitudes;
(b) environmental factors or organizational factors: type of
ward, such as emergency, psychiatry and intensive care
units, long-term care, or geriatric centres; inadequate number of staff, assistential pressure, lack of privacy, climate of
tension; (c) treatment-related factors, such as change of
medication and restraint; and (d) interactional factors and
societal factors (Curbow 2002, LeBlanc & Kelloway 2002,
May & Grubbs 2002, Martino 2003, Crilly et al. 2004,
Secker et al. 2004, Winstanley & Whittington 2004, Duxbury & Whittington 2005, Ergun & Karadakovan 2005,
Ayranci et al. 2006, Foster et al. 2007, Ketelsen et al.
2012 Blackwell Publishing Ltd

Aggressive behaviours in nursing

2007, Chen et al. 2008, Hahn et al. 2008, 2010, Kling

et al. 2009, Landau & Bendalak 2010, Paterson et al.
2010).
The impact on the target persons health may also differ
significantly, depending on the type and frequency of the
reported aggressive behaviour (Hoel et al. 2004) and can
have personal and organizational consequences. Among the
individual consequences, we emphasize worse psychological
well-being, such as: (a) increased levels of depressive symptoms; (b) anxiety symptoms; (c) psychosomatic health complaints; and (d) psychiatric pathologies (Einarsen et al.
1998, Rippon 2000, LeBlanc & Kelloway 2002, Mikkelsen
& Einarsen 2002, Stanko 2002, Martino 2003, Agervold &
Mikkelsen 2004, Chappell et al. 2006, Garca-Izquierdo
et al. 2006, Spector et al. 2007, Chen et al. 2008).
With regard to the type of violence and possible consequences, verbal aggression produces higher rates of anger
than physical aggression (Bussing & Hoge 2004, Needham
et al. 2005), and combined verbal and physical aggression
produce higher levels of state anxiety than only physical
aggression (Chen et al. 2005).
Aiken et al. (2001) verify that the high frequency of verbal
abuse experienced by nurses contributes to job dissatisfaction, leading to burnout and increasing workplace tension.
Higher turnover, negative consequences in productivity, the
increase in the rate of accidents, higher rates of sick leave
and presenteeism, risk of unemployment, and earlier retirement are also organizational consequences of violence
(Quine 2001, Ayranci et al. 2006, Chappell et al. 2006,
Farrell et al. 2006, Estryn-Behar et al. 2008, Hoel et al. 2011).

The study
Aim
The aim of this study was to develop and test the psychometric properties of an instrument, which permits the evaluation of professionals perception of aggressive behaviours
perpetrated by users towards nursing staff.

Participants
In a first qualitative phase of the study, three focus groups
were carried out in 2010 with a total of 21 participants (16
women and 5 men; 14 were nurses and 7 were technical
personnel for prevention of occupational hazards in the
healthcare service) and six in-depth interviews of nurses
from diverse hospitals were performed.
In a second quantitative phase aimed at the psychometric
assessment of the instrument, the research questionnaire
1419

K. Waschgler et al.

was applied in 2010 and 2011 to a total sample of 1,489

nurses from 11 public hospitals of Murcia, a south-eastern
region of Spain. The sample represents 29% of the total
nursing staff of this region. The global response rate of the
protocols administered was 70
5%. The sociodemographic
and socio-labour characteristics are presented in Table 1.
The mean age of the sample was 42 years (SD 9
75) and

Table 1 Sociodemographic characteristics.

Variable
Age (years)
2029
3039
4049
5059
6067
Missing data
Gender
Female
Male
Missing data
Marital status
Single
Married/common-law partner
Divorced, separated, widow/er
Missing data
Sick leave in the past 12 months?
Yes
No
Missing data
Type of contract
Permanent
Temporary
Missing data
Current type of shift
Permanent morning shift
Permanent night shift
Rotating shift
Others (morning/afternoon shift)
Missing data
Job tenure (years)
02
25
510
1015
+15
Missing data
Profession tenure (years)
02
25
510
1015
1520
+20
Missing data

1420

148
442
433
328
41
97

9
9
29
7
29
1
22
0
2
8
6
5

1231
244
14

82
7
16
4
0
9

83
4% were women. Of them, 64
3% had a permanent

contract and 51
1% worked in rotating shifts.

