Analyzing Patient-to-Worker Violence: A Qualitative Study of Incidents

This case study delves into the issue of patient-to-worker violence within a hospital setting, utilizing qualitative content analysis of documented incident reports to identify underlying catalysts and contributing circumstances. The research, conducted on a sample of 214 Type II incidents reported in 2011, reveals key themes related to patient behavior (cognitive impairment, demands to leave), patient care (use of needles, pain/discomfort, physical transfers), and situational events (use of restraints, care transitions, interventions). The findings underscore the importance of training hospital staff to recognize and mitigate specific risk factors, advocating for a social-ecological model to prevent patient violence towards staff. The study highlights the need for data-driven interventions and a deeper understanding of the social and environmental contexts in which such violence occurs, ultimately aiming to improve worker safety and patient care quality. Desklib provides access to similar case studies and resources for students.

Understanding patient-to-worker violence in hospitals: a
qualitative analysis of documented incident reports
Judith E. Arnetz, PhD MPH PT [Professor of Public Health Sciences],
Wayne State University School of Medicine, Detroit, Michigan, USA and Uppsala University,
Sweden
Lydia Hamblin, BA [Research Assistant and Doctoral Student],
Wayne State University School of Medicine, and Department of Psychology, Detroit, Michigan,
USA
Lynnette Essenmacher, MPH [Senior Data Analyst],
Detroit Medical Center, Detroit, Michigan, USA
Mark J. Upfal, MD MPH [Corporate Medical Director],
Detroit Medical Center and Wayne State University School of Medicine, Detroit, Michigan, USA
Joel Ager, PhD [Professor and Statistical Consultant], and
Wayne State University School of Medicine, Detroit, Michigan, USA
Mark Luborsky, PhD [Professor of Anthropology and Gerontology]
Wayne State University, Detroit, Michigan, USA and Karolinska Institutet, Sweden
Abstract
Aim—To explore catalysts to, and circumstances surrounding, patient-to-worker violent incidents
recorded by employees in a hospital system database.
Background—Violence by patients towards healthcare workers (Type II workplace violence) is
a significant occupational hazard in hospitals worldwide. Studies to date have failed to investigate
its root causes due to a lack of empirical research based on documented episodes of patient
violence.
Design—Qualitative content analysis.
Correspondence to J.E. Arnetz: [e-mail].
Portions of this work were presented at the Work, Stress and Health 2013 Conference in Los Angeles, California.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://
www.icmje.org/ethical_1author.html)]:
• substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;
• drafting the article or revising it critically for important intellectual content.
HHS Public Access
Author manuscript
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Published in final edited form as:
J Adv Nurs. 2015 February ; 71(2): 338–348. doi:10.1111/jan.12494.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Methods—Content analysis was conducted on the total sample of 214 Type II incidents
documented in 2011 by employees of an American hospital system with a centralized reporting
system.
Findings—The majority of incidents were reported by nurses (39·8%), security staff (15·9%) and
nurse assistants (14·4%). Three distinct themes were identified from the analysis: Patient
Behaviour, Patient Care and Situational Events. Specific causes of violence related to Patient
Behaviour were cognitive impairment and demanding to leave. Catalysts related to patient care
were the use of needles, patient pain/discomfort and physical transfers of patients. Situational
factors included the use/presence of restraints; transitions in the care process; intervening to
protect patients and/or staff; and redirecting patients.
Conclusions—Identifying catalysts and situations involved in patient violence in hospitals
informs administrators about potential targets for intervention. Hospital staff can be trained to
recognize these specific risk factors for patient violence and can be educated in how to best
mitigate or prevent the most common forms of violent behaviour. A social–ecological model can
be adapted to the hospital setting as a framework for prevention of patient violence towards staff.
Keywords
content analysis; healthcare workers; nursing; occupational health; work safety; workplace
violence
Introduction
Violence by patients towards healthcare workers (Type II workplace violence, IPRC 2001) is
a significant occupational hazard in general hospitals worldwide (Hahn et al. 2008).
