Identification of Workplace Violence

Risk Factors and Management Practices

in Healthcare Settings

Susan Goodwin Gerberich, PhD

School of Public Health, University of Minnesota, USA

OVERVIEW

• Healthcare Workforce: Globally and in the United States

• Injury: Intentional (Violence)

Definitions

Relevant Legislation

Magnitude

Risk Factors

Costs

• Example: Workplace Violence Study Conducted

• Strategies for Prevention and Control

HEALTHCARE WORKERS

GLOBALLY: 59 Million Workers

UNITED STATES (U.S.): 18 Million Workers

_________________________

Shortage of Healthcare Workforce

http://www.cdc.gov/niosh/topics/healthcare

http://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/

WORK-RELATED VIOLENCE

DEFINITIONS

WORK-RELATED VIOLENCE: intentional use of

physical force or emotional abuse, against an employee,

that results in physical or emotional injury and

consequences

• Physical Assault: occurs when one is hit, slapped,

kicked, pushed, choked, grabbed, sexually assaulted, or

otherwise subjected to physical contact intended to injure

or harm

• Non-Physical Violence: threat; sexual harassment;

verbal abuse; and bullying

One of the fastest growing complaints of

workplace violence

• Offensive unwanted aggressive behavior involving a real

or perceived power imbalance

• Behavior: Vindictive, intimidating, humiliating, and

repeated

• Types: Physical; Verbal; Social (exclusion or damage of

reputation); Cyberbullying

WORKPLACE BULLYING

AGAINST INDIVIDUALS OR GROUPS

The Occupational Safety and Health Act’s (OSH Act)

General Duty Clause requires employers to provide a safe

and healthful workplace – one that is free from recognized

hazards that are causing or likely to cause death or

serious physical harm

Employers who do not take reasonable steps to prevent or

abate a recognized violence or other hazard in the

workplace can be cited.

____________

https://www.osha.gov/Publications/osha3148.pdf;Public Law 91-596,2015; 84

STAT.1590; 91st Congress, S.22193, December 29, 1970; 2004

U.S. OCCUPATIONAL SAFETY AND

HEALTH ACT - 1970

NO FEDERAL STANDARD REQUIRES WORKPLACE

VIOLENCE PROTECTIONS

http://www.scientificamerican.com/article/epidemic-of-violence-against-health-care-workers-plagues-hospitals/

Some states (through legislation) require: • Penalties for assaults of nurses and / or other health care personnel

• Employers to provide workplace violence prevention programs

• Between 8% and 38% of healthcare workers experience

physical violence at some point in their careers –

many every day

• Even more threatened or exposed to verbal aggression

• Most violence perpetrated by patients and visitors

• Nurses and other staff directly involved in patient care,

emergency department staff, and paramedics – at

greatest risk World Health Organization – 2015

http://www.who.int/violence_injury_prevention/violence/workplace/en/

VIOLENCE AGAINST HEALTHCARE WORKERS:

A GLOBAL PROBLEM

• 18 million healthcare workers employed in the United

States – 11% of the total workforce

• Past 10 years - average: experienced over 50% of all

industry reported nonfatal violence-related injuries

involving lost work days

• 2014: ~80% of nurses reported being attacked on the job

within the past year; accounted for ~70% of all

reported industry nonfatal violence-related injuries

involving lost work days

VIOLENCE AGAINST HEALTHCARE WORKERS

IN THE UNITED STATES

U.S. Bureau of Labor Statistics

Count only assaults that resulted in lost time from work

• Non physical violence, including psychological trauma

or less severe physical injuries, are not reported.

Assaults reported by healthcare workers is considered

greatly underreported - reasons include:

• lack of awareness / perceived as unintentional

• fear of retaliation

• message within the healthcare industry that

“workplace violence is part of the job”

BURDEN OF WORKPLACE

VIOLENCE -- UNDERESTIMATION

https://www.osha.gov/

• Impacts, negatively, on psychological and physical well-

being

• Affects job motivation and, thus, productivity

• Compromises quality of care – places health-care provision

at risk

• Leads to immense financial loss in the health sector

COSTS OF VIOLENCE AGAINST

HEALTHCARE WORKERS

World Health Organization – 2015

http://www.who.int/violence_injury_prevention/violence/workplace/en/

FINANCIAL IMPACT OF

WORKPLACE VIOLENCE

IN THE UNITED STATES

• Estimated at more than $120 billion each year, overall;

~$84 billion specific to healthcare (70% lost work time cases)

• Liability cases where employer failed to take proactive,

preventive measures under OSHA guidelines cost

$3.1 million per person per incident

National Institute for Occupational Safety and Health

Institute of Finance and Management. (2011).

Benchmarks: Spending on workplace violence prevention.

WORKPLACE VIOLENCE

PLACES HEALTHCARE STAFF AND PATIENTS

AT RISK!!

