Staff perceptions of risk factors for violence and aggression in ambulatory care

Abstract

BACKGROUND:

Management of violent acts of patients and their visitors in psychiatric and hospital settings has been studied. However, violence has not yet been addressed in the ambulatory care environment.

OBJECTIVE:

To identify potential risk factors for patient and visitor violence [PVV] and staff perceptions of the impact of these risk factors in ambulatory care.

METHODS:

A review of psychiatric inpatient research was conducted examining violence and aggression including risk factors for PVV. Identified risk factors for violence were incorporated into a survey tool and distributed to staff in a community clinic asking for their perception of the impact of these risk factors on aggression in their work environment.

RESULTS:

Risk factors for violence and aggression were categorized as static or dynamic or as related to characteristics of staff or the environment of care. All of the risk factors were identified as possible contributors to PVV by the staff while items related to substance abuse and the clinic environment were selected by the staff as “highly likely” to contribute to PVV in their setting.

CONCLUSIONS:

Continued research is needed in this area to better understand risk factors for PVV and develop appropriate safety interventions and crisis training for ambulatory care settings.

Keywords

Workplace violence safety outpatient clinics

1 Introduction

In recent years, violence towards nurses and nursing staff has been garnering more attention. According to numerous studies and editorials, assault on nursing staff in the inpatient psychiatric setting is not a new phenomenon, and it is often overlooked as just part of the job [1]. In 2011, the Bureau of Justice Studies released a special report examining the incidence of workplace violence in employed persons age 16 and older from 1993 –2009 [2]. Across all occupations, nonfatal occurrences of rape, robbery, and assault (sexual, aggravated, or simple) occurred 5.1 times per 1,000 employees, while the healthcare field accounted for 10.2% of all incidences of nonfatal workplace violence [2]. Given that healthcare workers only represented 8.2% of workers, this rate is higher than expected. In addition, acts of violence are notoriously underreported in health care, especially by nurses and nursing staff likely due to the tendency to “blame the victim” with more experienced nurses receiving more blame if they are injured on the job. [1 , 4].

Thus far, studies examining violence in healthcare have focused upon safety within emergency departments and psychiatric units. According to the National Institute for Occupational Safety and Health [NIOSH], risk factors for violence within these environments include: working directly with volatile people (e.g., those with aggressive or violent tendencies, those who are cognitively impaired, and those who are drug- seeking), understaffing, long waits for service, staff working alone with a patient, overcrowded waiting rooms, poor environmental design (including poor lighting, temperature control, and uncomfortable seating), inadequate security, and lack of staff training for managing crises with volatile patients [5]. All of the aforementioned risks of violence are commonplace in the ambulatory care setting. Ambulatory settings are focused on creating a welcoming and open environment for all who enter and do not typically have security measures in place [6]. In 2015, there were approximately 1 billion office visits to physicians in ambulatory care settings with approximately 50% of these visits within primary care and general practice settings, most for routine check-ups and preventative care [7]. Security professionals often refer to the ambulatory care environment as a “soft target” because, on examination, it is difficult to find any preventative measures taken against violent acts [6].

Over one-third of all mental health care provided in the United States is provided by primary care providers [PCPs], with 24% of patients seen having a diagnosed mental disorder [8]. However, when looking at appointment utilization, these patients comprise approximately 70% of appointments in primary care practice [9]. Robinson and Reiter [10] suggest that psychological factors contribute strongly to the presentation and treatment outcomes of numerous chronic conditions (e.g.: asthma, hypertension, diabetes) and are responsible for 70% of office visits to a PCP for the management of chronic conditions.

As the population grows and practicing physicians retire, the United States is potentially facing a shortage of more than 100,000 doctors within the next 10 years and with primary care the largest sector, it is impacted by a reduced number of doctors, nurses, and physician assistants entering primary care practice [11]. This will serve to increase demand in primary care settings, resulting in even longer wait times for services and appointments [12].

2 Literature review

2.1 Violence in the inpatient psychiatric setting

Hardin [3] attributed the well-known underreporting of violence against nurses to the lack of a consistent definition of what, exactly, constitutes violence in a psychiatric setting. The author explained that, since violence is often looked at as “just part of the job,” there is room for interpretation when determining what constitutes a violent action. While most nurses agree that getting punched by a patient is a violent action, if a confused elderly patient was to slap a nurse, due to a perceived lack of intent by the patient to harm, interpreting if this was a violent action is difficult. It is also important for staff to recognize the early stages of aggression since violent behavior usually is not addressed until the behavior has already escalated [3 , 13].

2.2 Impact on staff and quality of care

Whether or not a physical injury is sustained, violence towards Health Care Providers [HCPs] can impact targeted staff in numerous ways, including: fear, anger, sadness, disappointment, irritability, sleeplessness, diagnosable Post Traumatic Stress Disorder [PTSD], significant disruptions to physical health, lower mental energy, decreased work efficiency, decreased decision making, increased stress, feeling more on guard at work and less satisfaction in their work [14]. Workers who experience violence are also more likely to quit their job, seek work elsewhere, or leave the profession [15, 16]. Colleagues of the targeted staff member may also experience a decrease in productivity and an increase in utilization of sick leave [17]. When working with a patient prone to violence, it is common for staff to engage in “patient-avoiding behaviors” as a method of coping [18]. These behaviors result in staff being “on guard,” spending less time in direct contact with patients, and less responsive to the patients’ needs overall [18]. These behaviors have a negative impact on the quality of patient care and, subsequently, a negative impact on patients’ perceptions and ratings of the quality of care received [14].

As primary care clinics have become busier and patients in these clinics have become more likely to be psychiatrically compromised, what has been done to foster the safety of HCPs and supplemental staff who practice in this environment? If the current dearth of literature on the topic is any indication, the answer is “not much.” This highlights the need for further study in the ambulatory care environment. This paper reports the results of a quality improvement project and has two objectives: first, to provide a review of evidence on patient and visitor violence [PVV] in psychiatric inpatient units and other health settings to identify risk factors for PVV that may be translated into the ambulatory care environment; second, to critique the relevance of these risk factors in the ambulatory care setting by seeking input from ambulatory clinic staff leaders in order to propose safety measures to implement in ambulatory care.

