Injuries due to assaults on psychiatric hospital employees in Washington State

National Development and Implementation of a Democratized Disruptive Behavior Reporting System in Health Care

INTRODUCTION

Workplace disruptive behavior/ violence (WDBV) is underreported in health care. This study evaluated a 7-year implementation of the Disruptive Behavior Reporting System (DBRS), the most robust consolidated WDBV reporting system developed in the United States within the Veterans Health Administration (VHA).

METHODS

After implementation of the system, implementation success was measured in real time by number of reports, types of staff entering reports, time to review the reports and time between when the incident occurred and report entry.

RESULTS

Over the seven years since implementation, there has been a significant increase in reporting within DBRS with more than 50,000 reports in fiscal year (FY) 2021 up from 0 to 2014. Types of staff reporting increased to 67 from 54. The median number of days to review events in FY19 Q2 was 4.79 days and the report latency has almost completely disappeared.

DISCUSSION

DBRS was designed to democratize reporting so staff can report WDBV anytime and anywhere playing a large role in the successful implementation. The increase in total number of reported events is an indication of the success of the system as it captures data historically lost due to underreporting.

CONCLUSION

DBRS development and implementation showcases how information systems can empower front-line personnel to voice behavioral safety concerns.

Differences in Hospitals' Workplace Violence Incident Reporting Practices: A Mixed Methods Study

Workplace violence (WV) is a significant and growing problem for health care workers. Increased recognition of the need for improved protections has led to policy initiatives at the state and federal levels, including national Joint Commission requirements that went into effect January 2022. California's WV prevention legislation was phased in during 2017-2018 and requires hospitals to use a new incident reporting system, the Workplace Violent Incident Reporting System (WVIRS) for Hospitals. We analyzed WVIRS data collected during the first three years of its implementation, July 1, 2017 - June 30, 2020. In addition, we collected qualitative data from six California hospitals/hospital systems during 2019-2020 to better understand reporting practices. Over the three-year period, the 413 hospitals using the WVIRS reported between zero and six incidents per staffed bed. Sixteen hospitals (3.9%) reported two or more incidents per staffed bed while the rest reported fewer than two incidents. Qualitative analysis identified that reporting procedures vary considerably among hospitals. Several organizations rely on workers to complete incident reports electronically while others assign managers or security personnel to data collection. Some hospitals appear to report only those incidents involving physical harm to the worker. Regulatory guidance for reporting practices and hospitals' commitment to thorough data collection may improve consistency. As hospitals throughout the U.S. consider practice changes to comply with new WV standards, those engaged in implementation efforts should look closely at reporting practices. Greater consistency in reporting across facilities can help to build evidence for best practices and lead to safety improvements.

The Effect of Abuse and Mistreatment on Healthcare Providers (TEAM): A Survey Assessing the Prevalence of Aggression From Patients and Their Families and Its Impact

OBJECTIVE

Aggression from patients and families on health care providers (HCP) is common yet understudied. We measured its prevalence and impact on HCPs in inpatient and outpatient settings.

METHODS

Four thousand six hundred seven HCPs employed by a community teaching hospital received an anonymous survey with results analyzed.

RESULTS

Of 1609 HCPs (35%) completing the survey, 88% of inpatient staff reported experiencing different types of aggression compared to 82% in outpatient setting. Almost half did not report it to their supervisor. Younger staff were more likely to report abuse. Negative impacts on productivity and patient care were reported. A third of all responders' indicated negative effects on mental health.

CONCLUSIONS

Despite negative impacts on staff wellbeing and productivity, patient/family aggression toward HCPs is highly prevalent and underreported. Our healthcare system needs measures to address staff security and wellness.

