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

Healthcare Professionals' Emotional Labor and Management of Workplace Violence with Underserved Patients in the Safety Net Context

Healthcare providers (HP) work in high-stress situations, interacting with patients and families who are often in crisis. HPs who work in safety net clinics, which provide care to uninsured, Medicaid recipients and other vulnerable populations, interact with patients who are frequently frustrated by long wait times, extensive paperwork, short appointments, and have generally lower health literacy. Many patients have chronic conditions and substance use disorders which has been associated with higher likelihood to be perceived as verbally aggressive and/or perpetrate workplace violence (WPV). Using interviews with 26 HPs at safety net clinics, we investigated how HPs manage interactions with aggressive patients and avoid burnout. Findings are based on emotional labor constructs describing why and how workers use emotion management strategies to smooth communication and relationships with clients/patients. According to our participants, HPs perform emotional labor to de-escalate interactions, prevent WPV, and to develop relationships with patients who might become regular clinic patients. We found that HPs perceive an influence of the clinic context on patient aggression management, hold initial perceptions that shape engagement with aggressive patients, and report emotional labor and burnout that came from interacting with aggressive patients to prevent WPV. We offer implications that extend research on emotional labor and burnout, provide guidance to healthcare organizations, and offer directions for future theory and research.

Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study

BACKGROUND

Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting.

OBJECTIVE

This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022).

METHODS

During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events.

RESULTS

In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators.

CONCLUSIONS

A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

Implementation of an Assault Prevention Quality Improvement Initiative in an Urban Emergency Department

BACKGROUND

Emergency department (ED) health care workers experience high rates of workplace violence (WPV).

LOCAL PROBLEM

Patient-to-staff physical assaults at an urban, academic adult ED ranged between 1 and 5 per month, with a rate of 0.265 per 1000 patient visits.

METHODS

A quality improvement initiative, guided by the Social Ecological Model framework that contextualized WPV in the ED setting, informed the development of a Risk for Violence Screening Tool (RVST) to screen adult patients presenting to the ED.

INTERVENTIONS

Plan-Do-Study-Act cycles were utilized to implement a violence prevention bundle that incorporated the RVST, an alert system, and focused assault reduction strategies.

RESULTS

Patient-to-staff physical assaults decreased to a rate of 0.146 per 1000 patient visits.

CONCLUSIONS

Risk for violence screening, an alert system, and assault prevention strategies provide opportunities for nurse leaders to promote ED workplace safety.

Anger: an underappreciated destructive force in healthcare

Anger is an emotional state that occurs when unexpected things happen to or around oneself and is "an emotional state that varies in intensity from mild irritation to intense fury and rage." It is defined as "a strong feeling of displeasure and usually of antagonism," an emotion characterized by tension and hostility arising from frustration, real or imagined injury by another, or perceived injustice. It can manifest itself in behaviors designed to remove the object of the anger (e.g., determined action) or behaviors designed merely to express the emotion. For the Roman philosopher Seneca anger is not an uncontrollable, impulsive, or instinctive reaction. It is, rather, the cognitive assent that such initial reactions to the offending action or words are in fact unjustified. It is, rather, the cognitive assent that such initial reactions to the offending action or words are in fact unjustified. It seems that the year 2022 was a year when many Americans were plainly angry. "Why is everyone so angry?" the New York Times asked in the article "The Year We Lost It." We believe that Seneca is correct in that anger is unacceptable. Anger is a negative emotion that must be controlled, and Seneca provides us with the tools to avoid and destroy anger. Health care professionals will be more effective, content, and happier if they learn more about Seneca's writings about anger and implement his wisdom on anger from over 2000 years ago.

Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety

Importance

Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety.

Objective

To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care.

Design, Setting, and Participants

In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022.

Main Outcomes and Measures

Themes and subthemes of nursing perspectives on EHR behavioral flags were identified.

Results

This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19-related strain and burnout).

Conclusions and Relevance

In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

Workplace's Development of Activities and Action Plans to Prevent Violence From Clients in High-Risk Sectors

INTRODUCTION

Interventions trying to prevent violence from clients towards employees tend to show limited effect on the risk or the frequencies of violent episodes, possibly due to a too-narrow focus on only one or a few preventive strategies. This study aimed to show what employees and line managers identify as key intervention areas for preventing violence and threats.

METHODS

The study is based on data collected during a participatory intervention study aiming to improve violence prevention in Danish psychiatric units and prison and detention centers. In the intervention study, employees and line managers from 13 work units developed 293 suggestions and 92 action plans to prevent workplace violence. Through qualitative thematic analysis of the suggestions and action plans, we identified the main categories that work units viewed as important and realistic to work with to improve violence prevention.

RESULTS

We identified 12 topics of violence prevention that work units considered relevant. Action plan topics used by more than half of the work units included: specific approaches to violence prevention (e.g., de-escalating techniques), communication between employees to transfer knowledge between shifts, and introduction to new employees and temporary workers. Topics used by three to five work units were: interdisciplinary corporation, communication and relational work, uniform approaches, organization of work, and staffing. Topics used rarely were: definition of violence and threats, policy and guidelines, support from colleagues and management, and engagement in violence prevention. For nine of the 12 topics, action plans were developed in both high-risk sectors.

CONCLUSIONS

The violence prevention action plans developed by work units from two high-risk sectors indicate that workplaces estimate the prevention of client-induced workplace violence to require activities on many levels and cannot be solved by a single focused approach. This variety of preventive activities needs to be considered when designing violence prevention interventions.

Nonfatal Violence Involving Days Away From Work Following California's 2017 Workplace Violence Prevention in Health Care Safety Standard

Objectives. To examine the impact of the California Occupational Safety and Health Administration's (Cal/OSHA's) 2017 workplace violence (WPV) prevention in health care safety standard on nonfatal violent injuries among health care workers (HCWs). Methods. We accessed estimated counts of WPV from the survey of occupational injuries and illness from 2011 to 2019 specific to HCWs. We used the Current Population Survey estimates of HCWs to create rates per 10 000. We conducted a longitudinal panel analysis and a comparative interrupted time-series analysis to examine the change in incidence and in rates associated with California's new standard. Results. Adoption of the 2017 safety standard led to an additional 3.48 reported WPV injuries per 10 000 HCWs in California, or an additional 473 injuries. Sensitivity analyses suggest other injuries did not change in the same period. Conclusions. It appears that the Cal/OSHA standard increased reporting of WPV injuries among HCWs in the first year of its adoption compared with the United States. Mandating reporting of all WPV incidents in the health care setting may be a means to ensure a more complete understanding of this public health problem. (Am J Public Health. 2022;112(11):1668-1675. https://doi.org/10.2105/AJPH.2022.307029).

