Hospital downsizing and patients' assaults on staff

Work organization, job insecurity, and occupational health disparities

BACKGROUND

Changes in employment conditions in the global economy over the past 30 years have led to increased job insecurity and other work organization hazards. These hazards may play a role in creating and sustaining occupational health disparities by socioeconomic position, gender, race, ethnicity, and immigration status.

METHODS

A conceptual model was developed to guide the review of 103 relevant articles or chapters on the role of work organization and occupational health disparities identified through a comprehensive search conducted by NIOSH. A second review was conducted of employment and workplace policies and programs designed to reduce the health and safety risks due to job insecurity and other work organization hazards.

RESULTS

There is consistent evidence that workers in lower socioeconomic or social class positions are exposed to greater job insecurity and other work organization hazards than workers in higher socioeconomic positions. Likewise, racial and ethnic minorities and immigrants are exposed to greater job insecurity. Limited research examining the effects of interventions targeting work organization hazards on disparities has been conducted; nonetheless, intervention strategies are available and evidence suggests they are effective.

CONCLUSIONS

Job insecurity and work organization hazards play a role in creating and sustaining occupational health disparities. Employment and workplace policies and programs have the potential to reduce these hazards, and to reduce disparities.

Overstretched and Unreciprocated Commitment: Reviewing Research on the Occupational Health and Safety Effects of Downsizing and Job Insecurity

Over the past two decades, a leading business practice has been often-repeated rounds of downsizing and restructuring (also referred to as reorganization, re-engineering, and a host of other euphemistic terms) by large private and public sector employers. Frequently associated with other practices such as outsourcing, privatization, and the increased use of temporary workers, downsizing/restructuring has increased the level of job insecurity among workers as well as leading to changes in work processes (including work intensification and multi-tasking) and management behavior. How has downsizing/restructuring and increased job insecurity affected the occupational health, safety, and well-being of workers, and what measures have employers, unions, and governments taken to address any adverse effects? The authors reviewed international studies of the occupational health and safety (OHS) effects of downsizing/restructuring and increased job insecurity undertaken over the past 20 years. After imposing quality filters, they obtained 86 studies. Analysis revealed that 73 (85%) of the studies found poorer OHS outcomes (using a range of measures). Studies were examined to see whether they provided clues as to the reasons for negative outcomes.

Situational variables and institutional violence: A systematic review of the literature

The impact of violence on institutions is not hard to discern: staff and patients are physically injured and may become psychologically disturbed, property is destroyed, and regimes and programs are disrupted and thereby impoverished. Furthermore, violent individuals are not only incarcerated for longer but are held in more expensive and more restrictive conditions. In order to manage institutional violence, risk factors need to be identified. Research directed at understanding institutional violence has tended to focus on person-centered explanations. However, human behavior does not occur in a vacuum of internal drives and motivations; situational factors are also relevant. A focus on situational risk factors may provide an additional means for managing institutional violence. The primary aim of this systematic review was to examine research that measured the impact of situational factors on institutional violence. The relationships among physical, verbal and/or sexual face-to-face violence and situational factors in prisons and closed psychiatric settings were reviewed. A descriptive and in-depth analysis of previous research findings was carried out. Findings indicated that a range of situational factors may impact on institutional violence. Methodological issues that influence the confidence that can be placed on these findings are considered. The implications of the findings are outlined.

Multiple Risk Factors for Violence to Seven Occupational Groups in the Swedish Caring Sector

Violence towards health-care personnel represent an increasing problem, but little is known in terms of how different occupational groups are affected. A questionnaire was sent to a stratified sample of 2,800 of 173,000 employees in the Swedish municipal health and welfare sector. Seven major groups working with the elderly or persons with developmental disabilities were considered: administrators, nursing specialists, supervisors, direct carers, nursing auxiliaries, assistant nurses, and personal assistants. The response rate was 85 percent. Fifty-one percent of respondents reported exposure to violence or threats of violence over one year. The most vulnerable groups were assistant nurses and direct carers (usually of the developmentally disabled). Individual characteristics, such as age and organizational tenure, were related to exposure. Work-related characteristics, such as type of workplace, working full-time with clients, organizational downsizing, and high workload, were also associated with risk. Greater knowledge of impacts on different professional groups and relevant prevention are required.

