A systematic review of the prevalence of patient assaults against residents

Assaults and Microaggressions Against Psychiatric Residents: Findings from a US Survey

OBJECTIVES

Psychiatric physicians may experience higher rates of assault than those in other fields. For many reasons, residents may be especially vulnerable. This study updates rates of assaults among US psychiatry residents as well as the reporting rates and emotional effects of these incidents. Little data exists to examine rates of microaggressions against psychiatry residents.

METHODS

A cross-sectional online survey was distributed through a national residency database via a snowball-sampling approach between June and September of 2021. The questionnaire asked about experiences of verbal, physical, and sexual assaults, as well as microaggressions and their impact. Descriptive analyses of the obtained data were conducted.

RESULTS

The survey was completed by 275 psychiatry residents from 29 states (63.6% women). At least one form of assault was experienced by 78.9% of participants with 74.5% experiencing verbal, 22.2% experiencing physical, and 6.2% experiencing sexual assault. At least one type of microaggression was experienced by 86.9% of trainees. Elevations in PTSD scores were seen in residents who identified as women and non-White and those physically injured or sexually assaulted. While 92.7% of residents stated their program provided training about assault, 25% of residents indicated they had no training on recognizing and responding to microaggressions.

CONCLUSIONS

Psychiatric residents experience widespread assault and microaggressions in the clinical setting but often do not report them. Due to the ubiquitous nature of these events, programs should provide training about early recognition and de-escalation techniques for agitation, responding effectively to microaggressions, and the importance of reporting events.

Workplace Violence in Orthopaedic Surgery: A Survey of Academy of Orthopaedic Surgeons Membership

INTRODUCTION

Workplace violence (WPV) in US health care is increasing, and many workers are likely to experience WPV during their careers. This study aims to assess the scope of WPV in orthopaedics.

METHODS

A 20-item survey adopted from the World Health Organization's 'Workplace Violence in the Health Sector Country Case Studies Research Instruments Survey Questionnaire' was sent to Academy of Orthopaedic Surgeons members, including residents and fellows. Deidentified responses were collected electronically over a 1-month period and assessed.

RESULTS

Overall, 1,125 Academy of Orthopaedic Surgeons members participated (5% response rate). Most respondents were male (86%) and identified with the majority ethnic group (80%). WPV of any type was reported by 77.1%. Verbal abuse was the most common type (71.6%), and patients were the most common perpetrators. WPV was most prevalent among traumatologists, tumor surgeons, female surgeons, and those with 0 to 15 years in practice. Female surgeons reported more WPV events per practice year (2.25 versus 0.65, P < 0.01) and increased likelihood of physical threats and physical assaults from coworkers ( P = 0.004).

DISCUSSION

WPV in orthopaedic surgery is largely perpetrated by patients and directed toward traumatologists, tumor surgeons, female surgeons, and less experienced surgeons. These data can be used to address safety measures in the workplace.

Psychiatric trainees' experiences of workplace violence: qualitative analysis

AIMS AND METHOD

We aimed to explore experiences of workplace violence in a New Zealand sample of psychiatric trainees and to identify barriers to achieving safe practice and ways of enhancing workplace safety. In a qualitative study, we used interpretive description to inform and design in-depth exploration of participants' experiences. We interviewed 12 psychiatric trainees. Data were analysed using reflexive thematic analysis.

RESULTS

There were three main themes: (a) violence as 'part of the job', leading to a culture of silence; (b) empowering trainees to address a sense of learned helplessness; and (c) conflict embedded within the unique nature of psychiatry.

CLINICAL IMPLICATIONS

Organisation-led systems-based procedures are instrumental in promoting workplace safety. Specific measures include peer-based support and implementing clear, tailored safety protocols, particularly for situations of crisis assessment. Training should include culturally focused education with specific guidance to mitigate violence.

