2 Institutes of Occupational Medicine and Industrial Hygiene, National Taiwan University ... Journal of Occupational Safety and Health 18: 163-176 (2010). 164.
Workplace Violence from Psychiatric Patients
Research Articles
Workplace Violence from Psychiatric Patients Wen-Ching Chen
1,2
3,4
5
Hai-Gwo Hwu Yi-Ping Lin Yue-Liang Leon Guo 7 2,6,8* Teh-Sheng Su Jung-Der Wang
2,6
1
Yu-Li Hospital, Department of Health, Executive Yuan, Taiwan
2
Institutes of Occupational Medicine and Industrial Hygiene, National Taiwan University
3
Department of Psychiatry, National Taiwan University Hospital
4
Department of Psychology, National Taiwan University
5
School of Humanities and Social Sciences, National Yang Ming University
6
Department of Environmental and Occupational Medicine, National Taiwan University Hospital
7
Department of Health and Safety and Environmental Engineering, Central Taiwan University of Science and Technology
8
Department of Internal Medicine, National Taiwan University Hospital
Abstract Workplace violence has attracted public attention in past few years, and has been identified as one of occupational hazardsA Regardless of nations or occupations, it has become a global problemA Among healthcare settings, workplace violence is the particularly serious in psychiatric wards mostly from patientsA In this article first addressed the types and definition of workplace violenceA The epidemiological investigations on medical workplace violence were then described, followed by examining risk factors of workplace violence from psychiatric patients and prevention methods with respect to institutions and organizations, environment and personal perspective, and finally, the conclusionsA This article is intended to raise the public's attention to workplace violence by introducing how psychiatric medical staff faces occupational violence from patients, and to serve as the reference for preventing workplace violence in healthcare settingsA In conclusion, workplace violence from psychiatric patients is preventableA While actively controlling patients' psychiatric syndromes, institutions and organizations should draw up a formal announcement to not tolerate violence, and establish a reporting system as well as create a culture of safety around teamworkA Psychiatric medical staff should also acquire the capability of handing and preventing violenceA Keywords: Workplace violence, Psychiatric department, Risk factors, Prevention methods
Accepted 15 January, 2010 Correspondence to: Jung-Der Wang, Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University, E-mail: jdwang@ntuAeduAtw
163
Journal of Occupational Safety and Health 18: 163-176 (2010)
workplaceA It seriously harms people's self-esteem
Introduction
and very likely to cause psychiatric illnesses so
Considering violence is a global problem,
workplace violence has been considered to be one
th
the 49 World Health Assembly in 1996 made
of occupational hazards [9]A
the announcement to take violence prevention
Workplace violence has become a common
as the most important task of public health [1,2]A
public issue that many countries have enacted
Workplace violence had long been neglected
relevant laws and regulations stipulating employers
before 1990, and it was not taken seriously until
should adopt constructive measures to prevent
the NIOSH reviewed labor death certificates in
workplace violence [10,11]A Taiwan in 2008 drew
1980s and found that 12A5% of labors were killed
up the draft of safety and sanitation rules for
in the workplace [3]A It is the third major cause
healthcare services industry [12], which regarding
of death next to car accidents and falling down
workplace and work stress, specifies employer
[4]A According to data of the US Bureau of Labor
responsibilities such as workplace violence
Statistics, a total of 69 medical personnel were
reporting system in the hospital, prevention
killed in hospitals from 1996 to 2000A Although
programs or policies against workplace violence,
these deaths were attention-getting, a large
and necessary violence prevention training for
proportion of incidents of workplace violence
labors etcA
were non-lethal harmsA Medical personnel are the
Workplace violence in healthcare settings is
high risk group of this type of harms occupying
particularly serious in the psychiatric ward and
nearly half the non-lethal harms of all occupations
emergency ward [9,13]A Patients in a psychiatric
[5]A Medical personnel have 16 times higher
ward are with mental disordersA They do not
probability to be attacked by patients as compared
necessarily have the intention to commit violent
with other workers, and the probability for nurses
acts (or use violent language), which are however
is 4 times higher than that for other medical
affected by their mental statusA Psychiatric patients
personnel [6]A Life is priceless, and workplace
thus have the right of counterplea for their crimesA
violence causes not only death, disabilities,
They can be exempted from punishment or have
illnesses, absence without leave, accidents and
their punishment mitigated in accordance with
higher staff rate of flow, but also labor slowdown,
