Hospital violence: site, severity, and nurses' preventive training.

A sample of 663 nurses was surveyed about exposure to violence at the work site; 243 (37%) had faced violence. Hospitals with low response rates to the questionnaire reported less assault, yet the violence admitted to was described as more deadly. More nurses at public than private hospitals had obtained some training to handle potentially violent situations. Serious assault was negatively related to amount of training. At the public psychiatric hospital, violent acts were most frequent, but the rate of deadly violence (e.g., rape, use of knives or guns, etc.) was lowest. The need to train staffs at general as well as psychiatric hospitals was discussed.     

Violence in hospitals and burnout among nursing staff

BackgroundNursing staff, especially in violence-prone emergency departments (ED), are at high risk of burnout. Frequently experienced violence is expected to have a strong impact on the nursing staff's burnout. This study aimed to examine the differences in the level of burnout between nursing staff who work in the ED and nursing staff who work in other inpatient departments, and its relationship with violence in various hospitals in Israel.MethodA cross-sectional study that utilized a three-part questionnaire: demographic data, degree of burnout, and frequency occurrence of violence events against nurses.Results150 nurses in EDs (N = 75) and inpatient departments (N = 75) were sampled. Significant differences were found between the two groups: Nurses in EDs experienced a higher degree of burnout than nurses in other hospital departments, and the degree of burnout was found to have a positive relationship with exposure to both verbal and physical workplace violence.ConclusionsNursing staff in EDs could develop a high degree of burnout, and exposure to workplace violence could exacerbate it. The physical and emotional safety of the staff is an important aspect in preventing burnout, and creating a secure work environment.     

The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center.

INTRODUCTION: This study investigated nurse perceptions of the incidence and nature of verbal and physical assault or abuse by patients and their family members or visitors. METHODS: A survey was given to ED, ICU, and general floor nurses in a 770-bed acute care north Florida medical center. RESULTS: The response rate was 68.8% (86 out of 125). Large percentages of nurses reported being victims of verbal assault or abuse and physical assault by patients and family members or visitors; 88% reported being verbally assaulted and 74% reported being physically assaulted while at work in the past year. ED nurses reported the highest rates of these incidences, with 100% reporting verbal assault and 82.1% reporting physical assault within the past year. Assaults were most commonly perpetrated by patients with cognitive dysfunction (79.1%), patients with substance abuse (60.5%), and persons who were angry because of the patient's condition (55.8%). Surprising information: the most common causes of assault by family members and visitors were anger related to enforcement of hospital policies (58.1%), anger related to the patient's condition/situation (57%), anger related to long wait times (47.7%), and anger related to the health care system in general (46.5%). DISCUSSION: Nurses were confused about what legally constitutes "assault" and "abuse"; nurse rights versus patient rights; and policies and procedures for reporting assault or abuse incidences. Our results indicate that nurses are experiencing abusive and assaultive behavior from family members and visitors just as often as they are from patients, and ED nurses are at higher risk. Nurses perceive a lack of institutional support and an institutional emphasis on patient rights and satisfaction and do not feel safe in the workplace.     

Postattempt: Human Environment and the Teenage Suicide Attempter

A sample of 663 nurses was surveyed about exposure to violence at the work site; 243 (37%) had faced violence. Hospitals with low response rates to the questionnaire reported less assault, yet the violence admitted to was described as more deadly. More nurses at public than private hospitals had obtained some training to handle potentially violent situations. Serious assault was negatively related to amount of training. At the public psychiatric hospital, violent acts were most frequent, but the rate of deadly violence (e.g., rape, use of knives or guns, etc.) was lowest. The need to train staffs at general as well as psychiatric hospitals was discussed.     

Nurses’ perceptions of the factors which cause violence and aggression in the emergency department: A qualitative study

There has been an increase in violence and aggression in emergency departments (EDs) in recent years. Among professional health care workers, nurses are more likely than other staff members to be involved in aggressive incidents with patients or relatives. This research study was undertaken to determine nurses’ perceptions of the factors that cause violence and aggression in the ED. Using a qualitative approach, twelve nurses working in an Irish ED were interviewed. Thematic analysis of the interview data revealed that environmental and communication factors contributed to violence and aggression in the ED. Participants perceived waiting times and lack of communication as contributing factors to aggression, and triage was the area in the ED where aggression was most likely to occur. A number of key recommendations arise from the study findings and they all relate to communication. To address the aggression that may arise from waiting times, electronic boards indicating approximate waiting times may be useful. Also, information guides and videotapes on the patient’s journey through the ED may be of benefit. Consideration to the appointment of a communication officer in the ED and communication training for ED staff is also recommended.     

