Occupational Medicine Advance Access originally published online on July 25, 2007
Occupational Medicine 2007 57(7):492-498; doi:10.1093/occmed/kqm064
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Receptionists' perceptions of violence in general practice
Mediscreen, Pennine Acute NHS Trust, HQ, Westhulme Avenue, Manchester, Oldham OL1 2PN, UK
Correspondence to: Patricia A Bayman, Mediscreen, Pennine Acute NHS Trust, HQ, Westhulme Avenue, Oldham OL1 2PN, UK. Tel: +44 161 627 8093; fax: +44 161 627 8287; e-mail: patbayman{at}aol.com
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Abstract |
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Background Violence and threatening behaviour towards health care employees is a recognized hazard. There is a lack of research into the perceptions of general practice (GP) receptionists about this important workplace hazard.
Aim To determine the factors that influence reception staff perceptions regarding the risk of future violent and threatening incidents at work.
Methods A cross-sectional survey using a self-administered postal questionnaire was carried out among reception staff working in 49 GPs in two UK National Health Service Primary Care Trusts.
Results Forty-nine (72%) practices agreed to participate. Two hundred and seven (68%) reception staff participated. Receptionists who reported having been threatened or attacked in the past 12 months were more likely to be worried about being threatened [odds ratio (OR) 4.9; 95% confidence interval (CI) 2.0–11.8] or attacked (OR 4.6; 95% CI 1.8–11.2) in the future. Receptionists with higher neuroticism scores were more worried about the future possibility of violence. Staff who felt safe and supported at work (P = 0.003) and staff who had lower background sources of stress at work (P < 0.001) were less likely to feel they would be threatened or attacked at work. Staff who had received training about violent and abusive incidents felt safer at work (OR = 1.27; 95% CI 1.04–1.55).
Conclusion Previous episodes of threats or attacks at work make receptionists more worried about future episodes. Factors which reduce reception staff anxieties about violence and threat at work are working in a supportive environment where work stressors are controlled and receiving training on how to deal with violent, threatening and difficult behaviour.
Keywords Aggression; general practice; occupation; occupational; receptionist; self-reported; violence; workplace stress
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Introduction |
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All employers, including National Health Service (NHS) employing authorities, have legal obligations under The Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999 to protect their employees, contractors and members of the public. This includes a requirement to recognize workplace hazards, carry out risk assessments including risk assessments for bullying, violence and work-related stress and to introduce control measures to reduce the risks [1,2].
A specific hazard likely to be encountered by NHS staff is violence, both physical and emotional. Guidance produced by the NHS Executive advises that much of the risk of violence is predictable and therefore preventable, and that risks should be assessed and a coherent overall preventative strategy put in place, which includes appropriate information, instruction and training for staff and access to debriefing or counselling services following a violent incident [3].
General practice (GP) reception staff are the first point of contact for patients entering or telephoning a practice and as a result they may take the brunt of patient frustrations. Past studies have shown that reception staff are likely to experience verbal abuse, threats and even physical violence [4–8]. However, few studies have attempted to ascertain the factors that influence whether or not reception staff feel safe at work. Most of the research in this area has concentrated on hospital doctors and nurses [8–14] or general practitioners [15–17].
This study is important and relevant because its purpose is to determine which factors are significant in influencing GP reception staff perceptions of the risk of violent and threatening incidents at work. Knowledge of these factors could aid risk assessment and assist in the identification of control measures that may need to be introduced in order to promote reception staff morale and increase their confidence in a secure and supported working environment.
