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).
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|
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|
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