Assaults against Mental Health Workers - Research Paper Example

?Running head: VIOLENCE AMONG MENTAL HEALTH WORKERS Violence Towards Mental Health Workers: An Empirical Study Introduction Violence towards staff members who work as mental health professionals has received considerable attention over the years owing to the increasing number of violent patients. Assaults against mental health workers caused by their psychiatric patients are a great concern as its outcomes have adverse outcomes on the victim (Arnetz and Arnetz, 2001). While some professionals assert that violence is inherent in their occupation as mental health workers and that they possess the skill and knowledge necessary to cope with such violence. In spite of such beliefs, mental health workers may suffer a number of physical and psychological effects brought about by their violent patients. In the United States, according to the National Crime Victimization Survey that had been carried out from 1999 to 2000, it was reported that there was an average rate of 12.6 job-related violent crimes annually for every 1,000 professionals in various occupations. More specifically, 16.2 violent crimes were reported for every 1,000 physicians and 21.9 for every 1,000 nurses. In addition, mental health care professionals, such as psychiatrists and custodial workers, experienced an average annual rate of 68.2 crime rates for every 1,000 (Stuart, 2003). Such occurrences are also likely to happen during the early phases of an individuals’ career. For instance, previous studies suggested that approximately 50% of psychiatrists will experience physical assaults caused by their patients during their training programs. The violence demonstrated towards mental health staff members has also been considered a concern owing to the increased need to allocate resources that are effective in treating violent patients (Whitley, Jacobson, and Gawrys, 1996). While violence can be influenced by complex behaviors in relation to medical components, social aspects should be considered as well. Research Problem Due to the occurrence of violence among mental health patients with which various forms of assaults have been reported towards mental health care workers, there is a need to examine the factors involved in such events. The current study aims to answer the following questions: 1. What are the effects of age, gender, and static and dynamic risk factors on the violent behavior of patients towards health care professionals in mental health care settings? 2. What are the physical and psychological effects of violence caused by mental health patients on health care professionals in the workplace? 3. What are the strategies used in effectively managing violent situations and avoiding similar occurrences in the future? Project Rationale As the current study aims to examine the causes and effects of patient- and workplace-related factors on violence that is evident in the workplace, it will employ a quantitative approach to research with which surveys will be used in obtaining primary data. The main goal of the study is to examine how certain aspects related to the patient and to the environment can influence violent behavior in the workplace, particularly in psychiatric wards or hospitals where patients can demonstrate violence towards mental health care workers. Surveys will be administered to both the health care professionals and their patients. The collection of secondary data will help provide a clear foundation that will enable the researcher to gain a comprehensive view of the content and other related factors to be examined. Moreover, as primary data will be collected through surveys, these will be interpreted through statistical analysis that may further increase the reliability of the findings. Through these, suitable conclusions and recommendations can be established. Significance of the Study In numerous high-risk areas, including inpatient psychiatric units and emergency departments, it is highly expected for violent behavior to be demonstrated by patients. Mostly, direct caregivers experience the assaults, although all staff members of mental health settings at a high risk to encounter physical and psychological outcomes from patient violence (Bourget, el-Guebaly, and Atkinson, 2002). Findings of this study can contribute to the present literature on patient violence in mental health settings in such a way that it will help determine the factors that significantly influence such violent behavior as well as its effects on the health care professionals. Consequently, this can contribute to the identification of effective approaches to worker assault in the clinical workplace, particularly the necessary responses, programs and interventions that can reduce or prevent both patient violence and its adverse effects on mental health workers. Limitations of the Study The study makes use of a quantitative approach to research with which the context wherein the variables are examined can be ignored. This form of research does not examine phenomena within a natural setting nor does it discuss the value and meaning of this for different individuals. Moreover, because of the use of survey questionnaires which provide pre-determined answers, respondents will not be able to present their responses using their own words and articulate their ideas. Definition of Terms Violence- refers to behavior that involves the physical force which has been intended to cause damage and pain on a person or object. This can also define an aggressive act or behavior brought about by strong emotions and detrimental forces. Mental Health- defined as an individual’s psychological state which serves an important purpose for satisfactorily adjusting one’s emotions and