___________________________________________________________ Violence in the Healthcare Workplace
be bidirectional [125]. Overall, workers who feel dissatisfied with their jobs and who do not experience belonging with their colleagues are more likely to perpetrate bullying [154]. Supervisors’ leadership styles also play a role in workplace bullying. Those who work under an individual with a construc- tive leadership style were less likely to experience workplace bullying [124]. Supervisors who provide supportive, direct, and constructive feedback are more likely to have employees with high work satisfaction, which can then lead to better patient care. Ultimately this can lead to a more positive work environment [157]. Work settings characterized by instability, such as changes and shifts in management, and the percep- tion that policies and procedures are unfair are associated with increased workplace violence [47; 157]. Aggressive acts against supervisors are often attributed to the perpetrators’ perceived injustices and their views that their work environ- ments were controlling [48; 157]. Perceived injustices may be organizational, interpersonal, or related to company policies or procedures. Perceived interpersonal injustices are related to employees’ views about how they are treated; employees may feel that they are being treated disrespectfully or rudely by those who are responsible for administering procedures [49]. Prolonged periods of layoffs or downsizing and witnessing oth- ers’ career successes while seemingly being overlooked oneself can adversely affect one’s sense of worth and self-esteem, which can trigger feelings of victimization [101]. Other researchers have similarly categorized injustices into two categories: procedural injustices and interactional injus- tices. Procedural injustices refer to the perceived fairness of the organization’s decision making, formal procedures, and other mechanisms to determine outcomes [50]. Interactional injustices refer to the employees’ perceptions about the quality of the interpersonal treatment they received when policies and procedures are carried out [50]. It has also been speculated that organizational settings with an identifiable predominant social group may breed bullying in the workplace. Certain fields, for example, may be traditionally male- or female-dominated, and an individual who represents the social minority may then be in an exposed position [51]. In other words, minority groups within a workplace may carry an elevated risk of being socially excluded from the workgroup [86]. Some studies have shown that men in female-dominated sectors were more likely to experience workplace bullying; conversely, in male-dominated fields, women who are viewed as gendered forerunners were more likely to be sexually harassed [52]. INTERPERSONAL FACTORS Certain personality characteristics of perpetrators or victims can be risk markers for workplace violence. For example, a psychiatric diagnosis has been identified as increasing the likelihood of perpetrating violence [53]. Of course, not all individuals with psychiatric disorders will perpetrate violence; however, certain diagnoses, including schizophrenia, schizoaf-
fective disorder, bipolar disorder, and major depression, are associated with an increased risk for violent behavior [89; 90]. Alcohol consumption and a history of aggression are also associated with violence against a healthcare provider or co- worker [48]. Jockin, Avery, and McGue found that individuals with low tolerance to stress and frustration are more likely to experience or perpetrate a nonfatal aggressive incident in the workplace [54]. Age is also a predictor of being a victim of workplace violence. Several studies have found that younger nurses, physicians, and other staff were more likely to be exposed to workplace violence than older workers [126; 127]. Personality variables are also related to likelihood to engage in bullying in the workplace. In a 2017 study, workers who exhibited higher levels of conscientiousness were less likely to bully at work [158]. Those who demonstrated greater conscientiousness were better able to self-regulate frustration. Similarly, agreeableness was negatively correlated with bully- ing perpetration. However, those who exhibited higher levels of neuroticism were more likely to report high stress levels and to perpetrate in bullying [158]. However, a separate study found that lower scores in agreeableness were a consequence of exposure to workplace bullying, not an antecedent [159]. FACTORS ASSOCIATED WITH HEALTH AND SOCIAL SERVICE SETTINGS OSHA has identified specific characteristics typically associated with health and social service settings that might contribute to the risk of workplace violence [7]. As jails and detention centers become increasingly crowded, hospitals have become temporary holding places for violent and disturbed individu- als. In Levin, Hewitt, and Misner’s focus group of 22 nurses, many felt that the police were using emergency rooms as a “holding tank” for patients who were intoxicated and volatile until they sobered up or calmed down [55]. In social service settings, negative perceptions of social workers are common, with persistent stereotypes of unsupported removal of children from families or withholding of services [189]. Individuals generally seek health and social services due to health distress or emotional, family, and/or psychological problem. Some patients are experiencing a crisis, and with this comes heightened emotional states, which can result in feelings of fear, loss of control, and anxiety. These emotions are associated with an increased risk of using violence as a coping mechanism [91]. Some argue that adverse events that occurred earlier in life may cause biologic changes leading to a hyperarousal state. Although individuals’ heightened arousal states may initially be a self-protection mechanism, these persons may tend to overreact to stressful situations (e.g., long wait times, noise, crowds), in some cases becoming violent [160]. Because persons who often seek social services are more often in distress, in crisis, and/or highly vulnerable, these arousal states may be heightened [189].
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