from two states examining the prezalence, nature, and risk factors of client ... of persons surveyed experienced client violence with gender and setting as ...
Families in Society: The Journal of Contemporary Human Services Copyright 1996 Families International, Inc.
Prevalence and Risk Factors for Client Violence toward Social Workers Christina E . Newhill ABSTRACT: The author reports findings from a random surwy of National Association of Social Workers members from two states examining the prezalence, nature, and risk factors of client violence toward social workers A malorit) of persons surveyed experienced client violence with gender and setting as significant tsartables in determining risk Implications for practice and policy are discussed IOLENCE IN THE WORKPLACE IS a critical concern in the United States. A wide range of workers, including utility workers, teachers, jitney and bus drivers, nurses, security guards, and social workers, have been victims of violence in the workplace (Burgess, Burgess, & Douglas, 1994; Fitzgerald, 1993; Young, 1992; Younger, 1993). Few people enter the social work profession thinking that they may become the target of violence from the very individuals they wish to help (Star, 1984); yet anecdotal evidence, along with some empirical data, suggests that physical and verbal violence by clients toward social workers is increasing in all settings (DilIon, 1992;Newhill, 1995). What causes social workers to become targets for a client’s violent behavior? The answer t o this question is complex and not entirely clear. Some argue that violence against social workers reflects the violence in society (Dillon, 1992). Longstanding societal problems such as unemployment, poverty, and racism create an environment in which violence thrives (Young, 1992). Others argue that the answer lies in the unique nature of the social worker’s role: the social worker is both caring and controlling; he or she often must interpret government regulations and dispense resources. As a result, J “client’s
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rage, frustration and helplessness [may] surface” (Euster, 1992, p. A14). For example, in June 1991, Arnold Bates, a 34-year-old food stamp applicant in a Baltimore welfare office, stabbed to death one of the caseworkers, Tanja Brown-O’Neill. T h e aggressive public reaction to this tragic incident was shocking and included people calling the agency threatening to “take out more of you social workers” (Dillon, 1992). Many social workers are caught between desperate clients and a government that is perceived by clients as the cause of their problems or as an entity that cannot or will not help them. T h e issue of violence perpetrated against social workers has not, until now, been accompanied by large-scale empirical investigations of its scope and prevalence across settings or of practice/policy implications. This lack of attention suggests that social workers may be neither adequately informed as to the potential hazards they face in their daily work nor provided with Christtna E . Newhill IS Assistant Professor, School of Social Work, Uniwrsit? of Pittsburnh, Pittsburgh, Pennsylcaniu. This article is based on work funded by grant 5-38443 from the Central Research and Development Fund, University of Pittsburgh
Client Violence Risk Factors Newhill
adequate training to enable them to manage these risks (Newhill, 1995).
Review of the Literature T h e literature addressing client violence toward human service professionals in the United States generally focuses o n health care disciplines other than social work, for example, psychiatry (Black et al., 1994; Hatti, Dubin, & Weiss, 1982; Madden, Lion, & Penna, 1976; Ruben, Wolken, & Yamamoto, 1980) and nursing (Burgess et al., 1994; Lanza, 1984; Vincent & White, 1994). These studies suggest that the true incidence of client assaults toward staff is high but hidden by underreporting (Lion, Snyder, & Merrill, 1981). Many studies have looked at client violence toward human services staff, but the samples have been restricted to particular cities (e.g., Bemstein, 1981; Whitman, Armao, & Dent, 1976) or practice settings, for example, inpatient units (Craig. 1982; Davis, 1991; Ghaziuddin & Chaziuddin, 1992; Hanson & Balk, 1992; Sheridan, Henrion, Robinson, & Baxter, 199@),community mental health centers (Edelman, 1978; Lion & Reid, 1983), and child protective services (Horejsi, Garthwait, & Rolando, 1994). Because of their small samples, these studies cannot address the question of the prevalence of client violence toward social workers across settings. Two studies specifically assessed client violence toward social work students. One investigation, an informal survey of social work gradua t e students a t t h e University of S o u t h e r n California, found chat client violence was one of the three most prevalent treatment issues in students’ field placements (Star, 1984). The other study, a survey of both social work students and field instructors a t the University of Georgia, reported that 26%) of the students had experienced some type of violence during their field placements (Tully, Kropf, & Price, 1993). Two studies examine violence toward social service workers in rural areas. The first study involved a random survey of social service workers in West Virginia (N = 83), reporting that physical violence by clients toward workers was common and occurred most often in corrections, healthimental health services, and services tor
persons with disabilities (Schultz, 1987). T h e other study looked at a sample of line workers and supervisors ( N = 166) employed by t h e Montana Department of Family Services (Horejsi e t al., 1994). T h i s study concluded t h a t threats and violence directed against child-protection workers are fairly common, particularly verbal threats and abuse. To date, no large-scale investigation of the prevalence of client violence toward social workers across settings has been undertaken-a significant gap in the literature. Such an investigation is critical to determine the prevalence and scope of this phenomenon. This article attempts to fill this void by reporting descriptive results from a recent exploratory survey of National Association of Social Workers (NASW) members in two states that examined the prevalence of client violence toward social workers. Client violence is defined as property damage, threats, and attempted or actual physical attacks. It was hypothesized that a majority of the respondents would report at least one incident of client violence occurring a t some point in their careers. The following sections report o n ( 1 ) how social workers perceive t h e issue of client violence, (2) the prevalence of client violence in social work practice, ( 3 ) whether respondents received education or training in violence management, (4) which practice settings tended to be high risk, ( 5 ) high-risk characteristics of the worker, and (6) high-risk characteristics of the client.
