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The Incidence and Risk Factors of Workplace Violence towards Female Nurses Reported via Internet in an Acute Psychiatric Hospital Wen-Ching Chen MD, PhD Der Wang MD, ScD

a b

c

c

, Chuan-Ju Huang MSc , Chiao-Chicy Chen MD, PhD & Jung-

a d

a

Institute of Occupational Medicine and Industrial Hygiene, College of Public Health , National Taiwan University , Taiwan b

Department of Health, Yuli Hospital, Executive Yuan , Taiwan

c

Taipei City Hospital, Song De Branch , Taiwan

d

Department of Internal Medicine and Department of Environmental and Occupational Medicine , National Taiwan University Hospital , Taiwan Published online: 17 Jun 2011.

To cite this article: Wen-Ching Chen MD, PhD , Chuan-Ju Huang MSc , Chiao-Chicy Chen MD, PhD & Jung-Der Wang MD, ScD (2011) The Incidence and Risk Factors of Workplace Violence towards Female Nurses Reported via Internet in an Acute Psychiatric Hospital, Archives of Environmental & Occupational Health, 66:2, 100-106, DOI: 10.1080/19338244.2010.511310 To link to this article: http://dx.doi.org/10.1080/19338244.2010.511310

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The Incidence and Risk Factors of Workplace Violence towards Female Nurses Reported via Internet in an Acute Psychiatric Hospital Wen-Ching Chen, MD, PhD; Chuan-Ju Huang, MSc; Chiao-Chicy Chen, MD, PhD; Jung-Der Wang, MD, ScD

ABSTRACT. The authors conducted a prospective follow-up study to explore incidence and risk factors related to workplace violence towards nurses. Seventy-seven volunteers were recruited to complete a baseline questionnaire. Participants then used a designated Web site to report violent incidents they encountered during a 6-month period. A generalized estimating equation was used for data analysis. A total of 74 members completed the study; 456 events were reported. The incidence rates of various types of violence are reported in this paper. Risk factors for violence included short duration of employment, marital status, and a high level of anxiety. Strategies to reduce future violence from psychiatric patients include preplacement education that targets this high-risk group of nurses and efforts to reduce the staff anxiety levels. KEYWORDS: anxiety, female nurse, incidence, psychiatric hospital, workplace violence

W

orkplace violence, either physical or psychological, has become a worldwide problem that permeates every work setting and occupational group.1 In the health sector, the United States Occupational Safety and Health Administration (OSHA) has devoted efforts to create guidelines and recommendations to prevent workplace violence.1 In 2002, the National Institute of Occupational Safety and Health (NIOSH) identified workplace violence as an occupational hazard in hospitals.2–4 Medical personnel have a 16 times greater likelihood of being attacked by patients as compared to workers in other fields, and the probability for nurses is 4 times greater than that the risk to other medical personnel.5 One of the most frequent health care settings in which violence occurs is the

psychiatric ward.3,4 In psychiatric wards, nurses compose the most vulnerable group6–8 and may face serious health problems.9 The magnitude of workplace violence in psychiatric wards varies greatly in different settings. From an epidemiologic viewpoint, reported incidence numbers generally consider the denominator as risk based on the number of patients receiving care, exposure dose, or intensity as the denominator.10–12 In addition to physical and verbal violence (PV, VA), some studies have explored bullying and mobbing (BM),9,13 sexual harassment (SH),14–16 and racial harassment (RH).17 We found that relatively few studies in the psychiatric field mention these issues,18 and we therefore determined that the problem deserves special attention.

Wen-Ching Chen and Jung-Der Wang are with the Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taiwan. Wen-Ching Chen is also with the Department of Health, Yuli Hospital, Executive Yuan, Taiwan. Chuan-Ju Huang and Chiao-Chicy Chen are with the Taipei City Hospital, Song De Branch, Taipei, Taiwan. Jung-Der Wang is also with the Department of Internal Medicine and Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taiwan. 100