the regulations stipulated in Article 19 of the New
lower service ability and quality, reduced
Criminal Code and Article 30 of the Mental Health
competitiveness, affected institutional image, staff
Act, but they will be imposed obligatory medical
demoralization, decline of customer reliance and
treatment at psychiatric hospitalsA According to
lower creativity etc that all can severely affect
previous investigations in Taiwan, about 90A0%
organizational and business operations[7,8]A
of workplace violence incidents at the psychiatric
Moreover, violence makes some people suffer
department are from patients [14]A Reports of the
from unfairness, discrimination and prejudice in the
US Ministry of Justice also suggested medical 164
Workplace Violence from Psychiatric Patients
personnel of the psychiatric department are at high
and keeping them at a distance, and concealing
risk of being attacked by patients [5]A
them from important information or official
Beginning with the definition and types of
letters, and cause them any loss or insults or harmA
violence and some epidemiological investigations,
Bullying/mobbing usually is repetitive and can last
this article discusses the methods to prevent
for a long timeA Sexual harassment may include
workplace violence from psychiatric patients
unsolicited verbal or physical behavior, which is
in terms of institutions and organizations,
sexually motivated and considered offensive by
environment, the assaulters (patients) and victims
the recipientsA Racial discrimination may indicate
(employees)A It is in the hope of providing a
any threatening behavior relating to race, skin
reference for preventing workplace violence in
color, language, nationality, religion, minor races,
other healthcare settingsA
birth place or identity which is not wanted and mutually beneficial, and is affecting self-esteem at
Definition and types of workplace violence
workA Assaulters in the incidents of workplace
Workplace violence is defined as being
violence can be divided into four types [18]: the
attacked and injured in job-related places
first type is criminal behavior such as store, bank
including on the way going to or off work,
and clinic robberies; in the second type, assaulters
and workplace violence in healthcare settings
are victims' clients or patients or individual cases;
generally means violent incidents occurred in
in the third type, assaulters are victims' colleagues
hospitals, private clinics, home care services,
including their superior and colleagues; in the
daytime hospitalization, halfway homes, nursing
fourth type, assaulters are not those described
home and so on [15-17]A It can be divided into
previously but personal enemies, and the incidents
physical and psychological violence that the
occurred in the workplace, for instance, family
later includes abuse, bullying/mobbing, sexual
violence happened in the workplace, or commercial
harassment and racial discriminationA Bullying
collectors collecting debts in the workplaceA
may cover malevolent, mean or rude behaviors
Based on previous studies, among the incidents of
by virtue of physical strength or powerA It may
workplace violence at the psychiatric department,
also indicate the conduct to threaten and force the
94A9% incidents of physical assaults and 86A7%
recipients to do something they unwilling to do,
incidents of abuse are from patients that are
and cause them an insult and harmA For example,
classified into the second typeA However, there are
senior students threaten and force junior students
still 7A1% verbal insults coming from the superior,
to massage them or do laundryA Mobbing may
and 11A4% bullying/mobbing events and 9A5%
be defined as that a group of people (usually the
cases of sexual harassment from colleagues that
superior and/or colleagues) treat the recipients
are grouped into the third type [14]A This article
unfairly such as intentionally ignoring, excluding
only focused on violence from patients, but like 165
Journal of Occupational Safety and Health 18: 163-176 (2010)
other workplaces, other three types of workplace
(ILO) / International Council of Nurses (ICN) /
violence can also happen in psychiatric wardsA In
World Health Organization (WHO) / International
Taiwan, each county and city government offers a
Public Services International (PSI) in their
compliant hotline for victims of sexual harassmentA
investigations targeting nurses of general hospitals
The Council of Labor Affairs is recommended to
in Australia and Chile [22]A The investigation
include physical assaults, abuse, bullying/mobbing
results showed that the one-year prevalence of
and racial discrimination into the reporting scope,
physical violence, abuse, bullying/mobbing,
providing victims of workplace violence the ways
sexual harassment and racial discrimination is
to make complaints and better careA
respectively 3A0-17A0%, 27A4-67A0%, 10A5-23A0%, 0A7-8A0% and 0A8-2A7%A They also conducted the
Epidemiological investigation of workplace violence in healthcare settings
investigations using different questionnaires in the UK [23], Hong Kong [24], China [25] and the USA [26], and their results showed the prevalence
Violent incidents are likely to occur in
