Workplace abuse among correctional health professionals in New South Wales, Australia

Health professionals have a right to practise in a safe workplace, a workplace in which the risk of abuse – including physical, sexual, emotional and verbal abuse – is negligible. ^{1 – 4} Unfortunately, however, workplace abuse directed at front line health professionals is a common problem in several countries, ^{5 – 11} including Australia. ^{12 – 20} A recent systematic review of studies of the prevalence of patient-initiated abuse perpetrated against Australian general practitioners found 12 month period prevalence ratios ranging from 48 to 64%. ¹⁵ Similarly, a large study of nurses who were practising in Tasmania found a 1 month period prevalence of 64%. ¹³

In healthcare settings, incidents of workplace abuse may be perpetrated by patients, the visitors of patients, professional colleagues or non-professional staff. The negative impacts of such incidents are significant and wide ranging. In individual health professionals, exposure can lead to physical injury, anger, fear, sadness, helplessness, stress, anxiety, a loss of self-confidence and, in extreme cases, post-traumatic stress disorder and/or suicidal ideation, ^{14 , 16 , 19 , 21 – 25} all of which can place strain on relationships with work colleagues, family members and friends. ^{21 , 24 , 25} At the health facility level, workplace abuse has been linked to employee absenteeism, low workplace morale, staff turnover, reduced empathy for patients, reduced productivity at work, and increased risk of errors in the delivery of care, ^{12 , 13 , 16 , 19 , 21 , 23 – 25} all of which can undermine the quality of the delivery of health services. ^{12 , 19 , 21 , 24 , 25} In addition, the direct and indirect financial costs of workplace abuse, incurred by individuals, health organisations and the broader community, are substantial. ²⁶

The risk of workplace abuse appears to vary by health profession. Winstanley and Whittington ⁷ surveyed staff of a UK general hospital and found that a higher proportion of middle grade nurses (34%) than doctors (12%) were subjected to frequent verbal abuse while at work. Similarly, a recent Australian study found that, compared with general practitioners and allied health personnel, nurses were more susceptible to workplace abuse. ¹⁹ The risk also varies according to the practice environment. For example, Farrell et al. ¹³ found that nurses who practised in a hospital emergency department were about seven times more likely to be physically assaulted than nurses who worked in a medical general practice. Although studies have explored the magnitude of workplace abuse in a broad range of healthcare settings and among a range of health professions, little is known about the risk of abuse to nurses, doctors and other health professionals who deliver healthcare to inmates.

Many of the individual and social determinants of violence, such as impulsivity, mental illness, drug and alcohol abuse and a personal history of trauma, are disproportionately common in inmate populations. ^{27 – 29} The predisposition of some inmates to violence, coupled with the complex and often oppositional nature of the relationship between inmates and correctional staff, place correctional officers at a high risk of being abused while at work. ^{30 – 32} A few studies have explored workplace abuse among mental health professionals who were practising in forensic facilities. ^{30 , 33} It is not clear, however, whether the high risk of inmate initiated abuse among correctional officers is similarly high in correctional health professionals.

We conducted a cross-sectional, self-administered survey of workplace abuse among employees of Justice Health, a statutory health corporation established to facilitate the provision of healthcare to people who come into contact with the criminal justice system in New South Wales (NSW). The aims were to investigate the prevalence, sources and consequences of workplace abuse among staff, and to identify demographic and employment factors associated with incidents of abuse. This report describes findings among Justice Health staff who were employed as a health professional (including medical doctors, nurses and allied health professionals). Data describing workplace abuse among non-health staff are not presented here because a majority of these participants did not have direct contact with inmates.

In April 2010, all employees of Justice Health were invited via an email from the Chief Executive to complete a self-administered survey of workplace abuse. Of those who were invited to participate in the research, 710 were employed as a health professional: 590 nurses; 85 medical doctors; and 35 allied health professionals. The survey was delivered via the internet (http://www.surveymonkey.com). Because a small proportion of Justice Health employees do not have access to the internet while at work, the survey was also made available on the Justice Health intranet site for completion as a paper-based survey. Participants were instructed to return the paper-based surveys to the Centre for Health Research in Criminal Justice via the internal mail system. Following the initial invitation to participate in the study, several strategies were used to maximise the response rate, including, for example, reminder emails sent by the Centre for Health Research in Criminal Justice.

