Risk factors associated with patient and visitor violence in general hospitals: Results of a multiple regression analysis

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Abstract

Background

Patient and visitor violence (PVV) is the most dangerous occupational hazard that health professionals must contend with. Staff training is recommended to prevent and manage PVV. There is minimal research focusing on risk factors associated with PVV in general hospital settings. Therefore, staff training is mostly based upon expert knowledge and knowledge from psychiatric and emergency settings.

Objectives

This study investigates health professionals’ experiences with PVV in order to describe risk factors related to PVV that occur in general hospital settings.

Design

A retrospective cross-sectional survey was conducted in 2007.

Setting

A university general hospital in Switzerland.

Participants

2495 out of 4845 health professionals participated (58.0% nurses & midwives, 19.2% medical doctors, 3.6% physical therapists, occupational therapists & nutritionists, 6.1% ward secretaries, medical & radiology assistants, 6.3% nursing assistants or less qualified nursing staff and 5.1% other staff). All had direct patient contact and 82% were female.

Methods

Data were collected via questionnaires using the Survey of Violence Experienced by Staff German-Version-Revised, the German version of the shortened Perception of Aggression Scale and the Perception of Importance of Intervention Skills Scale. Descriptive statistics and multiple logistic regression analyses were used.

Results

Risk factors associated with PVV depend upon the form of violence. Those trained in aggression management and/or those who work predominantly with patients over 65 years of age experience twice as much PVV as others. Health professionals working in emergency rooms, outpatient units, intensive care units, recovery rooms, anesthesia, intermediate care and step-down units also experience PVV more often. When health professionals are older in age, are from the medical profession, are students, or when they have an attitude rating preventive measures as being less important and aggression as emotionally letting off steam, they experience less PVV.

Conclusion

Training could change the perception and the recognition of PVV, and could therefore increase the risk of experiencing PVV. The health professionals’ specific occupation along with attitude and age, the patients’ age, the communication and the workplace are all relevant risk factors. Further studies should investigate the impact of aggression management training and other measures that would reduce PVV.

Introduction

Although incidents of violence occur in all workplace environments, it is well known that health professionals are at the highest risk (Chappell and Di Martino, 2006, Hahn et al., 2008a, Hahn et al., 2008b) for experiencing violence in the workplace. Workplace violence has serious consequences for the involved health professionals, as well as for the entire health care system. Patients are the most frequent group that afflict violence upon health professionals (Camerino et al., 2008, Hahn et al., 2008a, Hahn et al., 2008b). In order to prevent and manage patient and visitor violence (PVV) and to improve health professionals’ safety, strategies focusing on the organizational and individual level are recommended (ILO et al., 2002, International Council of Nurses, 2001). Although many countries have adopted occupational health and safety legislation and policies, the evidence supporting these recommendations is limited (Chappell and Di Martino, 2006, Pich et al., 2010).

Nursing associations and labor unions have called for intervention effectiveness research and more widespread protective regulations (International Council of Nurses, 2001, International Labour Office et al., 2002). Current research, however, describes only a small fraction of the problem caused by PVV (Campbell et al., 2011, Chappell and Di Martino, 2006). The majority of research has explored the prevalence of PVV (Hahn et al., 2008a, Hahn et al., 2008b, Koritsas et al., 2009) and has focused mainly on nurses’ experiences and/or on psychiatric or emergency settings (Camerino et al., 2008, Campbell et al., 2011). Larger settings such as medical, surgical, women & newborn, pediatrics, rehabilitation, ambulatory care (Hahn et al., 2008a, Hahn et al., 2008b) or geriatric care (Zeller et al., 2009), have been investigated to a lesser extent.

Definitions of violence in the literature are inconsistent (Bjorkly, 2006, Hahn et al., 2008a, Hahn et al., 2008b). This impedes both research and the development of prevention and intervention strategies when combating PVV (Chappell and Di Martino, 2006, Lau and Magarey, 2006). This inconsistency is connected to the fact that in the field of human aggression, no current theoretical approach can describe all forms of violence (Selg et al., 1997). In this study, violence refers to incidents in which health professionals are abused, threatened or assaulted in work-related circumstances. PVV is defined as any verbal, non-verbal or physical behavior that threatens or is harmful to others or to their property (Morrison, 1990). Verbal violence is defined as the use of abusive or offensive language (including sexually abusive language), derogatory remarks or profane and/or obscene comments. Threats are warnings of intent to injure another person with or without an object or weapon, to harass (also sexually) and to physically intimidate. Physical assault includes slapping, pinching, pushing, shoving, spitting or kicking, with or without the use of weapons (McKenna, 2004).

