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      Workplace Violence Against Chinese Frontline Clinicians During the COVID-19 Pandemic and Its Associations With Demographic and Clinical Characteristics and Quality of Life: A Structural Equation Modeling Investigation


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          Background: Workplace violence is a major concern for clinicians worldwide. There has been little data on the epidemiology of workplace violence against frontline clinicians during the COVID-19 pandemic. This study examined the pattern of workplace violence and its association with quality of life (QOL) against frontline clinicians during the outbreak of COVID-19 pandemic in China.

          Methods: A cross-sectional online study was conducted in China between March 15 and March 20, 2020. Frontline clinicians' experience with workplace violence was measured with six standardized questions derived from the Workplace Violence Scale, while anxiety, depressive, and insomnia symptoms, and QOL were measured using the General Anxiety Disorder Questionnaire, the Patient Health Questionnaire, the Insomnia Severity Index, and the World Health Organization Quality of Life Questionnaire, respectively. Univariate analyses, multivariable logistic regression analyses, and structural equation modeling (SEM) were conducted.

          Results: A total of 15,531 clinicians completed the assessment; 2,878 (18.5, 95% CI = 17.92–19.14%) reported workplace violence during the outbreak of the COVID-19 pandemic (verbal violence: 16.1%; physical violence: 6.9%). According to multivariable models, key correlates of workplace violence were male gender, longer work experience, higher education level, smoking, working in the psychiatry or emergency department, working in tertiary hospitals, being involved in direct care of infected patients, having infected family/ friends/ colleagues, and frequently using social communication programs. Clinicians working in inpatient departments were less likely to report workplace violence compared to those working in outpatient departments. SEM analysis revealed that both violence and emotional disturbances (anxiety, depression, and insomnia) directly affected QOL (standardized direct effect = −0.031, and −0.566, respectively, P < 0.05), while emotional disturbances partly mediated the association between work violence and QOL (standardized indirect effect = −0.184, P < 0.05).

          Conclusion: Frontline clinicians were vulnerable to workplace violence during the COVID-19 pandemic. Due to the negative impact of workplace violence on quality of care and clinicians' QOL, health authorities and policymakers should take effective measures to reduce workplace violence against clinicians.

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          Most cited references46

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          A brief measure for assessing generalized anxiety disorder: the GAD-7.

          Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.
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            Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

            Key Points Question What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)? Findings In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19. Meaning These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.
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              Comparative fit indexes in structural models.

              P. Bentler (1990)
              Normed and nonnormed fit indexes are frequently used as adjuncts to chi-square statistics for evaluating the fit of a structural model. A drawback of existing indexes is that they estimate no known population parameters. A new coefficient is proposed to summarize the relative reduction in the noncentrality parameters of two nested models. Two estimators of the coefficient yield new normed (CFI) and nonnormed (FI) fit indexes. CFI avoids the underestimation of fit often noted in small samples for Bentler and Bonett's (1980) normed fit index (NFI). FI is a linear function of Bentler and Bonett's non-normed fit index (NNFI) that avoids the extreme underestimation and overestimation often found in NNFI. Asymptotically, CFI, FI, NFI, and a new index developed by Bollen are equivalent measures of comparative fit, whereas NNFI measures relative fit by comparing noncentrality per degree of freedom. All of the indexes are generalized to permit use of Wald and Lagrange multiplier statistics. An example illustrates the behavior of these indexes under conditions of correct specification and misspecification. The new fit indexes perform very well at all sample sizes.

                Author and article information

                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                15 April 2021
                15 April 2021
                : 12
                [1] 1Unit of Psychiatry, Department of Public Health and Medicinal Administration, Faculty of Health Sciences, Institute of Translational Medicine, University of Macau , Macao, China
                [2] 2Center for Cognition and Brain Sciences, University of Macau , Macao, China
                [3] 3Institute of Advanced Studies in Humanities and Social Sciences, University of Macau , Macao, China
                [4] 4Department of Nursing, Beijing Tongren Hospital, Capital Medical University , Beijing, China
                [5] 5Department of Emergency Medicine, Beijing Tongren Hospital, Capital Medical University , Beijing, China
                [6] 6Beijing Key Laboratory of Mental Disorders, The National Clinical Research Center for Mental Disorders, The Advanced Innovation Center for Human Brain Protection, School of Mental Health, Beijing Anding Hospital, Capital Medical University , Beijing, China
                [7] 7School of Nursing, Hong Kong Polytechnic University , Hong Kong, China
                [8] 8New York University Shanghai , Shanghai, China
                [9] 9University of Notre Dame Australia , Fremantle, WA, Australia
                [10] 10Division of Psychiatry, School of Medicine, Graylands Hospital, University of Western Australia , Perth, WA, Australia
                Author notes

                Edited by: Yanhui Liao, Sir Run Run Shaw Hospital, China

                Reviewed by: Bao-Liang Zhong, China University of Geosciences Wuhan, China; Jiansong Zhou, Central South University, China; Jihui Zhang, The Chinese University of Hong Kong, China

                *Correspondence: Yu-Tao Xiang xyutly@ 123456gmail.com

                This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry

                †These authors have contributed equally to this work

                Copyright © 2021 Yang, Li, An, Zhao, Zhang, Cheung, Hall, Ungvari, An and Xiang.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                Page count
                Figures: 1, Tables: 3, Equations: 0, References: 51, Pages: 8, Words: 6121
                Original Research

                Clinical Psychology & Psychiatry
                Clinical Psychology & Psychiatry
                clinician, covid-19, frontline, workplace, violence


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