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research-article2023
1185942
sJp0010.1177/14034948231185942Clausen et al.
Beskæftigelsesudvalget 2022-23 (2. samling)
BEU Alm.del - Bilag 251
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Scandinavian Journal of Public Health,
1–7
ORIgInAl ARtICle
Acts of offensive behaviour and risk of disability pension in Danish
female eldercare workers: prospective cohort with 11-year register
follow-up
THOmAs ClAusen
1
, Jesper pIHl-THIngvAD
2,3
,
ebbe vIllADsen
1
& lArs l. AnDersen
1
Research Centre for the Working Environment, Copenhagen, Denmark,
2
Department of Occupational and
Environmental Medicine, Odense University Hospital, Odense, Denmark,
3
Department of Clinical Research, University of
Southern Denmark, Odense, Denmark
1
National
Abstract
Objectives:
To investigate whether acts of offensive behaviour (threats, violence, workplace bullying and sexual harassment)
in the workplace and type of perpetrator (internal or external to the workplace) of the offensive behaviours predicted risk
of disability pension in Danish eldercare workers.
Methods:
We merged survey responses from 8731 female eldercare
workers with a national register on social transfer payments (Danish register for evaluation of marginalisation (DreAm)),
including all types of disability benefits. using Cox proportional hazards models, we investigated the prospective association
between self-reported exposures at baseline and the risk of receiving disability pension (any type of disability benefit
payment) during 11 years of follow-up, while adjusting for potential confounders.
Results:
self-reported exposure to
threats (hazard ratio (Hr) 1.14; 95% confidence interval (CI) 1.00–1.32), violence (Hr 1.16; 95% CI 1.00–1.35) and
bullying (Hr 1.44; 95% CI 1.22–1.71) predicted increased risk of disability pension during follow-up, when adjusted
for age and educational attainment. When further adjusted for psychosocial working conditions only bullying remained a
statistically significant (Hr 1.39; 95% CI 1.16–1.67) predictor of disability pension. The results indicated no elevated risk
for participants reporting sexual harassment. moreover, we observed stronger associations between self-reported exposure
to threats, violence and workplace bullying and risk of disability pension when the perpetrator was internal to the workplace
(i.e. colleagues, managers and/or subordinates), than when the perpetrator was reported to be external to the workplace
(i.e. service users, and/or relatives of service users).
Conclusions: Results indicate that prevention of work-related
exposure to threats, violence and workplace bullying may contribute to reduce involuntary early retirement in
female eldercare workers.
Keywords:
Violence, threats, bullying, sexual harassment, aggression, healthcare, work environment, working conditions
Introduction
Healthcare workers are inherently engaged in the
provision of human services and, accordingly, it is
relevant to assess the consequences of acts of offen-
sive behaviour (e.g. workplace bullying, threats, vio-
lence, or sexual harassment) that healthcare workers
may encounter while undertaking their work tasks. A
recent meta-analysis indicates that exposure to so-
called workplace violence (i.e. threats, violence, or
sexual harassment) is widespread among workers in
the healthcare sector [1], yet limited knowledge exists
about the potential negative long-term consequences
for the affected workers.
Acts of offensive behaviour may have potentially
harmful effects on the psychological wellbeing of
Correspondence: Thomas Clausen, national research Centre for the Working environment, lersoe parkalle 105, DK-2100 Copenhagen, Denmark.
email: [email protected]
Date received 17 November 2022; reviewed 5 June 2023; accepted 16 June 2023
© Author(s) 2023
Article reuse guidelines: sagepub.com/journals-permissions
https://doi.org/10.1177/14034948231185942
DOI: 10.1177/14034948231185942
journals.sagepub.com/home/sjp
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Clausen et al.
measure of disability benefits as the endpoint. In the
analysis, we also investigate whether the observed
associations differ regarding the type of perpetrator
(internal vs. external to the workplace) in the reported
cases of offensive behaviours.
Methods
This study is based on questionnaire data that were
merged with register data on payments of disability
benefits from the Danish register for evaluation of
marginalisation (DreAm) [22]. Questionnaire data
were collected between late 2004 and spring of 2005.
