Professional Documents
Culture Documents
HEALTH CARE
Final Report
Associate Professor Debra Griffiths
Julia Morphet
Kelli Innes
School of Nursing & Midwifery, Monash University
January 2015
Research report #: 122-0115-R01
ISCRR is a joint initiative of WorkSafe Victoria, the Transport Accident Commission and Monash University. The
opinions, findings and conclusions expressed in this publication are those of the authors and not necessarily
those of Worksafe or ISCRR.
Table of Contents
EXECUTIVE SUMMARY -------------------------------------------------------------------------------- 1
PREAMBLE ------------------------------------------------------------------------------------------------ 3
INTRODUCTION ----------------------------------------------------------------------------------------- 6
PREVALENCE --------------------------------------------------------------------------------------------- 6
Consequences of violence in health care -------------------------------------------------- 8
Causes and risk factors -------------------------------------------------------------------------- 8
INTERVENTIONS TO REDUCE OCCUPATIONAL VIOLENCE IN HEALTH CARE --------- 9
Education ---------------------------------------------------------------------------------------------- 9
Patient risk assessment ------------------------------------------------------------------------ 13
Environmental factors--------------------------------------------------------------------------- 13
Organisational Policy---------------------------------------------------------------------------- 15
Code Grey ------------------------------------------------------------------------------------------ 16
Aggression Management Teams --------------------------------------------------------- 16
Zero Tolerance Policy ------------------------------------------------------------------------ 16
Restraint --------------------------------------------------------------------------------------------- 17
RECORDING INCIDENTS OF VIOLENCE --------------------------------------------------------- 18
CONCLUSION AND RECOMMENDATIONS ------------------------------------------------------ 25
REFERENCES ------------------------------------------------------------------------------------------- 26
ii
EXECUTIVE SUMMARY
This review examines the literature related to occupational violence in health care.
Occupational violence in health care is prevalent, with up to 95% of health care workers
reporting experiencing violence. In health care, patients, family and visitors of patients are
the primary source of violence and aggression, and therefore client-initiated violence is the
focus of this review.
Prevalence
Occupational violence occurs in a wide variety of health care settings. The common types of
violence experienced by health care workers are verbal and physical abuse. There are many
negative consequences of violence in healthcare, including increased incidents of
depression, sleep and anxiety disorders, drug and alcohol problems, Post Traumatic Stress
Disorder (PTSD), and reduced staff retention. Risk factors linked to occupational violence in
health care include patient characteristics, staff characteristics, organisational factors, and
physical design of the workplace and setting.
Interventions
A number of interventions have been introduced to reduce occupational violence in health
care. These interventions can be broadly grouped under the following headings: education,
patient risk assessment, environmental factors, organisational policy (including zero
tolerance), and restraint. There is a paucity of data evaluating the effectiveness of these
interventions.
Reporting
There are low reporting rates for occupational violence with estimates only 20% of events
are reported. Reasons for under-reporting include worker tolerance of violence, violence is
perceived as just part of the job, lack of co-worker and manager support, and lack of
Page 1 of 37
management action. The systems for reporting occupational violence include RiskMan, risk
assessment tools, integrated IT systems and paper based incident reports. There is limited
evaluation of the reporting systems.
Conclusion
The review is presented in three sections; i) prevalence of occupational violence in health
care (including risk factors, and sources of violence), ii) interventions aimed at reducing
occupational violence in health care, and iii) surveillance or reporting of occupational
violence in health care.
Page 2 of 37
PREAMBLE
This evidence review has been requested by Institute for Safety, Compensation and
Recovery Research (ISCRR) as occupational violence in health care is a problem and is a
priority area for state authorities. ISCRR and WorkSafe Vitoria are keen to understand the
current state of the evidence base in relation to occupational violence in health care. The
review intends to:
The
database
search
utilised
various
searching
strategies
such
as
Keywords,
Page 3 of 37
Keywords:
Type:
Discipline:
Health Science
Subject areas:
Year:
from 2005
The inclusion criteria for this review comprised peer reviewed research based papers related
to patient or family initiated violence, and government reports. Exclusion criteria included
workplace bullying, case studies, opinion papers and papers that only included an abstract.