The survey included questions relating to participants’ experiences of workplace abuse (including both verbal and physical abuse) during a recall period of 3 months. A definition of workplace abuse developed by Farrell et al. ¹³ was included in the survey to provide participants with a common definition on which to base their responses. The definition describes a range of forms of workplace abuse, including physical, sexual, verbal and emotional. However, these are grouped into two categories: physical abuse and verbal abuse (Box 1). Participants who had experienced abuse were asked about the specific types experienced and the perpetrators of the incidents. They were also asked to assess the impact of such experiences on their professional practice and, in the case of clinical staff, their intention to continue practising in the corrections environment. Demographic and employment data were also collected.

To maximise the validity of the information collected and to ensure results could be compared with previous research, the survey instrument included several questions that had been used in similar cross-sectional, survey research undertaken in Queensland ¹⁴ and Tasmania. ¹³ The survey instrument was pilot tested and then modified to expand the definition of workplace abuse and remove several demographic questions.

Data were analysed using SAS 9.2 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were calculated to describe and summarise survey responses. The Chi-square test was used to explore associations among categorical variables. A P-value of <0.05 was considered statistically significant. The study was approved by the Justice Health Human Research Ethics Committee.

A total of 320 medical, nursing and allied health staff completed a survey. We excluded 21 of these because no information was provided about workplace abuse experienced during the recall period, leaving 299 usable surveys; a response rate of 42%.

As shown in Table 1, 72% of participants were women and 67% were 40 years of age or older. Few (6%) spoke a language other than English in the home they grew up in.

Table 1.  Demographic and employment characteristics of participants

A majority (84%) of participants were nurses or nurse managers (Table 1). There was a significant association between sex and profession. A higher proportion of women (88%) than men (74%) worked as a nurse, and, conversely, a higher proportion of men (20%) than women (4%) were employed as a medical doctor. Sixty one per cent of participants worked in an adult correctional centre and 85% were permanent employees. A little more than two-thirds (71%) had worked for 10 years or more as a health practitioner. On the other hand, participants’ experience working in the corrections environment was limited (23% had worked for 10 years or more in a corrections environment).

In the preceding 3 months, 76% of participants had personally experienced some form of abuse in their workplace, all but one of whom recalled verbal abuse. Only 16% reported physical abuse.

Figure 1 illustrates that being glared at (80%), yelled at or shouted at (76%), and sworn at (74%) were the most commonly reported types of abuse. A significantly higher proportion of men (19%) than women (6%) reported being hit, kicked, grabbed, shoved or pushed. Similarly, a significantly higher proportion of men (33%) than women (19%) reported that they had been threatened with physical abuse.

Fig. 1.  Types of abuse experienced among those who reported some form of abuse.

Participants were asked to rate the safety of their workplace in relation to workplace abuse (using the Likert scale: very safe; safe; unsafe; very unsafe). Seventy per cent reported feeling ‘very safe’ or ‘safe’ in their workplace.

As highlighted in Fig. 2, of those who reported physical abuse during the recall period, 94% recalled at least one incident of physical abuse where a patient was the perpetrator. Similarly, of those who reported verbal abuse, most (79%) identified a patient as the aggressor in at least one incident of verbal abuse.

Fig. 2.  Sources of workplace abuse (if any).

Almost half (48%) of those who had been subjected to verbal and/or physical abuse reported that a health worker colleague perpetrated at least one incident (Fig. 2). There was no difference among nurses, medical doctors and allied health staff in their experiences of abuse perpetrated by a health worker colleague.

Among participants who had experienced verbal abuse in the previous 3 months, 58% felt that when faced with this form of abuse, their handling of the situation was usually ‘very good’ or ‘good’. Most (85%) of these participants felt that verbal abuse either ‘frequently’ or ‘sometimes’ decreased their productivity at work, and a similarly high proportion (79%) felt that verbal abuse ‘frequently’ or ‘occasionally’ increased their potential to make mistakes while at work.