We sent questionnaires to 12,744 eldercare workers
and obtained 9949 responses (78%). We were unable
to link two participants to the DreAm register and,
accordingly, we had 9947 participants who were eli-
gible for the present study. To ensure a more homo-
geneous study population, we excluded male
respondents (n=429) and workers not directly
engaged in care services (n=787), of which some
were also included in the excluded population of
men from the analyses. This resulted in a final sample
of 8731 eldercare workers, comprising social and
healthcare assistants, social and healthcare helpers,
other care staff with no or short-term education, reg-
istered nurses and therapists.
Outcome
We measured payments of disability benefits in the
DreAm register [22]. residents with permanent
loss of workability are eligible for disability benefits,
which are granted after a process involving authori-
ties at the municipal level of government. We defined
‘disability pension’ as receipt of disability benefits,
requiring permanent full or partial loss of workabil-
ity. Disability benefits comprises 13 categories of dis-
ability benefits payment in the DreAm register,
including so-called ‘flex jobs’, sheltered employment
and full disability pension.
Predictors
In the study questionnaire, we asked participants if
they had been exposed to any of the following acts of
offensive behaviour during the past 12 months:
threats, violence, workplace bullying and/or sexual
harassment. response options were: (1) Yes, daily;
(2) Yes, weekly; (3) Yes, monthly; (4) Yes, now and
then; and (5) no, never. For the statistical analyses
these response options were collapsed into two cate-
gories: (1) exposed (daily, weekly, monthly and now
and then); and (2) not exposed (never).
participants reporting exposure to any of the four
types of offensive behaviours were asked a follow-up
healthcare workers, as these acts can be considered
as offenses to the ‘selves’ of the affected employees
[2]. These offenses to the ‘self ’ may result in a deval-
uation of both the relational and personal self, which
can cause negative psychological reactions [3], which
again may increase the risk of early involuntary exit
from the labour market [4].
previous studies have found that acts of offensive
behaviours are associated with a series of adverse
outcomes. Accordingly, extensive research provides
evidence that self-reported exposure to workplace
bullying is prospectively associated with increased
risk of reduced mental health [5, 6], sickness absence
[7, 8], disability pension [9, 10] and suicidal behav-
iour [11]. Other studies indicate that self-reported
exposure to threats and/or violence in the workplace
are associated with reduced mental health [12], sick-
ness absence [7, 8] and disability pension [13].
Finally, self-reported exposure to sexual harassment
is associated with increased risk of depression [14]
and long-term sickness absence in one study that was
based on a mixed study population [15] but not in
another, that was based on eldercare workers [7].
previous studies among eldercare workers indicate
that workplace bullying is a stronger predictor of
adverse outcomes than threats, violence and sexual
harassment [7, 16].
One reason for this may be that the perpetrators of
workplace bullying primarily are internal to the work-
place (i.e. a colleague, a superior or a subordinate)
while the perpetrators of threats, violence and sexual
harassment primarily are external to the workplace
(i.e. service users, and/or relatives of service users)
[7]. previous studies indicate that the consequences
are more severe if perpetrators are internal rather
than external to the workplace [17, 18].
The challenges associated with ageing populations
in many western countries [19] and a projected short-
age of nursing staff in the Organisation for economic
Co-operation and Development (OeCD) countries
[20, 21] underscore the relevance of investigating
whether self-reported exposure to threats, violence,
workplace bullying and/or sexual harassment is associ-
ated with increased risk of disability pension. The
study is relevant for public health, as it contributes to
our understanding of these prevalent but modifiable
exposures as potential risk factors for long-term detri-
mental effects on healthcare workers. This knowledge
may contribute to developing long-term prevention
strategies to enhance retention of healthcare workers.