Substantial research has investigated the prevalence (Gerberich et al. 2004, Iennaco et al.
2013, Piquero et al. 2013) and nature (Hesketh et al. 2003, Hahn et al. 2012) of patient-to-
worker violence, but few studies have identified its root causes. Previous research has
focused on perceived reasons for patient violence among physicians (Carmi-Iluz et al. 2005,
Cai et al. 2011), nurses (Zernike & Sharpe 1998, Winstanley & Whittington 2004, Duxbury
& Whittington 2005, Chapman et al. 2009) and patients (Duxbury & Whittington 2005).
However, there is a lack of empirical research based on documented episodes of patient
violence in general hospitals. Analysis of recorded incidents can provide a better
understanding of determinants of patient-to-worker violence. This is a critical first step
towards the development of data-driven, effective interventions.
Background
Compared with workers in other industries, hospital workers have high rates of non-fatal
workplace assault injuries (Peek-Asa et al. 1997, Janocha & Smith 2010), most of which
result from violent acts by patients (Janocha & Smith 2010). Among hospital workers, the
risk of violence from patients is greatest among nurses (Arnetz 1998, Winstanley &
Whittington 2004, Hahn et al. 2012), mental health professionals and security staff (Arnetz
et al. 2011a). Both physical and non-physical violence from patients has negative
implications for worker health and safety (Gerberich et al. 2004, Fujishiro et al. 2011) and
the quality of patient care (Arnetz & Arnetz 2001, Sofield & Salmond 2003, Roche et al.
Arnetz et al. Page 2
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

2010). However, hospitals’ efforts to reduce workplace violence are hampered by the lack of
standardized surveillance of violent events and knowledge of why such violence occurs.
In a seminal paper on workplace violence research, Runyan (2001) stated that, ‘Improving
our understanding of the circumstances where violence against workers occurs will help us
develop intervention strategies’ (p. 169). Since then, despite substantial research on patient
violence in hospitals, its root causes have not been identified. Two literature reviews on
violence in the health sector (Gillespie et al. 2010, Pompeii et al. 2013) summarized the
knowledge regarding risk factors. For patient/patient visitor perpetrators, risk factors
included mental health disorders, drug and/or alcohol use, previous history of violence and
possession of weapons. Risk factors for healthcare worker targets of violence were age,
gender, marital status, hours worked, years of experience and previous workplace violence
training. Notably, results regarding these factors were not consistent across studies (Gillespie
et al. 2010, Pompeii et al. 2013). Situational risk factors included time of day, the presence
of surveillance cameras (Gillespie et al. 2010), long wait times and short staffing (Pompeii et
al. 2013). Knowledge of risk factors is of course critical to the development of effective
violence interventions (CDC/NIOSH 2004). However, improved awareness of such general
risk factors does not provide hospital administrators with sufficient intervention guidelines.
Instead, there is a need to better understand the specific social and environmental context
where the violence occurs (Runyan 2001).
Several models explaining patient aggression and violence have been developed, but most
focused on psychiatric care (Whittington & Wykes 1994, Nijman et al. 1999, Duxbury &
Whittington 2005). Numerous theories of interpersonal violence have been proposed
(Anderson & Bushman 2002), but the empirical evidence for these theories in general
hospital settings is limited. A patient-centred model of patient aggression towards healthcare
staff in general hospitals suggests that the anxiety of being a patient hampers the patient’s
cognitive abilities, resulting in misinterpretation of situations and/or staff behaviour and
eliciting an aggressive response (Winstanley 2005). In another model (Arnetz & Arnetz
2001), the patient–staff interaction was considered central to the development of violence,
but the interaction was affected by the immediate (ward) work environment.
