Archives of Environmental & Occupational Health
ISSN: 1933-8244 (Print) 2154-4700 (Online) Journal homepage: http://www.tandfonline.com/loi/vaeh20
Assessment and Analysis of Workplace Violence in a Greek Tertiary Hospital George Mantzouranis, Eleftheria Fafliora, Vasileios G. Bampalis & Ioanna Christopoulou To cite this article: George Mantzouranis, Eleftheria Fafliora, Vasileios G. Bampalis & Ioanna Christopoulou (2015) Assessment and Analysis of Workplace Violence in a Greek Tertiary Hospital, Archives of Environmental & Occupational Health, 70:5, 256-264, DOI: 10.1080/19338244.2013.879564 To link to this article: http://dx.doi.org/10.1080/19338244.2013.879564
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vaeh20 Download by: [University of Nebraska, Lincoln]
Date: 02 November 2015, At: 23:32
Archives of Environmental & Occupational Health (2015) 70, 256–264 C Taylor & Francis Group, LLC Copyright ISSN: 1933-8244 print / 2154-4700 online DOI: 10.1080/19338244.2013.879564
Assessment and Analysis of Workplace Violence in a Greek Tertiary Hospital GEORGE MANTZOURANIS1, ELEFTHERIA FAFLIORA2, VASILEIOS G. BAMPALIS2, and IOANNA CHRISTOPOULOU2 1
Health Center Aitolikou, Department of General Medicine, University Hospital of Patras, Patras, Greece Department of General Practice, University General Hospital of Patras, Patras, Greece
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
2
Received 5 July 2013, Accepted 4 December 2013
This study sought to assess workplace violence in a Greek tertiary hospital for the first time. The authors conducted a descriptive study with 175 participants and examined the characteristics of violent episodes, the responses of victims and the administration, and the perception of workplace safety in addition to the implications of these incidents. The vast majority of employees (83.4%) had experienced work-related violence; however, half of them (52%) had not reported the incident to the hospital administration. Verbal violence was the most common type of incident (98.6%). Nurses and other health care staff reported feeling safer than physicians (odds ratio [OR] = 4.47, 95% confidence interval [CI]: 1.94–10.28 and OR = 2.80, 95% CI: 1.64–8.74, respectively). A large proportion of victims (72.6%) suffered psychological consequences following the violent incident. This study reveals the high prevalence of workplace violence in a Greek tertiary hospital and underscores its negative impact on health care workers. Keywords: Greece, health care sector, workplace violence
According to the results of the 4th European Working Conditions Survey in 2005, 1 in 20 European workers reported exposure to bullying and/or harassment in the preceding 12 months, and a similar proportion reported having been exposed to violence.1 Therefore, providing a safe working environment for all employees is one of the top priorities of the European Union. In particular, life scientists and health professionals experience the most exposure to violence.1 Many studies show high rates of violence in the health care sector, although the reported prevalence varies.2–21 In 2001–2002, the National Health Service (NHS) reported 95,501 cases of violence and aggression against its staff in the United Kingdom.22 Verbal violence is the most common form of workplace violence, with nurses increasingly targeted.2–12 Physical violence is also prevalent; weapons are frequently brought into emergency departments (EDs), and workdays have been lost because of injuries caused by physical attacks.3,5,6,11,13 Factors such as long wait times, dissatisfaction with treatment, and mental illness contribute to the occurrence of violence.2,5,6, 10,14,15 It is noteworthy that a high percentage of violent incidents against health care workers remains unreported for a variety of reasons.1,5,6 Many health care workers report that they do not feel safe in their own workplace.5–7,13,16 All of these fac-
tors have a negative impact on the well-being of the affected personnel.6,10–12,14,17,18 Training programs are highlighted as a means of teaching health care workers how to handle violent incidents.2,3,5–7,11,13,14 In Greece, almost 3% of workers have been subjected to workplace violence and/or threats of violence.1 Furthermore, Greece has a high prevalence of psychosocial work factors that are recognized as occupational risk factors for various health complications (eg, bullying, job strain, and increased psychological demands).23 Additionally, work-related violent incidents in Greece are only occasionally reported, and often there is no detailed follow-up examination. The complete lack of systematic records and research on the causes and consequences of violence in health care underlies our inability to design effective intervention measures. To the best of our knowledge, this is the first time that a systematic study of violence in health care settings has been conducted in Greece. The aim of this investigation was to evaluate the frequency, types, causes, and consequences of violence in the health care sector and to underscore the importance of implementing viable measures to make the workplace safer and thus more productive.
