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某精神科醫院職場暴力的質性研究

前言
暴力,是全球性的問題,1996年的第四十九屆聯合國世界衛生委員會就宣佈預防暴力是當今公共衛生上的首要任務(1),根據WHO的統計每年全世界大約有一千六百萬人以上的人死於暴力,在15-44歲的年齡層裡是第一大死亡原因,占此年齡層的男性死亡人數的14%,占女性死亡人數的7%(2)。
職場暴力, 在1990年以前大部分被忽略而且被低估(3),直到美國職業安全衛生研究所(NIOSH)回顧1980年代的勞工死亡診斷書,發現其中與工作相關的死亡有八分之一是死於他殺,職場暴力在近年才逐漸受到大眾注意。根據美國的官方統計,職場的單一死亡原因,他殺事件在男性的勞工中是僅次於車禍的第二大死亡原因,而在女性勞工中則佔第一位(1);在毆盟,據估計大約有三百萬勞工(佔約2%)在職場受到肢體的暴力攻擊;另外,在英國的一項研究也發現,大約有53%的職員在工作的時候受到肢體和心理的暴力傷害,而有78%的員工曾經目睹這樣的的行為(1)。美國職業安全衛生研究所在2002年4月發行一本小冊子(4),大力宣導,希望世人注意職埸的暴力事件,同時提醒大眾注意暴力乃是職業危害之一,而且此類攻擊事件仍在持續增加(5)。所以關於職業危害,由於社會形態的改變,民眾知識水準的提昇,己由傳統的物理、化學、輻射、生物、人因工程等有形的危害物轉而注意到無形的心理危害如工作壓力、過勞死、和職場暴力、性騷擾等等(4;6)。在這本宣傳小冊中,尚提到職埸暴力最易發生的地方乃是醫院,尤其是以精神科醫院(或綜合醫院裡的精神科病房),急診室,候診室和老人病房(4)。
在精神科醫院, 有56%的住院醫師在病房內遭受病人的肢體攻擊,有54%在急診室遭受病人手持武器的攻擊(7;8),護士更是最容易被精神病人攻擊的目標(9;10),精神病人對工作人員的攻擊,不但造成身體上的傷害,對心理上的傷害也造成不小的衝擊(7; 11),往往造成病房工作士氣的低落、醫療照顧品質的降低、工作人員的流動率和社會成本的增加(12),同時,對於攻擊事件的處理常常也是所有醫護團隊人員最感壓力的照護問題(11)。
本院為慢性精神病人長期收容醫療照護的精神科專科醫院 (24) 。從本院參加的台灣醫療品質指標計畫(TQIP),成人身體攻擊事件的通報資料(九十年第四季)為27.27%;相較於group1(全台灣所有參加TQIP的精神科療養院的平均值) 9.64%; group2(除了美國以外的全世界)5.29%; 以及group3(包含美國在內的全世界) 3.87%,顯然高出太多且具統計學上的意義;再由九十一年第季的非自願約束資料,本院為1648.33?; group1為762.91? group2為 574.71?; group 3為 53.61?; 亦有同樣發現。故了解本院工作人員被病人攻擊的發生率、盛行率和其相關因素,實為克刻不容緩的重要任務,希望將來能因此而找出最有效的介入方法,期能減低暴力的發生率,營造一個健康安全的工作環境。

研究方法
從去年(民國九十一年)七月開始針對近五年來曾被病患攻擊的工作人員採隨意取樣,進行深入訪談,會談方式採半結構式之會談,主要訪談內容包括事件發生的經過(現場重現),如當時的人時地,前因後果,求助的方式,後續的處理,心理的衝擊以及最重要的,對此一事件的感想以及從中學習到的教訓,從被害人的角度提供意見以供後進的工作人員參考,期能有效降低工作人員被攻擊的發生率.另外尚隨機選擇未被攻擊的工作人員,同樣做深入訪談,因為他們本身沒有被攻擊的經驗,所以重點是放在談他們面對病人攻擊威脅時的處理方式以及他們自認為未被攻擊的主要原因加以澄清,同時也請他們提供預防暴力的意見,另外為了讓收集的資料更具客觀性所以透過對病人活動的觀察,如病人服藥時的狀況、以及對病人的訪談,期能找到病人暴力事件發生的真正原因。