Despite the increased attention given to violence, very few studies have investigated risk factors associated with PVV in accident and emergency health care settings (Ferns, 2005), geriatric health care settings (Kamchuchat et al., 2008) or in general health care settings (Lanza et al., 2006). A risk factor is the characteristic of a person, a situation or an environment that is associated with the likelihood that violence, in an interaction, will occur. In order to develop appropriate assessment and prevention strategies, studies investigating risk factors were conducted in the field of psychiatric and mental health care (Amore et al., 2008, Bjorkly et al., 2009, Flannery et al., 2006). Based upon these studies, the occurrence of PVV in mental health care is explained utilizing social-interactional models (Richter and Whittington, 2006).

Evidence regarding risk factors is crucial in order to conduct prevention and intervention studies and to evaluate and enhance training programs (McPhaul and Lipscomb, 2004, Wells and Bowers, 2002). There are a lack of theoretical models and research that explore the predisposing factors for PVV in the general hospital setting, or that describe the reasons for violent behavior (Campbell et al., 2011, Koritsas et al., 2009). Therefore, a working model to investigate risk factors was developed for this study. This model includes elements of the general aggression model (GAM) by Anderson and Bushman (2002). The GAM describes how the behavior of a person in a situation can lead to violent behavior. It considers the input, which are the characteristics of a person and a situation. The routes of the situation are the cognitive, affective and arousal impacts. The outcomes of the underlying appraisal and decision-making process are thoughtful action or impulsive action, which then lead to the social encounter. The GAM is a general model; it does not take into account the specific situation and contextual risk factors relevant for patient and visitor violence in the general hospital setting. More specific information is required about the personal risk factors of patients, visitors and professionals, and the situation in which the violent interaction takes place. According to Curbow's (2002) description of the origins of violence at work, in the health care sector, it is focused on the interaction between health professionals and patients or on other sources of violence (for example, visitors). In accordance to this model, the nature of the interaction is influenced by the individual factors of the persons involved and is embedded within the hospital organization, the community and the broader environment. The interaction also depends upon the actual work setting and the individual source of violence. However, with the other models, much of the information used originates from psychiatric or mental health settings, emergency or home and community care settings. Therefore, the results of prevalence and descriptive studies regarding PVV in general hospitals were integrated into the working model (see Table 1). In accordance to these sources, the following risk factors associated with patient and visitor violence in general hospitals were included in the working model: (1) the characteristics of health professionals, (2) the characteristics of patients and/or visitors, (3) health professionals’ interactions with patients and visitors during the treatment process, (4) the characteristics of the work environment and organizational procedures and (5) the social context or cultural background of the health care system (Hahn et al., 2010, Hahn et al., 2011). Table 1 describes these five factors in more detail. In the first column the factors are listed, in the second column the elements which describe the factors are shown and in the third column the studies which describe these elements are included, as associated with patient and visitor violence in the general hospital setting. The fourth column shows which elements are included in the instruments for utilization in this study.

Section snippets

Aim

As discussed above, evidence regarding the factors included in the working model is limited. The aim of the present study is, therefore, to explore the risk factors associated with patient and visitor violence directed against health professionals. It will be investigated from the perspective of a variety of health professional groups working in different wards in general hospital settings.

Design and setting

A retrospective cross-sectional survey utilizing postal questionnaires was conducted between May and July

Participants

The questionnaire was completed and returned by 2495 health professionals from different general hospital units (response rate = 51.55%). Response rates varied among the participating staff, with the highest rates coming from nurses & midwives (58.11%) and the lowest from medical doctors (39.63%). The majority of the participants were female (82.02%), with almost half being between 30 and 45 years of age and having between 0 and 4 years of experience at the present workplace. Most of the

Discussion

The aim of this study was to explore the experiences of health professionals having experienced PVV in the general hospital setting, in order to describe important risk factors within this setting. This study confirmed existing evidence that PVV is a significant problem for health professionals in general hospitals, and that verbal violence is the most prevalent form experienced (Camerino et al., 2008, Moreno-Casbas et al., 2011). The results distinguished different risk factors for different

Conclusion

This study demonstrates that PVV in general hospitals is a serious workplace problem for all health professionals, and is not restricted to high-risk areas, such as emergency rooms and psychiatric wards. With the large sample size, this study facilitates the analysis of complex models and assists in identifying the health professionals’ age, attitude and profession, the age of the patient and the workplace, as relevant risk factors. Knowledge of them is necessary in order to implement adequate

Contributions

SH, RJGH, THD, and VH contributed toward study design; SH and VH contributed toward data collection; SH and MM contributed toward data analysis; SH, MM, VH, ThD, GK, and RJGH contributed toward manuscript preparation.

Conflict of interest: There is no conflict of interest in this study.

Funding: The study was supported by the Bern University of Applied Sciences, Switzerland and the University Hospital Inselspital, Bern, Switzerland.Ethical approval: The study was approved by the State of Berne

Acknowledgments

The authors would like to thank the University Hospital of Berne, which enabled us to conduct this study. We are also very grateful to all of the health professionals who completed the many surveys. The authors would like to thank Tannys Helfer and Rebekah Kenyon for their careful editing.

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