The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research

In this review of a range of studies on the health and safety effects of precarious employment in industrialized societies published since 1984, the authors examine the overall findings and methodological issues and identify areas in need of further research. Of the 93 published journal articles and monographs/book chapters reviewed, 76 studies found precarious employment was associated with a deterioration in occupational health and safety (OHS) in terms of injury rates, disease risk, hazard exposures, or worker (and manager) knowledge of OHS and regulatory responsibilities. Of the more than 25 studies each on outsourcing and organizational restructuring/downsizing, well over 90 percent find a negative association with OHS. The evidence is fairly persuasive for temporary workers, with 14 of 24 studies finding a negative association with OHS. The evidence is less strong for small business, and a handful of studies on part-time workers found no clear association with negative OHS outcomes (in some cases the reverse). Further research is needed to more clearly link health effects to particular business practices and neoliberal policies and to explore the regulatory implications of the growth of precarious employment. The authors suggest some ways to conceptualize the association between precarious employment and occupational health.

Characteristics of assaultive psychiatric inpatients: updated review of findings, 1995-2000

The present paper reviewed the studies of the characteristics of assaultive psychiatric inpatients from 1994 to the present. These studies partially confirmed earlier findings that assaultive patients are older persons with a diagnosis of active psychosis or other neurological abnormality and histories of violence toward others and substance-use disorder. However, the recent studies also document the profile of a second group of assaultive patients: younger females with personality disorders and histories of violence toward others, substance-use disorder, and personal victimization. Since there is a paucity of published empirical research on Alzheimer's and dementia patients for this topic, the implications from the present findings for long-term care and clinical intervention are examined.

Violence towards health care staff and possible effects on the quality of patient care

Much of the research on violence in the health care sector has focused on the immediate and long-term effects of patient violence on staff victims. There is a lack of studies, however, examining whether individual reactions to violent episodes, such as anger and increased fear in one's work, have any measurable effect on staff behaviour toward their patients, and ultimately on the quality of patient care. The aim of the present study was to investigate whether an association exists between staff experiences with violence and patient-rated quality of patient care. A theoretical model was presented, suggesting that violence or threats experienced by health care staff have a negative effect on the quality of health care services offered, as measured by patients. In addition, it was theorised that there would be an association between staff work environment and staff reports of violence. Six questionnaire studies, three concerning hospital staff's views of their work environment and three dealing with patients' perceptions of the quality of care, provided the data for evaluating the model. Work environment and quality of care studies were carried out simultaneously at a single hospital in 1994, 1995, and again in 1997. Regression analysis was used to see which combination of work environment and quality of care variables would best predict a positive overall grade for quality of care from the patient perspective. Violence entered consistently as an important predictor into each of the three best regression equations for 1994, 1995, and 1997, respectively. The results of this analysis suggest that the violence experienced by health care staff is associated with lower patient ratings of the quality of care. The study indicates that violence is not merely an occupational health issue, but may have significant implications for the quality of care provided.

Effects of community services on disability and symptoms. PRiSM Psychosis Study. 4

BACKGROUND

Community care for people with psychosis can be provided via several different service models. The study compared two models: standard community treatment with high patient: staff ratios, and intensive community treatment in which there was more of an emphasis on community involvement and lower patient:staff ratios.

METHOD

All people fulfilling diagnostic criteria for psychosis and living in two defined geographical areas in south London were identified. These people were provided with either an intensive or standard service depending on their address. Their social behaviour and symptoms were measured at the beginning of the study and after two years.

RESULTS

There is little evidence of any effects of the two service models on levels of symptoms. However, the standard service did seem to be advantageous in reducing social disability for those with medium or low levels of disability.

CONCLUSIONS

The effect of intensive community services was the opposite to that predicted. Despite improvements in outcomes (e.g. hospital admission), there were no advantages for this type of service in the measures of disability or symptoms. In fact, the standard service was effective in reducing disability, whereas in the intensive service there was no change.