Instruments for Measuring Violence on Acute Inpatient Psychiatric Units: Review and Recommendations

OBJECTIVE

Violence by patients against inpatient psychiatric unit staff is common, causing considerable suffering. Despite the Joint Commission's 2018 requirement for behavioral health organizations to use standardized instruments, no identified gold standard measures of violence and aggression exist. Therefore, accurate data are lacking on the frequency of patient-to-staff violence to guide development of safer institutional clinical policies or to assess the impact of targeted interventions to reduce violence. To inform recommendations for developing standardized scales, the authors reviewed the scoring instruments most commonly used to measure violence in recent studies.

METHODS

A comprehensive literature search for violence measurement instruments in articles published in English from June 2008 to June 2018 was performed. Review criteria included use of instruments measuring patient-to-staff violence or aggression in acute, nonforensic, nongeriatric populations. Exclusion criteria included child or adolescent populations, staff-to-staff violence, and staff- or visitor-to-patient violence.

RESULTS

Overall, 74 studies were identified, of which 74% used structured instruments to measure aggression and violence on inpatient psychiatric units during the past 10 years. The instruments were primarily variants of the Observed Aggression Scale (OAS); 26% of the studies used unstructured clinical notes and researcher questionnaires. Major obstacles to implementing measurement instruments included time and workflow constraints and difficulties with use.

CONCLUSIONS

In the past 10 years, OAS variants with evidence of validity and reliability that define aggression and violence have been consistently used. The authors propose that adapting the Modified OAS to collect real-time clinical data could help overcome barriers to implementing standardized instruments to quantify violence against psychiatric staff.

The physical and mental health of acute psychiatric ward staff, and its relationship to experience of physical violence

To evaluate and describe the physical and mental health of staff on acute psychiatric wards and examine whether violence exposure is linked with health status. We undertook a cross-sectional survey with 564 nursing staff and healthcare assistants from 31 psychiatric wards in nine NHS Trusts using the SF-36, a reliable and valid measure of health status and compared summary scores with national normative data. Additional violence exposure data were collated simultaneously and also compared with health status. The physical health of staff was worse, and their mental health was better than the general population. Physical health data were skewed and showed a small number of staff in relatively poor health while the majority were above average. Better physical health was associated with less time in the current post, a higher pay grade, and less exposure to mild physical violence in the past year. Better mental health was associated with being older and from an ethnic minority background. Violence exposure influenced physical health but not mental health when possible confounders were considered. Mental health was strongly influenced by ethnicity, and further research might highlight the impact on own-group ethnic density on the quality of care. The impact of staff whom are physically unwell or impaired in the workplace needs to be considered as the quality of care may be compromised despite this being an example of inclusiveness, equal opportunities employment, and positive staff motivation.

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

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

Threats or violence from patients was associated with turnover intention among foreign-born GPs - a comparison of four workplace factors associated with attitudes of wanting to quit one's job as a GP

OBJECTIVE

General practitioners (GPs) are crucial in medical healthcare, but there is currently a shortage of GPs in Sweden and elsewhere. Recruitment of GPs from abroad is essential, but foreign-born physicians face difficulties at work that may be related to turnover intention, i.e. wanting to quit one's job. The study aims to explore the reasons to why foreign-born GPs may intend to quit their job.

DESIGN

Survey data were used to compare four work-related factors that can be associated with turnover intentions; patient-related stress, threats or violence from patients, control of work pace, and empowering leadership, among native-born and foreign-born GPs. These work-related factors were subsequently examined in relation to turnover intention among the foreign-born GPs by means of linear hierarchical regression analyses. The questionnaire consisted of items from the QPS Nordic and items constructed by the authors.

SETTING

A primary care setting in a central area of Sweden.

SUBJECTS

Native-born (n = 208) and foreign-born GPs (n = 73).

RESULTS

Turnover intention was more common among foreign-born GPs (19.2% compared with 14.9%), as was the experience of threats or violence from patients (22% compared with 3% of the native-born GPs). Threats or violence was also associated with increased turnover intention. Control of work pace and an empowering leadership was associated with reduced turnover intention.

PRACTICE IMPLICATIONS

The organisations need to recognise that foreign-born GPs may face increased rates of threats and/or violence from patients, which may ultimately cause job turnover and be harmful to the exposed individual.