Nurses’ perceptions of dealing with death in the emergency department

BackgroundProviding end-of-life care to patients and their families in the emergency department (ED) is challenging, with high workloads, the busy environment, and a focus on providing lifesaving treatments to patients at odds with providing end-of-life and palliative care.AimThe purpose of this study was to investigate nurses’ experiences of providing end-of-life care in EDs, including their perceptions of the most vital elements of care, ability to provide aspects of care, as well as perceptions of their role, communication processes, family presence/involvement, and the ED environment.MethodsNurses (n = 211) working in Australian EDs for at least 12 months completed an anonymous online survey.FindingsNurses identified vital elements of care for dying patients including adequate pain control and a move away from burdensome treatments, sensitive care of families and family access to loved ones, and a quiet environment. However, nurses were not always able to provide such care to their patients. Often, the ED was seen as an unsuitable place for end-of-life care or care of families once the patient had died, and communication between staff and between staff and families was challenging.DiscussionThe ED physical environment, lack of staff training and debriefing, and lack of time to communicate with family, particularly after death, may compromise nurses’ ability to provide end-of-life care that is satisfying to them, their patients, and families.ConclusionThere is a need for focus on the ED physical environment, staff training, and consideration of the emotional experiences of frontline nurses caring for patients at the end of life.     

Violent events and security programs in California Emergency Departments before and after the 1993 Hospital Security Act.

INTRODUCTION: Health care workers have long been recognized as having a high risk of work-related assault. In response to a growing threat of violence in hospitals, California implemented the Hospital Security Act (AB508) in 1993. This study compares surveys of emergency nurses before and after implementation of AB508. METHODS: In 1990, the CAL/ENA surveyed emergency departments in California to enumerate violent events and describe security programs. Using the CAL/ENA membership directory, hospitals were resurveyed in 2000 to identify changes from the original survey. Surveys were mailed to the ED nurse manager or equivalent. Survey responses were anonymous. RESULTS: Most hospitals reported fewer violent episodes after the implementation of AB508. However, 32% of hospitals reported that 5 or more verbal threats occurred monthly, and 5% reported that 5 or more violent injuries occurred monthly. Overall, hospitals reported improvements in security programs. The most notable increase was in employee training, which rose from 34% to 95.6% of reporting hospitals. However, almost a quarter of hospitals reported not having general violence prevention policies, and many believed that security personnel were inadequate. DISCUSSION: Although results reported here cannot be directly attributed to AB508, the increase in security program components suggests that hospitals are responding positively to reduce violence. The high prevalence of threats and violent events reported indicates a persistent risk of violence against health care workers.     

Emergency nurses' experience with violence: does it affect nursing care of battered women?

OBJECTIVE: To determine what effect nurses' experience of interpersonal violence had on proposed nursing care of battered women ED patients. METHODS: One hundred ninety-five emergency nurses completed surveys on their personal experiences with violence involving patients or intimate partners and on their proposed nursing care of battered women given 2 vignettes. RESULTS: Seventy percent of participants experienced violence perpetrated by a patient; 40% of the nurses reported violence perpetrated by their intimate partners; and 19% had used force on their partners. Prior assault of a nurse by a patient or partner did not affect the proposed nursing care that would be provided by that nurse to battered women ed patients. Female nurses who committed violence against their intimate partners proposed less nursing care than did those who did not commit violence against their intimate partners for the vignette describing a woman who had received minor injuries. CONCLUSIONS: This study documents the vulnerability of nurses to assault by patients and intimate partners. This vulnerability does not affect their proposed nursing care of battered women. An exception is nurses who themselves commit violence against intimate partners. Findings point to the need to increase safety for nurses in the workplace and provide employee assistance to help nurses confront violence at home.     

The Overcrowded Emergency Department: A Comparison of Staff Perceptions

OBJECTIVES: To study perceptions of physicians and nursing staff about real-time demands and capacity of an emergency department (ED). To use ED data to calculate proposed demand ratios called Real-time Emergency Analysis of Demand Indicators (READI) scores. To compare the READI scores with ED staff perceptions of demand and capacity. METHODS: This prospective study used a computerized clinical management system to provide data about ED demand and capacity. Physicians and staff charge nurses were surveyed about perceptions of ED demand and capacity. Results were compared with mathematical READI scores, which are proposed to objectively assess ED demand. Kappa scores were used to measure intrarater reliability between the physicians' and charge nurses' assessment of demand and between the staff assessments and the READI scores. RESULTS: Kappa scores of the perception of excess demand were as follows: between two physician groups, kappa = 0.392; between one physician group and charge nurses, kappa = 0.453; and between a second physician group and charge nurses, kappa = 0.243. Comparing respondents who indicated that demand had or had not exceeded capacity, one of the READI ratios, the Bed Ratio, showed a significant difference in mean, 0.245 (95% confidence interval = 0.153 to 0.336), between groups. CONCLUSIONS: Real-time data may be used to predict ED demand and resource needs. Subjective assessment of excess ED demand did not correlate between physician groups or between physicians and charge nurses. Although there was a trend toward predicting excess demand with one of the READI scores, these scores did not correlate to staff perceptions.     

