Elsevier

Social Science & Medicine

Volume 52, Issue 3, February 2001, Pages 417-427
Social Science & Medicine

Violence towards health care staff and possible effects on the quality of patient care

https://doi.org/10.1016/S0277-9536(00)00146-5Get rights and content

Abstract

Much of the research on violence in the health care sector has focused on the immediate and long-term effects of patient violence on staff victims. There is a lack of studies, however, examining whether individual reactions to violent episodes, such as anger and increased fear in one’s work, have any measurable effect on staff behaviour toward their patients, and ultimately on the quality of patient care. The aim of the present study was to investigate whether an association exists between staff experiences with violence and patient-rated quality of patient care. A theoretical model was presented, suggesting that violence or threats experienced by health care staff have a negative effect on the quality of health care services offered, as measured by patients. In addition, it was theorised that there would be an association between staff work environment and staff reports of violence. Six questionnaire studies, three concerning hospital staff’s views of their work environment and three dealing with patients’ perceptions of the quality of care, provided the data for evaluating the model. Work environment and quality of care studies were carried out simultaneously at a single hospital in 1994, 1995, and again in 1997. Regression analysis was used to see which combination of work environment and quality of care variables would best predict a positive overall grade for quality of care from the patient perspective. Violence entered consistently as an important predictor into each of the three best regression equations for 1994, 1995, and 1997, respectively. The results of this analysis suggest that the violence experienced by health care staff is associated with lower patient ratings of the quality of care. The study indicates that violence is not merely an occupational health issue, but may have significant implications for the quality of care provided.

Introduction

Violent behaviour towards health care personnel has been shown to often have long-term psychological effects on its victims, including post-traumatic stress disorder, even when physical injury is not present (Caldwell, 1992, Wykes and Whittington, 1991, Wykes and Whittington, 1994). Aggressive or violent behaviour from patients can cause staff to put their role as caregivers into question, resulting in feelings of guilt and self-doubt (Holden, 1985, Graydon et al., 1994, Mezey and Shepherd, 1994, Wykes and Whittington, 1994), or what Holden termed “cognitive dissonance” (Holden, 1985). Several studies have examined the immediate and long-term effects of violence on staff (Lanza, 1983, Rix, 1987, Ryan and Poster, 1989, Wykes and Whittington, 1991, Croker and Cummings, 1995). However, few studies have examined whether individual reactions, such as increased fear, anger, irritability, sleeplessness and cognitive disturbances, have any affect on staff behaviour toward patients, and ultimately on patient ratings of the quality of care provided.

How serious an occupational stressor is violence, and what are its possible consequences for health care staff, their work environment, and their patients? The present study investigated the association between violence towards staff and the quality of patient care in a single general hospital in Sweden. Violence in this study was broadly defined, encompassing threatening behaviour, verbal aggression as well as physical assault, and was based on staff self-reporting in written questionnaires. While questionnaire respondents were asked to describe the nature of the violence they had experienced, the analyses presented here do not distinguish between verbal and physical violence. This lack of distinction is based on previous research that has indicated that risk factors for threats of violence and actual physical violence are virtually identical (Flannery et al., 1995, Arnetz et al., 1996, Arnetz et al., 1998). In addition, threats of violence and verbal aggression can have as negative an effect on health care staff as physical assault (Arnetz et al., 1996, Flannery et al., 1995, Graydon et al., 1994, Smith and Hart, 1994). Quality of care was measured from the patient’s perspective, also by means of written questionnaires. Work environment and quality of care studies were carried out simultaneously at the hospital, first in 1994, again in 1995, and a third time in 1997.

Previous research has focused on risk factors for violence and has aimed at understanding the aetiology of aggressive and violent behaviour towards health care workers (Lanza, 1988, Lanza et al., 1991, Lanza et al., 1994, Whittington and Wykes, 1994, Arnetz et al., 1996, Arnetz, 1998). Building further on this research, the present article presents a model of the possible consequences of violence towards health care staff on the quality of health care that they provide (Fig. 1). According to this model, violence experienced by health care staff has a negative association to patient ratings of the quality of health care services offered.

In a general essay on work satisfaction, stress and performance in the caring professions, Wallis (1987) proposed a schematic model linking the negative effects of work stress on job satisfaction, and thereby on performance. Performance in the caring professions was, in this working model, the quality of patient care. Although the model lacked methods for measuring performance, it cited patient satisfaction, psychological health of patients, and interpersonal relations between staff and patients as possible quality outcome measures. Wallis suggested that “patient-avoiding behaviours” were a possible staff strategy for coping with stress that might have negative consequences for the quality of patient care.