However, there is a lack of empirical research based on documented episodes of patient
violence in general hospitals. Whittington et al. (1996) conducted content analysis of
incident descriptions provided by general hospital staff and identified three main precursors
to patient violence: the mental state of the patient; receiving care and treatment from staff;
and delays in receiving care or treatment. That study was conducted in a single hospital in
the UK and examined incidents based on recall from only a small percentage of hospital
employees, limiting generalizability of its results. One study examined over 3000 reports of
violent events that occurred in Australian healthcare facilities between 2000–2002. The most
common contributing factors were identified as patient-related, staff-related and system- or
security-related (Benveniste et al. 2005). However, the methods used in content analysis in
that study were not reported. A recent study examined descriptions of assaults experienced
by nurses in emergency rooms and found factors related to the workplace, the aggressor, the
nurse and the assault situation (Gillespie et al. 2013). That study was based on the results of
Arnetz et al. Page 3
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

a questionnaire with a response rate of less than 6% and may not be generalizable due to
non-response bias.
In-depth analysis of recorded incidents could potentially provide critical insight into social
and contextual determinants of patient-to-worker violence that are not captured in cross-
sectional or epidemiological data. Knowledge of such determinants is critical to the
development of data-driven, effective interventions.
The study
Aim
The aim of this study was to explore the causal dynamics and circumstances surrounding
patient-to-worker violent incidents recorded over 1-year in an incident database in a multi-
site hospital system.
Design
Qualitative content analysis was conducted, using an inductive approach. This approach is
similar to grounded theory (Strauss & Corbin 1998), but assigns codes for main themes that
are relevant to the research objectives, rather than using codes to develop theory. The
purpose is to create meaning by developing summary themes from complex raw data
(Thomas 2006).
Participants
The study was carried out in a large hospital system in the Midwest United States. The
hospital system, comprised of seven hospitals with approximately 15,000 employees, is
partnering with the research team in a federally funded project aimed at reducing workplace
violence in hospitals (Arnetz et al. 2014). The seven hospitals include one paediatric
hospital, one rehabilitation hospital and five specialty hospitals. Two hospitals are situated in
suburban environments, five are urban.
Data collection
Incidents of adverse events on the job, including workplace violence, are reported
electronically by employees to Occupational Health Services (OHS) using a central
reporting system. This computerized reporting system is standardized throughout the
hospital system and is accessible from any hospital computer. Employees report
demographic information and select whether the incident falls under injury, illness, exposure
and/or workplace violence, providing a description of the incident in a textbox. Date, time,
work shift and incident location are also reported by the employee, as well as any events
preceding the incident, injuries incurred and witnesses to the incident. Hospital system
policy requires that employees report all adverse events, including incidents of workplace
violence, within 72 hours of occurrence; there is no retaliation or risk of reprisal against
employees who report incidents in good faith. This reporting system has been in place since
2003 and has been described previously (Arnetz et al. 2011a,b).
Arnetz et al. Page 4
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

The hospital system uses ‘workplace conflict’ as an umbrella term for workplace violence.
This encompasses acts of physical assault, harassment, intimidation, threats and verbal
aggression (CDC/NIOSH 2002, Arnetz et al. 2011b) that occur on their property or during
the course of an employee’s work-related activities on behalf of the hospital system. All
incidents of workplace violence are categorized by OHS data analysts according to
perpetrator type (I–IV), i.e. (I) criminal intent, (II) customer/client, (III) employee/former
employee and (IV) non-employee with personal relationship with a worker (IPRC 2001).
The current study focused on reported incidents of workplace violence where the perpetrator
was a patient or patient visitor (Type II workplace violence).
Ethical considerations
Research Ethics Committee approval for this study was granted by the Human Investigation
Committee of Wayne State University. Informed consent was not obtained from hospital
employees as the data set was de-identified and researchers had no ability to link specific
incident reports to individual employees.
Data analysis
Qualitative content analysis was conducted on the total sample of 214 Type II incidents
reported by employees from the hospital system’s seven hospitals in 2011. An OHS data
analyst removed all personal identifiers before researchers received the data. Using a data-
driven inductive approach (Boyatzis 1998), content analysis was used to examine the
circumstances surrounding the violent incidents. Content analysis is typically used in an
effort to organize written data into a more systematically structured format (Tong et al.