Warning: medical education is hazardous to your mental health. Medical students should make an informed decision to begin and continue training

For decades there has been ample evidence that training to become a physician and practicing medicine is hazardous to one's health and wellness. In the face of the extremely high rates of suicide, substance abuse, depression and burnout in the medical student, resident, and physician populations, it would be dishonest to suggest medical education and practice is all gain and no pain. This article is directed to members of the medical education community and challenges stakeholders to view their teaching and training of medical students as an intervention requiring free and informed consent. We hope this exercise shifts the paradigm of educators and enables students to enter medical training from a free and informed position.

Violence Against Psychiatric Trainees: Findings of a European Survey

OBJECTIVES

Violence by patients against health care professionals has been widely described. Although psychiatric trainees are particularly exposed, little is known about the extent, context, and impact of violence toward them in Europe.

METHODS

A cross-sectional online survey was distributed between June 2018 and December 2019 among European psychiatric trainees through professional networks, using a snowball approach. The questionnaire asked about experiences of verbal abuse and physical and sexual assaults, as well as their context and impact. Descriptive analyses of the obtained data were conducted.

RESULTS

The survey was completed by 827 trainees from 39 countries (68.4% females). Most (83.6%) reported having been abused/assaulted at least once (of these, 92% verbally, 44.1% physically, and 9.3% sexually). Emergency rooms and inpatient units were the most frequent settings. Psychological impact of these events was commonly reported. Most respondents did not report abuses and assaults to their supervisors. They also described a lack of training for staff and aggression management plans at their institutions or of being unaware of their existence.

CONCLUSIONS

Violence from patients is reported by many psychiatric trainees across countries in Europe, with very frequent verbal abuse and worrisome figures of physical and sexual assaults. Particularly concerning are the low proportion of trainees reporting to authorities, the lack of staff training and management protocols, and trainees' lack of awareness about those resources. Despite the study limitation of a small response rate, these results support a call for urgent efforts to address this problem in Europe, and possibly beyond.

Inpatient violence in a psychiatric hospital in the middle of the pandemic: clinical and community health aspects

Healthcare workers are at a high risk of violence all over the world. The hostility toward nurses, physicians, and hospital staff has reached the point that it can be considered a public health problem. In this paper, we focus on the harassment, aggression, and violence that many healthcare workers have encountered while treating unstable psychiatric patients in the middle of the COVID-19 pandemic. We present a case with a history of violence toward mental health workers, review psychopathological and clinical aspects, and discuss how both the COVID-19 pandemic and current challenges in psychiatric hospital settings increase the frequency and severity of these attacks and how this affects the team on inpatient psychiatric units. We used the CARE guidelines to provide the most accurate and transparent information about the patient and relevant psychosocial aspects. We also pooled more than 20 unique sources to cover all aspects of violent behaviors in all psychiatric settings for all age groups. We concluded that a lack of nursing staff, the mental burden imposed by difficult patients, and poor communication between team members are some of the factors contributing to patient violence. An incomplete understanding of the problem creates barriers to change on both personal and systematic levels. Constant violence and abuse against healthcare workers cause stress, decreased productivity, and work dissatisfaction. To improve the safety of healthcare professionals, especially in inpatient psychiatric settings, several system-based changes should be implemented.

Association of proton-pump inhibitor use with adverse health outcomes: A systematic umbrella review of meta-analyses of cohort studies and randomised controlled trials

AIMS

The aim was to perform an umbrella review to summarise the existing evidence on proton-pump inhibitor (PPI) use and adverse outcomes and to grade the certainty of evidence.

METHODS

Electronic databases were searched up to July 2021 for meta-analyses of cohort studies and/or randomised controlled trials (RCTs). Summary effect sizes from a random-effects model, between-study heterogeneity, 95% prediction interval, small-study effect, excess significance and credibility ceilings were devised to classify the credibility of evidence from meta-analyses of cohort studies, whereas the GRADE approach was used for meta-analyses of RCTs.

