Workplace Violence Against Healthcare Providers

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By Alicia Abbot, MPO, and John T. Brinkmann, MA, CPO/L, FAAOP(D)

Introduction

Workplace violence has been increasing for many years, but it is hitting the healthcare professions hardest.1 A crime survey conducted in 2014 by the International Association for Healthcare Security and Safety found that violent crimes in the U.S. healthcare system increased by 25 percent from 2012 to 2013.2 Nearly 24,000 physical assaults in the work environment occur every year, with almost 75 percent affecting healthcare providers.3-4 Due to this increased risk of assault while working, healthcare workers are nearly four times as likely to need time off due to an injury caused by workplace violence than any other reason (i.e. illness, family leave, etc.).3 A 2001 U.S. Bureau of Justice Statistics (BJS) document reported an annual incidence of 16.2 assaults per 1,000 physicians, 21.9 assaults per 1,000 nurses, and 8.5 assaults per 1,000 healthcare workers with varying job titles.5 In 2011 the incidence of assaults on nurses nearly doubled the 2001 rate to 39 assaults per 1,000 nurses per year.1 The U.S. Department of Labor reported that of the 100 fatalities that occurred in a healthcare workplace among social service employees in 2013, 27 were due to violent attacks and assaults.4

The Occupational Safety and Health Administration (OSHA) has defined workplace violence as "violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty."4 The BJS defines workplace violence as "nonfatal violence (rape/sexual assault, robbery, and aggravated and simple assault) against employed persons age 16 or older that occurred while they were at work or on duty."1 Though OSHA and the BJS have defined workplace violence, a lack of definition consensus prevents direct comparison of research before 2000 on the topic of workplace violence in healthcare. In 2000, Rippon attempted to create a consensus definition of aggression, which he defined as "behavior with intent that is directed at doing harm to a living being whether harm results or not, or with willful blindness as to whether harm would result."6 Rippon also set out to increase the validity and reliability of future research focused on workplace violence in healthcare by categorizing it by type, mode, and impact.6

The increased workplace violence in the healthcare sector compared to other occupations may be connected to patients' feelings of loss of control and the stress people experience in situations that require medical intervention.7 Some authors have made connections between increased violence and longer wait times to see healthcare personnel, unrestricted access to facilities with the implementation of open visitation, and the high-ranking hospital administration's lack of security knowledge.2 Violence initiated by a patient is often perpetrated by those who present with cognitive impairment, mental health issues, and/or drug and alcohol abuse.7 In many healthcare and allied health professions, close contact with patients is essential for quality and thorough patient care. The job-related act of encouraging or compelling a patient to do something they may not want to do, in fields such as occupational and physical therapy, increases the risk for violence and the inability to protect oneself from violent patient attacks.8 The effects of workplace violence by a patient on a nurse or physician are also well documented.9,12,14,15 These range from affecting the healthcare worker personally, affecting his or her ability to provide proper care to future patients, and affecting the desire to continue to work in the healthcare sector.12

While assault against nurses and physicians has been well documented and researched, assaults against allied health professionals has not been documented as thoroughly.1,9-11 Some of the published research includes information about "other healthcare workers," which may include allied health professionals, but few articles focus on the allied health professions.12 For example, in a survey administered in the United Kingdom in 2004, as many as 23 percent of respondents from the departments of radiology, physiotherapy, and occupational therapy had experienced some form of physical assault in the past year, and 25 percent of those respondents had experienced verbal aggression at least once a month.13

A literature review was performed to discover and assess the effects of healthcare worker–directed violence on healthcare providers as well as the effect on patient care and to apply current knowledge of the subject to O&P practice. Though all four types of workplace violence are seen in some form in the healthcare sector, this review focused only on violence perpetrated by the client/patient (Type II).

Methods

A review of the literature from 2000 forward was performed using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and PsycINFO. The first study to find a strong link between quality of care and workplace violence was published in 2001.14 Data from 18 research studies was systematically extracted and recorded. Of the 18 articles that fit the inclusion/exclusion criteria, 14 articles used surveys or questionnaires to determine the rates of workplace violence and the effects.9,10,12,14-24 Other types of studies used in the articles include face-to-face meetings, phenomenological analysis, and written narratives.12,17,25-26 Table 1 shows the study design, population, violence type, and outcome measures used in each of the included articles.