Intensive care units nurses' burnout, organizational commitment, turnover intention and hospital workplace violence: A cross-sectional study

AIMS

This study aimed to (1) assess the relationship between intensive care unit (ICU) nurses' burnout, organizational commitment and turnover intention, (2) examine the moderating effect of the organizational commitment on the relationship between ICU nurses' burnout and turnover intention, and (3) explore the prevalence and influencing factors of hospital workplace violence among ICU nurses.

DESIGN

Cross-sectional study design.

METHODS

Data were collected from August to October 2020 and a convenience sample of registered nurses was recruited. To control common method biases, one-month temporal separation, Harman's single-factor analysis and method of latent variables were adopted. The moderating effect was tested by SPSS Hayes PROCESS Macro. Chi-square and logistic regression were used to examine workplace violence data.

RESULTS

Organizational commitment (β = -.23, 95% confidence interval -.45 to -.03) and continuance commitment (β = -.15, 95% confidence interval -.24 to -.16) have negative moderation effects on the relationship between emotional exhaustion and turnover intention. 77.7% of ICU nurses experienced workplace violence, male and staff nurses, and nurses with lower professional titles and shorter working years have greater odds of experiencing this violence.

Mental Health Status of Medical Staff Exposed to Hospital Workplace Violence: A Prospective Cohort Study

Objective

Hospital workplace violence is one of the most frequently reported types of workplace violence in the world, and it harms the mental and physical health of medical staff. Existing research on workplace violence focused more on cross-sectional studies, than longitudinal studies. Therefore, this study examined the dynamic impact of hospital workplace violence on the mental health of medical staff, with the aim of providing appropriate countermeasures and suggestions for hospitals to develop targeted psychological intervention measures in time for medical staff who experience workplace violence.

Design

A prospective cohort study.

Participants

A total of 112 medical staff who had experienced workplace violence in the hospital for the first time were chosen.

Setting

An unconditional latent variable growth curve model was established based on the average value of the general health scale scores of medical staff, and gender and violence types (intimidation threats, physical violence) as control variables. Each medical staff was assessed for depression and anxiety at 4 different time points and the changes in the trajectories was observed.

Results

There were significant differences in the incidence of mental health and anxiety among medical staff at different observation times. There were significant individual differences in the initial mental health status, growth rate of anxiety and depression of medical staff.

Conclusions

Hospitals should undertake various psychological intervention strategies based on the staff's mental health to safeguard those who have experienced workplace violence.

Physicians' Experiences With Mistreatment and Discrimination by Patients, Families, and Visitors and Association With Burnout

Importance

Burnout is common among physicians and is associated with suboptimal patient outcomes. Little is known about how experiences with patients, families, and visitors differ by physician characteristics or contribute to the risk of burnout.

Objective

To examine the occurrence of mistreatment and discrimination by patients, families, and visitors by physician characteristics and the association between such interactions and experiencing burnout.

Design, Setting, and Participants

This cross-sectional survey was conducted from November 20, 2020, to March 23, 2021, among US physicians.

Exposures

Mistreatment and discrimination were measured using items adapted from the Association of American Medical College's Graduation Questionnaire with an additional item querying respondents about refusal of care because of the physicians' personal attributes; higher score indicated greater exposure to mistreatment and discrimination.

Main Outcomes and Measures

Burnout as measured by the Maslach Burnout Inventory.

Results

Of 6512 responding physicians, 2450 (39.4%) were female, and 369 (7.2%) were Hispanic; 681 (13.3%) were non-Hispanic Asian, Native Hawaiian, or Pacific Islander; and 3633 (70.5%) were non-Hispanic White individuals. Being subjected to racially or ethnically offensive remarks (1849 [29.4%]), offensive sexist remarks (1810 [28.7%]), or unwanted sexual advances (1291 [20.5%]) by patients, families, or visitors at least once in the previous year were common experiences. Approximately 1 in 5 physicians (1359 [21.6%]) had experienced a patient or their family refusing to allow them to provide care because of the physician's personal attributes at least once in the previous year. On multivariable analyses, female physicians (OR, 2.33; 95% CI, 2.02-2.69) and ethnic and racial minority physicians (eg, Black or African American: OR, 1.59; 95% CI, 1.13-2.23) were more likely to report mistreatment or discrimination in the previous year. Experience of mistreatment or discrimination was independently associated with higher odds of burnout (vs score of 0 [no mistreatment], score of 1: OR, 1.27; 95% CI, 1.04-1.55; score of 2: OR, 1.70; 95% CI, 1.38-2.08; score of 3: OR, 2.20; 95% CI, 1.89-2.57). There was no difference in the odds of burnout by gender after controlling for experiencing mistreatment and discrimination score and other demographic factors, specialty, practice setting, work hours, and frequency of overnight call.

Conclusions and Relevance

In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct.

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.

Effects of Integrated Workplace Violence Management Intervention on Occupational Coping Self-Efficacy, Goal Commitment, Attitudes, and Confidence in Emergency Department Nurses: A Cluster-Randomized Controlled Trial

Patient and visitor violence (PVV), the most prevalent source of workplace violence, is largely ignored, underreported, and a persistent problem in emergency departments. It is associated with physical injuries, psychological distress, and occupational stress in nurses. A randomized controlled trial was conducted in Taiwan from January to December 2020. This study aimed to test the efficacy of an integrated Workplace Violence Prevention and Management Training Program on PVV in 75 emergency department (ED) nurses from a hospital. Cluster sampling was used because the policy of subdivision strategy was enforced during the COVID-19 pandemic. ED nurses received either the intervention or 1-hour in-service class. Data were collected from questionnaires. Data were analyzed mainly by the repeated measure analysis of variance and generalized estimating equations. The intervention had positive effects on developing stronger goal commitment, improving occupational coping self-efficacy, increasing confidence in ability to deal with violent situations, and modifying attitudes toward the causes and management of PVV in ED nurses (p < 0.05). The marginal R2 of the generalized estimating equation model for goal commitment, occupational coping self-efficacy, confidence, attitudes toward aggression in ED and aggressive behavior variables was high as 0.54 (p < 0.001), 0.45 (p < 0.001), 0.58 (p < 0.001), 0.29 (p < 0.05), and 0.72 (p < 0.001), respectively. These study models could effectively predict changes in the mean values. The benefit was driven by the effect of the intervention in ED nurses. Thus, the intervention, when applied in conjunction with routine in-service class, could exert synergistic improvements on outcomes measured in nurses.

Violence Against Physicians in the Workplace: Trends, Causes, Consequences, and Strategies for Intervention

PURPOSE

Violence against healthcare professionals has become an emergency in many countries. Literature in this area has mainly focused on nurses while there are less studies on physicians, whose alterations in mental health and burnout have been linked to higher rates of medical errors and poorer quality of care. We summarized peer-reviewed literature and examined the epidemiology, main causes, consequences, and areas of intervention associated with workplace violence perpetrated against physicians.