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Risk factors of workplace violence in psychiatry According to Haddon’s matrix,19,20 workplace violence is conceptualized like other public health problems to result from interactions among the host (female nurses), agent (psychiatric patients), and environment (setting, culture, social value norms, and atmosphere). For example, patients affected by psychotic symptoms21–23 and an unstable personality24,25 are usually restricted from leaving the unit, and the door of a psychiatric ward is often closed and locked. Such restrictions inside the hospital can often foster an atmosphere of anger that leads to violence.26 Regarding the host, worrying about the potential for violence from patients can be a source of occupational stress among nurses.27–29 A previous survey in a psychiatric hospital found that higher anxiety levels among staff were associated with a higher prevalence of violence.30 However, it remains unclear if these higher anxiety levels are a consequence or predictor of violence. In this study, we hypothesized that this stress was a source of violence in some work settings; therefore, we asked the nurses the same question about their anxiety level before we conducted this study—”To what extent do you fear workplace violence from patients?”—in order to secure the temporal sequence and determine if a higher anxiety level among nurses would be associated with a higher frequency of violence from patients. Internet site for reporting violence Many studies have reported disadvantages with using paper questionnaires; these disadvantages include missing data, extensive time requirements, and errors in collecting, coding, or entering data into a database.31,32 In contrast to a paper version, an Internet-based reporting system may better protect privacy,33 allow for more effective collection of unfavorable clinical events,34 and be more efficient for follow-up of patients.35 Feasibility and reliability of data have also been confirmed.36–38 Therefore, we used the questionnaire on a Web site to collect data. Purposes of this study We conducted a prospective, follow-up study, using an Internet reporting system to explore the incidence of various types of workplace violence (PV, VA, BM, SH, RH) towards female nurses in an acute psychiatric ward. Furthermore, we attempted to ascertain as to whether or not the anxiety level of female nurses can serve as a predictor of violence. METHODS Definition of workplace violence Workplace violence is defined as being attacked or injured at a job-related site. This definition includes incidents that occur when one is arriving or leaving work. Types of violence can be physical or psychological; the latter includes verbal abuse, bullying, mobbing, and sexual and racial ha2011, Vol. 66, No. 2

rassment. Bullying may entail malevolent, mean, or rude behavior enacted by virtue of physical strength or power. Mobbing usually refers to a group of people (usually the supervisor or colleagues) who treat the recipient unfairly. Examples include intentionally ignoring, excluding, or distancing the victim, as well as concealing important information or official letters from the victim. Bullying and mobbing are usually repetitive and can persist for a considerable length of time. Sexual harassment may include unsolicited verbal or physical behavior that is sexually motivated and considered to be offensive by the victim. Racial harassment refers to any threatening behavior related to race, skin, color, language, nationality, religion, minor races, birthplace, or identity. Such behavior is unwanted, is not mutually beneficial, and affects one’s self-esteem at work.39,40 Process of the study The study was approved by the institutional review board of the Song De Branch Hospital of Taipei City. The hospital employs a total of 99 female nursing staff members. Each of these individuals was invited to join the study; 77 joined and gave informed consent. The participation rate was 78%. We designed a reporting system using a Web site from the Health Bureau of Taipei. The Web site was tested for 1 month to ensure it worked properly; the confidentiality of participants was deemed to be secure. Each subject was provided an account number and password to access the Web site. Before the study, all of them were required to fill out a questionnaire for baseline information, including demographics, working history, and a question indicating their anxiety level: “To what extent do you fear workplace violence from patients?” Response options for this question were (1) none, (2) slight, (3) moderate, (4) quite a bit, and (5) very much. This question was part of a questionnaire developed by ILO/ICN/WHO/PSI39,40 that was translated into Chinese, validated for content validity, and test-retest reliability (.85) and then translated into English to verify accuracy of the original translation.30 The study period was October 1, 2005, through March 31, 2006. During this period, participating nurses were regularly reminded by the study coordinator once or twice weekly to report all violent events. Such reports were made via the Web site where 3 reporting forms were available: the event form, the victim form, and the perpetrator form. The event form contained 12 questions about the type of violence, its severity, and the date, time, and details about the situation. The victim form contained 17 questions about the psychological impact, how to call for help, how to prevent such an event, etc. The perpetrator form included 20 questions about who conducted the violence, (patient, coworker, or supervisor). If the perpetrator was a patient, further questions were asked about the patient’s diagnosis, the onset of his or her disease, his or her history of violence, etc. All forms were designed to be used with a simple-click pattern and usually required 3 minutes to complete. After completing a report, the 101

participant automatically received a letter via the Web site to console them and thank them for their cooperation. Also included was a small gift valued 2 to 3 US dollars. All data entered into the Web site were automatically converted into a database that allowed for direct statistical analysis. Not all details from the data are included in this paper.