Sensitivity and specificity of the Brøset Violence Checklist as predictor of violence in forensic psychiatry

BACKGROUND

Violence and aggressive behavior within psychiatric facilities are serious work environment problems, which have negative consequences for both patients and staff. It is therefore of great importance to reduce both the number and the severity of these violent incidents to improve quality of care.

AIMS

To evaluate the specificity and sensitivity of the Brøset Violence Checklist (BVC) as a predictor of violent incidents for Danish forensic psychiatry patients.

METHOD

A total of 156 patients were assessed three times daily with the BVC for 24 months. All aggressive or violent incidents were recorded using the Staff Observation Aggression Scale-Revised (SOAS-R). SOAS-R scores of 9 or more defined violent incidents. Data were analyzed using standard logistic regression models as well as models incorporating a random person effect. We used receiver operating curve (ROC) analysis to evaluate different BVC thresholds.

RESULTS

Of a total of 139,579 BVC registrations we found 1999 scores above 0 and 419 violent incidents. The BVC score was a strong predictor of violence. For the standard cut-off point of 3, specificity was 0.997 and sensitivity was 0.656. For the general risk of violence seen in this study, the risk of violence given a BVC score > 3 (positive predictive value) was 37.2%, and the risk of violence given a BVC score < 3 (negative predictive value) was 0.1%.

CONCLUSION

The BVC showed satisfactory specificity and sensitivity as a predictor of the short-term risk of violence against staff and others by patients in a forensic setting.

Development and application of a population-based system for workplace violence surveillance in hospitals

BACKGROUND

A unique and comprehensive reporting and population-based violence surveillance system in a multi-site hospital system is presented.

METHODS

Incidence rates and rate ratios (RR) were calculated by year, hospital, violence type, and job category in six hospitals, 2003-2008.

RESULTS

Incidence rates per hospital for the 6-year period ranged from a low of 1.52 to a high of 10.89 incidents/100 full-time equivalents (FTEs), with the highest risk at a hospital with an outpatient mental health facility (RR = 7.16, 95%CI = 5.17-10.26). Rates for worker-on-worker violence exceeded rates for patient-to-worker violence from 2004 to 2008. Mental health technicians (RR = 13.82, 95%CI =  1.13-17.29) and security personnel (RR = 2.25, CI = 1.68-3.00) were at greatest risk for violence.

CONCLUSIONS

This surveillance system provides ongoing information on professional groups and hospital departments at risk and trends in violence reporting over time. It can be used to determine where appropriate violence prevention efforts are most needed, and to evaluate violence interventions.

Work Ability of Health Care Shift Workers: What Matters?

This paper aims at identifying variables associated with inadequate work ability among nursing personnel at a public hospital, considering factors related to socio-demographic, lifestyles, working conditions, and health outcomes. A cross-sectional study was conducted in a university hospital in São Paulo, Brazil, as part of a larger research study on tolerance to 12 h night work. Nursing staff included registered nurses, nurse technicians, and nurse aides; in total, there were 996 healthcare workers (878 female; 118 male) at the time of the study. Some 696 workers (69.9%) of the population agreed to participate. Data collection (October 2004-July 2005) was based on a comprehensive questionnaire about living and working conditions (including incivility at work, work demands, work control, and support), mental and physical health symptoms (fatigue and sleep problems), and work ability. This report presents analyses of the adapted Brazilian version of the Work Ability Index (WAI) and associated variables. The study population worked one of the following shift schedules at this hospital: 12 h nights followed by 36 h off or 9 h or 6 h day (morning or afternoon) shifts. The mean age of the respondents was 34.9 (S.D.+/-10.4) years of age; 31.5% of the participants held two jobs. Statistical analyses using a hierarchical multiple logistic regression model were performed to evaluate the factors associated with inadequate (moderate and low scores) of the WAI. The significantly associated factors were socio-demographic (income responsibility, sole breadwinner, raising kids, age group), working conditions (thermal discomfort, organization of the workplace, and verbal abuse), and health outcomes (high body mass index, obesity, sleep problems, and fatigue). In spite of limitations of the study design, results indicate that the nursing profession is associated with stressful working conditions, contributing to inadequate WAI. This is in addition to bad living conditions and precarious work. Intervention measures, either at the workplace or at individual levels, are necessary to prevent a decrease in work ability, even in this quite young working population.