Frequency of violence towards healthcare workers in the United States' inpatient psychiatric hospitals: A systematic review of literature

The purpose of this systematic review is to determine the frequency of violent or aggressive behaviour towards healthcare workers in inpatient psychiatric settings in the United States. To achieve this aim, five databases were searched to find English-language quantitative studies reporting prevalence or incidence data of violence or aggression directed towards staff members in inpatient psychiatric settings. No limitations were set based on publication date, and intervention studies were included only if baseline data were provided. Of 335 total studies found, 38 full-text articles were suitable for full-text analysis based on inclusion and exclusion criteria, and 14 were included in the final review. Years of data collection ranged from 1986 to 2018, and a range of psychiatric facilities were represented, from small, private hospital units to large forensic institutions. Researchers utilized surveys, real-time incident reporting tools, and government databases, or a combination of strategies, to collect data related to workers' experiences on the job. Included research indicates that workplace violence in the U.S. inpatient psychiatric setting is a widespread problem, with 25-85% of survey respondents reporting an incident of physical aggression within the year prior to survey, and statewide workers' compensation findings indicating 2-7 claims due to assault per 100 000 employee hours. There are substantial differences between findings based on measurement strategy, making it difficult to arrive at a single estimate of prevalence nationally. As management of this persistent problem receives continued attention from stakeholders, it becomes increasingly important to define and measure the problem with the most appropriate tools.

Workplace violence against security personnel at a university hospital in Egypt: a cross-sectional study

Background: Violence is common among security personnel. To the best of the authors' knowledge no recent studies have investigated this problem. This study aimed to estimate the prevalence and associated factors of violence against hospital security personnel and describe circumstances of violence, type of perpetrators, and victims' response. Methods: In total, 170 security personnel from a university hospital in Egypt were recruited in this cross-sectional study. Data were collected using the Arabic version of a questionnaire developed by the International Labour Office. Results: The majority (87.3%) of security personnel reported violence exposure in the past year. Being a woman and working more than 5 years were independent predictors of violence exposure. The commonest forms of physical violence were pushing and beating. Verbal abuse and threats were the commonest emotional violence. Patients and their relatives/friends were the commonest perpetrators of violence. Conclusions: Violence is common among hospital security personnel in this setting. Adequate training and recruitment of more security personnel may contribute to decreasing violence.

Injuries and Assaults in a Long-Term Psychiatric Care Facility: An Epidemiologic Study

The objectives of this study were to document the high rates of acute injuries and physical assaults among nurses and certified nursing assistants working in long-term psychiatric care facilities and to identify risk factors for assaults and injuries to inform prevention strategies. A mixed-design cohort study was conducted. Acute injury and physical assault data were obtained from administrative records. Using staff rosters and schedule records, incidence rates were calculated by job title, gender, shift, and floor. Rates were also reported by severity, body part, type, and nature. Targeted interviews with staff members provided measures of physical lifting and resident combativeness. Injury rates were calculated by degree of lifting and assault rates were calculated by degree of resident combativeness. Overall rates of injuries (55.6 per 100 person-years) and assaults (67.3 per 100 person-years) were substantially higher than expected. Predictably, injuries were associated with resident lifting and assaults were associated with contact with combative residents. A higher risk of assault was found among women and higher risks of injury and assault were observed among full-time employees compared to per diem or pool agency workers. In addition, weekend shifts were found to have a higher rate of injuries and a lower rate of assaults than weekday shifts. In similar longterm care facilities with psychiatric populations, efforts should be made to reduce lifting and avoid circumstances that agitate residents. Work organization factors should be taken into consideration when developing interventions.

Reporting Violence to a Health Care Employer: A Cross-Sectional Study

The purpose of this cross-sectional study was to identify individual and employment characteristics associated with reporting workplace violence to an employer and to assess the relationship between reporting and characteristics of the violent event. Current and former employees of a Midwest health care organization responded to a specially designed mailed questionnaire. The researchers also used secondary data from the employer. Of those who experienced physical and non-physical violence at work, 57% and 40%, respectively, reported the events to their employer. Most reports were oral (86%). Women experienced more adverse symptoms, and reported violence more often than men did. Multivariate analyses by type of reporting (to supervisors or human resources personnel) were conducted for non-physical violence. Reporting work-related violence among health care workers was low and most reports were oral. Reporting varied by gender of the victim, the perpetrator, and the level of violence experienced.