RECENT FINDINGS

We performed a review utilizing several databases, by including the most relevant studies in full journal articles investigating the problem. Workplace violence against doctors is a widespread phenomenon, present all over the world and related to a number of variables, including individual, socio-cultural, and contextual variables. During the COVID-19 pandemic, incidence of violence has increased. Data also show the possible consequences in physicians' deterioration of quality of life, burnout, and traumatic stress which are linked to physical and mental health problems, which, in a domino effect, fall on patients' quality of care. Violence against doctors is an urgent global problem with consequences on an individual and societal level. This review highlights the need to undertake initiatives aimed at enhancing understanding, prevention, and management of workplace violence in healthcare settings.

Does Exposure to High Job Demands, Low Decision Authority, or Workplace Violence Mediate the Association between Employment in the Health and Social Care Industry and Register-Based Sickness Absence? A Longitudinal Study of a Swedish Cohort

BACKGROUND

The aim of this paper was to investigate if job demands, decision authority, and workplace violence mediate the association between employment in the health and social care industry and register-based sickness absence.

METHODS

Participants from the Swedish Longitudinal Occupational Survey of Health who responded to questionnaires in 2006-2016 (n = 3951) were included. Multilevel autoregressive cross-lagged mediation models were fitted to the data. Employment in the health and social care industry at one time point was used as the predictor variable and register-based sickness absence >14 days as the outcome variable. Self-reported levels of job demands, decision authority, and exposure to workplace violence from the first time point were used as mediating variables.

RESULTS

The direct path between employment in the health and social care industry and sickness absence >14 days was, while adjusting for the reverse path, 0.032, p = 0.002. The indirect effect mediated by low decision authority was 0.002, p = 0.006 and the one mediated by exposure to workplace violence was 0.008, p = 0.002. High job demands were not found to mediate the association.

CONCLUSION

Workplace violence and low decision authority may, to a small extent, mediate the association between employment in the health and social care industry and sickness absence.

Nurses' Experience With Type II Workplace Violence and Underreporting During the COVID-19 Pandemic

BACKGROUND

Type II (customer-on-worker) workplace violence (WPV) against nurses and its underreporting are ongoing safety and health challenges in health care. The COVID-19 pandemic has strained patients and nurses and, in turn, may have increased WPV. The purpose of this cross-sectional study was to describe and compare a sample of nurses' reported prevalence of Type II WPV and their reporting of these events during the pandemic.

METHODS

Data from an online survey of registered nurses (N = 373) working in hospitals were included. Prevalence was calculated for physical violence and verbal abuse, and their reporting of these events, including the experience of violence between nurses who did and did not care for patients with COVID-19.

FINDINGS

Overall, 44.4% and 67.8% of the nurses reported experiencing physical violence and verbal abuse, respectively, between February and May/June 2020. Nurses who provided care for patients with COVID-19 experienced more physical violence (adjusted odds ratio [aOR] = 2.18, 95% confidence interval [CI] = [1.30, 3.67]) and verbal abuse (aOR = 2.10, 95% CI = [1.22, 3.61]) than nurses who did not care for these patients. One in 10 nurses felt reporting the incident was more difficult during the pandemic.

CONCLUSION/APPLICATION TO PRACTICE

A significant proportion of nurses who cared for patients with COVID-19 experienced more physical violence and verbal abuse, and more difficulty in reporting to management. As the pandemic continues, health care organizations need to recognize that workers may be at an elevated risk for experiencing WPV and may be less likely to report, resulting in an urgent need for prevention efforts on their part.

It Takes Two to Tango: Public Attitudes Toward Prevention of Workplace Violence Against Health Care Staff: A Mixed-Methods Study

Workplace violence (WPV) directed toward health care staff by patients and their relatives has become one of the major problems faced by health care systems around the world. Incidences of WPV have increased over the past decade, crossing borders and cultures and creating a worrisome global phenomenon. To date, most of the research has examined health care workers' perceptions of strategies that might prevent violence. Although the public, as prospective patients, has a central role in this state of affairs, little is known about public attitudes to prevention of violence in health care settings. In light of this, the current mixed-methods study aimed to explore public attitudes toward appropriate preventive and punitive measures that should be employed to diminish the occurrence of WPV incidents in health care settings. Five hundred sixty Jewish Israeli individuals participated in the study. Quantitative findings indicate the public's overall agreement and positive attitudes toward preventive and punitive measures aimed at reducing WPV against health care staff. Qualitative findings revealed two main themes: "focusing on the staff" by improving their work conditions, training them to deal with violence, and providing a sense of security, as well as "focusing on the public" by teaching tolerance, raising awareness of zero tolerance to violence, and punitive measures. The Israeli public believes that to deal with the problem of violence in the health care system, it is necessary to act simultaneously on two levels: health staff and the health care system, and the general public. In view of these findings, we recommend that policy makers address this issue by adopting preventive measures, such as increasing the number of health care personnel, workshops for the staff on dealing with violence, campaigns against violence in health care settings, and enforcing appropriate punitive measures against attackers.

Health Care Worker Violent Deaths in the Workplace: A Summary of Cases From the National Violent Death Reporting System

BACKGROUND

Violent workplace deaths among health care workers (HCWs) remain understudied in the extant literature despite the potential for serious long-term implications for staff and patient safety. This descriptive study summarized the number and types of HCWs who experienced violent deaths while at work, including the location in which the fatal injury occurred.

METHODS

Cases were identified from the Centers for Disease Control and Prevention's National Violent Death Reporting System between 2003 and 2016. Coded variables included type of HCW injured, type of facility, and location within the facility and perpetrator type among homicides. Frequencies were calculated using Excel.

FINDINGS

Among 61 HCW deaths, 32 (52%) were suicides and 21 (34%) were homicides; eight (13%) were of undetermined intent. The occupations of victims included physicians (28%), followed by nurses (21%), administration/support operations (21%), security and support services (16%), and therapists and technicians (13%). Most deaths occurred in hospitals (46%) and nonresidential treatment services (20%). Within facility, locations included offices/clinics (20%) and wards/units (18%). Among homicide perpetrators, both Type II (perpetrator was client/patient/family member) and Type IV (personal relationship to perpetrator) were equally common (33%).

CONCLUSION/ APPLICATIONS TO PRACTICE

Suicide was more common than homicide among HCW fatal injuries. Workplace violence prevention programs may want to consider both types of injuries. Although fatal HCW injuries are rare, planning for all types of violent deaths could help minimize consequences for staff, patients, and visitors.

