Trends in Workplace Violence in the Remote Area Nursing Workforce

Transcription

1 Trends in Workplace Violence in the Remote Area Nursing Workforce Authors: Tess Opie Sue Lenthall Maureen Dollard John Wakerman Martha MacLeod Sabina Knight Sandra Dunn Greg Rickard Institutions: Centre for Applied Psychological Research University of South Australia City East Campus Adelaide SA 5000 Centre for Remote Health PO Box 4066 Alice Springs, NT 0871 Graduate School for Health Practice Charles Darwin University Casuarina NT 0909 University of Northern British Columbia 3333 University Way Prince George, BC V2N 4Z9 Corresponding Author: Tess Opie Address: Centre for Applied Psychological Research University of South Australia City East Campus Adelaide SA Telephone: Fax:

2 Trends in Workplace Violence in the Remote Area Nursing Workforce ABSTRACT Objective To assess incidence of workplace violence in the remote area nursing workforce and compare present data to data collected 13 years previously. Design The research adopted a cross-sectional design, using a structured questionnaire. Setting Health centres in very remote Australia. Subjects 349 nurses working in very remote regions across Australia. Main Outcome Measure The main outcome measure was Posttraumatic Stress Disorder (PTSD) symptoms, as assessed using the PTSD Checklist (PCL). Results Findings indicate decreases in all incidents of reported violence in the workplace between 1995 and Verbal aggression, property damage and physical violence remain the most frequent types of violence experienced. Despite decreases in reported workplace violence, nurses working in very remote regions in Australia remain fearful for their personal safety. Conclusion Working in fear for your personal safety can function as a major occupational stressor. The research has implications for workplace interventions that target violence in the remote area nursing workforce. Key Words Remote Area Nurse, Workplace Violence, Posttraumatic Stress Disorder (PTSD). 2

3 Introduction There are decreasing numbers of health practitioners with increasing remoteness across Australia (Productivity Commission, 2006). However, nurses represent the largest and most evenly geographically distributed health discipline. They thus play a critical role in the delivery of services in very remote regions. Nurses working in isolated, remote areas are also subject to multiple stressors, one of which is violence in the workplace (Lenthall et al., 2009). Violence in the workplace has been identified as a significant contributor to turnover in the remote area nursing workforce (Morrell, 2005; Kelly, 1999; Fisher et al., 1996). Whilst the issues of violence and personal safety in this context have long been acknowledged by numerous government and organisational bodies (CRANA, 1992), it was not until 1995 that a systematic examination reported that remote area nurses experienced frequent and serious episodes of violence, with verbal aggression, property damage and physical violence the most common (Fisher et al., 1996, p. 1). Thirteen years later, we again, examined violence against nurses working in very remote Australia. The frequency of various forms of workplace violence and their relationships to Posttraumatic Stress Disorder (PTSD) symptoms in this population were assessed. A key purpose of this paper is to draw comparisons between the data to determine whether violence against nurses working in very remote Australia has changed over time. Method Using a cross-sectional design, a structured questionnaire was distributed to nurses working in very remote regions across Australia, according to the ARIA+ classification system of remoteness (Australian Institute of Health and Welfare, date). 3

4 Ethics approval was granted by four human research ethics committees in the Northern Territory and South Australia. The questionnaire assessed various workplace demands and resources. Violence in the workplace was the job demand of particular relevance to this paper. The construct was assessed by asking respondents how often they had experienced eight different manifestations of workplace violence in the preceding 12 months. Violence categories comparable to the 1995 study included verbal aggression or obscene language, property damage, physical violence or assault, sexual harassment, sexual abuse or assault, and stalking. Definitions of each of these categories were provided to encourage a more consistent standard of interpretation. The outcome measure used was Posttraumatic Stress Disorder (PTSD) symptoms, which was assessed using the Posttraumatic Stress Disorder Checklist (PCL) (Weathers et al., 1993). The PCL provides a list of 17 fundamental symptoms of PTSD which are clustered into three main symptom categories, including reexperiencing symptoms (e.g. nightmares or flashbacks), hyperarousal symptoms (e.g. easily startled), and avoidance and psychic numbing symptoms (e.g. trying to avoid activities, places or people). It asks respondents to rate if and how they have been bothered by any of the listed reactions (symptoms) over the past month, in relation to a traumatic experience or event. Responses correspond with a 5-point scale ranging from 1 (not at all) to 5 (extremely). Accordingly, the PCL yields a continuous measure of PTSD symptom severity. Also of relevance was an assessment of nurses perceptions of community violence and their personal safety. This was achieved by asking respondents how often they felt concerned about violence in the community and their personal 4