2007). The current study used conventional content analysis, where codes and code
categories are derived from the data analysis, rather than preceding and guiding the analysis
(Hsieh & Shannon 2005). One researcher read the incident descriptions and assigned codes
for each of the identified common themes surrounding patient violence. As similar codes
became apparent, they were aggregated into main themes. A second researcher employed the
same method and coded the incidents independently. When the researchers met to discuss
their findings, the initial consensus level exceeded 90%. Coders then jointly reviewed the
discordant codings and discussed differences successively until consensus was reached; no
incidents were excluded due to coding disagreement. A third researcher who was not
involved in the coding read through the incident descriptions and confirmed the final themes
and sub-themes.
Rigour
To maintain integrity using qualitative methods, the consolidated criteria for reporting
qualitative research, COREQ (Tong et al. 2007), were used when planning and executing
this study. Guba and Lincoln’s (1989) criteria for judging qualitative rigour, i.e. credibility,
transferability, dependability and confirmability, were followed. Credibility, analogous to
internal validity, was achieved by thoroughness in data collection and analysis; the two
researchers responsible for developing the coding scheme developed in-depth familiarity
with the data. Transferability parallels external validity and means that the results can be
communicated and made understandable. This was achieved by using relevant incidents as
examples from various locations across the hospital system. Dependability is similar to
Arnetz et al. Page 5
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

reliability and was achieved by a review of the data by a third author who was not involved
in the coding. Finally, confirmability parallels the criterion of objectivity, reducing
researcher bias and was achieved through researcher triangulation and the use of verbatim
quotes to show how results were grounded in the material.
Findings
Approximately 90% of the 214 incidents concerned some form of physical violence directed
towards hospital employees; 34% ( n= 72) resulted in injuries requiring time away from
work. The majority of incidents were reported by nurses (39·8%), security staff (15·9%) and
nurse assistants (14·4%). Those reporting incidents were primarily female (66·7%), had a
mean age of 41·4 years (range 20–72, SD 12·6 years) and had been employed for an average
of 7·4 years (range 0–34, SD 7·9 years). Incidents were reported by each of the hospital
system’s seven hospitals, ranging from 8 at a suburban specialty hospital to 64 at an inner
city acute care hospital. Over 30% were reported by acute care nursing units; 15% were
reported by psychiatric units; 15% were from security staff; and 12% were from emergency
departments. Remaining incidents were from intensive care, surgery and outpatient units.
Three distinct overall themes were identified that reflected the major causal dynamic
regarding patient violence towards hospital staff: Patient Behaviour, Patient Care and
Situational Events. Patient Behaviour referred to patients as the direct reason for violence
and included two sub-themes: Cognitive Impairment and Demanding to Leave. Patient Care
encompassed incidents that occurred in the course of providing care and/or working in close
proximity with the patient. Patient Care had three sub-themes: Needles, Pain/Discomfort and
Physical Transfers. Situational Events encompassed situations where patient freedom of
mobility was infringed and included four sub-themes: Restraints, Transitions, Intervening
and Redirecting. An overview of the themes, sub-themes and their respective definitions is
provided in Table 1. Each theme and sub-theme is further described below with verbatim
examples of text describing the violent event.