Minnesota nurses' study: perceptions of violence and the work environment

Work-related violence is an important problem worldwide, and nurses are at increased risk. This study identified rates of violence against nurses in Minnesota, USA, and their perceptions of the work environment. A sample of 6,300 randomly selected nurses described their experience with work-related violence in the previous year. Differences in perceptions of the work environment and work culture were assessed, based on a nested case-control study, comparing nurses who experienced assault to non-assaulted nurses. Annual rates of physical and non-physical assault, per 100 nurses, were 13.2 (95% CI: 12.2-14.3), and 38.8 (95% CI: 37.4-40.4). Cases were more likely than controls to report: higher levels of work stress; that assault was an expected part of the job; witnessing all types of patient-perpetrated violence in the previous month; and taking corrective measures against work-related assault. Controls versus cases were more likely to perceive higher levels of morale, respect and trust among personnel, and that administrators took action against assault. Nurses frequently experienced work-related violence, and perceptions of the work environment differed between nurses who had experienced physical assault, and those who had not. Employee safety, morale, and retention are particularly important in light of the nursing shortage, and knowledge of nurses' perceptions will assist in tailoring interventions aimed at reducing the substantial risk of physical assault in health care settings.

Changes in the occurrences of coercive interventions and staff injuries on a psychiatric intensive care unit

The purpose of this study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention on a psychiatric intensive care unit. The intervention aimed to improve nursing care by addressing patient violence from multiple perspectives. During the study, the unit was reorganized toward a higher concentration of severely disturbed patients. The results showed an increased proportion of coercive interventions without a corresponding increase in staff injuries. Use of coercive interventions is discussed in relation to a safe environment for both patients and staff.

Difference in Work-Related Violence by Nurse License Type

Nurses are at considerable risk for work-related violence. This study compared the experiences of work-related violence among registered nurses (RNs) and licensed practical nurses (LPNs) to quantify differences in risks and exposures and to gain insight into possible interventions. A random sample (n = 6,300) of licensed Minnesota nurses was surveyed regarding the previous 12-month period. Nurses self-reported violent events and demographic information. After adjustment for potential confounders and nonresponse, LPNs had an increased risk for both physical assault (odds ratio = 1.4; 95% confidence interval = 1.1-1.9) and nonphysical violence (odds ratio = 1.2; 95% confidence interval = 1.0-1.5) compared to RNs. Some exposures resulted in increased risks for both types of violence for RNs and LPNs: working primarily in psychiatric departments and long-term care facilities. In contrast, working in clinics resulted in decreased risks for both license types. Some risks varied by license type. Risk of physical assault was increased for LPNs working with neonatal/pediatric patients, whereas RNs' risk was decreased. RNs' risk of physical violence increased while providing care, whereas LPNs' risk increased while supervising care. A better understanding of how this problem varies by license type and work setting will assist in designing efficacious interventions.

Prevalence of violence and its relation to caregivers' demographics and emotional reactions: an explorative study of caregivers working in group homes for persons with learning disabilities

The aim of the study was to investigate the prevalence of violence directed towards caregivers working in group homes for persons with learning disabilities, and to examine the relation between violent incidents and caregivers' demographics such as gender, age, years in service, years at the present workplace and education, as well as emotional reactions to violence expressed by the caregivers. A questionnaire was distributed to all caregivers, i.e. Registered Nurses, assistant nurses and nurse's aides, working in group homes for persons with learning disabilities. The results showed that 31% of the caregivers (n = 120) had been exposed to violence during the preceding year with physical violence being the most common type of violence. All categories of caregivers were exposed to violence and emotional reactions were common. Weak relations were found between reported exposure to violence and various demographics among caregivers, such as age and education. Daytime work was the only independent factor in a regression model predicting violence towards the caregivers. Feelings of powerlessness, insufficiency and anger were the most frequently reported emotional reactions elicited by violent situations.