5 safety. Responses corresponded with a 7-point scale, ranging from 0 (never) to 6 (everyday) (ref). Data from the questionnaire were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 16 (ref). Findings A comparison of demographic information demonstrated that the two samples (the present study sample and 1995 study sample) share similar population characteristics. Sample sizes (and response rates) were 349 (34.6%) and 237 (41.4%), for the present and previous studies, respectively. Over 90% (90.8%) of participants in the current study were female, as compared to 88.5% in 1995; 41.8% of current participants had been working remotely for more than 5 years compared to 43.8% in Both studies were conducted at a national level. There were differences between the samples. Only 51.1% of the current sample was aged between 30 years and 50 years (mean age =???), compared to 73.4% of participants from the previous study (mean age =???). The 1995 sample included only remote area nurses who were members of the Council for Remote Area Nurses of Australia (CRANA) Inc., whilst the present sample included nurses working in very remote Australia, irrespective of membership of professional organisations. There was a much higher proportion of single nurse posts in the previous study. A comparison of demographic characteristics between each of the study samples is displayed in Table 1. 5

6 Table 1. A comparison of demographic characteristics between the present study sample and the 1995 sample. Comparison Measures Context of Silence 1995 Study Back from the Edge 2008 Study Sampling frame Membership of Council of All nurses working in Very Remote Area Nurses of Australia Remote Australia (CRANA) Inc. Sample size Return rate 41.4% 34.6% Females 88.5% 90.8% Aged between 30 and % 51.1% Employed in communities < % 28.20% % 30.60% % % 6% Staffing Only RN in community % Worked with one other RN % Findings indicate decreases in all incidents of reported violence in the workplace, between 1995 and 2008 (Table 2). Verbal aggression, property damage and physical violence remain the most frequent types of violence experienced. Declines in the incidents of property damage and physical violence were significant at p < 0.01 level, as were declines in sexual harassment and sexual abuse/assault, but to a lesser extent (p < 0.05). No significant changes in frequency were found for verbal 6

7 aggression or stalking. As expected, there were significant positive correlations between all types of workplace violence and reported PTSD symptoms (see Table 2). However, despite statistically significant decreases in reported workplace violence, RANs in the 2008 sample continued to express concerns for their safety. In the present study, 86.4% of RANs indicated that they felt concerned about violence in the community (33.2% of whom felt concerned at least once a week), while 66.4% reported that they felt concerned about their personal safety (14.3% of whom indicated feeling concerned about this at least once a week). These findings are dissimilar to those of the 1995 study, wherein 46% of respondents were fearful for their personal safety when on-call, however only 25% of respondents in 1995 indicated that they disagreed with the statement, the security at my residence makes me feel safe. However, these results should be considered with caution, as the data are not directly comparable. Table 2. A comparison between type of violence experienced and frequencies of occurrence, with correlations between violence and PTSD Symptoms. TYPE OF VIOLENCE FREQUENCY CORRELATIONS EXPERIENCED Fisher et al., 1995 Opie et al., 2008 () WITH PTSD SYMPTOMS Verbal aggression 82.1% 79.5%.249** Property damage 46.7% 31.6% **.158** Physical violence 45.1% 28.6% **.228** Sexual harassment 31.8% 22.5% *.205** Sexual abuse/assault 10.6% 2.6% *.161** Stalking 8.3% 4.9%.175** ** = significant at the 0.01 level (2-tailed). * = significant at the 0.05 level (2-tailed). 7

8 Note:, significance tests here refer to chi square difference tests between Opie et al., (2008) percentages and Fisher et al., (1995) percentages for each type of violence. Discussion The study found that self-reported incidents of workplace violence have decreased significantly in the past 13 years. Reasons for this decrease may include the reduced number of single nurse posts, better home and health facility security, or improved organisational systems for nurses attending to on-call and after-hours duties. However, these improvements have not been implemented across all remote health care facilities and more universal changes need to occur. Despite apparent decreases in workplace violence, nurses working in very remote Australia remain fearful for their security and well-being. Further, those reporting higher levels of exposure to violence reported higher levels of PTSD symptoms, including difficulty sleeping, difficulty concentrating, irritability, feeling distant or cut off, reliving of the trauma and feeling emotionally upset when reminded of the trauma. Working in fear for your personal safety can function as a major occupational stressor, and indeed, violence in the workplace has been cited as a common reason for resignation in the remote area nursing workforce (Morrell, 2005; Kelly, 1999; Fisher et al., 1996). Whilst incidents of violence towards nurses working in very remote Australia have decreased significantly over the past 13 years, frequencies of violence remain at alarming levels with two thirds of remote area nurses reporting concern for their personal safety. This is especially concerning in light of the co-occurring phenomenon of under-reporting (Carter, 1999/2000; Gallant-Roman, 2008; Hegney et al., 2006). 8