The screening process started with the publication title and the abstract then the full text to
assess the coverage, objectivity, currency and authority of the identified publications.
Overall, 1301 records were identified within the databases, and other sources of grey
literature provided a further 199 records. After removing 750 duplicate records and 38
inaccessible records, the remaining 712 papers were screened by title and abstract, and 287
removed based on inclusion and exclusion criteria. The remaining 425 full-text articles were
examined and assessed against the inclusion criteria, resulting in the exclusion of a further
345 papers. 80 papers were included in the final review (Figure 1).
Page 4 of 37
Identification
Included
Eligibility
Screening
Records screened
(n = 712)
Records excluded
(n = 287)
Studies included in
literature review
(n = 80)
Page 5 of 37
INTRODUCTION
In the past decade an expansive body of research has been published on occupational
violence and the health professions. In an effort to standardise the definition of occupational
violence in health care, the International Labour Organization, International Council of
Nurses, World Health Organization, and Public Service International developed the following
definition; Incidents where staff are abused, threatened or assaulted in circumstances
related to their work including commuting to and from work, involving an explicit or implicit
challenge to their safety, wellbeing or health.(1)
In health care, patients and family / visitors of patients are the primary source of violence
and aggression, and therefore client-initiated violence is the focus of this review. The review
is presented in three sections; i) prevalence of occupational violence in health care
(including risk factors, and sources of violence), ii) interventions aimed at reducing
occupational violence in health care, and iii) surveillance or reporting of occupational
violence in health care.
PREVALENCE
Studies show that occupational violence in health care is prevalent and is a recurrent
phenomenon. The research comprises a range of studies, with many focussing on nurses
Page 6 of 37
and to a lesser extent other groups of health workers. The literature does nevertheless
examine most areas of work health professionals undertake including: acute care in both
metropolitan
(3, 4)
and remote
(5)
7)
13)
community
care,(14, 15) and pharmacies.(16) The common types of violence experienced by health care
workers include: verbal abuse,(5, 9, 10, 12, 14, 16, 17) physical abuse,(5, 6, 10, 12, 17) and less commonly
sexual harassment,(5, 9, 12) intimidation,(12) stalking,(5, 9, 12, 17) and property damage.(5, 17)
There are numerous studies conducted in workplaces where high levels of occupational
violence are deemed to occur. One survey of Australian medical practitioners showed that
occupational violence ranged from 2%-29% for physical aggression from patients, and 15-75%
for verbal aggression from patients.(11) Another Australian study reported that there were 5.5
Code Blacks per 1,000 patients in the emergency department (ED).(4) A Code Black is a
hospital-wide internal security response to actual or potential aggression involving a weapon
or a serious threat to personal safety.(18) A study of varied health professionals found 10-95%
of respondents reported experiencing violence from patients, and 20-40% of respondents
reported the source from relatives or carers of patients.(19)
The literature reflects research studies with enormous variation in focus, aim, definitions and
study design. Many studies rely on self-reporting of occupational violence where definitions
and perceptions vary. Studies are frequently explorative and descriptive in character.
Therefore, the manner in which prevalence is measured differs immensely from the
identification of health workers perceptions to the physical lodgement of workers
compensation claims. Despite these data, which show a high rate of occupational violence
in health care, the International Council of Nurses estimates that only one in five incidents
(20%) of occupational violence in health care is reported.(20)
Page 7 of 37
Staff characteristics that have been linked with violence include being young and
inexperienced,(2,
9, 11)
female,(9,
10)
Page 8 of 37
Occupational violence is also more prevalent at night (1800 0600) than during the day.(4)
36)
prevented or managed.(36-40) These interventions can be broadly grouped under the following
headings: education, patient risk assessment, environmental factors, organisational policy
(including zero tolerance), and restraint. In the following section, the literature examining
each group of interventions will be presented.
