Client Violence towards Childcare Workers: A Systematic Literature Review

Díaz Bórquez, Daniela; Calderón-Orellana, Magdalena; Inostroza Correa, Alejandra; Varas González, Gonzalo

doi:https://doi.org/10.1155/2023/5556520

Health & Social Care in the Community

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Abstract Introduction Materials and Methods Results Background Discussion Conclusions Data Availability Conflicts of Interest Acknowledgments References Copyright Related Articles

Review Article | Open Access

Volume 2023 | Article ID 5556520 | https://doi.org/10.1155/2023/5556520

Client Violence towards Childcare Workers: A Systematic Literature Review

Daniela Díaz Bórquez,¹Magdalena Calderón-Orellana,²Alejandra Inostroza Correa,³and Gonzalo Varas González⁴

Academic Editor: Tushar Singh

Received04 Mar 2023

Revised21 Jul 2023

Accepted29 Aug 2023

Published09 Sept 2023

Abstract

Client violence against childcare workers is a relevant problem due to its impact on their well-being and the service they provide due to their significant role in the child protection process. This study explored violence against childcare workers using a systematic literature review. PubMed, Science Direct, ResearchGate, and Google Scholar were searched for studies that included the words workers, childcare workers, child protection workers, social workers, user violence, client violence, child violence, parental violence, client aggression, client-perpetrated violence, residential childcare, childcare centres, and/or child protection centres. A total of twenty studies were included. Most studies described violent incidents, often directly involving children or their parents. The results indicate that the effects of violence significantly impact the life and well-being of workers and those workers and organizations naturalize it. It is necessary to advance in the denaturation of violence in the workplace and agree on a violence definition to implement preventive measures such as induction, training, and supervision.

1. Introduction

Work violence, understood as “direct exposure to negative, systematic, and prolonged behaviour at work” [1], has been studied in health and care services for legal, productive, or public health reasons [2–4]. It has also aroused public and academic interest due to its magnitude [5–7] and the effects it generates, such as negative behavioural, emotional, cognitive, and physical outcomes, for professionals [8].

Although it is possible to describe forms, antecedents, and results of work violence between workers [9, 10], external violence—in which the aggressors are the clients—has not been sufficiently addressed in social services dedicated to the care of children. The reason for this lack of interest could be related to the naturalization of the phenomenon, the focus of most studies on clients of social services, and the limited expectations of change [11, 12].

In this context, it is necessary to advance the study of violence in childcare workers and understand the specificities assumed by the phenomenon, which differ from other sectors for varied reasons. In the first place, most of the users of care services—children and adolescents—use these services involuntarily. In other words, they did not actively choose to be part of a residential program [13], but they participate because of the interposition of judicial and/or protection measures. At the same time, children and adolescents will be in care centres for a long or indefinite time, which depends on the judicial system [14]. Moreover, many of these users of care and protection services will move from one program to another during their lifetime [15], which can lead them to naturalize certain conditions of protection and care spaces that are directly linked to violence [16]. On the other hand, it is necessary to emphasize that these clients, unlike those in most other sectors and industries studied, are developing progressive autonomy [17], and the majority are legally not responsible for their actions but are the state’s responsibility. Finally, the service origin is related to child rights violations and, therefore, to the mistreatment that users have experienced through direct violence or negligence.

Research on client violence in social services that care for children is a key in developing prevention strategies that recognize the particularities related to users who are children and adolescents and are under government protection. Furthermore, it will contribute to strengthen a key role in protection systems—the childcare workers—as they are responsible for demands that involve enhanced “caring,” including emotional and physical proximity [18]. In this way, taking care of the well-being of workers is a key because it is negatively related to turnover, which has significant negative effects on the well-being of the children, as well as financial repercussions on the organization [19].

Thus, through a systematic literature review, we intended to describe the experiences of violence and its prevalence in childcare workers, recognize their coping strategies, and identify preventive measures and highly useful information for decision-making in public policies and the academic world.

2. Materials and Methods

To meet the study’s objectives and get an updated and general view of research in this area, a systematic literature search—based on PRISMA guidelines [20]—was conducted about client violence in residential childcare, understood as an alternative to assist and care for children who are traditionally in the care of the State due to a judicial measure.