研究結果
會談十六位個案,其中男性四位,均為”班長”,其餘十二位為女性,有兩位為病人,一位為護理長,其他九位為護士,這十六位個案當中,除了病人和一位男性醫務助理(班長),沒有被暴力攻擊之外,其他的十四位均有被攻擊的經驗。
嚴重程度:均屬第一級,菸青,流血,頭暈,頭痛,嘔吐,頭部撕裂傷,最嚴重者為肋骨折斷,均有2到3 天的公傷假。
發生地點:急性病房發生的次數最多,共有七件,占約一半,(其中有兩件為性騷擾),其次為萬寧復健園區,屬於慢性?,其他如祥和和新興之仁愛之家相對而言較少,發生之時間:發生在白班者有六件,大小夜合計有八件。
發生的情境,侵犯病人領域者有三件,如向病人拿取手上的東西,碰觸病人的身體,抽血, 有四件是發生在例行工作如巡房,發藥,發煙(為什麼我只發三支?)以及督促病人工作時(如督促病人洗澡,打掃),另有兩件是欲阻病人行為時(如病人打架時欲加以制止) 。
在求助方面,當時沒有求助,或無法求助,自行處理者占大多數,共約十件,自同仁求助有二件,其他病人發現而介入者二件。
在感受方面,有耽心,焦慮,害怕, 「賺的是生命錢,今天上班如果沒有被打,這一天就賺到了」1;生氣、無奈, 「走精神科本來就有危險」2,3;自責, 「自己警覺心不夠」4,10; 「反應不夠快」4, 「靈敏度不夠」 13、羞恥10、難過、傷心、痛哭3;錯愕「為什麼是我?是我那裡不對?」5;驚嚇、呆立、愣住9.有兩位有類似創傷後症候群6,7, 「晚上做惡夢」、「害怕走入病房」、「沒有人陪伴在旁就會害怕」7、「怕遇到個案」、「很想辭職不幹」10、 「很想離開」6;另有幾位是「沒有感覺」13、「是病人,不計較」4、 「可以包容」、 「並不對病人生氣」、 「心甘如飴」11; 另也有人「認命而已,根本沒辦法」8。
在預防方面的建議:大多提到提高警覺,保持距離, 「不要單獨一人,要有人陪」2-7, 「不要直接去碰觸病人」5,另外就是「介入病人或做處置時先向病人說明,如果不同意就不要勉強」6, 「心態上要調整,不要對病人大小聲」12, 「注意背後,最好背對著牆壁做事」11, 「同一班人力應至少兩人」1, 「最好不要排兩位資淺的同在一個班」 12,「被暴力攻擊的同仁互相經驗交流」14,「職前訓練,衝突的處理,情緒管理」,有三分之二以上的工作同仁「會被病人激怒」9, 「沒有同理心」4,亦也些人認為「是文化的問題,很難改變」13。
從病人的角度來看: 「很多工作是班長要做都叫我們做」15, 「東西我們還沒吃的都先拿起來」 15, 「吃飽飽等領薪水」16, 「沒有尊嚴」, 「沒有隱私,沒有自由」 15, 16,「醫師動不動就約束打針」16, 「病人誰敢生氣,誰就沒好日子過」 16。

討論
暴力研究的模式(Model),根據世界衛生組織(WHO)的方式,是採用生態研究的模式( Ecological Model),亦即同時考慮病人,工作人員以及兩人的互動關係,另外尚得考慮病房環境,醫院組織等所謂社區的因素,最後,則關係到整個國家社會文化的因素,暴力是這些因素相互影響的結果,無法以單一的原因來加以解釋(1)。
在病人以及病房環境方面,己有相當多的文獻探討(22;23;25-28),但在員工部分以及和病人互動部份以及文化的部份,就少有人探討,暴力方面的質性研究也很少有文獻提及,本研究採質性研究的方式試圖去了解暴力的真相,去同理工作人員被攻擊後的心理衝擊,發現除了病人的因素以外工作人員的態度和與病人溝通互的方式也是重要的暴力因子,另外病房的管理,病房活動以及日常生活的安排,也是重要的原因。
在以後的研究設計將著重於此方面的因素的探討。