Among participants who had experienced physical abuse in the previous 3 months, 52% felt that when faced with this form of abuse, their handling of the situation was usually ‘very good’ or ‘good’. All of these participants felt that physical abuse decreased their productivity at work, and 92% felt that physical abuse increased their potential to make mistakes while at work.

Fifty per cent of those who had personally experienced abuse in their workplace during the recall period reported that they had thought about quitting their current job because of those experiences.

Table 2 highlights that a significantly higher proportion of women than men (80% v. 66%, X ²  = 6.156, d.f. = 1, P = 0.013) reported that they had been subjected to verbal abuse during the recall period. No difference was found between women and men in their experiences of physical abuse.

Table 2.  Factors associated with workplace abuse

A significantly higher proportion of participants who worked in a forensic or prison hospital than those who worked in a correctional centre (28% v. 14%, X ²  = 5.975, d.f. = 1, P = 0.015) reported physical abuse during the recall period (Table 2).

Although verbal abuse was reported by a majority of participants, a much smaller proportion reported physical abuse. Seventy per cent felt safe in their workplace. Patients were identified as the main perpetrators of workplace abuse, followed by fellow health staff. Participants felt that incidents of abuse increased their potential to make errors while providing care to patients and reduced their productivity while at work. About half of those who had experienced workplace abuse during the recall period reported that the incident(s) had prompted them to think about quitting their position. Sex was significantly associated with verbal abuse, and the practice environment was significantly associated with physical abuse.

Comparison of results of cross-sectional studies of workplace abuse is challenging due to factors such as inconsistencies in the way investigators conceptualise the phenomenon and variation in the recall periods used. We attempted to overcome these challenges by adopting a similar design to two large Australian studies: Hegney and colleagues’ cross-sectional survey of nurses who were practising in a range of healthcare settings in Queensland ¹⁴ and Farrell and colleagues’ study of workplace abuse among nurses in Tasmania. ¹³ Comparison of our results with the results of these studies is appropriate because a majority (67%) of Justice Health employees are nurses.

Our finding that 76% of participants had experienced some form of workplace abuse exceeds the 46% prevalence found in the study by Hegney et al. ¹⁴ which also used a 3 month recall period. It is important to note, however, that the two studies differed in that our survey instrument included a comprehensive definition of workplace abuse, which may have captured a greater range of incidents. In fact, the definition included in our survey instrument was very similar to the definition used in the study by Farrell et al. ¹³ which found a 1 month period prevalence of 64%, a proportion more in step with our finding. The prevalence of workplace abuse among Justice Health staff who worked in a correctional or forensic facility but not as a health professional (i.e. non-health staff) was 33% (data not shown), which was much lower than the prevalence found in health professional staff (76%).

Sixteen per cent of participants in our study had experienced physical abuse during the recall period. Although unacceptably high, this proportion is lower than the proportions reported by Roche et al. (50%) ¹² and Farrell et al. (30%, and even higher among aged care (49%) and emergency department (58%) nurses). ¹³ The results of our study suggest that the risk of physical abuse is lower among correctional health professionals than it is among health workers who practise in a community setting – the risk appears to be especially low when compared with those who work in unpredictable hospital wards, such as emergency departments.

Several factors might explain the relatively low occurrence of physical abuse found in our study. Here we focus on factors that might reduce the risk of inmate initiated physical abuse. First, in NSW, in gaol health clinics, correctional officers are present to monitor inmates while they receive medical treatment from a correctional health professional. The presence of correctional officers, coupled with the risk of incurring further punishment should they harm a health worker, may dissuade some inmates from being physically abusive. Second, supplementary security measures, such as the mandatory use of duress alarms by Justice Health staff and omnipresent video surveillance of inmates, may discourage violent behaviours. Third, the screening and ongoing monitoring of inmates to identify and manage those who may become physically violent may be done effectively by Justice Health employees and correctional staff in NSW. Finally, it is possible that a high proportion of inmates are aware that Justice Health is an independent statutory health corporation and therefore do not see its employees as being aligned with correctional officers – correctional officers are at a very high risk of physical abuse in the workplace. ^{30 – 32}

