Aggression in Healthcare - Classification Models

Classification Models

Classification (LeBlanc and Barling 2004)

Patient-on-Professional aggression can be classified as Type II; where the perpetrator commits a violent act whilst being served by the organisation, with which they have a legitimate relationship (LeBlanc and Barling 2004). It is uncommon for such attacks to result in death (Peek-Asa, Runyan, Zwerling 2001), however they are evidently responsible for approximately 60% of non-fatal assaults at work (Peek-Asa and Howard 1999). Within this classification that is based on the relationship between the perpetrator and victim, Type I aggression involves the perpetrator entering the workplace to commit a crime–having no relationship to the organisation or its employees. Type III deals with a current/former employee targeting a co-worker or supervisor for what they perceive to be wrong-doing. Type IV aggression involves the perpetrator having an ongoing/previous relationship with an employee within the organisation. (LeBlanc and Barling 2004).

Internal Model (Nijman et al. 1999)

The internal model associates aggression with factors within the person, including mental illness or personality (Duxbury et al. 2008). This model is supported by the numerous studies correlating a link between aggression and illness (Duxbury and Whittington 2005). A person’s traits can relate to their expression of aggression–narcissists for example, tend to become angry and aggressive if their image is threatened (Anderson and Bushman 2002). Sex tends to affect aggression–with certain provocations affecting each sex differently (Bettencourt and Miller 1996). It was found that males tend to prefer direct aggression, and females indirect (Österman et al. 1998) (Anderson and Bushman 2002). A study by Hobbs and Keane, 1996 explains that patient factors commonly related to or causative of patient violence include; male sex, relative youth or the effects of alcohol or drug consumption (Hobbs and Keane 1996). A study conducted amongst General Medical Practitioners in the West Midlands found that men were involved in 66% of aggression cases; rising to 76% with regard to assault/injury (Hobbs and Keane 1996)–the main male perpetrator being aged under 40 years of age. Patient anxiety, a particular problem associated with dentistry, tended to be the most likely instigator for verbal abuse and the second most likely reason for threatening verbal abuse (Hobbs and Keane 1996).

External Model (Nijman et al. 1999)

This model is based on the idea that social & physical environmental influences affect aggression (Duxbury et al. 2008). This includes the provisions for privacy, space and location (Duxbury and Whittington 2005). Motivation for aversion, possibly due to pain during dental treatment, can increase aggression (Berkowitz, Cochran, Embree 1981)–as can general discomfort, such as that resulting from sitting in a hot waiting room (Anderson, Anderson, Dorr 2000) or in an uncomfortable position (for example in a reclined dental chair) (Duxbury et al. 2008). Alcohol intoxication or excessive caffeine intake tends to indirectly exacerbate aggression (Bushman 1993). The Hobbs & Keane (1996) study states the involvement of drugs and alcohol; in 65% of cases at one Accident & Emergency Department and in 27% of all general practice cases. The study denotes intoxication to be the main reason for assaults and injury (along with mental illness) (Hobbs and Keane 1996). Frustration, defined by Anderson and Bushman (2002) as “the blockage of goal attainment”, can also contribute to aggression–whether the frustrations are fully justified or not (Dill and Anderson 1995). Such frustration-related aggression tended to be against the perpetrator and persons not involved in failure to reach the goal. Prolonged waiting times in A&E departments and general practice led to aggression due to frustration; it generally being directed towards receptionists–with approximately 73% of doctors becoming involved (Hobbs and Keane 1996).

Situational/Interactional Model (Nijman et al. 1999)

This deals with factors involved in the immediate situation, for example interactions between patients and staff (Duxbury et al. 2008). There are numerous studies that support the correlation between staff with a negative attitude and patient aggression (Duxbury and Whittington 2005). Provocation has been said to be the most important cause of human aggression (Anderson and Bushman 2002)–examples include verbal and physical aggression against the individual (Anderson and Bushman 2002). It was found that perceived injustice, in the context of equality amongst staff for example, positively correlated to workplace aggression (Baron 1999).

Expressions of Hostility (Baron 1999)

This is related to “behaviours that are primarily verbal or symbolic in nature” (Baron 1999). In terms of Staff-on-Staff hostility, this can involve he perpetrator talking behind the targets back. With Patient-on-Professional hostility however, this can deal with the patient assuming false knowledge over the professional–with the patient belittling their opinions (Baron 1999).

Obstructionism (Baron 1999)

This involves the perpetrator conducting actions that aim to “obstruct or impede the target’s performance” (Baron 1999). Failures to pass on information or respond to phone calls for example, are ways in which Staff-on-Staff obstructionism can be demonstrated. Patient-on-Professional obstructionism can be demonstrated by a failure on behalf of the patient to comply with the professional conducting a certain task. An unwillingness to allow the professional to diagnose the patient and a failure to turn up to appointments are examples of such obstructionism.

Overt Aggression (Baron 1999)

This normally relates to workplace violence, and involves behaviours including; threatening abuse, physical assault and vandalism (Baron 1999). This again can occur with regard to both, Staff-on-Staff and Patient-on-Professional aggression.

Buss’ Three-Dimensional Model of Aggression (1961)

Buss (1961) differentiated aggression into a three dimensional model; physical-verbal, active-passive and direct-indirect–active-passive being removed in 1995 when Buss refined the categories. Physical assault would come under the category physical-direct-active, whereas obstructionism relates to physical-passive–be it direct or indirect. Verbal abuse or insults relate to verbal-active-direct aggression, whereas the failure to answer a question when asked, for example with regard to lifestyle choices or habits, can come under the verbal-passive-direct category–providing the reasons for not answering are directed at the healthcare worker (e.g. hostility), as opposed to fear for example (Rippon 2000).