of physical violence and abuse are respectively
healthcare settings as compared with other types of
5A3-21A0% and 38A0-73A0%A May et al investigated
workplace because patients are usually tense and
the workplace violence, which nurses experience
nervous while seeking medical attention, and they
in the emergency ward in the USA, and the results
often expect too much from medical personnel that
showed the prevalence of physical violence and
they hope their problems can be solved quicklyA
abuse are respectively 74A0% and 88A0% [27]A
However, as medical treatment is limited, patients
In Taiwan, according to the studies of Lin et al
tend to get angry when they feel disappointed, and
conducted in South Taiwan, about 62A0% nurses
then possibly attack medical personnel [13]A The
have suffered from workplace violence, mostly
real prevalence and incidence rate of workplace
abuse [28]A As shown by the research of Privitera
violence in healthcare settings are generally
et al to survey the prevalence of violent incidents
underestimated because victims do not report for
from psychiatric patients, 43A0% nurses have been
many reasons [19-21]A Some literature review and
threatened in past one year, and 25A0% nurses
investigation reports on one psychiatric hospital,
have been attacked [29]A According to previous
which treats acute mental sickness and one
studies in Taiwan, the one-year prevalence that
psychiatric hospital providing chronic psychiatric
nurses have been attacked in the workplace is
care in Taiwan are discussed belowA
61A7%, and the prevalence of physical violence, abuse, bullying/mobbing, sexual harassment and
Prevalence of workplace violence in
racial discrimination are respectively 35A1%,
healthcare settings
50A9%, 15A8%, 9A5% and 4A5% (See Table 1); the prevalence of abuse is the highest [14]A
Di Martino et al adopted the questionnaires developed by the International Labor Organization 166
Workplace Violence from Psychiatric Patients
Chen [34] set up an in-hospital reporting
Table 1 One-year prevalence of workplace violence
system in one hospital providing treatment of
at one psychiatric hospital (%)
acute mental illness in North Taiwan and one
n=222 Any forms of violence
61A7
Physical violence
35A1
Abuse
50A9
East TaiwanA Chen intended to understand the frequency of frontline workers such as nurses or
Bullying/mobbing
15A8
Sexual harassment
9A5
Racial discrimination
4A5
hospital for treating chronic mental illness in
caregivers who are attacked by patients with acute and chronic mental illnessA Each of the subjects in
Incidence rate of workplace violence in healthcare settings
Chen's research signed a consent form and had an account number and passwordA
According to data of the US Bureau of Labor
While they participated in the research,
Statistics, about 2A0 per 10,000 labors suffer
they reported using the online system when they
from injuries due to workplace violence, and the
felt they were hurt or offended, or suffered from
numbers for medical workers, social workers and
violence (definition of violence is based upon that
nurses are respectively 9A3, 15A0 and 25A0 [30]A
set by the International Labor Organization (ILO)
Research of Carmel and Hunter conducted at
/International Council of Nurses (ICN) / World
the state hospitals in California indicated 16 per
Health Organization (WHO) / Public Services
100 nurses each year suffer from violence [31]A
International (PSI) [22], and described clearly in
Shown in investigations of the US Ministry of
the reporting questionnaire)A Once they completed
Justice, there are in average 12A6 per 1000 labors
the reporting, the computer sent out a message to
suffering from workplace violence each year,
comfort those who were harmed and thanked for
and 16A2 per 1,000 physicians and 21A9 per 1,000
their reportingA
nurses are attacked in the workplace each year; in
The reporting rate is usually low as pointed
psychiatric wards, 68A2 per 1,000 workers suffer
out in literature [14] so subjects who suffered from
from workplace violence, suggesting psychiatric
workplace violence from patients and completed
hospitals are the workplace where there are
the reporting were given NT$50 (abuse) and
frequent violent incidents [5]A
NT$100 (violence other than abuse) in reward for
In Taiwan, the incidence rate of workplace
their reporting; this amount of money was only
violence from psychiatric patients to nurses is
1/300 to 1/500 of their monthly salary so that
1A11-1A95 (attempts stated in medical records/1,000
should not encourage false reportingA
patients) as suggested by research of Chou et al
The 77 nurses of the first hospital reported
[32] whereas research of Chi et al indicated 0A09%
456 incidents in half a year, giving an incidence
(patient's attempts/number of hospitalized patients
rate of 11A6 in a total, which includes physical
each month) [33]A
violence 2A4, abuse 7A9, bullying/mobbing 0A3, sexual harassment 1A0 and racial discrimination 0A0 167
Journal of Occupational Safety and Health 18: 163-176 (2010)
(Table 2)A The 167 workers of the second hospitals
Risk factors of workplace violence from psychiatric patients
