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Article Excerpt
Violence towards health-care personnel represent an increasing problem, but little is known in terms of how different occupational groups are affected. A questionnaire was sent to a stratified sample of 2,800 of 173,000 employees in the Swedish municipal health and welfare sector. Seven major groups working with the elderly or persons with developmental disabilities were considered: administrators, nursing specialists, supervisors, direct carers, nursing auxiliaries, assistant nurses, and personal assistants. The response rate was 85 percent. Fifty-one percent of respondents reported exposure to violence or threats of violence over one year. The most vulnerable groups were assistant nurses and direct carers (usually of the developmentally disabled). Individual characteristics, such as age and organizational tenure, were related to exposure. Work-related characteristics, such as type of workplace, working full-time with clients, organizational downsizing, and high workload, were also associated with risk. Greater knowledge of impacts on different professional groups and relevant prevention are required.
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Violence at work is a topic that has received growing international attention in recent years (Chappell and Di Martino 1998). Personnel in the health-and-welfare sector seem to be more exposed than other workers are (Barab 1996; Peek-Asa 2001). Recent research indicates that violence, including serious acts of violence, against psychiatric staff is on the increase (Soares, Lawoko and Nolan 2000; Whittington 1997). In Sweden, caring personnel are among those workers most subject to threats and violence at work. The sector accounts for over half of all reported work injuries caused by violence, with a substantial increase in the rate of such injuries having been recorded during the 1990s (Nordin 2000).
Traditionally, work-related violence in the caring sector has been investigated specifically in the arenas of psychiatric and acute medical care. Other areas within the health-care and welfare sector, such as services to persons with developmental disabilities, the elderly and physically ill, have received far less research attention (Wynne et al. 1997; Saveman et al. 1999). In fact, only a handful of studies can be found in these areas (e.g. Colenda and Hamer 1991; Dougherty et al. 1992; Ghaziuddin and Ghaziuddin 1992; Lusk 1992; Gage and Kingdom 1995; Kendra 1996; Kendra et al. 1996; Kiely and Pankhurst 1998; Gates, Fitzwater and Meyer 1999; Lee et al. 1999; Fazzone et al. 2000), and very few are concerned with Sweden in particular (e.g. Saveman et al. 1999; Menckel, Carter and Viitasara 2000; Menckel and Viitasara 2002).
Some occupational groups are more exposed than other groups. Carers who have direct, everyday contact with patients or clients seem to be the most heavily exposed (Arnetz, Arnetz and Soderman 1998), but registered nurses, doctors and personnel who make occasional visits to the homes of care recipients also report significant exposure to threats and violence (Arnetz, Arnetz and Soderman 1998; Nolan et al. 1999). A further exposed group consists of home-care personnel, who also provide health services and other forms of assistance (Kendra 1996; Kendra et al. 1996; Fazzone et al. 2000; Riopelle et al. 2000). Among Swedish carers, both older and younger workers, and both men and women, are affected, but women appear to be more exposed than men in all age groups (SWEA 2001). The difference between the genders increases with age. In recent years, an increased number of reported injuries due to violence is also evident among nursing auxiliaries, assistant nurses, registered nurses, personal assistants, and home carers in general (SWEA 2001).
There are several definitions of workplace violence. For instance, the literature makes a distinction between direct (personal exposure) and indirect (witnessing) violence (Barling 1996; Wynne et al. 1997). The literature also makes a distinction between psychological and physical violence (Wynne et al. 1997; Chappell and Di Martino 1998). Accordingly, a definition of violence may include acts of both verbal and physical aggression. In recent years, the definition of workplace violence also includes bullying or mobbing and sexual harassment (Chappell and Di Martino 1998).
Work-related violence can have consequences for both individuals and the work environment. Physical, psychological and behavioral effects of assault have all been reported (Chou, Kaas and Richie 1996). Exposure to violence can lead to burnout (Colenda and Hamer 1991) and other stress reactions (Lusk 1992; Arnetz and Arnetz 2001), and may also have consequences for leisure time. Symptoms such as irritation, fatigue, sleep disturbance, anxiety and apathy are common (Menckel, Carter and Viitasara 2000). Violence may also impact on work conditions and patient care (Chou, Kaas and Richie 1996; Kendra et al. 1996; Arnetz and Arnetz 2001; Duncan et al. 2001). Further possible effects of work-related violence are absenteeism and reduced work motivation (Gates 1995; Barling, Rogers and Kelloway 2001).
Several studies have referred to patient characteristics as an explanation for work-related violence or as a risk factor to which personnel are exposed (Petrie, Lawson and Hollender 1982; Colenda and Hamer 1991; Dougherty et al. 1992), but systematic analysis of other possible risk factors related to workplace violence is lacking. Such factors might include, for example, demographic characteristics of care providers with regard to age, gender or occupational experience (Whittington and Wykes 1994; Arnetz, Arnetz and Petterson 1996; Whittington, Shuttleworth and Hill 1996; Cole et al. 1997; Kiely and Pankhurst 1998; Gates, Fitzwater and Meyer 1999; Lee et al. 1999; Nolan et ai. 1999; Fazzone et al. 2000; Soares, Lawoko and Nolan 2000).