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Methods |
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The study was a cross-sectional survey design undertaken among reception staff working in GPs in two Primary Care Trusts (PCTs) based in the north-west of England. Within the PCTs, practices were located both in local towns and semi-rural areas, giving a varied socioeconomic mix of the patient population. All 68 practices within the two PCTs were written to and invited to participate in the study. The letter was followed up with a telephone call to the practice manager and a visit to the practice by P.B. A self-administered questionnaire was used to gather the required information from receptionists. The majority of questions required the respondent to tick a box. The questionnaire was made up of six sections and space for comments was available at the end. Section 1 asked general information including date of birth, hours worked and experience. Sections 2–4 were based on questions used in the British Crime Survey 2000 [18]. These questions ask about violent or threatening behaviour by members of the public while at work, worry about such behaviour and training. Section 5 was the Health and Safety Executive First Pass Filter Tool ‘Sources of Stress at Work’. This tool was designed to establish the basic levels of stress within a workplace [19]. Section 6 was a personality questionnaire based on The Neuroticism, Extraversion and Other—Five Factor Inventory (NEO-FFI) which is an accepted dimensional model of personality [20]. In this study, the neuroticism (N) sub-scale from the NEO-FFI was used as a measure of personality.
Permission to carry out the study was approved by the Human Resources Director of each PCT, the local ethics committee, the local medical committee, and the research and development committees for each of the PCTs.
The questionnaires for the reception staff were addressed personally and left with the practice manager for distribution. The questionnaires were coded but identification was confidential to the authors and used solely to follow-up non-responders. Non-responders were sent one further questionnaire, addressed to them personally at the practice address. The questionnaires were initially piloted in two randomly selected practices, where eight questionnaires were distributed and seven completed questionnaires were returned. These questionnaires were included in the study as no rephrasing of questions was required.
The data from the questionnaires were analysed using SPSS (Statistical Package for the Social Sciences) version 13. The NEO-FFI score was calculated according to the neuroticism sub-scale of Costa and McCrae's Five-Factor Inventory [20]. The NEO-FFI has a minimum possible value of 12 and a maximum of 60, with higher scores indicating higher levels of neuroticism. A total composite score for sources of stress was calculated from the six items on the reception staff questionnaire (demands, control, support, relationships, role and change). A total of these six scores gave a score which had a minimum possible value of 0, representing no stress, to a maximum of 18, representing maximum stress in all aspects.
Summary statistics are presented as numbers and percentages for categorical variables and means and standard deviations for continuous variables. A t-test was used to compare mean NEO-FFI scores for the participants in this study with population norms. Spearman's rank correlation coefficients are presented to show the relationship between NEO-FFI scores and other continuous staff-related variables.
Possible factors which may influence staff perceptions of violence and which are represented by categorical variables such as stress score were cross-tabulated with outcome measures such as worry about violence and feelings of security. These cross-tabulations were analysed using the Pearson chi-squared test or Fisher's exact test, as appropriate.
Analysis of variance was used to compare continuous data such as age, years of experience, hours worked per week, NEO-FFI scores and stress scores in more than two groups. Where the groups were ordered categories, the test for linear trend across group's means was tested. The t-test was used to compare continuous variables with dichotomous ones.
Logistic regression was used to determine which of the possible predictors considered were significant independent predictors of whether the receptionist was worried about being threatened or attacked while at work, and whether they felt safe at work (outcome measures). Odds ratios (ORs) with 95% confidence intervals (CIs) are presented for significant predictors. A P-value of <0.05 was considered to indicate statistical significance.
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Results |
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Forty-nine (72%) practices agreed to participate in the study. Data were collected for 56 ‘surgeries’ in total as six of the practices had one or more branch surgery. Two hundred and seven (68%) reception staff returned a completed questionnaire and were included in the study. Of these, 42 (20%) completed questionnaires were received after sending out a second follow-up questionnaire. Reception staff characteristics are shown in Table 1.
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Fifty-two (27%) receptionists were worried about being threatened and 46 (22%) were worried about being physically attacked by a member of the public while at work. Seventy-four (37%) thought they were likely to be threatened by a member of the public while at work in the next 12 months, but only 14 (7%) thought that they were likely to be physically attacked. Fifty-eight (29%) felt that worrying about being threatened or attacked at work affected their health. In the preceding 12 months, 54 (26%) could recall being threatened by a member of the public while they were at work, and 1 (0.5%) had been physically attacked.
The mean reception staff scores (28.4) for the neuroticism sub-scale of the NEO-FFI were significantly higher than the population norm (20.54) (P < 0.001).