Table 1: Included study characteristics

Authors Study Design Population Violence Type Outcome Measure
McKenna et al. (16)Survey Nurses Verbal, Sexual, Physical -
Eker et al. (12)Survey, Face-to-Face meetings Combination (chiefs, doctors, residents, nurses, receptionists, CNAs, etc.) Verbal, Physical, Combination (verbal and physical) -
Chapman et al. (17)Survey, Semi-structured interview Nurses - -
Ryan et al. (18)Qualitative Assessments Combination (Psychiatrists, Psychologists, nurses, teachers, social workers, direct care staff, administration) Physical Beck Depression Inventory II, Beck anxiety Inventory, Impact of Events Scale, PTSD diagnostic scale, White Bear Suppression Inventory, Brief Symptom Inventory, Experience of Assault Questionnaire
Kurumlarinda et al. (19)Survey Nurses Verbal, Physical, Emotional, Sexual -
jussab et al. (25)Phenomenological Analysis Clinical Psychologist Verbal, Physical -
Atawneh et al. (9)Questionnaire Nurses Verbal, Physical -
wolf et al. (26)Narratives Nurses Verbal, Physical -
hahn et al. (20)Survey HCP with patient contact Verbal, Physical Survey of Violence Experience by Staff (SOVES-G-R)
Walsh et al. (21)Questionnaire Reporting HCPs Verbal, Physical Impact of Event Scale Revised
Wildgoose et al. (22)Survey Clinical Staff - General Health Questionnaire, Impact of Events Scale
bernaldo et al. (23)Questionnaire Doctors, Nurses, Support Staff Verbal, Physical Maslach Burnout Inventory, General Health Questionnaire
bonner et al. (24) Questionnaire Nurses Physical Impact of Event Scale, Beck Depression Inventory, Post- traumatic Stress Disorder Symptom Scale, General Health Questionnaire, Hospital anxiety and depression Scale
Stubbs et al. (8)Systematic Review Physiotherapists, Nurses Physical -
valente et al. (27)Post Incident Review Nurses Sexual -
gates et al. (15)Questionnaire Nurses Physical Healthcare Productivity Survey, Impact of Events Scale- Revised
roche et al. (10)Survey Nurses Verbal, Physical, Emotional -
arnetz et al. (14)Survey Various HCPs Verbal, Physical -


An overwhelming number of the articles discussed violence against nurses, but other occupations included physiotherapists, occupational therapists, physicians, medical residents, clinical psychologists, social workers, and support staff such as certified nursing assistants and medical assistants. Fifteen of the articles addressed physical violence, 11 verbal violence, four sexual violence, and two address-ed emotional violence. Two of the articles did not specify the type of workplace violence considered in the research. Ten different outcome measures were used in the articles.

Seventeen studies reported that violence perpetrated by a patient had notable negative effects on the healthcare professional. The documented effects on healthcare professionals can be found in Table 2. Diagnosable post-traumatic stress disorder was found in survivors of workplace violence in four articles reviewed. The healthcare professionals also expressed general fearfulness in and out of the workplace after surviving an incident of workplace violence. Many survivors of workplace violence in healthcare settings also acknowledged avoiding talking or thinking about the incident with coworkers, family, and friends. They often cited anger as a consequence of the violence they experienced. Survivors of patient-perpetrated workplace violence required an increased amount of time off work following the attack and reported more sleepless nights than they had prior to the attack. When returning to work after experiencing violence, survivors reported experiencing flashbacks of the incident while treating other patients, which led to difficulty treating current patients and anticipating caring for future patients. Survivors reported lacking confidence in their expertise after an attack, even in skills and expertise they were confident in before the attack. Survivors of violence reported battling intrusive thoughts throughout their workday and in their home life. Many healthcare professionals had thoughts of quitting their position after an attack and were much more likely to leave the profession than their unharmed counterparts due to an increased level of burnout.