behaviors. Literature Review This section will present the variables relating to the study’s objectives and questions in order to establish a more consistent foundation for this research. In particular, the factors that influence patient violence towards mental health care professionals will be examined along with their effects on these workers and the possible interventions to reduce or prevent violent incidents in the clinical workplace. Patient Population A number of studies examined the psychiatric population that is most likely to demonstrate violent behavior in order to identify the factors that strongly contribute to clinical workplace violence. Violence can be influenced by gender, age, and level of mental illness (Vanderslott, 1998); however, one of the challenges of conducting studies on violent behavior is that violence has not been provided with a definition that has been generally accepted. While a number of studies characterize violence with threatening behavior and verbal abuse, others have also referred to it as harming one’s self as well as others and their properties. In addition, many studies have also focused on physical assaults against peers whereas other researchers only limited their focus on assaults against staff members. However, certain studies have investigated the relationship between violence and severe mental illness with which contradictory results were obtained. In the study conducted by the National Institute of Mental Health, different psychiatric conditions had been explored with which 17,803 patients were used as a sample; results indicated that patients who were suffering from severe mental illness, such as bipolar disorder or schizophrenia, can be strongly expected to be aggressive and violent (Omerov, Edman, and Wistedt, 2004). On the other hand, other studies such as that of an article that was issued in the New England Journal of Medicine, results suggested that severe mental illness seldom occurs and does not contribute to the general rate of violence among the overall population (Anderson and West, 2011). The risk of such mental health disorders was significantly lower than other factors, such as drug abuse; hence, individuals who have no mental health condition yet abuse drugs and alcohol are highly likely to demonstrate violent behavior than patients who actually suffer from mental disorders. In addition, it was concluded that the aggressive behavior exhibited by mentally ill patients can result from a wide range of aspects. Although there has not been a considerably large rate of psychiatric patients who show violence towards health staff members, evidence from past research has pointed out that specific groups of mental health patients are at a higher risk of being aggressive, such as patients who have psychoses, does not adhere to treatment, and abuse drugs or alcohol, compared to other groups of patients. In a study conducted by Tardiff, Marzuk, and Leon (1997), the researchers focused on the rates of violence that were exhibited by patients who have mental disorders before being admitted. They also investigated the types of patients who were at a higher risk for violent behavior as well as the nature of aggressive occurrences. It was found out that 14% of the patients who had been admitted to the hospital were already violent towards others even a month before their admission. Similar findings were asserted by Faulkner, Grimm, McFarland, and Bloom (1990) who created questionnaires that were administered to psychiatrists in order to investigate their experiences with patients’ attacks and threats. In a sample of 115 psychiatrists, 72% of them reported that their violent patients have schizophrenia or other severe mental health illness. Patients who have also been diagnosed with a mental disorder for 2 to 4 times were more likely to exhibit violent behavior than those who were only diagnosed once (Rueve and Welton, 2008). Gender Differences As typically considered by the society, males demonstrate violence and aggression more often than their female counterparts. For example, in the United States, reports indicate that there are a considerably large number of men who commit violent crimes, comprising 90% of those who committed murder and 82% of those who committed other crimes of violence. A number of studies, however, have indicated that mental health disorders reduce such discrepancies in gender and may eradicate it simultaneously (Krakowski and Czobor, 2004). As the study of Tardiff et al. (1997) has found out, female patients can be expected to be aggressive just as their male counterparts; moreover, the nature of the aggressive attacks were found to be similar for both genders. These violent occurrences were typically targeted towards family members and, although the use of weapons was not common, more than one third of the violent assaults led to physical injuries. Additionally, a study that explored the significant association between aggressive behavior and positive psychotic symptoms in men also found a similar relationship in women. However, findings showed that increased physical violence in women may suggest an excited feeling and increased level of stimulation linked to acute psychotic symptoms. However, among males, acute psychotic symptoms do not have a strong influence on violent behavior, although it can increase their violent tendencies, such as antisocial behaviors (Krakowski and Czobor, 2004). Age Age can also influence the violent behaviors demonstrated by patients who experience mental health conditions. James, Fineberg, Shah, and Priest (1990) carried out a study to examine 60 violent and non-violent psychiatric patients within duration of 15 months. Findings indicated that young patients aged 25 years old and below can be