OCCUPATIONAL VIOLENCE

AGAINST NURSES

STUDY DESIGN: TWO PHASES

PURPOSE

PHASE 1: Initial Comprehensive Study to determine magnitude and consequences of all work-related violence for a one-year period of time PHASE 2: Case-Control Study to identify specific risk factors for work-related physical assault, based on exposures prior to the assault for cases and a randomly assigned period for controls

STUDY COHORT

Registered Nurses (56,713) and Licensed Practical Nurses

(21,740) in the Minnesota licensing databases

PHASE 1 - INITIAL COMPREHENSIVE STUDY

Cohort of 6,300 nurses randomly sampled from population

PHASE 2 - CASE-CONTROL STUDY

Cases (N= 475): Persons who reported being physically assaulted

and worked as nurses in Minnesota during a 12-month study

period

Controls (N = 1425), 3:1 ratio: Persons who reported not being

physically assaulted and worked as nurses in Minnesota during a

12-month study period

STUDY DEFINITIONS

Provided to the participants to ensure they all had identical

information as a basis for responding to questions

______________________________________

Physical Assault: occurs when you are hit, slapped, kicked, pushed, choked,

grabbed, sexually assaulted, or otherwise subjected to physical contact

intended to injure or harm

Non-Physical Violence: includes: threat; sexual harassment; and verbal abuse

Threat: use of words, gestures, or actions with the intent of intimidating,

frightening or harming.

Sexual Harassment: any type of unwelcome sexual behavior (words or

actions) that creates a hostile work environment.

Verbal Abuse: yelling, swearing, calling names, using other words intended to control or hurt.

CONTACT PROCEDURES

Initial Survey: Survey, cover letter (with informed

consent information); prepaid, return envelope

Case-Control Survey: Survey, cover letter (with

informed consent information); prepaid, return

envelope

Follow-Up to Optimize Response: as many as four

follow-up mailings were utilized.

Validity Studies: to validate physical violence incidents

and exposure information

ANALYSES

• Descriptive analyses to identify incidence rates and

consequences of work-related violence

• Multivariate analyses to identify “risk and

protective” factors:

•• numerous factors controlled for to minimize

bias (Greenland et al., 1999)

•• adjustments made for non-response

and unknown eligibility (Horvitz and Thompson, 1952)

CONCEPTUAL MODEL FOR THE

OCCURRENCE OF WORK-RELATED

PHYSICAL ASSAULT EVENTS

Nurses’

Characteristics

Characteristics

of Others

Environmental

Factors

Occupational

Physical

Assault

STUDY RESPONSE RATES Registered and Licensed Practical Nurses

Overall

Phase 1: Comprehensive Study 80% (RNs, 74%; LPNs, 78%)

Phase 2: Case-Control Study 67% Cases (N= 475) - 68%

Controls (N = 1425) - 66%

WORK-RELATED VIOLENCE RATES* PER

100 PERSONS PER YEAR

Physical Assault Non-Physical Violence

TOTAL 13.2 (12.2, 14.3) 38.8 (37.4, 40.4) ___________________________________________________________ RN 12.0 (10.9, 13.3) 38.5 (36.7, 40.3) LPN 16.4 (14.2, 18.7) 39.7 (36.8, 42.9)

Conservative estimates: allowed a maximum of one event for those

injured

*Adjusted For Non-response / Unknown Eligibility (95% C.I.)

PERPETRATOR CHARACTERISTICS

Characteristics

Specific

Assault

657 events

%

Ongoing

Assault

54 events

%

Non-Physical

Violence

2,182 events

%

Patient or

Client

97

91 67

Perceived to

be Impaired

89

91

51

Male 59

56 73

SYMPTOMS AND FEELINGS

POST-EVENT

Symptoms/Feeling

s

Specific

Assault

%

Ongoing

Assault

%

Non-

Physical

%

Frustration 46 57 61

Anger 33 33 60

Fear, Anxiety, Stress 23 33 40

Irritability 13 11 27

Fatigue 9 22 20

Sadness 7 11 21

Headaches 3 7 10

SYMPTOMS AND FEELINGS

POST-EVENT (Continued)

Symptoms/Feelings

Specific

Assault

%

Ongoing

Assault

%

Non-

Physical

% Difficulty Concentrating /Sleeping

5

10

24

Shame / Low Self-Esteem 2 2 14

Depression 2 7 15

Flashbacks / Nightmares

/Hallucinations

<1 8 7

Other 2 2 2

None 34 24 12

WORK-RELATED

CONSEQUENCES OF VIOLENCE

Consequences

Single

Assault

%

Ongoing

Assault

%

Non-

Physical

%

TOTAL - Changes 10 7 21

Restricted or

modified work

6

---

9

Quit work 1 2 6

Transfer: voluntary/involuntary/ leave of absence

3

2

5

Other <1 3 2

EXPOSURES OF INTEREST

(comparisons between cases and controls to

identify risk and protective factors)

