Translational Models of Workplace Violence in Health Care
Decision makers have little time to study literature on the prevention and management of workplace violence (WPV). In a health care workplace setting, identifying the person, stimulus, and environmental interactions that can lead to violence is a complicated process. Those in positions of leadership make decisions that affect many individuals, agencies, and communities. Often, they come from different professional backgrounds yet need ways of rapidly understanding concepts of violence that transcend their profession, training, or experience. Translational models (TMs) in WPV visually summarize and inter-professionally facilitate this understanding of concepts, enhancing the chances of more effective collaborative solutions to WPV. The purpose of this article is to demonstrate how TM can be used in interprofessional settings to find effective solutions to reduce WPV.
Keywords: translational model; workplace violence; health care; organizational health; translational science
There are many competing definitions and theories of workplace violence (WPV) spread across professional literature in nursing, medicine, social work, law enforcement, judiciary, and business management. Finding effective solutions to reducing WPV is a daunting task. Interprofessional communication and cooperative synergy is essential to identifying and implementing needed solutions. Even those who work or do research in the field struggle to understand the numerous concepts and jargon between and even within professions. Decision makers in health care now more than ever may not have direct clinical experience themselves. Multiple disciplines jointly run healthcare systems. When WPV occurs, or in its prevention, multiple professionals and agencies need to collaborate.
Translational science (TS) refers to a highly collaborative process of the translation of basic research findings more rapidly and efficiently into practice. It is multidisciplinary by nature and transdisciplinary in practice. Multidisciplinary refers to a primary discipline with other discipline-specific experts used on as required basis. Transdisciplinary refers to discipline-specific experts with working knowledge of other discipline's roles. In this way, a small number of people can assess and respond to situations with knowledge that transcends their own formal training and broadens the ability to meet the complex needs that often underlie WPV. Interdisciplinary refers to discipline-specific experts with knowledge of other disciplines' roles to facilitate collaboration, used regularly (Direnfeld, 2009).
The application of such TS in translational models (TMs) would make interprofessionally accessible a wealth of complicated, often profession-specific research in WPV. TM would reduce the interprofessional communication, procedure, and jargon barriers or "Tower of Babel" phenomenon that interferes with better collaboration between fields (Michalski & Privitera, 2011). Translational models (TMs) in WPV visually summarize and inter-professionally facilitate the understanding of concepts, enhancing the chances of more effective collaborative solutions to WPV.
Decision makers have little or no time to study literature on the complex terms and interactions that can lead to violence in a health care workplace setting. The goal of TM would be to help multiple disciplines and professions achieve a working common knowledge base of complex interactions between person, stimulus, and environment that produce violence. More effective WPV prevention and intervention initiatives are hoped to follow from more informed interprofessional collaboration. TM of WPV would be useful in a spectrum of settings: from global, national, state, and organizational policy-making efforts to site-specific initiatives.
THEORETICAL BACKGROUND OF VIOLENCE TYPOLOGY
The
Violence is "the intentional use of physical force or power threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation" (WHO, 2002, p. 5). Intentional force or power toward an individual is likely to have more psychological impact on the victim than unintentional force or power (Forbes et al., 2014). However, it is our opinion that unintentional force or power that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation should also be included as violence. Psychological impact of the unintentional version may still be significant and hence should be considered as violence from a victim-centered perspective and for purposes of unifying violence prevention efforts.
Four modes of infliction of violence have been described: sexual, physical, psychological, and deprivation. Three subtypes of violence are driven by the victim-perpetrator relationship: self-directed violence, interpersonal violence, and collective violence. Collective violence is further subdivided into social (to advance a particular social agenda), crime of hate, terrorism, and mob violence; political: war and state violence such as genocide, torture, abuses of human rights, and so forth; and economic violence. Economic violence occurs by attacks of larger groups motivated by economic gain-disrupting economic activity, denying access to essential services, and creating economic division and fragmentation (WHO, 2002).
The ecological model for understanding violence put forth by Dahlberg and Krug (2002) conceptualizes violence as the result of multiple levels of influence on behavior. Their model puts individual within a relationship, then within community, then within society (Dahlberg & Krug, 2002). This model illustrates contextual issues in the complexity of the person-stimulus-environment interaction.