RESULTS

In meta-analyses of cohort studies, 52 of the 91 examined associations were statistically significant (P ≤ .05). Convincing evidence emerged from main analysis for the association between PPI use and risk of all-site fracture and chronic kidney disease in the elderly population. However, none of these associations remained supported by convincing evidence after sensitivity analyses. The use of PPI is also associated with an increased risk of mortality due to COVID-19 infection and other related adverse outcomes, but the quality of evidence was weak. In meta-analyses of RCTs, 38 of the 63 examined associations were statistically significant. However, no associations were supported by high or moderate-quality evidence.

CONCLUSION

This study's findings imply that most putative adverse outcomes associated with PPI use may not be supported by high-quality evidence and are likely to have been affected by underlying confounding factors. Future research is needed to confirm the causal association between PPI use and risk of fracture and chronic kidney disease.

Encountering Patient Suicide During Psychiatric Training: An Integrative, Systematic Review

BACKGROUND/AIM

Patient suicide is an adversity that can be considered an "occupational hazard." It has been identified as one of the most stressful adverse events during psychiatric training. The aim of this study was to systematically review the literature assessing the impact of patient suicide on trainees.

METHODS

We conducted a systematic review on the MEDLINE, Science Direct, Scopus, and Web of Science databases. Studies that reported prevalence of patient suicide, quantitative or qualitative assessment of psychological and professional impacts, coping strategies, and support or educational and postvention programs were deemed eligible for inclusion.

RESULTS

Of the 1994 articles identified, 22 were included. The literature on the topic was scarce, and the quality of the studies was moderate. No article dealt with nonpsychiatric residents. During their training, 46.4% of psychiatric trainees encountered at least one patient suicide. The traumatic impact was significantly more intense in trainees compared to senior physicians. A negative impact on their professional practice was reported by 17% to 39% of trainees. Formal institutional support for the affected trainees was described as having major shortcomings, and informal support from peers and families was reported as the most helpful response. However, 52% of impacted trainees considered encountering patient suicide a useful and beneficial experience.

CONCLUSION

The frequent posttraumatic symptoms and the negative professional consequences following patient suicide are worrying phenomena that highlight the need to improve suicide prevention and postvention programs during psychiatric training. Identifying trainees with personal vulnerability factors should be a major concern during the postvention process.

Prevalence of intimidation, harassment, and discrimination among resident physicians: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to establish the prevalence of intimidation, harassment, and discrimination (IHD) reported by resident physicians during their training, to identify factors associated with reported IHD, and to identify adverse sequalae associated with IHD.

METHODS

This review followed the PRISMA guidelines. Eight electronic databases were searched for cross-sectional studies reporting the prevalence of IHD among resident physicians. Prevalence estimates were pooledacross studies using random-effects meta-analysis, with variance stabilization using Tukey double arcsine transformation. Heterogeneity was assessed with forest plots, the I ² statistic, subgroup analyses, and multivariate meta-regression.

RESULTS

52 cross-sectional studies were included in the meta-analysis. The overall pooled prevalence of IHD was 64.1% (95% confidence interval [CI], 51.0-77.1). Verbal, physical, and sexual IHD were the most common forms of IHD reported by residents. Training status (55.5%), gender (41.7%), and ethnicity (20.6%) were the most commonly cited risk factors for IHD. The most common sources of IHD were relatives/friends of patients, nurses, and patients (cited by 50.7%, 47.8, and 41.7%, respectively).

CONCLUSIONS

The prevalence of IHD among resident physicians is high and associated with multiple negative outcomes, including burnout. Despite the availability of multiple anti-IHD interventions, reports of IHD appear to be rising in many residency programs.

Women's leadership in academic medicine: a systematic review of extent, condition and interventions

OBJECTIVES

Because culture reflects leadership, the making of diverse and inclusive medical schools begins with diversity among leaders. The inclusion of women leaders remains elusive, warranting a systematic exploration of scholarship in this area. We ask: (1) What is the extent of women's leadership in academic medicine? (2) What factors influence women's leadership? (3) What is the impact of leadership development programmes?