Methods Address correspondence to Eleftheria Fafliora, Department of General Practice, University General Hospital of Patras, Aidipsou 2, GR-26332, Patras, Greece. E-mail: [email protected]
Study Population The survey was conducted at the University General Hospital of Patras (UGHP), a tertiary hospital, over a period
Archives of Environmental & Occupational Health
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
of 1 month (20 March 2013 to 20 April 2013). Only health professionals who come in contact with patients or their friends and relatives were included in the study (eg, physicians, nurses, nurse assistants, administrative personnel, and laboratory technicians), which resulted in a target population of 1,405 professionals. Personnel who do not come in contact with patients or their friends and relatives (eg, cooks, electricians, and other technical staff) were excluded. Prior studies that used similar hospital fieldwork methodology had response rates of 80% and 88.3%.3,6 We ultimately administered 205 questionnaires and obtained 175 completed questionnaires for a response rate of 85.3%. Instrument To assess the level of workplace violence in the health sector, we developed a new questionnaire based on the one created by the International Labour Office, the International Council of Nurses, the World Health Organization, and Public Services International.24 Elements from other relevant studies were also included in the questionnaire.5,6,11 However, we adjusted the questions to better align with the conditions and social culture in Greek workplaces. Because the health care personnel in the studied hospital (and in Greece in general) almost exclusively comprise members of the indigenous population, no questions on racial harassment were included. Additionally, “aggressive voice tone” and “insults–characterizations” were included as separate types of verbal violence because we expected that they occurred most often. Because uninsured immigrants and Romani frequently visit the ED of UGHP and are often accused of violent incidents, we also incorporated a relevant question regarding these populations. All of the participants were asked to answer 60 questions. Four of the questions used a Likert response scale, but most of them required a single answer or potentially multiple answers (Supplemental Material). The initial questions addressed the demographic characteristics of the participants: age, sex, profession, and years of service. Additional questions aimed to clarify the prevalence and characteristics of violence: frequency, type, departments, possible perpetrators, causes, and consequences. At the end, the participants were asked to complete questions about their reaction to violence, whether they feel safe in their workplace, and the support they receive from their superiors. To assist the personnel in understanding the terms associated with psychological and physical violence, we translated the following definitions given by the World Health Organization and incorporated them into the questionnaire25: Physical violence: The use of physical force against another person or group that results in physical, sexual, or psychological harm, including beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching, among other actions. Psychological violence: The intentional use of power, including the threat of physical force, against another person or group that can result in harm to physical, mental, spiritual, moral, or social development, which includes verbal abuse, bulling/mobbing, harassment, and threats.
257 Procedure We first conducted a pilot pretest. Ten employees completed the questionnaire, and their comments were used to adapt the survey so that it was easier to follow; these employees were excluded from subsequent studies. The final questionnaire was then distributed by the research team. During the main part of the study and on typical working days, the researchers invited every eligible health care worker on site (ED, hospital wards, laboratories, and administrative offices) to participate and returned the next day to collect the completed questionnaires. Every health care worker participated only once. All of the participants were properly informed about the aims of this study and that the data would remain anonymous and confidential. The current study was approved by the Committee of Research, Ethics and Deontology and the Scientific Board of the UGHP. Data Analysis We first calculated the proportions of responses and the corresponding standard errors. We conducted multiple multifactorial analyses to determine the effects of age, sex, profession, years of work experience in general, and years of work experience at UGHP (5 main predictor variables) on all of the other questions, which were the dependent variables for the study. We used multinomial logistic regression for multifactorial analysis of each categorical dependent variable, except when there were less than 5 events per predictor variable, in which case the analysis was considered unreliable and was not conducted.26 For questions with multiple responses, dummy variables were created prior to performing a multinomial logistic regression for each dummy variable. Ordinal regression analysis was used to assess the effect of predictor variables on ordinal dependent variables (ie, variables with Likert-scale responses). The 5 predictor variables were inserted in 1 step for each type of regression analysis unless statistical limitations were present, as specified in Results. Missing data were minimal and therefore not included in the factorial analysis. All of the statistically significant effects of the predictor variables are included in Table 3. The statistical analysis was performed using SPSS version 17.0 (SPSS, Chicago, IL, USA).
