Understanding patient-to-worker violence in hospitals: a qualitative analysis of documented incident reports

Behind the white coat: Unraveling the patterns of workplace violence in an Italian healthcare setting - An epidemiological exploration

AIM

In the present study, we aimed to provide an epidemiological and descriptive overview of violence against healthcare workers in an Italian university hospital, presenting and characterizing the risk factors in the department where such events occur and to propose ways to prevent aggressive behaviors.

METHODS

We retrospectively analyzed violence against healthcare workers by patients and attendants at an Italian university hospital from 2020 to 2022. Aggressions were documented in anonymous incident reports collected by the hospital's Clinical Risk Unit. The frequencies and percentages were calculated via a descriptive analysis. Chi-square tests were used to compare the wards with the most aggressions to other wards.

RESULTS

Of the 219 included cases, the aggressors were primarily male patients and the victims female nurses. Most of the aggressions occurred in the psychiatry and emergency department. Among the aggressors, 41.1%, had a psychiatric diagnosis or neurocognitive impairment. Over half the cases involved physical aggression. Compared to other wards, psychiatric wards showed an even distribution of aggressor gender, a higher proportion of male victims, fewer verbal aggressions, and less impact from environmental factors. Notably, female aggressor status (p < 0.001, OR = 8.687) and involvement in physical assaults (p < 0.001, OR = 15.236) were identified as independent risk factors associated with aggression in psychiatric settings.

CONCLUSION

Our findings align with the literature in that most of the incidents occurred in the psychiatry and emergency medicine departments and involved nurses. However, physical rather than verbal aggression predominated. Notable distribution, risk factor, and qualitative differences were observed between the psychiatric and non-psychiatric services, which warrants further investigation. Our results could be useful in implementing better prevention strategies based on the type of ward.

Staff and Work Environment Factors Associated With Workplace Violence in Hospitals: Comparison of Units With High Versus Low Rates of Violence

OBJECTIVE

This study examined healthcare worker perceptions of physical environment and safety climate contributors to workplace violence.

METHODS

Inpatient hospital employee (2015) convenience sample survey ( n = 327) comparisons were via Mann-Whitney, Wilcoxon rank sum, or chi-squared to determine response differences by workplace violence experience (yes/no) and hospital units (higher/lower) violence rates.

RESULTS

Employees with workplace violence experience and units with higher violence rates identified a higher number of contributing physical environment factors. Safety climate ratings were higher among employees without workplace violence experience but did not differ between hospital units with higher and lower violence rates.

CONCLUSIONS

Prioritization of staff perceived climate safety and physical environment contributors can support organizational efforts to mitigate specific workplace violence hazards on hospital units.

Perspectives of physicians on risk factors for patient aggression and violence against physicians in Chinese hospitals: a Q-methodology study

BACKGROUND

The prevalence of patient (and their relatives/friends) aggression and violence against healthcare professionals in general, and physicians in particular, is a recognized problem worldwide. While numerous risk factors for such aggression and violence from patients (and their relatives/friends) have been identified, little is known about which risk factors are perceived as relatively most important in a specific context and among a particular group, and about the potentially differing views on the relative importance. This lack of insight prohibits preventive measures being tailored to address the main risk factors.

METHOD

We conducted a Q-methodology study to investigate physicians' perspectives on risk factors for aggression and violence from patients (and their relatives/friends) against physicians in Chinese hospitals. A total of 33 physicians from public Chinese hospitals participated in this study and were asked to rank 30 risk factors according to their importance in triggering violent incidents. In addition, respondents were asked to explain their ranking of most and least important risk factors.

RESULTS

By employing a by-person factor analysis, four distinct perspectives on the importance of risk factors were identified: (1) unmet expectations of treatment and lack of resources; (2) perpetrator's educational background and personal characteristics; (3) distrust and limited protection measures; and (4) perpetrator's emotional well-being and poor interaction. There was a consensus across perspectives that failure to meet perpetrator's expectations is one of the most important risk factors and that physician's gender is one of the least important risk factors in the occurrence of patient (and their relatives/friends) aggression and violence against physicians in Chinese hospitals.

CONCLUSIONS

This study has identified four distinct perspectives held among physicians on the risk factors for patient aggression and violence against physicians in Chinese hospitals. These insights enable the development and prioritization of targeted measures to address specific risk factors according to the dominant views among physicians.

Association between workplace violence from patients and the mental health status of healthcare workers in Zhuhai China: a cross-sectional study

Objective

Workplace violence (WPV) poses a serious occupational risk. This study aims to explore the association between WPV from patients and the occurrence of insomnia, depression, and anxiety among healthcare workers.

Methods

Information about the WPV from patients was collected by a self-designed questionnaire. Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Insomnia Severity Index (ISI) were used for the assessment of mental health. Logistic regression was used to explore the association between WPV from patients and insomnia, depression, and anxiety. Mediation analysis was used to evaluate the mediation effect of depression and anxiety on the relationships between WPV from patients and insomnia.

Results

Of 10,413 included healthcare workers, 40.05% experienced verbal violence, 6.44% experienced physical violence from patients in the past year. There is a significant association between verbal violence and insomnia (OR = 1.780, 95% CI: 1.591-1.990), depression (OR = 1.823, 95% CI: 1.640-2.026), and anxiety (OR = 1.831, 95% CI: 1.606-2.087), as well as physical violence (insomnia: OR = 1.220, 95% CI: 1.002-1.481; depression: OR = 1.274, 95% CI: 1.052-1.540; anxiety: OR = 1.316, 95% CI: 1.058-1.630). Moreover, depression and anxiety mediated the relationship between WPV and insomnia, the mediated proportion was 62.21% in the association between verbal violence and insomnia, and 60.22% in the association between physical violence and insomnia.

Conclusions

The association between WPV from patients and heightened risks of mental health issues emphasizes the necessity of supportive work environments. Recognizing the mediating role of depression and anxiety stresses the significance of tailored mental health training for healthcare staff.

Haddon matrix model: Application to workplace violence in a hospital setting

The aim of this study was to identify hospital-based workplace violence (WPV) risk factors with the Haddon Matrix Model (HMM) to determine its potential utility to conceptualize multiple risks for WPV events. This descriptive study utilized two independent convenience samples Data from behavioral emergencies (2014-2015) for patient violence (N = 192) and from health care staff (N = 380) 12-month violence survey responses (2015) in a Midwestern academic hospital were analyzed. Logistic regression examined patient features associated with physical violence. Survey questions pertained to employee, environment, and cultural factors associated with WPV; responses were examined with Chi-square and two-sample t-tests. Violence risk factors populated the 4 Haddon Matrix domains at pre-event time frames as Host (worker)-age/demographics, Agent (patient)-age/gender, Physical Environment-door/window structure, and Social Environment-worker safety. Risks at event time frames populated for Agent-behavior/delirium, and Physical Environment-event medication/patient identification. The Haddon Matrix identification of hospital violence risks indicates its utility as a comprehensive approach to workplace violence.

Understanding the Experience of Workplace Violence in Hospitals as Documented by Nursing Staff: Using the READ Approach

Background: Workplace violence has a significant impact on patients, families, and staff safety. Workplace violence can produce traumatic results for those involved; the importance of preventive measures needs to be paramount in health service policy and process. Health care staff are required to document their experiences of violent incidents after every occasion, usually via an incident reporting system, which allows for a free text description of the event. There is a lack of understanding of how health care staff document reports of violence and how they explain the events. Methods: This study aims to determine the circumstances surrounding workplace violent events as documented by health care staff. The four-step Review, Extract, Analyze, and Document (READ) approach to document analysis was used to examine workplace violence incident reports over 12 months (September 2021-September 2022) in a tertiary referral hospital. Findings: Six categories of workplace violence were found: (a) "Escalation Dynamics"-patterns and progression of how violence incidents intensify; (b) "Warning Behaviors"-verbal or non-verbal signals that may foreshadow physical violence if not addressed; (c) "Authoritative Institutional Interventions"-how aggression correlates to protocols involving security personnel or law enforcement; (d) "Care Delivery Methods"-how certain treatment procedures and approaches might inadvertently elicit violence; (e) "Situational Stressors"-external circumstances or changes that act as triggers for violence; and (f) "Unprovoked triggers"-sudden and seemingly unprovoked violent outbursts. Conclusions and application to practice: Workplace violence in health care is a multifaceted interplay of events with the nurse involved in all aspects of the process. These findings can be used by occupational health nurses in education and policy development. The findings can be used to focus education on how violent incidents may escalate and provide more opportunities for de-escalation by health care staff.