A Qualitative Study of Workplace Violence in a Psychiatric Hospital

Introduction
Violence is a global problem. In 1996, the 49th U.N. World Health Committee announced that prevention of violence is the first priority health task for the year (1). Based on WHO statistics, more than 16 million people die each year around the world as victims of violence. Violence is the leading cause of death in the 15-44 year old age bracket or 14% of the total male deaths for those ages, and 7% of female deaths (2).
Before 1990, workplace violence was largely ignored and underestimated (3) until the U.S. based NIOSH came up with a worker death evaluation report in the 1980s that showed 80% of work-related deaths are caused by homicide. Only in recent years have people taken notice of workplace violence. Official U.S. government statistics reveal that for the single cause of workplace death, homicide comes first followed by car accidents for male workers; but for female workers, car accidents come first (1). In the EU, estimates show that around 3 million workers (about 2%) were victims of physical violence in the workplace. Moreover, a British study discovered that around 53% of employees suffered from physical or psychological violence at work and 78% of employees were eyewitnesses to such kinds of violent behavior (1). NIOSH, in an April 2002 booklet (4) has vigorously promoted the hope that people around the world will take notice of workplace violence occurrences. It also encourages people to be aware of the danger of workplace violence since these types of situations are on the rise (5). Thus, for dangers at work, the changing society and increased standard of public awareness have focused attention from traditional tangible harm from physical, chemical, radiological, biological, man-made structures to non-tangible harm such as work pressure, death from overwork, workplace violence, and sexual harassment (4, 6). The booklet also mentions that the easiest place where such violence can be observed is in hospitals, especially in psychiatric care hospitals (or the psychiatry ward in multi-service hospitals), emergency rooms, waiting rooms, and elderly wards (4).
In psychiatry hospitals, 56% of the doctors have suffered physical violence from patients while 54% were attacked using weapons in the emergency room (7, 8). Nurses are easy targets by psychiatric patients (9, 10). These attacks on workers by psychiatric patients not only cause bodily harm but also have a large psychological impact as well (7, 11). Moreover, such incidents dampen hospital ward atmosphere and lowers medical care quality while increasing worker turnover rate and social costs (12). In addition, handling of violent incidents is usually done by medical teams who feel the pressure of problems of care giving (11).
This hospital takes care of long-term treatment and care of chronic psychiatry patients in the psychiatry department (24). From the time that this hospital joined the Taiwan Quality Medical Index Program (TQIP), adult violence incident reported (Fourth Quarter, 2001) was 27.27%. Compared with group 1 (the average value of all Taiwan psychiatry department and care units who joined TQIP) with 9.64%, group 2 with 5.29% (The whole word except the U.S.), and group 3 3.87% (Inclusive of the U.S. and the rest of the world), our figure is too large and it has statistical value. Using the 2nd quarter of 2002 on non-volunteered obligatory data, our hospital reported 1648.33%, group1 was 762.91% group 2 was 574.71%, and group 3 was 53.61%. Thus, understanding the reason for the violent incident rate on this hospital’s workers, prevalence rate, and other related factors is a very important task. It is hoped that in the future, an effective way of dealing with the matter and lowering violent incidents will foster a safer and healthier working environment.

Research Method
From the start of July last year (2002), we initially unertook a random sampling of workers who were subject to violence by patients in the past five years. We did an in-depth interview in a semi-structured interview format. Main content of the discussion included the occurrence of the incident (actual re-enactment) with the same persons in the same place, causes and effects, how help was called for, post-incident handling, psychological effects, and most importantly, their feelings regarding the incident and what they learned from it. From the victim’s point of view, they offered suggestions for co-workers who may meet the same situations. It is expected that this can effectively decrease the violence incidence rate on workers. Furthermore, we randomly selected workers who were not subjects of violence, also interviewing them since they do not have any experience about such acts. The main point is to see how they will deal with patient’s violent threats and what they think helped them avoid being attacked. We also asked them to offer some protection measures. To give more objectivity to the collected data, we observed patient activities such as how they take their medicines and interviews on the patients. These will serve to discover the real reasons behind patient violence incidents.