Ten articles reported the overall patient quality of care was impacted after workplace violence experiences. The documented effects on healthcare quality after workplace violence can be found in Table 3. Quality of care was reduced as survivors reported being fearful of their patients as well as being reluctant to care for specific patients or any patients after experiences with violent patients. In three articles, survivors of healthcare worker–directed violence reported knowingly spending less time with their patients after the attack. Survivors reported decreased communication with their patients, patients' families, and coworkers after an incident of workplace violence. Survivors also reported having reduced interest in being a part of patient care, as well as continuing in their current positions, often reporting looking for a different position or leaving the field completely. One article found that physiotherapists often reduced their expectations for their patients after experiencing an incident of workplace violence from a patient. Survivors also found that they had reduced empathy and gave reduced emotional support to patients and their families after returning to work. After an attack by a patient, survivors admitted to lacking concentration that led to missed medication administration, increased falls in their patients, and increased errors in the administration of care to their patients.

Table 2: Results for effects on the healthcare professional after a workplace violence incident.

# PTSD Fear Avoidance Anger Time off Sleep-less Flash-backs Lack of Confidence Intrusive thoughts Thoughts of Quitting
(16) X X X
(12)X X
(17) X X X
(18) X X X X
(19) X X X
(25) X X X X
(9) X X X X
(26) X X X
(20) X
(21) X X
(22) X
(23) X
(24) X X X X X
(8)X X X X X X X
(27)X X X X X X
(15) X X X X X X
(10)
(14) X X X
Total 4 11 8 8 8 4 4 4 3 4

 

Table 3: Results for effects on quality of care after an incident of workplace violence by a patient.

# Less time spent with patients Fear and Reluctant to treat DECREASED ABILITY and desire to Communicate Reduced Interest in Job Reduced Expectations Reduced Empathy and Emotional Support Decreased ability to Concentrate
(16)X
(12)X X X
(17) X X
(18)
(19) X X
(25) X
(9)
(26)
(20)
(21)
(22)
(23)
(24)
(8)X X X X
(27) X X
(15) X X
(10) X
(14) X
Total 3 4 2 4 1 1 4


Discussion

This review demonstrates sufficient evidence that workplace violence perpetrated by patients has a negative effect on the healthcare worker as well as the quality of care they can provide to future patients.

Workplace Violence and O&P

Most of the subjects researched were nurses. Many healthcare providers spend extended periods of time with their patients, ranging from days to months, while O&P practitioners typically see patients for appointments of shorter duration, often with extended periods of time between appointments. O&P practitioners provide devices that could potentially reduce pain or increase a patient's ability to be active, rather than causing pain or a disturbance by performing actions such as drawing blood, waking a patient up for assessment or testing, or offering medication, all of which were found in research to be the beginning of assaults.16 Additionally, patients often have time to process their diagnosis before being seen by an O&P practitioner. Nurses and physicians, on the other hand, are often delivering bad news related to a patient's health and well-being, which causes higher levels of stress within the patient. Increased levels of stress and feelings of loss of control have been attributed to higher rates of violence perpetrated by patients.7

There are also similarities between O&P practitioners and the researched healthcare professionals. O&P practitioners must be in close contact with their patients to provide adequate treatment. Close contact and palpation in sensitive areas can cause patients to be uncomfortable and unpredictable. Close contact with a patient has been attributed to the increased incidence of assault on physiotherapists.8 O&P clinicians often encourage a patient to do or wear a device that could cause discomfort and inconvenience even when properly fitted to the patient. Encouraging a patient to do something they do not want to do, such as walking or getting out of bed after surgery, has been shown to cause a higher rate of assaults on physiotherapists.8 O&P practitioners often work with patients alone in an enclosed room, with limited options for escape if a high-risk situation develops, which has been documented as leaving healthcare professionals vulnerable and unprotected.19 The settings in which O&P practitioners provide services, including the operating room, recovery room, patient room, outpatient clinic, and the emergency department, and factors such as medications and pain, can cause patients to react in unpredictable ways. Emergency department workers report the highest rates of workplace violence perpetrated by patients, with 100 percent and 81 percent of workers reporting at least one incident of verbal and physical assault, respectively, in the past year.3,19

Clinical Application

This review demonstrates the importance of awareness of workplace violence perpetrated by patients. Many clinicians may believe that patient perpetrated violence is an expected part of the job, or assume that it won't happen to him or her. While violence against healthcare workers does occur, it should not be accepted as a normal part of the job.7,19 Research demonstrates that survivors of this type of violence are affected in many ways that can have a negative impact on the quality of care.

