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Tellson A, Huddleston P, Powell K, Tolentino R, Cassity W, Weller S, Vaughn B. Beyond the Basics: Partnerships and Innovations for Empowerment to Address Workplace Violence, a Call to Action. Nurs Adm Q 2024; 48:297-304. [PMID: 39213403 DOI: 10.1097/naq.0000000000000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Workplace violence (WPV) has become a crisis for health care workers, with a significant increase in violent events taking place in health care settings across the nation. Health care organizations should develop a comprehensive WPV program that includes recognition, management, and reporting of all types of WPV. A large health care system developed strategies and a program to address WPV. The health care system believes that a safe and respectful work environment is foundational to the goal of zero preventable harm. The "Safety in the Workplace" initiative was designed to raise awareness of concerning behaviors and to offer tools and resources for identifying, responding to, and reporting incidents of violence, aggression, or disruptive behaviors of WPV. During a 6-month pilot of a WPV bundle, there was a 44% reduction in physical violence reports and a 44% reduction in reported incidents of WPV. From June 2020 to June 2021, there was a 10% decrease in WPV overall.
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Affiliation(s)
- Alaina Tellson
- Baylor Scott & White Health, Dallas, Texas (Dr Tellson, Mss Powell and Tolentino, and Messrs Cassity and Weller); Baylor Scott & White Medical Center, Irving, Texas (Dr Huddleston); and Baylor Scott & White All Saints Medical Center, Fort Worth, Texas (Dr Vaughn)
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2
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Zaboli A, Sibilio S, Magnarelli G, Mian M, Brigo F, Turcato G. Nurses in the eye of the storm: a study of violence against healthcare personnel working in the emergency department. Emerg Med J 2024; 41:501-502. [PMID: 38448216 DOI: 10.1136/emermed-2023-213646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Alto Adige Health Agency, Bolzano, Italy
| | - Serena Sibilio
- Public Health, Universität Basel Institut für Pflegewissenschaft, Basel, Switzerland
| | | | - Michael Mian
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Alto Adige Health Agency, Bolzano, Italy
- Claudiana Higher Provincial School of Health Professions, Bolzano, Italy
| | - Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Alto Adige Health Agency, Bolzano, Italy
| | - Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Alto Vicentino Hospital (AULSS-7), Santorso, Italy
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3
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Jeanmonod D, Irick J, Munday AR, Awosika AO, Jeanmonod R. Compassion Fatigue in Emergency Medicine: Current Perspectives. Open Access Emerg Med 2024; 16:167-181. [PMID: 39045605 PMCID: PMC11264384 DOI: 10.2147/oaem.s418935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/11/2024] [Indexed: 07/25/2024] Open
Abstract
Compassion fatigue (CF), or loss of ability to empathize or feel compassion for others for whom one cares, is a growing concern for emergency physicians (EP). EPs, by the nature of their jobs, work under unpredictable conditions at odd hours with high levels of exposure to traumatic events. They are placed under substantial psychological, physical, and cognitive pressure, with little opportunity to recover or reflect. CF occurs when this workplace stress leads to feelings of being overwhelmed, helpless, unsupported, and unable to cope. Additionally, primary traumatic stress from threats of workplace violence and secondary traumatic stress (STS) from witnessing the suffering of others increase the likelihood of developing CF. Unchecked, this progression to CF causes reduction in quality of care to patients, reduction in patient satisfaction, increased levels of EP depression and anxiety, increased levels of EP substance use, and increased attrition from the specialty. To truly improve CF, individuals and organizations should be aware of the contributors to CF: namely, emotional exhaustion, depersonalization, primary and STS, and personal achievement. EPs should maximize their resilience to CF by using cognitive behavioral techniques and mindfulness, taking care of their physical health, seeking meaning and development within their work, developing hobbies outside of work, and creating boundaries between work and home. Organizations should actively address the known drivers of physician burnout: workload and job demands, efficiency and resources, meaning in work, culture and values, control and flexibility, work community, and work-life integration. Organizations should also provide adequate safety within facilities to reduce the threat of primary trauma and should supply adequate support and destigmatization for post-traumatic symptoms for EPs suffering from STS.
