122 occupational violence in healthcare

OCCUPATIONAL VIOLENCE IN 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

i

This research report was prepared by

Associate Professor Debra Griffiths, Julia Morphet, Kelli Innes

of

School of Nursing & Midwifery, Monash University

Department of Medicine, Nursing and Health Sciences

Monash University

For Worksafe Victoria

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.

ii

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

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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

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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.

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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:

1. Identify the evidence concerning prevalence and distribution of occupational violence

across the range of health / social care settings;

2. Seek to identify effective interventions that have reduced occupational violence; and

3. Consider evidence to better inform practice in surveillance from within and outside

the sector.

A thorough search of literature on prevalence of occupational violence in the health care

setting in Australia and the interventions commonly used nationally and internationally was

conducted. Types of studies included peer reviewed research, systematic reviews, meta-

analysis, and grey literature including discussion, reports and legal documents published in

English since 2005. Studies were identified from searching electronic databases, references

from articles identified, grey literature and thesis resources. The electronic databases

included Scopus, PubMed, Medline, CINAHL, LexisNexis, AMED, Australian Public Affairs

and Google Scholar. Grey literature was sought from Victorian Government documents,

Work Safe, Australian Nursing Federation, and US Government documents.

The database search utilised various searching strategies such as Keywords,

Boolean/Proximity Operators, Search phases, Truncation/Wildcards; Subject headings and

particular Database search tips to identify the most relevant publications. The keyword

search terms included occupational violence, workplace violence, workplace aggression,

intervention, prevention, healthcare, report, legislation, and Australia.

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The following example illustrates a search strategy conducted in Scopus database:

Keywords: workplace violence OR occupational violence AND intervention

Type: Article, Conference paper, Article in press, Book chapter, Book

Discipline: Health Science

Subject areas: Nursing, Health professions, Social science and Psychology; and

Medicine

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).

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Figure 1: Flow Diagram of study selection

Records identified through database searching

(n = 1301)

Sc

ree

nin

g

Inc

lud

ed

E

lig

ibil

ity

Ide

nti

fic

ati

on

Additional records identified through other sources

(n = 199)

Records after duplicates (n = 750) & inaccessible papers (n = 38) removed (n = 712 remaining)

Records screened (n = 712)

Records excluded (n = 287)

Full-text articles assessed for eligibility

(n = 425)

Full-text articles excluded, with reasons

(n = 345)

Studies included in literature review

(n = 80)

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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)

Occupational violence in health care is often classified by source or perpetrator type,

including:

external violence, perpetrated by people outside of the organisation with a criminal

intent;

client-initiated violence, initiated by patients, or patients families against health care

providers; and

horizontal or internal violence, perpetrated by co-workers, supervisors and other

health care workers.(2)

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

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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) settings, mental health,(6, 7) aged care,(8) and community

environments including general practice (GP) clinics,(9-11) paramedics,(12, 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)

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Consequences of violence in health care

There are many negative consequences of violence in healthcare. These include increased

incidents of depression, sleep and anxiety disorders, drug and alcohol problems and Post

Traumatic Stress Disorder (PTSD).(21) While injuries caused by physical violence may be

obvious, injury caused by verbal abuse may not be obvious. There is increasing evidence to

suggest that verbal abuse has long term harmful consequences.(22) Workers exposed to

repeated episodes of violence were more likely to suffer from poor psychological health as a

consequence.(23) It has been reported that psychological injuries are not necessarily related

to the severity of the violence but the frequency of exposure.(23) In addition, these authors

assert that those who witness violence have a greater risk of developing mental health

issues. Finally, studies reveal that many staff had resigned from their position due to verbal

or physical abuse,(16, 24) and a further 24% of staff had considered resigning for the same

reason.(24)

Causes and risk factors

A number of risk factors have been linked to occupational violence in health care. These can

be divided into four categories: patient characteristics, staff characteristics, organisational

factors, and physical design of the workplace and setting. Patient characteristics that have

frequently been linked with occupational violence in health care include being male,(11) drug

and alcohol toxicity,(11) mental illness,(4, 11) and organic illness or confusion.(4, 25) One study

also reported that 50% of violence in hospital wards comes from patients aged more than 70

years,(8) however this may reflect the demographics of the hospitalised patient population,

more than the age itself.