The psychometric properties of the Life History of Aggression evaluated in patients from a psychiatric emergency setting

Aggression is a major concern in psychiatric units even more so in emergency settings and is prevalent across many mental disorders. Since a prior history of aggression remains a crucial predictor of violence in hospitalized patients, appropriate tools assessing the history of violence are essential to implement management plans. The Life History of Aggression (LHA) is a widely-utilized instrument. Yet, its psychometric properties have not been thoroughly evaluated and it has neither been validated in a variety of psychiatric illnesses nor in psychiatric emergency settings. To fill this gap, the properties of a French version of the LHA administered to 1097 psychiatric patients in this setting were examined. The internal consistency, construct validity, test-retest reliability and convergent validity were analysed. Regarding the internal consistency, the Cronbach's alpha varied between 0.83 and 0.89. The confirmatory factor analysis showed that it had one underlying factor, though gender invariance was not observed. Amid 148 patients reassessed within 30 days, the test-retest reliability produced a strong correlation coefficient above 0.80. Lastly, as for convergent validity, the scale was significantly correlated with a validated drug misuse scale. Hence, the LHA retains very good psychometric properties even when evaluated in a psychiatric emergency setting, justifying its clinical pertinence.

Worksite Walkthrough Intervention: Data-driven Prevention of Workplace Violence on Hospital Units

OBJECTIVE

The aim of this study was to describe the implementation of a data-driven, unit-based walkthrough intervention shown to be effective in reducing the risk of workplace violence in hospitals.

METHODS

A structured worksite walkthrough was conducted on 21 hospital units. Unit-level workplace violence data were reviewed and a checklist of possible prevention strategies and an Action Plan form guided development of unit-specific intervention. Unit supervisor perceptions of the walkthrough and implemented prevention strategies were reported via questionnaires. Prevention strategies were categorized as environmental, behavioral, or administrative.

RESULTS

A majority of units implemented strategies within 12 months' postintervention. Participants found the walkthrough useful, practical, and worthy of continued use.

CONCLUSIONS

Structured worksite walkthroughs provide a feasible method for workplace violence reduction in hospitals. Core elements are standardized yet flexible, promoting fidelity and transferability of this intervention.

Characteristics of Patients Involved in Physical Assault in an Acute Inpatient Psychiatric Setting

BACKGROUND

Although aggressive behavior in psychiatric settings is a major concern, very few studies have focused exclusively on physical assault in a general inpatient psychiatric population.

OBJECTIVES

This study had 3 main goals: (1) to evaluate the prevalence of assaultive behavior in an acute psychiatric hospital; (2) to identify the clinical and socio-demographic factors associated with assaultive behavior during hospitalization; and (3) to explore whether a diagnosis of schizophrenia spectrum disorder increases the risk of assaultive behavior.

METHODS

We conducted a retrospective chart review of patients admitted to acute units in a psychiatric hospital between 2009 and 2012. A subset of occurrence reports identified by a multidisciplinary team as "physical assault" was included in the analysis. Using logistic multivariate regression analysis, these patients were compared with a randomly selected nonassaultive control group, matched for length of stay to identify factors associated with assaultive behavior.

RESULTS

Of 757 occurrence reports, 613 met criteria for significant assault committed by 356 patients over 309,552 patient days. The assault incident density was 1.98 per 1000 patient days. In the logistic regression model of best fit, the factors significantly associated with assaultive behavior were age, legal status, and substance use. A diagnosis of schizophrenia spectrum disorder was not significantly associated with assaultive behavior.