Results Out of 205 employees, 175 employees completed the questionnaire (85.37% response rate). Demographically, 63.4% of the participants were younger than 40 years, and 52% were female. The sample consisted of physicians (57%), nurses (21.7%), and other health care staff (21.1%). The mean amounts of work experience in general and in the study hospital were 11.0 and 7.6 years, respectively (SD: 8.4, range: 0.02–30 and SD: 7.8, range: 0.02–24, respectively). Descriptive data are shown in Tables 1 and 2 and statistically significant multivariate analyses in Table 3. We evaluated the frequency and characteristics of workplace violence among the health care staff (Table 1). A striking number of individuals claimed to have suffered workplace violence
258
Mantzouranis et al.
Table 1. Frequency and Characteristics of Workplace Violence Among Health Care Professionals and Suggested Possible Causes of Violence (N = 175) Yes Workplace violence
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
Frequency of workplace violence Has a colleague experienced violence?a Have you been subjected to violence?
n
%
Yes SE
Workplace violence Suggested possible causes of violence Long waiting time
153
87.4
2.4
146
83.4
2.6
126
86.3
2.4
144
98.6
0.8
Was the violence physical?
33
22.6
2.9
Have you experienced sexual harassment?b
27
18.4
2.7
If yes: (n = 146) Have you been subjected to violence in the last year? Was the violence verbal?
n
%
SE
155
88.6
2.2
124
70.9
3.2
115 94
65.7 53.7
3.4 3.5
87
49.7
3.5
69
39.4
3.4
55
31.4
3.3
40
22.9
3.0
Inappropriate rooms (eg, inadequate cleaning, small number of rooms) Cultural or linguistic differences that lead to communication problems Inappropriate staff behavior Patient/patient’s relative or friend has a psychiatric disorder Scene of violent incidents (n = 146)
39
22.3
2.9
37
21.1
2.9
28 28
16.0 16.0
2.6 2.6
Increased stress of patients/patients’ relatives and friends Lack of sufficient personnel Patients/patients’ relatives and friends believe that priority is not being kept Alcohol or substance abuse by the patients/patients’ relatives and friends Patients/patients’ relatives and friends do not comply with the staff’s guidance Insufficient information given to patients/patients’ relatives and friends Insufficient staff training in violence management
Types of verbal violence among respective victims (n = 144) Aggressive tone of voice
92
63.9
3.3
Insults–characterizations
72
50.0
3.5
Threats Other
48 3
33.3 2.1
3.3 1.0
15 11 4
54.5 33.3 12.1
2.1 2.0 1.4
Emergency department Wards Outpatient department
88 34 31
60.3 23.3 21.2
3.4 2.9 2.9
5
15.2
1.5
Other
16
11.0
2.1
2
6.1
1.0
Types of physical violence among respective victims (n = 33) Beating Pushing Use of knife/gun/other object Destruction of personal belongings Other
Note. % and SE are the percentage of respondents and standard error of proportion. aThree missing responses. bOne missing response.
(n = 146, 83.4 ± 2.6%) or to know a colleague who had (n = 153, 87.4 ± 2.4%). Moreover, all of the nurses knew a colleague who had experienced workplace violence, which was significantly different from the results observed in other professional groups (p = .010 for Pearson’s chi-square test among the 3 professional groups; multifactorial analysis for this pre-
dictor not applicable, and there was no influence of other predictor variables). The nature of the violence against the victims was predominantly verbal (98.6 ± 0.8%), but physical violence was not negligible (22.6 ± 2.9%). Interestingly, of the different types of verbal violence, threats were reported less often by nurses or other staff than by physicians and also
259
32.9
Note. % and SE are the percentage of respondents and standard error of proportion. aOne missing response. bTwo missing responses. cThree missing responses. dNine missing responses. eForty-two missing responses.