3 Methods

3.1 Literature review

A literature review was performed utilizing Scopus, ProQuest Social Sciences, PsychInfo, Ovid Medline, and PubMed databases looking at resources from all dates to the present. The search terms used in each database were specific to violence (aggression, assault, abuse), psychiatry (psychiatric unit, inpatient psychiatry), ambulatory care (primary care, outpatient office), and safety and de-escalation (intervention, nurse safety, staff safety). Papers were excluded if they focused on intimate partner violence or violence amongst coworkers. To be reviewed, papers had to examine risk factors for PVV, the impact PVV has on staff morale or quality of patient care, or intervention/de- escalation techniques for managing PVV [results reported in 21]. Searches were run on a monthly basis from September 2015 –October 2016. Titles, abstracts, and full text articles were reviewed to determine if an article met inclusion criteria. When full text articles met inclusion criteria, data related to risk factors for PVV, barriers and facilitators to PVV, impact of PVV on staff and quality of care, and interventions promoting staff safety were extracted into an evidence matrix. From the master evidence matrix, data regarding patient and visitor risk factors for PVV as well as staff and environmental risk factors for PVV were extracted into a risk factor matrix (see Table 1). The search identified a total of 71 sources, of which 28 met full inclusion criteria for this review and 10 of which addressed risk factors for PVV. Results from the literature review were summarized narratively.

Table 1
Risk factor matrix

Static Dynamic Staff-Related Environmental

Anderson & West (2011)

Hx of Violence
Male Gender
Young Adulthood
Lower Intelligence
Hx of Head Trauma
Hx of Neurological Impairment
Hx of Military Service
Weapons Training
Past Dx of Major Mental
Illness
Hx of Impulsivity
Hx of Victimization Substance Abuse/Dependence
Persecutory Delusions
Command Hallucinations
Depression
Hopelessness
Dissociative State
Suicidality
Treatment Nonadherence
Impulsivity
Access to Weapons
Homicidality

Hahn et al. (2013)

Older Age Younger AgeRegistered NurseAggression TrainingFrequent Visitor Contact Emergency RoomOutpatient Ward

Price et al. (2015) De-escalation training

Hamrin et al. (2009)

Hx of Personality DisordersDementiaGenderExtremes of Age PsychosisManiaHallucinationsIntoxication High Staff AnxietyObservational SkillsCommunication SkillsJob Satisfaction

Speroni et al. (2014)

Diagnosis of Alzheimer’sDiagnosis of Dementia Drug-Seeking BehaviorImpaired by Drugs or Alcohol

Gunenc et al. (2015) ImpulsivityNegative AttitudeMedication Noncompliance

Bowers et al. (2013)

Social Deprivation of PopulationSchizophrenia Temporary or UnqualifiedEthnic Minority Groups Physical Environment

NIOSH (2002)

Cognitive ImpairmentDrug SeekingAggressive/ViolentTendencies Working with Volatile PeopleWorking alone with P/VLack of Crisis Training UnderstaffingLong Waits for ServiceCrowded Waiting RoomsPoor lightingPoor temperature controlUncomfortable SeatingInadequate Security

NIAAA (2010)

Hx of VictimizationHx of Physical AbuseParents Engaged in CriminalActivitiesYounger AgeLower Socioeconomic Status UnemploymentSubstance Abuse/IntoxicationSubstance WithdrawalPsychosisMania

Ridenour et al. (2015)

Hx of Personality Disorder Younger AgeAggression/Crisis TrainingTemporary or Unqualified

Static	Dynamic	Staff-Related	Environmental
Anderson & West (2011)
Hx of Violence Male Gender Young Adulthood Lower Intelligence Hx of Head Trauma Hx of Neurological Impairment Hx of Military Service Weapons Training Past Dx of Major Mental Illness Hx of Impulsivity Hx of Victimization	Substance Abuse/Dependence Persecutory Delusions Command Hallucinations Depression Hopelessness Dissociative State Suicidality Treatment Nonadherence Impulsivity Access to Weapons Homicidality
Hahn et al. (2013)
Older Age		Younger AgeRegistered NurseAggression TrainingFrequent Visitor Contact	Emergency RoomOutpatient Ward
Price et al. (2015)		De-escalation training
Hamrin et al. (2009)
Hx of Personality DisordersDementiaGenderExtremes of Age	PsychosisManiaHallucinationsIntoxication	High Staff AnxietyObservational SkillsCommunication SkillsJob Satisfaction
Speroni et al. (2014)
Diagnosis of Alzheimer’sDiagnosis of Dementia	Drug-Seeking BehaviorImpaired by Drugs or Alcohol
Gunenc et al. (2015)	ImpulsivityNegative AttitudeMedication Noncompliance
Bowers et al. (2013)
Social Deprivation of PopulationSchizophrenia		Temporary or UnqualifiedEthnic Minority Groups	Physical Environment
NIOSH (2002)
	Cognitive ImpairmentDrug SeekingAggressive/ViolentTendencies	Working with Volatile PeopleWorking alone with P/VLack of Crisis Training	UnderstaffingLong Waits for ServiceCrowded Waiting RoomsPoor lightingPoor temperature controlUncomfortable SeatingInadequate Security
NIAAA (2010)
Hx of VictimizationHx of Physical AbuseParents Engaged in CriminalActivitiesYounger AgeLower Socioeconomic Status	UnemploymentSubstance Abuse/IntoxicationSubstance WithdrawalPsychosisMania
Ridenour et al. (2015)
Hx of Personality Disorder		Younger AgeAggression/Crisis TrainingTemporary or Unqualified

For this review (results presented in section 4.1), the ambulatory care environment is defined as freestanding primary care clinics. In this environment a “visitor” is considered to be anyone accompanying a patient to an appointment (e.g. spouse, caregiver, friend, etc.). PVV is being defined as verbal, nonverbal, or physical acts from patients and/or visitors that threaten staff or may lead to injury of “the psychological, social, or physical well-being” of staff [19, p1].