Older receptionists were less likely to think they would be threatened in the next 12 months (P = 0.006) and were less likely to have received training in dealing with violent, abusive or difficult behaviour. Those who worked longer hours were more likely to think that they would be threatened or attacked in the next 12 months. They were also more likely to recall either themselves or colleagues having been threatened or attacked. The number of years worked as receptionist did not significantly affect reception staff responses to the questionnaire. Staff with higher scores for the neuroticism sub-scale of the NEO-FFI were more likely be worried about being threatened or attacked at work, were more likely to feel unsafe at work and were more likely to recall either themselves or a colleague having been threatened or attacked (Table 2).
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A composite stress score was obtained for 203 (98%) receptionists (four receptionists left all six items blank). The mean stress score was 3.5 (SD 2.7), range 0–15. The composite stress score was compared with the responses to questions 1–7 of the reception staff questionnaire. The linear trend across the three mean source score values was significant for all seven questions (Table 3). There is a strong significant relationship between a higher stress score (receptionists who feel under more pressure at work) and responses to all seven questions.
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Receptionists who had been a victim of threat or attack at work within the last 12 months were significantly more likely to worry about it and to report that it was likely to happen to them again in the future. They were also more likely to feel that their health was affected by worrying, and that they were not safe in their working environment. There was a strong relationship across all six questions (Table 4).
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One hundred and ninety (92%) had received either formal or informal training (or both) in the role of a GP receptionist. One hundred and sixty-one (78%) had received either formal or informal training (or both) in dealing with violent, threatening or difficult behaviour from members of the public (including patients and their relatives).
To test the hypothesis that staff who feel safe and supported at work feel less likely to be threatened, a variable was created using staff who feel both safe and supported at work. One hundred and sixteen (56%) of staff fitted into this category. Table 4 shows that staff who are supported and feel safe in their working environment are significantly less likely to worry about being attacked at work, less likely to think they will be threatened or attacked in the next 12 months and less likely to report that their health is affected by worrying.
Logistic regression was carried out with the dependent variable ‘How worried are you about being threatened by a member of the public while you are at work?’ dichotomized into ‘very or fairly worried’ compared with ‘not very or not at all worried’, and using the possible predictors described above as independent variables. The most significant independent predictor was whether the receptionist had already been threatened or attacked in the previous 12 months (OR = 4.9, 95% CI 2.0–11.8, P < 0.001). This is after taking all the other variables into account. One other variable was found to be a significant independent predictor of worry about being threatened. This was the NEO-FFI score (OR = 1.11; 95% CI 1.04–1.18, P = 0.001).
A similar logistic regression with worry about being attacked as the dependent variable gave similar results. Previous threats/attacks were the most significant predictor (OR = 4.6; 95% CI 1.8–11.2, P = 0.001), followed by NEO-FFI score (OR = 1.09; 95% CI 1.02–1.17).
Finally, staff who had received training (formal or informal) in dealing with violent, threatening or difficult behaviour felt significantly safer at work (OR = 1.27, 95% CI 1.04–1.55, P = 0.005).
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Discussion |
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The principal findings in our study were that receptionists who reported having been threatened or attacked in the past 12 months were nearly five times more likely to be worried about being threatened or attacked in the future. We also found that the degree of neuroticism exhibited by individuals was a significant predictor of worry about future threats or attack at work. Staff who felt safe and supported at work and staff who had lower background sources of stress at work were less likely to feel they would be threatened or attacked at work in the future. Staff who had received training about violent and abusive incidents felt safer at work. The results of this study provide supportive evidence for the hypothesis that GP reception staff who are supported and who feel safe in their working environment worry less about violent and threatening incidents occurring.
We also found that older staff were less anxious about being threatened and receptionists as a whole scored higher than the general population on the neuroticism questionnaire.
