Downloaded from http://journals.lww.com/jonmd by BhDMf5ePHKbH4TTImqenVKNoQAGGabrf7Vb88UgriCMSPN35zR6cDasVp2eLx8s6 on 04/16/2020 Aggression and Violence Toward Healthcare Workers in a Psychiatric Service in Italy A Retrospective Questionnaire-Based Survey Jacopo V. Bizzarri, MD,* Daria Piacentino, MD, PhD, MSc,*† Georgios D. Kotzalidis, MD, PhD,‡ Sabine Moser, PsyD,* Simone Cappelletti, MD, PhD,§ Gerd Weissenberger, RN,|| Maurizio Pompili, MD, PhD,‡ and Andreas Conca, MD* Abstract: Workplace violence and aggression are receiving increasing atten- tion, especially when perpetrated in at-risk services such as psychiatric and emer- gency departments. Many healthcare providers have been victims of verbal aggressions (VAs) and physical aggressions (PAs), as well as injuries (INs), at the hands of patients. We conducted a 1-year retrospective questionnaire-based survey to assess workplace violence and aggression experienced by staff working at the Psychiatric Service of the Health District of Bolzano-Bozen (Italy). We per- formed parametric statistics. Logistic regression estimated the size of the associ- ation between PA occurrence and staff characteristics. Our psychiatric service's employees were frequent victims (91.5%) of 1 or more aggression/injury in the previous year. VAs and INs showed comparable frequencies among the three sites of our service, that is, the inpatient (INP), the outpatient (OUTP), and the rehabil- itation (REHAB) units, differently from PAs, which were more common at INP (p < 0.001). The logistic regression model showed that female sex, working at INP, and a shorter psychiatry work experience predicted PAs occurrence. Most of the staff felt they could benefit from aggression management. Findings show that VAs, PAs, and INs are common among our psychiatric service's employees and point to the need to provide staff training on de-escalation. Key Words: Aggression, de-escalation, nurses, psychiatrists, training, violence (J Nerv Ment Dis 2020;208: 299–305) W orkplace violence is a major concern in healthcare services and has received growing attention in recent years. It is defined as any incident in which an individual is abused, threatened, or assaulted in circumstances relating to their work. This can include verbal abuse or threats, as well as physical attacks (Health and Safety Executive, 2016). European (Franz et al., 2010; Fröhlich et al., 2018; Gascón et al., 2009; Merecz et al., 2006; Schablon et al., 2012; Schablon et al., 2018), North American (Moylan and Cullinan, 2011; Ridenour et al., 2015), Australian (McKinnon and Cross, 2008), African (James et al., 2011), Chinese (Zeng et al., 2013), and Taiwanese (Chen et al., 2008; Chen et al., 2009) studies focused on violence and aggression perpetrated in different healthcare settings. Most studies were con- ducted among nurses and found the highest rate of violence and aggres- sion in psychiatric and emergency departments (Camerino et al., 2008; Gascón et al., 2009; Franz et al., 2010; Magnavita and Heponiemi, 2012; Merecz et al., 2006). Verbal aggressions (VAs) were the most frequent, with profes- sionals in psychiatric settings reporting them between 51% and 100% in the prior year, more specifically, in increasing order: 50.9% (Chen et al., 2008), 96.7% (Franz et al., 2010), 100% (Merecz et al., 2006), and 100% (James et al., 2011). Physical aggressions (PAs) were also very frequent, with a past-year prevalence of 11% to 71%, more specif- ically, in increasing order: 25% (Privitera et al., 2005), 35.1% (Chen et al., 2008), 64.4% (James et al., 2011), 78.7% (Franz et al., 2010), and 79.5% (Merecz et al., 2006). This high variability is likely due to different study settings and assessment tools. Work-related VAs and PAs can reduce job satisfaction and pro- ductivity (Dellasega et al., 2014), increase absenteeism (Farrell and Cubit, 2005), negatively affect quality of patient care (Arnetz and Arnetz, 2001), and produce emotional trauma and physical injuries (INs) in healthcare staff (Magnavita, 2011). In Italy, a number of studies have been conducted as regards vi- olence and aggression toward healthcare staff (Camerino et al., 2008; Ferri et al., 2016; Magnavita, 2011; Magnavita et al., 2011; Magnavita and Heponiemi, 2012; Magnavita, 2014; Zampieron et al., 2010). Magnavita (2011) assessed violence toward health workers in a psychiat- ric rehabilitation unit over the years 1996–2009. The majority of workers had been subjected to PAs over time. In 2002, the author, with the help of a small interdisciplinary team, implemented a violence pre- vention program with educational, organizational, and medical mea- sures, which contributed to a significant reduction in assault rates. The same team (Magnavita and Heponiemi, 2012) showed that (1) nurses and physicians in a public healthcare service were the profes- sional categories most exposed to PAs and threats, and (2) psychiatric departments were the services with the highest risk of violence (50% of all VAs and PAs). These findings match those of a study (Zampieron et al., 2010), which reported that 49% of nurses working in two Italian healthcare institutions were victims of aggressions in the previous year (82% VAs). Risk was highest for women at emergency, geriatric, and psychiatric departments. Another study (Palumbo et al., 2016) found mental health workers, particularly psychiatrists, to be the healthcare professionals at the highest risk for workplace violence, especially VAs. Considering the high prevalence of VAs and PAs in psychiatric departments, we conducted a survey to assess workplace violence and aggression among the health professionals of our psychiatric service. Moreover, due to discordant study findings regarding the risk factors for aggressions, such as sex and duration of employ- ment, we assessed specific risk and protective factors for aggressive behavior among the professionals working in the different settings of our psychiatric service. *Department of Psychiatry, Central Hospital, Sanitary Agency of South Tyrol, Bolzano-Bozen, Italy; †Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Division of Intramural Clinical and Basic Research and National Institute on Drug Abuse Intramural Research Program, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland; ‡Department of Neurosciences, Mental Health, and Sensory Organs, School of Medi- cine and Psychology, and §Department of Anatomical, Histological, Forensic Medicine, and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy; and ||ProDeMa, Institute for Professional De-escalation Management, Kuchen, Germany. Send reprint requests to Daria Piacentino, MD, PhD, MSc, Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Division of Intramural Clinical and Basic Research and National Institute on Drug Abuse Intramural Research Program, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 10 Center Dr (10CRC/15330), Bethesda, MD 20892-1108. E‐mail: daria.piacentino@nih.gov. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/20/20804–0299 DOI: 10.1097/NMD.0000000000001126 ORIGINAL ARTICLE The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020 www.jonmd.com 299 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.