were followed up for one yearA They reported a total of 972 incidents, giving an incidence rate (per
Risk factors of workplace violence in
worker per year) of 5A9, which includes physical
psychiatric hospitals were discussed below
violence 1A7, abuse 3A7, bullying/mobbing 0A2,
in terms of institutions and organizations,
sexual harassment 0A3 and racial discrimination
environment, assaulters and victims (See Figure 1)A
0A0 (Table 3)A The incidence rate of violence at the hospital providing acute treatment was higher than that of the other hospital providing chronic
Environmental factors: eAgA closed and locked psychiatric wards, or the ward space and atmosphereA
care, but since the research subjects at these two hospitals were different and these two hospitals were also different in nature so it was difficult to
Events prior to committing violence eAgA being restricted from going out, not adapted to life in the ward or needs not satisfiedA
make a comparison of the research resultsA *
Table 2 Number of times (n), percentages (%) and incidence rates (per staff each year) a psychiatric hospital providing acute treatment Violence type Physical violence Abuse Bullying/mobbing Sexual harassment Racial discrimination Total *
n 94 312 11 39 0 456
% 20A6 68A4 2A4 8A6 0A0 100A0
Assaulters' violent behavior
Assaulters' psychiatric syndromes, unstable personality and loss of recognition and controlling ability caused by drugs
of reporting for workplace violence at
By reviewing and improving for any violent incidents without criticizing may encourage teamwork and develop a safe cultureA
Institutions and organizations: a clear policy and announcement to tolerate no violence, standard operational procedures for general work and handling violent incidents, design and lighting for passing in and out at the entrance and exit, security guards and monitors, violence reporting system and complaint making system for patientsA
Victims feel or experience violence
Victims' instant emotional and behavioral responses eAgA fear and anger
Victims' work stress, degree of anxiety, training for violence handling and communication skills, and work experience
To victims, the outcomes may include lawsuits, resignation or returning to workA
Process of event occurrence
Incidence rate 2A4 7A9 0A3 1A0 0A0 11A6
Event analysis process, training and communication skills Anxiety Stage
Compulsion Stage
Remission Stage
Figure 1 Workplace violence from psychiatric patients- a reference model of event development and analysis
Follow-up date: October 1, 2005 to March 31, 2006; number of subjects: 77
1A
*
Institutions and organizations: As revealed
Table 3 Number of times (n), percentages (%)
by research of Chen et al, all interviewees
and incidence rates (per staff each year)
commented that there was no adequate
of reporting for workplace violence at a
support for them after they were attacked,
psychiatric hospital providing chronic care
and more than half of them said they had no
*
Violence type
n
%
Incidence rate
Physical violence Abuse Bullying/mobbing Sexual harassment Racial discrimination Total
284 611 33 43 0 971
29A6 62A9 3A1 4A4 0A0 100A0
1A7 3A7 0A2 0A3 0A0 5A9
one to ask for helpA They also mentioned that alarm systems and monitors as well as prejob and on-job training are equally important [35]A The reporting rate was very low that only 31A0% victims of physical violence and
Follow-up date: September 1, 2005 to August 31, 2006;number of subjects: 167
fewer than 10A0% victims of other types of 168
Workplace Violence from Psychiatric Patients
2A
violence complete the reportingA This was
behavior due to decline of cognitive ability [48,54]A
mainly due to current workplace culture:
In particular in acute period, psychiatric patients
people think reporting a violent incident is
as affected by their conditions are more inclined
not important; they fear to be scolded and
to make an assault than normal people [50,55] for
blamed or that their merit rating will be
about four times higherA If they also have drug or
affected; they think making the reporting may
alcohol abuse, they are 15 times more likely to
not work; they have no ways or no one to
make an attack, but this type of patients occupies
report to; they feel shamed and guilty about
only 8% of total mental patients [49]A Patients who
being attacked so fear for making a report
are diagnosed with violent inclination, have past
[14]A
history of violence, have longer hospitalization
Environment: The door of a psychiatric
period, smoke, and have a higher score of violence
ward is often closed and lockedA Patients are
scale [32,40,41] have the potential to make an
usually restricted from going out and some
assault, but one cannot predict who are violent
needs such as discharge from the hospital
based on sex, age and other demographic variables
and smoking so they tend to get angry and
[40]A
commit an attempt [36,37]A Some studies
4A
Victims (employees): There are few studies
found out that violence is associated with
focusing on this aspectA Anderson's research
conditions [38-43], length of hospitalization
pointed out that people suffering from
period [44] and interaction between patients
violence in childhood are prone to physical