A Realist Review of Violence Prevention Education in Healthcare

Violence from patients and visitors towards healthcare workers is an international concern affecting the safety and health of workers, quality of care, and healthcare system sustainability. Although the predominant intervention has been violence prevention (VP) education for healthcare workers, evaluating its effectiveness is challenging due to underreporting of violence and the inherent complexity of both violence and the health care environment. This review utilized a theory-driven, realist approach to synthesize and analyze a wide range of academic and grey literature to identify explanations of how and why VP education makes a difference in preventing violence and associated physical and psychological injury to workers. The review confirmed the importance of positioning VP education as part of a VP strategy, and consideration of the contexts that influence successful application of VP knowledge and skills. Synthesis and analysis of patterns of evidence across 64 documents resulted in 11 realist explanations of VP education effectiveness. Examples include education specific to clinical settings, unit-level modeling and mentoring support, and support of peers and supervisors during violent incidents. This review informs practical program and policy decisions to enhance VP education effectiveness in healthcare settings.

Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium

Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.

Whose fault is it? Attribution of causes of patient violence among exposed and unexposed community-based family physicians

Extensive research has dealt with violence directed at healthcare workers in hospital settings; however, few studies have examined community-based settings. Furthermore, there is also scant literature regarding the perceptions of healthcare providers who were exposed to violence, compared to those who were not. This study aims to narrow these gaps in the literature by examining community-based family physicians' (CBFPs) perceptions in a large national Health Maintenance Organisation (HMO) regarding patient-initiated violence. Using a voluntary online survey, directed at all CBFPs working at the HMO, 412 CBFPs were surveyed on the following issues: exposure to violence initiated by patients or their family members; perceptions of violent occurrences and possible safety measures. The differences between CBFPs who had been exposed to violence and those who had not were compared. The majority of CBFPs reported experiencing verbal attacks (64%), and a small percentage experienced property-related violence (11.7%) or physical violence (3.4%). Comparing CBFPs who were exposed to violence with those who were not, regarding their perceptions of the 'causes of violence', revealed three differentiating factors: 'waiting time', 'failure to meet the patient's expectations' and 'the nature of the physician-patient encounter'. Regarding the desired preventive actions, the four differentiating factors were as follows: 'reduction in the number of patients per physician', 'improved queue management processes', 'longer meetings' and 'violence prevention training'. Conducting separate analyses, according to violence type (verbal abuse, vandalism or physical violence), indicated finer differentiations. In terms of Attribution Theory, one might argue that CBFPs who were directly exposed to patients' aggression attributed internal locus to the attacker, and tended to blame the attacker's personal characteristics and cultural values. Conversely, family CBFPs who were not attacked attributed external locus to situational factors such as waiting time, not receiving service, and the nature of the interaction between the attacker and the CBFP.

Violence on the Job: The Experiences of Nurses and Midwives with Violence from Patients and Their Friends and Relatives

Violence in healthcare is recognised as a significant workplace issue worldwide, with nurses recognised as the profession at greatest risk. The purpose of this study was to explore nurses' and midwives' experiences of violence in different clinical areas, work sectors and geographical regions. A cross-sectional design was employed to survey the membership of the New South Wales Nurses and Midwives' Association about their experiences with violence from patients and/or their friends and relatives in their workplace. A total of 3416 participants returned a completed questionnaire and more than three-quarters of had experienced an episode of violence in the preceding six months. Participants working in the public health sector reported significantly more physically violent behaviours than their colleagues in the private sector. No statistically significant difference between the rates of violence (overall) was identified between different geographical areas. Violent behaviours were reported across all clinical settings, with emergency departments, mental health and drug and alcohol settings reporting the highest proportion of episodes. The results of this large study highlight the high levels of violence that nurses and midwives experience in the workplace across all sectors of employment, geographical regions and clinical settings.

Occupational Violence and PTSD-Symptoms: A Prospective Study on the Indirect Effects of Violence Through Time Pressure and Nontraumatic Strains in the Occupational Context

OBJECTIVE

The aim of this study was to assess whether frequency of occupational violence (OV) affects posttraumatic stress disorder (PTSD) symptoms through nontraumatic strains in the occupational context.

METHODS

Twelve-month prospective survey data on 1763 Social educators were used. Path-analysis measured direct and indirect pathways of frequency of OV on PTSD through change in time pressure, change in burnout, change in sense of safety at work, and change in coping with regret in patient work.

RESULTS

Forty-two pct. of the variance in PTSD symptoms was predicted; F (20, 1541) = 36.8, P < 0.001, R = 0.42. Frequency of OV indirectly affected level of PTSD through all the mediators; estimated indirect effects = 0.14, 95% confidence interval 0.07 to 0.22.

CONCLUSION

PTSD resulting from OV is not only a result of the violent acts themselves but is also caused by nontraumatic strains. It is essential to include the broader context of work environment factors in prevention of work-related PTSD.

Workplace Violence and Neurosurgery: Insights from a Nationwide Survey

OBJECTIVE

Workplace violence (WPV) against neurosurgeons is an understudied phenomenon, as previous research has focused on high-risk specialties like emergency medicine and psychiatry. We sought to fill in this gap in the literature by determining the frequency and type of WPV that neurosurgeons experience.

METHODS

We sent a 26-question online survey to members of the American Association of Neurological Surgery via SurveyMonkey. This survey contained questions about WPV experienced over the previous two years, as well as questions about security measures and workplace protocols for WPV.

RESULTS

We received 107 responses of 4757 surveys disseminated, a response rate of 2.25%. Although small, this response rate is representative of historical survey response rates. In total, 53.3% of our sample reported WPV, and 4.7% reported at least one physical assault. In total, 50.5% of respondents were afraid of becoming a victim of WPV, and 40.4% felt less secure today than when they began practicing. A total of 17.8% of respondents reported that they had obtained a weapon or a concealed weapon permit due to a perceived threat. Tests for association revealed that early career and female neurosurgeons were significantly more likely to receive verbal threats than other neurosurgeons (P = 0.049 and 0.01, respectively).

CONCLUSIONS

WPV is prevalent in neurosurgery at rates comparable with a range of other specialties. Many neurosurgeons feel unsafe in the workplace, with some taking significant actions such as weapon acquisition. An opportunity for education and resources regarding WPV exists, especially among early career and female neurosurgeons.

Workplace Violence in Outpatient Physician Clinics: A Systematic Review

Workplace violence (WPV) has been extensively studied in hospitals, yet little is known about WPV in outpatient physician clinics. These settings and work tasks may present different risk factors for WPV compared to hospitals, including the handling/exchange of cash, and being remotely located without security presence. We conducted a systematic literature review to describe what is currently known about WPV in outpatient physician clinics. Six literature databases were searched and reference lists from included articles published from 2000-2019. Thirteen quantitative and five qualitative manuscripts were included which all focused on patient/family-perpetrated violence in outpatient physician clinics. No studies examined other violence types (e.g., worker-on-worker; burglary). The overall prevalence of Type II violence ranged from 9.5% to 74.6%, with the most common form being verbal abuse (42.1-94.3%), followed by threat of assault (14.0-57.4%), bullying (2.5-5.7%), physical assault, (0.5-15.9%) and sexual harassment/assault (0.2-9.3%). Worker consequences included reduced work performance, anger, and depression. Most workers did not receive training on how to manage a violent patient. More work is needed to examine the prevalence and risk factors of WPV in outpatient physician clinics for purposes of informing prevention efforts in these settings.