9 The under-reporting of workplace violence is not a new concept in the nursing literature, and the possible explanations for this have been explored by a number of researchers (Carter, 1999/2000; Gallant-Roman, 2008; Jackson et al., 2002; Rippon, 2000). Confusion surrounding exactly what constitutes workplace violence has been cited as one plausible reason for under-reporting (Carter, 1999/2000; Gallant-Roman, 2008; Hegney et al., 2006), as has the belief on behalf of nurses that workplace violence is simply part of the job (Jackson et al., 2002) and that the patient may not always be fully responsible for his or her actions (Carter, 1999/2000, p. 5). Gallant- Roman (2008) suggested that perception is central to distinguishing between offensive and non-offensive behaviour. It is possible that the nursing profession would benefit considerably from education programs aimed at increasing awareness and identification of violence in the workplace. It is also possible that nurses working in very remote regions across Australia are aware of the nature of workplace violence but simply choose not to report. Fisher et al. (1996, p. 198) identified that nurses working remotely are reluctant to draw attention to themselves and the state of their job conditions for fear of drawing unwanted media attention to local community problems. Limitations Although we established some sample equivalence, different sampling strategies were used for the two studies. It is plausible that the 1995 sample were motivated to establish membership with CRANA in an effort to gain support for workplace issues such as violence, thus skewing the 1995 results. The issue of workplace violence is also a difficult one to research as victims may be traumatised and have often been deprived of the appropriate emotional support (Rippon, 2000). 9

10 Such experiences may have deterred potential participants from responding to our survey. Conclusion Incidents of violence towards RANs have decreased over the past 13 years. Whilst it appears there have been some gains, these incidents remain at unacceptable levels. Violence against remote area nurses is a fundamental violation of their human rights (Fisher et al., 1996, p. 198) and places this population at a greater risk of developing conditions such as PTSD (Kelly, 1999). Recommendations This research has implications for workplace interventions that target violence in the remote area nursing workforce. Such interventions could include education programs for remote area nurses targeting the identification of workplace violence, improved security at the home, the workplace and when attending to on-call or out-ofhours duties, and the abolition of single nurse posts in remote Australia. 10

11 References Australian Institute of Health and Welfare Rural, regional and remote health: a guide to remoteness classifications. AIHW. Cat no. PHE 53. Canberra: AIHW. Carter, R. 1999/2000. High risk of violence against nurses. Nursing Management, 6, 5. Council of Remote Area Nurses of Australia Inc. Occupational Health and Safety of Remote Area Nurses. Position paper prepared by Queensland Members of CRANA Executive, Fisher, J., Bradshaw, J., Currie, B., Klotz, J., Robbins, P., Reid Searl, K., & Smith, J Violence and remote area nursing. Australian Journal of Rural Health, 4, Gallant-Roman, M.A Strategies and tools to reduce workplace violence. American Association of Occupational Health Nurses Journal, 56, Hegney, D., Eley, R., Plank, A., Buikstra, E., & Parker, V Workplace violence in Queensland, Australia: The results of a comparative study. International Journal of Nursing Practice, 12, Jackson, D., Clarke, J., & Mannix, J Who would want to be a nurse? Violence in the workplace a factor in recruitment and retention. Journal of Nursing Management, 10, Kelly, K Preventing job-related post-traumatic stress disorder among remote health practitioners: Best Practice Guidelines. Alice Springs, Council of Remote Area Nurses Australia (CRANA) Inc. Lenthall, S., Wakerman, J., Opie, T., Dollard, M., Dunn, S., Knight, S., MacLeod, M., & Watson, C What stressors remote area nurses? Current knowledge and future action. Australian Journal of Rural Health, 17, Morrell, K Towards a typology of nursing turnover: The role of shocks in nurses decisions to leave. Journal of Advanced Nursing, 49, Productivity Commission, Australia s Health Workforce, Productivity Commission, Editor Australian Government. Rippon, T.J Aggression and violence in health care professions. Journal of Advanced Nursing, 31, Weathers, F.W., Litz, B.T., Herman, D.S., Huska, J.A., & Keane, T.M. (1993, October). The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX. 11