Further, differences in the work conditions under which various occupational groups operate may give rise to differential exposure. Work-related characteristics, such as type of caring setting, form of employment (full-time or part-time working), working hours, work conditions (e.g. frequency of contact with care recipients, working in the homes of clients, working alone), organizational change (e.g. downsizing), and workload are factors that may decrease or increase exposure and risk. A handful of studies have attempted to relate one or several of these factors to workplace violence (Cole et al. 1997; Arnetz, Arnetz and Soderman 1998; Nolan et al. 1999, 2001; Arnetz and Arnetz 2000, 2001; Soares, Lawoko and Nolan 2000). However, the literature lacks studies that clearly define the prevalence of the problem of violence for specific groups of health-care professionals (Arnetz, Arnetz and Soderman 1998).
The limited knowledge of threats and violence within the health-care and welfare sector formed the background to an initiative taken by Sweden's National Institute for Working Life, together with the Swedish Association of Local Authorities and employees' trade unions, for a research project on the area (see Menckel and Viitasara 2002). The present study is one part of the project.
Aims of the Study
The aims of the study are to examine the extent of threats and violence aimed at various professional (i.e. occupational) groups in the Swedish municipal health-care and welfare sector, and to analyze individual and work-environment factors with regard to risk. More specifically, we raise the following questions:
1) Are some occupational groups more exposed than others? In such case, which are the most heavily exposed groups and what are their rates of exposure?
2) Which individual and work-related characteristics do the exposed employees (i.e. victims of violence) possess? Do these differ between occupational groups?
3) Which individual and work-related characteristics predict exposure to threats and violence among different occupational groups?
4) Which individual and work-related characteristics predict frequency of exposure to threats and violence among different occupational groups?
METHOD
Subjects and Procedures
The study sample was drawn from the seven largest occupational groups in the municipal health-care and welfare sector in Sweden: administrators, nursing specialists, job supervisors, direct carers, nursing auxiliaries, assistant nurses, and personal assistants. From a total of 172,881 employees on monthly pay in the employment register of the Swedish Association of Local Authorities of November 1998, 400 individuals were randomly sampled from each stratum (occupational category). The group of personal assistants was also stratified by gender, so that 200 men and 200 women were included in the sample. Data were weighted in order to make each stratum representative of the population from which it was drawn, and in order to calculate correct overall estimates. Table 1 presents population size, sample size, response rate, and weight by occupational group.
Data were collected by postal questionnaire, administered by Statistics Sweden (SCB). Questionnaires were mailed to subjects' home addresses, accompanied by a cover letter outlining the general purpose of the study, assuring the confidentiality of responses, and explaining that participation was voluntary. Two follow-up mailings were made to nonrespondents. In addition, a telephone follow-up was conducted with the two occupational groups (nursing auxiliaries and personal assistants) that had the lowest response rates after the reminder letters (61% and 59%, respectively). The final response rate was 85 percent for the total sample, ranging by occupational group from 79 percent (for personal assistants) to 88 percent (for nursing auxiliaries and direct carers).
Exposure to Violence
For this study, workplace violence was defined as both verbal (e.g. threat, screaming, telephone threat) and physical (e.g. scratch/pinch, slap, spit, shove/push) aggression towards personnel (see Menckel and Viitasara 2002). This definition has been used in several Swedish studies of threats and violence in health-care work (e.g. Arnetz, Arnetz and Soderman 1998; Soares, Lawoko and Nolan 2000). The present study focuses only on direct violence. A victim of violence is a member of health-care and welfare personnel who has been personally exposed to some or both types of these aggressions. Violent acts are typically committed by patients/clients, but sometimes also by the relatives and/or acquaintances of patients, or colleagues.
Measures
The survey was based on a questionnaire that had previously been employed in a large investigation of violence in Swedish hospitals (Arnetz, Arnetz and Soderman 1998; Arnetz and Arnetz 2000, 2001). The questions, which were modified to reflect the provision of care and welfare services in a municipal setting, referred to the year preceding data collection. There was a total of 29 items, an with forced-response alternatives. The variables used for the present study fell into three major categories: (1) violence and threats of violence (exposure, frequency of exposure), (2) individual characteristics (occupational and organizational tenure), and (3) work-related characteristics (e.g. workplace characteristics, nature of employment contract, working hours, job characteristics). The questionnaire also contained questions on types of consequences of violence and preventive strategies taken by the organization (for details of the full questionnaire, see Menckel and Viitasara 2002). Data from the questionnaire were supplemented by information on age and gender taken from the employment register of the Swedish Association of Local Authorities. Definitions and response codes for the variables used in the present study are presented in Table 2.
Statistical Analyses
Chi-square tests were used to test for differences between occupational groups with regard to exposure to threats or violence (based on the total material), and also frequency of exposure (based on those who had been exposed to violence at least once over the preceding year.) (Research Question 1). Chi-square testing was also used to establish whether individual and work-related characteristics of exposed staff differed between occupational groups (Research Question 2). To address the third research question, concerning the identification of risk factors for exposure to threats or violence, logistic regression--with separate analyses for the seven occupational...
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