expected to be more aggressive compared to their older counterparts. Similarly, a survey that was carried out among 115 psychiatrists also indicated that patients aged 30 years old and below are more assaultive. Younger patients have also been more often reported to take responsibility for more than one violent incident. Additionally, other studies have pointed out that differences in age groups are a factor in exploring patients who have mental health disorders with which acute symptoms are more often experienced by younger patients (Anderson and West, 2011). While numerous studies have looked into the different aspects of patient violence, a number of similarities have been found, such as more occurrences of violent assaults among the younger patients, especially those experiencing psychotic disorders. Static and Dynamic Risk Factors Aside from age and gender, other risk factors for violent behavior have been identified. Static risk factors refer to the characteristics of patients which cannot be altered through medical interventions, including a history of previous violence and demographics. The most typically static factor that has been linked to future violence is prior history of violence with which the risk of possible violence in the future can increase based on the frequency of previous violent activities. Potential for violence has also been associated with impulsivity. Other static risk factors can include lower levels of intelligence, neurological impairment, previous experience with the military or with weapons training, as well as being diagnosed with a severe mental illness (Rueve and Welton, 2008). In contrast, dynamic risk factors refer to variables which can be possibly improved by means of clinical intervention with which the most often reported risk factor is the abuse or dependence on substance, such as alcohol or drugs. Other relevant dynamic risk factors can include non-adherence to treatment, delusions and hallucinations, depression, suicidality, and having access to weapons (Kraus and Sheitman, 2004). When evaluating risk, it is necessary to meet the following concerns: the perception of the patient regarding his condition, adherence to medication, access to weapons, and the environment in his home, including a form of support system. Some of the most critical risks to mental health workers depend on the situations where possible danger is overlooked or not recognized. The reasons behind such attacks carried out by psychiatric patients significantly differ but, most often, there is no consistent basis (Rueve and Welton, 2008). Therefore, the factors that contribute to clinical workplace violence caused by mental health patients, especially towards staff members, remain to be an important concern. Occurrences and Effects of Clinical Workplace Violence There have been a number of studies that explore psychiatric professionals who are prone to the highest risk of being assaulted or attacked by their patients. The study of Erdos and Hughes (2001) pointed out that the workers who spend the most time with their psychiatric patients are those who are at the highest risk of being assaulted. Typically, workers who are at the highest risk are the nurses. Other studies also looked into the effects brought about by the violent behavior of patients which affect the staff members. While in a number of occurrences mental health care workers sustained minor injuries leading to absences from work or limited assignments, a smaller percentage of workers experienced multiple and possibly life-threatening injuries, including lacerations, fractures, and loss of consciousness (Merecz et al., 2004). The study of Erdos and Hughes (2001) also indicated that almost half of mental health staff members in their study had long absences from work whereas 65% needed at least one year for their recovery. A number of victims had also been reported to experience posttraumatic stress disorder (PTSD), including a change in their sleeping patterns, increase in body tension, or overall body soreness (Richter and Berger, 2006). In another study by Sheridan, Henrion, Robinson, and Baxter (1990), nurses in mental health care settings were also reported to be at the greatest risk of being attacked by their patients. In particular, their regular contact and close interaction with their patients along with their responsibility of setting limits have further placed them in a vulnerable position. At times, psychiatric professionals can be considered by patients as their adversaries. Privitera, Weisman, and Cerulli (2005) also investigated the rates of patient violence towards staff members, identifying practices nurses, professional nurses, and physicians to mostly experience assaults from their patients. Even non-clinical staff members, such as those at the front desk, were highly endangered as well. Aside from these, violence that has been experienced staff members at clinical settings has had a negative influence on the quality of services that these workers provide. For example, in earlier studies such as that of Wallis (1987), a schematic model was developed that helped associate the adverse outcomes of job-related stress on a worker’s job satisfaction as well as on performance. Although such model was not able to completely measure staff performance, it included the satisfaction and psychological health of patients along with the interpersonal relationships between workers and patients in order to assess quality outcomes. It was suggested that one of the ways with which staff members coped with stress in the workplace was to avoid their patients which can have a negative impact on their quality of patient care. Similarly, it was believed that violence strongly affects the communication between the