Toward prevention of behavioral emergencies in a general hospital insights from a one-year series

BACKGROUND

Behavioral emergencies endanger hospital staff and patients. The objective of this study was to identify patient characteristics that could be used to predict and prevent these incidents.

METHODS

We analyzed a one-year consecutive series of behavioral emergencies that triggered the rapid response team at a general hospital, comparing study patients with controls who did not trigger a rapid response. Standard parametric or nonparametric tests, as appropriate, were used to compare the 2 groups in univariate analyses, and multivariable logistic regression analysis was used to identify the best combination of variables for stratifying the risk of such an event.

RESULTS

There were 109 behavioral emergencies involving 83 patients. Comparison of patients who did (n = 83) or did not (n = 22,849) trigger a rapid response revealed marked differences between the two groups with respect to age, sex, and the prevalence of psychiatric comorbidities and various conditions that can diminish cognitive function. Substance use disorder was the most frequent principal diagnosis in the study group, accounting for 10.8% (9/83) of study patients vs. 0.6% (132/22849) of controls (p < 0.0001). The presence of a condition that can impair cognition (substance intoxication and withdrawal, epilepsy, cerebrovascular disease, traumatic brain injury, delirium, dementia) was associated with a 13-fold increase in the risk of a behavioral disturbance (95% CI, 8 to 22-fold).

CONCLUSIONS

Brief cognitive assessment of patients susceptible to cognitive impairment, along with diligent prophylaxis and management of substance withdrawal and delirium, may facilitate prevention of behavioral emergencies.

Workplace violence and health in human service industries: a systematic review of prospective and longitudinal studies

OBJECTIVES

To provide systematically evaluated evidence of prospective associations between exposure to physical, psychological and gender-based violence and health among healthcare, social care and education workers.

METHODS

The guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Medline, Cinahl, Web of Science and PsycInfo were searched for population: human service workers; exposure: workplace violence; and study type: prospective or longitudinal in articles published 1990-August 2019. Quality assessment was performed based on a modified version of the Cochrane's 'Tool to Assess Risk of Bias in Cohort Studies'.

RESULTS

After deduplication, 3566 studies remained, of which 132 articles were selected for full-text screening and 28 were included in the systematic review. A majority of the studies focused on healthcare personnel, were from the Nordic countries and were assessed to have medium quality. Nine of 11 associations between physical violence and poor mental health were statistically significant, and 3 of 4 associations between physical violence and sickness absence. Ten of 13 associations between psychological violence and poor mental health were statistically significant and 6 of 6 associations between psychological violence and sickness absence. The only study on gender-based violence and health reported a statistically non-significant association.

CONCLUSION

There is consistent evidence mainly in medium quality studies of prospective associations between psychological violence and poor mental health and sickness absence, and between physical violence and poor mental health in human service workers. More research using objective outcomes, improved exposure assessment and that focus on gender-based violence is needed.

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.

Prevalence of type II workplace violence among home healthcare workers: A meta-analysis

BACKGROUND

Home healthcare workers (HHWs) provide medical and nonmedical services to home-bound patients. They are at great risk of experiencing violence perpetrated by patients (type II violence). Establishing the reliable prevalence of such violence and identifying vulnerable subgroups are essential in enhancing HHWs' safety. We, therefore, conducted meta-analyses to synthesize the evidence for prevalence and identify vulnerable subgroups.

METHODS

Five electronic databases were searched for journal articles published between 1 January 2005 and 20 March 2019. A total of 21 studies were identified for this study. Meta-analyses of prevalence were conducted to obtain pooled estimates. Meta-regression was performed to compare the prevalence between professionals and paraprofessionals.

RESULTS

Prevalence estimates for HHWs were 0.223 for 12 months and 0.302 for over the career for combined violence types, 0.102 and 0.171, respectively, for physical violence, and 0.364 and 0.418, respectively, for nonphysical violence. The prevalence of nonphysical violence was higher than that of physical violence for professionals in 12 months (0.515 vs 0.135) and over the career (0.498 vs 0.224) and for paraprofessionals in 12 months (0.248 vs 0.086) and over the career (0.349 vs 0.113). Professionals reported significantly higher nonphysical violence for 12-month prevalence than paraprofessionals did (0.515 vs 0.248, P = .015).

CONCLUSION

A considerable percentage of HHWs experience type II violence with higher prevalence among professionals. Further studies need to explore factors that can explain the differences in the prevalence between professionals and paraprofessionals. The findings provide support for the need for greater recognition of the violence hazard in the home healthcare workplace.

Providing Health Care in the Shadow of Violence: Does Emotion Regulation Vary Among Hospital Workers From Different Professions?

Research into violence against health care staff by patients and their families within the health care services shows a rising frequency of incidents. The potentially damaging effects on health care staff are extensive, including diverse negative psychological and physical symptoms. The aim of this qualitative study was to examine how hospital workers from different professions reacted to patients' and visitors' violence against them or their colleagues, and how they regulated their emotional reactions during those incidents. The research question was as follows: How do different types of hospital workers regulate the range of their emotional reactions during and after violent events? Participants were 34 hospital workers, representing several professional sectors. Data were collected through in-depth semistructured interviews, which were later transcribed and thematically content analyzed. Five themes were revealed, demonstrating several tactics that hospital workers used to regulate their emotions during incidents of violent outbursts by patients or visitors: (1) Inability to Manage Emotion Regulation, (2) Emotion Regulation by Distancing and Disengagement Tactics, (3) Emotion Regulation Using Rationalization and Splitting Tactics, (4) Emotion Regulation via the Use of Organizational Resources, and (5) Controlling Emotions by Suppression. Hospital workers who experienced dissonance between their professional expectations and their emotional reactions to patients' violence reported using various emotion regulation tactics, consequently managing to fulfill their duty competently. Workers who did not experience such dissonance felt in full control of their emotions and did not manifest responses of emotion regulation. Others, however, experienced intense emotional flooding and failed to regulate their emotions. We recommend developing health care staff's awareness of possible emotional implications of violent incidents, for themselves as people and for their intact functioning at work. In addition, we recommend further development of health care staff training programs for coping with violent patients and enhancement of formal and informal organizational support.

Role of security guards in Code Black events in medical and surgical settings: A retrospective chart audit

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

A Systematic Review of Workplace Violence Against Emergency Medical Services Responders

Emergency Medical Service (EMS) responders deliver patient care in high-risk, high-stress, and highly variable scenarios. This unpredictable work environment exposes EMS responders to many risks, one of which is violence. The primary goals of this systematic literature review were to (1) define the issue of violence experienced by EMS responders and (2) identify the risk factors of violence associated with the EMS profession. An innovative inclusion of industrial literature with traditional peer-reviewed literature was performed. Of 387 articles retrieved, 104 articles were assessed and reviewed. Career exposure for EMS responders to at least one instance of verbal and/or physical violence was between 57 and 93 percent. There is a great need for rigorously designed, nationally representative examinations of occupational exposures in order to better understand the temporal associations of violence, cumulative occupational stressors, and the outcomes of physical and psychosocial injuries that are occurring as a result of exposures to violence.