The main aim of the present study is, therefore, to
investigate whether self-reported exposure to work-
place bullying, threats, violence and/or sexual harass-
ment is associated with an increased risk of disability
pension among female eldercare workers in Denmark
in a prospective analysis using a register-based
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Acts of offensive behaviour and disability pension
Table I. Descriptive statistics for main study variables.
granted disability benefits during follow-up
Yes
granted disability benefits during follow-up (% (n))
self-reported exposure to threats (% (n))
self-reported exposure to violence (% (n))
self-reported exposure to workplace bullying (% (n))
self-reported exposure to sexual harassment (% (n))
Age (mean (sD))
emotional demands (mean (sD))
a
role conflicts (mean (sD))
a
Influence at work (mean (sD))
a
Quality of leadership (mean (sD))
a
sD: standard deviation.
a
scales
3
no
88.1 (7696)
34.5 (2635)
21.2 (1597)
11.4 (866)
8.4 (84)
45.1 (10.2)
45.9 (18.3)
41.6 (15.5)
44.9 (20.4)
57.0 (21.7)
P
value
n.a.
0.1601
0.0842
<0.0001
0.0849
<0.0001
0.4009
0.3819
0.2999
0.4121
11.9 (1035)
36.8 (370)
23.6 (235)
16.1 (163)
10.2 (765)
47.1 (7.8)
46.3 (19.9)
41.2 (16.8)
45.7 (22.1)
56.4 (22.4)
measuring emotional demands, role conflicts, influence at work and quality of leadership are scored from 0 to 100, with a score of 100 indicating the
highest level of the measured dimension.
question if the perpetrators had been: (1) colleagues;
(2) managers; (3) subordinates; (4) patients/service
users, or relatives of patients. For the statistical analy-
ses, these categories were collapsed into the following
categories: (1) internal perpetrators (colleagues,
managers and/or subordinates); and (2) external per-
petrators (service-users or relatives of service-
users).
Confounders
potential confounders included age (continuous
variable), education (categories of specific health-
care education, e.g. social and healthcare assistant,
social and healthcare helper, nurse, nurse aide, ther-
apist, none) and psychosocial working conditions.
We measured psychosocial working conditions
using the following scales from the Copenhagen
psychosocial Questionnaire (COpsOQII) [23]:
emotional demands (Four items. sample item: Is
your work emotionally demanding? Cronbach’s alpha:
0.81). role conflicts (Four items. sample item: Are
contradictory demands placed on you at work?
Cronbach’s alpha: 0.66). Influence at work (Four
items. sample item: Do you have a large degree of
influence concerning your work? Cronbach’s alpha:
0.75). Quality of leadership (Four items. sample
item: To what extent would you say that your immedi-
ate superior gives high priority to job satisfaction?
Cronbach’s alpha: 0.89).
Statistical analysis
We used Cox proportional hazards regression analysis
to estimate hazard ratios (Hrs) and 95% confidence
intervals (CIs) of risk of disability pension during fol-
low-up. participants were followed in the DreAm
register for 11 years (until the end of June 2016). We
censored participants from the analysis in the case of
voluntary early retirement pension, state pension,
emigration, or death. Individuals who registered pay-
ments of disability benefits in any given week during
the follow-up period, were referred to as ‘events’ of
disability pension. The estimation method was maxi-
mum likelihood and we used the pHreg procedure
in sAs 9.4 (sAs Institute, Cary, nC, usA). We
found that the proportional hazard assumption was
satisfied through visual inspection.
variables describing the four types of acts of
offensive behaviour and the two types of perpetra-
tors were posed as predictors in the analysis. In the
analysis of each of the four types of offensive behav-
iours, we used participants not reporting exposure
to the investigated type of offensive behaviours as
the reference group. The analyses were adjusted in
three steps. In model 1, we adjusted associations for
age and educational attainment. In model 2, we sup-
plied model 1 with four variables describing psycho-
social working conditions. We deployed the same
procedure in the analysis of internal versus external
perpetrators for the four types of offensive
behaviours.
Results
Table I shows descriptive statistics for the main study
variables. During 11 years of follow-up, we recorded
1035 (11.9%) cases of disability pension in the study
population. Table I shows that self-reported exposure
to threats, violence, workplace bullying and sexual
harassment was more prevalent among participants
who were granted disability pension during follow-
up, but this difference was only statistically signifi-
cant for workplace bullying.
model 1 in Table II shows that self-reported expo-
sure to threats and violence is associated with
increased risk of disability pension, when adjusted for
age and educational attainment. This association was
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Clausen et al.
