Tak, S., Sweeney, M., Alterman, T., Baron,

Tak, S., Sweeney, M., Alterman, T., Baron, S., & Calvert, G. (2010). Workplace Assaults on Nursing Assistants in U.S. Nursing Homes: A Multilevel Analysis. American Journal of Public Health October 100 (10):1938-1945.

This particular topic provokes my interest because it considers the potential of risk to a population that usually is closely supervised to ensure that they do not inflict damage to vulnerable populations. Looking at the potential for damage to nurses is an important consideration because of the anticipated increase in the numbers of persons to be hospitalized in the future. These researchers appear qualified to conduct this research as their academic training has exposed them to engage in this level of assessment and dialogue. All of the researchers have obtained terminal degrees as well as Masters Degrees. All but one of the researchers has a Master of Public Health which indicates that they have been exposed to many of the concepts and theoretical framework discussed in the paper.

The problem outlined in this study is the unavoidable risk of assault inflicted by nursing home residents upon nursing assistants. The purpose of this research is to identify risk factors for injury to nursing assistants. The factors were considered at the individual and the organizational levels. The authors expressed that due to the dearth of information pertaining to the characteristics of organizations that are associated with violence in the workplace this type of study was needed. The problem was clearly identified. The authors stated the problem as follows: "Nursing assistants are at high risk of injury from violent assault at work, and their risk exceeds that of other health care workers."

The area is important to study because it expands the knowledge in an area of nursing that is both under theorized and explored. More specifically it is looking at violent behavior that results in physical injury to nursing assistants in nursing homes and not on wards. Consequently the purpose of the study was to identify the risk factors associated with violent injuries on nursing assistants. This is highly relevant to the nursing profession because of the role nursing assistant's play in the care of patients. It was also relevant because these types of injuries degrade the working conditions and contribute to staff leaving the facilities. Additionally, as the authors expressed the need for nursing staff in the future will increase as a direct result of the increase in life expectancy.

The research question was not specifically identified by the authors and the reader is left to conjure what that question may be. From the structure of the article it may be possible to conclude that the question the research sought to answer is: what are the individual and organizational factors that influence the types of physical injuries sustained by nursing assistants? One of the clear features of the work was the useful operationalization of physical injury as human bites. The authors surmised that such an activity would be difficult to forget and consequently should be reported with greater reliability.

The literature review was limited and focused on injuries to nurses in general and a description of the increases in nursing assistants. The majority of the sources used for the review consisted of primary research. The oldest study was undertaken in 2003 and the most recent was 2008. The use of the sources left the reader wondering if something was missing in terms of identifying literature that may have be qualitative in nature that could add useful context to the study (Creswell 1994).

The authors did not specify a theoretical framework that guided the study. They noted a number of descriptive studies that assisted in understanding the magnitude of the problem. Explanatory studies that would have assisted in theory testing were not presented by the researchers. In the absence of a clear statement of the theoretical framework the reader is unable to appropriately assess the fit between theory and design of the study. The measurement of the variables and their conceptual definitions are also difficult to assess because the reader is not told of the theory engaged by the researcher.

The study utilized data that was collected from two different sources, the National Nursing Assistant Survey (NNAS) and the National Nursing Home Survey (NNHS). Both studies used a cross-sectional design to collect the data. The researchers did a comparative analysis of data from both sources to provide a less biased set of data on the subject. The objectives identified by the researchers can be satisfied by this design; the design would allow the researchers to examine both the reported experiences of nursing assistants with violent clients as well as the associated hospital conditions where the act took place.

The potential for harm to the subjects of the study was minimal. The main contention appeared to be the loss of job by the respondent should the information be leaked to their employer. The researchers sought to allay these fears by restating that the data was highly confidential and would not processed anonymously. There is reference to nurses declining participation and consequently it appears that there was informed consent. There is no reference in the article to the study being approved or reviewed by an IRB.

The sample was taken from state certified nursing assistants, based on that criterion 4274 nurses were eligible to participate in the study. The actual sample consisted of 3017 nursing assistants with 2888 actually responding to the questions in the instrument.

The data were collected using a structured questionnaire which was administered to the participants via the telephone. The validity and reliability of the instruments were not stated in the research. The researchers did not state how the sample was selected but did note that between 1 and 9 participants of each facility were randomly selected to participate in the study.

The study employed data at all the levels. The main dependent variable however was collected as a dichotomous nominal level variable, where 1=bite occurring and 0=no bite occurring. The data were analyzed using the Rao -- Scott design-adjusted X2 test as well as Odds-Ratio assessment of risk. The level of significance used in the study was 0.05 which is consistent with other research in the field (Gravetter, & Wallnau, 2008). The authors discuss the meaning of the results and identify inconsistencies with other studies in the field. The most important finding of the study was that 35% of the nursing assistants reported that they had received physical injuries because of aggression by the residents of the nursing home.

The data collected by the researchers provide clear answers to the research question as several factors were identified possible contributors to the levels of violence observed. The researchers were very careful to remain within the parameters of the data collected and noted areas that were interesting to note but could not be supported by the data (Marini, & Singer 1988). Another conclusion that is possible from the data is that the lack of awareness by facility managers influences the levels of violence that nursing assistants are subjected to.