3.2 Participants

Participants were members of the primary care clinic staff and leadership at an outpatient community health center. The survey was introduced during a monthly staff meeting as part of a quality improvement project. Staff participation was anonymous and voluntary. Staff members included nurses, medical assistants, nurse practitioners, medical receptionists and call center representatives. Respondents were grouped by the type of care they provide: direct care (those who have direct, clinical interactions with patients and visitors, e.g. nurses and medical assistants), and indirect care (those who may or may not have face-to-face contact with patients and visitors but do not provide clinical encounters, e.g. medical receptionists and call center staff). Institutional Review Board [IRB] approval was not needed as the survey was collecting staff opinions, not personal data, and staff were not subject to interventions.

3.3 Instrument

Current research has not identified risk factors for violence and aggression in ambulatory care. Based on methods for the use of expert panels in research [20], risk factors for violence and aggression identified in the literature were compiled in a staff survey and used a Likert-scale for the rating of staff perceptions with a score of “1” indicating the identified risk factor is not likely to lead to an act of violence and a score of “5” indicating an act of violence is very likely to occur.

3.4 Data collection

During the staff meeting, the survey was distributed and reviewed. Over a period of one week in August 2017, reminders were provided and completed scales were collected. Data was entered into an excel spreadsheet for analysis.

3.5 Data analysis

The mean score of each item was determined and a mean score of 4 or higher was considered an indicator of the staff’s perception that the item was likely to contribute to acts of violence within their ambulatory care setting. Mean scores and standard deviations were calculated for each item, as well as by direct or indirect care categories and t-tests were evaluated to determine if there were differences by type of care group. The Satterthwaite method was used rather than the pooled standard error formula when differences in sample variances were present. Chi-square analyses were performed to examine differences in perception of risk factors based upon staff role as direct or indirect caregivers within the clinic. Despite small sample size, t-tests and Chi-square analyses were utilized to determine trends and patterns within these data. These data were also compared with responses extracted from Patient Satisfaction Surveys completed in the clinic from March 2016 –January 2018 [21]. Areas that were overlapping between staff data and patient satisfaction surveys were selected as focus areas for the quality improvement project. The project was carried out in a Plan –Do –Study Act [PDSA] format [22; methods and results presented in 21].

4 Results

4.1 Risk factors for PVV

The literature review was summarized into four categories of risk factors for violence and aggression: Static and Dynamic based on prior research [23], as well as Staff-Related, and Environmental based on the context of the project. These risk factors were compiled and utilized as items on the staff survey.

Static risk factors for violence and aggression are those that cannot be changed and involve patient and visitor demographics as well as their social and psychiatric history. These risk factors included: extremes of age (older or younger) [23 –26], male gender [23, 25], lower socioeconomic status [26], social deprivation [27], lower intelligence [23], and parent engagement in criminal activities [26]. Common static risk factors were a past history of: violence [23], head trauma [23], neurological impairment [23], military service [23], physical abuse [26], impulsivity [23], victimization [23, 26], weapons training [23], dementia [25], personality disorder [25, 28], schizophrenia [27], Alzheimer’s Disease [29], and major mental illness [23].

Dynamic risk factors are those that can be changed with intervention and involve patient and visitor demographics, and current symptoms of psychiatric disturbance and substance abuse. These risk factors included: unemployment [26], treatment nonadherence [23, 30], access to weapons [23], negative attitude [30], persecutory delusions [23], command hallucinations [23], depression [23], psychosis [25, 26], hallucinations [25], hopelessness [23], suicidality [23], impulsivity [23, 30], homicidality [23], aggressive/violent tendencies [5], cognitive impairment [5], drug-seeking behavior [5 , 31], intoxication [25 , 31], substance dependence [23, 31], substance withdrawal [26, 31], and impairment by drugs or alcohol [26 , 31].

Risk factors related to staff characteristics included: younger age [24, 28], being a registered nurse [24], completing aggression/crisis training [24 , 32], frequent visitor contact [24], high staff anxiety [25], temporary/unqualified staff [25 , 28], belonging to ethnic minority groups [27], working with volatile people [26], working alone with patients and visitors [26], and a lack of crisis training [26].

Risk factors related to the environment of care included: poor physical environment [27], understaffing [26], long waits for service [26], overcrowded waiting rooms [26], poor lighting [26], poor temperature control [26], uncomfortable seating [26], and inadequate security [26].

4.2 Staff perceptions of risk factors for PVV

Surveys were distributed to staff in an ambulatory care clinic to determine their perceptions of PVV in their environment. Thirty-six surveys were distributed, eighteen were completed and returned. Given the small sample size, data were reviewed in aggregate to protect anonymity. Respondents were aged 18 –60 and predominantly female. Staff participants included nurses, medical providers, behavioral health clinicians, and front desk and call center staff.

Of the 51 risk factors examined, 20 had a total mean score of 4 or above on a scale of 1–5 (e.g.: aggressive/violent tendencies (4.72), substance withdrawal (4.5), homicidality (4.5), intoxication (4.4)), 25 had a mean score of 3.0 to 3.99 (e.g.: depression (3.0), suicidality (3.06), uncomfortable seating (3.11), and 6 had a mean score of 2.00 to 2.99 (e.g.: belonging to ethnic minority groups (2.28), hopelessness (2.72)).. No risk factors had overall mean scores at the extreme ends of the range (<2 or 5). Results are summarized in Table 2.