RANGE OF VIOLENT ACTIONS
Mega violence includes extreme WPV outcomes, such as threats, assaults, and homicide. These events may be low in frequency when considering a typical workday's events but have high impact on individuals and the health care system when they occur. Mega violence would include behaviors that meet or exceed law and society's common perception of violence and represent severe transgressions against individuals.
Micro violence in its different forms is a subject of violence research and scholarship. Aggressive physical and verbal behaviors that do not meet the threshold of mega violence but are significant enough to be the subject of policy, social justice, or ethical considerations would be included. One example is workplace incivility, which has been defined as low-intensity deviant behavior with ambiguous intent to harm the target in violation of workplace norms (Andersson & Pearson, 1999; Lewis & Malecha, 2011). Other examples would be disrespect, deprivation of human needs, belittlement, and bullying, micro aggressions of micro assault, micro insult, micro inequities, and micro invalidation. Micro situational antecedents would also be included.
Micro aggression (Pierce, Carew, Pierce-Gonzalez, & Wills, 1977, 1978) focused on racial interactions that are nonphysical aggression, verbal, behavioral, and environmental indignities.
On the lower end of this micro violence spectrum would include those behaviors that are significantly noxious to individuals and are often to be avoided by "proper" upbringing, normative social behaviors, organizational health, and good psychosocial safety climate in work environments. These behaviors can be emotionally and physically toxic to individuals when persistent or chronic. Unreasonable expectations, offensive actions or words, or the lack of action or words (Baron & Neuman, 1998), badgering behaviors, hassling others, persistent aggravations from coworkers, supervisors, poorly designed work procedures, policies, and multiple uncoordinated mandates on staff and subsequent management demanding behaviors would be examples.
Deprivation of Human Needs as Micro Violence
Law and ethics help stipulate the consequences of perpetrating sexual and physical violence. However, the extent of psychological impact of deprivation can be singular or multifactorial in source, acute or delayed in manifestation, and sometimes effects are chronically diffused into whole cultures. It is harder to trace back to the responsible source of deprivation because it can be inflicted by forms of collective violence (social, political, and economic methods of violence).
Maslow's description of human needs (Maslow, 1943) has been the subject of much discussion and debate over the years. Human needs include physical and nonphysical elements needed for human growth and development and those things humans are innately driven to attain. The authors agree with Dick's observation that what we call Maslow's hierarchy of needs operates best as taxonomy to understand behavior rather than a theory of psychology that predicts behavior (Dick, 2001).
This taxonomical approach in a background of hierarchy is represented as a pyramid and has been further refined as shown in Figure 1. Other writers expanded Maslow's concepts to include the following: freedom, distributive justice, participation, and identity (Burton, 1990; Marker, 2003; Rothman, 1997). There are strong merits to have certain human needs in hierarchy. However, above those needed for physical existence, hierarchy near the top is not as clear to assign, especially when including other authors' contributions after Maslow's death in 1970. Human needs taxonomy as described by Maslow (1943), Burton (1990), Rothman (1997), and Marker are conveyed in the non-hierarchy approach of Table 1.
In our experience of working with people who were homeless because of chronic mental illness, they need several weeks of experiencing the reality that they would sleep and eat at a specialized shelter before they could begin addressing treatment goals. When these basic needs are unmet, human beings will have difficulty attending to higher order tasks (Mandt & Bowen, 2005). The need for safety and security is met when environments are consistent and therefore predictable. When environments are chaotic and unpredictable, individuals will not have the perspective that they are safe. When safety and security needs are unmet, relationships will not be healthy and they are likely to be manipulative in nature. People whose basic human needs are intentionally or unintentionally deprived will experience this deprivation as a form of violence. The individual's perception of the violent stimulus severity (and subsequent choices of reactive behavior) may be affected by whether the deprivation is acute versus chronic, single versus accumulated, high intensity versus low intensity, or immediately life-threatening versus chronically life-threatening.