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Affiliation(s)
- Donald Jeanmonod
- Department of Emergency Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
| | - Jennifer Irick
- Department of Emergency Medicine, St. Luke’s University Health Network, Easton, PA, USA
| | - Adam R Munday
- Department of Emergency Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
| | - Afopefoluwa O Awosika
- Department of Emergency Medicine, St. Luke’s University Health Network, Easton, PA, USA
| | - Rebecca Jeanmonod
- Department of Emergency Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
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Sethi R, Lyver B, Gorla J, Singh B, Hanagan T, Haines J, Toppings M, Schulz-Quach C. Developing a customised set of evidence-based quality indicators for measuring workplace violence towards healthcare workers: a modified Delphi method. BMJ Open Qual 2024; 13:e002855. [PMID: 38964885 PMCID: PMC11227823 DOI: 10.1136/bmjoq-2024-002855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/22/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Workplace violence (WPV) is a complex global challenge in healthcare that can only be addressed through a quality improvement initiative composed of a complex intervention. However, multiple WPV-specific quality indicators are required to effectively monitor WPV and demonstrate an intervention's impact. This study aims to determine a set of quality indicators capable of effectively monitoring WPV in healthcare. METHODS This study used a modified Delphi process to systematically arrive at an expert consensus on relevant WPV quality indicators at a large, multisite academic health science centre in Toronto, Canada. The expert panel consisted of 30 stakeholders from the University Health Network (UHN) and its affiliates. Relevant literature-based quality indicators which had been identified through a rapid review were categorised according to the Donabedian model and presented to experts for two consecutive Delphi rounds. RESULTS 87 distinct quality indicators identified through the rapid review process were assessed by our expert panel. The surveys received an average response rate of 83.1% in the first round and 96.7% in the second round. From the initial set of 87 quality indicators, our expert panel arrived at a consensus on 17 indicators including 7 structure, 6 process and 4 outcome indicators. A WPV dashboard was created to provide real-time data on each of these indicators. CONCLUSIONS Using a modified Delphi methodology, a set of quality indicators validated by expert opinion was identified measuring WPV specific to UHN. The indicators identified in this study were found to be operationalisable at UHN and will provide longitudinal quality monitoring. They will inform data visualisation and dissemination tools which will impact organisational decision-making in real time.
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Affiliation(s)
- Rickinder Sethi
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | | | - Jaswanth Gorla
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | | | | | | | | | - Christian Schulz-Quach
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
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5
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O'Brien CJ, van Zundert AA, Barach PR. The growing burden of workplace violence against healthcare workers: trends in prevalence, risk factors, consequences, and prevention - a narrative review. EClinicalMedicine 2024; 72:102641. [PMID: 38840669 PMCID: PMC11152903 DOI: 10.1016/j.eclinm.2024.102641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024] Open
Abstract
Workplace violence (WPV) against healthcare workers (HCW) is a globally growing problem in healthcare systems. Despite decades of research and interventions violent incidents are rising in their severity and frequency. A structured review of PubMed and Scopus databases and supplementary internet searches, resulted in a synthesis of evidence covering multiple countries and healthcare worker populations. High rates of WPV are increasingly common due to unmet patient expectations, poor communication, long wait times and organizational factors such as resourcing and infrastructure. We highlight links between WPV and poor worker health outcomes, staff turnover, reduced patient safety and medical errors. Few prevention and mitigation activities have shown sustained effects, highlighting the challenges in understanding and addressing the complex interplay of factors that drive violence against HCWs. The rapidly rising incidence of WPV requires special consideration and action from multiple stakeholders including patients and visitors, healthcare providers, law enforcement, media and policy makers.
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Affiliation(s)
- Conor J. O'Brien
- The Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Herston Campus, Brisbane, QLD, Australia
- The University of Queensland, Faculty of Medicine, Herston, QLD 4006, Australia
| | - André A.J. van Zundert
- The Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Herston Campus, Brisbane, QLD, Australia
- The University of Queensland, Faculty of Medicine, Herston, QLD 4006, Australia
| | - Paul R. Barach
- The University of Queensland, Faculty of Medicine, Herston, QLD 4006, Australia
- Thomas Jefferson University, Philadelphia, PA, United States
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Acquadro Maran D, Giacomini G, Scacchi A, Bigarella R, Magnavita N, Gianino MM. Consequences and coping strategies of nurses and registered nurses perceiving to work in an environment characterized by workplace bullying. DIALOGUES IN HEALTH 2024; 4:100174. [PMID: 38516220 PMCID: PMC10953936 DOI: 10.1016/j.dialog.2024.100174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/08/2024] [Accepted: 02/23/2024] [Indexed: 03/23/2024]
Abstract
Aim The aim of this study was to analyze the well-being and coping strategies of nurses working in an organizational setting perceived as characterized by workplace bullying. The innovative aspect of this study is that we considered only those who perceive to work in an organizational environment characterized by workplace bullying, and not those who see themselves as victims and those who perceive they work in an organizational environment not characterized by workplace bullying. Method A questionnaire with the NAQ-R, PGWBI, Val.Mob. and Brief COPE scales was administered to nurses. To better understand this phenomenon, a comparison was made between 331 nurses and 166 workers in other professions who also work in an organizational environment perceived to be characterized by workplace bullying. Results In both groups (nurses and workers), the results were approximately the same in terms of personal bullying and workplace bullying episodes and the number of physical and emotive symptoms. The PGWBI score was lower for nurses than for workers in other fields. Among the individual symptoms, nurses and registered nurses were more likely to report gastritis, insomnia and heartburn than workers in other contexts. Workers in other contexts were more likely than nurses to report symptoms of anxiety, fear, feelings of insecurity, inferiority and guilt. In terms of coping strategies, nurses were more likely than other workers to report distraction, substance use, emotional support, disengagement, venting, positive reframing, humor, and religion. Workers in other professional context were more likely than nurses to report active coping, denial, instrumental support, planning, acceptance, and self-blame. Conclusion Results suggest that the consequences of working in a perceived organizational environment characterized by workplace bullying are similar for both groups of workers, with nonstatistical differences in perceived workplace bullying episodes and sum of physical and emotive symptoms. Implication Overall, findings suggest that workplace bullying prevention is a fundamental element in training workers in all types of workplaces and should be an integral part of curriculum activities.