Education
Education and training of health care staff is the most frequently reported component of
occupational violence prevention programs. This approach to managing or reducing
occupational violence is typically comprised of educating health care staff on:
Situational awareness and risk assessment, i.e. methods for recognising and
identifying potentially violent situations;(7, 39-49)
Page 9 of 37
Familiarising staff with organisational policies and procedures, i.e. reporting systems,
security systems, and the right and ability to withdraw to safety at any time.(40, 45-47, 49)
Several reports were also located in which a focus was on public awareness and patient
education in relation to acceptable behaviours.(29, 35, 37, 38, 40) These projects aimed to reduce
occupational violence in health care by informing patients about hospital processes and
appropriate behaviour.
The 2011 Inquiry into Violence and Security Arrangements in Victorian Hospitals and, in
particular, Emergency Departments, listed 39 recommendations for managing violence in
health care, including nine that specifically focused on staff communication, education and
training.(36) Since then projects have examined staff training programs to address prevention
and management of aggression and violence in Victorias hospitals, and organisation wide
responses to patient aggression and violence.(39) However there is great variability in the
effect of education and training on occupational violence management. One important issue
with this relates to the methods used to evaluate training. Many of the studies evaluated the
outcomes of the educational intervention using self-reported knowledge,(48,
confidence,(34,
56, 58)
52, 56)
57)
self-
rather than
quantifiable changes in acts of occupational violence. One important finding identified that
the training was found to reduce distress among community healthcare workers, and
increase general mental wellbeing.(52)
A small number of studies used pre and post tests to measure quantitative differences in
knowledge.(45, 48, 50, 55) For example, in one study, 104 participants were filmed in simulated
settings using de-escalation techniques. Each participant completed a pre and post training
simulation, and experts in de-escalation (who were blind to which scenario was pre and post)
Page 10 of 37
scored performance using the De-escalating Aggressive Behaviour Scale. The mean deescalation score rose from 2.74 to 3.65 (p<0.001) after training.(50)
An educational program that combined online education with a table top exercise was
reported to result in an immediate increase in knowledge, and a further knowledge increase
six months after the event.(45) However despite a demonstrated increase in knowledge about
the causes of violence, participants in one study did not feel any more confident to manage
or reduce occupational violence following the training.(48)
Break-away (escape) training has been mandatory for staff working in mental health in the
National Health Service in the United Kingdom.(55,
59)
efficacy of break-away training.(55, 56, 59, 60) Evaluation of break-away training has identified
challenges, with too much content delivered in a short period of time. One study found that
21 different techniques were demonstrated in a 7.5 hour training day, with a mean average
time of just over 13 minutes for each participant to observe and practice each skill. (59) Other
studies examining the outcomes of the break-away training found that many participants who
had previously completed break-away training, were unable to apply those skills in scenarios
on the ward, and were unable to break-away from potentially life threatening holds.(55, 60)
Few studies examined the frequency of violent incidents pre and post the educational
intervention.(7, 43, 49, 54, 57, 61, 62) Four of those studies identified a reduction in the number of
reported violent incidents following the training.(7, 54, 61, 63) One study, in which de-escalation
techniques were taught, examined the frequency with which the hospital emergency
response security team were called, both before and after the introduction of the training. (54)
The authors reported an increase in the frequency of calls to security staff, from 0.78 per
1,000 ED patient visits, to 1.76 per 1,000 ED patient visits, in a 12 month period. However,
the authors used correlations to examine the number of trained staff per call-out, and found
a significant reduction in hospital emergency response calls, when a higher proportion of
Page 11 of 37
trained staff were on shift. They concluded that the training was effective at reducing the
frequency of violence, and subsequent calls to security staff.(54)
Two other studies found that training in communication, de-escalation and situational
awareness resulted in a reduction in the frequency of violent incidents. (7, 61) It is important to
note however that in one of these studies, environmental changes were implemented
concurrently with the training, and it is unclear therefore if the reduction in violence was a
result of the education, environmental changes, or a combination of both.(7)
Perhaps the most effective education programs reported in the literature were based on
group debriefing after aggressive or violent incidents in the workplace.(63, 64) In one study
during the debrief, staff would identify the motivations underlying the aggressive or violent
behaviour, and discuss strategies that could be used in future situations. This program was
reported to reduce the rate of violent incidents over a one year period,(63) and was reportedly
an effective means of alleviating psychosocial impact of stress on nurses who were exposed
to violence.(64)
One concern that has been raised in relation to an emphasis on education and training as a
form of occupational violence prevention, is that it places the burden of minimising and
managing violence onto the health care staff who have completed the training, rather than
on organisations to make changes to environmental and staffing issues.(2)
Training in the identification and management of patients at risk of violence seems a natural
and appropriate measure.(65) However, studies demonstrate mixed results.(66) Research is
needed to identify the essential components of a training program, the frequency of refresher
programs, and to investigate effects of training on the number, type and severity of
aggressive incidents. While education and training programs are a common component of
occupational violence prevention programs, and have been shown to increase knowledge
regarding risk factors associated with occupational violence, and self-confidence to manage
Page 12 of 37
occupational violence, there are scant large-scale, well-designed studies that can strongly
support their effectiveness in reducing the incidence of occupational violence.
