Workplace safety in healthcare settings

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Workplace safety in healthcare settings is similar to the workplace safety concerns in most occupations, but there are some unique risk factors, such as chemical exposures, and the distribution of injuries is somewhat different from the average of all occupations. Injuries to workers in healthcare settings usually involve overexertion or falling, such as strained muscles from lifting a patient or slipping on a wet floor. [1] There is a higher than average risk of violence from other people, and a lower than average risk of transportation-related injuries. [1]

Contents

Aggression in the healthcare

Aggression was, in 1968, described by Moyer [ who? ] as "a behaviour that causes or leads to harm, damage or destruction of another organism". [2] Human aggression has more recently[ when? ] been defined as "any behaviour directed toward another individual that is carried out with the proximate intent to cause harm". [3]

The definition can be extended to include the fact that aggression can be physical, verbal, active or passive and be directly or indirectly focused at the victim–with or without the use of a weapon, and possibly incorporating psychological or emotional tactics. [4] It requires the perpetrator to have intent, and the victim to attempt evasion of the actions. Hence harm that is accidental cannot be considered aggressive as it does not incorporate intent, nor can harm implicated with intent to help (for example the pain experienced by a patient during dental treatment) be classed as aggression as there is no motivation to evade the action. [3] A description of workplace violence by Wynne, Clarkin, Cox, & Griffiths (1997), define workplace violence to be incidents resulting in abuse, assault or threats directed towards staff with regard to work–including an explicit or implicit challenge to their safety, well-being or health. [5]

The rate of aggression within the health care varies by country, globally 24% of healthcare workers experience physical violence each year and 42% experience verbal or sexual abuse. This rate has been decreasing in North America and increasing in Australasia. In Europe, rates of verbal abuse have decreased and physical violence have remained stable over the past decade. [6] : 7 

Aggression and violence negatively impact both the workplace and its employees. For the organisation, greater financial costs can be incurred due increased absences, early retirement and reduced quality of care. [7] [8] For the healthcare worker however, psychological damage such as post-traumatic stress can result, [4] in addition to a decrease in job motivation. [7] Aggression also harms patient care. Rude remarks from patients or their family members can distract healthcare professionals and cause them to make mistakes during a medical procedure. [9]

A survey from the British National Audit Office (2003) stated that aggression and violence accounted for 40% of reported health and safety incidents amongst healthcare workers. [5] Another survey looking into the abuse and violence experienced in 3078 general dental practices over a period of three years found that 80% of practice personnel had experienced self-reported verbal abuse, abuse or violence. [10] It was reported that, over 12 months in Australian hospitals, 95% of staff had experienced verbal aggression. [11] In the UK over 50% of nurses had experienced aggression or violence over a 12-month period. [12] In the United States, the annual rate of nonfatal, job-related violent crime against mental healthcare workers was 68.2 per 1,000 workers compared to 12.6 per 1,000 workers in all other occupations. [13]

In the United States, the emergency department is one of the most high-risk places to work in a hospital, which makes sense because most individuals in the emergency room are people who have just been injured and need to be rushed to the hospital. That situation is very stressful and scary for most people, so it may lead to emotions that are not truly meant, including aggressive emotions. Nurses' reports of patient aggression is not always taken seriously, which can make nurses less likely to report, ultimately leading to mental health issues. [14]

It was stated that nonfatal injuries because of aggression were three times more frequent against health care professionals than private industry workers. [15]

Causes

Many factors are correlated with an increased risk of violence. Regarding workplace design, poor delineation of staff only areas, overcrowding, poor access to amenities and unsecured furnishing increase the risks of violence. Regarding work practices, waiting times, poor customer service, working alone, lack of training, low level of staff empowerment, lack of deescalation training, lack of straff training in the cause of violence, the use of physical restraint and the presence of cash on-site is correlated with violence. Physicians who are unprepared, lacking in education about violence including descalation, lacking in medical skills of social skills, less experienced, overworked are more likely to be involved in violence. The physicians interpersonal style, personality and emotional state are correlated with violence. [16] : 17 

Patients who experience poverty or social exclusion, or lack the language of cultural competence to interact with physicians are more likely to be involved in violence. As well as those with certain injuries or disorders, such as head injuries, some psychiatric disorders, or thyroid disorders. Stressors, lack of respect and perceived respect, experience of poor healthcare historically, and intoxication are also risks for violence. [16] : 17 

