De-escalating aggression and violence in the mental health setting

Aggressive and violent incidents in the health-care setting are increasing phenomena around the world. The evidence from current literature suggests that changes in health-care access, nursing staff shortages and patient acuity are some of the possible causes. De-escalation is a valuable intervention that can be used by nurses to help counter the growing problems of aggression and violence. The de-escalation project, discussed in the present paper, aimed to explore de-escalation as an important therapeutic process and is an event of considerable potential in the management of aggression and violence. While de-escalation is not a new tool, particularly in the mental health-care setting, an educative programme aimed at renewing nurses' knowledge and skills in de-escalation is a timely project. The final de-escalation kit included a large glossy poster, a nursing staff survey, an in-service education session and a literature-based discussion paper. The de-escalation kit can be of considerable benefit to those nurses who are transient within the workplace, such as casual and agency nurses.     

Workplace Violence in Healthcare Settings: Risk Factors and Protective Strategies

This article describes the risk factors and protective strategies associated with workplace violence perpetrated by patients and visitors against healthcare workers. Perpetrator risk factors for patients and visitors in healthcare settings include mental health disorders, drug or alcohol use, inability to deal with situational crises, possession of weapons, and being a victim of violence. Worker risk factors are gender, age, years of experience, hours worked, marital status, and previous workplace violence training. Setting and environmental risk factors for experiencing workplace violence include time of day and presence of security cameras. Protective strategies for combating the negative consequences of workplace violence include carrying a telephone, practicing self‐defense, instructing perpetrators to stop being violent, self‐ and social support, and limiting interactions with potential or known perpetrators of violence. Workplace violence is a serious and growing problem that affects all healthcare professionals. Strategies are needed to prevent workplace violence and manage the negative consequences experienced by healthcare workers following violent events.     

The effectiveness of a training program for emergency department nurses in managing violent situations

An Australian Institute of Criminology report (1999) highlighted the health industry as the most violent industry in Australia with registered nurses recording the second highest number of violence-related workers compensation claims, ranking higher than prison and police officers. Workplace violence has become such a common phenomenon that many nurses accept it as a part of nursing. Nurses employed in emergency departments (EDs) are considered to be especially vulnerable to workplace violence. Although there have been a number of studies reporting on the incidence of workplace violence and its consequences upon nurses, to date there have been no empirical studies that have evaluated interventions which are thought to reduce its occurrence and impact. This study investigated the effectiveness of a one-day training program in which ED nurses participated. In particular, their knowledge, skills and attitudes relating to management of workplace violence were examined. Results show that a training program has many positive outcomes which enhance nurses' ability to manage aggressive behaviours. With some basic training, ED nurses can be more prepared to manage violent and potentially violent situations, and by doing so may in fact reduce the incidence of aggression in their workplace by 50%. This has largely been achieved by raising the awareness of ED nurses to the nature of the problem, developing their knowledge and skills in managing aggressive behaviour, and improving their attitudes toward potentially violent patients.     

Countering workplace aggression: an urban tertiary care institutional exemplar

PURPOSE: The purpose of this process improvement project was to provide nursing staff with evidence-based knowledge and skills to manage patients and/or visitors with the potential for violence. SIGNIFICANCE: Current statistics describing workplace violence in healthcare settings are alarming. Workplace violence significantly impacts nursing practice and may contribute to physical injuries, psychological trauma, decreased productivity, and low morale among nurses. This is particularly germane to those nurses who have been inadequately trained to manage aggressive patients and/or family behaviors. RATIONALE: Following a series of disruptive episodes on the pulmonary-medical service that occurred at our facility in the winter of 2006, an employee safety team was formed to address the issue of workplace violence. Around this same time frame, a team comprising system hospital representatives was also initiated to globally address workplace violence. METHODS/DESCRIPTION: A Workplace Violence Education Program was devised to equip nurses with information, skills, and practical tools that will empower them when encountering clinical situations characterized by disruptive or abusive patient and/or family behaviors. The ultimate goal was to diffuse progressive, escalating aggressive behaviors in the clinical setting. FINDINGS/OUTCOMES: Evidence-based approaches formed the basis of an educational offering focusing on workplace violence prevention and management. This informational intervention was devised to empower clinical nursing staff with knowledge to enhance judgment, decision making, and implementation of behavioral strategies to reduce the likelihood of patient/family behaviors escalating to aggression. CONCLUSION: Interdisciplinary collaboration that included clinical experience, expertise, and knowledge generated from current literature reviews contributed to a successful educational program for nurses focusing on a historically neglected topic--workplace violence.     

