Work Place Violation in Health Care

    Workplace
violence is defined as “violent acts (including physical assaults and
threats of assaults) directed toward persons at work or on duty” (National
Institute of Occupational Safety and Health (NIOSH), 2002). Most workplace
violence falls into one of four categories:

Types 

Type
1 (Criminal Intent): Results while at criminal activity ( eg , rubbery) is
being committed and the perpetrator has no legitimate relationship to the
workplace.

Type 2 (Customer/Client): The perpetrator is a customer or client at the work place
( eg , health care patient) and becomes violent while being served by the
worker.

Type 3 (worker-on-worker): Employees or past employees of the workplace are the
perpetrators in this case.

Type 4  (Personal Rel leading cause of occupational injury death. among all workers
and the leading cause among women. Workplace homicides have declined from a
high of 1,080 in 1994 to 609 in 2002; on average 846 workers per year have died
as a result of homicide since 1992 Notably, 80% of workplace homicides involve
the use of a firearm (NIOSH, 1996).

Steps At National Level

    Nonfatal
assaults are much more common than fatal assaults. Although both share many of
the same risk factors ( eg , contact with the public, working with volatile
people, working in small numbers, and working in community-based settings)
health care. rather than retail workers represent the majority of victims of
nonfatal workplace violence. According to the Department of Justices 

National
Crime Victimization Survey (NCVS), 1.9 million incidents of workplace violence
occurred in the workplace each year from 1992-1996 ( Warchol , 1998). Twelve
percent of all victims reported physical injuries; 6% of the workplace crimes
resulted in injury that required medical treatment, and only 44% of all
incidents were reported to the politics.

Statistics of Past

    Workplace
violence is a documented occupational hazard in the health care and service
sectors (NIOSH, 2002; Lipscomb & Love, 1992; Warchol , 1998). The health
care sector leads all other industries in nonfatal workplace assaults. In 2000,
48% of all nonfatal injuries resulting in days away from work from violent acts
and assaults occurred in the health and social service sector (BLS, 2001), 

The
incidence rate for violent acts and as saults resulting in days away from work
was 9.3 per 10,000 full-time workers for health services workers compared to an
overall private sector injury rate of 1 per 10,000 full-time workers (BLS),
Among victimizations reported in the NCVS, mental health professionals had an
incidence rate of 79.5 per 1,000 workers compared with an overall rate of 14.8
per 1,000 workers. 

Nurses had an incidence rate of 24.8 per 1,000 workers, the
highest rate in the “medical” category ( Warcholl . Violence in
mental health has an extensive history, with the first documented case of a
patient fatally assaulting a psychiatrist in 1849 (Bernstein, 1981 ).

Until the
1990s, most studies that examined the risk of violence to psychiatrists and
other therapists focused on the victim’s role, the assaultive patient’s
characteristics, and contextual factors surrounding the assault.Only recently
have environmental risk factors been a focus of research and nurses and aides
the subjects of study.

    Bentley
and colleagues (1997) compared the number of workers compensation claims from a
Washington State psychiatric hospital, formal incident reports, and the number
of incidents of assault reported on a survey measuring attitudes and
experiences related to assaults. She found that 73% of staff surveyed reported
at least a minor injury related to a patient assault in the past year. 

Only 43%
of those reporting moderate, severe, or disabling injuries related to assault
filed a workers compensation claim. The survey found an assault incidence rate
of 437 per 100 employees per year, a rate that underestimated incident reports
of assaults by a factor of more than five ( Bensley et al.).

    Environmental
and organizational factors have been associated with patient assaults,
including understaffing (especially during times of increased activity such as
meal times), workplace security, time of day, unrestricted access to movement
and transporting patients (NIOSH, 2002).

    SS Lee, Gerberich , Waller, Anderson,
and McGovern (1999) found that among 105 nurses who had filed a workers
compensation claim for work-related assault injuries, the presence of security
personnel reduced the rate of assault while the perception that administrators. 

    Considered assault to be part of the job, having received assault prevention
training, a high patient/personnel ratio, working primarily with mental health
patients, and working with patients who had a long stay in hospital increased
the risk of assault.

Violent Behavior of Patient 

    The
one patient characteristic that has been singled out as a strong risk factor
for violence is a history of violent behavior. A number of studies have
documented that a small number of patients are responsible for the majority of
assaults ( Hillbrand , Foster, & Spitz, 1996).

     Drummond, Spart, and Gordon
(1989) examined an intervention designed to identify patients with a history of
violence and found that flagging charts of patients with histories of
assaultive or disruptive behavior reduced assaults against staff by 91%.

Psychological Aspects

    Many
psychiatric settings now require that all patient care providers receive annual
training in the management of aggressive patients. However, few studies have
examined the effectiveness of such training. Those that have generally found
improvement in nurses knowledge, confidence, and safety after taking an
aggressive behavior management program ( Hurlebaus & Link, 1997). 

    Carmel
and Hunter (1990) examined the relationship between participation in training
and aggressive behavior by inpatients on 27 inpatient wards in a California
State hospital and found that wards with higher staff attendance at the
training experienced lower rates of injury. Lehmann et al. (1983) found
significantly higher knowledge and confidence in trained staff.

Research Results

    Runyan,
Zakocs , and Zwerling (2000) re viewed 137 papers mentioning violence
prevention intervention and found that only ten of the papers reflected
databased intervention. 

    All interventions took place in health care; five
studies evaluated violence prevention training interventions (including Lebmann
and colleagues, and Carmel & Hunter), three examined post incident
psychological debriefing programs, and two evaluated administrative controls to
prevent violence. All were quasi-experimental, without a formal control group
and with equivocal findings.

Research Evaluation

    Research
evaluating intervention directly at the primary, secondary, and tertiary
prevention of violence across health care settings is critically needed to
reduce workplace violence and ultimately improve patient care. A secure and
healthy work environment is essential to a positive environment of care.