Building further on Wallis’ model, we focus on violence towards staff as a specific source of stress in health care work. We propose that, even in non-psychiatric settings, violence becomes the mode of communication between patient and caregiver when normal communication is lacking. In Fig. 1, violence is illustrated in the form of concentric circles, or ellipses, the common centre being the interaction between staff and patient. The patient–staff interaction is defined as the central aspect in the development of violence. This interaction is affected by the immediate environment, which we call the ward environment. This is the work environment for the health care worker, at the same time being the care environment for the patient. We suggest that violence has a negative effect not only on caregivers, but on patients as well. Violence from patients has a negative effect on health care staff, causing more negative attitudes toward work tasks and the patients themselves. This negative climate affects the patient–staff relationship, with the caregiver on his/her guard, spending less time with patients, and less responsive to patients’ needs. Similar reactions are experienced by the patient, who thus feels less satisfied with the quality of health care services being offered in a more negative caring environment. Thus, violence has an indirect negative effect on the ward environment, and ultimately on the quality of care, as perceived by patients.

The course of events described above may have some association to staff burnout, which has been defined as “a syndrome of physical and emotional exhaustion, involving the development of negative self-concept, negative job attitudes, and loss of concern and feeling for clients” (Pines & Maslach, 1978). Several studies have suggested that burnout in staff can lead to deterioration in the individual’s involvement in his or her work and in the quality of care or services provided (Maslach and Jackson, 1981, Weisman and Nathanson, 1985, Firth and Britton, 1989, Schaufeli and Enzmann, 1998). “Stress”” from patients, including violent behaviour, has been associated with the depersonalisation component of burnout in nurses (Leiter and Harvie, 1996, Prosser et al., 1997). Each of these studies measured only staff members’ own perceptions of staff–patient relationships, with no measurement of patient views. Caplan (1993) compared nursing staff and patient perceptions of the ward atmosphere in a maximum security forensic hospital. She found that both staff and patients were affected by the potential for violence, but were nonetheless positive about the therapeutic ward atmosphere.

The feedback loop in Fig. 1 suggests that negative aspects of the ward environment may also be conducive to the development of violent behaviour in patients. In the present study, our schematic model of violence as a negative aspect of the ward environment was proposed and evaluated. The primary aim of the study was to investigate whether an association exists between staff experiences with violence and patient-rated quality of care. Specifically, would staff reports of patient violence towards staff predict lower quality of care ratings from patients? In addition, we theorised that changes in staff ratings of their work environment over time would be associated with changes in reported violence towards staff.

Section snippets

Methods

Evaluation of the described model was based on six studies carried out at the Örebro Regional Hospital (RSÖ), a large general (non-psychiatric) hospital in central Sweden. At the time the studies were first initiated, RSÖ was an 850-bed hospital employing approximately 4500 staff. In 1994, as part of its overall quality improvement efforts, the hospital conducted simultaneous questionnaire studies of the work environment of hospital staff, as well as of patients’ views of the quality of care.

Violence towards hospital staff: data based on individual questionnaire responses

All data concerned with staff experience with violence at work was based on individual questionnaire responses. Descriptive statistics were used to analyse the items related to violence for all responding hospital staff in 1994, 1995 and 1997, respectively. In earlier studies, younger staff (Whittington and Wykes, 1994, Arnetz et al., 1996) and male health care staff (Aiken, 1984, Carmel and Hunter, 1989, Arnetz et al., 1996) have reported significantly more experience with workplace violence.

Staff reports of violence at work

Staff experience with violence or threats of violence at work as reported in the 1994, 1995, and 1997 questionnaires, respectively, is summarised in Table 3. Responses to the question regarding exposure to violence during the past year, i.e., responses in 1995 and 1997, were similar, with just under 12% reporting experiences with violence. However, there were a greater number of non-respondents to the violence question in 1995 (6%, n=141), compared to 1997 (3%, n=60). A greater percentage of

Discussion

The results presented here indicate that there is an association between violence experienced by health care staff and patient-rated quality of care. This study was possible due to the unique quality improvement efforts at the Regional Hospital (RSÖ) in Örebro, Sweden, where three parallel evaluations of the hospital staff’s views of their work environment and patients’ perceptions of the quality of care have been conducted. Other studies have linked violence with work environment factors (

Acknowledgements

This work was supported by grants from The Swedish Working Life Fund. We would like to thank Mr. Ove Petersson, and Ms. Carine Norström, senior project management at the Regional Hospital, and all the staff and patients of the Regional Hospital in Örebro, Sweden. The helpful comments of two anonymous referees are gratefully acknowledged.

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