‘Violence is Not Part of Our Job’: A Thematic Analysis of Psychiatric Mental Health Nurses’ Experiences of Patient Assaults from a New Zealand Perspective

This paper describes psychiatric mental health nurses’ (PMHN) experiences of patient assaults within mental healthcare settings using a thematic analytical approach. The aim of the study was to explore and describe psychiatric mental health nurses’ experiences of patient assaults. The major findings of the study related to the nature and impact of assaults and supportive strategies associated with violence perpetrated by patients against psychiatric mental health nurses. Perpetrator risk factors for patients include mental health disorders, alcohol and drug use and the inability to deal with situational crises. The injuries sustained by nurses in the context of the study include lacerations, head injuries, dislocations and bruises. Psychological harm has also occurred, including quite severe mental health problems, such as post-traumatic stress disorder. Protective strategies for combating negative consequences of workplace violence include practice of self-defence, social support and a supportive and consultative workplace culture with access to counselling services and assistance in all aspects, including finances. The paper concludes that while healthcare employers need to provide better support services to the healthcare professionals who are assaulted, the legal system also needs to acknowledge that assaults against nurses are a violation of human rights and violence should not to be tolerated as part of working in mental healthcare settings.     

Violence, aggression and physical assault in healthcare settings

All healthcare professionals are at risk from violent and aggressive patients, however, it has been found that nurses are at particular risk. The actual incidence is difficult to determine because the definition of what constitutes a physical assault or a violent event is vague. This article considers how the terms violence, aggression and physical assault are conceptualised in the healthcare setting and suggests that nursing staff need to identify and act on any incident that compromises their personal safety.     

Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence

Aims and objectives. The purpose of the study was to explore the meaning(s) that emergency department nurses ascribe to acts of violence from patients, their family and friends and what impact these meaning(s) have upon how they respond to such acts. Background. Violence in the health sector is of international concern. In high acuity areas such as emergency departments, nurses have an increased risk of violence. The literature further suggests that violence towards nurses in emergency departments is under‐reported. Design and methods. This study was undertaken in 2005, at a regional Australian Emergency Department with 20 consenting registered nurses. Using an instrumental case study design, both qualitative and quantitative data were generated. Qualitative data were collected using participant observation, semi‐structured interviews, informal field interviews and researcher journaling. Quantitative data of violent events were generated using a structured observational guide. Textual data were analysed thematically and numeric data were analysed using frequency counts. Mixed methods and concurrent data analysis contributed to the rigour of this study. Findings. Emergency department nurses made judgments about the meaning of violent events according to three factors: (i) perceived personalization of the violence; (ii) presence of mitigating factors; and (iii) the reason for the presentation. The meanings that were ascribed to individual acts of violence informed the responses that nurses initiated. Conclusions. The findings show that violence towards emergency department nurses is interpreted in a more systematic and complex way than the current definitions of violence make possible. The meanings given to violence were contextually constructed and these ascribed meaning(s) and judgments informed the actions that the nurses took in response to both the act of violence and the agent of violence. Relevance to clinical practice. Understanding the meaning(s) of violence towards nurses contributes to the discussions surrounding why nurses under‐report violence. Further, these findings bring insights into how nurses can and do, handle violence in the workplace.     

Violence against nurses in hospitals: prevalence and effects

There is abundant evidence to suggest that violence in healthcare settings, especially in emergency departments (EDs) and psychiatry, is escalating and that nurses are particularly vulnerable. The authors, therefore, investigated the prevalence and effects of violence against nurses in an ED in a general hospital setting in Kuwait. A 12-item frequency-weighted questionnaire was used to measure rates, frequency and severity of violence. The questions related to the experience of violent incidents during the past year. Seventy out of 81 nurses experienced verbal insults or threats of imminent violence and 13 were also physically attacked during the 1-year period. Sixty-seven out of 70 nurses suffered from one or more after-effects, including flashbacks, sleeplessness, fearfulness, depression or taking time off work. Violence in healthcare services often reflects the community in which service is provided. Our findings suggest that doctors experience more violence but nurses suffer from more after-effects of violence at work.     