The effect of simulated problem learning in nursing ethics on moral sensitivity, empathy and critical thinking of nursing students: A quasi-experimental study

AIM

Compare the effects of Simulation with problem-based learning (SPBL) and Problem-based learning (PBL) in nursing ethics education on nursing students' moral sensitivity, empathy, critical thinking, test scores and teaching satisfaction.

BACKGROUND

Promoting nursing students' individual and ethical and abilities through education is an essential way to improve their ethical performance and build trustful relationship with patients. Despite significant efforts in this area, few have evaluated the effectiveness of Simulation with problem-based learning and Problem-based learning as applied to nursing ethics education.

DESIGN

A quasi-experimental design based on a non-equivalent control group pre-test/post-test.

METHODS

A quasi-experimental design was used. Participants were 161 undergraduate nursing students from two levels of a university, 88 subjects in the experimental group were taught using Simulation with problem-based learning and 73 subjects in the control group were taught using Problem-based learning. A pre-test, post-test and questionnaire were used to assess the effectiveness of student nursing ethics education. χ2 test was used to examine group differences in students' characteristics and satisfaction with teaching post-intervention. Student's t-test was used to assess group differences in scale scores and test scores.

RESULTS

Compared to the pre-test, empathy as well as critical thinking were significantly higher in the PBL group (P<0.05), but there was no significant change in moral sensitivity (P>0.05); moral sensitivity, empathy and critical thinking were significantly higher in the SPBL group (P<0.05). Moreover, this study also showed that improvement in moral sensitivity, empathy, critical thinking and grades was more significant in the SPBL group of nursing students compared to the PBL group (P<0.05) and no statistically significant difference was found between the two groups in terms of teaching satisfaction (P>0.05).

CONCLUSION

The use of Simulation with problem-based learning in nursing ethics education has a positive impact on nursing students' competency development and knowledge acquisition. Nurse educators should consider this teaching method and promote change to increase the effectiveness of nursing ethics education.

Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience

BACKGROUND

Workplace violence is a global public health issue and a major occupational hazard cross borders and environments. Nurses are the primary victims of workplace violence due to their frontline roles and continuous interactions.

OBJECTIVE

The present study aimed to investigate the status of workplace violence, turnover intention, compassion fatigue, and psychological resilience among Chinese nurses, and explore the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses.

METHOD

A cross-sectional study was conducted among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China. Data was collected through an online questionnaire, which included a demographic information form, the Workplace Violence Scale (WVS), the Turnover Intention Questionnaire (TIQ), the Compassion Fatigue Scale (CF-CN), and the Connor-Davidson Resilience Scale (CD-RISC). Descriptive statistics and correlation analysis were employed to examine the relationships among the main variables. A moderated mediation analysis was further conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience.

RESULT

The present survey recruited a convenience sample of 1,141 clinical registered nurses, who reported experiencing multiple types of workplace violence during the past year. Correlation analysis revealed significant positive correlations between workplace violence and turnover intention (r = 0.466, P < 0.01) as well as compassion fatigue (r = 0.452, P < 0.01), while negative correlation between workplace violence and psychological resilience (r=-0.414, P < 0.01). Moderated mediation analysis revealed that compassion fatigue mediated, while psychological resilience moderated, the positive relationship between workplace violence and turnover intention (all P < 0.05).

CONCLUSION

This study underscores the mediating effect of compassion fatigue and the moderating role of psychological resilience in the relationship between workplace violence and turnover intention among Chinese nurses. Future efforts should be undertaken to develop effective preventive measures and intervention strategies at individual, organizational, and national levels to mitigate workplace violence and foster supportive work environment.

CLINICAL TRIAL NUMBER

Not applicable.

"Working in the emergency department is not a job; it's like a war" A narrative inquiry and interpretive phenomenology of the violence experienced by emergency nurses in Turkey

AIMS

This study aims to reveal the violent experiences of nurses working in the emergency department and the meanings they attribute to them.

METHODS

This research was conducted as narrative inquiry and interpretive phenomenology and recruited 15 nurses. Interviews with nurses actively working in the emergency department and who had been exposed to violence by patients or their relatives were conducted with a semi-structured interview form. The consolidated criteria for reporting qualitative research (COREQ) checklist was used.

RESULTS

In the study, three themes were determined (1) Unpredictable event, (2) Interminable effects of violence, and (3) Like a bottomless pit. With seven sub-themes.

CONCLUSIONS

This study underlined that violence applied to nurses by patients or relatives of patients in the emergency department is an unexpected situation that causes negative emotions. Violence affects all aspects of life and limits communication with the patient. Coping with a violent situation is challenging for nurses, and they demand support from the management.

Violence in the healthcare workplace

PURPOSE OF REVIEW

Healthcare workers experience a disproportionate frequency of workplace violence. Identifying commonalities among incidents of workplace violence provides an opportunity for change to prevent and mitigate future violence.

RECENT FINDINGS

Despite a continued decline in overall workplace violence, the rate of violence in the healthcare sector is steadily rising. While healthcare workers make up 13% of the workforce, they experience 60% of all workplace assaults. Environmental, structural, and staffing issues may all contribute to the increased rates of workplace violence affecting healthcare workers.

SUMMARY

Comprehensive proactive workplace violence prevention programs can significantly reduce the frequency of violence and the negative impact on employees and institutions. Analyzing the factors that contribute to violence in the healthcare workplace provides the potential to mitigate these risks and reduce episodes of violence.

Nurses' experiences of racism in mental health settings through patient and family interactions: A systematic review

Nursing staff engage readily with patients and associates in mental health/forensic inpatient settings. These settings are known to have instances of workplace violence directed towards staff and such violence includes racism. Racism is a form of workplace violence that must be better understood and supported within this complex setting. Completing a systematic review to coalesce preexisting research and suggested interventions can be beneficial to supporting nurses. Systematic review following PRISMA guidelines. CINAHL, PsycInfo, Medline, British Nursing Database and Web of Science databases were searched. Reviewers screened the papers for inclusion (29 articles out of 7146 were selected for inclusion) and completed the quality appraisal using the Mixed Methods Appraisal Tool. Subsequently, data extraction was completed, and findings were summarised through narrative synthesis. The way racism was conceptualised impacted how data was collected, reported and interpreted; racism was silenced or exposed depending on how studies were undertaken. If exposed, evidence indicates racism is a problem but is not always acknowledged or acted upon. Some evidence determined racism led to negative work-related outcomes. The literature provided limited examples of interventions. These included changing education/orientation for staff, openly discussing racist events and better planning for patients among colleagues and management. Increasing diversity within the workforce requires more research exploring and addressing issues related to racism towards nurses. Narratives of racism being normalised and embedded in mental health/forensic settings need to be challenged.

Risk factors for violence in an emergency department: Nurses' perspectives

OBJECTIVE

Work-related violence remains a significant problem in healthcare settings, including EDs. Violence risk assessment tools have been developed to improve risk mitigation in this setting; however, incorporation of these tools into standard hospital processes remains scarce. This research aimed to explore nurses' perspectives on the Bröset Violence Checklist used in routine violence risk assessment and their recommendations for additional items.