Patient behaviour
Patient Behaviour was the dominant theme, accounting for nearly 40% of all of the reported
incidents of patient-to-worker violence. The aggressive behaviour in these incidents was
initiated by the patient and analysis revealed two main sub-themes of catalysts, Cognitive
Impairment and Demanding to Leave. Cognitive impairment implies that the patient’s
mental competency was in some way impacting their ability to interact normally with
hospital staff. Examples noted in the incident descriptions were dementia, confusion,
agitation, intoxication due to alcohol or drugs and children. This behaviour was often
unpredictable and seemed to take the employee by surprise:
Was comforting confused patient and he put his hand around my neck and tried to
choke me. (Patient Care Associate)
I was sitting at bedside of a confused patient. She had been laying down, got up
quickly and punched me in the left side of the face. (Registered Nurse)
Arnetz et al. Page 6
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

The second sub-theme, Demanding to Leave, concerned patients demanding and/or
attempting to leave the hospital before being discharged:
While trying to stop an ETOH [alcoholic] patient from leaving the ED [emergency
department], the ED nurse was struck on the right cheek with a closed fist by the
patient. When the patient was taken to the ground by security and ED staff along
with the injured nurse, the patient bit the injured nurse on the right leg. (Security)
Patient was at the nurses’ station demanding discharge, abruptly started striking at
me, hitting and scratching my face and neck. (Psychiatric Social Worker)
Patient care
The Patient Care theme encompassed incidents where hospital staff were providing patient
care, which often entailed working in close proximity to the patient. Three sub-themes were
identified from the analysis: Needles, Pain/Discomfort and Physical Transfers. The use of
any type of needle, whether giving an injection or inserting an intravenous (IV) line, was a
common cause of physical violence from patients:
Patient needed lab work drawn and became very hostile, aggressive and violent
with staff. He was verbally abusive with profanity and physically abusive by hitting,
biting, scratching and pushing. Attempted to grab patient’s arm to prevent him from
hitting the ER [emergency room] tech who was drawing his blood and the patient
hit me in the left side of my face…patient hit my eye, ear, cheek and head. Patient
then tried to bite me, but could only get my clothing. (Registered Nurse)
While attempting to draw blood the patient yanked her arm and attempted to bite
the RN [Registered Nurse]. RN was stuck trying to prevent herself from harm.
(Manager)
The Pain/Discomfort sub-theme concerned physical procedures that did not include the use
of needles, but that caused direct pain or physical discomfort to the patient. Examples were
intubation and positioning the patient for x-rays or other types of scans:
Employee was hooking up tube feeding, patient got agitated and kicked employee
in the face. (Patient Care Associate)
I assisted the nurse with inserting a NG [nasogastric] tube into a patient’s nose and
the patient began fighting and kicking. I was bit and scratched on the forearm.
(Patient Care Associate)
The third sub-theme, Physical Transfers, concerned incidents where staff physically assisted
patients, such as moving between a wheelchair and an examination table or a bed:
During transport…patient became agitated, jumped off stretcher, proceeded to
strike employee. Employee tried to grab patient for her safety and she scratched
employee and broke skin. Patient fell on floor, at this time nursing manager helped
to transport. (Patient Transporter)
Patient was being transferred to a stretcher for a procedure and the patient kicked
employee in the side of his head with full force. After incident he has a headache.
(Manager)
Arnetz et al. Page 7
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Situational events
The third main theme, Situational Events, concerned circumstances where patients were
between points of care or their movement was infringed. Analysis revealed four sub-themes:
Restraints, Transitions, Intervening and Redirecting.
The Restraints sub-theme encompassed incidents where the patient was being held or where
either physical or chemical restraints were applied:
Patient…admitted with overdose, he was in 2 point restraints, became combative
and verbally abusive to staff. While attempting to place patient in 4 point restraints
patient thrashing and hitting at staff. RN #1 left thumb hyperextended, RN #2 left
forearm was hit with patient’s head, resulting in pain/contusion. PCA was punched
in arm. (Registered Nurse)
Patients also became violent during transitions, which was the second sub-theme under
Situational Events. These incidents mainly took place during the hospital admission process
or in the postoperative or recovery room:
I was in OR [operating room] #3 waiting for the patient to wake from anaesthesia.
