广州市医院工作场所暴力流行病学研究
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摘要
背景和目的
暴力是一个国家和地区无可讳言的社会安全问题。广泛渗透于社会各个领域的暴力并没有被阻隔于医院之外,实际上,社会暴力正流向医院,卫生工作人员在其工作场所遭受暴力对待经常发生。暴力作为公共卫生问题被忽略的原因之一是缺乏明确的定义。关于工作场所暴力,国际上过去一直没有完整而统一的定义。世界卫生组织关于工作场所暴力的最新定义是：工作人员在其工作场所,受到辱骂、威胁或袭击,从而造成对其安全、幸福或健康的明确或含蓄的挑战。此概念的拓展解释还包括以下三点：①暴力事件必须发生在工作场所；②暴力发生在工作人员上班期间；③暴力受害者一定是工作人员。按照受害者遭受暴力的部位不同,工作场所暴力分为心理暴力、身体暴力和性暴力。心理暴力是指故意用力(含体力威胁)反对他人或集体,从而导致对身体、脑力、精神、道义和社会发展的损害,包括口头的辱骂、威胁、攻击和折磨,但当事人之间没有身体接触。身体暴力指任何以体力伤害身体的攻击行为,例如打、踢、拍、扎、推、咬等。体力攻击的结果可能未导致承受暴力的一方任何伤害,也可能造成轻度损伤、明显损伤、功能障碍或永久性残疾等。性暴力是指任何违背受害者意愿的有关性的言语和动作,包括性骚扰(或性挑逗)、性袭击以及强奸(或强奸未遂)。到目前为止,国内的情况是,一方面,社会各界对医院工作场所问题未予足够的重视,尚未见到比较成熟的相关行政法律条文,工作场所暴力方面的专业研究开展得并不多；另一方面,由于国内政治经济及文化背景、医院配置、卫生管理制度等方面和国外不太一样,故其他国家有关工作场所暴力的研究成果及防治经验也就不一定完全适合我国。在一定范围内对有代表性人群进行抽样调查,可以反应某一种暴力在特定时间中的发生情况。通过在广州市辖区内医院开展工作场所暴力流行病学调查,探讨医院工作场所暴力发生现况及影响因素,可以为如何处理存在已久的医患纠纷问题提供新的思路和解决之道。只有处理好医患纠纷,解决好医患矛盾,才能保障医院正常的医疗秩序,还医务人员一个宽松安全的工作场所,还病人一个舒适满意的诊疗环境。本研究通过在广州市辖区内部分医院开展工作场所暴力流行病学调查,探讨医院工作场所暴力发生现况及影响因素,最终旨在提供国内有关医院工作场所暴力的基线资料,唤起广大一线卫生工作人员乃至全社会对医院工作场所暴力问题的重视,同时为卫生行政部门制定医院工作场所暴力预防与控制措施以及维护医院正常工作秩序提供理论依据。
方法
广州市下辖10个区、2个县级市。本研究以广州市辖区内12个行政区划的20家不同级别医院共7198名在岗工作人员作为研究对象。此次调查的医院在岗工作人员包括在医院工作的所有职业人群,例如医生、护士、临床工人、医技人员、行政人员、后勤人员和保卫人员等,因休假、出差、旅游或外出学习等原因而不在岗达一周以上的工作人员不在本次研究之列。本研究采取整群抽样与分层抽样相结合的调查方法。首先,将广州市辖区内医院总体按行政区划分成12个群；其次,按医院级别将每个群分成3个组别,并在每个组别中随机抽取一定数量的医院,抽取拟调查的医院；最后,对于被抽中的医院,原则上将所有医院工作人员作为研究对象。每家医院在经过培训的调查专职人员(各科室主任和／或护士长)指导下,所有在岗工作人员在同一时间段内(一般1—3天,最长不超过7天)集中填写调查前12个月在医院场所本人所遭受的暴力情况,然后由各科室主任和／或护士长逐一收回本科室调查表。根据世界卫生组织的有关文件和工作场所暴力的定义设计调查表,此调查表经不同年龄的医院工作人员试填,收集反馈意见,根据发现的问题和反馈的意见对调查表的项目进行补充、修改和删除；修改后的调查表先在一家医院进行小样本(30人)的预调查,再次校正调查表。正式调查开始后调查表的内容不再做任何改动。医院工作场所暴力定义如下：卫生工作人员本人在工作时间内,在医院场所遭受到心理暴力、身体暴力和(或)性暴力。本研究使用社会学统计软件包SPSS17.0进行调查表的录入和数据分析处理。包括对医院工作场所暴力的流行特征作统计描述,针对暴力相关特征及暴力认知作卡方检验。建立单因素及多因素logistic回归模型,分析探讨工作场所暴力经历与受访者相关因素的关系。第一步,将8个受访者相关因素逐一进行单因素二分类logistic回归分析,筛选出包括性别、年龄、教育程度、婚姻状况、聘用形式、职业类别和工龄等7个特征变量；第二步,为了排除混杂因素的干扰,就单因素回归筛选出来的变量采用向后删除法进行多因素logistic回归分析,最终共有4个变量进入回归模型,分别是受访者性别、年龄、聘用形式、职业类别。本次研究采取以下质量控制方法：①采用封闭式调查表,减少了受访者主观臆断,每份调查表简明附上调查的目的、要求及填写方法,使受访者一目了然,也减少了顾虑；②只对过去12月中发生的暴力事件进行调查。为减少回忆偏倚的发生,对于暴力的详细描述只调查过去12个月中印象最深刻的一次暴力事件；③调查前取得每家医院相关领导的支持,做好科主任和护士长的动员和培训工作,以确保调查工作顺利完成；④调查样本包含了不同级别、性质、地理位置的20家医院,样本量大,具有较好的代表性；⑤回收的调查表严格按统一标准筛选,排除无效问卷后,由专人录入。
结果
本研究共调查了广州市辖区内20家不同级别医院共7198名在岗工作人员。有3家医院因种种原因造成调查表回收率过低被全部弃用(共111份)。最终实际作为本次研究对象者为来自17家医院的5950名工作人员,共收回调查表5147份,应答率为86.50%(5147/5950)。5147份调查表经过逐一筛选,排除无效问卷(86份),得到有效问卷5061份,有效应答率为98.33%(5061/5147)。最终分析结果显示,5061名医院工作人员在过去的12个月中遭受工作场所暴力者2947人,工作场所暴力的发生率为58.23%。其中心理暴力的发生率为56.85%,身体暴力的发生率为12.85%,性暴力的发生率为6.99%。至少有14名医院工作人员曾因暴力伤害造成了身体功能障碍或永久残疾,7人曾遭受强奸(或强奸未遂)。急诊科、精神病医院工作人员,医生和护士,正式职工,男性、年龄小于30岁的工作人员是医院工作场所暴力的危险职业人群。心理暴力以急诊科工作人员发生率最高,为83.02%,身体暴力和性暴力则以精神病医院工作人员发生率最高,分别为45.10%和20.23%。病人亲属、年龄在40岁以下,尤其是31—40岁的男性施暴者是医院工作场所暴力最常见的施暴者人群；病房和白班时间分别是医院工作场所暴力最常见发生地点和发生时间。工作场所暴力发生的原因包括病人死亡、病人意识不清、酗酒或药物滥用、施暴者精神障碍、病情无好转、诊疗费用太高、候诊时间过长、对服务不满意、未满足病人的要求等因素。
结论
广州市辖区内医院工作场所暴力高发,发生率为58.23%。医院工作场所暴力以心理暴力为主,心理暴力的发生率为56.85%,身体暴力的发生率为12.85%,与国际上同类研究相似。性暴力的发生率为6.99%,迄今尚未检索到国内外有关针对医院职业人群性暴力发生情况的专业研究。医院工作场所暴力危害严重,造成受害者身体、心理和精神上的伤害。如前所述,心理暴力发生率极高,尤其是在急诊科工作人员中,发生率高达83.02%,很少有人能幸免；身体暴力和性暴力的发生尽管不及心理暴力普遍,但其所造成的后果比心理暴力严重得多。医院工作场所暴力还给受害者个人、医院和国家带来沉重的经济负担。医生或护士,正式职工,男性、年龄小于的30岁的工作人员等是医院工作场所暴力的危险职业人群。医院工作场所暴力的干预重点应落实在急诊科、精神病医院工作人员。建议在二级或以上综合性医院急诊科以及精神病医院加强安全保卫工作,增加员工工作场所暴力防范意识。医院工作场所暴力的高危因素来自于医院(医院管理部门及医务工作者个人)和病人两个方面,包括病人死亡、病人意识不清、酗酒或药物滥用、施暴者精神障碍、病情无好转、诊疗费用太高、候诊时间过长、对服务不满意、未满足病人的要求等。其中未满足病人的要求、病情无好转、诊疗费用太高最容易导致医院工作场所暴力的发生,特别是未满足病人的要求,对23.40%的暴力事件难辞其咎。该结果提示医院应规范管理、提高服务质量与诊疗技术,卫生行政部门推行、促进及深化医疗卫生改革迫在眉睫,亦势在必行。工作场所暴力尚未引起全社会的重视,打骂医务人员被认为是不必大惊小怪的小事,医院工作人员中也有1/5左右的人从未听说过工作场所暴力和认为没有必要重视这一问题。工作场所暴力的预防与控制是一项系统工程,建议从政策、管理、工程、教育等多方面实施干预。在所有干预措施中,政策干预是关键,建议卫生行政部门就医院工作场所暴力问题立法,并成立包括流行病学、立法、司法及公安等领域的专家组成工作场所暴力防治委员会(或防治小组),处理工作场所暴力相关问题和提供法律及专业指导。此外,开展职业道德、职业安全和尊重医务人员工作的宣传,营造讲文明的社会风尚亦是防制工作场所暴力的重要措施。
Background and Objective:
Violence inevitably is a serious problem to social security for a country or district. And violence, which has permeated everywhere, in fact, can be probed in all kinds of hospitals. The main cause why violence was neglected by all is the shortage of an obvious definition. There was no complete and suitable definition in the past few years on violence although it is always needed. The only one was given by World Health Organization in the year of 2005 like this:Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health. Three key points should be included on this term of definition.1 the incident of violence is found out in the very workplace,2 the duration of time is completely unanimous to the work shift, and 3 health staffs are the only victims. Workplace violence is classified in three different types according to the accurate body locations about violence experience:Physical violence, psychological violence and sexual violence. Physical violence is the use of physical force against another person or group, which results in physical, sexual or psychological harm. It includes among others, beating, kicking, slapping, stabbing, shooting, pushing, biting and pinching. Psychological violence is intentional use of power, including threat of physical force, against another person or group, which can result in harm to physical, mental, spiritual, moral or social development. It includes verbal abuse, bullying/mobbing, harassment and threats. Sexual harassment is any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to feel threatened, humiliated or embarrassed. Physical and psychological violence often overlap in practice making any attempt to categorize different forms of violence very difficult. Some of the most frequently used terms relating to violence are presented below. Assault/attack is intentional behavior that harms another person physically, including sexual assault. Abuse is behavior that humiliates, degrades or otherwise indicates a lack of respect