Workplace violence against doctors in a tertiary care hospital

AIM

This study aimed to evaluate the magnitude and factors associated with violence against doctors.

MATERIALS AND METHODS

An online survey of doctors working in a tertiary care hospital in India was done by using the modified version of the workplace violence (WPV) in the Health Sector Questionnaire, developed by the World Health Organization.

RESULTS

Out of the 353 participants, 193 doctors (54.6%) reported being exposed to violence at their workplace in the past 6 months. Participants from the medical branches (57.8%), senior residents (60.3%), and those who were posted in emergency services (79.4%) and night duty (56.1%) reported more violence. The most common type of WPV was verbal abuse (91.2%), and the perpetrators were relatives of the patients (51.7%). The possible perceived reasons for WPV were patient overload (69.7%), prolonged duty hours and excessive workload (69.7%), and long waiting periods for patients/caregivers (66.9%). The majority of the participants considered that recruiting an adequate number of professional and paraprofessional staff (75.6%) can lead to a reduction in WPV.

CONCLUSIONS

The present study suggests that more than half of the doctors working in a tertiary care hospital in India face WPV. There is a lack of specific redressal mechanism to address WPV. Accordingly, there is a need to develop a mechanism for reporting of WPV and to implement preventive strategies at the individual level and at the system level. There is need for strengthening and implementing laws and making new policies to reduce WPV.

Prevalence of Workplace Physical Violence against Health Care Professionals by Patients and Visitors: A Systematic Review and Meta-Analysis

Workplace physical violence against health care professionals perpetrated by patients and visitors has been a persistent problem worldwide. Prevalence estimates varied vastly across studies and there was a lack of quantitative syntheses of prevalence studies. This review aimed to quantify pooled one-year prevalence estimates at the global and regional levels. A systematic literature search was performed in the databases of PubMed, PsycINFO, Web of Science, and Embase between 1 January 2000 and 8 October 2018. Studies providing information about one-year prevalence of self-reported workplace physical violence against health care professionals perpetrated by patients or visitors were included. Heterogeneity between studies was evaluated using Cochran's chi-squared test (Cochran's Q) and I2 values. Subgroup analysis and meta-regression were used to explore heterogeneity. A total of 65 eligible studies reported one-year prevalence estimates for 61,800 health care professionals from 30 countries. The pooled one-year prevalence of workplace physical violence against health care professionals perpetrated by patients or visitors was 19.33% (95% confidence interval (CI): 16.49%-22.53%) and the overall heterogeneity was high across studies. We noted geographic and staff categories variations for prevalence estimates through subgroup analysis. The meta-regression showed that sample size, type of health care setting, and quality score were significant moderators for heterogeneity. One in five health care professionals experienced workplace physical violence perpetrated by patients or visitors worldwide annually. Practical intervention was needed to ensure safety of health care professionals.

Psychopathology in Violent Offenders Against Healthcare Workers

Workplace violence in healthcare is gradually becoming a major concern in many countries around the world and research has usually been focused on the victims of violence. The aim of this study was to investigate the psychopathology of individuals who commit violence against healthcare workers. The study included 50 subjects (patient or relative of patient) aged 18-65 years who had committed violence against a healthcare worker (study group) and a control group of 55 subjects with no history of violence. A Sociodemographic Questionnaire, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Barratt Impulsiveness Scale (BIS-11), State-Trait Anger Expression Inventory (STAXI), and Eysenck Personality Questionnaire-Revised Short Form (EPQ-RSF) were administered to both the study group and the control group. A psychiatric disorder was diagnosed in 50% of the violent offenders group and in 16.4% of the control group. It was determined that 54.8% of the patient relatives and 44.4% of the patients themselves who committed a violent act against healthcare workers had at least one psychiatric diagnosis and these rates did not differ between the patients and their relatives (χ² = 0.492, p = 0.483). Comparisons of the scale scores between the groups revealed that the STAXI scores (p < .001), BIS-11 total scores (p < .001), BDI, and BAI scores were statistically significantly higher in the violent offenders group. Considering the higher rates of psychiatric disorders and higher levels of anger and impulsivity among people who commit violent acts against healthcare workers, psychotherapeutic interventions such as stress and anger management interventions, improvement of interaction and communication between patients, their relatives and healthcare workers, and the implementation of rehabilitating punitive programs for violent offenders may be beneficial to reduce the rates of violent behavior against healthcare workers.

Examining Risk of Workplace Violence in Canada: A Sex/Gender-Based Analysis

Objectives

Workplace violence (WPV) is a serious issue, resulting in significant negative health outcomes. Understanding sex/gender differences in risk of WPV has important implications for primary prevention activities.

Methods

Utilizing two waves of the Canadian General Social Survey on Victimization (N = 27,643), we examined the likelihood of WPV, and sub-categories of WPV, for women relative to men. Using a sex/gender analytical approach, a series of logistic regression models examined how the associations between being a woman and each of the outcomes changed upon adjustment for work and socio-demographic characteristics.

Results

After adjustment for work hours, women were at more than twice the risk of WPV compared to men (odds ratio = 2.12, 95% confidence interval 1.52-2.95). Adjustment for work characteristics attenuated, but did not eliminate this risk. Differences in associations were observed across sub-categories of violence, with adjustment for work characteristics attenuating sex/gender differences in physical WPV, but having minimal impact on sex/gender differences in sexual WPV.

Conclusions

Work characteristics explain a substantial proportion of the sex/gender differences in risk of physical WPV. However, even after adjustment for work characteristics, women still showed an elevated risk relative to men for almost all types of violence (as defined by nature of the violence, sex of the perpetrator, and relationship to the perpetrator) examined in this study. Future investigations should examine why these differences between women and men remain, even within similar occupational contexts.