The patient woke and all of a sudden began violently kicking and pushing. In the
process of restraining him from falling off the bed he started kicking me in the
chest. (Registered Nurse)
Intervening, the third sub-theme, included attempts made by hospital staff to stop a patient
from acting out or harming himself or others. The majority of these incidents were reported
by security staff:
Security officer was injured while attempting to control patient. Patient was
disruptive and threatening medical staff. Security officer was kicked to the chest
area by patient while attempting to place her in a wheelchair. (Security Team
Leader)
The fourth and final sub-theme was Redirecting. This theme entailed staff actions to help
patients back to their hospital room or their hospital bed:
I was trying to keep the patient from leaving the room and going to the elevator by
standing in front of her room door. She got mad and scratched my face. I grabbed
her hands to keep her from scratching me again and then she bit my thumb. (Patient
Care Associate)
Discussion
The aim of this study was to explore the causal dynamics and circumstances surrounding the
total sample of patient-to-worker violent incidents recorded by hospital system employees
over 1-year. The analysis revealed three overarching themes that pinpointed Patient
Behaviour, Patient Care and Situational Events as catalysts for patients’ violent behaviour
directed towards staff. In a broad sense, these themes are similar to some of those reported in
previous research. Whittington et al. (1996) also identified the mental state of the patient,
corresponding to our Cognitive Impairment sub-theme to Patient Behaviour, as a main risk
Arnetz et al. Page 8
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

factor for hospital patient violence. The same study reported the additional categories of
‘receiving care and treatment’ and ‘delays in receiving care and treatment,’ both of which
correspond to our Patient Care theme. In a much larger study, Benveniste et al. (2005) also
described three main themes related to patients, staff and security issues.
However, it is the sub-themes that emerged from this analysis that help shed light on the
underlying reasons for patients’ violent behaviour. Incidents that fell under the Cognitive
Impairment and Demanding to Leave sub-themes indicated that patient characteristics were
the direct catalysts for incidents. Underlying many of the patient behaviours was some
degree of confusion or severe agitation. While staff may expect and even understand the
violence in such cases as being ‘part of the job’ (McPhaul & Lipscomb 2004), many of the
incidents falling into this category described patient behaviour that took staff by surprise. In
the examples given here, one patient tried to choke the Patient Care Associate who was
comforting her, while another punched a nurse who was sitting at the patient’s bedside.
These incidents suggest the need for increased awareness and sustained vigilance among
staff working in close proximity with cognitively impaired patients.
The incidents describing patients who were demanding to leave the hospital did not always
provide enough detail for us to understand the reasons for their behaviour. For example, one
of the incidents described here took place in the ED and may have been sparked by
frustration over a long wait time, a factor pinpointed in previous research (Whittington et al.
1996, Gillespie et al. 2013). Intoxication by alcohol and/or drugs, common among patients
seeking ED care (Gillespie et al. 2013), may have also played a role. Importantly, these
findings have identified patients demanding to leave the hospital as a specific risk factor for
violence, which may or may not be influenced by cognitive impairment.
The sub-themes related to Patient Care indicate that violence occurred when patients were
subjected to treatments that involved pain or discomfort as well as when they were being
assisted with physical transfers. In their cross-sectional survey, Hahn et al. (2012) also found
that patient violence occurred most often when staff were working in close personal contact
with patients. Patient fear may have been an underlying factor in all of these sub-themes.
Winstanley (2005) also theorized that the anxiety of being a patient was a cause of violence
directed towards staff. This may have been the case in the incidents involving needles or
physically uncomfortable procedures, such as those described here. In a study of emergency
nurses, violent patient behaviour was also linked to nursing practices such as inserting an
intravenous line or indwelling catheter and administering injections (Gillespie et al. 2013).
Similar to the incidents where patients were demanding to leave, several of these
documented events suggested that they seemed to happen without warning, taking staff by
surprise. Several of the incidents cited here resulted in potentially serious employee injuries,
including needle sticks and bites.
In incidents falling into the four Situational Events sub-themes, violence occurred when
patients were transitioning between points of care or when healthcare staff had to restrain,
restrict or redirect patients for their own or others’ safety. The Transitions sub-theme
encompassed incidents that occurred during the actual admission process or when patients
were being moved from one unit to another as part of their care process. Patients awaiting
Arnetz et al. Page 9
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

admission may be anxious and/or experiencing pain, or frustrated over wait times, all of
which might contribute to their violent behaviour. Violence from patients in the ED has also
been reported while nurses were conducting triage assessments (Gillespie et al. 2013).
