Coping with Trauma Exposure at work in Forensic and Clinical Psychiatry

Workplace trauma exposure in the psychiatric health care setting has a major
impact on caregivers* functioning and health (Schablon, Wendeler et al. 2018).
In the literature on current trauma exposure at the workplace several related
concepts are being used including severe incidents, workplace violence,
secondary or vicarious trauma, physical and psychological violence,
occupational stressors and aggression towards staff (Baum 2016). This protocol
will study all these forms of trauma exposure in forensic and clinical
psychiatry using the term: workplace trauma exposure.
The prevalence of these forms of trauma exposure has been studied with
increasing interest since the last years of the previous century. Poster (1996)
provides us with an overview of studies done in the UK, Australian and United
States presenting percentages of nurses working in acute and inpatient
psychiatry experiencing an assault (lifetime and previous year) . In the UK
more than 90% had experienced a physical assault during their career and 34%
more than 10 physical assaults, in Australia 85% of nurses experienced targeted
aggression towards them and in the United States 76% of nurses were physically
assaulted at least once in their career (Poster 1996). Two more recent studies
describe similar results: Itzhaki, Bluvstein et al. (2018) reported that almost
89% of mental health nurses working in acute and inpatient psychiatry in Israel
experienced verbal aggression in the last year and 56% physical violence. Niu,
Kuo et al. (2019) reported rates that were very similar (82% verbal aggression
and 56% physical aggression) in acute inpatient psychiatry in Taiwan in the
previous year.
These aggressive incidents can have severe consequences. Schablon, Wendeler et
al. (2018) found that between 27% and 44% of employees felt high levels of
self-reported stress as a result of the incidents. This survey was conducted in
Germany amongst nurses working in inpatient psychiatry, geriatric care, other
residential facilities and day care centres (N=1984), of whom 94% had
experienced verbal abuse and 70% physical abuse (Schablon, Wendeler et al.
2018). Additionally, in their systematic review, Lanctot (2014) found various
categories of consequences of workplace violence for healthcare workers,
including decreased physical, psychological and emotional functioning and
various aspects of impaired worker performance (quality of care, financial,
social and general impact).

Workplace trauma exposure in frontline and treatment staff versus non-clinical
staff
The group with most exposure to workplace violence are nursing staff who work
in inpatient units (Schablon, Wendeler et al. 2018). Magnavita and Heponiemi
(2012) found that nurses in public health care, also called frontline staff,
were more likely to encounter aggressive behaviour due to the increased amount
of time spent caring for patients, compared to treatment staff who have less
encounters with patients.
Frontline staff can be defined as the men and women working on the psychiatric
wards in the direct and 24 hour care of admitted patients. They see patients
many times during their shifts. There is much more interaction between
frontline staff and patients than there is between treatment staff (comprising
of physicians, social workers, psychiatrists and psychologists) and patients.
Treatment staff may see the patients as little as once per two weeks,
specialists sometimes even less. Finally, most non-clinically working staff
have only minimal contact with patients, since usually they work in offices
outside patient wards.

Childhood adversity and benevolent experiences as moderators for the
association between workplace trauma exposure and professional quality of life
In recent years focus has shifted from psychiatric patients (who have
relatively high levels of trauma and neglect in childhood), to professionals
(psychologists, social workers, psychiatrists and direct support staff) working
in mental health care, who also have higher incidence levels of childhood
adversity than the general population (Esaki, 2013; Thomas, 2016; Keesler,
2018; Felitti, 1998; Anda, 2004; Herzog, 2018).
In his landmark study Felitti et al. (1998) first investigated to what extent
the general population had experienced childhood adversity prior to the age of
12, and the impact of this adversity in later life. He defined these
adversities, which he called an *Adverse Childhood Experience (ACE)*, as
exposure to childhood emotional, physical or sexual abuse, and household
dysfunction. The impact of ACE*s on many life domains, including mental and
physical health, has been demonstrated in several studies that followed (for
instance: Anda, 2004 and Herzog, 2018).
Interestingly, in professionals working in health care services, higher levels
of ACE*s have been demonstrated as compared to professionals working in other
areas. For example, in a study by Thomas (2016) it was found that Master of
Social Work (MSW) students had experienced a relatively high number of ACEs as
compared to the general population. Almost 80% experienced one or more ACEs and
42% four or more. The most frequently cited ACEs were physical abuse, emotional
neglect and substance abuse (all > 40%) and about one-third reported mental
illness and emotional abuse (Thomas, 2016).
Esaki (2013) reported that approximately 70% of child service providers
reported at least one ACE, 54% two or more ACEs and 16% four or more ACEs,
which is nearly twice as high as the general population.
Keesler (2018) investigated Direct Support Professionals (DSP) (N=386). DSPs
provide support and care to people with intellectual and developmental
disabilities. His online survey revealed 75% of the DSPs experienced one or
more ACEs and 30% four or more ACEs. Female DSPs and persons who worked less
than a year in this setting reported significantly higher ACE scores than males
and more experienced staff (Keesler, 2018).

To date however, no research is known to the authors about the incidence of
Adverse Childhood Experiences (ACEs) in frontline staff, treatment staff and
non-clinical workers in general and forensic in- and outpatient psychiatry.
Also there might be a graded difference between frontline staff, and treatment
staff and non-clinical staff in the incidence of childhood adversity.

Benevolent Childhood Experiences
In addition, there is increasing scientific interest into the counterpart of
Adverse Childhood Experiences (ACEs): Benevolent Childhood Experiences (BCEs)
(Narayan, Rivera et al. 2018). It is believed that higher BCEs are protective
against the long term effects of ACE*s and that this is associated with
resilience, less trauma related symptomatology and less stress exposure during
pregnancy (Narayan, Rivera et al. (2018); Sheerin, Amstadter et al. (2019).
Very little is known about ACEs and BCEs in frontline staff, treatment staff
and non-clinical workers, and how they interact in case of stressors at the
workplace.

Professional Quality of Life and workers performance
Previous or ongoing stressors have been shown to be risk factors for a negative
mental health outcome of current critical incidents (Brewin, Andrews et al.
2000). Remarkably, not much is known about the personal histories of frontline
staff, treatment staff and non-clinical staff, both negative and positive, and
how this influences their professional quality of life and coping strategies
with traumatic events.

In summary, the topics addressed above indicate the importance and relevance of
gaining more knowledge about the associations between workplace trauma exposure
and professional quality of life in frontline and treatment staff, compared to
non-clinical staff, and how this association is moderated by ACE*s and BCE*s.
This study has conceived the following aims to diminish this gap in our
understanding.

The primary research questions are:
1. What is the extent of Adverse and Benevolent Childhood Experiences in
frontline staff and treatment staff in general and forensic inpatient
psychiatry in comparison to non-clinical staff?

2. To what extent is the relation between workplace trauma exposure and
professional quality of life moderated or mediated by childhood adversity and
benevolence?

Cross-sectional design

The nature and extent of the burden and risks associated with participation are:
1. Answering questions about adverse childhood experiences and stressful
experiences at work can be experienced as confronting and invoke negative
emotions.
2. Completing the questionnaires will take 30-45 minutes. The questionnaires
may be completed in parts to diminish the burden.


This study covers the very important subject of investigating new pathways to
improving the professional quality of life in frontline staff. The burden of
completing several questionnaires is acceptable within the scope of this study.