Table II. Hazard ratios (Hrs) and 95% confidence intervals (CIs) for risk of disability pension during 11 years of follow-up for four types
of acts of offensive behaviour.
At risk
Cases
n/%
model 1
Hr
Threats
violence
Workplace bullying
sexual harassment
Yes
no
Yes
no
Yes
no
Yes
no
3005
5631
1832
6696
1029
7603
849
7683
370/12.3
636/11.3
235/12.8
761/11.4
163/15.8
849/11.2
84/9.9
914/11.9
1.14
1
1.16
1
1.44
1
0.89
1
model 2
95% CI
1.00–1.32
–
1.00–1.35
–
1.22–1.71
–
0.71–1.12
–
Hr
1.13
1
1.14
1
1.39
1
0.86
1
95% CI
0.99–1.30
–
0.98–1.34
–
1.16–1.67
–
0.68–1.09
–
model 1: hazard ratios are adjusted for age and educational attainment.
model 2: model 1 plus psychosocial working conditions.
Table III. Hazard ratios (Hrs) and 95% confidence intervals (CIs) for risk of disability pension during 11 years of follow-up for acts of
offensive behaviour: stratified by internal and external perpetrators of acts of offensive behaviour.
Type of offensive behaviour
Type of
perpetrator
Internal
external
Workplace bullying
Internal
external
sexual harassment
Internal
external
Yes
no
Yes
no
Yes
no
Yes
no
Yes
no
Yes
no
At risk
Cases/%
model 1
Hr
95% CI
0.93–1.84
–
0.95–1.24
–
1.21–1.71
–
0.82–1.95
–
b
model 2
Hr
1.26
1
1.07
1
1.39
1
1.17
1
b
95% CI
0.88–1.78
–
0.93–1.23
–
1.15–1.68
–
0.75–1.83
–
b
Threats or violence
a
235
8278
3171
5342
928
7704
139
8493
18
8514
833
7699
34/14.5
957/11.6
374/11.8
617/11.5
147/15.8
865/11.2
21/15.1
991/11.7
b
b
1.31
1
1.09
1
1.44
1
1.26
1
b
83/10.0
915/11.9
1
0.90
1
–
0.71–1.12
–
1
0.87
1
–
0.69–1.09
–
model 1: hazard ratios are adjusted for age and educational attainment.
model 2: model 1 plus psychosocial working conditions.
a
For
data protection purposes, we analyse a combined measure of threats and violence, due to a low number of cases (<5) in the analysis of violence from
internal perpetrators.
for groups smaller than five persons cannot be reported due to data protection regulations.
b
results
statistically significant. In model 2, we observe
increased but statistically non-significant Hrs, when
further adjusted for psychosocial working conditions.
Table II also shows that self-reported exposure to
workplace bullying predicts significantly increased
risk of disability pension in both models, and that the
association between self-reported exposure to sexual
harassment and risk of disability pension is not statis-
tically significant in either model.
Table III shows results from analyses in which
the association between offensive behaviours and
risk of disability pension is stratified by type of per-
petrator (internal vs. external). Due to too few cases
of disability pension, it was not possible to report
results for sexual harassment from internal perpe-
trators, and for the same reason we decided to con-
struct a combined measure of threats and violence
for this analysis.
The results show that threats/violence and sexual
harassment were most frequently reported to be per-
petrated by external perpetrators, whereas persons
internal to the work organisation were the most fre-
quent perpetrators of workplace bullying. Table III
shows that eldercare workers who report being
exposed to workplace bullying from internal perpetra-
tors (i.e. colleagues, managers and/or subordinates)
had a significantly higher risk of disability pension,
when compared with non-exposed participants. We
also found elevated but statistically non-significant
Hrs for disability pension for participants reporting
exposure to threats/violence from internal perpetra-
tors and for participants reporting exposure to work-
place bullying from external perpetrators. Finally, the
results show higher Hrs for self-reported exposure to
threats/violence and workplace bullying from internal
perpetrators than from external perpetrators.