Regarding the interactions that preceded aggression, misunderstandings or disputes about medical issues, patients being or feeling dismissed, dissatisfaction with care, physical contact, frustration with the patients intention, and involuntary treatment are correlated with violence. [17] : 438 

Ways of classifying aggression and violence

Most studies on violence in nursing are empirical in nature with little theoretical analysis. A systematic review on theoretical framings suggested an indisciplinary approach to capture the nuances of violence in a healthcare setting. [18] : 10 

Classification [19]
Patient-on-professional aggression can be classified as Type II; where the perpetrator commits a violent act whilst being served by the organisation, with which they have a legitimate relationship. [19] It is uncommon for such attacks to result in death, [20] however they are evidently responsible for approximately 60% of non-fatal assaults at work. [21] Within this classification that is based on the relationship between the perpetrator and victim, Type I aggression involves the perpetrator entering the workplace to commit a crime–having no relationship to the organisation or its employees. Type III deals with a current/former employee targeting a co-worker or supervisor for what they perceive to be wrong-doing. Type IV aggression involves the perpetrator having an ongoing/previous relationship with an employee within the organisation. [19]
Internal Model [22]
The internal model associates aggression with factors within the person, including mental illness or personality. [23] This model is supported by the numerous studies correlating a link between aggression and illness. [24] A person's traits can relate to their expression of aggression–narcissists for example, tend to become angry and aggressive if their image is threatened. [3] Sex tends to affect aggression–with certain provocations affecting each sex differently. [25] It was found that males tend to prefer direct aggression, and females indirect. [3] [26] A study by Hobbs and Keane, 1996 says that patient factors commonly related to or causative of patient violence include; male sex, relative youth or the effects of alcohol or drug consumption. [27] A study conducted amongst General Medical Practitioners in the West Midlands found that men were involved in 66% of aggression cases; rising to 76% with regard to assault/injury [27] –the main male perpetrator being aged under 40 years of age. Patient anxiety, a particular problem associated with dentistry, tended to be the most likely instigator for verbal abuse and the second most likely reason for threatening verbal abuse. [27]
External Model [22]
This model is based on the idea that social and physical environmental influences affect aggression. [23] This includes the provisions for privacy, space and location. [24] Motivation for aversion, possibly due to pain during dental treatment, can increase aggression [28] –as can general discomfort, such as that resulting from sitting in a hot waiting room [29] or in an uncomfortable position (for example in a reclined dental chair). [23] Alcohol intoxication or excessive caffeine intake tends to indirectly exacerbate aggression. [30] The Hobbs & Keane (1996) study states the involvement of drugs and alcohol; in 65% of cases at one Accident & Emergency Department and in 27% of all general practice cases. The study denotes intoxication to be the main reason for assaults and injury (along with mental illness). [27] Frustration, defined by Anderson and Bushman as "the blockage of goal attainment", [3] can also contribute to aggression–whether the frustrations are fully justified or not. [31] Such frustration-related aggression tended to be against the perpetrator and persons not involved in failure to reach the goal. Prolonged waiting times in A&E departments and general practice led to aggression due to frustration; it generally being directed towards receptionists–with approximately 73% of doctors becoming involved. [27]
Situational/Interactional Model [22]
This deals with factors involved in the immediate situation, for example interactions between patients and staff. [23] There are numerous studies that support the correlation between staff with a negative attitude and patient aggression. [24] Provocation has been said to be the most important cause of human aggression –examples include verbal and physical aggression against the individual. [3] It was found that perceived injustice, in the context of equality amongst staff for example, positively correlated to workplace aggression. [32]
Expressions of Hostility [32]
This is related to "behaviours that are primarily verbal or symbolic in nature". [32] In terms of Staff-on-Staff hostility, this can involve he perpetrator talking behind the targets back. With Patient-on-Professional hostility however, this can deal with the patient assuming false knowledge over the professional–with the patient belittling their opinions. [32]
Obstructionism [32]
This involves the perpetrator conducting actions that aim to "obstruct or impede the target's performance". [32] Failures to pass on information or respond to phone calls for example, are ways in which Staff-on-Staff obstructionism can be demonstrated. Patient-on-Professional obstructionism can be demonstrated by a failure on behalf of the patient to comply with the professional conducting a certain task. An unwillingness to allow the professional to diagnose the patient and a failure to turn up to appointments are examples of such obstructionism.
Overt Aggression [32]
This normally relates to workplace aggression, and involves behaviours including; threatening abuse, physical assault and vandalism. [32] This again can occur with regard to both, Staff-on-Staff and Patient-on-Professional aggression.
Buss' Three-Dimensional Model of Aggression [33]
Buss differentiated aggression into a three-dimensional model; physical-verbal, active-passive and direct-indirect–active-passive being removed in 1995 when Buss refined the categories. Physical assault would come under the category physical-direct-active, whereas obstructionism relates to physical-passive–be it direct or indirect. Verbal abuse or insults relate to verbal-active-direct aggression, whereas the failure to answer a question when asked, for example with regard to lifestyle choices or habits, can come under the verbal-passive-direct category–providing the reasons for not answering are directed at the healthcare worker (e.g. hostility), as opposed to fear for example. [4]
Struggle for recognition theory
A theory of violence based on struggle for recognition has been applied in healthcare settings. In this theory, nonrecognition and misrecognition of facts about the patient are causes of interpersonal conflict and violence. [18] : 6  In a study of the interpersonal factors preceding violent incidents, healthcare workers identified unmet needs, involuntary assessment and unsolicited touch as correlated. [34]