Report and Prevent: A Quality Improvement Project to Protect Nurses From Violence in the Emergency Department

IntroductionMost nurses experience some form of workplace violence resulting in a stressful work environment, employee injury, and turnover. The aims of this project were to develop and evaluate strategies to improve the reporting of workplace violence as well as to empower emergency nurses to prevent assaults and protect themselves.MethodsThis quality improvement project had 2 phases. The phase I educational intervention focused on the importance of reporting workplace violence. Pre- and postintervention surveys measured experiences with workplace violence and reporting. The phase II educational intervention focused on de-escalation and self-protection strategies, training, safety, confidence, and emergency nurses’ preparedness to defend themselves. Responses were analyzed using Wilcoxon signed-rank and McNemar tests.ResultsTwenty-five emergency nurses participated in phase I, with >90% reporting that they had been assaulted in the past month. Most did not report a workplace assault, which was unchanged after the intervention. Thirty-four emergency nurses participated in phase II, with a postintervention increase reported in the perceived helpfulness of learning self-protection techniques for the emergency nurses’ work life (Z = –2.179, P = 0.029).DiscussionThis study was consistent with the literature in that emergency nurses often do not report workplace assaults. Most of the emergency nurses surveyed had been assaulted. Although the educational interventions did not achieve the desired outcome, it is clear that additional interventions for individual nurses and institutions need to be developed and refined to increase reporting and prevent workplace assaults.     

Impact of hospital security programmes and workplace aggression on nurse perceptions of safety

Aim To assess how nurses’ perception of their safety and risk of violence was affected by their work environment and whether this perception correlated with their actual risk. Background The work environment has an impact on nurses’ perception of their risk of violence and this perception affects worker productivity, quality, employee retention, worker satisfaction and their actual safety. Methods A cross-sectional survey was conducted in person of 314 emergency department nurses and 143 psychiatric nurses, and assault data was collected from injury logs. Results This study found that nurses in the emergency and psychiatric units differed in their perception of violence and safety. The workplace elements that led to a perception of lower risk of violence were not correlated with a lower rate of injury from violent acts. The nurses’ beliefs about the adequacy of security equipment, security guards and the frequency of verbal abuse were strongly correlated with perceived safety. Conclusion Several factors that influence nurses’ perception of their risk of violence are not well correlated with their actual risk. Implications for nursing management Managers must address workplace elements that affect nurse perceptions because this has an impact on quality and employee retention. They must also address factors that have an impact on the actual risk of violence because this study showed, for the first time, that these may differ from perceptions.     

Preventing workplace violence from negligent hiring in healthcare

Negligent hiring is emerging as one of the prime causes of healthcare employer liability for workplace violence. Healthcare administrators have been found liable for violent acts of employees both within and outside their normal scope of employment. The authors discuss negligent hiring doctrine and what the US courts have decided on negligent hiring cases. The discussion shows how liability in healthcare institutions can occur, and how the respondeat superior doctrine may no longer serve to limit employer liability. The authors suggest how to develop screening practices to reduce work-place violence and minimize negligent hiring lawsuits.     

Defining the severity of workplace violent events among medical and non-medical samples. A pilot study.

The purpose of this study was to describe and compare medical and non-medical individuals' violence severity rank for 13 commonly cited events illustrative of workplace violence. One hundred thirty-six college students were provided a short checklist of 13 violent events in the workplace to determine the violence severity rank for each event. Two groups of college students with (n = 69) and without (n = 67) medical background participated. Student and registered nurses (medical group) agreed on the violence severity ranking of all 13 often-cited workplace violence events. Non-medical and medical groups, however, did not always agree on the degree of violence severity, especially for physical and sexual workplace violence events. Differences between groups may be explained by the possibility that nurses are socialized or desensitized in practice to possibly accept some workplace violence events as "part of the job." Gastroenterology nurses can benefit from this study by raising their sensitivity to and awareness of workplace violence in the practice setting.     

Violence and aggression in the intensive care unit: What is the impact of Australian National Emergency Access Target?

IntroductionViolence in healthcare settings is a concern for healthcare professionals and patients. Media reports, and debate within the healthcare profession, and the academic literature infer that workplaces such as intensive care units are becoming exposed to increasing violence. Increases in the incidence of violent behaviour are sometimes attributed to the increased pressure on emergency departments to accelerate the throughput of patients to meet targets. To ensure the wellbeing of patients and staff, there is a need to evaluate the impact of such targets. The aim in this study was to evaluate the incidence and to describe the context in which patients' aggressive and violent behaviours occurred since the introduction of the National Emergency Access Target in a local tertiary Australian intensive care unit.MethodsA retrospective examination of events triggering violence-related emergency codes from 12 months before the introduction of the National Emergency Access Target up until 12 months after its implementation (2011–2013).ResultsA small increase in the number of Code Grey/Code Black activation was identified after the introduction of the target (before = 18, after = 29). Admissions following drug overdoses, isolated head trauma, and cardiac arrest were the presentations most likely to have been associated with a violence-related emergency call. Female registered nurses, male critical care registered nurses, and clinical nurse specialists were the most at risk of occupational violence. Male nursing staff members were found to be more likely to be involved in incidences of verbal violence (p < 0.003).ConclusionAlthough there was a minimal increase in the overall number of emergencies triggered by violent behaviour, valuable information on the type of occupational violence occurring towards healthcare professionals and patients in this setting was found. We suggest that these findings add further important detail to the existing understanding of the problem of occupational violence. These detailed insights can further inform policy development, professional education, and practice.     