48
15.1
16
Loss of professional confidencea
Did you suffer a physical consequence after the incident?c
26.4
28
Diminished will to take care of patients
52.8 38.7
68.9
56 41
73
12.3
13.2
76.4 75.5 43.4 28.3 22.6
79.2
72.6
%
Wish for workplace changeb Poor work performance
Loss of job satisfaction
13
Guilt
Work performance
14
Loss of self-esteema
84 81 80 46 30 24
Disappointment
106
Stress Angera Diminished life qualityb Feara Depressive symptoms
Emotions
If yes, what? (n = 106)
Did the incident have a psychological impact on you?a
Consequences of workplace violence
n
Yes
3.3
2.4
3.0
3.4 3.3
3.1
2.2
2.2
2.9 2.9 3.3 3.0 2.8
2.7
3.4
SE
%
SE
How often do you feel safe in your workplace? (n = 175)a
Was the support from the hospital administration satisfactory? (n = 68)a Do you think that the care for your safety is satisfactory? (n = 146, question addressed only to victims)a Do you feel safe in your workplace? (n = 175)
Do you consider your workplace hostile? (n = 175)e How did you react to the violent incident? (n = 146) Responded verbally Ignored it Called the security staff Other Did you take time off from work after the incident? (n = 146)a Did you report the incident to the hospital authorities? (n = 146)b Did the hospital administration respond? (n = 68)c
Is workplace safety sufficient? (n = 175)d
1.3
38.3
8.9
% 4.4
3.4
2.2
SE 1.3
n 78
% 44.6
SE 3.5
Always/Often
67
13
n 3
4.4
3
3.5
3.4 3.0 3.4 1.7 2.0
3.4
2.7
Very/Quite
46.6
41.4 25.5 37.9 6.9 9.6
37.7
18.3
68
60 37 55 10 14
66
32
34.3
39
% 7.4
3.4
3.8
SE 1.6
n 60
% 34.3
SE 3.4
Sometimes
60
57
n 5
Moderately
Perception of safety and administration’s support in the workplace
n
Yes
26.9
51.4
% 86.7
3.1
3.5
SE 2.1
n 36
% 20.5
SE 2.9
Rarely/Never
47
75
n 59
Slightly/Not at all
Table 2. Consequences, Personal Reactions, and Evaluation of Administration’s Support After a Violent Incident and Perception of Safety in the Workplace (N = 175)
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260 1.12 0.33 1.60 0.74 1.52
0.18∗ 0.06–0.55 2.43∗ 1.03–5.69 2.49∗ 1.02–6.12 2.81∗ 1.18–6.64 0.32∗ 0.10–0.97
1.02
1.07
0.91–1.17 0.84–1.05 0.89–1.15 0.87–1.11 0.84–1.09
0.84–1.05
0.84–1.02
0.98–1.21 0.90–1.13 0.89–1.11
1.03 0.94 1.01 0.98 0.96
0.94
0.93
1.09 1.01 1.00 0.85∗ 0.74–0.97
1.08
1.01
1.02
0.95
1.10
0.97
1.02
0.94
1.01
0.77
OR
0.23–1.13
95% CI
0.51
OR
95% CI
0.94–1.20
0.92–1.13
0.96–1.21
0.91–1.11
0.93–1.11
0.85–1.07
0.97–1.24
0.87–1.08
0.91–1.14
0.84–1.04
0.90–1.15
0.73
0.22–2.45
1.0
1.99
3.82∗ 1.23–11.8
0.18
0.02–1.17
4.11
0.70
0.20–3.20
0.33∗ 0.14–0.75
0.81
0.38
95% CI
—
0.96–17.6
0.21–2.28
0.09–1.54
95% CI
0.09–1.60
1.0
—
2.43
1.85
1.55
0.43
1.0
1.0
1.0
1.0
—
—
—
...
0.60–4.59
—
—
—
—
(Continued on next page)
0.65–9.13
0.59–5.74
0.34–6.97
0.13–1.42
1.67
4.61∗ 1.74–12.1
1.0
1.0
0.43–6.77
0.70–7.41
2.29
1.71
1.0
1.0
0.22∗ 0.07–0.66 0.16∗ 0.04–0.51
0.39
0.71–20.7 9.80∗ 1.84–52.0
0.65–6.12
OR
Other professional
0.18∗ 0.05–0.66 0.24∗ 0.06–0.95
OR
0.72–25.1 17.6∗ 3.23–96.0
—
0.26–4.15
—
95% CI
0.30–1.39 4.71∗ 1.14–19.3 0.13∗ 0.03–0.44
0.77–2.91
0.31–1.21 0.05∗ 0.01–0.28
0.22∗ 0.09–0.53 6.97∗ 1.37–35.4
0.65
1.50
0.61
3.84
4.28
1.0
1.05
1.0
OR
0.30–7.71 6.11∗ 1.49–24.9
0.16–3.43
0.32–7.95
0.07–1.43
0.21–5.99
0.16–3.70
Multinomial logistic regression modelsa
95% CI
1.17∗ 1.04–1.31 0.88∗ 0.79—0.98
OR
Nurse
Physician
Age
ISSN: 1933-8244 (Print) 2154-4700 (Online) Journal homepage: http://www.tandfonline.com/loi/vaeh20
Assessment and Analysis of Workplace Violence in a Greek Tertiary Hospital George Mantzouranis, Eleftheria Fafliora, Vasileios G. Bampalis & Ioanna Christopoulou To cite this article: George Mantzouranis, Eleftheria Fafliora, Vasileios G. Bampalis & Ioanna Christopoulou (2015) Assessment and Analysis of Workplace Violence in a Greek Tertiary Hospital, Archives of Environmental & Occupational Health, 70:5, 256-264, DOI: 10.1080/19338244.2013.879564 To link to this article: http://dx.doi.org/10.1080/19338244.2013.879564
View supplementary material
Accepted author version posted online: 23 Jan 2014.
