A Vicious Cycle: Workplace Victimization of Psychiatric Workers

Background: Psychiatric staff are at high risk for victimization at work. For example, approximately 30% of 586 nurses in 7 states reported being assaulted in the prior year (Carroll & Morin, 1998) and in multinational samples career assault rates of approximately 75% have been found (Dehn, 1999; Quintal, 2005). Patients, supervisors, coworkers, and visitors are all potential sources of aggression and assault for staff. Identifying the risk factors for assault and aggression are critical to designing interventions to prevent their occurrence. Previous research has fairly consistently identified males, less experienced staff, having high patient contact, and using patient containment procedures, as associated with risk for patient assault but other risk factors such as reactivity to conflict, anger, and aggression from other staff are less well established. The goal of this study is to examine existing and novel risk factors for patient-on-staff aggression and assault.

Methods: Clinical staff (n = 328) at a large public mental hospital in California completed a one hour online survey about their occupational stressors and strains (26% response rate). Participants reported their position, gender, race/ethnicity, and years of experience and rated the frequency of assaults, aggression, use of patient containment procedures, staff-on-staff conflict, staff-on-staff criticism, and anger. Lastly, they rated their reactivity to conflict. Linear regressions were used for all analyses predicting patient-on-staff aggression and assault.  

Results: The sample was 67% female and 60% racial/ethnic minorities. The majority of staff were psychiatric technicians or nurses (59.4%) 36.7% were clinical staff (e.g., psychologists, social workers), and 3.9% were supervisors (administrative, clinical).

In the last 12 months 69.8% of staff reported at least one physical assault, for 41.5% their most serious assault was severe (e.g., kicked, punched, hit-in-the-head), and for 28.4% their most serious assault was mild (e.g., being grabbed or touched, spitting). Staff used patient containment procedures frequently (78.3%). Staff-on-staff conflict and criticism were frequent as well (94.2% reported conflict, and 93.5% reported criticism).

In a regression model predicting patient-on-staff assault, psychiatric technicians and nurses were at higher risk of assault than clinical (β=-.12,p=.03) positions. More frequent patient aggression (β=.26,p<.001), use of containment procedures (β=.29, p<.001), and being more reactive to conflict (β=-.13 ,p=.009), were also associated with more patient-on-staff assaults.  Gender, job experience, staff criticism and conflict were not assault frequency.

Conversely, patient aggression was significantly associated with staff-on-staff conflict (β=.19,p<.001) but not staff-on-staff criticism, and the frequency (β=.19, p<.01), but not the severity, of patient-on-staff assaults. Staff who utilized containment procedures (β=.43, p<.001) experienced more verbal aggression from patients. Gender, position, job experience and reactivity were not related to the frequency of patient aggression.

Implications. Patient assault and aggression are pervasive issues for psychiatric workers. Psychiatric technicians and nurses work closely with patients and therefore are at the highest risk for assault. Those who are at highest risk for patient aggression also reported staff aggression, which suggests a possible link or feedback between aggression from staff and patients on wards, and they could be targeted for an intervention to prevent or manage verbal conflicts.