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Statistical analysis Each violent incident that was recorded was then classified into 1 of the following 5 different categories: physical violence (PV), verbal abuse (VA), bullying or mobbing (BM), sexual harassment (SH), and racial harassment (RH). The incidence rate for each type of violence was calculated. Violent incidents tended to be rare, sometimes repeat encountered and allowed for a Poisson distribution. Therefore, we constructed analysis using generalized estimating equations (GEEs) to explore the following risk factors: age, duration of employment, marital status, religious beliefs, social drinking, and anxiety level. When the 95% confidence interval (CI) for the rate ratio did not include the value 1, the rate was considered to be significant. When the rate ratio was less than 1, the factor was considered to be protective. Conversely, if the value was greater than 1, the factor was considered to increase one’s risk for violence. We used SAS 9.1 software for data analysis. RESULTS Demographic characteristics of participants In the follow-up period, one cohort member terminated her employment during the first month, another terminated during the second month, and a third retired during the second month. Thus, a total of 74 members, all of whom were female, completed the study. About two thirds were college-educated and about one third was married but did not specify a religious preference or identify as a social drinker. The mean age was 33 years (SD = 7.5); more than half were older than 30. The mean duration of employment was 7.9 years (SD = 6.2); more than half had worked in the hospital more than 6 years. Over half of the participants were not concerned or were only slightly concerned about workplace violence (Table 1). Incidence of violence A total of 424 violent events were reported in this study. Of these events, PV, VA, BM, and SH accounted for 88, 289, 11, and 36, respectively. The incidence rates were 11.4 (total), 2.3, 7.8, 0.3, and 1.0 per staff-year, respectively. There was no racial harassment reported. Nurses’ perceptions of violence All violent events were perpetrated by hospitalized patients. About 46.7% of these patients were diagnosed with 102

Table 1.—-Frequency Distribution (%) of Demographics Among Cohort Members (N = 74) Demographics

%

Age ≤30 years >30 years Duration of employment Less than 6 years More than 6 years Marital status Married Single Religion reported Yes No Social drinking Yes No Concerned about violence Not at all or slightly Moderately Quite a bit and very much

45 55 45 55 34 66 65 35 32 68 56 30 14

schizophrenia, and 33.1% were diagnosed with bipolar disorder. Most perpetrators had a poor understanding of their disorder. In about 80% of incidents, the patient showed some antecedent sign of violence. Additionally, over 80% had a previous history of violence and psychotic symptoms. In the victims’ opinion, only about 20% of events were preventable. They also believed that more than 90% of these events occurred in the acute care ward. Table 2 shows the results from the GEE model for the 4 types of workplace violence. We found no statistically significant difference in gender and educational level of the nurse and thus did not include those variables in the model. Age and duration of employment were highly correlated (Pearson correlation coefficient:.86); therefore we only used duration of employment in the model. For PV, we found that a shorter duration of employment, married status, and an anxiety level that was moderate, quite a bit, or very high were significant risk factors. Risk factors for VA were shorter duration of employment and married status. Shorter employment duration was the only significant risk factor for BM. These findings are summarized in Table 2. We did not find any significant risk factor for sexual harassment. Table 3 summarizes the frequency of distribution of anxiety level and types of violent events stratified by a previous history of physical violence in cohort members at baseline. Cohort members with a previous history of PV did not appear to have an increased level of anxiety. When we limited the analysis to those without a previous experience of violence, workers with a higher level of anxiety at baseline had a significantly increased risk of physical violence and a rate ratio as great as 5.00 (1.07–23.46). Archives of Environmental & Occupational Health

Table 2.—-Crude Rate Ratios (CRRs), Adjusted Rate Ratios (ARRs), and 95% Confidence Intervals (CIs) of Physical Violence (PV), Verbal Abuse (VA), and Bullying or Mobbing (BM) Using Generalized Estimating Equation (GEE) Analysis Physical violence (PV) (n = 88)

Bullying or mobbing (BM) (n = 11)

Demographics

CRR

ARR

95%

CI

CRR

ARR

95%

CI

CRR

ARR

95%

CI

Younger (≤30 years)/Older (>30 years) Shorter/Longer employment duration∗ Marital status (Married/Single) Religious preference marked (Yes/No) Social drinking (Yes/No) Anxiety: Moderate/Slightly or None Anxiety: Quite a bit or Very/Slightly or None

1.63 1.56 1.96 1.44 1.28 1.44 1.35

— 3.08 3.99 1.35 1.22 2.75 3.00

— 1.47 1.97 0.57 0.57 1.14 1.21

— 6.44 8.06 3.16 2.58 6.61 7.44

1.42 1.42 1.43 1.76 1.19 0.21 1.72

— 2.07 2.05 1.90 1.26 1.29 2.16

— 1.13 1.13 0.95 0.59 0.55 0.97

— 3.80 3.73 3.81 2.72 3.06 4.82

5.59 5.59 2.30 1.05 1.28 2.30 1.13

— 5.46 1.21 1.15 1.54 3.66 2.48

— 1.63 0.28 0.16 0.22 0.49 0.45

— 18.33 5.24 8.47 10.73 27.45 13.64

∗ Shorter:

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Verbal abuse (VA) (n = 289)

less than 6 years; longer: more than 6 years of employment duration.