CONCLUSIONS

Clinicians should take extra precautions for involuntarily admitted young patients with a history of substance use, as they are more likely to exhibit assaultive behavior. A diagnosis of schizophrenia spectrum disorder in itself is not significantly associated with assaultive behavior. Screening instruments such as the Dynamic Appraisal of Situational Aggression may be useful in assessing risk of assault.

Hospital workers bypass traditional occupational injury reporting systems when reporting patient and visitor perpetrated (type II) violence

BACKGROUND

Under-reporting of type II (patient/visitor-on-worker) violence by workers has been attributed to a lack of essential event details needed to inform prevention strategies.

METHODS

Mixed methods including surveys and focus groups were used to examine patterns of reporting type II violent events among ∼11,000 workers at six U.S. hospitals.

RESULTS

Of the 2,098 workers who experienced a type II violent event, 75% indicated they reported. Reporting patterns were disparate including reports to managers, co-workers, security, and patients' medical records-with only 9% reporting into occupational injury/safety reporting systems. Workers were unclear about when and where to report, and relied on their own "threshold" of when to report based on event circumstances.

CONCLUSIONS

Our findings contradict prior findings that workers significantly under-report violent events. Coordinated surveillance efforts across departments are needed to capture workers' reports, including the use of a designated violence reporting system that is supported by reporting policies. Am. J. Ind. Med. 59:853-865, 2016. © 2016 Wiley Periodicals, Inc.

Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents

This study examined differences between self-report and actual documentation of workplace violence (WPV) incidents in a cohort of health care workers. The study was conducted in an American hospital system with a central electronic database for reporting WPV events. In 2013, employees (n = 2010) were surveyed by mail about their experience of WPV in the previous year. Survey responses were compared with actual events entered into the electronic system. Of questionnaire respondents who self-reported a violent event in the past year, 88% had not documented an incident in the electronic system. However, more than 45% had reported violence informally, for example, to their supervisors. The researchers found that if employees were injured or lost time from work, they were more likely to formally report a violent event. Understanding the magnitude of underreporting and characteristics of health care workers who are less likely to report may assist hospitals in determining where to focus violence education and prevention efforts.

Resident aggression toward staff at a center for the developmentally disabled

Few studies have examined factors contributing to nonfatal assaults to staff working in residential care facilities. The authors evaluated resident assaults toward direct care/nursing staff at an intermediate Care Facility for Individuals with Mental Retardation (ICF/MR), which included observations of work areas, employee interviews, calculation of injury and assault rates for 2004 to 2007 from Occupational Safety and Health Administration Logs, and review of state ICP/MR guidelines. Most staff interviewed reported having been injured during physical restraint of a resident and the average rate of injury from assault at the center evaluated was higher than the average national rates for the health care and social assistance sector for the same time period. The center lacked policies and developing a post-incident response and evaluation program to assist staff in coping with the consequences of assault and/or occupational injury.

Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (Type II) on hospital workers: a review of the literature and existing occupational injury data

PROBLEM

Non-fatal type II violence experienced by hospital workers (patient/visitor-on-worker violence) is not well described.

METHODS

Hospital administration data (2004-2009) were examined for purposes of calculating rates of type II violent events experienced by workers. We also conducted a review of the hospital-based literature (2000-2010) and summarized findings associated with type II violence.

RESULTS

484 physical assaults were identified in the data, with a rate of 1.75 events/100 full-time equivalents. Only few details about events were captured, while non-physical events were not captured. The literature yielded 17 studies, with a range proportion of verbal abuse (22%-90%), physical threats (12%-64%) and assaults (2%-32%) reported. The literature lacked rigorous methods for examining incidence and circumstances surrounding events or rates of events over time.

DISCUSSION

For purposes of examining the impact of type II violence on worker safety, satisfaction and retention, rigorous surveillance efforts by hospital employers and researchers are warranted.

Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study

BACKGROUND

Patient overcrowding and violent assaults by patients are two major problems in psychiatric healthcare. However, evidence of an association between overcrowding and aggressive behaviour among patients is mixed and limited to small-scale studies.