and workers [45,46]A
violence [56]A Di Martino et al concluded
Assaulters (patients): Media have long been
that people with more work stress tend to
exaggerating psychiatric patients that the
suffer from workplace violenceA Furthermore,
public think they are dangerous and may
research also found out that workplace
attack people at any timeA Workers in a
violence in the psychiatric department is
psychiatric ward may also have the same
also one source of major work stress [58]A
thoughtA About half the workers think this
It seems to be reciprocal causation between
is part of their job and it is inevitable and
work stress and workplace violenceA Chen et
unpreventable [14]A
al found that people with higher anxiety (who
Nevertheless, only very few of mental
are more anxious about being assaulted) are
patients are aggressive, and most of this type of
more likely to be attacked in the workplaceA
patients have psychotic syndromes [47-51] such
On-job education about violence prevention
as auditory hallucination, delusion or multiple
can reduce the anxiety and enhance
personality disorder [52], or lose control of their
confidence as well as lower the incidence
emotion and behavior because of use of alcohol
rate of violence [34]A People who are with
and illegal drugs [47,53], or have disorderly
less work experience or at a younger age
3A
169
Journal of Occupational Safety and Health 18: 163-176 (2010)
and unmarried tend to suffer from physical
and interaction between assaulters and victims
violence and abuse [14]A About 7A7% of
[59], in fact, is also associated with the society,
people suffering from physical violence were
national economic development and politics, that
attacked by weapons injuring nearly half of
is, the ecological model promoted by the World
them (46A2%), one third (30A8%) of them
Health Organization [1]A Due to limited space of
requiring medical care (occupying about
publication, this point will not be discussed further
1A1% of all physical violence victims); a
in detail in this articleA
majority of their injuries were minor [14]A
Prevention methods against workplace violence from psychiatric patients
Their receptions after being assaulted varied from the most severe posttraumatic stress disorder, anxiety, fear and sleeplessness to
The progress of violence from psychiatric
indifference and enduring the hurt peacefully
patients can be divided into three stages, anxiety,
[35]A In general, those with less work
compulsion and remission (See Figure 1)A In light
experience, particularly, new employees, had
of the three prevention stages of public health,
enormous psychological trauma after being
stages of anxiety, compulsion and remission stand
attacked; it takes a long time for them to
for primary, secondary and tertiary preventionA
recover, but some of them resign their jobA
The prevention measures are as shown in Table
The happening of violence while affected
4, and described below in view of institutions and
by institutions and organizations, environment,
organizations, environment, assaulters and victims:
Table 4 Primary, secondary and tertiary preventions against workplace violence from psychiatric patients Institutions and organizations
Environment
Assaulters (patients)
Victims (employees)
Primary prevention
The announcement to tolerate no violence; maintenance of security facilities including entrance control and lighting etcA
Teamwork and safe culture, good relationships between labors and managers, and complete workplace violence prevention measuresA
Providing patients the ways to express and make complaints to effectively voice their discontent and indignationA
Providing necessary training to prevent workplace violence such as communication skills, understanding, recognizing assaulters and handling methods etcA
Secondary prevention
Setting up alarm systems, providing the ways for employees to evacuate from the scene, well-trained security guards and professional legal consultantsA
Setting up the standard operational procedures (SOP) for handling violent incidents and follow-up review, and appropriately modifying the SOP when necessaryA
Applying strict security control of patients going in and out of wards, avoiding attacks with tools, lowering the severity of harmsA
Skills for handling violent incidents such as training for non-violent risk responses, and exercises and inspection for the handling proceduresA
Tertiary prevention
Monitors can help understand Organizing a group of employees Giving necessary interventions how an even occurs, and analyze to support and comfort victims, to assaulters by medication it for future violence preventionA and help them get back to workA for controlling and stabilizing patients' emotions, or applying necessary quarantine and restriction measures to themA
Establishing a reporting system for employees to make a complaint after suffering from violenceA
1A
Institutions and organizations: The low
outcomes so institutions or organizations
reporting rate of violent incidents is partially
should protect victims and employees who
because victims fear for any negative
make the reporting from punishment, and 170
Workplace Violence from Psychiatric Patients