Mental Health issues due to abuse

Nurses dealing with more mental health issues is something that has come from dealing with workplace violence. In a study, it was found that somewhere between sixty and ninety percent of nurses are exposed to physical or verbal violence at some point in their work. [35] This shows how real it is within a nurse's daily work life. The violence can severely take a toll on someone's mental health. The article states, "A systematic review of 68 studies found workplace violence was most strongly associated with negative psychological outcomes, including post-traumatic stress disorder, depression, anxiety, sleep disturbances and fatigue". [36] With this being stated, it gives the readers a good idea of why workplace violence is so dangerous for healthcare workers.

Interventions

When dealing with aggression and violence in the workplace, training and education are the primary strategy for resolution. [37] There are a number or personal factors that can help reduce aggression within the healthcare setting, which include improved interpersonal skills, with an awareness of patient aggression and knowledge regarding dealing with emotional patients. [5] Although assertiveness is crucial when it comes to the interpersonal skills possessed by healthcare workers, it has been shown by numerous studies that nurses tend not to be very assertive. [5] Training is therefore usually offered by organizations with regard to assertiveness, and deals mainly with improving self-esteem, self-confidence and interpersonal communication. [38]

The Health Services Advisory Committee (HSAC) recommends a three-dimensional foundation by which to deal with violence in the workplace. It involves "researching the problem and assessing the risk, reducing the risk and checking what has been done". [37]

In 1997, HSAC provided the following guidelines as to what good training involves: [37]

Identifying whether patients are currently at risk of violence

The STAMP violence assessment framework lists elements of patient behaviour that are correlated with violence, and was developed in 2005 by Luck, Jackson and Usher. This model was later extended by the authors into an 18-point violence assessment tool. [18] : 3  Looking at the predictors in the violence assessment tool, resisting nonconsensual healthcare was found to be the best predictory of violence, followed by aggressive language and yelling. [39] : 5 

Assertiveness training

Although many studies looking at the effectiveness of training have provided inconclusive results, [5] a study by Lin et al. positively correlated the improvement of assertiveness and self-esteem with an assertiveness training programme. [38] The programme targets difficult interactions that we may face in day-to-day life and includes both, behavioural and cognitive techniques. [38] The effectiveness of training is measured using the Assertive Scale, Esteem Scale, and Interpersonal Communication Satisfaction Inventory. [38]

Evaluating the effectiveness of training

It remains that training is not universally or consistently offered to healthcare workers. [37] Beale et al. found that the levels of training offered ranged from nothing to high-level restraint/self-defense training. [40] A report by the National Audit Office (NAO) in 2003 found that, within mental health trusts, a reactionary approach tends to prioritise over prevention. Although criticised by many; restraint, seclusion and medication are used (Wright 1999, Gudjonsson et al. 2004). [24] Breakaway techniques, restraint, rapid tranquilisation or isolation tend to be recommended when violence is instigated with a failure to prevent aggression. [24] This correlates to the level of training offered, which dominates in these areas, however lacks in situation risk assessment and customer care [37] –methods that are vital in a preventative approach to prevent escalation of the situation, causing for reactionary measures to be brought into play.