Nurses' experience of violence in Alberta and British Columbia hospitals.

This study examined responses to a survey on violence in the workplace from a sample of 8,780 registered nurses practising in 210 hospitals in the Canadian provinces of Alberta and British Columbia. Findings relate to the frequency of violence against nurses, reported as the number of times they experienced a violent incident in the workplace. Nearly half (46%) of those surveyed had experienced 1 or more types of violence in the last 5 shifts worked. Frequency varied by type: emotional abuse 38%, threat of assault 19%, physical assault 18%, verbal sexual harassment 7.6%, sexual assault 0.6%. Further, 70% of those who had experienced violence indicated they had not reported it. Patients constituted the main source of all types of violence. The most prevalent type, emotional abuse, was further explored for its possible determinants. This was also the type of violence most evenly distributed among sources (patients, families, co-workers, physicians). Multiple regression modelling using the individual nurse as the unit of analysis showed the significant predictors of emotional abuse to be age, casual job status, quality of care, degree of hospital restructuring, type of unit, relationships among hospital staff, nurse-to-patient ratios, and violence-prevention measures; using the hospital as the unit of analysis the predictors were found to be quality of care, age, relationships with hospital staff, presence of violence-prevention measures, and province. These findings illustrate important differences in models that use the individual and the institution as the unit of analysis. Implications include targeting prevention strategies not only at the nurse but, perhaps more importantly, at the hospital. Overall, the findings suggest that health-care institutions are not always healthy workplaces and may increasingly be stressful and hazardous ones.     

Supplemental nurse staffing in hospitals and quality of care

OBJECTIVE: To promote evidence-based decision making regarding hospital staffing, the authors examined the characteristics of supplemental nurses, as well as the relationship of supplemental staff to nurse outcomes and adverse events. BACKGROUND: The use of supplemental nurses to bolster permanent nursing staff in hospitals is widespread but controversial. Quality concerns have been raised regarding the use of supplemental staff. METHODS: Data from the 2000 National Sample Survey of Registered Nurses were used to determine whether the qualifications of supplemental nurses working in hospitals differed from permanent staff nurses. Data from Pennsylvania nurse surveys were analyzed to examine whether nurse outcomes and adverse events differed in hospitals with varying proportions of nonpermanent nurses. RESULTS: Temporary nurses have qualifications similar to permanent staff nurses. Deficits in patient care environments in hospitals employing more temporary nurses explain the association between poorer quality and temporary nurses. CONCLUSION: Negative perceptions of temporary nurses may be unfounded.     

Doctors' and nurses' perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice

Background. The importance of interdisciplinary collaboration has been attested to by a number of authors. Some have suggested that Nurse Practitioners (NPs) may be able to improve collaboration between doctors and nurses, but this assertion does not appear to have been researched. Aims and objectives. To investigate doctors’ and nurses’ perceptions of interdisciplinary collaboration in two neonatal intensive care units, and to assess the impact of a Neonatal Nurse Practitioner (NNP) practice model on these perceptions. The study was conducted as part of a larger project to develop a NNP model of practice. Design. Survey, pre‐ and post‐intervention. Methods. Medical and nursing staff in both units were surveyed before and after introduction of the NP model of practice. The instrument consisted of 25 statements relating to nurse–doctor interactions, with which respondents indicated their level of agreement on a five‐point Likert scale. The Mann–Whitney U‐test was used to compare scores for individual items and for overall collaboration between various groups of staff, and between the first and second surveys. Results. Significant differences between the responses of nurses and doctors were found on both surveys. Areas of disagreement chiefly concerned doctors’ behaviour and their attitudes towards nurses, rather than nurses’ behaviour or environmental factors. Doctors consistently reported a higher degree of collaboration than did nurses. Few differences were found between first and second surveys. Conclusions. Results suggest that problems in nurse–physician interactions exist in both units. No impact of the NNP role, as established in this project, on interdisciplinary collaboration could be demonstrated. Further research in this area is warranted.     