create humanistic, supportive and safe
Chen et al found that patients who commit
workplace culture [60,61]A By encouraging
assaults are often given drug injections or
employees to report any violent incidents,
rectification, or changed to the emergency
one can find out the risk factors and prevent
ward, or given Electro-Convulsive Therapy
violence by incident analysis (See Figure
(ECT) [19] by obtaining approval of at least
1)A Security guards, monitoring system
two specialist physicians, and consent of
and emergency lighting system should be
patients and their familyA Medical personnel
made availableA The standard operational
should also try to relieve patients' anxiety and
procedures for handling violent events and
help solve any problems after hospitalization
general routine work should be establishedA
by talking to them and their family more
Strict control and good lighting should be
oftenA
applied to all entrancesA Institutions and
2A
3A
4A
Victims (employees): Providing new
organizations should invest in pre-job and on-
employees pre-job training is the major
job training for employees, and familiarize
way to prevent violenceA Employees should
employees with workplace violence and
stay alert to signs of violenceA While being
prevention skills by giving them some
attacked, employees should keep calm and
exercises, and create a safe and teamwork
not fight with assaulters, and use some
cultureA
non-violent skills to escape from the scene
Environment: Patients should be allowed to
and seek for helpA Employees should only
go out for a walk and exercise more oftenA
attempt to bring the assaulters down when
If they are anxious for that they cannot
supporters for about four or five people arrive
be discharged from the hospital, medical
[62]A They should get familiar with these
personnel should calm them down by
skills in response to violence by exercises
listening to, supporting and respecting them,
and evaluationA Victims should have the
and giving them hopeA Patients should also be
way to deal with their displeasure to avoid
given the way to express their opinions and
developing more serious psychological
make complaintsA When they can effectively
problems in the future [63]A The objectives
reveal their anger and discontent, they will
of interventions after violent incidents are
cause fewer violent incidentsA
to reduce the impact of workplace violence
Assaulters (patients): There are some signs
and assure the violence will not happen
before patients attempt to attack from their
againA Victims throughout the entire recovery
face, eyes, voice and speech, and body
process should be well supported and
languagesA Some very dangerous patients
encouraged to get back to work early so as
should be given medication to eliminate
not to affect their work efficiency [64]A
the influence of their psychotic syndromesA 171
Journal of Occupational Safety and Health 18: 163-176 (2010)
Mercy JA, Zwi AB, Lozano R, EdsA World
Conclusion
report on violence and healthA 1st edA Geneva:
Workplace violence from psychiatric patients
World Health Organization; 2002A
is not fateful and inevitable as only very few
[2] World Health Organization(WHO)A Violence:
psychiatric patients are aggressive, and there
a public health priorityA Geneva: WHO; 1995A
are signs before they attempt to make assaultsA
[3] C a s t i l l o D N , P i z a t e l l a T J , S t o u t N A
Medical personnel of the psychiatric department
InjuriesA In: Levy BS, Wegman DH, EdsA
should actively control patients' mental conditions,
Occupational health, recognizing and
and be able to deal with their anxiety and conflictsA
preventing work-related disease and injuryA
In view of institutions and organizations, clear
1st edA Philadelphia: Lippincott Williams and
policies to tolerate no violence, a reporting
Wilkins; 2000A
system for employees to report any physical
[4] Bureau of Labor Statistics(BLS)A Violence
and psychological violent incidents, and a safe
in the workplace violence comes under close
teamwork culture should be established, in order
scrutinyA Washington DC: BLSA Available at:
to improve service quality, strengthen employees'
http://wwwAblsAgov/iif/oshwc/cfoi/cfch0006A
faith in the institutions or organizations, and
pdf; 2006A
prevent any violent incidentsA This article is
[5] National Institute for Occupational Safety and
intended to serve as the reference for preventing
Health(NIOSH)A Guidelines for preventing
workplace violence in healthcare settingsA It is
workplace violence for health care and social
expected to create a non-violent medical care
service workersA Washington, DC: NIOSH;
environment with the efforts of all medical
2004A
personnelA
[6] Elliott PA Violence in health care: what nurse managers need to knowA Nursing
Acknowledgement
Management 1997; 28: 38-41A
We are thankful for the partial funding to
[7] Simonowitz JAA Health care workers and
the research from the Central Region Office,
workplace violenceA Occupational Medicine
Department of Health (DOH), (Project NOA:
1996; 11: 277-91A
93042), the Yuli Hospital, DOH, Executive
[8] Bureau of Labor Statistics(BLS)A Survey
Yuan, Taiwan and the Institute of Occupational