for the dignity and worth of an individual. Bullying/mobbing is repeated and over time offensive behavior through vindictive, cruel or malicious attempts to humiliate or undermine an individual or groups of employees. Threat is promised use of physical force or power (i.e. psychological force) resulting in fear of physical, sexual, psychological harm or other negative consequences to the targeted individuals or groups. While the existence of personal physical violence at the workplace has always been recognized, the existence of psychological violence has been long under-estimated and only now receives due attention. Psychological violence is currently emerging as a priority concern at the workplace. It is also increasingly recognized that personal psychological violence is often perpetrated through repeated behavior, of a type which by itself may be relatively minor but which cumulatively can become a very serious form of violence. Although a single incident can suffice, psychological violence often consists of repeated, unwelcome, unreciprocated and imposed upon action which may have a devastating effect on the victim. So far, workplace violence problem is still not be paid so much attention on in China and no regulations or laws on it is found either. Professional studies on workplace violence in the field of epidemiology is not launched at all. At the same time, the result of research of workplace violence from abroad is not for sure fit for us China because of the special culture background, health facility and administrative regulation. A well-designed survey to a group of representative sample from a definite scope might show the prevalence and risk factors on workplace violence. All in one word, the basic objective of this project is to probe into prevalence of workplace violence in hospitals and analyze its related factors to lay a basis for maintaining normal working order in hospital and lawmaking against workplace violence.
Method:
Guangzhou City governs ten districts and other two counties. This research aimed on 7 198 hospital staff from 20 different health facilities located in Guangzhou city and all violence experiences received by them in the past 12 months were investigated. Every employee is eligible to this survey following the statistic method of cluster sampling and sratified sampling at the same time. The definition is given according to the latest definition of workplace violence from World Health Organization as below:any events that occurred to hospital staff, who suffered psychological, physical and/or sexual violence at work or on duty during the past 12 months preceding the survey. Social statistic database software tool SPSS 17.0 is used to analyze relative factors of workplace violence. All statistic variables include the epidemiological features of workplace violence from descriptive study, relative character variables from Chi-square test, and some risk factors from logistic regression model. Quality control were also considered in this research like:1 Closed questionnaire is used to reduce the subjective declare and aim of investigation, require and approach of finishing the form are given at the same time in the content; 2 Only the events occurring in the past 12 months proceeding this research are investigated to avoid the recalling bias; 3 Support and comprehension are gained from the supervisors from every hospital to make the survey work smooth; 4 The sample of research are large enough to represent all health facilities in Guangzhou city although we chose 20 health units with different grade, nature, level and location; 5 All questionnaires are held in and determined using the only criteria made before the stage of research design. Authorized professionals were charge in typing every questionnaire after deleting some which were thought invalid according to the criteria.
Results:
7 198 health staff from 20 hospitals with different grade, level, and location were involved in this investigation. Only 3 hospitals were rejected from this research because of the low receiving rate with the number of one hundred and eleven. The terminal objective populations were the 5950 health workers from seventeen hospitals.5147 survey forms are received with a replying rate 86.50 percent (5147/5 950). After screening following the defined principle,5 061 questionnaires were left eventually as valid forms and the valid replying rate was 98.33 percent (5 061/5 147). Among 5 061 hospital staffs investigated,2 947 have been subjected to workplace violence in the last 12 months preceding the survey, with a rate of 58.23%, accounting for 56.85% of psychological violence,12.85% of physical violence and 6.99% of sexual violence respectively. At least 14 health staff at various hospitals had been disabled or suffering from physical handicap due to violence, and 7 were victims of rape or attempted rape. Psychological violence occurred mostly to those working in the Emergency Departments,83.02% of the total, and physical and sexual assaults usually happened to staff in psychiatric hospitals,45.10% and 20.23% for each. Staffs who were most prone to violence in hospitals were those working in the Emergency Departments, psychiatrists, doctors and nurses, permanent staff, male below 30. Those who were apt to commit such violence to staff at work were relatives of patients, aged below 40, especially male between 31 and 40. Wards and day shifts were the location and time most likely for violence in hospital. The causes of such violence might be what happened to patients:their death, loss of consciousness, intoxication or abuse of drugs, committers' mental problems, lack of improvement in the patients' conditions, high treatment cost, lengthy waiting queues, dissatisfaction with the service or their requirements unmet, etc.