The study by Beale et al. therefore provides the following advice as to good practice: [37] [40]

See also

Related Research Articles

<span class="mw-page-title-main">Home care in the United States</span>

Home care is supportive care provided in the home. Care may be provided by licensed healthcare professionals who provide medical treatment needs or by professional caregivers who provide daily assistance to ensure the activities of daily living (ADLs) are met. In-home medical care is often and more accurately referred to as home health care or formal care. Home health care is different non-medical care, custodial care, or private-duty care which refers to assistance and services provided by persons who are not nurses, doctors, or other licensed medical personnel. For patients recovering from surgery or illness, home care may include rehabilitative therapies. For terminally ill patients, home care may include hospice care.

Abuse is the improper usage or treatment of a thing, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, assault, violation, rape, unjust practices, crimes, or other types of aggression. To these descriptions, one can also add the Kantian notion of the wrongness of using another human being as means to an end rather than as ends in themselves. Some sources describe abuse as "socially constructed", which means there may be more or less recognition of the suffering of a victim at different times and societies.

Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders, schizophrenia, schizoaffective disorder, mood disorders, addiction, anxiety disorders, personality disorders, eating disorders, suicidal thoughts, psychosis, paranoia, and self-harm.

Verbal abuse is a type of psychological/mental abuse that involves the use of oral, gestured, and written language directed to a victim. Verbal abuse can include the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual. It can also include the use of derogatory terms, the delivery of statements intended to frighten, humiliate, denigrate, or belittle a person. These kinds of attacks may result in mental and/or emotional distress for the victim.

Workplace bullying is a persistent pattern of mistreatment from others in the workplace that causes either physical or emotional harm. It can include such tactics as verbal, nonverbal, psychological, and physical abuse, as well as humiliation. This type of workplace aggression is particularly difficult because, unlike the typical school bully, workplace bullies often operate within the established rules and policies of their organization and their society. In the majority of cases, bullying in the workplace is reported as having been done by someone who has authority over the victim. However, bullies can also be peers, and subordinates. When subordinates participate in bullying this phenomenon is known as upwards bullying .The least visible segment of workplace bullying involves upwards bullying where bully- ing tactics are manipulated and applied against “the boss,” usually for strategically designed outcomes.

<span class="mw-page-title-main">Workplace violence</span> Assault, abuse or threat that occurs in the workplace

Workplace violence (WPV), violence in the workplace (VIW), or occupational violence refers to violence, usually in the form of physical abuse or threat, that creates a risk to the health and safety of an employee or multiple employees. The National Institute for Occupational Safety and Health defines worker on worker, personal relationship, customer/client, and criminal intent all as categories of violence in the workplace. These four categories are further broken down into three levels: Level one displays early warning signs of violence, Level two is slightly more violent, and level three is significantly violent. Many workplaces have initiated programs and protocols to protect their workers as the Occupational Health Act of 1970 states that employers must provide an environment in which employees are free of harm or harmful conditions.

A health professional, healthcare professional, or healthcare worker is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician, physician assistant, registered dietitian, veterinarian, veterinary technician, optometrist, pharmacist, pharmacy technician, medical assistant, physical therapist, occupational therapist, dentist, midwife, psychologist, audiologist, healthcare scientist, or who perform services in allied health professions. Experts in public health and community health are also health professionals.

The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, and is HL7 registered.

<span class="mw-page-title-main">Nursing</span> Health care profession

Nursing is a profession within the healthcare sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses can be differentiated from other healthcare providers by their approach to patient care, training, and scope of practice. Nurses practice in many specialties with differing levels of prescription authority. Nurses comprise the largest component of most healthcare environments; but there is evidence of international shortages of qualified nurses. Nurses collaborate with other healthcare providers such as physicians, nurse practitioners, physical therapists, and psychologists. There is a distinction between nurses and nurse practitioners; in the U.S., the latter are nurses with a graduate degree in advanced practice nursing, and are permitted to prescribe medications unlike the former. They practice independently in a variety of settings in more than half of the United States. Since the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.