68)
Aggressive Behaviour Risk Assessment Tool was predictive of future violence on the wards,
had good inter-rater reliability, and was simple to use.(8) The authors did not report if this
intervention reduced the incidence of occupational violence. The Alert System was also
found to be easy to use, and predictive of violence, however the authors reported that, while
the rate of violent incidents did reduce in the immediate post intervention period, they
returned to pre intervention levels six months after the intervention was introduced
(67)
. This
implies that while staff may be able to identify predictors of violence, they are not adequately
prepared to manage or de-escalate occupational violence.
Environmental factors
Changes to environmental structure have been commonly believed to reduce occupational
violence in health care. Features commonly described in the literature include:
flexiglass as a barrier between patients and staff, while ensuring a line of site,(26, 27)
metal detectors.(33)
Page 13 of 37
Yet there are few studies evaluating the effect of these interventions. Most of the studies that
have been undertaken, examined staff perceptions of safety, and found that staff felt safer
when rooms were secure,(7, 26, 27, 47, 69) and duress alarms and surveillance cameras were
present or metal detectors were in place.(33)
However, despite staff rating environmental safety as very important, (47) and reporting that
they felt safer following changes to environmental security, there is scant evidence that
environmental changes reduce the frequency of occupational violence in health care. Further,
it must be acknowledged that most occupational violence in health care is verbal. While
environmental changes can act as a barrier to physical violence, therefore reducing the
severity of violence, they are unlikely to reduce verbal violence.(27, 33)
One study of three emergency departments, that examined the effect of duress alarms,
surveillance cameras, locked doors, as well as non-environmental changes such as asking
each patient if they were carrying a concealed weapon, found that these interventions did
not reduce the frequency of violence.(31) Another study examined three mental health
facilities in which environmental changes were made. Changes included replacing solid
panel doors with transparent flexiglass to improve line of site, securing wardrobes to the floor
so they could not be picked up and used as a weapon, installing personal alarm systems,
and carpeting floors to reduce noise and therefore stimuli.(26) Focus groups and surveys
were conducted with staff in the facilities, who reported feeling safer, however no
evaluation of the rate of occupational violence was reported.(26)
The only study of environmental changes that reported a reduction in the frequency of
violent incidents was conducted in an aged care psychiatric rehabilitation centre.
The
authors reported that patients in single rooms were more likely to be violent toward staff, and
so the building was restructured, to enlarge room size and provide all patients with shared
rooms.(7) This allowed treatment by a team, rather than an individual health care worker,
ensuring no staff member was working in isolation. The authors reported a reduction in the
Page 14 of 37
frequency of violent incidents from 18-22 per year in the preceding six years, to 0-5 incidents
following the environmental changes.(7) These structural changes were supported with
education, so it is not clear if the reduction in violent incidents was a result of the
environmental changes, the education, or a combination of both.
Organisational Policy
Organisational policies related to occupational violence in health care need to clearly identify
unacceptable behaviours, and should include a statement of support from management, the
processes for reporting violent incidents, and expectations for staff training.(2) Several reports
in the grey literature highlight the importance of organisational policy in the prevention and
management of workplace violence.(35, 40) These papers suggest that health services must
clearly communicate that aggression and violence will not be tolerated, and that appropriate
action be taken when such behaviour occurs. Further, they suggest a staged approach to
the management of aggression and violence, that includes warnings, sanctions such as
restriction of visiting rights, alternate treatment arrangements, contracts of acceptable
behaviour, conditional treatment rights, refusal of service (except in life threatening
conditions), and prosecution.(40) Examples of organisational policies aimed at reducing
workplace violence and aggression in health care include the integration of Code Grey,
aggression management teams, and the zero tolerance policy, as described below.