METHODS

Thirty nursing staff who used the Bröset Violence Checklist (BVC) as standard practice for 5 years participated in two focus groups where 23 violence risk factors were presented. Using multiple methods, participants were asked to select and elaborate from a pre-determined list what they considered most useful in violence risk assessment in respect to descriptors and terminology.

RESULTS

Quantitative data showed most risk factors presented to the group were considered to be predictive of violence. Ten were regarded as associated with risk, and overt behaviours received the highest votes. The terms 'shouting and demanding' was preferred over 'boisterous', and 'cognitive impairment' over 'confusion'. Patient clinical characteristics and staff perceptions of harm, inability to observe subtle behaviour, imposed restrictions and interventions and environmental conditions and impact were also important considerations.

CONCLUSIONS

We recommend that violence risk assessment include: history of violence, cognitive impairment, psychotic symptoms, drug and alcohol influence, shouting and demanding, verbal abuse/hostility, impulsivity, agitation, irritability and imposed restrictions and interventions. These violence risk factors fit within the four categories of historical, clinical, behavioural and situational.

A systematic review and thematic synthesis of inpatient nursing staff experiences of working with high-risk patient behaviours

INTRODUCTION

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours.

AIM

The aim of the study was to examine nursing staff experiences of high-risk behaviours in inpatient mental health settings.

METHODS

Four electronic databases (CINAHL, Medline, PsycINFO, EMBASE) were searched. The protocol for this review was prospectively registered in PROSPERO (Ref: CRD42022334739). A meta-synthesis of nursing staff's experiences of high-risk behaviours in inpatient mental health settings was conducted.

RESULTS

We identified 30 eligible studies. Six themes were constructed from the meta-synthesis: the social contract of care; the function of risk behaviours; the expectation of risk; risk as a relational concept; navigating contradictions in care; the aftermath.

DISCUSSION

Nursing staff conceptualize risk as a meaningful behaviour shaped by patient, staff and environmental factors. Managing risk is an ethical dilemma for nursing staff and they require more training and support in ethical risk decision-making.

IMPLICATIONS FOR PRACTICE

Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

RELEVANCE STATEMENT

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours. This systematic review offers insights into how high-risk behaviours are experienced by nursing staff and makes recommendations about how to improve the understanding and management of them. Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

The importance and feasibility of hospital interventions to prevent and manage patient aggression and violence against physicians in China: a Delphi study

BACKGROUND

Aggression and violence by patient (and their relatives/friends) is widely acknowledged as a serious occupational hazard, with physicians being particularly susceptible to witnessing and experiencing such incidents within hospitals. Research has shown that the negative consequences of such aggression and violence are not only felt at the individual level, but also at the team and organizational levels. Understanding how to prevent and manage this behavior towards physicians in hospitals is urgent and not fully researched. While there are many potentially effective interventions, it is unclear which ones would be valuable and feasible for Chinese hospitals. Because patient aggression and violence may occur more frequently in Chinese hospitals than in other countries, this suggests that cultural differences play a role and that tailored interventions may be needed.

METHOD

We conducted a Delphi study to reach a consensus on the importance and feasibility of hospital interventions to prevent and manage patient (and their relatives/friends) aggression and violence against physicians in Chinese hospitals. Seventeen experts in China were invited to complete online questionnaires over three rounds.

RESULTS

After three rounds, consensus was achieved concerning 44 interventions, five other interventions were rejected, and no consensus was reached on another two. These interventions were clustered into eight categories: environment design, access and entrance, staffing and working practices, leadership and culture, training and education, support, during/after-the-event actions, and hospital policy. Each category is considered important in preventing and managing patient (and their relatives/friends) aggression and violence towards physicians in Chinese hospitals. This study also investigated the feasibility of the suggested interventions and found that 36 of the 44 interventions were considered not only relevant, but also feasible for implementation in Chinese hospitals.

CONCLUSIONS

This study provides an overview of interventions that can be implemented in Chinese hospitals to prevent and manage patient (and their relatives/friends) aggression and violence before, during, and after a violent incident occurs.

Emergency department staff experiences of the Bröset Violence Checklist

AIM

Work-related violence is a significant problem in healthcare settings and emergency departments are one of the highest at-risk locations. There have been significant challenges in identifying successful risk-mitigation strategies to reduce the incidence and impact of work-related violence in this setting. This research explores the perspectives of clinical staff who routinely use violence risk assessment to provide recommendations for improvements.

DESIGN

This qualitative research used interviews of staff who routinely use of the Bröset Violence Checklist in an emergency department. The study was conducted in April 2022.

METHOD

Interview transcripts were subjected to Thematic Analysis to explore participants' clinical experiences and judgements about the utility of the Bröset Violence Checklist.

RESULTS

Eleven staff participated in semi-structured interviews. Participants described themes about the benefits of routine violence risk assessment and the influence of the subjective opinion of the scorer with respect to the emergency department patient cohort. Four categories of violence risk factors were identified: historical, clinical, behavioural and situational. Situational risks were considered important for tailoring the tool for context-specificity. Limitations of the BVC were identified, with recommendations for context-specific indicators.

CONCLUSION

Routine violence risk assessment using the Bröset Violence Checklist was deemed useful for emergency departments, however, it has limitations.

IMPACT

This study's findings offer potential solutions to reduce violence affecting front-line workers and practical processes that organizations can apply to increase staff safety.

IMPLICATIONS

The findings produced recommendations for future research and development to enhance utility of the Bröset Violence Checklist.

REPORTING METHOD

EQUATOR guidelines were adhered to and COREQ was used.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was involved in this study.

The Prevalence of Type II Workplace Violence in US Nurses 2000 to 2022: A Meta-Analysis

BACKGROUND

Physical violence against nurses is a concern in the United States; however, its prevalence is not well quantified.

OBJECTIVE

We sought to describe the prevalence of workplace violence against nurses in the United States over a 22-year period.

METHODS

A meta-analysis was performed following a literature search of English texts through Scopus, CINAHL Plus, and Ovid MEDLINE. Inclusion criteria included the following: (1) primary reports of workplace violence incidents in the United States against nurses, (2) perpetrator was a patient, family member, or visitor, and (3) publications between January 1, 2000, and June 21, 2022. Reports where prevalence rates for nurses could not be calculated were excluded. Study quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

RESULTS

Thirty-seven studies met the inclusion criteria; 27 030 nurses were included. The pooled prevalence of workplace violence was 0.35 (95% confidence interval [CI]: 0.29-0.42; Q = 3189.40; I2 = 98.87). Pooled rates of workplace violence increased from 30% in 2000 to 2004 to 43% in 2020 to 2022; however, the overlapping CIs indicate that the increase may not be statistically significant. The mean prevalence of reported workplace violence among nurses who work in the emergency department, in corrections, and psychiatric mental health settings (pooled prevalence = 0.59, 95% CI: 0.46-0.71) was higher than that of nurses who worked in all other settings (pooled prevalence = 0.24, 95% CI: 0.18-0.30).

CONCLUSIONS

Workplace violence is a significant and potentially increasing problem for nurses in the United States. This critical problem requires an effective response from nurse policymakers.

Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study

BACKGROUND

Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting.

OBJECTIVE

This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022).

METHODS

During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events.

RESULTS

In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators.

CONCLUSIONS

A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

Implementation of an Assault Prevention Quality Improvement Initiative in an Urban Emergency Department

BACKGROUND

Emergency department (ED) health care workers experience high rates of workplace violence (WPV).

LOCAL PROBLEM

Patient-to-staff physical assaults at an urban, academic adult ED ranged between 1 and 5 per month, with a rate of 0.265 per 1000 patient visits.

METHODS

A quality improvement initiative, guided by the Social Ecological Model framework that contextualized WPV in the ED setting, informed the development of a Risk for Violence Screening Tool (RVST) to screen adult patients presenting to the ED.