DESIGN

Systematic review.

DATA SOURCES

A systematic search of six online databases (OvidMEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and ERIC) from the earliest date available to April 2018 was conducted. Bridging searches were conducted from April 2018 until October 2019. ELIGIBILITY CRITERIA: (1) Peer-reviewed; (2) English; (3) Quantitative studies (prospective and retrospective cohort, cross-sectional and preintervention/postintervention); evaluating (4) The extent of women's leadership at departmental, college and graduate programme levels; (5) Factors influencing women's leadership; (6) Leadership development programmes. Quantitative studies that explored women's leadership in journal editorial boards and professional societies and qualitative study designs were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers screened retrieved data of abstracts and full-texts for eligibility, assessment and extracted study-level data independently. The included studies were objectively appraised using the Medical Education Research Quality Study Instrument with an inter-rater reliability of (κ=0.93).

RESULTS

Of 4024 records retrieved, 40 studies met the inclusion criteria. The extent of women's leadership was determined through gender distribution of leadership positions. Women's leadership emergence was hindered by institutional requirements such as research productivity and educational credentials, while women's enactment of leadership was hindered by lack of policy implementation. Leadership development programmes had a positive influence on women's individual enactment of leadership and on medical schools' cultures.

CONCLUSIONS

Scholarship on women's leadership inadvertently produced institute-centric rather than women-centric research. More robust contextualised scholarship is needed to provide practical-recommendations; drawing on existing conceptual frameworks and using more rigorous research methods.

Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center

OBJECTIVES

Healthcare professionals are at higher risk for workplace violence (WPV) than workers in other sectors. This elevated risk exists despite the vast underreporting of WPV in the medical setting. The challenge of responding to this risk is compounded by limited empirical research on medical training environments. Understanding trainees' experience and educating them on workplace safety, WPV reporting, and awareness of resources are shared goals of educational and institutional leadership. In our setting, clear understanding and education were urgent after the enactment of a statewide "constitutional carry" law affording individuals a right to carry concealed firearms in all state-owned universities and hospitals, beginning in July 2017. We sought to examine the incidence of WPV affecting Internal Medicine trainees to understand the types of violence encountered, reporting rates, and the factors that influence reporting.

METHODS

We conducted a cross-sectional online survey of Internal Medicine residents and fellows in practice for the previous 12 months. Survey items included both forced choice and open-ended questions. Descriptive statistics were calculated and used to summarize the study variables. χ² tests were performed to examine whether sex differences existed for each of the survey questions. Qualitative responses were content analyzed and organized thematically.

RESULTS

Of 186 trainees, 88 completed the survey. Forty-seven percent of respondents experienced WPV, with >90% of cases involving a patient, a patient's family member, or a patient's friend. Verbal assault was the most common type of incident encountered. Trainees formally reported fewer than half of the violent incidents disclosed in the survey. Major factors that influenced reporting included the severity of the incident, condition of the patient, and clarity of the reporting mechanism.

CONCLUSIONS

Previous research indicates similar amounts and types of WPV. Likewise, a large percentage of the incidents are not reported. Addressing the key factors related to why physicians underreport can inform institutions on how to make systematic changes to reduce WPV and its negative impact. Future research is needed to examine whether specific interventions can be implemented to improve reporting and reduce the incidence of WPV.

Providing Good Care in the Shadow of Violence - An Interview Study with Nursing Staff and Ward Managers in Psychiatric Inpatient Care in Sweden

The aim was to describe the nursing staff and ward managers' experiences of safety and violence in everyday meetings with the patients. The qualitative content analyses resulted in four themes: the relationship with the patient is the basis of care; the organizational culture affects the care given; knowledge and competence are important for safe care; and the importance of balancing influence and coercion in care. The staff had a varied ability to meet patients in a respectful way. One way of creating a common approach could be to discuss and reflect upon different options in the meeting with the patient.