Deprivation of human needs in our workplaces and society at large, whether intentional or unintentional, can now occur massively and rapidly because of advances in technology. Human awareness and ability to accommodate or react is much slower than the speed of technology. This speed disconnect between rapid massive changes and human ability to recognize, accommodate, or react logically is likely contributory to rising rates violence in our workplaces and our society.
Micro violence is more frequent and needs to be better understood for its origins in the interaction between the person, a stimulus, and the environment/organization that leads to WPV. The role that environmental/organizational contributions play in production of micro violence and conversion of micro violence to mega violence is an emerging area of focus for potentially high-yield interventions in the reduction of WPV (Privitera, 2011; Privitera, Bowie, & Bowen, 2012).
Iceberg Model: Micro and Mega Violence
One way of conceptualizing this spectrum of micro to mega violence is an iceberg. Above the water line is mega violence. Below the water line is micro violence, which is more frequent but has not had the same universal recognition as being a form of violence. Although micro and mega violence are a continuum in reality, the water line signifies a threshold above which law and society recognize as significant transgression against one another.1
Although perceived to be a lesser significance level, the damage that occurs from either micro violence or its role as an antecedent to mega violence should not be underestimated. Better understanding of prevention and management of micro violence has potential for significant positive impact on WPV reduction (see Figure 2).
Environmental/Organizational Contributions to WPV: Missing Piece of WPV Event Analysis
Violence from patients, visitors and family, staff styles of interaction, and organizational contributions to violence (Bowie, 2011) are often controversial as well as socially and politically delicate. Staff may fear they will be blamed or lose their job and tend to underreport incidents. To improve accuracy of root cause analysis (RCA) of violent incidents, RCA frameworks should include person, stimulus, and environmental/organizational factors of the issues involved. Having access to TM allows for more thorough and contextual analysis of WPV events, making routine the assessment of all three spheres-legitimizing factors that may be otherwise difficult for subordinates to include in the routine process of RCA.
TMs were designed to visually summarize and integrate major contributing factors to violence and their interaction to more succinctly convey violence literature concepts. Relevant basic and clinical science research on major contributing factors to violence and their interaction were used to construct the concepts into these models. Much of the literature on WPV, for quality and reliability of scientific findings, focuses on specific narrow realms of study that can control select variables. Although scientifically sound, their scope of application may often be too narrow to be operationally useful for application across professions. Three major realms of study in WPV include (a) the person, (b) the stimulus, and (c) environment.
Environment would include organizational environment which is housed within a physical environment which is housed within a greater psycho-sociopolitical environment driven by many forces beyond the scope of this article (Prilleltensky, Prilleltensky, & Voorhees, 2008).
Three Main Interacting Factors in Violent Behaviors
Person. The tendency to violence can be envisioned along a continuum from high-risk to low-risk individual (see Figure 3).
In the high-risk range, aggression in an antisocial personality disordered individual will have a specific goal in mind. Medical and psychiatric conditions that alter the person's thinking caused by illness may make their perceptions paranoid, thinking they are fighting for their lives.
In the moderate risk range, aggression is triggered by past history of violence or posttraumatic stress disorder. For example, reactive aggression occurs in patients with borderline personality disorder who may have emotional sensitivity/dysregulation (Siever, 2008; Tuinier, Verhoeven, & Van Praag, 1996).
In the low range, consider the average reasonable individual's (ARI) risk. ARI is a concept borrowed from law to denote a hypothetical reasonable individual in society who exercises average care, skill, and judgment in conduct and who serves as a comparative standard for determining liability.
Using this concept and judging behavior against such a hypothetical reasonable individual, we may now acknowledge and account for types of stimuli and/or environments that may raise the odds for violence if the situation were dire enough.