Methodology T h e primary goal of this study was to examine the extent, nature, degree, and impact of client \. iolence toward social workers Anonymous questionnaires were sent to random samples ot social workers from Pennsylvania (N = 800) and California ( N = 800) Respondents mere identified via a computerized random selection procedure from e a c h state’s NASW membership directory. Membership in the social work profession’s national organization is a btatement of one’s professional identity and thus is a n appropriate and available frame from u h i c h to obtain samples of professional social Lburkers O n e thousand, one hundred and twen-
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ty-nine usable questionnaires were returned (71%). California and Pennsylvania were selected because both states are experiencing economic and demographic changes, increasingly volatile client populations as a result of deinstitutionalization, a n d cuts i n social service budgets, staffing levels, and service delivery systems. Both states also have large urban centers as well as rural areas.
Study Design Surveys were mailed to all prospective correspondents in January 1993, with a follow-up mailing to nonrespondents three weeks later. T h e original mailing included t h e questionnaire; a cover letter explaining the project, the voluntary nature of participation, and procedures to ensure anonymity; and a precoded return postcard. Respondents were asked to mail the postcard separately when they returned the questionnaire in order to reduce follow-up costs while preserving anonymity. Sixty-seven percent of the responses were received following the first mailing, and 33% were received following the second wave.
Instrumentation T h e questionnaire included both closedended and open-ended items. Questions were selected on the basis of issues reflected in the literature, direct recommendations from other clinicians and clinical researchers, and the author’s own clinical experience. T h e questionnaire was pretested with a group of 10 social workers and modified on the basis of their comments. T h e final version contained 107 items. Completion time varied from approximately I 5 minutes to one hour, depending on the extensiveness of the respondent’s prior experience with client violence. T h e questionnaire included definitions of the three types of client violence studied. Property damage: A client who intentionally damaged your property or agency property that you were using Threat: A verbal threat of harm or a threatening physical gesture by a client Physical attacks: Divided into t w o subcategories, actual physical attacks were “incidents in
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which the client directly laid hands on the social worker with the intent to harm.” Incidents in which physical contact occurred as a result of a weapon were also coded as actual physical attack. Attempted attacks were “incidents i n which the client attempted to physically attack t h e social worker but did not actually make physical contact.” R e s p o n d e n t s were asked to i n d i c a t e whether they had experienced any of these three types of client violence at any time during their career. If they had, more detailed information, including narrative descriptions of t h e event and its consequences, was obtained. If multiple incidents had occurred, respondents were asked to specify how many incidents they had experienced and to describe the most serious one.
Findings Respondent Characteristics Fifty-three percent of the sample was from Pennsylvania and 47% from California. Demographic indicators (Le., sex, race/ethnicity, and practice affiliation) suggest that the pooled sample of both states is representative of the national NASW membership as a whole for 1993. Respondents were overwhelmingly female (SO%), W h i t e (87%), and in their mid-forties (M = 44.8, SD = 12.3). Eighty-eight percent possessed an MSW as their highest degree. They had been in practice for an average of 14.6 years (SD = 10.1). Almost two-thirds (65%) characterized their sole practice function as direct services, 16% reported administrative or supervisory responsibilities, and 20% described other activities (e.g., planning, research, consultation) or a combination of functions, including direct practice. Findings on the major research questions are based o n respondent answers to specific questions and statistical analyses to identify differences among subgroups.
Perceptions and Attitudes Respondents were asked four questions regarding their perceptions and attitudes about violence as an issue for social work practice. T h e majority of respondents (78%) agreed t h a t client violence toward social workers is a signifi-
Client Violence Risk Factors Newhill cant issue for the social work profession in general. Although only 31% of t h e respondents agreed that client violence was a significant issue in their practice, 52% of the respondents indicated that they sometimes worried about their own safety while working with clients. Finally, more than 60% of the respondents indicated t h a t they preferred n o t to work with clients who are or may be violent. For example, one respondent said: We live in an increasingly violent society and this is reflected in our clients. I won’t put my life at risk and have chosen a population to work with that 1 can feel safe with.