Conclusion:
Prevalence of violence in hospitals all over Guangzhou city was quite high, recorded at 58.23%, and psychological violence,56.85%, was the major form. The rate of physical violence is 12.85 percent, which is suitable to peer result from other countries. Sexual violence, with a rate of 6.99%, is almost the only result about violence in hospital professional groups all around the world so far. Psychological violence has the highest rate, especially in Emergency Department, which is 83.02 percent, so that no staff working there can avoid not being harmed by the very kind of violence. Although the rates of physical violence and sexual violence do not go that high, these two types of violence do much harm to the victims of violence at degree of injuries. Among 2 661 hospital staff victims investigated in this research 14 were heavily harmed to disability or death for violence and other 7 were raped or attempted to rape. Harm from violence in workplace should never be belittled, for such violence might cause physical, mental and psychological trouble to the victims, bringing out heavy economic burden to the victims themselves, their hospitals or even the state as a whole. Staff in the Emergency Departments of hospitals, psychiatrists, doctors and nurses, permanent staff and male below 30 should be protected. We suggest that hospitals at grade 2 or above should strengthen safety security and all employees should learn to protect themselves against workplace violence. The causes of violence in hospitals might come from both the hospitals (the management and medical staff) and the patients like:death of patient, unconscious of patient, abuse of alcohol or drugs, mental disorder of perpetrator patient, no recovering or turning better as expected, high price on medicine or treatment, long time duration for clinic, dissatisfaction on serving from health staff, and patients' require not hitting its need. Amongst all factors listed above, high price on medicine or treatment, no recovering or turning better as expecting, and patients' require not hitting its need were more likely to bring about workplace violence. And the last one was responsible to 23.40 percent of violence found in this research. Results from this project show that administrators of hospitals should work hard in regulation, quality, and technology, and supervisors supervising hospitals should deepen to reform the health policies. Workplace violence does not yet catch the public's eyes so far and violence is considered one common phenomenon happening at hospitals.1/5 of health staff investigated in this research has never heard about this professional term workplace violence at all in his working career. Prevention and control of such violence was a complex system work, calling for working from various aspects such as policy, management, engineering as well as education and so forth. Furthermore, education on occupation moral, professional safety, and respect to health staff could assist in making better social circumstance and preventing and controlling workplace violence.
暴力是一个国家和地区无可讳言的社会安全问题。广泛渗透于社会各个领域的暴力并没有被阻隔于医院之外,实际上,社会暴力正流向医院,卫生工作人员在其工作场所遭受暴力对待经常发生。暴力作为公共卫生问题被忽略的原因之一是缺乏明确的定义。关于工作场所暴力,国际上过去一直没有完整而统一的定义。世界卫生组织关于工作场所暴力的最新定义是：工作人员在其工作场所,受到辱骂、威胁或袭击,从而造成对其安全、幸福或健康的明确或含蓄的挑战。此概念的拓展解释还包括以下三点：①暴力事件必须发生在工作场所；②暴力发生在工作人员上班期间；③暴力受害者一定是工作人员。按照受害者遭受暴力的部位不同,工作场所暴力分为心理暴力、身体暴力和性暴力。心理暴力是指故意用力(含体力威胁)反对他人或集体,从而导致对身体、脑力、精神、道义和社会发展的损害,包括口头的辱骂、威胁、攻击和折磨,但当事人之间没有身体接触。身体暴力指任何以体力伤害身体的攻击行为,例如打、踢、拍、扎、推、咬等。体力攻击的结果可能未导致承受暴力的一方任何伤害,也可能造成轻度损伤、明显损伤、功能障碍或永久性残疾等。性暴力是指任何违背受害者意愿的有关性的言语和动作,包括性骚扰(或性挑逗)、性袭击以及强奸(或强奸未遂)。到目前为止,国内的情况是,一方面,社会各界对医院工作场所问题未予足够的重视,尚未见到比较成熟的相关行政法律条文,工作场所暴力方面的专业研究开展得并不多；另一方面,由于国内政治经济及文化背景、医院配置、卫生管理制度等方面和国外不太一样,故其他国家有关工作场所暴力的研究成果及防治经验也就不一定完全适合我国。在一定范围内对有代表性人群进行抽样调查,可以反应某一种暴力在特定时间中的发生情况。通过在广州市辖区内医院开展工作场所暴力流行病学调查,探讨医院工作场所暴力发生现况及影响因素,可以为如何处理存在已久的医患纠纷问题提供新的思路和解决之道。只有处理好医患纠纷,解决好医患矛盾,才能保障医院正常的医疗秩序,还医务人员一个宽松安全的工作场所,还病人一个舒适满意的诊疗环境。本研究通过在广州市辖区内部分医院开展工作场所暴力流行病学调查,探讨医院工作场所暴力发生现况及影响因素,最终旨在提供国内有关医院工作场所暴力的基线资料,唤起广大一线卫生工作人员乃至全社会对医院工作场所暴力问题的重视,同时为卫生行政部门制定医院工作场所暴力预防与控制措施以及维护医院正常工作秩序提供理论依据。
方法
广州市下辖10个区、2个县级市。本研究以广州市辖区内12个行政区划的20家不同级别医院共7198名在岗工作人员作为研究对象。此次调查的医院在岗工作人员包括在医院工作的所有职业人群,例如医生、护士、临床工人、医技人员、行政人员、后勤人员和保卫人员等,因休假、出差、旅游或外出学习等原因而不在岗达一周以上的工作人员不在本次研究之列。本研究采取整群抽样与分层抽样相结合的调查方法。首先,将广州市辖区内医院总体按行政区划分成12个群；其次,按医院级别将每个群分成3个组别,并在每个组别中随机抽取一定数量的医院,抽取拟调查的医院；最后,对于被抽中的医院,原则上将所有医院工作人员作为研究对象。每家医院在经过培训的调查专职人员(各科室主任和／或护士长)指导下,所有在岗工作人员在同一时间段内(一般1—3天,最长不超过7天)集中填写调查前12个月在医院场所本人所遭受的暴力情况,然后由各科室主任和／或护士长逐一收回本科室调查表。根据世界卫生组织的有关文件和工作场所暴力的定义设计调查表,此调查表经不同年龄的医院工作人员试填,收集反馈意见,根据发现的问题和反馈的意见对调查表的项目进行补充、修改和删除；修改后的调查表先在一家医院进行小样本(30人)的预调查,再次校正调查表。正式调查开始后调查表的内容不再做任何改动。医院工作场所暴力定义如下：卫生工作人员本人在工作时间内,在医院场所遭受到心理暴力、身体暴力和(或)性暴力。本研究使用社会学统计软件包SPSS17.0进行调查表的录入和数据分析处理。包括对医院工作场所暴力的流行特征作统计描述,针对暴力相关特征及暴力认知作卡方检验。建立单因素及多因素logistic回归模型,分析探讨工作场所暴力经历与受访者相关因素的关系。第一步,将8个受访者相关因素逐一进行单因素二分类logistic回归分析,筛选出包括性别、年龄、教育程度、婚姻状况、聘用形式、职业类别和工龄等7个特征变量；第二步,为了排除混杂因素的干扰,就单因素回归筛选出来的变量采用向后删除法进行多因素logistic回归分析,最终共有4个变量进入回归模型,分别是受访者性别、年龄、聘用形式、职业类别。本次研究采取以下质量控制方法：①采用封闭式调查表,减少了受访者主观臆断,每份调查表简明附上调查的目的、要求及填写方法,使受访者一目了然,也减少了顾虑；②只对过去12月中发生的暴力事件进行调查。为减少回忆偏倚的发生,对于暴力的详细描述只调查过去12个月中印象最深刻的一次暴力事件；③调查前取得每家医院相关领导的支持,做好科主任和护士长的动员和培训工作,以确保调查工作顺利完成；④调查样本包含了不同级别、性质、地理位置的20家医院,样本量大,具有较好的代表性；⑤回收的调查表严格按统一标准筛选,排除无效问卷后,由专人录入。
结果