Research Results
We interviewed 16 cases with just four males and among them a “class president.” The other 12 were female: two patients, one nurse head, and nine nurses. From the 16 cases, aside from the patient and a male medical assistant (“class president”) who were not subjected to violence, the other 14 had violent incident experiences.
Degree of seriousness: All are first grade such as bruises, wounds, dizziness, headaches, vomiting, and head wounds. The most serious victim had broken bones and had to ask for a two to three day sick leave.
Location of incident: Most incidents happened in the emergency room, seven cases or half of the total (among them, two were sexual harassment). This is followed by recovery areas or chronic facilities. Others such as Yang He and Jenai House had fewer cases. Time of incident: six were during the day while eight were at night.
Situation of the incident: Three were about intruding into the patient’s territory such as getting something that the patient was holding, bumping into the patient’s body, taking blood samples, four were during normal ward inspection, giving medicines, giving cigarettes (why are there only three sticks?), and directing the patient to do something (telling them to take a bath or clean up the place). Two were attempts at stopping a behavior (such as preventing people from fighting and so have to use force).
Regarding asking for help, at that time no help was given or there was no way to call for it. Most handled the situation themselves, 10 cases while colleagues assisted in two cases. Two cases had the assistance from other patients.
Regarding their feelings, some felt ashamed, worried, scared, “I earned my life money, if today at work I was not beaten up, then I earned today” 1, anger, impatience, “the psychiatry department is really dangerous” 2,3, self blame, “I was not alert enough” 4,10, “I did not react quickly” 4, “I was not sensitive enough” 13, shame, sadness, hurt, pain3, astonishment “why me? Where did I go wrong?” 5, surprise, stunned, and taken aback9. Two persons had similar post-trauma syndrome6,7 “nightmares”, “fear to enter the ward”, “afraid if there’s no one to accompany me” 7, “fear of facing cases”, “wanting to resign but not brave enough” 10, “thinking of leaving” 6, two others “did not feel anything” 13, “it was a patient, and cannot argue with them” 4, “can be forgiven”, “it’s not right to get mad at the patient”, “happy to face it” 11. Some attribute it to “fate, unavoidable” 8.
Suggestions to prevent attacks: Most suggest improving awareness, keeping distance, “not to be alone, be with someone” 2-7, “do not directly touch a patient” 5. Others propose “before entering a place with a patient, make things clear first. If the patient does not want, do not force it” 6, “change one’s attitude, do not raise one’s voice” 12, “guard your back, stand with your back to the wall when working” 11, “two people should work together in a shift” 1, “it is best that no two inexperienced persons work in a shift” 12, “hold exchange of experiences of those who faced violence” 14, “previous training, attack and feelings management”, more than two-thirds are “angered by the patients” 9, “are not sympathetic” 4, and some even think that “it is a cultural problem and difficult to change” 13.
From the patient’s point of view, “many tasks should be done by the head but still asks us to do it” 15, “we haven’t finished eating something and they take it away” 15, “eating their full and getting the salary” 16, “no honor”, “no privacy, no freedom” 15, 16, “when the doctor moves, an injection is given” 16, “any patient who gets angry will have a hard time” 16.
Discussion
Violent behavior research model, based on WHO methods, uses an ecological model that takes into consideration the patient, worker, and the relationship between the two. In addition, one must consider the environment in the ward, hospital organization, and community factors. Finally, this is also related to factors in the whole country’s socio-cultural makeup where violence is the result of influences from these factors. There is no single reason to explain such behavior (1).
Regarding the patient and the ward environment, there are already several research done (22;23;25-28). However, only a few research deal with worker and patient interaction as well as cultural factors. In addition, only a few works are devoted to the quality of violence. Thus, this research uses a qualitative approach to seek understand the truth behind violence, comprehend the psychological impact on workers affected, and discover important other factors, aside from the patients, that contribute to violence such as worker attitude and method of communicating with patients. Ward management, activities, and plans for daily life are also important factors. Further research can focus on and discuss these factors.