Psychiatry: A discipline at specific risk of mental health issues and addictive behavior? Results from the national BOURBON study

BACKGROUND

Physicians are at risk for burnout, anxiety and depression.

OBJECTIVE

To explore the self-reported mental health status, substance use behavior and motives of a national sample of interns in psychiatry compared to other specialties.

METHODS

Interns of the 35 French Medicine faculties were recruited through mailing lists and social networks between December 2016 and May 2018 and fulfilled internet anonymized questionnaires.

RESULTS

Overall, 2165 interns (302 interns in psychiatry and 1863 in other specialties) mean aged 25.9 years (±2.8), 35% males were included in the present study. In multivariate analyses, interns in psychiatry were found to have higher rates of current tobacco smoking (aOR = 1.9 [1.4-2.5], p < 0.001), alcohol use disorder (aOR = 1.5 [1.2-2.0], p = 0.001), cannabis use disorder (aOR = 2.7 [1.8-4.2], p < 0.001)). They were more frequently followed by a psychiatrist and/ or a psychologist (aOR = 2.5 1.9-3.3], p < 0.001), they consumed more often antidepressants (aOR = 3.8 [2.2-6.6], p < 0.001) and anxiolytic (aOR = 1.8[1.2-2.8]; p = 0.006). They reported to have been more frequently exposed to sexual assault (aOR = 2.2 [1.1-4.8], p = 0.04) and physical assault (aOR = 1.9[1.3-2.9], p = 0.002), and to have lower vitality (β = 3.5 [0.6-6.4], p = 0.02). Interns in psychiatry reported to have more often experienced ecstasy (aOR = 1.6 [1.2-2.3], p = 0.004), mushrooms (aOR = 1.5 [1.1-2.2], p = 0.04), amphetamines (aOR = 1.9 [1.2-3.1], p = 0.009) and LSD (aOR = 1.8 [1.1-3.1], p = 0.04). Beyond classical motives for this consumption (party, group effect), interns in psychiatry reported to seek more frequently disinhibition (aOR = 1.7 [1.3-2.2], p < 0.001), dealing with anxiety (aOR = 1.7 [1.3-2.3], p = 0.001), and to seek both stimulant (aOR = 1.4 [1.1-1.9], p = 0.04) and sedative effects (aOR = 1.9[1.3-2.7], p = 0.001).

CONCLUSIONS

Interns in psychiatry are more exposed to violence during medical studies, they report lower vitality and increased substance use behavior. Their motives for consumption suggest mental health problems associated with increased engagement in psychotherapy and self-medication of antidepressant/anxiolytic. This population should be targeted as a specific vulnerable population among interns in medicine to prevent ulterior bad health outcomes.

How do we keep our residents safe? An educational intervention

OBJECTIVE

Recent evidence suggests that 25-64 % of psychiatry residents are the victims of assault by patients; only a minority, however, feel they receive adequate safety and violence training during residency. To address this disparity, the author designed, implemented, and assessed the effectiveness of a brief educational intervention focused on improving the residents' ability to recognize violence risk and increase attention to safety in the psychiatric interview.

METHODS

The subjects were 13 second-year psychiatry residents. Effectiveness was evaluated via the assessment of the residents' written responses describing their first clinical intervention after hearing a case vignette of a potentially violent patient (before and 1 month following the intervention). Responses were evaluated for any evidence of concerns for safety.

RESULTS

The number of residents citing safety concerns increased (38 to 92 %), as did the level of sophistication in their proposed interventions.

CONCLUSIONS

A brief educational intervention focused on violence risk and interview safety may be effective in increasing residents' attention to safety concerns in their clinical care, and further work will be beneficial to confirm and expand upon these findings.