of occupational injuries and illness in
Medicine and Industrial Hygiene, National Taiwan
cooperation with participating State agencies,
UniversityA
2007A Washington DC: BLS; Available from: http://wwwAblsAgov/iif/oshwc/osh/case/
References
osnr0031Apdf; Accessed June 15, 2009A
[1] Dahlberg LL, Krug EGA Violence - a global
[9] National Institute for Occupational Safety
public problemA In: Krug EG, Dahlberg LL,
and Health(NIOSH)AViolence: occupational 172
Workplace Violence from Psychiatric Patients
hazards in hospitalA Cincinnati: NIOSH 2002A
Available at: http://whqlibdocAwhoAint/
[10] Steven LS, Lawrence RM, Joseph JH,
publications/9221134466ApdfA Accessed May
Lennart LA Psychosocial and organizational
17, 2008A
factorsA In: Encyclopaedia of occupational
[18] Peek-Asa C, Runyan CW, Zwerling CA The
h e a l t h a n d s a f e t yA 4 t h e d A G e n e v a :
role of surveillance and evaluation research
International Labor Office; 1998A
in the reduction of violence against workersA
[11] Claravall LA Healthcare violence: A nursing
American journal of preventive medicine
administration perspectiveA The Journal of
1920; 141-8A
nursing administion 1996; 26: 41-6A
[19] Chen WC, Hwu HG, Wang JDA Staff
[12] Council of Labor Affairs, Executive
responses to different categories of workplace
Yuan(CLA)A Labor Safety and Health
violence in a psychiatric hospital in TaiwanA
Regulation for Health Care Workers(Draft)A
International journal of Occupational and
Taipei: CLA; 2008A(Chinese)
Environmental Health 2009; 15: 172-9A
[13] Smith-Pittman MH, McKoy YDA Workplace
[20] Ferns TA Under-reporting of violent incidents
violence in healthcare environmentsA Nursing
against nursing staffA Nursing Standard 2005;
Forum 1999; 34: 5-13A
20: 41-5A
[14] Chen WC, Hwu HG, Kung SM, Chiu HJ,
[21] Ferns T, Chojnacka IA Reporting incidents of
Wang JDA Prevalence and deteriminants of
violence and aggression towards NHS staffA
workplace violence of health care workers in
Nursing Standard 2005; 19: 51-6A
a psychiatric hospital in TaiwanA Journal of
[22] Di Martino VA Workplace vilence in the
Occupational health 2008; 55: 288-93A
health sector-coutry case studies Brazil,
[15] Institute of Occupational Medicine and
Bulgaria, Lebanon, Portugal, South Africa,
Industrial Hygiene, National Taiwan
Thailand, plus an additional Australian study:
University(OMIH)A Framework guidelines
synthesis reportA Geneva: International Labor
for addressing workplace violence in the
Organization/International Council of Nurses/
health sectorA Taipei: OMIH; 2004A(Chinese)
World Health Organization/Public Services
[16] Di Martino VA Framework guidelines for
International(ILO/ICN/WHO/PSI); 2002A
addressing workplace violence in the
[23] Whittington R, Shuttleworth SA Violence to
health sectorA Genea: International Labor
staff in a general hospital settingA Journal of
Organization/International Council of Nurses/
advanced nursing 2008; 24: 326-33A
World Health Organization/Public Services
[24] Kwok RP, Law YK, Li KE, et alA Prevalence
International(ILO/ICN/WHO/PSI); 2002A
of workplace violence against nurses in Hong
[17] Wo r l d H e a l t h O r g a n i z a t i o n ( W H O ) A
KongA Hong Kong Medical Journal 2006; 12:
Framework guidelines for addressing
9A
workplace violence in the health sectorA
[25] Chen ZH, Wang SY, Lu YC, Jing CXA 173
Journal of Occupational Safety and Health 18: 163-176 (2010)
Analysis on the epidemiological features and
187-95A
risk factors of hospital workplace violence in
[33] Chi MT, Jeang SR, Pan CC, Leu SJ, Chueh
GuangzhouA Chinese Journal of Epidemiology
CMA Enhancing the Capability of Medical
Occupational and Environmental medicine
Team to Manage Aggressive Events in Acute
2004; 25: 3-5A
Psychiatric WardsA The Journal of Nursing
[26] Gerberich SG, Church TR, McGovern
2008; 55: 59-67A(Chinese)
PM, et alA An epidemiological study of
[34] Chen WCA Workplace violence in psychiatric
the magnitude and consequences of work
hospitalsA [dissertation]A Taipei: National
related violence: the Minnesota Nurses'
Taiwan University; 2008A
StudyA Chinese Journal of Epidemiology
[35] Chen WC, Wang JD, Lew-Ting CY, Chiu
Occupational and Environmental medicine
HJ, Lin YPA Workplace violence on workers
2004; 61: 495-503A
caring for long-term institutionalized
[27] May DD, Grubbs LMA The extent, nature, and
schizophrenic patients in TaiwanA Journal of
precipitating factors of nurse assault among
Occupational Health 2007; 49: 311-6A
three groups of registered nurses in a regional
[36] Patton DA How reality orientation may impact
medical centerA Journal of Emergency
upon violence and aggression within acute
Nursing 2002; 28: 11-7A
psychiatric careA The International Journal of
[28] Lin YH, Liu HEA The impact of workplace
Psychiatric Nursing Research 2003; 8: 972-
violence on nurses in South TaiwanA
84A
International Journal of Nursing Studies
[37] Bensley L, Nelson N, Kaufman J, Silverstein
2005; 42: 773-8A
BA Patient and staff views of factors
[29] Privitera M, Weisman R, Cerulli C, Tu X,
influencing assaults on psychiatric hospital
Groman AA Violence toward mental health
employeesA Issues in Mental Health Nursing
staff and safety in the work environmentA