INTERVENTIONS

Plan-Do-Study-Act cycles were utilized to implement a violence prevention bundle that incorporated the RVST, an alert system, and focused assault reduction strategies.

RESULTS

Patient-to-staff physical assaults decreased to a rate of 0.146 per 1000 patient visits.

CONCLUSIONS

Risk for violence screening, an alert system, and assault prevention strategies provide opportunities for nurse leaders to promote ED workplace safety.

A Clinical Nurse Leader-Guided Behavior Management Consult Team to Impact Workplace Violence Against Nurses

BACKGROUND

Violence against nurses is a growing problem. Minimizing violence against nurses will contribute to a safer clinical environment.

LOCAL PROBLEM

An increase in violence against nurses was identified at a regional medical center in the Midwest.

METHODS

A clinical nurse leader (CNL)-led behavior management consult team was developed to support the clinical team with aggressive, disruptive, or violent patients. The team consulted, assigned interventions to address potential source(s) of agitation, provided clinical support and guidance, and developed clinical tools to manage future patients with similar behavior patterns.

RESULTS

Between April 2019 and January 2023, a total of 108 behavior management consults were completed. Staff appreciated the additional support from the team.

CONCLUSIONS

Implementation of a CNL-led behavior management consult team was found to be beneficial; other health care systems should consider implementing a similar consult team.

Understanding workplace violence against medical staff in China: a retrospective review of publicly available reports

BACKGROUND

Workplace violence against medical staff in China is a widespread problem that has negative impacts on medical service delivery. The study aimed to contribute to the prevention of workplace violence against medical staff in China by identifying patterns of workplace violence, key risk factors, and the interplay of risk factors that result in workplace violence.

METHODS

Ninety-seven publicly reported Chinese healthcare violent incidents from late 2013 to 2017 were retrospectively collected from the internet and analysed using content analysis. A modified socio-ecological model guided analysis of the violent incidents focusing on risk.

RESULTS

Physical violence, yinao, or a combination of physical and verbal violence were the typical forms of violence reported. The findings identified risk at all levels. Individual level risk factors included service users' unreasonable expectations, limited health literacy, mistrust towards medical staff, and inadequacy of medical staff's communication during the medical encounter. Organisational level risk factors under the purview of hospital management included problems with job design and service provision system, inadequacies with environmental design, security measures, and violence response mechanisms within hospitals. Societal level risk factors included lack of established medical dispute-handling mechanisms, problems in legislation, lack of trust and basic health literacy among service users. Situational level risks were contingent on risk factors on the other levels: individual, organisational, and societal.

CONCLUSIONS

Interventions at individual, situational, organisational, and societal levels are needed to systematically address workplace violence against medical staff in China. Specifically, improving health literacy can empower patients, increase trust in medical staff and lead to more positive user experiences. Organizational-level interventions include improving human resource management and service delivery systems, as well as providing training on de-escalation and violence response for medical staff. Addressing risks at the societal level through legislative changes and health reforms is also necessary to ensure medical staff safety and improve medical care in China.

Predictive care: a protocol for a computational ethnographic approach to building fair models of inpatient violence in emergency psychiatry

INTRODUCTION

Managing violence or aggression is an ongoing challenge in emergency psychiatry. Many patients identified as being at risk do not go on to become violent or aggressive. Efforts to automate the assessment of risk involve training machine learning (ML) models on data from electronic health records (EHRs) to predict these behaviours. However, no studies to date have examined which patient groups may be over-represented in false positive predictions, despite evidence of social and clinical biases that may lead to higher perceptions of risk in patients defined by intersecting features (eg, race, gender). Because risk assessment can impact psychiatric care (eg, via coercive measures, such as restraints), it is unclear which patients might be underserved or harmed by the application of ML.

METHODS AND ANALYSIS

We pilot a computational ethnography to study how the integration of ML into risk assessment might impact acute psychiatric care, with a focus on how EHR data is compiled and used to predict a risk of violence or aggression. Our objectives include: (1) evaluating an ML model trained on psychiatric EHRs to predict violent or aggressive incidents for intersectional bias; and (2) completing participant observation and qualitative interviews in an emergency psychiatric setting to explore how social, clinical and structural biases are encoded in the training data. Our overall aim is to study the impact of ML applications in acute psychiatry on marginalised and underserved patient groups.

ETHICS AND DISSEMINATION

The project was approved by the research ethics board at The Centre for Addiction and Mental Health (053/2021). Study findings will be presented in peer-reviewed journals, conferences and shared with service users and providers.

Workplace violence against healthcare workers using nationally representative estimates of emergency department data, 2015-2017

INTRODUCTION

Workers in the healthcare industry are at increased risk for workplace violence. The goal of this analysis is to determine the rate of injuries healthcare workers incurred as a result of intentional violence by patients in the workplace.

METHODS

Injuries linked to workplace violence that were treated in US emergency departments from 2015 to 2017 were identified using data from the National Electronic Injury Surveillance System-Occupational Supplement (NEISS-Work). All estimates and 95% confidence intervals were calculated using SAS® 9.4 Proc Survey to incorporate the stratified sample design of NEISS-Work.

RESULTS

Approximately 1.14 million injuries to workers in the healthcare industry were treated in US hospital emergency departments between 2015 and 2017. Intentional injuries by another person accounted for 15% of these healthcare-related injuries. The results also showed that male healthcare workers' rate of injuries was 2.3 times higher than their female counterparts despite composing a smaller proportion of the workforce. Injury rates were highest among the less-than-25 age group, and decreased as healthcare workers' age increased.

CONCLUSIONS

Workplace violence is a serious problem in today's healthcare settings that affects both employees and patient care. Although violence in the healthcare industry has been researched for decades, there has been an increase in violent incidents in this industrial sector. The disparity in injury rates by sex and age are areas of concern. Further research in these areas is necessary to understand the root causes of these incidents and inform violence prevention strategies.

Aggression in mental health care: Opportunities for the future-A qualitative study on the challenges when defining and managing aggression across inpatient disciplines

WHAT IS KNOWN ON THE SUBJECT?: Aggression towards caregivers is a global phenomenon in mental health care. Although attempts have been made to define aggression, there is no globally accepted definition. Discrepancies in defining aggression can lead to differences in judgement and a sub-par management of aggression. The fact that different disciplines work together in mental health care makes it an even more pressing matter as no research was found regarding a multidisciplinary definition of aggression. Currently, coercive measures, such as isolation, sedation or restraints, are the most common ways of managing aggression. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Mental healthcare nurses and psychologists defined aggression by previous experiences, and they also agree that there are no alternatives in managing aggression when non-coercive techniques do not work. Several opportunities and examples of best practice were given by the participants, but the consensus was that caregivers are in need of alternatives when they are face to face with acute aggression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is vital for residential units to agree on a definition of aggression and acute aggression. It is our belief that this can aid them in preventing and de-escalating aggression as well as diminishing the use of coercive measures. Further primary research exploring the opportunities of non-coercive techniques, a multidisciplinary approach and the relationship between a workplace culture normalizing aggression and the mental well-being of healthcare workers is also needed.

ABSTRACT

INTRODUCTION: Aggression by patients against healthcare workers is a global recurring phenomenon in mental health care. Discrepancies in defining aggression can lead to differences in judgement, which in turn causes difficulties in managing aggression. The multidisciplinary nature of mental healthcare makes a standardized definition an even more pressing matter. No studies, however, were found exploring the way different disciplines approach the definition of aggression. Although traditional methods of managing aggression rely on coercive methods, current research favours the use of non-coercive measures.

AIM

The aim of this study was to explore the different ways mental healthcare nurses and psychologists define and manage aggression in a residential unit.

METHOD

A qualitative research design was used, consisting of interviews and focus groups. Transcripts were analysed using a reflexive thematic approach.

RESULTS

Three major themes were found: (1) approaches towards defining aggression, (2) experiencing aggression and (3) managing aggression: the need for alternatives.