Submit your article to this journal
Article views: 152
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vaeh20 Download by: [University of Nebraska, Lincoln]
Date: 02 November 2015, At: 23:32
Archives of Environmental & Occupational Health (2015) 70, 256–264 C Taylor & Francis Group, LLC Copyright ISSN: 1933-8244 print / 2154-4700 online DOI: 10.1080/19338244.2013.879564
Assessment and Analysis of Workplace Violence in a Greek Tertiary Hospital GEORGE MANTZOURANIS1, ELEFTHERIA FAFLIORA2, VASILEIOS G. BAMPALIS2, and IOANNA CHRISTOPOULOU2 1
Health Center Aitolikou, Department of General Medicine, University Hospital of Patras, Patras, Greece Department of General Practice, University General Hospital of Patras, Patras, Greece
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
2
Received 5 July 2013, Accepted 4 December 2013
This study sought to assess workplace violence in a Greek tertiary hospital for the first time. The authors conducted a descriptive study with 175 participants and examined the characteristics of violent episodes, the responses of victims and the administration, and the perception of workplace safety in addition to the implications of these incidents. The vast majority of employees (83.4%) had experienced work-related violence; however, half of them (52%) had not reported the incident to the hospital administration. Verbal violence was the most common type of incident (98.6%). Nurses and other health care staff reported feeling safer than physicians (odds ratio [OR] = 4.47, 95% confidence interval [CI]: 1.94–10.28 and OR = 2.80, 95% CI: 1.64–8.74, respectively). A large proportion of victims (72.6%) suffered psychological consequences following the violent incident. This study reveals the high prevalence of workplace violence in a Greek tertiary hospital and underscores its negative impact on health care workers. Keywords: Greece, health care sector, workplace violence
According to the results of the 4th European Working Conditions Survey in 2005, 1 in 20 European workers reported exposure to bullying and/or harassment in the preceding 12 months, and a similar proportion reported having been exposed to violence.1 Therefore, providing a safe working environment for all employees is one of the top priorities of the European Union. In particular, life scientists and health professionals experience the most exposure to violence.1 Many studies show high rates of violence in the health care sector, although the reported prevalence varies.2–21 In 2001–2002, the National Health Service (NHS) reported 95,501 cases of violence and aggression against its staff in the United Kingdom.22 Verbal violence is the most common form of workplace violence, with nurses increasingly targeted.2–12 Physical violence is also prevalent; weapons are frequently brought into emergency departments (EDs), and workdays have been lost because of injuries caused by physical attacks.3,5,6,11,13 Factors such as long wait times, dissatisfaction with treatment, and mental illness contribute to the occurrence of violence.2,5,6, 10,14,15 It is noteworthy that a high percentage of violent incidents against health care workers remains unreported for a variety of reasons.1,5,6 Many health care workers report that they do not feel safe in their own workplace.5–7,13,16 All of these fac-
tors have a negative impact on the well-being of the affected personnel.6,10–12,14,17,18 Training programs are highlighted as a means of teaching health care workers how to handle violent incidents.2,3,5–7,11,13,14 In Greece, almost 3% of workers have been subjected to workplace violence and/or threats of violence.1 Furthermore, Greece has a high prevalence of psychosocial work factors that are recognized as occupational risk factors for various health complications (eg, bullying, job strain, and increased psychological demands).23 Additionally, work-related violent incidents in Greece are only occasionally reported, and often there is no detailed follow-up examination. The complete lack of systematic records and research on the causes and consequences of violence in health care underlies our inability to design effective intervention measures. To the best of our knowledge, this is the first time that a systematic study of violence in health care settings has been conducted in Greece. The aim of this investigation was to evaluate the frequency, types, causes, and consequences of violence in the health care sector and to underscore the importance of implementing viable measures to make the workplace safer and thus more productive.