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Affiliation(s)
| | - Gianmarco Giacomini
- Department of Sciences of Public Health and Pediatrics, University of Turin, Torino, Italy
| | - Alessandro Scacchi
- Department of Sciences of Public Health and Pediatrics, University of Turin, Torino, Italy
| | | | - Nicola Magnavita
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Michela Gianino
- Department of Sciences of Public Health and Pediatrics, University of Turin, Piazza Polonia, 94, Torino (I) 10126
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Arnetz JE, Baker N, Arble E, Arnetz BB. Workplace violence, work-related exhaustion, and workplace cognitive failure among nurses: A cross-sectional study. J Adv Nurs 2024. [PMID: 38712618 DOI: 10.1111/jan.16217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/28/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
AIM To examine the relationships between nurses' exposure to workplace violence and self-reports of workplace cognitive failure. DESIGN A cross-sectional study. METHODS An online questionnaire was administered in April 2023 to nurses in Michigan, US. Structural equation modelling was used to examine effects of physical and non-physical workplace violence (occupational stressors) and work efficiency and competence development (occupational protective factors) on workplace cognitive failure. RESULTS Physical violence was a significant predictor of the action subscale of cognitive failure. There were no direct effects of non-physical violence, workplace efficiency, or competence development on any of the workplace cognitive failure dimensions. Both types of violence and efficiency had significant indirect effects on workplace cognitive failure via work-related exhaustion. Work-related exhaustion predicted significantly higher scores for workplace cognitive failure. CONCLUSION Workplace violence and work efficiency exhibited primarily indirect effects on workplace cognitive failure among nurses via work-related exhaustion. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Nurses experiencing workplace violence may be at increased risk for workplace cognitive failure, especially if they are also experiencing work-related exhaustion. Workplaces that nurses perceive as more efficient can help to mitigate the effects of violence on nurses' cognitive failure. IMPACT This study addressed the possible effects of workplace violence as well as work efficiency and competence development on nurses' cognitive failure at work. Analyses revealed primarily indirect effects of workplace violence, and indirect protective effects of work efficiency, on nurses' cognitive failure via work-related exhaustion. This research has implications for healthcare organizations and suggests that efforts made by healthcare workplaces to prevent violence and work-related exhaustion, and to enhance work efficiency, may help to mitigate workplace cognitive failure among nurses. REPORTING METHOD We have followed the STROBE checklist in reporting this study. PATIENT OR PUBLIC CONTRIBUTION No Patient or public contribution.
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Affiliation(s)
- Judith E Arnetz
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Nathan Baker
- Department of Psychology, Michigan State University, East Lansing, Michigan, USA
| | - Eamonn Arble
- Department of Psychology, Eastern Michigan University, Ypsilanti, Michigan, USA
| | - Bengt B Arnetz
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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Coates A, Mihailescu M, Bourgeault IL. Emergency responses for a health workforce under pressure: Lessons learned from system responses to the first wave of the pandemic in Canada. Int J Health Plann Manage 2024; 39:906-916. [PMID: 38369691 DOI: 10.1002/hpm.3778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/20/2024] Open
Abstract
The global health workforce crisis, simmering for decades, was brought to a rolling boil by the COVID-19 pandemic in 2020. With scarce literature, evidence, or best practices to draw from, countries around the world moved to flex their workforces to meet acute challenges of the pandemic, facing demands related to patient volume, patient acuity, and worker vulnerability and absenteeism. One early hypothesis suggested that the acute, short-term pandemic phase would be followed by several waves of resource demands extending over the longer term. However, as the acute phase of the pandemic abated, temporary workforce policies expired and others were repealed with a view of returning to 'normal'. The workforce needs of subsequent phases of pandemic effects were largely ignored despite our new equilibrium resting nowhere near our pre-COVID baseline. In this paper, we describe Canada's early pandemic workforce response. We report the results of an environmental scan of the early workforce strategies adopted in Canada during the first wave of the COVID-19 pandemic. Within an expanded three-part conceptual framework for supporting a sustainable health workforce, we describe 470 strategies and policies that aimed to increase the numbers and flexibility of health workers in Canada, and to maximise their continued availability to work. These strategies targeted all types of health workers and roles, enabling changes to the places health work is done, the way in which care is delivered, and the mechanisms by which it is regulated. Telehealth strategies and virtual care were the most prevalent, followed by role expansion, licensure flexibility, mental health supports for workers, and return to practice of retirees. We explore the degree to which these short-term, acute response strategies might be adapted or extended to support the evolving workforce's long-term needs.