DISCUSSION

In this study, aggression is defined by how aggression has been experienced, both mental health nurses and psychologists agree that there are no alternatives in managing aggression when non-coercive techniques do not work. Aggression is considered an integral part of the job indicating an "aggression-tolerating" workplace.

IMPLICATIONS FOR PRACTICE

Three implications for practice were identified: (1) It is vital for residential units to agree on a broad-based definition of aggression, (2) further primary research exploring the opportunities of non-coercive techniques and a multidisciplinary approach is crucial and (3) the relationship between a workplace culture normalizing aggression and the mental well-being of healthcare workers also needs further study.

Workplace's Development of Activities and Action Plans to Prevent Violence From Clients in High-Risk Sectors

INTRODUCTION

Interventions trying to prevent violence from clients towards employees tend to show limited effect on the risk or the frequencies of violent episodes, possibly due to a too-narrow focus on only one or a few preventive strategies. This study aimed to show what employees and line managers identify as key intervention areas for preventing violence and threats.

METHODS

The study is based on data collected during a participatory intervention study aiming to improve violence prevention in Danish psychiatric units and prison and detention centers. In the intervention study, employees and line managers from 13 work units developed 293 suggestions and 92 action plans to prevent workplace violence. Through qualitative thematic analysis of the suggestions and action plans, we identified the main categories that work units viewed as important and realistic to work with to improve violence prevention.

RESULTS

We identified 12 topics of violence prevention that work units considered relevant. Action plan topics used by more than half of the work units included: specific approaches to violence prevention (e.g., de-escalating techniques), communication between employees to transfer knowledge between shifts, and introduction to new employees and temporary workers. Topics used by three to five work units were: interdisciplinary corporation, communication and relational work, uniform approaches, organization of work, and staffing. Topics used rarely were: definition of violence and threats, policy and guidelines, support from colleagues and management, and engagement in violence prevention. For nine of the 12 topics, action plans were developed in both high-risk sectors.

CONCLUSIONS

The violence prevention action plans developed by work units from two high-risk sectors indicate that workplaces estimate the prevention of client-induced workplace violence to require activities on many levels and cannot be solved by a single focused approach. This variety of preventive activities needs to be considered when designing violence prevention interventions.

What is the impact of patient violence in the emergency department on emergency nurses' intention to leave?

AIM

To examine the impact that patient violence, experienced in the emergency department, has on emergency nurses' intention to leave their job.

BACKGROUND

Emergency departments have become known for their overcrowding, chaos, unpredictability and violence. Emergency nurses are at high risk of experiencing workplace violence, which is cited in the literature as having a direct effect on general nurses' intention to leave. A high rate of nursing turnover may lead to short staffing, jeopardize the quality of patient care and increase overcrowding and wait times.

EVALUATION

A systematic review was undertaken in CINAHL, Medline and Psych INFO databases using published data until November 2021. Six articles were included, and PRISMA guidelines were adhered it.

KEY ISSUES

Workplace violence in the emergency department had a direct impact on emergency nurses' intention to leave and decreased their job satisfaction. Verbal abuse is the most experienced form of workplace violence.

CONCLUSIONS

Workplace violence experienced by emergency nurses in the emergency department had a direct positive impact on their intention to leave and subsequently negative impact on their job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

This review may inform clinical decision-making and aid in the development of clinical practice guidelines for a workplace violence prevention programme, specific to the emergency department.

Is there a role for ethics in addressing healthcare incivility?

In a healthcare setting, a multitude of ethical and moral challenges are often present when patients and families direct uncivil behavior toward clinicians and staff. These negative interactions may elicit strong social and emotional reactions among staff, other patients, and visitors; and they may impede the normal functioning of an institution. Ethics Committees and Clinical Ethics Consultation Services (CECSs) can meaningfully contribute to organizational efforts to effectively manage incivility through two distinct, yet inter-related channels. First, given their responsibility to promote a humane, respectful, and professional climate, many CECSs and Ethics Committees may assist institutional leadership in evaluating and monitoring incivility policies and procedures. Second, when confronted with individual incidents of patient/family incivility, Ethics Consultants can and often do work with all stakeholders to address and mitigate potentially deleterious impacts. This manuscript presents an overview of the multifaceted ethical implications of incivility in the healthcare environment, discusses the inherent qualifications of Ethics Consultants for assisting in the management of incivility, and proposes specific mitigating actions within the purview of CECSs and Ethics Committees. We also invite healthcare organizations to harness the skills and reputation of their CECSs and Ethics Committees in confronting incivility through comprehensive policies, procedures, and training.

Psychiatric nurse's perceptions of their interactions with people who hear voices: A qualitative systematic review and thematic analysis

WHAT IS KNOWN ON THE SUBJECT?: There is no qualitative systematic review of nurses' perceptions of their interactions with people hearing voices. There are some studies exploring the interventions provided by community psychiatric nurses to people hearing voices; these give a sense of what interactions may contain. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: Nurses across both community and inpatient mental healthcare settings feel uncertain about how to interact with people hearing voices, sometimes feeling like they can do little to help. Their interactions are affected by the workplace culture, education and training and concern for their own safety. Nurses rely on a therapeutic relationship for all interactions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This is an under investigated area of mental healthcare. None the less this qualitative systematic review highlights that nurses are unclear about how to interact with service users hearing voices with the resultant outcome that service users in great distress may only be receiving minimal benefit from their interactions with the nurses caring for them. ABSTRACT: Aims and Objectives The aim of this qualitative systematic review and thematic analysis was to identify and synthesize results from studies that explored psychiatric nurses' perceptions of their interactions with service users experiencing auditory hallucinations (hearing voices). Method Qualitative systematic review and thematic analysis. Results Five studies that met the inclusion criteria were identified. Nurses reported that they felt uncertain about what to do for service users hearing voices, struggled to have interactions with voice hearers, but greatly valued the therapeutic relationship with service users. Nurses also reported that they required more education and training on how to interact effectively with people hearing voices. Finally, various workplace challenges were identified as an important factor mediating nurse interaction with service users hearing voices. Discussion Existing evidence shows that nurses lack clarity about how they can interact effectively and in a way that helps service users who are hearing voices. Significant barriers that they must overcome in order to be more certain of their role in caring for people hearing voices are difficult to engage service users and workplace challenges that were not conducive to helpful interactions and conversations. Implications for Practice Nurses caring for people hearing voices require more and better education and training with a view to them becoming more confident and competent when interacting with this service user group. Furthermore, healthy workplace cultures and maintaining a safe environment are necessary for effective caring interactions with people hearing voices.

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.

Workplace violence against emergency health care workers: What Strategies do Workers use?

Background

Workplace violence by patients and bystanders against health care workers, is a major problem, for workers, organizations, patients, and society. It is estimated to affect up to 95% of health care workers. Emergency health care workers experience very high levels of workplace violence, with one study finding that paramedics had nearly triple the odds of experiencing physical and verbal violence.

Many interventions have been developed, ranging from zero-tolerance approaches to engaging with the violent perpetrator. Unfortunately, as a recent Cochrane review showed, there is no evidence that any of these interventions work in reducing or minimizing violence.

To design better interventions to prevent and minimize workplace violence, more information is needed on those strategies emergency health care workers currently use to prevent or minimize violence.

The objective of the study was to identify and discuss strategies used by prehospital emergency health care workers, in response to violence and aggression from patients and bystanders. Mapping the strategies used and their perceived usefulness will inform the development of tailored interventions to reduce the risk of serious harm to health care workers.

In this study the following research questions were addressed: (1) What strategies do prehospital emergency health care workers utilize against workplace violence from patients or bystanders? (2) What is their experience with these strategies?

Methods

Five focus groups with paramedics and dispatchers were held at different urban and rural locations in Canada. The focus group responses were transcribed verbatim and analyzed using thematic analysis.