The review in a previous step considered the identification of the key concepts referring to the main terms used by the bibliography on the subject, which was conducted through different searches and their iterations. The primary sources used to collect documents were the websites and databases of international journals, such as ResearchGate, Google Scholar, Science Direct, and PubMed.

Once the themes and keywords related to violence at work in social services, especially childcare services, were recognized, a systematic review of the literature was conducted. The definitive literature review searched for articles published from 2002 until 2022 and was carried out in June 2022.

The systematic search used key concepts that can be classified into three types: (a) to identify workers, concepts such as workers, childcare workers, and child protection workers and social workers were used; (b) to identify the type of violence (client violence), the concepts of violence, user violence, client violence, child violence, parental violence, client aggression, and client-perpetrated violence were used; and (c) to identify the workplace where the violence is perpetrated and differentiate it from research on other types of social services, concepts such as residential childcare, childcare centres, and child protection centres were tracked. We considered research articles in peer-reviewed journals and reports on experiences in child and youth residential care based on empirical backgrounds.

A total sample of 31 texts met the requirement of including at least two of the concepts used in the searches in either the title or the summary section, eliminating duplicate articles. Then, all articles that did not incorporate empirical materials or did not comply with the article format were excluded, leaving a total of 24 articles. Finally, those that did not refer directly to the subject, but referred to issues such as working conditions, work environment, work ethic, and compassion fatigue without directly addressing the phenomenon of violence against these workers, were excluded, limiting the articles to 20. Finally, the selected texts were reviewed by two researchers independently, looking for information about the authors, the year of publication, the objective of the study, the methodology used, the data and instruments, and the results. The procedure is detailed in Figure 1.

3. Results

The studies finally included in this review were 20, published between 2004 and 2021. Specifically, six were published between 2004 and 2012, while 14 were published between 2013 and 2022. Moreover, nearly half of the articles (9) have been published in the last five years, indicating the growing interest in the topic. The investigations reported in the articles are centred on seven countries: USA (7), Canada (6), England (4), Norway, South Korea, Finland, and Switzerland, each with one article. Regarding the methodology, eight studies used qualitative methodology and 9 used quantitative methodology. Three studies employ a mixed-methods approach. Lastly, the authors with the most articles are Lamtothe and Litlechild, each with four articles in the list. The details of the selected articles are presented in Table 1.

3.1. The Concept of Violence

The literature reported a wide range of concepts of client violence in childcare services. This diversity of concepts leads to inconsistent definitions of violence [21]. For example, Smith et al. [22] used the National Institute for Occupational Safety and Health definition, which described workplace violence as “violent acts, including physical assault and threats of assault, directed against individuals on the job or in service.” This concept integrates several types of violence. However, the definitions related to aggressions that are not physical, such as psychological violence, threats, and verbal aggression, are not clear. It should be noted that precise threats or verbal abuse toward workers have been most problematic. Probably, this type of behaviour requires a more univocal definition on the part of the policies and procedures developed by childcare centres [23].

Lamote et al. [24] defined violence based on Schat and Kelloway’s [25] proposal. They made the distinction between violent behaviours and psychological violence. The first is related to physical violence (e.g., biting, kicking, or suffocating). The second involves potentially harmful behaviours or symbolic violence, such as shouting, intimidation, property damage, or insults.

On the other hand, Shin [26], based on Spencer and Munch [27], conceptualized client violence as “actual physical assaults, threats, or any other events that social workers perceive as violent” [27]. In this case, the workers’ perception of the facts as violent is a key in defining these events as situations of violence.

Finally, Radey and Wilke [28] discussed the importance of structural inequality and social position in understanding workers’ experience of violence. This perspective highlights how the difference in worker status can imply different attitudes, perceptions, stressors, or resources that workers have to face violence.

In addition to the diversity of conceptualizations, the imprecision about what behaviours constitute violence or abuse must be noted. This highlights the necessity of defined violence and violent behaviours to advance the strategy to face these behaviours [29].

In empirical research, different definitions of violence affected how the phenomenon was studied. The differences in conceptions were represented in the heterogeneity of methodologies, scales, and instruments used to investigate the subject. So, the diversity of methodologies translates into difficulty in aggregating and comparing information, affecting a standardized understanding of violence in childcare centres [30].