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Affiliation(s)
- Alison Coates
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Mara Mihailescu
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ivy Lynn Bourgeault
- School of Sociological & Anthropological Studies, University of Ottawa, Ottawa, Ontario, Canada
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Brigo F, Brigiari G, Mian M, Turcato G, Sibilio S, Zaboli A. Impact of the COVID-19 pandemic, its related social restriction measures and vaccination campaign on emergency department attendances for epileptic seizures: An interrupted time-series analysis. Epilepsy Behav 2024; 154:109763. [PMID: 38554646 DOI: 10.1016/j.yebeh.2024.109763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/29/2024] [Accepted: 03/23/2024] [Indexed: 04/02/2024]
Abstract
AIM To investigate the impact of the outbreak of the COVID-19 pandemic, its related social restriction measure (national lockdown) and vaccination campaign on emergency department (ED) accesses for epileptic seizures. METHODS Retrospective observational analysis conducted on a consecutive cohort of patients who sought medical care at the ED of the General Hospital of Merano, Italy, from January 1, 2015, to December 31, 2021. We investigated the monthly ED attendances for epileptic seizures between the periods before and after the outbreak of the COVID-19 pandemic and the national lockdown (March 2020) using an interrupted time-series analysis with data standardized for 1000 accesses/month. As a further temporal cutoff, we used the start of the national vaccination campaign. RESULTS Between January 1, 2015, and December 31, 2021, a total of 415,005 ED attendances were recorded; 1,254 (0.3 %) were due to epileptic seizures. No significant difference was found in the rate of standardized ED accesses for epileptic seizures in March 2020 (time point of interest) to the pre-pandemic trend (0.33/1000; 95 %CI: -1.05 to 1.71; p = 0.637). Similarly, there was no difference between the pre- and post-pandemic trends (-0.02/1000; 95 %CI: -0.11 to 0.06; p = 0.600). When adopting January 2021 as time point of interest, we found no difference to the pre-vaccination trend (0.83/1000; 95 %CI: -0.48 to 2.15), and no difference in the pre- and post-vaccination trends (-0.12/1000; 95 %CI: -0.27 to 0.04). CONCLUSIONS The COVID-19 pandemic and its related social restrictions (lockdown), as well as the COVID-19 national vaccination campaign, had little impact on ED accesses for epileptic seizures.
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Affiliation(s)
- Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy.
| | - Gloria Brigiari
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Michael Mian
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy; College of Health Care-Professions Claudiana, Bozen, Italy
| | - Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
| | - Serena Sibilio
- Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy
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Lyver B, Gorla J, Schulz-Quach C, Anderson M, Singh B, Hanagan T, Haines J, Sethi R. Identifying quality indicators to measure workplace violence in healthcare settings: a rapid review. BMC Emerg Med 2024; 24:29. [PMID: 38360571 PMCID: PMC10870575 DOI: 10.1186/s12873-024-00943-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Workplace violence (WPV) in healthcare is a growing challenge posing significant risks to patient care and employee well-being. Existing metrics to measure WPV in healthcare settings often fail to provide decision-makers with an adequate reflection of WPV due to the complexity of the issue. This increases the difficulty for decision-makers to evaluate WPV in healthcare settings and implement interventions that can produce sustained improvements. OBJECTIVE This study aims to identify and compile a list of quality indicators that have previously been utilized to measure WPV in healthcare settings. The identified quality indicators serve as tools, providing leadership with the necessary information on the state of WPV within their organization or the impact of WPV prevention interventions. This information provides leadership with a foundation for planning and decision making related to addressing WPV. METHODS Ovid databases were used to identify articles relevant to violence in healthcare settings, from which 43 publications were included for data extraction. Data extraction produced a total of 229 quality indicators that were sorted into three indicator categories using the Donabedian model: structure, process, and outcome. RESULTS A majority of the articles (93%) contained at least 1 quality indicator that possessed the potential to be operationalized at an organizational level. In addition, several articles (40%) contained valuable questionnaires or survey instruments for measuring WPV. In total, the rapid review process identified 84 structural quality indicators, 121 process quality indicators, 24 outcome quality indicators, 57 survey-type questions and 17 survey instruments. CONCLUSIONS This study provides a foundation for healthcare organizations to address WPV through systematic approaches informed by quality indicators. The utilization of indicators showed promise for characterizing WPV and measuring the efficacy of interventions. Caution must be exercised to ensure indicators are not discriminatory and are suited to specific organizational needs. While the findings of this review are promising, further investigation is needed to rigorously evaluate existing literature to expand the list of quality indicators for WPV.