Results

It became apparent that emergency healthcare workers use a variety of strategies when dealing with violent patients or bystanders. Most strategies, other than generic de-escalation techniques, reflect a reliance on the systems the workers work with and within.

Conclusion

The study results support the move away from focusing on the individual worker, who is the victim, to a systems-based approach to help reduce and minimize violence against health care workers. For this to be effective, system-based strategies need to be implemented and supported in healthcare organizations and legitimized through professional bodies, unions, public policies, and regulations.

Effect of Safewards on reducing conflict and containment and the experiences of staff and consumers: A mixed-methods systematic review

Safewards is an internationally adopted framework that provides interventions to reduce conflict and containment in healthcare settings. This systematic review evaluated the effect of Safewards on conflict and containment events in inpatient units and the perceptions of staff and consumers. Quantitative, qualitative, and mixed-methods studies were considered for inclusion. Following the Joanna Briggs Institute methodology, two reviewers independently screened, appraised, and extracted data. Qualitative data were synthesized using inductive-thematic analysis. Quantitative and qualitative data were integrated with a convergent-segregated approach and presented in tabular and narrative format. A search of 13 databases and grey literature yielded 14 studies of variable methodological quality. Four studies reported reduced rates of conflict and one study reported reductions that were not statistically significant. Six studies reported reductions in rates of containment, three studies found no statistical significance and one study reported statistically significant reductions at follow-up. Staff and consumers in four studies reported an improved experience of safety. Three themes were developed as follows: (i) therapeutic hold, cohesion, support and the environment, (ii) conflict, containment and the experience of safety, and (iii) the complexities of adapting and embedding change. This review found most staff and consumers reported Safewards improved therapeutic relationships, cohesion, and ward atmosphere. Staff and consumers reported improved ward atmosphere, leading to consumer-centred, recovery-oriented care. Safewards improved the experience of safety from the perspective of staff and consumers when combined with ongoing training, leadership and time for consolidation. While results are promising they should be used cautiously until more robust evidence is established.

Preventing patient violence in hospitals: Applying critical decision method interviews to understand how skilled staff think and act differently

AIMS

Our aims were to understand how hospital staff who are skilled at managing aggressive patients recognize and respond to patient aggression and to compare the approaches of skilled staff to the experiences of staff who were recently involved in incidents of patient violence.

BACKGROUND

Violence from patients toward staff is prevalent and increasing. There is a need for greater understanding of effective approaches to managing patient aggression in a wide variety of hospital settings.

METHODS

We conducted grounded theory qualitative research applying Critical Decision Method interviews at two hospitals. Skilled staff and incident-involved staff were asked to describe experiences involving aggressive patients and the data were analyzed qualitatively.

RESULTS

Our interviews (N = 23) identified positive approaches and challenges to managing aggressive patients. Positive approaches included: maintaining empathy for the patient, allowing the patient time and space, exhibiting a calm demeanor, not taking things personally, and implementing strategies to build trust. Challenges included: inadequate psychiatric resources, balancing priorities between patients with urgent physical needs and those exhibiting difficult behaviors, and perceiving pressure to de-escalate situations quickly. Incident-involved staff were more likely to describe the challenges listed above and a limited tolerance for patients whose behavior they perceived as unjustified or detracting from other patients' care.

CONCLUSION

The Critical Decision Method proved valuable for highlighting nuanced understandings of skilled staff that sometimes contrasted with perceptions of incident-involved staff. Our findings support investigation of novel approaches to training such as peer coaching and improving empathy through increased understanding of mental illnesses and addiction.

Healthcare professionals' and patients' attitudes toward the causes and management of aggression in Estonian psychiatric clinics: a quantitative cross-sectional comparative study

BACKGROUND

To enhance patient aggression management efficacy and to reduce the use of coercive interventions in inpatient psychiatric care, it is important to know the attitudes of all involved parties towards the aggression and its management.

AIMS

This study aimed to explore attitudes of the psychiatrists, nurses and inpatients toward the causes and management of patient aggression in Estonian psychiatric clinics. A frequency of aggressive behaviour experienced by professionals, the relationships between the attitudes, participation in coercion, and a frequency of aggression, were also identified.

METHODS

To assess attitudes towards the causes and management of patient aggression, the Management of Aggression and Violence Attitude Scale was implemented.

RESULTS

The survey comprised of 63 psychiatrists, 197 nurses and 199 inpatients. The patients and the professionals had similar as well as different attitudes toward aggression and its management. Patients expected professionals to take a more personal approach when aggression occurs; in some cases, allowing the patients to deal with negative emotions on their own but, if necessary, isolating or restraining the violent people.

CONCLUSIONS

There is a need of training programs that focus on dealing patient aggression to foster a culture of safe, patient-centred care and to reduce aggression in psychiatric clinics.

Workplace Violence Against Doctors in Bangladesh: A Content Analysis

Workplace violence in healthcare settings is a common global problem, including in Bangladesh. Despite the known presence of workplace violence in healthcare environments of developing countries, there is limited understanding of factors that lead to hospital violence in Bangladesh. This study aims to explore factors that influence incidents of violence against healthcare professionals in Bangladesh, as reported by doctors via social media forum. Content analysis was conducted on 157 reported incidents documented on "Platform," the online social media most used by medical students and doctors in Bangladesh. Posts by doctors detailing experiences of physical or verbal violence at their workplace between July 2012 and December 2017 were included in this study. The majority of reported incidents were reported by male doctors (86%) and from government hospitals (63.7%). Findings showed that primary healthcare centers experienced more violence than secondary and tertiary facilities. This may largely be due to insufficient human and other resources in primary care settings to meet patient demand and expectations. Most of the events happened at night (61%), and as a result, entry-level doctors such as emergency duty doctors and intern doctors were commonly affected. Six themes were identified as vital factors in workplace violence against doctors: patients' perspectives, delayed treatment, power practice, death declarations, extreme violence, and care-seeking behaviors. Most incidents fell under the categories of delayed treatment and power practice at 26.8 and 26.1%, respectively. This study identified possible factors for reported violence in hospital settings. To address and reduce these incidents, hospital administrators should be aware of risk factors for violent behavior and design appropriate measures to prevent workplace violence. Further qualitative and quantitative research is needed to appropriately address the consequences of violence on healthcare workers and implement measures to mitigate these events.

Causes of workplace violence against nurses from patients and their relatives: A qualitative study

BACKGROUND

Nurses are frequently exposed to violence in workplaces. Although the causes of workplace violence have been widely analyzed, there are only a limited number of qualitative studies dealing with violence against nurses from patient and their relatives with a comprehensive and multi-directional approach.

AIM

This study aimed to explore the causes of violence against nurses exercised by patients and/or their relatives in different departments of Turkish hospitals.

METHODS

This study utilized a qualitative descriptive design. Participants were chosen with purposive sampling and maximum variation sampling method from five different hospitals. Semi-structured in-depth interviews were conducted with 34 nurses working in different positions and departments. The interviews were recorded with audio recorders and the data were analyzed with a content analysis.

RESULTS

Four major themes emerged from the nurses' perspective concerning causes of workplace violence including the followings: (1) health care system, (2) health institutions, (3) health professionals, and (4) patients and their relatives. The themes "health care system" and "health institutions" include four subthemes, "health professionals" include five subthemes and "patients and their relatives" include twelve subthemes.

CONCLUSION

There are various causes why nurses are exposed to violence in the workplace by patients and/or their relatives. Since the causes of violence are a multifaceted issue, prevention strategies of violence against nurses should be planned and implemented accordingly.

Workplace violence in primary hospitals and associated risk factors: A cross-sectional study

AIM

To investigate the characteristics of workplace violence at primary hospitals in Southeast China and identify associated risk factors.

DESIGN

A cross-sectional survey design was used for this work.