3.2. Prevalence of Client Violence among Childcare Workers

While all selected articles focused on client violence, only a few examined its prevalence and characteristics. Littlechild et al. [31] researched 590 workers, of whom 72% were childcare workers. The authors observed that 48% had received threats of denunciation from parents, 42% received threats to themselves, and 16% had received threats to their relatives. Finally, the researchers noted that 50% had dealt with hostile parents at least once a week.

In South Korea, Shin [26] investigated client violence toward childcare workers. A sample of 207 national protection and welfare service workers in Korea reported that childcare services’ workers experienced more client violence than community service workers. Also, childcare workers were more concerned regarding client violence and had a greater need for actions to promote the safety of the working environment. The situation was endorsed in Canada, where Lamothe et al. [24] confirmed that residential child protection workers described a higher frequency of violence, especially physical violence, than those who worked in community settings.

Meanwhile, Radey and Wilke [28], through a study conducted in the United States on 1,501 workers new to child protection showed that 75% of them experienced nonphysical violence, 37% threats, and 2.3% of them suffered physical violence. The elderly and experienced workers received less violence than the rest. The study indicated that more incidents were reported in the first months of work.

Also, in the United States, Radey et al. [32], through qualitative interviews with a sample of 34 workers, reported that the vast majority suffered various kinds of physical and nonphysical violence. The workers who were exposed to screaming experienced violence more frequently than others.

4. Background and Consequences of Client Violence

Studies regarding client violence antecedents are limited. We only found two articles that reported antecedents of client violence. According to workers’ perceptions, Radey [33] reported predictable patterns of violent circumstances and people, such as being alone, dealing with parents whose families were separated, or children and parents being violent. On the other hand, a study based on a sample of 30 clients and 43 workers reported that victimization and the perpetration of violence by workers were statistically related [34].

Concerning the effects of client violence, Littlechild [29] examined the experiences of social workers and child protection managers concerning handling client violence towards child protection social workers in England. The research found that the effects of violence on workers depended on different aspects such as concerns about the effects of user violence on their work; the significance of managers promoting worker safety, especially when intimidations are not always obvious to others; staff support actions; responding to violent clients; and ways in which workers’ experiences are used to improve risk assessment and management.

The same author [23] examined, in England and Finland, the effects of client violence towards child protection social workers. The findings suggested that workers’ effectiveness was compromised when they performed their roles in family support and child protection in certain situations.

In the United States, Horwitz et al. [35] confirmed that negative workplace events—including client violence—were associated with the effects of workplace trauma among child welfare workers.

In a research study by Hunt et al. [36], workers reported that poorly handled parental hostility affected their practice quality. The violence experienced had a significant negative impact on their personal and professional lives.

Kim and Hopkins [37], in a sample of 435 childcare workers, studied the role of the work environment in prevention and postvictimization, excluding supervisors and administrators who did not handle domiciliary visits. The results suggested that frequent exposure to unsafe work environments was associated with lower levels of organizational engagement.

Littlechild et al. [31] confirmed that 66% of workers believed that dealing with parents who abused them negatively impacted their work and their own families. Forty-two percent (n = 250) said they agreed or strongly agreed that vulnerable children were most at risk because workers did not receive sufficient supervision and support when dealing with hostile and bullying parents.

In the United States, Smith et al. [22] developed research to analyse the workforce’s problems in a residential treatment centre linked to client violence. Based on ethnography and data analysis from multiple sources (interviews and participant observation), workers reported that exposure to violence by clients sometimes resulted in serious physical injury and/or leave, as well as substance abuse, anxiety, sleep disturbance, and memory loss. Participants reported that client violence was the most difficult part of their jobs and cited it as a reason to quit or want to leave youth care work.

Similar results were reported by Lamothe et al. [24], who found that workers who experienced violence from clients suffered psychological, organizational and motivational, and clinical consequences.

Kind et al. [38] investigated the impact of clients’ verbal and physical aggression on the risk of developing a high cortisol concentration in the hair as an indicator of chronic stress exposure and exhaustion in a Swiss population of professional caregivers working in residential youth centres. This longitudinal analysis suggested that the psychophysiological stress response is primarily associated with combined physical and verbal aggression. However, the emotional exhaustion associated with verbal aggression should not be overlooked.