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Affiliation(s)
- Brendan Lyver
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jaswanth Gorla
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christian Schulz-Quach
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
- Centre of Mental Health, University Health Network, Toronto, ON, Canada.
- University Health Network, 200 Elizabeth St, M5G 2C4, Toronto, ON, Canada.
| | - Melanie Anderson
- University Health Network, 200 Elizabeth St, M5G 2C4, Toronto, ON, Canada
| | - Brendan Singh
- University Health Network, 200 Elizabeth St, M5G 2C4, Toronto, ON, Canada
| | - Trevor Hanagan
- University Health Network, 200 Elizabeth St, M5G 2C4, Toronto, ON, Canada
| | - Jennifer Haines
- University Health Network, 200 Elizabeth St, M5G 2C4, Toronto, ON, Canada
| | - Rickinder Sethi
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre of Mental Health, University Health Network, Toronto, ON, Canada
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Hou Y, Corbally M, Timmins F. Violence against nurses by patients and visitors in the emergency department: An integrative review. J Adv Nurs 2024; 80:430-445. [PMID: 37658637 DOI: 10.1111/jan.15837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023]
Abstract
AIM This integrative review explored violence against emergency nurses by patients/visitors, examining its nature, contributing factors and consequences. DESIGN Integrative review. DATA SOURCES Articles were obtained from PubMed, CINAHL, EMBASE, Web of Science and PsycInfo databases, up until December 2021. REVIEW METHODS 26 articles were reviewed, evaluating study quality with the Crowe Critical Appraisal Tool and synthesizing conclusions through theme development and coding. RESULTS This review delves into the issue of violence perpetrated against emergency nurses by patients and visitors. It elucidates three overarching themes: the nature of violence, the contributing factors and the consequences of such acts. CONCLUSION The findings inform healthcare policy for the development of prevention approaches while identifying research gaps and emphasizing the need for alternative study designs and methodologies. IMPACT This review has implications for nursing practice, policymaking and research, emphasizing the need for stakeholder engagement and tailored interventions for at-risk emergency nurses. NO PATIENT OR PUBLIC CONTRIBUTION This project was an integrative review of the literature therefore no patient or public contribution was necessary. WHAT ALREADY IS KNOWN Violence by patients and visitors in healthcare settings, especially in emergency departments, has garnered considerable attention. WHAT THIS PAPER ADDS This review specifically examines violence-targeting emergency department nurses from patients and visitors, assessing its characteristics, contributing factors and consequences. IMPLICATIONS FOR PRACTICE/POLICY The findings will guide stakeholder engagement in developing interventions to support vulnerable emergency nurses.
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Affiliation(s)
- Yongchao Hou
- Emergency Department, ShanXi Provincial People's Hospital, Taiyuan, ShanXi, China
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Melissa Corbally
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Fiona Timmins
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
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12
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Brigo F, Mian M, Turcato G, Sibilio S, Zaboli A. The effect of the COVID-19 pandemic and its related social restriction measures on emergency department visits for transient global amnesia: an interrupted time-series analysis. Neurol Sci 2024; 45:11-12. [PMID: 37945932 DOI: 10.1007/s10072-023-07168-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Francesco Brigo
- Innovation, Research and Teaching Service, (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13, Bolzano, Italy.
| | - Michael Mian
- Innovation, Research and Teaching Service, (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13, Bolzano, Italy
- College of Health Care-Professions Claudiana, Bozen, Italy
| | - Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
| | - Serena Sibilio
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Merano-Meran, Italy
| | - Arian Zaboli
- Innovation, Research and Teaching Service, (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13, Bolzano, Italy
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13
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Busch IM, Rimondini M, Scott SD, Moretti F, Cecchin D, Wu AW, Giraudo C. Workplace violence in radiology: results of a systematic review. Occup Med (Lond) 2023; 73:541-546. [PMID: 38072465 DOI: 10.1093/occmed/kqad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Workplace violence (WPV) is a growing issue in health care with far-reaching consequences for health workers' physical and psychological well-being. While some medical specialities like emergency medicine have always been considered at higher risk for WPV, several studies have also reported its occurrence in radiology. AIMS This systematic review aimed to comprehensively synthesize the types of WPV in radiology, its psychological impact, and the underlying risk and protective factors. METHODS We searched five electronic databases (PubMed, Web of Science Core Collection, Scopus, PsycINFO and CINAHL) and additional literature, including grey literature, and established weekly search alerts. Two reviewers independently conducted all methodological steps, involving a third reviewer in case of disagreement. RESULTS Of the 12 205 retrieved records, 103 full-text articles were evaluated, and 15 studies were included. Across studies, verbal aggression, sexual harassment (mostly against women) and physical violence were experienced by up to 100%, 85% and 46% of health workers, respectively. Perpetrators were patients and patients' caregivers, followed by co-workers. Victims suffered from various psychological symptoms, such as anxiety (22%-54%), fear (6%-39%), depression (32%) and repeated disturbing memories (21%). Risk factors included female gender, understaffing, worker inexperience, poor communication and lengthy waiting times. Social support and security personnel presence were among the identified protective factors. CONCLUSIONS Health workers are at high risk of experiencing WPV in the radiological setting, with a strong psychological impact. Radiological departments should create a safe healthcare environment that actively manages the identified risk factors and offers psychological support to affected workers.