The strengths of this study are that it covers all practices in two PCTs involving a varied mix of inner city and semi-rural geographical areas. The sample of receptionists is therefore likely to be representative of reception staff throughout the UK. Both sample size and response rates were satisfactory and compare favourably to those reported in other studies carried out in primary care [4,7]. PB personally conducted all the interviews as consistently as possible in order to reduce the risk of introducing bias in the questioning. However, a single interviewer may have inadvertently introduced bias.
A potential weakness of this study is that some practices and receptionists refusal to participate may have been associated with factors relevant to the study. Although the majority of practices that did not participate declined because of time pressures prior to the introduction of the new GP contract, one did not consider violence to be a problem. Non-responders among reception staff may also have felt that violence was not a problem and therefore the study was not relevant to them. Responders will have had individual concerns and this could have resulted in the introduction of bias. It is possible that receptionists who have been threatened or assaulted have left their jobs, and the population of receptionists surveyed could be a ‘survivor population’. This is a potential source of bias in this study, as in any cross-sectional study. Some questions may have been subject to recall bias, although retrospective questions were mainly limited to recall within the last 12 months.
The most consistent factors affecting how worried the receptionists were about being threatened or attacked were previous threat or attack and personality as measured on the NEO-FFI scores. These findings support previous studies in non-health care staff who suggest that the fear of future workplace violence was predicted by prior exposure to violence, and that it was this fear that predicted impaired psychological and physical health [21,22]. It appears from our study and other studies that the worry or fear caused by previous threats or attack could predict worry about further events occurring in the future. It is important that this is recognized and that support mechanisms are developed for this group of employees.
The personality or more specifically the degree of neuroticism exhibited by individual receptionists was found to be a significant predictor of worry about being threatened or attacked at work. It is difficult to know if it was the ‘worry about being threatened or attacked’ contributing to the personality or vice versa. This group were also more likely to have been the victim of threat or attack in the past and this leads to the possibility that they may have been exhibiting the negative effects of exposure to previous violent or abusive behaviour. These results need to be interpreted with caution. However, receptionists with a higher neuroticism score are more worried about the future possibility of violent incidents occurring.
As a group, the receptionists scored significantly higher than the general population on the personality questionnaire. There is a growing interest in psychology and organizational literature in the role of personality in organizational behaviour and job performance, and a considerable amount of research has focussed on this [23,24]. Worrying, nervous, emotional and highly-strung employees have been found to perform better in certain types of role [23]; however, we were unable to find any references specifically relating to receptionists and personality, and this may be an area worthy of further research.
Reception staff felt safer at work where they had received training relating to dealing with violent and abusive behaviour. These findings support those of previous studies by Riopelle [25] where adequate training appeared to enhance workers sense of safety and security at work and Schat [26] where informational support, i.e. providing the person with information and training whether informally or formally, significantly moderated the effects of workplace violence on emotional well-being. Previous research has often concluded that reception staff would benefit from more training in this area [4,7,15,16]. The level of training delivery in our study (78%) was higher than that reported by Calvert in 1997 [4] (in which training had been received by 15%). These results are encouraging and would suggest that this workplace hazard is now being taken seriously.
Another very significant factor affecting reception staff perceptions of how safe they felt at work was support, both adequate support to do their jobs (P < 0.001) and post-incident support (P = 0.002). This again supports the findings of Schat [26] that support from within the organization acted as a buffer against the negative consequences associated with the experience of workplace violence, and that instrumental support (providing direct help or assistance from co-workers, supervisors or managers) significantly moderated the effects of workplace violence on emotional well-being, somatic health and job-related effect.
Background sources of stress at work were significant in affecting reception staff perceptions. Receptionists who felt under increased pressure at work were more anxious and were more likely to have been a victim of threat or attack at work. These results suggest that a key factor in reducing anxieties is empowerment at work in terms of job demands, control, role, change and support.
The results of this study extend the research into violence against primary care staff by looking in particular at reception staff and their perceptions of violence in the workplace. The major practical implication of this research for GP is that the implementation of staff support, both organizational and post-incident, together with training in dealing with violent and abusive incidents can help to mitigate the negative effects of workplace violence on both the member of reception staff and the organization.
Key points
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Conflicts of interest |
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None declared.
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References |
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