Violence towards emergency department nurses by patients

Emergency department (ED) violence is a significant problem in many hospitals. This study identified the incidence of violence by patients towards nurses in two EDs. Patient factors related to violence were identified and the circumstances surrounding the violent incident were described. Of the 71 ED nurses who participated, 50 (70%) reported 110 episodes of violence in a five-months period. That is approximately five violent incidents per week. Violence was reported most often on evening shifts (n=41, 37%). The nurses' perceived that the perpetrators of violence were under the influence of alcohol (n=30, 27%) and drugs (n=27, 25%) and displayed behaviours associated with mental illness (n=42, 38%). Nurses in this study were sworn at (n=67, 61%), pushed (n=11, 10%), hit (n=3, 3%), and kicked (n=3, 3%). Identification of trends and patterns of violence is necessary so that better health care planning and service provision as well as effective preventative and safe strategies for nurses in the workplace can be implemented.     

Violence toward health care workers in emergency departments in west Turkey

The aims of this study were to describe the epidemiology of violence in Turkish emergency departments (EDs), and to provide a more specific focus on violence. This study was conducted in 18 EDs in west Turkey for 3 months. Emergency staff in the EDs were asked to recall experiences of violence directed at them at work over the previous year. We then put these experiences into five categories: verbal abuse, specific threats, physical action with or without injury, sexual violence, and the last category, acts not falling in the other four categories. The data were analyzed using chi-square test and percent ratios. Of the 195 respondents answering the questions regarding violence against them, 72.3% (141/195) had experienced some form of violence. Most of the respondents stated that they had experienced verbal/emotional abuse (69.5%), followed by specific threats (53.2%), and physical action (8.5%). Groups experiencing the highest percentage of any type of violence during the previous year were as follows: 30-39-year-olds (82.1%), nurses and physicians (80.8% and 78.0%, respectively), public hospital health care staff (81.0%), staff working for 61-120 months (82.8%), those working between 8:00 a.m. and 5:00 p.m. (81.8%), and those working in low deprivation practices (79.6%). Most of the aggressors were patients' relatives (89%) as compared with patients' themselves (52%). Half of those experiencing physical action (50% [6/12]) during the course of the last year received support and inability reports due to minor injuries. There were no major injuries such as lacerations or fractures. We recommend that training to deal with violence in the workplace be specifically targeted at members of staff who are most likely to be at risk of threats of violence and actual physical aggression.     

Violence towards nursing staff in emergency departments in one Turkish city

AIM: To determine the incidence of violence faced by nurses in emergency departments (ED) in a Turkish city, whether any of the incidents were reported and what legal action was taken. The second aim was to identify nurses' attitudes towards these incidents and the relevance of their professional background. METHODS: Data were collected by questionnaire from the nurses working in the ED of four major hospitals in Izmir, Turkey. The questionnaire consisted of 34 questions seeking socio-demographic data, information on verbal and physical victimization and legal processes. RESULTS: Sixty-six nurses (72%) agreed to participate in the study. One third (34.8%) of participants were relatively new in the profession (0-5 years), and the majority of nurses (71.2%) had an ED experience of less than 5 years. The incidence of verbal violence (98.5%) was significantly more frequent than physical violence (19.7%). However, most incidents remained unreported (83.5%); most of the reported cases did not result in legal action (63.7%). Almost half of the nurses believed that possible explanations for the violent incidents they faced were because they were less competent and inexperienced in the profession than more senior colleagues. DISCUSSION: Victimized respondents mostly preferred to remain silent and did not report the incidents to the hospital administration since they believed that this would not result in legal action. It seems evident that our country lacks legal processes concerning job (workplace) violence. Effective legislative arrangements are necessary. Nurses and other ED staff also need continuing education concerning their rights and personal safety.     

The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety.MethodWe observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes.ResultsMechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors.ConclusionWe recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.     

Screening for and treating intimate partner violence in the workplace.

The WHO has declared that violence is a leading worldwide public health problem with intimate partner violence one of the most common forms of violence against women (2002). Health care providers are frequently among the first to see victims of intimate partner violence and must strive to provide appropriate and effective care to abused women. Violence by intimate partners can be prevented. Occupational health nurses have a unique opportunity to intervene with abused women. Routine screening for intimate partner violence increases the likelihood of violence identification, leading to early intervention that may prevent trauma and injury. Occupational health nurses can foster a caring and confidential workplace where abused women feel safe to disclose the violence in their lives and trust that the nurse will provide treatment. A safe and healthy workplace, where abused women feel comfortable disclosing intimate partner violence and seeking treatment may also protect coworkers from the stress and violence that may potentially affect them. Occupational health nurses need to add screening for and treatment of intimate partner violence to their current health promotion and prevention activities to benefit all employees.