1995; 16: 433-46A
Occupational Medicine 2005; 55: 480-6A
[38] Ferris SA Factors influencing the ward
[30] Bureau of Labor Statistics(BLS)A Survey
atmosphereA Acta Psychiatrica Scandiravica
of occupational injuries and illness, 2000A
1986; 73: 600-6A
Washington DC: BLS; 2001A
[39] James DV, Fineberg NA, Shah AK, Priest
[31] Carmel H, Hunter MA Staff injury from
RGA An increase in violence on an acute
inpatient violenceA Hospital & Community
psychiatric wardA A study of associated
Psychiatry 1989; 40: 41-6A
factorsA The British Journal of Psychiatry
[32] Chou KR, Lu RB, Mao WCA Factors relevant
1990; 156: 846-52A
to patient assaultive behavior and assault in
[40] Miller RJ, Zadolinnyj K, Hafner RJA Profiles
acute inpatient psychiatric units in TaiwanA
and predictors of assaultiveness for different
Archives of Psychiatric Nursing 2002; 16:
psychiatric ward populationsA The American 174
Workplace Violence from Psychiatric Patients
Journal of Psychiatry 1993; 150: 1368-73A
study of patient assaults on nursing staff
[41] Nijman H, Merckelbach H, Evers C,
in a psychiatric unitA Canadian Journal of
Palmstierna T, Campo JA Prediction of
Psychiatry 1989; 34: 399-404A
aggression on a locked psychiatric admissions
[49] Swanson JW, Holzer CE, III, Ganju VK,
wardA Acta Psychiatrica Scandinavica 2002;
Jono RTA Violence and psychiatric disorder
105: 390-5A
in the community: evidence from the
[42] Palmstierna T, Huitfeldt B, Wistedt BA The
Epidemiologic Catchment Area surveysA
relationship of crowding and aggressive
Hospital & Community Psychiatry 1990; 41:
behavior on a psychiatric intensive care unitA
761-70A
Hospital & Community Psychiatry 1991; 42:
[50] McNiel DE, Binder RLA The relationship
1237-40A
between acute psychiatric symptoms,
[43] Palmstierna T, Wistedt BA Changes in the
diagnosis, and short-term risk of violenceA
pattern of aggressive behaviour among
Hospital & Community Psychiatry 1994; 45:
inpatients with changed ward organizationA
133-7A
Acta Psychiatrica Scandinavica 1995; 91: 32-
[51] McNiel DE, Eisner JP, Binder RLA The
5A
relationship between command hallucinations
[44] Greenfield TK, McNiel DE, Binder RLA
and violenceA Psychiatric Services 2000; 51:
Violent behavior and length of psychiatric
1288-92A
hospitalizationA Hospital & Community
[52] Nestor PGA Mental disorder and violence:
Psychiatry 1989; 40: 809-14A
personality dimensions and clinical featuresA
[45] Chen SC, Hwu HGA Aggressiveness in
The American Journal of Psychiatry 2002;
Psychotic Patients: Psychopathological
159: 1973-8A
Theory and Clinical ManagementA Taiwanese
[53] Tiihonen J, Isohanni M, Rasanen P, Koiranen
Journal of Psychiatry (Taipei) 2002 ; 16 :
M, Moring JA Specific major mental disorders
261-75A(Chinese)
and criminality: a 26-year prospective study
[46] Whittington R, Wykes TA Aversive stimulation
of the 1966 northern Finland birth cohortA
by staff and violence by psychiatric patientsA
The American Journal of Psychiatry 1997;
The British Journal of Chinical Psychology
154: 840-5A
1996; 35: 11-20A
[54] Brennan PA, Mednick SA, Hodgins SA Major
[47] Arseneault L, Moffitt TE, Caspi A, Taylor PJ,
mental disorders and criminal violence
Silva PAA Mental disorders and violence in a
in a Danish birth cohortA Arch of General
total birth cohort: results from the Dunedin
Psychiatry 2000; 57: 494-500A
StudyA Archives of General Psychiatry 2000;
[55] Walsh E, Buchanan AA Criminal and violent
57: 979-86A
hebavior in schizophreniaA In: Murray RM,
[48] Cooper AJ, Mendonca JDA A prospective
Jones PB, Susser E, van Os J, Cannon MA 175
Journal of Occupational Safety and Health 18: 163-176 (2010)
EdsA The epidemiology of schizophreniaA
the workplaceA Journal of the Royal Society
Cambridge University Press; 2008A
of Health 2002; 122: 226-32A
[56] Anderson CA Workplace violence: Are some
[61] Whittington R, Wykes TA Staff strain and
nurses more vulnerable? Issues in Ment al
social support in a psychiatric hospital
Health Nursing 2002; 23: 351-66A
following assault by a patientA Journal of
[57] Di Martino VA Relationship of work stress
Advanced Nursing 1992; 17: 480-6A
and workplace violence in health sectorA
[62] Farrell G, Cubit KA Nurses under threat:
Geneva: International Labor Organization/
a comparison of content of 28 aggression
International Council of Nurses/World
management programsA International Journal
Health Organization/Public Services
of Mental Health Nursing 2005; 14: 44-53A
International(ILO/ICN/WHO/PSI); 2002A
[63] Warshaw LJ, Messite JA Workplace violence:
[58] Shen HC, Cheng Y, Tsai PJ, Lee SH,
preventive and interventive strategiesA Journal
Guo YLA Occupational stress in nurses in
of Occupational Environmental Medicine
psychiatric institutions in TaiwanA Journal of
1996; 38: 993-1006A
Occupational Health 2005; 47: 218-25A
[64] Du CL, Lai CF, Wang JDA Delayed return-
[59] Davis SA Violence by psychiatric inpatients:
to-work in workers after non-severe
a reviewA Hospital & Community Psychiatry
occupational upper extremity fracture in
1991; 42: 585-90A
TaiwanA Journal of the Formosan Medical
[60] Fleming P, Harvey HDA Strategy development
Association 2007; 106: 887-93A
in dealing with violence against employees in
176