Methods Address correspondence to Eleftheria Fafliora, Department of General Practice, University General Hospital of Patras, Aidipsou 2, GR-26332, Patras, Greece. E-mail: [email protected]
Study Population The survey was conducted at the University General Hospital of Patras (UGHP), a tertiary hospital, over a period
Archives of Environmental & Occupational Health
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
of 1 month (20 March 2013 to 20 April 2013). Only health professionals who come in contact with patients or their friends and relatives were included in the study (eg, physicians, nurses, nurse assistants, administrative personnel, and laboratory technicians), which resulted in a target population of 1,405 professionals. Personnel who do not come in contact with patients or their friends and relatives (eg, cooks, electricians, and other technical staff) were excluded. Prior studies that used similar hospital fieldwork methodology had response rates of 80% and 88.3%.3,6 We ultimately administered 205 questionnaires and obtained 175 completed questionnaires for a response rate of 85.3%. Instrument To assess the level of workplace violence in the health sector, we developed a new questionnaire based on the one created by the International Labour Office, the International Council of Nurses, the World Health Organization, and Public Services International.24 Elements from other relevant studies were also included in the questionnaire.5,6,11 However, we adjusted the questions to better align with the conditions and social culture in Greek workplaces. Because the health care personnel in the studied hospital (and in Greece in general) almost exclusively comprise members of the indigenous population, no questions on racial harassment were included. Additionally, “aggressive voice tone” and “insults–characterizations” were included as separate types of verbal violence because we expected that they occurred most often. Because uninsured immigrants and Romani frequently visit the ED of UGHP and are often accused of violent incidents, we also incorporated a relevant question regarding these populations. All of the participants were asked to answer 60 questions. Four of the questions used a Likert response scale, but most of them required a single answer or potentially multiple answers (Supplemental Material). The initial questions addressed the demographic characteristics of the participants: age, sex, profession, and years of service. Additional questions aimed to clarify the prevalence and characteristics of violence: frequency, type, departments, possible perpetrators, causes, and consequences. At the end, the participants were asked to complete questions about their reaction to violence, whether they feel safe in their workplace, and the support they receive from their superiors. To assist the personnel in understanding the terms associated with psychological and physical violence, we translated the following definitions given by the World Health Organization and incorporated them into the questionnaire25: Physical violence: The use of physical force against another person or group that results in physical, sexual, or psychological harm, including beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching, among other actions. Psychological violence: The intentional use of power, including the threat of physical force, against another person or group that can result in harm to physical, mental, spiritual, moral, or social development, which includes verbal abuse, bulling/mobbing, harassment, and threats.
257 Procedure We first conducted a pilot pretest. Ten employees completed the questionnaire, and their comments were used to adapt the survey so that it was easier to follow; these employees were excluded from subsequent studies. The final questionnaire was then distributed by the research team. During the main part of the study and on typical working days, the researchers invited every eligible health care worker on site (ED, hospital wards, laboratories, and administrative offices) to participate and returned the next day to collect the completed questionnaires. Every health care worker participated only once. All of the participants were properly informed about the aims of this study and that the data would remain anonymous and confidential. The current study was approved by the Committee of Research, Ethics and Deontology and the Scientific Board of the UGHP. Data Analysis We first calculated the proportions of responses and the corresponding standard errors. We conducted multiple multifactorial analyses to determine the effects of age, sex, profession, years of work experience in general, and years of work experience at UGHP (5 main predictor variables) on all of the other questions, which were the dependent variables for the study. We used multinomial logistic regression for multifactorial analysis of each categorical dependent variable, except when there were less than 5 events per predictor variable, in which case the analysis was considered unreliable and was not conducted.26 For questions with multiple responses, dummy variables were created prior to performing a multinomial logistic regression for each dummy variable. Ordinal regression analysis was used to assess the effect of predictor variables on ordinal dependent variables (ie, variables with Likert-scale responses). The 5 predictor variables were inserted in 1 step for each type of regression analysis unless statistical limitations were present, as specified in Results. Missing data were minimal and therefore not included in the factorial analysis. All of the statistically significant effects of the predictor variables are included in Table 3. The statistical analysis was performed using SPSS version 17.0 (SPSS, Chicago, IL, USA).