Table 2
Staff perceptions of risk factors of PVV in ambulatory care

Mean (SD) Very Likely #(%)

Unchangeable (Static)

Demographic:

Parent Engagement in Criminal 3.94 (0.94) 14 (77.8)

Activities

Social Deprivation 3.89 (0.96) 13 (72.2)

Lower Socioeconomic Status 3.44 (0.92) 9 (50.0)

Lower Intelligence 3.22 (1.11) 8 (44.4)

Gender 3.17 (1.20) 9 (50.0)

Age 2.83 (0.92) 4 (22.2)

History of:

Violence 4.50 (0.62) 17 (95.5)

Physical Abuse 4.17 (0.71) 17 (95.5)

Impulsivity 4.11 (0.76) 16 (88.9)

Head Trauma 3.94 (0.94) 12 (66.7)

Victimization 3.89 (0.83) 13 (72.2)

Neurological Impairment 3.78 (0.94) 10 (55.6)

Military Service 3.50 (1.29) 10 (55.6)

Weapons Training 3.33 (1.08) 9 (50.0)

Psychiatric History:

Major Mental Illness 4.28 (0.75) 17 (95.5)

Schizophrenia 3.94 (1.00) 15 (83.3)

Personality Disorder 3.72 (1.02) 13 (72.2)

Alzheimer’s Disease 3.33 (1.24) 8 (44.4)

Dementia 3.22 (1.26) 8 (44.4)

Mean (SD) Very Likely #(%)

Changeable (Dynamic)

Demographic:

Access to Weapons 4.06 (0.64) 15 (83.3)

Negative Attitude 4.00 (0.77) 13 (72.2)

Treatment Nonadherence 3.72 (0.75) 12 (66.7)

Unemployment 2.83 (1.15) 5 (27.8)

Psychiatric:

Aggressive/Violent Tendencies 4.72 (0.46) 18 (100.0)

Homicidality 4.50 (0.79) 17 (95.5)

Impulsivity 4.28 (0.57) 17 (95.5)

Psychosis 4.22 (0.43) 18 (100.0)

Dissociative State 4.22 (0.65) 16 (88.9)

Command Hallucinations 4.06 (0.73) 14 (77.8)

Mania 4.00 (0.84) 14 (77.8)

Persecutory Delusions 3.94 (0.87) 13 (72.2)

Hallucinations 3.94 (0.73) 13 (72.2)

Cognitive Impairment 3.78 (0.88) 13 (72.2)

Suicidality 3.06 (1.35) 7 (38.9)

Depression 3.00 (1.41) 7 (38.9)

Hopelessness 2.72 (1.49) 7 (38.9)

Substance Abuse:

Substance Withdrawal 4.50 (0.62) 17 (95.5)

Impairment by drugs or alcohol 4.50 (0.62) 17 (95.5)

Intoxication 4.44 (0.62) 17 (95.5)

Drug-Seeking Behavior 4.39 (0.61) 17 (95.5)

Substance Dependence 4.17 (0.79) 16 (89.9)

Mean (SD) Very Likely #(%)

Staff-Related Risk Factors

Temporary/Unqualified Staff 4.00 (0.84) 14 (77.8)

Working with volatile people 4.00 (1.08) 14 (77.8)

Lack of Crisis Training 3.94 (1.00) 14 (77.8)

Mean (SD) Very Likely #(%)

High staff anxiety 3.83 (0.99) 13 (72.2)

Working alone with P/V 3.83 (0.92) 14 (77.8)

Frequent visitor contact 3.56 (0.92) 11 (61.1)

Registered Nurse 3.33 (1.19) 10 (55.6)

Younger Age 2.83 (0.99) 3 (16.7)

Aggression/Crisis Training 2.39 (1.24) 3 (16.7)

Belong to Ethnic Minority Group 2.28 (1.23) 3 (16.7)

Environmental Risk Factors

Overcrowded waiting rooms 4.28 (0.83) 16 (88.9)

Long waits for service 4.22 (0.81) 16 (88.9)

Understaffing 4.17 (0.71) 15 (83.3)

Inadequate Security 4.11 (0.96) 16 (88.9)

Poor physical environment 4.00 (1.08) 12 (66.7)

Poor temperature control 3.83 (0.92) 13 (72.2)

Poor lighting 3.44 (0.92) 9 (50.0)

Uncomfortable Seating 3.11 (1.08) 7 (38.9)