Methodology
Figure 1 shows an outline of the procedure employed.
Qualitative data collection
In the qualitative phase, following the guidelines of Krueger
(1991), two trained interviewers and two observers directed
three discussion groups with a previously established script.

Qualitative
phase

3 focus groups
N = 21
16 women, 5 men
14 nurses and 7 TPRL
55 items

Focus groups

386
1009
85
9

25
9
67
8
5
7
0
6

488
977
24

32
8
65
6
1
6

884
492
113

59
4
33
0
7
6

445
37
752
238
17

29
9
2
5
50
5
16
0
1
1

360
419
294
151
203
62

24
2
28
1
19
7
10
1
13
6
4
2

19
122
388
278
209
384
89

1
3
8
2
26
1
18
7
14
0
25
8
6
0

Review I

Group of experts
27 items

In-depth
interviews

6 interviews with
nurses

Review II

Group of experts
21 items

Quantitative
phase

Administration of the
instrument (N = 1489)

Construction

N = 695
Exploratory factor
analysis
N = 794
Confirmatory factor
analysis

Validation

N = 1489
Correlations with job
satisfation, MBI and
GHQ-28

External
validation

10 items
2 factors
Alpha = 083

Figure 1 Outline of the procedure.

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JAN: RESEARCH METHODOLOGY

Through this procedure, we collected information about the

relationship with patients and relatives as sources of hostility in the healthcare staffs work.
Qualitative data analysis
In the framework of qualitative analysis of the focus
groups, after transcription, we identified categories of
behaviours (verbal, non-verbal, and physical violence),
which were the basis to draft the items, respecting the content of the focus groups to the upmost. The items were
reviewed and compiled by a group of experts, by consensus
and following explicit and previously established criteria
(Togerson 1958, Dunn-Rankin 1983, Vellis 1991). This
group of experts was made up of three university professors, two doctoral candidates, the general director of the
nursing department of a hospital, and five practicing nurses.
The items were drafted to express potentially aggressive
or conflictive situations that can emerge at the healthcare
staffs workplace. A 6-point Likert-type response scale was
used to rate the frequency of exposure to the type of hostility at work, ranging from 0 (never)5 (daily).
Quantitative data collection
In the quantitative phase, all the public hospitals of the
south-eastern region Murcia (Spain) participated. We randomly selected a first group of participants from six hospitals (N = 695), which was used to construct the instrument
and a second sample from five hospitals (N = 794), which
was used to validate the instrument. The protocol was
administered through the service directors, using a randomized procedure to avoid over-representation of the people
who were more sensitized to the problem.
Quantitative data analysis
To reduce the number of items and to refine the scale
(Figure 1), we carried out exploratory factor analysis with
principle component and varimax rotation and various
criteria were combined: (a) each factor should explain at
least 5% of the total variance; (b) the factor loading of
the items should be at least 0
50; (c) an item could not
load on two factors with more than 0
40; and (d) the items
contained in each factor should have adequate internal
consistency (a > 0
70; Nunnally & Berstein 1994).
To analyse the fit of the factor structure to the resulting
model of exploratory factor analysis, we performed confirmatory factor analysis. Following the recommendations for
this analysis (Hu & Bentler 1999), diverse fit indexes were
employed: Root mean square error of approximation
(RMSEA), comparative goodness-of-fit index (CFI), and
normed fit index (NFI). Moreover, to assess the goodness
2012 Blackwell Publishing Ltd

Aggressive behaviours in nursing

of fit, the goodness-of-fit index (GFI) and the Tucker-Lewis

index (TLI) were also taken into account. According to
Bentler and Bonnet (1980), values of NFI, GFI, and TLI
equal to or higher than 0
90 and of CFI equal to or higher
than 0
93 reflect a good fit; and RMSEA values lower than
0
05 reflect an excellent fit, whereas values between 0
05
and 0
08 reflect adequate fit. As chi-square is very sensitive
to sample size and overrates the non-fit of a model (Bollen
1989), it was not taken into account and particular
attention was paid to the above-mentioned indexes. To
assess the reliability of the resulting scale, we studied the
internal consistency with Cronbachs alpha. The analyses
were carried out for the global scale and for each one of
the subscales obtained in the factor solution. Lastly, we
analysed the external validity with Pearson correlational
analysis between the factors of the scale and the validation
scales.