Transitioning patients from surgery to recovery or from procedures to holding rooms was
also a catalyst for violence and may have been explained by patient confusion, fear or pain.
When patients were being redirected by staff or by security, as was often the case in the
Intervening sub-theme, they were being prevented from causing harm to themselves or to
others. Similar to the Demanding to Leave sub-theme, the actual catalyst for the violent
behaviour was not always clear from the incident reports and many of the incidents may
have concerned patients with cognitive impairment. Nevertheless, healthcare and security
staff were injured, some of them seriously, by violent patient behaviour during this type of
incident and staff need to be aware of the increased risk for violence in transitioning
situations.
Incidents where patients had to be restrained, either by physical holding or the application of
chemical or mechanical restraints, represent a complex mixture of events. In the example
cited here, a patient with a drug overdose was admitted in two-point (arms immobilized)
restraints. Due to extremely combative behaviour, staff attempted to apply four-point (arms
and legs immobilized) restraints, resulting in more violent behaviour and injury to three staff
members. In this case, although restraints were already in place, the violent behaviour (that
may have instigated the initial application of restraints) worsened. In the USA, the Joint
Commission, which is responsible for accreditation of hospitals, provides standards on
restraint and seclusion for non-violent crisis intervention. The standards mandate that
restraints be used in hospital settings only when they are clinically justified or when
warranted by patient behaviour that threatens the physical safety of the patient, staff or
others (The Joint Commission 2009). Research indicates that restraints are used on a daily
basis, for example, in many hospital emergency departments and even more frequently in
psychiatric emergency units. While their intention is to keep patients and staff safe from
harm, injuries do occur (Zun 2003). Another restraint issue involves patients arriving to the
hospital in police custody (Gillespie et al. 2013), which often entails removing handcuffs,
which may have to be replaced with restraints applied by hospital staff if patients exhibit
violent behaviour.
Implications for workplace violence prevention
These findings support previous cross-sectional research in mental health settings,
suggesting that both individual (‘internal’) and situational/interactional (‘external’) factors
explained violence towards staff from patients (Duxbury & Whittington 2005). The Patient
Behaviour theme clearly suggests that individual patient characteristics were the direct
catalysts for the violent events. But the other themes – Patient Care and Situational Events –
indicate that patients became violent as a reaction to staff actions or behaviour. Previous
research has suggested that individual patient, staff and ward/environmental factors
contribute to patient violence (Arnetz & Arnetz 2001, Nijman 2002, Levin et al. 2003), but
these studies did not identify the catalysts that led to the actual violence. Findings based on
the examination of documented incidents in the current study offer insight into specific
factors and situations that put hospital workers at increased risk for violent patient
Arnetz et al. Page 10
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

behaviour. Knowledge of these specific risk factors is an important first step in the
development of measures that can prevent work-place violence (CDC 2009) in hospital
settings.
A model for prevention of patient-to-worker violence in hospitals
Based on the findings in the current study, we suggest an adaptation of the four-level Social–
Ecological Model advocated by the Centers for Disease Control and Prevention (CDC) as a
framework for societal violence prevention (Dahlberg & Krug 2002, CDC 2009). The
proposed model for prevention of workplace violence in hospitals can be illustrated as a
series of concentric circles (Figure 1). This model suggests that catalysts to patient violence
may stem from individual factors in patients and/or healthcare workers; factors influencing
the relationship between patients and healthcare workers in the process of patient care;
factors in the immediate work environment; and factors in the larger organization, in this
case the hospital or hospital system. In developing efforts to prevent workplace violence, the
identification of risk factors at each of these levels will facilitate the establishment of level-
specific interventions (CDC 2009). The sub-themes that emerged from this study pinpointed
Cognitive Impairment and Demanding to Leave as individual-level (patient) factors;
Needles, Pain/Discomfort and Physical Transfers as relationship-level factors; and
Restraints, Transitions, Intervening and Redirecting as work environment or situational
events that resulted in violence towards staff. Each of these sub-themes presents possible
areas in which to develop violence intervention and prevention strategies. As illustrated in
the model, the individual, relationship and work environment factors are embedded in the
larger organization. The organizational factors influencing this study included the hospital
system’s policies regarding workplace violence and patient and worker safety; continuous
monitoring of violent events; and the centralized, accessible reporting system for
documenting violent incidents. Violent events may also be the result of a combination of
factors, thus requiring intervention on multiple levels. For example, a violent act with
employee injury might result from an interaction between a cognitively impaired patient
(individual-level) and a nurse in a highly stressful, fast-paced unit (work environment). A
close examination of the documented incident might suggest the need for interventions
related to patient–employee communication, a review of work unit procedures, as well as a
close examination of workload and staffing levels. Systematic study of incident descriptions
provides us with indications of where and on which levels interventions may be most useful.