AIMS

This study examined the association between ward overcrowding and violent physical assaults in acute-care psychiatric in-patient hospital wards.

METHOD

Longitudinal study using ward-level monthly records of bed occupancy and staff reports of the timing of violent acts during a 5-month period in 90 in-patient wards in 13 acute psychiatric hospitals in Finland. In total 1098 employees (physicians, ward head nurses, registered nurses, licensed practical nurses) participated in the study. The outcome measure was staff reports of the timing of physical assaults on both themselves and ward property.

RESULTS

We found that 46% of hospital staff were working in overcrowded wards, as indicated by >10 percentage units of excess bed occupancy, whereas only 30% of hospital personnel were working in a ward with no excess occupancy. An excess bed occupancy rate of >10 percentage units at the time of an event was associated with violent assaults towards employees (odds ratio (OR) = 1.72, 95% CI 1.05-2.80; OR = 3.04, 95% CI 1.51-6.13 in adult wards) after adjustment for confounding factors. No association was found with assaults on ward property (OR = 1.06, 95% CI 0.75-1.50).

CONCLUSIONS

These findings suggest that patient overcrowding is highly prevalent in psychiatric hospitals and, importantly, may increase the risk of violence directed at staff.

Assessing risk for violence on home health visits

The objective of this study was to develop and test measures for assessing risk of violence toward staff during home visits. Home visiting health workers from public and private home visiting programs in a Mid-Atlantic state (n = 130) were surveyed to assess exposure to risky home visits, verbal and physical violence, and workplace violence safety climate. Two measures demonstrated evidence of reliability and validity moving the safety research closer to developing tools and processes for protecting home care clinicians.

Occupational safety and health interventions to reduce musculoskeletal symptoms in the health care sector

INTRODUCTION

Health care work is dangerous and multiple interventions have been tested to reduce the occupational hazards.

METHODS

A systematic review of the literature used a best evidence synthesis approach to address the general question "Do occupational safety and health interventions in health care settings have an effect on musculoskeletal health status?" This was followed by an evaluation of the effectiveness of specific interventions.

RESULTS

The initial search identified 8,465 articles, for the period 1980-2006, which were reduced to 16 studies based on content and quality. A moderate level of evidence was observed for the general question. Moderate evidence was observed for: (1) exercise interventions and (2) multi-component patient handling interventions. An updated search for the period 2006-2009 added three studies and a moderate level of evidence now indicates: (1) patient handling training alone and (2) cognitive behavior training alone have no effect on musculoskeletal health. Few high quality studies were found that examined the effects of interventions in health care settings on musculoskeletal health.

CONCLUSIONS

The findings here echo previous systematic reviews supporting exercise as providing positive health benefits and training alone as not being effective. Given the moderate level of evidence, exercise interventions and multi-component patient handling interventions (MCPHI) were recommended as practices to consider. A multi-component intervention includes a policy that defines an organizational commitment to reducing injuries associated with patient handling, purchase of appropriate lift or transfer equipment to reduce biomechanical hazards and a broad-based ergonomics training program that includes safe patient handling and/or equipment usage. The review demonstrates MCPHI can be evaluated if the term multi-component is clearly defined and consistently applied.

Occupational risk due to violence in a psychiatric ward

OBJECTIVES

This study aimed to elucidate causes of aggression from clinical records of a psychiatric ward of a major urban public hospital where aggression towards Health Care Workers [HCWs] was the second leading cause of hospital work-related injuries after needlesticks.

METHODS

Psychiatric patients'clinical records for the period 2002-2005 were examined and coded. Data were analysed with the case-control approach to identify the determinants of the aggressive behavior towards HCWs, after adjustment for age, gender, nationality and diagnosis of the patients.

RESULTS

We examined 2.196 records and identified 321 individuals who had become violent at least once towards nurses, pshysicians or other patients or relatives during their hospitalization. The victims of the aggressive behavior were mainly nurses. A history of involuntary admission was strongly associated with aggression [OR 4.5, 95% CI 3.4-5.9]. Diagnosis, gender and nationality of the patients were not predictive of aggressive behavior towards HCWs.