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Affiliation(s)
- I M Busch
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
| | - M Rimondini
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
| | - S D Scott
- University of Missouri Health Care and Sinclair School of Nursing, Columbia, MO 65212, USA
| | - F Moretti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
| | - D Cecchin
- Department of Medicine, University of Padova, 35121 Padova, Italy
| | - A W Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - C Giraudo
- Department of Medicine, University of Padova, 35121 Padova, Italy
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14
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Brunelli L, Scarpis E, Lo Presti T, Fiorillo F, Campanella F, Zuliani P, Farneti F, Croci E, Pellizzari B, Cocconi R, Arnoldo L. Health professionals who have worked in COVID-19 immunization centers suffer the effects of violence. Front Public Health 2023; 11:1264301. [PMID: 37799152 PMCID: PMC10548233 DOI: 10.3389/fpubh.2023.1264301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
Background The phenomenon violence against health professionals has received increasing attention in recent years because of its frequency and significant impact on victims' mental health and disruption of health services. Despite this attention, little is known about the incidence of workplace violence in the highly politicized immunization services. Therefore, we decided to examine the prevalence of workplace violence in the COVID-19 immunization campaign, the risk and protective factors, and the impact on victims' mental health. Methods Between March and April 2022, we conducted an anonymous online survey among health professionals working in COVID-19 vaccination centers in the Friuli-Venezia Giulia Region (Italy). We used the Questionnaire for Workplace Violence in Healthcare Settings and the Impact of Event Scale-Revised. Results Of the 200 participants, 93 (46.5%) reported being victims of an act of violence during the vaccination campaign, 60 of them verbally and 7 physically. In 35.5% of cases, the IES score indicated a possible post-traumatic stress reaction in the victim. Opinions on measures to prevent violence and support workers in the workplace differed according to the sex of the health professional, with women emphasizing the need for self-defense training and improvement of security arrangements (p < 0.001). Conclusion One-third of health professionals involved in the COVID-19 immunization campaign reported that their mental health was affected by workplace violence. Public health professionals dealing with politicized and debated issues such as immunization should receive more attention, as should the implementation of a more structured and multidisciplinary approach to the problem within healthcare organizations.
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Affiliation(s)
- Laura Brunelli
- Department of Medicine, University of Udine, Udine, Italy
- Clinical Risk, Quality and Accreditation Unit, Friuli Centrale Healthcare University Trust, Udine, Italy
| | - Enrico Scarpis
- Medical Directorate of Palmanova-Latisana Hospital, Friuli Centrale Healthcare University Trust, Udine, Italy
| | | | - Francesca Fiorillo
- Regional Transplant Centre, Friuli Centrale Healthcare University Trust, Udine, Italy
| | - Fabio Campanella
- Neurosurgery Unit, Friuli Centrale Healthcare University Trust, Udine, Italy
| | - Paola Zuliani
- Clinical Risk, Quality and Accreditation Unit, Friuli Centrale Healthcare University Trust, Udine, Italy
| | - Federico Farneti
- Clinical Risk, Quality and Accreditation Unit, Friuli Centrale Healthcare University Trust, Udine, Italy
| | - Eleonora Croci
- Department of Prevention, Giuliano Isontina Healthcare University Trust, Trieste, Italy
| | - Barbara Pellizzari
- Department of Prevention, Friuli Occidentale Healthcare Trust, Pordenone, Italy
| | - Roberto Cocconi
- Clinical Risk, Quality and Accreditation Unit, Friuli Centrale Healthcare University Trust, Udine, Italy
| | - Luca Arnoldo
- Department of Medicine, University of Udine, Udine, Italy
- Clinical Risk, Quality and Accreditation Unit, Friuli Centrale Healthcare University Trust, Udine, Italy
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15
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Odes R, Lee SJ, Hong O, Jun J. The effect of COVID-19 on workplace violence in California's hospitals: An interrupted time series analysis. J Adv Nurs 2023; 79:2337-2347. [PMID: 36762706 DOI: 10.1111/jan.15588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/16/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023]
Abstract
AIM This study used California's unique Workplace Violent Incident Reporting System (WVIRS) to describe changes in workplace violence (WV) exposure for hospital-based healthcare workers during the pandemic. DESIGN Interrupted time series analysis. METHODS We compared the linear trends in weekly WV incidents reported during the period before the COVID-19 pandemic (7/1/2017-3/20/2020) to the period following California's shutdown (3/21/2020-6/30/2021). We created mixed effects models for incidents reported in emergency departments (EDs) and in other hospital units. We used hospital volume data from the California Department of Health Care Access and Information. RESULTS A total of 418 hospitals reported 37,561 incidents during the study period. For EDs, the number of reported incidents remained essentially constant, despite a 26% drop in outpatient visits between the first and second quarters of 2020. For other hospital units, weekly incidents initially dropped-parallel to a 13% decrease in inpatient days between the first and second quarters of 2020-but then continued parallel to the trend seen in the pre-COVID period. CONCLUSION WV persists steadily in California's hospitals. Despite major reductions in patient volume due to COVID-19, weekly reported ED incidents remained essentially unchanged. IMPACT Surveys and media reported that WV increased during the pandemic, but it has been difficult to measure these changes using a large-scale database. The absolute number of WV incidents did not increase during the pandemic; however, the trend in reported incidents remained constant in the context of dramatic decreases in patient volume. New federal WV prevention legislation is being considered in the U.S. California's experience of implementation should be considered to improve WV reporting and prevention. PUBLIC CONTRIBUTION There was no public contribution to this study. The goal of this analysis was to summarize findings from administrative data. The findings presented can inform future discussion of public policy and action.