Instruments
Besides the sociodemographic and occupational variables,
to study the properties of the instrument, we used the following scales, which assess diverse psychosocial variables:
The Overall Job Satisfaction of Warr et al. (1979),
adapted in Spanish by Perez and Hidalgo (1995). It includes
15 items divided into two subscales: Intrinsic Satisfaction
and Extrinsic Satisfaction. All items are evaluated using
a 7-point scale, ranging from 1 (very dissatisfied)7 (very
satisfied).
The Maslach Burnout Inventory General Survey of
Schaufeli et al. (1996) in the Spanish version of Salanova
et al. (2000). This scale has 16 items grouped into three
dimensions: Emotional Exhaustion, Cynicism, and Professional Efficacy. All the items are rated on a 7-point scale,
ranging from 0 (never)6 (always).
The General Health Questionnaire GHQ-28 (Goldberg
& Hillier 1979) according to the adaptation in Spanish of
Lobo et al. (1986). This questionnaire comprises four subscales with seven items each: (a) Somatic Symptoms of psychological origin; (b) Anxiety and Insomnia; (c) Social
Dysfunction; and (d) Depressive Symptomatology.
Table 3 shows the internal consistency values (alpha
Cronbach) of all the instruments used in this study.

Ethical considerations
The research project was approved and financed by the
Instituto de la Mujer [Womans Institute], which depends
on the Ministerio de Trabajo y Asuntos Sociales [Spanish
Ministry of Work and Social Affairs].
1421

K. Waschgler et al.

Table 2 Matrix of rotated components, explained variance, and Cronbachs alpha (internal consistency).
Factor I non- physical
violence

Item
1. Users get angry with me because of delay
2. Users get angry with me because
of the lack of information
3. Users accuse me unfairly of not fulfilling my obligations,
committing errors, or complications
4. Users give me dirty or contemptuous looks
5. Users question my decisions
6. Users exaggeratedly make me responsible for any trifle
7. Users make ironic comments to me
8. Users have even shoved, shook, or spit at me.
9. Users have even grabbed me or touched me in a hostile way
10. Users show their anger at me by breaking doors, windows, walls, etc.
Explained variance (%)
Cronbach alpha

We requested the collaboration of each hospital in writing and explained the study. The managers and the nursing
directors of all the hospitals approved participation in the
study. Each questionnaire included certain information to
ensure that consent was informed and voluntary. Response
confidentiality was guaranteed, as the questionnaires were
returned in an envelope that was handed out along with
each one. The envelopes were opened by research team
members and a code assigned to the questionnaires for data
analysis.

Results
Qualitative analysis and development of items
We obtained an initial pool of 55 items that reported
aggressive user behaviours; in turn, the items were divided
into three subcategories: verbal violence, non-verbal violence, and physical violence. Subsequently, the exhaustive
review of the items by the group of experts concluded by
eliminating 50% of the items for various reasons, especially
drafting problems, or overlapping contents, so that finally,
27 items remained. Lastly, to cognitively validate the items,
the results of the in-depth interviews were also reviewed by
the group of experts and six more items were eliminated,
leaving a total of 21 items.

Exploratory factor analysis factor interpretation and

labelling
Using the construction sample, we performed factor analysis following the above-mentioned criteria. This led to a
final scale of 10 items made up of two factors, which
1422

Factor II physical
violence

0
758
0
727
0
723
0
692
0
681
0
675
0
626

35
12
0
84

0
870
0
813
0
728
22
01
0
76

explained 57
13% of the variance. The Kaiser-Meyer-Olkin

sample adequacy measurement value was high and adequate (KMO = 0
864; George & Mallery 1995). Table 2
shows all the values obtained from the exploratory factor
analysis.
The first factor, called non-physical violence, explains
35
12% of the variance, with an alpha of 0
84 and includes
seven items about violent verbal and non-verbal acts by
users, such as patients, relatives, or caregivers (i.e. Users
make ironic comments to me and Users give me dirty and
contemptuous looks). The second factor, which we called
physical violence by users, explains 22
01% of the
variance, with an alpha of 0
76 and it has three items
(i.e. Users have even shoved, shook, or spit at me).