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Acts of offensive behaviour and disability pension
Discussion
This prospective cohort study among female eldercare
workers showed that self-reported exposure to threats,
violence and workplace bullying predicted an increased
risk of disability pension. When stratified by the type
of perpetrator, we observed the strongest association
between self-reported exposure to threats/violence
and workplace bullying and risk of disability pension
when the perpetrator was internal to the workplace
(i.e. colleagues, managers and/or subordinates).
Comparison with previous studies
Only a few studies have investigated the association
between acts of offensive behaviour and registered
disability pension [9, 10, 13]. Our results suggest that
both threats and violence increase the risk of disabil-
ity pension and this finding is partially supported by
earlier studies. For instance, Friis et  al. [13] found
that employees across occupations, who reported
exposure to physical workplace violence, had a higher
risk of disability pension 3 to 10 years after the vio-
lent incident. However, the risk estimates were only
statistically significant in the 8th year [13].
The results of this study are also in line with previ-
ous studies indicating that the consequences of offen-
sive behaviours are more severe if the perpetrator is
internal rather than external to the workplace [17, 18].
In the present study, we found no increased risk of
disability pension for eldercare workers reporting
exposure to sexual harassment. In our review of the
literature, we identified no studies that investigated
associations between sexual harassment and disabil-
ity pension. However, several studies identified asso-
ciations between sexual harassment and depressive
symptoms [14, 24], which is a predictor for disability
pension [4].
Theoretical considerations
According to the ‘stress-as-offence-to-self’ perspec-
tive [2], acts of offensive behaviour should be
expected to have a negative impact on the self-esteem
and self-worth of targets, which implies that expo-
sure to acts of offensive behaviour over extended
periods may increase the risk of adverse outcomes,
such as disability pension. The findings from this
study support this hypothesis by showing that self-
reported experiences of threats, violence, and, in par-
ticular, workplace bullying predict increased risk of
disability pension among female eldercare workers.
moreover, the findings of this and previous studies
on workers in eldercare show that self-reported expo-
sure to workplace bullying is a stronger predictor of
5
adverse labour market outcomes, such as the risk of
long-term sickness absence [7] and turnover [16],
than self-reported exposure to violence, threats and/
or sexual harassment. These findings indicate that
workplace bullying constitutes a special form of offen-
sive behaviour that should be understood as being dif-
ferent from threats, physical violence and sexual
harassment. Also, the results suggest that workplace
bullying may have more severe long-term effects than
violence, threats and/or sexual harassment. One
explanation for this finding may be that, in eldercare,
the perpetrators of workplace bullying most often are
internal to the workplace (e.g. colleagues, managers
and/or subordinates), whereas the most frequently
reported perpetrators of the other types of offensive
behaviours are external to the workplace (e.g. service
users, and/or relatives of service users) (see Table III).
bullying from colleagues, managers and/or subordi-
nates may therefore reduce the available sources of
social support in the workplace. Workplace bullying
might therefore not only be harmful as an exposure in
itself, but could also affect the experience of strain
from other factors at work, including other acts of
offensive behaviour, because it reduces the protective
element of social support [25].
Indeed, the study demonstrated that acts of offen-
sive behaviour perpetrated by colleagues, managers
and/or subordinates (i.e. internal perpetrators) pre-
dicted a higher risk of disability pension than acts
perpetrated by persons external to the workplace.
Aside from the mechanisms hypothesised above, one
main reason for this difference could be due to the
victims’ experience of the perpetrators’ ‘intent to
hurt’. studies have shown that the interpretation of
the intent to hurt is central to the toxicity of the
offensive acts [26]. Acts of offensive behaviour from
clients in eldercare may often be attributed to the
cognitive impairments of the client rather than the
clients’ actual intent to harm the caretaker [27], and,
accordingly, it may be perceived as being less per-
sonal and hurtful. However, acts of offensive behav-
iour from colleagues, managers and/or subordinates
are more likely to be interpreted with an intent to
hurt and devaluate the victim, while the effects of
offensive behaviours from this group of perpetrators
are perceived as more harmful and leading to more
detrimental long-term effects.