CONCLUSIONS

Involuntary admission to a psychiatric ward might be a cause of violent behavior towards health care workers, mainly nurses.

Anger and assaultiveness of male forensic patients with developmental disabilities: links to volatile parents

This study with 107 male forensic patients with developmental disabilities investigated whether exposure to parental anger and aggression was related to anger and assaultiveness in a hospital, controlling for background variables. Patient anger and aggression were assessed by self-report, staff-ratings, and archival records. Exposure to parental anger/aggression, assessed by a clinical interview, was significantly related to patient self-reported anger, staff-rated anger and aggression, and physical assaults in hospital, controlling for age, intelligence quotient, length of hospital stay, violent offense history, and childhood physical abuse. Results are consonant with previous findings concerning detrimental effects of witnessing parental violence and with the theory on acquisition of cognitive scripts for aggression. Implications for clinical assessment and cognitive restructuring in anger treatment are discussed.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

Violence against emergency department workers

The purpose of this study was to describe the violence experienced by Emergency Department (ED) workers from patients and visitors during the 6 months before the survey. Two hundred forty-two employees at five hospitals who came in direct contact with patients or visitors completed a survey. The study found that most workers had been verbally harassed by patients or visitors at least once. There were at least 319 assaults by patients and 10 assaults by visitors. Sixty-five percent of subjects assaulted stated that they did not report the assault to hospital authorities. Sixty-four percent of subjects had not had any violence prevention training during the previous 12 months. There were significant relationships among violent experiences, feelings of safety, and job satisfaction. ED workers are at high risk for violence, and efforts are needed to decrease the incidence of violence. Such efforts are likely to have a positive impact on job satisfaction and retention of ED workers.

The Effect of a Training Course on Nursing Students' Attitudes Toward, Perceptions of, and Confidence in Managing Patient Aggression

Patient aggression is a problem in many health care settings, and nursing students are among the most vulnerable to experiencing such aggression. Training courses have been suggested to help nurses better manage patient aggression. Such courses can lead to changes in attitudes toward and perceptions of, as well as greater confidence in managing, aggression. In this quasi-experimental study, we investigated the effect of a training course on nursing students' attitudes toward, perceptions of, and confidence in managing patient aggression. Students in the intervention group demonstrated enhanced confidence but no change in attitude after the training course, while students in the control group remained stable on all measures. The short time frame of the study, the training course itself, and the instruments used for monitoring attitudes toward aggression are possible reasons for these results. We tentatively conclude that it is possible to enhance nursing students' perceived confidence in managing patient aggression without changing their fundamental views of it.

Non-somatic effects of patient aggression on nurses: a systematic review

AIM

This paper describes a systematic review of the predominant non-somatic effects of patient assault on nurses. Background. Patient aggression towards nurses is a longstanding problem in most nursing domains. Although reports on the consequences of physical aggression are more numerous, the non-physical effects create much suffering.

METHOD

A systematic review of literature from 1983 to May 2003 was conducted using the Medline, CINAHL, PsychINFO and PSYINDEX databases. Articles from international journals in English or German and reporting at least three non-somatic responses to patient aggression were included.

FINDINGS

The electronic search produced 6616 articles. After application of the inclusion and exclusion criteria, 25 texts from eight countries and four domains of nursing remained. Twenty-eight main effects were found, and these were categorized using a system suggested by Lanza and including bio-physiological, emotional, cognitive, and social dimensions. The predominant responses were anger, fear or anxiety, post-traumatic stress disorder symptoms, guilt, self-blame, and shame. These main effects occurred across most countries and nursing domains.