Confirmatory factor analysis model fit analysis

Subsequently, we used the validation sample to test the fit
of the factor model. The analyses indicated a GFI of 0
96,
a CFI of 0
95 and a NFI and TLI of 0
94, and, lastly, an
RMSEA of 0
070. Taking into account the reference
criteria, we concluded that the model presents a good fit.
Figure 2 shows the results of the analysis.

Reliability of the Hospital Aggressive Behaviour ScaleUsers (HABS-U)

Analysis in the elaboration group (N = 695) yielded a
Cronbach alpha of 0
83 for the total scale and the alpha
values of the factors were 0
84 for Factor I and 0
76 for
Factor II. The validation group (N = 794) and the total
sample (N = 1,489) obtained practically identical Cronbach
alpha values.
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JAN: RESEARCH METHODOLOGY

Aggressive behaviours in nursing

130

Item 1

084

Item 2

074

047

Item 3

063
076

062

Item 4

094

Item 5

081

087

Item 6

063

080

Item 7

122
Non-physical
voilence

066

022
019

Figure 2 Confirmatory factor analysis.

008

Item 8

015

Item 9

016

Item 10

Correlates of the HABS-U study of external validity

To analyse criterion validity, we calculated the correlations
between the two factors of the HABS-U and job satisfaction, burnout components, and the four health components
assessed with the GHQ-28. In this phase of the study, we
used the entire sample of all 11 hospitals (N = 1,489).
We found statistically significant correlations (P < 0
001)
between the factors of the HABS-U and the validation scales.
Table 3 shows the correlations found between the diverse
HABS-U factors and above-mentioned validation scales.
The MBI and GHQ-28 validation scales correlated significantly and positively with the HABS-U, except for the
variable professional efficacy, which was not statistically
significant in any case. We also verified that higher

Physical
voilence

085
069

exposure to aggressive behaviours was related to higher

levels of burnout and greater impact on the health indicators assessed by the GHQ-28.
On examining the differences between the two subscales,
non-physical and physical violence, higher correlations were
generally found between the frequency of exposure to nonphysical user violence and emotional exhaustion (r = 0
26,
P < 0
001), cynicism (r = 0
22, P < 0
001), and somatic
symptoms (r = 0
19, P < 0
001). Whereas in physical
violence, we observed higher correlations with depression
(r = 0
1, P < 0
001), cynicism (r = 0
1, P < 0
001), and
intrinsic satisfaction (r = 0
09, P < 0
001). Job satisfaction
correlated significantly and negatively with the subscales
of the instrument designed. Higher frequency of exposure
to physical (r = 0
091, P < 0
01) or non-physical

Table 3 Correlations between factors and psychosocial variables.

Variable

Cronbachs alpha

Total satisfaction
Extrinsic satisfaction
Intrinsic satisfaction
MBI- Emotional exhaustion
MBI Professional efficacy
MBI Cynicism
GHQ-Total
GHQ Somatization
GHQ Anxiety insomnia
GHQ Social dysfunction
GHQ Major depression

0
87
0
70
0
84
0
85
0
86
0
70
0
91
0
85
0
86
0
74
0
82

HABS-U
0
178***
0
162***
0
173***
0
250***
0
042
0
240***
0
225***
0
196***
0
196***
0
111***
0
165***

FI Non-physical
0
153***
0
143***
0
145***
0
260***
0
046
0
220***
0
217***
0
195***
0
191***
0
128***
0
134***

FII physical
0
091**
0
076**
0
095***
0
044
0
004
0
097***
0
072**
0
051
0
058*
0
004
0
100***

MBI, Maslach Burnout Inventory; GHQ, General Health Questionnaire.

*P < 0
05.
**P < 0
01.
***P < 0
001.
2012 Blackwell Publishing Ltd

1423

K. Waschgler et al.

What is already known about this topic

Workplace violence perpetrated by patients and rela-

tives is very common in nursing.

The type of ward or facility is significantly related to

workplace violence
Standardized instruments to assess this phenomenon

are needed, which would enable us to prevent and

intervene in this kind of violence and assess the
efficacy of the programmes.