	Mean (SD)	Very Likely #(%)
Unchangeable (Static)
Demographic:
Parent Engagement in Criminal	3.94 (0.94)	14 (77.8)
Activities
Social Deprivation	3.89 (0.96)	13 (72.2)
Lower Socioeconomic Status	3.44 (0.92)	9 (50.0)
Lower Intelligence	3.22 (1.11)	8 (44.4)
Gender	3.17 (1.20)	9 (50.0)
Age	2.83 (0.92)	4 (22.2)
History of:
Violence	4.50 (0.62)	17 (95.5)
Physical Abuse	4.17 (0.71)	17 (95.5)
Impulsivity	4.11 (0.76)	16 (88.9)
Head Trauma	3.94 (0.94)	12 (66.7)
Victimization	3.89 (0.83)	13 (72.2)
Neurological Impairment	3.78 (0.94)	10 (55.6)
Military Service	3.50 (1.29)	10 (55.6)
Weapons Training	3.33 (1.08)	9 (50.0)
Psychiatric History:
Major Mental Illness	4.28 (0.75)	17 (95.5)
Schizophrenia	3.94 (1.00)	15 (83.3)
Personality Disorder	3.72 (1.02)	13 (72.2)
Alzheimer’s Disease	3.33 (1.24)	8 (44.4)
Dementia	3.22 (1.26)	8 (44.4)
	Mean (SD)	Very Likely #(%)
Changeable (Dynamic)
Demographic:
Access to Weapons	4.06 (0.64)	15 (83.3)
Negative Attitude	4.00 (0.77)	13 (72.2)
Treatment Nonadherence	3.72 (0.75)	12 (66.7)
Unemployment	2.83 (1.15)	5 (27.8)
Psychiatric:
Aggressive/Violent Tendencies	4.72 (0.46)	18 (100.0)
Homicidality	4.50 (0.79)	17 (95.5)
Impulsivity	4.28 (0.57)	17 (95.5)
Psychosis	4.22 (0.43)	18 (100.0)
Dissociative State	4.22 (0.65)	16 (88.9)
Command Hallucinations	4.06 (0.73)	14 (77.8)
Mania	4.00 (0.84)	14 (77.8)
Persecutory Delusions	3.94 (0.87)	13 (72.2)
Hallucinations	3.94 (0.73)	13 (72.2)
Cognitive Impairment	3.78 (0.88)	13 (72.2)
Suicidality	3.06 (1.35)	7 (38.9)
Depression	3.00 (1.41)	7 (38.9)
Hopelessness	2.72 (1.49)	7 (38.9)
Substance Abuse:
Substance Withdrawal	4.50 (0.62)	17 (95.5)
Impairment by drugs or alcohol	4.50 (0.62)	17 (95.5)
Intoxication	4.44 (0.62)	17 (95.5)
Drug-Seeking Behavior	4.39 (0.61)	17 (95.5)
Substance Dependence	4.17 (0.79)	16 (89.9)
	Mean (SD)	Very Likely #(%)
Staff-Related Risk Factors
Temporary/Unqualified Staff	4.00 (0.84)	14 (77.8)
Working with volatile people	4.00 (1.08)	14 (77.8)
Lack of Crisis Training	3.94 (1.00)	14 (77.8)
	Mean (SD)	Very Likely #(%)
High staff anxiety	3.83 (0.99)	13 (72.2)
Working alone with P/V	3.83 (0.92)	14 (77.8)
Frequent visitor contact	3.56 (0.92)	11 (61.1)
Registered Nurse	3.33 (1.19)	10 (55.6)
Younger Age	2.83 (0.99)	3 (16.7)
Aggression/Crisis Training	2.39 (1.24)	3 (16.7)
Belong to Ethnic Minority Group	2.28 (1.23)	3 (16.7)
Environmental Risk Factors
Overcrowded waiting rooms	4.28 (0.83)	16 (88.9)
Long waits for service	4.22 (0.81)	16 (88.9)
Understaffing	4.17 (0.71)	15 (83.3)
Inadequate Security	4.11 (0.96)	16 (88.9)
Poor physical environment	4.00 (1.08)	12 (66.7)
Poor temperature control	3.83 (0.92)	13 (72.2)
Poor lighting	3.44 (0.92)	9 (50.0)
Uncomfortable Seating	3.11 (1.08)	7 (38.9)

N = 18, SD = standard deviation.

Regardless of level of patient contact, staff opinions were in agreement that risk factors related to substance abuse (dynamic) are highly likely to contribute to acts of aggression in the ambulatory care environment. Staff also agreed that a history of violence and abuse (static) were highly likely to contribute to aggression. Static risk factors of history of diagnosis of a personality disorder, schizophrenia or major mental illness as well as the dynamic risk factors of psychosis, mania, persecutory delusions and command hallucinations were noted as psychiatric factors highly likely to contribute to acts of aggression by all staff. Staff characteristics deemed highly likely to contribute to acts of aggression were working alone with patients and visitors, having a high amount of patient contact, and a lack of crisis training while understaffing, overcrowding, poor temperature control, long waits for service and inadequate security were identified as environmental risk factors that were highly likely to lead to aggression in the clinic.

Direct care staff (N = 11) rated schizophrenia, access to weapons, mania, persecutory delusions, hallucinations, temporary/unqualified staff, working with volatile people, lack of crisis training, and high staff anxiety as “highly likely” to contribute to PVV.

Indirect care staff (N = 7) rated parent engagement in criminal activities, social deprivation, history of head trauma, history of neurological impairment, history of medical service, negative attitude, depression, poor physical environment, and poor temperature control as “highly likely” to contribute to PVV. It is notable that the indirect care staff did have one risk factor that received a mean score of 5: history of violence.

Chi square analyses revealed significant differences between groups on the item related to being a registered nurse (p = 0.001) with direct care staff rating this item more likely to contribute to acts of aggression than indirect care staff. Direct care staff also rated a history of weapons training significantly more likely to contribute to acts of aggression than indirect care staff (p = 0.02). Indirect care staff, however, rated a diagnosis of depression and uncomfortable seating in the waiting room as more likely to contribute to acts of aggression than direct care staff (p = 0.02 for both items) (results are summarized in Table 3).

Table 3

Differences in direct and indirect staff perceptions of PVV risk factors

	Mean (SD) Range 1–5				‘Very Likely’ N (%)
	Direct Care	Indirect Care	t-value, df	p-value	Direct Care	Indirect Care	χ², df	p-value
Unchangeable (Static)
History of:
Weapons Training	3.55 (1.29)	3.00 (0.58)	–1.04, 16	0.31	8 (72.7)	1 (14.3)	5.84,1	0.02
Violence	4.18 (0.60)	5.00 (0.00)	–4.50, 10	0.00	10 (90.9)	7 (100.0)	0.67, 1	0.41
Head Trauma	3.64 (0.92)	4.43 (0.79)	–1.87, 16	0.08	6 (54.6)	6 (85.7)	1.87, 1	0.17
Changeable (Dynamic)
Psychiatric
Mania	4.09 (0.83)	3.86 (0.90)	–0.56, 16	0.58	10 (90.9)	4 (57.1)	2.82, 1	0.09
Depression	2 (18.1)	5 (71.4)	4.1, 1	0.02
Substance Abuse
Drug-Seeking Behavior	4.18 (0.60)	4.71 (0.49)	–1.96, 16	0.07	10 (90.9)	7 (100.0)	0.67, 1	0.41
Intoxication	4.27 (0.65)	4.71 (0.49)	–1.54, 16	0.14	10 (90.9)	7 (100.0)	0.67, 1	0.41
Substance Withdrawal	4.27 (0.65)	4.86 (0.38)	–2.15, 16	0.05	10 (90.9)	7 (100.0)	0.67, 1	0.41
Impairment by Drugs or Alcohol	4.27 (0.65)	4.86 (0.38)	–2.15, 16	0.05	10 (90.9)	7 (100.0)	0.67, 1	0.41
Staff-Related Risk Factors
Registered Nurse	3.91 (0.83)	3.71 (1.38)	–2.05, 16	0.06	9 (81.8)	1 (14.3)	7.9, 1	0.001
Younger Age	3.18 (0.87)	2.29 (0.95)	–3.20, 16	0.01	3 (27.2)	0 (0.0)	2.29, 1	0.13
Environmental Risk Factors
Uncomfortable Seating	2.64 (1.03)	3.86 (0.69)	–2.76, 16	0.01	2 (18.1)	5 (71.4)	5.1, 1	0.02