Violence against emergency department workers

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

The Impact of Patient Aggression on Carers Scale: instrument derivation and psychometric testing

Patient aggression towards carers constitutes a problem for patients and carers alike. Patients' aggressive behaviour often leads to adverse consequences for carers, especially nurses. Various extensive instruments have been developed to measure such adverse effects on carers. The 'Impact of Patient Aggression on Carers Scale' (IMPACS) is a short instrument intended for use in monitoring negative consequences of such incidents. The items of the IMPACS were derived basically from a review of the literature on negative effects of patient aggression on nurses. The IMPACS was administered to a convenience sample of nurses working on 14 psychiatric acute admission wards in the German speaking part of Switzerland. Factor analysis led to the exclusion of three of the original items and to an interpretable three-factor solution with all factors demonstrating eigen values higher than 1. The factors demonstrate moderate to good internal consistency. Canonical correlation analysis using the dimensions of the Maslach Burnout Inventory (MBI) produced a correlation coefficient of 0.457, thus demonstrating external reliability. In spite of some caveats such as possible response bias and the necessity of the investigation of the test-retest stability of the scale this study suggests that the IMPACS is a good measure of adverse effects and thus merits further development.

Risk factors for work-related assaults on nurses

BACKGROUND

Work-related homicides have been the subject of considerable study, but little is known about nonfatal violence and relevant risk factors.

METHODS

We surveyed 6300 Minnesota nurses who were selected randomly from the 1998 licensing database and determined their employment and occupational violence experience. In a nested case-control study, we examined environmental exposures and physical assault. Cases of assault in the previous 12 months and controls randomly selected from assault-free months were surveyed about prior-month exposures.

RESULTS

After adjustment by multiple logistic regression, incidence of physical assault was 13.2 per 100 persons per year (95% confidence interval = 12.2-14.3). Among 310 cases and 946 control subjects, odds ratios for assault were increased: in nursing homes or long-term care facilities (2.6; 1.9-3.6), emergency departments (4.2; 1.3-12.8), and psychiatric departments (2.0; 1.1-3.7); in environments not "bright as daylight" (2.2; 1.6-2.8); and for each additional hour of shift duration (1.05; 0.99-1.11). Risks were decreased when carrying cellular telephones or personal alarms (0.3; 0.2-0.7).

CONCLUSIONS

These results may guide in-depth investigation of ways protective and risk factors can control violence against nurses.

Engendering health disparities

How is gender implicated in our exploration of health disparities in Canada? Set against the backdrop of federal government policy, this review paper examines the ways in which gender intersects with other health determinants to produce disparate health outcomes. An overview of salient issues including the impact of gender roles, environmental exposures, gender violence, workplace hazards, economic disparities, the costs of poverty, social marginalization and racism, aging, health conditions, interactions with health services, and health behaviours are considered. This review suggests health is detrimentally affected by gender roles and statuses as they intersect with economic disparities, cultural, sexual, physical and historical marginalization as well as the strains of domestic and paid labour. These conditions result in an unfair health burden borne in particular by women whose access to health determinants is--in various degrees--limited. While progress has certainly been made on some fronts, the persistence of health disparities among diverse populations of women and men suggests a postponement of the vision of a just society with health for all that was articulated in the Federal Plan on Gender Equality. Commitment, creativity and collaboration from stakeholders ranging from various levels of government, communities, academics, non-governmental agencies and health professionals will be required to reduce and eliminate health disparities between and among all members of our society.

Workplace Violence: A Survey of Emergency Physicians in the State of Michigan

STUDY OBJECTIVE

We seek to determine the amount and type of work-related violence experienced by Michigan attending emergency physicians.

METHODS

A mail survey of self-reported work-related violence exposure during the preceding 12 months was sent to randomly selected emergency physician members of the Michigan College of Emergency Physicians. Work-related violence was defined as verbal, physical, confrontation outside of the emergency department (ED), or stalking.

RESULTS

Of 250 surveys sent, 177 (70.8%) were returned. Six were blank (3 were from retired emergency physicians), leaving 171 (68.4%) for analysis. Verbal threats were the most common form of work-related violence, with 74.9% (95% confidence interval [CI] 68.4% to 81.4%) of emergency physicians indicating at least 1 verbal threat in the previous 12 months. Of the emergency physicians responding, 28.1% (95% CI 21.3% to 34.8%) indicated that they were victims of a physical assault, 11.7% (95% CI 6.9% to 16.5%) indicated that they were confronted outside of the ED, and 3.5% (95% CI 0.8% to 6.3%) experienced a stalking event. Emergency physicians who were verbally threatened tended to be less experienced (11.1 versus 15.1 years in practice; mean difference -4.0 years [95% CI -6.4 to -1.6 years]), as were those who were physically assaulted (9.5 versus 13.1 years; mean difference -3.6 years [95% CI -5.9 to -1.3 years]). Urban hospital location, emergency medicine board certification, or on-site emergency medicine residency program were not significantly associated with any type of work-related violence. Female emergency physicians were more likely to have experienced physical violence (95% CI 1.4 to 5.8) but not other types of violence. Most (81.9%; 95% CI 76.1% to 87.6%) emergency physicians were occasionally fearful of workplace violence, whereas 9.4% (95% CI 5.0% to 13.7%) were frequently fearful. Forty-two percent of emergency physicians sought various forms of protection as a result of the direct or perceived violence, including obtaining a gun (18%), knife (20%), concealed weapon license (13%), mace (7%), club (4%), or a security escort (31%).