COMMENT This study not only supports the use of an Internet format to report incidents of workplace violence but also provides empirical evidence that a high level of anxiety in a worker in psychiatric health care may be particularly vulnerable to physical violence. In other words, anxiety may signal to a psychiatric patient a sense of vulnerability that makes an assault more likely. Thus, in addition to other countermeasures, we propose that reducing the anxiety level of workers is a viable, proactive measure to reduce workplace violence. Such a strategy could be implemented during preplacement ori-

Table 3.—-Frequency Distributions of Various Violent Events and Anxiety Levels Stratified by Previous History of Violence in Cohort Members at Baseline Previous violent experience

Baseline anxiety level Not at all Slightly Moderate Quite a bit Very Type of workplace violence Physical violence Verbal abuse Bullying or mobbing Sexual harassment ∗ Using

Yes (n = 60)

No (n = 17)∗

1 32 21 6 0

0 11 2 3 1

70 253 10 34

24 59 1 5

generalized estimating equation (GEE) analysis and considering the group with an anxiety level of “slightly or not at all” to be the referral group, the rate ratio and confidence interval (95% CI) of the group with an anxiety level of “more than moderate” was 5.00 (1.07–23.46).

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entation and training for professionals preparing to provide psychiatric services. Using Haddon’s matrix20,41 as an injury prevention framework, we summarized our results into possible ways to prevent violence at psychiatric ward, as given in Table 4. First, at the host level, we found that a high or extreme level of anxiety appears to be a consistent predictor of various types of violent events after controlling for other variables, including duration of employment and marital status, as shown in Table 2. Our results indicate that there is still a significant tendency for physical violence even when analysis was limited to those who did not have a previous experience with violence (Table 3). In some cases, anxiety might serve to irritate patients and precipitate violent action; this theory has been corroborated by other investigators.42,43 A paper also suggested that psychiatric patients might perceive certain uneasy behaviors by nurses as “provocations” and then carry out an act of violence.44 Thus, we conclude that a high anxiety level among staff may be associated with physical violence from psychiatric patients. We propose that pre-employment orientation for new psychiatric nurses should include methods to reduce anxiety for pre-event control. The variables of age and duration of employment correlated with each other in this study; therefore we constructed a model that only included duration of employment. We found that a shorter duration of employment significantly increased the risk of PV, VA, and BM; these findings are corroborated by those of other studies.30,45,46 From our observations, senior staff members were usually more skillful in dealing with complicated situations with patients, whereas younger staff were less skilled and may have been more vulnerable to PV, VA, or BM. Another possible explanation may be that senior staff members were accustomed to odd behaviors of psychiatric patients. These staff members may have been more tolerant of violent behavior, or they may consider certain acts to be less violent, part of the patients’ psychiatric symptoms, or “unintentional” actions, thereby not identifying such events with the World 103

Table 4.—-Proposed Preventive Actions for Workplace Violence According to the Framework of Haddon’s Matrix

Host (female nurses) Pre-event (before the violence)

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Event (during the violence)

Postevent (after the violence)

Agents (psychiatric patients)

Providing necessary training to Providing patients with Improving the security system reduce the anxiety necessary medication to of facilities, including (especially for nurses with control psychotic symptoms, entrance and exit control, shorter employment and multiple channels to lighting and monitors duration), improve make complaints or communication skills, and discontent recognize potential assaulters Improving skills of handling Applying strict security control Setting up alarm systems, violence incidents and of patient entry and exit of providing well-trained activating help and staff wards, avoiding attacks with security guards to evacuate protection system tools, lowering the severity the victims from the scene of harms Establishing a convenient and efficient reporting system for the affected nurses