Total Staff Sample Size N = 18 Direct Care N = 11 Indirect Care N = 7.

5 Discussion

The review of evidence to identify risk factors for PVV confirmed that many of the risk factors for violence identified in psychiatric patients (e.g.: younger age, lower socioeconomic status, substance abuse) are general risk factors for violence in the population at large [32]. In particular, alcohol and drug users are seven times more likely than nonusers to engage in violent behavior [30]. While research on PVV has focused on inpatient and psychiatric environments, simply having a psychiatric diagnosis is not a guarantee that an act of violence or aggression will occur. In fact studies show that individuals with a psychiatric diagnosis are at greater risk of being a victim of violence than of being violent towards others [34].

Our knowledge of static risk factors speaks to the importance of taking a comprehensive psychosocial history –in addition to a medical history –so that staff may be aware of a variety of factors that may make a patient’s behavior more unpredictable and volatile. This knowledge allows staff to be proactive in the prevention of acts of violence and aggression (e.g.: not seeing a patient with a history of violence during “off” clinic hours, calling 911 for ambulance transport when symptoms of intoxication or withdrawal are present).

In the clinic where staff perceptions were examined, the static risk factors for PVV rated most highly were a history of violence and a history of a diagnosis of major mental illness. Both of these areas can be determined by taking a comprehensive psychosocial history during a patient’s intake, however, this is not information that a clinic would have available about someone accompanying a patient to a visit. Training regarding warning signs of anger and escalating behavior could help make up for this knowledge deficit about the history of visitors to the clinic.

The dynamic risk factors most highly rated were related to substance abuse and dependence, including impairment by drugs or alcohol or drug-seeking behavior. A practical suggestion would be to provide training regarding signs and symptoms of intoxication and withdrawal as well as to develop protocols for how to assess, treat, and, when applicable, transfer patients out for further intervention in an effort to identify these risk factors earlier so appropriate intervention may take place before an act of violence or aggression occurs.

Staff and environmental risk factors that were highly rated by clinic staff were overcrowded waiting rooms, working with volatile people, unqualified staff, and long waits for service. Studying patterns in scheduling in the clinic can help determine times of higher volume of patients and visitors so that additional staff may be scheduled to adequately support what patients and visitors need during that time. Closer attention to the type and duration of appointments being scheduled with providers during these times may also help to keep appointments running on time which would serve to lessen the occurrence of long waits for service.

The review also calls attention to the lack of consensus regarding what constitutes PVV [24 , 28]. In fact, Anderson and West [23] noted that there is no universal definition of violence. However, how can effective interventions be proposed when there is no clear definition of the behavior that is being targeted? An agreed upon definition of PVV is needed in the research so that a common target may be identified for intervention and facilities may have a clear protocol for the reporting and management of events. It has been reported that de-escalation training may subject HCPs to an increased number of aggressive events due to increased interaction with patients while their behavior is escalating [32], however, research has also postulated that improved skills in de- escalation lead to increased efforts at, and involvement in de-escalation as well as more frequent exposure to lower-levels of PVV (e.g.: verbal as opposed to physical) [25].

There is agreement that interventions targeting communication amongst staff, communication between HCPs and patients and their loved ones, and awareness of increasing anger and frustration in patients and loved ones may be helpful and lead to decreased incidents of PVV [33 , 35–37]. These data point out the need to investigate effective methods of communication in outpatient clinics when staff identify early signs of anger and aggression.

Differences in staff opinions call attention to some areas for education, training, and intervention. Direct care staff rated nurses more likely to experience PVV. This could be due to direct care staff having a better understanding of the exposure nurses have to patients and visitors during clinic visits than the indirect care staff. This could also indicate indirect care staff do not believe any one role is more at risk of experiencing PVV than another. This difference calls attention to the need for staff education regarding colleagues’ roles and responsibilities within the clinic. Direct care staff also rated a history of weapons training significantly more likely to contribute to PVV suggesting they are somewhat desensitized to acts of verbal aggression and possibly anticipate that an act of violence or aggression would involve the presence of a weapon. This points to a need for de-escalation and crisis training in the ambulatory care environment so staff may understand the possibilities of violence and aggression and the different levels of PVV and the patterns of escalating behavior.

Indirect care staff rated a diagnosis of depression as more likely to contribute to acts of aggression. These staff members interact with patients over the phone and during clinic check-in/check-out. It is possible they find depression more likely to contribute to acts of violence and aggression due to experiences in which patients with diagnosed depression were irritable or angry and became verbally aggressive. It is also possible that direct care staff rated depression lower because they find themselves to be more “on alert” when a patient has a diagnosis of a serious mental illness than one of depression because, as indicated above, direct care staff seem to be more highly focused on acts of aggression and violence involving weapons. Indirect care staff also rated uncomfortable seating in the waiting room as more likely to contribute to acts of violence and aggression This is likely due to these staff being present in the waiting room and hearing patient and visitor complaints about the seating which is not something that a patient or visitor would often mention to their direct care providers.