Based on a sample of 33 people, Radey, et al. [33] studied the characteristics of client violence and how they affect CPS worker health in the United States. The authors concluded that workers generally experienced one of two narratives. First, workers suffered spontaneous attacks, experienced extensive agency support and responsiveness, and perceived no health consequences, or workers perceived premeditated personal attacks without agency support and experienced psychological distress.

Lamothe et al. [21] confirmed that client psychological distress and aggression are common among child protection workers (CPWs). This study concluded that distress and aggression were linked in complex ways, with psychological distress predicting subsequent victimization in the short but not in the long term. CPWs had a small emotional margin of error to prevent client aggression, implying that any wrong approach in avoiding violence can lead to aggression toward workers. So, violence prevention programs should reflect this fact. A similar situation was confirmed by Brend [39] whose study reported that violence generates psychological distress in residential childcare workers.

Geoffrion et al. [40] reported that workers’ exposure to verbal client violence was related to increasing restraint and seclusion intervention use by workers. Meanwhile, perceived communication and openness were related to a lower level of restraint and seclusion use.

4.1. Coping Strategies

Studies reporting on strategies for coping with client violence were limited in the literature consulted. Only in some studies were the actions that followed violent events reported. Littlechild et al. [31] confirmed that only 23% of those who participated in the study acknowledged that their organization had procedures—existing guidelines that everyone used—for dealing with violent parents, and only 14% (n = 83) had reported threats to the police.

In Canada, Lamothe et al. [24] indicated that passive actions were observed in the face of acts of violence, which justified violence. Some workers perceived violence as “part of the job,” meanwhile others described it as a “call for help” on behalf of clients. Regarding active coping strategies, participants approached colleagues and supervisors and used the resources made available to them by the organization where they worked.

For their part, Hunt et al. [36], in a sample of 590 childcare workers in England, analysed the experiences of workers related to supervisory and management responses after interactions with hostile and intimidating parents. The results reported that the overwhelming issue in the responses was the lack of support and supervision workers received, often in stressful and frightening circumstances. Finally, Radey et al. [32] noted that workers commonly felt their agencies treated violence as “business as usual.”

4.2. Preventive Actions

In relation to client violence prevention, Øien and Lillevik [41] developed a study that answered the following questions through six semistructured interviews and a focus group: Does personal competence make a difference in violence prevention, and how is this “personal competence” expressed? The study found that workers’ attitude was important to avoid unnecessary confrontations. The results also reported that staff who sought to find the reason behind the aggression and were deeply concerned about the well-being of young people tended to alleviate conflicts rather than trigger it.

Then, a second study by Radey and Wilke [28] observed that institutionalized mandatory reporting procedures with definitions of nonphysical violence, threats, and physical violence could promote a culture of safety rather than an attitude based on violence being part of the job.

Finally, in Canada, Lamothe et al. [42] investigated the interactions between CPWs recovering from a recent experience of client aggression and their supervisor. For this study, researchers were particularly interested in documenting perceived supervisor support in the context of client aggression rather than the characteristics and typologies of supervisor support presented by other authors. This quasi-experimental design—the largest within this review—used mixed methods to assess the consequences of workplace trauma and the organizational response to it (i.e., supervisor support and peer support program). Their findings suggested that the organizational context needs to be reshaped to allow supervisors and employees to manage the consequences of customer aggression more effectively; otherwise, they are likely to continue to use simple action strategies, undermining their resilience. In this regard, they highlighted the importance of improving “perceived social support,” not just tangible forms of social support [43]. Specifically, the findings of this paper suggested that participants’ needs could be met with regular “reflective supervision” [44].

5. Discussion

Through the literature review, we have systematized the studies produced and published regarding client violence in children’s residential care. Thus, it is possible to establish that client violence is experienced by most workers in the area, with high prevalence rates [24, 26, 28, 31, 32], in different parts of the world and that it is strongly naturalized as a regular part of the work performed by workers [22, 24, 28].