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Affiliation(s)
- Rachel Odes
- National Clinician Scholars Program, Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Soo-Jeong Lee
- Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - OiSaeng Hong
- Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Jin Jun
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
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16
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Zhang S, Zhao Z, Zhang H, Zhu Y, Xi Z, Xiang K. Workplace violence against healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023:10.1007/s11356-023-27317-2. [PMID: 37209334 DOI: 10.1007/s11356-023-27317-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/26/2023] [Indexed: 05/22/2023]
Abstract
Workplace violence (WPV) is a prevalent phenomenon, especially in the healthcare setting. WPV against healthcare workers (HCWs) has increased during the COVID-19 epidemic. This meta-analysis determined the prevalence and risk factors of WPV. A database search was conducted across six databases in May 2022, which was updated in October 2022. WPV prevalence among HCWs was the main outcome. Data were stratified by WPV/HCW type, pandemic period (early, mid, late), and medical specialty. WPV risk factors were the secondary outcome. All analyses were conducted through STATA. Newcastle Ottawa Scale evaluated the quality. Sensitivity analysis identified effect estimate changes. A total of 38 studies (63,672 HCWs) were analyzed. The prevalence of WPV of any kind (43%), physical (9%), verbal (48%), and emotional (26%) was high. From mid-pandemic to late-pandemic, WPV (40-47%), physical violence (12-23%), and verbal violence (45-58%) increased. Nurses had more than double the rate of physical violence (13% vs. 5%) than physicians, while WPV and verbal violence were equal. Gender, profession, and COVID-19 timing did not affect WPV, physical, or verbal violence risk. COVID-19 HCWs were more likely to be physically assaulted (logOR = 0.54; 95% CI: 0.10: 0.97). Most healthcare employees suffer verbal violence, followed by emotional, bullying, sexual harassment, and physical assault. Pandemic-related workplace violence increased. Nurses were twice as violent as doctors. COVID-19 healthcare employees had a higher risk of physical and workplace violence.
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Affiliation(s)
- Shuisheng Zhang
- Department of Geriatrics, Jilin Academy of Chinese Medical Sciences, No. 1745, Gongnongda Road, Changchun, 130012, Jilin, China
| | - Zhen Zhao
- Department of Geriatrics, Jilin Academy of Chinese Medical Sciences, No. 1745, Gongnongda Road, Changchun, 130012, Jilin, China
| | - Huan Zhang
- Nursing Department, Changchun Children's Hospital, Changchun, 130061, Jilin, China
| | - Yanhua Zhu
- Department of Geriatrics, Jilin Academy of Chinese Medical Sciences, No. 1745, Gongnongda Road, Changchun, 130012, Jilin, China
| | - Zhongyuan Xi
- Department of Pulmonary Disease, Jilin Academy of Chinese Medical Sciences, Changchun, 130012, Jilin, China
| | - Ke Xiang
- Department of Geriatrics, Jilin Academy of Chinese Medical Sciences, No. 1745, Gongnongda Road, Changchun, 130012, Jilin, China.
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17
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Kuhlmann E, Falkenbach M, Lotta G, Tenbensel T, Dopfer-Jablonka A. Violence against healthcare workers in the middle of a global health crisis: what is it about policy and what to learn from international comparison? Front Public Health 2023; 11:1182328. [PMID: 37275483 PMCID: PMC10232894 DOI: 10.3389/fpubh.2023.1182328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/13/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction Violence against healthcare workers is a global health problem threatening healthcare workforce retention and health system resilience in a fragile post-COVID 'normalisation' period. In this perspective article, we argue that violence against healthcare workers must be made a greater priority. Our novel contribution to the debate is a comparative health system and policy approach. Methods We have chosen a most different systems comparative approach concerning the epidemiological, political, and geographic contexts. Brazil (under the Bolsonaro government) and the United Kingdom (under the Johnson government) serve as examples of countries that were strongly hit by the pandemic in epidemiological terms while also displaying policy failures. New Zealand and Germany represent the opposite. A rapid assessment was undertaken based on secondary sources and country expertise. Results We found similar problems across countries. A global crisis makes healthcare workers vulnerable to violence. Furthermore, insufficient data and monitoring hamper effective prevention, and lack of attention may threaten women, the nursing profession, and migrant/minority groups the most. There were also relevant differences. No clear health system pattern can be identified. At the same time, professional associations and partly the media are strong policy actors against violence. Conclusion In all countries, muchmore involvement from political leadership is needed. In addition, attention to the political dimension and all forms of violence are essential.