The ARI concept becomes even more salient to discussions of organizational contributions to WPV and professional burnout within health care settings. Self-sacrifice and self-effacement are taught in professional schools by clinical mentors. Recognition of a reasonable emotional and physical human limit of self-sacrifice and self-effacement of health care providers and staff is only recently being legitimized in publication on such topics of physician, nursing, and social work burnout. Current concepts of professional burnout have moved away from blaming the individual to a host of similar organizational factors that contribute to WPV (
Stimulus. The tendency to induce violence can be envisioned along a continuum from high range to low range of stimulus. In the high-range stimulus, a highly noxious stimulus is more likely to provoke a violent response or aggressive act done in self-protection. Incivility may be a midrange to the low-end stimulus example. Lower level stimuli may be supervisor promotion of role overload, unreasonable work expectations, and multiple uncoordinated administrative mandates that may exist in the environment by force of their reporting to authority above them. Human nature has been shown to follow authority mandate despite lack of reasonableness (Milgram, 1963). Below this, a benign statement can be misperceived as offensive, or there may be no stimulus at all (see Figure 4).
Environment. Is the environment a protective factor to the interaction between the person and stimulus that otherwise would have led to a mega violent outcome, or might the environment be an aggravating factor to the interaction between person and stimulus? Organizational and environmental contributions to violence are often overlooked when much of the literature focuses on relationships between two individuals involved in dispute, failing to capture the systemic environmental contribution (Bowie, 2011; Daffern, Mayer, & Martin, 2004; Guglielmi et al., 2011; Jeurissen, 1997; Johnson, 2009; Papadopoulos et al., 2012; Skjørshammer, 2003; Thoroughgood, Hunter, & Sawyer, 2011; see Figures 5 and 6).
An example of this organizational component within health care services is regulatory incrementalism of mandates. Incrementalism is a process by which small additive changes in procedures, regulation, or policies from multiple sources can slowly accumulate over time, affecting work environment. Increasing expectations on health care staff because of well-meaning regulations, law, political pressure, and insurance methods to lower usage of patient benefits cumulatively add up to unreasonable levels of stress (Bowen, Privitera, & Bowie, 2011). There exists no central monitoring agency to manage how far these expectations on staff should be allowed to go. There are multiple uncoordinated quality, financial, political, and regulatory forces on hospitals, providers, and staff, each blind to the cumulative end user impact. The financing of health care complicates the lack of coordination further by adding profit factors that drive expected behaviors. The profit environment feeds into patient distrust of the intentions and behaviors of health care systems, providers, and staff (Constantino & Privitera, 2011). Such initially low-level incremental pressure can over time grow and eventually lead to WPV directed at staff because of distraction from attention to the patients' needs, and irritability, lack of patience from staff because of unreasonable workloads. Bullying between staff occurs and also directed at health services users (Bowie, 2011).
Yerkes-
Conversion of Micro Violence to Mega Violence
Lanza, Zeiss, and Rierdan (2006) reported that workers who have experienced nonphysical violence (e.g., micro violence) of being shouted at, sworn at, made to feel inadequate, needed information withheld, and so forth have more than sevenfold risk of experiencing physical violence (e.g., mega violence) than those that did not.
A review of the violence theory literature was done by the authors to examine mechanisms of how smaller adversarial behaviors may progress to macro violence. Several relevant theories were identified. Those that relate to additive effects of stressors are the frustration-aggression hypothesis (Brennan, 1998; Dollard & Miller, 1939), the negative affect escape model (Baron & Bell, 1975) and excitation-transfer theory (Zillmann, 1983a, 1983b). All of these theories would take into account the environment of the individual(s) involved and help us understand the mechanisms of environmental contribution to violence.
In the frustration-aggression hypothesis (
The negative affect escape model (Baron & Bell, 1975) postulates that an unpleasant environmental stimuli that increase in intensity, such as loud noises, provocations, crowding, unpleasant odors, or heat (creating negative affect), may lead to aggression from those stimulated to nullify the source of the stimuli (Donnerstein &Wilson, 1976; Evans & Lepore, 1997). The risk of aggression (fight response) increases up to a certain point. As the unpleasant environmental stimuli continue to increase past this point, passivity or leaving the environment may occur (flight response).
The individual's response may be modulated by perception of the risk coming the potential victim's way. Whether the precipitant is an obvious attack versus a subtle personal insult (ambiguous precipitant) will make a difference in the potential victim's interaction with environment. In the obvious attack situation, the perception of personal attack continuously goes up linearly with increase of negative affect. In the ambiguous precipitant situation (e.g., subtle personal insult), perceived personal attack goes up with increasing negative affect to a point but then trails off as negative affect continues to rise (Anderson & Bushman, 2002).