The finding that self-reported exposure to work-
place bullying increases the risk of disability pension is
in agreement with previous studies [9, 10]. These
studies also demonstrate that self-reported exposure
to workplace bullying predicts an increased risk of dis-
ability pension and report similar risk estimates for
disability pension as reported in the present study. The
study from Clausen and colleagues [9] also showed
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Clausen et al.
from external perpetrators. moreover, we collapsed
the categories ‘threats’ and ‘violence’ to ensure suffi-
cient statistical power in the analysis comparing
external versus internal perpetrators. This choice
appears meaningful because exposure to violence
and threats often co-occur, and classic definitions of
workplace violence include both threats and violence
(e.g. schat and Kelloway [30]). In addition, due to
low statistical power, it was not possible to stratify the
analysis of the association between sexual harass-
ment and disability pension by internal/external per-
petrator. Finally, it may be considered a limitation of
the study that we used dichotomised measures of
offensive behaviours. previous studies have indicated
a dose–response relationship between acts of offen-
sive behaviour and work-related outcomes [7, 16].
However, to ensure a robust estimation of the risk of
disability pension that is associated with acts of offen-
sive behaviour, we decided to operationalise the inde-
pendent variables as binary measures.
Conclusions
This study showed that self-reported exposure to
threats, violence and workplace bullying predicted an
increased risk of disability pension among female
eldercare workers. The results also show that acts of
threats/violence and workplace bullying from inter-
nal perpetrators had stronger associations with disa-
bility pension than from external perpetrators. The
results suggest that efforts to prevent acts of offensive
behaviour may reduce cases of disability pension,
thereby also taking measures against the projected
shortages of healthcare workers over the coming
decades.
Declaration of conflicting interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship, and/
or publication of this article.
Funding
The author(s) disclosed receipt of the following
financial support for the research, authorship, and/
or publication of this article: The data collection for
this study was financed by a grant from the Danish
parliament (sATs, 2004). Jesper pihl-Thingvad
was generously funded by the research fund of the
region of southern Denmark journal# 22/8605
efond1398.
ORCID iD
Thomas Clausen
-8253-4449
https://orcid.org/0000-0002
that the association was moderated by leadership sup-
port. For bullied workers with high levels of leadership
support, the study found no significant increase in risk
of disability pension, whereas the risk of disability pen-
sion was significantly increased for bullied workers
reporting low leadership support. In a study on the
association between workplace violence and sleep dis-
turbances, gluschkoff and colleagues [28] found that
individuals reporting high levels of organisational jus-
tice reported lower levels of sleep disturbances than
participants reporting low levels of organisational jus-
tice. These findings imply that the availability of job
resources (e.g. leadership support or the perception of
organisational justice) is important for the possibilities
of the exposed workers to cope with offensive
behaviours.
Strengths and limitations
This study has both strengths and limitations. First,
the study is based on a large, homogenous group of
female eldercare workers, which reduces the poten-
tial bias from socioeconomic confounding. second,
the register-based measure of disability pensioning
eliminates potential loss to follow-up and possible
common methods biases [29]. The study also counts
several limitations. First, it may be a limitation that
we excluded male participants from the analysis.
However, there were few men in the study popula-
tion, and thus we do not have statistical power to test
whether differences between men and women exist.
second, the small number of men make it difficult to
generalise the results to male eldercare workers.
Accordingly, the study is powered to make general
conclusions about female eldercare workers and is
not generalisable to other occupational groups.
However, the seriousness of the results urges for
research in the general working population. second,
the entire work-life history of the participants cannot
be captured in a single questionnaire, and, accord-
ingly, other unreported exposures may also influence
the risk of disability pension. Third, this study oper-
ates with an 11-year follow-up, which may imply a
risk of misclassification. Fourth, the predictors in the
study are based on self-reported measures related to
offensive behaviours. This implies a risk of reporting
bias and this potential source of bias must be taken
into account in the interpretation of the results. Fifth,
although it is a strength of the study that we were
able to distinguish between internal and external
perpetrators for threats, violence and workplace bul-
lying, some of these analyses may be underpowered,
which implies that the study yields false-negative
findings in the cases of threats and/or violence from
both types of perpetrators and workplace bullying
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Acts of offensive behaviour and disability pension
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