CONCLUSION

Work-related violence exposure is not uncommon in EDs. Many emergency physicians are concerned about the violence and are taking measures, including personal protection, in response to the fear.

Violência no trabalho em enfermagem: um novo risco ocupacional

Este estudo tem como objetivo apresentar uma revisão da literatura sobre o tema violência no trabalho em enfermagem. Os principais aspectos com relação à violência no trabalho em enfermagem encontrados na literatura foram: os tipos de violência, a prevalência da violência no ambiente de trabalho; os fatores associados ao risco, as conseqüências para os trabalhadores e prevenção destes eventos. Os trabalhadores estão expostos a variadas formas de violência, trazendo graves conseqüências à saúde, necessitando assim que outros estudos sejam desenvolvidos em relação à temática, principalmente, em nosso país.

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.

Threats and violence in Swedish care and welfare--magnitude of the problem and impact on municipal personnel

The problem of threats and violence at work has received increasing attention in Sweden in recent years. Exposure is especially high among health-care personnel in social services. A nationwide survey of prevalence, work environment and risk situations was conducted. A questionnaire was sent to a stratified sample of 2800 local government employees in the care and welfare sector, working mainly with the elderly or persons with developmental impairments. Seven occupational groups, including supervisors, specialists and other categories of carers, were included, and represented a population of more than 170 000 employees. The response rate was 85%. The results indicated that as many as 51% of the population had been affected by threats/violence, either verbally or physically, over the previous year. Moreover, the results suggest that over 9% of the employees in the care sector experienced acts of violence or threats on a daily basis, and several times a month by 67%. The most vulnerable groups were assistant nurses and direct carers. Verbal threats appear more common (79%), but 66% appear to have experienced physical assaults. Stratified estimates suggest that feelings of anger (41%) and helplessness (31%), but also minor physical injuries (18%), are frequent reactions. Organizational change in the workplace and high workload entailed increased risk. Threats and violence in health-care settings are a major work-environment issue. Greater knowledge of consequences for organization, work situation and health of personnel is needed.

Risk for Violent Behavior in Patients with Chronic Pain: Evaluation and Management in the Pain Facility Setting

OBJECTIVE

Recent evidence indicates that physicians are at high risk for patient-perpetrated violence. The objectives of this article, in association with case reports of patients with chronic pain (PWCP), are the following: to review the literature and determine if pain physicians could be at risk for PWCP-perpetrated violence; to review the current evaluation and management procedures for potentially violent patients; and to identify some situations specific to PWCPs that can heighten the risk of PWCP-perpetrated violence.

DESIGN

Previous literature on patient-perpetrated violence against physicians was reviewed. In addition, literature on the evaluation for risk of violent behavior and management of violent behavior was also reviewed. Seven potentially violent PWCPs are described, including some who had threatened pain physicians and institutions. PWCP-specific situations thought to be instrumental in increasing the risk of PWCP-associated violence were identified.

SETTING

Pain facility (multidisciplinary center). RESULTS OF REVIEW AND ANALYSIS OF CASE REPORTS: The literature on patient-perpetrated violence against physicians indicates that, statistically, pain physicians could be at risk for this type of violence. Seven PWCP cases of threatened or potentially violent behavior are described. These case report data indicate that PWCPs with the potential for violence against physicians or institutions do present for treatment at pain facilities. All seven PWCPs were in a number of situations specific to chronic pain that increased the possibility of violent behavior. These situations are described.

CONCLUSIONS

In the evaluation for risk of violence against physicians or institutions by PWCPs, one needs to understand PWCP-specific situations. Management of potential violent behavior cannot be effective without this understanding.