___________________________________________________________ Violence in the Healthcare Workplace
that provides a formal and informal venue for the victim to express their feelings, be made available. Providing training on how to deal with workplace violence, also referred to as informational support, has been associated with a decreased level of somatic symptoms and negative feelings [85]. However, social support does not appear to influence the fear of future violence or neglect of one’s job duties [85]. Fear of future violence has not been found to affect an individual’s level of commitment to their workplace and organization [59]. These findings are a bit perplexing; however, it is important to note that workplace violence was not categorized in these studies to differentiate aggression perpetrated by a stranger and aggression initiated by co-workers. When LeBlanc and Kelloway took this into account, they found that aggression perpetrated by co-workers adversely affected emotional and psy- chosomatic well-being and level of organization commitment; however, it did not influence fear of the future or intent to quit [60]. Workplace aggression perpetrated by a stranger or patient increases the likelihood of future violence, as individuals are then more likely to bring weapons to work for self-defense [44]. Finally, public-initiated aggression also increased the likelihood of an employee leaving the organization [60]. In addition to the adverse emotional and health consequences a victim of violence experiences, there are also organizational consequences, including increased job dissatisfaction, reduced level of work performance, higher amounts of sick leaves taken and absenteeism, reduced commitment, and leaving the job or even the profession [190]. These organizational consequences can in turn lead to economic ramifications. Figures vary depending upon how one defines workplace violence and how one calculates “cost.” In 1994, it was approximated that 1.751 million workdays were lost, resulting in $55 million in lost wages [61]. However, this does not take into account litigations filed against the organizations, medical expenses incurred, and negative morale, which may influence job satisfaction, trigger- ing future attrition and turnover. ETHICAL AND LEGAL ISSUES Confidentiality and the limits it imposes are key ethical issues that emerge when discussing the topic of workplace violence. Generally, healthcare professionals and other clinicians can- not disclose information learned in a clinical setting. Yet, the question is: Should protecting the privacy and maintaining the confidence of a patient’s disclosure outweigh the greater social good? The duty to protect is related to the Tarasoff legislation. Although the act of violence that resulted in the Tarasoff Law did not occur in the healthcare workplace, it has clear implications for any case in which a practitioner suspects an individual is capable of violence. This law resulted from a case in 1968, involving a male student, Prosenjit Poddar. Poddar met Tatiana Tarasoff at a school function, where she declined his romantic interests. Poddar had a history of depression
and had visited the university’s health services. Soon after meeting Tarasoff, his depression worsened. He disclosed to his counselor that he had thoughts of harming and even killing a girl whom he met, and Poddar’s description clearly matched Tarasoff. Poddar was committed to a hospital, and the police were contacted. However, when the police interviewed Pod- dar, they found him lucid and issued a warning. Ultimately, the hospital where Poddar was sent did not commit him. Two months later, he shot and killed Tarasoff after missing several counseling appointments [62]. Tarasoff’s parents sued, which resulted in the Tarasoff Law. This law states that therapists, clinicians, and other mental health counselors have the duty to protect third parties from harm. The case was reheard in 1976, resulting in a change in terminology, from “duty to warn” to “duty to protect” [63]. As a result of this legislation, clinicians have a duty to protect the third party by warning the targeted victim or others who can then warn the intended victim, notifying law enforcement, and implementing other steps to protect the potential victim [63]. Healthcare workers and other helping professionals are obli- gated to promote good and avoid harm (i.e., adhere to the ethical principle of beneficence). Demeaning, threatening, and humiliating are often the underlying motivations in bullying behaviors, all of which violate the principle of beneficence [165]. The codes of ethics of various professions explicitly discuss the relationship practitioners are to have with their colleagues. For example, the Code of Ethics for Nurses out- lines the necessity for extending respect and integrity for all individuals—colleagues as well as patients [129]. In the Code of Ethics of the National Association of Social Workers, the respectful relationships social workers are to have with their colleagues and how to resolve disputes are outlined [130]. ASSESSING RISK Borum and Reddy argue for the need to have a fact-based line of inquiry when clinicians work with patients who may be a risk to others [63]. They maintain that clinicians should consider: Is the client on the path towards violence? If the answer is affirmative, how fast is the client moving and where can one intervene? Although this line of inquiry was not specifically developed for the workplace, it can be applied to workplace violence perpetrated by patients or clients. To help answer these two questions, further assessment may be conducted and information garnered in six areas, which may be remembered by the acronym ACTION [63]: • Attitudes: The clinician should assess the strength of the patient’s conviction that use of violence toward the intended victim will accomplish his/her goals. To what extent does the patient feel that the potential use of violence is justified? What violent fantasies does the patient hold? What expectations does the patient have that he/she will be successful using violence?
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