METHODS

We distributed a workplace violence questionnaire among medical staff at primary hospitals in Southeast Zhejiang Province, China. The data were collected between December 2016 and December 2017. We analysed the categorical data by using the chi-square test and expressed it as frequencies. The risk factors were analysed by using multiple logistic regression analysis.

RESULTS

Among the 2,560 questionnaires, 1,842 (71.9%) medical staff indicated that they had experienced workplace violence. Verbal assault was the most common type, followed by physical and sexual assault. Furthermore, gender, age, marital status, education, technical position and number of hospital beds' numbers were independent risk factors.

Comparison of patients' and staff's perspectives on the causes of violence and aggression in psychiatric inpatient settings: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Aggression and violence are persistent problems in psychiatric inpatient units. Violence preventive factors have been identified from both staff's and patients' perspectives. Violent and aggressive inpatient incidents have not been adequately explained in research and reviews to date. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review is novel in that it provides a comparison of patients' and staff's perspectives and identified that these differ and were influenced by factors attributable to the inpatient culture. The one contributory factor both agreed upon was the role of staff's interpersonal skills in either exacerbating or de-escalating aggression and violence. The inpatient culture was found to engender differing perceptions of most contributory factors to violence and aggression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: While staff's interpersonal skills were identified as a primary influence on whether their interaction with patients contributed to aggression and violence, this was shaped by the inpatient environment's culture. Patient-centred interactional skills need to focus on the patients' needs for respect and active participation rather than engendering feelings of disrespect or coercion. Patient-centred communication skills that demonstrate an understanding of the patient's experience in the inpatient environment need to be core skills for mental health nurses. ABSTRACT: Introduction High rates of aggression and violence are a persistent problem in inpatient mental health environments. A comparison of staff's and patients' perceptions of the causes may provide novel insights. Aim This review aimed to compare patients' and staff's perspectives on the causes of aggression and violence in inpatient environments. Method An integrative review of the literature was conducted with a search of Ovid (Medline, Embase, PsycINFO) databases and manual searching. Results Thirty articles met criteria for inclusion. Interactions prior to aggressive or violent incidents were characterized by patients as disrespectful and coercive, and by staff as indicative of the patient's mental state or personality. Both groups identified the importance of patient-centred communication skills. Discussion The review identified that patients and staff have differing perspectives on the causes of violence and aggression. There was an interactional dynamic between staff and patients that was shaped by the culture of the inpatient setting. Implications for Practice Understanding how the inpatient culture plays a role in shaping a dynamic between patients and staff and developing communication skills that acknowledge this may help reduce violence and aggression in inpatient settings.

Development and effectiveness of tabletop exercises in preparing health practitioners in violence prevention management: A sequential explanatory mixed methods study

BACKGROUND

Workplace violence in healthcare remains a significant issue for healthcare professional, in terms of risk to patients and staff. One part of a workplace violence prevention and management programme is to educate staff in their response to critical events. Drawn from the disaster management literature, tabletop exercises were used in this study to simulate workplace violence and educate staff on the appropriate emergency response during a violent event. The use of tabletop exercise in this context is a novel approach to workplace violence prevention management.

AIM AND OBJECTIVE

This study describes the development and effectiveness of tabletop exercises in preparing health practitioners in violence prevention and management emergency response systems.

METHODS

Using a sequential explanatory mixed method design. The study comprised of two phases 1) quasi-experimental (quantitative) and 2) focus group (qualitative) to evaluate the effectiveness of the violence prevention management tabletop exercises. COREQ guidelines were followed the qualitative arm of the study and the TREND statement for the quantitative part of the study.

RESULTS

Statistically significant improvements in healthcare professional confidence levels were found two weeks post the tabletop exercises. A post focus group revealed three categories concerning the participant's experiences of the tabletop exercises, (role clarity, adult learning and organisational support).

CONCLUSION

Tabletop exercise may provide a, low cost, context specific novel approach to educating staff in emergency violence response systems at a tertiary referral hospital. Educators and policy makers may consider the use of tabletop exercises in the ongoing work in preparing health care staff for workplace violence.

RELEVANCE TO CLINICAL PRACTICE

Successful tabletop exercises should consider a local ward level context, the use of adult learning principles, have high level organisational support and cover role clarity as a key learning area.

The Causes of Occupational Accidents and Injuries in Romanian Firms: An Application of the Johansen Cointegration and Granger Causality Test

Organizational risks are present in any activity, so it is important to manage them properly. The jobs are dynamic and involve a series of processes and activities. The entire human resource is exposed to several risks. If these risks are approached correctly, the organizational capacity to achieve its objectives and vision will increase considerably. This paper aims to investigate the relationships between work accidents (fatal and non-fatal) and the causes that contribute to their occurrence (causes dependent on the executor, causes dependent on the means of production, workload-dependent causes, and work-dependent causes—the work environment). The augmented Dickey–Fuller (ADF) test is employed to check the data stationarity series, while the Johansen test determines the cointegration relation of variables. The data have been collected from Romanian organizations. The vector error correction model (VECM) and Granger causality test are applied for speed of adjustment, nature, and direction of variables’ relationship. This research demonstrated that both data series are free from the unit-root problem at first difference. The lag length criterions select the third lag for model fitness, and Johansen cointegration declares that variables are cointegrated for the long term. The vector error correction model shows the speed of adjustment from the short to the long run is 83.35% and 42.60% for work and fatal accidents. The study results show that fatal accidents have a series relationship with selected cases for the short run and have a long-run relationship with the means of production. Fatal accidents are directly related to means of production. Fatal accidents are not designed by executors, workload-dependent causes, or work environments in the short run. Fatal accidents are directly related to the means of production and sudden incidents happening in the long run. Fatal accidents are considered by executors, workload-dependent causes, or work environments in the short run. In the long run, fatal accidents are directly related to the means of production and sudden incidents happening.

The symptoms and factors associated with post-traumatic stress disorder for burns nurses: a cross-sectional study from Guangdong province in China

BACKGROUND

The symptoms of post-traumatic stress disorder (PTSD) among medical staff has become a significant issue. Environments related to burns are highly stressful for nurses and can lead to PTSD, thus affecting their mental health. It is vital to consider that the quality of burns care, and the outcomes of such treatments, may be threatened if nurses experience PTSD. We evaluated PTSD symptoms in burns nurses and explored the correlations between demographic characteristics, work-related characteristics, professional identity, turnover intention, and PTSD symptoms.

METHODS

This was a cross-sectional study involving 273 nurses working in burns unit from Guangdong, China, between July and August 2019. Nurses were recruited from 30 hospitals and completed three validated psychological questionnaires: Post-traumatic Stress Disorder Checklist-Civilian Version (PCL-C), Professional Identity Scale for Nurses (PIS), and Turnover Intention Questionnaire (TIQ). We also collated information relating to socio-demographic and work-related characteristics.

RESULTS

The cut-off point for the PCL-C was defined as 38 points; 17.22% (n=47) of participants scored higher than or equal to 38. The PCL-C score was negatively correlated with professional identity level (P < 0.01) and positively correlated with turnover intention (P < 0.01). The workplace, mean monthly income, experience of workplace violence, and professional identity level, were important factors and all associated with the severity of PTSD.

CONCLUSION

PTSD symptoms were common in burns nurses. Attention should be paid to the mental wellbeing of these staff. Screening processes need to be initiated to identify individuals suffering from PTSD and take appropriate early interventional action.

Beyond the numbers: Utilising existing textual data for qualitative research in pharmacy and health services research

INTRODUCTION

Qualitative research is a well-established branch of scientific enquiry that draws insights from experiences.^{1, 2}Within social and administrative pharmacy research, interview and focus group methods are a mainstay of collecting data. However, other disciplines such as sociology, psychology and anthropology, use existing data that is routinely to provide a substance for qualitative inquiry. Drawing on our experiences of using interdisciplinary research methods, this paper presents three case studies where textual data was qualitatively analysed and critically examines the strengths and weaknesses of these method in relation to pharmacy practice.