Staff characteristics that have been linked with violence include being young and

inexperienced,(2, 9, 11) female,(9, 10) or being an international medical graduate,(10) while

increasing age(11) and increasing experience(9) were found to be protective.

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Organisational factors linked to occupational violence in health care include understaffing,

the culture and the climate of the work environment.(2) The physical design of the workplace,

including level of security (locked doors, blind spots, lighting, surveillance cameras),(2, 26-29)

and accessibility(2, 29) have been found to influence the prevalence of violence. Finally, the

hospital setting also influences the prevalence of occupational violence in health care, with

violence more common in public hospitals than private hospitals,(30) and more common in

emergency departments(31-33) and mental health units (7, 26, 34) than other hospital wards.(11, 35)

Occupational violence is also more prevalent at night (1800 0600) than during the day.(4)

INTERVENTIONS TO REDUCE OCCUPATIONAL VIOLENCE IN HEALTH

CARE

A number of interventions have been introduced to reduce occupational violence in health

care. In Victoria, several reports have been prepared for or by Government Departments,

outlining the prevalence of violence in health care,(35, 36) and ways in which it can be

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)

Conflict management, i.e. de-escalation strategies and communication strategies for

defusing or preventing potentially violent situations;(7, 33, 37, 39, 40, 42, 44, 45, 47-54)

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Physical self-defence techniques including break-away (escape) training and patient

restraint methods;(34, 55, 56)

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, 57) self-

confidence,(34, 56, 58) or self-efficacy to deal with aggressive patients,(42, 52, 56) 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)

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scored performance using the De-escalating Aggressive Behaviour Scale. The mean de-

escalation score rose from 2.74 to 3.65 (p

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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

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occupational violence, there are scant large-scale, well-designed studies that can strongly

support their effectiveness in reducing the incidence of occupational violence.

Patient risk assessment

Risk assessment tools have been introduced in both community and hospital settings in

Canada(67, 68) and USA.(8, 68) The purpose of the risk assessment tools was to identify patients

who might be at risk of violence toward staff and then flag the risk with other staff, either

through the patient notes(8, 68) or a patient wrist band.(67) Kim et al.(8) found that the

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:

locked doors,(27, 28, 35, 40, 47)

surveillance cameras,(28, 29, 35, 47)

duress alarms,(7, 26, 35, 40, 47)

flexiglass as a barrier between patients and staff, while ensuring a line of site,(26, 27)

removal of blind spots,(7, 26)

secure observation rooms,(69) and

metal detectors.(33)

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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

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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.

The effectiveness of the environmental structure as a means to reducing occupational

violence in health care has not been appropriately evaluated, however staff perceptions of

safety are an important consideration for staff mental well-being. In light of this,

environmental security measures should be considered in high risk health care settings.

There is a need for future research to examine the effect of environmental security features

on the incidence of occupational violence in health care.

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.

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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)

Aggression Management Teams

Aggression management teams (AMT) have been recommended as one way to manage

aggressive or violent behaviour.(35, 69) AMT members may be drawn from any area of the

health service, and receive specific additional training in de-escalation of violence and

aggression. AMT members respond to Code Grey (or Code Black) calls, and support the

local team members to care for the patient or visitor.(35)

Zero Tolerance Policy

Zero tolerance policies were first introduced in the United Kingdom in 1997, and were later

introduced in NSW, Australia in 2003. The premise of a zero tolerance policy is the

understanding that specified behaviour will not be tolerated under any circumstances, and

that there will be a non-negotiable sanction imposed whenever that behaviour occurs.(70)

The zero tolerance policy aims to change the attitudes and acceptance of violence in the

health care setting, and send a message to patients and families about their obligations

toward those who provide care.(2) Under a zero tolerance policy, staff are encouraged by

management to press charges against individuals who are violent towards them, and those

patients known to be aggressive or violent are blacklisted and denied treatment.(70)

Prosecutions of patients and relatives for attacks on health care staff increased significantly

following the introduction of the zero tolerance policy in Britain.(2)

While advocated in many health care settings,(17, 71) there are many detractors to the zero

tolerance policy. Zero tolerance policies fail to discriminate between different causes of

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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.