Personal characteristics

Primary facility

Primary department/unit/area

Primary patient population

Primary professional activity

Specific environmental factors

MULTIVARIATE ANALYSES

CASE-CONTROL STUDY

• Violence, both physical and non-physical, is a significant

problem among nurses – Including:

• post-event physical and psychological problems;

• change in work status: restriction; quitting; transferring • Environmental exposures associated with increased risk:* Working in :

• nursing homes/long term care facilities (2.6x)

• emergency (4.2x) / psychiatric/behavioral departments (2x)

• environments with lighting darker than “bright as daylight” (2.2x)

• Environmental exposures associated with decreased risk:*

• Working in outpatient, clinic, and public health facilities (0.2-0.4)

• Working with neonatal/pediatric/adolescent populations (0.4)

• Carrying a cell phone/personal alarm (0.3-0.7)

*Case-Control Study: Statistically Significant Odds Ratios

SUMMARY OF FINDINGS: RISK AND PROTECTIVE

FACTORS THAT CAN SERVE AS A

BASIS FOR PREVENTION EFFORTS

RISK FACTORS

SUMMARY OF FINDINGS

(continued)

PERSONAL EXPOSURES O.R. (95% C.I.) • Shift type worked

Day Shift 1 (--)

Evening 1.55 (1.05, 2.27)

Day and Evening 2.88 (1.22, 6.80)

Night Shift 3.54 (2.31, 5.44)

• Patient contact hours

+5% Increase (change per hour) 1.05 (0.99, 1.105)- • Years worked as licensed nurse -2% Decrease (change per year) 0.98 (0.97, 1.001)-

ANECDOTAL COMMENTS

Examples among ~300

“Although my physical injury was severe - threatened my ability to continue in nursing - for me, the psychological aspect was worse. I experienced nightmares, decreased trust levels if anyone got too close to me. It was terrible.”

(>40 days restriction of normal activities; quit job)

__________________

“We have been told that this is part of the job and if we don’t like it, we can leave.”

(comment by numerous participants)

Gerberich et al., Minnesota Nurses’ Study

ACKNOWLEDGMENTS

• Support for this effort was provided, in part, by the:

••National Institute for Occupational Safety and Health, Centers for

Disease Control and Prevention, Department of Health and

Human Services (R01 OH03438);

••Center for Violence Prevention and Control, University of

Minnesota; Regional Injury Prevention Research Center,

University of Minnesota

• Collaborating Organizations Included:

••Minnesota Hospital and Health Care Partnership

••Minnesota Nurses' Association

••Minnesota Licensed Practical Nurses' Association

TOTAL WORKER HEALTHTM

Total Worker Health™ is a strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well-being.

“…is more than the sum of it parts – protection and promotion – it is a synthesis of all aspects of health that create worker well-being” – John Howard, MD, Director

National Institute for Occupational Safety and Health

http://www.cdc.gov/niosh/twh/

PREVENTION THROUGH A

TOTAL WORKER HEALTH™ APPROACH

Gerberich (adapted) http://www.cdc.gov/niosh/twh/

https://www.osha.gov/Publications/osha3148.pdf

BASELINE AND ONGOING

RECORD-KEEPING

Events and Interventions

REGULAR DATA REVIEW

Analyze Trends and Rates of

Injuries/Fatalities Relative to

Initial or Baseline Rates

EVALUATION AND

MODIFICATION

Policies, Programs, and

Interventions

EMPLOYEE SAFETY

AND HEALTH TRAINING

Provide Tools to Identify

Workplace Safety and

Security Hazards

WORKSITE ANALYSIS

Identify and Assess

Hazards

OCCUPATIONAL SAFETY AND

HEALTH PROTECTION AND

HEALTH PROMOTIONProvide Relevant: Engineering

Controls; Safety and Security

Technologies; Workplace

Design/Environment;

Adaptations for Workers; Human

Resources

MANAGEMENT COMMITMENT,

LEADERSHIP, AND RESOURCES

EMPLOYEE INVOLVEMENT

HEALTH AND SAFETY COMMITTEE

TOTAL WORKER HEALTHTM

ApproachOccupational Safety and Health

Protection and Health Promotion

Policy and Program Development,

Implementation, and Evaluation –

Ongoing Oversight

ONLINE TRAINING HELPS PROTECT

NURSES AND OTHER HEALTHCARE WORKERS

FROM WORKPLACE VIOLENCE

National Institute for Occupational Safety and Health, Centers for Disease Control http://wwwn.cdc.gov/wpvhc/Course.aspx/Slide/Intro_1

“A UNIVERSAL TRUTH:

NO HEALTH WITHOUT A WORKFORCE”

SHORTAGE OF GLOBAL (U.S.) HEALTH WORKFORCE:

• 2014: 7.2 (2.2) Million Workers

• 2035: 12.9 (3.9) Million Workers

http://www.who.int/workforcealliance/knowledge/resources/GHWA-a_universal_truth_report.pdf?ua=1

ZERO TOLERANCE FOR VIOLENCE