Results Out of 205 employees, 175 employees completed the questionnaire (85.37% response rate). Demographically, 63.4% of the participants were younger than 40 years, and 52% were female. The sample consisted of physicians (57%), nurses (21.7%), and other health care staff (21.1%). The mean amounts of work experience in general and in the study hospital were 11.0 and 7.6 years, respectively (SD: 8.4, range: 0.02–30 and SD: 7.8, range: 0.02–24, respectively). Descriptive data are shown in Tables 1 and 2 and statistically significant multivariate analyses in Table 3. We evaluated the frequency and characteristics of workplace violence among the health care staff (Table 1). A striking number of individuals claimed to have suffered workplace violence
258
Mantzouranis et al.
Table 1. Frequency and Characteristics of Workplace Violence Among Health Care Professionals and Suggested Possible Causes of Violence (N = 175) Yes Workplace violence
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
Frequency of workplace violence Has a colleague experienced violence?a Have you been subjected to violence?
n
%
Yes SE
Workplace violence Suggested possible causes of violence Long waiting time
153
87.4
2.4
146
83.4
2.6
126
86.3
2.4
144
98.6
0.8
Was the violence physical?
33
22.6
2.9
Have you experienced sexual harassment?b
27
18.4
2.7
If yes: (n = 146) Have you been subjected to violence in the last year? Was the violence verbal?
n
%
SE
155
88.6
2.2
124
70.9
3.2
115 94
65.7 53.7
3.4 3.5
87
49.7
3.5
69
39.4
3.4
55
31.4
3.3
40
22.9
3.0
Inappropriate rooms (eg, inadequate cleaning, small number of rooms) Cultural or linguistic differences that lead to communication problems Inappropriate staff behavior Patient/patient’s relative or friend has a psychiatric disorder Scene of violent incidents (n = 146)
39
22.3
2.9
37
21.1
2.9
28 28
16.0 16.0
2.6 2.6
Increased stress of patients/patients’ relatives and friends Lack of sufficient personnel Patients/patients’ relatives and friends believe that priority is not being kept Alcohol or substance abuse by the patients/patients’ relatives and friends Patients/patients’ relatives and friends do not comply with the staff’s guidance Insufficient information given to patients/patients’ relatives and friends Insufficient staff training in violence management
Types of verbal violence among respective victims (n = 144) Aggressive tone of voice
92
63.9
3.3
Insults–characterizations
72
50.0
3.5
Threats Other
48 3
33.3 2.1
3.3 1.0
15 11 4
54.5 33.3 12.1
2.1 2.0 1.4
Emergency department Wards Outpatient department
88 34 31
60.3 23.3 21.2
3.4 2.9 2.9
5
15.2
1.5
Other
16
11.0
2.1
2
6.1
1.0
Types of physical violence among respective victims (n = 33) Beating Pushing Use of knife/gun/other object Destruction of personal belongings Other
Note. % and SE are the percentage of respondents and standard error of proportion. aThree missing responses. bOne missing response.
(n = 146, 83.4 ± 2.6%) or to know a colleague who had (n = 153, 87.4 ± 2.4%). Moreover, all of the nurses knew a colleague who had experienced workplace violence, which was significantly different from the results observed in other professional groups (p = .010 for Pearson’s chi-square test among the 3 professional groups; multifactorial analysis for this pre-
dictor not applicable, and there was no influence of other predictor variables). The nature of the violence against the victims was predominantly verbal (98.6 ± 0.8%), but physical violence was not negligible (22.6 ± 2.9%). Interestingly, of the different types of verbal violence, threats were reported less often by nurses or other staff than by physicians and also
259
32.9
Note. % and SE are the percentage of respondents and standard error of proportion. aOne missing response. bTwo missing responses. cThree missing responses. dNine missing responses. eForty-two missing responses.