CONCLUSION

Despite differing countries, cultures, research designs and settings, nurses' responses to patient aggression are similar. Standardized questionnaires could help improve estimations of the real prevalence of non-somatic effects. Given the suffering caused by non-somatic effects, research should be aimed at preventing patient aggression and at developing better ways to prepare nurses to cope with this problem.

Impact of training on work-related assault

Although training is often recommended as a part of a comprehensive approach to address occupational violence, little empirical literature exists to support this recommendation. Over 40% of nurses responding to the Minnesota Nurses Study reported being trained about occupational violence, involving seven different training topics. Although at the univariate level, an increased risk was identified for nurses trained in managing assaultive/violent patients, no statistically significant results remained at the multivariate level. This lack of protection from training is consistent with previous research, although the explanations for this lack of effect remain unclear. Additional research is necessary to obtain more specific details on occupational violence training, including training content and methods, to understand more thoroughly the impact of training on occupational violence.

Predictors of aggression on the psychiatric inpatient service

Patients with severe mental illness are at increased risk to commit acts of aggression in the inpatient hospital setting. Aggressive behaviors have severe negative consequences for the patient, victims, clinical staff, and the therapeutic community as a whole. While risk factors of community and inpatient aggression overlap, many predictive factors diverge between the two settings. For example, while medication noncompliance has been a robust predictor of community aggression, this factor has little predictive value for inpatient settings where patients' pharmacotherapy is closely monitored. Relatively fewer investigators have examined a wide range of predictive factors associated with aggressive acts committed on the psychiatry inpatient service, often with conflicting results. The present study examined demographic, clinical, and neurocognitive performance predictors of self, other, object, and verbal aggressiveness in 118 acute inpatients. Results revealed that the arrival status at the hospital (voluntary vs involuntary), female gender, and substance abuse diagnosis were predictors of verbal aggression and aggression against others. Impaired memory functioning also predicted object aggression. Fewer symptoms, combined with higher cognition functioning, however, were significant predictors of self-aggressive acts committed on the inpatient service. The need for relating predictors of specific types of aggressiveness in schizophrenia is discussed.

An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study

AIMS

To identify the magnitude of and potential risk factors for violence within a major occupational population.

METHODS

Comprehensive surveys were sent to 6300 Minnesota licensed registered (RNs) and practical (LPNs) nurses to collect data on physical and non-physical violence for the prior 12 months. Re-weighting enabled adjustment for potential biases associated with non-response, accounting for unknown eligibility.

RESULTS

From the 78% responding, combined with non-response rate information, respective adjusted rates per 100 persons per year (95% CI) for physical and non-physical violence were 13.2 (12.2 to 14.3) and 38.8 (37.4 to 40.4); assault rates were increased, respectively, for LPNs versus RNs (16.4 and 12.0) and males versus females (19.4 and 12.9). Perpetrators of physical and non-physical events were patients/clients (97% and 67%, respectively). Consequences appeared greater for non-physical than physical violence. Multivariate modelling identified increased rates for both physical and non-physical violence for working: in a nursing home/long term care facility; in intensive care, psychiatric/behavioural or emergency departments; and with geriatric patients.

CONCLUSIONS

Results show that non-fatal physical assault and non-physical forms of violence, and relevant consequences, are frequent among both RNs and LPNs; such violence is mostly perpetrated by patients or clients; and certain environmental factors appear to affect the risk of violence. This serves as the basis for further analytical studies that can enable the development of appropriate prevention and control efforts.

Assessment of anger and aggression in male offenders with developmental disabilities

Systematic assessment of anger among people with developmental disabilities has been lacking, especially for hospital inpatients. Reliability and validity of anger self-report psychometric scales were investigated with 129 male patients, mostly forensic. Anger prevalence and its relationship to demographic, cognitive, and personality variables and to hospital assaultive behavior were examined. High internal and intermeasure consistency, and some concurrent validity with staff ratings, were found. Retrospective validity regarding physically assaultive behavior in the hospital was obtained. Hierarchical regressions revealed that patient-reported anger was a significant predictor of assaults postadmission, controlling for age, length of stay, IQ, violence offense history, and personality variables.