Education and prevention training should be integrated into education programs and facilities.16,28 A 2011 article reported that 94 percent of final year physiotherapy students in the United Kingdom stated that they did not feel confident in their ability to deal with violent and aggressive patients because they had not received any training for this type of situation.28 Kutlu reported in 2012 that only about 10 percent of healthcare institutions give any formal training and only 18 percent of states require violence prevention training in emergency department employees.19,29 Education about techniques such as de-escalation and restraint may reduce the incidence of assault by patients, as well as help students and practitioners feel more prepared and confident when entering the workforce.

The literature regarding healthcare worker–directed workplace violence offers a number of strategies practitioners can consider to prevent and de-escalate potentially volatile situations. The following suggestions can help practitioners feel more prepared for scenarios they may encounter.

Use de-escalation techniques with an agitated patient to help prevent violent behavior, such as:

  • Being aware of signs and symptoms of rising anger and agitation
  • Approaching the person in a calm and controlled manner, with a neutral posture and expression
  • Providing distraction
  • Using verbal techniques to calm the person down, including calm, respectful language and open-ended sentences—avoiding challenges and promises when possible
  • Withdrawing from the situation
  • Removing dangerous objects from the room when possible, and avoiding vulnerable positions such as turning your back to the patient
  • Taking note of exits in the vicinity

To manage a situation that may have already escalated to a physical altercation, having advance training can help prevent further injury.

  • Safe breakaway training teaches techniques that allow staff, if assaulted, to successfully remove themselves from holds to the body. Emphasis is also placed on protecting vulnerable areas of the body from further attack during any assault, for example by standing sideways rather than front facing to protect the groin area.1

The U. S. Occupational Safety and Health Administration has two documents about prevention and response to workplace violence in healthcare, "Preventing workplace violence: A roadmap for healthcare facilities," and "Guidelines for preventing workplace violence for healthcare and social service workers."2-3

These resources provide information on training to prevent workplace violence and well as guidance for helping survivors cope with the aftereffects of an encounter. Another article, "I just can't, I am frightened for my safety, I don't know how to work with her': Practitioners' experiences of client violence and recommendations for future practice," provides additional steps to aid in the healing process, in the unfortunate event that such strategies were unable to prevent an incident in the healthcare workplace.4

 

Challenges and Limitations

There were a number of challenges and limitations in this review. First, there is no consensus on the definition of violence or aggression in the published articles. The wide range of terms used for the same type of violence may have contributed to articles being excluded in the review. There is a lack of research in allied health fields, and it is difficult to compare the rates of violence in different professions. The wide range of duties among healthcare professionals also makes it difficult to generalize the results. Outcome measures are not used consistently in the literature, and many studies used subjective surveys rather than validated outcome measures.

Recommendation for Future Research

Future research on workplace violence within O&P should include prevalence surveys as well as a survey about the effects of workplace violence. Narrative description of incidents and validated outcome measures should also be incorporated into the research. Studies like this could be used to make students and practitioners aware of the signs and triggers for aggressive behavior, as well as provide recommendations for implementing security and safety measures. Clinical education programs should include education on workplace violence prevention and recovery strategies.

Conclusion

There is evidence that violence by patients against healthcare professionals has detrimental effects on the providers as well as the care future patients will receive. More research is needed in the allied health professions to improve education about the triggers, effects, and coping methods in that sector of healthcare. O&P practitioners can be placed in similar situations as other healthcare workers, and this research would guide the education of students and practitioners regarding how to remain safe while providing high quality care.

Alicia Abbott, MPO, is a resident at Miller Meier Limb & Brace, Bettendorf, Iowa. She received a bachelor's degree in biology from the University of South Dakota and a master's degree in orthotics and prosthetics from Northwestern University Prosthetics-Orthotics Center (NUPOC).

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at NUPOC. He has more than 20 years of experience treating a wide variety of patients.

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