48
15.1
16
Loss of professional confidencea
Did you suffer a physical consequence after the incident?c
26.4
28
Diminished will to take care of patients
52.8 38.7
68.9
56 41
73
12.3
13.2
76.4 75.5 43.4 28.3 22.6
79.2
72.6
%
Wish for workplace changeb Poor work performance
Loss of job satisfaction
13
Guilt
Work performance
14
Loss of self-esteema
84 81 80 46 30 24
Disappointment
106
Stress Angera Diminished life qualityb Feara Depressive symptoms
Emotions
If yes, what? (n = 106)
Did the incident have a psychological impact on you?a
Consequences of workplace violence
n
Yes
3.3
2.4
3.0
3.4 3.3
3.1
2.2
2.2
2.9 2.9 3.3 3.0 2.8
2.7
3.4
SE
%
SE
How often do you feel safe in your workplace? (n = 175)a
Was the support from the hospital administration satisfactory? (n = 68)a Do you think that the care for your safety is satisfactory? (n = 146, question addressed only to victims)a Do you feel safe in your workplace? (n = 175)
Do you consider your workplace hostile? (n = 175)e How did you react to the violent incident? (n = 146) Responded verbally Ignored it Called the security staff Other Did you take time off from work after the incident? (n = 146)a Did you report the incident to the hospital authorities? (n = 146)b Did the hospital administration respond? (n = 68)c
Is workplace safety sufficient? (n = 175)d
1.3
38.3
8.9
% 4.4
3.4
2.2
SE 1.3
n 78
% 44.6
SE 3.5
Always/Often
67
13
n 3
4.4
3
3.5
3.4 3.0 3.4 1.7 2.0
3.4
2.7
Very/Quite
46.6
41.4 25.5 37.9 6.9 9.6
37.7
18.3
68
60 37 55 10 14
66
32
34.3
39
% 7.4
3.4
3.8
SE 1.6
n 60
% 34.3
SE 3.4
Sometimes
60
57
n 5
Moderately
Perception of safety and administration’s support in the workplace
n
Yes
26.9
51.4
% 86.7
3.1
3.5
SE 2.1
n 36
% 20.5
SE 2.9
Rarely/Never
47
75
n 59
Slightly/Not at all
Table 2. Consequences, Personal Reactions, and Evaluation of Administration’s Support After a Violent Incident and Perception of Safety in the Workplace (N = 175)
Downloaded by [University of Nebraska, Lincoln] at 23:32 02 November 2015
260 1.12 0.33 1.60 0.74 1.52
0.18∗ 0.06–0.55 2.43∗ 1.03–5.69 2.49∗ 1.02–6.12 2.81∗ 1.18–6.64 0.32∗ 0.10–0.97
1.02
1.07
0.91–1.17 0.84–1.05 0.89–1.15 0.87–1.11 0.84–1.09
0.84–1.05
0.84–1.02
0.98–1.21 0.90–1.13 0.89–1.11
1.03 0.94 1.01 0.98 0.96
0.94
0.93
1.09 1.01 1.00 0.85∗ 0.74–0.97
1.08
1.01
1.02
0.95
1.10
0.97
1.02
0.94
1.01
0.77
OR
0.23–1.13
95% CI
0.51
OR
95% CI
0.94–1.20
0.92–1.13
0.96–1.21
0.91–1.11
0.93–1.11
0.85–1.07
0.97–1.24
0.87–1.08
0.91–1.14
0.84–1.04
0.90–1.15
0.73
0.22–2.45
1.0
1.99
3.82∗ 1.23–11.8
0.18
0.02–1.17
4.11
0.70
0.20–3.20
0.33∗ 0.14–0.75
0.81
0.38
95% CI
—
0.96–17.6
0.21–2.28
0.09–1.54
95% CI
0.09–1.60
1.0
—
2.43
1.85
1.55
0.43
1.0
1.0
1.0
1.0
—
—
—
...
0.60–4.59
—
—
—
—
(Continued on next page)
0.65–9.13
0.59–5.74
0.34–6.97
0.13–1.42
1.67
4.61∗ 1.74–12.1
1.0
1.0
0.43–6.77
0.70–7.41
2.29
1.71
1.0
1.0
0.22∗ 0.07–0.66 0.16∗ 0.04–0.51
0.39
0.71–20.7 9.80∗ 1.84–52.0
0.65–6.12
OR
Other professional
0.18∗ 0.05–0.66 0.24∗ 0.06–0.95
OR
0.72–25.1 17.6∗ 3.23–96.0
—
0.26–4.15
—
95% CI
0.30–1.39 4.71∗ 1.14–19.3 0.13∗ 0.03–0.44
0.77–2.91
0.31–1.21 0.05∗ 0.01–0.28
0.22∗ 0.09–0.53 6.97∗ 1.37–35.4
0.65
1.50
0.61
3.84
4.28
1.0
1.05
1.0
OR
0.30–7.71 6.11∗ 1.49–24.9
0.16–3.43
0.32–7.95
0.07–1.43
0.21–5.99
0.16–3.70
Multinomial logistic regression modelsa
95% CI
1.17∗ 1.04–1.31 0.88∗ 0.79—0.98
OR
Nurse
Physician
Age
