Workplace violence

The health service environment

Several health sector occupations, such as doctors, nurses and social workers, appear high in the list of occupations with high stress level, and healthcare workers are particularly at risk of workplace violence – almost one quarter of all violent incidents at work are concentrated in this sector. Ongoing restructuring in the health sector, varying from country to country and situation to situation, exacerbates this. People’s access to health care is endangered if health workers feel under strain in work situations where staff shortages, low pay, shift work, transport to work, and other conditions make them particularly vulnerable to stress and violence; many leave the profession for such reasons.

Scope and impact of violence and stress

For health workers, who have direct contact with people in distress, experiences of stress and of violence are so common that they may be considered an inevitable part of the job.

In the United Kingdom, recent reports show that between one quarter and one half of National Health Service (NHS) staff report significant personal distress, with many stressors being unique to health care. Levels of occupational stress are reportedly higher in the NHS than in otherwise comparable professions, with 28% of nurses suffering at least minor mental health problems, compared to 18% in the general employed population. The costs are high in terms of sickness rates (5%, costing the NHS £700 million each year) and loss of staff: over 30,000 nurses left the profession in 1996 alone, increasing the strain on those who remain.

Violence at work against health personnel is a widespread problem in developing, transition and industrialized countries. While ambulance staff are reported to be at greatest risk, nurses are more likely on average to experience violence at the workplace than other occupational groups. Since the large majority of the health workforce is female, the gender dimension of the problem is evident.

According to recent country surveys, a majority of healthcare workers experienced at least one incident of physical or psychological violence in the previous year: 75.8% in Bulgaria; 67.2% in Australia; 61% in South Africa; in Portugal, 60% in a health centre and 37% in a hospital; 54% in Thailand; 46.7% in Brazil. In several countries, the pattern seems to be that patients are the main perpetrators of physical violence, while staff are the main perpetrators of psychological violence. The country surveys confirm the difficulty of establishing a profile of people committing acts of workplace violence, and highlight the risks associated with generalization and stereotyping in this area. Psychological violence is more prevalent than physical violence, and is widespread throughout the health services: verbal abuse was the main area of concern, reportedly experienced by between 27% and 67% of respondents, followed by bullying and mobbing, reported by 10% to 30% of respondents.

Workplace violence is recognized as an important generator of post-traumatic stress disorder. According to surveys, between 40% and 70% of its victims report significant levels of PTSD symptoms, such as being super-alert and watchful, trying not to think or talk about what happened, feeling chronic fatigue or being bothered by repeated memories of the incident. An Australian study identified a significant relationship between exposure to bullying at work and emotional injury, highlighting the importance of psychological violence in stress generation.

This correlation between violence and stress is significant not only in assessing the overall impact on the individual but also in determining their global impact in terms of cost and efficiency for organizations and effectiveness of health systems. According to a survey of the American Nurses Association, 76% of 7,251 responding nurses reported increased patient load, 75% said this is resulting in declining quality of care. An American Medical Association report notes that many nurses leave their job, that nurses’ burnout rises with growing caseload, and that high nursing caseloads may account for 20,000 unnecessary deaths per year.

Causes

The reasons for workplace violence and stress are identified at organizational, societal and individual levels, showing complex interrelationships. The accumulation of stress and tension in demanding health occupations – under strain from societal problems and the pressure of health system reforms – contribute to emerging violence. At an individual level, health workers tend to rank the personality of patients as the leading factor generating violence, followed by the social and economic situation in the country and, well behind, work organization and working conditions. However, when categorized into individual, societal and organizational factors, all three contributing factors appear to be of equal importance in the analysis of risks of violence and stress, with organizational factors playing a key role.

Strategies addressing stress and violence

Analysing the origins and risk factors of workplace stress and workplace violence in the health sector is a precondition for developing policies and action in an appropriate way, identifying priority areas and allocating resources. With regard to workplace violence, current measures focus on a more immediate response, such as security measures and improvement of the physical environment, rather than on strategic and organizational factors. In the event of a violent incident, the support of victims should have first priority, providing medical and psychological aid at different stages, including peer and management support, as well as complaint procedures, legal aid and rehabilitation measures.

Recommendations from country reports on how to address workplace violence in the health sector reflect an approach that integrates interventions at organizational, societal and individual level, with a clear focus on preventive action. Interventions should focus on (a) general conditions in society and the legal framework; (b) normative interventions, such as guidelines and management competencies; and (c) interventions at the environmental and individual levels. In many countries, strategies could start by raising awareness and building understanding among health personnel and other parties concerned at all levels. The crucial role of social dialogue in defusing work-related stress and violence at work in the health sector is increasingly recognized. Consequently a participatory approach, whereby all parties concerned have an active role in designing and implementing anti-stress and anti-violence initiatives, is highly recommended.

In addition to the Framework guidelines for addressing workplace violence in the health sector, a training manual has been released to assist practitioners in implementing the guidelines.

Links to other websites dealing with workplace violence in health services

• ICN, International Council of Nurses, Guidelines on Coping with Violence at the Workplace, Geneva, 1999
• ILO-ICN-WHO-PSI, Framework guidelines for addressing violence in the health sector, 2003
• ILO, Code of practice on workplace violence in services sectors and measures to combat this phenomenon, Geneva, 2003
• Royal College of Nursing, Dealing with bullying and harassment: A guide for nursing students, London, 2002
• Royal College of Nursing, Bullying and harassment at work: a good practice guide for RCN negotiators and health care managers, London, 2002
• OSHA, US Department of Labor Occupational Safety and Health Administration, Recommendations for Workplace Violence Prevention Programs in Late-Night Retail Establishments, Washington, DC, 1998
• OSHA, US Department of Labor Occupational Safety and Health Administration, Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers, Washington, DC, 1996
• WorkSafe Western Australia Commission, Working Alone, Perth, 1999
• Occupational Safety and Health Service, New Zealand Department of Labour, Guidelines for the safety of the staff from the threat of armed robbery, Wellington, New Zealand, 1995
• DHHS (NIOSH) Publication No. 2002–101, VIOLENCE, Occupational Hazards in Hospitals, April 2002
• HDA, Health Development Agency, Working well together: Award-winning solutions to health and safety issues, London, 2001
• UAN, United American Nurses, National Labor Assembly Adopted Resolution on Preventing Violence in the Healthcare Workplace, 2000
• The Change Foundation. Commitment and Care: The benefits of a healthy workplace for nurses, their patients and the system. 2001
• WorkSafe B.C. Workers’ Compensation Board of British Columbia, Preventing Violence in Healthcare: Five steps to an effective program, British Columbia, 2005
• SAMHSA, US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration, Preventing Violence in the Workplace: Center for Mental Health Services Forum Report, 1994
• American Nurses Association, Preventing Workplace Violence, Maryland, 2002
• Texas Workers’ Compensation, Workers Health and Safety Division, Safety Education and Training Programs, Preventing Workplace Violence in Health Care Facilities
• European Foundation for the Improvement of Living and Working Conditions, Preventing Violence and Harassment in the Workplace, Luxembourg, 2003
• NSI, National Security Institute, Guidelines for Workplace Violence Prevention Programs for Healthcare Workers in Institutional and Community Settings, 1995
• Health Canada, Nursing education and violence prevention, detection and intervention, Canada, 2002
• NHS, National Health Service, A Safer Place to Work: Protecting NHS Hospital and Ambulance Staff from Violence and Aggression, London, 2003