Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions

BACKGROUND

Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents?

METHODS

We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas.

RESULTS

Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management.

CONCLUSIONS

As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Does organization matter? A multilevel analysis of the demand-control model applied to human services

The demand-control model (DC model) in occupational epidemiology suggests that health, an individual attribute, is partly determined by work organization, via the interplay of demand and control, job strain. The objective of this study was empirical assessment of the model's tenet of an organizational determination of individual health. An emerging analytic method, multi-level modelling, permits such an assessment. The study encompasses two large Swedish human service organizations. It was based on a nationally representative sample of 291 local organizational units (level 2) with 8296 employees (level 1), a median of 18 employees per unit. 5730 persons (69.1%) completed the questionnaire. Listwise deletion of missing data left a net study base of 4756 individuals in 284 units. Missing data were largely random. Demand and control were measured by standard questions and combined into a job strain index. Two such indices were calculated, one for quantitative demands and one for emotional demands. Individual attributes included age, gender, marital status, having children, social anchorage, and education. There were two dependent variables, self-assessed psychovegetative symptoms (worry, anxiousness, sadness, sleep difficulties, restlessness, and tension) and exhaustion (fatigue, feelings of being used up and overworked), both measured as summative indices. For psychovegetative health, a null model yielded 2.2% level 2 variance, unchanging when individual attributes were included in a random intercepts model. Inclusion of the strain variables rendered level 2 variance non-significant, decreasing level 1 variance by 23% and level 2 variance by 62%. For exhaustion, level 2 variation was 8.3% in the null model and 1.6% in the final model, with strain variables. The strain variables utilized in the DC-model thus draw a substantial part of their variation from the organizational level. It is concluded that the claim of the DC model to rely on organizational factors receives support.

The factor structure of the Maslach Burnout Inventory in two Swedish human service organizations

The Maslach Burnout Inventory, MBI, is a well established measure of burnout. Its validity outside the USA is, however, uncertain. The aim of the present study was therefore to apply the MBI on personnel in two Swedish human service organizations, comparing factor solutions and scoring norms to the original results. The population consisted of 5730 employees in the Social Insurance Organization (SIO) and the Individual and Family Care section (IFC) of the social welfare agencies. Principal components analysis, principal axes and alpha factor analyses were performed, all with varimax rotation. The suggested three factor solution showed to be remarkably stable irrespective of type of analysis. Score levels were somewhat lower on two subscales in the Swedish population. The conclusion is that the psychometric properties of the MBI seem to be very satisfactory and stable, at least in comparison between Sweden and USA. It is suggested that the dimensionality of MBI is rather invariant, but that the score levels covary with national, cultural, or professional contexts within the human services.

Psychosocial work environment in human service organizations: a conceptual analysis and development of the demand-control model

This paper concerns two models that were introduced in two different research domains during the 1970's. The first model regards human service organizations (HSO) as a specific type of organization. The second model, the demand-control model (DC model), concerns the joint effects of job demands and job control on worker health. In the HSO model, there are analyses of the content of jobs, considering the specific characteristics of HSOs, but little is said about the health effects of such work. Those effects stand in focus in the demand-control model. The aim of this paper is to analyze the relevance of the DC model for human service organizations. The paper argues that the object of human service work-the client relation-makes a difference for demand and control in the job. Demand is analyzed into work load, emotional demands and role conflict. Control is divided into administrative control, outcome control, choice of skills, closeness of supervision, control within and over a situation and ideological control. The conclusion is that in applications on HSOs, the basic concepts of the DC model must be developed.

Psychosomatic symptoms in human service work. A study on Swedish social workers and social insurance personnel

This study reports on subjective health of personnel in human services and other occupations. A mail questionnaire was sent to 8296 employees in the Social Insurance Organization (SIO) and the Individual and Family Care (IFC) in social welfare agencies. The response rate was 69.1% or 5730 persons. Perceived health was measured by a standard form widely used in occupational health services, FHV004D, here split into four principal components, indicating psycho-vegetative, musculoskeletal, immunological, and gastro-intestinal health. In relation to reference data on other human service personnel (nurses, teachers) and white collar workers (bank and insurance personnel), the studied groups scored much higher on psycho-vegetative symptoms (OR:s about 3), higher on musculo-skeletal symptoms (OR:s about 1.7), but had equal scores on the other symptom types. It is concluded that self-reported psychovegetative and musculoskeletal health is especially problematic in SIO and IFC, indicating stress in human service work. It is hypothesized that an adversary relation to clients can be an aggravating factor in that context.

Attributions (beliefs) and job satisfaction associated with back pain in an industrial setting

We investigated possible differences between management and workers in attributions about the cause and prevention of industrial back pain. 145 employees from upper management, lower management, and blue-collar ranks completed several questionnaires. Age, sex, job satisfaction, and history of back pain were also examined for possible confounding effects. There were significant differences in attributions between job levels, with upper management believing more strongly in causal factors related to the individual, while blue-collar workers attributed back pain more frequently to the work environment. This difference was significant even when the effects of age, sex, job satisfaction, and pain were controlled. A history of back pain increased attributions of cause related to the work environment. Job dissatisfaction increased the risk for back pain nearly sevenfold and dissatisfied people tended to attribute the cause of their pain to the work environment. These results highlight the intricate relationship between attributions, job satisfaction, and pain. Compliance and motivation for interventions might be enhanced by taking into account differences in attributions of cause and effective prevention.