Regarding definitions of violence, studies distinguish between two forms of violence. In this sense, physical violence is more distinguishable, and it is where there is less doubt regarding the interpretation of such actions as violent. However, actions associated with verbal aggression, attacks on furniture, or threats, among others, are more difficult to characterize and openly interpret as violence [29]. This has two implications. On the one hand, it is difficult to establish specific protocols that unequivocally determine that these actions are incorrect. On the other hand, it generates that the methodological approach of research on client violence against residential care workers is diverse.

The development of violence strategies requires a clear definition of what will be considered violence against residential care teams [23]. Based on the review, we believe that the concept of violence in social services that care for children should identify and integrate physical violence, verbal violence, sexual violence, and assault or damage to properties. Likewise, it is important to clearly identify the client since they can be children and adults. In both cases, different coping strategies are required, given the specific conditions of the children.

One issue that draws attention when reviewing the available literature on violence by clients against childcare workers is that most available evidence is limited to measuring violence and identifying its consequences. In contrast, research on prevention mechanisms, effective interventions, or coping strategies for violence by users against social service teams is bounded. Only three studies reported experience centred on prevention [21, 28, 41].

In this sense, the focus of studies on the measurement of client violence probably responds to the fact that preventive actions are limited in practice. The scarce development of preventive actions may be associated with the fact that they are thought to be complex to develop or are ineffective [11] because they are part of multiple kinds of symbolic and structural violence that cross the phenomenon. Following Radey and Wilke [28], if structural inequalities and social position acquire relevance in understanding these teams’ experiences of violence, it is impossible to think of coping strategies indifferent to these dimensions, which represent a challenge if this problem is faced in isolation by organizations dedicated to caring.

Regarding coping with violence, the literature, although fairly general, sheds some light on specific actions that could contribute in confronting this type of violence [31, 36]. First, it is necessary to establish clear policies to address violence at different times, such as the induction of new personnel or the specificity of coping protocols. At the same time, training in conflict and trauma must be promoted. Finally, accompaniment or reflective supervision as support for teams experiencing such violence is essential to prevent and cope with client violence. However, these actions are still alternatives to explore.

It is necessary to note that, geographically, all the studies were conducted in the context of developed countries. There are no reports from the global south, where the conditions of provision of social services present precarious working conditions [45], and services in general and residential care of children are more in demand [46]. So, it is important to promote studies in other cultures, as models for understanding violence attribute special and significant value to the social and cultural context, which must be addressed to comprehend the phenomenon globally [47].

The results show the need to deepen the characteristics of the residential care service for children and adolescents in macro social protection systems. Identifying specific characteristics can generate relevant information for developing prevention strategies at individual and organizational levels. Also, strategies are required that transcend the circumstantial provision of the service or the provider and allow critical analysis of the functioning of the different social systems and services involved. For example, prevention at a structural level should require coordination between residential services; health, security, and police systems; and the community where the residences are installed.

Regarding the specific characteristics of the phenomenon of client violence in residential services for children and adolescents, it is possible to point out that the particularity responds, in the first place, to the fact that violence is often part of the situation that originates the service—violence/negligence against children. On the other hand, users are involuntary—they do not actively choose to be part of a residential program. Rather, they do so because of judicial action, which is generally identified as a cause involved in the generation of violence. Likewise, children and adolescents’ stay in residential care is long term and uncertain. Finally, another characteristic observed is the naturalization of the phenomenon through different mechanisms. On the one hand, violence is naturalized as something related to work—almost inevitable—and on the other hand, it is justified as part of the violence that children have experienced.

6. Conclusions

Based on the literature review, we observed that it is possible to establish some lines of research and intervention. Thus, the results show the need to develop studies that observe and test preventive actions since the various articles consulted only one empirically measured prevention action. At the same time, it is necessary to understand the phenomenon in other contexts, advancing our understanding of it in contexts where services are highly demanded.

Our article allows us to advance in describing a phenomenon that urgently needs to be made visible and requires intervention from an interdisciplinary and intersectoral perspective due to its complexity, as it is a problem of public health, public management, social justice, and human rights.

Data Availability

The data supporting this SYSTEMATIC REVIEW are from previously reported studies and datasets, which have been cited.

Conflicts of Interest

The authors declare that they have no conflicts of interest or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

This work was financed by Mutual de Seguridad with social security resources from law no. 16,744 on work accidents and occupational health.

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Copyright © 2023 Daniela Díaz Bórquez et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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