Workplace violence in healthcare environments

Violence in the workplace is making headlines across the United States. Healthcare workers are not immune to violent encounters. Many healthcare workers will experience workplace violence at least once during their professional careers. Nurses are in a unique position to develop and provide assistance to implement prevention programs that can decrease the incidence and prevalence of violence in healthcare environments. This article reviews the definition of violence and its elements, and outlines a plan to reduce violence in healthcare environments.     

Workplace violence against nurses – Prevalence and association with hospital organizational characteristics and health-promotion efforts: Cross-sectional study

Purpose/objectivesTo determine the prevalence of workplace violence and explore the role of hospital organizational characteristics and health promotion efforts in reducing hospital violence among nurses in Taiwan.DesignCross-sectional survey.SettingOne hundred hospitals across Taiwan.SampleThe final sample in our study comprised responses from 26,979 nurses.MethodsThe data were obtained from a nationwide hospital survey, Physical and Mental Health and Safety Needs in Full-Time Health Care Staff, which was developed and conducted by the Bureau of Health Promotion, Taiwan, in 2011.Main research variablesThe main dependent variable was whether nurses had experienced violence within the past year. Physical violence, threatened or intimidated personal safety, verbal violence or sexual harassment were all included.FindingsOf the 26,979 nurses, 13,392 nurses (49.6%) had experienced at least one episode of any type of violence in the past year; 5150 nurses (19.1%) had been exposed to physical violence, and 12,491 nurses (46.3%) had been exposed to non-physical violence. The prevalence of having experienced any violence varied widely and ranged from the highest (55.5%) in an emergency room or intensive care unit to the lowest (28.3%) among those aged 55–65 years. After adjusting for other characteristics, younger nurses were significantly more likely to be exposed to any violent threat. Nurses working in public hospitals had a significantly higher risk of workplace violence than those working in private hospitals. Significant variations were also observed among work units. Although nurses working in a certified health promoting hospital (HPH) did not have a lower risk of workplace violence, those working in an outstanding HPH had a significantly lower risk of workplace violence. A similar pattern was observed for non-physical violence.ConclusionsWorkplace violence is a major challenge to workplace safety for nurses in hospitals. This large scale nurse survey identified individual, work and hospital characteristics associated with workplace violence among hospital nurses. Preventive efforts in reducing hospital violence shall be targeted these high risk groups and settings.Implications for nursingThis nationwide nurse survey assisted us in more clearly understanding the scope of the hospital violence facing nurses and identifying critical risk factors. The findings not only identified the most common locations of violence in hospitals but also suggested that extensive investments and efforts by hospitals in health promotion are crucial.     

Violence and aggression in the emergency department: A critical care perspective.

Aggression and violence are common in the Emergency setting, with nurses out-ranking police and prison officers in exposure to workplace violence. This paper examines the current literature to identify the incidence of violence within the ED, precipitators of violence and aggression and the government policy directive of 'zero tolerance'. Methods of managing violence and aggression are explored, including environmental management, de-escalation, pharmacological and physical restraint and seclusion and these are linked to course content recommended for staff training.     

Violence towards the caregiver. A growing crisis for professional nursing

The violence that permeates society at large does not stop at the hospital walls. Indeed, there exists mounting evidence (Carroll, 1998; Morgan, 1999; Trossman, 2001) to suggest that workplace abuse of healthcare professionals, specifically nurses, by patients is a common and widespread problem. New research indicates that violence in the health care workplace is actually a global phenomenon. International Labor Organization [ILO]; International Council of Nurses [ICN]; The World Health Organization [WHO]; Public Services International [PSI], (2001). More than 30 percent of nurses recently surveyed in seven states reported having been the victims of work place violence in the previous year. Patients had assaulted most of these nurses. (Colorado Nurses Association [CNA], 1998) Nurses are dying and suffering injuries at work as a result of violence (Doody 1995). The purpose of this paper is to increase nurses' awareness of the risk factors for violence in health care settings and to provide strategies for reducing nurses' exposure to these factors.