These findings suggest that client violence toward social workers is perceived by most workers as a significant issue for the profession although not necessarily for their own practice. However, the respondents perceived issues of safety and avoidance of situations that might compromise safety, for example, working with violent or potentially violent clients, as important.
Education and Training O n e objective of the study was to explore whether respondents had specialized education or training to address the prevention and management of client violence and whether such training met their practice needs. In the sample as a whole, 59% reported that they had had training on working with violent and potentially violent clients. From this group, 59% received the training a t their agency, 4% had received training as part of their MSW or BSW course work, 3% had training as part of their field placement, 6% sought training independently, and 22’/0 obtained training at more than one setting. T h e majority (54%) of those who had obtained training reported that it fully or mostly met their needs. Only 3% reported that the training did not meet their needs at all. More than three-fourths of the respondents (79%) reported that the training was helpful in their work with violent clients. Seventy-nine percent, however, stated they would like to obtain additional training. As one respondent stated: You can’t get training just once and he done i t . You need t o have periodic reviews and
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keep working o n improving your skills or you won’t be sharp when you need it.
Of those respondents who had not received training in working with violent clients, 69% indicated that they would like to get training if it was available. These respondents stated that they wanted to obtain training for protection and to learn skills to prevent violent incidents from occurring.
Nature and Prevalence of Violence A majority of the 1,129 respondents (57%; n = 648) reported they had experienced one or more types of client violence during their career. Of that group, 43% had their own or their agency’s property damaged by a client, 83% had been threatened by a client, and 40% experienced an attempted or actual physical attack by a client. Nearly half of the respondents (48%) experienced multiple incidents across categories (see Table 1). Many respondents offered graphic descriptions of their experiences, illustrating the variety of client behaviors and practice circums t a n c e s c a p t u r e d by t h e words “ p r o p e r t y damage,” “threats,” “attempted attacks,” and “actual attacks.” Property damage. O n e of my c.lients damaged two computers, broke a chair, broke the couch, broke t h e fish t a n k , and destroyed several books. T h e program director was in charge
TABLE 1. Prevalence of experiencing client violence at any point in respondents’ career by type of violence. Type of incident
%
N o incidents reported Property only Threat only Attack only Property and threat Property and attack Threat and attack Property, threat, and attack
42 5 22 2 7 1 10
12
Note N = 1,129 ”Percentages sum to more than 100 due to rounding.
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during the entire incident and took a powerand-control stance that escalated things. 1 felt sorry for the client because the staff handled the situation so poorly-it could have been avoided. Threat. I was working for CYS [Children and Youth Serviced. There was severe medical neglect of client’s infant. This was being discussed with client in regard to client’s refusal to take child to a physician. Client picked up a kitchen knife and threatened to kill me if 1 didn’t leave. Attempted attack. 1 would not give welfare to the person and as I went into another office, the fellow followed me and cornered me. A female staff person intervened and the man appeared unwilling to attack a female although he was after me for sure. Actual attack. As our interview was ending, 1 was pushed and then slammed into the wall w i t h a full-body slam by the patient. I managed to turn the situation around and held her against the wall. Male staff came and r e strained her. Sixty-three percent (n = 710) of t h e respondents stated that they knew of social work colleagues who had experienced at least one incident of client violence. On average, this group of respondents knew of four colleagues who had h a d property damaged by a client, five colleagues who had been threatened by a client, and three colleagues who had experienced an attempted or actual physical attack.
Type of Zncident by Primary Area of Practice Differences in type of incident by primary area of practice (see Table 2 ) was highly significant = 37.1, df = 8, p < ,001). Based on the percentage of respondents reporting incidents compared with the percentage of respondents reporting n o incidents for each setting, the settings of highest risk were criminal-justice services, drug and alcohol services, and child-protective/children and youth services. Seventyfive percent or more of the respondents in these settings reported at least one incident of client violence. Settings of moderate risk (more than 50% of respondents reporting incidents) included mental health services, developmental disabilities/mental retardation, school s o c d work, and family services. Medical/health care services and
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TABLE 2. Occurrence of incidents by primary area of practice. Primary area
No incidents
of practice
(%)
One or more incidents (%)
21 24
79 76
25
75
36
64
44 46 46
56 54 54
51 56
49 44
High nsk Criminal justice Drug/alcohol services Children and youch services
Moderate nsk
Mental health services Developmental disabilities/ mental retardation School social work Family services Lou’nsk
Medical/healrh care Services to aged Note:
N
=
1,129
services to the aged were comparatively low risk (less than 50% of the respondents reported incidents). Other settings had too few cases reported to warrant conclusions.
Client Characteristics Across types of violence, t h e majority of the clients involved were male: 76% of those were involved i n property damage, 73% in threats, and 60% in attempted or actual physical attacks. Significant gender differences were found between actual versus attempred physical attacks. T h e proportion of female clients involved in actual attacks was much higher than the proportion of male clients = 7.19, df = 2, p