professional and the patient (Arnetz and Arnetz, 2000). As the interaction between the staff and the patient is an essential dimension in the development of violence, such interaction can be influenced by the surroundings as well, particularly the ward environment. As this is the work environment for the staff members and is the care environment for the patients as well, violence will yield adverse outcomes not only on the staff members but on their patients as well. As violent behavior exhibited by patients has a negative influence on their caregivers, this can bring about unfavorable attitudes among these workers towards their tasks and towards their patients as well. Consequently, nurses and other mental health professionals can be expected to reduce the time they spend with patients, and their awareness of and responsiveness to their patients’ needs. In turn, a similar reaction may be experienced by patients who will feel less contented with the quality of services provided by their caregiver in such a negative environment. Therefore, as Caplan (1993) asserted in a study conducted in a maximum security forensic hospital, violence in the clinical workplace caused by patients can yield negative outcomes for both staff members and the patients themselves. Treatment and Prevention A wide range of treatment options have been made available to mental health workers who have become victims of their patients’ assaults. For example, the use of Critical Incident Stress Debriefing (CISD) which can be directly implemented within three hours; this can includes the various phases of introduction, fact, feeling, symptom, teaching, and re-entry. In the phase of introduction, the facilitator of a group will define the objective of such debriefing whereas the fact phase allows the participants to explain their roles during the occurrence (Trenoweth, 2008). Next, the phase for feeling provides these individuals with an opportunity to express their thoughts regarding the incident while the symptom phase allows them to explain both the physical and psychological effects along with their response to such stressful incident. The next phase for teaching then enables the instructor to define the symptoms which the participants must seek in themselves as well as in others. Lastly, the re-entry phase offers reassurance along with additional planning for the involved participants. As suggested by research, such form of intervention has been effective in reducing the adverse outcomes of traumatic incidents, including patients’ violence towards staff members. The major aim of debriefing is to provide assistance to victims for them to cope with such occurrences by means of reducing their negative feelings of fear and vulnerability as well as establishing a supportive environment. Other studies suggest that mental health workers be familiarized with the institutional procedures in relation to the reporting of violent behavior (Engel and Marsh, 1986). Numerous workers have been found to have no information about a clear procedure or policy regarding the reporting of violent assaults in the workplace. Moreover, only a few of these workers have been obtained a form of supportive counseling to cope with such attacks (Crabbe et al., 2004). A similar concern is the findings on practicing professionals, such as psychiatrists, which suggests that the inclination to not report violent behavior can continue even after training (Antonius, Fuchs, and Herbert, 2010). A number of factors can be attributed to the lack of reporting of violent attacks among workers, such as their perceptions of such incidents which they believe are an unavoidable part of their job and that these professionals working in mental health settings must be highly capable of caring for themselves. Additionally, a large number of agencies have not set reporting requirements and may discreetly discourage the reporting of violent incidents as this can result to additional work (Lindow and McGeorge, 2000). In relation, there have been few possibilities for workers to report violent behavior because they perceive their management to be unsupportive and not committed to addressing their employees’ needs. Furthermore, these workers fear that they will be negatively criticized by their supervisors. Aside from the reporting of violent incidents, previous research implied that excessive focus on the control of violence by means of medication, isolation, and restraint may not bring about long-term effects. It can be more helpful to provide interventions that can alter behavioral patterns. For instance, patients who have been experienced constant physical or chemical restraint can be expected to regard violence as a favorable means for expressing their feelings of anger and fear (Asnis, Kaplan, Hundorfean, and Saeed, 1997). Alternative interventions that patients can learn can include the verbal communication of feelings, addressing of needs by means of an assertive behavior rather than aggressiveness, recognition of one’s anger, and disconnecting themselves from such incident. Moreover, patients may also be able to realize how negative thoughts can directly instigate aggressive behavior; hence their need to learn ways with which they can enhance their skills for resolving conflicts (Asnis et al., 1997). Additionally, owing to limited budgets in the healthcare settings, institutions can make use of structured risk assessments which refers to an intervention that requires low costs and have been shown to have a positive influence on reducing violence. In a study conducted by Abderhalden, Needham, and Dassen (2008), violence risk assessment was examined in a psychiatric ward for inpatients. Risk assessment was carried out twice on a daily basis during the first three days