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RECORDING INCIDENTS OF VIOLENCE

There is a need for occupational violence to be reported. Reporting is the only accurate

method of establishing the risk factors, extent, patterns, contributing and precipitating factors

associated with occupational violence. Reporting allows for reflection and the ability to learn

from incidents of occupational violence, including the evaluation of any interventions

implemented.(75, 76) WorkSafe also highlight the importance of reporting violence, to ensure

that information regarding a risk of potential violence that may pose a threat to health and

safety be provided to staff who may come into contact with the client or to another health

service to which the client is referred.(40) WorkSafe recommend that this is done through alert

systems or file flagging.

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) Risk assessment tools provide rapid

identification and communication to colleagues of potential for occupational violence. The

reporting of potential risk may result in a decrease in actual incidents of occupational

violence as staff can initiate appropriate preventative measures.

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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

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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) Therefore rather than

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)

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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)

Another challenge widely recognised in the literature is the under-reporting of workplace

violence. To improve the accuracy in reporting the incidence of violence in healthcare, one

study analysed monthly reports of all calls to hospital security.(54) There were two reported

advantages to this method of data collection. Firstly, this measurement did not place an

additional burden on any staff, as security staff were already required to prepare a monthly

report of all call-outs. Secondly, this method avoided under-reporting of workplace violence,

which is widely acknowledged in health care.(54)

From the limited literature available, reporting systems for occupational violence need to be

centralised, user friendly and quick to complete.

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Table 1 Summary of reporting systems Author Reporting Format/

Whom

Information collected Process post completion

Arnetz et al.

(2011)(80)

Integrated

workplace violence

incident reports

Staff

Incident date, time,

location & work shift

Demographic data

Categorise report as

injury, illness, exposure, and/or

any form of verbal or physical

violence (workplace conflict)

Activity preceding event

Any injury that occurred

Description of any

object or substance that

caused harm

Details of witnesses

Categorises:

o Type I - criminal intent with no legitimate

relationship with the organisation

o Type II perpetrator is a client for who services

are being provided

o Type III between employees (current or former)

o Type IV perpetrator has a relationship with an

employee of the organisation

Violent incidents further categorised based

on the nature of the incident:

o assault

o combative patient

o combative person

o conflict

o harassment

o sexual harassment

o threat

o unprofessional behaviour

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Pawlin

(2008)(81)

Abuse data

recording tool

Date, time

Who was being abused

Form of abuse

How did abuse leave

you feeling

Assailant details

Police called

Outcomes of incident

Visual analogue scales

Numeric rating scales

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CONCLUSION AND RECOMMENDATIONS

This review confirms the prevalence of occupational violence across all health care

environments. Whilst a wide variety of interventions aimed at preventing or reducing violence

in health care have been implemented, few have been shown to reduce the incidence of

occupational violence. Further, there is evidence that the state-wide reporting system used

in Victoria to identify the frequency of occupational violence is burdensome and under-

utilised. The effectiveness of this reporting system has not been formally evaluated. Based

on the data in this literature review, the following recommendations are proposed:

Evaluation of the RiskMan reporting system exploring usability and obstacles to

use;

Introduction of a standardised data collection system to collect and evaluate incidents

involving hospital security staff;

Investigate the development of software to import patient medical record alert data

with hospital violence data collection systems (RiskMan);

Introduction of a state-wide patient management data system, which enables sharing

of patient files between health care providers, thus enabling the provision of informed

health care and increasing awareness of patients at risk of potential violence;

Evaluation of the efficacy of education programs in reducing the incidence of violence;

Evaluation of the effectiveness of environmental changes in reducing the incidence of

violence.

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