Addressing Risks of Violence against Healthcare Staff in Emergency Departments: The Effects of Job Satisfaction and Attachment Style

Violence in the workplace is one of the most serious issues affecting the healthcare sector. The incidence of violent behaviour towards healthcare workers is increasing worldwide. It is difficult to assess the extent of the problem, however, as violent incidents are underreported. In fact, many doctors and nurses see violence-perpetrated primarily by patients and visitors (friends and relatives of patients)-as a part of their job. Several studies indicate that violent behaviour against healthcare workers has serious consequences for the professionals involved, as well as for the wider healthcare system. The purpose of this study was to ascertain the prevalence of patient and visitor violence in a number of emergency departments in northeastern Italy and to explore the relationship between violence and certain psychosocial factors (adult attachment style, age, and job satisfaction). Data were collected using an online questionnaire. Our results demonstrate that patient and visitor violence in emergency departments is a serious risk for nurses and doctors and that it is affected by several factors relating to both patient pathologies and the way the workplace and work patterns are organised. Previous studies indicate that the most common form of violence experienced in these contexts is emotional violence and that nurses are more likely than doctors to suffer emotional and physical violence. Based on multiple regression analysis of the data, it appears that greater age and higher scores in secure attachment are associated with reduced experience of emotional violence from patients and visitors. Furthermore, our results show that the relationship between secure attachment and the amount of patient-and-visitor-perpetrated emotional violence experienced is mediated by levels of job satisfaction. We also discuss the potential implications of these results in terms of using staff training to prevent and manage patient and visitor violence and improve the safety of healthcare professionals.

Violence towards Emergency Nurses: The 2016 Italian National Survey-A cross-sectional study

AIM

To analyse the dimensions and characteristics of violence towards Emergency nurses in a national context (Italy).

BACKGROUND

Nurses are the most exposed to workplace violence, especially in Emergency Department contexts.

METHODS

A cross-sectional study was conducted in all Italian regions. Descriptive analyses were used to examine violence from patients and relatives (Type II violence) concerning personal characteristics of the Emergency nurses and perpetrators, environmental and organisational factors. Multinomial logistic regression analysis was used to investigate risk factors.

RESULTS

About 76.0% of Emergency nurses experienced verbal violence, 15.5% both verbal and physical violence and only 8.5% denied having experienced either. Older age and more experience in Emergency settings are protective factors. Working in the South of Italy significantly increases the probability of being exposed.

DISCUSSION

There are many factors explaining violence, but some correlations are not clear.

CONCLUSION

Factors that have a positive effect on this problem include: specific training for younger nurses, a strong alliance between users and health personnel to restore a relationship of trust between parties, physical barriers and appropriate architectural measures.

IMPLICATIONS FOR NURSING MANAGEMENT

Comprehensive approaches can represent an effective strategy to counteract workplace violence.

Security interventions are frequently undocumented in emergency department clinical notes

OBJECTIVE

To compare the documentation of security interventions in ED presentations between clinical notes and security records.

METHODS

Presentations (n = 680) were randomly selected from all ED presentations to a public tertiary referral hospital in Queensland, Australia between April 2016 and August 2017 that were perceived by the treating clinician as alcohol-related. Retrospective data, manually extracted from clinical notes and the security service database, were compared for the documentation of any security interventions. Security interventions were defined as observation without physical contact, verbal de-escalation or physical restraint by security officers.

RESULTS

Forty-one presentations had security interventions documented in the security services database and, of those, 20 (48.8%) had documentation in the clinical notes. Patients who required security interventions were admitted to hospital in higher proportions compared with those who did not (73.2% vs 26.8%, respectively, P < 0.0001).

CONCLUSION

The rate of documentation of security interventions in clinical notes was less than 50%. Documentation of critical information, including alerts and risks, in the clinical notes is an essential component of communication that the multi-disciplinary team use to ensure patient safety. Strategies aimed at improving the documentation of security interventions in clinical notes will help to optimise risk management and the safety of patients, staff and visitors along the continuum of care.

Impact of Behavior Management Training on Nurses' Confidence in Managing Patient Aggression

OBJECTIVE

The aim of this study was to evaluate the impact of behavior management training on nurses' confidence in managing aggressive patients.

BACKGROUND

Nurses are at a high risk of experiencing violence directed toward them by patients.

METHODS

This quality improvement project used a pre-and-post study design. A survey was administered within 1 month before behavior management training and 1 month after training, capturing participants' demographic and work characteristics, as well as their experiences with patient/visitor-perpetrated violence. Confidence was measured using the Confidence in Coping with Patient Aggression Instrument. Open-ended questions sought participants' thoughts on workplace violence prevention initiatives.

RESULTS

Thirty-eight confidence scores were assessed. Nurses' confidence in coping with patient aggression was significantly higher after behavior management training. Nurse participants described the training as "timely," "helpful," and "beneficial."

CONCLUSION

With an increased understanding of violent behavior stages and warning signs, a nurse is better able to manage a potentially violent situation.

Violence Management in a Nigerian Psychiatric Facility: Psychiatric-Mental Health Nurses' Current Practices and Their Effectiveness

Patient violence in mental health care settings is daunting and stressful, as well as increasingly burdensome for professionals in low/middle income countries, specifically Africa. Patient violence has contributed to increased work hazards for health care professionals and may lead to patients being sedated or restrained, potentially resulting in injury to either the patient or provider. The current study assessed Nigerian psychiatric-mental health nurses' current practices of violence management in a hospital in Southwest Nigeria. A qualitative approach, specifically focus group discussion, was used. Results of the study show that patients and providers are prone to maltreatment. Professionals desire involvement of armed military officials to combat acts of violence by psychiatric patients who take advantage of nurses' gender, inexperience, or being lonely on duty, as well as the time of day, to attack nurses. Professionals have reportedly died in the process of violence management. Intervention studies on violence management in African mental health care settings are a priority for future research. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 37-45.].

The trouble with reporting and utilization of workplace violence data in health care

AIM

The study aimed to evaluate the reporting, monitoring and use of workplace violence data in Victorian health services.

BACKGROUND

Surveillance of workplace violence is important in understanding the circumstances in which workplace violence occurs and development of relevant and appropriate prevention and intervention strategies.

METHOD

A descriptive exploratory approach was used. Fifteen staff from occupational health and safety, quality and safety, and nurse unit managers, from five major metropolitan health services were interviewed. Recorded interviews were transcribed verbatim and thematically analysed.

RESULTS

Three themes were identified: (a) "under-reporting of workplace violence," (b) "inconsistent guidance" caused subjective and variable data coding and (c) "application of data" described how health services used the data available to them, to inform the development and implementation of systems designed to prevent workplace violence.

CONCLUSIONS

Improved reporting systems may increase consistency in reporting, enable data sharing across organisations and assist in planning of prevention strategies.

IMPLICATIONS FOR NURSING MANAGEMENT

Staff should be encouraged to complete incident reports for each episode of workplace violence. Incident reporting systems must be simplified to reduce the burden of reporting. Nurse managers should advocate for the sharing of health service workplace violence data, to enable improved prevention across all services.

Quality Improvement Project to Manage Workplace Violence in Hospitals: Lessons Learned

BACKGROUND

The study of workplace violence has focused on quantifying the problem and profiling perpetrators and victims. Intervention studies are scarce. The diverse nature of violence risk in hospitals highlights the need for broad training in risk recognition and de-escalation.

LOCAL PROBLEM

A violence management program was piloted on a general medical unit following staff requests for measures to protect them from patient and visitor violence.