What this paper adds

The Hospital Aggressive Behaviour Scale Users is a

short questionnaire with good psychometric properties

for evaluating the exposure of nursing staff to user
violence.
The Hospital Aggressive Behaviour Scale Users provides information about the two most habitual forms
of aggression by patients and their relatives towards
nursing staff: non-physical and physical violence.
Workplace violence can lead to reduced job satisfaction, burnout, and lowered psychological well-being.

Implications for practice and/or policy

The systematic use of the Hospital Aggressive Behav-

iour Scale Users in the prevention of occupational

hazards could be useful for the early detection of risk
of user violence.
The Hospital Aggressive Behaviour Scale Users could
also be used as an indicator of the probability of psychological alterations and to detect hospital units with
low levels of workplace violence (to apply the findings
in these units that have high levels of workplace
violence).
The Hospital Aggressive Behaviour Scale Users
would be useful to appraise the efficacy of intervention
programmes (e.g. therapeutic management of aggression, risk assessment).

(r = 0
153, P < 0
001) aggressive behaviours by the users

was related to the workers lower job satisfaction.

Discussion
In this study, we constructed a scale for the assessment of
aggressive user behaviours towards the healthcare staff,
using for this purpose a qualitative and quantitative methodology. The large sample size, the participation of 11
1424

public hospitals of a south-eastern region of Spain and the

high response rate are all notable. The resulting instrument
is made up of 10 items, shows adequate psychometric
properties and is brief, easy to apply and to interpret and
has adequate reliability, as it was validated in a different
sample.
The factors resulting from the factor analysis, Non-Physical and Physical Violence, are along the lines of those found
in other studies (Wells & Bowers 2002, Luck et al. 2007,
Spector et al. 2007). In the study, carried out with the validation scales, our results are in accordance with other
research works (Quine 1999, May & Grubbs 2002, Bussing
& Hoge 2004, Needham et al. 2005, Ayranci et al. 2006,
Chappell et al. 2006). We highlight the importance of
assessing the level of exposure to diverse violent behaviours
from service users, because depending on the actor, violent
behaviours are different.

Study limitations
The use of self-reports may produce response bias in the
participants, exacerbating the common variance and artificially increasing correlations between variables. Although
we tried to minimize this limitation by randomizing the
participants and by rigorous control of anonymity, the
opportunity of using more sophisticated designs should be
studied (Taris 2000).
Correlations in this study are generally low. The correlations of the Physical Violence subscale are lower than those
of the Non-Physical Violence subscale, which is probably
due to the scarcity of violent physical behaviours. Despite
the low correlations obtained, our findings suggest that
working in a violent occupational environment could lead
to the development of burnout, psychosomatic symptoms,
loss of well-being, and even the onset of clinical syndromes.

Conclusion
Efforts are being made to introduce standardized measures
with the aim of providing more reliable insight both into
the causes and the risks of aggressive incidents (Nijman
et al. 2005). The systematic use of the HABS-U in the
prevention of occupational hazards can be useful for the
early detection of risk of user violence. Another possible
application of the instrument is its use as an indicator of
the probability of psychological alterations due to exposure
to violent behaviours at the workplace.
The lack of systematic staff training in therapeutic management of aggression and risk assessment, such as training
in key communication, observation and interpersonal skills
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JAN: RESEARCH METHODOLOGY

and de-escalation techniques, has been observed (Duxbury &

Whittington 2005, Jansen et al. 2005, Needham et al. 2005).
In this sense, the HABS-U could also be used to appraise the
efficacy of intervention programmes in nursing staff.
From another viewpoint and following the philosophy of
positive psychology (Seligman & Csikszentmihalyi 2000),
this instrument could be used to detect hospital units with
low levels of workplace violence. The in-depth analysis of
these units could lead to the identification of keys to good
occupational climates, to extrapolate the findings to units
that have high levels of workplace violence.

Funding
This research was supported by a grant from the Instituto
de la Mujer [Womans Institute], which depends on the
Ministerio de Trabajo y Asuntos Sociales [Spanish Ministry
of Work and Social Affairs] (exp. 152/07).

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
All authors meet at least one of the following criteria
(recommended by the ICMJE: http://www.icmje.org/ethical_
1author.html) and have agreed on the final version:
substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data.

drafting the article or revising it critically for important
intellectual content.

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