Workplace Violence from Psychiatric Patients

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


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


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


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


(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


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


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


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


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/

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