of being admitted to the hospital among patients who have acute psychiatric symptoms. The scores for risk assessment were then followed with the necessary action specific to the risk level of the patient. Risks assessments that are used to estimate violence potential can be a relevant step in foreseeing and preventing violent behavior among patients, and have been considered as significant in treating and managing mental health conditions. Such risk assessment has also been found to be appropriate for both genders and demonstrates analytical effectiveness for one year or so after the patient has been discharged from the psychiatric facilities. Antonius et al. (2010) also looked into the risk-assessment training carried out in mental health settings; findings indicated that less than half of the psychiatrists included in the study had acquired a form of training for managing violence in their clinical settings. In particular, they did not receive formal and sufficient training to handle violent patients and evaluate potential violence. Therefore, it was suggested that clinicians who have fewer experiences in violence management are more likely to become victims of patient assaults. In addition, inadequate training can also have an adverse influence on mental health care workers’ attitudes towards the treatment and management of their patients, thus establishing a less restorative environment. The need for formal and adequate training is then emphasized for health care professionals to handle their violent patients through effective assessment and treatment (Infantino and Musingo, 1995). Lastly, the increase of violent behavior among patients has been linked to the reduced number of full-time nursing personnel. There have been a number of reasons for such occurrence to take place; for example, it was suggested that patients who are likely to exhibit violence are typically psychotic and should experience stability and a positive connection towards others. It was suggested that staff members may reduce their interaction with patients who are more disturbed and unstable; in turn, extreme behavior, including aggressiveness, could be the most direct manner for patients to get attention. Therefore, it is important for psychiatric professionals to establish rational limits for behavior while being acquiring training for strategies with which violent behavior can be controlled. Methodology Research Approach Because the current study aims to identify the causes and effects of patient violence towards health care professionals in the mental health settings, this study will make use of a quantitative approach to research. A quantitative study is based on a positivist paradigm that aims to empirically investigate a certain phenomena by means of statistical and mathematical techniques (Creswell, 1994). Measurement plays an important role in quantitative research as it establishes the link between mathematical representations and empirical observations of relationships. Quantitative research makes use of statistical data by first collecting primary data based on a given hypothesis; such approach to research can also help recognize causal relationships among variables. As data is often collected through quick methods, such as through survey questionnaires, this helps conserve time and effort whilst providing precise data. When additional qualitative methodologies are needed for follow-up, these can be carried out through interviews, consequently resulting to a more complete understanding of the phenomenon that is being investigated (Ruane, 2003). On the whole, quantitative research can be an effective approach to finalizing outcomes and proving hypothesis. A number of advantages have distinguished the quantitative approach from its qualitative counterpart. For instance, a quantitative study can be replicated and evaluated to be compared with other studies that have similar topics. Hence, such methods allow individuals to easily sum up large information sources and make comparisons across various categories. In addition, increased accuracy of quantitative results can be expected, involving limited number of variables and utilizing methods that ensure validity and reliability. Bias is eliminated in a quantitative study in such a way that the researcher is encouraged to not have a direct interaction with his/her participants. External factors are not filtered out from quantitative research, thereby yielding results that are more balanced. Lastly, results can be easily finalized as the study narrows down all possibilities and directions if ever future research is further necessary, hence a yes or no response. Research Design For the researcher to determine the factors involved in patient violence towards mental health professionals, a descriptive-correlational design will be used in the study. This will enable the researcher to asses and document the variables that are being examined; in particular, the correlational research emphasizes the potential relationship between independent and dependent variables as determined by multiple regression (Jackson, 2011). Ascertaining the relationship between variables is often determined whether such relation can take place due to chance, hence the need for statistical techniques for measurement and testing of such relationship’s existence and intensity. Sampling and Subject Plan Sampling is characterized by the way with which units are selected from a target population; this can be classified into probability and non-probability forms of sampling. This study makes use of purposive sampling which requires that the selected sample adheres to a number of criteria in order to be of relevance to the research (Adler and Clark, 2008). Hence, these individuals should exhibit