Page 15 of 37
Code Grey
A Code Grey is a hospital-wide coordinated clinical and security response to actual or
potential aggression or violence (unarmed threat). When a Code Grey is called, an internal
alert or emergency response is activated.(18) The 2011 policy framework for preventing
occupational violence in health care recommended the introduction of Code Grey throughout
Victorian hospitals,(37) but they were only mandated in Victoria in 2014.(18)
Page 16 of 37
violence. For example, under the zero tolerance policy, the confused elderly patient who
strikes out in fear, is treated in the same way as the violent young male who is frustrated by
the waiting time. Zero tolerance policies rely on the use of external teams of security staff to
respond to episodes of violence, and remove the violent individual from the health care
setting. However, it has been suggested that use of external teams to manage occupational
violence can have a negative effect on staff confidence to manage occupational violence.(2) It
has also been reported that zero tolerance policies have a negative effect on staff
confidence to manage violence and aggression,(53) with staff attitudes toward violence
becoming increasingly rigid following their zero tolerance training. (53) Finally, zero tolerance
policies can have a negative effect on patients ability to make genuine complaints or to
express appropriate annoyance or irritation with inadequate service.(2) It has been suggested
that causal factors of violence must be addressed, and support and training provided to
health care staff, rather than the impositions of sanctions.(72)
Restraint
A small number of studies examined the use of chemical or physical restraint in the violent or
aggressive patient.(58, 62, 73, 74) One systematic review of restraint and seclusion found that
seclusion and restraint are ineffective means of reducing violent behaviour in adult inpatient
psychiatric settings.(74) Another study found that training in de-escalation did not reduce the
frequency of violent incidents, or the need for restraint. (62) However, other outcomes focused
on the most effective drug for chemical sedation, or best way to physically restrain a patient,
rather than the incidents of restraint, or ways to avoid restraint.(58, 73) These papers will not be
discussed in further detail.
Page 17 of 37
Despite the identified need, there are low formal reporting rates for occupational violence.
According to the International Council of Nurses, only 20% of occupational violence is
reported.(20) Reasons for underreporting of assaults and other types of violence include a
tolerance for occupational violence in practice environments, the perception of violence as
part of the job, lack of co-worker and manager support, including a lack of management
action and follow up, perceptions of incompetence for being unable to manage a combative
client and variations in terminology and definitions.(2, 3, 6, 77, 78)
Patient risk assessment tools are a mechanism for reporting potential occupational violence.
Examples of patient risk assessment tools, as previously discussed, include Aggressive
Behaviour Risk Assessment Tool(8) and The ALERT System.(67) The tools allow staff to
assess patients for risk of perpetrating violence, if patients display a risk it is noted or
flagged in their history or via wrist band.(8,
67)
Page 18 of 37
A key strategy described in the 2011 Victorian Government report on preventing workplace
violence in health care included the development of an effective reporting and monitoring
system, that would enable health services to report, monitor and compare the incidence of
violence.(37) Despite this, another contributing factor for the low reporting rate
(75, 79)
is the
lack of a systematic, continuous comprehensive and easy to use, monitoring and reporting
system.(80) Workers compensation claim data are one method used for measuring
workplace violence,(37) however these data are only collected when there is an injury
associated with the event. In Victoria, RiskMan was introduced in 2012 to collect
standardised data on occupational violence in all public hospitals. The Victorian Health
Incident Management System (VHIMS) is incorporated into the RiskMan database to collect
data on multiple occupational hazards.(37, 38) RiskMan collects data related to: the type of
incident, date and time of incident, site of incident, people involved, the outcome of the
incident, injuries sustained, and contributing factors (clinical, workplace design). It was
intended that VHIMS and RiskMan would enable the collation and analysis of data across
health services, to monitor trends and assess the impact of the implementation of
recommendations aimed at reducing violence.(37)
It was intended that RiskMan and VHIMS be formally evaluated twelve months after their
introduction (i.e. 2013), and a comprehensive evaluation again three years later, (37) however
there is no evidence that RiskMan has been formally evaluated, and evidence suggests it is
not being used effectively.(77)
One recent study found that RiskMan was not user friendly, was difficult to use, and time
consuming.(77) The system was viewed by study participants as rigid and offered no flexibility.