本研究共调查了广州市辖区内20家不同级别医院共7198名在岗工作人员。有3家医院因种种原因造成调查表回收率过低被全部弃用(共111份)。最终实际作为本次研究对象者为来自17家医院的5950名工作人员,共收回调查表5147份,应答率为86.50%(5147/5950)。5147份调查表经过逐一筛选,排除无效问卷(86份),得到有效问卷5061份,有效应答率为98.33%(5061/5147)。最终分析结果显示,5061名医院工作人员在过去的12个月中遭受工作场所暴力者2947人,工作场所暴力的发生率为58.23%。其中心理暴力的发生率为56.85%,身体暴力的发生率为12.85%,性暴力的发生率为6.99%。至少有14名医院工作人员曾因暴力伤害造成了身体功能障碍或永久残疾,7人曾遭受强奸(或强奸未遂)。急诊科、精神病医院工作人员,医生和护士,正式职工,男性、年龄小于30岁的工作人员是医院工作场所暴力的危险职业人群。心理暴力以急诊科工作人员发生率最高,为83.02%,身体暴力和性暴力则以精神病医院工作人员发生率最高,分别为45.10%和20.23%。病人亲属、年龄在40岁以下,尤其是31—40岁的男性施暴者是医院工作场所暴力最常见的施暴者人群；病房和白班时间分别是医院工作场所暴力最常见发生地点和发生时间。工作场所暴力发生的原因包括病人死亡、病人意识不清、酗酒或药物滥用、施暴者精神障碍、病情无好转、诊疗费用太高、候诊时间过长、对服务不满意、未满足病人的要求等因素。
结论
广州市辖区内医院工作场所暴力高发,发生率为58.23%。医院工作场所暴力以心理暴力为主,心理暴力的发生率为56.85%,身体暴力的发生率为12.85%,与国际上同类研究相似。性暴力的发生率为6.99%,迄今尚未检索到国内外有关针对医院职业人群性暴力发生情况的专业研究。医院工作场所暴力危害严重,造成受害者身体、心理和精神上的伤害。如前所述,心理暴力发生率极高,尤其是在急诊科工作人员中,发生率高达83.02%,很少有人能幸免；身体暴力和性暴力的发生尽管不及心理暴力普遍,但其所造成的后果比心理暴力严重得多。医院工作场所暴力还给受害者个人、医院和国家带来沉重的经济负担。医生或护士,正式职工,男性、年龄小于的30岁的工作人员等是医院工作场所暴力的危险职业人群。医院工作场所暴力的干预重点应落实在急诊科、精神病医院工作人员。建议在二级或以上综合性医院急诊科以及精神病医院加强安全保卫工作,增加员工工作场所暴力防范意识。医院工作场所暴力的高危因素来自于医院(医院管理部门及医务工作者个人)和病人两个方面,包括病人死亡、病人意识不清、酗酒或药物滥用、施暴者精神障碍、病情无好转、诊疗费用太高、候诊时间过长、对服务不满意、未满足病人的要求等。其中未满足病人的要求、病情无好转、诊疗费用太高最容易导致医院工作场所暴力的发生,特别是未满足病人的要求,对23.40%的暴力事件难辞其咎。该结果提示医院应规范管理、提高服务质量与诊疗技术,卫生行政部门推行、促进及深化医疗卫生改革迫在眉睫,亦势在必行。工作场所暴力尚未引起全社会的重视,打骂医务人员被认为是不必大惊小怪的小事,医院工作人员中也有1/5左右的人从未听说过工作场所暴力和认为没有必要重视这一问题。工作场所暴力的预防与控制是一项系统工程,建议从政策、管理、工程、教育等多方面实施干预。在所有干预措施中,政策干预是关键,建议卫生行政部门就医院工作场所暴力问题立法,并成立包括流行病学、立法、司法及公安等领域的专家组成工作场所暴力防治委员会(或防治小组),处理工作场所暴力相关问题和提供法律及专业指导。此外,开展职业道德、职业安全和尊重医务人员工作的宣传,营造讲文明的社会风尚亦是防制工作场所暴力的重要措施。
Background and Objective:
Violence inevitably is a serious problem to social security for a country or district. And violence, which has permeated everywhere, in fact, can be probed in all kinds of hospitals. The main cause why violence was neglected by all is the shortage of an obvious definition. There was no complete and suitable definition in the past few years on violence although it is always needed. The only one was given by World Health Organization in the year of 2005 like this:Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health. Three key points should be included on this term of definition.1 the incident of violence is found out in the very workplace,2 the duration of time is completely unanimous to the work shift, and 3 health staffs are the only victims. Workplace violence is classified in three different types according to the accurate body locations about violence experience:Physical violence, psychological violence and sexual violence. Physical violence is the use of physical force against another person or group, which results in physical, sexual or psychological harm. It includes among others, beating, kicking, slapping, stabbing, shooting, pushing, biting and pinching. Psychological violence is intentional use of power, including threat of physical force, against another person or group, which can result in harm to physical, mental, spiritual, moral or social development. It includes verbal abuse, bullying/mobbing, harassment and threats. Sexual harassment is any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to feel threatened, humiliated or embarrassed. Physical and psychological violence often overlap in practice making any attempt to categorize different forms of violence very difficult. Some of the most frequently used terms relating to violence are presented below. Assault/attack is intentional behavior that harms another person physically, including sexual assault. Abuse is behavior that humiliates, degrades or otherwise indicates a lack of respect for the dignity and worth of an individual. Bullying/mobbing is repeated and over time offensive behavior through vindictive, cruel or malicious attempts to humiliate or undermine an individual or groups of employees. Threat is promised use of physical force or power (i.e. psychological force) resulting in fear of physical, sexual, psychological harm or other negative consequences to the targeted individuals or groups. While the existence of personal physical violence at the workplace has always been recognized, the existence of psychological violence has been long under-estimated and only now receives due attention. Psychological violence is currently emerging as a priority concern at the workplace. It is also increasingly recognized that personal psychological violence is often perpetrated through repeated behavior, of a type which by itself may be relatively minor but which cumulatively can become a very serious form of violence. Although a single incident can suffice, psychological violence often consists of repeated, unwelcome, unreciprocated and imposed upon action which may have a devastating effect on the victim. So far, workplace violence problem is still not be paid so much attention on in China and no regulations or laws on it is found either. Professional studies on workplace violence in the field of epidemiology is not launched at all. At the same time, the result of research of workplace violence from abroad is not for sure fit for us China because of the special culture background, health facility and administrative regulation. A well-designed survey to a group of representative sample from a definite scope might show the prevalence and risk factors on workplace violence. All in one word, the basic objective of this project is to probe into prevalence of workplace violence in hospitals and analyze its related factors to lay a basis for maintaining normal working order in hospital and lawmaking against workplace violence.
Method:
Guangzhou City governs ten districts and other two counties. This research aimed on 7 198 hospital staff from 20 different health facilities located in Guangzhou city and all violence experiences received by them in the past 12 months were investigated. Every employee is eligible to this survey following the statistic method of cluster sampling and sratified sampling at the same time. The definition is given according to the latest definition of workplace violence from World Health Organization as below:any events that occurred to hospital staff, who suffered psychological, physical and/or sexual violence at work or on duty during the past 12 months preceding the survey. Social statistic database software tool SPSS 17.0 is used to analyze relative factors of workplace violence. All statistic variables include the epidemiological features of workplace violence from descriptive study, relative character variables from Chi-square test, and some risk factors from logistic regression model. Quality control were also considered in this research like:1 Closed questionnaire is used to reduce the subjective declare and aim of investigation, require and approach of finishing the form are given at the same time in the content; 2 Only the events occurring in the past 12 months proceeding this research are investigated to avoid the recalling bias; 3 Support and comprehension are gained from the supervisors from every hospital to make the survey work smooth; 4 The sample of research are large enough to represent all health facilities in Guangzhou city although we chose 20 health units with different grade, nature, level and location; 5 All questionnaires are held in and determined using the only criteria made before the stage of research design. Authorized professionals were charge in typing every questionnaire after deleting some which were thought invalid according to the criteria.
Results:
7 198 health staff from 20 hospitals with different grade, level, and location were involved in this investigation. Only 3 hospitals were rejected from this research because of the low receiving rate with the number of one hundred and eleven. The terminal objective populations were the 5950 health workers from seventeen hospitals.5147 survey forms are received with a replying rate 86.50 percent (5147/5 950). After screening following the defined principle,5 061 questionnaires were left eventually as valid forms and the valid replying rate was 98.33 percent (5 061/5 147). Among 5 061 hospital staffs investigated,2 947 have been subjected to workplace violence in the last 12 months preceding the survey, with a rate of 58.23%, accounting for 56.85% of psychological violence,12.85% of physical violence and 6.99% of sexual violence respectively. At least 14 health staff at various hospitals had been disabled or suffering from physical handicap due to violence, and 7 were victims of rape or attempted rape. Psychological violence occurred mostly to those working in the Emergency Departments,83.02% of the total, and physical and sexual assaults usually happened to staff in psychiatric hospitals,45.10% and 20.23% for each. Staffs who were most prone to violence in hospitals were those working in the Emergency Departments, psychiatrists, doctors and nurses, permanent staff, male below 30. Those who were apt to commit such violence to staff at work were relatives of patients, aged below 40, especially male between 31 and 40. Wards and day shifts were the location and time most likely for violence in hospital. The causes of such violence might be what happened to patients:their death, loss of consciousness, intoxication or abuse of drugs, committers' mental problems, lack of improvement in the patients' conditions, high treatment cost, lengthy waiting queues, dissatisfaction with the service or their requirements unmet, etc.
Conclusion:
Prevalence of violence in hospitals all over Guangzhou city was quite high, recorded at 58.23%, and psychological violence,56.85%, was the major form. The rate of physical violence is 12.85 percent, which is suitable to peer result from other countries. Sexual violence, with a rate of 6.99%, is almost the only result about violence in hospital professional groups all around the world so far. Psychological violence has the highest rate, especially in Emergency Department, which is 83.02 percent, so that no staff working there can avoid not being harmed by the very kind of violence. Although the rates of physical violence and sexual violence do not go that high, these two types of violence do much harm to the victims of violence at degree of injuries. Among 2 661 hospital staff victims investigated in this research 14 were heavily harmed to disability or death for violence and other 7 were raped or attempted to rape. Harm from violence in workplace should never be belittled, for such violence might cause physical, mental and psychological trouble to the victims, bringing out heavy economic burden to the victims themselves, their hospitals or even the state as a whole. Staff in the Emergency Departments of hospitals, psychiatrists, doctors and nurses, permanent staff and male below 30 should be protected. We suggest that hospitals at grade 2 or above should strengthen safety security and all employees should learn to protect themselves against workplace violence. The causes of violence in hospitals might come from both the hospitals (the management and medical staff) and the patients like:death of patient, unconscious of patient, abuse of alcohol or drugs, mental disorder of perpetrator patient, no recovering or turning better as expected, high price on medicine or treatment, long time duration for clinic, dissatisfaction on serving from health staff, and patients' require not hitting its need. Amongst all factors listed above, high price on medicine or treatment, no recovering or turning better as expecting, and patients' require not hitting its need were more likely to bring about workplace violence. And the last one was responsible to 23.40 percent of violence found in this research. Results from this project show that administrators of hospitals should work hard in regulation, quality, and technology, and supervisors supervising hospitals should deepen to reform the health policies. Workplace violence does not yet catch the public's eyes so far and violence is considered one common phenomenon happening at hospitals.1/5 of health staff investigated in this research has never heard about this professional term workplace violence at all in his working career. Prevention and control of such violence was a complex system work, calling for working from various aspects such as policy, management, engineering as well as education and so forth. Furthermore, education on occupation moral, professional safety, and respect to health staff could assist in making better social circumstance and preventing and controlling workplace violence.
引文
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[11]Peek-Asa C, Casteel C, Allareddy V, et al. Workplace violence prevention programs in hospital emergency departments. American College of Occupational and Environmental Medicine.2007,49:756-764.
[12]Davis S. Violence in psychiatric inpatients:a review.Hospital community psychiatry,1991,42:585-590.
[13]Flannery RB,Hanson MA,Penk WE. Risk factors for psychiatric inpatient assaults on staff.J Ment Health Administration,1994,21:24-31.
[14]Hunter M,Carmel H. The cost of staff injuries from inpatient violence. Hosp Community Psychiatry,1992,43:586-588.
[15]Chen WC, Wang JD. Workplace Violence on workers caring for long-term institutionalized Schizophrenic patients in Taiwan. J Occup Health.2007,49: 311-316.
[16]Hegney D, Eley R, Dip AP, et al. Workplace violence in Queensland, Austrilia:The results of a comparative study. International Journal of Nursing Practice.2006,12:220-231.
[17]Reid WH, Bollinger FM,Edwards JG. Serious assaults by inpatients. Psychosomatics,1989,30:54-56.
[18]Paola F, Malik T, Qureshi A. Violence against physicians. J Gen Intern Med, 1994,9:503-506.
[19]Greg W. National crime victimization survey-workplace violence,1992-1996. Bureau of Justice Statistics Special Report.1998,NCJ168634.
[20]Graydon J, Kasta W, Khan P. Verbal and physical abuse of nurses. Canadian Journal of Nursing,1994,7:70-89.
[21]Chalermrat Kamchuchat, Virasakdi Chongsuvivatwong, Suparnee Oncheuntit, et al. Workplace violence directed at nursing staff at a general hospital in Southern Thailand. J Occup Health.2008,50:201-207.
[22]Raeda Fawzi Abualrub, Mohammed F Khalifa, Mohammed Bakir Habbib. Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship.2007,39:281-288.
[23]Paterson B, Leadbetter D, Bowie V. Supporting nursing staff exposed to violence at work.International Journal of Nursing Studies,1999,36:479-486.
[24]Ergun FS, Karadakoran A. Violence towards nursing staff in emergency departments in one Turkish city. International Council of Nurses.2005,52: 154-160.
[25]Lenhoff K,McCarthy M. Depression subtyping in PTSD patients. Ann. Clin. Psychiatry,1997,9:235-240.
[26]Caldwell M F. Incidence of PTSD among staff victims of patient violence. Hospital and Community Psychiatry,1992,43:838-839.
[27]Available at:http://www.dartmouth.edu/Bbhstamm/ts.htm.
[28]Available at:http://www.trauma-pages.com/pg2.htm.
[29]王声湧.伤害：威胁年轻一代健康的严重卫生问题.中华预防医学杂志,2000,34：197-198.
[30]王声湧,池桂波.伤害的社会代价及其研究方法.中华预防医学杂志,2001,35：133-134.
[31]NIOSH. Violence:Occupational Hazards in Hospitals. DHHS (NIOSH) Publication No.2002,101.
[32]陈祖辉,王声湧,荆春霞.广州市两所医院工作场所暴力现象调查.中华预防医学杂志,2003,37： 358-360.
[33]Arnetz JE,Arnetz BB. Violence towards health care staff and possible effects on the quality of patient care. Social Science and Medicine,2001,52:417-427.
[34]Whittington R. Violence in psychiatric hospitals, Violence and Health Care,1994,20:21-24.
[35]Hunter M, Carmel H. The cost of staff injuries from inpatient violence. Hospital and Community Psychiatry,1992,43:586-588.
[36]Miller TR, Cohen MA, Rossman SB. Victim costs of violent crime and resulting injuries. Health Affairs,1993,12:186-197
[37]Crilly J, Chaboyer W, Creedy D. Violence towards emergency department nurses by patients. Accident and Emergency Nursing.2004,12:67-73.
[38]Privitera M, Weisman R, Cerulli C, et al. Violence toward mental health staff and safety in the work environment. Occupational Medicine.2005,55: 480-486.
[39]Stouffer K, Varnes J. Workplace violence:Implications for health promotion. Journal of Health Education,1998,29:140-143.
[40]Hofeldt RL. Medical workplace violence.Primary Care Update for OB/GYNs,2001,8:127-131.
[41]Lipscomb J, McPhaul K, Rosen J, et al. Violence Prevention in the Mental Health Setting:The New York State Experience. CJNR.2006,38:96-117.
[42]Saines JC. Violence and aggression in A & E:recommendations for action. Accid Emerg Nurs 1999,7:8-12.
[43]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health:summary. Geneva:World Health Organization Press,2002,44.
[44]Stith KG. Violence in the workplace:the armed and angry employee. Brief,1999,Fall:8-19.
[45]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health. Geneva:World Health Organization Press,2002,175.
[46]Flannery RB,Hanson MA, Penk W. Patients'threats:Expanded definition of assault. General Hospital Psychriatry,1995,17:451-453.
[47]Goodman R,Jenkins L,Mercy J. Workplace-Related Homicide Among Health Care Workers in the United States. Jama,1994,272:1686-1688.
[48]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health. Geneva:World Health Organization Press,2002,174-162
[49]Adib SM, Al-Shatti AK,Kamal S, et al. Violence against nurses in healthcare facilities in Kuwait International Journal of Nursing Studies,2002,39: 469-478.
[50]Fleming J. The long-term impact of childhood sexual abuse in Australian women. Child Abuse & Neglect,1999,23:145-159.
[51]Rice ME, Harris GT. Violent recidivism:assessing predictive validity. Journal of Consulting and Clinical Psychology,1995,63:737-748.
[52]Blackburn R, Coid JW. Empirical clusters of DSM-111 personality disorders in violent offenders. Journal of Personality Disorders,1999,13:18-34.
[53]Ednie KJ. Challenges for women in forensic psychiatry.San Francisco: Jossey-Bass,1996,6:43-48.
[54]Lanza ML. Nurses as patient assault victims:an update, synthesis, and recommendations. Archives of Psychiatric Nursing,1992,6:163-171.
[55]Ferns T, Diphe. Violence in the accident and emergency department-An international perspective. Accident and Emergency Nursing.2005,13: 180-185.
[56]陈祖辉,王声湧,卢业成等.医院工作场所暴力的流行病学特征及危险因素分析.中华流行病学杂志,2004,25：3-5
[57]Wykes T, Whittington R. Prevalence and predictors of early traumatic stress reactions in assaulted psychiatric nurses. Journal of Forensic Psychiatry,1998,9:643-658.
[58]Binder RL, McNiel DE. Staff gender and risk of assault on doctors and nurses. Bulletin of the American Academy of Psychiatry and Law,1994,22:545-550.
[59]Carmel H,Hunter M. Psychiatrists injured by patient attack. Bulletin of the American Academy of Psychiatry and Law,1991,9:309-316.
[60]Arnetz JE, Arnetz BB,Petterson LL. Violence in the nursing profession: occupational and lifestyle risk factors in Swedish nurses. Work and Stress,1996,10:136-140.
[61]Arnetz JE, Arnetz BB,Petterson LL. Violence in the nursing profession: occupational and lifestyle factors in Swedish nurses. Work and Stress, 1996,10:119-127.
[62]Hodge AN, Marshall AP. Violence and aggression in the emergency department:A critical care perspective. Australian Critical Care.2007,20: 61-67.
[63]Hodgkinson P,McIvor L, Phillips M,Patient assaults on sta. in a psychiatric hospital:a two year retrospective study. Medicine. Science and Law, 1985,25:288-294.
[64]Postner EC. A multinational study of psychiatric nursing staffs belief and concerns about work safety and patient assault. Archives of Psychiatric Nursing,1996,10:365-373.
[65]Love C, Hunter M. Violence in public sector psychiatric hospitals.Journal of Psychosocial Nursing and Mental Health Services,1996,34:30-34.
[66]Arnetz JE,Arnetz BB,Soderman E. Violence toward health care workers: Prevalence and incidence at a large, regional hospital in Sweden. Aaohn J,1998,46:107-114.
[67]Morrison JL, Lantos LD, Levinson W. Aggression and violence directed toward physicians. J Gen Intern Med,1998,13:556-561.
[68]Gacki-Smith J, Homeyer C, Juarez AM. Violence against nurses working in US Emergency Departments. The Journal of Nursing Adiminstration.2009, 39:340-349.
[69]Jenkins MG, Rocke LG,McNicholl BP, et al. Violence and verbal abuse against staff in accident and emergency departments:A survey of consultants in the Uk and the Republic of Ireland. J Accid Emerg Med,1998,15:262-265.
[70]Nolan P. A comparative study of the experiences of violence of English and Swedish mental health nurses.International Journal of Nursing Studies, 2001,38:419-426.
[71]Duncan SM, Hyndman K, Estabrooks CA, et al. Nurses'experience of violence in Alberta and British Columbia hospitals. Can J Nurs Res,2001,32: 57-78.
[72]James DV, Fineberg NA, Shah AK. An increase in violence on an acute psychiatric ward-A study of associated factors. Journal of Psychiatry, 1990,156:846-852.
[73]Hinchberger PA. Violence against female student nurses in the workplace. Nursing Forum.2009,44:37-47.
[74]Mayer BW, Smith FB, King CA. Factors associated with victimization of personnel in emergency departments. J Emerg Nurs,1999,25:361-366.
[75]McKay C. Violence to health care professionals. Care and medicine,1994,5: 12-16.
[76]Aderson C. Training effects to reduce reports of workplace violence in a community health care facility. Journal of Professional Nursing.2006,22: 289-295.
[77]Fottrell E, A study of violent behaviour among patients in psychiatric hospitals. British Journal of Psychiatry,1980,136:216-221.
[78]Holden RJ. Aggression against nurses. The Australian Nurses'Journal,1985,15:1544-1548.
[79]Brysiewicz P. Violent death and the South African emergency nurse.International Journal of Nursing Studies,2002,39:253-258
[80]Carol A.Protecting yourself from violence in the workplace.Nursing,2002,6: 58-63.
[81]Carmel H, Hunter M. Staff Injuries from Inpatient Violence. Hosp Commty Psych,1989,40:41-46.
[82]Hatch-Maillette MA, Scalora MJ. Gender, sexual harassment, workplace violence, and risk assessment:Convergence around psychiatric staffs perceptions of personal safety. Aggression and Violent Behavior,2002,7: 271-291.
[83]Lipscomp J, Silverstein B, Slavin TJ, et al. Perspectives on legal strategies to prevent workplace violence. The Journal of Law, Medicine,& Ethics, 2002,30:167-171.
[84]Herman AM, Jeffress CN. Guidelines for preventing workplace violence for health care and social service workers.U.S.Department of Labor and Occupational Safety and Health Administration:OSHA3148,1998:5,6.
[85]Fisher W. Restraint and seclusion:A review of the literature. American Journal of Psychiatry,1994,151:1584-1590.
[86]Kestler V. Limit setting:dealing with difficult patients. Orthop Nurs,1991,10: 19-23.
[87]Mckoy Y. Legal considerations of workplace violence in healthcare environments. Nursing Forum,2001,1:5-14.
[88]Presley D, Robinson G. Violence in the emergency department:nurses contend with prevention in the healthcare arena. Nurs Clin North Am, 2002,37:161-169.
[89]王声湧,黄庆道.伤害的预防与控制.广东.广州市辖区内地图出版社.第一版.2001,21.
[90]Lin YH, Liu HE. The impact of workplace violence on nurses in South Taiwan. International Journal of Nursing Studies.2005,42:773-778.
[2]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health. Geneva:World Health Organization Press,2002,28.
[3]Donatella Camerino, Madeleine Estryn-Behar, Paul Maurice Conway, et al. Work-related factors and violence among nursing staff in the European NEXT Study:A longitudinal Cohort Study. International Journal of Nursing Studies. 2008,45:35-50.
[4]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health: Summary. Geneva:World Health Organization Press,2002,15,16.
[5]王声湧,伤害流行病学.北京：人民卫生出版社,第一版.2003,15.
[6]陈祖辉,王声湧,卢业成等.医院工作场所暴力的流行病学特征及危险因素分析.中华流行病学杂志,2004,25：1-2.
[7]World Health Organization. New research shows workplace violence threatens health services. Press Release WHO/37,2002.
[8]Kowalenko T, Walters BL, Khare RK, et al. Workplace violence:A survey of emergency physicians in the State of Michigan. Annals of Emergency Medicine.2005,46:142-148.
[9]Krug EG, Ddhlberg LL, Mercy JA, et al. World report on violence and health. Geneva:World Health Organization Press,2002,2:29-30.
[10]American Psychiatric Association:clinician safety task force. Washington, DC, American Psychiatric Press,1992
[11]Peek-Asa C, Casteel C, Allareddy V, et al. Workplace violence prevention programs in hospital emergency departments. American College of Occupational and Environmental Medicine.2007,49:756-764.
[12]Davis S. Violence in psychiatric inpatients:a review.Hospital community psychiatry,1991,42:585-590.
[13]Flannery RB,Hanson MA,Penk WE. Risk factors for psychiatric inpatient assaults on staff.J Ment Health Administration,1994,21:24-31.
[14]Hunter M,Carmel H. The cost of staff injuries from inpatient violence. Hosp Community Psychiatry,1992,43:586-588.
[15]Chen WC, Wang JD. Workplace Violence on workers caring for long-term institutionalized Schizophrenic patients in Taiwan. J Occup Health.2007,49: 311-316.
[16]Hegney D, Eley R, Dip AP, et al. Workplace violence in Queensland, Austrilia:The results of a comparative study. International Journal of Nursing Practice.2006,12:220-231.
[17]Reid WH, Bollinger FM,Edwards JG. Serious assaults by inpatients. Psychosomatics,1989,30:54-56.
[18]Paola F, Malik T, Qureshi A. Violence against physicians. J Gen Intern Med, 1994,9:503-506.
[19]Greg W. National crime victimization survey-workplace violence,1992-1996. Bureau of Justice Statistics Special Report.1998,NCJ168634.
[20]Graydon J, Kasta W, Khan P. Verbal and physical abuse of nurses. Canadian Journal of Nursing,1994,7:70-89.
[21]Chalermrat Kamchuchat, Virasakdi Chongsuvivatwong, Suparnee Oncheuntit, et al. Workplace violence directed at nursing staff at a general hospital in Southern Thailand. J Occup Health.2008,50:201-207.
[22]Raeda Fawzi Abualrub, Mohammed F Khalifa, Mohammed Bakir Habbib. Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship.2007,39:281-288.
[23]Paterson B, Leadbetter D, Bowie V. Supporting nursing staff exposed to violence at work.International Journal of Nursing Studies,1999,36:479-486.
[24]Ergun FS, Karadakoran A. Violence towards nursing staff in emergency departments in one Turkish city. International Council of Nurses.2005,52: 154-160.
[25]Lenhoff K,McCarthy M. Depression subtyping in PTSD patients. Ann. Clin. Psychiatry,1997,9:235-240.
[26]Caldwell M F. Incidence of PTSD among staff victims of patient violence. Hospital and Community Psychiatry,1992,43:838-839.
[27]Available at:http://www.dartmouth.edu/Bbhstamm/ts.htm.
[28]Available at:http://www.trauma-pages.com/pg2.htm.
[29]王声湧.伤害：威胁年轻一代健康的严重卫生问题.中华预防医学杂志,2000,34：197-198.
[30]王声湧,池桂波.伤害的社会代价及其研究方法.中华预防医学杂志,2001,35：133-134.
[31]NIOSH. Violence:Occupational Hazards in Hospitals. DHHS (NIOSH) Publication No.2002,101.
[32]陈祖辉,王声湧,荆春霞.广州市两所医院工作场所暴力现象调查.中华预防医学杂志,2003,37： 358-360.
[33]Arnetz JE,Arnetz BB. Violence towards health care staff and possible effects on the quality of patient care. Social Science and Medicine,2001,52:417-427.
[34]Whittington R. Violence in psychiatric hospitals, Violence and Health Care,1994,20:21-24.
[35]Hunter M, Carmel H. The cost of staff injuries from inpatient violence. Hospital and Community Psychiatry,1992,43:586-588.
[36]Miller TR, Cohen MA, Rossman SB. Victim costs of violent crime and resulting injuries. Health Affairs,1993,12:186-197
[37]Crilly J, Chaboyer W, Creedy D. Violence towards emergency department nurses by patients. Accident and Emergency Nursing.2004,12:67-73.
[38]Privitera M, Weisman R, Cerulli C, et al. Violence toward mental health staff and safety in the work environment. Occupational Medicine.2005,55: 480-486.
[39]Stouffer K, Varnes J. Workplace violence:Implications for health promotion. Journal of Health Education,1998,29:140-143.
[40]Hofeldt RL. Medical workplace violence.Primary Care Update for OB/GYNs,2001,8:127-131.
[41]Lipscomb J, McPhaul K, Rosen J, et al. Violence Prevention in the Mental Health Setting:The New York State Experience. CJNR.2006,38:96-117.
[42]Saines JC. Violence and aggression in A & E:recommendations for action. Accid Emerg Nurs 1999,7:8-12.
[43]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health:summary. Geneva:World Health Organization Press,2002,44.
[44]Stith KG. Violence in the workplace:the armed and angry employee. Brief,1999,Fall:8-19.
[45]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health. Geneva:World Health Organization Press,2002,175.
[46]Flannery RB,Hanson MA, Penk W. Patients'threats:Expanded definition of assault. General Hospital Psychriatry,1995,17:451-453.
[47]Goodman R,Jenkins L,Mercy J. Workplace-Related Homicide Among Health Care Workers in the United States. Jama,1994,272:1686-1688.
[48]Krug EG,Dahlberg LL,Mercy JA, et al. World report on violence and health. Geneva:World Health Organization Press,2002,174-162
[49]Adib SM, Al-Shatti AK,Kamal S, et al. Violence against nurses in healthcare facilities in Kuwait International Journal of Nursing Studies,2002,39: 469-478.
[50]Fleming J. The long-term impact of childhood sexual abuse in Australian women. Child Abuse & Neglect,1999,23:145-159.
[51]Rice ME, Harris GT. Violent recidivism:assessing predictive validity. Journal of Consulting and Clinical Psychology,1995,63:737-748.
[52]Blackburn R, Coid JW. Empirical clusters of DSM-111 personality disorders in violent offenders. Journal of Personality Disorders,1999,13:18-34.
[53]Ednie KJ. Challenges for women in forensic psychiatry.San Francisco: Jossey-Bass,1996,6:43-48.
[54]Lanza ML. Nurses as patient assault victims:an update, synthesis, and recommendations. Archives of Psychiatric Nursing,1992,6:163-171.
[55]Ferns T, Diphe. Violence in the accident and emergency department-An international perspective. Accident and Emergency Nursing.2005,13: 180-185.
[56]陈祖辉,王声湧,卢业成等.医院工作场所暴力的流行病学特征及危险因素分析.中华流行病学杂志,2004,25：3-5
[57]Wykes T, Whittington R. Prevalence and predictors of early traumatic stress reactions in assaulted psychiatric nurses. Journal of Forensic Psychiatry,1998,9:643-658.
[58]Binder RL, McNiel DE. Staff gender and risk of assault on doctors and nurses. Bulletin of the American Academy of Psychiatry and Law,1994,22:545-550.
[59]Carmel H,Hunter M. Psychiatrists injured by patient attack. Bulletin of the American Academy of Psychiatry and Law,1991,9:309-316.
[60]Arnetz JE, Arnetz BB,Petterson LL. Violence in the nursing profession: occupational and lifestyle risk factors in Swedish nurses. Work and Stress,1996,10:136-140.
[61]Arnetz JE, Arnetz BB,Petterson LL. Violence in the nursing profession: occupational and lifestyle factors in Swedish nurses. Work and Stress, 1996,10:119-127.
[62]Hodge AN, Marshall AP. Violence and aggression in the emergency department:A critical care perspective. Australian Critical Care.2007,20: 61-67.
[63]Hodgkinson P,McIvor L, Phillips M,Patient assaults on sta. in a psychiatric hospital:a two year retrospective study. Medicine. Science and Law, 1985,25:288-294.
[64]Postner EC. A multinational study of psychiatric nursing staffs belief and concerns about work safety and patient assault. Archives of Psychiatric Nursing,1996,10:365-373.
[65]Love C, Hunter M. Violence in public sector psychiatric hospitals.Journal of Psychosocial Nursing and Mental Health Services,1996,34:30-34.
[66]Arnetz JE,Arnetz BB,Soderman E. Violence toward health care workers: Prevalence and incidence at a large, regional hospital in Sweden. Aaohn J,1998,46:107-114.
[67]Morrison JL, Lantos LD, Levinson W. Aggression and violence directed toward physicians. J Gen Intern Med,1998,13:556-561.
[68]Gacki-Smith J, Homeyer C, Juarez AM. Violence against nurses working in US Emergency Departments. The Journal of Nursing Adiminstration.2009, 39:340-349.
[69]Jenkins MG, Rocke LG,McNicholl BP, et al. Violence and verbal abuse against staff in accident and emergency departments:A survey of consultants in the Uk and the Republic of Ireland. J Accid Emerg Med,1998,15:262-265.
[70]Nolan P. A comparative study of the experiences of violence of English and Swedish mental health nurses.International Journal of Nursing Studies, 2001,38:419-426.
[71]Duncan SM, Hyndman K, Estabrooks CA, et al. Nurses'experience of violence in Alberta and British Columbia hospitals. Can J Nurs Res,2001,32: 57-78.
[72]James DV, Fineberg NA, Shah AK. An increase in violence on an acute psychiatric ward-A study of associated factors. Journal of Psychiatry, 1990,156:846-852.
[73]Hinchberger PA. Violence against female student nurses in the workplace. Nursing Forum.2009,44:37-47.
[74]Mayer BW, Smith FB, King CA. Factors associated with victimization of personnel in emergency departments. J Emerg Nurs,1999,25:361-366.
[75]McKay C. Violence to health care professionals. Care and medicine,1994,5: 12-16.
[76]Aderson C. Training effects to reduce reports of workplace violence in a community health care facility. Journal of Professional Nursing.2006,22: 289-295.
[77]Fottrell E, A study of violent behaviour among patients in psychiatric hospitals. British Journal of Psychiatry,1980,136:216-221.
[78]Holden RJ. Aggression against nurses. The Australian Nurses'Journal,1985,15:1544-1548.
[79]Brysiewicz P. Violent death and the South African emergency nurse.International Journal of Nursing Studies,2002,39:253-258
[80]Carol A.Protecting yourself from violence in the workplace.Nursing,2002,6: 58-63.
[81]Carmel H, Hunter M. Staff Injuries from Inpatient Violence. Hosp Commty Psych,1989,40:41-46.
[82]Hatch-Maillette MA, Scalora MJ. Gender, sexual harassment, workplace violence, and risk assessment:Convergence around psychiatric staffs perceptions of personal safety. Aggression and Violent Behavior,2002,7: 271-291.
[83]Lipscomp J, Silverstein B, Slavin TJ, et al. Perspectives on legal strategies to prevent workplace violence. The Journal of Law, Medicine,& Ethics, 2002,30:167-171.
[84]Herman AM, Jeffress CN. Guidelines for preventing workplace violence for health care and social service workers.U.S.Department of Labor and Occupational Safety and Health Administration:OSHA3148,1998:5,6.
[85]Fisher W. Restraint and seclusion:A review of the literature. American Journal of Psychiatry,1994,151:1584-1590.
[86]Kestler V. Limit setting:dealing with difficult patients. Orthop Nurs,1991,10: 19-23.
[87]Mckoy Y. Legal considerations of workplace violence in healthcare environments. Nursing Forum,2001,1:5-14.
[88]Presley D, Robinson G. Violence in the emergency department:nurses contend with prevention in the healthcare arena. Nurs Clin North Am, 2002,37:161-169.
[89]王声湧,黄庆道.伤害的预防与控制.广东.广州市辖区内地图出版社.第一版.2001,21.
[90]Lin YH, Liu HE. The impact of workplace violence on nurses in South Taiwan. International Journal of Nursing Studies.2005,42:773-778.