Our finding that verbal abuse was more commonly reported than physical abuse is consistent with previous studies. ^{9 – 11 , 13 , 15 , 17} The prevalence of verbal abuse found in our study (76%) is greater than that found by Farrell et al. (63%). ¹³ Although a recent study found that verbal abuse was less damaging than physical abuse in terms of the effect it has on the quality of patient care, ¹² the available evidence unequivocally demonstrates the negative impacts of verbal abuse and bullying in the workplace on both the quality of the delivery of health services and the health and wellbeing of victims. ^{12 – 14 , 16 , 19 , 21 – 25} Instances of inmate initiated verbal abuse may be fuelled, in part, by environmental and structural factors, such as gaol crowding and a lack of relevant vocational programs for inmates. ³⁰ Implementation of strategies that address such factors may be effective in reducing incidents of verbal abuse perpetrated against correctional health professionals, and may also reduce the already relatively low risk of physical abuse.

Health worker on health worker abuse (also known as horizontal abuse) is recognised as a common and often insidious phenomenon. ^{23 , 25 , 34} Among participants in our study who reported workplace abuse, just under half (48%) were abused at least once by a fellow Justice Health employee. This proportion is greater than that found in a recent study of Australian nurses (20%) ¹² and similar to the 50% found in a survey of allied and primary health professionals who were practising in NSW ³⁴ – the latter study used a 12 month recall period. Still, regardless of how the prevalence of horizontal abuse found in our study compares with previous research, the high level uncovered is a cause for concern. In the future, research might explore the unique determinants of horizontal abuse among correctional health professionals. This would allow the development and implementation of tailored preventive interventions.

At the time the current study was implemented, in response to the findings of a ‘Staff Climate Survey’, the Justice Health Executive had initiated a ‘Culture Improvement Project’, which involved liaising with staff in order to understand and address a range of issues relating to workplace wellbeing, including workplace bullying and harassment. This project and the preceding ‘Staff Climate Survey’ may have produced a heightened awareness of horizontal abuse among medical, nursing and allied health staff who participated in our study.

A majority of participants in our study who had experienced some form of workplace abuse during the recall period reported that such incidents reduced their productivity while at work and increased the potential for them to make errors while providing healthcare to inmates. Such impediments to the delivery of high quality healthcare are problematic because inmates have a right to a standard of care that is comparable to that available in the general community, ³⁵ particularly as many inmates enter gaol with pre-existing, often complex health problems. ^{27 – 29} Incarceration provides an opportunity to address these health problems before inmates are returned to the community.

Sex and the practice environment were significantly associated with workplace abuse. Heightened security within gaol health clinics might explain, in part, our finding that physical abuse was less common among participants who worked in a gaol health clinic than among those who worked in a forensic or prison hospital. Our finding that women were more likely than men to be verbally abused might be explained by the fact that a higher proportion of women than men worked as a nurse, and nurses were more likely than other professions to be subjected to verbal abuse. Further research is needed to identify high risk sub-groups among correctional health professionals.

There are two potential limitations of this study. First, a unique identifier was not used during implementation of the survey, and, although unlikely, it was therefore possible for a participant to complete more than one survey. During the process of cleaning the data, completed surveys were checked for duplicate entries and none were found. After consulting several experienced Justice Health clinicians and senior nurses about the study design, we decided against using a unique identifier because the feedback we received was that such a mechanism would have dissuaded some staff from completing a survey. Second, a 42% response rate, although quite typical of research using the methods we adopted, ^{13 , 14} introduces the potential of non-response bias in the findings.

Although the prevalence of physical abuse found in our study is unacceptably high, it is lower than proportions found in comparable studies of workplace abuse among health workers who practise in a community setting. On the other hand, verbal abuse and horizontal abuse appear to be relatively common in the corrections environment. In the future, research might attempt to identify the unique individual, environmental and systemic predictors of workplace abuse among correctional health professionals. This would allow the development and implementation of tailored preventive interventions.

The authors declare there are no competing interests.