METHODS

Three case studies were selected that access different types of existing, routinely collected data from pharmacy practice. This included 1) a study utilising boardroom meeting minutes, 2) a study using incident reports and 3) a study using WhatsApp messages as data. Each case study is described and critically examined. The strengths and weaknesses of this approach are based on our own reflections of completing the studies.

RESULTS

Relationships between people, products and organisations can be examined in documents, records and text that is routinely collected. Existing data can also provide insights into culture, working patterns, education and errors. Practical advantages of using existing data include faster data collection and access to first-hand, accounts of experiences of human relationship with pharmaceutical products and practice. Drawbacks of using existing data are that some data may be missing, participants may no longer be accessible for participant checking and the context of language may have changed.

CONCLUSION

This paper critically examined the use of methods rarely used in pharmacy practice research which draw on existing, routinely collected data. Adopting a wider range of data collection methods may will provide new understanding and insights into social and clinical pharmacy practice.

Effects of internal service quality on nurses' job satisfaction, commitment and performance: Mediating role of employee well-being

AIM

The attitudes and behaviours of nursing staff are critical to determine patients' satisfaction and to have a competitive advantage for any healthcare organization. This study is set to investigate the effects of internal service quality (ISQ) on nurses' job satisfaction, employee commitment, well-being and job performance in the healthcare sector of Pakistan. Further, this study also examines the mediating role of nurses' well-being for the relationship of job satisfaction and commitment with their job performance.

METHODS

This was a cross-sectional quantitative research. A self-administered survey was used to collect data from 412 nursing employees of 20 private sector healthcare centres operating in Pakistan. Partial least square of structural equation model (PLS-SEM) and structural equation modelling (SEM) were employed through Smart PLS 3.2.8 for data analysis.

RESULTS

Study results revealed that ISQ directly effects employees' satisfaction, commitment, well-being of the nursing employees. Moreover, employees' well-being has mediated job satisfaction and job performance relationship; however, well-being did not mediate the relationship between commitment and job performance.

User-friendly system (a smartphone app) for reporting violent incidents in the Emergency Department: an Italian multicenter study

BACKGROUND

Nurses, particularly emergency nurses, are among the health workers most exposed to workplace violence. Although reporting systems are increasingly used, under-reporting remains high. Recent studies suggest that the use of easy registration systems could facilitate violence reporting.

OBJECTIVES

To verify if a friendly reporting system based on a Mobile-app can facilitate the reporting of violent episodes and reduce under-reporting.

METHODS

Twenty emergency departments of five North and Central Italian regions participated in an interventional, multicentric, pre-post study to verify if a user-friendly reporting system based on a mobile app can facilitate the reporting of violent episodes and reduce under-reporting.

RESULTS

Three hundred and eighty-four out of 754 potentially eligible nurses answered the short questionnaire at time T0, and 318 registered for the use of the app. One hundred and eighty-nine answered the questionnaire at time T1. The t-Test for Paired Samples, although with a low mean difference, shows a significant difference in the change in the frequency of the reporting of violent episodes. The correlational tests showed no significant differences in the subgroups divided by demographic and professional characteristics. The usability of the app was considered very high.

CONCLUSIONS

The simplification of the reporting system and the preliminary acquisition of data on the characteristics of the ED and each nurse, can save time and facilitate the reporting, but technology alone is not enough to solve the under-reporting.

Nurse Work Environment and Stress Biomarkers: Possible Implications for Patient Outcomes

OBJECTIVE

To examine associations between nurse work environment, serum biomarkers, and patient outcomes in a large hospital.

METHODS

A work environment questionnaire was administered in 2017 to the total sample of nurses in a Midwestern hospital. A subsample of nurses (n = 83) provided blood samples. Correlation analyses examined associations between work environment ratings, biomarkers (dehydroepiandrosterone-sulphate [DHEA-S] and interleukin-6 [IL-6]), and unit-level patient outcomes.

RESULTS

Work stress was negatively correlated with DHEA-S (r = -0.23) and positively correlated with IL-6 (r = 0.31; P < 0.05). Psychological safety (r = 0.22) and competence development (r = 0.25) were both positively correlated with DHEA-S (P < 0.05). DHEA-S was negatively correlated with central line-associated bloodstream infections (rho = -0.61; P < 0.05).

CONCLUSIONS

Work environment-associated physiological mechanisms might adversely impact patient safety, in addition to nurse health.

The Role of Institution-Based Peer Support for Health Care Workers Emotionally Affected by Workplace Violence

BACKGROUND

Academic health centers with peer support programs have identified a significant increase in requests linked to workplace violence (WPV) exposure. However, no known research has focused on supportive interventions for health care workers exposed to WPV. This study aimed to describe the expansion of two long-standing programs-University of Missouri Health Care's (MU Health Care) forYOU Team, The Johns Hopkins Hospital's (JHH) RISE (Resilence in Stressful Events) team-to WPV support, retrospectively summarize the related data, and share generalizable lessons.

METHODS

A retrospective extraction and summary of the forYOU and RISE databases and the MU Health Care and JHH databases was performed tracking hospitalwide data on WPV. Two cases describe the experience of WPV victims.

RESULTS

Between 2009 and 2019, forYOU documented 834 peer support interventions, 75 (9.0%) related to WPV (57 one-on-one encounters, 18 group support encounters). In 2018-2019 the forYOU Team experienced an increase in WPV encounters, with 43 of the team's activations (20%) related to WPV. Between 2011 and 2019, RISE recorded 367 peer support interventions, 80 (21.8%) of which were WPV-related (61 group support encounters, 19 one-on-one encounters). Forty-eight (60.0%) of these 80 encounters occurred in 2018-2019 alone, marking an increase in WPV encounters. Nurses were the most frequent callers of both programs.

CONCLUSION

This study indicates the growing need for health care workers' support in the aftermath of WPV exposure in today's health care environment. Health care institutions should take a holistic approach to WPV, including timely access to interventional peer support programs.

Nurses' experiences and support needs following workplace violence: A qualitative systematic review

AIMS AND OBJECTIVES

To systematically identify, appraise and synthesise existing qualitative studies exploring nurses' lived experiences of workplace violence by patients, families and hospital visitors, identifying their support needs following workplace violence.

BACKGROUND

Workplace violence against nurses is a significant concern globally, as it leads to serious negative consequences for nurses, patients and organisations as a whole. Having adequate support is considered significant. While numerous studies have been conducted on workplace violence, few qualitative reviews have focused on identifying nurses' support needs following episodes of workplace violence.

METHODS

Four databases (MEDLINE, CINAHL, PsychINFO and Scopus) were systematically searched. Additionally, hand searching of prominent journals, grey literature and reference lists of included studies was also performed to identify additional research. The Critical Appraisal Skills Programme checklist for qualitative studies was used to assess all included articles. Thomas and Harden's three-stage approach to thematic analysis was followed, using the ENTREQ statement for reporting.

RESULTS

Ten studies published in English, conducted across eight countries, met the inclusion criteria. Four analytical themes relating to nurses' experiences were identified: "inevitable and unpredictable trauma in the career" "higher tolerance and understanding of unintentional violence," "positive learning or passive adjustment" and "struggle with the role and behaviour conflict." In terms of nurses' support needs, the analysis yielded two themes: "informal support needs" and "formal support needs."

CONCLUSION

Nurses experience significant and lasting psychological trauma due to workplace violence; however, the support for nurses remains seriously inadequate. Establishing an effective and robust support system based on nurses' needs must be viewed as a priority for organisations, as well as researchers.

RELEVANCE TO CLINICAL PRACTICE

Institutions and managers have a duty to maintain an awareness of nurses' experiences and support needs regarding workplace violence. There is a need for further policymaking and research, based on clinical practice, in order to develop effective preventive and interventive strategies regarding workplace violence.