Strengths and limitations
A major advantage of the current study over previous research was the use of actual
incidents recorded over a year at multiple worksites across several hospitals. Moreover, we
examined the total sample of patient-to-worker incidents that were documented by hospital
system employees. An additional strength was report uniformity due to the use of
standardized online forms. Despite using the total sample of reported incidents, results of
this study may be limited by underreporting, which is a recognized problem in workplace
violence research (Iennaco et al. 2013, Sato et al. 2013). Results may have also been
influenced by bias on the part of those documenting violent events. For example, the
hospital system requires employees to report any incident resulting in injury. This might
suggest that only the most serious incidents get documented. However, only 34% of the
Arnetz et al. Page 11
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

incidents in this 2011 sample resulted in a lost time claim, indicating that employees were
using the reporting system to document even less severe incidents. The incident reports are
subjective, representing only one perspective, usually that of the target of violence (although
on occasion, reports were filed by a third party). Moreover, the hospital staff who
documented these incidents seemed to focus on describing the cause of the injury rather than
the cause of the violent behaviour, which staff may or may not have understood. Recall bias
should be limited because employees are required to complete incident reports in 72 hours
of the actual event. However, a 24-hour limit would further diminish recall bias. Bias may
have also played a role in the researchers’ interpretation of the documented incidents,
although validation was carried out through a third researcher not involved in the coding.
Finally, all reports were collected from only one hospital system and the results of this study
may not be generalizable to all hospitals.
Conclusion
Qualitative content analysis of documented incidents of workplace violence can provide a
better understanding of determinants of patient-to-worker violence by providing insight into
the nature of specific risk situations. Hospital stakeholders have pinpointed such analysis as
an important and necessary complement to quantitative risk factor identification, deeming it
a critical component in the development of data-driven, effective interventions (Arnetz et al.
2014). Identifying dominant themes and sub-themes concerning patient violence towards
hospital workers informs administrators about specific potential targets for intervention.
Hospital staff can be trained to recognize these specific risk factors for patient violence and
can be educated in how to best mitigate or prevent the most common forms of violent patient
behaviour.
Implications for nursing
For nurses, violence prevention programmes should emphasize the increased risks of
physical assault when working with patients who are cognitively impaired, demanding to
leave, or in pain; and when using needles, restraints, performing physical transfers, or
redirecting patients in the course of patient care.
Acknowledgements
Funding
This study was funded by The Centers for Disease Control-National Institute for Occupational Safety and Health
(CDC-NIOSH), grant number R01 OH009948. The content is solely the responsibility of the authors and does not
necessarily represent the official views of CDC-NIOSH.
References
Anderson CA, Bushman BJ. Human aggression. Annual Review of Psychology. 2002; 53:27–51.
Arnetz JE. The Violent Incident Form (VIF): a practical instrument for the registration of violent
incidents in the health care workplace. Work & Stress. 1998; 12(1):17–28.
Arnetz JE, Arnetz BB. Violence towards health care staff and possible effects on the quality of patient
care. Social Science and Medicine. 2001; 52:417–427. [PubMed: 11330776]
Arnetz et al. Page 12
J Adv Nurs. Author manuscript; available in PMC 2016 August 31.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript