Understanding Reporting of Type II Workplace Violence Among Home Health Care Nurses

Abstract

Background: Home health care nurses (HHNs) work alone in patients’ homes. They experience high rates of Type II (client/patient-on-worker) workplace violence (WPV); however, little is known about the extent and factors of their reporting. Methods: A convenience sample of employees aged 18 years and older and working as an HHN or management staff were recruited from a U.S. nonprofit home health care agency. To describe the extent of reporting of WPV events, an HHN survey was conducted. To identify the barriers and facilitators to reporting, two HHN focus groups were conducted, and management key informant interviews were employed. Findings: We recruited 18 HHNs and five management staff into the study. Almost all HHNs reported to management the most serious forms of violence they experienced, and that HHNs reported WPV when they perceived that reporting was beneficial (alerting other nurses and management) and supported by management staff. However, they were unwilling to report when it was perceived as disadvantageous (reliving the trauma), discouraged (by a norm that experiencing violence is a part of the job), unachievable (unstandardized reporting process), and ambiguous (uncertain of what is reportable). Management staff perceived a lack of standardized reporting processes as a barrier when responding to HHNs’ reporting. Conclusion/Application to Practice: High reporting was related to strong support from management. Policies and procedures should clearly define WPV, the threshold for reporting, how to report, and how management will respond to the reports.

Background

Home health care nurses (HHNs) are the predominant workforce in the home health care industry, making up nearly 72% of employees in home health agencies (Harris-Kojetin et al., 2016). They provide skilled nursing services for chronically ill or disabled people in their homes. Home health care nurses are at high risk for client/patient-on-worker workplace violence (WPV, also called Type II WPV; University of Iowa Injury Prevention Research Center, 2001). According to the published research, one out of every five HHNs has experienced physical assault (Fujimoto et al., 2017), and more than half have suffered from non-physical aggression from their patients during their career (Canton et al., 2009). However, these rates are likely underestimated, similar to underestimations noted among workers in other U.S. health care settings (Arnetz et al., 2015; Pompeii et al., 2016). Underreporting leads to failure to understand the risks and reduce the hazard, resulting in underestimation of the true extent of the problem and limiting the knowledge of the full spectrum of violent events (Arnetz et al., 2015). In addition, the role of managers on violence reporting is often overlooked. Fagan and Hodgson (2017) noted that employers did not always or accurately record workplace injuries and illnesses.

Studies in non-home-health care setting identified factors attributable to health care employees’ underreporting of Type II WPV: lack of perceived intention to harm, not being seriously injured, lack of time, accepting violence as part of the job, a difficult or time-consuming reporting process, lack of follow-up from administration, fear of reprisal or blame, no reporting requirements unless behavior is abnormal for a patient, patient dissatisfaction with reporting, belief that reporting will not lead to any positive changes, and varying definitions of violence (Arnetz, 1998; Gates et al., 2006; Pompeii et al., 2016; Sato et al., 2013; Snyder et al., 2007). However, no studies have been conducted to understand the barriers and facilitators of HHN’s Type II WPV reporting. Such studies are needed to consider the unique context where HHNs work, which includes being alone in the home of the patient as a “guest,” and working out in the “field” and remotely from the management staff. These may create particular barriers and facilitators to HHNs’ reporting. Without understanding factors that may be particularly salient for HHNs, our efforts to develop and implement WPV prevention policies and programs are hampered. Therefore, the purposes of our study were (a) to describe the extend of HHN’s reporting of Type II WPV by violence type, and (b) to explore the barriers and facilitators of HHNs’ reporting of Type II WPV reporting, perceived by HHNs and management staff.

Methods

Study Design, Sampling, and Sample

This study employed quantitative (online survey) and qualitative (focus group and key informant interview) data collection and analysis. Study participants were recruited by two research members (H.D.B., X.L.) from a sampling frame of 29 HHNs and seven management staff (nursing coordinators, supervisors) at a nonprofit home health care agency in a southeastern United States. Separate emails of initial and subsequent reminders of study invitation to the online survey, focus groups, and key informant interviews were sent to the organization email addresses of each relevant employee groups in the sampling frame. Management staff at the agency supported the recruitment by informing the employees of the study. We included potential participants in the study if they were adults aged 18 years or above and currently working as an HHN or a management staff. The research members who were responsible for recruitment did not have affiliations with the home health care agency. Study participation was voluntary and anonymous. The study was approved by the Institutional Review Board of the University of Virginia.

Quantitative Data

To measure the extent of HHNs’ underreporting, an anonymous, 3-minute, online survey was developed. A direct link to the online survey was embedded in the invitation email to recruit survey participants. Equivalent paper-based surveys were made available for focus group participants who had not participated in the online survey, but decided to participate in the survey.

Three questions in the survey inquired about HHNs’ actual experience of subtypes of Type II violence in the past 12 months: physical violence, threats of harm, and verbal abuse. Physical violence was measured by the question, “How often have you been physically attacked (e.g., hitting, pinching, biting, scratching, choking, hair-pulling) by your patient or someone in the house in the past 12 months?” Threat of harm was measured by the question, “How often have you been physically or verbally threatened (e.g., yelling to harm, throwing an object at the door to threaten) by your patient or someone in the house in the past 12 months?” Verbal abuse was measured by the question, “How often have you been verbally abused (e.g., cursing, yelling, name-calling, insulting) by your patient or someone in the house in the past 12 months?” Subsequently, if HHNs experienced more than one event for each subtype of Type II violence and potential violence, they were asked whether they reported the one event they deemed most serious to (yes or no). The survey also included a question that asked the length of work in years as an HHN. Due to the small sample size and risk for identification of individuals, their demographics were not requested.

Qualitative Data

To identify the barriers and facilitators to reporting, we conducted two 1.5-hour focus groups among HHNs (eight and 10 HHNs each), in which we also explored the group norms related to WPV reporting (Bloor et al., 2001). A semi-structured focus group guide was created based on the theory of planned behavior (TPB), a framework widely used to predict human behaviors (Ajzen, 1985). According to the theory, three beliefs (behavioral, normative, and control) affect a person’s intention to perform a behavior which in turn is a strong predictor of actual behavior. We structured the focus group questions according to the TPB to include the three domains: behavioral beliefs (e.g., What are the benefits/disadvantages of reporting WPV?), normative beliefs (e.g., Who would support/oppose when you report an incident?), and control beliefs (e.g., What are the things that make it easy/difficult when you report an incident?).

In addition to the focus groups, we also conducted 30-minute individual interviews among five management staff to understand barriers and facilitators to them receiving and recording WPV reports from HHNs. The interviews were guided by a semi-structured interview guide that included questions covering the three domains: behavioral beliefs (e.g., What are the benefits/disadvantages of receiving and recording WPV incidents?), normative beliefs (e.g., Who would support/oppose when you receive and record incidents?), and control beliefs (e.g., What are the things that make it easy/difficult when you receive and record incidents?). The interviewees were also asked about their perspectives on the barriers and facilitators to HHNs’ reporting Type II WPV using a guide modified from the one used for focus groups.

Data Analysis

For the quantitative data, frequencies of experiencing and reporting Type II WPV in the past 12 months were reported for each subtype of violence and potential violence. The proportions of reporting these events were also calculated. For the qualitative data, all focus groups and interviews were audio-recorded and transcribed verbatim. We employed a qualitative descriptive approach for analysis (Colorafi & Evans, 2016). Both deductive and inductive approaches were used to analyze the transcripts of the focus groups and the interviews. The TPB provided an analytical and interpretive framework of its three constructs (behavioral, normative, and control beliefs) within which identified themes were structured (deductive). Open coding was also employed to allow for independent themes to develop beyond the three constructs to ensure that unexpected but important aspects of the data were not missed (inductive). The themes were structured on three levels: major themes (e.g., behavioral belief), categories (e.g., benefits, disadvantages), and subthemes (e.g., affirmation, telling my side of the story). Major themes and categories were mostly based on the TPB framework. A subtheme was the main unit of analysis, and these were identified by conducting a careful line-by-line analysis. Each potential theme was compared and contrasted with other potential themes. Initially, textual data from the first few transcripts of both focus groups and interviews were independently reviewed by two research members (H.D.B., X.L.), and a working analytical framework composed of agreed-upon codes was developed. The working analytical frameworks were iteratively reviewed and refined until the last transcripts were coded. All transcripts were coded and analyzed individually by three research members (H.D.B., X.L., M.C.) using Dedoose software (Dedoose Version 8.2.14, 2018), and the final themes were agreed upon by consensus.

Results

The Extent of HHNs’ Underreporting of Type II WPV

Eighteen of the invited 29 HHNs completed the survey (response rate 62%), of which one HHN conducted online and 17 used the paper-based survey made available for focus group participants. The average length of work experience in the home health industry was 12 years (median = 9 years), with a range between 2 months and 29 years. In the past 12 months, at least once, 5.6% (n = 1) of HHNs experienced physical violence, 33.3% (n = 6) threat of harm, and 50% (n = 9) verbal abuse. The proportions of reporting of physical violence, physical/verbal threat, and verbal abuse to management were 100% (n = 1), 100% (n = 6), and 89% (n = 8), respectively.

Barriers and Facilitators When HHNs Report Type II WPV

All 18 HHNs who completed the survey also participated in the focus groups. The following outlines the three major themes (behavioral beliefs, normative beliefs, and control beliefs) that emerged, as well as an additional theme of ambiguity on reportability.

Behavioral beliefs

One of the most frequently stated benefits of reporting was alerting other HHNs and management staff to an event of WPV. This prepared HHNs, who would later visit the same patient, for potential violence. This also allowed the management staff to evaluate the safety of HHNs while providing health care for the patient at home. One participant said, “I think I report it more for the next person [nurse] that might go out after me. And then you will report that to management and that information will be shared with your colleagues [nurses].” Another participant added, “It’s at least a flag to let us really decide if we should or shouldn’t take that patient, to begin with.”

Another frequently stated benefit to reporting was providing an opportunity to present their perspectives on the WPV incident when the patient or the family may speak differently. For example, one HHN stated, “I didn’t want the family of the patient calling and giving a version of the event that may not be the same as mine.” A participant in the group expressed agreement and said, “Because their [patients’] side can get twisted, such as ‘she tried to kill me’ . . . Yeah, they [management staff] want to know our side as much as possible.”

Another benefit was receiving affirmation from the management staff that they were not “overreacting” or being “emotionally sensitive” when HHNs think the incident was reportable. Home health care nurses pointed out that having to relive the incident is a disadvantage of reporting. One stated, “. . . but there is also the drawback of reliving the trauma of recording it and reporting it.”

Normative beliefs

The HHNs thought they were expected to tolerate violence to a certain level and were not supposed to report all violence. One participant said, “. . . you don’t report everything [violence]. We’re caregivers. We’re supposed to put up with a certain amount.”

Home health care nurses believed that reporting violence from patients with confusion, dementia, or brain injury was not a standard. As one HHN shared, a confused patient was “totally justified in trying to bite me [nurse]” when inserting a catheter. It was not right to report violence from a patient with brain injury because “their [patients] sense of right and wrong is skewed.” Also, as frontline health care professionals, they accepted patients’ aggressive vent of frustration about the health care system in general, which was unrelated to the direct care that they provided. One participant voiced,

. . . Even just access to things like getting to a doctor. They’re [the patients] frustrated by the situation, but we [nurses] tend to get some of that frustration pointed at us. And in those situations, I think we don’t report it.

Home health care nurses reported that the management staff and nurse colleagues supported reporting violence. HHNs did not feel “judged or there was going to be backlashed” from the management staff. HHNs felt supported when the management staff took an interest and asked, “Please let us know what is going on.” The management staff were perceived as “supportive” and “having their back,” and HHNs were willing to share what they experienced and report what happened. Also, HHNs shared violence experiences with their colleague nurses, believing that they could “discuss it [the incident] and never get the backlash or something to hurt my [the nurse’s] professional image.” However, HHNs perceived that primary care physicians were “difficult to get hold of” when they attempted to report violence, where the lack of response to HHNs’ report further hindered them from reporting incidents.

Control beliefs

The HHNs stated that they did not have time for reporting WPV due to their already busy, heavy workload. One said, “I would think that one of the biggest disadvantages is just the time. You know, the fact that it delays your work flow.” Another said reporting would be a challenge because “there is the time constraint where it’s like I’m feeling rushed. I’ve got to deal with the blood sugar, blood pressure, or whatever.”

Ambiguity on reporting

One theme was identified outside the TPB framework in which HHNs were uncertain as to what defined a reportable incident. They felt that, to be reportable, “it has to be a certain level of egregiousness and it can be reported, once it crosses that.” However, there was no clear-cut threshold for reporting noted by the HHNs. In this ambiguity, HHNs sought advice from their colleague nurses on what to do and whether to formally report the incident to management. Home health care nurses “ran” the incidents by their colleagues. This was more evident when the violence they experienced did not seem an “obviously” reportable one.

Oh, cause if it’s something like let’s say it just wasn’t a specific thing, like I wasn’t actually threatened but I just felt uncomfortable . . . I would probably not go directly to the administrators [management] . . . I would like to talk to one of my colleagues . . . so getting that feedback from somebody else who has been in the field for a while can tell me whether I’m going crazy or not . . .

Many HHNs stated there should be training on what constitutes violence and how to identify it. Scripted simulations on violent situations were also suggested.

Management perspectives

For behavioral beliefs, the management staff confirmed that HHNs’ reporting of Type II WPV was beneficial to HHNs because their report would be followed through and would be used to bring about necessary changes. The reporting resulted in “investigating what was going on” and “getting the nurse out of the home” when there were safety concerns. For normative beliefs, the management staff stated that it is important for HHNs to know that they would get support from management when reporting incidents. The management staff confirmed a need to make HHNs feel “comfortable” to talk, “receptive” to what they were saying, and “trustful” in taking the matter seriously. Management staff identified that a lack of attention or slow follow-up to a staff report of WPV would discourage nurses from reporting. The management staff also thought that some HHNs considered experiencing violence as part of their caring job, thus choosing to not report the incident. For control beliefs, the management staff identified a lengthy and unstandardized reporting process as factors for hindering HHNs’ reporting. Finally, the same theme was identified among the management staff that HHNs would be ambiguous on what constitutes a reportable violence incident. Home health care nurses may not report “because they [HHNs] don’t feel that it’s a huge issue, . . . If they feel like they were just spoken to inappropriately or cussed out.”

Barriers and Facilitators When Management Staff Receive and Record Type II WPV Reports

Analysis of the interviews revealed two themes including monitoring and analysis as a benefit and unstandardized receiving process as a challenge. For behavioral beliefs, management staff stated that the ability to monitor and identify potential trends and patterns was a benefit of receiving and collecting reports from HHNs.

You’d be able to see if it’s particular areas if it’s with a particular, you know, clinician, if it’s a particular group of type patients, you know, that sort of thing so that you can actually intervene.

For control beliefs, management staff pointed out that the unstandardized receiving process made the process difficult. Some were not sure what to ask when receiving reports from HHNs or questioned: “Do I write something down, do I not?” Without a standardized system of identifying and monitoring, a pattern of violence incidents could be unrecognized or overlooked until “it became a boiling point everybody in the office knows [about].” Then, the reporting would be dependent on an individual’s “judgment” rather than a policy or a procedure.

Discussion

In our sample, the proportions of reporting of actual Type II WPV incidents that HHNs deemed most serious were close to one (89%–100%), which was high relative to other studies. However, our sample size was small and not representative of HHNs. Underreporting of WPV has been consistently reported across studies. In a large cross-sectional study, Pompeii et al. (2016) observed that a large proportion of health care workers (n = 2,098) who experienced Type II violence indicated reporting their events, but only 10% reported into formal reporting channels such as the first report of injury form through employee health. In an earlier survey of 4,378 Minnesota registered nurses (RNs) and licensed practical nurses (LPNs) primarily working (91%) in non-home-health care agencies, 31% of physical WPV and 29% of non-physical WPV that occurred during the past 12 months were not reported to management (Gerberich et al., 2004). These proportions include Type II WPV as well as Type III WPV (worker-on-worker); 96.8% and 67.2% of physical violence and non-physical violence, respectively, were perpetrated by patient/client. In a survey of 27 nurses in a large Irish Accident and Emergency Department, 21% of physical assault and 63% of verbal abuse that occurred most recently by a patient or relative were not reported (Rose, 1997). Direct comparisons of the proportions of the latter two studies of nurses with those in our study are not plausible due to differences in the kinds of WPV incidents that were measured (most serious one vs. any in the past 12 months vs. most recent one) and the types of WPV (Type II WPV only vs. Type II and III WPV combined). Still, it is noteworthy that HHNs in our study stated that almost all experienced and potential violence incidents were reported to the management. This rarity asks for understanding of factors that affected reporting behaviors of HHNs, which the following findings from the qualitative analysis can provide insights into.

Our findings on barriers of Type II WPV reporting are largely comparable with factors identified in other health care settings: lack of time, belief that violence is part of the job, unstandardized reporting process, and ambiguity on the reportability of violence, including an unclear definition of violence (Arnetz, 1998; Gates et al., 2006; Pompeii et al., 2016; Sato et al., 2013; Snyder et al., 2007). In addition, we identified facilitating factors of the reporting and unique barriers among HHNs. The HHNs’ most cited benefit of reporting WPV was its ability to inform nurse colleagues and management of the risks of experiencing violence from the same patient or someone in the house. This altruistic motive for protecting their colleagues was clearly stated during the focus groups, possibly a particular attribute among HHNs. This facilitating factor for reporting WPV may be associated with the unique work environment of HHNs; they work alone in patients’ home, being separated from other nurses and management staff. Home health care nurses cannot easily share their violence experience with coworkers and managers during routine shift report and team huddles, which serves as a primary reporting mechanism among hospital workers (Pompeii et al., 2016). It is a possibility that the physical and psychological remoteness may heighten HHN’s sense of responsibilities for sharing and reporting WPV in an expectation that the information will be passed to their colleagues. The lone working environment where no witnesses are likely to be present other than the perpetrator and the HHN themselves may promote telling HHNs’ side of the study through reporting (Pompeii et al., 2016) and getting affirmation from their colleagues and management.

Our study showed that management staff were facilitators of HHNs’ WPV reporting. The management staff perform many duties including staffing and care management oversight that require skills, knowledge, and good behaviors and attitudes. Home health care nurses perceived the management’s concern and non-judgmental attitude in particular as distinguished aspects for their support. Home health care nurses found the same attitude from their colleagues and considered them supportive. Any fear of disapproval from the administration or other staff may contribute to staff not reporting the incident (Phillips, 2016). The pervasive, however, mistaken belief that violence is part of the job for health care workers seems to be more extensive and intensive among HHNs. As frontline health care workers who encounter their patients alone in the patient residence without immediate support, they are sometimes literally in the face of patients who may express dissatisfaction or exasperation about health care issues in general. The HHNs tend to accept taking the brunt of patient violence and consider it as part of their job although they are not direct contributors to the cause of violent behaviors.

A lack of agreement on definitions of violence (i.e., What are reportable violence incidents?) has been cited as a reporting barrier among hospital workers (Pompeii et al., 2016). This ambiguity was confirmed among HHNs, but the issue seems to be more complicated in the home health care field than other institutional settings due to the fact that nurses work in a patient home. As one of the HHNs stated, “Being in the patient’s home makes it unclear what is appropriate.” It deserves attention that HHNs consult their colleague nurses on what and whether to report to management. The lack of a standardized definition and extent of tolerability of violent behaviors that are reportable was associated with seeking advice from their colleagues. This finding illuminates the importance of peer support as a facilitating factor for WPV reporting. It can also imply that minor violence may not be reported to management if a colleague nurse advises against formal reporting to the management. As one HHN stated, reporting violence in patients’ home “blurs boundary and affects reporting.” Providing health care service in patient’s homes may affect the perception of HHNs as to what patient behaviors are appropriate in their private residence. Home health care nurses are viewed as “guests” in patient homes according to HHNs and managers. Although having not emerged as common themes, a few HHNs shared their experiences of racial harassment (e.g., patient making derogatory remarks based on HHN’s race) and sexual harassment (e.g., patient making sexual innuendo, displaying a porno videotape during the visit) when home-visiting their patients. Home health care nurses were not sure whether these constituted WPV or were reportable. Because these involve “an explicit or implicit challenge to their safety, well-being or health” (International Labour Office et al., 2002), they need to be clearly defined as forms of violence, reported, and addressed.

No significant discrepancies were found between managers and HHNs in their understanding of barriers and facilitators to HHNs’ WPV reporting. In addition, the management staff were cognizant that a lack of their follow-through of reported incidents or a lengthy procedure for responding to WPV reporting could deter HHNs’ reporting. This was also identified as a reporting barrier among hospital workers (Pompeii et al., 2016).

To the management staff, the opportunity of identifying the risk factors for Type II violence and monitoring the trend was a prominent benefit that motivates them to accurately receive and collect information. However, this was challenged when they could not verbalize knowledge of the agency policy and procedure that offers a standardized method of recording and addressing the incidents. The lack of standardized receiving process and the absence of standardized reporting process are two sides of the same coin. What HHNs report forms the basis of management staff efforts in prevention and intervention of violence and restoration of victimized workers.

It can be assumed that underreporting of WPV is expected among HHNs partly due to the needs for distant communication between the management staff and the HHNs working at remote locations. However, the strong support from management in our sample may be the main contributor to the HHNs’ high reporting behaviors, overcoming such physical limitation. Almost all responses (17/18) to high reporting rates from the survey were made by HHNs who also participated in the focus groups where management support was highly appreciated. A 33-year-veteran HHN stated her willingness to report because when “I [HHN] did report it, it got followed up on. It was not pushed to the back of the pile and say we’ll do it next week.” Nurses’ recognizing management staff as supporting and trusting them that they would pass the violence information to other colleagues also show their trust in the management support, which is not often reported in other health care organizations.

One limitation of this study is that our sample was drawn from a single home health care agency, a source of selection bias. This limits the transferability of the study results to diverse settings. Although we judged that themes were saturated within the sample, sampling from multiple agencies could have enabled identification of new themes. The inclusion of only currently employed HHNs and management staff could have resulted in an overestimation of reporting and overlook of certain barriers and facilitators of WPV reporting. The underreporting rates were based on HHNs’ self-reports which might have caused measurement bias. Some subthemes identified in our qualitative analysis had only a few discrete occurrences in the interviews and the focus groups. Although the frequencies are limited, the themes in each occurrence were noteworthy. Nevertheless, a larger sample size could have provided an opportunity for more solid identification of subthemes.

Implications for Occupational Health Nursing Practice

The findings offer HHNs and management insights into improving HHN’s WPV reporting. HHNs can be motivated to report WPV when the reporting behavior is perceived as beneficial (gives affirmation, can tell their side of the story, can alert nurses and management, knows that it will be followed through) and supported (by colleague nurses and management staff). However, they can decide not to report when the reporting is perceived as disadvantageous (reliving the trauma), discouraged (by the primary care physician’s lack of follow-up and norms that it is a part of the job and that reporting violence from patients with certain conditions is not acceptable), unachievable (due to lack of time, unstandardized reporting process, lengthy procedure), and ambiguous (uncertain of what is reportable). The management staff may not accurately receive and collect reports from HHNs when a standardized receiving process is lacking.

Workplace violence reporting and receiving process including the definition of WPV of various forms and subtypes (e.g., physical violence, physical/verbal threat, verbal abuse) should be explicitly stated in a policy (Pompeii et al., 2016). A simple, shortened reporting process needs to be developed in the context of the distant and peripatetic nature of home health care nursing. Understanding and utilizing the “community of HHNs” in their communications to alert the danger to each other and for consultations may facilitate WPV reporting. Finally, the management staff’s supportive attitude can help HHNs report WPV freely and comfortably.

Applying Research to Occupational Health Nursing Practice

This study identified barriers and facilitators to home health care nurses’ (HHNs) reporting of Type II (client/patient-on-worker) workplace violence (WPV). Home health care nurses’ altruistic motive for reporting to protect nurse colleagues from experiencing Type II WPV can be appealed to when promoting reporting behavior. Genuine concern and non-judgmental attitude of the management staff were facilitators of HHNs’ WPV reporting. The ability of managers to show support to HHNs can influence better relationships and enhance HHN safety. Also, by clearly defining and communicating within the agency what WPV constitutes, what the thresholds are for reporting, and how to report them, reporting practice can be improved.