It is important to remember that all risk factors on the staff survey had been identified as risk factors in the aggression and violence research conducted in hospitals and inpatient psychiatric units. When examining the perceptions of risk factors in the ambulatory care environment, not one risk factor was deemed unlikely to contribute to acts of aggression by all respondents. When looking at these data alongside patient satisfaction surveys [21], the environment of care presents as a large factor in the patient and visitor experience.

Results indicate many patients and staff note long wait times, lack of activities to keep patients and visitors engaged in the waiting room, and poor temperature control as highly likely to contribute to acts of aggression in this environment and as reasons for low patient satisfaction scores. This is in agreement with prior research showing patients and visitors to be more satisfied and perceive a higher quality of care in patient-centered environments [38]. Research has also shown waiting to be the activity patients and visitors engage in the most when presenting for an ambulatory care visit and the waiting room experience has been shown to have an impact on patients’ and visitors’ mood and overall psychological state [39, 40]. Furthermore, patients have been shown to rate interactions with staff more positively in more attractive care environments and feel more cared for, more welcome, and experience less anxiety and stress during their clinic visits [40]. It stands to reason, then, that efforts at minimizing violence and aggression in this environment must begin from the second patients and visitors enter the clinic and the waiting room experience is not to be ignored as part of the clinical encounter.

It is clear that PVV in the ambulatory care environment involves a number of factors, some of which may be specific to the clinic and the population served, and there is no one intervention that will fully address all of the aspects of PVV. It will be important for future research to evaluate whether these factors drawn from inpatient psychiatric and other settings are related to actual occurrence of aggression in ambulatory care. A combination of continued research, clinical interventions, staff training, addressing patients’ concerns in real time, and continued focus on creating a patient- centered environment are all needed in order to fully understand and address this issue (summarized in Table 4).

Table 4
Implications for action

Clinical:

- Training to take comprehensive psychosocial history that includes risk factors for aggression and violence^∧

- Scheduling of visits with high risk patients when other staff and/or security are available^∧

- Transporting intoxicated or withdrawing patients to appropriate treatment settings^∧

- Ability to better assess the level of intoxication and ingested substances at clinic visits

Improvement of Patient-Centered Environment

- Increasing comfort and attractiveness of environment^∧∼

- View waiting time as an important element of clinic visit^∧

- Active intervention to address patient satisfaction concerns^∧

- Managing wait times^∧∼

- Lack of information about delays∼

- Lack of activities to engage patients and visitors while waiting for providers^∧∼

- Poor temperature control∼

Research:

- Defining PVV

- Define standards for measurement of aggression in ambulatory care

- Does intervention improve communication between staff, HCP, and patients/visitors?

- Does de-escalation/crisis training reduce physical aggression while increasing staff exposure to verbal aggression?

- Does intervention increase identification of anger and frustration leading to earlier intervention?

Source of action: ^∧evidence based review; ∼patient satisfaction surveys.

6 Limitations

At this time, risk factors for PVV have not been examined in the ambulatory care setting and this research is a starting point for further work in this area. This work is limited in that it collected subjective staff opinions from a small sample that is not representative of all ambulatory care clinics and results cannot be generalized. Due to the small sample size, differences between individual groups could not be examined as anonymity would be lost. Violence and aggression were unable to be measured in this setting however, from clinical experience in this environment, the number of violent events that occur is quite low. Future research in this area may benefit from examining how often the police are called to the clinic, how often behavioral health staff are called in to help de-escalate a patient or visitor, and how often incidents regarding verbal aggression and threats are reported to possibly present a more descriptive picture of PVV in ambulatory care.

7 Conclusions

At this time, PVV towards healthcare workers has not been examined within the ambulatory care environment despite this environment managing over 1 billion patient visits annually. Further investigation into risk factors for violence and aggression that are most common in this environment is needed for effective safety interventions to be proposed and implemented.

Dedication

For Dr. Ruth McCorkle whose legacy lives on in all of her students.

Conflict of interest

None to report.

Footnotes

The supplementary figure is available in the electronic version of this article: .

References

Lanza

, Shattell

, MacCulloch

. Assault on nursing staff: Blaming the victim, then and now. Issues Ment Health Nurs. 2011;32(8):547–48.

Harrell

. Workplace Violence: 1993-2009 National Crime Victimization Survey and the Census of Fatal Occupational Injuries. 2011; Available at: http://www.bjs.gov/content/pub/ pdf/wv09.pdf.

Hardin

. Strategies for nurse leaders to address aggressive and violent events. J Nurs Admin. 2012;42(1):5–8.

Riemer

. Creating sanctuary: Reducing violence in a maximum security forensic psychiatric hospital unit. On the Edge. 2009;15(8).

National Institute for Occupational Safety and Health. Violence: Occupational hazards in hospitals (No. 2002-101). 2002.

Hesterman

. Soft target hardening: Protecting people from attack [Powerpoint Slides]. 2015; Available at: https://www.asisonline.org/Education-Events/Global-Conferences/Middle-East-Security-Conference-and-Exhibition-2015/Program-and-Events/Documents/Hesterman-Jennifer-SoftTargetHardeningProtectingPeoplefromAttack.pdf.

Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2015 State and national summary tablets. 2016; Available at: https://www.cdc.gov/nchs/data/ahcd/namcs summary/2015_namcs_web_tables.pdf.

World Health Organization. Mental disorders in primary care; a WHO education package. 1998; Available at: http://apps.who.int/iris/bitstream/10665/67186/1/WHO_MSA_MNHIEAC_98.1.pdf.

Russell

. Mental health care services in primary care: Tackling the issues in the context of health care reform. 2010; Available at: https://www.americanprogress.org/wp-content/uploads/issues/2010/10/pdf/mentalhealth.pdf.

10.