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Affiliation(s)
- Ellen Kuhlmann
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
- Health and Health Systems, Faculty I, University of Siegen, Siegen, Germany
| | | | - Gabriela Lotta
- Department of Public Administration, Getulio Vargas Foundation, São Paulo, Brazil
| | - Tim Tenbensel
- Faculty of Medical and Health Sciences, Health Systems, University of Auckland, Auckland, New Zealand
| | - Alexandra Dopfer-Jablonka
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
- German Center for Infection Research, Brunswick, Germany
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18
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Kuhlmann E, Brînzac MG, Czabanowska K, Falkenbach M, Ungureanu MI, Valiotis G, Zapata T, Martin-Moreno JM. Violence against healthcare workers is a political problem and a public health issue: a call to action. Eur J Public Health 2023; 33:4-5. [PMID: 36508506 PMCID: PMC9897982 DOI: 10.1093/eurpub/ckac180] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ellen Kuhlmann
- Clinic for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany.,EUPHA Health Workforce Research Section, European Public Health Association, Utrecht, Netherlands
| | - Monica Georgiana Brînzac
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babeș-Bolyai University, 3 Cluj Napoca, Romania.,EUPHAnxt, European Public Health Association, Utrecht, Netherlands
| | - Katarzyna Czabanowska
- Department of International Health, Care and Public Health Research Institute (CAPHRI), University of Maastricht, Maastricht, Netherlands
| | - Michelle Falkenbach
- European Observatory on Health Systems and Policies, Brussels, Belgium.,Department of Public and Ecosystem Health, Cornell University, Ithaca, New York, USA
| | - Marius-Ionut Ungureanu
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babeș-Bolyai University, 3 Cluj Napoca, Romania.,Center for Health Workforce Research and Policy, Faculty of Political, Administrative and Communication Sciences, Babeș-Bolyai University, Cluj Napoca, Romania
| | | | - Tomas Zapata
- World Health Organisation Regional Office for Europe, Copenhagen, Denmark
| | - Jose M Martin-Moreno
- Department of Preventive Medicine and Public Health, INCLIVA, University of Valencia, Valencia, Spain
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19
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Hruska B, Patterson PD, Doshi AA, Guyette MK, Wong AH, Chang BP, Suffoletto BP, Pacella-LaBarbara ML. Examining the prevalence and health impairment associated with subthreshold PTSD symptoms (PTSS) among frontline healthcare workers during the COVID-19 pandemic. J Psychiatr Res 2023; 158:202-208. [PMID: 36592534 PMCID: PMC9796598 DOI: 10.1016/j.jpsychires.2022.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
The COVID-19 pandemic has increased healthcare workers' (HCWs) risk for posttraumatic stress disorder (PTSD). Although subthreshold PTSD symptoms (PTSS) are common and increase vulnerability for health impairments, they have received little attention. We examined the prevalence of subthreshold PTSS and their relationship to physical health symptoms and sleep problems among HCWs during the pandemic's second wave (01/21-02/21). Participants (N = 852; 63.1% male; Mage = 38.34) completed the Short-Form PTSD Checklist (SF-PCL), the Cohen-Hoberman Inventory of Physical Symptoms, and the PROMIS Sleep-Related Impairment-Short-Form 4a. We created three groups with the SF-PCL: scores ≥11 = probable PTSD (5.5%); scores between 1 and 10 = subthreshold PTSS (55.3%); scores of 0 = no PTSS (39.2%). After controlling for demographics, occupational characteristics, and COVID-19 status, HCWs with subthreshold PTSS experienced greater physical health symptoms and sleep problems than HCWs with no PTSS. While HCWs with PTSD reported the greatest health impairment, HCWs with subthreshold PTSS reported 88% more physical health symptoms and 36% more sleep problems than HCWs with no PTSS. Subthreshold PTSS are common and increase risk for health impairment. Interventions addressing HCWs' mental health in response to the COVID-19 pandemic must include subthreshold PTSS to ensure their effectiveness.
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Affiliation(s)
- Bryce Hruska
- Department of Public Health, Syracuse University, Syracuse, NY, USA
| | - P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY, USA
| | - Brian P Suffoletto
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, USA
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