Participants were restricted to selecting categories, with no option for free text data.
Furthermore, the study found that despite acknowledging the importance of reporting
occupational violence, participants often had insufficient time to complete all of the RiskMan
requirements.(77) Instead, participants reported that they used the patient electronic file to
Page 19 of 37
flag patients who were violent, therefore warning their colleagues for future visits. (77) This
finding is in keeping with the recommendation by WorkSafe, who have highlighted the
importance of sharing information regarding risk for potential violence with colleagues. (40)
Despite being widely utilised to collect data on occupational violence in Victorian public
healthcare settings, there is a paucity of literature evaluating the effectiveness of RiskMan.
It has been suggested that the retrospective collection of data related to violence and
aggression in health care is challenging, because it only measures incidents that have
occurred, and does not reflect the prevention of incidents.(38,
80)
measuring positive outcomes, the tools used measure only negative outcomes. Arnetz et
al.,(80) propose that occupational violence should be treated like any other occupational
hazard such as needle stick injuries. Rather than retrospectively collecting information after
an incident, there should be a regular monitoring and surveillance. In response to this the
authors developed a reporting system that was integrated with other hospital databases
including human resources and occupational surveillance system. Relationships between
data, such as staff demographic data and occupational hazards, could be identified with
linked databases.(80)
In this reporting system staff completed an incident report, either paper based or
electronically, that was then submitted to the Occupational Health Services (OHS)
department. The details collected on the incident report are outlined in Table 1 Summary of
reporting systems. All data were then entered into the database and categorised by an OHS
analyst. Table 1 Summary of reporting systems, presents the categories. The integrated
system allowed for analysis of occupational violence to occur. The OHS department were
able to calculate incidence rates, characteristics of occupational violence, incidence by job
category, characteristics of employees reporting, incidence rates by worksite and
consequences of occupational violence.(80)
Page 20 of 37
An increase in reporting was noted after the introduction of this integrated system. There
was a rise in reporting from 1.84 incidents/100 full time equivalents in 2003, to 4.32
incidents/100 full time equivalents in 2005. The authors did note that it was difficult to
ascertain if the increase in reporting was due to the introduction of the system or an increase
in violence being perpetrated in hospitals. However, reporting was consistent over a six year
period demonstrating sustainability of the integrated system in reporting occupational
violence.(80)
In another study, in an effort to gauge the level of occupational violence in their emergency
department, staff developed an Abuse data recording tool.(81) The paper based tool was
approved by hospital management and piloted over a six month period. Staff designed the
tool to be simple, comprehensive and accurate in collecting data on occupational violence.
Visual analogue and numeric scales were used as staff were familiar with recording patient
data using such tools. Data collected in this tool is presented in Table 1 Summary of
reporting systems. Over the trial period there was a rise in reported incidents. A 33 fold
increase in reported incidents of occupational violence was seen during the trial period,
compared to the previous 18 months (4 vs. 44).(81)
From the limited literature available, reporting systems for occupational violence need to be
centralised, user friendly and quick to complete.
Page 21 of 37
Page 22 of 37
Reporting Format/
Information collected
Whom
Arnetz et al.
(2011)
(80)
Integrated
workplace violence
incident reports
Demographic data
Categorise report as
Staff
Categorises:
Description of any
assault
combative patient
combative person
conflict
harassment
sexual harassment
threat
unprofessional behaviour
Page 23 of 37
Pawlin
(2008)
(81)
Abuse data
Date, time
recording tool
Form of abuse
you feeling
Assailant details
Police called
Outcomes of incident
Page 24 of 37
Investigate the development of software to import patient medical record alert data
with hospital violence data collection systems (RiskMan);
Page 25 of 37
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