Robinson

, Reiter

. Behavioral consultation and primary care: A guide to integrating services. 2007; Available at: http://www.springer.com/us/book/9780387329734#otherversion=9780387329710.

11.

Agency of Healthcare Research and Quality. Primary care workforce facts and stats: Overview. 2010; Available at: https://www.ahrq.gov/sites/default/files/publications/files/pcworkforce.pdf.

12.

Mann

. New research shows shortage of more than 100,000 doctors by 2030. 2017; Available at: https://news.aamc.org/medical-education/article/new-aamc-research-reaffirms-looming-physician-shor/.

13.

Sullivan

, Bezmen

, Barron

, Rivera

, Curley-Casey

, Marino

. Reducing restraints: Alternatives to restraints on an inpatient psychiatric service - utilizing safe and effective methods to evaluate and treat the violent patient. Psych Quarterly. 2005;76(1):51–65.

14.

Arnetz

, Arnetz

. Violence towards health care staff and possible effects on the quality of patient care. Soc Sci Med. 2001;52(3):417–27.

15.

Celik

, Celik

, Agribas

, Ugurluoglu

. Verbal and physical abuse against nurses in Turkey. Int Nurs Rev. 2007;54(4):359–66.

16.

Lanctot

, Guay

. The aftermath of workplace violence among healthcare works: A systematic literature review of the consequences. Aggr Viol Beh. 2014;19:492–501.

17.

Nijman

, Bowers

, Oud

, Jansen

. Psychiatric nurses’ experiences with inpatient aggression. Aggr Beh. 2005;31:217–27.

18.

Wallis

. Satisfaction, stress, and performance: Issues for occupational psychology in the ‘caring’ professions. Work & Stress. 1987;1:113–28.

19.

American Psychological Association. Report of the American Psychological Association Commission on Violence and Youth, Vol. 1. 1991; Available at: https://www.apa.org/pi/prevent-violence/resources/violence-youth.pdf.

20.

Lazenby

, Dixon

, Coviello

, McCorkle

. Instructions on using expert panels to rate evidence-based content. New Haven, CT: Yale University

21.

Folgo

. Staff perceptions of risk factors for violence and aggression in ambulatory care. 2018.

22.

Agency for Healthcare Research and Quality. Quality Tool: Plan-Do-Study-Act (PDSA) Cycle. 2008; Available at: https://innovations.ahrq.gov/qualitytools/plan-do-study-act-pdsa-cycle.

23.

Anderson

, West

. Violence against mental health professionals: When the treater becomes the victim. Innov Clin Neurosci. 2011;8(3):34–9.

24.

Hahn

, Muller

, Hantikainen

, Kok

, Dassen

, Halfens

. Risk factors associated with patient and visitor violence in general hospitals: Results of a multiple regression analysis. Int J Nurs Stud. 2013;50(3):374–85.

25.

Hamrin

, Iennaco

, Olsen

. A review of ecological factors affecting inpatient psychiatric unit violence: Implications for relational and unit cultural improvements. Issues Ment Health Nurs. 2009;30(4):214–26.

26.

National Institute on Alcohol Abuse and Alcoholism. Alcohol use and alcohol use disorders in the United States, a 3 year follow-up: Main findings from the 2004-2005 wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. 2010; Available at: https://pubs.niaaa.nih.gov/publications/nesarc_drm2/nesarc2drm.pdf.

27.

Bowers

, Stewart

, Papadopoulos

, Iennaco

. Correlation between levels of conflict and containment on acute psychiatric wards: The city-128 study. Psychiatr Serv. 2013;64(5):423–30.

28.

Ridenour

, Lanza

, Hendricks

, Hartley

, Rierdan

, Zeiss

, et al. Incidence and risk factors of workplace violence on psychiatric staff. Work. 2015;51(1):19–28.

29.

Speroni

, Fitch

, Dawson

, Dugan

, Atherton

. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218–28; quiz 295.

30.

Gunenc

, O’Shea

, Dickens

. Prevalence and predictors of verbal aggression in a secure mental health service: Use of the HCR-20. Int J Ment Health Nurs. 2015;24(4):314–23.

31.

Friedman

. Violence and mental illness: How strong is the link? N E J Med. 2006;355:2064–6.

32.

Price

, Baker

, Bee

, Lovell

. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry. 2015;206(6):447–55.

33.

Iennaco

. Aggression and violence. In: Potter MS, Moller MD, editor. Psychiatric- Mental health nursing: From suffering to hope New York: Pearson; 2015. pp. 556-61.

34.

Stuart

. Violence and mental illness: An overview. World Psychiatry. 2003;2(2):121–4.

35.

Child

, Mentes

. Violence against women: the phenomenon of workplace violence against nurses. Issues Ment Health Nurs. 2010;31(2):89–95.

36.

Gillespie

, Gates

, Fisher

. Individual, relationship, workplace, and societal recommendations for addressing healthcare workplace violence. Work. 2015;51(1):67–71.

37.

Hallett

, Dickens

. De-escalation: A survey of clinical staff in a secure mental health inpatient service. Int J Ment Health Nurs. 2015;24(4):324–33.

38.

Becker

, Sweeney

, Parsons

. Ambulatory facility design and patients’ perceptionsof healthcare quality. Health Env Resch Design J. 2008;1(4):35–54.

39.

Leddy

, Kaldenberg

, Becker

. Timeliness in ambulatory care treatment. An examination of patient satisfaction and wait times in medical practices and outpatient test and treatment facilities. J Amb Care Mgmt. 2003;26(2):138–49.

40.

Leather

, Beale

, Santos

, Watts

, Lee

. Outcomes of environmental appraisal of different hospital waiting areas. Env and Beh. 2003;35(6):842–69.

41.

Becker

, Douglass

. The ecology of the patient visit: Physical attractiveness, waiting times, and perceived quality of care. J Amb Care Mgmt. 2008;31(2):124–37.