Risk factors for physical assault. State-managed workers' compensation experience

BACKGROUND

The estimation of incidence and evaluation of risk factors associated with nonfatal occupational assault injuries have rarely been documented in a statewide population context. A state-managed workers' compensation system can provide estimates of incidence of such injuries and allow evaluation of risk factors.

METHODS

Using claims data from the state-managed West Virginia Workers' Compensation, the incidence rates of workplace injuries resulting from physical assault were estimated for the period 1997-1999. Data on potential risk factors were obtained from the claim-related electronic data files, and the risk associated with each factor was assessed using proportional injury ratios (PIRs).

RESULTS

During the study period, 2122 compensated injuries were associated with workplace violence. The incidence of assault injuries was 108.2 cases per 100,000 employee years. Women sustained a higher incidence than men. Healthcare workers, public safety workers, and teachers accounted for almost 75% of all assault injuries. Workers in these occupations also differed from each other with regard to seasonality and timing of assault, perpetrator-victim relationship, and types of injury. Evidence of gender-occupation interaction indicated higher risk of assault injury in men compared to women across the three leading occupations. Nighttime work shifts were associated with greater risk of assault for female healthcare workers (PIR=1.8; 95% confidence interval, 1.09-2.87).

CONCLUSIONS

The healthcare sector sustained the bulk of assault injuries in West Virginia. Although the majority of healthcare-sector employees were women, the risk of assault injuries was higher in male employees. Risk factors and injury characteristics identified in this study, particularly for three high-risk occupations, should help develop strategies for preventing workplace violence. Protecting female healthcare workers on night-shift duty, especially in nursing home settings, appears to be an important target for intervention.

Assaults and nonpatient-induced injuries among psychiatric nursing staff in Bahrain

This retrospective study of incident reports at the psychiatric hospital in Bahrain was carried out to describe nursing staff injuries that were reported during 1992-1999. The average assault rate (4.4%) was much lower than that reported in Western countries. Of the 111 injuries, 44.0% occurred in wards assigned for patients with acute conditions, 27.5% in chronic condition wards, 5.5% in outpatients, and 22.9% in the community. Staff assaults by patients constituted 60.4% of all injuries, of which 64.2% occurred in the 1992-1995 period. The assault rate was highest in 1992 (6.8/100) and lowest in 1998 (1.1/100), while the rate for all injuries was highest in 1994 (12.0/100) and lowest in 1998 (3.3/100). Bahraini staff had higher assault (7.0/100) and total injury (14.8/100) rates than the non-Bahraini (5.5, 6.8/100, respectively). Odds ratios for assaults vs. nonpatient-induced injuries indicated that assaults were 2.3 times (95% CI: 1.05-4.95) more likely to occur in males, 5 times more likely (95% CI: 1.99-12.15) in non-Bahraini, 1.79 times more likely (95% CI: 0.81-3.95) in staff nurses, and 2.3 times more likely (95% CI: 1.05-5.01) in the evening. Suggestions for reducing assaults and nonpatient-induced injuries are discussed.

Impairing injuries among medical personnel

Medically impairing injuries among medical personnel (n = 209) were analyzed based on data obtained from the Work-Related No-Fault Liability Insurance's (TFA) injury registration system. Almost half (98; 47%) were injured during patient care, of which 29 were injured as a result of physical trauma inflicted by the patient. When moving themselves between the homes of the patients and between different wards, 94 (45%) were injured (18 in vehicle crashes). The injuries most often resulting in medical impairment were sprains and/or strains (101; 48%) and fractures (67; 32%). The injuries primarily affected the upper extremities (48%). Fifteen percent had a medical impairment of 10% or more, and in about half of the cases, the impairment was 1% to 4%. Every injured person was on sick leave for 7 months, on average, during the 2-year follow-up period. In 12% of the cases, the injury led to a disability pension.