METHODS

An independent pre/posttest design measured changes in participant knowledge. The Staff Observation Assessment Scale Revised (SOAS-R) was used for data collection on aggression pre- and postimplementation.

INTERVENTIONS

The violence management training program included in situ simulation training in de-escalation techniques.

RESULTS

Knowledge of de-escalation techniques to reduce violence risk increased. Important lessons were learned for ongoing program implementation.

CONCLUSIONS

Violence management programs can lead to more effective risk management. Instruments to collect data on aggression should be linked to mandatory incident reporting, and existing behavioral response teams should be involved in incident tracking.

Incidence rate of physical and verbal violence inflicted by patient and their companions on the radiology department staff of educational hospitals of medical university, Kermanshah, 2017

INTRODUCTION

Regarding the increasing risk of violence toward employees in diagnostic and therapeutic centers, radiology staff members are often exposed to forms of violence through direct contact with patients and with many professional stresses. The aim of this study is to investigate the causes and incidence of violence against radiographers in radiology departments of educational centers and hospitals.

MATERIALS AND METHODS

In this descriptive-analytic study, violence incidence was investigated in all 121 radiographers working in radiology departments of educational centers of Kermanshah in 2016. Data were collected by a reliable and stable researcher-made questionnaire. Data analysis was also performed using descriptive statistics and T test and Chi-square tests by STATA 11 software.

RESULTS

The results showed that 72.7% of radiographers had experienced violence in their work environment. Verbal violence (77.3%) was the most prevalent type where patient accompaniments were the most frequent cause of violence (54.7%), most of the violence incidents were at night shift (43.6%) and over-crowdedness was the most common cause of violence in the radiology department (21.0%). The verbal violence against radiographers younger than 40 was significantly higher (P = 0.04) than the age group above 40 years.

CONCLUSION

The incidence of verbal violence against radiographers in radiology departments is high which can be reduced by providing adequate human resource and equipment in radiology departments, re-training courses on the prevention and management of violent behavior and the suing the violent events against radiologists.

Organizational Determinants of Workplace Violence Against Hospital Workers

OBJECTIVE

To identify organizational factors contributing to workplace violence in hospitals.

METHODS

A questionnaire survey was conducted in 2013 among employees in a Midwestern hospital system (n = 446 respondents). Questions concerned employees' experiences of violence at work in the previous year and perceptions of the organizational safety climate. Logistic regressions examined staff interaction and safety climate factors associated with verbal and physical violence, respectively.

RESULTS

Interpersonal conflict was a risk factor for verbal violence (OR 1.49, 95% CI 1.04 to 2.12, P < 0.05) and low work efficiency was a risk factor for physical violence (OR .98, 0.97 to 0.99). A poor violence prevention climate was a risk factor for verbal (OR 0.48, 0.36 to 0.65, P < .001) and physical (OR 0.60, 0.45 to 0.82, P < .05) violence.

CONCLUSIONS

Interventions should aim at improving coworker relationships, work efficiency, and management promotion of the hospital violence prevention climate.

Utilizing compassion and collaboration to reduce violence in healthcare settings

Violence in healthcare settings is a global problem and violent acts are more likely to occur in emergency departments (EDs). Significant barriers to reporting workplace violence persist among healthcare workers. This, and lack of shared definitions and metrics, increase the difficulty of assessing its prevalence, understanding its causes, and comparing the impact of interventions to reduce its frequency. While risk factors for violence in EDs have been articulated, less is known about how the perspectives of patients and accompanying persons, and their interactions with ED staff may contribute to violence.

We discuss the nature and social context of ED violence and some approaches used to address this problem in the U.S. We argue that perpetrators of violence as well as healthcare staff who experience ED violence suffer when it occurs. While securing safety is paramount, compassionate practices to address this suffering and the social context from which it emerges should be developed and provided for all involved. Collaboration among stakeholders, including patients and family members, may lead to effective approaches to address this problem.

'First, Do No Harm': The Role of Negative Emotions and Moral Disengagement in Understanding the Relationship Between Workplace Aggression and Misbehavior

Workplace aggression is a critical phenomenon particularly in the healthcare sector, where nurses are especially at risk of bullying and third-party aggression. While workplace aggression has been frequently examined in relation to health problems, less is known about the possible negative impact such aggression may have on the (un)ethical behavior of victims. Our research aims to fill this gap. Drawing on literature on counterproductive work behavior (CWB) and the social-cognitive literature on aggression we investigated in two independent studies (NStudy1 = 439; NStudy2 = 416), the role of negative emotions - in particular anger, fear, and sadness, - and of moral disengagement (MD) in the paths between workplace aggression, CWB and health symptoms. The focus on these relationships is rooted in two reasons. First, misbehavior at work is a pervasive phenomenon worldwide and second, little research has been conducted in the healthcare sector on this type of behavior despite the potential importance of the issue in this context. We empirically tested our hypotheses considering a specific form of workplace aggression in each study: workplace bullying or third-party aggression. Results from the two empirical studies confirm the hypotheses that being target of workplace aggression (bullying or third-party aggression) is not only associated with health symptoms but also with misbehavior. In addition, the results of structural equation modeling attest the importance of examining specific discrete negative emotions and MD for better understanding misbehavior at work. In particular, this research shows for the first time that anger, fear, and sadness, generally aggregated into a single dimension, are indeed differently associated with MD, misbehavior and health symptoms. Specifically, in line with the literature on discrete emotions, while sadness is only associated with health symptoms, anger and fear are related to both health and misbehavior.

Enhancing the detection of injuries and near-misses among patient care staff in a large pediatric hospital

Objectives Compared to other industries, healthcare has one of the highest rates of non-fatal occupational injury/illness. Evidence indicates these rates are underestimated, highlighting the need for improved injury surveillance. This study aims to demonstrate the feasibility of integrating active data collection in a passive injury surveillance system to improve detection of injuries in a healthcare establishment. Methods Using digital voice recorders (DVR), pediatric healthcare providers prospectively recorded events throughout their shift for two weeks. This sample-based active injury surveillance was then integrated into an institutional surveillance system (ISS) centered on passive data collection initiated by employee reports. Results Injuries reported using DVR during two-week intervals from February 2014 to July 2015 were 40.7 times more frequent than what would be expected on the basis of the usual ISS reports. Psychological injuries (eg, stress, conflict) and near-misses were captured at a rate of 16.1 per 1000 days [95% confidence interval (CI) 14.1-18.3] and 35.6 per 1000 days (95% CI 32.7-38.8), respectively. Finally, 68% (95% CI 65-72%) of participants preferred using DVR either as an alternative or complement to the existing ISS. Conclusions This study showed that it is feasible to improve injury surveillance in a healthcare establishment by integrating active data collection based on voice recording within a passive injury surveillance system. Enhanced surveillance provides richer information that can guide the development of effective injury prevention strategies.