Workplace aggression is a specific type of aggression which occurs in the workplace. Workplace aggression is any type of hostile behavior that occurs in the workplace. It can range from verbal insults and threats to physical violence, and it can occur between coworkers, supervisors, and subordinates. Common examples of workplace aggression include gossiping, bullying, intimidation, sabotage, sexual harassment, and physical violence. These behaviors can have serious consequences, including reduced productivity, increased stress, and decreased morale.

Patient abuse or patient neglect is any action or failure to act which causes unreasonable suffering, misery or harm to the patient. Elder abuse is classified as patient abuse of those older than 60 and forms a large proportion of patient abuse.

The nursing organization workplace has been identified as one in which workplace bullying occurs quite frequently. It is thought that relational aggression are relevant. Relational aggression has been studied amongst girls but rarely amongst adult women. According to a finding, 74% of the nurses, 100% of the anesthetists, and 80% of surgical technologists have experienced or witnessed uncivil behaviors like bullying by nursing faculty. There have been many incidents that have occurred throughout the past couple of years. OSHA, which stands for "Occupational Safety and Health Administration" stated that from 2011 to 2013, the United States healthcare workers experienced 15,000 to 20,000 significant injuries while in the workplace.

<span class="mw-page-title-main">Holistic nursing</span> Medical care practice

Holistic nursing is a way of treating and taking care of the patient as a whole body, which involves physical, social, environmental, psychological, cultural and religious factors. There are many theories that support the importance of nurses approaching the patient holistically and education on this is there to support the goal of holistic nursing. The important skill to be used in holistic nursing would be communicating skills with patients and other practitioners. This emphasizes that patients being treated would be treated not only in their body but also their mind and spirit.. Holistic nursing is a nursing speciality concerning the integration of one's mind, body, and spirit with his or her environment. This speciality has a theoretical basis in a few grand nursing theories, most notably the science of unitary human beings, as published by Martha E. Rogers in An Introduction to the Theoretical Basis of Nursing, and the mid-range theory Empowered Holistic Nursing Education, as published by Dr. Katie Love. Holistic nursing has gained recognition by the American Nurses Association (ANA) as a nursing specialty with a defined scope of practice and standards. Holistic nursing focuses on the mind, body, and spirit working together as a whole and how spiritual awareness in nursing can help heal illness. Holistic medicine focuses on maintaining optimum well-being and preventing rather than just treating disease.

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<span class="mw-page-title-main">Patient-initiated violence</span> Occupational hazard

Patient-initiated violence is a specific form of workplace violence that affects healthcare workers that is the result of verbal, physical, or emotional abuse from a patient or family members of whom they have assumed care. Nurses represent the highest percentage of affected workers; however, other roles include physicians, therapists, technicians, home care workers, and social workers. Non clinical workers are also assaulted, for example, security guards, cleaners, clerks, technicians. The Occupational Safety and Health Administration used 2013 Bureau of Labor Statistics and reported that healthcare workplace violence requiring days absent from work from patients represented 80% of cases. In 2014, a survey by the American Nurses Association of 3,765 21% of nurses and nursing students reported physical abuse and over 50% reported verbal abuse within a 12-month period. Causes for patient outbursts vary, including psychiatric diagnosis, under the influence of drugs or alcohol, or subject to a long wait time. Certain areas are more at risk for this kind of violence including healthcare workers in psychiatric settings, emergency or critical care, or long-term care and dementia units.

<span class="mw-page-title-main">Oral care swab</span> Sponge on a stick used for oral care

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Debra Elizabeth Jackson is an Australian academic nurse and professor of nursing at the Susan Wakil School of Nursing at the University of Sydney, Australia. In 2021 she was awarded professor emerita in the faculty of health in the University of Technology Sydney. She holds a number of adjunct roles including honorary professor of nursing, Oxford Health NHS Foundation Trust, visiting professor at the Florence Nightingale Faculty of Nursing and Midwifery in King's College London, Bournemouth University, and Auckland University of Technology. She was previously the editor-in-chief of the Journal of Clinical Nursing and is now the editor-in-chief of the Journal of Advanced Nursing.

<span class="mw-page-title-main">Impact of the COVID-19 pandemic on healthcare workers</span>

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<span class="mw-page-title-main">Karen Hoare</span> Nurse practitioner & medical researcher at Massey University in New Zealand

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