The implication of these findings is that environmental factors can alter how a person perceives a stimulus and makes a strong case of how environment affects outcome even though the person and the stimulus remain constant. This can be seen in the way health staff or patients interpret stimuli: Was it an attack against themselves? Was it intentional? Environment can affect the perception of being attacked.
Environmental/Organizational Negative Affect Contributing to Outcome
Unpleasant Environment. Hot, noisy, or crowded places, poor environmental design can raise physiological arousal.
Behavior Interference With Normal Routines. Noise interfering with needed concentration and cognitive processing. New physical layout of an environment or new set of coworkers because of organizational restructuring can increase stress and irritability.
Cognitive Overload. If we receive too much information from an environment to cognitively process, it may affect functional competence and strain coping skills. These cognitive stressors can be from well-intended regulatory requirements and electronic medical record complexities (Van Merriënboer & Sweller, 2010). More ominously, these also come from profit-intended obstructions to patient care.
Excitation-Transfer Theory. Schachter and Singer in 1962 claimed that emotional arousal is nonspecific or ambiguous, and the individuals cognitively assign an emotion to what they are experiencing. Zillmann (1983a, 1983b) adopted and modified Schachter's view on this: Residual physiological excitation from essentially any excited emotional reaction, such as from pain or frustration from delay in receiving care, is capable of i ntensifying (transferring to) any other excited emotional reaction, such as fear of an impending procedure, or anger about how they were spoken to. Hence, patient arousal from pain, frustration with obtaining care, and so forth may be a contribution to their aggression toward staff from what otherwise may have been thought to be minimal provocation by the second stimulus. These previously mentioned barriers to their care of patients such as overloaded work assignments because of staff cutbacks, physiologically arouse staff which then can contribute to incivility or aggression by them toward patients and other staff with minimal provocation.
Figure 5 displays an interaction between person and stimulus in the setting of a healthy organizational environment. Some mega violence of homicide, assaults, and threats may still occur, but micro violence is less and less conversion of micro to mega violence occurs.
Figure 6 displays the aggravating effect of low organizational/environmental health (scenario of significant organizational contributions to WPV), giving visualization to a fairly intangible factor that has strong effects and is often overlooked in organizations. More micro violence and micro conversion to mega violence can result from the low organizational health environment.
IMPLICATIONS AND CONCLUSIONS
There is a need to conceptually summarize and integrate many existing pieces of research and clinical concepts of WPV in operationally useful ways.
WPV solutions require interprofessional collaboration. Excessive intraprofessional jargon and procedural differences impede such communication. Collaboration is needed between professions to prevent and lessen impact of WPV. TM of WPV by visually summarizing violence concepts and interactions that transcends jargon is a transdisciplinary method to assist the process of finding effective solutions to reduce WPV. In the wider health care policy literature, there is ongoing debate over the relative merits of security or zero tolerance policy (ZTP) frames on dealing with violence versus co-creationist safety models (
Visual conceptual models of TM convey information more rapidly and with less inter-professional jargon interfering with comprehension-increasing the chance of more effective and sustainable solutions to WPV.
Translational three interacting factor model of contributions to WPV more concisely demonstrates interaction beyond person and stimulus to include interaction with the environment of organization and the psycho-sociopolitical environment. More environmental/ organizational health can help prevent WPV and less environmental/organizational health is contributory to WPV. Psycho-sociopolitical environment has strong effects on the organizational environment within them. Hence, systemically informed approach to regulation, law, and policy and a stronger review of their potential unintended negative consequences by decision makers deserves more study. Dyadic models that only include person and stimulus to explain WPV are insufficient and may misattribute blame, missing prevention opportunities.
Organizational and environmental health needs more attention and further research as a means to lessen WPV in health care settings. TM of WPV may be of great assistance in helping this to occur. Further research using TM may help us close the information gap between scientists and decision makers to improve quality and effectiveness of outcomes.
NOTE
1. Law, society, and justice do not always fully agree on the included elements that constitute the threshold itself, but the threshold concept still remains operationally useful.
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