Providing necessary interventions by medication or change of ward

Health Organization (WHO) definition of violent events.47 To prevent potential confounding, we deliberately encouraged all staff members to report any subjective feeling of injury, both physical and psychological, in any cases involving a violent event. Also, we explained that the patient’s condition should not be an obstacle or consideration for whether or not to report an event. Another potential confounding factor was that senior staff members tended to be less familiar with operating a computer and may have found it more difficult to use the Web site to report an incident. To address this issue proactively, we taught all participants and provided them technical assistance if they wanted to assure that they were able to access the Web site to report events throughout the study without obstacles.36 To our knowledge, this study is the first to use Internet collection of data to report workplace violence. We hope that our strategy of providing a letter of consolation and a small gift served to reduce any feeling of discomfort among the affected nurses who reported incidents and thus allowed for a more accurate reporting rate. In fact, establishing such a system in the psychiatric ward can demonstrate a strong hospital policy and facilitate the preand postevent control. Second, at the agent control level, most perpetrators (more than 80%) had a history of previous violence and psychotic symptoms. This finding is compatible with results from a previous study.21 Thus, it is important to provide necessary medicines to every patient for pre- and postevent control of violence in a psychiatric ward. Third, on social environment level, our results indicate that being married is a risk factor for physical violence and verbal abuse. We hypothesize that a married nurse who works usually must attend to housework and/or children at home and 104

Physical environment (psychiatric wards)

Providing professional legal consultation and counseling services

Social environment (hospital policies) Publicly announcing the policy of zero tolerance to violence, developing a safe culture and team work for prevention, and paying special attention to the nurses who need assistance Establishing the standard operational procedures (SOPs) for systematic handling of violence incidents and follow-up review Evaluating the violence incident systematically to improve the policy of prevention

patients in the hospital; this additional responsibility could cause them to become more exhausted and tense compared to single nurses and thus more likely to have conflicts with patients. Thus, providing nurses who need assistance more support such as ensuring adequate staffing levels28 and providing good counseling resources in the team may be a way for pre-event control. We found that most victims (more than 90%) stated that the type of violence they experienced was a typical event that occurs in psychiatric wards, and about 80% of victims declared that this violence was not preventable. We attribute this result to the traditional Chinese culture, in which events are seen as out of the control of the individual and the result of fate and therefore not amenable to individual action. It is our observation that this attitude carries over into contemporary life as demonstrated by incident reports, conversational language, and behavior.28 Many believe that it is hard to change their circumstances and have little motivation to find a way to resolve the problem. For example, one victim stated in a qualitative paper, “If today I was not beaten up at work, then I earned one day.”28 Therefore, we recommend that a safety culture should be established in every psychiatric hospital. Other than incidents of physical and verbal abuse, some events of bullying, mobbing, and sexual harassment were reported. All perpetrators were patients, and no colleagues or supervisors were reported to be involved in spite of our reassurance to study participants that reports on the Web site would not be made public. Because the reporters were not anonymous, we suspect that the Internet reporting system may not have provided sufficient protection of confidentiality for the victim to report sensitive problem such as violence committed by a supervisor. Further studies to investigate this problem are needed.

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Limitations Participants in this study were self-referred and were paid 2 to 3 US dollars for completing online reports; these factors may have elevated the number of reported incidents. However, we found that most psychiatric staff members did not think that violence in psychiatry wards was a severe or important enough problem to report.48 Thus, the strategy we used was a reasonable approach to determine the level of violence on the psychiatric ward. Furthermore, although the Web site was convenient and easy to use, it presented some disadvantages. As mentioned previously, some participants were not comfortable using the Web site, and this problem may have reduced their motivation to report violent events. Similar to a concept from Haddon’s matrix,19,20,41 another limitation of this study was that we did not completely explore other risk factors, namely aggressors’ profiles, interpersonal factors that stem from interaction between nurses and perpetrators, and institutional and cultural elements. This study only focused on nurses’ characteristics, an approach that might be regarded as “blaming the victim,” and lead to a stereotyped impression that all psychiatric workers are at high risk of workplace violence. Additionally, the findings from this study were limited to one hospital. Thus, one should be cautious with generalizing conclusions from this study to other psychiatric hospital settings. ********** This paper was presented to the Section of Psychological Factors of EPICHO-MEDICHEM conference in Taipei, Taiwan, April 21 to 25, 2010. We are grateful for the funding support we received from the National Health Research Institutes under grant number NSC 96–2628-B-002–071-MY3. For comments and further information, address correspondence to JungDer Wang MD, ScD, Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, No. 17, Hsu-Chow R., Taipei, 10000 Taiwan. E-mail: [email protected]

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Archives of Environmental & Occupational Health

The incidence and risk factors of workplace violence towards female nurses reported via internet in an acute psychiatric hospital.

The authors conducted a prospective follow-up study to explore incidence and risk factors related to workplace violence towards nurses. Seventy-seven ...
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