certain characteristics which will ensure that they will present appropriate information to the researcher. Prior to the selection of respondents, a number of inclusion criteria will be developed by the researcher to select two sets of samples- one for the health care professionals and another for the patients, both groups from the mental health context. For the first group, the 25 individuals to be selected should have experience working with mental health patients in a psychiatric ward, is willing to participate in the study, and should be given the permission to be involved in the research process through the submission of a consent form. The second group should be comprised of another 25 mental health patients who have been admitted to an acute psychiatric ward, is also willing to participate in the study, and should also be given the permission to be involved in the research process through the submission of a consent form. All in all, the researcher aims to include 50 individuals, 25 professionals and 25 patients in a psychiatric ward and have experience with psychiatric facilities. Data Gathering Procedures The first step in collecting data is to gather literature that provides applicable information to the topic used in the study through a range of of academic sources, which can include journal publications, books and other literature that can be found online. In searching for such publications, the researcher will use the following keywords: “factors affecting patient violence towards health workers”; “effects of patient violence towards health workers”; and “treatment and prevention of patient violence towards health workers”. The collected secondary data will comprise the literature review, establishing a coherent framework for this study as related to important variables. After gathering the secondary data, the collection of primary data can be carried out with which a survey questionnaire can be drafted, incorporating age, gender, and static and dynamic risk factors to examine their effects on patient violence towards health care workers. Physical and psychological outcomes will also be integrated to identify the specific effects of patient violence on psychiatric professionals. Pilot testing will be carried out in order to verify the reliability of such tool. The researchers will also send consent forms to the respondents and the hospital to which they belong, enabling the researcher to carry on with the study. Method of Data Analysis When primary data have been obtained through survey questionnaires, the Statistical Package for the Social Sciences (SPSS) version 17.0 will be used to generate relevant statistics. These will then be analyzed to establish relevant conclusions and recommendations. The use of SPSS version 17.0 will complete the statistics that will help answer the study’s questions and objectives. These statistical outcomes will represent the factors that influence patient violence towards health care workers as well as the specific effects of patient violence on their caregivers. The descriptive statistics can be characterized through the use of percentages, frequencies, standard deviations which enables both the researcher and reader to attain a comprehensive understanding of the gathered primary data (Triola, 2008). Ethical Considerations It is important for the researcher to integrate ethical practices into the process of research for supporting and preserving the rights of the respondents (Gregory, 2003). Personal information, such as their names, will not be required to be indicated in the survey questionnaire. It is also favorable to assure the respondents that they are free to withdraw from answering the survey if they prefer to do so. As such, participant’s level of trust and confidence towards the researcher and the process can be increased. Budget / Anticipated Expenses There are no major expenses that are anticipated for the research, as it only involves the deployment of survey questionnaires to patients and professionals who are involved in caring for the mentally ill. As such, the following is the breakdown of the budget for the project: Activity Expense (In AUS Dollars) Replication of Questionnaires 40 Transportation Costs 200 Communication Costs 50 Other Expenses 100 Total The cost for the replication of the questionnaires is only $40, while transportation costs to and from the respondents hospital/s was pegged at $200. Communication costs via telephone is estimated to incur a total cost of $50. Other miscellaneous expenses have been allotted $100. Timetable The following table shows the estimated length of time necessary for each step of the research process. A total of 12 weeks is a conservative estimate for project completion. Activity Timeline Drafting and Approval of Proposal 1 week Gathering Secondary Data for Review of Related Literature 2 weeks Research Design and Methodology 1 week Pilot Testing of Instrument 1 week Validation of Instrument Gathering of Primary Data 3 weeks Encoding and Statistical Analysis 1 week Writing the Findings and Discussion Chapter 1 week Drating the Conclusions and Recommendations Chapter 1 week Revisions 1 week Total 12 weeks References Abderhalden, C., Needham, I., and Dassen, T. (2008). Structured risk assessment and violence in acute psychiatric wards: randomized controlled trial. British Journal of Psychiatry, 193, 44-50. Adler, E., and Clark, R. (2008). How it's done: an invitation to social research. Belmont CA: Thomson Learning. Anderson, A., and West, S.G. (2011). Violence against mental health professionals: when the treater becomes the victim. Innovations in Clinical Neuroscience, 8 (3), 34-39. Antonius, D., Fuchs, L., and Herbert, F. (2010). 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